Abdominal Aortic Aneurysm Disease: The Silent Killer

Posted By SHL Librarian

Presented by: Ronald L. Dalman, M.D.
Professor of Surgery
Stanford University Medical Center
September 26, 2007

Lecture Overview:
There has been considerable interest recently in public education and screening for Abdominal Aortic Aneurysm (AAA) after a front page Wall Street Journal article about it received the Pulitzer Prize for Health Reporting a few years ago. There are 30,000 deaths in the US each year related to AAA, a condition that years ago claimed the life of Albert Einstein and George C. Scott. AAA occurs when a portion of the aorta becomes worn out due to the loss of elastin, a protein that promotes tension in the skin and blood vessels. The cause of an aneurysm can be genetic but smoking is the single highest risk factor in causing AAA. Dr. Dalman provided a thorough overview of the definition and clinical management for small and large AAA. While there is no clear and well-proven treatment for small AAAs (between 3 and 5.5 cm), there are surgical options for the larger, more worrisome kind of aneurysm (5.5 cm or larger).

Who?

  • AAA is among the top 15 leading causes of death in mature adults
  • 6% of men
  • 1.5 % of women

What and Where?

  • An Abdominal Aortic Aneurysm (AAA) is an enlargement of the aorta. The aorta, which starts in the heart and moves through the left side of the chest, through the diaphragm and into the abdomen, is the largest artery in the body and supplies blood to the entire body.
  • An AAA occurs in the space between the lowest part of the sternum (the blood supply to the kidneys and other organs) and the part of the aorta where it splits into the iliac arteries (supplying blood to the legs).
  • According to Dr. Dalman, there are usually six years between the identification of a 3 cm AAA and the recommendation for surgery.
  • The most common symptom is pain, often confused with back pain.
  • The growth rate is about .4 cm annually, which translates to about two and a half years for an AAA to grow a centimeter.

There are two types of surgeries to treat AAA:

  1. Abdominal aortic aneurysm open repair
    A large incision is made in the abdomen to directly visualize the abdominal aorta and repair the aneurysm. A cylinder-like tube called a graft may be used to repair the aneurysm. Grafts are made of various materials such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, non-textile synthetic graft). This graft is sewn to the aorta, connecting one end of the aorta at the site of the aneurysm to the other end. The open repair is considered the surgical standard for an abdominal aortic aneurysm repair.
  2. Endovascular aneurysm repair (EVAR)
    EVAR is a procedure that requires only small incisions in the groin along with the use of x-ray guidance and specially-designed instruments to repair the aneurysm. With the use of special endovascular instruments and x-ray images for guidance, a stent-graft is inserted via the femoral artery and advanced up into the aorta to the site of the aneurysm. A stent-graft is a long cylinder-like tube made of thin metal mesh framework (stent), while the graft is made of various materials such as Dacron or polytetrafluoroethylene (PTFE). The graft material may cover the stent. The stent helps to hold the graft open and in place.
    For patient education information and additional information on surgical repair, please visit:
    http://www.vascularweb.org/

When?
AAAs that require treatment are most likely to occur in people over 55. Often an AAA is identified when a patient is screened with ultrasound or CT scan for another condition. People with a family history and with symptoms may be screened at any time depending on a doctor’s recommendation.

Why?
The highest risk factor for AAA is smoking (a risk of 5 on a scale of 1-5) and genetics (a risk of 1.5)

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Division of Vascular Surgery at Stanford University
http://vascular.stanford.edu/
The Division of Vascular Surgery at Stanford aims to provide a model of clinical and scientific excellence in the diagnosis and treatment of vascular diseases, to deliver the highest quality of care to our patients by a team of dedicated surgeons and nurses, and to achieve these goals within an environment that fosters compassion and respects the humanity of the individual person.

Link to Clinical Trial information at Stanford Medical Center:
Abdominal Aortic Aneurysms: Simple Treatment or Prevention (AAA: STOP)
http://aaastop.stanford.edu/
If you are a patient with a small abdominal aortic aneurysm (<5.5 cm in size) and over the age of 50, you may qualify for participation in the AAA: STOP study. The goal of AAA: STOP is to gather information on AAA risk factors and determine whether an exercise program modifies the progression of AAA disease. Please contact Julie White at Stanford University for more information on this research program by phone at (650) 498-6039 or by email at [email protected].

Medicare AAA Screening Benefit
http://www.vascularweb.org/patients/medicarescreening/index.html
The Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act provides for a free, one-time AAA screening as part of the “Welcome to Medicare” physical exam.
Men and women with a family history of AAA and men who have smoked at least 100 cigarettes during their life qualify for the Medicare screening.

Dr. Dalman’s Stanford Profile:
http://med.stanford.edu/profiles/Ronald_Dalman/

Neck Pain: The Latest in Evaluation and Surgery

Posted By SHL Librarian

Presented by: Ivan Cheng, MD
Assistant Professor of Orthopaedic Surgery
Stanford University Medical Center

Lecture Overview:

  • neckNeck pain is extremely common and most often stems from the wear and tear of normal aging
  • Most neck pain without serious pathology does not need to be treated surgically; physical therapy, exercise and rest are usually recommended first
  • Surgery for neck pain benefits only a small percentage of patients
  • While fusion has been the primary surgical option, today certain conditions can be treated with implants that preserve range of motion

Anatomically speaking, your head is something like a bowling ball perched on top of a stick. In that respect, it’s no wonder that neck pain is one of the most common ailments patients report to their doctor.

“As we age, the disc space tends to collapse,” said Ivan Cheng, MD, an orthopaedic surgeon who specializes in treating neck conditions. “It’s an arthritic process, and it happens to all of us.”

The neck is made up of seven cervical vertebrae. Like other joints, neck joints undergo wear and tear with age, which can cause pain and stiffness. As you age, the disks between the vertebrae start to collapse and can narrow the space surrounding the nerves. The discs in the neck also can herniate, causing it to protrude. Tissues and bony growths (spurs) also can press on the spinal nerves, causing pain, numbness or weakness in the hand, wrist, shoulder or arm. This condition is called cervical radiculopathy, which can occasionally mimic the symptoms caused by carpal tunnel syndrome or certain neurological disorders.

The first step is to identify the source of the trouble. X-rays can show if there are any degenerative disk problems, and many physicians use an MRI to image the discs, nerves, and spinal cord. An electromyography (EMG) may also be used to evaluate and record the electrical signals sent to the muscles.

