Specialty Of Plastic Surgery Research Articles

Aesthetic/Cosmetic Surgery and Ethical Challenges

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a "cosmetic" surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.

Aesthetic reconstructive surgery: Patient access to essential care requires expanded definitions

Nearly 10 years ago, when plastic surgeons in California engaged in long and hard-fought legislative battles to mandate third-party coverage of appropriate reconstructive procedures, we included a definition of reconstructive and cosmetic surgery in the bill to minimize misinterpretation: > “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance, to the extent possible. “Cosmetic surgery” means surgery that is performed to alter or reshape normal structures of the body to improve the patient's appearance.1 The resulting legislation is still one of the most comprehensive and effective in the nation. Innumerable patients have received necessary and appropriate treatment as a result of this landmark legislation, which is a great benefit to society and, ultimately, a great benefit to the specialty of plastic surgery. Notably, plastic surgeons still retain the right to choose whether to participate in third-party payer plans. After the California victory, Federal legislation in the form of the Women's Health and Cancer …

William P. Graham, III, M.D., 1934 to 2006

William P. Graham, III, M.D., a past chairman of the American Board of Plastic Surgery and past president of the American Society for Aesthetic Plastic Surgery, died in Wellington, Florida, on October 8, 2006, after a long illness. Dr. Graham was born in Plainfield, New Jersey, and grew up in Mechanicsburg, Pennsylvania, where he went to high school. In 1955, he received his bachelor’s degree from Princeton University. Dr. Graham attended medical school at the University of Pennsylvania, graduating with a doctorate in medicine in 1959. He completed his general surgery training at Colorado General Hospital, in Denver, Colorado, under Ben Eisman and at the University of California Medical Center in San Francisco. In 1965, he returned to the University of Pennsylvania, where he completed his plastic surgery residency under Dr. Henry Royster in 1967. While still a resident, he advanced the career of medical students and younger residents as a role model in surgery and teaching and by demonstrating his deep passion for the specialty of plastic surgery. Dr. Graham remained on the staff at the University of Pennsylvania until 1971, when he was recruited by Dr. John Waldhausen to be the first chief of the Division of Plastic Surgery at The Pennsylvania State University’s new Milton S. Hershey Medical Center. Dr. Graham was an outstanding technician and had few peers as a teacher. The seed for his career was planted in his youth, when he learned how to tie fishing flies. His teacher, impressed at the pupil’s skill and dexterity, suggested he become a surgeon. Dr. Graham not only maintained a passion for fly-fishing for the rest of his life but in the same way influenced many young students to enter plastic surgery. A residency program in Hershey was started in 1971, and to date it has graduated 52 residents under his and his successors’ direction. Dr. Graham had a tremendous impact on his trainees and medical students. He was the quintessential professional, always perfectly behaved, always respectful, and always perfectly groomed, wearing his trademark bow-tie whether it was 4 o’clock in the morning, when he often did his rounds, or midnight, while he was sewing up a laceration in the emergency room. Bill Graham practiced the full spectrum of plastic surgery. In the early years of the Medical Center he took general surgery call, and for his entire tenure at the Hershey Medical Center he performed head and neck cancer surgery and the lion’s share of the thyroid and parathyroid surgery. It was as a hand surgeon, though, that he developed a particular expertise. Together with his friend Eugene Kilgore, he coauthored The Hand: Surgical and Nonsurgical Management, for many years one of the standard hand surgery textbooks. Bill Graham authored more than 300 scientific articles, including 120 peer-reviewed publications and 37 book chapters. In 2001, his past residents, patients, and friends set up an endowment to establish a professorship in plastic surgery in his name. He was with all of them at the celebratory inauguration in 2003. Dr. Graham served as chairman of the American Board of Plastic Surgery in 1985 and president of the American Society for Aesthetic Plastic Surgery in 1992. He was active in many other professional and scientific organizations, including the American Society for Surgery of the Hand, the American Surgical Association, and the American Society of Plastic Surgeons. He was an honorary member of the British Society for Surgery of the Hand and also served as president of the Northeastern Society of Plastic Surgeons, chairman of the Association of Academic Chairmen of Plastic Surgery, chairman of the Plastic Surgery Research Council, and vice chairman of the Residency Review Committee. Dr. Graham is survived by his wife, Anne Moretta-Graham, his daughters from a previous marriage and their husbands, Susan P. and Eric R. Johnston of San Francisco, California, and Elizabeth A. Graham and Brad S. Feldman of Lexington, Mass., and his granddaughter, Miriam A. Feldman. Dr. Graham was a consummate gentleman, teacher, and mentor in the truest sense of the word. His friends, colleagues, and students will cherish the memory of this wonderful man, who abundantly lived the essential tenets as a leader in plastic surgery through service, sacrifice, and, above all, example.Figure: William P. Graham, III, M.D., 1934 to 2006.

