Plastic and reconstructive surgery

It really isn't just as simple as looks and money, say Abhilash Jain and Jagdeep Nanchahal

It is widely believed that plastic surgery is synonymous with cosmetic surgery. The underlying principles may be the same, although the work undertaken in the NHS by plastic and reconstructive surgeons differs from that undertaken in the private sector, where many procedures are done for cosmetic reasons. Although attention to aesthetics is important, plastic surgeons are involved in a huge and varied caseload that requires cooperation with all other surgical disciplines.

Plastic surgeons are expected to reconstruct virtually every region of the body and often work very closely with orthopaedic, breast, vascular, otonasopharyngeal, and maxillofacial surgeons. Owing to the great variety of operations plastic surgeons undertake it is likely that every medical discipline will come into contact with a team of plastic surgeons at some point. In this article we discuss the role of plastic and reconstructive surgeons and provide information for students considering a career in plastic surgery

About half the referrals to plastic surgery come from general practitioners, a third from emergency departments, and the remaining fifth (major reconstructive surgery) from other surgical specialties (www.baps.co.uk). The emergency caseload of plastic surgeons consists mainly of burns, hand injuries, maxillofacial trauma, and leg trauma, and operations are performed in cooperation with orthopaedic surgeons.

Burn injuries are traditionally looked after by plastic surgeons in the United Kingdom, and their management involves not only technical skill in reconstruction but also a detailed knowledge of physiology, as these patients can require extensive resuscitation.

Hand surgery is considered a subspecialty of both plastic and orthopaedic surgery, with one third of hand surgeons having trained as plastic surgeons. Most emergency referrals made to plastic surgeons are for hand injuries.

The combined management of extensive leg injuries by both plastic and orthopaedic surgeons results in a better outcome for patients. The input of plastic surgery into these complex cases can involve providing soft tissue cover for exposed fractures and vascular and nerve repair.

Maxillofacial trauma includes lacerations to lips and eyelids and facial fractures. The management of these injuries overlaps with work done by maxillofacial, otonasopharyngeal, and ophthalmic surgeons.

The elective caseload of plastic surgeons in the NHS revolves around reconstruction of congenital, traumatic, degenerative, and neoplastic conditions. Reconstruction of congenital deformities includes repair of cleft lip and palate, craniofacial defects, and hand deformities. This work is a collaborative effort with other healthcare workers, including paediatricians, speech therapists, occupational therapists, physiotherapists, and nurses.

Delayed reconstruction for trauma can entail complex surgery, which aims to not only improve appearance but, most importantly, function. Similarly, restoration of appearance and function after resection of tumours can present some of the most demanding problems to plastic and reconstructive surgeons. The loss of function that can follow major tumour resection must never be underestimated, but with proper preoperative counseling, and planning, the team approach to reconstruction can help return patients to as near normal as possible.

Other areas that plastic surgeons are involved in include the treatment of pressure sores and repair of urogenital defects. These lists are no means exhaustive, but they show the vast spectrum of work involved in plastic surgery.

Before and after

Cosmetic surgery principally involves improving appearance. Most cosmetic surgery takes place in the private sector, but operations that are considered “cosmetic” are performed in the NHS, such as breast augmentation for notable asymmetry and breast reduction, leading to significant physical and psychological benefits.

Trainees in plastic surgery can have limited exposure to what are considered traditionally aesthetic procedures, for example face lifts, but techniques learnt in reconstruction can be used in cosmetic surgery. Many trainees now undertake cosmetic fellowships after their Calman training to gain experience in these specialised procedures.

Because of its specialist nature, plastic surgery tends to occupy a very small part of undergraduate teaching, with many students having little exposure to reconstructive techniques. Students considering plastic surgery as a potential career will benefit from an attachment to a plastic surgery team during their undergraduate training. An appropriate elective project, either in this country or abroad, is also a good way of gaining experience at an early stage.

On completion of the preregistration house officer year, junior doctors wishing to become plastic surgeons will need to undertake at least two years of basic surgical training and obtain the membership diploma from one of the surgical royal colleges. Currently, numerous rotations are available that fulfil all the requirements of basic surgical training. It would be advantageous if the rotation included six months in plastic surgery, although most registrar training schemes will expect at least 12 months of plastic surgical experience at the senior house officer level. Experience in orthopaedics, otonasopharyngeal and maxillofacial surgery, and intensive care is also useful.

Plastic surgery remains a highly competitive specialty, and obtaining a specialist registrar training number can be difficult. Many trainees undertake formal research in order to boost their curriculum vitae, resulting in many trainees being in their late 20s or early 30s before starting higher specialist training. Higher surgical training in plastic surgery takes six years, during which time trainees obtain experience in all aspects of plastic surgery. In the later years, trainees are encouraged to subspecialise by undertaking formal fellowships in areas such as hand surgery, burns or craniofacial surgery, either in the United Kingdom or abroad. Between the fourth and sixth year of training, registrars must sit the intercollegiate examination in plastic surgery, after which they may be awarded the certificate of completion of specialist training.

There has been a recent expansion in consultant posts in plastic surgery, but as only a few hospitals have plastic surgical units, jobs are limited to specific geographical regions. Generally, consultants are expected to have a specialist interest, as well as being able to provide a general plastic and reconstructive service. Most consultants work predominantly in regional plastic surgical centers and provide services to outlying hospitals. But in the larger units the trend is to subspecialise to the exclusion of some other aspects of the service.

Plastic surgeons performing eyelid surgery

Technology and research are important aspects of plastic surgery. The routine use of microscopes allows surgeons to anastomose vessels less than 1 mm in diameter. This has allowed rapid advances in free tissue transfer. Lasers are also becoming routine, revolutionising the treatment of vascular skin lesions.

A common misconception amongst patients is that plastic surgeons can perform surgery without leaving a scar. Although we wish this were true, scarring is minimised by placing incisions in natural “lines” and in cosmetically less obvious areas, as well as the use of meticulous surgical technique. Research into the molecular causes of disease and an understanding of wound healing will improve our understanding of soft tissue reconstruction, and maybe one day we will truly be able to perform “scar-less” surgery.

Box 2: Useful websites

• British Association of Plastic Surgeons: www.baps.co.uk
• British Association of Aesthetic Plastic Surgeons: www.baaps.org.uk
• Royal College of Surgeons of England: www.rcseng.ac.uk
• Royal College of Surgeons of Edinburgh: www.rcsed.ac.uk

Abhilash Jain, ARC clinical research fellow, Charing Cross Hospital, London
Email: AJainUK@aol.com

Jagdeep Nanchahal, senior lecturer,


studentBMJ 2002;10:171-214 June ISSN 0966-6494

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