When the first face transplantation surgery was performed in Paris, France, in 2005 on a female victim of a dog mauling, it marked a medical milestone. The scope of transplantation surgery expanded, and nearly a decade later, 28 face transplantation procedures have been done worldwide, seven of which have occurred in the United States.

In recent years, the Department of Defense (DOD) has provided funds to civilian centers for face and hand transplantation surgeries and research in an effort to benefit war-injured soldiers who have suffered catastrophic injuries to the face or limbs for which traditional reconstructive procedures or prosthetics are insufficient.

But these initiatives also translate to improving lives across society in the civilian population.

“Currently in the United States, it’s considered still experimental surgery, so funding is certainly an issue,” said Army Col. Barry Martin, chief of plastic surgery at Walter Reed National Military Medical Center (WRNMMC), who recently discussed the state of these intensely complicated transplantation procedures and some of the current and future challenges.

Sometimes when there’s composite tissue loss, meaning bone, muscle, skin, and fat of the face, in the central portion of the face, it’s a very difficult area to rebuild through current conventional reconstructive procedures, so those are the patients we tend to believe may be a good candidate for a face transplant.”

“The military and the Defense Department [have] put in quite a bit of money and effort into advancing that science because of the potential possibility for some of our wounded warriors, and then consequently through translational initiatives, [to be] available for civilians,” he said.

Supported by funding from DOD agencies including the Armed Forces Institute of Regenerative Medicine and the Office of Naval Research, face or hand transplantation surgeries have been performed at the Cleveland Clinic, Brigham and Women’s Hospital, the University of Maryland Medical Center, and John Hopkins Hospital.

The face transplantation surgeries have all been performed on civilian trauma victims.

“To date, we have had no active-duty military members who have received a [face] transplant, although several have been evaluated by the civilian centers that are currently doing face transplantation,” said Martin.

The number of candidates for face transplantation in the military from wartime trauma can’t be accurately determined, Martin said, “because it hasn’t been established yet who really is that ideal candidate.” He explained that conventional techniques of reconstructing a face, like grafts or flap surgery, bringing in tissue from other places in the body to rebuild or re-create the missing part, is “fairly effective in most cases. Sometimes when there’s composite tissue loss, meaning bone, muscle, skin, and fat of the face, in the central portion of the face, it’s a very difficult area to rebuild through current conventional reconstructive procedures, so those are the patients we tend to believe may be a good candidate for a face transplant.”

“That’s kind of the holy grail,” said Martin of the immunosuppression issue. “That science is what could take this from an experimental, rarely performed operation to something that is much more routine and matter of fact.”

In an effort to assist health care providers and potential transplant patients in obtaining correct information and referrals, Martin said they’re establishing a tri-service transplant advisory board at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. It’s designed to be a one-call center staffed by surgeons and coordinators.

“If a practitioner, provider, patient – anybody, anywhere that has access to care in the military system – if they have a question, potential referral, or if a patient just wants to know if they may be a candidate or wants more information, they just have to call one place, and we’ll get that person or that provider to the resources and potential practitioners that may be able to help them,” he said.

Aside from face and hand transplantation, Martin said, “regenerative medicine initiatives have contributed probably most greatly over the last decade of wartime surgical care as far as the reconstructive aspect goes. Most of what we do as reconstructive plastic surgeons really is building on fundamentals that have been around in civilian and trauma surgery in the last couple decades. Nothing we’re doing around wartime is necessarily revolutionary, but it’s using those same principles to repair the damages brought on by war … But some of the advances in the molecular basis of healing and inflammation and wound care that is occurring through research and molecular initiatives, that’s what’s getting into the real science of controlling a wound.”

Martin explained that one of the major challenges, particularly in devastating war injuries, is that the surrounding tissue environment that they’re operating in is so inflamed and damaged that normal healing is very difficult. “Controlling those wounds through advanced wound care products and techniques is what allowed for some of our conventional type of reconstruction to have a better outcome,” he said.