Rebuilding Lives Frontline Medicine

This programme contains some strong language from the start

and some scenes which some viewers may find upsetting

The survival rate amongst injured troops in Afghanistan is the highest in the history of combat.

Wound on the right thigh. There's a massive wound on the right thigh.

But keeping them alive is just the beginning.

These unexpected survivors often have dreadful injuries.

They're young and they have a lifetime ahead of them.

'I want to see what medical science is doing to help them rebuild their lives...'

-Can you imagine yourself back in Afghanistan?

-Yeah, that's my job. That's what I do.

'..from extraordinary prosthetics to growing spare body parts.'

This doesn't look like the beginning of a scientific revolution, does it?

'I want to find out how the conflict is driving areas of innovation that could help many of us.

'From hand transplants...'

There's something extraordinary about the idea that this was once on somebody else.

'..to giving this man an entirely new face.'

As I chat to you, I forget that this face came from somebody who died.

Earlier this year I was in Camp Bastion in Afghanistan.

I saw lots of troops brought in with horrific injuries.

The injuries are: left below-knee, right below-knee with tissue damage up to the groin.

When I was training as a doctor

I saw some pretty terrible things, so I thought I was hardened.

But the fact they were all so young really got to me.

Like Corporal Chuck Donnelly, brought in with his left foot barely attached.

Suffered from an IED blast, approximately 45 minutes ago.

Do you know what happened?

I stepped on a fuckin' IED.

He's probably the same age as my son, Alex. 20.

It's really upsetting. Really, really upsetting. These guys are so young. Really young.

I was deeply affected by what had happened to him and to many others.

Now I'm travelling to America to catch up with Chuck, but also

to find out how this conflict is driving medical research.

When I last saw Chuck it was touch and go whether he'd be able to keep his left foot.

So I'm really keen to see how he's getting on.

-Hi, Chuck.

-Hi, Michael, how are you doing?

-Very good. Very nice to see you.

-Great to see you as well.

I have to say you're looking fantastic.

-Thank you very much.

-The last time I saw you, you were not looking great.

-It was a rough patch.

-But you lost a leg.

-It wasn't going to be too conducive to keep it,

so we made the decision to have it come off.

-How did you decide?

-It was a no-brainer. They told me that the injury was so extensive that

it was going to be 6-12 months before they could even start repairing the foot,

and then there would be time for healing, so they told me

it would be about a year before I'd be able to stand on it.

And that's barring any infections.

You want to get back to where you were. You want to be able to run, play sports,

and once I got my leg cut off I was up walking around three weeks later.

It was an ideal choice for me.

-How's this one, then?

-The difficulty with this leg is it's always at a 90 degree.

That's where I run into trouble, doing sports, things like that.

I have no flexion.

-Is it tiring?

-They say it takes 40% more energy to walk with a prosthetic.

If I walk around on an average day I won't even notice.

If I do something really strenuous or spend a lot of time on my feet it gets tired quickly.

-When I saw you before you weren't in a great place.

-It was a rough patch there!

'I was really shocked to see that Chuck had lost his leg.

'But I was also very impressed at how determined he is not to let his injury hold him back.

'Chuck is one of many.

'Because of he widespread use of IEDs -

'Improvised Explosive Devices -

'in Afghanistan, the number of amputees has risen dramatically in recent years.'

This is the Walter Reed National Military Medical Centre.

It is a vast military hospital.

You see a lot of soldiers wandering around here.

Also a lot of people missing limbs.

'Last year the number of American troops that lost limbs in Afghanistan doubled.

'I've come to meet head of amputee care Chuck Scoville.'

It's striking, isn't it? You see all these fit young guns,

but they just happen to be missing a limb, two limbs or three limbs.

To me they're kids.

They're young kids and they're just doing the things that young kids do.

Very similar age to... I've got three boys and a girl,

very similar ages to the older ones. 19, 20.

-Morning.

-Hey, how are you doing?

'Sgt Adam Jacks lost his right leg four months ago.'

Pretty smooth. How far have you got to go?

-I usually do about five to eight miles.

-What's the next stage?

Continuing my physical therapy and things like that.

Once I'm cleared, I do plan on returning back to my unit

and training with my Marines again.

Can you imagine yourself back in Afghanistan?

Yeah, I want to go back, that's my job, that's what I do.

So without war and things like that I wouldn't have no job.

'Despite their injuries, it seems that these guys have

'no intention of giving up their active lives.'

Do you think there's a difference between military patients

and civilian patients?

For the majority of patients, yes. Our military population is a young, active population.

Their desires and goals are to return to a very high level of function.

The vast majority of patients on the civilian side

are an older, often diabetic-disease population.

So their goals and aspirations are sometimes different than the population we deal with.

'I do admire the way the troops have such high expectations of themselves and their prosthetics.'

-Good morning.

-How are you?

-Good.

'Captain Bergan Flannigan was injured in February 2010.'

Is this is your morning ritual?

Yeah, just water and alcohol, just so it slides on easier.

-How's this one, then?

