Changing Plastic Surgery for the Better: Innovations in Regenerative Medicine, Biomaterials & Scars.
Updated: Oct 9
Regenerative medicine, biomaterials, and growth factors are regenerating new body tissues and reviving injured body areas. Dr. Srinjoy Saha is leading the charge in India to improve plastic surgery results with terrific new innovations that show just how far regenerative medicine and scar therapy can go. In this article, he provides a fantastic overview on how he produces remarkable plastic surgery outcomes and lead to happy, satisfied patients.
“When something is important enough, you do it even if the odds are not in your favor.” ~ Elon Musk.
After 8 years of an otherwise successful clinical practice in Kolkata, India, I was feeling a bit stagnated and frustrated. Traditional methods of reconstructive plastic surgery were just not working for many of our patients, especially for those with critical limb injuries and widely burnt body areas. Long hospitalization, long-duration surgeries and anesthesia, intricate and complicated procedures that consumed enormous resources, intensive care, costly medicines, and prolonged aftercare were increasing patient morbidity and overall costs. Combined, they were putting quality care outside the financial capabilities of so many patients. It was painful to see that many patients, even after spending their life’s savings, could not complete their full treatment and get desired results. Also, patients who were unfit for such complicated surgeries had limited options to go back into active life.
Taking the road less traveled.
Sometimes, I started doubting the effectiveness of what I had learned so far. Were we performing too much surgery for too little gains, was that amount of surgery really so necessary, or were we missing something completely? Biomaterials were not available in India at that time, and none of my teachers and colleagues had any experience of their use. While reading up the published articles from other countries about their applications, I wondered whether it would advance treatments in India as well. Amid these perplexing times came the Plastic Surgery Foundation’s selection letter for the Achauer scholarship award. Initially, I had to overcome a huge mental block and hesitation to tread the uncertain path I had in my mind. Ultimately, though, I converted the PSF scholarship award into an academic sabbatical for 6 months and sacrificed a flourishing practice. I spent this time learning over and beyond typical plastic surgery while serving as a fellow in tissue engineering at the plastic surgery department of the Brigham and Women’s Hospital and Harvard Medical School, Boston. To some of my colleagues, it appeared like a wild goose chase. In hindsight, however, taking the road less traveled appears to have made all the difference.
A fresh start.
This extended time-off provided me with a clean break from routine clinical care, and delve into the hitherto unknown world of clinical research, stem cells, biomaterials, and regenerative medicine. The Harvard catalyst courses provided a great opportunity to hear successful physicians and scientists talk about their own stories of converting great ideas from the bench to the bedside. Hearing many doctors talk about their success stories were incredible and instilled confidence. Learning directly from Drs. Matthias Donelan, Rox Anderson, Elof Eriksson, and Dennis Orgill, amongst many other stalwarts at Harvard, was a windfall. Alongside, I revised and refined my skills and knowledge in plastic surgery and aesthetic treatments as I learned from top plastic surgeons within the Harvard program. In this article, I will concentrate only on what inspired innovation. The intellectual climate and energy of Boston, along with its multicultural ethos, left a giant indelible footprint in my mind.
At the Harvard Catalyst courses and Boston Biomedical Innovation Center, I learned about different clinical research methodologies, along with the fundamentals of medical device development and management. Dr. Orgill had studied the development of collagen-GAG biomaterial in its initial days at the Massachusetts Institute of Technology and has worked on it since. During the times spent in his lab, I learned about the basics of a collagen-based biomaterial, negative-pressure therapy, stem cell culture, a method of amalgamating stem cells with a biomaterial, and the futuristic idea of conducting a skin transplant program. During the summers, Dr. John Greenwood came to Boston to talk about his extensive work on burns with a synthetic polyurethane biomaterial that he helped develop over many years. His results were fascinating and his new biomaterial provided a useful alternative to collagen, which had its own limitations. Dr. Elof Eriksson had retired a few years before I went to Boston, and was then busy with new developments while serving as an Emeritus Professor at Harvard. Still, he took time out of his precious commitments and guided me well, which provided great ideas for improvement. I learned how he was advancing treatments with small, simple, effective procedures, which would restrict the amount of surgeries. Amongst them were newer ways of performing negative-pressure therapy and wound resurfacing. All these lessons proved invaluable later on after I came back and started improvising on our own clinical methods and treatments.
Do not blindly believe what others say.
