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Origin and Future of Plastic Surgery

The art of plastic surgery is not confined to beautification. In fact, plastic surgery as a discipline took off during world war I paralleling need for soft tissue reconstruction from ballistic and artillery injuries to the face and limbs. Surgeons by necessity had to develop very creative ways to protect exposed vital structures such as vessels, nerves, bones, and muscle. The use of regional “flaps” became the rule. “Flaps” is the term for general surgical procedures that involve the relocation of tissue on the body from one area to another to provide tissue coverage.

A modern example of a flap is the TRAM flap, or transverse rectus abdominus myocutaneous flap used for breast reconstruction after mastectomy. While it is a long winded name, the TRAM flap is basically a surgical procedure where part of the skin, muscle, and fat of the belly is cut and moved to the chest wall as a unit to make a breast. In essence, a woman gets a tummy tuck and a breast at the same time. It is a rather ingenious use of tissue, and is a wonderful example of one of the guiding principles of reconstructive surgery: Rob Peter to pay Paul. That is, tissue is taken from an area called a donor site, and transposed to a site that needs soft tissue coverage, called a recipient site. A simple example of this principle is the skin graft. Deep burns may extend to tissue levels below the skin, such as the fat or muscle. To expedite the healing process, skin is harvested in an area that will heal well and leave an inconspicuous scar, and applied to the burned area, or defect. The defect will incorporate the skin graft and cover the burned area with new skin. Because the skin is taken at just 12 thousandths of an inch thick, the donor site will heal without difficulty.

Despite popular belief, plastic surgery did not adopt its name as a result of the common use of plastic implants. Plastic surgery comes from the Latin word “plastikos”, which means “to mold”. Historically, the essence of plastic and reconstructive surgery was the molding or reshaping the human body using one’s own tissues. In recent decades, plastic surgery took on a different meaning. We are now reshaping the body with artificial implants, such as silicone breast implants, saline breast implants (including the silicone “gummy bear” breast implants), cheek implants, lip implants, butt implants, chin implants, calf implants, and injectable products such as Juvederm, Restylane, Perlane, Sculptra’ Radiesse , and Belotera.

While medicine advanced so did surgical techniques and procedures. The most recent advancement in plastic surgery has been the reshaping of human form with tissue from another person. This, of course, is transplant surgery, and in its most common form in plastic surgery, involves face and hand reconstruction. Face and hand transplant surgery is an exciting field of plastic surgery. While the actual operative technique of face and transplant surgery is not easy, it certainly isn’t the most difficult surgery to perform. So why isn’t hand transplantation and face transplantation more common? Three words: Risk versus benefit. Livers, hearts, and kidneys in the United States are transplanted daily. They are life saving surgeries. Thus the benefit is living. Hard for a risk to outweigh that, right? But when a hand or face receives a transplant, it isnt life saving. In fact, it can be life threatening, as we will see. And yet it is often front page news. Why? For one, it makes an interesting story because it is rare, and hence, exotic. Two, the hands and face are external, and the psychological transformations from surgeries to restore function or a more normal appearance (face transplants have limitations in achieving animation) are profound to say the least.

Transplant surgery involves taking someone else’s body part and attaching it to another person in a way that it integrates and becomes healthy, living tissue in the recipient. However, when someone else’s body part or organ is transplanted into another person, the recipient’s immune system will identify the transplanted tissue as foreign, and hence, attack it. With all of the body’s might, a fierce fight will ensue and ultimately result in the rejection and subsequent death of the transplanted organ. Thus, the way doctors get transplants to survive is to deregulate the recipients immune system with medications. This results in the recipients increased susceptibility to infections and certain types of cancers. But again, a small price to pay for the benefit of life. For limbs and faces, the reward is quite different. And, the risk is even greater, because the immune suppression that needs to be induced in the recipient of a transplanted face or hand is much stronger than that of Liver or kidney. Transplanted tissues that involve skin incite a much more powerful rejection than internal organs.

The world of plastic and reconstructive transplant surgery is still in it’s early stages. I predict within the next decade, we will find more clever and safe ways to modify the recipients immune system. Hand and face transplants will become more commonplace, but never as common as liver and kidney for the simple reason that more kidneys and livers fail than hands are absent or faces mutilated.

The next frontier of plastic surgery will be the manipulation of genes or cells within the body to promote the growth of new “like” tissue. Cells will identify what is missing (ie. nerves, skin, tendon, etc.) and provide the mechansims to fill in the gaps.