Stem Cells in Medicine

The most common and accepted use of stem cells in medicine is a bone marrow transplant in which physicians attempt to change a patient’s blood cells from one type to another.  In the case of cancers like leukemia or diseases like sickle-cell anemia, the transplant aims to erase all the diseased cells and replace them with a new line of blood-type cells derived from donor stem cells.  The process itself is painful and has variable success rates, but when it works patients can be cured.

The Fountain of Youth drove explorer Ponce de Leon to the discovery of new worlds, and this mythical fascination with renewal pre-dates the Ancient Greeks.  Today, promise lies in small cells called stem cells that have the ability to self-renew and transform into cells of differing types.   The International Society for Cellular Therapy has defined stem cells by the following criteria: (i) they are adherent to plastic material in the laboratory, (ii) they express specific proteins on their outer surface much like you have unique traits that identify your heritage, and (iii) these cells can be directed to transform into bone cells, fat cells, cartilage cells, etc.  The potential to form new organs and to revitalize aged tissues are the reasons that stem cells are researched so intensely and need to be scrutinized carefully.  Stem cells can be harvested from an embryo or an adult.  Embryonic stem cells are removed “in utero” from a fertilized egg and these cells have the greatest potential; however, their acquisition is controversial and their use highly regulated.  Adults have an abundant supply of stem cells originating from blood and tissues.  Cord blood is a commonly harvested source of adult stem cells originating from the blood stream (hematopoietic stem cells).

In addition, stem cells are found in your fat, bones and cartilage to name a few sites.  These cells are called mesenchymal stem cells and they differ from hematopoietic stem cells in the markers expressed on their surface.  Differing stem cells appear primed to better renew differing tissues, and the key is determining the correct factors that drive these cells to become a certain tissue type.  So far, there is much promise and a few successes utilizing stem cells to treat diseases.  In addition to the bone marrow transplant, many clinical trials and experimental studies are underway attempting to harness the potential of stem cells.  The few mentioned here are only the tip of a large and growing iceberg.

During a heart attack the muscle cells within the heart die and are replaced by scar tissue.  Your heart then changes shape and size in an attempt to successfully pump blood again; however, it rarely recovers the same capacity it had before the attack.  Current therapies aim to prevent a future attack; however, physicians in Europe are using stem cells retrieved from patient’s bone marrow to regenerate muscle in the scarred areas.  The early results have shown a modest gain in muscle cells and function.  Long-standing wounds from trauma, diabetes or venous insufficiency are a serious problem and can take up to years to heal, sometimes never closing at all.   Recent studies using stem cells in fat taken from liposuction specimens have shown improved healing rates and new blood vessel formation in problem wounds.  In our own lab at Emory University, we have shown a four-fold increase in blood vessel formation with the addition of these stem cells.  The next step is to apply these techniques to improve the quality of damaged skin and organs.

The notions that paralyzed patients can walk again and that kidneys can be built in the lab are the reasons the U.S. government has invested heavily over the last decade in stem cell research.  They are also the reasons that many companies and even physicians have licensed and marketed the promise of these cells without ensuring the efficacy.  We have the basic building blocks, but directing these cells to become complete organs or prevent cancer is beyond our current knowledge.  You should be excited at the future potential, but be cautious about current promises that appear too good to be true.

Breast Augmentation – Is it safe?

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In a word, Yes. Breast augmentation is a safe and transformative procedure; however, as with all surgeries there are a few complications you should be aware of.  The implant companies will tell you that their devices are designed to last 10 years; however, this is both variable and often the lesser of more common problems.  Approximately one in four women that undergo implantation will require a second revision surgery in within the next four years, and the main causes for this are (i) a hardening and possible pain in the breasts from contracture, (ii) dissatisfaction with size, and (iii) implant rupture.  Below is my attempt to address each of these as well as an answer to breast cancer detection in augmented women.

Capsular Contracture

All implanted materials cause an immune response in your body that results in a “scar” surrounding the device.  These are called capsules.  They can actually be a good thing if they remain soft as they keep the implant stable and in the correct place.  At times these capsules can become thick, hard and even cause pain; a phenomenon called capsular contracture.  How often does this happen?  In patients undergoing cosmetic breast augmentation it occurs anywhere from 8% to 40% with an increasing rate the longer you have your implants.