Dr. Matthias Donelan’s concept of scar rehabilitation at the Massachusetts General Hospital and Shriners Hospital Boston was a revelation. Amongst his commandments were: scars are your friends and not your enemies, relaxed scars are happy scars, tight is never right, scar excision is for oxymorons, sins of commission are the worst, etc. It turned our conventional teachings on slash-bang scar treatment upside down (slash means scar excision, and bang, plastic surgeries like flaps and grafts). Earlier, during my training and early years of practice over many years, I’d treated hundreds of burn scar contractures in the traditional method. My thesis in the University of Mumbai and important international presentations were also on burn scar reconstructions. At that time, I had taken completely scarred tissues as unknown perforator-based flaps and used them for reconstructing the limbs successfully. Then, it was considered a novelty because others had not been able to perform a viable flap with scarred tissues. All along, I’d blindly followed, mastered, and incrementally improved the traditional methods of scar management. However, Dr. Donelan’s concept was radically different and his methods changed everything. I'd to see his long-term results to believe him - they were so riveting. It was a great introduction to the necessity of critical thinking in everything that we do in life. It's worthwhile to note that at many of the Harvard lectures and conferences, I’d seen many people stress upon the need for critical thinking in every aspect of life.
Further down the rabbit hole.
The refreshing interactions with Dr. Rox Anderson at the Massachusetts General Hospital were one of the biggest positives during my stay in Boston. He’s a famous dermatologist, inventor, and radical thinker, who had been the brain behind many remarkable innovations in aesthetics. I found him innovating continuously, wanting to make our current treatments simpler and more effective by combining the principles of engineering and medicine. He was knowledgeable, imaginative, curious, thoughtful, and open to ideas. I saw, learned, and imbibed the basics of innovation while shadowing him during his procedures and clinics. Most of his brilliant forward-thinking ideas would originate from routine clinical work. Like the celebrated artist Henri Matisse, he would see the uniqueness in the mundane and imagine things differently. These revelations sent me to a new wonderland, and I realized what it meant to be a Neo and take the red pill. Ideas are everywhere, and brilliant imaginations would eventually become the new reality!
There and back again: A remarkable journey.
After coming back to India, starting again at my place of work in Kolkata turned out to be an uphill task. Meanwhile, the international companies that Dr. Orgill and Dr. Greenwood were associated with, brought their biomaterials to India. After obtaining regulatory clearances, they became commercially available from 2019. When I first tried to apply the new concepts into clinical practice, I plowed a lonely furrow amongst the sneers of non-believers and doubting thomases. Serving a backward populace with little knowledge, high expectations, limited understanding and no appreciation did not help matters. But gradually, faith and persistence produced excellent results. Foremost among them would be the creation of new soft tissues as a flap-alternative over an extensive area of barren skull bones. Performed on a grieving mother who had lost her only daughter in a grievous car accident that she herself survived by the skin of her teeth, this new procedure saved her from potential disability and financial ruin. This case has now been published and is available in the archives of the US National Library of Medicine. It also got recognised for presentation by the American Society of Plastic Surgeons in 2021, and remains amongst the top papers to be selected globally.
Amongst other notable improvisations is an improved method of tissue-engineered salvage of critically injured muscles and tendons. This method has successfully helped many accident survivors to go back to an active lifestyle with minimal surgeries and lesser costs. One such clinical case would be available in the archives of the US National Library of Medicine soon, and its presentation in the innovation symposium of the Indian plastic surgeons conference is imminent. Several other improvements and innovations have made a big, successful difference in the lives of the patients, and are in different stages of publication. In my place, some cheers are now audible from the corners, as more and more people are realizing the unique benefits. In my clinical practice, an avant-garde amalgamation of cells, biomaterials, and growth factors appear to be just as effective as lengthy flap surgeries, making a vast majority of flaps appear superfluous. A minimalist approach to plastic surgery reduces surgical time, lessens tissue loss, maximises tissue salvage, minimises anaesthesia, and prevents disability. It also reduces hospitalization, lowers morbidity, rehabilitates early, and decreases health-care costs. Patient acceptance and satisfaction rates of these novel minimalist procedures are high.
Is the human body as bountiful as the sun, and regeneration as bright?
It has been marvelous to see the immense regenerative capabilities of the body in the recent past. While treating patients with traumatic fingertip amputations in a novel way using biomaterials, the fingertips regenerated almost completely, nails sensation and all, resulting in a normal finger. Patient-reported outcomes were excellent, and results surpassed what other surgeons across the world have achieved until now. Then, in patients with sizeable areas of exposed bones and tendons, applying tensile forces and growth factors differently has regenerated new soft tissues even without the use of any biomaterials! And, in patients with ugly burn contractures, combining biomaterials and growth factors with plastic surgery has remarkably improved the efficacy of scar rehabilitation. The patients are now experiencing better healing with fewer procedures when compared to traditional approaches. All these findings make me wonder whether we have fully understood or harnessed the wonderful healing capabilities of the human body. It appears that just as we have barely utilised the immense energy produced by the sun, similarly, we have barely harnessed the amazing regenerative growth capability of the human body.
“You shouldn’t do things differently just because they’re different. They need to be... better.” ~ Elon Musk.