Most neck pain can be alleviated by physical therapy and/or anti-inflammatory medication. Other options, like radiofrequency neurotomy, a less invasive procedure that disables a nerve from transmitting pain signals, and steroid injections, anti-inflammatory agents injected directly into the epidural space close to the affected nerve, have not shown consistent long-term results, Dr. Cheng said. He referred to a long-term study that tracked more than 200 people with neck pain over the course of 10 years: Fewer than one-third continued to report problems after receiving nonsurgical therapy.“

The majority of people do NOT need surgery,” said Dr. Cheng. “The best therapy is usually active exercise, which is critical and often overlooked.”

However, there are cases when surgical intervention is required, such as stabilizing the neck after a dislocation or fracture, tumors, or to control certain degenerative or inflammatory diseases.

Surgeons use an anterior approach to remove the faulty disc and replace it with bone, or a posterior approach that creates new space for the nerve root by inserting a plate to relieve the pressure. Patients have reported about an 85 percent improvement using these approaches.

While fusion has been the “gold standard” in neck surgery for years, Dr. Cheng said that some studies have shown an increased rate of problems adjacent to the fused bone, and more research is needed to determine if this is indeed the case. Today surgeons are looking more toward disc replacement, which tends to preserve natural movement and range of motion. To date, the FDA has approved the use of two artificial replacement discs.

“One thing to remember is that the improvement in neurologic symptoms is due to alleviating pressure on the nerve or spinal cord, and not the implant itself,” Dr. Cheng said. “But overall disc replacement implants have been very successful in terms of reducing pain and disability.”

Surgery is also called for in certain types of myelopathy, the gradual loss of nerve function often caused by the compression of the spinal cord that can result in reduced awareness of the extremities. A patient with this type of myelopathy does not always have pain but can experience poor coordination, loss of fine motor movement, and slow reflexes. Surgery is done to halt the progression of symptoms and possibly restore some function.

“Myelopathy does not resolve on its own,” said Dr. Cheng. “It’s prolonged and slowly progressive, and once it affects the gait, it’s often too late. You don’t want the problem to go long enough for significant neurologic problems to show.”

About the Speaker
Dr. Cheng received his MD from Harvard Medical School and completed his residency in orthopaedic surgery at University of California, Davis, and his spine surgery fellowship at Washington University in St. Louis. Board-certified in Orthopaedic Surgery, Dr. Cheng has received many awards for his work, including the Timothy Bray Trauma Award from UC Davis, the Saul Halpern Orthopaedic Teacher of the Year Award from Stanford, the International Society for the Study of the Lumbar Spine Prize in Clinical Research, and Outstanding Paper Awards from the North American Spine Society.

In addition to the latest techniques in spinal reconstruction, Dr. Cheng is also trained in minimally invasive surgery and in motion-preserving surgery.

For More Information:

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About Dr. Cheng
http://med.stanford.edu/profiles/stanfordhospital/researcher/Ivan_Cheng/

Stanford Hospital Orthopaedic Surgery & Sports Medicine
http://stanfordhospital.org/clinicsmedServices/COE/orthopaedics/

Stanford Department of Orthopaedic Surgery
http://ortho.stanford.edu/

Modern Rhinoplasty: Aesthetic and Functional Surgery of the Nose

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Presented by: Sam Most, MD, FACS
Director, Division of Facial Plastic Surgery
Stanford University Medical Center
November 5, 2009

Lecture Overview:

  • Breathing problems can be caused by fixed or variable structures in the anatomy of the nose.
  • Rhinoplasty reshapes the internal and external components of the nose.
  • Functional rhinoplasty can improve breathing function and sometimes enhance facial harmony.
  • There is no ideal profile, and each patient needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries

Our noses look the way they do for a reason. Not only are they an essential component of the movement of air during respiration, they also filter particles, provide the sense of smell, help in vocal communication, and regulate humidification.

The nose is made up of a fleshy casing over cartilage, somewhat like the set-up of a tent. And like a tent, changes to the support system can change the appearance of the covering. Understanding normal nasal airflow is a complex formula based on the laws of fluid dynamics in which changes in radius affect flow rate.

Breathing problems can be caused by variable obstacles, such as when the lining of the nose thickens from allergies or sinusitis, or with fixed obstacles, which include the septum; internal structures called turbinates; and the internal nasal valve, the narrowest section of the airway.

“The anatomy of the nose dictates that any changes done to the outside will affect the inside as well,” said Sam Most, MD, director of Stanford’s Division of Facial Plastic and Reconstructive Surgery, who spoke at a presentation sponsored by Stanford Hospital Health Library. “You’re not just changing the shape of the nose. The most important aspect to consider is how to improve or maintain nasal airway function.”

Restoring Function
For many people, rhinoplasty, or a nose-job, is traditionally thought of as an operation to change the shape of the nose. However, in any rhinoplasty, function must be considered along with aesthetics-a mistake too often made by inexperienced rhinoplasty surgeons. Functional rhinoplasty is surgery that exclusively addresses fixed obstacles-the structures within the nose, though it can be combined with aesthetic (traditional) rhinoplasty.

Fixed obstacles include the septum, which is rarely perfectly straight and can sometimes block the nasal passage. A septoplasty can be performed to manipulate and straighten the septum, with almost no changes to the appearance. When swollen, an abnormal turbinate can also block the passage by changing the vascular lining. Dr. Most said the first line of defense in this case should be medical therapy, such as antihistamines or nasal steroids. If those don’t help, surgical options include radiofrequency ablation, microdebridement to remove the soft tissue, or a mucosal-sparing resection.

One of the most common causes of nasal obstruction is internal valve collapse, which may be caused by trauma or prior surgery. The degree of collapse is determined by the angle of the valve to the septum and wall. Surgery to address this problem can affect the appearance even though the primary goal is to improve breathing by widening the airway, said Dr. Most, so it is often combined with other procedures.

There are two adjacent zones involved in lateral wall support problems. For Zone 1, external nasal valve dilator strips often provide temporary relief by increasing the size of the nasal valve area. “First we try to treat this problem medically,” said Dr. Most. “But when there is a structural problem, then you need to restore the nasal structural support.”