Dynamics of Hospital-Based Plastic Surgery

Legislative regulations, decreasing reimbursements for office procedures, and malpractice premiums have transformed plastic surgery from an office-based specialty into a hospital-based one. Simultaneously, hospital economics has altered, wherein the "business model" has all but subsumed the old "medical care" model. Integration between plastic surgeons and the new hospital structure has been difficult for both. Limited understanding of the financial dynamics of hospital-based practices, unfamiliarity with the administrative processes, and resistance to accept and assimilate changes by both sides pose hurdles, in some situations even forcing plastic surgeons out of hospital settings. Using well-defined financial terminology, changing national development in health care policy, and hospital-based administrative strategies as a backdrop, this study finds common ground for the plastic surgery specialty to coapt with the hospital. Key missing elements in the interaction between plastic surgeons and hospital administrations and ways of integrating these components are identified. To do so effectively, plastic surgeons must first understand the basic tenets of management that drive hospital administrators, participate at every level they can in guiding these processes, and assume leadership roles that will ultimately dictate the way they work and conduct their professional lives. It is critical that plastic surgeons engage in important processes that govern the economics of hospital-based health care delivery. This commitment will also ensure that all three groups (the patients, physicians, and hospital administrators) achieve a degree of satisfaction. The message to plastic surgeons is clear: be proactive and lead a campaign of change.

Some pioneers in plastic surgery of the facial region.

Much of this complex history comes from Europe, with contributions and advances from dentists, otolaryngologists, and general surgeons. Prior to World War I there wasnospecificplasticsurgeryspecialty.For example, Sir Harold Gillies, an otolaryngologist, learned many dental skills and techniques from Charles Auguste Valadier, a rogue French practitioner of dentistry and maxillofacial surgery. (Valadier is said to have treated most of his patients in an automotive vehicle described as a “traveling dental parlour” around 1900.) Gillies,extraordinarilyinnovative,technically superb, and politically adept, was called by some the “father of plastic surgery,” although such a descriptor probablydoesnotpayproperhomageandcredit to his many European predecessors. Gillies drew heavily from these surgeons and teachers in Britain and continental Europe,astheythemselveshadadvancedtheir own training and expertise.

ASJ advisors provide multispecialty perspectives

Stanley A. Klatsky, MD , is Editor in Chief of Aesthetic Surgery Journal. With this issue of Aesthetic Surgery Journal , we are proud to introduce the members of our Interspecialty Advisory Board (IAB). While ASJ has often called on recognized experts outside the plastic surgery specialty to write articles, participate in panels, or clarify points of controversy in original manuscripts, the IAB is a more formal recognition of the importance of interspecialty contributions to our journal. …

The changing rules for office-based surgery

Edward S. Truppman, MD, Aventura, FL , is a past president of the American Association for Accreditation of Ambulatory Surgery Facilities. Twenty years ago, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) was established as a voluntary accreditation organization. The specialty of plastic surgery recognized the need for quality assurance and peer review of surgery performed in the office setting. To seek such review voluntarily was unheard of in 1980, which made the creation of AAAASF a profound tribute to the specialty's dedication to excellence. Among the states that took action to make accreditation mandatory, California and Florida led the way. The various office surgery rules developed by these states were applied to most surgical specialties in which intravenous sedation or general anesthesia is used. Under these rules, the surgeon must maintain complete documentation of each surgical procedure, including anesthesia records, informed consent as to surgical risks, and information on the anesthesia provider. Limits have been set on lipoplasty volumes and the maximum amount of lidocaine (per kg) to be injected. The facility must be registered with the Department of Health, and the surgeon must report any serious adverse incidents within 15 days of …

Why am I here?

