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Face reconstruction could soon use ‘shape-shifting’ material

Injuries, birth defects (such as cleft palates) or surgery to remove a tumor can create gaps in bone that are too large to heal naturally. And when they occur in the head, face or jaw, these bone defects can dramatically alter a person’s appearance. Researchers reported that they have developed a “self-fitting” material that expands with warm salt water to precisely fill bone defects, and also acts as a scaffold for new bone growth.

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Study finds more women receiving breast reconstruction after mastectomy

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Study finds more women receiving breast reconstruction after mastectomy

A new study finds that the majority of women who undergo mastectomy for breast cancer go on to get breast reconstruction, a practice that has increased dramatically over time.

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Tissue Fusion to commercialize laser surgical device developed at University of Colorado

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Tissue Fusion to commercialize laser surgical device developed at University of Colorado

Tissue Fusion and the University of Colorado recently completed a license agreement that will allow the company to continue developing a new surgical device that utilizes lasers, rather than staples and sutures, to close wounds during nasal surgery.

Body contouring after bariatric surgery helps obese patients keep the weight off

Patients who have plastic surgery to reshape their bodies after bariatric procedures are able to maintain “significantly greater” weight loss than those who do not have surgery, according to a new study by Henry Ford Hospital researchers.

“As plastic and reconstructive surgeons, we are encouraged by the idea that improved body image can translate into better long-term maintenance of a healthier weight, and possibly a better quality of life for our patients,” says Donna Tepper, M.D., a Henry Ford plastic surgeon and senior author of the study.

Study results will be presented Oct. 11 at the annual conference of the American Society of Plastic Surgeons in Chicago.

Used to help obese patients lose weight, bariatric surgery includes several types of procedures that limit the amount of food the stomach can hold, including removal of a portion of the stomach or constricting it with a gastric band. Such weight loss can be significant, and result in a lower risk of diabetes and heart disease.

“Bariatric surgery has a measurably significant positive impact on patient illness and death,” Dr. Tepper says. “However, even with the technical and safety advancements we’ve seen in these procedures, their long-term success may still be limited by recidivism.

“There is a high incidence of patients who regain weight after the surgery.”

The new study followed 94 patients who underwent bariatric surgery at Henry Ford from 2003 through 2013.

Of those, 47 subsequently had body recontouring procedures.

Some previously obese patients opt for plastic surgery – such as face or breast lift, so-called “tummy tuck” or lifts of sagging upper arms, thighs or buttocks – to remove inelastic excess skin and tissue after substantial weight loss and to reshape or recontour their bodies.

The Henry Ford researchers recorded each patient’s Body Mass Index, or BMI – a weight-to-height ratio used to determine degrees of obesity – both before their bariatric surgery and 2.5 years after the procedure.

“Of the patients who underwent contouring surgery, the average decrease in BMI was 18.24 at 2.5 years, compared to a statistically significant 12.45 at 2.5 years for those who did not have further surgery,” Dr. Tepper explains.

While these findings suggest that aesthetic procedures following bariatric surgeries may contribute to improving their long-term results, Dr. Tepper says future studies will look at changes in BMI after five years, as well as how different types of contouring procedures may maintain weight loss.

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Stem cells from fat tissue show promise in reconstructive surgeries for face and skull

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Stem cells from fat tissue show promise in reconstructive surgeries for face and skull

A new study released in Stem Cells Translational Medicine shows that many patients with defects to the skull, face or jaw bone might benefit from reconstructive surgery combining stem cells taken from adipose (fat) tissue seeded on resorbable scaffolds.

These defects can be due to congenital malformations, such as cleft lip and palate, or to traumatic injuries or surgery to remove a tumor. The use of a patient’s own bone is still considered the gold standard for reconstructing these defects, but this requires yet another surgery to harvest the bone for the reconstructive procedure. The Stem Cells Translational Medicine study tracked the case of 13 patients undergoing regenerative medicine procedures.

