The purpose of this article is to examine how plastic surgeons learn to use novel technology in their practices. In addition, a critical evaluation of current teaching methods as they relate to surgeon competence in these new technologies is discussed.
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Plastic surgeons’ cooperation with industry has played a pivotal role in the development of many of the new technologies that characterize reconstructive and aesthetic procedures.
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While many of these technologies represent non-invasive ancillary devices, their uses are characterized by variable levels of complexity.
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Underappreciation of the subtle nuances of seemingly simple devices by inadequately trained practitioners could lead to diminished patient safety and optimal clinical outcomes. Even though industry plays a big role in educating practitioners on the use of the latest medical devices, it does not fully satisfy conditions of competent use.
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Plastic surgery professional associations and individuals with expert level knowledge in specific devices, must take ownership of educating its members and setting competency benchmarks.
Overview
Invasive and noninvasive plastic surgical procedures have undergone exponential growth over the last 30 years, due in part to an expansion of extensive basic and clinical research. During the 1960s and 1970s, introduction of contemporary microsurgical techniques by plastic surgeons ushered in a vast catalog of skin and muscle flaps that, to this day, are used for the most challenging reconstructive cases. In the 1980s, innovation of refined aesthetic surgery techniques yielded continuing advances in facial aesthetic surgery and body contouring, thereby complementing advances in reconstructive surgery. It was during this decade that plastic surgeons took on the moniker of being plastic and reconstructive surgeons. In the 1990s, the introduction of surgical products, devices, and noninvasive technologies further advanced the plastic and reconstructive surgeon’s toolkit, at times supplanting them all together. Examples include botulinum toxin injections or soft tissue fillers to reduce the appearance of facial rhytids, minimally invasive office-based procedures, and a variety of laser-assisted skin and other tissue treatments. In this article, the authors address the adoption of these technologies as well as strategies that plastic surgeons may adopt for mastery of these techniques. Mention of specific technologies in this article is done for demonstrative purposes to illustrate how practitioners of plastic surgery gain competence in their safe and effective use.
New methods in plastic surgery: interplay of technology and technique
The practice of plastic surgery combines knowledge of basic and clinical science in addition to development of technical skill. The acquisition of technical and manual skill, however, is closely associated with the use of surgical technology. Learning to use a surgical instrument and applying it appropriately to human tissue is defined as technique. Advances in surgical methods in plastic surgery combine new techniques, new applications of existing techniques, and new medical devices ( Table 1 ). The 1 paramount requirement for successful application of any and all of these 3 modalities is the plastic surgeon’s closest mentor: detailed knowledge of surgical anatomy and physiology.
| New Techniques |
|
| New Indications of Existing Techniques |
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| New Medical Devices |
|
Data elucidated from evidence-based research and clinical trials as well as structured technical cases form the building blocks for the clinician to safely extrapolate indications for the use of new or existing technologies to treat existing surgical challenges or address aesthetic concerns. The first reported use of botulinum toxin was in 1980 for the treatment of strabismus and blepharospasm. Since then, indications, (albeit some off-label) have grown to include treatment of glabellar frown lines, facial and cervical dystonias, and as of October 2010, migraine headaches as described by multiple authors. Successful application of botulin toxin for nonsurgical management of migraines helped advance surgeons’ understanding of muscle function alteration and its impact on adjacent nerve structures, and a permanent solution to migraine headaches using transection of the corrugator supercilii muscles, a technique described as part of the classical browlift procedure, was proposed and effectively applied.
Techniques in microsurgery first developed in 1921 with the indication to surgically repair a labyrinthine fistula of the middle ear. Vascular surgeon Jules Jaconson is credited for the first true microvascular anastomosis, coupling 1.4 mm vessels in 1960. In 1963, this application was extended for replantation of a partially amputated digit, and, in 1966, transfer of a second toe for thumb reconstruction was performed by Dong-yue Yang and Yu-dong Gu in Shanghai, China. Since then, microsurgical techniques have been applied toward peripheral nerve reconstruction by extension of cable grafts, and in microlymphatic surgery in the treatment of chronic lymphedema. With the advent of face transplantation over the last 5 years, this technique has evolved exponentially to something that may have never been conceptualized had it not been for earlier advancements. The history of microsurgery and teaching of microsurgery at different levels (beginner, intermediate, and advanced) exemplifies the importance of appropriately targeted continuing education and maintenance of skills.