Capsular contracture appears to have two distinct time-points: (i) early, thought to be due to poor sterility or poor surgical technique, and (ii) late, likely due to a chronic inflammatory response.  Early contracture occurs in the first several months and is noted by a hardening of your breast and often a migration of the implant up toward your collar bone.  This is thought to be caused by bad infection, bleeding, or fluid collecting around the implant during your surgery.  Late contracture occurs in the following years and is likely due to an indolent bacterial coating on the implant from the initial surgery or from gel bleeding from within the implant.

Treating contracture can be difficult, and prevention is the key.

Once it develops, many techniques can be used.  The easiest and least often chosen is to remove the implants.  The next option is to change the location of the implant (from over the muscle to under or vice versa) or change the type of implant.  A new method is emerging in which your surgeon places a piece of cadaver skin product (either from pigs or humans) between the implant and your breast tissue.  These are called ADMs or biologics and the early results are impressive.  All of these options can be expensive, but check with your implant company as you may be reimbursed for part of your procedure.

Size Dissatisfaction

Most women that are dissatisfied with their size want to be larger.  In reviewing our patients over the last ten years, only about 6% undergo a revision surgery to have their implant volume changed.  Of these women, two out of three want to be larger and on average about 75cc bigger (roughly half a cup size).  Most of the women wanting larger implants were under the muscle and those actually requesting smaller implants were above the muscle.  Age, BMI and initial implant volume did not appear to influence a patient’s desire for larger or smaller breasts.  Comprehensive pre-operative planning is crucial here, and for a detailed discussion please see.

Implant Rupture

The silicone surface of modern breast implants are extremely durable.  Implant rupture rates of the newer generation implants are approximately 1% at six years.  It is clear that the shell strength diminishes over the lifetime of the implants and that rupture rates increase with time.  The implant companies warranty their devices for ten years; therefore, revision surgery for rupture should be covered.

If a silicone breast implant ruptures and leaks gel into your breast tissue, your overall health is not at risk.  Patients may not even know when gel implants have ruptured, because the capsule surrounding the implant holds the gel inside.  These silent leaks may only be picked up on mammography or MRI.  However, if a saline device leaks you will experience a deflation of your breast as the fluid is resorbed by the body.  In either case, see your plastic surgeon to discuss your surgical options.

Implants and Breast Cancer

Neither saline or silicone gel implants lead to an increased rate of breast or other cancers.  Most patients want to know whether implants can hinder breast cancer detection.  The answer to this is both yes and no.

Yes, implants decrease the ability of a radiologist to detect breast cancer on a mammogram.  Breast implants are not as pliable as breast tissue, and the best images are created when the breast is squeezed so there is less density for the xrays to travel through.  Dr. Ecklund created a different screening protocol for augmented women to help increase the yield of mammograms; however, it still lags behind non-augmented patients.

No, despite a lower sensitivity to detect breast cancer on mammography the cancers found in augmented patients are the same size and stage as other women.  In fact, the disease free survival and overall survival for augmented women is the same as other women.  One reason is thought to be that the implant sitting under the breast tissue actually thins your tissue and makes it easier to feel a developing tumor.

The take home message is that an implant can make it harder for your radiologist to detect cancer in your breast, but this does not affect the development of or survival from breast cancer.

Breast Augmentation – How Do I Choose?

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Breast augmentation is one of the leading cosmetic procedures in the United States.  In the right hands it is a safe and life changing operation with minimal recovery.  As plastic surgeons we strive for your complete satisfaction, and this can be accomplished by honest and educated dialogue.  Your input is extremely important! What follows is a primer on breast augmentation and points to consider when talking with your surgeon

Implant type

Breast implants available in the U.S. are primarily made by three companies: Mentor, Allergan, and Sientra.  All implants are safe, and each company has a different profile to offer.  Implants are defined by their shape, fill material, and surface texture.  Ask your surgeon which implant company they prefer and then read the company’s literature to discern slight differences for each characteristic. Your first choice is silicone or saline implants.  Silicone gel implants feel more natural with less imperfections, but they require larger incisions and cost more ($1900/pair versus $900/pair for saline).  Over twenty years of research have proved they are safe, and I would recommend them to family and friends.  Saline is also a good option, and these implants can be placed through small incisions under your arm or even through your belly button.

