The statement, “First, do no harm,” is a pretty good admonition to physicians, even though it doesn’t actually appear in the Hippocratic oath. But for patients who need major reconstructive plastic surgery, it would appear that the possibility of experiencing more harm pales in comparison to the good that surgeons can do for them. Such was the case for some of the exceptional surgeries reported at last month’s meeting of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) in Toronto.
In the midst of a conference that was concerned primarily with aesthetics, four surgeons who participated in a panel on major facial reconstruction revealed their remarkable accomplishments with patients who had encountered skin cancer or severe trauma to the face. Many of these patients were from lower socioeconomic groups, and their conditions had been long neglected.
Some of the patients’ stories were poignant, while others bordered on the amusing. One older gentleman who lived in the country wanted only to go fishing and put off having his face reconstructed until his tumor had become far advanced. The face of an actor from a large city was rebuilt successfully, but the surgery left him with scars and limited movement on one side—which helped him land gangster roles in television programs. And, sadly, a woman with melanoma in her lower lip had successful surgery, but the cancer metastasized and she died 18 months later.
The surgeons on the panel were:
• Mark Wax, MD, FACS, FRCS, Oregon Health and Sciences University, Portland;
• Douglas A. Girod, MD, FACS, University of Kansas, Kansas City;
• Ralph Gilbert, MD, FRCSC, University of Toronto; and
• Eric Genden, MD, FACS, Mount Sinai School of Medicine, New York City.
Each one presented his cases to the others, and challenged them to develop a surgical plan on the spot. What impressed me the most was how detailed a plan each came up with in so little time, and how similar the plans were in most cases to those actually executed.
One pearl that emerged from the ensuing discussions was to use simple, durable procedures. Most of the patients in these cases were very unlikely to return for follow-up treatments, so the use of a series of gradual reconstructive steps was out of the question.
Facial reconstruction generally calls for local tissue transfer, but major cases like these require more drastic measures, such as the use of “foreign” free flaps. The latissimus dorsi flap, scapula flap, radial forearm flap, and posterior scalping flap were all used in the cases presented. All of the procedures had structural, functional, and aesthetic components. Not unexpectedly, the functional—eating, speaking, facial expression—presented the greatest challenges.
In an era when the term “do-gooder” is often used pejoratively, people who do this sort of good are to be commended. The profession of plastic surgery occasionally makes the news for the wrong reasons, but the real shame is that the important stories of restoration of quality of life to many unfortunate patients don’t make the news as frequently as they should. The AAFPRS panelists described their accomplishments in a matter-of-fact, almost blasé manner, but I think that ways should be found to bring their—and your—good works to light as often as possible.