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Reporting on facial reconstructive surgery offers window into how war spurs innovation Date: 02/11/16

Liza Gross

By Liza Gross

A 2014 medical piece for Discover on soldiers’ facial reconstruction came about in an indirect and unexpected fashion.

The original inspiration came from a character in the HBO series “Boardwalk Empire” who had lost much of his face in WWI and wore a mask to conceal his injuries. I wanted to know more about these masks, which it turns out had been beautifully crafted by the sculptors Francis Derwent Wood, Anna Coleman Ladd and their teams. The masks came into play after surgeons had done all they could to repair the demolished faces of men who’d somehow survived grievous battlefield injuries. The masks gave soldiers with truly harrowing facial injuries the courage to go out in public.

I wrote a short essay about the trauma associated with disfiguring facial injuries, which relates to how our identity is so tied up in how we look and how others respond to our looks. Our tendency as a society to look away from such injuries was even evident in news coverage of men returning from WWI. Stories tended to celebrate those who lost limbs but never showed the unfortunate fellows with facial injuries.

I didn’t think too much more about it until I went to a press conference at an American Association for the Advancement of Science (AAAS) conference on facial reconstruction, during which Todd Nelson and Colonel Robert Hale spoke. Nelson had miraculously survived an IED blast that ripped off most of his face, and Hale was one of his surgeons. They both talked about the limitations of modern medicine to repair the devastating wounds that Nelson and so many others suffered in Iraq and Afghanistan. I started reading stories about wounded soldiers and was surprised that I couldn’t find much about these facial injuries. I decided to call Hale to learn more about the state of research on facial repair, and what he thought it would take to advance the field enough to really help people like Nelson.

Preparing to interview soldiers

One of the biggest challenges in this story had nothing to do with the research but with my personal feelings about the war in Iraq and how we went to war. I also had little experience reporting on military issues. I decided to find someone who was steeped in military life and military medicine, so I could learn as much as I could about the culture before I went to a military hospital or started interviewing sources. I wanted to know what it’s like to be a soldier and a combat surgeon, how they deal with the stress, how they deal with so much bloodshed and death around them, that sort of thing.

It turns out that my brother-in-law knows a longtime combat surgeon, who had trained him as a medical resident. The surgeon, Michael Baker, is an expert on the history of battlefield medicine and had intimate knowledge of the special bond that soldiers develop with one another – a bond that comes from being responsible for whether your buddy lives or dies. Baker really helped me get my bearings in what was an alien world for me. Of course, I’d also done my own research on the history of battlefield medicine, but there’s nothing like talking to people who have lived through it. After talking with Baker, I felt better equipped to interview high-ranking military officers like Hale, as well as soldiers who’d nearly lost their lives in battle. I also felt like I had a better grasp of what it’s like to serve in the military, which helped me place myself in the shoes of the people I interviewed.

I feel my advance preparation assured Hale that I was taking this assignment as seriously as he took his work. I spoke with him on several occasions, in person and by phone, and he was very open. He wanted to talk about the types of injuries he saw, including those he couldn’t possibly fix. He was also very honest about the limitations of modern medicine and what seemed like a losing battle to keep pace with the damage caused by what he called the wicked weapons of war.

Even though Baker helped me understand what it’s like to serve in the military, I was still a bit worried about what it would be like to interview soldiers like Nelson, who had come home with these really horrific injuries. Many of these guys were pretty young and came back without hands or arms or noses, injuries that most of us just couldn’t imagine. Hale put it best: Civilians would have to be hit by a train, lit on fire and shot to get such injuries. I wasn’t worried that I would want to look away from their injuries but that I would get too personally affected by what they had been through. I have an overdeveloped sense of empathy, which is sort of double-edged sword. In a way, being empathetic is important for understanding and telling someone’s story. But it also can be distracting.

One soldier talked about how kids on the street would stare and laugh at him as he walked by with his own kids. I could feel tears start to well in my eyes, and I just had to fight to control my emotions. It helped that these guys were eager to tell their stories. I interviewed a lot of people that didn’t make it into the story, but they helped me understand what it’s like to go to war and come home physically transformed. In every case, they wanted to share their experiences, including their memories of when they got hit and how they struggle with recovery. They hope it will help the next guy. It was a humbling experience to spend time with these soldiers.

Interestingly, a few of the researchers I interviewed were the most difficult sources to interview. They were transplant surgeons and seemed to be convinced that since I was a reporter, I was going to sensationalize or exploit the soldiers and their injuries and make a mockery of the work they were doing. Before I even said a word, they chided me for taking a macabre interest in disfiguring injuries. I assured them that I was reporting on how science was or wasn’t helping soldiers with these injuries, and they relaxed a little. But in the end, their research didn’t make it into the story, simply because it wasn’t relevant for Nelson.