Breast implants come in a variety of shapes.  First, determine if you like the round shape of traditional implants or the newer anatomic or tear-drop shape.  The anatomic implants give more lower breast fullness with less of a shelve or ridge in the upper breast.  These may look more natural, but they also show less cleavage.   They can also flip or rotate and not all surgeons are familiar with implanting them.  Second, implants are defined by their height, width, and projection.  You can measure the width of your breast in centimeters starting approximately 2cm to the side of midline and ending at the lateral crease of your natural breast.  Once you know this, you can determine the variations in height and projection to choose from.  More height will give you greater upper breast fullness and cleavage, while increasing projection will take some of this away and place more fullness in the center of the breast.

Implant location

Implants can be placed above the chest muscle (directly under the breast tissue) or under the chest muscle.  There is much debate by plastic surgeons as to which is better, but in reality either location can make beautiful breasts.  Most surgeons agree that if you have minimal breast tissue to start with then the implants should be placed under muscle to hide them better.  Otherwise, this is your choice.  Implants placed under the muscle often have less of the “fake” look; however, sometimes they can move when you use your chest muscles (hyper-animation).  Placing the implant above the muscle usually gives more cleavage, but imperfections can be felt more easily since they have less covering tissue.  Ask your surgeon what he or she feels is best for you.

Incisions

Incisions can vary from 2cm up to 6cm in length and can be placed under your breast, around you areola, in your armpit or even in your belly button.   The most common location is under your breast as this provides direct access to your breast tissue and chest muscle.  I do not recommend the areola incision.  Although the scar is well hidden, your surgeon will have to cut some of your breast ducts which exposes the implant to bacteria as it is inserted.   The choice of incision is not as important, and often your surgeon will go with the one he or she is most familiar with.

Implant size – choosing the right fit

This is the hardest and most important decision you and your doctor must make. Your job is to determine a range or window that you think you want and clearly discuss this with your surgeon.  Do not accept anyone telling you they know what will fit you best! First, accurately determine what size you are now.  All women use bra sizes even though this is an inaccurate estimate.  Take the time to go to a store like Curves and have a professional size you.  Remember that your breasts change slightly when ovulating and menstruating.

Now the hard part is to decide what size you would like your breasts to be.   Bringing in photos of celebrities is terribly misleading and often complicates the process as those women have different builds than you.  Instead, decide if you want to be a C cup or a D cup (as an example).  The internet is full of tips and tricks to help you decide.  One includes filling bags with a certain volume of salt and placing them in your bra.  No matter the method, try and determine an estimate or range you would be happy with (e.g. full C to small D). This can help us determine a spectrum (say from 300cc to 400cc) of implants to bring to the operating room.  The final decision is then made by the surgeon on the operating table with your wishes in mind.

Finally, know that most women that are dissatisfied with their size want to be larger. In reviewing our patients over the last ten years, only about 6% come back requesting to be changed.  Of these women, two out of three want to be larger and on average about 75cc bigger (roughly half a cup size).  Most of the women wanting larger implants were under the muscle and those actually requesting smaller implants were above the muscle.

I hope this helps you organize the myriad of information and choices you have.  The most important part of this operation is your trust in and honest dialogue with your surgeon.  Choose your doctor first, then your implants.

The Keller Funnel: What is it and How Does it Work?

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The Keller Funnel is a new FDA Class I device used for inserting a breast implant into the breast cavity.  The funnel is composed of a rip-stop nylon sleeve with a hydrophilic inner coating.  The company has made 5 claims espousing the use of the funnel over standard techniques.

  1. Employs a no touch delivery technique
  2. Reduces surgery time and physician fatigue
  3. Decrease the force on the implant shell
  4. Decreases incision length
  5. Lessens tissue trauma

Not all of these claims can be proven; however, we have found that using the funnel dramatically reduces the contact of skin to the implant surface.  In fact, the funnel results in a 27 fold decrease in skin contact and halves the amount of bacterial transfer during implantation.  In my opinion, this will result in significantly less infections and likely will reduce the incidence of capsular contracture.  For more information, please read the following article: Aesthetic Surgery Journal-2012-Moyer.pdf

Other groups have also reported a decrease in the stress experienced by the implant shell.  If true, implants may last longer and the risk of rupture is less.

Breast Cancer – What’s Next?

