Innovations in Plastic and Reconstructive Surgery: An Expert Interview With Robert T. Grant
Innovations in Plastic and Reconstructive Surgery: An Expert Interview With Robert T. Grant
Editor's Note:
What represents "state-of-the-art" in plastic surgery is changing at a rapid pace as the field takes advantage of medical advances such as stem cell therapy and tissue transplantation. As new techniques are incorporated, procedures are refined, and new uses are found for products already on the market. The field is also undergoing a philosophical shift in the goals of plastic surgery for many patients. Robert T. Grant, MD, is Plastic Surgeon-in-Chief at the New York-Presbyterian Hospital, and the University Hospitals of Columbia and Cornell. He spoke to Medscape's Pippa Wysong about some of the exciting new developments in the field of reconstructive and plastic surgery.
Medscape: What is state-of-the-art now for breast reconstruction?
Dr. Grant: Several things are state-of-the-art. One exciting area is the use of fat cell transplants, a technique that avoids rejection issues, and is useful for treating small breast contour defects and small partial mastectomy defects. At this point, fat cells can't be transplanted to large spaces or for a full breast, but maybe in 10 or 15 years this will be possible. Implant techniques using the patient's own tissue have also become very refined. I think we're at the point where the next paradigm shift is going to be away from these kinds of surgical procedures and toward the stem cell revolution.
Medscape: Are stem cells at a useful stage yet?
Dr. Grant: The future holds promise with stem cells. The Holy Grail is to avoid using foreign body materials like implants -- even though they are well-established safe and effective technologies. We're not quite there yet with stem cells, but 1 day we'll be able to manipulate stem cells harvested from the patient's own fat, and use them to fill the remaining skin envelope to reconstruct the breast.
Medscape: What are some of the concerns about stem cells at this point?
Dr. Grant: There are some concerns that stem cells could potentially trigger a cancer-causing type of reaction, or simply increase the risk for cancer. The risk is unclear and studies looking into this are underway. Still, it would be an exciting and valuable tool if we could avoid having to do deal with the complications of some of the reconstructive surgeries, the donor site scars, and other defects. Using just the patient's own tissue would be a great advance. We might see the use of stem cells, to some degree, in 5 years. From my perspective, this is the most exciting innovation that I see on the leading edge of what is possible and not just theoretical.
Medscape: The fear of stem cells and cancer -- what's the reason behind that?
Dr. Grant: We manipulate stem cells to create lines of different cell types -- such a muscle cell line, bone cell line, or a fat cell line. The question is, do we really have the ability to turn them off when they get mature? In the past, some of the experiments with stem cells encountered problems with malignancies. In some of the early trials of gene therapy tissue-engineering, the patients suffered untoward side effects that were worse than the disease for which they were being treated. Before these technologies come into practice, we want to make sure they help patients and do no harm. Studies are continuing, but look promising.
Medscape: So, stem cells from fat could turn into actual breast adipose tissue?
Dr. Grant: Yes. Or they could be used to form cartilage so people might not need certain orthopaedic operations and replacements. Or, stem cells could be used for cartilage grafting purposes -- which would be useful in reconstructing a congenitally missing or deformed ear in a child. Stem cell technology is promising for a wide variety of congenital deformities and reconstructive deformities. A huge plus would be avoidance of rejection by using cells derived from a patient's own body. Rejection issues would become moot and immunosuppression wouldn't be needed.
Medscape: What else is state-of-the-art?
Dr. Grant: The pace of change in the technologies that we use for minimally invasive surgery is incredibly fast. Take laser- and light-based treatments for treating the skin as examples. Plus, there are advances in the applicability of the neurotoxins, like Botox® (botulinum toxin type A) and Dysport® (abobotulinumtoxin A), and the dermal fillers, like Restylane® and Juvederm®, for indications that extend way beyond their original US Food and Drug Administration (FDA)-approved uses.
