Plastic Surgery: Technique or Discipline?

Abstract

The definition of “plastic surgery” has been subject to a variety of interpretations. To the practitioner who has completed formal training in plastic surgery, it is defined and inherently recognized as a specialty that encompasses a vast body of knowledge and that requires a comprehension of fundamental principles and concepts that allows one to plan and execute a particular operation. In other words, it represents a discipline. To the practitioner who has not completed formal training in plastic surgery, it is often defined literally as the ability to mold or create. In other words, it represents a technique. These varying interpretations are creating a milieu for surgeons who have not completed a formal residency in plastic surgery to impinge on the specialty with the effect of misleading patients and creating a foundation for poor outcomes. The purpose of this editorial is to educate individuals who are of the opinion that plastic surgery is a technique that can be performed by anyone. The timeliness of this editorial is in response to the noticeable increase in the number of practitioners who are interested in performing operations that are inherently within the domain of plastic surgery. Many of these practitioners are board certified in specialties other than plastic surgery, and all of them have one denominator in common: none of them have completed a residency in plastic surgery as defined by the American Board of Medical Specialties.1 This phenomenon is not new, especially among the specialties somewhat related to plastic surgery in which there is some degree of technical overlap. This editorial is not directed at practitioners of those specialties, because many of the fundamental concepts and principles that are used to solve complex problems are similar. This editorial is directed to practitioners within specialties that are completely unrelated to plastic surgery in terms of training requirements and practice profile. It is recognized that the number of individuals who violate the boundaries of their specialty is small; however, they do exist, and they are making their interests and intentions known. Although there are a number of operations that are vulnerable to encroachment, the focus of this editorial is on reconstructive and aesthetic surgery of the breast. I have had the experience of dealing with this unpleasant issue regarding boundaries on several occasions. I will elaborate on three. At a recent national symposium, I was approached by a surgeon who was interested in learning how to perform certain cosmetic and reconstructive operations related to the breast. He asked if I would be agreeable and allow him to spend 1 or 2 weeks with me in the operating room. When asked why women in need of reconstructive breast surgery were not referred to a plastic surgeon, the response was that there were no plastic surgeons in the community. This practitioner believed that women within his community would be better served by him providing services that were not currently available. While his intention may have been genuine, I had serious reservations and declined the request, based on the fact that this surgeon had not received formal training in plastic surgery and was therefore not qualified to perform it. It was clear, however, that he felt otherwise and proceeded to convey that the “techniques” would be relatively easy to learn and perform. In another example, I was contacted by an attorney to see whether I would be willing to review a legal case for the defense involving a boardcertified physician who had performed a reduction mammaplasty. The patient decided to litigate because of complications and a poor outcome. Further questioning revealed that this board-certified physician was a dermatologist who had additional certification from the American Board of Cosmetic Surgery.2 I explained to the attorney that it would be difficult to defend this case, because it was performed by a dermatologist who had not received formal training in plastic surgery and that the American Board of Cosmetic Surgery was not a board that was recognized by the American Board of Medical Specialties. Received for publication November 21, 2005; accepted January 10, 2006. Copyright ©2006 by the American Society of Plastic Surgeons