The cutting edge of surgery

Modern-day plastic surgery was effectively born during the first World War, when the urgent management of major burns and other injuries led to the development of effective plastic surgical techniques. Essential reconstructive surgery using many of these same techniques is still carried out – but cutting-edge science and medical breakthroughs means it is more sophisticated than ever, with astounding results.

Trauma is a major portion of the plastic surgeon’s daily work and these can range from road traffic accidents to machinery incidents. Dealing with the aftermath of illnesses such as cancer – typically head and neck cancer or breast cancer – also require the skills of a plastic surgeon.

Incidentally, there is no actual plastic involved – the word “plastic” comes from the Greek word, plastikos, meaning to mould or to sculpt. Techniques originally developed for the reconstructive aspect of plastic surgery have found applications on the cosmetic side, and vice versa.

One of these techniques is fat grafting, which has been equally revolutionary in aesthetic and reconstructive medicine. While this technique was first described in the 1800s, advances in recent years mean it is being used to great effect in both fields.

Breast reconstruction is an area where increasingly sophisticated techniques in fat transfer are allowing for more natural and sustainable results. Figures show that most women who have had a breast or both removed due to cancer are now opting for a reconstruction. In addition, genetic screening means there is a cohort of women with a family history of the disease who are choosing to undergo pre-emptive mastectomies of their breasts.

Richard Hanson is a plastic, reconstructive and aesthetic surgeon, with a special interest in breast surgery and hand surgery. He works in the Mater Private Hospital and explains that breast reconstruction techniques have “completely transformed”. Implants are no longer used as standard practice – instead, highly technical microsurgery allows for a new breast to be sculpted from grafted fat (typically from the abdominal area), and the result is infinitely more natural and realistic. Often, nipple preservation is now possible and thus the patient emerges from surgery (or surgeries – Hanson says it may take two or three to perfect the result) with a breast almost identical to the one she has lost.

“We now try and offer breast reconstruction with just skin and fat, as that’s what the breast is made of. It is about form and function – one of the principles of plastic surgery is replacing like with like,” he explains.

The advantage is that this is forever, he says. “It will age the same as a normal breast, but you won’t have any other issues. If you try and do it with an implant, you will have to manage and maintain the implant. Doing it this way also means you can still have other treatments such as radiotherapy – implants means outcomes from this are very poor.”

Fat transfer

Fat transfer has revolutionised practice in this area in the past five to 10 years, says Hanson.

“Using fat transfer, we can further refine the size and the shape of the breast by taking fat from a patient’s flanks or thighs. The breasts get that natural drop. How I would have trained to do breast reconstruction and how I do it nowadays are completely different.”

Underpinning many of the advances in reconstructive medicine is a technique known as microsurgery. This subdiscipline of plastic surgery focuses on repairing intricate structures such as blood vessels and nerves less than a few millimetres in diameter. Hanson says it is a tool and a way of thinking that allows plastic surgeons to “embody the true tenets of plastic surgery”.

“Currently, microsurgery focuses on an easy recovery for the patient while maximising on the aesthetics. It is about refinement, approaching normal, and achieving the balance between form and function,” explains Hanson.

It was microsurgery that enabled recent advances in the field, such as hand transplants and face transplants. “Combining successes in replantation with microsurgical technique and coming full circle with the reconstructive history of transplantation, the first successful human hand transplant was performed in 1998 in Lyon, France,” says Hanson.

Several hundred hand transplants have been carried out since then, but there have been other improvements in hand reconstructive techniques over the years, helping patients who have had accidents, or those with crippling arthritis, he adds. Similarly, the first face transplant was a novelty that attracted global attention, but many more have been carried out in the intervening years.

Supermicrosurgery

The next progression of plastic surgery is the evolution of supermicrosurgery, which refers to joining blood vessels less than 0.8mm in diameter, Hanson says. “Mirroring the history of microsurgery, this technique began with replantation of fingertip injuries. Special instruments, sutures and microscopes were developed to facilitate the challenges of very small structures. Now we can replace these very small tiny joints and we have lots of tiny implants we can use.”

Looking even further into the future, the next step, he says, will be robotic assistance in microsurgery. “This will enhance human precision and dexterity to improve clinical outcomes even further.”

According to aesthetic doctor Dr Peter Prendergast, clinical director of Venus Medical, there has been an explosion of research into the therapeutic effects of fat grafting and its application in regenerative medicine.

“Adult fat has a lot of stem cells and there are now different ways to harvest these stem cells from the fat,” he explains. “Fat grafting improves the quality of the skin, making it especially good for people who have suffered burns. The stem cells in the fat nearly always produce regenerative properties in the skin, so the skin looks much better even though you are grafting the fat deep under the skin.”

Prendergast used this to rehabilitate a client who received a facial nerve injury due to a complication during a facelift, with fantastic results. He adds that this technique is now routinely used in patients who have had severe burns, giving unprecedented results.