Rivaling Nature

The war in Iraq has increased demand for limb and facial plastic surgeons

In Iraq, as in past conflicts, combat technology outpaces medical technology. Protected by innovative body armor, soldiers sustain far fewer injuries to the torso, but limbs and heads remain terrifyingly vulnerable. "In World War I, Harold Gillies converted all the dentists overnight into plastic surgeons," says Dr. Joseph Rosen, a plastic surgeon at Dartmouth-Hitchcock Medical Center who works with soldiers injured in Iraq. "Now we're seeing an increased demand for limb and facial plastic surgeons."

Sophisticated frontline casualty care has saved the lives of many soldiers who would have died of similar injuries in previous conflicts. But survivors must now live with what is often massive damage. Improvised explosive devices (IEDs)—typically roadside bombs hidden on convoy routes—are to this war what artillery fire was to World War I; the explosive blast itself shears off body parts, while concussive force causes internal injuries and permanent brain damage. "We're used to thinking about losing an arm or an eye or an ear," Rosen says. "When you lose all these things simultaneously—the blast injuries take your arms with your face; that's what makes these polytrauma injuries—they're not the sum of their parts, they're much worse."

The severity of facial wounds is also greater. "We had a colleague here who trained under Gillies," Rosen recalls. "When I looked at his 25 cases of facial injuries from World War II and I look at the cases today, the cases today are of an order of magnitude substantially worse. Between World War I and World War II, the change wasn't that much, but in the change to this present war with the blast injuries, we shifted from high-energy transfer to massive-energy transfer."

Rosen envisions an ambitious timeline of possible treatment, with reconstruction through surgery representing the first stage, and regeneration of a missing body part through tissue engineering being the ultimate, futuristic goal. "That's more like the year 2050," Rosen allows. In between these options is transplantation—of a hand, a limb, a face. In November 2005, French surgeons pioneered a partial face transplant. More accurately characterized as a "soft tissue transplant," the operation is suitable only for those who have retained an underlying normal facial structure. "No one is yet proposing a full re-provision of the whole face including the underlying bony structures," cautions Dr. Andrew Bamji, curator of the Gillies Archives in Sidcup, England. Dazzling advances in medical and biotechnology notwithstanding, the choices offered facially damaged soldiers of the Iraq War remain essentially the choices of World War I: if reconstructive surgery cannot produce adequate results, the soldier may elect to wear prosthetic covering.

"Generally, they choose facial prostheses not so much as a mask, but because they want to wear glasses, or sunglasses, and they need a nose," says Erin Donaldson, a clinical anaplastologist for Living Skin, a company specializing in lifelike prostheses. Most of Donaldson's clients are civilians who have suffered burns, or facial cancer, or were born with congenital defects. But she has also worked with soldiers disfigured in earlier wars. Prostheses typically substitute for a single part, such as a nose, or a portion of a face, rather than affording full-face coverage. "Most of our patients find out about facial prosthetics on the Internet," she says. Some of her patients had previously worn dust masks colored with cosmetic foundation.

Advanced artificial skin technology, in particular, has allowed amazingly realistic creations; of one client's new nose Donaldson says, "It looked ridiculously good—you really couldn't tell." But despite such advances, wearers of prosthetic faces confront many of the same drawbacks today as in World War I. Breath moisture creates problems, steaming up glasses and interfering with adhesives; and even the most sophisticated prosthesis does not move. "If it's an eye, it can't blink," Donaldson says, "but it does protect your anonymity. It's not for your friends and family, it's not to fool people close to you. It's for the split second when you cross paths with someone in a grocery store."

Facial prostheses that can make lifelike, expressive movements—smiles and frowns and all the nuanced expressions that flow across the human face—are the ambitious goal of robotics expert David Hanson. The founder and CEO of Hanson Robotics, he has won acclaim for his cutting-edge, human-like robots and his invention of a substance closely resembling human skin. Called Frubber, from "facial rubber," the synthetic skin mimics the cell structure of the real thing and allows expressive movements to be battery powered by minimal energy.

"The first versions, you would have a robotic mask that would be removed, and washed and probably replaced every few years," Hanson speculates. Acknowledging that many people manifest deep-seated unease with robotic hardware that mimics humans too closely, he is confident that such technologies will eventually find acceptance. Hanson hopes to try out some types of facial prostheses on patients within the next year before beginning clinical trials. "We had a fairly careful analysis showing that it's feasible at least to have an animated eye and eye region, including an eyelid and eyebrow, within three years."

"My patients would probably try it, and then never wear it," says Donaldson of a full-face robotic mask. "What if it breaks? You're back to square one." Unless a patient is missing actual facial parts, Donaldson advocates confronting the world with the face that remains. "It's society that should change," she says. "It's the public that needs to be educated."

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