Plastic surgery under challenging conditions


Humanitarian Aesthetic Surgery

Patrick Knipper, President of Interplast-France

Humanitarian plastic surgery is being performed in France, day in, day out, by plastic surgeons. We can be humane without engaging in “humanitarian” work. Oddly, though, it is also possible to do engage in a humanitarian exercise without being humane: some “volunteers” appear to see humanitarian work as an opportunity to travel, rather than as an opportunity to help human beings in distress.

Even when performed for “humanitarian” reasons, plastic surgery must address the aesthetic dimension. Many surgeons still feel that “humanitarian aesthetic surgery” is a contradiction in terms. How can one envisage cosmetic surgery when the object of the mission is to meet the most basic demands for surgery? Aesthetic surgery is still considered as something undertaken to prettify patients who are not really ill, as opposed to the “real” surgery provided by the “humanitarian” surgeon, who is there to help those in actual need of surgery.

Let us remember, though, that it is not for us to decide what is and what is not important to a given patient. We are here to meet the patient’s demand, regardless of the nature of, and the background to, this demand. It may, undoubtedly, be more ego-boosting for a surgeon to say that, but for his operation, the patient would have been left with a functional deficit; however, the ultimate objective of surgery should be the satisfaction of the patient. And if something that looks good is more likely to function better, then why not ensure that a good functional result is also aesthetically pleasing? Regardless of the countries visited, the patients we have encountered during our missions have taught us that, to them, the cosmetic result was as important as the functional outcome, or that the two aspects were indissociable..

There was also a cosmetic consideration in the reconstruction of the elbow of a young man in Benin, who had had a severe Buruli ulcer. His right elbow was contracted, with extensive fibrosis, especially over the anterior aspect. We performed a wide resection, and managed to release the elbow completely. The defect was covered by a pedicled myocutaneous latissimus dorsi flap. Elbow mobility was excellent, and the postoperative course was uneventful. We were happy to have restored function to the patient’s elbow, since, with a working elbow, the young man would be able to work in the fields, and, consequently, think of having a family. We were very aware of this association between the functional and the expected social outcome. However, the flap was still a bit bulky, and did not look very attractive. We explained to the patient that the flap would get thinner by and by. But how does one get the concept of secondary muscle atrophy across? Also, Buruli ulcers are painless. Following surgery, the patient obviously had some pain. We had performed a successful operation, but in the patient’s eyes we had done more harm than good.

In noma, the repair of some of the facial mutilations also serves an – often tacit – cosmetic purpose, even though the highly sophisticated techniques employed are designed for reconstruction. Noma, also known as cancrum oris, is an infective ulcerative and necrotic gingivostomatitis which, nowadays, affects mainly African children (in the so-called noma belt of Africa ). Malnutrition, poor oral hygiene, and a variety of systemic diseases are risk factors. Mortality has been greatly diminished by the use of antibiotics and proper nutrition. At the postulcerative stage, the patients are left with major orofacial disfigurement.

I vividly remeber a young girl from Togo , who came to us accompanied by some nuns from northern Nigeria . She had been living alone, outside her village, and had been raped repeatedly. Her face was terribly disfigured by noma, with a huge, foul-smelling cleft from the corner of the mouth right up to the temporal region. The nuns had been unable to anything for her, so they had decided to bring her to us.

Basically, there was nothing wrong with her physiologically or in terms of laboratory parameters. She just could not chew. She was getting enough nutrition from (manioc-based) liquid feeds, and did not appear to have any nutritional deficiencies. So why did we operate on her? To restore function, that’s why. To reconstruct her face, that’s also why. We think that she was happy to be able to close her mouth a bit more, and to move her jaw, however little. Above all, we think that she was happy to have a face again that might no longer need to be hidden behind a veil. In more than one way, she was healed – and that was cause for happiness.

These examples prompted us to think about the true purpose of surgical missions under challenging conditions. Plastic surgery is only one modality, in a vast array of treatment approaches. Healing, function – those are the results that satisfy us surgeons. But what about pain relief? What about the fact that this girl, with her new-found face, was no longer being raped? Who can say what “healing” really means?

Humanitarian aesthetic surgery has taught us that cosmesis is essential for repair, and that there is no need for trying to justify cosmesis by saying that it is a byproduct of reconstruction: cosmesis is an integral part of reconstruction. Reparing a cleft lip in a little Asian girl could be seen as reconstructive surgery, or as aesthetic surgery. One might say that it is reconstructive surgery, because that is more ” significant “, or because it involves reconstruction of the muscles of the lip. The little girl might want a prettier, a more cosmetically appealing lip. So that would make cleft-lip repair an aesthetic procedure. However, the “why” is unimportant, since the “how” – the technique – will be the same, and since the surgeon will always try to achieve the best, and the most cosmetic, result. It follows that the reason for which the surgery is performed is the only criterion for calling a particular operation a reconstructive or an aesthetic procedure. Once the operation has been decided upon, the execution of the procedure will be the same. In the final resort, it is not definitions that matter: what counts is that the little Asian girl will be happy, and, as we hope, will be “pretty” happy.

In practical terms, and however paradoxical it may sound, we have learnt not to do aesthetic surgery, but to do surgery with a view to achieving an aesthetic result, even when working on a so-called humanitarian mission.

Patrick Knipper,  Paris


The complete article with a lot of very interesting ideas concerning  „Plastic Surgery under challenging conditions“ and many surgical techniques are described in detail on the homepage of INTERPLAST France.  www.Interplast-France.net

It can be downloaded for personal pratical information. You will find the complete article with all photos also on the INTERPLAST-CD No 1  in English and French which you can order on our contact site.

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