A medical research contract established through the Army Contracting Command -- Aberdeen Proving Ground has led to the nation's first full face transplant and the first combination face and hands transplant.
This contract was established as part of a biomedical translational initiative directed by the Assistant Secretary of Defense for Health Affairs under the direction of Thomas J. Bouchard, Natick Contracting Division, deputy chief, to advance the treatment of military members injured in Iraq and Afghanistan and it led to the nation's first full face transplant and the first combination face and hands transplant.
"The request for proposal was issued with a goal to fund the demonstration and validation of innovative technologies to improve the clinical outcome of wounded warriors," Bouchard said.
"The plan was to discover technologies that would restore wounded warriors to active duty, improve the form or function of service members, or assist in reclaiming their independence in daily living tasks. I never dreamed that a biomedical translational initiative would result in a medical outcome at the magnitude of face transplantation."
The solicitation was released in May 2009 with the instructions that winning proposals would be funded under negotiated contracts. According to Bouchard, there were 24 offers and of these, four were in the competitive range.
The source selection team selected the University of Pittsburgh, Penn., and Brigham and Women's Hospital, Boston, Mass. The Brigham and Women's Hospital was awarded a $3.4 million contract for face transplantation to treat severe facial deformity. The University of Pittsburgh was awarded a $1.6 million contract to treat devastating facial injuries using innovative fat tissue grafting techniques.
According to Col. Janet R. Harris, Clinical and Rehabilitative Medicine Research Program, Army Medical Research and Materiel Command, Fort Detrick, MD.,
improvised explosive devices injuries account for 26 percent of some degree of facial injury.
Under the contract with BWH, three face transplants have been completed to date. Prior to the actual transplant, an individual must be deemed an acceptable candidate.
"To be deemed eligible for a face transplant, the patient must have suffered extreme disfigurement," said Dr. Bohdan Pomahac, director, Plastic Surgery Transplantation, BWH. "An eligible patient has injuries that typically include extensive loss of soft tissues, underlying muscles, cartilage or bone, that render conventional surgical methods ineffective. The candidate must have lost at least 25 percent of the face and at least one major structural unit such as nose or lips."
According to Pomahac, the appearance of the donor is not likely to be replicated in the recipient. The underlying facial bones and muscle of the recipient will change the shape of the facial tissue graft from the donor and will largely determine its shape and final appearance.
During the 10 to 15 hour surgery, one team of medical professionals removes the facial graft from the donor as another team prepares the recipient for the new face. The team works to connect the blood vessels between the donor face and the patient to restore circulation before the nerves, bone, cartilage and muscles are connected.
"Once the vessel flow is reestablished and circulating, the face comes alive," said Dr. Pomahac.
"To integrate the face, each nerve of the donor face must be dissected and then reconnected to the responding nerves of the recipient. Connecting the nerves is not easy work and must be performed under a microscope. To put it in perspective, one nerve is the size of 10 to 15 pieces of hair."
Following the surgery, the transplant recipient will gradually regain functionality in the face as well as inside the mouth to enable smile and facial animation.
"After approximately three months of healing, the facial sensation will be restored," according to Pomahac. "In six to nine months regeneration of the motor functions will occur and over time we expect many more improvements."
The procedure involves taking fat from part of the body and grafting it into the head and face to precisely shape facial form, said Dr. J. Peter Rubin, chief, Division of Plastic and Reconstructive Surgery and Co-Director of Adipose Stem Cell Research.
"Although fat grafting has been used for several decades for cosmetic purposes, this study will be the first time that this technology is used to accurately restore form."
Rubin said surgeons can rebuild the facial bone structure, but there is still an unmet need in the precise restoration of facial features.
"Although we can reconstruct bony structures very well, it is the surrounding soft tissue that gives a person recognizable features."
Specially designed equipment and surgical instruments were created for the procedures. Patients that benefit from this procedure include those with visible facial deformities that can be corrected by filling in defects or cavities. To date, Rubin and his team have completed 14 procedures.
"I envision a very strong partnership with the military medical community and this partnership will leverage the strengths of both parties to benefit the wounded warrior," Rubin concluded.
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