-It can do anything you want.

Especially this one. I only wish it was a little lighter.

when I put my combat boots on, it adds a little and when I'm in uniform it's definitely harder to walk in.

-What happened?

-I was hit by an IED. We were dismounted on a patrol with the Afghan Police.

As I walked by a motorcycle it blew up.

Soon as they picked me up and put me on a stretcher, I saw my foot fall on the ground.

I was like, "Oh, I'm going home!"

-Can I see you in action?

-Yeah, sure.

Do you try out different sorts of legs?

-To find one that suits?

-This is my fourth one I've tried.

I've tried two mechanical knees. I liked them, but you definitely have to watch how you're walking.

If you're just casually walking and you catch something, you're doing down flat on your face.

-Not a good look!

-No, I've done that a lot!

'These troops have the best artificial limbs there are.

'Even so, they have limitations.

'There is constant demand for better.

'The large numbers of wounded and the extreme nature of their injuries

'has resulted in the military investing huge amounts of money on new treatments and technologies.'

The US Department of Defence are spending an awful lot of money

on medical research and development.

According to this website they're going to spend nearly 640 million alone this year.

The research they're mainly interested in is the practical stuff that can be got from the laboratory

to the patient as quickly as possible.

'And much of that money is going into improving prosthetics.

'I'm at the Massachusetts Institute of Technology to meet Professor Hugh Herr,

'who believes artificial legs could one day be as good as real ones.'

Morning. Hi there, Hugh.

Michael Mosley.

-Hello, Michael.

-Hello, I have come to see your legs.

-Fantastic, hopefully me as well.

-Absolutely! Can I have a look?

-Sure.

This is the world's first bionic lower limb.

'When he was l7, Hugh lost his legs in a climbing accident.

'so he has a very personal interest in hi-tech prosthetics.'

It's a beautiful piece of engineering, I must admit.

Let me chat about how it's attached.

When I push this button, the leg comes off.

So I can just pop it off.

Would you like to...

Thank you. Oh, that's heavy.

Can you talk me through it?

There's a motorised system in here that moves the ankle joint,

and this is just packed full of electronics.

There's various computers and sensors inside.

'It's normally hard work walking with a prosthetic.

'But Hugh's systems mimics the actions

'of the muscles and tendons in a human leg.'

-Can we just stroll around?

-Sure, if you give me my leg back!

That is very neat.

Do you think you can keep up?

MICHAEL LAUGHS

Wow, you're going so fast!

Slightly squeaky sound.

Yeah, a bit.

Very impressive! Right.

'Hugh understands only too well

'the limitations of standard prosthetics.'

There are three problems that amputees face.

One is they walk with more energy so they're more tired at the end of the day.

The second is they walk more slowly.

The third is their stability is arrested.

It's not uncommon for amputees to fall.

So this device allows the amputees to walk with normal energy levels.

We've shown it scientifically.

It allows people to walk at normal speeds, we've shown it.

And it improves stability.

'Hugh's new leg not only reduces the energy it takes to walk,

'it also helps with balance,

'detecting what angle the foot should be when it hits the ground.'

So what happens when you're walking on stairs?

Can you describe it to me?

There's five computers and 12 sensors.

One of the sensors on board is called an inertial measurement unit.

It was originally developed for missile technology, missile navigation,

and we're using it on board to determine what speed the person's walking at,

what the terrain is.

So the sensor actually tells the computers the orientation,

the positions of the limb in space.

From those positions we can determine, are they stepping up a step,

are they on level surface or a slope? What's the angle of the slope?

The computers adjust the output of the muscle-like motor system appropriately,

-giving the person more energy and more stiffness.

-Right.

'This project has been part-financed by the military,

'which has, so far, invested 7 million.'

How much difference has military funding made to the development of this sort of thing?

Tremendous difference.

Before the conflicts in Iraq and Afghanistan I had to struggle

to get even a modest amount of money for research.

So if there hadn't been the conflicts it would have happened but much more slowly?

Much, much more slowly.

This is just the beginning. It's going to get far more interesting.

Next we'll build a bionic knee, which we'll attach to this.

Ultimately we'll have an ankle and foot that fully articulates

so we can take over completely the balance of the amputee's body.

So this is just a modest beginning.

Imagine where we'll be in 20 years.

'US troops get this new design of artificial leg free.'

They hope soon to be able to make it available to civilians,

albeit at a fairly hefty price.

I think that Hugh's feet are incredibly impressive.

To be able to replicate the human feet in that way

has required a lot of expertise and an awful lot of money.

Now, some of it has come from the private sector

but the thing that's really driving it is military funding.

When I was in Afghanistan, I saw quite a number of young men

who'd lost their legs as a result of standing on mines.

And a few others who'd also lost a hand.

I've was thinking today just how useful your hands are -

you need them for doing everything, from brushing your teeth,

feeding yourself, doing up your buttons -

and just how difficult it would be to live life without a hand.

'In trying to help upper-limb amputees,

'the US military have turned to an ingenious way of controlling artificial arms,

'one originally developed by civilian scientists.