There are many important issues that constantly surround us, issues that we confront every day and night as we care for the injured. Most cannot be adequately addressed in a few minutes because of their scope and influence on our professional lives and the lives of our patients. None, however, are unimportant. Allow me to list a few of these: ● Solving the problem of alcohol as a trauma potentiator ● The importance of rehabilitation as the final pathway for our patients ● Profitability in trauma: how are we going to do more with less? ● Recognizing the importance of spirituality to us and our patients However, following the advice of one of my good friends and predecessors in EAST, I have decided to play from my strengths in this address. I will speak to you today as a surgical specialist, one who began his surgical career and training as a general surgery resident with an interest in trauma, and one who has been most fortunate to be asked by his colleagues to serve in various positions in this organization. In so doing, I hope to provide for you an answer to a simple question I have often posed for myself: ● Why am I here? I am sure many of you have been asking yourselves this same question. In fact, I have had some members come right up to me and ask me just how in the hell is it that I have come to be president of EAST? But because I hold this organization and this office in such great esteem, I have been thinking critically about this. Each morning and night when I sit at my desk at home with the EAST gavel in front of me, I am reminded that as a surgical specialist, my roots, like those of my specialty of plastic surgery, are in trauma. Furthermore, this may well be the reason that I am where I am today. It is not by a mistake or mere providence that we come to the positions we occupy in our professional and personal lives. We must all discern why we are where we are. In my case, I feel that there is something I have to contribute, and I must figure out what that is and thereby answer this question: why am I here? In my professional life, I frequently find myself wearing two hats, that of a plastic surgeon and that of a plastic surgical traumatologist. Perhaps a better metaphor would be to say that I often stand with one foot in the boat of trauma and one foot on the dock of plastic surgery. Generally, all seems well until the dock moves relative to the boat, or the boat begins to sail away from the dock. Either could produce a certain amount of personal discomfort. Fortunately, I have not yet had to jump onto to the dock or into the boat, and it is my intention not to do so. However curious I might find my position to be, it is clear to me that I should examine the important interdependence of trauma and the surgical specialist as we deliver care to our injured patients. To do this, I would like to address several questions: ● Is trauma care important to the surgical specialist? ● Are the surgical specialists important to trauma? ● What problems exist that may threaten our interdependence, and how do we solve them?

Plastic surgery in the new millennium

The end of centuries, and especially millennia, have always been a time for soothsayers. Such times offer rich pickings, especially for the prophets of doom! The last 50 years have seen a meteoric development in the specialty of Plastic Surgery. However, as the end of the century and millennium approaches, the voice of disquiet can be increasingly heard amongst Plastic Surgeons. The cause of this anxiety is the increasing number of Plastic Surgery techniques that are being performed by non Plastic Surgeons. Some even speak of the demise of Plastic Surgery as a specialty, or at least its marginalisation to cosmetic surgery. Has the specialty of Plastic Surgery really been a star which has burned too brightly? Is it really in danger of burning out? My central thesis is that the specialty of Plastic Surgery is unique and has an important contribution to make into the future. Plastic Surgery differs around the world such that some of what I say is specific to conditions in Britain. I will start by considering what is meant by the term 'Plastic Surgery'. After a brief look at the past I will review the likely future changes in the techniques of Plastic Surgery. Then I will move on to explore the future of the specialty and the factors that will determine its future. Finally I will offer some immediate priorities.

Perspective: committed to excellence.

Perspective: committed to excellence.

Pediatric facial fractures: analysis of differences in subspecialty care.

At the University of Michigan, the pediatric facial fracture call schedule rotates through the plastic surgery, otolaryngology, and oral surgery services. This situation provides an opportunity to evaluate differences in the management of pediatric facial fractures between subspecialty groups. At this hospital, a retrospective review of all pediatric facial fracture cases within a 5-year period was undertaken. Sixty patients with 82 facial fractures were studied along subspecialty lines. Differences in patient groups, practice patterns, and treatment strategies based on subspecialty assignment were found. Overall treatment followed traditional lines, with plastic surgeons involved in all types of pediatric facial fractures, whereas otolaryngology and oral surgeons were more limited in their operative scope, despite equal call responsibilities. It is believed that the managed care arena is a competitive environment in which it will be important to know the strengths and weaknesses of the plastic surgery specialty, as well as those of competing specialties, as patient contracts are negotiated. The overlap of plastic surgery, otolaryngology, and oral surgery in the care of facial trauma could result in plastic surgeons being left off of managed care participant lists. This study highlights plastic surgeons as efficient deliverers of quality care for pediatric facial fractures. Although the treatment of these fractures has fallen into the duties shared by all three subspecialties, data such as those presented here should strengthen our ability to succeed in the evolving environment of managed care.

