Broadening the Mind

(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 e need for Plastic Surgeons to provide a cancer reconstructive service, including microsurgery, continues to increase. 1. Breast cancer. e further development of an immediate breast reconstruction service using microsurgical techniques is urgently required. is is occurring to a variable extent in existing Plastic Surgery units, o en limited by consultant manpower and facilities, but not occurring in breast cancer units without Plastic Surgery on site. 2. Head & neck cancer. ere 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. e 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 e cient 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 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. e 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 e identi cation 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. is has had increasing recognition over the last few years by doctors, patients and the media. e 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. e SIMT identi ed patients who had breast implants in the public hospitals and contacted them to explain and discuss BIA-ALCL. is 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. is 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. is 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. is 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. is 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. is 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

Surgery unit due to inadequate manpower, theatre resources or both. Trauma Provision Establishing an e cient trauma service to deal with the large volume of injuries referred to Plastic Surgery, which requires a dedicated daily Plastic Surgery trauma theatre in all centres. is facility currently only occurs in two hospitals/hospital groups, Cork and Beaumont/Connolly. e Major Trauma Report has recommended two major trauma centres to deal with major truama, one in Cork and one in Dublin. is will require an increased number of Plastic Surgeons, resources and facilities to deal with as outlined above. Cosmetic Surgery and its Regulation As outlined above, cosmetic/aesthetic surgery is an integral part of Plastic Surgery but currently the regulation of Plastic Surgery services is lacking. is has been an ongoing challenge for the specialty of Plastic, Reconstructive & Aesthetic Surgery in many countries for some time, although many jurisdictions have instituted a regulatory framework. IAPS and RCSI are working together to urge the regulatory authorities in Ireland to address this de cit, which puts patients at risk. Breast Implants, BIA-ALCL and Other Issues with Implants is is outlined above. Although a rare malignancy, BIA-ALCL can result in signi cant patient concern, especially in breast reconstruction patients, who have already had a breast cancer. Many patients are now requesting removal of breast implants or conversion from a poor aesthetic outcome of their breast reconstruction where breast implants were inserted, to autologous tissue reconstruction, mainly with the “DIEP” (Deep Inferior Epigastric Perforator) ap. A priority is the establishment of a Breast Implant Registry (similar to those existing for other implants such as hip replacements) in Ireland, as has occurred in many countries in North America, Europe and Australasia.

ARE THERE ANY SUBSPECIALTY AREAS THAT YOU SEE PARTICULAR NEEDS IN, AND HOW CAN THEY BE ADDRESSED? Cancer Care and Microsurgical Reconstructive

Services ere is a speci c need for an adequate and equitable cancer reconstructive services in the entire country. As outlined above, this is available in some cancer centres and availability is limited in others due to inadequate manpower and resources. is is especially the case with breast reconstruction, especially immediate reconstruction using autologous tissue such as the DIEP ap. e same issue exists for advanced head & neck cancer, which requires a complete reconstructive service, including microsurgery, to allow more extensive curative resections to be carried out. is resource varies from centre to centre and requires improvement as the need for complex reconstruction of these cancers continues to increase. Hand and Trauma Services ere is particular need for hand surgery emergency services which should be available in all centres on a daily basis but only occurs in one or two centres and needs to be increased. It would still require most hand injuries to be managed in the local trauma units rather than the major trauma centre. e establishment of major trauma centres requires considerable expansion in Plastic Surgery manpower and services to deal with complex lower limb compound fractures, extensive limb degloving injuries and so tissue loss, major burns, extensive cranial/facial injuries which will be triaged to these major trauma units and dealt with in conjunction with other specialists, particularly orthopaedic surgeons in lower limb trauma. Reconfi guration of Paediatric Plastic Surgery With the new Children’s Hospital opening in the next few years, this will require reorganisation of current services for Paediatric Plastic Surgery, which currently occurs in both the existing Children’s Hospitals in Temple Street and in Crumlin. ese services include cle lip & palate, paediatric craniofacial surgery, congenital hand surgery, congenital vascular malformations, ear deformities, congenital facial palsy and paediatric burns. While currently all consultants who deal with Paediatric Plastic Surgery are specialised in their various areas, they are also all attached to an adjacent public hospital, either St James’s or the Mater hospital. When the Children’s Hospital opens, it will require both recon guration of current consultant’s practice as well as consultant expansion to provide an adequate service. is is also likely to have an e ect on the adult Plastic Surgery services provided.

WHAT WOULD YOU SAY TO SURGICAL TRAINEES CONSIDERING A

CAREER IN THIS SPECIALTY? I would strongly encourage trainees to consider a career in the specialty of Plastic, Reconstructive & Aesthetic Surgery. Plastic Surgeons are referred a huge variety of problems in many di erent areas including hand surgery and hand injuries, trauma services including upper limb, major lower limb and facial injuries, skin cancer and reconstruction, breast reconstructive surgery, head & neck cancer and reconstruction, facial palsy surgery, burns, Paediatric Plastic Surgery such as cle lip & palate, aesthetic surgery, and many others. All ages are dealt with, from babies with congenital deformities to very elderly patients with complex cancer or degenerative problems.

Plastic Surgeons have always been surgical innovators, developing new techniques and ways to approach a particular problem, evolving as newer ways of managing problems and new techniques are described and developed. More recent advances developed by Plastic Surgeons include microsurgery, tissue expansion, autologous fat transfer, skin substitutes, negative pressure wound therapy techniques, to name but a few. Collaborative surgery with other specialties is an integral part of Plastic Surgery. Plastic Surgeons require exibility to work with other specialties as well as constantly adjusting to new techniques during their career. Research in Plastic Surgery is also an exciting eld, with many opportunities both nationally and internationally.

In Ireland, the specialty of Plastic, Reconstructive & Aesthetic Surgery continues to expand, with consultant numbers having almost tripled in the last 25 years from ten in 1996 to over 30 in 2020. e need and demand for Plastic Surgeons will continue to increase, which is a challenge and a great opportunity for any future surgeon.

DATES FOR YOUR DIARY

e Irish Association of Plastic Surgery Winter Meeting will take place, now virtually, on 10 December 2021; Charter Day; Plastic Surgery Section, Friday 24 February 2022; Plastic Surgery SpR interviews, 16 March 2022. ■