The times they are a-changin’

I remember my desire to be a plastic surgeon.

Thought it sounded pretty cool.

As I toured the various specialties, trying to choose what to do, I was struck by how potent being a plastic surgeon felt. You met someone and you could help them. Time was spent working out what didn’t work or what might not look right and the plastic surgeon knew how to make that better.

As a service registrar, the plastics dressing clinics were almost enjoyable. Actually they WERE enjoyable. Invariably, the satisfaction rate was high and people were grateful, from the larrikin with the boxer’s fracture, to the woman with a reconstructed breast following the terror of cancer. Plastic surgeons seemed happy and were more than willing to talk about their work over a beer. That seemed like a good sign to me.

Each plastic surgeon seemed to be able to define themselves. Each chose what they were interested in. Whether it be in the face, hand, breast or to regularly perform techniques such as facial ostetomies, fat injection or microvascular anastomoses—what a strange bunch of bedfellows. Equally intriguing were the personalities that gravitated easily towards aesthetic surgery versus the burns surgeon or, as in my case, paediatric surgery.

Using a military analogy, if orthopods are like the marines, plastic surgeons are like the rangers. We are taught basic skills by generous mentors then choose what we love and define ourselves through further training to be the best we can be. Two plastic surgeons standing side-to-side could not be less alike.

And this is the enigma. There are few other occupations where we teach one another, knowing full well that our students will become our competitors. We share our knowledge with each other, gifting our experience without fees, patents, non-disclosure contracts and non-compete clauses. We pass on to one another the attention to subtleties, creativity and ethics that we learnt ourselves. This is what defines us as a specialty; the importance of detail, our desire for excellence and our ability to evolve. We are more an attitude than a surgical specialty.

Now more than ever, we find ourselves competing not only with ourselves but many other specialties. We are not bound by an anatomical specialty and that means that every procedure we do can be claimed by someone else. There is nowhere for us to rest our weary heads. No, not the skin cancer, or the breast augmentation or even the cleft lip. In the age of disruption, I do feel some consolation and camaraderie with the taxi driver. How unfair, it would have seemed to them, to have their boundaries completely disregarded by the ridiculously convenient Uber. Don’t boundaries mean anything anymore?

We live in this new world.

When I graduated, I remember the furore surrounding advertising (in print in the yellow pages!) if you dared to put a border around your name. The rules enforced on what one could say before Fat Cat went to bed now seems a world away.

And it is increasingly difficult to duck-dive the wave of social media. Everyone is an expert and everyone has an opinion. And there is no requirement to qualify it. Twitter brawls can emerge from naming someone from the comfort of your armchair and inciting a war of words analogous to a schoolyard fight, with the potential crowd of virtual onlookers ensuring egos will prevent any peaceful de-escalation.

That primal chant augmented beyond any concrete arena “Fight! Fight! FIGHT!” An endless tide of opinion available to support you, or to oppose you. Whatever you choose to believe.

The power of a single comment can likewise misrepresent a successful practice with one vindictive post. Somewhat in retaliation, there are ways to respond and influence perceptions about who we are, what we do and how well we do it. And the cycle continues.

My head spins. A new world indeed. ‘Better get back to basics’, I hear and feel my old mentors gloating over me. When in doubt, take a breath.

I am filled with gratitude for my family choosing this great country to raise us in. The term great has been hijacked of late. But it is great. It’s a true meritocracy that has rewarded a scrawny kid born in Malaysia and it has naturally evolved that I would want to give back. I am thankful for all the giants of plastic surgery in Western Australia who spent time teaching me in those formative years. One does not realise the sacrifice until the shoe is on the other foot. A bit like parenting, so I’ve been told.

I chose cleft surgery. I loved it from the first moment I saw the surgery. All of us as cleft surgeons share a passion. We find commonality in our desire to create a perfect lip and nose, together with a palate that works well and allows the maxilla to grow. We all know the handcuffs of perfectionism, as we torture ourselves with the minute details of tissues, in our quest to relieve ourselves of the burden of not being good enough. We know each other.

Once enticed, we devote years in pursuing this subspecialty craft, which remunerates modestly, haunts us with the deforming face of time, and then provokes fears of confronting our failures long after we can do anything about them. And how blessed we are.

I wasn’t even sure I would be good at surgery. I still don’t know if I am good at surgery. And perhaps it’s that notion, the haunting voice that sits in my head that tells me I am not good enough, that drives me to create as close to perfection as I can, reflected on the face that sits in front of me.

As I finish each surgical attempt, how the minute asymmetries of the lip accuse me, how that persisting nasal slumping chides me. At least with time and age, the voice grows softer. It’s still there. Maybe it’s more of a friend these days.

What a gift we have as plastic surgeons. To be able to change the way even one life is lived. To do our best to minimise the pain felt by our patients, from the cruelty that potentially resides in the dark side of all of us—the judgement of appearance. You must be faulty because you look that way.

Like many of you, I am thankful that I am in a place in life to be able to give back. And how ideally suited is our love of plastic surgery to enable this, to give away something that was given to us? Even in these darker times, we will evolve. Change is not new to us as plastic surgeons. As always, we will find a way and giving back is a good start.

David Chong is a cleft surgeon at the Royal Children’s Hospital, Melbourne, Victoria, Australia. He is President of Australasian Cleft Lip and Palate Association (ACLAPA), Chairperson Cleft Surgery Training Program for Operation Smile and Chairperson State Advisory Committee to MDA National Medical Indemnity Insurance