BASICS: PLASTIC SURGERY AND TOTAL PATIENT CARE

This information is intended to assist those who have general questions about plastic surgery. It includes information about how plastic surgery fits into medical care, how plastic surgeons are trained, and the types of cases that plastic surgeons commonly treat. Remember, each case is unique and a great deal depends upon the patient's individual circumstances. Specific questions about surgery can be best answered in a consultation with a board-certified plastic surgeon.

What Is Plastic Surgery?

Taken from the Greek word "plastikos", meaning to mold or give form, plastic surgery is the specialty of medicine dedicated to restoring and reshaping the human body. It encompasses both reconstructive surgery, which is performed on abnormal structures of the body caused by birth defects, developmental problems, injuries, infection, tumors or disease; and cosmetic surgery, which is performed to reshape or restore normal structures of the body to improve appearance and self-esteem.*

History suggests that the practice of plastic surgery has ancient roots. However, plastic surgery as a defined specialty became fully recognized during World War I. Today, scientific advances in the field allow plastic surgeons to achieve improvements in form and function thought to be impossible 10 years ago.

*Definition as adopted by the American Medical Association (AMA) and the American Society of Plastic Surgeons (ASPS).

Who Is a Plastic Surgeon?

A board-certified plastic surgeon is a doctor trained to be a concerned care-giver, a wound-care expert, a problem-solver, an artist-designer and a meticulous surgeon in the operating room. It's important to realize that not every doctor who has claimed the title "plastic surgeon" has the same training. The truth is, anyone with a medical degree can call himself or herself a plastic surgeon; there are no laws that require doctors offering specialty care to meet certain qualifications.

In checking a plastic surgeon's credentials, patients are advised to consider a doctor who has completed an accredited residency training program specifically in plastic surgery. Such a program includes two or three years of intensive training that covers the full spectrum of reconstructive and cosmetic procedures.

Patients are encouraged to consider a doctor certified by the American Board of Plastic Surgery (ABPS). By choosing a plastic surgeon who is certified by the ABPS, a patient can be assured that the doctor has graduated from an accredited medical school and completed at least five years of additional residency training — usually three years of general surgery (or its equivalent) and two years of plastic surgery. To be certified by the ABPS, a doctor also must practice plastic surgery for two years and pass comprehensive written and oral exams.

Good credentials do not guarantee a successful outcome, but they can guide you to select a surgeon whose training and background will help you to meet your personal goals.

To Locate a Board-Certified Plastic Surgeon

Patients may call the Plastic Surgery Information Service at 1-888-4-PLASTIC to receive the names of plastic surgeons in their area who are certified by the ABPS. This service, operated by the American Society of Plastic Surgeons, Inc. (ASPS), a national medical specialty society requiring ABPS certification as a condition for membership, can verify if a particular doctor is certified in plastic surgery, or has completed required training and is working toward certification.

Cases That Warrant a Plastic Surgeon's Care

Although much depends upon the patient's unique circumstances, there are certain situations that almost always warrant the specialized care that a plastic surgeon can provide. (See List I.) Typically, a plastic surgeon is consulted when a child is born with a defect that affects function and/or normal appearance or when accident, injury, disease or aging causes a physical abnormality. Plastic surgeons also are consulted in hand surgery, microsurgery, and craniofacial and maxillofacial surgery.

Emergency cases, such as facial lacerations, burns, trauma and bite wounds, are also commonly treated by plastic surgeons. A patient who requests a plastic surgeon in the emergency room — rather than allowing the "on-duty" doctor to close a significant wound — is more likely to be satisfied with the end result.

Insurance Coverage

Reconstructive surgery is covered by most health insurance policies, although the specifics of coverage may vary greatly. Some carriers may fully cover reconstructive procedures, others may pay only a portion of the cost.

Cosmetic surgery, however, is usually not covered by health insurance because it is elective and not considered a medical necessity. Some plastic surgeons accept major credit cards or offer financing programs that allow patients to make manageable monthly payments for cosmetic surgery.

Keep in mind that there are a number of "gray areas" in plastic surgery that sometimes require special consideration by an insurance carrier. (See List II.) For example, eyelid surgery — a procedure normally performed to achieve cosmetic improvement — may be covered if drooping eyelids obscure a patient's vision. In assessing whether the procedure will be covered, the carrier often looks at the primary reason the procedure is being performed: is it for relief of symptoms or for aesthetic improvement?

The Other Doctors Involved

There are many cases in which a "team approach" is needed to best treat specific cases. Plastic surgeons commonly work in tandem with family practice physicians, general surgeons, pediatricians, oncologists, orthopedic surgeons and neurosurgeons. Sometimes, numerous specialists are needed for a single case. For example, a child undergoing cleft-lip and palate repair might be overseen by a surgical team that includes a plastic surgeon, otolaryngologist, pedodontist, orthodontist and speech pathologist.

A Consultation

A personal consultation with a plastic surgeon allows a patient to find out if he or she feels comfortable with the surgeon and his or her office staff. Typically, a consultation may take anywhere from 15 minutes to an hour. Some plastic surgeons offer no-cost consultations, while others may charge.