Consider the wide variety of conditions for which botulinum toxin is used -- it's not just for treating lines and wrinkles in the forehead. Botulinum toxin is now being used for lines and wrinkles around the mouth and for the little tight bands in the neck. Botulinum toxin is also being used to treat migraines. In the future the botulinum toxin molecule might be modified so the part that deals with migraine symptoms is active, but not the part that affects the muscle action. It's also being used for patients who have excess sweating in the armpits; and for a variety of medical conditions to help fine-tune the imbalances that people may have as a result of strokes, cerebral palsy, or other neurologic conditions. Some research is showing that the botulinum toxin molecule could potentially be modified so it could be applied as a cream instead of given by injection.
That's just 1 example of the potential and new uses of some of these agents. Things are changing fast. We'll have all sorts of new variations of these materials in our treatment arsenals within the decade.
Medscape: In many areas in medicine, things are becoming smaller, less invasive. What's happening in that direction?
Dr. Grant: Part of the innovation in plastic surgery is that it's becoming much less surgical. When I first started about 20 years ago, many of things that are now routine were not even invented. Now, the philosophy is really "less is more." We're starting to do not so much anti-aging, but rather 'age maintenance' procedures. The reality is, we'll never reverse time but, we can certainly use all of these tools to help patients look as good as they can within the context of their ages, life experiences, and lifestyles. Plastic surgery is becoming part of the arsenal of things that a person has access to as they consider how they're going to live their lives and what kind of life they want to lead. Just like you choose to eat right and exercise, you can include some of the things plastic surgeons offer -- whether they are minimally invasive, noninvasive, or surgical. Now, we help people continue to look like themselves and not undergo radical transformations.
Medscape: So, there's been a shift in what the plastic surgeon does?
Dr. Grant: In a sense, yes. I tell people that while 'extreme makeovers' might work great for houses, they don't necessarily work great for people. One of the big innovations in plastic surgery is a change in the philosophy of the role of the plastic surgeon -- the role of surgery in people's lives and what surgery actually is designed to do. It's much more sophisticated than just moving tissue around; it's making sure you use it as a tool that really helps people achieve their esthetic and lifestyle goals. It's more than being a technical success that the surgeon is judging. Now, we're focused much more on outcomes from the patient perspective -- not just patient satisfaction but also their perception of what it is that they want out of the whole process of interaction with plastic surgery. It's more than having an operation with no complications.
Medscape: Are there any up-and-coming tools of the trade?
Dr. Grant: The really interesting thing will be the eventual approval, in the United States, of the form-stable silicone gel breast implants. They're currently available outside the United States. They will make a big difference for women having both cosmetic and reconstructive breast operations. We're just waiting for the FDA to complete its review.
Medscape: What's new or different about these implants?
Dr. Grant: Well, the currently available silicone gel breast implants are a liquidy kind of silicone -- the kind that has been around for a generation. In the newer generation of silicone implants, sometimes called 'gummy bear' implants, the silicone is more cross-linked. It's not as liquidy. Traditionally, a concern about silicone implants is that when the shell that holds the silicone in place fails, liquid silicone can leak out into breast. This doesn't cause major health problems for the patient, but the removal of the silicone and exchange to a new implant is sometimes problematic. Because the cohesive gel is stable in these newer implants, it doesn't leak anywhere if the shell breaks. Not only do those implants potentially look and feel better, but they also address the main concern people had about silicone implants.
Medscape: Are there any other state-of-the-art items on your radar?
Dr. Grant: Well, we have our tools for microvascular surgery, and craniofacial surgery, which have all been very well refined. Some of the principles of tissue transfer for transplantation, such as in face transplants, is teaching us a lot. We're learning that when you transfer tissues composed of many different kind of cells (face transplants have skin, bone, muscle, and tendon) the immunosuppression needed is very different than the immunosuppression needed after a solid organ transplant like when just a kidney is transplanted. More research and innovations are occurring at that immunologic level -- another area to watch.