“To our knowledge, this study represents the first GMP-compliant application for autologous adipose-derived stem cells in the treatment of defects at various sites of the cranio-maxillofacial skeleton,” said the study’s lead investigator, George K. Sándor, M.D., DDS, Ph.D., of the University of Tampere (UT), Tampere, Finland. He and Susanna Miettinen, Ph.D., were lead investigators on the study conducted by scientists and clinicians who, in addition to UT, came from the University of Oulu (Oulu, Finland) and Central Hospital (Jyväskylä, Finland).

Isolated reports of hard tissue (bone) reconstruction in the skull, face or jaw (cranio-maxillofacial skeleton) exist, but multi-patient case series are lacking. This study aimed to review the experience of 13 people with hard tissue defects at four anatomically different sites: the frontal sinus (three cases), cranial bone (five cases), the jaw (three cases) and the nasal septum (two cases).

Stem cells were harvested from adipose tissue in each patient’s abdomen, treated in the lab and then seeded onto resorbable scaffold materials for implantation back into the patient. The scaffolds were constructed with either bioactive glass or ß-TCP (a bone graft substitute). In some cases a protein called rhBMP-2, which plays an important role in the development of bone and cartilage, was added, too.

The results were promising. All three of the frontal sinus cases and three of the five cranial defect cases were successfully treated. (The other two cranial cases in which non-rigid resorbable containment meshes were used sustained bone resorption to the point that they required a redo procedure.) One of the two septal perforations failed after a year due to an infection resulting from the patient’s own actions, but the other healed successfully.

The three patients with reconstructed jaw defects also had good results; in fact, two of them chose to have dental implants placed directly into the stem cell-seeded grafts after healing, allowing these patients to once again enjoy a normal diet.

While the resorption of some of the constructs in the cranial defects was more than expected, “Nevertheless,” Dr. Sándor said, “the majority of these challenging defects – 10 of 13 – were successfully treated with integration of the stem cell-seeded constructs to the surrounding skeleton at the defect sites.” Dr. Miettinen added that the next steps should involve more animal studies and tracking of long-term results in humans.

“This case series, involving various sites of defect, illustrates the potential promise of engineering replacement bone in the lab to avoid harvesting bone from the patient,” commented Anthony Atala, M.D., editor of Stem Cells Translational Medicine and director of the Wake Forest Institute for Regenerative Medicine.

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Adipose stem cells used to reconstruct 13 cases with cranio-maxillofacial hard-tissue defects, Authors: George K. Sándor, Jura Numminen, Jan Wolff, Tuomo Thesleff, Aimo Miettinen, Veikko J. Tuovinen, Bettina Mannerström, Mimmi Patrikoski, Riitta Seppänen, Susanna Miettinen, Markus Rautiainen and Juha Öhman, Stem Cells Trans Med February (2014) doi: 10.5966/sctm.2013-0173

STEM CELLS Translational Medicine

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STEM CELLS Translational Medicine. “Stem cells from fat tissue show promise in reconstructive surgeries for face and skull.” Medical News Today. MediLexicon, Intl., 24 Feb. 2014. Web.
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STEM CELLS Translational Medicine. (2014, February 24). “Stem cells from fat tissue show promise in reconstructive surgeries for face and skull.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/273074.

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Type of breast cancer surgery women undergo influenced by surgeons and health care settings

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Type of breast cancer surgery women undergo influenced by surgeons and health care settings

Breast cancer is one of the few major illnesses for which physicians may not recommend a specific treatment option. North American women are more likely to opt for precautionary breast surgery when physicians don’t specifically counsel against it, according to a new study.

The research, presented at the American Society of Breast Surgeons Annual Meeting in Las Vegas, also demonstrates how clarity during consultations and the capability of clinical facilities also play important roles influencing a woman’s breast cancer treatment choices.

There is more than one type of preventative breast surgery but this study looked only at cases where cancer has been diagnosed in only one breast. This form prophylactic breast surgery, called a contralateral prophylactic mastectomy, entails removing the healthy breast at the same time as the cancerous breast. The procedure can reduce the risk of breast cancer recurrence in women who have a strong family history of breast or ovarian cancers and in women who have a genetic mutation that makes breast cancer more likely.