'It allows the user to control their limb with their mind.

'I've arranged to meet one of the first people with this system,

'ex-US Army Sergeant Glen Lehman.'

Good morning. Hello, Glen. Hello - Michael.

-So, what happened?

-I was on patrol in Iraq on 1st November 2008.

I was the 4th vehicle in a four-vehicle convoy.

We were travelling down a road very similar to this.

My vehicle came to the intersection and they threw two hand grenades at my truck.

The grenade travelled through and separated the arm here.

There was a piece of flesh hanging and it travelled the length of the bones on the forearm,

and it flayed it and exited right here, at my thumb.

-So there was nothing left?

-There was nothing left.

Can we try going to the store and seeing you in action?

'Glen operates his artificial arm

'just by thinking about what he wants it to do.'

What are you thinking as you do that?

I'm just thinking about grabbing the bottle with my hand

and closing my hand and then just picking it up.

-Does it take a lot of practice?

-It does, actually.

'It's not the arm itself that's really special,

'but the surgery he had which allows him to control it.'

'To find out more, I've come back to Walter Reed with Glen

'to meet his surgeon, Colonel Martin Baechler.'

-How you doing?

-Hi, Dr Baechler.

-How you doing?

-Good, how are you?

-Hello. Michael Moseley.

-Nice to meet you.

Why don't you have a seat here. How are things going for you?

Good. I don't have any problems that I know of.

Can you take it off? We'll look at your residual limb.

'Glen had surgery where they took the nerves that once controlled his hand

'and moved them to the muscles in his upper arm.'

Flex elbow.

And extend elbow.

OK, and close fist, closing hand.

And palm up.

So, if you're thinking, basically different muscles are moving,

and that's what's actually animating the hand?

Right. Basically the nerves that were cut and used to supply

the amputated part, we re-routed those to healthy local muscle.

'Glen's operation was filmed.

'It's something Glen himself has never seen.'

So this is the first time you've seen it?

This is the first time I've seen anything with myself.

'The operation re-routes the three main nerves

'that once controlled the amputated hand.'

It's a very elegant, simplistic surgery.

It gives you much better intuitive control over your prosthetic.

That's the median nerve right there.

So the median nerve would normally be doing what sort of things?

The median nerve controls the thumb, opposition, controls a large portion of grip

and controls a large portion of wrist flexion.

'But now that nerve has been connected to a muscle

'in his upper arm.'

Now the median nerve will grow back down into the muscle

and re-enervate it.

Now that muscle will contract based on what the brain is thinking

and the prosthesis will interpret what the brain's thinking by the signal from the muscle.

'When Glen thinks "open hand",

'the nerve that would have opened his hand now moves a muscle in his upper arm instead.

'Electronic sensors detect and respond to that movement.'

The sensors tell the motorised hand to do exactly what he's thinking.

They're sensing the electrical activity of the muscle.

It connects it just like a light switch.

How did you feel about it when the suggestion was made that Dr Baechler would be re-routing you?

I was pretty excited.

The idea of getting more control out of the prosthetic, making it more natural, was pretty exciting to me.

'The surgery is clever,

'but the arm itself only has three different movements - a human arm has 30.

'So, the military are investing 50 million dollars

'to develop better ones, that are controlled in the same way as Glen's.

'This one, designed at the John Hopkins University, has 22 different movements.

'They're hoping to offer it to veterans in 2012.

'It's an impressive advance but, like all artificial hands,

'there is no sensation of touch.'

The obvious alternative to a mechanical hand is to have

a flesh and blood one, a hand transplant.

I've been following that particular story for nearly 12 years.

My first thoughts when I saw my hand was that it was a miracle.

The total join actually goes around in quite a jagged...join.

'Clint Hallam had the world's first hand transplant in 1998.

'But he needed powerful anti-rejection drugs

'to prevent his body's immune system attacking the donor hand.'

Initially it seemed to work but he didn't really take the drugs and developed side effects.

Diabetes, also gynaecomastia - male boobs, if you like - and as a result

the hand started to reject, and then it looked really horrible.

'Without drugs, Clint's body violently rejected the hand.'

Yes, my body, or my mind, HAS said, "Enough is enough."

'Eventually, he had his hand removed.'

That sort of made me, and a lot of people,

wonder whether hand transplants were the right way to go,

because these drugs... if you didn't take the drugs, then your hand...rotted.

But if you did take the drugs, there was a risk of side-effects

and they calculated that it would cut 10 years off your life.

'I'm really interested in the trial of a new approach to hand transplants,

'one that dramatically cuts the amount of anti-rejection drugs a patient needs to take.

'The trial involves both military and civilian patients.

'And I've come to meet one of the first participants.

'Chris Pollock lost both hands in a farming accident.'

-Can you feel that?

-I can feel that, yeah.

-Was sensation a big reason why?

-Oh, yes.

With hooks, you don't feel anything.

You had to guess at everything. Now, you pick things up and you don't even realise you're doing it.

