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Plastic surgeons reveal reality of global hot topics in cosmetic surgery

Article-Plastic surgeons reveal reality of global hot topics in cosmetic surgery

Boston — Stem cell therapy advancements continues to be an issue of great interest among the cosmetic surgery field, but the lack of scientific evidence leaves many surgeons concerned, according to experts speaking at the Aesthetic Meeting 2011 in Boston.

Stem cell facelifts and biofilms were among the topics that a panel of plastic surgeons discussed during the Global Hot Topics forum at the American Society for Aesthetic Plastic Surgery’s annual meeting, aimed at vetting new and emerging technologies in plastic surgery, according to moderator William P. Adams Jr., M.D., associate clinical professor, plastic surgery, University of Texas Southwestern Medical Center, Dallas.

“Often, new devices, techniques or technologies are released and marketed … way ahead of the science. That’s what Hot Topics is really about: basically, to sort out what’s real science versus hype and marketing,” Dr. Adams said.

Top picks: Stem cells in plastic surgery
The use of stem cells in plastic surgery is a classic example of technology that has no currently proven scientific foundation, according to Dr. Adams.

Peter B. Fodor, M.D., who presented on stem cells, said the miraculous results from stem cell therapy in any specialty are, at this point, isolated and anecdotal cases.

“If one were to Google ‘stem cell facelifts,’ for example, some 200,000 or so results come up. But, do a literature review of bona fide and peer-reviewed journal articles on the topic and only about 20 relevant articles on stem cell supplemented fat grafting and almost no articles on stem cell facelifts are found.

“So, there is a major disconnect, here, between reality and hype,” said Dr. Fodor, past president of the American Society for Aesthetic Plastic Surgery and associate clinical professor of plastic surgery at University of California, Los Angeles.

A history of stem cell research helps to put reality into perspective, according to Dr. Fodor, who was part of the stem cell research at UCLA as early as 2002. He notes that it is important to realize that there are stark differences between embryonic stem cells, usually collected from umbilical cord blood, and stem cells harvested from adult subjects.

Basically, allogenic embryonic stem cells are associated with rejection issues, as well as ethical, political and religious concerns, he said.

“The same concerns do not apply to … stem cells procured from adults and used autologously, for therapies in the same person. In either case, however, there are serious concerns and questions that still remain about the use of stem cells in plastic surgery and other specialties,” Dr. Fodor said.

Cosmetic surgery applications
Researchers have uncovered information that could someday be applied to cosmetic surgery procedures. For example, about 10 years ago, a number of centers, including the University of Pittsburg and UCLA, found that subcutaneous fat is abundantly rich in adult stem cells. While there are only about 75 cc of bone marrow available in an average adult for stem cell isolation, there are thousands of cc of subcutaneous fat present in most adults.

Furthermore, the stem cell yield per cc of fat is 100 to 1,000 times more than in the same volume of bone marrow. And bone marrow harvesting is more cumbersome and uncomfortable for the donor than liposuction, according to Dr. Fodor.

UCLA researchers have also proven that, with appropriate induction factors, subcutaneous fat-derived stem cells have the ability to be grown in the laboratory into other tissues, such as bone, cartilage, muscle, nerve or fat.

“But just because we can make cartilage, at this point in time, it does not mean that we can engineer a joint. This is the direction in which the research could eventually take us,” he said.

Researchers also found stem cell potency is related to patient age: the younger the patient, the more potent the stem cells.

“The feeling is that the stem cells will retain the age at which they were collected, even though the person continues to age,” Dr. Fodor said. “It all sounds very exciting. The problem, however, is that there are a lot of snake oil salesmen prematurely touting stem cell therapies.”

Renewed interest
While much of the research focus for stem cells has been on cardiac applications, such as post myocardial infarction, according to Dr. Fodor, there is a renewed interest in researching applications in plastic surgery.

There is evidence that stem cells injected in the margins of a pressure wound have an uncanny ability to speed healing. And fat enriched with stem cells seems to work well when injected to refine residual deformities in connection with breast reconstruction, he said.

There is, however, no solid peer-reviewed evidence in the medical literature that stem cells can be applied successfully to facelifts.

“Actually, it has not even been defined what a stem cell facelift is. Is it to take fat, isolate the stem cells and inject them into the face blindly? Is it using fat and adding stem cells and injecting that? Or while doing a facelift, you’re also injecting stem cells?” he said. “Theoretically, by injecting fat into faces, you’re injecting stem cells (as well), because fat is inherently rich in stem cells. These are only some of the many questions surrounding the concept of stem cell facelifts.”

There are also questions about serious health issues. Dr. Fodor says stem cells can accelerate the growth of active cancer cells, but not necessarily those in a dormant stage.

For now, the safest stem-cell application in cosmetic surgery is to store patients’ fat-derived stem cells for future use, he said. Dr. Fodor has been doing this in his practice, upon patient request, since 2002.

Biofilm update
New evidence helps to confirm that biofilms have been shown to cause health issues in plastic surgery procedures; mainly, breast implant related capsular contracture. Biofilms could also be linked to latent post soft tissue filler infections and granulomas.

Contracture around breast implants is the most common medium- to long-term complication following breast augmentation, said Anand Deva, B.Sc., M.B.B.S., M.S., F.R.A.C.S., associate professor, Macquarie Cosmetic and Plastic Surgery and head of the Surgical Infection Research Group, Macquarie University, Sydney.

“There is now clear evidence that bacteria can attach to the surface of breast implants at the time of surgery to form a biological coating (biofilm), which can go on to cause inflammation and contracture,” Professor Deva said. “We are now working on strategies to prevent bacterial access to implants at the time of surgery and early results are very promising.”

Professor Deva and his group have been looking at the issue of biofilm and prosthetics for more than a decade.

“We have used basic scientific investigation, field studies of patients with failed prosthetics and laboratory models to show conclusively that biofilm is the single most important cause of prosthetic failure in medicine,” he said. “The range of prosthetics is vast — from orthopaedic pins, artificial heart valves, replacement knees and hips and even contact lenses. For cosmetic surgery, our focus has been on breast implants. More recently we have also turned our attention to the problem of biofilm in injectable fillers.”

In a study funded by the Aesthetic Surgery Education and Research Foundation, Professor Deva and colleagues looked at currently unapproved antibiotic impregnated bioabsorbable polymer, which could help prevent biofilm formation, Dr. Adams said.

This product essentially is an absorbable piece of mesh, impregnated with antibiotics and implanted with the breast implant to sterilize the pocket, Dr. Adams said. In a pig model, the researchers showed all of 14 of the animals that had the implants without the product developed capsular contracture, while none of the 14 that had the product developed the contracture.

“I think it has become mainstream thinking that bacteria and biofilms are the leading cause of capsular contracture. This is important research because we’re going to need to develop strategies to prevent the formation of biofilms to reduce morbidity,” Dr. Adams said.

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