distant part. The deformities dealt with in plastic surgery for the most part involve the skin or adjacent soft parts, rather than the bones and joints, the ligaments or tendons. The treatment of large denuded surfaces, requiring skin grafting, and of intractable surface wounds, should also come under the care of the plastic surgeon.
It is imperative that the surgeon who expects to do plastic and reconstructive work should have had a thorough general surgical training before attempting to specialize in this branch. Above all he must know, and thoroughly appreciate the principles governing the healing of tissues and the repair of wounds. A special knowledge of the resistance and utility of tissues more or less infiltrated with scar tissue is also necessary, because in many instances normal tissue is unavailable. A knowledge of the surgical handling of children is also very important in civil practice.
In reconstructive surgery of the jaws and palate, the plastic surgeon should have the constant advice and coöperation of a skilled dental and oral surgeon. This combination has proved to be of inestimable value in France and England, and also in Germany, where those of the wounded who require reconstructive work on the face are concentrated in special hospitals.
In choosing an operation for the repair of a defect on the face or other exposed portions of the body, care must be taken that the scar left by shifting the flap used for this repair does not cause the patient as much concern as the original defect.
My experience has been that we seldom, if ever, find two plastic cases exactly alike, and that no cut and dried methods can be employed. Each case should be carefully studied, and the various methods of repair considered from every standpoint. This endless variety in itself brings a certain fascination to the operative treatment and to the after-care of these patients. Sound surgical judgment is often necessary to determine what should be done; whether or not a plastic procedure should be finished at one operation; how far to go in the initial operation, and when to follow with the secondary procedures. The results in certain groups of cases are very slow, and in these the process is one of gradual building up. In such cases the entire series of operations should be planned with regard to the ultimate result and not to the immediate relief of the condition. The post-operative treatment and dressings should be done by the surgeon himself or directly under his eye, because successful results in a great measure depend on skillful and judicious after-treatment.
