Photo by Craig Mohr
The New Face Of Plastic Surgery
Plastic surgery repairs lives, yet many still think it frivolous. Now, thanks to improved technology and techniques that restore function as well as form, the image of reconstructive and cosmetic surgery is getting a face-lift.
One of the first thoughts that occurred to
Jorge Esparza when a work-related accident mangled the fingers of his right
hand was that he would have trouble tossing a ball to his 2-year-old son.
Then came the questions about how he would ever earn a living for his family,
how he would drive a car or write or do anything he had, as a right-handed
person, previously taken for granted.
Soon after the accident all the fingers on his injured hand had to be amputated, leaving him disabled. After seeking the advice of numerous physicians Esparza found his way to Randy Sherman, M.D., professor of surgery at the USC School of Medicine, where he underwent a complex microvascular reconstructive procedure known as "double toe transplantation." Esparza's second toes from each foot were removed and transferred to his hand. Now, after eight months of intensive rehabilitation, not only are the transplants functional, but they look very much like his own fingers.
Craig Nakata lost functional use of his hands over seven years as a result of scleroderma, a disease that causes the body's skin and connective tissue to harden. By early this year, the 35-year old man lost almost all function as his fingers had curled into a permanent fist-like position.
"It had become a real nuisance. I could still work and do data entry, but it was hard to pick things up and I kept dropping things," he says.
Nakata was referred to USC and Garry Brody, M.D., professor of surgery. Following two operations this year to straighten his fingers, Nakata says he has experienced significant improvement in function: "I told someone else with the same problem as me that I thought the surgery was well worth it."
In their wildest dreams, Esparza and Nakata never thought they would visit a plastic surgeon. For repairs to their hands, however, they were referred to the division of plastic and reconstructive surgery at the USC School of Medicine. Like the growing number of patients who need repair because of damage caused by accidents, burns or disease, Esparza and Nakata came to realize that plastic surgery today is not just about face-lifts and nose jobs.
"The most comprehensive way to describe a plastic surgeon is, they are doctors who care for wounds," says Sherman, who is chief of the division of plastic and reconstructive surgery. "Whether you define wounds as secondary to trauma, congenital deformities, defects left by cancer removal or burns, non-healing ulcers from rheumatoid diseases or infections, or psychological wounds caused by aging, plastic surgeons practice the art of wound healing and have been doing so for many hundreds of years. It is the only medical specialty that worries about both function and form."
Indeed, according to the American Society of Plastic and Reconstructive Surgery, four of the top five procedures performed by plastic surgeons in the U.S. are reconstructive, not cosmetic-including tumor removal, hand surgery and laceration repair. Because of the increasing numbers of patients treated for breast cancer, the number of breast reconstructions performed by plastic surgeons climbed 70 percent between 1992 and 1997. Public perception of the field is slowly changing, partly as a result of increased media exposure to the reconstructive side of plastic surgery. Still, Sherman notes, an overwhelming majority of coverage is devoted to cosmetic surgery.
Even in Los Angeles, where plastic surgery is often identified with celebrities who wish to ward off time, more and more regular folks are looking at the specialty less cynically. "Thank goodness my neighbor came with me to the emergency room, because she was the one who thought of asking for a plastic surgeon," says Paula Monopoli, whose 5-year-old son Richard ran through a sliding glass door and needed 40 stitches above and below his eye. Monopoli credits both the plastic surgeon's operative techniques and postoperative care with minimizing long-term marks from the accident.
Part of the credit for the new view of plastic surgery goes to advances in the field that makes surgeries like Esparza's possible. "Many of the techniques we use today were not in existence 10 to 15 years ago," notes Bala Chandrasekhar, M.D., associate professor in the division. "We had to develop solutions step by step, and in developing them, techniques were created to successfully rebuild lives."
Chandrasekhar recalls one patient who had become a recluse due to a cancer surgery that removed almost half his face, from his scalp, through one eye, down his cheek, his nose and jaw and even part of his brain. The team of surgeons, coupling basic plastic surgery principles with several innovative techniques, used tissues from the surrounding scalp to cover the brain while other tissues were transplanted from his back to rebuild his face. Then, incorporating a new technique called osteointegration, a prosthetic mask made of silicone rubber was created to fit onto small tabs implanted in the facial skeleton. "The prosthetic is a true art form: every detail is painted on, much as is done with cinematic special effects," says Chandrasekhar. "It is a seamless match to his own face-eyebrow, eye and nose. With one exception-his eyelid doesn't blink. Now he feels comfortable going out and participating in life once again."
Perhaps the greatest advance in plastic surgery, say surgeons, is in the area of reconstructive microsurgery, which allows plastic surgeons to transplant tissue from one region of the body to rebuild an injured or absent part elsewhere. Combining sophisticated technology with years of training and experience in reconstructive surgery, plastic surgeons can move tissue along with two supporting blood vessels to the transplant site. After connecting these tiny vessels (about the diameter of a hair) to similar vessels in the recipient area, the living transplanted tissue is reshaped to rebuild the specific defect. So a toe becomes a thumb, a piece of bowel becomes an esophagus, or a leg muscle helps create a smile.
