May 19, 2012

Giving: Where does your money go

Through this newsletter you are meeting researchers who are investigating clinically relevant questions that will keep plastic surgery at the cutting edge of medicine. You are also meeting our generous members and other friends who are supporting the research that will keep plastic surgery at the forefront of medicine.

Yet you may be asking; how does this research really impact my practice and benefit my patients today?

Since 1988 the Plastic Surgery Foundation (PSF) has funded 764 grants and awarded nearly $8 million to support translational research that is directly impacting patient care. This research includes:

  • Pioneering approaches to wound healing
  • Advancing craniofacial surgery and microsurgery
  • Identifying new insights in the use of reconstructive flap surgery
  • Developing endoscopic techniques in aesthetic and reconstructive procedures
  • Exploring neo-cartilage formation
  • Addressing craniosynostosis
  • Investigating injectable delivery systems
  • Examining nerve autografts

Funding for these initiatives would not have been possible without the generous support of ASPS members and our industry partners. For more information about studies funded by the PSF or to support our current and future research initiatives, please visit the Foundation section of the ASPS/PSF website or contact Susan Hacker, CFRE, Individual Giving Associate, via e-mail at shacker@plasticsurgery.org

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PSF National Endowment Grant award winner - Breast reconstruction disparities drive her research

The Researcher: Amy Alderman, MD
Title: Associate Professor of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
Project: "Breast Reconstruction Decision Making & Outcomes in Latinas & African Americans"

What is the aim of your project?

Dr. Alderman: To improve access to reconstruction for breast cancer patients, especially in under-served populations, and determine the factors - other than insurance coverage - driving the low use and large disparities in post-mastectomy breast reconstruction. Our prior research suggests that rates are low with wide geographical and racial variations: For example, 35 percent of women in Atlanta compared to only 8 percent in Connecticut receive immediate breast reconstruction despite living within 1,000 miles of each other; and blacks, hispanics and asians are half as likely to receive immediate reconstruction compared to whites. These disparities have persisted despite the 1998 Women's Health and Cancer Rights Act that mandated insurance coverage of breast reconstruction.

At what stage are you in your research?

Dr. Alderman: The field work has now been completed and we are having fun analyzing all of the wonderful data collected. We will be submitting an abstract to the ASPS meeting and look forward to sharing our results with the plastic surgery community.

What will be the project's relevance or applicability?

Dr. Alderman: Understanding the patient and delivery system-level factors contributing to the aforementioned disparities in breast cancer reconstruction after mastectomy, is an important aspect of women's health and can inform current initiatives aimed at improving all cancer care - not just those limited to breast cancer. Considerable energy by health policy leaders and women's health advocates was spent implementing the Women's Health and Cancer Rights Act, but little to no effect has been observed. Our results will help elucidate why the legislative efforts were ineffective and will inform more effective practice-level and patient initiatives to improve the quality of cancer care. Our results will also assist the agenda of the American College of Surgeons' (ACS) Commission on Cancer to set standards for quality multidisciplinary cancer care and will be used in the commission's surveillance of hospitals' treatment patterns and outcomes.

What led you to embark on this project?

Dr. Alderman: I was accepted into the Robert Wood Johnson Clinical Scholars Program at the University of Michigan- Ann Arbor and Michigan's School of Public Health during my surgical residency in the late 1990s. These were unique opportunities to learn new research skills in both quantitative and qualitative methodologies, and focus on health policy issues that affect patients and surgeons. Also, I have had excellent mentors such as Ed Wilkins, MD, and Kevin Chung, MD, who have also been formally trained in health services research. I currently have a career development award from the Robert Wood Johnson Foundation and my primary mentor is Steven Katz, MD, MPH, who is a national leader in quality-of-care cancer research. Furthermore, I am a plastic surgeon because of Jim Madden, MD, and Luis Vasconez, MD.

What's next for your research?

Dr. Alderman: Our research will inform the development of patient-decision aids that can be integrated into a plastic surgery practice. Reconstruction is rarely incorporated into the decision-making process for surgical breast cancer care, but the mastectomy decision is intimately tied to decisions regarding reconstruction. In addition, I will work with ACS's cancer commission to develop, disseminate and evaluate effective educational breast cancer decision aids that contain breast reconstruction information.

Has your research affected or attracted other investigators in this field?

Dr. Alderman: PSF-supported research on breast reconstruction is truly a multi-disciplinary effort involving institutions across the nation. Our team of collaborators includes internists, oncologists, social scientists, researchers from the University of Michigan and Harvard's School of Public Health, and a general surgeon from Memorial Sloan-Kettering Cancer Center in New York, to name a few.

Has the PSEF grant helped your research gain additional funding?

