State of the Union: Plastic and Reconstructive Surgery in 2020
An interview with Robert Grant, MD, Chief of the joint Division of Plastic Surgery at NewYork-Presbyterian, Columbia and Weill Cornell.
Before we get into it, I have to ask; are plastic surgery, cosmetic surgery, and aesthetic surgery the same thing? All of which are different from reconstructive surgery?
Plastic surgery is sort of the umbrella term. It comes from the Greek term plastikos, which means to shape or mold—not because we pull people's skin so tight when we do face surgery that they look like they're plastic!
What's very challenging for patients is, of course, the marketing is way ahead of the science. People use expensive words so that they can charge expensive prices. Cosmetic surgery was not enough so people started saying aesthetic surgery just because I guess there are more vowels in it; you can charge more for a vowel than you can for a consonant. But they're the same.
The whole area of plastic surgery includes both the reconstructive world and the cosmetics world. And cosmetic surgery is surgery on a normal body part to change its appearance, whereas reconstructive surgery is dealing with a body part that is either abnormal because of a congenital malformation or due to trauma or cancer or some other operation.
And it's a gray area because many people are suffering real self-image problems from having a cosmetic issue. So, it is not something medically necessary, but the mental and social health benefits of undergoing cosmetic surgery are very clear in terms of improving the quality of people's lives. When I’m doing aesthetic surgery, one of my coin sayings is: "I don't add years to your life, but I add life to your years."
That’s nice. I like that.
To be honest, that’s a hybrid of something I saw in a real estate ad 25 years ago when I first started my practice, so I can’t say that it’s mine. But that's the difference. Coming to see me for an aesthetic procedure isn't going to make you live any longer, but it could make you live a lot happier. Unlike reconstructive surgery, where unless we do a reconstructive operation, say if somebody has an infection after some sort of implant has been placed, it’s not only a quality of life issue but a quantity of life issue too.
[Editor’s note: We agreed to buy all the vowels and will be using “aesthetic”, the most current term, for the rest of this interview.]
So, what’s new in plastics? Let’s start with reconstructive surgery.
Well, in the reconstructive world we're thrilled to be partnering with the breast program as that service continues to rejuvenate (a fun plastic surgery word) under the leadership of Dr. Rao. The entire spectrum of reconstructive procedures is available to our patients. And the initiative which I lead is something called pre-pectoral breast reconstruction, where we've come full circle—now instead of having to put the implant reconstructions under the muscle of the chest wall, we are putting them back on top of the chest where the breast was.
The reason for that change is the technology of the implants and expanders are better—better mastectomy skin flaps so that the tissues heal, more nipple-sparing and skin-sparing mastectomies so that we have a pocket sort of already made. We don't have to put an expander in and stretch the pocket, and so the results are much more natural.
Are you usually doing the reconstruction at the same time as the mastectomy?
Many times, we do it at the same time, so patients can have something called direct-to-implant reconstruction. They have their mastectomy and reconstruction completed in one step. Not all patients or candidates do that, but for the appropriate candidate, it works very well. As well as the full range of microsurgery, making use of the patient's own spare parts.
When you say spare parts, does that mean the reconstructed breast is made of their own tissue?
It is. The most common one would be the operation where the excess tissue from the tummy, sort of below the belly button and above the pubic area, is lifted free from the patient with its attached artery and vein. And that artery and vein are sewn into an artery and vein up by the chest so that that tissue has a blood supply and stays alive. And we use that extra tummy tissue to reconstruct the breast mound after the mastectomy.
Wow. How does that work? Is recovery time the same as it would be for an implant?
It's a much bigger operation and it's not for everybody. You need to have the right amount of tissue and be otherwise healthy because it requires operating in two sites—the belly and the chest. So, the recovery is significantly longer, patients are in the hospital longer, the risks of that and much more general anesthesia and it's an operation you want to make sure the patient is able to handle from a physiologic point of view.
But the big advantage is that they don't ever have to have implants since implants don't last forever; on average, implants last somewhere around 10 years. So, you're committing the patient to another type of operation at some point down the road.
Do you ever use a patient’s own tissue and an implant together?
We do! As an example, one of the things that we do many times, even when a patient has had a breast implant reconstruction, is some fat grafting. The patient gets some of their fat harvested, typically from the belly, and we use that fat to sort of blunt the transition from the area below the clavicle to where the implant begins so the patient ends up with a much more natural-looking line.
We don't have the ability to transfer enough fat to totally reconstruct the breast, that's why if you want to have your own tissue used exclusively, you need to have one of the microsurgery type of operations I mentioned earlier. But it is a great advance in terms of making the reconstruction look so much more natural without just looking like you've had implants and nothing else.
In the future, do you think you’ll be able to reconstruct with tissues or fat that aren’t the patient’s own?
One of the really exciting things in plastic surgery is the field of what's called: composite tissue allotransplantation, or CTA. And that's where tissue of different types is transplanted from one person to another.
