Not In Vain

Plastic surgery exists for those who don’t want the attention

By Megy Karydes

Not everyone who seeks out plastic surgery is looking for breast augmentation or rhinoplasty services. In fact, for wounded veterans or burn victims, just looking like themselves and being able to function in society are among the reasons they undergo hours of treatment. Dr. Robert Galiano and his team of plastic surgeons at Northwestern Memorial Hospital are shaping the way regenerative surgery is done with help from the U.S. Army—and their results are promising.

“Oftentimes, what we have to do as plastic surgeons is rob Peter to pay Paul,” says Galiano, referring to the fact that in order to reconstruct one part of the body, the surgeon must remove living tissue from another part of the body.

Current methods of facial reconstruction for burn victims include face transplantation or skin grafting. Transplantation is both costly and extremely difficult, and grafting is not ideal either, Galiano said.

Regenerating tissue would be ideal, but it is not possible to grow tissue without a blood supply since the cells need the blood supply to survive, according to Galiano.

“You can’t grow tissues in a test tube.”

“Currently, if we need to reconstruct an entire nose because it’s been damaged due to trauma or cancer, if it’s missing the skeleton, bone or cartilage, for example, we can re-create the nose bit by bit by assembling pieces linked to a blood vessel on the forearm,” he says. (See fig. 1.) “When it’s ready, we transfer the pieces and reassemble it on the nose using microsurgery.” The result is almost patchwork and underscores the fact that basic body functions, like simple movement of the facial muscles, still suffer.

The Body as an Incubator

Figuring there must be a better way, Galiano began experimenting with tissue engineering in 2006. His thought process: What if we could use the body as an incubator to grow new organs? His research focused on growing tissue inside mice using advanced methods, but the research was halted due to lack of funding.

At the same time, Colonel Robert Hale, commander of the U.S. Army Dental and Trauma Research Detachment in San Antonio, and Army researcher Kai Leung, were seeking ways to help soldiers whose faces had been almost completely burned in the Iraq and Afghanistan wars.

Galiano and his Northwestern University colleagues, doctors Thomas Mustoe and Claudia Chavez-Muñoz, started collaborating with Army colleagues Dr. Kai Leung and Colonel Robert Hale and University of Texas Arlington engineer Eileen Moss after receiving an Army grant.

“Through our collaboration, we basically are developing a mask that we can place on the patient to grow skin tissue,” says Galiano. “It’s called the Biomask project. It’s a significant undertaking [and] also very exciting.”

The Biomask, a bioreactor-mimetic, would work by allowing a doctor to essentially build a face out of individual cells. A doctor would apply a mask wherein the exterior protects the burn victim’s healing face, while the interior, made up of sensors, actuators and medicine-delivery tools, makes a three-dimensional mold of the face and determines which parts of the face need to be thicker or thinner.

The Biomask is currently undergoing testing at the microscopic level, and Galiano estimates that they are at least three years away from human clinical trials. When complete, he feels it will revolutionize the care of the soldier with severe facial burns.

This type of research and innovation is what drives Galiano as a surgeon. “Unlike other physicians who specialize, such as neurosurgeons and cardiologists, plastic surgeons don’t [focus on one aspect] of the body,” he notes. “Neurosurgeons know they are going to primarily work with the brain and nerves. Cardiologists work with patients with heart problems. As plastic surgeons, we work from the top of the body to the bottom. Inside and out. Because of our training, we tend to be more innovative and creative than other specialties, and that has led to some significant advances in medicine.”

Plastic Surgery that Wants to Go Unnoticed

He recognizes that this type of work doesn’t always get the recognition it deserves in our celebrity-obsessed, image-based culture that tends to place more value on aesthetics than on plastic surgery as the important medical specialty that it is. As such, health insurance plans aren’t always quick to cover plastic surgery when they think it’s just simply cosmetic.

It doesn’t help that the type of work associated with burn victims and soldiers often goes unnoticed because most patients are uncomfortable allowing their patient health information to be shared online, even with their personal information not disclosed. Health Insurance Portability and Accountability Act (HIPAA) regulations require patients to approve what type of information is shared. Visit almost any plastic surgeon’s practice website, and it’s unlikely you’ll find these types of services listed.

“[Health insurance companies] used to say that breast reconstruction due to breast cancer shouldn’t be covered because it was considered cosmetic,” says Galiano. “Now most plans will cover it [because it is now recognized] that having breasts is a part of who we are and how we function. Likewise, the function of a face is that it is supposed to look like a face, and any deformity is more than simply cosmetic—facial deformities strike at the heart of how a patient views him or himself and interacts with others.”

For some patients with severe facial burns or congenital defects or diseases, plastic surgery may not be a good option. “Skin grafting may work for some patients, but for others, time may be their best friend; sometimes we can’t improve on what Mother Nature provides,” he says. “In some cases, the body will do better to heal itself than any surgeon. However, the scars that result are never ideal, and there has been a lack of major advances in improving or even preventing scars, which is a sort of Holy Grail for plastic surgeons.”

Galiano notes that those cases are becoming more rare as research in plastic surgery problems, such as scars and tissue engineering, will provide more opportunities for surgeons to improve the care of patients. Currently, research is being done that allows physicians to harvest skin cells from patients after liposuction and to use the fat cells to help treat scars and rejuvenate skin on other patients.

“We are scientists,” says Galiano. “We are creative and always trying to innovate, constantly trying to figure out ways to do things better in order to help our patients. So many lives and futures have been damaged by disease or trauma, and our goal is to make our patients happy. It’s exciting to believe that our research efforts will one day help restore a sense of normalcy to our patients.”

Galiano recommends patients who might have been affected by trauma or disaster to seek a consultation with a plastic surgeon. “We are plastic surgeons, and although our work is mostly cosmetic, it’s cosmetic in the most global sense of the world.” [email_link]

Published in Chicago Health Winter/Spring 2013