Dr. Alderman: Yes. The PSF funding provided data to support a larger study funded by the NIH. We are currently looking at a more diverse patient population with a special emphasis on Latinas. We will be looking at access to reconstruction along with surgical satisfaction and quality of life outcomes. In addition, we will be surveying the patients' significant others to determine the impact of the mastectomy and reconstruction on personal relationship issues. The PSF support significantly aided our efforts to obtain NIH funding for a larger, multi-center population-based study.

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How research impacts my practice

By Michael Neumeister, MD

I am a very busy clinician, so what has research done for my practice? At first glance it may be a little difficult to identify how research influences what I do on a day in and day out basis for my hand and reconstructive practice. I consider myself extremely lucky to have an active basic science as well as clinical research lab within my division.

Recently, we have finished interviewing candidates for next year's residency program. Needless to say, I am extremely impressed with the quality of the applicants. Within the context of the interviews, I found myself expressing my enthusiasm for plastic surgery and saying that I love going to work every day but I also love going home at night. My reasons for saying this are not only the clinical work, great people, and energetic residents but also the prospect of, "What can I improve upon today?"

Research has offered significant influence and improvement in my practice. I think improvement in patient care through change is accomplished by five integrated processes: observation, reflection, insight, innovation, and implementation. Research has been essential to keeping me invigorated about plastic surgery through these five processes. In the operating theatre and in the clinics we are faced with reconstructive challenges on a daily basis. Each procedure and each examination of a patient can lead to questions about offering the best or optimal treatment. Questions arise from observations of outcomes that can be improved upon in some form or function. These observations lead to reflection of how we can change our approach or design of various procedural techniques. The biggest part of insight into a new paradigm or procedure is simply believing in a new concept. This open minded process, seen in many plastic surgery researchers and clinicians is what drives our innovation.

Innovation has the greatest impact on my practice and more importantly, research carves the path for most innovations. Research is not merely bench work that may have implications in the distant future. It may also be bench research that is immediately applicable or translational to our clinical practice, or it may be clinical research that is based out of evidence from multiple sources. As an example of this process where research has lead to innovative change in my practice, I recall the early research in flap prefabrication and physiology by other researchers including Julian Pribaz, MD. This line of research proved that transposed vessels will supply the overlying skin through neovascularization (prefabrication). This overlying skin can be elevated on this transposed pedicle as an axial local or free tissue transfer. Armed with this information and some research from our lab on tissue engineering, I have had the opportunity to take this to the operating theatre and use it clinically for a prefabricated tracheal reconstruction in a patient that had no fewer than 30 procedures for tracheal stenosis. The neotrachea was prefabricated on the thigh using the descending branch of the lateral circumflex femoral vessels. After maturing, the tissue engineered neotrachea was transferred to a defect created in the trachea with a successful outcome. In this case, research and flap physiology in tissue engineering resulted in a new technique to treat recalcitrant tracheal stenosis.

There are many areas of research that can affect a plastic surgeon's practice. The many aspects of both cosmetic and reconstructive surgery lend themselves well to a variety of research avenues. For instance, tissue engineering has applications for both cosmetic and reconstructive surgery to the development of new tissues to be utilized for contouring, replacement of lost tissue or reconstruction of lost function. Alternatively, evidence based data and research directs us to provide "best care" to our patients. Tissue engineering and evidence based research are only two examples of how research affects my practice. With all of this being said, one must always remember to go back and reflect again on what the changes have accomplished through improvement in patient care and outcomes. One must continually analyze ways to improve upon new techniques. The process is not static but it is an endless cycle that drives our desire to constantly improve.

What I believe is most important to realize about research is that the research done in the lab or in the clinics today may not always be quite matured or developed enough to apply to one's practice today. But the cumulative research efforts by all surgical scientists may be applicable in weeks, months or years to come. Applying older research from flap prefabrication and new research in tissue engineering has lead to new innovations. It behooves us as doctors to reflect not only on our own practices but also on the works of previous researchers. Old and new research developments are readily available with the current technology being at our fingertips literally every minute of the day.

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Strong belief in the future of the specialty leads to paving the way for others

The great support from the Endowment for clinically oriented research is evident in plastic surgery today. As a specialty, we face ever increasing challenges from multiple sectors inside and outside of medicine. "Our best tool is to stay at the forefront of things through our own directed research supported by the Endowment, as administered through the Plastic Surgery Foundation," says Dr. Little. He recalls when, at the advent of the Endowment, Norman Cole, MD took on the initiative of fundraising for the Endowment himself. "... those of us who were interested got involved," says Dr. Little. "We wanted to establish something meaningful to ensure the future of the specialty, and we did so, through the National Endowment fund, and later, the Maliniac Circle." The Circle is reserved for plastic surgeons who have contributed or will contribute to the National Endowment for Plastic Surgery, or to a separate PSF fund, at least $100,000 through estate bequests or life insurance policies, or $50,000 in cash or securities. Dr. Little chose to bequest $80,000 to the National Endowment and contribute $20,000 in cash.