In Zone 2, closer to the nostrils, the valve has no resistance to negative pressure and needs to be repaired. Adding cartilage (alar batten grafts) has not been proven to be effective in the long term said Dr. Most; another, more promising technique involves using a suture to stiffen the area to counteract the force when breathing.

Cosmetic Surgery
Aesthetic rhinoplasty is about both form and function. Although ideal standards have been analyzed using tip rotation, chin position, and other factors, there really is no ideal nasal form, said Dr. Most. “There’s no cookie-cutter rhinoplasty, where one size fits all,” he emphasized. “Each person needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries.”

Computer imaging has drastically changed the practice of cosmetic surgery, providing an educational opportunity for both the surgeon and the patient in terms of outcome and possibilities. Procedures are done on an outpatient basis and usually take between 1-1/2 to 3 hours or more. Most people will experience post-surgery bruising, and final results can take as long as one year as the soft tissue and skeleton settle and adjust.

Dr. Most showed several before-and-after shots of patients, showing some of the more common rhinoplasty procedures, ranging from rotation of the nasal tip (the direction of the tip of the nose) by adjusting the tip’s cartilage to straightening a crooked nose by manipulating the supporting structures. He suggested that people of Asian or African descent retain an ethnically appropriate appearance by augmenting the nasal bridge without choosing an overly Westernized profile.

About 30 to 40 percent of his referral practice involves revisions to earlier rhinoplasties, he said. “Revisions are complex because of scarring so they really need to be done by experts who know the options for repair.”

About the Speaker
Sam Most, MD, FACS, is director of Stanford’s Division of Facial Plastic Surgery and an associate professor of Otolaryngology-Head and Neck Surgery. His research and clinical priorities involve assessments of new and existing plastic surgery techniques to enhance results and quality of life for patients. He received his MD from Stanford, did his internship at Yale-New Haven Hospital, and completed his residency and fellowship at University of Washington Medical Center, where he was chief of the Division of Facial Plastic Surgery. Dr. Most has been on the Stanford faculty since 2006.

For More Information:

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About Dr. Most
http://stanfordhospital.org/profiles/Sam_Most//

Stanford Plastic Surgery
http://www.stanfordface.com/

Stanford Department of Otolaryngology
http://med.stanford.edu/ohns/

San Francisco Rhinoplasty
http://www.sfrhinoplasty.com/

Robotic Surgery in Urologic Oncology

Posted By SHL Librarian

Presented by: Mark L. Gonzalgo, MD, PhD
Associate Professor of Urology and Director of Robotic-Assisted Urologic Cancer Surgery
Stanford University School of Medicine
January 14, 2010

Lecture Overview:

    robotic.JPG

  • Since the early 2000s, when robotic surgical systems were first used to treat prostate cancer, urologic surgeons have increasingly employed the technology and expanded its applications to kidney and bladder cancer.
  • Robotic surgical systems may offer advantages in the treatment of certain cancers, however they are not a “magic tool” and should be considered simply as one of the methods at a surgeon’s disposal.
  • The most important consideration for the cancer patient is not the surgical technique, but rather the skill and experience of the surgeon.
  • There is a dearth of randomized clinical trials involving robotic surgical systems and additional research is needed.

No matter the type of surgery used to combat prostate, kidney or bladder cancer, the urologic surgeon’s goals are the same: control the cancer and interfere as little as possible with the patient’s quality of life. Surgeons have traditionally employed either “open” or laparoscopic surgery methods to remove these cancers, which collectively strike more than 300,000 Americans annually.

Robotic surgical systems have added a new tool to the surgeon’s arsenal, allowing for increased surgical dexterity and a three-dimensional, high-resolution view of the operative area.

These robotic instruments have garnered attention, in part, for the futuristic imagery they evoke. We may eventually learn that they offer significant advantages with regard to post-surgical complications, blood loss, nerve preservation, and recovery times, but it is important to remember that robotic systems are only as good as the surgeons who employ them, explained Dr. Mark L. Gonzalgo, director of Robotic-Assisted Urologic Cancer Surgery at Stanford University Medical Center, at a January presentation sponsored by the Stanford Health Library. “Robotic instrumentation is simply another tool at the surgeon’s disposal,” he said. “It is not a magic tool.”

“One of the most interesting aspects of robotic instrumentation is that the surgeon is dislocated from the patient, at a console about 10 or 15 feet away,” Dr. Gonzalgo explained. “Because the surgeon is not next to the patient, he or she relies on a specialized surgical team at the bedside.”

Robotic Surgery and Prostate Cancer
Today, most prostate cancers are detected at an early stage through PSA (Prostate-Specific Antigen) screening and rectal exams. Most are curable. Risk factors for prostate cancer include age, race and family history.  According to statistics shared during the presentation, 192,280 men in the United States were diagnosed with prostate cancer in 2009 and 27,360 died.

If surgery is determined to be the preferred treatment, the primary options are: a retropubic prostatectomy (the incision is made in the abdominal wall), a perineal prostatectomy (the incision is made in the area between the anus and scrotum), laparoscopic surgery (small incisions are made in the abdomen and a camera is used as a surgical aid), and robotic-assisted laparoscopic surgery (a robotic surgical system allows the surgeon to see vital anatomical structures more clearly and to perform a more precise surgery).

No matter the option deemed appropriate for the particular patient, “the challenge for the surgeon is how to best remove the cancer while sparing the nerves and surrounding anatomy in order to preserve sexual and urinary function,” said Dr. Gonzalgo.

Questions remain about the extent to which robotic-assisted laparoscopic surgery leads to superior outcomes.

Dr. Gonzalgo cited an October 2009 study that appeared in the Journal of the American Medical Association. The study, which relied on statistics from Medicare databases, had “several limitations,” according to Dr. Gonzalgo. However, it is one of the few upon which we can draw conclusions.  The study showed that robotic-assisted surgery resulted in shorter hospital stays and fewer post-surgical complications. However, it also showed an increase in post-surgical urinary incontinence and erectile dysfunction. “When you look into the studies that have been published, it turns out what matters most is the experience of the surgeon and the accompanying knowledge of the anatomy,” Dr. Gonzalgo said.

Robotic Surgery and Kidney Cancer
In 2009, 57,760 Americans were diagnosed with kidney cancer and 12,980 died from the disease. The primary risk factors are smoking and there are also familial forms of kidney cancer. As is the case with prostate cancer, more people are being diagnosed at the cancer’s early, more-treatable stages. In addition, surgical advances in the past five to ten years have meant that far fewer patients are losing their entire kidneys in surgery.