There's something extraordinary about the idea that this was once on somebody else.

-It is really exciting, I think.

-Yes. Can I see you in action?

-Sure. Would you like some eggs?

-That would be lovely.

'Chris had a double hand transplant in February 2010.'

Here we go.

Sorry, Michael, you're going to have to have scrambled eggs.

-I'll go for scrambled eggs, I prefer scrambled eggs.

-I'll throw these in the trash.

'Worldwide, over 30 people have had hand transplants.

'Normally, they take large numbers of harmful anti-rejection drugs.'

-Very good.

-Thank you.

So, what level of drugs are you taking at the moment?

I'm only taking one anti-rejection medicine.

Would you have done it, do you think, otherwise?

No, because I did have some information given to me

right after my accident and I read about it and it was like,

four or five different medicines. I thought, I'm already on enough.

Really what sold me is the one medicine, having one medicine.

-Do you think of them as your hands now?

-Yes. I do.

'I was nervous when Chris offered to drive me

'to his physiotherapist's, but he was in complete control.'

Do you know anything much about the donor?

I often wonder to myself, I wonder what that person did.

It's short-lived. I don't ponder on it for ages.

I just kind of think about it for a minute or two then I'm on to the next thing.

-This is your second home, is it?

-It is.

-You spend so much time here.

-Yes.

'Chris is still learning how to use his new hands.'

That's improved, with the small muscles working so much better.

Just rolling them around, is that what you're doing?

And has there been a lot of improvement?

Just even in six months I see a difference.

'Chris's own nerves are slowly growing into the new hands.'

I ask him to close his eyes and I touch a finger.

-This is difficult.

-Yeah, it's pretty difficult.

He knows he's being touched but he can't always tell you which digit's being touched.

So, I just do this and what's your immediate thought?

I can tell you're touching me but I just can't tell which finger.

-Right, and when I do this? Can you?

-My thumb.

But when I just squeeze?

It feels like you're squeezing my middle finger.

-I'm actually squeezing your thumb but it feels like your middle finger?

-Exactly, exactly.

Right, yes.

I enjoyed meeting Chris and I was really impressed by what

he can do with his hands, or at least, somebody else's hands.

'And now, I want to find out how his medical team were able to

'cut his anti-rejection drugs down to just one.'

'Chris had his operation in Pittsburgh.

'I've come here to meet Dr Losse,

'who is overseeing the transplant trial

'and was part of the original surgical team.'

Chris was a very good match, I have to say. I looked at it, and thought, "Ooh, yeah."

I guess that's the most fascinating thing about what you're doing,

is the fact that the amount of immunosuppressant you have to take is so dramatically reduced?

-Mm-hm.

-So, what do you actually do?

On the day of transplantation,

the patient is given a rather significant immunosuppressant.

It really turns down your immune system.

-You are then given the donor's arm.

-The hand is basically attached?

The hand is attached and the next day you're started with a single drug.

You're given, two weeks later, the donor's bone marrow.

'This is a donor hand being removed.'

Wow.

I have never seen anything like this before.

I've seen hands being attached

but I've never seen a hand being detached from a dead person.

'With Dr Losse's procedure, they also remove bone marrow,

'which contains the donor's immune cells.'

The second team, our team, stays behind,

closes up the donor site and then retrieves the vertebral bodies.

So you take the spine, you separate the spine out from the dead person

and you basically mince that, do you, to retrieve the bone marrow?

It's quite gruesome, when you think about it.

'Two weeks later, the marrow is injected into the donor.

'What happens next is still being researched.'

So, you are infused an IV infusion of what looks to be

a blood transfusion of the donor's bone marrow, and somehow -

this is all theoretical -

it's felt to help re-educate the immune system

so that it tolerates the donated arm.

'It's thought that immune cells from the donor's bone-marrow

'alter the recipient's immune system,

'so it no longer aggressively attacks the new arm.'

I find it extraordinary how much has changed in a short period of time.

This really is an area which is a rocketing, isn't it?

-There's huge need.

-Right.

-You just go to places like Afghanistan

and you see all these young men with bits blown off

and you can absolutely see why you'd want to have a transplant programme available.

And the military's been very supportive and that's how

many of the programs function here.

'Medics like Dr Losse

'are increasingly finding their research projects

'supported by the US military.

'But they are not natural bedfellows.'

I think a lot of doctors are probably quite uncomfortable about military funding,

but there is a long tradition of doing so

and diseases like malaria, yellow fever, would probably

never have been overcome if it hadn't been for military might.

-Hi there.

-Hey there, how are you?

-Good, thanks.

-Could I have a cup of tea?

-Sure, large or small?

-Small, please.

'Nowadays, the military are funding projects which are far more futuristic,

'some would say speculative.'

Regenerative medicine is a really sexy buzz-phrase in medical circles at the moment.

The idea is that rather than simply replacing or repairing

a damaged organ, what you do is you grow new tissue,

even whole new organs.

Recently, the US military announced they were part of a consortium

putting together 250 million into regenerative medicine.

