On 28th June 2014 there was the assassination of the Crown Prince of Austria, Franz Ferdinand Carl Ludwig Joseph Maria, Archduke of Austria-Este in Sarajevo. The Austro-Hungarian Empire declared war to Serbia, where the steps of assassins led. Triple Alliance and Triple Entente joined the war and World War One started. This was special in many ways. It was the first war to which the United States of America also contributed; the first war where also colonies of the fighting European states joined the battles; the first war that is called the “world war”. It was the first time when weapons of mass destruction were used; it was the first time for tanks, flame gun and also chemical weapons to be used. It was the first war in which the life of public was stigmatized even more than the life of the soldiers. The conflict was destructive, however, even such horrors result in positives and one of them was undoubtedly a great development of reconstructive surgery. The result of such development was that doctors from various surgical specialities, who dealt with reconstructive surgery, joined together in some way and a separate specialty – plastic and reconstructive surgery – was established. A bit later, plastic surgery was associated with aesthetic surgery, which is actually a sort of reconstructive surgery.
Plastic surgery is not a specialty that deals with treatment of some system or type of a disease. Plastic surgery performs the procedures everywhere in the whole body; it treats patients and complications from every other specialty and any type of disease. What is the unifying factor is the surgical technique and philosophy, i.e. work that is a combination of destruction and reconstruction, which is at the border between surgery and aesthetics, craft and art.
The Czech school of plastic surgery has a unique tradition, which dates back to the academician František Burian. František Burian was actively present in the birth of plastic surgery as a separated specialty; thanks to him, in the Czech Republic there was established one of the first departments of plastic surgery in the world and thanks to him the Czech plastic surgery is still known worldwide. František Burian also contributed to establishing of the journal Acta Chirurgiae Plasticae, which has been published since 1959 and which is special by its tradition and focus. In the subtitle of the journal it reads that it includes wider range of specialties, which are at the border of reconstructive surgery and aesthetic surgery – plastic surgery, hand surgery, maxillofacial surgery and burn surgery.
Plastic surgery in our country is a very respectable specialty, which is able to do exceptional things, which deals with exceptional complications, congenital disorders, treats defects after injuries, after resection of tumours, deals with replantations, and hand surgery.
In the recent years, plastic surgery in our country is however endangered and there is gradual weakening, or even slow destruction happening. It is a slow process and therefore inconspicuous, many of us do not realize it. Destruction comes from outside and from inside.
Internal destruction comes directly from us, from plastic surgeons. It has undoubtedly economical reasons. This is manifested by the phenomenon that many plastic surgeons after completing the training immediately leave partially or completely from clinical workplaces to private practice and deal only with aesthetic surgery and they are not interested in the development of reconstructive surgery. Even the general problems of the current life philosophy should not be omitted, which can be characterized by the words “do not bind yourself, get free” or “have fun”, etc. When I ask the students (the number of male students is alarmingly declining) during my teaching classes what they want to do after completing the studies, only a very small percentage of them want to do surgical specialties. The argument is that it is “poorly paid hard work”, which is unfortunately not illogical. Students and also young colleagues often lose the desire to achieve something, to be exceptional, to bring something new and it seems that the only motivation of their efforts and work is financial benefit. Undoubtedly another economical effect is great and logically poorly understandable undervaluation of complex specialized reconstructive procedures, when the site where these procedures are performed is persecuted for poor management, which certainly cannot positively motivate anyone in the development of reconstructive surgery.
Weakening from outside is more visible, we are more aware of it, but unfortunately only in the field of aesthetic surgery. All medical specialties try to gain as much as possible from aesthetic surgery and aesthetic medicine, mainly non-invasive and mini-invasive specialties are very active from this point of view. They openly claim that it should be based in legislation that these procedures should be performed only by a doctor with specialisation in this field, and it is not plastic surgery. Weakening is however also significant in reconstructive surgery. Only a few years ago there was only minimal number of doctors from other specialties than plastic surgery attending hand surgery congresses. It is now completely different. More and more doctors now start to perform reconstructive microsurgical procedures, mainly in trauma and maxillofacial surgery, which has previously been an untouchable domain of plastic surgery.
I do not mean to complain about these attempts or say that it is wrong. On the contrary, I admire these doctors and those departments. They are motivated by the effort to achieve something, to bring something to the field and to develop it. Thus, exactly what we, as plastic surgeons, are slowly losing. Part of their activities is caused by the fact that recently, it has been a real problem to find a plastic surgeon, who would be willing to perform promptly and willingly these superspecialized demanding procedures.
And this is what I consider alarming. Plastic surgery can maintain the respect of other medical specialties, insurance companies, ministry officers and patients only when it keeps strong and exceptional reconstructive surgical part. Aesthetic surgery is important, it is important to perform it at a high level and with elegance, but it will not provide us with any respect, admiration or strong position.
The success of a medical specialty is manifested also by publication and scientific activity. We can be proud that the Journal of the Plastic Surgery Society, Acta Chirurgiae Plasticae, has been published for more than 50 years, however its respect and viability copies the overall situation in our specialty.
I was asked to assemble the first issue of Acta Chirurgiae Plasticae in 2016 as a member of the editorial board. It was not a simple task since there were only three months reserved for it. We would like to present here the work of our and also foreign authors, which concerns important areas of plastic surgery. The article from the field of hand surgery comes from the colleagues from Switzerland and it deals with the differential diagnostics of symptoms in the area of the nail bed of the fingers. The article from reconstructive surgery of the breasts was written in cooperation with the Technical University in Liberec, and using numerical analysis it describes differences in reconstructive possibilities using breast implants. The article from maxillofacial surgery describes the possibility of mini-invasive treatment of condylar fractures of the mandible and it comes from the Department of Maxillofacial Surgery of the General University Hospital in Prague. The case report written by the colleagues from the Trauma Centre of the Military Hospital in Prague describes reconstruction of a forehead defect after an impressive fracture. The other two articles deal with allogeneous transplantations of composite tissues, which I consider to be the top topic of the current reconstructive surgery from the technical as well as ethical point of view. The first article comes from the colleagues from Belgium and deals with tracheal transplantation; the other article is a brief summary of current knowledge in this field. And finally, there is a presentation of general and extensively discussed topic, prevention of thromboembolic disease and pulmonary embolism in plastic and aesthetic surgery.
Dear colleagues, it has been more than one hundred years since Czech plastic surgery developed in the front position of the world plastic surgery. Now it is retreating although it has been flourishing in the world. It is only up to us whether we maintain its respect and strong position from the medical as well as economical point of view. It is disputable from the scientific point, but people say “if we put a frog to a kettle with boiling water, it tries to get out, to rescue itself”. However, if we put it to a kettle with cold water and heat it up very slowly, it loses protective reflexes and it lets itself to be boiled slowly. I do not want to be sort of a pessimist, however I have a feeling that we are sitting in lukewarm water in a kettle under which is a fire. There is fire but we do not see it, or we do not want to see it. I therefore pray with the words on the statue on the Wenceslas Square: “St. Wenceslas, do not let us die nor those yet to come!”
Martin Molitor, M.D., Ph.D.
Department of Plastic Surgery
Hospital na Bulovce and the First Faculty of Medicine, Charles University