During the consultation, the surgeon will explain the procedure, the risks involved, and the probability of success. Patients are encouraged to bring a list of their own questions, as well as a note pad to jot down any information not included in take-home reading materials the surgeon may provide. The plastic surgeon will review a patient's medical history to evaluate any medical condition that might affect the surgical result. The patient's expectations and goals are also discussed to make certain the desired surgical outcome is realistic.

Predicting Surgical Results

A patient's age, skin type, general health, genetic background and the nature of his or her condition can all affect any final result. Patients who smoke may not heal as quickly as non-smoking patients. Patients with sun-damaged skin may not achieve the same degree of improvement as those without sun-damaged skin.

Though there is no way to exactly predict a surgical outcome, the surgeon will examine the known patient variables before surgery begins and can project an estimate of the surgical result. Patients can take comfort in knowing that most of the procedures performed today have been refined over several decades.

In recent years, some plastic surgeons have begun using computer-imaging machines during consultations to show patients an estimate of post-operative appearance. A photograph of the patient is transferred to a computer screen and then altered by the surgeon to approximate the post-operative result. Doctors who use imaging find that computer-generated pictures can enhance doctor-patient communication. It's important for the patient to realize that a computer image may not match reality and represents no guarantee of outcome. No computer can take into account a patient's skin elasticity, bone structure, blood supply and healing ability.

Types of Anesthesia Used by Plastic Surgeons

Three basic types of anesthesia are used for plastic surgery procedures. A local injection, which numbs only the immediate area to be operated on, is used mainly for less invasive procedures. Local injection plus sedation allows the patient to remain awake, yet relaxed through the entire procedure and is a common type of anesthesia used for cosmetic surgery procedures. General anesthesia, which allows a patient to sleep though the procedure, is usually used when large areas of the body are involved or in children.

Whether a procedure is performed in an in-office surgical facility, a hospital or a freestanding surgery center usually depends upon the complexity of the operation and the plastic surgeon's recommendation.

For cost-containment and convenience, an increasing number of procedures — especially cosmetic operations — are being performed in freestanding or office-based surgical facilities on an outpatient basis. Patients planning to have surgery in this type of facility should ensure that it is properly equipped and staffed, that it has access to a nearby hospital, that the anesthesia will be administered by a well-trained professional, and that the doctor has privileges to perform the same procedure at an accredited hospital.

One additional sign of a quality facility is accreditation by the American Association for Accreditation of Ambulatory Plastic Surgery Facilities (AAAAPSF). This organization not only inspects the facility itself, it requires that the practicing physicians are certified in plastic surgery and have operating privileges at a local accredited hospital. AAAAPSF re-inspects facilities every three years. A patient can check if a plastic surgeon's facility is accredited by phoning ASPS at 1-800-635-0635.

List I: Problems Commonly Treated by Plastic Surgeons*

Birth defects and developmental abnormalities

· Birthmarks, including port-wine stains and hemangiomas, congenital nevi

· Abnormal breast development

· Cleft-lip and palate deformities

· Hand deformities

· Skull and facial bone deformities

· Prominent and deformed ears

Acquired deformities including those resulting from trauma or disease

· Scars

· Wounds, soft tissue deformity from trauma or disease

· Burn scars

· Growths and tissue defects including cancer treatment and mastectomy

· Poorly-healed wounds, scars that limit movement

· Lacerations

· Severed limbs, fingers or toes

· Skull and jaw injuries|

· Hand injuries and acquired problems

· Congenital and developmental breast deformity

Cosmetic concerns

· Excess body fat

· Disproportionate or sagging breasts

· Skin problems: wrinkling, uneven pigmentation, sun-damage, unwanted tattoos

· Sagging facial skin and muscles, loose neck skin

· Hair loss

· Facial features to improve the appearance of the nose, cheekbones, chin shapes

* This represents a partial list.

List II: Procedures That May be Covered by Insurance*

Abdominal surgery, when it is performed to:

· Alleviate health problems, such as back pain, sores, rashes, hernia

· Restore the ability to walk normally.

Breast surgery, when it is performed to:

· Correct congenital asymmetry;

· Reduce overly-large breasts that are causing health problems (shoulder grooving, neck and back pain, etc.)

· Reconstruct a breast lost to disease

· Correct congenital absence of breast

· Reduce over-developed male breasts - gynecomastia.

Ear surgery, when it is performed to:

· Correct congenitally-deformed ears

· Reconstruct ears that are deformed by disease or injury

Eyelid surgery, when it is performed to:

· Correct drooping upper eyelids that are obscuring vision

· Correct out-turned or in-turned lower eyelids

Facial surgery, when it is performed to:

· Correct an asymmetrical appearance caused by facial paralysis;

· Treat conditions affecting the facial muscles, lips and cheeks

· Treat traumatic deformities

· Correct head and neck deformities

Hand surgery, when it is performed to:

· Treat carpal tunnel syndrome

· Correct Dupuytren's contracture, treat tendon and nerve injuries

· Correct syndactyly (fused fingers) and other congenital deformities

Nasal surgery, when it is performed to:

· Correct deformities resulting from birth defects or disease

· Treat injuries or nasal deformities that may affect breathing

* Numerous individual circumstances affect whether a procedure is covered. Patients should obtain written verification of coverage and prior authorization for the treatment from their carriers.