A bad facial wound can be a crippling burden to someone who just wants to feel good about looking in the mirror, who wants to walk into a restaurant without attracting stares or grimaces. A face is a person's identity, the one part of the body that can't be hidden. Since the war in Iraq began, Capt. Amy Wandel and three other plastic surgeons at San Diego Naval Medical Center have been fixing damaged faces as best they can - cheeks blown apart by bomb blasts, eye sockets damaged by gunfire. One patient lost the tip of his nose to a bullet; another lost half his ear to a piece of shrapnel. On this particular May morning, Wandel was scheduled to operate on Navy Petty Officer Alfonso Verni, who lost the left side of his jaw in an accident aboard a Navy destroyer in the Persian Gulf. A piece of a whirring helicopter blade broke loose and struck him in the face, leaving pieces of his mandible scattered over the flight deck. This would be Wandel's seventh surgery on Verni, a 25-year-old married father of two. The left side of his face was a patchwork of crooked scars.
He gave the thumbs-up sign as he was wheeled into the operating room.
The goal today was to remove some scar tissue so Verni's mouth muscles would be more flexible.
The end result, Wandel hoped, would be that her patient would have something approximating a normal, happy-looking smile.
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Wandel, who will retire this fall after nearly 27 years in the Navy, heads a small team of plastic surgeons who are playing an important, if little-noticed, role in the war in Iraq: trying to make the bodies of the wounded look as normal as possible.
Before the war, the plastic surgeons at the medical center spent their time doing reconstructive surgery on cancer patients, car-accident victims and the occasional Marine wounded in a training exercise. Sometimes they performed cosmetic surgery, in part to keep their skills sharp. These days, however, they spend most of their time tending to the casualties of war. Wandel's team has treated some 200 wounded soldiers and Marines who have suffered gunshot, mortar, shrapnel and blast wounds, and burns of various kinds.
A 49-year-old mother of a son and four stepchildren, Wandel is slender, with shoulder-length blond hair and an easy smile. In the operating room, she has been known to wear a surgical cap decorated with moons, suns and stars.
Wandel tries to maintain a clinical distance from the horrors her patients experienced on the battlefield. She approaches a surgery the way a mathematician might confront a logarithmic equation. But at night, when she has time to reflect on all the horrible things she has seen, she sometimes feels compelled to sit in her San Diego backyard and have a conversation with God. "God, I need to talk to you," she'll say, and then she'll proceed to talk out loud for a minute or two, maybe longer if she's in a particularly pensive mood.
After one emotionally draining operation on a wounded father of four, Wandel talked to God for 45 minutes. "Normally at the end of my conversations I feel better," she said, "so indirectly I'll feel like God's helping me." Wandel is continually amazed by the sheer toughness of her young patients, most of whom have been literally scarred for life. The vast majority, she has noticed, are extremely reluctant to complain about their injuries. Many are eager to return to Iraq, so they can rejoin their buddies.
"These are young men that are the age of my son," she said. "Many of them have injuries that will prevent them from having a normal life, and they've got the rest of their lives to deal with that." Wandel and her fellow plastic surgeons treat more than facial injuries.
She helped rebuild the leg of a Marine who suffered a direct hit by a rocket-propelled grenade.
She also helped reconstruct the penis of an 18-year-old Marine whose groin was struck by a piece of shrapnel - a wound that was both disfiguring and psychologically devastating. After three surgeries she was able to "assure him that he'd able to have sex and pee normally," she said. "He was very happy."
In many cases, Wandel improvises as she goes along. There's no simple textbook solution for some of her patients' gruesome injuries. In the case of a Marine whose hands were blown apart, her team took muscle from his back and used it to reconstruct his forearm. Facial wounds pose a particular challenge because the goal is improving appearance as well as function. One Marine lost all the skin, muscle and bone from the side of his face in a bomb blast. Wandel's team rebuilt his jaw using a piece of his thigh bone. "He's never going to look absolutely normal," she said, "but he looks presentable now."
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It took a few moments for Verni to realize the entire left side of his jaw was missing.
It was August 2004, and the Navy boatswain's mate had been standing on the flight deck of the destroyer Preble, directing a hovering helicopter to a landing spot. Suddenly, the copter lurched forward. Its main rotor smashed into a wall, sending bits and pieces of the blades flying in every direction.
One of those pieces sheared the side of Verni's face. He stumbled around in a daze, confused by the looks of horror on his crew mates' faces as they stared at his wound. Then he reached for his jaw and realized nothing was there.
As if things weren't bad enough, the ship's sprinkler system suddenly began showering saltwater onto his bloody face, sending searing pain through his entire body. The next thing Verni knew, he was lying on a stretcher as a helicopter whisked him to another ship, the Belleau Wood, for emergency care.
