The Role Of A Plastic Surgeon
Plastic surgeons perform both reconstructive and aesthetic surgery. Majority of NHS plastic surgery is reconstructive surgery that focuses on restoring the function and look of affected body parts following trauma or illness.
Aesthetic surgery is growing in popularity with the majority of it being done privately. Plastic surgeons can work with children and adults or both depending on their subspeciality and areas of interest.
Reconstructive surgery includes hand operations, cleft lip and palate reparations, head and neck reconstruction, breast reconstruction, and skin/soft tissue cancer procedures. Aesthetic surgery includes otoplasty, liposuction, facelifts, breast reduction/enhancement and blepharoplasty.
A career in plastic surgery suits those with great attention to detail and manual dexterity due to the precise techniques used in plastic surgery such as microsurgery. Other surgical techniques and procedures often used in plastic surgery include skin grafts, tissue expansion and flap surgery.
As with any surgical speciality, plastic surgeons work within a multidisciplinary team. In theatre, plastic surgeons work with anaesthetists, theatre nurses, other surgeons and medical students. Outside the theatre, plastic surgeons work with pharmacists, physiotherapists and psychologists. At consultant level, plastic surgeons are expected to lead their team.
There is a mix between inpatient and outpatient load. This will depend largely on subspecialty and areas of interest. Depending on the complexity of surgery, some patients will have long term follow ups allowing for continuity of care (1).
Plastic surgery is rewarding as procedures have the capacity to drastically improve a patient's quality of life. Qualities required include visuospatial awareness, hand-eye coordination, leadership skills, stamina to cope with the role and communication skills. Personal emotional resilience is required due the exposure to patients who have undergone severe trauma and disfigurement.
Women are represented in all surgical specialities and at all levels of surgical training however there are still fewer female surgeons compared to male counterparts. Only 25% of plastic surgeon consultants in England are female based on 2019 data from NHS Digital (2)
Plastic surgery is a fast-growing speciality due to the increasing demand for aesthetic surgery and the potential to use stem cell technology to replace current fillers. In the future, plastic surgery might include more non-invasive, non-surgical treatments such as fat-freezing and fat burning as fat reduction techniques. (3)
A Typical Week
A standard contract for a full-time consultant is divided into 10 Programmed Activities (PAs) and 2.5 Supporting Professional Activities (SPAs). Programmed activities include theatre sessions, pre and post-op care and outpatient clinics. Supporting professional activities can be tailored to each surgeon’s interest and can include research, teaching or appraisals.
A Typical Day As A Plastic Surgeon:
- 09:00-12:00 - Outpatient clinic
- 12:30-13:30 - MDT/ward rounds
- 14:00-17:00 - Theatre list
Different surgeries will vary in length as they can range from local anaesthetic surgery to complex surgeries requiring other speciality surgeons. There is a mix of planned and elective surgeries. Night on-calls could happen on occasion to deal with emergency surgeries such as patients with severe burns/trauma patients following accidents.
On-call commitments will vary in different institutions and different levels of a plastic surgeon’s career.
The Route To Becoming A Plastic Surgeon
Becoming a plastic surgeon is highly competitive. Following completion of the two-year foundation programme, trainees enter core surgical training where they rotate between different surgical specialities each rotation lasting 4-6 months. In 2019, there were 2.93 applicants for every core surgical training post (4).
Candidates must pass the MRCS (Membership of the Royal College of Surgeons) exam at the end of their core training. For entry to plastic surgery speciality training, candidates must have spent at least six months in a plastic surgery post.In 2019, 149 doctors applied for 38 ST3 training places, a ratio of 3.62 (4).
Plastic surgery speciality training lasts six years during which trainees must pass the Intercollegiate Speciality FRCS Plast examination prior to receiving their Certificate of Completion of Training (CCT).
Speciality training is divided into the intermediate (ST3-ST6) and final (ST7-ST8) stages. The intermediate stages build knowledge expected of all plastic surgeons while the final stages allow trainees to focus on their sub-specialist interest and skills associated with it.
TIG (Training Interface Group) Fellowships are increasing in popularity among trainees in the final stages of speciality training. TIG is a special interest area that combines certain curriculum elements from another speciality. These are available in oncoplastic breast surgery, major trauma and skin oncology to name a few.