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Who Gets Breast Cancer?  

Breast cancer is the most common cancer in females, affecting one of every nine women who live to eighty years of age.  Common risk factors include a personal or family history of breast cancer (especially first degree relatives diagnosed at a younger age), increasing age, increased estrogen levels whether from medications or your body’s production, and above average alcohol consumption.   All women should perform monthly self-exams and schedule a mammogram beginning at 40 years of age.  If you are diagnosed with breast cancer, the first hours to weeks can be terrifying, but remember that this is most often a curable disease.  What follows is a primer on the path to potential cure.

What Happens if I Have It?

Once diagnosed, you and your doctors will team together to formulate a specific plan for your cancer.  Breast cancer is treated with a combination of four therapies:  surgery, radiation, chemotherapy, and receptor-based medications.  Surgical excision and radiation therapy treat the specific tumor in your breast, while chemotherapy and receptor-based therapies treat your entire body to rid any remaining cells.  Your treatment plan will include some or all of these regimens in concert.

Almost all breast cancers are primarily treated by surgical excision.  Depending on the size and stage of your tumor, you may need to have all of your breast tissue and nipple removed (mastectomy) or you may be eligible to have only a portion of tissue removed (lumpectomy).  In both cases, the lymph nodes in your underarm will be sampled to make sure the cancer has not spread beyond the breast itself.  No matter what surgery you need, you should consult with a plastic surgeon to discuss all your reconstruction options (see more details later in this article).

Radiation

Physicians often use high-energy waves, called radiation, to improve the chances of completely eliminating the cancer in your breast.  If you undergo a lumpectomy then you will need to have radiation therapy.  On the other hand, if you undergo a mastectomy there is still a possibility you will need radiation if: (i) the cancer is greater than 5cm in size, (ii) four or more lymph nodes in your underarm are positive, or (iii) the remaining breast tissue still shows microscopic cancer.  Radiation treatment is given daily over a period of five to eight weeks in order to limit the amount of damage to surrounding tissues.  Each appointment is relatively quick (30 minutes) and painless; however, over time you may experience pain, dryness and stiffness in your surrounding skin.

Chemotherapy and Other Medications

Medical therapies, in conjunction with surgery and radiation, aim to treat your entire body.  Chemotherapy is given as a pill or intravenous injection, and often multiple drugs are needed.  Side effects can be serious; therefore, you and your medical oncologist will target a treatment regimen that targets your cancer while trying to minimize harm to your body.  Hormone therapy and/or antibody therapies may be warranted if your specific cancer shows an affinity to react with these drugs.  Pathologists will determine if your cancer responds strongly to hormones like estrogen and progesterone. If so you are recommended to take a drug like Tamoxifen for a total of five years.  Finally, a new drug called Herceptin targets those tumors with specific HER proteins on the surface and has shown significant improvements in response and survival.

What is Breast Reconstruction?

All the previous therapies aim to treat your cancer, but just as important is to care for your emotional, physical and spiritual health. Please see or ask to be referred to a plastic surgeon to discuss all options available, because the path to recovery includes feeling whole again.

Implant-Based Reconstruction

After a mastectomy or breast conserving surgery you will still have your breast skin and possibly your nipple and areola; therefore, your plastic surgeon needs to create a breast mound underneath.  The simplest way to do this is to place a tissue expander (analogous to a balloon that holds water) at the time of your cancer surgery.  Several weeks later once your breast skin has healed and the swelling has resolved, your surgeon will slowly begin to inflate the expander (in the office) in order to make space for a future breast implant.  Once you have reached the appropriate volume, you will go back to the operating room to exchange the expander for a permanent implant and to create a new nipple should you not have one.  Generally this encompasses a period of four to eight months, and this technique works best if you do not need radiation or if you undergo mastectomies of both breasts (the cancer side and the non-cancer side).  In some cases, an implant can be placed directly at the time of your cancer surgery; thereby obviating the need for multiple expansions in the office.

Autologous Reconstruction

Another option is to take your own skin, fat and muscle from one area of your body and move it to your breast.  Tissue can be used from your back (latissimus flap), your abdomen (TRAM flap – pioneered by Atlanta native Dr. Carl Hartrampf), or other areas like your thighs and bottom.  Adding an implant to this surgery may be necessary depending on the amount of excess fat you have and your desired breast size.  Although this surgery takes longer in the operating room and longer to recover from, you generally have a more natural appearing and softer breast.  Finally, this option can be performed at the time of your mastectomy or at a later date after all your cancer treatments are complete.