Medscape: This is an exciting time to be in plastic surgery. Thanks for sharing your thoughts.
Editor's Note:
What represents "state-of-the-art" in plastic surgery is changing at a rapid pace as the field takes advantage of medical advances such as stem cell therapy and tissue transplantation. As new techniques are incorporated, procedures are refined, and new uses are found for products already on the market. The field is also undergoing a philosophical shift in the goals of plastic surgery for many patients. Robert T. Grant, MD, is Plastic Surgeon-in-Chief at the New York-Presbyterian Hospital, and the University Hospitals of Columbia and Cornell. He spoke to Medscape's Pippa Wysong about some of the exciting new developments in the field of reconstructive and plastic surgery.
Medscape: What is state-of-the-art now for breast reconstruction?
Dr. Grant: Several things are state-of-the-art. One exciting area is the use of fat cell transplants, a technique that avoids rejection issues, and is useful for treating small breast contour defects and small partial mastectomy defects. At this point, fat cells can't be transplanted to large spaces or for a full breast, but maybe in 10 or 15 years this will be possible. Implant techniques using the patient's own tissue have also become very refined. I think we're at the point where the next paradigm shift is going to be away from these kinds of surgical procedures and toward the stem cell revolution.
Medscape: Are stem cells at a useful stage yet?
Dr. Grant: The future holds promise with stem cells. The Holy Grail is to avoid using foreign body materials like implants -- even though they are well-established safe and effective technologies. We're not quite there yet with stem cells, but 1 day we'll be able to manipulate stem cells harvested from the patient's own fat, and use them to fill the remaining skin envelope to reconstruct the breast.
Medscape: What are some of the concerns about stem cells at this point?
Dr. Grant: There are some concerns that stem cells could potentially trigger a cancer-causing type of reaction, or simply increase the risk for cancer. The risk is unclear and studies looking into this are underway. Still, it would be an exciting and valuable tool if we could avoid having to do deal with the complications of some of the reconstructive surgeries, the donor site scars, and other defects. Using just the patient's own tissue would be a great advance. We might see the use of stem cells, to some degree, in 5 years. From my perspective, this is the most exciting innovation that I see on the leading edge of what is possible and not just theoretical.
Medscape: The fear of stem cells and cancer -- what's the reason behind that?
Dr. Grant: We manipulate stem cells to create lines of different cell types -- such a muscle cell line, bone cell line, or a fat cell line. The question is, do we really have the ability to turn them off when they get mature? In the past, some of the experiments with stem cells encountered problems with malignancies. In some of the early trials of gene therapy tissue-engineering, the patients suffered untoward side effects that were worse than the disease for which they were being treated. Before these technologies come into practice, we want to make sure they help patients and do no harm. Studies are continuing, but look promising.
Medscape: So, stem cells from fat could turn into actual breast adipose tissue?
Dr. Grant: Yes. Or they could be used to form cartilage so people might not need certain orthopaedic operations and replacements. Or, stem cells could be used for cartilage grafting purposes -- which would be useful in reconstructing a congenitally missing or deformed ear in a child. Stem cell technology is promising for a wide variety of congenital deformities and reconstructive deformities. A huge plus would be avoidance of rejection by using cells derived from a patient's own body. Rejection issues would become moot and immunosuppression wouldn't be needed.
Medscape: What else is state-of-the-art?
Dr. Grant: The pace of change in the technologies that we use for minimally invasive surgery is incredibly fast. Take laser- and light-based treatments for treating the skin as examples. Plus, there are advances in the applicability of the neurotoxins, like Botox® (botulinum toxin type A) and Dysport® (abobotulinumtoxin A), and the dermal fillers, like Restylane® and Juvederm®, for indications that extend way beyond their original US Food and Drug Administration (FDA)-approved uses.