While plastic surgeons have pioneered many of the technologies through laboratory-based research, cooperation with industry has also played a major role. This is perfectly exemplified by the modern era of breast augmentation. After observing disastrous results with injection of paraffin for breast reconstruction during the early part of the 20 century, plastic surgeons Thomas Cronin and Frank Gerow developed the first silicone breast prosthesis in conjunction with the Dow Corning Corporation, which subsequently led to the first augmentation mammoplasty in 1962. Silicone implants have undergone numerous modifications since then to increase the viscosity of silicone polymer and to house it within a more durable shell. These developments have led to enhancements in breast shape with minimization of comorbidities and such problems as silicone gel extravasation, gross implant rupture, or formation of capsular contracture. Newer examples of applications of silicone implant technology include sixth generation form-stable implants, development of advanced texturing techniques for implant adherence, and combined use of implants with acellular dermal matrix products to optimize implant pocket and inframammary fold position in breast reconstruction.
Plastic surgery has evolved through the innovation of its practitioners. A great part of this innovation has come as a result of plastic surgeons responsibly embarking on off-label use of US Food and Drug Administration (FDA)-approved products (note that the use of products not approved by the FDA is illegal unless they are done in the setting of an approved clinical study or during life-threatening emergencies where the product is already under clinical investigation). This legal practice has been the driving force behind extending the indications for
Botulinum toxin for use on facial rhytids other than the glabellar region (which in and of itself was FDA-approved in 2002)
Closed capsulotomy for capsular contracture
Breast implant overfilling and endoscopic breast augmentation
The leukotriene inhibitor Singulair has been used to prevent capsular contracture or hypertrophic scarring, and human growth hormone has been used for its antiaging effects. Nonetheless, off-label use has to be tempered with a thorough knowledge of reported clinical and scientific precedents in the literature. Additionally, the practitioner has to educate the patient, through informed consent, before embarking on off-label uses of approved products. This not only strengthens the bond between physician and patient, but also serves to legally protect the surgeon from intent-to-harm clauses if litigation should ensue. Current examples of creative, sometimes off-label application of biomaterials are discussed elsewhere in this issue by Kim and Evans et al.
As surgical technology continues to grow, so does the responsibility of plastic surgeons at every level from medical student to independent practitioner, to achieve proficiency in various techniques using new technology. Given the dynamic nature of plastic surgery as a field, continuing medical education (CME) and maintenance of competency have become vital to sustainability in an increasingly regulated and competitive health care arena. In the next section, the authors discuss how knowledge and skill levels are acquired at different levels of training ( Table 2 ) and how independent practitioners maintain high performance and patient safety standards.
| Baseline Surgical Knowledge | Surgical Skills | Learning of New Techniques and Technology | |
|---|---|---|---|
| Student Resident in training Practitioner | Very little Basic surgery Advanced surgery | Very little Basic and ACGME- defined requirements (see Box 1 ) Advanced and versatile | Part of general curriculum
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a The term, champion of industry, defines a physician with special training or expertise in a particular technological development or medical device who, with or without the manufacturer’s support, is heavily involved in educating and training potential and future users of the device.
New methods in plastic surgery: interplay of technology and technique
The practice of plastic surgery combines knowledge of basic and clinical science in addition to development of technical skill. The acquisition of technical and manual skill, however, is closely associated with the use of surgical technology. Learning to use a surgical instrument and applying it appropriately to human tissue is defined as technique. Advances in surgical methods in plastic surgery combine new techniques, new applications of existing techniques, and new medical devices ( Table 1 ). The 1 paramount requirement for successful application of any and all of these 3 modalities is the plastic surgeon’s closest mentor: detailed knowledge of surgical anatomy and physiology.
| New Techniques |
|
| New Indications of Existing Techniques |
|
| New Medical Devices |
|
Related posts:
Are We Witnessing the Emergence of a Superspecialty?
Applications of Biomaterials in Plastic Surgery
Robot-Assisted Plastic Surgery
Impact of Reconstructive Transplantation on the Future of Plastic and Reconstructive Surgery
Advances in Autologous Breast Reconstruction with Pedicled Perforator Flaps
Microsurgical Advances in Extremity Salvage
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