On Feb. 7, Sens. Ted Cruz and Bernie Sanders met at George Washington University to debate the future of the Affordable Care Act. The debate centered on the financial burden of healthcare, but also swerved into issues with medicine that impact its financial compensation. At that point, Sanders denounced the shortage of primary care physicians providing services in the medically underserved belts of America. He partially attributed this to the high cost of medical education in the United States.

“We need tens of thousands of more doctors in this country. We have a major crisis in primary care. There are areas in urban America and rural America where people literally can’t find a doctor to serve their needs.” Sanders yelled. “You go to medical school, you could come out hundreds of thousands of dollars in debt. And then you’re going to become a plastic surgeon, not doing primary care in an urban area or rural America.”

This comment was largely ignored by national media outlets. CNN’s Reality Check Team, which later ran an article evaluating claims made during the debate, did not contest or verify this particular statement.

But someone else did. Debra Johnson, a board-certified plastic surgeon and the president of the American Society of Plastic Surgeons, sent a letter to Sanders’ office expressing her view — the comment about plastic surgeons was reductive. In the letter, Johnson explained how plastic surgery is crucial to healthcare. She stressed that plastic surgery is not just cosmetics — that while many of her colleagues perform elective cosmetic procedures like rhinoplasties and breast augmentations, many of them are also providing life-saving care, like wound regeneration and melanoma treatment. Many times they are dismissed as nonessential physicians, but a health care system needs plastic surgeons. A glance at the breadth and depth of the work done by plastic surgeons at any major medical center reveals this. At Yale New Haven Hospital, it’s no different.

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The Yale Department of Plastic and Reconstructive Surgery has its offices at 330 Cedar St., a short walk from Yale New Haven Hospital. The department’s seven attending physicians see patients in the Yale Physicians Building, operate in the surgical pavilions, and extend their care to all of Yale’s medical centers, treating thousands of patients each year. All attending physicians are certified by the American Board of Plastic Surgery. Additionally, Yale facilitates graduate medical education through 12 plastic and reconstructive surgery resident physicians, each of whom spend six years after medical school learning the technique and thought processes of plastic surgery.

Yale’s department is comprised of seven different programs, each of which treats different medical concerns. A look at the departmental website reveals that, along with the Cosmetic Surgery Center, the department contains the Airway and Sleep Disorders Program, the Breast Reconstruction Program, the Hand and Microsurgery Program, Melanoma and Skin Cancer, the Craniofacial Program and the Maxillofacial and Orthognathic Surgery Program. Only one of these programs is directed towards patients seeking cosmetic surgery, which is at odds with the sensationalized portrayal of plastic surgery as only being cosmetic surgery. Amongst the news articles accompanied by gruesome pictures of surgeries gone wrong, television shows like “Dr. 90210,” “Botched” and “Nip/Tuck” paint a salacious picture of plastic surgery that is not true, according to Yale’s surgeons.

“Cosmetic surgery we make no apologies for — we think it offers a great deal of support for people who have identified a particular disability that they would like to have corrected … But that’s only one feature of plastic surgery,” said John Persing, chief of Plastic and Reconstructive Surgery at Yale New Haven Hospital.

While he attested that media depiction of plastic surgery may have an effect on patients’ perception of the field, he also theorized that the biased portrayal may negatively affect prospective physicians.

“I think [media depiction of plastic surgery] is an incorrect portrayal of plastic surgery, and I think it turns off young people who are trying to do something meaningful with their lives,” Persing said. After all of that preparation that you’re going through in medicine — the hope is that you’ve got that mindset where you want to help people. And if there’s a belief that what you’re doing and spending all of this time for is something trivial, I would think it turns off a lot of young people who are idealistic and want to make a positive impact in someone’s life.”

To this end, many plastic surgeons are attempting to educate the public about what plastic surgery actually is and what is isn’t, according to Derek Steinbacher, director of Craniofacial Surgery at Yale New Haven Hospital. They see it as a way to improve communication with their patients but also as a way to help portray the vastness of the field so that everyone — patients and providers alike — can use that knowledge to inform decision about their futures.