'I'm heading to the McGowan Institute of Regenerative Medicine,

'where they're growing bits of human from a most unlikely source.'

'A team led by Dr Stephen Badylak

'are using pigs' bladders to regrow lost or damaged human muscle.'

Pig's bladder is something that is easily obtainable.

It's a throwaway part from the agricultural industry.

'A pig's bladder, like any tissue, is made up of cells

'that grow on a biological scaffold known as a matrix.'

And you'll see that, as we remove the outer layers,

the matrix that's left on the more inner layers now is not constrained

by these muscle sets, so it starts to stretch out very quickly.

'Dr Badylak discovered that when this extracellular matrix, ECM,

'is introduced to areas of damaged muscle,

'it encourages the local cells to grow, replacing lost tissue.'

The interesting thing about the matrix is the sophistication

that Mother Nature has put into what it's made of.

It's got collagen fibres that give it structure and form.

It's got growth factors in it that tell the cells there

what to do and, depending upon where you put the tissue, the cells that are there say,

"I should become a muscle," or "I should become a nervous tissue," that sort of thing.

It just...it doesn't look like it's the beginning of

some sort of scientific revolution, does it?

You look at that and you don't go "Wow."

'Before the ECM can be used, it's dried into a sheet.'

What Scott's making will eventually look like this.

This is the same material. That's bladder matrix.

We can take this material and we can pulverise it, basically,

comminute it into a powder, which would look like this.

'I was feeling rather sceptical

'until Dr Badylak showed me a time-lapse

'of muscle stem cells growing on ECM.'

So what we have here is a video that watched these cells

for eight days, and you can start to see that these cells,

which were little round cells, start to become long

and start to form a structure that's starting to look like muscle.

'It is amazing. Without the ECM, these cells would not have grown.'

The bottom line is that something in the matrix

has the ability to instruct a muscle stem cell

to turn into a muscle-like tissue.

It's very cool.

I mean, the way that you can see, before your very eyes, muscle fibres forming.

'I know that the science is impeccable,'

but there is something a bit implausible

when you have a look at this bit of pig's bladder,

and somehow it's going to be turned, ground down into a powder

and it becomes this sort of magic substance which can repair anybody.

I know they're doing clinical trials at the moment,

so I'm keen to catch up with some of the people who have had it put into them,

and see what benefits, if any, they've got from it.

Corporal Isaias Hernandez was the first to try this experimental treatment.

He was caught in a mortar blast in Iraq in 2004.

70% of the muscle in his right thigh was blown away.

He was told his leg would have to be amputated.

Hi there.

-How's it going?

-Good. Just doing another work-out.

Ooh, wow. It's quite dramatic on the leg there, isn't it?

To cover it up, they took some from my left side, put that in here,

but it was still weak, though. I couldn't really do anything, walk, even stand.

Sitting and standing up from a seat would be difficult.

'Isaias was desperate to keep his leg,

'so he opted to have his thigh opened up and sheets of ECM inserted.'

-Is that real muscle there, then? Can I see?

-Yes, yes.

It's very impressive.

How quickly did you start to notice the difference?

As far as the feeling, within a few days,

there was a little different tingling, different twitching.

I could feel it wanting to push more further.

'This lump of muscle is where the ECM was placed.'

Before ECM, I couldn't cycle.

Now I can do up to 35, 40-mile rides.

Walking, running, I can go up and down stairs.

It's made a big difference.

'Isaias is planning to have another course of ECM

'to try and regain even more muscle.'

The idea that you can just put this stuff in and it turns back into muscle is... It is startling.

'I am genuinely impressed.

'Regenerative medicine has been promising wonderful things for so long

'that it's great to see it finally making real progress.'

And there are plenty of scientists who, after slogging away for decades,

think this is just the beginning.

I'm in Winston-Salem, North Carolina,

to meet a man who's printing body parts.

So, in terms of the military, of course,

our major interest has been how can we start applying these technologies for our wounded warriors?

'Dr Anthony Atala is working on a range of military-funded projects.

'He first prints body parts, like ears and fingers,

'and then he sprinkles them with stem cells.

'He's also working on a machine that can print skin cells

'on to a patient with open flesh wounds.

'It's intended for use in battlefield hospitals.'

This is actually one of our printers that we're creating for the military,

which is a skin printer.

Just imagine that this here is the patient bed,

and that the patient's laying right here.

-Do you want to give it a try?

-OK. Do I just put my hand...

-Yes, just put your hand in there.

-OK.

-Right, so I'm imagining that that's a big burn, or something like that?

-That's right.

'It's all rather Star Trek.

'The machine measures the size and depth of your wound,

'then sprays it with human skin cells that have been cultivated in the lab.'

So how long before you expect to see it actually in use?

We expect to see this in patients hopefully fairly soon.

We're hoping to get this within the next five years.

'Dr Atala also believes that in future we will use printers

'to create fully-working complex human organs, such as the kidney.'

The whole concept behind this type of printing

is that we're printing it layer by layer with all the internal structures that it needs.

