Facial plastics after ENT

[Airborne]

All:

As I am planning to start the application process for ENT in a few months, I have a few questions about facial plastic surgery and ENT.

I realize that after ENT, one can enter a facial plastics fellowship (1 year) which does not lead to board certification. Does this training allow one to do the complex reconstructions? Or are you limited to blepharoplasty, otoplasty, face-lifts and the like? I am quite keen on getting into the major reconstructions following H&N cancer resections.

Alternatively, there is the 2 year Plastic Surgery fellowships. In these, one learns all aspects of plastic surgery (hand, breast, etc) and does not focus per say on the face - but does achieve board certification in the end.

I guess my question is can an ENT surgeon enter a general plastics fellowship and given the choice, which would lead to a better facial plastics surgeon at the end of training.

I have read previous threads in this area, but they really don't seem to address this issue.

Maybe it's six of one, half dozen of the other, but some insight into this is very welcome.

Airborne

---

Members don't see this ad.

 

[Lab Rat North]

Depends on who you are trying to impress. Patients don't know a real plastic surgeon from an ENT facial surgeon, it's all the same to them, they only care about your office and reputation, not your extent of training. If you are angling for non-cosmetic, academic based reconstruction, then a real plastic fellowship carries more weight. ENT trained peaople may tell you different, but the real reconstructive surgeons are plastics people, and a lot of them still think you should suffer through 5 of general surgery first....

Lab Rat North

 

[droliver]

Originally posted by Lab Rat North
Patients don't know a real plastic surgeon from an ENT facial surgeon

This is unfortunately true & somewhat deliberate in desighn by ENT's that wanted to do lucrative cosmetic surgery without doing real plastic surgery training, while coming up with a new "facial plastic surgeon" title. More & more though, many consumers are getting better educated & learning to make some of the distinctions b/w what a board-certified Plastic Surgeon is & what everyone else is with the alphabet soup of other board-certificates & certificates.

 

[Airborne]

Would you have similar reservations with the Orthopaedist who has completed a hand fellowship (not plastics) and does complex hand reconstructions?

 

[droliver]

Of course not, a fellowship trained orthopedic hand surgeon is pretty qualified to do pretty much any hand case they feel comfortable with (although many would not feel comfortable with some of the soft-tissue or vascular work required & defer those).

This isn't necessarily a reflection on the quality of the work done by ENT's, oral surgeons, dermatologists etc... although its hard to argue against getting the best training available. It has to do with the marketing that has developed around cosmetic surgery, and the desire to blur distinctions b/w the specialties (and their qualifications) by non-plastic surgeons

 

[Lab Rat North]

There are so many legit crossover areas, like ortho spine / neurosurg spine, ortho hand / plastics hand, that are not money/cosmetic based. Look how many people want a peace of the aesthetic pie, Plastic Surgeons, ENTs, OMFS, even Derm now....

 

[Airborne]

I completely agree that many specialties are flocking to aesthetics, most likely due to the fee for service atributes of this area. However, it would seem that many areas would be complementary (as indicated by LRN) - I was going with that idea when I suggested the ENT/Facial plastics route... It makes sense that during you residency you are trained in deep resection of tumor (and all the associated anatomy, techniques, etc.) and these would potentially lead to a better transition to facial reconstructive plastics - and since this is the isolated are of focus, could be reasonably accomplished with an ENT fellowship. As far as aethetics training as an ENT, as far as I can tell, most residents do wish for more of this type of training, although several programs provide quite an large amount of time in this area ( > 6 months).

Clearly, as an MSIII, I'll have to wait until I'm well into my ENT residency (with any luck!) before such decisions are made. No doubt, the more interesting surgeries are the H&N cancer resections with the complex reconstructions (IMHO). In the end, either way is a difference of only a year.

 

[Lab Rat North]

speaking of ENT, their is a sweet program out of Kaiser Oakland, research time, home call, smallish services, good staff, etc.

 

[neutropeniaboy]

Originally posted by droliver
This is unfortunately true & somewhat deliberate in desighn by ENT's that wanted to do lucrative cosmetic surgery without doing real plastic surgery training, while coming up with a new "facial plastic surgeon" title. More & more though, many consumers are getting better educated & learning to make some of the distinctions b/w what a board-certified Plastic Surgeon is & what everyone else is with the alphabet soup of other board-certificates & certificates.

I don't think it's deliberate in design at all, and I think your comment comes from some resentment of the fact that there's more and more overlapping of fields now.

