Plastic surgery is a broad spectrum of both reconstructive and cosmetic surgical procedures. The word comes from Plastikos, the word for molding. Plastic surgery has been an advanced surgical specialty that has lead the way in management of burns, cleft lip and other congenital deformities, traumatic injuries including replantation of amputated parts, microvascular surgery, hand surgery and cosmetic surgery of the face, breast and body. Plastic surgery has been around for centuries but, the use of silicone plastic has been around for only about 35 years. Many physicians and surgeons may refer to themselves in the generic sense of a "plastic surgeon" but, a plastic surgeon is a very identifiable entity. That is someone who has undergone the long and rigorous training in an accredited plastic surgery residency and, has taken the appropriate examinations to receive certification by the American Board of Plastic Surgery. Because of the broad spectrum encompassing plastic surgical training, there is overlap with other surgical specialties including ENT, orthopedics, ophthalmology and general surgery. In addition there is overlap with the medical specialty of dermatology.
Plastic surgical procedures are by nature very visible. Both reconstructive and cosmetic surgical procedures are usually done on the body surface and consequently are visible for examination and scrutiny. Scarring is not necessarily under the control of the surgeon and, it is not unusual for patients to be dissatisfied with the amount of scarring. An unfavorable result with scarring does not necessarily equate with substandard care or malpractice. Every case needs to be evaluated separately and the contacts under which the scarring occurred needs to be scrutinized. There are situations that involve scarring which by their very nature reveal substandard care. The most common episode is scarring following extravasation or leakage of intravenous caustic material if this caustic material leaks out of the veins it can result in thrombosis of the blood vessels and possible loss of overlying skin. This becomes a scarified area which is a manifestation of the iatrogenic injury.
Breast Reduction Surgery:
Decreasing the size of the breast is performed to relieve symptoms of neck, back or shoulder discomfort secondary to enlarged breasts. There are several surgical techniques for breast reduction, however all of them result in some type of visible scar on the breast mound itself. The risks of the operation involve potential loss of the nipple, skin or breast tissue. Nonhealing wounds and repeat surgical procedures are not uncommon with any one of those type of complications. Substandard care can occur under those circumstances if the patient selection was inappropriate for the specific operative procedure. The larger the reduction the more potential risks. Smoking also increases the risk of complications.
Since the Food and Drug Administration moratorium in 1992 the number of silicone gel implants used for breast augmentation has dropped precipitously. They are now only used in controlled studies. The use of saline implants with the silicone shell continues. However the saline implants do not yield the same cosmetic result as the gel implant. Wrinkling of saline implants is very common. At the present time there is no scientific evidence to support a causal relationship between connective tissue disorders and silicone breast implants. There are well known local problems that can occur with breast implants. Those involve capsular contracture or scar tissue formation around the implant, infection of the implant, failure of the implant or hematoma or bleeding around the implant. There is potential for substandard care and management of those complications. Appropriate and timely diagnosis and intervention are important in the proper management of these patients.
Facelifts, nose jobs, eye lifts or suction assisted lipectomy of the face and neck areas are very common operations. The potential for unsatisfactory results is high. More often than not these cases involve poor results which do not necessarily equate with substandard care. Preoperative informed consent is very critical as is patient selection. Even disastrous post surgical complications such as blindness following a blepharoplasty may not be medical malpractice. However failure to diagnose and properly treat that complication may be substandard care.
Body Contour Surgery:
Abdominoplasties or tummy tucks and suction assisted lipectomy also can result in unsatisfactory postoperative results. Serious complications can result following a tummy tuck with potential for loss of large amounts of abdominal wall skin. Once again these disastrous results do not necessarily equate with substandard care. However if inappropriate patient selection was utilized then there can be potential medical legal issues.
A number of traumatic injuries are evaluated at walk-in clinics and emergency rooms. Failure to diagnose a tendon or nerve injury on the day of trauma does not necessarily equate with substandard care. Usually a short delay in a diagnosis will not result in any damage. However, if a significant length of time evolves before the correct diagnosis is made then under certain circumstances this delay in diagnosis will impact the ultimate diagnosis adversely. In those situations substandard care may potentially exist on the basis of failure to diagnose.
Since so much of plastic surgery involves elective procedures and luxury type of surgery it is very important that the expectations of the patient are realistic and in line with those of the surgeon. Therefore proper documentation of informed consent becomes critical. The general guidelines are that informed consent should involve a meaningful discussion or interaction between the surgeon and patient so that the patient can make an informed decision. The disclosure by the surgeon should involve the diagnosis, the nature and purpose of the suggested procedure, the reasonable foreseeable risks associated with that procedure and the chance of success or failure of the procedure. Cosmetic surgical procedures can often involve informed consent issues.
Full documentation of the circumstances under which any unfavorable procedure or result occurs is critical to the final evaluation for the potential of merit in all of the above cases. The evaluation will be made in a dispassionate way based on the available facts.