Plastic surgery - the danger in delay

In the concluding part of his article, DR. V. SRINIVASAN stresses on the need to take prompt action, especially where surgical correction is needed. Delay can lead to irreversible damage. In the first part of this piece published on December 26, the author had defined plastic surgery, and described the situations in which reconstructive and cosmetic surgery are performed.

DOES delay in seeking plastic surgical correction alter the result?

Delay definitely creates serious and sometimes irreversible damage in certain situations. It causes additional problems in children, both physical and psychological. It is better to seek medical opinion and defer surgery rather than assume that a delay will not be harmful.

Reconstructive surgery:

In children:

In congenital anomalies, a delay in seeking surgical correction causes certain problems.

Distorted growth of that area makes the problem more complex. Subsequent surgical correction is more difficult and the result less pleasing.

It delays acquiring certain essential skills like normal speech in a cleft palate, hand coordination in a child with deformed digits or a missing thumb.

The child develops a psychological problem and may avoid schooling. For example, deformed ears, fingers. It also increases parental anxiety and stress.

In acquired deformities of the hand, face, leg and the chest wall due to burns and injuries, often the deformity itself is a result of delaying surgical procedure like grafting, suturing or repair. Sometimes it is the result of not wearing the prescribed splints or not following proper physiotherapy after surgical procedures.

Delaying corrective surgery again causes and/or worsens the same problem. If the child is older he may avoid school and socialising. The scars on the surface can cause considerable distortion of skeletal growth creating a bone or joint problem which requires major procedures to correct. The scars can ulcerate.

In adults and children:

Delaying the removal of tiny lesions on the face like moles and cysts allows them to become bigger, which needs longer incisions during surgery and hence longer scars.

*Delaying repair of a cut tendon, nerve or refixing a badly joined fracture of the hand bone denies the person the full use of that hand. After six to nine months, even if the nerve is repaired the muscles may not recover. In a child, the malunited bone contiues to grow in a deformed way. A patient who does not have prompt surgery done for his cut finger tendon ends up having complex staged tendon grafting done later. The result may not be satisfactory.

Delaying surgical coverage of wounds and expecting natural healing to take place leads to severe infection, ugly scars and contractures. Leaving wounds over bones and fractures exposed leads to problems with fracture union and invites chronic infection of the bone.

In certain cases, repeated breakdown of scars can lead to cancerous changes.

Cosmetic surgery

Unlike reconstructive procedures, delaying cosmetic surgery often does not create any specific structural problem except postponing the fulfilment of the patient's desire to look and feel better. A plastic surgeon has to give due respect to the mental agony of the patient.

Causes of delay in seeking plastic surgery are:

Ignorance about the availability of surgical treatment for minor and major deformities or disabilities of the face, hand, genitalia, breasts.

Lack of public awareness as to which problem needs a plastic surgeon's help since the speciality has no anatomical demarcation as in neurosurgery or urology.

Not knowing where specialised plastic surgery centres exist and what they can offer.

A wrong assumption that plastic surgery is unsafe in babies or children (Safe anaesthesia in major centres can handle all types of cases).

Assuming that the initial stitching or dressing given as first aid is the final treatment and not seeking further care.

Accepting a result and not wanting further improvement.

Not adhering to the schedule of sequentially staged procedures for complete improvement and rehabilitation due to a lack of awareness and motivation. eg, management of cleft lip and palate, certain complex hand anomalies.

Seeking a scarless and a 100 per cent result and refusing surgery which can significantly improve form and function.

Postponing surgical corrections till the time for a matrimonial alliance arises.

Postponing a treatment indefinitely since it is not life threatening.

Assuming that plastic surgery is very expensive.

Feeling shy and falsely believing that surgery for improving one's appearance is wrong and unnecessary.

When should plastic surgery be done?

Congenital anomalies, all corrections should be done before a child reaches school going age. Again it depends on the deformity. The most important aspect is to see a paediatrician and a plastic surgeon. If associated cardiac or other internal anomalies are there, they need corrections too. A well co- ordinated plan is essential.

The list of anomalies on the face, hands and genitalia is too long to specify an individual time-frame. In general, cleft lip is corrected by three months of age, cleft palate by one year, ear deformities by six to eight years, hand anomalies and abnormalities of the male genitalia between six months to four years.

In acquired deformities and defects, the patient should be individually assessed.

All wounds should be covered as early as possible and definitely before five days if one is sure that the wound cannot heal on its own. Delay only causes infection and poor healing and ugly scarring.

All severed body parts - tendons, nerves should be repaired early. A postponement will lead to poor results.