Otolaryngologists do far more manipulation of the head and neck than general surgeons do during their years of residency. They perform all the routine "plastic" incisions during routine head and neck procedures, so their training involves, by definition, cosmesis.

By the end of their fellowships, otolaryngologists have more experience than fellowship trained (general) plastic surgeons do with respect to facial surgery. With the extra year or two of facial plastics, an otolaryngologist is by no means "cashing in" on a market that should a priori be dominated by general plastic surgeons. For that matter, an otolaryngologist having completed his or her years of residency is finely qualified to do head and neck cosmetics.

Cosmesis can be an integral part of every otolaryngologist's practice.

I'll say two more thiings.

First, the idea of an otolaryngologist doing breast augmentation, liposuction, etc. perverts the field of otolaryngology.

Second, the fact that more plastic surgeons do reconstruction is based upon the fact that many of the flaps used to reconstruct come from other regions of the body, regions the otolaryngologist isn't specifically trained to manipulate. Furthermore, every substantial free flap involves microvascular reanastomosis. This is additional training.

 

[droliver]

Originally posted by neutropeniaboy
I don't think it's deliberate in design at all, and I think your comment comes from some resentment of the fact that there's more and more overlapping of fields now.

Otolaryngologists do far more manipulation of the head and neck than general surgeons do during their years of residency. They perform all the routine "plastic" incisions during routine head and neck procedures, so their training involves, by definition, cosmesis.

By the end of their fellowships, otolaryngologists have more experience than fellowship trained (general) plastic surgeons do with respect to facial surgery. With the extra year or two of facial plastics, an otolaryngologist is by no means "cashing in" on a market that should a priori be dominated by general plastic surgeons. For that matter, an otolaryngologist having completed his or her years of residency is finely qualified to do head and neck cosmetics.

No one argues the qualifications for ENT's who wish to branch into cosmetic surgery of the face. It makes perfect sense financially with the dramatic reimbursement declines from the 3rd party payer system.

However, I strongly disagree with you and believe (as do most Plastic Surgeons, including those with ENT backgrounds) that the term Facial Plastic Surgeon was essentially a marketing manuever
to capitalize on the field dominated in pop culture traditionally by Plastic Surgeons. The term "general" plastic surgeon has also become part of the language used in advertising & patient interaction by these non-PRS trained ENT's to imply that they are somehow the subspecialist compared to the "general" plastic surgeon. A whole crop of boards has come up around cosmetic surgery(none recognized by the American board of medical specialties @ this point)to let people declare they are "board-certified" as Plastic or Cosmetic Surgeons, when in point of fact they are not.

They can call themselves anything they want (aesthetic, cosmetic, Head/neck reconstructive,etc.... surgeons), but the Plastic Surgeon tag was kind of appropriated for one reason only.....$$$$

 

[Lab Rat North]

Totally true. I'm definetly not rying to exonerate those GS - PRS trained people who do aesthetics, but EVERY SINGLE ENT RESIDENT I have met throughout med school, residency, and fellowship was doing ENT to fastrack to facial aesthetics. And hey, I don't blame them. Another difference between plastics fellowship and supraclavicular training is tissue handling; ENT i general may be taught to be kinder to tissue than general surgeons, but this concept is a focus during the PRS training...

 

[droliver]

Originally posted by Lab Rat North
. Another difference between plastics fellowship and supraclavicular training is tissue handling; ENT i general may be taught to be kinder to tissue than general surgeons, but this concept is a focus during the PRS training...

Tissue handling is relative, it all depends on what tissue you're working with (ie. bone, muscle, vessels, nerves, skin, bowel,fascia), location of your wound, and the pathology of your patients. Plastic surgeons tend to be more cognative about cutaneous soft tissues b/c scar formation is such a focus of the field and often a walking advertisement for your work, especially on the face. On the other hand if you're getting an APR (for instance) it seems kind of silly to debate the merits of layered closure vs skin stapling of an abdominal incision. I have been teased for some time now though by my attendings & fellow residents b/c I obscess over skin closure, I've always thought is was good practice for my technique & many of my friends in Plastic Surgery were like that as well. I don't think anyone in particular "handles tissues" the best.

 

[jargon124]

Hi all - Just wondering - Where do oculoplastics-trained opthalmologists fall into the mix. So they compete with plastics as well as ENT facial plastics? Seems like a crowded place to be...

