tag:theconversation.com,2011:/fr/topics/reconstructive-surgery-7422/articlesReconstructive surgery – The Conversation2018-11-06T17:19:01Ztag:theconversation.com,2011:article/1061912018-11-06T17:19:01Z2018-11-06T17:19:01ZWorld War I: the birth of plastic surgery and modern anaesthesia<figure><img src="https://images.theconversation.com/files/244092/original/file-20181106-74763-t94fws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reconstructive surgery carried out between 1916 and 1918.</span> <span class="attribution"><span class="source">Wellcome Images</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>The metrics from World War I are horrific. In all, there were <a href="https://files.nc.gov/ncdcr/wwi%20lesson.pdf">37m military and civilian casualties</a> – 16m dead and 21m wounded. Never before had a conflict brought such devastation in terms of death and injury. In response, during the four years of the war, military surgeons developed new techniques on the battlefield and in supporting hospitals which, in the war’s final two years, resulted in more survivors of injuries that would have proved mortal in the first two.</p>
<p>On the Western Front, 1.6m British soldiers were successfully treated and returned to the trenches. By the end of the war, 735,487 British troops <a href="http://www.greatwar.co.uk/research/books/british-official-history-volumes.htm">had been discharged</a> following major injuries. The majority of the injuries were caused by <a href="https://www.smithsonianmag.com/history/the-shock-of-war-55376701/">shell blasts and shrapnel</a>. </p>
<p>Many of the injured (16%) had injuries affecting the face, over a third of which were categorised as “severe”. Historically, this was an area where very little had been attempted, and survivors with major facial injuries were left with major deformities that made it difficult to see, breathe easily, or eat and drink – as well as looking horrific. </p>
<p>A young ENT (ear, nose and throat) surgeon from New Zealand, <a href="http://broughttolife.sciencemuseum.org.uk/broughttolife/people/haroldgillies">Harold Gillies</a>, working on the Western Front saw attempts to repair the ravages of facial injuries and realised that there was a need for specialised work. The timing was right, because the military medical leadership was recognising the benefit of establishing specialist centres for dealing with specific injuries and wounds, such as neurosurgical and orthopaedic injuries or victims of gassing. </p>
<p>Gillies was given the go ahead, and by January 1916 was setting up Britain’s first plastic surgery unit at the <a href="https://www.forces-war-records.co.uk/units/3680/cambridge-military-hospital">Cambridge Military Hospital in Aldershot</a>.
Gillies toured base hospitals in France to seek suitable patients to be sent to his unit. He returned expecting about 200 patients – but the opening of the unit coincided with the opening of the <a href="https://theconversation.com/why-the-battle-of-the-somme-marks-a-turning-point-of-world-war-i-60741">Somme offensive</a> in 1916, and more than 2,000 patients with facial injuries were sent to Aldershot. Treatment was also needed for sailors and airmen suffering from facial burns.</p>
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Read more:
<a href="https://theconversation.com/why-the-battle-of-the-somme-marks-a-turning-point-of-world-war-i-60741">Why the Battle of the Somme marks a turning point of World War I</a>
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<h2>A strange new art</h2>
<p>Gillies described the development of plastic surgery as a “<a href="https://blog.sciencemuseum.org.uk/exposing-the-face-of-war/">strange new art</a>”. Many techniques were developed by trial and error, although some mirrored <a href="https://tzmvirginia.files.wordpress.com/2013/12/zizsser-rats-lice-and-history.pdf">work</a> that had been done <a href="https://www.ncbi.nlm.nih.gov/pubmed/18286429">centuries previously in India</a>. One of the main techniques Gillies developed was <a href="http://news.bbc.co.uk/1/shared/spl/hi/picture_gallery/07/magazine_faces_of_battle/html/6.stm">tube pedicle skin-grafting</a>. </p>
<p>A flap of skin was separated but not detached from a healthy part of the soldier’s body, stitched into a tube, and then sutured to the injured area. A period of time was needed to allow a new blood supply to form at the site of implantation. It was then detached, the tube opened and the flat skin stitched over the area that needed cover.</p>
<p>One of the first patients to be treated was Walter Yeo, gunnery warrant officer on HMS Warspite. Yeo sustained facial injuries during the Battle of Jutland in 1916, including the loss of his upper and lower eyelids. The tube pedicle produced a “mask” of skin grafted across his face and eyes, producing new eyelids. The results, although far from perfect, meant that he had a face once again. Gillies went on to repeat the same sort of procedure on thousands of others.</p>