Consider the wide variety of conditions for which botulinum toxin is used -- it's not just for treating lines and wrinkles in the forehead. Botulinum toxin is now being used for lines and wrinkles around the mouth and for the little tight bands in the neck. Botulinum toxin is also being used to treat migraines. In the future the botulinum toxin molecule might be modified so the part that deals with migraine symptoms is active, but not the part that affects the muscle action. It's also being used for patients who have excess sweating in the armpits; and for a variety of medical conditions to help fine-tune the imbalances that people may have as a result of strokes, cerebral palsy, or other neurologic conditions. Some research is showing that the botulinum toxin molecule could potentially be modified so it could be applied as a cream instead of given by injection.
That's just 1 example of the potential and new uses of some of these agents. Things are changing fast. We'll have all sorts of new variations of these materials in our treatment arsenals within the decade.
Medscape: In many areas in medicine, things are becoming smaller, less invasive. What's happening in that direction?
Dr. Grant: Part of the innovation in plastic surgery is that it's becoming much less surgical. When I first started about 20 years ago, many of things that are now routine were not even invented. Now, the philosophy is really "less is more." We're starting to do not so much anti-aging, but rather 'age maintenance' procedures. The reality is, we'll never reverse time but, we can certainly use all of these tools to help patients look as good as they can within the context of their ages, life experiences, and lifestyles. Plastic surgery is becoming part of the arsenal of things that a person has access to as they consider how they're going to live their lives and what kind of life they want to lead. Just like you choose to eat right and exercise, you can include some of the things plastic surgeons offer -- whether they are minimally invasive, noninvasive, or surgical. Now, we help people continue to look like themselves and not undergo radical transformations.
Medscape: So, there's been a shift in what the plastic surgeon does?
Dr. Grant: In a sense, yes. I tell people that while 'extreme makeovers' might work great for houses, they don't necessarily work great for people. One of the big innovations in plastic surgery is a change in the philosophy of the role of the plastic surgeon -- the role of surgery in people's lives and what surgery actually is designed to do. It's much more sophisticated than just moving tissue around; it's making sure you use it as a tool that really helps people achieve their esthetic and lifestyle goals. It's more than being a technical success that the surgeon is judging. Now, we're focused much more on outcomes from the patient perspective -- not just patient satisfaction but also their perception of what it is that they want out of the whole process of interaction with plastic surgery. It's more than having an operation with no complications.
Medscape: Are there any up-and-coming tools of the trade?
Dr. Grant: The really interesting thing will be the eventual approval, in the United States, of the form-stable silicone gel breast implants. They're currently available outside the United States. They will make a big difference for women having both cosmetic and reconstructive breast operations. We're just waiting for the FDA to complete its review.
Medscape: What's new or different about these implants?
Dr. Grant: Well, the currently available silicone gel breast implants are a liquidy kind of silicone -- the kind that has been around for a generation. In the newer generation of silicone implants, sometimes called 'gummy bear' implants, the silicone is more cross-linked. It's not as liquidy. Traditionally, a concern about silicone implants is that when the shell that holds the silicone in place fails, liquid silicone can leak out into breast. This doesn't cause major health problems for the patient, but the removal of the silicone and exchange to a new implant is sometimes problematic. Because the cohesive gel is stable in these newer implants, it doesn't leak anywhere if the shell breaks. Not only do those implants potentially look and feel better, but they also address the main concern people had about silicone implants.
Medscape: Are there any other state-of-the-art items on your radar?
Dr. Grant: Well, we have our tools for microvascular surgery, and craniofacial surgery, which have all been very well refined. Some of the principles of tissue transfer for transplantation, such as in face transplants, is teaching us a lot. We're learning that when you transfer tissues composed of many different kind of cells (face transplants have skin, bone, muscle, and tendon) the immunosuppression needed is very different than the immunosuppression needed after a solid organ transplant like when just a kidney is transplanted. More research and innovations are occurring at that immunologic level -- another area to watch.
Medscape: This is an exciting time to be in plastic surgery. Thanks for sharing your thoughts.
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