 

[droliver]

The oculoplastics guys I know tend to have pretty limited (in scope) practices & do lots of blephs, lid reconstruction, some orbit fractures, & some general opthomology. I would guess some in other places have branched into some of the other cutaneous aesthetic work (lasers, BOTOX, peels). I'm not aware of it, but I would not be surprised if some were also doing simple facelifts & hair transplant procedures.

 

[Crusher]

It really does seem like there is a lot of interest in facial plastics following ENT residency. Is there really enough demand in the metro areas for this many facial plastic surgeons or are they doing general ENT 4 days/wk and plastics one day?? Any ideas?

 

[Eyeluvu]

Regarding oculoplastics, I may be biased, but I feel they are much more competent in dealing with eyelid/orbital surgery than the general plastic surgery trained surgeon. The amount of exposure they get concentrated to that area is much much more than what 2 years of PRS fellowship can provide. Out of the whole 2 year fellowship, how much is devoted to lids/orbits, etc.

As an example, all of the plastic surgeons I know repair ptosis by doing blepharoplasties. Blephs should only be done when the problem is due to redundant skin, which, in many cases, it is not. In these cases, the typical blepharoplasties are then doomed to fail. The proper procedure would be ptosis repair, which your friendly neighborhood oculoplastics guy should be able to do. This would involve accurately diagnosing the etiology of the ptosis and fixing it accordingly. I hate to say it, but I'm sure most plastics guys are not very comfortable dealing the levators, Mullers muscle, etc. Heck, I'd be surprised if they knew what Herring's law of equal innervation was. Instead, they will want to do your simple blepharoplasty.

Don't get me wrong, I have nothing but respect for plastic surgeons. However, there is no way that in 2 or even 3 years of doing TRAM flaps, breast augmentations and reductions, etc, they would be as well trained as someone dedicating 2 full years after a full ophtho residency in dealing with periorbital stuff. However, as was said in previous posts, the general public or even most docs aren't aware of this. So they will go to the person who does the best marketing.

 

[droliver]

Actually, traditional blephs are one of the simpler cosmetic operations done & don't require too much technical skill (mostly judgement- how much skin to excise). There are MANY advanced lid techniques being described & taught with infinite variations of them described monthly in the journals, and very successful treatments for ptosis are included. Most plastic surgeons I know (including family members in the field) are pretty intimately familiar with with the anatomy of the lid, orbit, and facial soft-tissues so I don't buy into the "Oculoplastics are the real plastic surgeons of the eyelid" (see earlier comments about ENT/facial plastic surgery and head/neck aesthetics).

I will say that I know a Oculoplastic surgeon who does the most exquisite work. The PRS fellows here have him staff some blephs on some of our VAMC patients (yes that's as funny as it sounds )

 

[DuneHog]

Originally posted by droliver
They can call themselves anything they want (aesthetic, cosmetic, Head/neck reconstructive,etc.... surgeons), but the Plastic Surgeon tag was kind of appropriated for one reason only.....$$$$

I don't think this is entirely true. If you want to do cosmetic surgery, you should use the term that is most widely recognized by the public: plastic surgery. Why should otolaryngologists or any other non GS+PRS specialist trained to do cosmetics and reconstruction have to use a more complicated term that is not as well recognized by the public? Put another way, if I want to sell tires, it makes the most sense to advertise them as tires and not circumfrential rubber wheel cushions. ENT/Facial Plastics do the same facial cosmetic procedures that traditional plastic surgeons do, so what's wrong using the same terminology? Assuming they've done an adequate number of cases, the final result probably has more to do with the surgeon than the training route they went to to arrive at cosmetics anyway.


I'm curious how traditional plastic surgery fellowships view otolaryngology and ortho applicants? I would guess that many of the GS+PRS trained folks still prefer to accept GS applicants into their programs. Are ENT or Ortho applicants at a disadvantage when applying for these spots?


Also, I have wondered how the "cosmesis pie" is currently divided among the various specialists? Do general plastic surgeons out in practice do a lot of facial cosmetics, or do you think many of them now end up doing other cosmetic procedures (breast, lipo, abdominoplasty) with less competition?

 

[droliver]

Originally posted by DuneHog
If you want to do cosmetic surgery, you should use the term that is most widely recognized by the public: plastic surgery. Why should otolaryngologists or any other non GS+PRS specialist trained to do cosmetics and reconstruction have to use a more complicated term that is not as well recognized by the public?