<p>There was need for larger facilities for surgical and postoperative treatment and also rehabilitation of the patients, together with the different specialities involved in their care. Gillies played a large part in the design of a specialist unit at <a href="http://qmh.oxleas.nhs.uk/news/pioneer-gillies-and-queen-marys-featured-britains-/">Queen Mary’s Hospital in Sidcup</a>, southeast London. It opened with 320 beds – and by the end of the war, there were more 600 beds and 11,752 operations had been carried out. But reconstructive surgery continued long after hostilities ceased and, by the time the unit finally closed in 1929, some 8,000 military personnel had been treated between 1920 and 1925.</p>
<p>The details of the injuries, the operations to correct them and the final outcome were all recorded in detail, both by early clinical photography and also by detailed drawings and paintings created by Henry Tonks, who although trained as a doctor, had given up medicine for painting. Tonks became a war artist on the Western Front but then joined Gillies to help not only in the recording of the new plastic procedures, but also with their planning.</p>
<h2>The only real advances</h2>
<p>The complex facial and head surgery necessitated new ways of delivering anaesthetics. Anaesthesia generally had advanced as a speciality during the war years – both in the way it was administered, and also how doctors were trained (previously, anaesthetics had often been given by a junior member of the surgical team).</p>
<p>The survival from operations requiring anaesthesia was improving, although techniques were still based on chloroform and ether. The Queen Mary’s anaesthetic team developed a method of passing a rubber tube from the nose to the trachea (windpipe), as well as working on the endotracheal tube (mouth to trachea) whch was made from commercial rubber tubing. Many of their techniques remain in use today. As an <a href="http://homepage.eircom.net/%7Eodyssey/Quotes/History/Keegan_Soldiers.html">Austrian doctor wrote in 1935</a>: </p>
<blockquote>
<p>Nobody won the last war but the medical services. The increase in knowledge was the sole determinable gain for mankind in a devastating catastrophe.</p>
</blockquote>
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<p><em>The author would like to acknowledge the assistance of Norman G Kirby, Major General (Retired), Director of Army Surgery 1978-82.</em></p><img src="https://counter.theconversation.com/content/106191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Kirby does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medical advances were the only positive things to come out of the Great War.Robert Kirby, Professor of Clinical Education and Surgery, Keele UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867802018-01-08T16:50:52Z2018-01-08T16:50:52ZHow partnerships are helping cleft lip and palate surgeries in Kenya<figure><img src="https://images.theconversation.com/files/200913/original/file-20180105-26145-4a6og7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Zawadi Juluis Saidi had reconstructive surgery on her cleft lip at a Dar es Salaam hospital. African children face huge barriers to surgery.</span> <span class="attribution"><span class="source">Reuters/Sala Lewis</span></span></figcaption></figure><p>About <a href="https://learningenglish.voanews.com/a/a-23-2006-02-05-voa2-83128007/125493.html">6% of all children worldwide</a> are born with a birth defect. More than <a href="http://www.who.int/mediacentre/factsheets/fs370/en/">300 000 babies</a> with birth defects die annually within a month of being born. </p>
<p>The <a href="http://www.who.int/genomics/anomalies/en/">most common</a> birth defects are those that affect the skull or facial bones such as cleft lips and palates. These happen when parts of the <a href="https://www.webmd.com/oral-health/cleft-lip-cleft-palate#1">developing face fail to fuse</a> in the early months of pregnancy. A <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=6537">cleft lip</a> affects facial appearance. </p>
<p>The cause of <a href="https://www.mayoclinic.org/diseases-conditions/cleft-palate/basics/causes/con-20024619">cleft palates</a> is <a href="https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html">largely unknown</a>. Some studies have suggested that <a href="https://www.standardmedia.co.ke/health/article/1144025343/taking-folic-acid-during-pregnancy-may-prevent-cleft-lip">poor nutrition</a>, infections, consumption of tobacco, alcohol and certain medicines during pregnancy may be responsible. Inherited defective <a href="https://academic.oup.com/hmg/article/13/suppl_1/R73/617511/Genetics-of-cleft-lip-and-palate-syndromic-genes">genes</a> have also been identified as a probable cause. </p>
<p>Treatment is designed to restore a normal look as well as improve affected functions such as a baby’s ability to suckle as well its ability to speak properly later in life. But it’s not always easy for children with cleft lips or palates to get the help they need, particularly in poorer countries.</p>