The Legitimacy of Aesthetic Surgery

The prominent position of aesthetic surgery within the plastic surgery specialty is a relatively recent phenomenon. There was a time, not so long ago, when “proper” plastic surgeons who performed aesthetic surgery would not openly discuss it with their peers. Aesthetic procedures were done only in small private hospitals, not in university centers. This was the scenario in the early to mid 60s, when residency programs offered little or no training in aesthetic surgery. Training programs might be cited for deficiencies in hand surgery or perhaps cleft lip and palate …

Anesthesia for Male Aesthetic Surgery

The male patient for aesthetic plastic surgery should expect to have a good experience, with few, if any complications from anesthesia. Proper planning is essential to the process, from setting up the surgical facility to selection and preparation of patients. Anesthetic techniques should be adapted to the needs of each patient, with his safety and comfort the most important consideration. Anesthesia for plastic surgery has progressed from simple injection of local anesthetics to sophisticated sedation and general endotracheal techniques. Better anesthetic drugs, monitors, and procedures for dealing with complications have made anesthesia a major factor in the advances of the plastic surgery specialty. Male patients frequently have different medical problems than their female counterparts have, including cardiovascular disease, hypertension, and smoking history. Other problems include back discomfort and prostate enlargement, both factors that must be taken into consideration with local sedation anesthesia techniques. The use of basic monitoring equipment has made ambulatory surgery safer for patients and has been instrumental in reduction of medication-related complications. Monitoring standards changed in anesthesia in the late 1980s to include electrocardiogram (EKG), precordial or pretracheal continuous monitoring, blood pressure, and pulse oximetry. In addition, if general anesthesia is used, end-tidal carbon dioxide and temperature monitoring and oxygen analysis of the anesthesia gases are also recommended. General anesthesia is being utilized more frequently in cosmetic surgery procedures and offers many advantages over local and conscious sedation techniques. The modern agents and techniques permit the patient to recover quickly, with minimum postoperative sequelae, and provide obvious comfort during the operative procedure. The traditional anesthesia technique for facial plastic surgery has been local anesthesia supplemented by sedation. This technique requires a combination of skillful local administration, selection of appropriate sedation drugs in proper doses, and a cooperative patient. Ideally, the selection and administration of drugs and monitoring of the patient should be by an anesthetist, who understands drug interactions and synergistic and additive effects of sedation drugs. Facility set-up, professional personnel, and recovery and discharge criteria are essential to good anesthesia care for the male aesthetic patient.

The Practice of Hand Surgery

This is a generally excellent text that covers the surgical management of disorders affecting the hand in the broadest spectrum from congenital anomalies through arthritis in the elderly as well as the full gamut of reconstructive procedures, procedures addressed at neurological deficits relating to hand dysfunction, and rehabilitation. The fact that this book has gone into an expanded second edition speaks generally well for its acceptance by the surgical community, principally those working on the hand in both the orthopedic and plastic surgery specialties. As is typical with major text efforts of this type today, it has multiple (47) contributors, and it is a tribute to the editors that there is at least a reasonably coherent format and style throughout, even extending to some degree to illustrations and chapter organization. The references are probably as up-to-date (through 1985) as the publishing of a major textbook will allow. This text is

CONTEMPO '87 Crushes Disturbs, Saddens, Amazes, and Disappoints

To the Editor. —As a member of the American Medical Association and a practicing plastic surgeon, I read with great interest the CONTEMPO '87 series of state of the essays.1I am saddened and amazed thatJAMAchose to ignore the specialty of plastic surgery for the second year in a row. This is especially surprising when one considers the important and innovative contributions made by plastic surgeons in the fields of microsurgical free-tissue transfer, skin allografting and skin substituting, care of complex congenital and traumatic craniofacial deformities, and functional muscle transfer. In the same issue, an essay was included about innovations made in the field of otolaryngology, citing tissue expansion and the pectoralis flap as new contributions, referencing 1986 journal articles. The tissue expander was developed by Radovan2and presented to the plastic surgery community more than ten years ago, and modifications and new applications have

Plastic Surgery in the Twentieth Century

Plastic surgical operations are among the oldest and have been developed increasingly from ancient times down to the present. However, the age of medical specialization did not begin until the latter part of the nineteenth century, and the specialty of plastic surgery is largely a child of the twentieth century. Most of the operations we do today have been created by plastic surgeons with the past 50 years, but were made possible only by the rapid developments in other surgical specialties and in all of medicine and science. The relationship with other specialties has been an interdependent one, and this is likely to be the pattern of the future. Plastic surgery, bridging the anatomical specialties as it does, must continue to draw bits of information here and there from them and to synthesize these into major contributions of great benefit to all. The specialty will grow in direct proportion to the success of the innovators within it in fulfilling their crucial role.

The establishment of the specialty of plastic surgery and its contributions to other specialties

The establishment of the specialty of plastic surgery and its contributions to other specialties

Sir Harold Gillies

SIR Harold Gillies, the subject of this month's Historical Vignette, was the otolaryngologist instrumental in founding the specialty of plastic surgery. Our readers will enjoy this beautifully and accurately written vignette by his close personal friend and colleague, Sir Victor Negus.