Recent developments in plastic surgery
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7359.319 (Published 10 August 2002) Cite this as: BMJ 2002;325:319
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Thank you for your interesting comments on the opening sentence
"Misconceptions still abound that plastic surgeons are predominantly
cosmetic surgeons", in our review paper on recent developments in plastic
surgery. We were encouraged to learn of the results of your questionaire
study, but of course without detailed knowledge of the methodology used,
care is needed in interpreting these results as to whether they truly
disprove the popular belief that plastic surgeons are predominantly
cosmetic surgeons.
We note that your survey was undertaken in Oxford, Aylesbury, and
Slough, where, of course, all three places have local plastic surgery
units. It would be interesting to know if your results were typical of
other regions, including those where there were no local plastic surgery
units on site.
Unfortunately it has been our personal experience that there is
indeed great misconception (from the general public to hospital doctors)
as to the fundamental nature of the work undertaken by NHS plastic
surgeons. There are many recent developments in the techniques of plastic
surgery which are applicable to the management of many surgical
conditions. An appreciation of this will help us all deliver the best care
to the patient at need.
Competing interests: No competing interests
Johnson states that ‘misconceptions still abound that plastic
surgeons are predominantly cosmetic surgeons’.1 Certainly current media
obsession with cosmetic surgery might lead the casual observer to think
this is the case. But is there an evidence base for this commonly espoused
assertion? In the United States public respondents drew a distinction
between plastic (and reconstructive) surgery and cosmetic surgery.2 In
this country, public respondents were unable to list five conditions
treated by plastic surgeons.3 To investigate public and professional
perceptions of plastic surgery we undertook a study using closed-ended
format questions. Respondents were invited to match nine surgical
specialists with forty conditions or procedures, which included 20 managed
routinely managed by plastic surgeons. Responses were received from 1004
members the public attending accident and emergency departments in Oxford,
Aylesbury and Slough, 335 general practitioners in Oxfordshire and 228
medical students at Oxford University. Response rates were 42%, 65% and
67% respectively.
Public responses demonstrated an understanding of the range of
conditions managed by plastic surgeons. Cosmetic procedures, such as
rhinoplasty, and those with a large aesthetic element, such a breast
reduction, were strongly associated with plastic surgery. Responses also
showed an appreciation of the reconstructive role of plastic surgeons,
particularly for procedures of the head and neck, such as ear
reconstruction after trauma. Evidence suggests that the public obtain an
increasing proportion of their health information from informal sources
such as magazines and the internet.4 Despite this we were surprised to
find that public respondents were poorly informed about the role plastic
surgeons play in the management of some high profile conditions, including
burns and cleft lip. We were not surprised to find that general
practitioner and medical student respondents were better informed.
However, they did not associate plastic surgeons with hand surgery.
Instead this was considered the remit of the orthopaedic surgeon.
Plastic surgery covers a broad spectrum of conditions and is unique
amongst surgical specialities in being technique-driven rather than being
constrained by anatomical site, pathological process or patient subgroup.
This versatility promotes the innovation that Johnson highlights in his
paper. There is little evidence that plastic surgeons are perceived to be
predominantly cosmetic surgeons. On the contrary we have shown that the
public and our colleagues have a broad understanding of the range of
conditions managed by the speciality with a few specific exceptions.
Reviews such as this promote awareness of efforts to improve patient care
and help banish ill-founded misconceptions.
1. Johnson D, Whitworth IH. Recent developments in plastic surgery.
BMJ 2002;325:319-22. (10 August)
2. Kim DC, Kim SK, Mitra A. Perception and misconceptions of the plastic
and reconstructive surgeon. Ann Plast Surg 1997;38(4):426-30.
3. Park AJ, Scerri GV, Benamore R, McDairmid JG, Lamberty BG. What do
plastic surgeons do? J R Coll Surg Edinb 1998;43(3):189-93.
4. Borzekowski DL, Rickert VI. Adolescent cybersurfing for health
information: a new resource that crosses barriers. Arch Pediatr Adolesc
Med 2001;155(7):813-7.
Competing interests: No competing interests
Has the pendulum swung too far in immediate Breast Reconstruction?