<p>For example, reconstructive surgery for cleft lip and palate or access to treatment is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396861/">limited in developing countries</a>. This is because of limited surgical expertise, <a href="http://www.sciencedirect.com/science/article/pii/S1743919114002076">lack of funds</a> for setting up specialised units and low awareness among the general public. The total number of cleft surgeons in Africa is not known but compared to other specialities, trained cleft surgeons are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396861/">still relatively few</a>.</p>
<p>There is an urgent need to address the financial, infrastructural, and socioeconomic barriers for cleft care in Africa. Improving funding for primary health facilities, training more reconstructive surgery specialists and bolstering public education are good places to start. Partnerships are key. When governments, hospitals and non governmental organisations work together, more children get the treatment and care they need.</p>
<h2>Early diagnosis and treatment</h2>
<p>About <a href="http://www.who.int/mediacentre/factsheets/fs370/en/">nine out of ten</a> severe birth defects occur in low and middle income countries. That’s about <a href="http://www.cpcjournal.org/doi/abs/10.1597/15-221">1:700 live births</a>.</p>
<p>Birth defects can be diagnosed <a href="https://www.ncbi.nlm.nih.gov/pubmed/22081485">during pregnancy by an ultrasound</a> that provides pictures of the foetus’ facial features. In other cases, the defect is only noticed when the baby has been delivered. </p>
<p>The severity of a birth defect can vary from a notch on the upper lip or a depression in the palate to more severe forms which manifest as large gaps in one or both sides of the lip and gum. In some cases, the nose is also affected. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200899/original/file-20180105-26172-be6tw4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">An infant after cleft lip surgery.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>Some developing countries still have adults living with the defect. But in developed countries, it’s rare to find an adult with an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825062/">unoperated cleft lip and palate</a> due to early access to treatment. </p>
<p>Since clefts are not life threatening, it is advisable to operate on affected children when they are big enough to withstand anaesthesia and the trauma of surgery. The optimal time for cleft lip surgery is when the child is three months old whereas 12 months is ideal for cleft palate repair.</p>
<h2>Partnerships can work</h2>
<p>Clefts are repaired at various public and private hospitals in Africa in partnership with governments, hospitals and non-governmental organisations.</p>
<p>They include: </p>
<ul>
<li><p><a href="https://www.smiletrain.org/">Smile Train</a>, for which <a href="https://smiletrainorg.wordpress.com/tag/kenya/">I volunteer</a>, partners with hospitals in most African countries. In 2015, Smile Train performed its one millionth cleft surgery in Dar-es-Salaam at a hospital run by a healthcare organisation known as Comprehensive Community Based Rehabilitation in Tanzania (CCBRT). </p>
<ul>
<li><a href="https://www.operationsmile.org/">Operation Smile</a> conducts cleft surgery missions in Rwanda, Ethiopia, Ghana, Malawi, Democratic Republic of Congo (DRC), Madagascar and South Africa.</li>
<li><a href="https://www.operationsmile.org/">Help a Child Face Tomorrow</a> does free surgeries in Kenya, Rwanda, Democratic Republic of Congo, Somaliland and, beyond Africa, in Bangladesh. </li>
<li><a href="https://www.spaltkinder.org/en/about-us.html">Cleft-Kinder-Hilfe</a>, a German NGO, has also performed these surgeries in parts of at Kakamega, Kitale and Litein in western Kenya as well as at Kangundo Hospital.</li>
</ul></li>
</ul>
<p>The criteria for selecting volunteers is having a surgery speciality qualification and once selected, specific training for cleft management is acquired in courses, workshops and scientific meetings sponsored by the not for profits. </p>
<p>More work is underway to <a href="http://www.cpcjournal.org/doi/abs/10.1597/10-199?code=acpa-premdev">facilitate exchange of knowledge and experience</a> across the continent. For example, the <a href="http://PAACLIP.org">Pan African Association of Cleft Lip and Palate</a> brings together experts and stakeholders from a range of African countries. Doctors and other experts will learn and exchange knowledge and ideas with their peers with the aim of improving the quality of treatment of cleft lips and cleft palates on the continent.</p>
<h2>Way forward</h2>
<p>This is all positive progress. In the coming years, more specialist surgeons should be mentored and trained to collaborate with charitable organisations in providing treatment. </p>