“Five to ten years ago, a patient with a tumor that was two centimeters in size likely would have had his entire kidney removed,” Dr. Gonzalgo said. “That’s not true today. We are learning more and more about ways of preserving kidney function via partial nephrectomy.”

Treatment options for kidney cancer include surgery (open, laparoscopic, and robotic-assisted laparoscopic), ablative therapies (the use of cold or heat energies to destroy cancer cells) and active surveillance, also known as watchful waiting or observation.

Dr. Gonzalgo cited a recent study, the largest of its kind, which involved nearly 2,000 patients with kidney tumors of seven centimeters or less who underwent partial removal of their kidneys. The study compared laparoscopic surgery to traditional open surgery and found equivalent functional and early cancer outcomes.  Minimally-invasive partial nephrectomy, however, was associated with a higher complication rate compared to open partial nephrectomy highlighting the importance of surgical experience with this procedure.

Robotic Surgery and Bladder Cancer
In 2009, 70,980 people in the United States were diagnosed with bladder cancer and 14,330 died from the disease.  Smoking is a primary risk factor.  At the turn of the century in England, doctors found a correlation between bladder cancer and certain chemicals used in the manufacture of textiles, making bladder cancer one of the first cancers to be associated with exposure to environmental agents.

Evidence of blood in the urine is the most common way bladder cancer is detected. Often, the blood is at microscopic levels and is detected as part of a physical examination. Other times, the patient may observe blood in his or her own urine. Other symptoms of bladder cancer include an increase in the frequency of urination and painful urination. These symptoms are often associated with other health issues and are not necessarily indicative of cancer.

Cystectomy is the term for the surgical removal all or part of the bladder. The surgeon’s goal is to excise the cancer with the least impact possible on the patient’s quality of life. The surgeon will employ one of several techniques to make up for the loss of all or part of the bladder and urethra, including using a portion of the small intestine to create a conduit or an internal reservoir for the urine. Dr. Gonzalgo reported that researchers are in the early stages of using stem cells to create native bladders for transplant. “We are hopeful that in five to ten years, this could become a reality,” he said.

Meanwhile, surgeons are increasingly using robotic systems in bladder surgery, citing less blood loss, fewer transfusions, and shorter hospital stays. The robotic systems can potentially result in longer operating times. Nevertheless, length of the surgery is more dependent on the skill and experience of the doctor than any other factor, Dr. Gonzalgo said.

About the Speaker
Mark L. Gonzalgo, MD, PhD, is an Associate Professor of Urology and the Director of Robotic-Assisted Urologic Cancer Surgery at the Stanford University School of Medicine. He focuses on the treatment of prostate, bladder, kidney, and testicular cancer. He also is engaged in research into the role of DNA methylation in prostate and bladder cancer, which looks at how certain genes may be useful molecular markers for disease detection.  He received his MD and PhD from the University of Southern California, did his residency at Johns Hopkins, and completed a fellowship in urologic oncology at Memorial Sloan-Kettering Cancer Center.

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Robotic-Assisted Urology Surgery at Stanford Hospital
http://stanfordhospital.org/clinicsmedServices/clinics/urology/robotic_surgery.html

Stanford Cancer Center
http://cancer.stanford.edu/

Stanford Urology
http://stanfordhospital.org/clinicsmedServices/clinics/urology/

Minimally Invasive Cardiac Surgery

Posted By SHL Librarian

Presented by: Michael Fischbein, MD, PhD
Assistant Professor, Cardiothoracic Surgery
Stanford University Medical Center

Lecture Overview:

  • Heart surgery traditionally involves an invasive procedure and the heart is stopped so that surgeons can make the necessary repairs
  • Minimally invasive techniques are being studied to treat a number of heart conditions for certain high-risk patients that previously have been treated only by open heart surgery
  • Smaller incisions mean shorter hospital stays and less recovery time
  • New techniques include replacing heart valves percutaneously and repairing aortic dissections (tears) and aneurysms with endovascular stent grafts

For most patients, heart surgery requires an invasive procedure called a sternotomy (an incision in the chest to access the heart), cardiopulmonary bypass (ability to stop the heart), a hospital stay, and a lengthy recovery period. Both cardiologists and surgeons have developed new, minimally invasive techniques that offer an alternative to certain high-risk patients, particularly older adults who might not recover quickly from major surgery.

Minimally invasive heart surgery is performed through a small incision using specialized surgical instruments. Because the incision is smaller, procedures are less painful and require shorter recovery time. While some of these procedures are still in the testing phase, early results have been extremely promising, said Michael Fischbein, MD, PhD, an assistant professor of cardiothoracic surgery, who described several surgical alternatives at a presentation sponsored by the Stanford Health Library and the San Carlos Public Library.

“There has been incredible progress in technology in the past year or two,” he said.

Coronary Artery Disease
Coronary artery disease is a condition in which plaque builds up inside the coronary arteries, blocking the supply of oxygen-rich blood to the heart muscle, which can lead to angina or heart attacks.

During a coronary artery bypass grafting procedure (CABG), blood flow is rerouted through a new artery or vein grafted past the diseased sections of the coronary arteries. Though a CABG traditionally requires open-chest surgery, it can be done both with and without the use of a heart-lung bypass machine. Certain medical centers are working on performing this operation with robotic assistance without a sternotomy.

Aortic Stenosis
The most common blockage, called aortic stenosis, is the narrowing of the aortic valve, which tends to calcify as we age. When the narrowing becomes significant enough to impede the flow of blood from the left ventricle to the aorta, heart symptoms can develop (chest pain, shortness of breath, or dizziness). Though many elderly Americans show the symptoms of severe aortic stenosis, many are not referred for surgery because of excessive risk factors, age, or comorbidities.

“Once symptoms show up, patients have a 38 percent mortality rate at one year,” said Fischbein. “About half these people are deemed too sick for surgery.”

Stanford is involved in a trial for percutaneous valve replacement that allows surgeons to access the heart by threading a catheter through the femoral artery via the groin, similar to the process used for angioplasty.

“Percutaneous aortic valve replacement is good for high-risk patients who wouldn’t do well on a heart-lung machine,” said Fischbein. “There’s no incision, and no bypass. There’s reduced chance of infection, less procedural pain, shorter recovery period, and hopefully cost effective.”

