Being a plastic surgeon requires a lot of explaining

I am posting this article by Dr. Peter Neligan,  a well respected and internationally famous plastic surgeon.    Please understand that plastic surgery is so much more than "cosmetic or aesthetic" surgery.   The most gratifying part of plastic surgery is to be able to put someone back together and improve their lives.

Enjoy!

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by Dr. Peter Neligan, Professor of Plastic Surgery, University of Washington, Seattle, June 2013

A new crop of medical students will begin a residency in plastic surgery this summer. They have worked long and hard to secure these coveted spots.  As a service to them and the profession, I wanted to take this opportunity to help make their path a little easier by offering a bit of advice.

When asked what you do, simply say that you are a surgeon. I avoid saying plastic surgeon because it invariably prompts awkward facial expressions and comments to the effect that I am just the person they’ve been waiting to meet, nod nod, wink wink! In many people’s minds, plastic surgery is synonymous with cosmetic surgery, yet I do no cosmetic surgery. This usually strikes people as very odd. A plastic surgeon who doesn’t do cosmetic surgery is like an auto-mechanic who doesn’t fix cars, or a teacher who doesn’t teach.

So what do I do? Strictly speaking I should describe myself as a reconstructive microsurgeon, although that usually draws blank stares. The truth is that while cosmetic surgery is probably the most visible and perhaps the most glamorous aspect of plastic surgery, it’s a relatively small part of the specialty. The breadth of the specialty fills a six-volume Plastic Surgery textbook I edited this year.  Only one of these volumes is dedicated to aesthetic surgery.

Some say that plastic surgeons are the last general surgeons. We don’t own a disease like cancer doctors do, and we don’t own a part of the body like heart surgeons do. We work all over the body on all kinds of diseases and frequently with other physicians in a multidisciplinary group. We’re not only misunderstood by the public, but also by many of our medical colleagues.

Several years ago, on Christmas Day, I finished an emergency case in the operating room. One of my cardiac surgery colleagues had done a coronary artery bypass graft on a patient several days before. The sternotomy wound became infected, and the patient became gravely ill.  As a reconstructive plastic surgeon,  I was called upon to remove the infected tissue and reconstruct the patient with muscle flaps to provide healthy cover for his exposed heart.  As I was leaving the hospital, I saw an internist colleague in the lobby. He called out, “Hey Peter, what are you doing here on Christmas Day? Somebody drop their face?” My cardiac surgery colleague set him straight and told him I had just saved his patient.

On another occasion, I treated a young woman who developed a cancer in the floor of her mouth.  I reconstructed the defect by taking bone and soft tissue from her leg, transferring it to her face and shaping it to reconstruct the missing jaw, the floor of her mouth and tongue. I reconnected the small blood vessels that nourished this tissue to blood vessels in her neck using an operating microscope. When I spoke to her family at the end of this 8-hour case, they looked confused and asked when she would be seeing the plastic surgeon. This kind of misconception happens all the time.

The history of plastic surgery is one of innovation.  Plastic surgeon Dr. Joseph Murray performed the world’s first kidney transplant in Boston in 1954. Five years later, he performed the world’s first successful allograft and, in 1962, the world’s first renal transplant on a cadaver. He received the Nobel Prize in 1990.

What, you might ask, was a plastic surgeon doing transplanting kidneys? His experience treating burn patients sent back from World War II gave him wide exposure to skin grafting and raised issues of immune rejection that he studied using the kidney as a single organ model.  In recent years, too, plastic surgeons are leading the way in hand and face transplantation, continuing Dr. Murray’s tradition of innovation.

I’m very proud to be a plastic surgeon, but it requires a lot of explaining.  To my early-career colleagues, I wish you a successful and satisfying career and a dash of good humor.  Chances are,  you’re going to need it!

Peter Neligan is a professor of plastic surgery and otolaryngology, University of Washington Medical Center and editor of Plastic Surgery, 3rd edition published by Elsevier.

Are you goal oriented?

Are you a goal oriented person?

If you are reading this blog, I'll have to assume that the answer is yes. And with that yes I would say that you are not only goal oriented, but that your goals are set very high.  I would encourage any of you seeking a career in surgery to set extremely high goals for yourself. Never be satisfied with the status quo. If you aim high enough, you may actually achieve something quite significant, even if it is not that exact goal.   There should be no day that passes by where you did something that you could not have done better.  

One of the beauties of plastic surgery is that there is an immediate result.   There's an immediate satisfaction of the work that you have done as a surgical artist.   To that end, I am never satisfied with the result at hand, and I always wonder what other ways I could have gotten this result even better!   If you read the biographies of successful people, I believe many of them live by two strong principles.