<p>International partnerships should be encouraged to enable medical teams in Africa to perform similar treatments. A sustainable collaborative approach is needed to accelerate progress towards improved and sustainable surgical care of facial clefts in Africa.</p><img src="https://counter.theconversation.com/content/86780/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Kimani Wanjeri is a volunteer surgeon with Smile Train a charitable organization that performs free cleft surgeries world-wide. </span></em></p>Fixing facial birth defects helps a child’s optimal growth. But collaboration is needed if developing countries are to increase access to reconstructive surgery.Joseph Kimani Wanjeri, Lecturer - Department of surgery Speciality: Plastic & Reconstructive Surgery, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/258802014-06-16T04:49:36Z2014-06-16T04:49:36ZThe pleasure doctor fighting to restore clitorises after female genital mutilation<figure><img src="https://images.theconversation.com/files/50980/original/x3wddxgs-1402591570.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The final cut.</span> <span class="attribution"><span class="source">Anselm Skogstad</span></span></figcaption></figure><p>Marci Bowers’ clinic in California is famous for those seeking gender-reassignment surgery. Her work as a gynaecological surgeon over the past 25 years has made her one of the leaders in this field – and also in restoring sexual function in clitorises. She is one of only a handful of surgeons who performs this surgery on women who have suffered female genital mutilation (FGM) or cutting. </p>
<p>Reconstructive surgery to repair the physical damage of FGM has been around a long time. But the technique to restore clitoral function began developing only a decade ago, pioneered by French urologist and surgeon <a href="http://www.youtube.com/watch?v=ob3wsi30ZlQ">Pierre Foldès</a>. His idea was to not only reconstruct the clitoris, but also nerve networks to restore sexual sensation. After training with Foldès, Bowers performed the first clitoral repair surgery in the US in 2009. Since then, she’s operated on around 100 women.</p>
<p>For many women and girls who undergo FGM, it’s a traumatic experience. FGM is <a href="http://www.who.int/mediacentre/factsheets/fs241/en/">the partial or total removal</a> of the external female genitalia or other injury to the female genital organs for non-medical reasons. <a href="http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/">Up to 140m women and girls</a> live with the consequences of this practice and it is widespread in 29 African countries, but it also occurs in Asia, the Middle East, Latin America and <a href="https://theconversation.com/uk-letting-down-victims-of-female-genital-mutilation-14867">among migrants</a> from these areas.</p>
<p>The clitoris is an important part of a woman’s sexuality and along with the severe medical and psychological consequences that cutting can have, it can also come with psycho-sexual problems.</p>
<h2>The clitoris</h2>
<p>The clitoris <a href="http://www.sciencedirect.com/science/article/pii/S0022534701685720">is a complex organ</a>, and when a woman undergoes cutting, only the visible part of the clitoris is cut off. But it is much larger than most people ever assume. <a href="http://www.bumc.bu.edu/sexualmedicine/physicianinformation/female-genital-anatomy/">It has a root</a> that is about 10cm long that lies beneath the surface, arching around the vagina. It is this that reconstructive surgeons use to rebuild a working organ. </p>
<p>“It’s only like losing the visible tip of the iceberg,” Bowers says. The surgery, also known as clitoroplasty, involves removing scar tissue, pulling the remaining clitoris up to the surface, and then stitching it into its natural place. </p>
<p>According to Bowers, the restoration of sexual pleasure is possible because the whole clitoris is sensory, not just the tip. Along with better cosmetic appearance, sensation, and reduction in pain and infection, Bowers says that patients have reported having orgasms for the first time. </p>
<p>But it’s not just about the restoration of sexual sensation. “The number one reason is restoration of identity,” she said. Women who have been cut feel their sense of womanhood has been stolen from them and they want that back. “They want their body back and to feel more normal. It’s about not being different any more.”</p>
<h2>The fall out</h2>
<p>As good as all this might sound, the procedure is controversial. In 2012, Foldès and colleagues <a href="http://www.sciencedirect.com/science/article/pii/S0140673612604000">published an article</a> in The Lancet assessing the immediate and long-term outcomes of reconstructive surgery. Over an 11-year period they operated on nearly 3,000 patients, and of the 29% who attended a one-year follow-up consultation, more than half said they were having orgasms and nearly all reported feeling clitoral pleasure. </p>
<p>But a <a href="http://bit.ly/1inPeKY">group of British doctors</a> responded in a critical letter to The Lancet. In addition to the lack of a control group, they said the Foldès’ claims were anatomically impossible in cases of <a href="http://www.who.int/reproductivehealth/topics/fgm/overview/en/">type 2 FGM</a> – the partial or total removal of the clitoris and the labia minora. “Where the body of the clitoris has been removed, the neurovascular bundle cannot be preserved … There is therefore no reality to the claim that surgery can excavate and expose buried tissue,” they wrote.</p>