The technique is being tested in 22 medical centers in the United States, and Stanford is the only test site in Northern California. So far, about 600 people in the U.S. and about 2,000 people in Europe have received a stainless steel stent with a bovine pericardium valve delivered through the femoral artery.
Another option used at Stanford is a mini-sternotomy, which involves a small incision and partial sternotomy. The heart is stopped and an incision made in the aorta to expose the faulty valve. Surgeons can then remove the valve and sew in a new biological or mechanical one.

Thoracic Aortic Surgery
The thoracic aorta can develop abnormal dilations or bulges (aneurysm); the wall may tear, allowing blood to separate the middle and outer layers (dissection); or it may be injured from severe trauma (transection). These conditions can cause the aorta to burst or rupture, causing severe internal bleeding that can rapidly lead to shock or death.

Traditional surgery involves a large incision to repair the abnormal aorta, and procedures often last six hours or more. A minimally invasive technique called endovascular stenting was designed and introduced at Stanford in 1996. The stent graft is placed inside the aorta above and below the aneurysm, allowing the blood to pass through it without pressure on the weak spot caused by the aneurysm or dissection.

A dissection (tear) in the ascending aorta (Stanford Type A) is considered an emergency condition that cannot be treated with minimally invasive methods. A dissection that occurs in the descending aorta (Stanford Type B) is still treated through blood pressure control unless there are complications. If the patient is relatively young or has a connective tissue disease, open surgical repair is performed because the Dacron grafts have exceptional longevity. Endovascular stent grafts may not last as long, which make them more suitable for older patients and as a transition to stabilize a precarious condition.

An aortic transection is caused by a trauma like a car accident—the force can cause a tear in the aorta. Only about 20 percent of the people with this condition even make it to the hospital, said Fischbein, and even then, the mortality rate tends to be high, often because other injuries need to be addressed first. However, using a minimally invasive delivery system allows more rapid response to these patient needs: He described a young man with severe abdominal injuries from a car accident who received a stent graft while in the cath lab, which repaired his aortic injury.

About the Speaker
Michael Fischbein, MD, PhD, is a Stanford assistant professor of cardiothoracic surgery with a special interest in adult thoracic aortic diseases. He has received a number of research and teaching awards, and is a member of several professional medical associations, including the American Heart Association, the International Society of Heart and Lung Transplantation, the Longmire Surgical Society, and the Society of Thoracic Surgeons. He received his MD from Boston University School of Medicine and his PhD in microbiology and immunology from UCLA, where he performed his general surgery training and served as chief resident of the Department of Surgery. He joined Stanford in 2003 for his cardiothoracic surgery residency and joined the faculty in 2006.

For More Information:

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Stanford Heart Center
http://www.stanfordhospital.com/clinicsmedServices/COE/heart/default

Department of Cardiothoracic Surgery
http://ctsurgery.stanford.edu/

American Heart Association
www.americanheart.org/

Surgical Treatment Of Emphysema

Posted By SHL Librarian

Presented by: Joseph Shrager, MD
Chief, Division of Thoracic Surgery
Stanford University Medical Center
May 21, 2009

Lecture Overview:

  • Emphysema is a type of chronic obstructive pulmonary disease, the fourth leading cause of death in the U.S.
  • In emphysema, the tissues that support the shape and function of the lung are destroyed
  • Smoking is the leading cause of emphysema
  • A large national study showed that lung volume reduction surgery (LVRS) can help certain patients with advanced, heterogeneous disease
  • Only a limited number of patients qualify for LVRS
  • Stanford is one of only a few centers expert in LVRS for emphysema

Normally, the lungs are very spongy and elastic. During inhalation, the chest wall inflates, expanding the tissue like a sponge soaking in water. A type of chronic obstructive pulmonary disease (COPD), emphysema is characterized by the  gradual destruction of the air sacs at the ends of the airways called alveoli.

As it progresses, emphysema turns the alveoli into large, irregular pockets with holes in their inner walls. The deterioration makes the alveoli less effective and keeps oxygen from reaching the bloodstream. In addition, the elastic fibers that hold open the lung’s airways are slowly destroyed in emphysema, so they collapse during exhalation, making it difficult to breathe.

Smoking is the leading cause of emphysema, and COPD ranks as the fourth leading cause of death in the United States.

“Medical treatments may slow, but they do not reverse, the process,” said Joseph Shrager, MD, chief of the Division of Thoracic Surgery, who discussed ways to treat the disease at a presentation sponsored by the Stanford Health Library. “There’s really no therapy available to halt the downward course.”

Among non-surgical therapies, only oxygen therapy in patients with low blood oxygen levels appears to improve survival, he said.

Unlike other types of COPD, like chronic bronchitis and asthma, which are mainly inflammatory conditions, emphysema is a structural problem that is sometimes amenable to surgery, he said.

Surgery for emphysema evolved from a procedure used to treat giant bullae: When these large dilated airspaces were removed, nearby lung tissue could expand. The same logic held for emphysema—removing a portion of the damaged lung created more space for the working areas. The theory underlying lung volume reduction surgery (LVRS) is to reduce the lung size by taking out the parts that are taking up space but not contributing much to the exchange of oxygen and CO2. The airways will be held open better and the breathing muscles will return to a more normal position, making breathing easier.

“You are generally better off taking out more rather than less of the lung tissue,” said Dr. Shrager, who has performed 67 LVRS surgeries to date using both traditional sternotomy to open the chest and less-invasive thorascopic techniques.

LVRS was first used to treat emphysema in the 1950s but  didn’t gain popularity until the 1990s. In 1997, the National Emphysema Treatment Trial was established to clarify the risks and benefits of the surgery. The study showed that certain patients had impressive, improvement in function and in quality of life, and it helped identify the criteria for the people who would most benefit from this approach. One group of patients even showed an improved longevity after the operation.

The ideal patient for LVRS has heterogeneous disease, with some sections of the lung more affected than others; has severe disease, with lungs more than double the normal size; and has emphysema, not chronic bronchitis. Age is not necessarily a factor—only physiology.

“Only a limited number of patients qualify for LVRS, and it’s important to be careful in patient selection,” said Dr. Shrager. “We screen at least twice as many patients as we do surgeries on because we want to provide a successful result. Stanford is one of only about 30 centers in the country experienced in treating emphysema by surgery, and the results have been outstanding.”