"It's like unplugging an electrical appliance in one room, taking it to another room and plugging it in," says Sherman. "Similar concepts used in heart or lung transplantation apply here, however, instead of transferring the identical type of tissue from one person to another we harvest different types of tissue and transplant them within the same individual."
Microsurgery is also increasingly used to reconnect or transplant nerves severed in accidents. Sherman recalls one patient, a vice president of a newspaper company, who was shot in the arm during an attempted carjacking. "He lost both nerve and biceps muscle function resulting in the inability to flex his elbow or raise his wrist and fingers." After reconstructive microsurgery to transplant a muscle from his back to restore elbow flexibility, the transfer of muscles to his forearm to restore hand function and nerve repair, the patient began rehabilitation and regained complete use of his hand and arm.
Paramedics and emergency crews have learned how to store and protect severed tissue, which extends the time tissue may survive for replantation. A young woman whose scalp was completely torn off when her hair caught in an industrial mixer at work was able to undergo immediate replantation because of the excellent performance of the paramedics. "The machine took off her entire scalp, one ear, part of her forehead and eyebrows-all in one piece," recalls John Gross, M.D., assistant professor of clinical surgery. "We had maybe six or eight hours to salvage the tissue, but the paramedics knew how to induce 'cold ischemia,' using ice. The technique slowed down the metabolism of the tissue, giving us more time to replace the severed scalp."
In the area of aesthetics, new techniques and technologies have given plastic surgery an image as a cutting-edge arm of medicine. Laser technology has added depth and versatility to facial rejuvenation. Liposuction, says Brody, is a fairly recent technology-and yet today is one of the top five procedures performed by plastic surgeons nationwide. An aging population, he says, seems to be more comfortable with, what he calls, the basic human drive to maintain or improve the body. "It's a myth that social pressures drive people to cosmetic plastic surgery," he says. "Most people have it in spite of social pressures, often over the objections of family. There's probably five percent of the population that has a single focus concern about a body part that is severe enough that they're willing to have surgery to fix it."
The specialty has also enhanced its image with a strong tradition of volunteering services for those who cannot pay. "Most plastic surgeons, at some point along their career path, will find their way into volunteer missions either domestically or across the globe," says Sherman, who, along with most of his USC colleagues, is involved in the professional volunteer organization Operation Smile. Traveling to countries in Latin America, Asia, Africa or the Middle East for several weeks at a time, the plastic surgeons bring both the technological skills and compassion needed to repair cleft lips and palates, burn wounds and other deformities caused by the ravages of disease.
That is not to say plastic surgeons today do not face challenges. Plastic surgeons still haven't conquered scar tissue, notes Brody. "There is a great need for a major breakthrough on scarring." Although plastic surgeons are experimenting with injections of growth hormones at scar sites, "right now we're just working at the edges, particularly when it comes to burn scarring."
At academic medical centers like USC, plastic surgeons often work as a team, combining expertise for the best results. Teamwork sometimes includes working with physicians from other institutions to develop new procedures. Sherman and Ronald M. Zuker, M.D., head of pediatric plastic surgery at The Hospital for Sick Children in Toronto, have successfully collaborated on several surgeries to correct Moebius syndrome, a birth defect that robs its young victims of the facial muscles necessary for smiling. In that rare condition, two important nerves-the sixth and seventh cranial nerves, which control blinking, eye movements and facial expressions-are not fully developed, causing facial paralysis. People with Moebius syndrome cannot smile or frown, and some cannot blink or move their eyes from side to side.
One of Sherman and Zuker's success stories is 11-year-old Mallory Wofford. After two surgeries, spread eight months apart, she was able to smile for the first time in her life.
The surgeons harvested muscle from Wofford's thigh, transplanted it to nerves and blood vessels in her face, then precisely positioned the muscle to contract on command. Now, if she bites down, she can make a smile. The smile remains a conscious act, notes Sherman. "Initially, there's no connection between the brain that reacts when she's happy or hears a joke. Mallory has to decide to smile. Amazingly enough, over time her smile becomes a natural, almost unconscious act."
Joann Wofford, Mallory's mother, says that she has always been a happy child but the ability to smile has helped her to make an emotional connection with others. "It is the first time we have seen her smile. What more can we ask for?" Mrs. Wofford says.
Mallory Wofford is one of only a handful who has had the procedure to correct Moebius syndrome. Thanks to continued news coverage of Wofford's operation, Sherman has received a number of calls from others with Moebius syndrome who might benefit from the operation.
For patients like Esparza and Wofford, plastic surgery has given them the opportunity to face their future with a renewed sense of self. "I can play with my son, we can box, we can play catch," Esparza says. "I'm doing some therapy, and with time and effort will be able to work again. To a young man, that means I can look forward."