A bystander to the evolution of plastic surgery

I have a new favorite doctor show, “The Knick” on Cinemax, airing on Friday nights.   The show stars Clive Owen as the charismatic cocaine-addicted chief of surgery Dr. John Thackery at a fictitious New York City hospital called The Kickerbocker at a time when surgery was one foot out of the barbershop.  The tagline is, as they say, priceless: “Modern medicine had to start somewhere.”

On the third episode, last Friday night, Dr. Thackery performs a pedicle skin graft from the upper arm to cover a gaping hole in a woman’s face where her nose used to be, before she got syphilis.   Back in those days, this was a marvelous feat.  Real progress in what we now know as reconstructive surgery didn’t come until the end of World War I, when Sir Harold Gillies, a New Zealand otolaryngologist later known as the “father of plastic surgery,” established the first hospital ward for the facially wounded in Queen Mary’s Hospital in Kent.

For over fifty years, I have been a bystander to the evolution of plastic surgery.  As a teenager I remember the heady early days of microvascular surgery; my father, Dr. Melvin Spira reattaching the scalp of a man whose hair got caught in machinery, then the tales of sewing back severed fingers and ultimately entire limbs with gradually improving functional results.  In the 1970s the great French surgeon Dr. Paul Tessier, pioneer in techniques for cranio-facial surgery to correct birth defects came to the United States to teach, and I remember a Saturday morning clinic at my father’s office, where mothers whose children’s facial deformities were so severe that these kids had, literally, never seen the light of day waited in line to be seen by the great surgeon who could give them back a normal appearance, and thus a life.

Plastic surgery, like my own specialty of radiation oncology, has become one of the “lifestyle” specialties to which medical students aspire, particularly those with an artistic bent and good hands, and for good reason.  Cosmetic procedures are highly reimbursed, and are done during “regular” working hours. Walking around here in San Diego and Los Angeles, surely two of the plastic surgery capitals of the world, it’s easy to spot who has had “a little work” done.  Having one face lift might be a good thing (I wouldn’t know because, as I’ve covered in previous blog pieces, my imagination runs wild with the possibilities of complications and I am far too chicken for elective surgery), but have three and you become one of “our ladies of perpetual surprise”: eyebrows at the hairline.  Same goes for breasts; it is not normal for the “girls” to be rigidly immobile as their owner pounds away at the Stairmaster.

Last year, I mentored a medical student who had started his medical education thinking that he wanted to become a plastic surgeon.  After a beloved aunt developed breast cancer and needed radiation, he started to think that perhaps he would rather become a radiation oncologist because he enjoyed dealing with cancer patients.  He was an outstanding student, and I was quite sure that he would be accepted, and do well in either specialty.  I assured him that with his gifts, and his compassion, he could combine his interest in helping cancer patients with his interest in reconstructive and restorative surgery. Residency interviewers for plastic surgery residencies have a difficult job these days: All of the applicants say they want to do reconstructive surgery, but most end up doing cosmetic work.

Apparently my student was convincing when he said he wanted to do plastic surgery to help cancer patients.  He started his plastic surgery residency at Stanford last month.  Dr. John Thackery of “The Knick” may be fictional, but I hope that my student leads the way in new innovations in reconstructive surgery.  My cancer patients may depend on it.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.

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  • RenegadeRN

    “Our ladies of perpetual surprise” ..Ha Ha! Loved it, almost spit out my tea laughing. So true.
    What cracks me up is the doc who is the skin expert, yet looks looks like a molded wax figurine…. Uh, no, I don’t think I want YOUR recommendations for a younger face… Thanks for the morning laugh.

    • Miranda Fielding

      I probably shouldn’t say this, but my mother, who passed away after a long struggle with dementia, had had three facelifts, two done my my father himself (don’t get me started on plastic surgeons operating on family members–most of them do it!). During the final stages of the illness, my Dad would say with pride, “But isn’t she the PRETTIEST lady in the nursing home!”. Yup, she was, for what that was worth to her.

      • RenegadeRN

        Sounds like they were BOTH happy then! Guess that’s what counts. Who am I to judge?

