Portal de Periódicos da CAPES

Algorithm agony

2013; Elsevier BV; Volume: 66; Issue: 2 Linguagem: Inglês

10.1016/j.bjps.2012.11.001

1878-0539

M. Felix Freshwater,

Summer has ended and the academic year has started. Now new residents have begun to present treatment plans at our weekly clinical conferences. Some residents have spent the summer learning their plastic catechisms. The “reconstructive ladder” is one of the most common plastic catechisms. When they have been asked for solutions to plastic problems they have said with great confidence and even greater enthusiasm, “Well, let me apply the reconstructive ladder.” Those words have the same unsalutary effect on me as hearing fingernails scratching on a whiteboard. The earliest description of the term “reconstructive ladder” that I have found was in Mathes and Nahai's 1982 monograph.1Mathes S.J. Nahai F. Clinical applications for muscle and musculocutaneous flaps. C.V. Mosby, St. Louis, MO1982Google Scholar Unfortunately, Mathes and Nahai's thought model has morphed into a mindless, rhythmic regurgitation that could be confused with a plastic rap free verse in iambic pentameter:Negative pressure, split thickness skin graftRegional skin flap, tissue expanderFree tissue transfer, cadaver transplant Too often, climbing the reconstructive ladder yields results identical to those of Wile E. Coyote, the famous Looney Tunes character in “The Road Runner” animated cartoons. While mindlessly pursuing the roadrunner, Wile E. routinely climbs ladders long after he has run out of rungs or he speeds off cliffs spinning his legs while treading air as if it were water. Not until it is too late does Wile E. look down and realize that rather than catching the roadrunner he has fallen victim to the law of gravity. As Wile E. heads earthward, he always waves adieu to the audience. Unbeknownst to him, Wile E. is trapped in an algorithm. He obeys a specific set of rules that define a sequence of operations. aWikipedia suggests: “While there is no generally accepted formal definition of ‘algorithm’, an informal definition could be ‘a set of rules that precisely defines a sequence of operations’”. http://en.wikipedia.org/wiki/Algorithm - Informal_definition accessed 09.30.2012. Before the roadrunner arrives, Wile E. purchases a complicated contraption from the Acme Corporation and then lies in wait for his prey. Invariably the contraption fails to trap the roadrunner, resulting in Wile E. pursuing the bird with reckless abandon. Wile E.’s algorithm produces reliable results — disaster for him and laughter for us. The reconstructive ladder is the simplest treatment algorithm. Algorithms pose a plethora of problems:•Algorithms give the novice a false sense of security — one blithely follows the decision tree and arrives at a solution. While the novice will reach a solution, too often, as Wile E. Coyote repeatedly discovers, it is the wrong solution.•Algorithms demand static conditions, once one when enters the algorithm's maze, the only exit is at the end. If clinical conditions change while in the maze, then one cannot adapt, one must abort and start from the beginning.•Algorithms are a rote way of fulfilling tasks. They stifle independent thought and creativity. There is a place for algorithms. Properly designed algorithms are useful for physician extenders such as physician's assistants or nurse practitioners. Algorithms may be helpful to beginners because they are like training wheels on a bicycle. Like training wheels, algorithms may be used to gain confidence, but then they should be rapidly discarded. Otherwise, like training wheels, algorithms prevent the cyclist from achieving his full potential. Bill Little introduced Millard to the term “o-filling” when he was the latter's trainee. It is the process by which a person wiles away his time doodling by filling in the hole whenever the letter “o” appears on a page. It is a mindless type of activity and requires little skill and even less judgment. Millard described the term “o-filling” when he wrote:“Transfer of tissue without aesthetics is only filling holes or o-filling.”2Millard Jr., D.R. Principlization of plastic surgery. Little, Brown & Co, Boston, MA1986Google Scholar Though the act of “o-filling” enjoys immense popularity, the pejorative term never gained acceptance beyond Millard's circle. Far easier to understand than “o-filling” is the commonplace word that fulfills the same description — “meatpacking”, the work of a butcher, not the artistry of a plastic surgeon. Sadly, too many algorithms focus on filling holes or packing meat and ignore two fundamental precepts of plastic surgery — the restoration of form and the restoration of function. The precepts are interrelated. As Gillies noted in 1920:“In planning the restoration, function is the first consideration, and it is indeed fortunate that the best cosmetic results are, as a rule, only to be obtained when function has been restored”.3Freshwater M.F. A critical comparison of Davis' principles of plastic surgery with Gillies' plastic surgery of the face.J Plast Reconstr Aesthet Surg. 2011; 64 ([Epub 2010 Mar 30]): 17-26Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar One irony of Mathes and Nahai's book is that they were fully cognizant of the need for esthetic judgment. Unfortunately, too many of their readers started climbing their reconstructive ladder without reading the book's preface. Had they done so, the first words that they would have encountered were:“What we need to see now are a few harpsichords rather than so many logs – recognizable, new artistic, and fully acceptable noses, cheeks, chins, necks, legs and arms rather than indistinguishable globs and blobs of transported tissue in those areas.”4McDowell F. Logs vs. harpsichords, blobby flaps vs. finished results.Plast Reconstr Surg. 1979; 64: 249Crossref PubMed Scopus (15) Google Scholar These words, cited by Mathes and Nahai, were from an editorial written during the first decade after the dawn of both microvascular and musculocutaneous flaps by Frank McDowell, the editor of Plastic and Reconstructive Surgery. He was describing how surgeons had sacrificed esthetic outcomes for the expediency of tissue transfers. Algorithms are not substitutes for artistry. Remembering the awful effect of hearing “reconstructive ladder”, suffering through “plastic rap” and invoking McDowell's message about “logs vs. harpsichords” gave me an auditory admonition for those obsessed with algorithms, “You can't play Bach on bark.” None. None.