Editorial “Plastic Surgery”… Beware Maurice Y. Nahabedian, M.D. Washington, D.C.

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he specialty of plastic surgery has traditionally been attractive to those that are innovative, think conceptually, and are geared toward problem solving. Plastic surgeons learn many of the concepts, principles, and techniques during their residency and fellowship years and then apply what they learned toward the betterment of their patients and for colleague education. In essence, plastic surgery represents a tremendous body of knowledge that requires a fundamental and rigorous training for one to become competent and qualified to perform it. Many physicians distinguish themselves by being mentors and educators to their peers, residents, and students. Among the community of plastic surgeons, there is a brotherhood/sisterhood that is based on sharing of ideas, principles, concepts, and techniques to improve outcomes. We are happy to teach other plastic and reconstructive surgeons but are sometimes reluctant to teach physicians from other specialties, not because we are proprietary but because it is important to protect our domain. As an example, with the recent movement in oncoplastic breast surgery, there was controversy over who should be performing the reconstructive portion of the operation: the breast surgeon or the plastic surgeon.1,2 Much of this was perpetuated based on the European experience, where it remains common for breast surgeons to perform reconstructive procedures such as tissue expansion, reduction mammaplasty, and latissimus dorsi flaps. In the United States, most plastic and breast surgeons have maintained their boundaries and decided instead to work together; thus, many of these issues have been amicably resolved. In an ideal world, this Editorial would report that all is well; unfortunately, a series of observations have prompted concern. There appears to be a new movement involving graduates from plastic From the Department of Plastic Surgery, Georgetown ­University Hospital. Received for publication October 14, 2013; accepted October 16, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000032

surgery residency programs that are now seeking opportunities with general/breast surgeons. The nature of these opportunities includes fellowships in breast oncology or breast surgery or association with a group of breast surgeons. Whether their intent is to remain as a general/breast surgeon is unclear. The ramifications of this are complex and potentially damaging to the future of our specialty. We all agree that patient safety and improving outcomes is a priority, but I do not believe that teaching a plastic surgeon how to perform a mastectomy and teaching a breast surgeon how to perform breast reconstruction is the answer. I do not believe that most plastic surgeons are interested in performing partial or total mastectomies, but I do believe that there are some breast surgeons who are interested in performing breast reconstruction and breast reduction. All that is necessary is to study the European experience, where prosthetic reconstruction is now almost completely within the domain of the breast surgeons, with the plastic surgeons performing only the more complex microvascular reconstructions, to see that this risk is real. This is not a direction that we as a specialty should encourage, condone, or permit. There are several relevant factors that I believe are perpetuating this movement that include a global increase in the amount of prosthetic breast reconstruction performed, economic pressures during an era of declining reimbursement, and industry influence to increase sales. With the paradigm shift that has occurred in the United States, there is an evolving interest among a few breast surgeons to become more involved with prosthetic breast reconstruction. I appreciate that most breast surgeons in the United States are comfortable with the present arrangement of working with their plastic surgeons; however, I suspect that some are not. Possible reasons Disclosure: Maurice Y. Nahabedian, M.D., is a speaker and consultant for LifeCell Corp. No financial or administrative assistance was used in preparing this Editorial.

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Plastic and Reconstructive Surgery • April 2014 may include declining reimbursement, need to increase revenue, or the ability provide a service that may not be available in some communities. Plastic surgeons should be aware and should not forget that we do not regulate or dictate referral patterns and that we typically receive referrals based on our expertise, likability, advanced training, and ability to deliver good outcomes. Plastic surgeons should not assume or take for granted that prosthetic breast reconstruction, reduction mammaplasty, and pedicled flap reconstruction are protected and solely within our domain. If a small number of plastic surgeons decide to cross the line to teach and mentor our breast surgery colleagues, our specialty will certainly change. Whether this change is perceived as negative or positive will depend on which side of the line you are on. Breast and plastic surgeons may not be the sole force perpetuating this movement; it may also be perpetuated by industry. The goal of industry is to manufacture and distribute products that in this case include tissue expanders, implants, and acellular dermal matrices. When it comes to the marketing and distribution of devices, there are no ground rules. Any physician can purchase an implant or tissue expander or an acellular dermal matrix. Some companies have accepted an obligation to sell to “plastic surgeons only” and, in my opinion, should be congratulated. Many companies provide educational seminars and workshops for physicians to gain hands-on experience with these devices with the intent being to educate and train surgeons on their proper use. Unfortunately, there are no rules stating that only plastic surgeons can participate; it is essentially up to the company to invite whomever they want. Fortunately, most companies act responsibly and recognize that use of these devices by surgeons who have not completed a formal residency in plastic surgery provides a foundation for poor outcomes, the consequences of which could lead to increased malpractice claims and eventual litigation. Let us not forget that plastic surgery of the breast remains on top of the list when it comes to malpractice claims. However, during these difficult economic times, some companies may take the shortsighted route and consider expanding the number of potential buyers to increase sales.

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The decision to prepare this Editorial was not based on criticizing the community of general and breast surgeons, because I am sure that the vast majority are content with the current arrangement. My intent is to raise the awareness of plastic surgeons, because there are a few breast and plastic surgeons who wish to foster this movement. My opinion on this matter continues to remain that breast and plastic surgeons should work in a collaborative manner when it comes to ablative and reconstructive surgery and not independently. This provides the strongest foundation for minimizing adverse events and optimizing surgical and patient outcomes. It can be stated that reconstructive plastic surgery is somewhat fragile because of its relatively small constituency and its dependence on referrals from other surgeons and physicians. To assume that prosthetic breast reconstruction or oncoplastic surgery could not be adequately taught to a breast surgeon is shortsighted because, with increasing surgical experience and time, breast surgeons can acquire the skill set to perform these operations, especially if fully trained plastic surgery graduates are teaching it to them. As a specialty, our best strategy will be to recognize what is occurring and take appropriate measures to deter it. We should educate and emphasize to our residents and members the importance of protecting our specialty. Based on circumstances such as these, there are some that have cautioned about the decline of plastic surgery if we neglect to survey the landscape and fail to recognize those surgeons that do not respect boundaries associated with each specialty and those plastic surgeons that are not committed to its preservation. Maurice Y. Nahabedian, M.D. Department of Plastic Surgery Georgetown University Hospital 3800 Reservoir Road, NW Washington, D.C. 20007 [email protected]

REFERENCES 1. Nahabedian MY. Plastic surgery: Technique or discipline? Plast Reconstr Surg. 2006;118:1653–1655. 2. Losken A, Nahabedian MY. Oncoplastic breast surgery: Past, present, and future directions in the United States. Plast Reconstr Surg. 2009;124:969–972.

"Plastic surgery"… beware.

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