Editor - Johnson and Whitworth review developments in plastic surgery
and discuss the organizational implications of delivering an immediate
breast reconstruction service.1 Undoubtedly the practice of immediate
breast reconstruction has increased on the basis of its potential
advantages with respect to psychological adjustment, aesthetic results,
hospital costs and oncologic safety. Despite current evidence, a recent
questionnaire of UK breast surgeons revealed that 57% of respondents
preferred delayed to immediate breast reconstruction citing the
interference with adjuvant therapy in the majority of cases.2 Although,
immediate reconstruction has not been shown to delay adjuvant chemotherapy
or radiotherapy, there is increasing concern regarding the long-term
cosmesis in immediate breast reconstruction followed by radiation therapy.
There is no controversy regarding the contra-indication of radiotherapy
following a subpectoral implant or expander/implant with Vandeweyer and
Deraemaecker reporting capsular contracture following radiation in all 6
patients out of 124 whom they evaluated.3 Pre-operative selection of
oncologically 'risker' patients potentially requiring radiotherapy should
include an image-guided core biopsy in all cases and a MRI scan in lobular
cancers or cases with questionable proximity to the pectoralis muscle.
Despite patient motivation for immediate reconstruction, borderline cases
should be carefully informed as to the long-term consequences of possible
radiotherapy on cosmesis and advised to have a delayed procedure.
The debate may swing to suggest that certain types of immediate
breast reconstruction may be cosmetically superior in the context of
radiotherapy. There is little published evidence on the Latissimus Dorsi
(LD) flap and implant under these circumstances, however a patient
questionnaire assessing quality of life and overall appearance conducted
in Edinburgh, reported that 35% of such patients (26 out of 75 patients)
were more critical of their final cosmetic outcome post-irradiation.4
Surely we should advise autogenous tissue reconstruction in patients at
risk of radiotherapy, with the possibilities of either an extended LD or
TRAM flap. I am not aware of published evidence on the former, however
the latter is controversial with regard to sustained aesthetic excellence
following radiotherapy. Tran et al 19995, report a poor track record of
the TRAM regarding cosmesis at 3 yrs after radiotherapy with 24% of
patients (total 41) requiring revisional surgery and 56% noting a firm
reconstruction.
Notwithstanding the potential cosmetic derangement induced by post-
operative irradiation, there is also evidence to suggest that implant-
related reconstructions independent of radiation or type of implant show a
linear decrease in cosmetic excellence over 2-5 years on the basis of
capsular contracture and the failure of the implanted side to undergo
normal ptosis.6 Although the study focuses on subpectoral implants, there
is a need for both breast and plastic surgeons to similarly report their
results on LD/implant reconstructions and that these patients are followed
for a minimum of 5 years with the attempt by all affiliated specialist
colleagues in oncoplastic breast surgery to define a standardized and
internationally acceptable method of assessing cosmesis. Undoubtedly
there needs to be a concerted research collaboration between breast and
plastic surgeons to resolve some of these emerging clinical dilemmas.
Zoë Winters
Consultant Breast Surgeon and Senior Lecturer (King James
IV Professorship)
Bristol Breast Unit and University Department of Surgery, Bristol Royal
Infirmary, Bristol BS2 8HW
zoe.winters@bristol.ac.uk
1 Johnson D, Whitworth IH. Recent developments in plastic surgery.
BMJ 2002;325:319-222. (10 August)
2 Callaghan CJ, Couto E, Kerin MJ, Rainsbury RM, George WD, Purushotham
AD. Breast reconstruction in the United Kingdom and Ireland. BJS
2002;89:335-340.
3 Vandeweyer E, Deraemaecker R. Radiation therapy after immediate breast
reconstruction with implants. Plastic and Reconstructive Surgery
2000;106(1):56-60.
4 Daltrey IR, Gilroy A, Dixon JM. Immediate breast reconstruction: the
factors affecting cosmesis and patient satisfaction. Europ. J. Cancer
2001;37(55):32 (Abstr. 0-92).
5 Tran NV, Evans GRD, Kroll SS, Baldwin BJ, Miller MJ, Reece GP, Robb GL.
Postoperative adjuvant irradiation: effects on Transverse Rectus Abdominus
muscle flap breast reconstruction. Plastic and Reconstructive Surgery
2000;106(2):313-317.
6 Clough KB, O'Donoghue JM, Fitoussi AD, Nos C, Falcou MC. Prospective
evaluation of late cosmetic results following breast reconstruction: I.
Implant reconstruction. Plastic and Reconstructive Surgery
2001;107(7):1702-1709.
Competing interests: No competing interests