Final Thoughts: Breast cancer affects you but it does not own you or define you.  All cases are treatable and most are curable.  Know that you are not alone on this journey as you have the support of millions of survivors, your family, your physicians and our God.

Atlanta Plastic Surgery, P.C. Adds Surgeon and Expands to Forsyth (Cumming) Location

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Recently joining Atlanta Plastic Surgery, P.C.’s team of highly skilled plastic and reconstructive surgeons, Hunter Reid Moyer, M.D. opens a new location in Cumming, GA (North Fulton) for patient convenience.

ATLANTA, GA, September 18th, 2012 – One of the oldest and most renowned plastic surgery practices in the city, Atlanta Plastic Surgery offers patients multiple office locations in the greater Atlanta area for added convenience. The practice remains dedicated to providing optimal plastic and reconstructive surgery care and welcomes their newest plastic and reconstructive surgeon Dr. Hunter Moyer.

Receiving an undergraduate degree from the Georgia Institute of Technology, Dr. Moyer graduated from Emory University School of Medicine where he then completed residencies in general surgery as well as plastic surgery. Like all of the surgeons at Atlanta Plastic Surgery, he believes the best way to provide patients with superior care is to continually research and perfect developments in the fields of plastic and reconstructive surgery.

He spreads his knowledge through published articles, surgical journals, and plastic surgery textbook chapters on subjects such as acellular dermal matrix technology and the Keller Funnel™ for breast augmentation.  Dr. Moyer and the other plastic and reconstructive surgeons of Atlanta Plastic Surgery help advance the field of breast procedures through regular participation in conferences like the Atlanta Breast Surgery Symposium held every January.

Dr. Moyer’s interests include cosmetic surgery for the face, breasts and body, but he is very passionate about breast reconstruction. He enjoys problem-solving and performing procedures that are intricate and detailed. Dr. Moyer is dedicated to treating patients with the very best care and is available whenever a patient needs him.  In fact, he is hosting an open house event on Thursday, September 27th, 2012 from 6 pm to 8 pm to give patients and colleagues an opportunity to meet him and see his new office. Attendees will enjoy complimentary wine and catered hors d’oeuvres as well as discounts on certain treatments (more details below).

About Dr. Hunter Moyer

Hunter R. Moyer, M.D. is a plastic surgeon in the Atlanta area who graduated with a medical degree from Emory University School of Medicine, where he also completed his plastic and reconstructive surgery residencies. He is an active member of the Plastic Surgery Research Council and Georgia Society of Plastic Surgeons. He is also a Resident Member of the American Society of Plastic Surgeons. Dedicated to continual research in order to advance plastic and reconstructive surgical technology, Dr. Moyer has published articles in journals like Annals of Plastic Surgery and Plastic and Reconstructive Surgery on topics like tissue rejuvenation, breast implant design and more.  Dr. Moyer’s new Northside Forsyth office is located at 1400 Northside Forsyth Drive, Suite 390, Cumming, GA 30041.

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Great Experience

“Dr. Moyer is caring, professorial, and just a great guy in general. I never felt like he was in a hurry, he took time to answer all my questions. His advice about the “procedures” that I want preformed were honest! He could have lead me down the road of extensive/expensive surgery, but instead explained how I could achieve what I wanted with less recovery time and less expense. Dr. Moyer personally called me the next day (Saturday) to see how I was doing! I now love my eyes…. I no longer look like I am half asleep or feel self conscious about my eyelids. It took years off my life and face.. Thank you Dr. Moyer!”

—–N. Brown

Made me feel so confident and comfortable every step of the way!

“You want a surgeon who is patient, knowledgeable and meticulous.  Dr. Moyer has all of those qualities and performs with a servant spirit. I cannot say enough about him and his staff who exceeded my expectations and made me feel so confident and comfortable every step of the way! I am thrilled with my results and have happily referred my friends to him.”

—–Uplifted client, Cumming, GA

Dr. Moyer is very professional…

“Dr. Moyer is very professional, very kind and I just love to go and have different procedures done by him.”

–T.Nielsen