What is plastic surgery?

Photo credit: http://artificialhand.blogspot.ca/

I realize that there are a lot of faithful readers of my blog that date back to 2007, and hopefully some folks who go back further to my ramblings on the JPFitness forums. To those who have tolerated me for this many years, you probably don’t need to read this. But for those of you joining this quasi-regularly scheduled program, it may seem odd that a plastic surgeon should be writing about fitness at all (which I didn’t really think about until I was asked to introduce myself on the podcast interviews.)

So I’m going to be a little indulgent (I mean, more than usual–let’s face it, I don’t write about anything I don’t want to write about on this blog, so the whole thing is self-indulgent) and talk a little bit about what plastic surgery actually is, and why it may be more relevant to fitness and nutrition than you might think.

In some ways, plastic surgery is the victim of its own media success; and it has done rather little to alter this. Rare is the cardiologist who has to describe what he/she actually does ,because the cardiologist on TV is not _that_ different than the ones in real life. I mean, it’s pretty easy; even on TV, the cardiologist is the doctor that takes care of the heart. There are, of course, differences between the actor that plays one on TV and a real one, but broadly speaking, the _definition_ is the same.

Unlike most surgical specialties, however, plastic surgery doesn’t focus on any particular body part, or tissue type. The name “plastic surgery” is derived from the Greek word, “plastikos”, which means “to form.” Though some of the techniques in plastic surgery date back into ancient times (the technique used for some nasal reconstructions dates back to 600-700 BC), the specialty of plastic surgery is quite young, with its roots in World War I and II, when the development of weaponry capable of inflicting extraordinary damage created problems that had never been before. As a result, our specialty has evolved to one where we operate all over the body and with all tissue types (bone, muscle, tendon, ligament, blood vessels, nerves, fat, skin) with the unifying goal of restoring form and function.

As a fledgling medical student, I really didn’t know what plastic surgery was. It wasn’t even remotely close to my radar. There are still physicians who don’t know what plastic surgeons do. When I tell people that I’m a plastic surgeon, I usually get one of two responses: 1) talk about earning potential while they think of aesthetic surgery (boob jobs, liposuction, Botox and facelifts), or 2) utter disdain while they think of aesthetic surgery (boob jobs, liposuction, Botox and facelifts.) Rarely, I’ll get the third response, which is the question, “Cosmetic or reconstructive?”

This is a tricky question because I don’t see there being a distinct line between the two alleged poles. As a result of not having a specific anatomic area (unless you want to say, “Everything except viscera, the spinal cord and brain,”) plastic surgery is much more about an approach to solving a problem. The techniques used in “aesthetic” surgery are basically the same as those used in “reconstructive” surgery; they’re all part of the same toolbox. Just because there’s preceding trauma, or a birth difference doesn’t change the goal of what we do: to improve function and form.

Broadly speaking, plastic surgery has 7 sub-areas: Microreconstructive (where skin and fat and/or muscle and/or bone is taken with its blood supply and transferred to reconstruct another part of the body), Burns, Aesthetic, Hand, Pediatric, Craniofacial and Wounds. Of these, you can do extra training after a residency that covers all these topics (called a fellowship) in all of them except for ‘Wounds’, which is something almost all plastic surgeons deal with on some level (usually non-healing wounds or ulcers.)

My fellowship is in Hand surgery, which encompasses everything in the hand and wrist, as well as the peripheral nerves from the brachial plexus to the fingertips. Most of what I see is trauma-related. If you can imagine a way to injury a hand or wrist, I’ve probably seen it. Some of what I deal with is degenerative (like rheumatoid or osteoarthritis) or nerve-related (like carpal tunnel syndrome.) My practice is pretty varied though. In addition to hand and wrist stuff, I do a lot of skin cancer surgery, some breast surgery (mostly reductions) and our centre gets a lot of facial trauma and burn trauma as well. I don’t have much aesthetic surgery in my practice; the other stuff keeps me busy enough as it is (which isn’t to say I’m not interested in it, but that I haven’t reached a point in my career where I want to make it a priority in my practice.)

Above all, plastic surgeons, like all surgeons, are anatomists. The ability to do surgery has everything to do with understanding where you can and cannot cut; what you can take and what you have to preserve. It also has nothing to do with anatomy, because most of all, it about understanding when you should and when you shouldn’t cut at all. I don’t think there is a specialty in which the concept of the trade-off is more obvious or apparent for both the surgeon and the patient. Understanding the function of each piece of anatomy that we operate on allows us to make decisions on what is ‘expendable’. And this understanding only expands as we get real-time feedback from patients about what it’s like to live after surgery. In plastic surgery, this basically includes skin, fat, muscles, tendons, some ligaments, most blood vessels and almost all of the peripheral nerves.

It is both a special and weird place to know someone else’s body more intimately than they do from both a knowledge-base and actual physical-base. I mean, when’s the last time your finger was in your eye socket, never mind, someone else’s eye socket? It gives a whole new meaning to the saying, “You can pick your friends. You can pick your nose. But you can’t pick your friend’s nose.” It’s a position of privilege but also terrifying trust.

But enough about me. I’ll get something back on the irregular schedule soon enough.