For some time now I have been thinking about when a surgeon actually deskills through not doing a particular operation. In particular, this applies to plastic surgeons after completion of NHS type training with no previous exposure to cosmetic patients – when do they also up-skill?

To risk controversy, I remember being told that no one doing less than 25 cleft cases should be doing cleft lip and palate. Similarly, if not regularly doing free flap or reconstructive surgery then perhaps the surgeon should accept the inevitable and resign from doing such procedures and move over?

The problem is that there is often a clearly protectionist, biased view in defence of a patch, and who is to say that the results are actually any better in the hands of the surgeon doing the most cases? Most plastic surgeons feel able to do any surgery and perhaps this is wrong.

Most newly qualified plastic surgeons imbibe gradually into cosmetic surgery and it may take over five years to build up a substantive practice. Rhinoplasty, facelift, blepharoplasty, buttock augmentation are all simple examples where plastic surgeons may rarely have access to patients nowadays, especially in the early years. When do we say passing that the FRCS(Plast) exam as a fourth year trainee is not a measure of the procedures that that surgeon should be practicing? Personally, I think potential patients should keep safe by knowing the truth! 

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