<p>They also said that the campaign against FGM “could be undermined by a false proposition that the ill effects can be reversed”.</p>
<p>Bowers doesn’t agree – both in terms of the surgery and of undermining efforts to fight FGM. “You see the clitoris every single time, 100% of the time. You can’t deny it’s there,” she says. According to Bowers, their response reflects antiquated but persistent notions of female sexuality. The work of NGOs is important, she argues, but if something can be medically fixed, it should be fixed.</p>
<p>And she’s not short of patients. Twice a year she leaves her <a href="http://www.theguardian.com/society/2013/aug/25/surgery-for-female-genital-mutilation">reported 14-month waiting list</a> for US$21,000 gender reassignment surgery to operate for free on women who come to her for clitoroplasty, although patients still pay a $1,700 admin fee to the clinic.</p>
<p>She’s adamant that she only helps those who want it and who, she says, often come to her unhappy, angry and sad with husbands and partners. “We were only there to help women who found that they were suffering as a result of FGM,” she says. It’s probably fair to say, then, that Bowers is an evangelist for reconstructive surgery. </p>
<h2>The pleasure hospital</h2>
<p>Bowers became involved in the FGM reconstruction surgeries because of Clitoraid, a private, non-profit organisation that helped fund her training in Paris. The organisation is backed by volunteers of <a href="http://content.time.com/time/nation/article/0,8599,404175,00.html">the Raëlian movement</a> – one of the world’s largest UFO religious sects – whose members believe that humans were created by extra-terrestrials. Clitoraid promote free sexuality, sexual freedom and pleasure for all women. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/50982/original/2653tqr5-1402592913.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sixth sense.</span>
<span class="attribution"><span class="source">Marci Bowers </span></span>
</figcaption>
</figure>
<p>Bowers’ own motivation doesn’t come from a Raëlian perspective, she says, but from her own philosophy that human beings have a sixth sexual sense. “When the sexual sense is taken away, it’s no different than if someone had taken away your sense of smell or your sense of taste.” </p>
<p>It’s clear, though, that her belief runs in parallel with the aims of Clitoraid, which has concentrated its work in the small West African nation of Burkina Faso, recently building a hospital nicknamed the “pleasure hospital” to offer reconstructive operations free of charge. The hospital was supposed to have opened its doors in March 2013 with local medical staff and trained surgeons, but the government stopped the project because of licensing issues. Clitoraid has said its authorisation was revoked following pressure from the Catholic Church and accusations that the group would attempt to convert women to the Raelian movement. The group still intend to open next year.</p>
<p>Ultimately, Bowers claims the enjoyment of sexual activity is a human right. “Sexuality is part of what makes us human beings and what makes life pleasurable,” she says. Before transitioning to life as a woman, she herself was born male. And this, she says, gives her empathy with victims of FGM. “For me, womanhood didn’t come without my own sacrifices and struggle. I empathise with women who have to have surgery to achieve and regain their womanhood. They are struggling to regain their identity, just like I had to do once upon a time myself.” </p><img src="https://counter.theconversation.com/content/25880/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annemarie Middelburg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Marci Bowers’ clinic in California is famous for those seeking gender-reassignment surgery. Her work as a gynaecological surgeon over the past 25 years has made her one of the leaders in this field – and…Annemarie Middelburg, PhD Candidate, Tilburg UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/243862014-03-17T06:00:36Z2014-03-17T06:00:36ZThe printed face is just the beginning of a 3D revolution<figure><img src="https://images.theconversation.com/files/43965/original/7mfx2bwx-1394805487.jpg?ixlib=rb-1.1.0&rect=0%2C140%2C1920%2C1471&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The floodgates are open, bring on the age of 3D printing.</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/File:Miniature_human_face_models_made_through_3D_Printing_(Rapid_Prototyping).jpg">S zillayali</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The news that a man in Wales was able to have his <a href="http://www.bbc.co.uk/news/uk-wales-26534408">face reconstructed</a> after a serious motorbike accident has brought the wonder of 3D printing to the mainstream. It’s the result of changes in regulation and improvements in the technology and is the start of something much, much bigger.</p>