All post burn contractures (distorted parts like fingers, neck, axilla etc), post traumatic and post infective deformities of the digits and face should be prevented. When detected, correction should be done as soon as possible, initially with splints and physiotherapy, and subsequently, in six months or so, by plastic surgery. In adults, a delay can cripple a patient and the joints become stiff and do not regain mobility. He or she can end up staying away from work for a longer time.

Cosmetic surgery

Unlike problems treated with reconstructive surgery, this procedure is not time-bound. One tries to avoid tampering with the normal growth process of the adolescent till the growth of the part has stabilised. In fact, till adolescent growth is complete, one does not perform surgery on the nose (rhinoplasties) and on the breasts (augmentation or reduction mammoplasties) except in certain cases. Dermabrasion is not done when acnes are active. Treatment for gynaecomastia (enlarged male breasts) is sometimes done during early adolescence if it is severe and bothersome. Abdominoplasties and liposuctions are generally not done during the first three months after child birth.

Is plastic surgery expensive?

It is not as expensive as one imagines it to be and in some centres it is affordable. Unlike certain major superspecialities which depend on sophisticated investigations, hi-tech equipment, expensive disposables and ICU, to carry out complex procedures, plastic surgery, though dependent on certain specific instruments, relies more on surgical skill, technique and perfect execution of a chosen procedure. It is upto individual surgeons or institutions to set the price. In major institutes, all categories of procedures (reconstructive and cosmetic surgery) are offered as affordable packages to people from different walks of life. Patients are not denied treatment on account of not being able to afford treatment.

It is often a very young child, a teenager or a young adult with his entire life ahead or a middle aged person in the prime of his career who needs to spend an amount to get treated so as to improve the quality of his life. Unfortunately, even patients who can afford these procedures and who are willing to spend money on life-threatening problems seem to hesitate spending even a fraction of the same amount on plastic surgery to improve the quality of life.

Who benefits from plastic surgery?

It is the common man who seeks the reconstructive aspects of plastic surgery. Congenital anomalies are more common among the less affluent sections as they are exposed to infections, malnourishment and anaemia. It is the common man as pedestrians, scooterists and transport drivers, who are more likely to be involved in accidents, resulting in skin loss over crucial body parts. It is often skilled and unskilled labourers who sustain complex hand injuries. Burns are also common in this segment. Unfortunately, it is the common man who does not get or seek proper surgical treatment the first time and ends up with a disability or deformity.

Cosmetic surgery used to be sought only by the affluent at one time. Nowadays with more awareness, a "liberated attitude", and westernised trends, persons from all strata of society seek cosmetic surgery. Some of them need it to improve their chances of employment in certain specific areas and others for certain personal reasons.

Unique aspects of plastic surgery

The results of surgery are for everyone to see. A person may not appreciate the end result of a reconstructive procedure unless he has compared the injured part or the deformed area preoperatively. In reconstructive surgery, a balance is struck between form and function.

Though a plastic surgeon may perform reconstructive and cosmetic surgery, problems needing either technique are entirely different and one cannot substitute the other. While performing reconstructive surgery perfect results are sought aesthetically. While performing cosmetic surgery, principles of reconstructive surgery are applied. Because of the diverse situations for which these are done, it will be unfair to compare their results. The most perfect reconstruction may sometimes fall short of the "normal or beautiful" look the patient seeks which, unfortunately, cosmetic surgery cannot improve further.

Cosmetic surgery most often involves altering contours either by removing tissue or adding tissue or implants beneath the skin or discarding skin, and soft tissue through crease lines. There is no role for skin grafts and flaps in cosmetic surgery. When such procedures are required to solve a problem, the plastic surgeon will apply the principles of reconstructive surgery to achieve an attainable aesthetic end result.

Conclusion

It is neither justifiable nor necessary for a person to live with a visible deformity or disfigurement or a functional impairment which can be corrected by plastic surgical procedures. Neglecting or postponing this results in the person getting teased during childhood, avoiding socialisation later, having difficulty while seeking matrimonial alliance and sometimes ending up modifying one's vocation or profession to accommodate a disability.

While it is the parent's responsibility to seek plastic surgery for his/her child, even adults, out of ignorance, fear of surgery, misconception about expense or demanding unreasonably perfect results, deny themselves and their dependents a dramatic improvement in their life.

The importance of interaction and cooperation with other specialities in planning and coordinating major procedures cannot be overemphasised to give the best possible result. Centres of excellence in plastic surgery have, in addition, to well-trained and experienced plastic surgeons, an excellent group of supportive personnel from the departments of physiotherapy, occupational therapy, orthotics and prosthetics, speech therapy and orthodontics who look after all needs of a patient in rehabilitation.

(Concluded)

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