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Plastic surgery and innovation in medicine
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Introduction
What is different about plastic surgery compared to other areas of specialty practice? I pointed out in the last edition of this textbook that plastic surgeons do not own a disease like oncologists do, or a body part like heart surgeons do. We do not concentrate on a system like orthopedists or urologists do, we are everywhere, operating from head to toe and flitting between systems; peripheral nerves, lymphatics, tendons, moving tissue from one place to another, enhancing function, features, and appearances. Our specialty is also dynamic, constantly changing and evolving. Just in the past 15–20 years the areas of vascularized composite allotransplantion, perforator flaps, fat grafting, distraction osteogenesis in the craniofacial skeleton, just to name a few, have been developed and become mainstream. These areas and others continue to evolve. This is one of the reasons why this textbook needs constant revision ( ).
This endless development and evolution has followed a pattern. The pattern has been that plastic surgery develops solutions for a given problem, we perfect these techniques and not infrequently other specialties adopt these procedures and ultimately take them over. Meanwhile we move on to another problem. This has already happened in many different areas in different parts of the world. For example, head and neck surgery, particularly in the US, is most frequently performed by head and neck surgeons, most of whom are trained in otolaryngology. Initially otolaryngologists did the resections and partnered with plastic surgeons to do the reconstructions. Personally, head and neck reconstruction consisted of approximately 70% of my practice at one time. Gradually, head and neck surgeons took over the reconstructions, including microsurgical reconstructions, with the result that currently, in the US, most head and neck cases, resection and reconstruction, are done by head and neck surgeons. When I trained in Ireland in the 1970s, plastic surgeons did the head and neck resection as well as the reconstruction. Now many plastic surgery programs in the US and elsewhere no longer do head and neck surgery in any appreciable volume; we do less and less head and neck reconstruction, let alone resection. The same is true of hypospadias. Again, when I trained, plastic surgery did all the hypospadias repairs, an area that has now been taken over by urologists. Surgeons were reconstructing eyelids but the specialty of oculoplastic surgery did not exist. Otolaryngologists had not yet branched into facial plastic surgery. Part of the reason for these developments is that plastic surgeons are generally not the gatekeepers for most diseases. Patients with breast cancer see a breast surgeon, patients with skin cancer see a dermatologist. Plastic surgeons are consulted by these other specialties to reconstruct whatever defect the patient is left with and, in many cases, we are referred patients after a failed attempt at reconstruction by the other specialty, some of whom have little surgical training.
Adaptation and change
This ability to change and adapt is a strength and we can see this in other spheres. For example, this ability to adapt, change, and incorporate new ideas is what has made English such a dominant language. It is the reason that Apple has become an industry leader. The same is true of Amazon. This is the essence of innovation. There are numerous examples in Biology that underline how the power of adaptation is the power of survival. For plastic surgery the same holds true and while some fear the demise of the specialty, I would argue that while we adapt and develop, there will always be a place for plastic surgery.
This pattern of change and adaptation has been the blueprint of plastic surgery and we are stronger for it. Why is this? To answer that question, we need to look at what has happened historically. When we look back, we realize that what has been the hallmark of development in plastic surgery is innovation. While it is true that we are not the only ones who innovate, it is something that is in our culture and is something we have seen in all subspecialty areas of plastic surgery.
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