#1.   They set very high goals. 

#2. They are not afraid of failure.  

There are bound to be some failures that seem to be a roadblock to success.   It is this ability to take on challenges,  learn from mistakes, to always reach higher, that will set you in the right direction to success!

Angelina Jolie, Mastectomy, and her Breast Cancer Treatment

I applaud Angelina Jolie's candid approach to her recent treatment for breast cancer.  Because of her “star” status, she is able to put a significant spotlight upon current issues in breast cancer treatment today.  This includes the BRCA gene, which places her at high risk for breast cancer, that many people may not know much about.   It also highlights her approach to this situation with her getting prophylactic bilateral mastectomies and immediate breast reconstruction with tissue expander implants.

Many people may wonder why someone would want to undergo bilateral mastectomies at this stage of her life while not actually having breast cancer but having a high risk gene.   She explains it quite well:  she wants to decrease her chances as best as possible, even at the cost of losing her breasts.   The complete removal of the breast tissue (mastectomy) early on decreases the chances for breast cancer significantly in the future.   In the meantime, she can undergo breast reconstruction which will still allow her to have excellent breast aesthetics.   By undergoing prophylactic mastectomy with nipple preservation, she will also avoid any radiation treatment which can severely deform the breasts--radiation has its own set of problems including wound issues, implant infections, contracture, radiation changes to the heart and lung.

The other option that she may have considered is autologous breast reconstruction using her own tissues without an implant. This includes the DIEP breast flaps from her abdomen transplanted to her chest via microsurgical technique which would preserve her “super six pack.”   This would allow her to have breast reconstruction at the same time with her own tissues and would get a potential tummy tuck as well.    My guess is that Angelina Jolie did not have enough abdominal tissue to undergo bilateral breast reconstruction and that is why she chose tissue expander and implants.   She will need to undergo several expander injections and another operation for a final silicone implant.

One of the great joys of my practice is in caring for women who have beaten breast cancer.  They are courageous and very knowledgeable about their options in breast reconstruction after mastectomy.   It is very common now for me to see patients who seek to undergo prophylactic mastectomies and immediate breast reconstruction just like Angelina.   She is definitely not alone in the fight against breast cancer and seeking the best medical options and care.

I thank and applaud Angelina Jolie’s courage in sharing this deep and personal part of her life to help others.   She is a super star in my book.

Is money your motivation?

Lately, I have a number emails and questions regarding the salary or the earning potential of plastic surgeons.  Some have also explained to me that money is their key motivation to become a plastic surgeon.   Those of you considering a career in plastic surgery who are focused on money should look elsewhere for a profession.    I say this not because money cannot be made as a plastic surgeon, but because money should not be your motivator for anything, let alone for a long, arduous education and training program path as plastic and reconstructive surgery.   

If money is your object, there are many other ways to start earning money with much less education and training.  Four years of college, 4 years of medical school, 6-8 years of surgical residency training, possible fellowship training  = 14 - 17 + years before you start earning anything of substance.  This means that you are about 30-33 years old.  That's 10 years of serious earning potential gone down the drain.  During those 10 years as a resident, you will be earning barely enough to scrape by and likely will be accumulating more debt.   If money is your key motivator, you will be easily disillusioned.     

The difficult paths in life are filled with obstacles that make money the weakest motivator.   If you embark on a career in plastic and reconstructive surgery, you have to love what you do, have passion, and high ideals.   Money will come with hard work, creating quality, and improving people's lives.   These values will always be rewarded and people will seek your expertise for many years to come -- and that, is something that money cannot buy.

Plastic Surgery Training Programs

Plastic Surgery training has been rooted in the principles of general surgery training for many decades. The traditional path to become a plastic surgeon usually meant you completed 5-7 years of general surgery, and then completed another 2-3 years of "plastic and reconstructive surgery" fellowship. That's almost 10 years of training after your 8 years of undergrad/med school.

Most specialties, such as orthopedic, neurosurgery, etc, have moved beyond so many years of general surgery, and have abbreviated time (1 year), and the rest of the their training is in their specific field. Plastic Surgery has also moved toward this route with "Integrated" programs. These programs have typically 3 years of general surgery, and 3 years of plastic surgery, hence the term "3 and 3 program." The vast majority of the top plastic surgery institutions at major academic centers have moved toward this model.