And so, once the cells are printed, it creates a new tissue and the concept would be,

can we then implant it and will it be functional?

Which, of course, is the next step for us.

The 3D printer uses a scan of the patient's own kidney

to build an exact replica.

It creates an entire organ from human kidney cells grown in the lab.

Can you imagine within your lifetime you would see kidneys

being manufactured, effectively, and implanted in people?

I think...that's certainly the hope.

Although growing your own organs is some way off,

military funding is undoubtedly helping push it along.

But doctors faced with major injuries need solutions now,

and at the moment that means patching things up and repairing, rather than replacing.

And, of course, much of what doctors know about repairing humans

comes from the battlefield.

Plastic surgery was utterly transformed

by the First and Second World War.

Since then, there have been enormous numbers of innovations.

But even so, it has reached its limits.

With so many troops coming out of Iraq

and Afghanistan with severe facial injuries,

the US military have decided to put 3.4 million

into one of the most challenging areas of modern surgery -

face transplants.

There are plenty of people, on and off the battlefield,

who suffer from terrible facial injuries,

but I wonder how many would consider having such an extreme procedure?

I've come to Boston, to the Brigham and Women's Hospital,

to meet one of the world's leading face transplant surgeons, Dr Bohdan Pomahac.

-Good morning.

-Morning. How are you?

-Hi. Michael Mosley.

Good-looking boy, isn't he?

He was, until he stepped on that live wire about ten years ago.

'Mitch Hunter was just 20 years old when his car crashed into a pole

'containing a 10,000 volt electrical cable.

'The injuries to his face were horrendous.'

Ooh. Ahh.

That was the actual arrival, following injury.

There's something about it.

I was prepared for it, but that was...that's a shock.

'For ten years, plastic surgeons tried to rebuild his face.'

There are a number of issues here.

Obviously, he's lost all of the skin from the face.

Where's this skin come from, then?

-That's from the thighs or elsewhere.

-It's a very different sort of tissue, isn't it?

-Yeah.

Different colour, different texture. Doesn't look, doesn't feel like skin.

He actually has no normal sensation in the face.

And he lost a bulk of his lips,

so this is when he's trying to close his mouth,

and he has huge gaps, so he was drooling.

This is state of the art of conventional reconstruction.

-How many operations would he have had to get to this point?

-Maybe 20, 25.

That's the best we can do without the transplant.

Face transplant, presumably you have to take so much tissue away

that, if a face transplant fails, is it not catastrophic?

What we try very hard, and will do in his case as well,

is not to destroy anything that's functional

and anything that would not be reconstructable to essentially the picture that he looks like now.

So, even if the face fails, we would be able to restore

his appearance the way he looks now relatively simply, maybe in one or two operations.

'Mitch is one of eight face transplants the military are funding Dr Pomahac to do.'

There are a few groups around the world

that have spent a lot of time designing the operations

and developing their own operative approach,

and I think we have planned on simplifying it,

making it more reproducible and easier for people to do,

and I think we've accomplished that goal.

But with every operation we learn an enormous amount of information.

Dr Pomahac makes a face transplant sound almost easy.

But it is extremely experimental. Only a handful have been done.

And there are plenty of things that can go wrong.

-How are you? We met last time you were here. How are you doing?

-Pretty good.

'After living with a badly damaged face for ten years,

'Mitch is about to have a completely new one.

'It's a massively complex operation.

'First, a team of 14 surgeons has to carefully remove his old face.

'When Dr Pomahac arrives with the donor face on ice,

'the whole operation becomes a race against time.'

When the blood supply stops or the circulation stops in donor,

we have four hours to reconnect and re-establish the flow.

So it's a fairly tight window, especially if you travel to get a donor from elsewhere.

'Painstaking microvascular surgery

'is needed to attach Mitch's arteries to the new face.

'This allows his heart to start supplying his new face with blood.'

Blood supply is absolutely critical.

Without blood supply to the face, it's not going to be alive.

'Three of Mitch's nerves are also attached

'to give the face sensation and movement.

'Finally, the face is stitched to Mitch's own skin.

'After 14 hours, the operation is complete.'

Hi there. Can I pay for this one?

'Mitch was Dr Pomahac's third face transplant.'

How did the operation go, then, for you?

It went well. It went very well.

Actually, it was the shortest we have done.

Not that we would rush, but it's a reflection of things going smoothly.

Does he have any sensation, or any facial movement?

Just after the operation, there's really not much of a sensation.

It's numb and swollen.

The first sensation develops within a month, two.

And it's very crude, and then it continues to improve.

And in about 18 months I would expect he's going to be feeling near normal.

'I'll meet Mitch once the swelling on his face has had more time to go down.'

Dr Pomahac's work is impressive,

but there is one organ doctors are as yet unable to transplant.

Eyes.

With so many troops in Afghanistan being blown up by improvised explosive devices,

it is inevitable that some will be left permanently blind.

I've come back to the UK to look at the trial of a new piece of technology

that could restore a sense of sight.

The first Brit to be enrolled in the trial is Lance Bombardier Rob Long.