“While effective for such groups,” explained Dr. Andrea Covelli, lead author and a University of Toronto general surgery resident whose research work was supervised by Dr. Nancy Baxter of St. Michael’s Hospital. “The number of prophylactic mastectomies across North America has risen among women without these underlying conditions – among women who have only an average risk of developing cancer in their non-cancerous breast.”

Previous national studies have shown that instances of prophylactic breast surgery among early-stage, average risk women have increased nearly twelvefold in the United States over the last decade. In Canada, rates increased by 140 per cent between 2008 and 2010.

Dr. Covelli interviewed 45 surgeons in North America to identify factors that determine the course of treatment.

In the United States, some states legislate that surgeons present all treatment options to patients. The research found that surgeons complied in the 20 states with such legislation but generally surgeons did not recommend one procedure over another. Instead, they encouraged patient choice. Canadian surgeons discussed similar surgical options with their patients. However, they more often specifically recommended breast-conserving surgery and counseled against prophylactic mastectomies.

“We learned that surgeon’s recommendations and detailed consultations influenced women’s decisions for breast cancer treatment,” said Dr. Covelli. “Consultations were especially important when it came to MRI findings. When MRI results were presented without detailed explanations, women were more likely to opt for prophylactic mastectomies.”

MRI exams have a high rate of false-positive results so patients who were given their exam results without detailed explanations were often concerned about new disease in addition to the recently diagnosed tumour.

Findings show that MRI exams were ordered less frequently in Canada than in the United States. It also showed that Canada’s surgeons often had more opportunity to discuss potential for inaccuracies with patients.

If women were being treated at health care facilities with access to immediate reconstruction, they were also more likely to choose prophylactic surgery.

“The availability of immediate breast reconstruction was another main factor in patients’ decisions,” said Dr. Covelli.

Immediate reconstruction was associated with the choice of prophylactic mastectomy and is more widely available in the United States than in Canada. In both countries, many patients requested a prophylactic mastectomy after returning from a consult with a reconstructive surgeon.

“We need to look at what happens during that consult to better understand patient decision-making,” said Dr. Covelli. “Patients should ask for their doctor’s opinion if helpful to them. Most surgeons have years of experience treating breast cancer and can provide valuable counsel and advice.”

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Hospital, St. Michael’s. “Type of breast cancer surgery women undergo influenced by surgeons and health care settings.” Medical News Today. MediLexicon, Intl., 3 May. 2014. Web.
13 Jun. 2014.

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Hospital, S. (2014, May 3). “Type of breast cancer surgery women undergo influenced by surgeons and health care settings.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/276215.

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Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin

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Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin

Skin laxity and fat buildup under the chin is a common concern among facial aesthetic patients. Although surgery has long been the mainstay for reducing fat in this area, which is also known as the submental region, new research being presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS) being held April 24 – 29, 2014 in San Francisco, CA, shows the potential of a novel injectable drug for submental fat reduction. Steven H. Dayan, MD who practices in Chicago, IL, will present the latest data from clinical trials of a new, investigational injectable drug, ATX-101, during “ATX-101, A Submental Contouring Injectable Drug for the Reduction of Submental Fat” on Saturday, April 26th.

“An unfavorable profile can make people look older and heavier, negatively affect self-esteem, and cannot usually be significantly altered by diet or exercise,” said Dr. Dayan. “We are excited to present trial results on this potential first-in-class submental contouring injectable, which, if approved, could offer physicians and their patients a non-surgical option to eliminate fat under the chin, resulting in a thinner and more contoured profile and jawline.”

Dr. Dayan is presenting the first disclosure of a pooled analysis of two positive ATX-101 Phase III trials (REFINE-1 and REFINE-2) evaluating the reduction of submental fat. Results of the pooled analysis, conducted by KYTHERA Biopharmaceuticals, found that:

68.2 percent of ATX-101 (2 mg/cm2) subjects demonstrated a simultaneous improvement of at least one grade from baseline on clinician and patient reported rating scales vs. 20.5 percent in placebo (p<0.001). After two treatments, 52.2 percent of subjects achieved at least a one grade change from baseline in the clinician submental fat ratings, and 71.5 percent after four treatments. Response to ATX-101 was consistent across demographic and baseline subgroups with approximately 80 percent of subjects treated with ATX-101 demonstrating at least a one grade improvement in the clinician submental fat ratings regardless of age, gender, race, BMI, Fitzpatrick Skin Type and baseline severity. ?? Those treated with ATX-101 reported significant improvement in the visual and emotional impact of chin fat, including appearing thinner and more youthful, compared with those treated with placebo (p<0.001).