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Steinbacher recounted how he was interested in studying anthropology and facial morphology while a student, and then his exposure to cleft lip and palate cases led him to plastic surgery. After dental school, Steinbacher attended medical school, then residency, and is now an attending physician at Yale New Haven Hospital specializing in cleft, craniofacial and maxillofacial surgery. Other plastic surgery attendings and residents described differing paths to the specialty, many of which also evolved naturally over the course of increased exposure to the field.

“You know, in medical school, one of the first decisions that people make is surgery versus medicine,” Arvind Gowda, a first-year plastic surgery resident at Yale, said. He remembered how he was initially interested in urology — a medical and surgical field focused on diseases of the urinary tract. “I planned on going into urology all the way to my fourth year of medical school,” Gowda said.

By his fourth year, Gowda had seen many urologic surgeries. Many of those surgical teams included plastic surgeons. “I started reading about the underlying principles of reconstructive surgery, then decided very last minute to go for plastics,” he said. Gowda even said he was blown away by the scope of plastic surgery and found it to be the most intellectually stimulating surgical field.

“For me, it was always about the reconstructive side of things,” said Ean Saberski, a third-year plastic surgery resident at Yale. Saberski related how he had become interested in plastic surgery after he saw an abdominal wall reconstruction, and realized how nuanced the field was.

Dr. David Tsai, a second-year plastic surgery resident, remembered when he first started looking into different specialties as a third-year medical student.

“I saw a lot of diabetes, high blood pressure management — a lot of trying to treat symptoms. What I liked about plastic surgery was that the focus was more about improving the quality of someone’s life right now.”

Many of the surgeons interviewed stressed this quality over quantity of life an important part of their medical practice.

“We cannot always extend someone’s life. But we can give someone’s sense of self back through breast reconstruction [post-mastectomy], we can give them their smile back, their hands back, their work back, their ability to function in society back,” Tsai said. “We’re trying to improve someone’s day to day life.”

For medical students who have an interest in plastic surgery, the next step is to apply for further training — a plastic surgery residency.

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“Plastics one of the most competitive specialties to get into,” Steinbacher said.

Each year, fourth-year medical students decide which medical specialty they would like to continue to learn. Once they have determined where they will go, they apply to a residency program. Plastic surgery, as a specialty, is one of the most difficult surgical programs to gain admittance to, according to an annual report published by the National Resident Matching Program.

There are two typical training tracks to becoming a plastic surgeon: independent and integrated. An integrated residency is typically six years, with the focus of the first couple of years on general surgery, then the final years on the totality of plastic surgery, according to Steinbacher.

The independent track involves preliminary training in a surgical specialty like general surgery or orthopedic surgery (typically five years), and is then followed by a three-year fellowship in plastic surgery, Steinbacher said.

The longevity and specificity of the training is significant in terms of being able to practice as a competent plastic surgeon, said Michael Alperovich, assistant professor of plastic surgery at Yale New Haven Hospital and plastic surgery attending physician. He stated that because most plastic surgery cases are not so “cookie-cutter,” there is much critical thinking and extensive practice necessary to be skilled in the field.

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“When people think of a plastic surgery, they should know that plastic surgery is about restoring a patient’s form and function,” Alperovich said. To him, the work concerns the restoration of something that was damaged through congenital birth, trauma, surgery, injury or a myriad of other circumstances.

Persing listed cases that plastic surgeons can and do treat. “Everything from trauma treatment, any skin laceration, any scar, facial broken bones, skin fractures, burn injuries — there are many conditions we treat within plastic surgery,” he said.

Alperovich and Tsai both admitted that it was sometimes difficult to describe what plastic surgeons do because of the many parts of the human body on which they operate.

“It’s a joke we have — that plastic surgery covers the skin, and all of its contents,” Tsai said.

Alperovich explained further: “Cardiac surgeons operate on the heart. No one else operates on the heart. Neurosurgeons operate on the brain. No one else touches the brain. Orthopedic surgeons do femur fractures. No one else does femur fractures. But we operate head to toe, cradle to grave. We reconstruct all over the body. So we have no privileged part that we work in. What sets plastic surgeons apart is a way of thinking.”