Picking the right medical studies for my research

Medical studies were really the foundation of my reporting, including some published during WWI. Modern facial reconstruction was born of surgeons’ desperate efforts to re-create the noses, mouths and chins that were blown off by artillery. I saw Hale as the modern counterpart to Sir Harold Gillies, who is widely regarded as the father of modern plastic surgery. So I needed to understand the techniques that Gillies pioneered to understand why they no longer worked for Hale.

After reading historical papers by Gillies and others, I read studies that Hale and his colleagues published and watched his lectures about research going on in his lab at the Army Institute for Surgical Research. Another great resource was the Armed Forces Institute of Regenerative Medicine (AFIRM), which details research projects funded through several private and public entities, and includes annual reports that describe the research, its status and next steps.

There are so many different medical techniques and fields involved in caring for war wounds. I had to get a handle on the latest research in emergency medicine, burn medicine, biofilms (a cause of antibiotic-resistant infections), skin and bone reconstruction, stem cell research and reconstructive medicine and transplant medicine. Also, any time you write about transplant medicine, you need to understand immunosuppression, and the therapies patients have to take so their body doesn’t reject tissue from another person.

With each one of these fields I could have spent months reading papers to get up to speed on the latest research. To help me manage this task, I chatted with experts in the different fields to find out what some of the landmark studies are that I should be looking at, both historically and more recently. They also helped me figure out which research was close to being used in the field compared with techniques that could be years away. Then I read the papers and looked through the references to see what came before those studies. I also searched PubMed to find studies that cite the key papers and read those too.

Making the medical research less abstract

I write about basic science a lot, so in some ways the medical papers were more straightforward than a lot of fields I’ve covered. For several years, I wrote summaries of primary research in biology, covering everything from structural biology to theoretical ecology. I grew familiar with the way scientists think about research questions, standard lab techniques, how science sometimes plods along, what experiments can and can’t tell you, and how scientists sometimes “over-interpret” their data.

Even so, there are some arcane techniques used in medicine – or at least they seemed arcane to me. I’d end up contacting the corresponding author to have them explain it to me. It can be hard to picture what’s actually happening to a patient as they’re being operated on. Because I wanted to fully understand what Nelson and others were experiencing, I’d ask an author to walk me through the steps of treating someone with the technique described. That way I’d know what the procedure entailed as well as what came before and what happened afterward.

I also wanted to know what occurred when a surgery didn’t work, which happened a lot. And because I especially wanted to know exactly what Nelson had experienced, I asked Hale to walk me through Nelson’s treatment, from the time he was hit by the IED to the time he finally said he’d had enough of the surgeries. Hale was very generous in walking me through Nelson’s operations and explaining protocols he’d used for other soldiers who had sustained all sorts of horrific injuries.

Staying focused on the big picture

While there were many different areas of research involved in this story, on one level it was just one field, military medicine, and one phenomenon, how war spurs innovation in medicine. When I thought about it that way, it seemed more manageable and helped me focus my reporting. If you can distill the big story into its essence like that, then you’ll probably find that key figures emerge who can help you navigate the landscape, tell you what the major advances are and who else talk to.

When it comes to military medicine and facial injuries, you immediately find a legendary figure like Gillies, who transformed the way these injuries are treated. For me, Gillies anchored the story conceptually, both in terms of people and medical research. Hale was carrying on Gillies’ transformative work, both in terms of the science and the story. Both were really heroes in their total dedication to helping these wounded soldiers.

A final note

Besides having a hard time grappling with my feelings about the war, I also worried that readers with strong feelings that we had gone into Iraq under false pretenses would not appreciate the hardships these soldiers endured. I had a line at the end of the story that implicitly acknowledged society’s role in sending these soldiers to war. One of the editors wanted to take it out, but kept it in after I pointed out that, in a sense, we were all complicit in sending Americans to war, so it was our responsibility not to look away – figuratively and literally – when they return with disfigured faces. It was one way I reconciled my personal feelings about the war with its human costs, and my responsibility to tell the story as I saw it.

As a reporter, it’s not my job to please sources and, in fact, in much of my work, I do quite the opposite! But in this case, it was immensely gratifying for me when Nelson told me how much he loved the article and that he couldn’t wait to share it with people whose eyes glaze over when he tries to explain the research to them.

Liza Gross is an independent journalist based in the San Francisco Bay Area who writes frequently about health, science and the environment.