“Eliminating fat in the submental region not only plays a critical role in helping restore overall facial balance and harmony, but can also lead to vast improvements in self-perception as well as the first impression projected,” said Dr. Dayan. “We are looking forward to sharing our findings, which show how a noninvasive injection might offer patients the treatment option they’ve been desiring.” The pooled analysis also found that 80.9 percent of ATX-101 treatment-emergent adverse events were mild and 1.4 percent of ATX-101 subjects discontinued the studies due to adverse events. The most common adverse events observed in the clinical trials included temporary injection site events of pain, swelling, bruising and numbness. The incidence and severity of pain and swelling declined after the first treatment session.

ATX-101 is a proprietary formulation of a purified synthetic version of a naturally occurring molecule (deoxycholic acid) that aids in the breakdown of dietary fat. It is currently in late stage clinical trials for the reduction of submental fat, which commonly presents as a double chin. When injected into subcutaneous fat, ATX-101 contours the area under the chin by destroying fat cells while leaving surrounding tissue largely unaffected. It has been evaluated in double-blind, randomized, placebo- controlled clinical trials being conducted in the US and Canada with over 2,500 participants who have moderate-to-severe submental fat. Detailed data from a pooled analysis will be revealed during Saturday’s presentation.

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ATX-101, A Submental Contouring Injectable Drug for the Reduction of Submental Fat: A Pooled Analysis of Two Pivotal Phase 3 (REFINE-1 and REFINE-2) Multicenter, Double-Blind, Randomized, Placebo-Controlled Trials, Steven H. Dayan, MD, Derek H. Jones, MD, Jean Carruthers, MD, FRCS(c), Shannon Humphrey, MD, Fredric S. Brandt, MD, Patricia Walker, MD, PhD, Daniel Lee, MS, Paul F. Lizzul, MD, PhD, Frederick C. Beddingfield III, MD, PhD

The American Society for Aesthetic Plastic Surgery (ASAPS)

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The American Society for Aesthetic Plastic Surgery. “Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin.” Medical News Today. MediLexicon, Intl., 30 Apr. 2014. Web.
13 Jun. 2014.

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The American Society for Aesthetic Plastic Surgery. (2014, April 30). “Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/276078.

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Skill development in robotic microsurgery assessed by new tool

A new standardized assessment provides a useful tool for tracking surgeons’ progress as they develop the skills needed to perform robot-assisted microsurgery, reports a study in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“The Structured Assessment of Robotic Microsurgical Skills (SARMS) is the first validated instrument for assessing robotic microsurgical skills,” according to the report by ASPS Member Surgeon Dr Jesse C. Selber of the University of Texas MD Anderson Cancer Center, Houston. Initial assessments using the SARMS show that, after a steep initial learning curve, surgical trainees display steady improvement in their ability to perform robot-assisted microsurgery tasks.

SARMS Tracks Development of Robotic Microsurgery Skills

The researchers describe the development and testing of the SARMS as a standard technique for evaluating technical skills for robot-assisted microsurgery. The SARMS consisted of 11 items – six evaluating microsurgery skills and five evaluating robotic skills.

After the SARMS was validated, expert surgeons used it to grade videos of surgical trainees performing robot-assisted microvascular anastomoses – joining and suturing tiny artificial blood vessels, just three millimeters in diameter. Each of nine trainees was graded on five videos, made as they gained experience with the robotic surgical system. Changes in scores in each area were assessed, along with the time required to complete the procedure.

The SARMS scores documented general improvement in microsurgical skills with each practice session. On a five-point scale – from “novice” to “expert” – the trainees’ average ratings of overall skill and performance increased from around two to around four.