This problem solving leads to a larger trend within the field: innovation.

Plastic surgery is a field of firsts — last year, the first full face transplant was led by Eduardo Rodriguez, a plastic surgeon. The first kidney transplant — which won a Nobel prize in 1990 — was performed by Joseph Murray, a plastic surgeon. The pioneers in hand surgery were plastic surgeons, Alperovich said.

And last year, Deepak Narayan, chief of plastic surgery at the Veteran Affairs Connecticut Health System’s West Haven campus, collaborated with Yale virologists to treat a patient suffering from a disastrous chest infection with bacteriophages — a treatment that has never been done before. The patient recovered, and Narayan continued with his other research projects, mostly focused on the genetics of pediatric growth disorders and melanomas.

“That’s the beauty of plastic surgery,” Narayan said. “You can do whatever the hell you want.”

In additional to this bench-to-bedside research, plastic surgeons at Yale innovate in other spaces.

Steinbacher, a physician who is deeply interested in the interface between medicine and technology, is a mentor for the undergraduate biomedical engineering course, Medical Software Design. His team is trying to create an algorithm that predicts how moving bone affects the soft tissue underneath.

Global innovation is a parallel focus, as the surgeons attempt to make plastic surgery accessible to all. Many surgeons are working to bring surgery to developing countries, as it is a relatively quick and cost-effective method to drastically improve someone’s life, Persing said.

“Someone who has cut tendons in their hand from an injury can’t open and close their hand,” he said. “It doesn’t sound like a big deal, but in reality, if you’re a laborer, you use that hand in order get your family food to eat, so you need to have that functioning properly.” He maintained that while global public health is very aware of issues like the lack of immunization and lack of access to clean water, surgical disease is not given the same weight.

Early this year, a group of plastic surgeons from Yale traveled to Uganda to perform free reconstructive surgery for patients in need. The trip was an effort through the organization, Changing Children’s Lives, Inc., a nonprofit founded by Mark Weinstein, a Yale-affiliated, board-certified plastic surgeon.

“We mostly operate on cleft lip palate cases — the incidence of which is diminished in the United States, but is very high in places like Africa and Southeast Asia,” Weinstein said.

The team of surgeons, nurses, and anesthesiologists operated on 83 cases in five days in Uganda.

“It’s a good thing to be able to give to various parts of the world that otherwise might not get the care,” Weinstein said. He remarked that “making the world beautiful is not the majority of what plastic surgeons do,” even if that is the distorted perception that much of the public has about the specialty.

While all of the surgeons interviewed maintained that the brunt of the care they deliver is rooted in reconstructive work, they all pushed back at the possible stigma that cosmetic surgery receives.

“If a 55-year-old woman has a facelift, maybe that helps her feel good about herself. What’s wrong with that?” Weinstein asked. Saberski agreed, saying that he does not think twice about someone receiving cosmetic procedures of any kind.

“If you saw a 15-year-old walking around with braces would you say anything about it?” he asked, highlighting the similarity between cosmetic dentistry and cosmetic surgery.

Persing observed, “I remember when I was growing up, people used to be concerned about whether someone changed the color of their hair. It was a big deal. Does she or doesn’t she dye it? As you know now, no one cares.” He said that while undergoing plastic surgery is not as trivial as dyeing one’s hair, it has become more accepted in recent years. But acceptance by some does not necessarily shield the field from misunderstanding.

“When I go to Uganda, and there’s a 19-year-old girl with a four-month-old baby who has a cleft lip, and I operate on [the child] to give him quality of life, that’s plastic surgery. Maybe Bernie Sanders doesn’t understand that,” Weinstein said, referring to the comment made at last month’s debate. But Sanders is not the only one to incorrectly characterize the field of plastic surgery. The misrepresentation stems from a misunderstanding that seems trivial at first — who cares if nonphysicians don’t intimately understand the material that physicians take years to learn? Looking deeper, however, it seems that this mischaracterization could lead to more than a bruised reputation, it could potentially lead to horrendous patient outcomes.

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Indeed, most of the public doesn’t understand plastic surgery, according to Alperovich.

