The University of Southampton

Author: Elsie Clutterbuck

More Than Metal: The Science, Ethics and Reality of Facial Implants

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After learning about prosthesis (replacing a body part or joint) and orthosis (external support promoting healing) I reflected on my own experience. I had a Le Fort I osteotomy, a surgery to reposition the upper jaw. This doesnā€™t fit either prosthetic or orthosis categories, but is somewhere in between. Ā I knew metal implants were used for this, but hadn’t considered why or how they work.

The best person to learn from was the surgeon himself, so on my previous visit I interviewed with questions based on topics discussed in the lecture:

Me: What material was used in the metal implants and why?

Surgeon: Medical grade titanium, because its biocompatible

Me: How was the metal implanted to hold the jaw?

Surgeon: There are two stages. Primary stability is done in surgery, itā€™s the tightening of screws into the bone and then you find the bone grows in the threads of the screws and will grow in and over and around the plates, osteointegration itā€™s called and thatā€™s the secondary stability

Me: How does it change for different sizes and shaped jaws?

Surgeon: There’s a website here, you can even find the whole guide if you want about all the screws they make and where they use them, different plates, different sizes. So, in the face depending on how much load it has to take you change how thick the plates are.

The website mentioned, which allowed me to visualise how the implants were used:

Website Link

He provided me with my x-ray, showing exactly how the implants are positioned:

The interview, the website and x-ray gave me a deeper understanding of the role of the metal implants. This led me to create this image, showing how the implants are used:

The interview revealed similarities between facial implants and joint replacements, particularly the porous material that I observed in the practical, which allows bone to grow into to stabilise.

Although biomedical engineers design implants to reduce failures, they do occur due to infection, breakdown between implant and bone, and migration of implant. The lecture on this topic made me curious if the same was true for metal implants in the face.

Further reading showed in a study of 485 orthognathic cases, 93 complications were recorded, including failure of fixation, requiring re-intervention (Zaroni et al. 2019). This made me reflect on the ethical considerations when offering this surgery. Unlike prosthetics, which are needed due to pain, orthognathic surgery, is often for aesthetics and ease of eating, both of which are not essential. This raises an ethical dilemma: if not needed, is it worth the risks, even if minimal?

The legal and ethical solution to this is informed consent. This video helped me understand what this actually entails:

I felt the NHS definitely achieved this in my case by repeated discussions over several years. However, I believe knowing the risks doesnā€™t compare to experiencing them. Something I found extremely useful before my surgery was finding others on social media who had had the same or similar procedures. It showed me the reality of recovery and possible complications. I believe informed consent could be improved by sharing first-hand experiences so I designed a template for a website which would facilitate this.

My Website Template

This would allow more in-depth discussions on what the recovery process is like and how other people experienced complications, rather than just the surgeonsā€™ perceptions. Personally, the minimal risks were worth the outcome, but seeing others who had same procedure helped me make a truly informed decision.

Embryonic Stem Cells: Medical Breakthroughs vs. Moral Boundaries

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What Are Embryonic Stem cells?

Stem cells have the unique ability to change into other types of cells, offering exciting possibilities for future medical treatments. The most versatile type are embryonic stem cells (ESCs), which can self-renew and are pluripotent meaning they can change into any cell type. These cells are collected from 3ā€“5-day-old embryo called a blastocyst.

Image: A basic diagram of embryonic stem cells https://www.eurogct.org/embryonic-stem-cells-where-do-they-come-and-what-can-they-do-0

What can these cells potentially be used for?

In many diseases damaged cells cannot replace themselves. For example, after a heart attack, the body cannot replace lost heart tissue. Therefore, thereā€™s a wide range of potential uses including treatment of Alzheimerā€™s, blindness, deafness, lung disease and autoimmune diseases. A key example from Shufaro and Reubinoffs paper in 2004 is in the treatment of neurological diseases like Parkinson’s disease and multiple sclerosis, which may one day be cured by stem cells.

Stem cell treatments are not only a futuristic idea. In his book, Embryonic stem cells and the law: crafting a humane system of regulation, Joshua Weiser shares his experience with a reoccurring tumour in his leg. The removal left him with scar tissue causing him a lot of pain. Stem cells were injected to allow new tissue to grow, which was lifechanging for Joshua, relieving him of his pain.

The ethical debate

Protest outside a lab in San Diego, California, in 2002 https://www.spiegel.de/fotostrecke/photo-gallery-the-future-of-stem-cell-research-fotostrecke-95152.html

The prominent ethical issue of ESCs centres on when life begins, at conception, or later in development. The Catholic Church for example opposes research involving human embryonic stem cells. In a conference for the Centre for Stem cells and Regenerative Medicine, the Catholic Bishops stated that ā€œwe must protect life at all timesā€.  

A news article example of an ESC protest https://www.nature.com/articles/21946.pdf

This statement from an interview with the president of the Harvard stem cell institute demonstrates the opposing view: ā€œIt is important to be clear about the embryo from which stem cells are extracted. It is not implanted and growing in a womanā€™s uterus. It is not a foetus. It has no recognizable human features or form. It is, rather, a blastocyst, a cluster of 180 to 200 cells, growing in a petri dish, barely visible to the naked eye.ā€. I believe the reason this debate is so divided is because once someoneā€™s opinion has formed it cannot be changed and often no amount of evidence will alter this.

What are the laws?

Christopher Reeve https://www.yorkshirepost.co.uk/whats-on/arts-and-entertainment/christopher-reeves-story-uk-cinema-release-date-age-rating-runtime-cast-list-4844415

As opinions of ESCs are so varied, the laws can be very different worldwide. The UK has one of the most permissive set of laws with the Human Fertilisation and Embryology Act (legislation.gov.uk, 2008), which allows research on fertility, contraception, gene and chromosomal abnormalities, and potential disease cures. On the other hand, some countries do not allow ESC research, for example Italy, which prohibited ESCs in 2009. Ā A famous advocate for stem cell research was the Superman actor Christopher Reeve, who became quadriplegic after a horse-riding accident in 1995. The US was considering banning ESCs at the time and his inspiring work helped prevent this.

What Are The Alternatives?

To avoid ethical concerns, adult stem cells can be used, but these cells are limited as they cannot produce all cell types. In 2007 induced pluripotent stem cells (iPSC) were first discovered by Dr Shinya Yamanaka. This video shows how these cells are made and some of the ways they are used:

 I believe whenever possible, alternatives should be prioritised. However, in cases where there are no other options, I personally believe ESCs should be used and are justified, as the potential scientific breakthroughs could save lives. That said, it is important to consider the differing beliefs and therefore ensure informed consent is gained from anyone donating embryos.

References

legislation.gov.uk (2008). Human Fertilisation and Embryology Act 2008. [online] Legislation.gov.uk. Available at: https://www.legislation.gov.uk/ukpga/2008/22/contents.

Shufaro, Y. and Reubinoff, B.E. (2004). Therapeutic applications of embryonic stem cells. Best Practice & Research Clinical Obstetrics & Gynaecology, 18(6), pp.909ā€“927. doi:https://doi.org/10.1016/j.bpobgyn.2004.07.002.