Though advanced cases can be treated with lung transplantation, Dr. Shrager said there is usually a wait of one year or more for a transplant, and four-year survival rates are about 60 percent. Also, with the need for lifelong immunosuppressant drugs, he added, “you are replacing one disease with another.”  Lung transplant is therefore reserved for emphysema patients who are not candidates for LVRS.

About the Speaker
Joseph Shrager, MD, is a professor of cardiothoracic surgery and chief of the Division of Thoracic Surgery at Stanford. His clinical expertise is in surgery for lung cancer, emphysema, and mediastinal masses, and his research focus is in the molecular physiology of the diaphragm and other respiratory muscles. He received his MD from Harvard Medical School, trained in surgery at the University of Pennsylvania, and completed his thoracic surgery training at Massachusetts General Hospital. He served as chief of thoracic surgery at Pennsylvania Hospital and the Hospital of the University of Pennsylvania before joining Stanford in 2008. Dr. Shrager is listed as one of “America’s Top Doctors” and appeared for several years as a “Top Doc” in Philadelphia Magazine.

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Stanford Division of Thoracic Surgery
http://thoracicsurgery.stanford.edu/

Stanford Chest Clinic
http://stanfordhospital.org/clinicsmedServices/clinics/pulmonaryMedicine/

National Emphysema Treatment Trial
http://www.nhlbi.nih.gov/health/prof/lung/nett/lvrsweb.htm#what

Minimally Invasive Aesthetic and Functional Jaw Surgery

Posted By SHL Librarian

Presented by: Sabine Girod, MD, DDS, PhD, FACS
Associate Professor, Oral and Maxillofacial Surgery
Stanford University Medical Center
October 20, 2011

When it comes to your face, how you look and what lies beneath your skin are intimately related. Facial aesthetics are based on balance and symmetry, which are determined by the set of your bones and teeth. From Nefertiti to Mona Lisa, attractive faces share uniform proportions that are balanced and relatively symmetrical. Research has shown that most people seem to have similar ideas about what constitutes an attractive face, which generally features wideset eyes, a large forehead, prominent cheekbones, thick lips, and a small, short nose and chin.

But aesthetics are only part of the issue, said Sabine Girod, MD, DDS, PhD, FACS, an associate professor of surgery, at a presentation sponsored by the Stanford Health Library. Dr. Girod specializes in oral and maxillofacial surgery (OMS), a specialty that combines dental, medical, and surgical skills.

While skeletal and dental structures are the basis of good looks, more than your self-esteem can suffer when things are off-kilter. Poor skeletal structure or jaw alignment can cause chronic pain, dental or orthodontic problems, sleep disorders, breathing problems, or speech impediments.

“In OMS we do a lot of initial and ongoing analysis of both the bones and teeth to determine where the deficiencies and imbalances are and what changes we can make to improve symmetry and function,” Dr. Girod said. “Often we can change these asymmetries by doing oral surgery. In a case of a recessive jaw, for example, the right surgery can change move the jaw forward, which can balance the facial features, improve function, and make the bite better.”

Improving Function and Appearance
Surgical techniques have changed drastically over the past decade and most are now minimally invasive, leaving no facial scars. For problems like an imbalanced lower jaw or receding jaw, orthognathic surgery combines orthodontic treatment with surgery to correct function and balance between the teeth, jaws, and facial structures. Various techniques can be used to correct anomalies, such as when the jaws do not align or when the teeth do not fit. The surgeon will realign the jaw, working from the inside of the mouth or under the lip, and will stabilize the jaw by using small plates held in place with bands.

“The plates are stable enough that you don’t need to wire the jaw shut any more,” said Dr. Girod, who showed several before and after photos of patients. “After about 10 days we can take out the elastic bands and the patient can start on soft food. The jaw never needs to be wired shut.”

Addressing Sleep Disorders
Orthognathic surgery is used to treat people with obstructive sleep apnea, a condition that affects more than 13 million people in the United States—though less than one-quarter receive treatment. People with apnea experience recurrent episodes throughout the night in which their throat closes and they cannot pull enough air into their lungs. The lack of oxygen causes the person to awake repeatedly, which leads to extreme daytime drowsiness. People with untreated sleep apnea face a greater risk of stroke and are more likely to have heart disease, along with hypertension, arrhythmia, and stroke.

Dr. Girod is a specialist in maxillo-mandibular advancement, a surgery for obstructive sleep apnea that realigns the jaw. Because the procedure not only corrects the compressed airways but also affects the person’s profile, she utilizes computer simulation to plan the operation, using three-dimensional virtual planning programs to anticipate the end result.

“We always try to correct function in a way that makes the patient look good,” she said. “This procedure affects not only function but aesthetics, and most patients have been very happy with the results.”

Dr. Girod is also involved in refining a technique called distraction osteogenesis, which stimulates the growth of new bone. The jaw is cut and pulled apart slowly with a distractor in small increments—about a millimeter a day—allowing new cells to grow between the segments. She compared it to the process used to lengthen a leg and said that the technique can correct asymmetries and discrepancies in both the upper and lower jaw.

Minimally Invasive Procedures
Another minimally invasive procedure called orthodontic distraction has shown to remedy facial deformities and enhance orthodontic treatment in children, eliminating the need for jaw surgery later on. The technique pulls on the bone, rather than the teeth, and can correct many jaw problems during the child’s growth..

“You can pull on the bone while the sutures are still open,” said Dr. Girod. “It takes about a year, but all they have to do is use these rubber bands day and night. The idea is to avoid any other treatment later on. We’ve been seeing a lot of success and positive development with this approach.”

About the Speaker
Sabine Girod, MD, DDS, PhD, FACS is an associate professor in the Department of Surgery and chief of Stanford’s Oral Medicine and Maxillofacial Surgery Service. She is also director of the Stanford Plastic Surgery Adult Clinic. An expert in oral and maxillofacial surgery, Dr. Girod has a special interest in refining virtual surgical simulations to plan surgical outcomes. She received her degree in dentistry from the University of Bonn in Germany and continued her medical training, residencies, and fellowship at Harvard Medical School, the University of Cologne, and Hannover Medical School in Germany.  She has been at Stanford since 2000.

