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Innovative Approaches to Advance Reconstructive Plastic Surgery: A Harvard Experience

Updated: Mar 2, 2023


Dr Srinjoy Saha, Clinical Associate Professor in Plastic Surgery and Consultant Plastic Surgeon, Apollo Hospitals Kolkata.

 


“When something is important enough, you do it even if the odds are not in your favor.” ~ Elon Musk.

Introduction: The Frustration with Traditional Methods

After eight years of otherwise successful clinical practice in Kolkata, India, I felt stagnated and frustrated. Traditional methods of reconstructive plastic surgery were not working for many of our patients, especially those with critical limb injuries and widely burnt body areas. Lengthy hospitalisation, long-duration surgeries and anaesthesia, intricate and complicated procedures that consumed enormous resources, intensive care, costly medicines, and prolonged aftercare increased 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 could not complete their treatment and get desired results even after spending their life savings. Also, patients unfit for such complicated surgeries had limited options to return to active life.


Taking the Road Less Traveled by: The Decision to Attend Harvard


Sometimes, I started doubting the effectiveness of what I had learned. Were we performing too much surgery for too little gain, was that surgery really necessary, or were we missing something completely? Biomaterials were unavailable in India then, and none of my teachers and colleagues had any user experience. While reading up on the published articles from other countries about their applications, I wondered whether it would also advance treatments in India. 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, I converted the PSF scholarship award into an academic sabbatical for six months and sacrificed a flourishing practice. I spent this time learning over and beyond routine 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 travelled has made all the difference.


A Fresh Start: Learning about Clinical Research, Stem Cells, Biomaterials, and Regenerative Medicine


This extended time off gave me a clean break from routine clinical care while delving into the unknown world of clinical research, stem cells, biomaterials, and regenerative medicine. The Harvard catalyst courses provided an excellent opportunity to hear successful physicians and scientists talk about their stories of converting great ideas from the bench to the bedside. Hearing several doctors talk about their success stories was incredible and instilled confidence. It was a windfall learning directly from several physician-scientist stalwarts at Harvard. Simultaneously, I was also able to revise and refine my clinical skills and knowledge in plastic surgery and aesthetic treatments as I learned from top plastic surgeons within the Harvard program. But, 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.


Different Lessons: Learning from Harvard Plastic Surgeons and Tissue Engineering Experts


At the Harvard Catalyst courses and Boston Biomedical Innovation Center, I learned about different clinical research methodologies and the fundamentals of medical device development and management. Dr Orgill studied the evolution 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 valuable alternative to collagen with 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 he was advancing treatments with minor, simple, practical procedures, which would restrict the number of surgeries. Amongst them were newer ways of performing negative-pressure therapy and wound resurfacing. All these lessons proved invaluable after I returned and started improvising on our clinical methods and treatments.


Do Not Blindly Believe What Others Say: The Importance of Critical Thinking


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 means plastic surgeries like flaps and grafts). Earlier, during my training and early years of practice, I'd treated hundreds of burn scar contractures with the traditional method. My thesis at the University of Mumbai and important international presentations were also on burn scar reconstructions. At that time, I had taken wholly scarred tissues as unknown perforator-based flaps and used them to reconstruct the limbs successfully. Then, it was considered a novelty because others could not perform a viable flap with scarred tissues. I'd blindly followed, mastered, and incrementally improved the traditional scar management methods. However, Dr Donelan's concept was radically different, and his plans changed everything. I had to see his long-term results to believe him - they were riveting. It was a great introduction to the necessity of critical thinking in everything we do. At many of the Harvard lectures and conferences, I've seen many people stress the need for critical thinking in every aspect of life.


Further Down the Rabbit Hole: The Positive Experience of Interacting with Top Experts


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 has been the brain behind many remarkable aesthetic innovations. 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 realised what it meant to be a Neo and take the red pill. Ideas are everywhere, and brilliant imaginations will eventually become the new reality!


Returning to India with New Approaches to Reconstructive Plastic Surgery


After returning 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 in 2019. When I first tried to apply the new concepts into clinical practice, I ploughed 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 bare skull bones. Performed on a grieving mother who had lost her only daughter in an unfortunate car accident that she 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 US National Library of Medicine archives. It also got recognised for presentation by the American Society of Plastic Surgeons in 2021. It remained among the top papers to be selected globally.



There and Back Again: Plastic Surgery Innovations Advancing Treatments in India.


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 return to an active lifestyle with minimal surgeries and lesser costs. One such clinical case will soon be available in the US National Library of Medicine archives. Its presentation at the innovation symposium of the Indian plastic surgeons' conference is imminent. Several other improvements and innovations have made a big, successful difference in the patients' lives and are in different stages of publication. In my place, some cheers are now audible from the corners as more and more people realise the unique benefits. In my clinical practice, an avant-garde amalgamation of cells, biomaterials, and growth factors is as effective as lengthy flap surgeries, making most 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 hospitalisation, lowers morbidity, rehabilitates early, and decreases healthcare 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 marvellous 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 typical finger. Patient-reported outcomes were excellent, and results surpassed what other surgeons worldwide have achieved until now. Then, in patients with sizeable areas of exposed bones and tendons, applying tensile forces and growth factors has regenerated new soft tissues even without using any biomaterials! Additionally, combining biomaterials and growth factors with plastic surgery has remarkably improved the efficacy of scar rehabilitation in patients with ugly burn contractures. 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 tremendous healing capabilities of the human body. Just as we have barely utilised the immense energy produced by the sun, similarly, we have barely harnessed the impressive 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.

Disclaimer:

This article and the information contained within it are for educational purposes only. It should not be construed or used as a medical opinion or advice. This article does NOT intend to supplement the advice of a trained, licensed medical professional in your area.

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