© Borgis - Postępy Nauk Medycznych 3/2016, s. 166-171
Co nowego w chirurgii plastycznej?
What’s new in plastic surgery?
Department of Plastic Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Warsaw
Head of Department: Bartłomiej Noszczyk, MD, PhD
Artykuł zarysowuje niektóre nowe osiągnięcia i trendy w chirurgii plastycznej. Wśród nich niektóre, jak alloprzeszczepy twarzy i kończyny górnej, mogą być uznawane za nowe gałęzie w chirurgii plastycznej, jako że przeszczepianie organów nie było dotychczas związane z rozwojem tej dyscypliny. Inne, jak rekonstrukcje piersi, rozwijały się wraz z chirurgią plastyczną, by dopiero ostatnio wywrzeć silny wpływ na rozwój innych gałęzi medycyny, jak medycyna regeneracyjna. Jest to wynikiem metod opracowanych przez chirurgów plastycznych dla przetwarzania tkanki tłuszczowej i jej skutecznego przeszczepiania w chirurgii twarzy i piersi. Innym przykładem całkowicie nowych dziedzin opracowanych w chirurgii plastycznej i obecnie kształtujących przyszłość medycyny bionicznej są połączenia typu maszyna-nerw obwodowy. Inne osiągnięcia chirurgii plastycznej jak chirurgiczne leczenie migren stały się przyczyną kontrowersji i twórczego fermentu w nauce, ponieważ wyniki uzyskiwane po operacjach wydają się rzucać nowe światło na etiologię tej choroby. Artykuł wymienia także nowe zasady w przejrzystości artykułów naukowych, ponieważ należą one do tych dziedzin, gdzie chirurdzy plastyczni stali się pionierami we wdrażaniu nowych zasad opracowanych w innych dziedzinach nauki.
This article summarizes a number of the new trends and developments in plastic surgery. A number of which, such as face or upper extremity transplantation, can be considered new branches in plastic surgery, since organ transplantation was not previously associated with this discipline. Others, such as breast reconstruction, have evolved alongside plastic surgery and only recently have been exerting a strong influence on the progress of other medical disciplines like reconstructive medicine. This is a result of the methods developed by plastic surgeons in the field of fat processing and its efficient transplantation in face and breast surgery. Nerve-machine interfaces also serve as an example of completely new fields developed in plastic surgery which are currently shaping the future of bionic medicine. Other plastic surgery developments, such as migraine surgery, are the cause of controversial and creative ferment in science, because the results obtained from the surgical treatment of migraines have shed new light into headaches aetiology. The article also mentions transparent medical publishing as this belongs to those areas where plastic surgeons have been early-adopters of new trends derived from field leaders.
Plastic surgery encompasses a wide range of procedures which can be carried out over the surface of the human body. The intention of the surgery is, however, limited to two simple goals, that of the restoration of the body’s form, and of the body’s function. Restoration is therefore the key word that defines this discipline. Since restoration can be considered the act of bringing something back that existed before, or the act of bringing something into existence which should exist if all were natural and expected, then plastic surgery encompasses the entire body’s form, as well as its beauty with all the pretence and vanity associated. Traditionally, plastic surgery has been divided into reconstructive and aesthetic surgery. Recently, however, plastic surgery has also been associated with regenerative medicine which focuses on research and the quest for replacement tissues and organs. While reconstructive surgery concentrates more on restoring those body parts that are perceived to be below the norm, aesthetic surgery operates on those body parts that are normal, but considered unsatisfactory to the patient. Regenerative medicine is currently targeted at reconstructive surgery, but with future endeavours, will come to serve beauty too.