He said that the majority of plastic surgeons, particularly at university centers, are reconstructing surgeons. But, in the public understanding of plastic surgery exists the heady issue of media preoccupation with surgical beautification, which is further muddied by the fact that many of those who claim to be plastic surgeons are not actually trained in plastic surgery.

Alperovich continued. “There’s a media obsession with plastic surgery, we know that. “Dr. 90210,” “Botched,” they show this one-sided, caricature-like appearance of what a plastic surgeon is. And another thing — a lot of the people you read about doing liposuction in their garage, people injecting liquid silicone in their butts — these are not plastic surgeons. These are not people who are board certified by the American Board of Plastic Surgery. These are people who are pretending to be plastic surgeons.”

Alperovich said that the requirements to be a member of the ABPS are very high. The board has a strict code of ethics. “So if you make absurd claims like ‘I have scarless surgery’ or ‘I am the number one plastic surgeon in the world’ you’ll actually get cited and potentially banned from ABPS,” Alperovich said. Both Alperovich and Weinstein commented on the strong regulatory body within the specialty to maintain a standard of care, a set of ethics and an accurate representation of each surgeon’s surgical outcomes.

Alperovich speculated that the miscommunication stems from lacking advocacy.

“Ultimately we only train about 150–200 plastic surgeons nationwide every year, so it’s a small number of us. And there are many more people who claim to be plastic surgeons. There are also these fake boards — the American Board of Cosmetic Surgery, the American Board of Vaginal Rejuvenation, for example — none of these are real.” said Alperovich. They are not cited by the American College of Graduate Medical Education, and they are not the committee that regulates boards of medicine, Alperovich said. But the American public doesn’t know that the American Board of Cosmetic surgery is fake, whereas the ABPS is an extremely regulated and difficult board to gain membership to.

Rod Rohrich, founding chair of the Department of Plastic Surgery at University of Texas Southwestern Medical Center and editor of the specialty’s flagship publication, Plastic and Reconstructive Surgery, also weighed in on the issue of plastic surgery misrepresentation, especially as surgeons do not have to be appropriately credentialed to market themselves as plastic surgeons.

“Everybody is famous on their own website. But there are only about 7000 board-certified plastic surgeons in the United States. And at the end of the day, if a patient doesn’t do their research, it becomes an issue of patient safety.” said Rohrich. He added that a large part of his practice is fixing the outcomes of procedures gone wrong.

Tmedia misrepresentation of plastic surgery could lead to disastrous patient outcomes that can be life-threatening and difficult to correct.

Steinbacher recounted his experience treating a patient who appeared on the television show “Botched.”

“The patient that I saw had something done. She wasn’t pleased with the result, and then because of the media attention and the popularity of “Botched,” she went on that show to get it fixed,” Steinbacher said. “When they were done [attempting to correct the mistake], she didn’t get a better result. After that, the patient came to me, and we tried to fix it.”

“It’s not an informed or intelligent tactic to disparage what was done before, by another surgeon,” he added. “But, it’s always better to do it as well as you can initially, instead of having it redone a second or a third time.”

Gowda spoke to a lack of understanding from fellow medical professionals of what he does as a plastic surgeon, citing the pervasiveness of media glamorization as a potential source.

“A problem with plastic surgery in the media is that some people almost promote the misconception of plastic surgery. They actively promote something that’s not real. For example, “The Bachelor” is not a real portrayal of actual dating — just like that, these Hollywood plastic surgeons are not an actual portrayal of plastic surgeons.” said Gowda.

But despite the shadows, all the surgeons said that they continue to approach the field with a sense of wonder and thrill at its possibilities.

“I love plastic surgery because it allows us to operate anywhere in the body. We don’t have a specific organ system, we’re really the organ of innovation,” Rohrich said.

And Tsai, when asked about his belief in the field, quoted Gaspare Tagliacozzi, a man often cited as a father of modern plastic surgery, who said in 1589, “We restore, repair and make whole those parts … which nature has not given or which misfortune has taken away, not so much that they may delight the eye, but that we should buoy up the spirit and help the mind of the afflicted.”