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About Dr. Girod
http://stanfordhospital.org/profiles/Sabine_Girod

Stanford Oral Medicine and Maxillofacial Surgery
http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/oralsurgery/

Stanford’s Division of Plastic Surgery
http://plasticsurgery.stanford.edu/

American Association of Oral and Maxillofacial Surgeons
http://www.aaoms.org/jaw_surgery.php

Breast Reconstruction: What Every Woman Needs to Know

Posted By SHL Librarian

Presented by: Gordon Lee, MD
Assistant Professor, Plastic and Reconstructive Surgery
Stanford University Medical Center
July 24, 2013

Watch the video

Plastic surgery in one form or another has been around for hundreds of years. Although most people today think primarily of cosmetic procedures, the fundamental premise is to reconstruct or repair parts of the body. The “plastic” comes from the Greek, plastikos, which means “to mold or to shape.”

For the one in eight American women dealing with the aftereffects of breast cancer treatment, such as a mastectomy or lumpectomy, reconstructive surgery can restore their body’s natural shape and form, and provide life-enhancing psychological benefits, such as improved self-esteem and confidence. Breast reconstruction can be done at the same time as the cancer surgery or it can be done as a delayed procedure.

“The goal of any reconstructive surgery is to restore symmetry and balance,” said Gordon Lee, MD, an assistant professor of plastic and reconstructive surgery and director of Stanford’s microsurgery program, at a presentation sponsored by the Stanford Hospital Health Library. “It’s a personal choice. It’s not about chronological age, but about physiologic age, as long as the woman is in relatively good health.”

Implants
The most common breast reconstruction option is implants, and in fact almost two-thirds of all women choose some form of implant at some point after breast cancer surgery, he said.

“Implants are considered a safe procedure for both cosmetic and reconstructive surgery,” he added. “They require only a brief surgery and can be done at the same time as the mastectomy or can be done later. Recovery is relatively rapid, and the result can be quite good.”

Breast implants are made of either silicone gel or saline. Saline implants are filled with sterile salt water, while silicone implants are filled with a thick Jell-O-like fluid. Most women feel that silicone breast implants look and feel more like natural breast tissue, said Dr. Lee, and about 95 percent of his patients chose silicone over saline.

The implants first require tissue expansion, a process that stretches the chest skin and soft tissues to make room for the breast implant. The process takes place gradually, typically over several months, as the cavity is stretched in stages. Once the implant is in place, surgeons can construct and tattoo a nipple as an outpatient procedure.

There are some complications to implants, including the possibility of infection, asymmetry, ripples, hardness, and the need for revisional surgery later on. Implants can also rupture. If a saline breast implant ruptures, the implant will deflate, causing the breast to decrease in size and shape. The saline is absorbed by your body, with no health risks. If a silicone breast implant ruptures, it is often not noticed since the silicone tends to remain trapped in place. Women with a silicone implant need to get an MRI every three years to ensure it remains intact.

Using Your Own Tissue
Women can also use tissue transplanted from another part of the body, a process called autologous reconstruction. A flap of tissue is detached, usually from the abdomen, thighs, or butt, and moved to the chest, where it is formed into the shape of a breast. Using specialized surgery techniques such as microsurgery, the tissue is stitched into place along with its blood vessels and subcutaneous fat.

Breast reconstruction using transplanted tissue usually lasts a lifetime and looks natural. However, the procedure can be lengthy and requires a longer recovery time, and not every woman is a good candidate, Dr. Lee said.

The most common approach is the TRAM flap, which transfers tissue, vessels, and sometimes some muscle from the transverse rectus abdominis, a muscle in the lower abdomen. Surgeons can either cut the tissue and reconnect it (a free TRAM flap) or move it up under the skin (a pedicle TRAM flap).

“A TRAM flap is great for some women because they get a tummy tuck along with the breast reconstruction,” said Dr. Lee, “sort of like a two-for-one surgery.”

In another technique called a DIEP flap, fat, skin, and blood vessels—but no muscle—are cut from the lower belly and moved up to rebuild the breast. Because the DIEP flap requires highly specialized training and expertise in microsurgery, not all surgeons can do the procedure and it’s not available at all hospitals.

Another variation is called a SIEA flap, named for the superficial inferior epigastric artery, a blood vessel that runs just under your skin in the lower abdomen. This approach works in only a small number of patients, said Dr. Lee.

For women who do not have sufficient abdominal fat, flaps can also be taken from the thighs, hips, or butt, although these options are much less common. Stanford is one of only a few comprehensive medical centers on the West Coast to offer the full range of procedures for patients to choose from.

Using Your Own Tissue With an Implant
Another tissue transplant option uses the latissimus dorsi muscle, which is located in the upper back. An oval flap of skin, fat, muscle, and blood vessels is moved under the skin around to the chest to rebuild the breast. The blood vessels remain attached to their original blood supply in the back. The transplanted skin can then be stretched to accommodate an implant.

Because there’s usually not much fat on this part of the back, a latissimus dorsi flap is a good option for women who have had radiation, since radiated skin does not stretch. The procedure leaves a scar, but most surgeons try to place the incision so that it’s covered by a bra strap or leave a scar within the natural lines of the skin.

Surgical Issues
Research has shown that the more a surgeon performs a procedure, the better the results, said Dr. Lee, so be sure to ask your doctor how many reconstructions he or she has done. Be sure your surgeon is Board Certified by the American Board of Plastic Surgery and ask about areas of expertise and specialized training in microsurgery.

Women considering breast reconstruction should be aware of the possible risks associated with surgery, advised Dr. Lee. Complications range from infection to clot development, flap necrosis (where the transplanted skin dies), seroma (a fluid-filled mass), or ripples under the skin. Recovery times vary, and women who smoke, are diabetic, or are greatly over- or underweight are not good candidates for surgery.

Some women prefer to have breast reconstruction immediately, which has less scarring and often shows better results, but can delay follow-up chemotherapy or radiation therapy if complications occur. Others choose to delay reconstruction. Since every woman is different, only an individualized consultation with an experienced plastic surgeon can help you decide which option is best for you.

For women who do not want to undergo additional surgery, an external prosthesis or foam bra can be used for a natural appearance. Available in many colors, sizes, and shapes, these prostheses can be made of silicone, foam rubber, fiberfill, or cotton.

