Surgeon Andrew Greensmith played a leading role in the operation that last year separated the conjoined Bangladeshi twins, Krishna and Tishna. He returns to Dunedin to take part in the city's International Science Festival next month. Reporter John Gibb talks to him about the surgical marvels of the future.
The steady hand, keen eye and sharp blade of surgeon Andrew Greensmith reshape the way his patients look.
In doing so, and most famously in the case of conjoined Bangladeshi twins, Krishna and Tishna, he changes their lives.
In a world ever more obsessed by appearance it seems likely that people in his field will continue to push the boundaries of what is possible. As they do so, Mr Greensmith, a University of Otago medical graduate, hopes society will also consider the importance it places on cosmetic concerns and the need for tolerance of differences.
Advanced surgery will in future offer new hope for people with facial deformities, he says. says.
Mr Greensmith, now a Melbourne-based plastic and craniofacial surgeon and consultant at the Royal Melbourne Children's Hospital, believes that face transplants are likely to become more frequent over the next five years to 10 years, if problems involving drugs to suppress the immune response can be resolved.
"Yes, absolutely, if we can work out the pharmacology to control the immune system in a safer way."
Those likely to benefit include people with facial deformities - arising either through accident, or from medical conditions - who can suffer from bullying and other negative social attitudes.
"These examples show just how badly people may suffer from facial deformities - how far surgical techniques have come but how little society has changed - as society becomes more materialistic and self-centred, in some ways there is seemingly less tolerance of facial or bodily difference/deformity and less empathy in general sometimes.
"Face transplants, when we work out how to produce safer anti-rejection drugs, will offer great hope to people with extreme conditions such as neurofibromatosis."
Neurofibromatosis is a condition in which tumours can grow on nerve tissue, causing skin changes and bone deformities.
Over the past five years, plastic surgeons had "started to explore and perform face and limb transplants", Mr Greensmith said.
Plastic surgeons had been "technically able to do these operations" because of their pioneering development of the field of microsurgery - the world's first kidney transplant having been performed by Boston plastic surgeon and Nobel laureate Joseph Murray.
Nevertheless, many surgeons had "held off, knowing that the anti-rejection drugs required lifelong following these ops are, in fact, life-threatening in the long term".
"However some plastic surgeons have recently controversially pushed ahead despite this, in patients so terribly affected by absence of limbs or extreme facial deformity that they argued that it was worth the risk."
About a dozen such operations had been completed in the past five years, but there had already been a "significant number of deaths", so the procedure remained controversial.
But there was also a "strong case" for society to increase its understanding of, and to rethink its attitudes to, people who looked different.
"That is a moral and ethical argument that all societies have to deal with. As plastic surgeons, in some cases, even with face transplants, we can only make major improvements in appearance but patients may still look far from normal and that will always be the case.
"Society tends to fear what they do not understand, including facial difference, and that leads to discrimination/cruelty and stigma which are all influenced by cultural beliefs," he said.
"As plastic surgeons, many of the techniques that we are leading in cosmetic surgery, such as fat grafting for rejuvenation, are being used in reconstructive problems like neurofibromatosis.
"The two fields of cosmetic/aesthetic surgery and reconstructive surgery cross over and should never be separated.
"Plastic surgeons are the only specialty involved in both and I believe you cannot be a good reconstructive surgeon without a good aesthetic eye and being a good aesthetic surgeon, and vice versa," he said.
He was also asked whether replacement organs, grown outside the body, were likely to be replaced in the body over the next five to 10 years.
"At this stage we are still a long way from tissue engineering to the stage of having 'off the shelf' organs/ limbs etc. We have, however, started to be successful in engineering real human tissues in an early form in the laboratory, often from stem cells.
"Yet this is only at the stage of producing a type of cell , such as beating heart muscle cells, breast tissue, ears, but without the structure/shape of these organs and without structural integrity.
"Plastic surgeons are leading many of the research teams in this field."
However, working out "how to produce such organs in a durable form" was probably up to 20 years away, at least.
Asked what the recent conjoined twins operation and its successful outcome contributed to the future of surgery, he said that plastic surgeons were "constantly innovating in many aspects of surgery".
"This spirit of innovation is alive and well and bodes well for the future.
"The success of the conjoined twins surgery has certainly advanced the knowledge and treatment of this condition worldwide, with the operation being recognised in the field as probably the most successful so far."
A key to success with the twins' surgery was "meticulous planning"- and "many years already working on a weekly basis as a team on complex and at times very risky reconstructive challenges involving children's skulls and faces in those afflicted by birth defects involving the face and skull. This is what the field of craniofacial surgery is all about".
"There are very few people ever trained in the field of craniofacial surgery, a subspecialty of plastic surgery, due to the rarity of the conditions treated," Mr Greensmith said.
"The twins just represented an absolutely extreme version of what we do on a regular basis, with the added complexity of involving two patients and where failure was likely to be life-threatening and not salvageable.
"Training in the New Zealand system, we are strongly grounded in the principles outlined by the late Sir Harold Gillies, the father of modern plastic surgery, and a New Zealander hailing from Dunedin."
As well as giving a keynote address during the latest New Zealand International Science Festival (July 6-11), Mr Greensmith will also take part in a medical forum for doctors and give a fully-booked workshop for children on ear and nose reconstruction.
"It is a great excuse to revisit my university town and rekindle some fond memories."
It was likely to be "quite emotional" coming back, including heading down to the Captain Cook for a beer, or visiting St Clair beach again "even in winter" - a place where he had previously enjoyed surfing.
"Dunedin was always the place that held the best memories - a close-knit university town with a student camaraderie probably not rivalled in many parts of the world.
"The city is very special and I have been back half a dozen times since including graduation, but not for maybe 14 years now."
• CATCH HIM
Melbourne-based plastic surgeon Andrew Greensmith will give a keynote talk on "The Cutting Edge - Achieving Surgical Marvels" at the St David Lecture Theatre. $10 for adults.
Bookings are recommended at http://www.scifest.org.nz.
He will also run a facial reconstruction workshop for children, now fully booked, at the Otago Settlers Museum, and take part in a medical forum for GPs and health sector staff during the latest New Zealand International Science Festival (July 6-11).
