How to work in... plastic surgery
Dr Tom Clarke, F2 doctor, and Mr Yii, consultant plastic surgeon, break the mould and create a new picture of this evolving specialty
Surgical practice is constantly changing. It has developed to the extent that the attributes, knowledge and technical skills required have led to surgeons becoming increasingly specialised. This article focuses on plastic and reconstructive surgery, one of the nine surgical specialties. Many of the other specialties concern particular anatomical areas, whereas plastic surgery is defined by the surgical techniques themselves.
What is plastic surgery?
There are two major components to plastic surgery: reconstructive and aesthetic. Reconstructive surgery accounts for around 80% of work and is concerned with restoration of function and appearance to the human body secondary to pathological processes or trauma. Aesthetic (or “cosmetic”) surgery essentially concerns changing a patient’s appearance through individual choice. Usually aesthetic surgery is not available on the NHS.
Obtaining a training post in plastic surgery is easier said than done
Currently there are around 50 NHS plastic surgery units in the United Kingdom. Patients are broadly differentiated as urgent (emergency) or elective cases. Plastic surgery provides a wide range of both. Emergency work includes burns, soft tissue injuries and hand trauma. Elective work includes congenital and acquired conditions, such as cleft palate, breast reconstruction and hand surgery.
Plastic surgery sub-specialties
Nearly all plastic surgeons will find a sub-specialty of interest, such as:
- Congenital – Cleft lip and palate, craniofacial, facial and ear deformities, genitourinary abnormalities, and congenital skin conditions.
- Breast surgery – Reconstruction following cancer, and cosmetic breast surgery.
- Skin and cancer - Excision and reconstruction of benign and malignant skin lesions.
- Trauma – Reconstruction of facial and limb trauma.
- Hand and upper limb surgery – Congenital hand abnormalities, trauma, and degenerative conditions.
- Aesthetic surgery – A wide range of aesthetic procedures are available in modern practice.
Plastic surgery techniques
Plastic surgeons use a wide range of techniques in both reconstructive and aesthetic work.
- Skin grafts – Healthy skin is taken from one area (the donor site), and used to cover an area of damaged skin (the recipient site).
- Tissue expansion – Skin is stretched, causing it to expand and grow.
- Flap surgery – Healthy tissue with blood supply attached is connected to another part of the body. This technique can be used to repair complex defects.
- Microsurgery – Use of magnification and small sutures is used to restore neurovascular supply to living tissue.
Much research in plastic surgery focuses on increasing the understanding of the blood supply of tissues, wound healing and scar management, particularly in the management of burns.
Training
Obtaining a training post in plastic surgery is easier said than done. There are a very limited number of training posts compared to other specialties and competition is fierce. In 2008 there were nine posts in the UK with an average of 23 applicants per ST3 post. The first stage is to gain a place in CoreSurgical Training (CST), which lasts for two years. First of all, trainees need to decide – is this for me?
Think… what would make me stand out from the crowd?
Gaining experience in the specialty by speaking to plastics trainees, and spending “taster” days in the specialty, can help. Demonstrating dedication is essential and, in addition to the above, attendance at clinics and making an effort to participate in audit and research is key. The Plastic Surgery Trainees Association (PLASTA) is an excellent resource. It is the online community representing the interests of future plastic surgeons in the UK.
During the Foundation Years, and earlier if a career path has been decided on, trainees must prepare themselves for applying to train in plastic surgery. Preparing early and tailoring the surgical portfolio and logbook is quintessential. Preparation for interviews is also paramount; no matter how impressive a candidate’s portfolio, if suitability for the post cannot be communicated effectively at interview then this could make all the difference. Think… what would make me stand out from the crowd?
After CST applications for ST 3 are made, specialty training lasts for approximately six years. During these years, trainees complete all parts of the Intercollegiate Surgical Curriculum Programme (ISCP) syllabus, attain required levels of competence and pass all parts of the Intercollegiate examination. This includes membership of the Royal College of Surgeons (MRCS) and then Fellow of the Royal College of Surgeons (FRCS) examinations. After this, trainees are eligible to be awarded the Certificate of Completion of Training (CCT) and are able to practise independently.
Working in plastic surgery
A large proportion of the workload involves urgent or emergency cases and there is a busy on-call commitment. These range from severe facial and limb injuries to burns. There are also many opportunities to work abroad. Trainees are starting to undertake a fellowship in cosmetic surgery once they have attained the CCT.
This will likely become more common in an effort to ensure aesthetic procedures are performed by properly trained and experienced surgeons. A career in the specialty can be hard work and, at times, stressful, but many trainees find that the rewarding nature of the work outweighs these issues. The limited number of training posts is an issue, but once a training post is acquired, trainees enjoy a satisfying career.
Plastic surgeons work on a daily basis with surgeons from the other surgical specialties. These include ENT, maxillofacial and orthopaedic surgeons. Many of the techniques developed by plastic surgeons underpin work carried out by these other specialties, especially reconstruction.
What the future holds
With modern surgery techniques evolving exponentially, surgical practice in general will undoubtedly become more specialised. This has been compounded by the introduction of the European Working Time Directive (EWTD), which has restricted the number of hours that junior trainees are contracted to work. Given this, surgical trainees who wish to become fully experienced in this specialty will find the constraints of the EWTD challenging; after all, it would be difficult to leave in the middle of an operation, wouldn’t it?
Plastic surgery at a glance
- Personality: Manual dexterity and an aptitude for practical skills, a steady hand, motivated, dedicated, organised, excellent communication skills, stamina, ability to adapt skills and practice in an ever-advancing field of surgery
- Best bits: The reward of patient satisfaction and psychological well-being with improvement not only in physical appearance, but also function
- Worst bits: Competition, on-call commitments, potential for litigation
- Stress: Demanding work with, at times, prolonged periods of stress
- Salary: Variable,depending on private work
- Competition: Fierce