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(melanoma and non-melanoma skin cancer) as well as complex reconstruction in other cancers such as breast cancer, head & neck cancer, ano-perineal cancers and sarcoma reconstruction, usually done in conjunction with other specialties. Weekly virtual meetings were held by NCCP during the various COVID-19 crises over the last 18 months so all surgical specialties providing cancer care, including Plastic Surgery, could discuss and assess cancer contingency plans during the pandemic. IAPS provided information on the clinical issues with skin cancers as well as complex cancer reconstruction. Skin Cancer IAPS developed guidelines for the management of skin cancers during the pandemic in conjunction with RCSI as part of RCSI’s guidelines for surgical practice during COVID-19. Expansion of skin cancer services by Plastic Surgery remains a priority as the population ages. Melanoma and NMSC guidelines, protocols and KPIs are being established by the NCCP (National Cancer Control Programme) with input from IAPS. Complex Cancer Reconstruction The need for Plastic Surgeons to provide a cancer reconstructive service, including microsurgery, continues to increase. 1. Breast cancer. The further development of an immediate breast reconstruction service using microsurgical techniques is urgently required. This is occurring to a variable extent in existing Plastic Surgery units, often limited by consultant manpower and facilities, but not occurring in breast cancer units without Plastic Surgery on site. 2. Head & neck cancer. There is also increasing need for microsurgical head & neck reconstruction in the centres dealing with head & neck cancer. 3. Ano-rectal/perineal cancers. Newer reconstructive services are increasingly required in advanced distal ano-rectal and perineal cancers, requested by colorectal surgeons and gynaecological cancer surgeons. Trauma Care Trauma is an integral part of Plastic Surgery, comprising 30-50% of the workload. The most common injuries referred are hand injuries, such as complex lacerations, tendon, nerve injuries or compound open fractures. Developing trauma services where plastic surgical trauma can be dealt with in an efficient manner within dedicated Plastic Surgery trauma units used to dealing with a large number of hand, lower limb and facial injuries requires adequate Plastic Surgery manpower with Plastic Surgery trauma clinics and daily Plastic Surgery trauma theatre facilities. Daily dedicated Plastic Surgery 26
trauma theatre facilities currently only exist in two units (Cork & Beaumont/ Connolly) but are required in all units to avoid repeated cancellations of Plastic Surgery trauma due to other specialties’ emergency cases being prioritised and/ or scheduled cases being cancelled to do the trauma cases instead. The planned development of Major Trauma Centres will also require major Plastic Surgery involvement, with the recent Trauma Report recommending “at least twelve Plastic Surgeons as a minimum” in each major trauma centre. Consultant and Service Expansion Much work is ongoing to ensure adequate consultant expansion in conjunction with RCSI and the NDTP (National Doctors Training & Planning) section of the HSE. IAPS has set up a Consultant Manpower Committee to identify and plan for adequate consultant expansion over the next decade. In addition, the National Clinical Programme in Surgery (a HSE/RCSI initiative) has recently established a Clinical Lead in Plastic Surgery who is working to develop a Model of Care in Plastic Surgery. IAPS are working with the Clinical Lead, RCSI & HSE to develop adequate and equitable Plastic Surgery services throughout the country Breast Implants and BIA-ALCL The identification of a rare new malignancy associated with certain Breast Implants called Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) was recognised by the WHO as a new entity in 2016. This has had increasing recognition over the last few years by doctors, patients and the media. The HSE established a SIMT (Safety Incident Management Team) to investigate this new entity in Ireland and to recommend how to manage patients with breast implants, both for breast cancer reconstruction and cosmetic augmentation. The SIMT identified patients who had breast implants in the public hospitals and contacted them to explain and discuss BIA-ALCL. This resulted in a considerable amount of work for Plastic Surgeons to explain this rare cancer to patients and the generally very good outcome with early detection and treatment. Guidelines for follow-up of breast implant patients are being developed. It is recognised now that a major priority is to establish a National Breast Implant Registry as many countries worldwide have done over the last decade. This work is ongoing and IAPS remains closely involved and committed to establishing a Registry. Cosmetic Surgery Regulation Cosmetic/Aesthetic Surgery is an integral part of the specialty of Plastic, Reconstructive & Aesthetic Surgery, but currently the regulation of Cosmetic/Aesthetic Surgery services is lacking in Ireland. This has been recognised in several European countries, many of which have instituted a more robust regulation of Cosmetic Surgery for the protection of patients. During my term, RCSI established a Short Life Working Group (SLWG) to review cosmetic surgery and make recommendations concerning regulation. A past President of IAPS, who is also a member of RCSI Council, chairs this SLWG. This work is ongoing and regulation of this area of Plastic Surgery remains a major issue in Ireland. WHICH PARTICULAR CHALLENGES, IF ANY, ARE FACED BY YOUR SPECIALTY IN IRELAND AT PRESENT? Consultant and Service Expansion As outlined above – to expand current
existing units and services as well as establish new units, particularly in the major cancer trauma centres in Limerick and Waterford. Cancer Care To improve skin cancer care in both melanoma and NMSC in all areas of Ireland. Complex cancer reconstructive services in conjunction with other specialties, with all reconstructive options available to all patients regardless of location, remains a challenge. This is particularly the case with both immediate and delayed breast reconstruction techniques utilising microsurgical techniques to use the patients’ autologous tissue only to reconstruct the breast, thus avoiding the need for breast implants. This service is not available to patients who attend cancer centres that do not have a Plastic Surgery unit and to a varying degree in other units who do have a Plastic
