The Role of Plastic Surgery in Critical Care Medicine with Dr. Benjamin Levi

This episode of Scrubcast features Dr. Benjamin Levi, our honored guest at the 2024 Emile F. Holman Lecture. He shares insights on his motivation for merging plastic surgery with critical care, emphasizing the holistic care of burn patients from acute treatment to long-term reconstructive surgery.

Levi’s primary research focus is on heterotopic ossification. He explains how injuries can lead to bone formation in unintended locations and the implications for patient care. He highlights how each of the places he’s lived, worked, and studied contributed uniquely to his research and clinical practice.

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Joining us today from Texas is Dr. Benjamin Levy. Welcome.

Benjamin Levi: Thank you so much. Great to be here.

Rachel Baker: Dr. Levy is our honored guest at the 2024 Emil F. Holman Lecture.

Now, for Holman Day, each of our divisions chooses the speaker on a rotating basis. And this year, it was the Division of Plastic Surgery's turn. So imagine my surprise when my initial online stalking of Dr. Levy revealed he is Chief of Burn, Trauma, Acute, and Critical Care Surgery at UT Southwestern. You are a trained and board- certified plastic surgeon, right?

Benjamin Levi: That is correct, yes.

Rachel Baker: So this is pretty uncommon for a plastic surgeon to go into critical care. What motivated you down this pathway?

Benjamin Levi: Yeah, [00:01:00] it definitely is a path less chosen and one that you also have a phenomenal person, Dr. Cliff Schechter, who has followed a similar path. I have had an interest in burn surgery really since I was introduced to medicine.

And what's so unique about burn surgery is it's one of the few fields of surgery where you get to take care of patients across the continuum of care, and you get to take care of adults and kids. So if a patient, a burn patient comes in, they've had, you know, one of the worst days of their lives. They have one of the most painful injuries.

And as a burn surgeon, you get to take care of them in that moment. You get to help them through their initial surgeries. And if, if you haven't trained in plastic surgery, usually that's where your relationship with that patient ends. And what is so unique, I think, to be a burn surgeon and a plastic surgeon is that that really is just the beginning of your relationship with the patient.

You get to care for them beyond their discharge from the [00:02:00] hospital when they come now with scars and other areas that they would like attention. to help improve the quality of their life, um, the appearance of their scars, as well as the pain and tightness and itching that come along with burn scars. And, you know, as a plastic surgeon, you have the tools to do that because we're trained in how to improve scars.

We're trained in laser treatments. We're trained in, um, tissue rearrangements. Um, scar, uh, rehabilitation or reconstruction. So for me, it really is the opportunity to be able to take care of a patient and all their care from their initial injury, critical care, and then their reconstructive care years down the road.

So that really, for me, is what is so inspiring and, you know, I was the, the beneficiary of a, uh, burn surgeon who I felt really, um, offered that continual care, um, as a, the, the kind of fourth aspect of this is, is the [00:03:00] research side, right? And, and what I say is so unique is that as burn and plastic surgeons, we can ask research questions that other people won't be And, um, when I was, uh, a kid, I was on the unfortunate side of the patient doctor relationship as a patient in a burn center, uh, from when I was 12.

And even though when I left the hospital at that point and wanted nothing to do with, uh, a hospital again, I was looking for a job about six years later in, uh, high school and the doctor took care of me, offered a job to work in his research laboratory.

Rachel Baker: Oh, how cool.

Benjamin Levi: And so it was really there that when I went back and I worked with him in the research laboratory and then he took me on rounds to see burn patients.

He took me, uh, to his clinic, to the operating room. And I think there I really saw that you can not only take care of patients on the continuum of their care. You could also then ask research questions that you could then answer and [00:04:00] really not just enhance the care of the patient in front of you. Bye. A larger number of patients that might benefit from the research you're doing.

Rachel Baker: That is a fantastic story. Thank you so much for sharing that with us. So this next question that I have actually is coming from Dr. Clifford Schechter, as you mentioned, our own burn guru. He says, you have lived in five very different parts of the U. S. Chicago, Palo Alto, Ann Arbor, Boston, and now Dallas, any insights into the best place to live?

Benjamin Levi: You know, I think all places are unique and offer something special. And you know, I, I was thinking about Dr. Langer often talks about for stem cells to grow, you need the appropriate seed and you need the appropriate soil. And I think by being in different cities. And seeing different ways of doing things, it really supports a [00:05:00] seed to do something different.

And so while I may be the same seed, in each soil that I've been in, I, I think I've benefited from the soil there. And each program, you know, there are places that have really dynamic researchers, places that have dynamic clinical care, places that have a combination of both. And, you know, I think especially in the.

science field, I find that the science will actually move in a direction where there's expertise and there is a lot of regional expertise. So, you know, when I was at Stanford, there is this expertise in pediatric, regenerative medicine and stem cell biology. And so for there, you know, to be able to ask questions that are specific to stem cell biology was unique.

