Field medics doubted Nelson could survive evacuation to the U.S. military hospital in Germany, much less to Brooke’s burn facility in Texas. When he arrived at Brooke two days later, hospital staff made plans to donate his organs.
That turned out to be premature. But when Hale, one of the Army’s top facial trauma surgeons, first saw Nelson, still clinging to life, he also saw the young man’s future. Hale knew that even if his patient survived, no doctor could fully restore what was lost in Afghanistan: the face that Nelson and his friends and loved ones knew as Todd. And the ability to pass strangers on the street without attracting stares.
Hale had left a thriving Los Angeles plastic surgery practice in 2003 to serve America’s wounded. But while working in dusty Army field hospitals during tours in Kuwait and Afghanistan, he found himself cursing the pitifully inadequate tools available to counter the human wreckage left by suicide bombs. Even at Brooke’s state-of-the-art facilities, he had to treat the facial wounds of a new kind of warfare with techniques that had changed little since their invention almost a century ago. Modern medicine had no answer for homemade bombs that pulverize bone and liquefy flesh. Hale, moved by Nelson’s plight, vowed to bring the tools of medicine in line with the weapons of war.
The history of wartime medicine has long been written by battle-tested surgeons like Hale, who, in a strange symbiosis between war and medicine, have conjured new remedies to heal the wounded. The trenches of World War I exposed men’s faces to a fusillade of shrapnel, spurring unprecedented surgeries to reconstruct what remained. The mine-filled battlegrounds of Korea and Vietnam likewise gave birth to techniques for repairing severed arteries and veins to salvage limbs.
Most recently, the improvised explosive devices, or IEDs, that littered the streets and battlefields of Iraq and Afghanistan led to innovations in combat medicine and evacuation procedures. These advances, combined with enhanced protective gear, helped produce the highest U.S. combat survival rates in history: Today less than 10 percent of combat casualties die from their wounds, compared with 19 percent in World War II and 16 percent in Vietnam.
But body armor and helmets don’t protect the face. And the advances that saved so many lives in Iraq and Afghanistan left surgeons struggling to fix harrowing facial injuries in numbers unrivaled since World War I. Some 40 percent of those severely wounded in Iraq and Afghanistan suffered devastating blows to the face. All Hale and his fellow surgeons could offer was the prospect of 30, 40, even 100 operations that closed wounds but left cheeks without feeling, mouths too small to open, eyelids locked in position. Countless veterans, Hale knew, would live out their days with faces they would not recognize as their own.
A fit 57-year-old with a strong jaw and imposing presence, Hale is leading a massive effort to bring the science of facial repair into the 21st century. Now commander of the Dental and Trauma Research Detachment at the U.S. Army Institute of Surgical Research in San Antonio, he has brought the best and brightest minds of regenerative and transplant medicine to the task of healing some of the most grievous wounds of modern warfare.
Hale was seeing patients at his Los Angeles surgery center shortly after Sept. 11, 2001, when a U.S. Army clerk called, asking if he would return to active duty. The surgeon had been honorably discharged five years before, after deep cuts in military spending. But Hale had always enjoyed the yearly check-ins with his Reserve unit. And to his dismay, he increasingly found himself “taking care of rich people with small problems.” When the Army called, Hale said yes.
Today less than 10% of combat casualties dies from their wounds, compared with 19% in World War II and 16% in Vietnam. But body armor and helmets don't protect the face.
By September 2003 he was in a field hospital in Kuwait, just south of U.S. military actions in Iraq. President George Bush had announced the end of major combat operations in Iraq several months before, and Hale expected the occasional casualty amid routine dental care. And that’s what he saw — at first.
But within weeks, guerrilla warfare kicked into high gear. Hale saw casualties every day, most with jaws severed by high-powered rifles or faces crushed in vehicle rollovers. Frequently, all he could do was jam pins through remnants of skin to temporarily hold bone fragments together, prepare his patient for evacuation and hope for the best. He quickly exhausted the field hospital’s surgical supplies and called his old sales rep, who express-mailed a donation of $300,000 worth of bone plates and screws.
Hale’s tour was supposed to last three months, but when his commander said they didn’t have a replacement for him, Hale asked his wife to sell his surgical practice and agreed to stay on another 90 days.
After six months in Kuwait, Hale was sent to an active combat base in Afghanistan. There he saw as many as 15 patients a day bearing what he calls the “wicked injuries” of IEDs.
The Army finally found a replacement for Hale in August 2004. Exhausted from 11 months’ service, he boarded a military jet to Germany and slept the whole way. Home in Los Angeles, Hale opened his mailbox one day to find two Bronze Stars for his extended service, one for each theater of war. Slowly, he recovered from the strain of combat care and saw a few old patients at a friend’s office.
But Hale’s appetite for private practice was gone. In March 2005, he dusted off his uniform, rejoined the Army full time and moved with his wife and two young sons to San Antonio to help soldiers like those he’d seen overseas. He joined the teaching faculty at Brooke, preparing doctors and nurses headed to combat zones for the horrific facial injuries they’d see — and the frustration they’d feel when they couldn’t repair the damage.
Hale’s own frustration grew as he treated the wounded at Brooke with tools from his grandfather’s war — creating lips from tongues, fashioning jaws from leg bones, papering faces with skin taken from wherever he could get it. Inevitably, he’d reach a point where he was just “dragging scar tissue around,” he says.
Then, in November 2005, French surgeons performed the world’s first partial face transplant, on a woman whose Labrador mix had mauled her. Hale immediately saw the technology as a wounded soldier’s ticket to a new life. He flew to Washington, D.C., hoping to persuade military leaders to fund transplant research.
But the brass weren’t buying it. Face transplants require a lifetime of immune-suppressing drugs to keep the body from rejecting the tissue. The drugs increase patients’ susceptibility to infections, cancer and other serious health problems, and Hale’s superiors believed the risk and expense were unjustified for injuries some considered cosmetic.
Hale returned to Brooke, resolved to make do with the tools he had.
Then he met Todd Nelson.