The advantage of these programs is that you have an earlier start and focus to plastic surgery training. In your junior years, you will also have exposure to other specialties such as ENT, Dermatology, Orthopedic, etc, making your background that much more focused and relevant. You will be in "plastic surgery" much sooner than the usual 5 years and will finish sooner. It is the future of training and the way most programs have moved toward. It is the way I trained at the University of Chicago, and I am most grateful for my program's opportunities and forward thinking.

The disadvantage is that these programs are highly competitive. Usually there are 2 spots per medical center, and there are probably 50 programs at this time. The other disadvantage that most people don't realize is that you have made the "early decision" to go into plastic surgery. This is often times a premature decision when you see the number of people who drop out of the programs. You might think that no one would do this, but it happens more often than you think. The reasons are many: burnout, change of heart to different specialty, dislike for general surgery, etc.

There are many changes going in plastic surgery education. The breadth of plastic surgery is great, and our time in training is limited. To gain depth in the specialty requires one to start training earlier in the field. This is the way all surgical specialties are headed.

What is the difference between a Plastic Surgeon and a Cosmetic Surgeon?

The difference is everything, the difference is nothing.

It depends on whose perspective it's coming from. By definition, all plastic surgeons are trained and capable of performing "cosmetic surgery," but not all Cosmetic Surgeons are Plastic Surgeons. What does this mean? It means that the true education, training, and ability of a Plastic Surgeon encompasses ALL that is cosmetic surgery, but those who call themsevles "cosmetic surgeons or cosmetic doctors" are not all Plastic Surgeons. The reason is that there are many different groups of doctors and even nondoctors, who would like to have the mystique and therefore the "confusion" of cosmetic surgery or plastic surgery next to their names without the true training of a plastic surgeon. In other words, there is the "real deal" and then the "wannabes."

This distinction is extremely important if you consider the importance of education, training, and ability of the person who will be making permanent changes to your face, hands, breast, body, etc with such instruments as a scalpel, electrocautery, or a suction cannula. Much of what is done in surgery is irreversible and the best chance for success is always the first chance. Why would you risk your face to someone who might have taken a weekend course to call themsevles a "cosmetic doctor"?

You might ask, "So what is the big deal? So what if a family practice doctor or a chiropractor says s/he is a 'cosmetic doctor/surgeon'?" The problem is that those who don't know the difference will likely think that this "cosmetic doctor" is a plastic surgeon. Next thing you know, you've just had your face or body irreversibly botched up by this person. It's about safety and real credentials. If you had trained to be an elite in the special forces of the military, a Navy SEAL or an Army Green Beret, you would not take kindly to someone military or nonmilitary stating they were something "like a SEAL or Green Beret." You either are the real thing, or are not. You either took the difficult, real path to the destination, or you did not.

There is only one plastic surgery board that is sanctioned by the American Board of Medical Specialities (AMBS), the gold standard of medical specialties, and it the American Board of Plastic Surgery (ABPS). For those of you who are embarking on the path to become a plastic surgeon, you need to know this difference and understand what it takes to become a part of an elite specialty where only 200 true plastic surgeons are produced per year at major academic medical centers. You can choose to join other boards with "plastic or cosmetic" in their names, but they are not true speciality boards. Some of these boards do carry some weight, but there is still only one that is part of the ABMS.

So back to the question. It depends on who you are. If you are a real plastic surgeon, the difference is everything; if you are not, you'd like to say the difference is nothing.

Healthcare reform and its meaning to plastic surgeons.

Health-care reform is essential to the well-being of this country and to the well-being of medicine as a profession. The government has taken on a very complicated problem that seems to have very few good solutions. I do believe that the United States, as the most advanced and industrialized nation in the world, should have health care for every citizen. This must be balanced with continued research and advancement, and the least amount of government intervention in the doctor-patient relationship. For the medical profession, this means that we must continue our autonomy to advance the science and the art of medicine and surgery.

Some of you may be embarking on a career in plastic surgery, thinking that health-care reform and health care issues are not that relevant to a cosmetic surgery practice. This could not be further from the truth. Plastic surgery is rooted in the basic principles of wound healing, improving lives, and restoring lost form and function. Health care reform is more relevant to our profession today as the services we provide as plastic surgeons are being constantly monitored and valued by outside organizations that know little about what we do. Because the media have stereotyped plastic surgeons as being only about "nip and tuck," people forget about the major reconstructive surgical procedures that we perform on a daily basis. My practice is somewhat unique in that it is balanced with both cosmetic surgery and reconstructive surgery. I enjoy this balance, and I am passionate about my work.

Becoming a plastic surgeon is about helping your fellow man or woman. Healthcare reform in its principles is about this very same issue. We need to balance this goal with the conflicting political forces that seem to make this goal much more difficult than it has to be.