About the Speaker:
Gordon Lee, MD, is an assistant professor, associate chief of clinical affairs in plastic and reconstructive surgery, and director of Stanford’s microsurgery program. He is nationally recognized for his contributions to surgical education and training in plastic surgery, and conducts ongoing research in surgical outcomes of breast reconstruction. Dr. Lee received his medical degree from Stanford and did his internship and residency at UCLA, followed by a fellowship at MD Anderson Cancer Center in Texas. He is Board Certified in Plastic Surgery by the American Board of Plastic Surgery.

For More Information

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About Dr. Lee
http://stanfordhospital.org/profiles/frdActionServlet?choiceId=printerprofile&&fid=7663&profileversion=full

Plastic and Reconstructive Surgery
http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/plasticReconstructive

Breast Cancer Surgery
http://cancer.stanford.edu/surgery/breast.html

Division of Plastic and Reconstructive Surgery
http://plasticsurgery.stanford.edu

 

 

 

Aesthetic and Functional Maxillofacial Surgery

Posted By SHL Librarian

Presented by: Sabine Girod, MD, DDS, PhD, FACS
Associate Professor, Plastic and Reconstructive Surgery
May 19, 2016

Oral and maxillofacial surgery is a surgical specialty for the diagnosis and surgical treatment of diseases, injuries, and defects of the upper and lower jaw. Procedures range from repairing congenital deformities to realigning jaw placement to replacing bone removed during cancer treatment.

Poor skeletal structure or jaw alignment can cause chronic pain, dental or orthodontic problems, sleep disorders, breathing problems, or speech impediments. Since facial malformation or damage is so apparent, it can create psychological and emotional trauma as well as a social stigma for the patient.

“Procedures can make a huge change in a person’s appearance. It’s more than just surgery—it really does change people’s lives,” said Sabine Girod, MD, DDS, PhD, FACS, an associate professor of surgery, who spoke at a presentation sponsored by the Stanford Health Library. Dr. Girod specializes in oral and maxillofacial surgery (OMS), a specialty that combines dental, medical, and surgical skills.

Improved Techniques
Surgical techniques have changed drastically over the past decade. Instruments have been refined, and stabilizing techniques have made procedures safer, more comfortable, and with more predictable outcomes. Procedures have been shortened to as little as three to four hours, and most are now minimally invasive and done on an outpatient basis. Corrections are performed inside the mouth or under the lip, leaving no facial scars.

Orthognathic surgery is used when jaws don’t meet correctly, such as when the lower jaw juts out or teeth are misaligned, to correct function and balance. This not only improves facial appearance but also ensures that teeth meet correctly and function properly. The surgery can improve chewing, speaking, and breathing, as well as improve the appearance of the chin and jaw.

The practice has been used for more than 30 years, though in the past a patient’s jaw usually was wired shut for several weeks after the procedure to keep it stabilized while the bone realigned. Today small titanium plates are attached to the jaw that can be adjusted with bands that can easily be taken off for talking or eating. Food must be soft to avoid putting pressure on the jaw as it heals.

“The plates are stable enough that the jaw never needs to be wired shut,” said Dr. Girod. “The plates used in orthognathic surgery represent one of the field’s most dramatic advances.”

Growing New Bone
Distraction osteogenesis is the surgical technique of generating new bone by progressive stretching of divided segments. The jaw is cut and pulled apart slowly with a distractor in small increments, which allows new cells to grow between the segments. Once the new bone is strong enough, Dr. Girod removes the distraction device. The technique is used mostly in children with congenital deformities but also is used in adults to correct asymmetry and misalignment in the upper and lower jaw.

Since children’s bones are not yet completely fused, another minimally invasive procedure called orthodontic distraction can be used to repair facial and jaw deformities. The facial bones are pulled out using plates inserted into the jaw bones that are adjusted with rubber bands over time.

“There is a benefit to doing these corrective procedures in kids while they are young instead of waiting for them to get older,” Dr. Girod said. “Not only is the bite corrected, the facial deformity is removed and there is an improvement in facial aesthetics.”

Dr. Girod is a specialist in maxillomandibular advancement, a surgery for obstructive sleep apnea that opens the airway for easier breathing during sleep. Current treatment involves realigning the jaw 10-15mm; she is involved in studies to determine whether less displacement of the jaw will result in predictable and positive outcomes

Revolutionary Advances
Another revolutionary improvement is in the use of computer imaging. Computer modeling and virtual simulation are used both to plan procedures before Dr. Girod and her team head into the operating room and to show patients how they will look after the surgery.

“I used to make plaster molds of each patient to plan the surgery. Now I prepare with computer modeling,” she said. “It’s a big improvement.”

Treatment begins with meticulous measurements, photos, X-rays, skeletal analyses, and CT and MRI imaging scans that are consolidated into a composite image. Computer modeling creates precise three-dimensional mockups that are used to plan the operation and practice the steps that need to be taken. Dr. Girod uses Digital Imaging and Communications in Medicine (DICOM), a system for storing, printing, and transmitting medical imaging information, to create virtual fly-throughs of the skull to assess all aspects of the patient’s anatomy. This painstaking planning process ensures that the surgery will result in improved symmetry and function.

“I can see in three dimensions exactly how I need to move the jaw and go into surgery with guides for navigation and follow-up,” she said. “The advances over the past 10 years are simply amazing and bring us that much closer to providing personalized care.”

Dr. Girod has a special interest in refining virtual surgical simulations to plan surgical outcomes. She is collaborating with Da Vinci, a company that designs robotic surgical systems, to apply robotics to enhance facial contouring procedures, and she described new inroads in augmented reality that use surgical navigation systems that superimpose X-rays over the patient during an operation. Other research is developing “smart” contact lenses that project anatomical images into the eye.

About the Speaker
Sabine Girod, MD, DDS, PhD, FACS is an associate professor of surgery (plastic and reconstructive surgery) and, by courtesy, of otolaryngology-head and neck surgery. An expert in oral and maxillofacial surgery, she is chief of Stanford’s Oral Medicine and Maxillofacial Surgery Service and director of the Stanford Plastic Surgery Adult Clinic. She received her degree in dentistry from the University of Bonn in Germany and continued her medical training, residencies, and fellowship at Harvard Medical School, the University of Cologne, and Hannover Medical School in Germany. She has been at Stanford since 2000.

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About Dr. Girod

Maxillofacial Surgery Clinic

Stanford Oral Medicine and Maxillofacial Surgery

Division of Plastic Surgery