Trainees can opt to complete a fellowship post speciality training completion and prior to applying to a consultant post. (5)
Some trainees may need to self-fund extra education courses due to limited funding for plastic surgery training.
Showing interest in plastic surgery is key to gain a competitive edge when applying for posts. At the medical student level, this can be done by undertaking electives in plastics or by attending BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons) medical student days. These entail lectures and practical sessions with the purpose of introducing students to the different aspects in plastics.
During core surgical training, candidates should build up evidence of their interest and experience in plastic surgery. This can be done by carrying out audits, presenting and publishing within plastic surgery. Training courses such as Advanced Trauma Life Support (ATLS) and Basic Surgical Skills and Care of the Critically Ill Surgical Patient (CCrISP) completion will also boost candidate’s application for ST3 posts (1).
St Andrew’s Centre has a world-renowned burns and plastic surgery service. Plastic and reconstructive surgery in the North Bristol NHS Trust is considered a regional centre of excellence.
Subspecialties within plastic surgery include:
Paediatric plastic surgery
Congenital plastic surgery: cleft lip and palate, deformities, genito-urinary and upper limb anomalies, and skin conditions.
Breast surgery: congenital defects, aesthetic surgery, reconstruction following breast cancer.
Skin surgery: usually in conjunction with skin cancer management, includes skin excision and reconstruction.
Trauma plastic surgery: reconstructive surgery to face and lower limbs following trauma.
Hand and upper limb surgery: congenital hand anomalies, hand injury repair and treatment of degenerative hand disease.
Cancer: skin lesion and malignant tumour removal, head and neck cancer and breast reconstruction following breast cancer. (6)
Research in plastic surgery is also growing rapidly with the opportunity to present findings in national and international conferences. There is the opportunity to get involved in different topics ranging from microsurgery, wound healing tissue engineering and composite tissue allotransplantation.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849. Salaries can be further enhanced with NHS excellence awards.
As with any speciality, there is the potential to enhance NHS earnings via private practice. JRSM reported in 2008 that the total income for plastic surgeons was £217,727 with NHS income making up £75,004 and private income making up £142,723 making the ratio 1.90.
This ratio is the highest of all the medical and surgical specialities. It is followed by trauma and orthopaedic surgery that sits at 1.40 and then neurosurgery at 1.00 (7).
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
The Journal of Plastic, Reconstructive and Aesthetic Surgery (JPRAS) previously known as the British Journal of Plastic Surgery publishes the latest procedures with audit and outcome studies. it contains up-to-date papers and review articles.
The Scar Free Foundation is the research funding body set up by BAPRAS. It supports patient’s health relating to reconstructive/plastic surgery.
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Plastic surgery [Internet]. Health Careers. 2020 [cited 15 June 2020]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/plastic-surgery
Statistics — Royal College of Surgeons [Internet]. Royal College of Surgeons. 2020 [cited 16 June 2020]. Available from: https://www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics/
The future of Cosmetic Surgery [Internet]. Northdownshospital.co.uk. 2020 [cited 14 June 2020]. Available from: https://www.northdownshospital.co.uk/news/the-future-of-cosmetic-surgery
2019 Competition Ratios [Internet]. 2020 [cited 8 August 2020]. Available from: https://specialtytraining.hee.nhs.uk/Portals/1/Competition%20Ratios%202019_1.pdf
The training pathway | BAPRAS [Internet]. Bapras.org.uk. 2020 [cited 14 June 2020]. Available from: http://www.bapras.org.uk/professionals/training-and-education/careers-in-plastic-surgery/the-training-pathway
Plastic surgery curriculum [Internet]. Gmc-uk.org. 2020 [cited 14 June 2020]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/curricula/plastic-surgery-curriculum
Morris S, Elliott B, Ma A, McConnachie A, Rice N, Skåtun D et al. Analysis of consultants' NHS and private incomes in England in 2003/4. Journal of the Royal Society of Medicine [Internet]. 2008 [cited 14 June 2020];101(7):372-380. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442143/table/tbl3/