It differs from solid organ transplantation. It's very different if you're transplanting a face than transplanting a kidney or a liver—the immunology is different. Interestingly, the surgical techniques are not that different. There’s just a lot of things to sew together, so typically that's an operation that takes some time and it's done by teams of surgeons.
Hopefully, the government will, or commercial insurance will consider those medically necessary procedures so that we can join in those particular reconstruction modalities. We have the technical ability to do it here, it's just the resource issue at this particular point in time.
Would it be similar to other transplants in that the patients would need to take lifelong medication to avoid organ rejection after the procedure?
Yes, it would. The issue with face transplants or hand transplants, for example, is that you're betting that the quality of life the patient has now is worth whatever decreased years of life they may have down the road if they develop the complications of the immunosuppression. And what is becoming increasingly clear that the benefits are significant and worth whatever risks are associated with the immunosuppressant medicines.
That gets us back to the fat—harvesting fat from somebody else. Fat is an amazingly immunogenic type of material. It looks kind of bland, it's just fat, but it has stem cells in it. It holds some of the greatest density of stem cells, and researchers are investigating the use of stem cells in many ways for repair and regeneration of tissues. Many people are familiar with PRP, platelet-rich-plasma. It’s being used to help people with orthopedic injuries and other things. We are still very much in the research world of manipulating stem cells to help repair and reconstruct different tissues.
So yes, there might be a point in time where we take fat and are able to use that in more ways than just a filler substance. But I don't think any of the indications in which I would envision using fat, or the stem cells within fat, would justify the risk of immunosuppression if I were, say, to donate some of my excess fat to you.
Right, that’s fascinating. On the flip side, how has implant technology gotten better?
The technology of implants in breast reconstruction is very exciting. For many years when silicone implants were only available as part of a research study, there wasn't a lot of innovation going on because it was a minimal market. But once the restriction was lifted, the innovation both for implants and for reconstruction has really exploded. It's a very exciting time for breast implants and the types of associated techniques that are used to enhance the results.
That brings us to FDA warning and recall of textured implants—Is it safe to say you only use smooth implants? And is the issue with texture itself?
Yes. To answer your first question, we do not use textured implants, so both the expanders and implants are all smooth. While no one can say they avoid any complication, we absolutely minimize the risks of implant-based complications because of that.
It appears that the textured surface causes a state of chronic inflammation, and that chronic inflammation long-term leads to something called a lymphoproliferative disorder, or in the most severe cases, a type of lymphoma, which is a kind of blood cell cancer. Certainly, the incidents of that happening are many, many, many, many degrees lower than the incidents of breast cancer itself, but the information about that is still in flux. So, obviously, if we can avoid using those types of devices then we don't have to add that element of risk to the reconstruction.
It's been particularly upsetting, in all honesty, because we do a lot of prophylactic mastectomies as more and more people understand the genetic basis of cancer. So, women are opting to have bilateral mastectomies and reconstruction because our reconstruction techniques, like the device-based reconstruction and this pre-pectoral implant, have gotten so good. But here they've undergone mastectomy to minimize their risk of getting breast cancer and they've learned that the device used may end up giving them another kind of cancer. At the very least, now we've gotten to the point where we can eliminate that by not having to use textured implants, and that's a big advance.
What would you say has been the biggest change in plastic surgery in the last five years?
I think the biggest change in the aesthetic world is that people are very much looking forward to having less as more. And the whole philosophy about aesthetic surgery is becoming much more focused on the ethnicity of the people who are interested in it, in that the cultural competency of plastic surgeons has to really reflect the interest in the cultural background and expectations of the particular population.
Aesthetic plastic surgery started in northern Europe amongst the white population. And one of the wonderful things I enjoy about being at Columbia is the diversity of the patients that we care for—and with that the tapering and expanding of aesthetic expectations.
Another important change is around gender and gender identity. Something not part of the tradition of plastic surgery in the past, but now it is increasingly important to be able to address the critical and very legitimate needs of somebody who feels like they're trapped inside an exterior that doesn't reflect who they are on the interior. So that's really a very exciting thing.
It sounds like what you’re saying is that plastic surgery, in general, is really honing in on the individualized approach to care.
Right, exactly. And while paradoxical perhaps, coming from a middle-aged white man, one of the things that I'm proudest as our residency program director is that we have resident graduates who reflect the wonderful diversity of New York and America.
It shouldn't just be the generation ahead of me and my generation who are deciding what the standards are or what are reasonable procedures. It’s terribly exciting to see more women and more people of color become plastic surgeons and have the discussion about aesthetic plastic surgery becoming a much more diverse and rich conversation.
Absolutely. With that said, have surgical techniques changed in the last five, ten years?
One of the things that's different about plastic surgery than other specialties is that all of our work is on the surface. There's very little minimally-invasive plastic surgery and that is something that I don't envision changing. If you have a big amount of excess skin because you lost 100 pounds after a successful weight loss operation, there's no minimally invasive way to remove that.
