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Dividing up the territory
J Oral Maxilloiac 55:321, 1997
Surg
Dividing
Up The Territory
What determines the scope of a specialty? This is not an easy question to answer. Although it sometimes begins as an anatomic division, regional and functional interrelationships often lead to overlap and one then finds several specialties including similar procedures within their field. Other times scope seems to be determined arbitrarily as specialty boards lay claim to operations they believe should be done only by their practitioners. There also seem to be regional and local variations in scope as areas are negotiated between specialists based on individual training and expertise. Thus, there does not appear to be one way in which scope can be established, and therefore territorial arguments continue to wax and wane. In recent times, defining the scope of corrective surgery of the facial region has become a controversial issue. One specialty has laid claim to this area, stating that it falls only within its domain, and has attempted to prevent other specialties from treating patients requiring these procedures. Thus, oral and maxillofacial surgeons are now constantly being challenged, the argument being that they are encroaching into an area that has not traditionally been a part of their field. To refute this argument one needs only to look at the definition of what constitutes cosmetic, reconstructive, and plastic surgery. Cosmetic (esthetic) surgery has been defined as those procedures performed to reshape normal structures to improve the patient’s appearance. In the facial region, practitioners from otolaryngology, plastic surgery, ophthalmology, dermatology, and oral and maxillofacial surgery all do various forms of cosmetic surgery. Thus, from the standpoint of facial cosmesis, no single specialty can claim sole jurisdiction over the field. Reconstructive surgery differs from cosmetic surgery in that it is performed on structural abnormalities causedby congenital or developmental derangements, disease,or trauma rather than normal structures. It is generally performed to improve function, but it may also be done to improve appearance. Reconstructive surgery is also not the exclusive domain of any surgical specialty, because all specialties working in the facial region do some reconstructive procedures. In fact, it is a part of every surgical operation. Whenever tissues are incised, extrapated or transplanted within the body, reconstruction is a part of the repair. Therefore, reconstructive facial surgery, just like cosmetic surgery, is not specialty-specific.
Just as corrective surgery can be divided into both cosmetic and reconstructive procedures, plastic surgery also has a double meaning. Because the term technically implies changing form, it too encompassesboth operations performed for improvement in normal appearance and those designed to bring a deformed or less than normal appearanceinto the range of normality. Although the specialty of plastic surgery involves both of these aspects,as already discussed,many other surgical specialties also do various kinds of cosmetic operations, and all do reconstructive surgery within the boundaries of their field. Therefore, in a real sense,all of the specialistsworking in the area can be considered as regional facial plastic and reconstructive surgeons. Oral and maxillofacial surgeonshave a long history of involvement in corrective surgery of the facial region. They were the early pioneers in the management of cleft lip and palate, as well as in orthognathic surgery. It was only after plastic surgery became a recog-nized specialty that the oral and maxillofacial surgeons’ role in the former area became diminished. However, they have continued to be the leaders in orthognathic surgery, and have also made some of the major contributions in the areas of facial trauma and jaw reconstruction. Therefore, participation of the oral and maxillofacial surgeon in various forms of soft and hard tissue correction in the facial region is not an encroachment on the scope of other specialties but rather it is a natural progression within the already existing boundaries of the specialty. This is different than creating a new specialty that encompassesmany procedures and techniques that are already a part of other surgical fields. Because of the various established specialties already working in the facial region, overlap in the performance of surgical procedures is an inevitable consequence. However, it is unlikely that divisions in scope that well satisfy everyone can ever be developed. Therefore, the solution to this problem probably lies in allowing unrestricted competition in areas of existing overlap rather than trying to establish arbitrary rules about what one specialty can or cannot do. In such circumstances, there will not only be better relations among the various specialties, but also it could lead to better cooperation when an interdisciplinary approach is really necessary. DANIEL M. LASKIN
321
Surg
Dividing
Up The Territory
What determines the scope of a specialty? This is not an easy question to answer. Although it sometimes begins as an anatomic division, regional and functional interrelationships often lead to overlap and one then finds several specialties including similar procedures within their field. Other times scope seems to be determined arbitrarily as specialty boards lay claim to operations they believe should be done only by their practitioners. There also seem to be regional and local variations in scope as areas are negotiated between specialists based on individual training and expertise. Thus, there does not appear to be one way in which scope can be established, and therefore territorial arguments continue to wax and wane. In recent times, defining the scope of corrective surgery of the facial region has become a controversial issue. One specialty has laid claim to this area, stating that it falls only within its domain, and has attempted to prevent other specialties from treating patients requiring these procedures. Thus, oral and maxillofacial surgeons are now constantly being challenged, the argument being that they are encroaching into an area that has not traditionally been a part of their field. To refute this argument one needs only to look at the definition of what constitutes cosmetic, reconstructive, and plastic surgery. Cosmetic (esthetic) surgery has been defined as those procedures performed to reshape normal structures to improve the patient’s appearance. In the facial region, practitioners from otolaryngology, plastic surgery, ophthalmology, dermatology, and oral and maxillofacial surgery all do various forms of cosmetic surgery. Thus, from the standpoint of facial cosmesis, no single specialty can claim sole jurisdiction over the field. Reconstructive surgery differs from cosmetic surgery in that it is performed on structural abnormalities causedby congenital or developmental derangements, disease,or trauma rather than normal structures. It is generally performed to improve function, but it may also be done to improve appearance. Reconstructive surgery is also not the exclusive domain of any surgical specialty, because all specialties working in the facial region do some reconstructive procedures. In fact, it is a part of every surgical operation. Whenever tissues are incised, extrapated or transplanted within the body, reconstruction is a part of the repair. Therefore, reconstructive facial surgery, just like cosmetic surgery, is not specialty-specific.
Just as corrective surgery can be divided into both cosmetic and reconstructive procedures, plastic surgery also has a double meaning. Because the term technically implies changing form, it too encompassesboth operations performed for improvement in normal appearance and those designed to bring a deformed or less than normal appearanceinto the range of normality. Although the specialty of plastic surgery involves both of these aspects,as already discussed,many other surgical specialties also do various kinds of cosmetic operations, and all do reconstructive surgery within the boundaries of their field. Therefore, in a real sense,all of the specialistsworking in the area can be considered as regional facial plastic and reconstructive surgeons. Oral and maxillofacial surgeonshave a long history of involvement in corrective surgery of the facial region. They were the early pioneers in the management of cleft lip and palate, as well as in orthognathic surgery. It was only after plastic surgery became a recog-nized specialty that the oral and maxillofacial surgeons’ role in the former area became diminished. However, they have continued to be the leaders in orthognathic surgery, and have also made some of the major contributions in the areas of facial trauma and jaw reconstruction. Therefore, participation of the oral and maxillofacial surgeon in various forms of soft and hard tissue correction in the facial region is not an encroachment on the scope of other specialties but rather it is a natural progression within the already existing boundaries of the specialty. This is different than creating a new specialty that encompassesmany procedures and techniques that are already a part of other surgical fields. Because of the various established specialties already working in the facial region, overlap in the performance of surgical procedures is an inevitable consequence. However, it is unlikely that divisions in scope that well satisfy everyone can ever be developed. Therefore, the solution to this problem probably lies in allowing unrestricted competition in areas of existing overlap rather than trying to establish arbitrary rules about what one specialty can or cannot do. In such circumstances, there will not only be better relations among the various specialties, but also it could lead to better cooperation when an interdisciplinary approach is really necessary. DANIEL M. LASKIN
321