Plastic surgery in the modern NHS

Contrary to the media’s portrayal and the public’s perception of plastic surgery, the vast majority of procedures carried out in the UK today by plastic surgeons are reconstructive, not cosmetic. That’s why you will find us as a key member of many of the care teams in acute Trusts and Health Boards, even if our base is elsewhere.

From the top of the head to the tip of the toe, from newborn babies to the very elderly, the modern NHS plastic surgeon treats a wide range of conditions with the ultimate aim of repairing people and restoring appearance and function.  These can be considered in two main groups: congenital (present at birth) and acquired during life.

Of the congenital conditions we treat with reconstructive surgery, some of the most common are: cleft lip and palate; vascular anomalies, such as major birthmarks; congenital deformities of the genitalia such as hypospadias; craniofacial conditions and hand anomalies.

Acquired problems include:
•    cancer (the major part of our elective workload), especially primary and metastatic skin cancer; breast cancer reconstruction, head and neck cancer, penile cancer and soft tissue sarcoma
•    trauma, most commonly involving the hand and face but also working with orthopaedic colleagues, open fractures of the limbs
•    the consequences of severe infection (necrotizing fasciitis, meningococcal septicaemia)
•    burns
•    and some hand conditions (nerve compression, paralysis, arthritis).

MODERN PLASTIC SURGEONS
Using a wide range of increasingly innovative reconstructive techniques, today’s plastic surgeons are a critical part of the mix; not just mending holes and repairing damage through the transfer of tissue from one part of the body to another, but restoring the body, or the function of a specific part, whilst minimising the visual impact of the initial wound or defect, and the impact of the surgery itself.

To really understand the role of plastic surgery in the NHS today, it helps to look at the history of the specialty.

Plastic surgery developed between the wars in freestanding units, often in the countryside outside major cities. But that approach proved unsustainable for modern healthcare. Plastic surgery has become a highly innovative and collaborative specialty, increasingly applying knowledge from research in wound-healing and repair, anatomy, physiology and circulation to create a set of skills and techniques that can be applied to a range of conditions and circumstances.

Today, plastic surgeons are connected to major hospitals so that more patients can benefit from their collaborative work with consultant colleagues in other disciplines and they can benefit from the support of critical care and other colleagues. Unlike most other surgical specialties, plastic surgery is not defined by anatomical structures and boundaries (e.g. colorectal surgery, breast surgery, foot and ankle surgery) but by a common set of principles and techniques that can be applied in a variety of circumstances with safety as the starting point.

This need for closer working with a range of other hospital specialties and the strong links to trauma services has meant that there has been a significant expansion in the specialty in the last twenty years to over 60 UK centres and units based increasingly in university or major teaching hospitals.

All the NHS Strategic Health Authorities now have at least one “regional” plastic surgery centre providing outreach services to smaller hospitals, often across a large geographical catchment area. A number of smaller sub-units have also been created to meet demand for the specialty. The devolved nations have their own centres and networks. Plastic surgeons are used to peripatetic working and being asked to operate with others away from their base hospitals. 

This expansion of providers has been matched by an expansion in consultant numbers; however, plastic surgery still remains a relatively small surgical specialty with around 330 UK consultants meaning that not everyone gets the access that they should. Plastic surgeons find that wherever they go they are in much demand from patients and colleagues alike.

The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) wants every patient to have the best treatment available and they and the Department for Health   agree that the number of plastic surgeons needs to almost double to meet the needs of the current UK population, with a target of one consultant per 100,000 population. Fortunately plastic surgery remains one of the most popular surgical specialties and we are able to recruit trainees of both sexes and consultants without the difficulty that some others experience at the moment. 

The benefits plastic surgeons can bring to both patient outcomes and the NHS bottom line can best be demonstrated by some patient stories.

CASE STUDY - ALISHA
Alisha is four years old now but she was born with fingers on one hand that were extremely short and fused. This is a condition called symbrachydactly. Although her thumb was almost normal, without fingers to pinch against, the use of her hand was very limited. Her parents were very worried that she would be disabled and the paediatricians asked a plastic surgeon at the regional centre who specialises in children’s hand anomalies to see her.

