To most people plastic surgery equates with cosmetic surgery; yet its origins could not be further removed, for it grew out of necessity in the treatment of war injuries.
The traumatic injuries that war causes presented the surgeons of the First World War with cases the like of which they had never seen. Massive facial injuries with underlying facial bone and mandibular fractures stimulated ear, nose and throat surgeons to deal with areas that fell between the specialties as they then existed. Those defects required soft tissue cover and bone reconstruction in a complex series of operations.
With the development of microsurgery a new phase was entered, allowing the immediate transfer of large areas of skin to cover important defects – as in lower limb injuries – the replantation of amputated digits and hands, the transfer of toes to reconstruct amputated digits – especially the thumb – and the reconstruction of congenital hand defects using microsurgical techniques. Vascularised bone transfers improved the function and reconstruction of the lower limb and also the mandible. Nowadays most plastic surgeons will deal with three areas: the management of skin cancer, cosmetic surgery and one reconstructive interest. It is therefore important to know the areas of expertise that each consultant plastic surgeon has.
In the regional centre in which I worked I used to concentrate on hand surgery in children and adults. One colleague specialised in ear reconstruction, another in cleft lip and palates; yet another in facial palsy etc. Each of these colleagues would be asked to perform medical reports in those areas of expertise. All would be capable of commenting on scars – their method of production, prognosis and whether or not surgical scar revision would help.
Some plastic surgeons are concentrating on the cosmetic/aesthetic side of the specialty almost exclusively. This is an area fraught with difficulties; dysmorphophobia, patient expectations, complications, the need for revision surgery, finance and – worst of all – advertising, which not only can be misleading but often is designed to mislead. This area, and indeed all areas of medicine, are complicated by the entirely unreasonable expectations of the modern patient, many of whom are looking for a guaranteed outcome which surgery simply cannot supply.
Case Study
The client , a mechanic, was referred for a medical report following an injury sustained while at work. While he was working on an engine another mechanic started it. The fan hit the tip of his left thumb, amputating it halfway up his nail bed.
Upon completion of hospital treatment he was left with an extremely curved nail, a contracted and flexed terminal portion of the thumb and a sensitive thumb tip. He could no longer work as a mechanic.
The extent and duration of any continuing disability was of crucial importance: the question was: "Will this gentleman ever return to his occupation as a mechanic?"
It was suggested that a neurovascular island flap was taken from the ulnar side of his middle finger. That allowed the contracted thumb tip to be released. New skin was inserted with its own blood supply. It allowed the retention of the nail, which was felt to be important to him as a mechanic.
I last saw him some three months after surgery. His flap had settled in beautifully and he had been back at work as a mechanic from some two months after the operation.
In formulating the medical report it was clear that the patient was in a situation which would prevent him from continuing in his employment, but which could be altered by appropriate surgical techniques. One of the benefits of such reports is the provision of a second opinion to the patient and to the instructing solicitor, often with significant benefits to the patient.