Looking out of the windows of St Thomas’ Hospital at 7.45pm on July 7 last year, David Ross realised that the surrounding streets and bridges over the Thames were empty. Only then did he discover, from a television screen in the intensive care unit, precisely how the patients on whom he had operated throughout that day had been injured. So intense was the focus of the surgical team that there had been no time to consider what had happened.
“We hadn’t had a chance to stop for a second,” he says. “In the evening I got the department together and we saw every patient who had been admitted with a potential soft-tissue wound, from someone with an isolated burn on the hand to patients who had undergone amputations. These young, fit people had gone to work that day and suddenly found themselves with severe injuries in an environment that was wholly alien to them, and many couldn’t hear us because their eardrums had been damaged. So we couldn’t reach out to these people.”
As the head of plastic surgery at St Thomas’, Ross’s task at this point was to begin to formulate plans of care for these patients. General surgery and orthopaedic colleagues had already administered life-saving treatment and removed foreign bodies, and the task of his team had been to clean wounds — a procedure that was to continue. “After a few days you can start to get the wounds covered, transferring tissue from one part of the body to another, then you can start to think about reconstruction. Two patients have undergone work which will probably take another six to eight months. And that’s just the physical part of the injuries.”
In a culture in which youth and physical perfection increasingly determine an individual’s value, it is often forgotten that the primary task of plastic surgeons is not to tighten the faces of the affluent but to care for people who need their help. Plastic surgery inevitably involves aesthetic considerations, but it is a much broader discipline than the industry that uses ads in magazines to promote purely cosmetic facelifts, liposuction and breast enlargements. This is why, from next week, the British Association of Plastic Surgeons will be known as the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS).
“People often see plastic surgery as cosmetic, and it’s important to establish that our role is all-encompassing,” Ross says. “It has an enormous role to play in the management and rehabilitation of patients who have either lost a breast through cancer or needed reconstruction after the removal of part of the mouth, head or neck.
“Patients don’t just want treatment for their cancer, they want to look as normal as possible. They have high expectations, and we have been responsible for that because we’re getting better and better results.
“This is where reconstructive and aesthetic concerns overlap. If I reconstructed a woman’s breast after mastectomy, I might want to do a procedure on the other breast that is cosmetic — lift it, augment it or reduce it — to give her symmetry. I want to apply exactly the same discipline, the same care and the same aesthetic eye as I would if she had come to me privately for an aesthetic procedure. Just because it is reconstructive doesn’t mean that you want to give them any less of an appealing, restorative, psychologically fulfiling result.
“But our success is both our strength and our downfall. We haven’t had the capacity to deal with the growth of cosmetic work. You then have companies springing up, importing surgeons from overseas and from other specialities. Some are experts, some inadequately trained, and this is when patients find themselves in vulnerable situations.”
The transfer of tissue from one area of the body to another was practised in India from at least 600BC but did not become a speciality until the 1840s, when the term “plastic” (from the Greek plassein, to mould or shape) surgery was first used. Techniques were further developed during the First and Second World Wars. But it is only recently that the innovative techniques and skills honed to repair congenital deformities and injuries caused by trauma and burns, and to restore patients after treatment for cancer, have been demanded by the healthy public.
The British cosmetic surgery industry was reported to have grown by a third in the year to 2005. Elective operations are now a standard reason for seeking a bank loan, and procedures once regarded as morally dubious and prohibitively expensive are flaunted as a sensible consumer choice.
Ross attributes this to four convergent factors: aspiration, the availability of cosmetic surgery in a society that “wants things now”, and the media and Citydriven equation of youth with success, all underpinned by increasing affluence. “With the baby boomer generation you have a tranche of people who are living longer, who have money. They don’t feel their age and don’t want to look their age, either,” he says.
“We’re seeing increasing demand from patients because of career maintenance, issues of staying competitive, and remarriage. The techniques are being marketed aggressively, sometimes as a lunchtime procedure, which is reprehensible. Where once the consultant surgeon had taken 16 or 17 years to get there, now people are being referred through a magazine to a GP, a beautician or a nurse practitioner, which is clearly detrimental to the public good.
“I don’t think there’s anything morally questionable about the patient who wants to find out whether someone can do something about their saggy neck, but there are patients who are psychologically and emotionally vulnerable. They should be identifed and offered psychological help, not surgery.”
Ross qualified as a doctor in 1986, started training as a plastic surgeon in 1990 and is now a consultant surgeon who specialises in working with patients who have had cancer (elective cosmetic surgery is not available on the NHS). He also has a private practice: in the past year he has referred two patients to a psychologist and both had good results, he says.
“The biggest key to success with aesthetic work, and to some extent reconstructive work, is to understand what the patient wants. Can you fulfil it? If both answers are yes, you’ll get a good outcome. If there is a disparity, a well-trained accredited surgeon will say ‘I’m not going to meet your expectations’. I will add ‘and please don’t go looking for someone to fulfil what you want, because there will be surgeons who say that they can do it’. By and large, accredited surgeons are not trying to sell surgery.”
Ross is still treating a July 7 patient who suffered severe head and limb injuries. “She says her surgery is not about repairing tissue per se but to take her away from 7/7. She doesn’t want to be associated with it, she wants to move on and her surgery is what is taking her forward.
“It’s not about being unmarked in public, but she doesn’t want to be seen as different — ‘Where did you get that scar?’ — and to have to relive what happened day in, day out. So for her the reconstruction is about aesthetics, too. It’s an important point.”
British Association of Plastic, Reconstructive and Aesthetic Surgeons: 020-7831 5161, www.bapras.org.uk
What exactly is plastic surgery?
Plastic surgery treats the consequences of: trauma and burns; cancer (such as skin, breast, sarcoma); congenital abnormalities; tissue infections; and degenerative conditions such as arthritis. It is also concerned with normalising and improving appearance.
Reconstructive surgery is the plastic surgery undertaken to restore function and appearance after cancer, injury, infection or birth abnormality — eg, breast reconstruction after mastectomy, hand surgery after an injury at work, or repairing a child’s cleft lip and palate. All reconstructive surgery has an aesthetic element.
Aesthetic surgery is done purely because the patient has an aesthetic concern. Such elective procedures are often called cosmetic, but not everyone doing cosmetic surgery has been trained as a plastic surgeon.