I think our advances are in various techniques and technologies that facilitate wound healing. We end up giving people the best chance at a successful outcome the first time, and that includes a better understanding of the impact of things like smoking and diabetes on wound healing and nutrition. Now there are technologies that help us in terms of skin substitutes, things that we can put on wounds and scars to enhance the healing process. We can't eliminate scarring, but we certainly have lots of things to make scarring better than it was before.
How have those approaches made scarring better?
One example that I like to share is that we see a number of patients of color, who are at higher risk for abnormal healing and scars—something called keloids. If they had a C-section and then have a keloid after the C-section and have another baby, oftentimes we're asked to manage that wound closure to minimize the risk of the keloid coming back a second time.
A technology that shows great promise that we're investigating is the use of something called negative pressure on the incision. After we close the incision, having cut out the keloid so that the patient has normal skin again, we put this sponge on that's connected to a vacuum. The sponge takes the pressure off of the scar so that the early and important phase of inflammation that's associated with wound healing is not as robust, and the pathway toward abnormal scarring never happens.
These are people who not only have physically unattractive bulky scars, but they're also symptomatic. They itch, they're easily traumatized, they bleed. We've had great success in the impact of that kind of a situation.
Wow, that’s pretty amazing. How long does the vacuum stay on the wound?
A week or two. And this whole field of negative pressure incisional therapy is an advance from open wound therapy with negative pressure, which is something called a VAC, or vacuum-assisted closure.
The indications for different uses of that technology are one of the really exciting things in wound healing in general. And not just for plastic surgery, orthopedic surgeons are using it for their incisions, like for knee replacements. General surgeons are using it for their trauma operations; cardiac surgeons are using it in patients who have open heart surgery and they may be big breasted where the weight of the breast is pulling apart the incision. They're using it to stent the incision in the immediate postoperative period. It’s really exciting to see.
And that's just one example of technologies that are improving healing for all populations, not just in plastic surgery, and are led and championed by plastic surgeons and some of the clinical research that we're doing here at Columbia.
Let’s jump to something a bit more abstract—would you say that being a plastic surgeon requires a specific form of doctor-patient communication? It sounds like you need to be able to read people and see what they see to be able to translate their request into a pleasing result.
Oh, that’s the big difference in plastic surgery, absolutely. The way to conceptualize it is that while we're operating on the surface, ultimately, the end organ we're operating on is the mind. You have to be very comfortable understanding the synchrony—that the end object of what you're operating on is different than the impact it has when the person internalizes that change. So, the successful people are able to very specifically outline expectations with the patient and how they may or may not meet those expectations.
At the end of the day, all I can do is move tissue around. I can't make people treat you differently. These things may help you feel better or affect relationships in a positive way, but they're not going to have a direct cause and effect.
Would you say the big business of non-surgical offerings out there, like lasers, fillers and peels, have changed the scope of aesthetic surgery you do?
Well first, one concern that I have is the way it’s made to look easy, so you just have to say "buyer beware." Aesthetic surgery, cosmetic dermatology, are a business and you have to make sure that you're being cared for by somebody who is true to the calling of what I hold myself to, what I hold my residents to—people who are doctors because they want to care for patients and put the patient's interests first.
When you put your interests first, particularly your financial interests, then it's a set-up for bad things happening. You just don't have the knowledge, experience, background. Plastic surgery, cosmetic or aesthetic surgery, is an honorable and well-respected field. If you want to do it, train to be a plastic surgeon or a dermatologist. Do it the right way. Don't decide to offer Botox or laser treatments because you're unhappy with the reimbursements that your chosen specialty is offering. That's just not the right motivation, in my mind, to do it. And that type of thing is everywhere.
Our relationship with the cosmetic dermatologists here at Columbia is one of the very enjoyable aspects of my practice. Lindsey Bordone is a fantastic dermatologist and articulate partner in terms of being able to offer things like skincare and cosmetic laser surgery, things that are just as helpful in their own way as the right indication for an eyelid operation or a facelift operation or whatever else.
There are a lot of very good people who are not plastic surgeons doing fillers and injectables, but the litmus test we always use, perhaps to excess, is if this was your spouse or your mom or your brother or sister, would you do that to them based upon your level of training and experience? The reality is no. It's not just in plastic surgery, but in the entire department of surgery, the standard is always that we want our patients to get the care that the surgeon would give or expect if it was a member of their family.
My last question is about looking ahead—what are you most optimistic about for the future of plastics?
The future of plastic surgery is extremely exciting because there are some unbelievably smart, talented people in the generation behind me who I've been lucky enough to train and who I get to interact with every day. There’s a marriage of innovation, technology, and creativity that drives plastic surgery.
For example, when I trained, there were no such thing as fillers and Botox, that's something we had to learn. The implant crisis, the first implant crisis, was still on the horizon when I was training. The advances that I've seen in microsurgery and craniofacial reconstruction, in congenital surgery with the kind of results our enormously talented pediatric craniofacial surgery team is getting. The things that they're able to do were not invented when I was training. And I've only been doing this for 35 years. In human terms, that's a relatively short period of time.
I think the future is unbelievably exciting in terms of what plastic surgery will do for people. Again, it’s all about enhancing the quality of life.
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