And the time that I was there was really when that stem cell field was taking off. I was in a perfect lab with Dr Longacre, uh, the perfect soil to do that. And here in Texas, you know, what is really unique is that the state of Texas invests heavily in research and their investment [00:06:00] is in two big areas.

One is cancer and one is in trauma research. So it's really the only state that has invested in trauma as a disease process. And I think people often think of, you know, when you say, like, what are the most deadly diseases, right? Everyone says. Heart disease, diabetes, cancer. Each of those disease processes costs about 300 million for the healthcare system.

If you look at trauma, it's the CDC estimates 4. 1 trillion. Right? And it's because trauma affects not just the people who, you know, are unfortunate to maybe not survive the trauma. It often affects young people, and they're living with the effects of that trauma for the rest of their life. That affects, you know, how many years of occupation if it's a 30 year old patient, right?

For me, if I think of where our research has gone and how the support of the soil around it, I would say those were, you know, how the soil at Stanford helped. The [00:07:00] soil here in Texas, um, at, at University of Michigan, you know, it is such an incredible place for junior faculty that there's so many, Research footprint and the number of people there and their, you know, biomedical engineering is huge.

So we were able to do some research in biomedical engineering that I thought was really, you know, unique to there. And in Boston, I will say that the burn program there has a real rich history and they also are attached to a Shriner's hospital. And so to have the opportunity to work both at a institution that is a center of excellence for burn care, and then across the street is one for pediatric burn care.

Um, you know, that was a unique opportunity. And there I was actually going, the Harvard Dental School had a unique program in bone research. And so I would go across town oftentimes after my shifts to, to work in, in their research labs. And, you know, Chicago, uh, is, is my [00:08:00] hometown certainly has a special place.

for me in my heart and there, the place where I started in the research lab and as a patient at Loyola's Burn Center has always been a center of excellence for burn care and research. And they were really one of the first institutes. It was called the Burn and Shock Trauma Research Institute. It was one of the first institutes that really was focused on this idea of burn and trauma as its own disease entity that I think we've been able to, you know, really build on over the years.

Rachel Baker: I feel like that was a very politically correct answer. The correct answer, of course, is West Coast, Best Coast.

Benjamin Levi: Well, my wife is from there, and she would agree, uh, to that, too.

Rachel Baker: Well, so let's dive into some of this research that you've been talking about. Heterotopic ossification. 10 syllables. So we're going to shorten that down to H O.

I pulled this definition from your 2022 article in science advances. Um, a disorder characterized by aberrant mesenchymal lineage [00:09:00] cell differentiation.

What can you break this down for a person who, um, did not take Latin? Uh,

Benjamin Levi: I will say that you're one of the first people who's pronounced all these words correct on the first try. So. Outstanding. Uh, including people who have MD and PhD in their names. Basically, the way that I think about it is basically bone forming where it's not supposed to.

Okay. Right? So we have bone in our skeleton. Yeah. That's where it's supposed to be.

Rachel Baker: Right.

Benjamin Levi: And what happens is that you have cells that are around your tendons, ligaments, muscles that normally are there and will, if you're injured, they'll lay down collagen to help repair the injury.

Rachel Baker: Okay.

Benjamin Levi: If they're in the tendon, they can also turn into tendon cells.

If they're in the muscle, they support the muscle cells. Now, if you have a big injury, so let's [00:10:00] say you, you're in a car crash, and you have a, you know, a head injury and you're, a hip fracture. Or, let's say there was a, fortunate for soldiers, an IED explosion, so big amount of energy. Or a burn patient that has a burn greater than 30 percent of their body.

When those cells that normally are there to repair small things are exposed to this large injury, they get confused, and instead of repair, they turn into bone.

Rachel Baker: Whoops.

Benjamin Levi: Yes. And, when you have bone outside of the skeleton, it is. problematic, often because the bone forms around nerves. Oh. So it, that hurts.

Rachel Baker: Yeah.

Benjamin Levi: Ow. And we've done a lot of work on understanding how nerves play a role in that. And it will form in joints, and so patients are unable to move. The most common joints affected are the elbow and the hip. Mm hmm. In burn patients, it's usually the elbow. [00:11:00] And, um, and then hip is very common because there's so many hip replacements done every year.

Rachel Baker: Right, yeah.

Benjamin Levi: The amount of energy it takes to break your hip is high, so usually you have a high energy injury. And so when you end up with bone in those joints, it really restricts patients. They can't move their joints. It hurts. Mm hmm. And then the surgeries that we do are big, invasive surgeries and even in the best of hands, we never able to really restore patients back to what they were before the injury.

And so really what we're trying to understand is, cause this process starts pretty early after an injury. We don't see the bone by x ray or whatever imaging until about the earliest four to six weeks.

Rachel Baker: Oh, okay. Interesting. Okay.

Benjamin Levi: And so what we really want to do is we want to figure out who is going to go on to develop this process early.