Allotransplantation in plastic surgery
Traditionally organ transplantation was not linked to plastic surgery. This changed in 2002 when the general public became aware that face transplantation would soon be possible. After the first successful operation in 2005 the original social disapproval changed into gradual agreement (1). Today we no longer question the ethical justification, but have instead new concerns that address more practical and political issues such as costs, and patient allocation. New important questions include issues that were not previously perceived when this procedure was in its developmental stage. Should face transplantation be performed in developing countries where the social need for such treatment is higher than in rich societies where dramatic disfigurements are rare due to prevention? Will ethnical differences between donors and recipients still be important in such circumstances? The relative shortage of facial donors can impose elastic contraindications for candidate selection. Perhaps also gender matching should no longer be important? Recent data shows that it is possible that appearance is not critical, since the transfer of individual facial features is probably negligible (1). Interesting questions also concern the limits of secondary revisions after face transplantation. Recently, major skeletal revisions with Le Fort III osteotomy were performed for malocclusion. Blepharoplasty was also justified, because of the loose skin excess of both eyelids (2). It has been speculated that secondary procedures should also include various nerve transfers for sensory and motor neurotisation (3). The nerve transfers that are now considered a new paradigm shift in plastic surgery are briefly described below.
There is interesting new data concerning upper extremity transplantations. The modern era of forearm and arm transplantation started first with French and American operations in 1998 and 1999 respectively. Since that time more than 107 transplanted upper limbs have been reported. Currently, the main centres that have experience with these procedures exist in the USA, France, Germany, Poland, Austria, Spain, and China. The total loss rate is 22.4%, however the majority of losses occurred after combined procedures, where the patients received hand and leg, or hand and face transplants. Such patients were also more prone to fatal results (4). The most successful functional outcomes were reported for patients with distal forearm transplantations. These patients expect faster recovery, with limited sensory and motor reinnervation. More proximal defects are characterized by weaker hand grip and only minor discriminative sensation. However, even for transhumeral transplantations, protective sensation and some motor function is to be expected which should be regarded as a substantial improvement on the baseline (4). Although surgically complicated, upper limb transplantation is even more challenging from a medical point of view. The success rate of these procedures is strongly dependent on advanced immunosuppression, and the majority of complications are related to postoperative and lifelong medical therapy. It is therefore important that upper extremity transplantations be performed by multidisciplinary centres with professional experience in solid organ transplantations.
There have recently been a number of very interesting changes taking place in breast reconstructive surgery. The two main reconstruction methods currently rely on the use of implants, or autologous tissue, or a combination of both. Reconstruction using implants is the simplest solution, especially in cases of one-stage treatment decisions. In such cases, the reconstruction is performed immediately after a skin sparing mastectomy. A sparing mastectomy preserves a well-perfused envelope, enabling the implant to be covered with skin and muscle. This method is particularly suitable for slim patients with small breasts. In larger and ptotic breast patients, two-stage reconstruction is usually selected (5). It consists of postponing the final reconstruction until the end of the oncological treatment. One of the main disadvantages of secondary reconstructions is the scarcity of tissues needed for a safe implant cover. Traditionally, this problem has been solved by preparing the skin with an expander, or using a tissue flap from the latissimus dorsi (LD) muscle, as an additional implant cover. Such a flap contains both muscle and skin, therefore it covers the implant with a thick layer of well perfused tissues. Recently, much attention has been paid to acellular dermal matrices (ADM) that allow for the safe covering of the implant and its fixation to the chest. However, the ADM has to be covered with well vascularized and elastic skin. Since this requires the preparation of the breast with an expander, the basic benefit of ADM is limited to muscle preservation (5).
Autologous tissue reconstructions without implants evolved from the initial use of pedicle flaps to free flaps which require microsurgical anastomoses. The reconstruction of a slightly ptotic, natural breast requires the harvesting of a large amount of skin and subcutaneous tissue. Such a large flap can only be achieved by using abdominal skin. In mature patients these tissues are generally loose and flaccid, thus removing their excess improves the shape of the abdomen. They can be transferred with one of the abdominal rectus muscles, supplied by the superior epigastric artery and vein. This flap is referred to as the transverse rectus abdominis myocutaneous (TRAM). Its disadvantage is, however, related to the need to harvest the muscle which causes a weakening of the abdominal wall. An alternative to a pedicled is a free TRAM, taken with a small fragment of the rectus muscle and its primary blood supply from inferior epigastric vessels. This removes the need to pull the muscle under the skin to its new position on the chest. The free TRAM is anastomosed with the internal mammary (IM), or thoracodorsal arteries (TD) (5).