The future of plastic surgery is motivation to contribute

Dr. Little is among the first 13 Charter Members of the Maliniac Circle. Dr. Little states, "We were successful in that we were able to create something that really counts. Nothing like the National Endowment exists elsewhere in plastic surgery...it is the best way for us to continue the life of this vibrant specialty." The initial contributors wooed by Dr. Cole established a significant basic corpus of funds that will exist in perpetuity, from which only the interest income can be spent. Dr. Little's original motivation was to see the Endowment grow successfully as a fund that was self perpetuating and surviving, as well as to rally others to contribute to ensure the future of the specialty; and that's what he did. He believes an attractive feature of the Endowment is that you may contribute in the form of a bequest to the Society rather than upfront in cash. This allows the typical plastic surgeon to make a larger gift commitment than might otherwise be possible. Over the last number of years, the Maliniac Circle has attracted over 85 individuals, and according to Dr. Little, "These individuals truly care about the future of plastic surgery...they have made a monetary commitment to ensure the future of the specialty."

Kiehn and Millard were mentors along the way

During a time when fellowships were less available, Dr. Little chose to secure and complete two plastic surgery residencies in order to see plastic surgery from two points of view. His two residency directors, Clifford Kiehn, MD, and D. Ralph Millard, MD, became his key plastic surgery mentors. "I think most of us as plastic surgeons, when asked questions about mentors, speak about those who trained us and who influenced us...in my case, they were both my chiefs. Dr. Kiehn first introduced me to plastic surgery. He was the most gifted surgical technician I've ever met in any specialty. He had an ease in surgical style and ability that I've never seen anyone match since." Dr. Little pursued and secured a second residency under D. Ralph Millard, MD. "Dr. Millard had made multiple contributions to the specialty and was also a gifted technician and wonderful thinker on the basis of his principled approach to plastic surgical problem solving," says Dr. Little. Though neither were full-time faculty members, Kiehn and Millard both gave enormous time and effort to their training obligations. They did all their teaching from private practice, without salary or personal financial support from the university, and each made a great impact on the specialty with their commitments to education.

Principle driver of the future is research

Dr. Little views research that has early clinical impact as the principle driver for the future of the specialty. This was the principle on which the Endowment was established. "Those who gave at a significant level did so because they knew it would support research, and research is important as the key Endowment priority, because plastic surgery doesn't have any other source of support quite like this," he says. He further acknowledges that it was becoming more and more difficult to find traditional sources of funding for research. "We needed to fund our own research. Only plastic surgeons fully understand what they contribute to the overall health of society," states Dr. Little. Before the Endowment, the PSF awarded smaller seed grants to investigators. Though these seed grants were important, they mostly encouraged young people to stay in research. "There wasn't really much of a source to go to for research," recalls Dr. Little. He feels that both ASPS and PSF, throughout their history, have done a good job funding programs in education, as well as clinical issues and practice management; but research was falling behind. "Research is where the need was and continues to be - there are no other arenas that foster the survival of plastic surgery more; we need to conduct our own research in our own areas of interest, for the betterment of our specialty," he says. "Without it how can we ever hope to remain the leaders and thinkers in surgery that we consider ourselves?"

Endowment is a perfect fit

"I have a very rosy outlook on the future of the Endowment. If we respect our original promises and goals, in 15...20...30 years, the Endowment will be a great resource for plastic surgery worldwide," states Dr. Little. The concept is that what you give remains and continues giving long after you've left the specialty. "The Endowment will remain an institution of unparalleled importance in terms of survival and growth for plastic surgery," he adds. For those who are young and have a long practice road ahead of them, they may identify with that and realize in the long run nothing is more important to the health of their careers. "Research allows us to continuously validate what we do and expand the focus of our creative discipline." Dr. Little feels that, "despite day-to-day pressures, we are lucky to be in this specialty, and we all have a natural affinity to want to give back."

Philanthropy is in our blood

Dr. Little is no stranger to philanthropy. A past president of the PSF, he has served on multiple committees, including the Endowment, and has also supported efforts in volunteer missions overseas. He humbly states, "I've tended to give to things to the degree that I can throughout my life...giving back is in our blood as plastic surgeons." Dr. Little has been able to lead over 60 volunteer reconstructive surgery missions to the island of Hispaniola, home to the nations of Haiti and the Dominican Republic. According to Dr. Little, these trips were an act of good faith, a neighborly act if you will. "I've never thought of international service as a travel club...I simply chose needy neighbors," he says. "I've been privileged to make a small contribution to both and have done it as a good neighbor."

