DOI: 10.1097/01.prs.0000278006.98901.63

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PMID: 17805140

Issn Print: 0032-1052

Publication Date: 2007/09/15


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What Is Plastic Surgery and Who Decides?

Thomas R. Stevenson

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Excerpt

We are finishing a face lift consultation and my nurse puts away our mirror. Amy, rearranging her hair, asks a familiar question, “Why do they call it plastic surgery?” I fumble through an explanation of Carl von Graefe's use of “plastic,” meaning “to mold,” and add something about having “nothing to do with a class of chemical compounds, but is a discipline that includes reconstructive and aesthetic surgery.” Amy's eyes glaze over. Obviously confused but satisfied there is an answer, she walks into my manager's office for a price quote. I am left with her question and my own interpretation of it. Amy really wants to know, “What is plastic surgery?” The answer depends on whom you ask.
Quiz a U.S. citizen about our specialty and chances are you'll receive a response referencing movie stars and breast augmentation. A crude colloquial noun often will substitute for “breast.” You might get a script outline from last week's plastic surgery reality television show. Press a little further and you may hear a reference to nose jobs and face lifts—occasionally cleft lip repairs or breast reconstructions. If you mention pressure sore closure or limb salvage, digital replantation, or hand surgery, the reply might be, “That's plastic surgery?” Such is our specialty's public perception.
Insurers have a clearer idea of surgery's scope but limited concerns regarding plastic surgery's future. Give them an ICD-9 and CPT code, and they will tell you if it is covered and what they will pay. Reimbursement is based on a negotiated fee-for-service scale. A plastic surgeon in private practice can decide if payment is sufficient, accepting only those insurance plans that pay enough and rejecting others. Plastic surgeons in large multispecialty groups or academic practice may not be allowed to turn down patients whose plans reimburse poorly. Thus, most private practitioners are pushed toward performing lucrative cosmetic procedures while other plastic surgeons are threatened with insolvency. Most of us do some cosmetic surgery. That part of our practice requires expertise, involves few emergency calls, and pays the bills. But who among us entered residency simply hoping to be a successful cosmetic surgeon? Unfortunately, if whittled down to a financially viable “chip,” plastic surgery would be one knife stroke away from disappearing. No, third-party payers and financial considerations should not circumscribe our specialty.
Plastic surgery's accrediting and credentialing organizations are the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. Each group has a slightly different view of what constitutes our specialty. The Plastic Surgery Residency Review Committee precisely delineates the variety and number of procedures each plastic surgery resident must perform in order for his or her program to stay accredited. Provide inadequate case volume and a training program risks loss of accreditation. Through written and oral examination processes, American Board of Plastic Surgery certification is granted only to those candidates who are familiar with a broad range of problems faced by plastic surgeons. The Residency Review Committee and American Board of Plastic Surgery determine what information a plastic surgery residency must impart and what a graduating resident must know to be board certified. These two organizations declare what a plastic surgeon starts out being, not what that surgeon will be doing in a mature practice.
Plastic surgeons are encouraged by the board to maintain certification. Board certification is time-limited. If a plastic surgeon wishes to maintain certification, that surgeon must regularly assess his or her patient management abilities, identify deficiencies, and objectively demonstrate an effort to improve.
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