"I said to myself, 'I'm not going to die here,' " he recalled. " 'I cannot leave my family and my kids.' "
Doctors later told Verni that his heart stopped beating during the flight and again during emergency surgery. Along with the damage to his jaw, he also had lost four teeth.
In the following months, Verni received medical treatment in Kuwait, Germany and Bethesda, Md., before arriving at San Diego Naval Medical Center, where Wandel and her team went to work on him. They took bone from his hip and fused it with a piece of metal to craft a makeshift jaw. They took skin from his forearm to patch up his face. Months later, his body began rejecting the metal, and they had to operate again to remove it. To this day, the lower left side of his face has a soft, fleshy patch instead of a jawline. Verni's wife, Imelda, a nursing student, remembers the first time she saw her husband after his injury. It wasn't his disfigured jaw that she noticed first. It was how small he looked - frail, hunched over. It was as if the whole ordeal had made him physically shrink. "It was shocking," she said.
It took months after Verni, a Calexico native, arrived in San Diego for him to muster the courage to leave his home. His first public excursion was a shopping trip to Wal-Mart. His wife asked if he was emotionally prepared for the stares. "You know how kids are," she told him.
He said he didn't care.
At the Wal-Mart, he made funny faces at all the kids who looked his way. If he was going to frighten little children, he figured, he might as well have fun doing it.
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Wandel was wearing her sun-and-moon surgeon's cap as she leaned over Verni's face.
He was lying unconscious on an operating table, the tattoo of his wife's name on his upper left chest exposed to the doctors hovering above him.
Soft-rock music played in the background as the doctors sponged his face with antiseptic.
The lead surgeon was happy with her work to date on patient Verni.
"He doesn't drool," Wandel said. "And he talks normally." But he still couldn't move the side of his mouth. He still had a web of unattractive scars on his left cheek. And, of course, his smile was still off.
Removing some scar tissue near the corner of his mouth - the purpose of today's procedure - would loosen up his lip muscles. The doctors snipped, they cut, they cauterized, to the soundtrack of the Dave Matthews Band.
Wandel noted that her patient had been so badly injured that he could have suffocated in the immediate aftermath of the accident. "He's actually very lucky," she said.
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A week later, Verni was back at the hospital to have his stitches removed. His 2-year-old son sat on Imelda Verni's lap, watching intently as a doctor pulled out the threading. Verni's Navy job these days is performing manual labor on the submarines at the Point Loma base. He plans to stay in the military at least four more years but isn't sure what he'll do after that. He doesn't have terribly strong opinions about the war. But he sometimes wonders whether invading Iraq was a mistake. "I'm just doing my job," he said. "But a lot of people are getting killed over there."
Verni has no illusions that his face will ever look the way it did before the accident. He still needs more surgeries, including teeth implants. His best hope is that his face will one day look "75 percent" normal again.
"I got to suck it up, pretty much," he said. "I ain't got no choice. But I'm here. That's all that matters."
After a few minutes, Wandel walked in to check on her patient. Verni asked if it was OK to eat hot sauce now.
"Smile for me," she commanded.
He gave her a grin. The left side of his face was stiff and swollen, like a boxer's after a 12-round fight. Still, compared with the way his jaw looked after the accident, the improvement was almost miraculous. "Good," Wandel declared. "It's getting better. It's getting way better."
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Wandel worries about the psychological impact a disfiguring injury can have on a person over the course of a lifetime. Many of her military patients are simply happy to be alive. But who knows how their physical deformities will affect them 10 years down the road?
"Hopefully, we've learned something from the Vietnam conflict about how to care for our injured and disabled," she said. Because the Vietnam War was so unpopular, she added, "veterans of that war were forgotten." As for the wisdom of the war in Iraq, she says she's not in a position to judge whether invading that country was the sensible thing to do. She thinks the military is doing the best job it can. "I've always been proud to be an American, but I'm even prouder now having worked on these young men and women," she said. "I'm very proud of the courage that they exhibit."
After Wandel retires from the Navy this fall, she plans to open a small practice in nearby National City, where precious few doctors are available to perform reconstructive surgery.
She'll miss her life as a Navy doctor - the camaraderie, the simplicity of being able to operate without bureaucratic hassles such as insurance paperwork.
Providing medical treatment to military personnel has a unique set of rewards, she said. By and large, they're a class of patients "who want to get better and who are thankful for the care they get." And if she has helped improve their lives even a little bit - helped someone walk without crutches or hold utensils or smile normally again - then she's glad to have done her part.