The National Endowment lives up to his expectations

"Since its inception, I think the Endowment has done well" says Dr. Little. "The PSF has long possessed the sophisticated infrastructure for managing research and properly vetting the various grant requests in plastic surgery. Through the PSF, we involve some of the best and brightest research minds today, both within the university and outside. I think there's not another agency quite like it; and I've never had doubts of the ability of our Foundation to manage the grant applications and the difficult task of allotting funds to meaningful research from the multiple worthy requests." He believes that those that haven't participated in the Endowment will likely become contributors as they come to understand what it does for them. Dr. Little believes we all benefit from the efforts of the Endowment in some way. He feels that when people focus on the funding track-record of the Endowment, many will stand up and want to be seen as contributors to this effort on behalf of the specialty as a whole.

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Where are they now: PSF and Bahman Guyuron, MD

Investigator: Bahman Guyuron, MD
Award: 2004 National Endowment for Plastic Surgery Grant
Project: "Placebo-Controlled Surgical Treatments of Migraines"
Institution: Case Western Reserve University

When did you receive your first PSF award and what was the focus of your project?

Dr. Guyuron: I received my first PSF award in 2004. The award was funded through the National Endowment for Plastic Surgery in the amount of $100,000. The focus was on the surgical treatment of migraines and the study included a sham surgery control arm. The study showed that patients who underwent the actual surgery demonstrated statistically significantly improvements in all migraine headache measurements at one year compared to the control group.

What are you working on now?

Dr. Guyuron: We have several research projects at different stages. The one that has the potential for yielding ground breaking information is electron microscopic and proteomic differences between patients who have migraine headaches and those who do not. In this study, we are comparing a segment of the zygomaticotemporal branch of the trigeminal nerve on patients in these two groups. We also have several additional clinical research studies investigating the socio-economic aspects of migraine surgery and the factors contributing to the success or failure of migraine surgery. Additionally, we are completing several ongoing studies on identical twins.

Since you've received your PSF award, what significant scientific findings have you made in your continued efforts?

Dr. Guyuron: We have recently completed a 5 year follow-up of patients who were part of our comprehensive migraine study that was initially published in 2005. This 5 year follow-up study not only confirms our findings from our previous studies that the surgical treatment of migraine headaches in properly selected patients is likely to succeed, it provides evidence that the obtained results are enduring. Another study we have done that has yielded significant scientific findings involves our investigation of the environmental factors that influence facial aging in identical twins which was published in 2009. We observed that a twin with greater sun exposure appeared 2-7 years older than the other twin, a heavier twin over the age of 40 (a BMI difference of at least 4 points which is roughly 24 lbs) appeared up to 3 years younger, a twin who smoked appeared about 2-6 years older (depending on the length of time that twin smoked), a twin on hormone replacement therapy for at least 16 years appeared 2 to 3 years younger, a twin who avoided alcohol was perceived as younger, a divorced twin appeared 2 years older, and a twin with current or past use of antidepressants appeared up to 7 years older. A third significant study we have completed recently reported on the complication and revision rates of primary external rhinoplasty.

What applicability in today's world does your research have?

Dr. Guyuron: Plastic surgeons are becoming only known for fillers, injectables, and suction lipectomy, whereas traditionally they were known for healing wounds and reconstruction of missing parts. The discovery of a surgical treatment that eliminates pain will remind the public once more of what plastic surgery is mostly about. Our research has opened the doors for a new field in plastic surgery. Even if 1% of migraine patients undergo surgery, that translates to approximately 300,000 patients. Since an average patient has 2.5 trigger sites, this culminates in 750,000 procedures. However, the fact that so many patients will experience relief from a devastating pain is thrilling. Up to the point that we discovered a surgical treatment for migraine headaches, there was no treatment that would offer the patients lasting relief.

What would you like to see the researchers of today/tomorrow do with your work?

Dr. Guyuron: I am hopeful that our work will be the foundation for additional research in the pathophysiology of migraine headaches. Furthermore, I am hopeful that this work will evoke enough research to make the operation even simpler and more successful.

What advice would you give someone just embarking on their research career?

Dr. Guyuron: Research is exciting, rewarding, and the contributions are enduring. Discovering something new is always fascinating. There are some requirements to be an accomplished researcher. You have to have a passion for discovering new information. Often, the completion of research projects can be tedious and thus a researcher must also possess tenacity to get to the end point. I encourage new researchers to follow their dreams and keep searching for new ways to serve patients, the reward for which is unparalleled.

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Did you enjoy this issue of foundation? We would like to hear about it! Please direct your comments and inquiries to us at research@plasticsurgery.org. 

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