I was first exposed to the field of pediatric plastic surgery as a medical student at the inaugural Harvard Plastic Surgery Symposium, and it was here that my career path was solidified. While one speaker began, I stayed behind a moment to finish a much-needed cup of coffee. Just then, a man approached and asked to join me. It was not until we shook hands and introduced ourselves that I realized before me stood Dr. John Mulliken, Director of the Craniofacial Centre at Boston Children's Hospital, and one of the leaders in pediatric plastic surgery. As a young medical student considering a career similar to his own, I asked his reasoning for choosing this field. He told me that a pediatric plastic surgeon not only makes a tremendous impact on his or her patients' lives, but it also provides an ongoing technical and intellectual challenge. He went on to say that one must be liberally educated and well-rounded, able to function as "...an amateur pediatrician, obstetrician, radiologist, developmental biologist, genetic counselor, and social worker" (J. Mulliken, personal communication, 2008). My subsequent clinical experiences in pediatric plastic surgery have only confirmed what Dr. Mulliken told me so many years ago. There were, however, many aspects I was not prepared for, as I would come to learn.

In preparation for my first pediatric plastic surgery rotation as a resident, I read zealously about embryology and complex craniofacial anomalies. While I could explain the embryologic basis for facial clefting and draw a Millard unilateral cleft lip repair, I was speechless when facing a new or expecting mother asking me, "What caused this?" or "Is my baby going to be OK?" Those were the times I reached for my genetic counselor and social worker skills sets, only to come up empty. I quickly realized a central paradigm of pediatric medicine: there are always two patients, the child and the parent/guardian(s). The professional, and often personal, experience of nurses in the clinic setting goes a long way to help patients and their families understand what to expect throughout their treatment course. It is their unique perspective that allows patients and their families to endure sometimes-difficult treatments of pediatric disorders. While doctors will often say things like, "Soft foods only," families do not always understand the practicalities. A nurse with the experience to know what it feels like to be a parent preparing foods for their child, searching for concrete guidelines, however, will say, "Nothing that needs to be chewed." Although it may seem subtle, it saves the parents tremendous anxiety; it spares both the nurses and the physician from repeated phone calls; and it ultimately translates to better care for our patients.

Moreover, many of the problems treated by pediatric plastic surgeons are complex congenital anomalies that often require multidisciplinary treatment teams. For example, a typical "cleft team" consists of a plastic surgeon, an otolaryngologist (ENT), a dentist, orthodontist, speech-language pathologist, audiologist, geneticist, pediatrician, psychologist or social worker, and a nurse coordinator. With so many specialties involved in each patient's care, it is the plastic surgery nurse who most often assumes the role of care coordinator, working with patients, families, and other providers to ensure that treatment is progressing appropriately. This importance of an experienced nurse in this role cannot be overemphasized. The intimate knowledge of each patient and family that nurses can share with the team very often helps guide treatment choices, including which procedure among several would be best for a particular patient. A very involved treatment course may be suboptimal for children with particular family circumstances that would preclude compliance. More often than not, it is the relationship between the nurses and families that provides the insight needed to design individualized treatment plans.

Over time, nurses often become part of an extended family, growing very close with patients and families. They become a source of support and practical knowledge often overlooked by specialized teams, who deal with these problems everyday. Most parents experience some degree of anxiety when dealing with a cleft child, which is not surprising. The treatment of cleft lip and/or palate is difficult and lengthy, often requiring five to seven operations spanning 18 or more years (Salyer, Genecov, & Genecov, 2004). The relationships patients and families build with the members of their health care team are essential to good outcomes. The assurances and information that nurses are able to provide families unfamiliar with these problems throughout the treatment process are invaluable to all parties.

As a trainee, one of the most difficult aspects of pediatric plastic surgery to understand is that, unlike most reconstructive surgery, the patient is changing-often dramatically-over time. Personally, I struggled with understanding why our adolescent cleft patients returned to clinic seeking secondary rhinoplasty when we took so much time and care to address the nasal deformity in a primary cleft lip repair, or why an oronasal fistula would develop in a meticulously repaired cleft palate. One of my early preceptors explained to me that one key to pediatric plastic surgery was thinking "...fourth-dimensionally," that is, considering each patient individually and preempting the effects of time when devising a treatment plan (J. Corcoran, personal communication, 2012).

To me, this is what was meant when Dr. Mulliken described the constant intellectual challenge of this field. There is no "right" way to treat all of our patients-each patient, even with similar pathology to another, is very unique, and treatment plans must adapt to the individual.

The fourth dimension is critically important in providing the appropriate level of care for our pediatric patients with complex problems managed by multidisciplinary teams. Nowhere is this more important than in pediatric plastic surgery, where the nurses are critical to providing this level of care and build longitudinal relationships with patients that transcend medicine. It is here, as much as any place in outpatient medicine, that our experienced and valued nurses are the glue that holds everything together and makes it possible to deliver the highest-quality care to our patients.

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