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Brigham gets $3.4m for face transplants

Defense pact aids veterans, civilians

In April at Brigham and Women’s Hospital, James Maki became the nation’s second face transplant recipient. In April at Brigham and Women’s Hospital, James Maki became the nation’s second face transplant recipient. (Yoon S. Byun/ Globe Staff/ File)
By Liz Kowalczyk
Globe Staff / December 21, 2009

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The US military has awarded Brigham and Women’s Hospital a multimillion-dollar contract to pay for face transplants for veterans who have survived catastrophic war injuries in Iraq and Afghanistan, but are left severely deformed.

The Department of Defense is hoping that the Boston doctors will be able to complete face transplants on six to eight patients over the next 18 months, which would nearly double the nine known procedures completed worldwide. In April, the Brigham performed its first face transplant, which was the second done in this country.

The $3.4 million award, which also will be used to provide the surgery to civilians, is a signal that face transplantation could be poised to move into mainstream medicine four years after the first such operation, on a French woman, was met with fierce ethical objections.

Doctors and military officials said they are unsure how many veterans will qualify but estimate the number could be as high as 200.

Patients must be missing at least 25 percent of their faces and cannot be significantly helped by conventional plastic surgery, among other criteria.

“All you have to do is walk through the wards here and you’d find patients you’d consider,’’ said Dr. Barry Martin, chief of plastic surgery at Walter Reed Army Medical Center in Washington. “We’re left dealing with some pretty horrific injuries on patients who are going to live.’’

Because of improved body armor and trauma care on the battlefield, more injured soldiers are surviving. There are nine wounded veterans for every fatality in Iraq and Afghanistan, compared with three wounded for every death in prior conflicts, said Dr. Joseph Rosen, a plastic surgeon at Dartmouth-Hitchcock Medical Center in New Hampshire. But with the growing number of wounded veterans have come more severe injuries that the military is struggling to treat.

Many of the veterans with damage to their faces were injured by improvised explosive devices and are recuperating at Walter Reed. Although some have other injuries such as brain damage and missing limbs that limit their ability to work, others return to military jobs, living on or near bases. As is the case with civilians who have lost portions of their faces to burns, disease, or traumatic injury, some of these veterans struggle with going out in public, relationships, and work.

“We certainly expect that by providing a new face, that would be a big step toward them leading more useful and productive lives,’’ said Rosen, who is a consultant to Walter Reed and will help the military monitor its contract with the Brigham. “It’s very important to address these new problems and come up with viable solutions. It’s not enough just to keep soldiers alive.’’

The Brigham contract, along with a smaller award given to the University of Pittsburgh for facial reconstruction surgery, is the first money given out under a Defense Department initiative begun earlier this year to quickly move innovative medical procedures into mainstream practice. The military received 24 proposals, but funded just two.

“We feel [face transplants] are mature enough that with a little more funding we can push this into clinical practice within 18 months,’’ said Terry Rauch, director of defense medical research and development for the Defense Department.

Brigham doctors are developing the transplant program, including recruitment materials for veterans. Information about the program will probably be posted on websites viewed by veterans, and military officials will contact veterans through a registry the government keeps of the wounded.

The contract with the military requires the hospital to measure results, including assessing whether the transplants improve patients’ lives and enable them to return to work.

The military also is interested in studying and improving the use of immunosuppressant drugs, which patients must take following a transplant to prevent rejection of the donor tissue. Since most veterans are young, they would have to stay on the drugs, and cope with the side effects, for decades.

“We really want to help them,’’ said Dr. Bohdan Pomahac, who leads the Brigham face transplant team. “They have given up their faces for our country.’’

Last April, Pomahac and a 35-member medical team replaced a large portion of the face of James Maki, a Massachusetts man severely injured in a subway accident.

The Brigham has another patient with a facial injury who may undergo a transplant and would be covered under the Department of Defense contract. The surgery costs $250,000 to $300,000 and is not covered by insurance.

Maki is doing well. During an exam earlier this month, he could smile, indicating that the muscles and nerves of the transplanted face are integrating with his own. Doctors believe an episode of what they initially thought was rejection was actually rosacea, a skin condition Maki apparently inherited from the donor, Joseph Helfgot of Brookline, who died from complications after a heart transplant.

Maki, whose face was badly burned and whose nose was lost when he fell onto the electrified third rail at the Ruggles subway station, said he feels more comfortable in public. But he said people still stare. Pomahac said his scars will fade and become less noticeable with time.

Asked whether veterans who have suffered horrific facial injuries are reluctant to leave the hospital, Martin, the Walter Reed plastic surgeon, said they don’t often show their struggles - at least to him.

“I like to think they’re a pretty tough lot,’’ he said. “But what they tell me isn’t what they necessarily feel inside.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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