He is 23 years old, and has lost the sight in both eyes.

He relies heavily on his wife, Em.

I was on tour in Afghanistan last year,

and, erm, I was on patrol, and my patrol 2IC triggered an IED.

Unfortunately, he was killed.

One other guy was injured apart from me...

and, yeah, the IED took both my eyes.

How do you feel about it?

We haven't got a choice but to be strong and get on with it, cos there's nothing...

You're not going to get your eyes back, are you? There's no choice.

-What do you miss most about not being able to see?

-Um...

People's faces. People's faces is...

When you first meet someone, it's great to see what they look like.

My wife's face, in particular, I really miss seeing that.

'Today, Rob is going to try out a new device called BrainPort.'

That's the specs, and that's the camera,

and it's attached to a cable, which goes to the control device, OK?

'The trial is led by military surgeon Wing Commander Rob Scott.'

They feel so snazzy!

-They're very cool, actually!

-Yeah, yeah.

The camera is now working.

If you put the device onto your tongue...

'The camera turns what it sees into 400 black and white pixels,

'which are felt as tiny electric shocks on the tongue.

'The brighter the image, the stronger the shock.'

-Do you notice some kind of...

-Mm-hmm.

-..going side-to-side?

-What do you think?

-Yeah, it's interesting.

-It's a bit weird, isn't it?

It's interesting. It's not what I expected, it's really interesting.

I think what we'll do is get you to see some shapes.

-Handle this side.

-No, it's actually the other side, have another look.

And trace around it.

'After a few hours' practice, Rob attempts to follow a white line on the floor.'

-Can you see that?

-Ooh.

What are you seeing, Rob?

The sensation is there's a line

going up my tongue in the direction that hopefully this is going.

-Can you see another line?

-Mm-hm.

-What direction?

I'd say this line goes to about here,

and then there's another line going up that sort of direction.

Well, if you think you see it, follow it.

It comes to about here and then sort of veers that way.

What do you think the most likely uses of this sort of technology are?

It's really designed to get him able to orientate himself outside,

so that he can maybe see a post or a lamppost, or a sign

or a manhole cover that might be there or not there while he's outside.

So a bit of a warning of things.

It is quite remarkable when you think you've got the camera there,

it's taking the data, it's feeling on his tongue,

and somehow his brain is translating that into a three-dimensional object.

It takes, obviously, time.

You've seen him do it for a while, what do you think?

I'm really impressed, cos I thought it would take days and days

just to see outlines, but straight away he's getting stuff.

I'm really amazed. Within a couple of hours...

'Rob will take it away and see how useful it is in everyday life.'

Although Rob was following the white lines and all that very impressively,

and he could, after a while, detect shapes,

it wasn't really, in the end, any of that which blew me away.

It was his relationship with Em and the fact,

which is incredibly obvious in retrospect but didn't occur to me beforehand,

that what he really wanted from that piece of technology,

and what anybody who's blind, I imagine, would want,

is just the ability to see other people's faces,

to be able to react to other people, see whether they're smiling, laughing at your jokes.

There is nothing available that would let people like Rob see someone's face,

but American scientists, with military funding,

are working on something that might help blind people recognise faces.

I've come to Carnegie Mellon University.

COMPUTER: 'Hello there.'

'Walk past my desk and turn down the corridor on your right.'

-OK, thank you.

-'If you don't want to talk anymore...'

-I don't, thank you!

'Here, Dr Amy Nau is working on the next generation of BrainPort.'

-Hi there, hello.

-Hi.

-This is a very prototype-y piece!

I recognise my friend here, which is a BrainPort, but this is what?

What we're trying to do is we're trying to take the BrainPort to the next level.

Today we're working on facial recognition software.

That's important because, if you have no sight, you can't tell if someone's in front of you or not.

So what we're trying to do is find a way that we can present that information to the tongue,

and a simple way that we can let the patients recognise things quickly.

'This device has software which targets people's faces.

'It exaggerates features, like a fringe.

'These become white pixels, which are felt on the tongue.'

So I can see there that, Carl,

it's basically sampling your hair and your eyebrows.

-Is that right?

-Broadly speaking, yeah.

-Would you like to try it?

-I would love to try it.

You will be blind for the rest of this session.

So you'll tell me... First of all I'll get some sense. This is Carl?

So you will try to differentiate between me, Amy, and Carl.

OK. What I'm sensing at the moment is a sort of oval,

-and that would be Carl's hair, yeah?

-Correct.

-OK.

That is interesting, because as soon as you sat there,

whereas Carl has got hair at the top, you've got hair at the bottom.

It's the beard, isn't it?

So, you have to guess who we are.

I'll keep saying when you should guess who it is.

Guess who this is.

I think that's Amy.

-Who's that?

-Amy.

-How am I doing?

-Not so well, actually!

THEY LAUGH

'But, after a bit of time, I was able to sense a difference between the faces.'

-Who is this?

-I think that's Yasser.

That's not Yasser, I think it's Carl.

And who is that?