<p>The use of a combination of CT scanning and 3D printing methods to treat patients who are suffering from injury or defect is incredibly powerful. As has happened in Stephen Power’s case, it allows expert surgeons to manipulate the precise geometry of the patient’s face or other part of the body before the operation. That means the necessary parts can be designed and manufactured in a normal, albeit slightly compressed, design timescale.</p>
<p>Power suffered a number of impact injuries in his accident, he broke his cheekbones, top jaw and nose and fractured his skull. Several months later, doctors printed a symmetrical model of his face using CT scans and were then able to create implants and plates to rebuild his features. </p>
<p>But the majority of the techniques used to help Power have actually been around for decades. A very similar story to this was detailed in a BBC documentary nearly 20 years ago.</p>
<p>The fundamental patents that have been held for 20 years – including a particularly important piece of intellectual property owned by 3D printing company Stratasys – have now expired. That means that we are likely to see <a href="https://theconversation.com/explainer-what-is-3d-printing-and-whats-it-for-9456">3D printing</a> really come into its own. These patents largely covered the manufacturing processes involved in 3D printing and now that this knowledge is no longer locked up by companies, people like Power can benefit more easily.</p>
<p>It has meant that low-cost 3D printing machines can be produced, enabling a better-served marketplace to emerge and a community of print-at-home enthusiasts, designers and innovators to get to work. They are <a href="http://www.thingiverse.com/">printing</a> toys, jewellery and even prosthetics.</p>
<p>But the hold up has also been about technology. Innovation in the field, and particularly in metal 3D printing, has really sped up in recent years.</p>
<p>Metal 3D printing produces components in biocompatible materials such as titanium from 3D data produced by a design system or CT scan. In the past five years these machines have improved to such an extent that they can now be used to make implantable parts.</p>
<p>The University of Liverpool built the first metal 3D printer in the UK, which has led to the production of implants for dentistry, orthopaedics and even veterinary treatment. And now the progress of 3D printing technology is gathering pace and this is largely due to more people being able to access and experiment with the devices in a variety of settings.</p>
<p>We’re likely to see a lot more stories like Power’s facial reconstruction in the future. For every wonder application that succeeds there are likely to be more failed ideas that never catch on but now that people all over the world can try things out, the possibilities are enormous. It will mean that 3D printing will be an every day occurrence and a normal way to treat patients rather than front page news. </p><img src="https://counter.theconversation.com/content/24386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Sutcliffe receives funding from EPSRC, TSB, Industrial sponsorship. He works for University of Liverpool, Renishaw AMPD and owns shares in Fusion Implants Ltd.</span></em></p>The news that a man in Wales was able to have his face reconstructed after a serious motorbike accident has brought the wonder of 3D printing to the mainstream. It’s the result of changes in regulation…Chris Sutcliffe, Researcher, Centre for Materials and Structures, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/186712013-10-03T13:45:40Z2013-10-03T13:45:40ZStem cells offer a more natural approach to plastic surgery<figure><img src="https://images.theconversation.com/files/32419/original/t8rtc9mg-1380801321.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C768&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Man in the mirror.</span> <span class="attribution"><span class="source">Shareski</span></span></figcaption></figure><p>The potential of stem cells is everywhere in medicine - from growing new tissue that could go on to provide replacement organs, repairing damage from disease or injury and in reconstructive surgery.</p>
<p>And a team of Danish researchers recently <a href="http://bit.ly/1fKCUW2">suggested in The Lancet</a> that stem-cell enriched fat grafts had the power to transform reconstructive surgery, including procedures such as breast surgery. Not only can they improve the survival of grafts, but also success of a more natural approach to reconstruction. </p>
<p>Stem cells are a class of undifferentiated cells that are able to become (differentiate into) specialised cell types, and they repair and replace cells in tissues. They have three vital characteristics: they are long-lived, they are self-renewing (we can make more of them) and can differentiate into more mature, specialised cells. Adult stem cells, also known as somatic stem cells, are found throughout the body and can multiply to regenerate damaged tissue or replace dying cells. They can be derived from many sources, including from fatty (adipose) tissue.</p>