So we work on early diagnostic strategies and then we want to prevent it from [00:12:00] occurring. And so a lot of our studies are how to prevent that process. And so it, you know, afflicts a large number of patients across a wide array of specialties. So I mentioned the burn, the hip fractures, the hip replacements.

It's also seen in patients with spinal cord injuries. It's seen in patients with traumatic brain injuries. So it is, it does really impact a large number of patients, both in the civilian population. And then it was one of the most common problems that they were seeing after recent conflicts in Iraq and Afghanistan.

Rachel Baker: Well, so here I was thinking you were a burn guy and now we're talking about bones. How, how did this happen?

Benjamin Levi: Yeah, well, so my interest was in burns and then I wanted to come work with Dr. Longacre at Stanford

Rachel Baker: and

Benjamin Levi: the research that he was doing was in bone. And so he asked a really important question, which was one of the opposite problem that we see is that patients with bone injuries that are non healing.[00:13:00]

Or if someone's had, has a defect from a bone injury, we can't just borrow bone from one place to another. It's not like skin, right? If you have a small burn, oftentimes I could take skin from one place, move it to another. And so what Dr. Longacre figured out was that there are other cells in the body that can turn into bone.

And so at the time that I was in the lab, we were studying, as it turns out there are cells in your fat tissues that can turn into bone. And so, yeah. Yeah.

Rachel Baker: Oh, that's weird.

Benjamin Levi: So I would go, actually, when I was in his laboratory, I'd go to a local, one of the um, liposuction clinics that was affiliated with Stanford and we'd get the liposuction fat and we'd isolate cells and we found a population of those cells that actually were good at turning into bone.

This is wild. And we were using that to really harness that to heal bone defects and so when I was going on towards the end of my fellowship in Dr. Langer's lab and, you know, I'm like, okay, well I'm going back to be a bone surgeon. [00:14:00] And I want to do something different from what I was doing there.

Rachel Baker: And

Benjamin Levi: I saw a patient when I went back to the University of Michigan to finish my clinical training that had this heterotopic ossification problems.

Like, man, you know, here I was for two years trying to figure out how to make bone and this guy has an injury to his skin and he's forming too much bone. And so there must be something here that we could, you know, unravel that would maybe even help for the stuff that I was doing before. But really. Also prevent this from happening.

So that was really how I made that link is patients and that to me, I think, you know, really gets back to what I think is so unique about clinician scientists, which is the things that we see help guide a clinical solution to something. And, you know, we often talk about that, you know, as clinicians, we can really solve problems.

It's not just about pathways. In basic science, there is a lot of stuff about pathways, and they are important. It's so important, though, you also can apply that to a clinical problem that can have an [00:15:00] impact on a patient.

Rachel Baker: Fantastic. This is great. It's so interesting. But unfortunately, we are about at that time in our episode where we ask each of our guests the same two questions.

And the first one is, who is a surgeon you admire and why?

Benjamin Levi: I've felt lucky to have so many incredible surgeons across my career. And I think the two that have the most impact on my day to day life. Uh, as a surgeon and scientist would be Dr. Gomelli, who was the burn surgeon, took care of me as a patient, allowed me to work in his laboratory, and really had been a lifelong mentor.

And Dr. Longacre, who has shown really the world that plastic surgeons can do really high level science. And so I think the combination of those two have had a lasting impact on me in my clinical care, in my research focus, and I certainly am forever grateful for the impact that both of them have had.

Rachel Baker: Awesome. The second question is, what is the best advice [00:16:00] you have received, in ten words or less?

Benjamin Levi: It's so important to enhance the human experience

of everyone we interact with. Patients, family. Colleagues, staff, trainees, that may be more than 10 words.

Rachel Baker: The gist of with everyone we interact with, I think is, that's perfect, right? It's not just the patients, it's about all of the people that you're interacting with. I love that you include families and your trainees and that's, that's wonderful.

Yeah,

Benjamin Levi: and that's actually where your question last, when I was reading over your question yesterday about where I've lived and my favorite place, I think where it, it does get back to is that. The happiness really derived from, from self and from family. Right. And so, yeah, I've been so lucky to have an incredible family with me at all those places.

And so [00:17:00] wherever I am, I could find that happiness.

Rachel Baker: Well, it has been a pleasure chatting to you. I have just one final question before you go, and it's from one of our trainees who will be presenting to you later this month. What are you looking for in an exceptional presentation?

Benjamin Levi: I love seeing trainees and their excitement about their work, excitements and engagement in their topic, because there's so many interesting things that we can ask.

And it has to be something that someone's really excited about. And that I think It's the most important because research really never ends. It's really endless questions and if someone has that excitement, they will always find something new to pursue.

Rachel Baker: Well, thank you so much for coming on the show. It was a pleasure and I look forward to seeing you at Holman Day.

Benjamin Levi: Yeah, no, thank you so much. It really is an extreme honor to be part of that research day to come back to a place that has been so special to me and with so many people that I look up to is a true honor. So thank you so [00:18:00] much.

Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts.

Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds. And our chair is Dr. Mary Hawn.