  • Lisa

    I think reconstruction surgery after mastectomy is often pushed by plastic surgeons, in part because it is reimbursed by insurance and it the income stream form such surgeries may be more steady than the income generated by cosmetic procedures.

    As a breast cancer patient, I hope the OP student learns to fully inform women about the pros and cons of breast reconstruction. When I was facing a mastectomy (multi-centric breast cancer) I was told, over and over, that I would be able to have immediate reconstruction. My breast surgeon was the only doctor who didn’t push reconstruction. although he did ask me to see a plastic surgeon so ‘I could be fully informed.’ Sadly, the plastic surgeon tried to sell me on implant reconstruction, which she was the only type of reconstruction she did. She didn’t discuss analogous tissue transplant with me; she didn’t discuss possible complications with me; she didn’t discuss the option of not having reconstruction with me other than to dismiss that option.

    My experience is not unique, even though I would like to think it is.

    • Miranda Fielding

      Lisa, I have written about this subject before, especially addressing the idea of taking off a healthy breast and then reconstructing both, which is a HUGE undertaking. I think with this student’s rotation through radiation oncology, he will have a balanced view. But with most of the plastic surgeons I know, it’s not about the income because they don’t make that much from even a complicated flap reconstruction. It’s more about the aesthetics and symmetry and a conventional sense of beauty than the money, in my opinion.

      • Lisa

        It may be about aesthetics and symmetry and even a ‘conventional sense of beauty,’ but I am suspicious. When I read about things like BRA Day (http://www.bradayusa.org/), sponsored primarily by plastic surgeons, it is hard not to be. When I hear the stories of other women, who feel that they were pressured into reconstruction and who certainly were not fully informed about all of their options, it is hard not to be.

  • Markus

    Former oncologist here. I have been to Buenos Aires a couple of times which has the highest rate of cosmetic breast surgery in the world. Walking around town I saw very few obvious ones, and I pride myself in recognizing them. I used to watch the Oscars to see who had reconstruction, but I came to the conclusion that it was 100%.
    On a serious note, there has been an increase in mastectomy rates in recent years despite the fact that the original lumpectomy plus RT randomized clinical trial still looks good 30 years later. Why aren’t radiation docs more vocal on this?

    • Lisa

      Many mastectomies are fear driven. Seriously, I think the rate of mastectomy rates are increasing because reconstruction is made to look like an attractive option. Many people look at reconstruction as a chance to have a ‘boob job.’ That and doctors really do not do a good job of eduction women about their chances for recurrence and survival rates with a lumpectomy and rads versus a mastectomy.

      • Markus

        My morning paper stated that a recently completed study showed no advantage to the prophylactic bilateral mastectomy over lumpectomy plus RT. The NSABP 06 trial showing the equality of lumpectomy plus RT to mastectomy remains standing; the trial was completed in 1984. Pretty robust in my book.
        Susan Love used to say that mastectomy was the only form of psychosurgery legal in the US.

        • Lisa

          Dr. Love’s comment is rather funny.

          But is psychosurgery always wrong? Look at my case, I was initially treated for breast cancer with two lumpectomies; then another tumor was discovered. At that point, mastectomy was my only choice as I had cancer in three quadrants of the the breast. I didn’t want reconstruction, so decided to have a bilateral mastectomy so I would be symmetrical. I felt like it was my only option as walking around with one very large breast that would have been impossible to match with a prosthesis was unacceptable to me If one of my doctors had told me that the bilateral mastectomy wasn’t an option, I don’t know I wouldn’t have treated my breast cancer because my life would have been truly miserable.

          There are no easy answers; I think doctors need to do a lot better job of educating women about the outcome of lumpectomies & rads versus mastecomies. But women still need to have all options available to them.

    • Miranda Fielding

      We try to be vocal and I’ve written a blog piece on the subject of prophylactic mastectomy for the unaffected breast which has been published here. One problem is still fear of radiation, combined with some fairly recent negative publicity about heart toxicity in patients who were treated with archaic techniques from 30 years ago. Another is that we are doing so many more MRI’s with so many more false positives, that women’s anxiety level re: breast cancer is higher than ever. Plus the general misconception that “having it off” is more definitive treatment than lumpectomy and radiation. People still do not understand that in many cases, cancer is a systemic, not a localized disease.