At the age of one, Alisha had an operation to transfer two toes from her foot to the hand in a complex microsurgical operation so that she had two new “fingers” to use with her thumb. An adjustment was also made to the thumb to make it work better. Now Alisha can use her hand to pick things up, to do colouring and drawing and she can use both hands to eat. This sort of surgery has only become possible since plastic surgeons developed the skills to move tissues from one place to another and to join the arteries, veins and nerves using a microscope. This is particularly challenging in a small child but doing the surgery at an early age has allowed Alisha to learn to use both her hands naturally as she grows up.

CASE STUDY – RHODRI
Rhodri is 22. He had bought a motorbike because it would be easier to get around the city and to go away for weekends with his fiancé. Unfortunately he had to brake suddenly in the wet one day and he came off the bike under a lorry. His left leg was badly broken and the bone was actually sticking out. The ambulance took him straight to the regional centre for open fractures and there he was looked after by orthopaedic surgeons and plastic surgeons who specialise in these injuries. By working together they were able to save his leg and repair the damage to the bone and skin, although it did require a “flap” operation. The orthopaedic surgeon told him that without that his fracture would not have healed and he could have been in hospital for months with infection and might have had to have an amputation. Rhodri is back at work now but his fiancé made him sell the bike!

CASE STUDY - MARISA
Marisa liked to look her best and to live healthily, so she couldn’t really believe it when she felt the lump in her breast - after all she was only 30. Her GP confirmed that there was something there and within a few days she had been seen in the breast clinic and the diagnosis of breast cancer was confirmed. The breast care nurse explained that although unfortunately the tests meant that she would need a mastectomy, she could have a breast reconstruction at the same time if she wished. She met with the breast surgeon and also a plastic surgeon who specialised in breast reconstruction and worked with the breast cancer team. They told her about the different ways that a new breast could be made. Although it was more complicated and would take longer to get over, she chose to have an “autologous” reconstruction using some of her own tissues from her tummy and avoiding a silicone implant which might need to be replaced in a few years and could give her problems. She is getting on with her life now; the scars are fading and she has got her confidence back.

CASE STUDY – ARTHUR
Well into his retirement, Arthur was rushed into hospital with stomach pain. He hadn’t been well for some time. He had to have emergency bowel surgery and unfortunately the wound burst after a few days and then became infected. It couldn’t be re-stitched and he ended up in hospital for eight months with all sorts of special dressings but it just wouldn’t heal up. The general surgeon asked the plastic surgeon to visit when he was next doing a clinic in the district hospital and after discussion, Arthur was transferred to the regional plastic surgery centre where an abdominal wall reconstruction was carried out. Two weeks later he was able to be discharged home, much to his and his wife’s relief.

Plastic surgery has moved in from the outskirts and is now a core component of the NHS, working on its own and with others to deliver high-quality, safe patient outcomes and cost effective care.  A highly skilled, innovative specialty, today’s plastic surgeons are as likely to spend their time dealing with unscheduled care as they do elective procedures.  Problem solvers by nature, they are increasingly called upon to provide solutions where other specialties have run out of options or through collaborative working to allow colleagues to achieve better outcomes for patients.

GREATER ACCESS TO PLASTIC SURGEONS
BAPRAS believes hospitals across the UK would do well to make the business case for greater access to plastic surgeons to enhance the range of skills available to patients and to support the work of other specialists. Indeed a modern NHS has plastic surgeons available to play their part in a large number of clinical pathways and care teams: many patients already benefit from this: do yours?

ABOUT BAPRAS
BAPRAS, the British Association of Plastic, Reconstructive and Aesthetic Surgeons, is the official professional membership body for reconstructive and aesthetic plastic surgeons and the voice of Plastic Surgery in the UK. It aims to increase the understanding of the professional specialty and scope of plastic surgery, promoting innovation in teaching, learning and research. To find your nearest plastic surgery provider or for further information on the treatments described in this article, please visit www.bapras.org.uk.

ABOUT THE AUTHOR
Hamish Laing is a consultant plastic surgeon at the Welsh Centre for Burns and Plastic Surgery, ABM University Health Board, South Wales.