UCLA's Operation Mend treats the visible - and invisible - wounds of war

The program was created to care for post-9/11 veterans.

Israel Del Toro, a master sergeant in the Air Force, was serving in Afghanistan in 2005 when his Humvee hit a massive bomb buried underground. Nearly his entire body was burned in the subsequent explosion, his face disfigured. He has since undergone more than 100 surgeries, yet maintains a positive attitude and contagious smile.

Army Specialist Joseph Paulk was serving in Afghanistan in 2007 when his vehicle struck anti-tank mines. He lost all of his fingers and suffered severe burns to his face and vocal cords. Despite having to re-learn how to walk, talk, swallow and live without the use of his hands, he’s excited about life and remains active in his favorite sports: snowboarding and soccer.

Dr. Jo Sornborger is executive director for military medicine at UCLA Health.

Del Toro and Paulk are two of the many veterans who’ve found healing through UCLA’s Operation Mend, a partnership between UCLA Health and the United States military that provides comprehensive surgical and psychological treatment to post-9/11 service members and their families. As the nation marks 20 years since the 9/11 attacks and the recent withdrawal of troops from Afghanistan, Operation Mend is preparing to expand its services to reach more of the 4.2 million post-9/11 veterans.

“What Operation Mend provides is care,” says Jo Sornborger, PsyD, executive director for military medicine at UCLA Health. “I believe that the greatest gift we provide is time — sitting with our warriors and their family members and saying, ‘What is it like for you? How can we create a path that provides you an opportunity to remember how resilient you are and how capable you are, and then stand beside you as we’re filling in these gaps?’ And that’s what we do.”

Dr. Sornborger says veterans’ training, resiliency and commitment can be channeled into healing from even the most catastrophic injuries.

“One of the most brilliant things about our mind is its quest to heal,” she says. “Even if we repeat negative coping strategies over and over, we have an internal quest to heal, and I believe so strongly in that process.”

Origins of Operation Mend

Operation Mend was established in 2007, inspired by philanthropist and former Ronald Reagan UCLA Medical Center board member Ronald A. Katz and his wife, Maddie Katz. After watching a news report about a young Marine seriously burned by an explosion while serving in Iraq, the couple imagined connecting wounded warriors with the nation’s top plastic surgeons.

“I think it is the private sector’s duty to stand up and do something extra to help,” Ronald Katz said at the time.

The Marine featured in the news report, Cpl. Aaron P. Mankin, became Operation Mend’s first patient. He was riding in a 26-ton tank when an improvised explosive device ripped through it, killing six Marines and severely injuring many others, including Mankin, whose ears, nose and lips were burned away.

“I gave my face to my country,” Mankin said in 2012 during an address to veterans of the wars in Iraq and Afghanistan. He has undergone nearly 60 operations since returning home, calling his surgically repaired face “a multimillion dollar mug.”

He says the military’s use now of high-tech protective gear means today’s service members tend to survive wounds that might previously have proved deadly.

Operation Mend’s doctors specialize in advanced reconstructive surgeries that aim to restore the physical appearance of veterans who are severely burned in battle. More than 500 such procedures have been completed to date.

“As I’ve come out of the operating room looking better and better each time, that makes each day better and better,” Mankin says.

Paulk, who had all 10 fingers amputated, said the disfiguring burn scars across his face upset him even more.

“I could live without certain things your fingers can provide you. I’ve adapted. I’ve overcome,” he says. “But my face, you can’t really hide it. It’s the center of attention. It’s what everybody looks at. It’s what everybody sees. It’s kind of who you are.”

Over many procedures, surgeons removed scar tissue, repositioned his eyes and repaired his nose and lips. “Now that I’m kind of put back together, you can definitely tell my expressions,” Paulk says. “When I smile, it actually looks like a smile.”

His surgeon and executive medical director of Operation Mend, Christopher Crisera, MD, says Paulk experienced “a profound physical transformation, but also a profound emotional transformation.”

Besides plastic surgery, medical services provided by Operation Mend include facial prosthetics, orbital reconstruction, orthopedic surgery and joint reconstruction, spinal surgery, hand surgery, care for amputated digits and limbs, and treatment for hearing, balance and speech disorders.

“In all respects, my transition has been easy, because you see my scars. I wear my uniform everywhere I go,” Mankin says. “But there are those among us — in our community, in our families — who have scars that are never seen.”