“The results showed an initial steep ascent in technical skill acquisition, followed by more gradual improvement,” Dr Selber and coauthors write. Across the five sessions, average operative time decreased gradually, from about 30 to 19 minutes.

Previous experience performing conventional microsurgery – under the operating microscope, but without robotic assistance – was the main factor affecting the trainees’ skill level. The SARMS items showed good to excellent consistency among the different expert raters.

Tool Will Aid Training in Robot-Assisted Plastic Surgery

Surgical robots have emerged as a potentially valuable tool in many surgical disciplines, including plastic and reconstructive surgery. By eliminating tremor of the surgeon’s hand and scaling hand motion, surgical robots are capable of “superhuman precision” – expanding the ability to perform delicate microvascular manipulations that would be all but impossible with the unaided human hand.

The SARMS score developed and evaluated in this study provides a new, standardized tool for evaluating trainees’ skill and performance as they gain experience with robotic microvascular surgery. The results suggest that surgical trainees can expect a tough going at first, but show gradual improvement in skills and shorter procedure times over as little as five practice sessions.

“Standardized evaluation and systematic learning of both robotic and conventional surgical techniques is necessary, and is the foundation of competency-based training, which itself is the future of surgical education,” Dr Selber and coauthors conclude. Dr Selber will give a special “Tech Talk” on the topic of Robotics at “Plastic Surgery – The Meeting,” the annual scientific meeting of the ASPS, to be held October 10-14, 2015 in Chicago, Ill.

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Reorganization of blood vessels after face transplantation surgery

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Reorganization of blood vessels after face transplantation surgery

For the first time, researchers have found that the blood vessels in face transplant recipients reorganize themselves, leading to an understanding of the biologic changes that happen after full face transplantation. The results of this study were presented at the annual meeting of the Radiological Society of North America (RSNA).

Face transplantation is a recent development in reconstructive surgery for patients who have lost some or all of their face from injury or disease. The first full face transplantation in the United States was carried out at Brigham and Women’s Hospital in Boston in 2011. Hospital specialists subsequently performed full face transplantations on three additional patients.

As part of the procedure, surgeons connect the patient’s major arteries and veins to those from a donor face, or facial allograft, to ensure healthy circulation in the transplanted tissue. Because the technology is new, not much is known about the vascular changes that help blood penetrate, or perfuse, into the transplanted tissue. The development of new blood vessel networks in transplanted tissue is critical to the success of face transplant surgery.

“All three patients included in this study at Brigham and Women’s maintain excellent perfusion, or blood flow, the key element of viability of the facial tissues and the restoration of form and function to those individuals who otherwise had no face,” said study co-author Frank J. Rybicki, M.D., Ph.D., FAHA, FACR, director of the hospital’s Applied Imaging Science Laboratory. “We assumed that the arterial blood supply and venous blood return was simply from the connections of the arteries and the veins at the time of the surgery.”

To learn more, Dr. Rybicki and Kanako K. Kumamaru, M.D., Ph.D., research fellow at Brigham and Women’s Applied Imaging Science Laboratory, used 320-detector row dynamic computed tomography angiography (CTA) to study the facial allografts of the three patients one year after successful transplantation. The CTA technology offers imaging over 16 centimeters of coverage, enabling the researchers to view collateralization, a process in which the body stimulates existing blood vessels to elongate, widen and form new connections. Collateralization often results from anastomoses, or branches formed between adjacent blood vessels.

CT angiography after face transplantation
CT angiography after face transplantation. The donor’s external carotid artery (pink) was successfully anastomosed to the recipient’s vessel (rectangular area). Branches distal to the ligation (white line) receive blood flow from collateral vessels (arrows).
Credit: Radiological Society of North America

“The key finding of this study is that, after full face transplantation, there is a consistent, extensive vascular reorganization that works in concert with the larger vessels that are connected at the time of surgery,” Dr. Kumamaru said.

Results showed that the new blood vessel networks course posteriorly, or toward the ears and even farther behind the head, in addition to the large arteries and veins that course anteriorly in the face, or close to the jaw.

