Indian Journal of Plastic Surgery Medknow Publications on behalf of Indian Journal of Plastic Surgery ISSN: 0970-0358 EISSN: 1998-376x Vol. 38, Num. 2, 2005, pp. 193-194

Indian Journal of Plastic Surgery, Vol. 38, No. 2, July-December, 2005, pp. 193-194

Letter To Editor

Treatment principles in plastic surgery

Sandhir RK

C-31/ Z-1, Block-C, Dilshad Garden,Delhi-110095, India

Correspondence Address:C-31/ Z-1, Block-C, Dilshad Garden,Delhi-110095, India. E-mail: sandhir@touchtelindia.net

Code Number: pl05045

Dear Sir,
Plastic surgery has undergone a sea change with advancement in knowledge and technology. It has reconstructive and aesthetic surgeries as its branches. However the practice of either of them requires knowledge and training in both as these are interdependent branches. The following statement clarifies the relationship to an extent.

"Aesthetic surgery is cosmetically customized reconstructive surgery."

The practice of plastic surgery is a surgical challenge and the surgeon needs to work within the surgical principles and limitations. It may be difficult for a common individual to accept such limitations or complications of surgery as he is under the mesmerizing effect of computerized and touched dream images of selected few. The presented problems may not have easy solutions. The results are neither mathematical nor can always be anticipated completely.

The goals of surgery are high. The road to success is zig- zag with multiple paths and pitfalls. The surgeon chooses the surgical technique. Patient and others however, are the final evaluators of result as per their perception, aspirations and information (or misinformation). A successful operation from surgeon's view may look like a failure to the patient. It becomes a debatable public issue. It has serious implications because the society views doctor patient relationship as any other provider - consumer relationship rather than a sacred trust. The unpleasant situations may be avoided by skilled and friendlier communications. The aim should be to explore the needs, ideas, motives, peer pressures, attitudes towards life, financial implications or any other relevant information in a particular case. The surgeon (doctor) has to be prognosis oriented (Hippocratic teachings). The prognosis should be explained in detail and patient's reaction towards it assessed. The 'in totality" knowledge helps in building up a realistic attitude towards surgery. It wins the patient over to surgeon's side.

Winning is overemphasized. The only time it is really important is in surgery and war. (AlmcGuire).

A good commander collects the information and understands the importance of aggression, defense and retreat even without a fight in a particular battlefield. He plans methodically to win the war. Similarly, a surgeon, on the basis of his communication with the patient should have a clear management plan. The scope for modifying plans, as in military operations always exists. There is however need to adhere to certain basic treatment principles.

The treatment principles may be classified into surgical or non-surgical groups. It depends on their application during operative or non-operative plan or period.

(i) Surgical: - These principles include (a) Life preservation (b) Function restoration and (c) Aesthetic appearances.

The efficacy of any surgical intervention plan is related to achieving these objective principles in this order only.

(a) Life preservation: - The reconstruction should not in anyway endanger the life of patient. It is always better to opt for a safer course.
Example; - In polytrauma the priority should be given to the management of life threatening head or abdominal injury rather than to time consuming digital revascularisation.

(b) Function restoration:- Functional restrictions have tremendous effects on the lives of persons. The aim should be to improve it. Any reconstruction, which fails to address it, may not be acceptable to the patient.
Example: - A tailor had severe contracture of right little finger. It had been operated once before. The reoperation was not likely to restore normal finger movements. He requested for amputation as he was unable to hold scissors because of its obstruction. The restoration of hand function for his profession required either normal functioning finger or removal of obstruction.

(c) Aesthetic appearance:- The reconstruction should be as pleasing as possible after meeting the above criteras. The surgeon should consider the recipient site results along with donor site defects.
Example:- A defect on the nasal dorsum is more pleasingly repaired with a forehead flap when compared to a free flap from dorsum of foot.

(ii) Non-surgical:- These principles are based on (a)Emotional support and (b)Holistic approach. These are applicable during preoperative, postoperative period or when no surgical intervention is planned.

(a) Emotional support:- The patients are under tremendous psychological stress because of the deformities. Their economic condition, status, social interaction and even life at home are jeopardized. They feel that the miracles of modern surgery will reverse the condition to total normality. This however is not always true. There are always some doubts and anxiety on the part of patient whenever any intervention is done on the body. The patient requires reassurance at each step of treatment. The emotional support develops full confidence of the patient in the doctor. The trustworthy doctor patient relationship helps the patient to look to doctor as his own doctor. It helps in the recovery and acceptance of results. A doctor who does not develop patient's confidence merely acts as a trained technician.
Example:- This has been taken from other specialty The point is more clearly illustrated since no external deformities are involved which may contribute to patient's unhappiness. An old lady underwent angioplasty successfully. The patient felt restlessness and uneasiness immediately after discharge from the hospital. The treating doctor however had no words of reassurance. Another doctor sympathetically explained the disease process, treatment, and prognosis and reassured her. Treatment with anti anxiety drugs helped the patient towards normalcy in a few days. The reassurances and the emotional support helped in recovery of the patient.

Holistic approach:- This approach manages the patient along all aspects of life. There are deformities, which are either uncorrectable or partially correctable. It needs an honest appraisal by surgeon and acceptance of the limitations of surgical techniques. The attitudes affect our behavior towards problems. There is need to evoke inner strength in the individual. True happiness does not depend on outer appearances but on inner self.

"Happiness depends on ourselves" (Aristotle)

Universal law of Belief says that whatever we believe, with feeling becomes our reality. There is need to develop belief in oneself.

"No one can make you feel inferior without your consent." (Eleanor Roosevelt)

The inferiority feelings associated with deformities need to be overcome. It may be achieved by cultivating values at physical,mental or philosophical levels. It may require training in self-control that builds up confidence, belief and determination in oneself. The person accepts his problems including that of body image without attaching undue importance to them. It helps in crossing the bridge of life in a happy, useful and dignified manner in this competitive world.

Example:- The residual deformities of extensive burns are difficult to correct totally. The patient looses confidence and tends to withdraw completely from the society. The holistic approach can transform the person's thinking into positive one with a will to live a normal life.

These principles, which may not be totally infallible, helps in solving a large number of problems. Their application requires close cooperation between three main pillars of any treatment plan. The pillars are patient, close relatives of patient and the doctor. Once the understanding develops between these pillars, the combined strength wins the battle against deformities. The trophy is a productive life. It has the potential of beating glamour by the shinning radiance of its achievements.

Copyright 2005 - Indian Journal of Plastic Surgery