I think that's Amy.

Right, three out of three.

Ultimately, the purpose of all the medical innovations I have seen

is to help rebuild lives.

And there is one last person whose life has been transformed beyond recognition.

This is Indianapolis, Indiana, and it's home to Mitch Hunter,

who had his face replaced by Dr Pomahac.

I haven't seen him since the operation,

and I have no idea what to expect.

It's been four months since Mitch had his operation.

BABY CALLS

-Hello.

-Hello.

Hi, Mitch. Michael.

-Who's this?

-Nice to meet you, Michael. This is Clayton.

Hi, Clayton. Hello. How old's he?

He is 16 months.

I've seen the photos of you after the accident,

and I have to say this is one hell of an improvement.

It is extraordinary, isn't it?

There's a resemblance between you and Clayton.

I wasn't quite sure whether what I was going to see

was what you looked like before,

or a sort of halfway house between you and whoever the donor was.

Do you think you look like you?

Starting to.

Right.

Still a bit of extra skin in some places,

but I think once everything's said and done and finalised,

I think I'll look a lot like I used to.

Sorry to manhandle you, Mitch, can I move you around here?

I want to look at your face in the light. Thank you.

Can I have a look at the scarring?

So it goes all the way around there,

all the way round there,

and round up there.

And you can absolutely see...

Mm-hm.

..where they must have taken the face and put it on.

I must admit, it is...

It far exceeds my expectations.

I didn't know what I was expecting,

but frankly, I was expecting something a bit...rough.

It was a lot different to what I expected too.

Was it a bit...initially, presumably immediately after the operation,

it was pretty...?

It was really, really swollen.

It looked like my face would be on a 200lb, 300lb guy,

it was that swollen.

Your speech is good, has it improved?

It has improved, it's not as good as I would like it to be.

It's getting better and better as I do my facial exercises and stuff.

-What do you have to do?

-Smile, scrunch my eyes.

-Give me the range.

-Um...

Like smiling, either side,

scrunching the nose, raising the eyebrows, pursing the lips.

-This is, obviously, before, when I was in the military.

-Yeah.

That's me last year.

Why did you want to have the transplant?

I've had kids hide and run behind their mom scared.

That was hard to cope with cos my friends started having kids,

my older brother had a kid.

I didn't want, you know, any kids to be afraid of me.

As I chat to you, I forget for long chunks of time that this is

not the face you were born with.

That this face came from somebody who died not so very long ago.

It really is starting to feel more like mine everyday,

and the sensation that I've gained back is just extraordinary.

I wanted to find out how people close to Mitch

felt about his new face.

Anyone for water?

'His brother, Mark, is just one year older

'and bears a strong resemblance to how Mitch once looked.'

We were very close, we were a year and just a couple of weeks apart.

And everybody always thought we were twins.

So do you find it at all spooky that that face belonged to someone else?

Definitely don't find it spooky. I didn't know how I was going to react,

but I walked in the door and it was my brother.

'Mitch's relationship with Katarina began two years ago

'when Mitch still had his scarred face.'

-What do you think about this?

-I think it's crazy.

The fact that medical science has come so far,

where they are able to do that, it's just... It's amazing.

When you first kissed him, after the face, was that strange?

Yeah, I had never kissed him with lips before.

So when you kiss, you feel it?

Sometimes even hot food, I can feel the heat.

Yeah. So it's all still coming back. And is that recent?

I would say within the first month I started getting sensation

and I think I'm going on to fourth or fifth month

and it's ten times better than what it was the first month.

Yes.

I can feel a lot, like I can feel the breeze on my face now.

Which is nice, isn't it?

It's just amazing how much sensation I've gained back in such a short time.

-And will it go on improving?

-Uh-huh.

'Mitch said to me earlier that his real reason for doing this'

was for his child.

And also just so he could just walk down the street,

not have adults stare at him, not have children point and go,

"There's the monster," and run away screaming.

And in all my time when we were just chatting, nobody was looking.

Nobody was paying any real attention.

So I think, if nothing else, that is what that surgery has achieved.

And actually I think it's probably achieved a lot more than that,

because I think it has absolutely exceeded everyone's expectations.

He's getting facial expression back, he's getting sensitivity back.

I think it's truly remarkable.

It feels like I've been on a long journey from Afghanistan to this cafe in Indianapolis,

yet Mitch's new face, like everything I've seen recently, is linked to the current conflicts.

The devastating injuries suffered by so many troops has driven a demand

for new medical treatments and technologies.

But though the results of this boom in medical research will help some of the wounded,

I suspect the real benefits will take a lot longer to emerge.

I was just thinking that I've seen some terrible things over the last few months,

and they're just a tiny fraction of the pain that these conflicts have created.

But I was also thinking I've seen some magnificent things.

Things which are at a terribly early stage

may turn out to be hugely significant.

And I hope that when we look back in years to come, we'll say,

"Yes, the conflicts were terrible,

"but perhaps some good did come out of them."

Subtitles by Red Bee Media Ltd

E-mail [email protected]