 Let me move on to another young surgeon. This is my pleasure to introduce Dr. Bader Schachter. Bader is a resident here. He's currently administrative chief resident in surgery here. He's a graduate of the Eastern Virginia Medical School. Bader completed two years of basic science research, in which he did work on anastomotic leaks with Dr. John Alberti. During that time, he wrote a number of great papers and won almost every single teaching award you can get, both here at the university as well as nationally. And Bader's going to be going off to do a pediatric surgery fellowship at Washington University next year. Good morning. I have no disclosures to report. So it's clear from the faces I usually observe after showing pictures such as these that scars carry more than just their physiologic consequences. And in her book, I feel bad about my neck. Nora Ephron writes this, because even if you're being operated on for something serious or potentially serious, even if you honestly believe that your health is more important than vanity, even if you wake up in the hospital room thrilled beyond imagining that it wasn't cancer, even if you feel elated, grateful to be alive, full of blinding insight about what's important and what's not, even if you vow to be eternally joyful about being on the planet Earth and promise to never complain about anything ever again, I promise you that one day soon, sooner than you can imagine, you will look in the mirror and think, I hate this scar. And so we should start by defining what a scar is, in the medical sense at least. A scar forms as the body's attempt to heal a wound. It's the natural endpoint of inflammation and fibrosis. And it results from trauma, infection, certain disease process, and our atrogenically, often from many of the providers in this crowd. We should also talk about the adjective normal, because as one might imagine, the adjective normal is very prominent in the literature regarding scars, because what is normal is important to our patients. The sense of what is normal may differ between provider and patient. For instance, in the case of scar revision, surgeon may seek to improve the aesthetic of a scar, maybe the color matching or the contour where the patient looks to return to a pre-injury state. And this differing viewpoint can lead to significant consequences. What is normal can also vary geographically. In parts of Nigeria, pediatric umbilical hernias or bellybutton hernias are nearly ubiquitous or at least more common than they are in this country. There are published reports of mothers actually bringing their children to the hospital to say, why doesn't my kid have a bellybutton hernia like all the other kids? And certain tribal cultures, such as the Gamus in Eastern Africa embrace the tendency to scar with hypertrophic scars and keloids for purposeful injury for decorative purposes. In Southeast Asia, the neck incision that's associated with thyroid surgery and other neck surgery holds a social stigma. And as a result, surgeons have developed innovative ways to avoid the neck incision, including trans-axillary approaches or through the armpit, as well as hiding incisions in the nipple. The risk from this surgery, as you can imagine, is significantly different than the standard neck incision and maybe even greater than just a standard neck incision. In the end, what is normal or perhaps better said, what is acceptable is often determined by the perception of the patient. And this stands in concert with our understanding of autonomy. Thus we must set reasonable expectations during consultation. And consultation is a dialogue of shared decision making in which the physician provides judgment, technical guidance and expertise and the patients express their values and preferences. Another frequent question posed in this field is our scar revisions elective. Elective being defined as potentially unnecessary, at least not immediately necessary. Most of us would agree that a penetrating knife wound to the colon is not elective, that would be an emergency. Most of us would agree that cosmetic breast augmentation is elective in the purest sense. But what about a colon cancer? I know that if I were diagnosed, I would want my surgery as soon as possible, but certainly there's no need to remove that on the day of diagnosis. This distinction is seen within the field of scar management as well. Revision of an unsightly hysterectomy scar can be viewed as elective or certainly more elective than a scar that's limiting closure of the eyelid and exposing the patient to exposure keratopathy or keeping the eye open so much so that it gets dry. Perhaps an easier distinction to draw is that between reconstructive procedures and cosmetic procedures. And this distinction really comes from two giants in the field of plastic surgery, Sir Harold Gillies and D Ralph Millard, who defined the goal of a reconstructive procedure as that which improves the abnormal, whereas the goal of a cosmetic procedure, that which improves the normal or the status quo. What we're really asking on the past few slides is this, is a scar just a cosmetic problem like a larger than average nose or does it qualify as a pathology in its own right? We use the field of scar management as a prism to discuss the more fundamental issue, what constitutes a healthcare problem. The prevailing contemporary governing model of healthcare is the biopsychosocial model which expands on the traditional biomedical model that is physiologic problems to include patient-centered aspects of illness like social, psychological and behavioral facets. There are those such as well-known ethicist Leon Cass who would advocate a conservative view of healthcare. He said, medicine as well as the community which supports it appears to be perplexed regarding its purpose. It is ironic but not accidental that medicine's greatest technical power should arrive in tandem with great confusion about the standards and goals for guiding its use. For without a clear view of its end, medicine is at risk of becoming merely a set of powerful means and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire selling his services upon demand. Cass espouses his belief that patient happiness and other quality of life measures constitute false goals in healthcare. He implies that the paternalistic view may be more superior, that physicians should guide the delivery and the limits of healthcare. Others, including our own Dr. Siegler have advocated a more liberal definition. The more liberal view states that an issue becomes a health matter when the doctor and patient agree that it is one. In this view, one of the central goals of medicine is to improve the patient's quality of life and determination of what improved quality rests largely, albeit not exclusively, on the patient. Changes in the relationship of the doctor and the patient during the past 50 years from a paternalistic model to one of autonomy and now to one of shared decision-making suggests that the more liberal view is now the dominant ethical paradigm. Further, Cass' proposal that medicine address only narrowly construed medical or physiologic abnormalities seems to have been rejected in favor of ever expanding realm for medical interventions. This change in ethical attitude is reflected clearly in the field of scar management. The question of access is quickly raised. If scar interventions are deemed an important part of clinical care, should they be distributed equally? Almost every procedure creates an iatrogenic scar. Should a plastic surgeon be available to close every incision at every hospital? How about in the middle of the night for emergency procedures? And clearly there needs to be a balance here between optimal medical treatment and available resources. Think as a final note, we should really pay attention to disfiguring scars. These patients are not often seen because many live lives of seclusion and isolation. One of the most controversial cases in the ethical issues of scar management was that of Miss Isabel D'Norre. Prior to this case, ethical issues abounded regarding face transplant, including is it ethically permissible to give a patient immunosuppression, which could be lethal for a non-physiology, non-physiological threat? Do these procedures change the identity of the recipient? And if the transplant fails, will you leave the patient more disfigured than they were before? So in 2005, Miss D'Norre underwent the first successful partial facial transplant. This means including the nose and the mouth. Since then, approximately 30 patients have been transplanted with a mortality of 11%. Miss D'Norre passed away 11 years after her original transplant, just recently actually, she passed away in April and news of her death wasn't published until September. And it's reported that she passed away due to immunosuppression related cancers. So in conclusion, the patient perspective directs the management of scars. Expectations of the patient and surgeon should be concordant before any intervention is undertaken. And decision-making is really a shared decision-making approach in which the physician provides the technical guidance and the patient expresses their values and preferences. Thank you for the opportunity to speak with you this morning. I wanna acknowledge that this project actually arose out of an invitation to write a book chapter by Dr. Korkowski and Dr. Shoemaker. I wanna thank the co-authors, Dr. Singh, Gottlieb, Angelos and Siegler and I wanna thank the McLean Center as well.