It is currently believed that the best method for microsurgical reconstruction involves the deep inferior epigastric perforator (DIEP) flap, because its dissection preserves the rectus muscles. Over the past few years the use of this flap has enjoyed a growing popularity, despite its higher cost (6). It relies on perforating artery which runs between the epigastric inferior and the flap. When the perforator is dissected it can be pulled out from between the muscle fibres, together with its main inferior epigastric vessels. In its recipient area it is usually anastomosed with the internal mammary artery.
The choice of vessels that supply blood to the flap is the subject of much scientific debate. The IM artery has a constant course and a much greater flow than the TD artery. However, it is less accessible, i.e. it runs under the ribs (7). Furthermore the use of IM to breast reconstruction excludes its later application in the reconstruction of coronary arteries where it is considered to be the best material. The advantage of TD artery, in turn, is its easy access, especially after a previous biopsy of the sentinel node. Moreover, the TD microvascular anastomosis is located in the armpit, away from the reconstructed breast. In this situation the breast can be easily shaped and improved, without the fear of secondary damage and impaired flow (8). A drawback to the use of TD vessels for microvascular reconstruction is, in turn, the subsequent elimination of secondary reconstructions using the LD muscle which is supplied by this artery.
Modern breast oncology often uses breast conserving techniques (BCS) which, are considered the standard of excellence. Although growing trend in BCS was recently reversed (9), conserving techniques still have a significant influence on modern attitudes towards breast reconstructive surgery. Small losses after lumpectomies no longer require complex reconstructions. The role of reconstructive surgery is therefore substituted by oncoplastic techniques, i.e., local flaps on glandular tissue. Although such methods are adopted from breast reduction plastic surgery, oncoplastic techniques are, usually performed by oncological surgeons, simultaneously with a lumpectomy. If, despite local glandular flaps, the breast remains irregular or hollow, it can be additionally filled with autologous fat. Fat grafts are very much associated with the completely new trend in reconstructive surgery which could revolutionize breast surgery.
Fat grafting and breast surgery
The first attempts at fat grafting for breast reconstruction were performed in the nineteenth century. In the 1980s, the huge increase of popularity of fat transfers occurred as a result of the development of minimally invasive liposuction techniques, and tumescent anaesthesia. However, at this time an unsolvable problem led to the low efficiency of transplantation which resulted from fat absorption, and its calcification. Because of these two problems, as well as the concerns for the safety of patients exposed to unreliable mammographies after calcifications, the American Society of Plastic Surgeons (ASPS) banned fat transfers to the breast. This position was accepted by other national societies and was upheld until 2012 when new fat grafting techniques became available.
It is currently believed that two main factors determine the effectiveness of fat transplantation to the breast. These are the use of micrografting techniques, and the preoperative expansion of the breast with external expanders. Micrografting, which relies on the transfer of microlobules or microribbons of fat dispersed between well-vascularized tissues, prevents the creation of cysts. It has now been proved that fat inside even minor cysts cannot be vascularized before adypocytes breakdown (10). The use of micrografts, however, is effective only when the increase of the volume of the transplanted tissue does not cause a compression of the breast blood vessels, and does not restrict flow. The volume of fat can only safely be increased by increasing the preoperative volume of the breast. For this purpose, external expansion with sealed domes is applied to the breast, or to skin at the site of the mastectomy defect. The domes are a registered medical product known as the Brava system.
In a recent paper, the inventor of the Brava system, and his team, presented the results of operations of 488 patients whose breasts were reconstructed using fat transfers (11). The authors performed the reconstructions of partial defects after BCS, and of breasts after complete mastectomies. In some patients immediate reconstructions were also performed. Their results can be regarded as excellent. Although labour intensive, breast reconstruction with autogenous fat is minimally invasive, and requires only basic surgical skills. In this respect it significantly outperforms conventional reconstruction methods. It would therefore not be surprizing, if it soon displaces traditional techniques.
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