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I am constantly reminded about how different things are these days. Different especially in how plastic surgeons view themselves. When I began my training there was a segmentation between ‘real’ plastic surgeons (meaning those that did traditional reconstructive plastic surgery) and the cosmeticians (those surgeons who did cosmetic surgery). Even as a trainee I found this disingenuous. My experience was that as a plastic surgeon got more senior in his or her practice they tended to do more cosmetic surgery. The peculiar tension between experienced, respected plastic surgeons and what they were actually doing, versus the ridicule and shame heaped upon them for doing cosmetic surgery, always made me uneasy and was difficult to understand. This tension apparently all got too much when a group of surgeons decided to get together and announce their interest in aesthetic surgery. This group of surgeons formed their own society and proudly proclaimed themselves as aesthetic plastic surgeons. Thus the beginning of the long, cold journey between those surgeons who perceived themselves as real plastic surgeons, and those surgeons who did cosmetic surgery.

The real plastic surgeons at that time would have told you that the only reason to do cosmetic surgery was for the money. The cosmetic surgeons, on the other hand, as they felt progressively more disenfranchised from the rest of the speciality, felt increasingly obliged to define themselves as an exclusive, esoteric, and separate part of our speciality. I remember quite distinctly how pleased I was to become a member of the American Society of Plastic Surgeons in the mid 80's, but I also remember being even more pleased when I was elected a member of the American Society for Aesthetic Plastic Surgery. This somehow to me at the time, seemed a more exclusive club. Then the explosion of sub-speciality societies began. The Lipoplasty Society, the Hand Society, the Peripheral Nerve Society, the Microsurgical Society and on and on and on. These were the dark days. Some of us hesitated to identify ourselves as plastic surgeons – we wanted to be known as aesthetic surgeons or we wanted to be known as reconstructive plastic surgeons or lipoplasty surgeons or craniofacial surgeons. This fractionation of our speciality has come home to roost. Which of us now, in the span of just 20 years, would argue that aesthetic plastic surgery is not an important part of our speciality? The very feeling that drove the creation of separate societies has disappeared. With the encroachment all around us from not only other surgical specialities, but appearance medicine specialists and non surgeons, the need to come together has become critical.

Over the last several years I have evolved a view that aggressive sub-specialisation marketing has damaged our ability to compete in the modern marketplace. We are forcing our younger colleagues to make choices about how they want to spend their continuing education dollars, and forcing them to decide which meetings to attend based on making a choice about practice interests. In certain parts of the world, such as North America, it is difficult to run a solely reconstructive practice that is financially viable. Many of our younger colleagues feel pressured to choose aesthetic surgery and virtually reject all the other foundations of plastic surgery for economic reasons. I believe the old model, namely that of real plastic surgeons versus cosmetic surgeons, is ready for the rubbish bin. With our profession and its recognition within Society under severe threat, it is important for us all to call ourselves plastic surgeons. It is important that those of us with interests in aesthetic surgery embrace our reconstructive colleagues, our micro vascular colleagues and our craniofacial colleagues. We must embrace them unconditionally and reintegrate our various different societies so that once again we have a large tent, not a collection of small side shows. If we are going to effectively communicate our professional strengths compared with other physicians and surgeons determined to compete on our patch, it is essential that we have the strength in numbers to speak with just one voice. This has so many implications for us in terms of work that has to be done.

First, training of our registrars has to be broad based and quantifiable. An excellent example of a newer quantifiable model has recently been started in Australasia under the capable leadership of Howard Webster and the Australian Society of Plastic Surgeons. An online log book has been developed superseding the less analytic previous system. It allows both trainees and supervisors to track and document progress through the training years, in a manner which truly documents skill acquisition and progressive experience. The collection of this data will be vitally important in terms of presenting a case about why we are the most qualified to perform a certain subsection of our speciality. A good example is the frequently heard argument by facial plastic surgeons that they in fact have done more facelifts, more facial flaps, more head and neck reconstruction etc., than plastic surgical trainees. If we are to demonstrate the truth of the matter and stand on firm ground as a speciality, we do need to be able to document exactly what our trainees are getting in the way of experience. This is a critical area, especially in relation to aesthetic surgery. As everyone around us becomes a self-designated specialist in this area, we need to assume a broad based public stance as a speciality around the issue of patient safety. We need to be able to quote chapter and verse regarding training and experience and do so with real data and not just anecdotal warm fuzzy feelings.

Second, we must act cohesively to try and tame the debacle that has become our individual marketing efforts. Larger and larger adverts, deeper and deeper discounts for services, auctioning services in raffles; we are trying desperately to convince not only the public, but colleagues around us that we are the most qualified to do, in particular, cosmetic surgery. There are certainly none of us spending huge dollars trying to convince the public and government that we are the pressure sore and chronic leg ulcer specialists! Can you imagine the amount of money that would be available if we pooled our marketing dollars and had a common, professionally run, broad based marketing campaign aimed at branding plastic surgery – we would be everywhere!! Over the past decade the American Society has led the way in terms of re-branding the speciality. The plastic surgery brand is now recognisable by a large percentage of the American public. The so-called clipped toenail logo, that was so controversial when it was introduced, has gone steadily and inexorably forward so that the logo and branding one's self as a plastic surgeon has some meaning to the wider community. The confusion caused by branding with equal weight other sub-speciality societies and interests is, in my view, counterproductive. It dilutes our influence as a group and hampers our ability to compete in the marketplace. I am not suggesting that we give up the time tested ways of increasing a practice's profile; namely good patient care, excellent communication, and visible charitable work within the community, but we must do something to separate ourselves from the quicksand of competition that clearly pulls us to a lower level.

Thirdly, with this suggested reintegration, we have the ability to be a force not only in the legislative arena, but also in the commercial marketplace with third party payers. The California Society of Plastic Surgeons is really the poster child of a cohesive group of surgeons that has, for many years, acted in the public interest within the State and regional legislatures. Their level of sophistication with political lobbying and their crisis management with particular pieces of legislation has averted numerous disasters for speciality in California. Many of the strategies used by the California Society have been adopted by the American Society of Plastic Surgeons and have been quite effective in giving a voice to plastic surgery within North American politics. Allowing a unified voice to speak on behalf of plastic surgery also has tremendous advantages in the commercial sector where third party payers, are in my experience, willing to listen and work with us as a speciality to try and find the proper balance between excellent patient care and reimbursement levels. Putting our marketing dollars and efforts into these large platform ideas clearly benefits us all. Who among us is really interested or enthusiastic about spending more and more of our income on larger ads in the Yellow Pages, or more exotic technology to enhance our individual web presences? In my view, it is a cycle that ultimately is not sustainable.

It is certainly not my intention to lecture or imply any special wisdom. Perhaps these musings are merely a product of reaching a certain point in a career where the big picture has begun to seem more important than individual issues. I am as influenced and concerned about my own circumstances and practice as any, but I have come to see that the obsessive positioning to differentiate ourselves from the people around us, has truly become counterproductive. If we could all let go of our own self interest and egos just a bit, then I believe the rewards would be not only tangible, but internal as well. Perhaps the real toll that has been taken for each of us has been at the expense of our spirit. I say we come together as a group and strengthen ourselves morally, financially, and spiritually.

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Conflict of interest statement 

The authors have no financial or personal relationship with other people or organisations that could inappropriately influence our work.