Restoring America’s Wounded: Advanced Surgical Technique Research

By: Laura Curtin, FHP&R Staff Writer

Use of improvised explosive devices in Iraq and Afghanistan has caused a marked increase in severe blast trauma, but today’s military medical care has allowed many of the injured to survive. In fact, approximately 90 percent of the wounded survive serious injuries sustained on the battlefield.

“Survival rate… is thanks to research in combat casualty care, the great medical care we have in theatre, plus the military’s phenomenal evacuation system [from the battlefield],” Col. Jan Harris said. Col. Harris is a science manager for Department of Defense (DoD) funded research projects within clinical and rehabilitative medicine. This general area of research is specifically for the purpose of restoring function and quality of life to America’s wounded through advanced therapies.

Returning Service members to duty and helping them lead productive and fulfilling lives are of critical importance to the military and medical communities. There are many research investigations occurring to advance rehabilitation of the injured. Some research studies within the clinical and rehabilitative medicine portfolio work with prosthetics and amputee care; others focus on repairing vision, mitigating chronic pain, regenerative medicine techniques, and healing burns. One study specifically focuses on improving appearance and quality of life for civilians and Service members who have experienced facial trauma.

U.S. Navy Machinist’s Mate 1st Class Michael Lammey and his wife look at the ribbons he has earned during his Navy career at Brooke Army Medical Center in San Antonio, Texas, Aug. 12, 2009. Lammey is recovering at the hospital after being burned when a boiler exploded aboard the submarine tender USS Frank Cable (AS 40). (U.S. Navy photo by Mass Communication Specialist 2nd Class Jhi L. Scott/Released)

Service members are returning from the battlefield with limb, head, face, and other injuries that can take years to treat. These injuries can result in significant lifelong impairment, but with the help of researchers, recovery may include more options as techniques improve and medical science evolves.

Low Risk and Minimally Invasive Surgery

A very severe facial trauma typically requires 30 to 40 surgeries just to close wounds and allow some functionality. In some cases the individual is left with a severely disfigured face. Even less severe facial trauma can leave behind scars. Visible facial injuries can impact the ability to integrate back into society, affecting both personal relationships and employment opportunities. While current medical procedures can do a lot to reconstruct these injuries, physicians consistently strive to find better ways to accurately restore facial features.

One method under investigation is called structural fat grafting for craniofacial trauma. The fat grafting technique is a common cosmetic and reconstructive procedure, and was performed approximately 65,000 times by plastic surgeons in the United States last year. Fat grafting, in this particular case, is where the surgeon transfers excess fat deposits from other areas of the body to the injured face. Using a very specialized technique, this low risk and minimally invasive procedure adds contour to the injured face. The wounded person’s physical appearance can typically improve after this outpatient procedure.

Dr. J. Peter Rubin is an associate professor of plastic surgery for the McGowan Institute of Regenerative Medicine at the University of Pittsburgh School of Medicine. Dr. Rubin currently serves as a principal investigator of DoD-funded research that strives to accurately restore wounded warriors after combat related injury.

Dr. Rubin’s fat grafting project utilizes specialized instruments to inject fat into scar tissue planes at the exact site of injury to offer an improved aesthetic appearance for the patient. Reconstructive and cosmetic procedures can increase the volume and shape of the injured body site. The best technical ability and guidance are administered to accomplish the surgery.

Dr. Rubin explains that “the area of investigation is to see how well the specialized technique lasts over time, as injected fat can lose volume. We measure volume of the fat graft with high definition CT scan and 3D typography. A psychologist works with participants at every point of the process to assess quality of life immediately after the battlefield injury, in preparation for the procedure and again after the surgery.”

Important project goals include validating the treatment and then educating military physicians on the specialized technique for use at military treatment facilities. Also important to the research study is if the Service members’ perception of quality of life improves after the procedure.

In September, the fat grafting study had begun treatment for approximately 10 of the 20 total participants approved for the study. Patient enrollment is ongoing until all 20 patients have been identified; viable candidates are those with any visible deformity of the face or head at least three months into recovery from the initial facial trauma. Men and women who are active duty or former members of the United States Military may be eligible. Prior surgery of the face or skull does not prevent participation in this study, as fat grafting is often used to further improve the results after other surgical procedures. For more information about this study, please contact Ms. Carlynn Graves by email at crj9@pitt.edu.

“I think that it is the soft tissue overlying the bones and skull that gives humans the most recognizable traits, which injury [to the face] seriously changes. This outpatient procedure has the potential to make a big difference in appearance and integration back to society,” Dr. Rubin said.

About DoD’s Research Investment Initiatives

The DoD’s Office of Force Health Protection & Readiness manages a portion of the DoD’s investment in medical research and development. Specifically, the Defense Medical Research and Development Program (DMRDP) manages research, development, testing, and evaluation plans for using Defense Health Program (DHP) funding.

Within the DMRDP are six major research portfolios that address a variety of operational needs in research. DMRDP is involved with directing science that addresses wounded warrior focus topics outlined by the Secretary of Defense. These important areas include traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), prosthetics, eye injury, and other deployment and battlefield injuries.

Each research portfolio is managed by joint program committee teams of experienced medical and military personnel. Col. Harris chairs one of the six joint program committees within the DMRDP – the Clinical and Rehabilitative Medicine (CRM) portfolio. CRM focuses on methods for restoring and rehabilitating war injuries.

Main areas of the CRM portfolio are neuromusculoskeletal injury, acute and chronic pain, regenerative medicine, and sensory system traumatic injury. The DHP investment for this portfolio area is currently funding many research studies along with several clinical trials. Related research projects are funded through the Services, other government agencies, academic institutions and industry. A large collaborative group executes clinical trials. “Four military treatment facilities are part of a large clinical consortium. It includes Walter Reed Army Medical Center, San Antonio Military Medical Center, Navy Medical Center San Diego, and Navy Medical Center Portsmouth,” Col. Jan Harris explained.

The CRM portfolio also includes research efforts that are directed at TBI-related sensory dysfunction (such as visual and hearing dysfunction), and cognitive rehabilitation in the context of TBI. CRM encompasses fundamental research to better understand both injury and healing mechanisms through clinical trials. The clinical trials aid in establishing safety and effectiveness of new products and treatment strategies. The DoD’s research investments offer hope not just for wounded Service members, but also for the broad medical community in finding improved methods for better patient healing.