“We have found that since the vessels more commonly associated with the back of the head are critical to maintain the perfusion via vascular reorganization, it is essential to visualize these vessels and determine that they are normal pre-operatively,” Dr. Kumamaru said. “Patients under consideration for face transplantation have universally had some catastrophic defect or injury.”

The authors note that the findings could help improve surgical planning and assessment of potential complications in face transplant patients. For instance, previous literature recommends the joining of multiple arteries and veins to ensure adequate blood flow in the facial allograft. However, performing these multiple connections causes longer operation time compared with a single anastomosis.

“Our findings support the simplified anastomosis for full face transplant procedure that, in turn, can potentially shorten the operative time and reduce procedure-associated complications,” Dr. Rybicki said.

CT angiography CT angiography before (left image) and after (right image) face transplantation. The donor’s facial artery (yellow) was successfully anastomosed or reconnected to the recipient’s vessel.
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Co-authors are Elizabeth George, M.B.B.S., Bohdan Pomahac, M.D., Michael L. Steigner, M.D., Geoffroy C. Sisk, M.D., Kurt Schultz, R.T., Dimitris Mitsouras, Ph.D., David S. Enterline, M.D., and Ericka M. Bueno, Ph.D.

Radiological Society of North America

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Reconstructing faces using human stem cells from fat

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Reconstructing faces using human stem cells from fat

Researchers in London, UK, are investigating the effectiveness of stem cell therapies for facial reconstruction.

A joint team, from London’s Great Ormond Street Hospital for Children and University College London’s Institute of Child Health, has published the findings of their research in the journal Nanomedicine.

This follows the recent news that another UK-based team, of The London Chest Hospital, has begun the largest ever trial of adult stem cells in heart attack patients.

Great Ormond Street has a proven track record in facial reconstruction, particularly with regard to treating children with a missing or malformed ear – a condition called microtia. This kind of reconstructive surgery involves taking cartilage from the patient’s ribs to craft a “scaffold” for an ear, which is then implanted beneath the skin.

Despite successes with this method, the researchers thought the treatment may be improved by bringing stem cells into the process.

To do this, the doctors would take a small sample of fat from the patient and extract stem cells from it. The stem cells would then be placed onto a special ear-shaped scaffold, called a “POSS-PCU nanoscaffold.”

Stem cells
Using human stem cells from the patient’s own fat, researchers say they may be able to improve the effectiveness of facial reconstruction.

The cells are treated with chemicals that encourage them to transform into cartilage cells, before being inserted under the patient’s skin.

This new version of the technique reduces side effects and the chance of the new ear being rejected by the patient’s body. It also makes the treatment less invasive, as cartilage taken from the patient’s rib to build a scaffold does not grow back.

One of the study’s authors, Dr. Patrizia Ferretti, told the BBC: “It is really exciting to have the sort of cells that are not tumorogenic, that can go back into the same patient – so we don’t have the problem of immunosuppression – and can do the job you want them to do.”

So far, the researchers have been able to create cartilage on the scaffold using stem cells, but more safety testing is required before the procedure can be tested in patients.

As well as using this kind of stem cell therapy to grow new ears, the researchers believe the same procedure could be used to create noses and tracheal transplants.

Another benefit of generating body parts using stem cells would be that the new body part will grow as the child grows.

Neil Bulstrode, consultant plastic surgeon at Great Ormond Street and an author on the paper, says:

“It is such an exciting prospect with regard to the future treatment of these patients and many more. Currently I take the rib cartilage from the chest to make an ear, but if we could produce a block of cartilage using stem cells and tissue engineering, this would be the Holy Grail for our field.”

Medical News Today also reported recently on research into growing artificial heart valves for children using stem cells.

Written by David McNamee

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McNamee, David. “Reconstructing faces using human stem cells from fat.” Medical News Today. MediLexicon, Intl., 3 Mar. 2014. Web.
13 Jun. 2014.

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McNamee, D. (2014, March 3). “Reconstructing faces using human stem cells from fat.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/articles/273461.

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