Invisible wounds of war

For many veterans, those invisible scars are caused by post-traumatic stress disorder, a condition characterized by persistent emotional and mental distress after witnessing or experiencing a terrifying event. According to Operation Mend’s 2021 Stewardship Report, 60% of combat veterans have seen someone killed or injured in action. At least 36% of veterans believe they have symptoms of PTSD.

Though Operation Mend was initially conceived to provide complex facial plastic surgery to wounded service members, the program expanded in 2016 to include psychological treatment for PTSD and mild traumatic brain injuries.

This expansion included the development of Operation Mend’s intensive treatment program, unique in its provision of PTSD counseling and services for veterans and their caregivers.

The six-week program includes three weeks of treatment at UCLA. Military service members and their spouse or caregiver are brought to Los Angeles for a concentrated healing regimen that includes individual and group therapy, qigong, acupuncture, art and equine therapies and even some Southern California sightseeing. The treatment continues through telemedicine and local agencies upon returning home.

All of Operation Mend’s surgical and psychological services are provided at no cost to military veterans and their families.

It’s critical to include caregivers in the healing process, Dr. Sornborger says, as they often face their own trauma in adjusting to a suddenly changed reality. As many as 80% of caregivers meet criteria for PTSD, according to Operation Mend.

“With military caregiving, you become a caregiver overnight,” Dr. Sornborger says. “There are many paths that that caregiver may have wanted to take and hoped and believed they could, and those paths seem cut off to them. So the focus of what the caregiver participates in is: What were those paths and how can I get back to that?”

PTSD affects as many as 40% of military veterans, says Bruce Kagan, MD, PhD, a staff psychiatrist with the Veterans Administration Greater Los Angeles Healthcare System and medical director of Operation Mend’s intensive treatment program. Most PTSD programs for veterans have a 50% completion rate, he says, but Operation Mend’s intensive treatment program has a 97% completion rate.

“It’s harder to drop out when you’re 3,000 miles from home,” Dr. Kagan says of the program, which brings in veterans from across the country. “But I think the fact that you’re with staff, you’re with clinicians all day long, gives you a lot of chances to handle the distress that comes from the treatment.”

Increasing PTSD awareness

Post-traumatic stress disorder is what Dr. Sornborger calls an “interpersonal injury” that arises in response to sustained inhumanity. “You cannot feel emotions and be inhumane at the same time,” she says, “so there is a protective factor.”

Military service members adapt so well to this protective response while in combat that it remains in place when they get home, resulting in “emotional dysregulation,” Dr. Sornborger says. Veterans can often feel disconnected from their partner, children, friends and community; yearning for that connection is what drives many Operation Mend patients to seek help, she says.

Unfortunately, there can be a 10-year delay between returning from duty and pursuing PTSD treatment — a trend first observed with Vietnam veterans that persists with 9/11 war veterans. Unless these service members are being treated for physical injuries that bring them under a doctor’s care, psychological injuries can often simmer for years untreated.

PTSD can contribute to substance-use issues as a strategy for managing deeply held pain. Operation Mend will be instituting a substance-use component within the intensive treatment program later this year, Dr. Sornborger says.

“We’re filling gaps where we can,” she says. “And working to maintain the same level of comprehensive care that Operation Mend has always had — family first.”

While recovering from catastrophic physical injuries and psychological wounds such as PTSD may be a long and painful process, growing awareness of the challenges veterans face has made accessing treatment a little easier.

“There’s a greater openness,” Dr. Sornborger says. “There’s more access to warriors telling their stories — on websites, social media, blogs — so there’s access to tacit permission. But mental health is still overrun by the need that is far greater than the number of providers.”

Dr. Kagan says the VA hospital where he works is six stories tall, “and I’ve always argued it should be five stories of psychiatry and one of orthopedic surgery.”

He agrees that awareness of PTSD and the toll it can take on individuals and relationships is greater than ever, adding that the VA has trained thousands of therapists and psychiatrists to work with veteran populations over the past 40 years. So when veterans from the post-9/11 wars needed help, there was help available.

“When these wars came, we kind of knew what to do, which was get these veterans in early and treat them with respect,” he says. “We would treat them as people who have suffered and also as having something for which there is hope.”

For Army Specialist Paulk, being treated through Operation Mend was a lifesaving salve.

“They really take care of us like we’re family,” he says. “I can see it in their eyes that they really appreciate what myself and every other veteran in America has done for them.”

Learn more about Operation Mend and the services it provides to veterans.

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