<p>Stem cells have the potential to revolutionise plastic and reconstructive surgery, a speciality which focuses on restoring form and function. And introducing them to techniques in this field, such as fat grafting (otherwise known as lipofilling, where a patient’s own fat is harvested to increase its volume elsewhere in the body) could improve the outcome of the procedure and its longevity.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/32413/original/zp8bygkj-1380797349.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A breast procedure without implants.</span>
<span class="attribution"><span class="source">Tips Times</span></span>
</figcaption>
</figure>
<p>Lipofilling is commonly performed in plastic surgery to replace lost volume. The procedure is used to improve breast symmetry following breast reconstruction surgery, augmentation and for congenital breast deformities without using breast implants. </p>
<p>But one of its drawbacks is the variation in how quickly the fat graft is reabsorbed by the body. Some studies have suggested <a href="http://cdn.intechopen.com/pdfs/33483/InTech-Autologous_fat_grafting_factors_of_influence_on_the_therapeutic_results.pdf">a gap as wide</a> as 20-80%. The Danish researchers in the Lancet suggest that by enriching these fat grafts with fat-derived stem cells, the amount of graft that survives absorption by the body is substantially improved.</p>
<p>While this has been shown in animal studies, the result in humans is a significant step forward for reconstructive medicine. It adds greatly to the prospect of stem cell use in clinical practice especially in breast reconstruction where large volumes of lipofilling are required. </p>
<p>It has the potential to significantly reduce the number of operative procedures a patient may require. It is also a step forward in other procedures where lipofilling is used such as filling in scars and traumatic defects.</p>
<h2>Nerve and burn injuries</h2>
<p>Stem cells are also being used tissue engineering and other areas of reconstructive medicine. For example, in patients with traumatic nerve injuries, artificial conduits are being used to guide new regrowth and have emerged as an alternative to nerve grafts taken from elsewhere in the body. Fat-derived stem cells have also been incorporated into these nerve conduits in recent experimental studies so that they differentiate into Schwann cells, which play and important role in conducting nerve impulses, to promote nerve regeneration.</p>
<p>There is a potential for the use of epidermal stem cells in burns. The stem cells can be sprayed on directly or transferred onto a scaffold of skin substitute or graft. This has been shown to <a href="http://www.ncbi.nlm.nih.gov/pubmed/21200267">improve wound healing</a>. In the same way, these stem cells have also been used to heal chronic wounds such as ulcers either as epidermal stem cells sprayed directly on to the wound or through fat-derived stem cells injected into the wound.</p>
<h2>Cosmetic procedures</h2>
<p>Cosmetic procedures and in particular facial rejuvenation has become an integral part of aesthetic plastic surgery. Many people are now opting to counter volume loss and wrinkles as they age. Synthetic fillers are used for this but they <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/filler-injections-can-cause-permanent-damage-say-doctors-398943.html">have significant limitations</a>. One of the fundamental principles of plastic surgery is replacing like with like and using fat grafts from a patient’s own body is preferable. But the unpredictability of retention means that many still opt for a synthetic substance.</p>
<p>One must be aware, however, that studies show that stem cells do retain memory of their donor site. This has implications for cosmetically sensitive areas such as the area surrounding the eye should the patient gain weight. So if fat-derived stem cells were taken from the hip, for example, if the patient put on weight they might put on more where the graft is.</p>
<p>Claims are also being made that these cell therapies <a href="http://fabfitfun.com/stem-cells-in-skin-care">improve skin quality</a> and tightening. While this would be a boon for the beauty and cosmetics industry, there’s no concrete evidence for this.</p>
<p>There is no doubt that this is an important and exciting field. Stem cells look to become the corner stone of regenerative medicine. And in reconstructive surgery there is yet more to come.</p><img src="https://counter.theconversation.com/content/18671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ash Mosahebi works as a Consultant Surgeon for a number of NHS organisations as well as in private practice.</span></em></p>The potential of stem cells is everywhere in medicine - from growing new tissue that could go on to provide replacement organs, repairing damage from disease or injury and in reconstructive surgery. And…Ash Mosahebi, Honorary Senior Lecturer, UCLLicensed as Creative Commons – attribution, no derivatives.