A STARK warning was given to Professor Brian Avery, one of the UK's leading experts in skull reconstruction, by one of his young patients. "If you don't operate on me, I will kill myself," the desperate 12-year-old boy told the surgeon.

For the last 18 years, Prof Avery and his neurosurgeon colleague Sidney Marks have been operating on babies and small children born with severe deformities. But because he is taking up a major post within the Royal College of Surgeons, he is no longer able to continue with the highly specialised service, dealing with around 60 cases a year.

Unfortunately, this is likely to mean that North-East families who need this kind of challenging surgery are going to have to travel much further afield, to places like Liverpool and Birmingham and even Glasgow.

Normally, the best time to operate on babies with serious malformations is shortly after birth because the bones of the skull are more malleable. But some older children slip through the net and end up having to have surgery later in life. The suicide threat came from a 12-year-old boy - and he seemed deadly serious.

"This boy had a long, very narrow head and he was being teased at school. He told me if I didn't perform the operation, he would commit suicide," says Prof Avery. "This kind of deformity can lead to very severe psychological problems during childhood and a tough time at school."

Before the two surgeons began their ambitious programme of skull reconstruction on Teesside in the late 1980s, very few babies in the area were able to have this kind of highly specialised surgery.

"It is bone carpentry, really," says Prof Avery, who makes the sophisticated techniques employed sound easy.

Some of the surgery carried out involves cutting into and taking out large sections of a child's skull. Because children's skulls are quite soft, it is possible to actually bend the bone into shape.

Until recently, the reshaped bone structure had to be held in place by metal pins and plates - which sometimes led to follow-up operations to remove unwanted metal. "A few years back I carried out a minor operation on a young boy after we put a metal plate in his skull," Prof Avery recalls with a smile. "It seemed that every time he headed a football, it hurt."

Recent technological innovations mean that plates and screws are now available in a biodegradable material which is strong enough to do the job but simply melts away after a while.

Prof Avery makes reconstructive surgery sound straightforward but there is no doubt that it can be challenging and potentially dangerous for the patient, with some operations lasting for up to ten hours.

"One in six of the children I see might get an operation," he says. "They can lose huge quantities of blood relative to their size, and they all need blood transfusions."

Prof Avery is sad that his new job as Dean of the Faculty of Dental Surgery means he will no longer be able to offer the service to the population of the North-East, but he hopes he will be able to have a positive impact on the training of tomorrow's hospital dentists and maxillofacial surgeons.

He does worry, though, that North-East families with small children will now be faced with long journeys just for an outpatient appointment.

Prof Avery is also concerned about the impact of the European working time directive on the Health Service, predicting that it will make the existing shortage of specialist surgeons even worse and accelerate the concentration of specialist surgery to fewer and fewer sites.

"Shorter working hours will mean surgeons will end up working in a very narrow range of surgical procedures," says Prof Avery, who is keen to pursue the issue of working hours in his new national role, which oversees the training and career development of tomorrow's hospital dentists.

While his future focus is switching to the national arena, Prof Avery takes particular pleasure that all of his young patients have pulled through quite traumatic surgery.

"After 18 years we have just done our last major operation on a child and I am happy to say that we have never had any major complications or deaths," says Prof Avery, who will continue to see a limited number of patients on two days a week.