Again this has to do with non-plastic surgeons trying to blur the difference b/w specialties.

I'm curious how traditional plastic surgery fellowships view otolaryngology and ortho applicants? I would guess that many of the GS+PRS trained folks still prefer to accept GS applicants into their programs. Are ENT or Ortho applicants at a disadvantage when applying for these spots?

I think all things being equal, its probably the easiest transition for General Surgeons to Plastic Surgery then the other eligible specialties just because they have the broadest background head-to-toe when they start. ENT's certainly begin way ahead on familiarity on some of the anatomy of the Head & neck & facial fractures, but often have a diffucult time I'm told with a lot of the reconstructive procedures and the vascular work sometimes required for free flaps. Orthopedics have extensive hand training and fracture fixation techniques, but lack experience with most everything else. It's probably hardest to learn the vascular & microvascular techniques, burn care, and complex wound management during training for these other fields with little previous exposure for most of them (a few ENT programs dabble with microsurgery, but I can't imagine you'd get enough practice to get real comfortable)

Fully trained Gen. Surgery applicants have by far the highest match rates for the traditional fellowship spots that are left. A lot of PD's prefer that because they say it makes their job easier during training (ie. they feel you need less supervision with a lot of the procedures). My compatriot here this July will be an ENT & this is not uncommon here. They have long felt that you get the best synergy b/w fellows by having people with diverse backgrounds, which I think is a great idea.

Do general plastic surgeons out in practice do a lot of facial cosmetics, or do you think many of them now end up doing other cosmetic procedures (breast, lipo, abdominoplasty) with less competition? [/B]

Plastic Surgeons do a lot of facial cosmetics. Some only do that as its some of the most lucrative work (much better per case then then the other stuff quite often). A lot would choose to do that exclusively if they could for that reason, but your practice & reputation have got to be huge to be able to exclude everything else. BTW, there goes that term "general plastic surgeon" creeping into your vocabulary..... There are only Plastic Surgeons & a large group of other providers who do aesthetic surgery & the like.

 

[mary]

I agree that the lines between specialties are being blurred, and while this may give PRS's sleepless nights, I think it makes sense that people who are trained to operate on the head and neck solely for five years plus an additional year of focus on facial plastics call themselves facial plastic surgeons. I would prefer to have someone trained in ENT/facial plastics do the reconstruction for me or my family member, rather than someone who has to split their time between facial plastics, breast surgery, liposuction, etc. Just my humble opinion.
mary

 

[droliver]

Mary,

in the same way that me being trained & able to moonlight in an ER, remove a uterus, or do a nephrectomy does not (and will never) make me an Emergency Medicine Specialist, a Gynecologist, or a Urologist - an ENT doing cosmetic surgery does not make him a plastic surgeon. It is a distinct specialty with explicit qualifications & not just some subset of skills that are acquired.

In addition, if for whatever reason you do need an advanced reconstructive procedure done on your face it is very likely in most places it would be a fully trained Plastic Surgeon who's skills would be required. Most ENT & facial-plastic ENT surgeons do not do & are not trained to do those procedures that extend beyond local flaps for reconstruction. In addition, many facial plastic surgeons do 0% reconstructive surgery (as do many Plastic surgeons for that matter) & the focus of those facial plastic fellowships (witness their popularity) is heavily weighted towards aesthetic procedures. The recent popularity of this fellowship for ENT residents has NOTHING to do with experience with reconstruction & is another example of market forces driving interest in a specialty

 

[mary]

Thanks for your reply. I am just curious and would like to learn more about why PRS are more qualified. Are you referring specifically to those who go to combine plastics programs, therefore have three years of plastics, or do you think that those who do five years general surgery then a one year plastics fellowship are equally qualified to do the reconstructive surgery? If the latter is true, then I don't see why an ENT who has done a one year fellowship is not up to par (especially if that fellowship had training in reconstructive surgery)? That may be a philosophical question, since I believe your claims about the field being market driven and reconstructive surgery may not be a focus of the ENT fellowships. I am not trying to be sarcastic or anything, I am genuinely interested in your opinions. I have been thinking about ENT as a career, but debating doing plastics combined or general w/ plastics fellowship. I just enjoy detail oriented surgeries, and reconstructive surgery seems very rewarding. I know most of the reconstruction for both congenital anomalies and trauma done here is done by OMFS people, which is rather interesting. Thanks,
Mary

 

[droliver]

Mary,

Traditional PRS fellowships are all 2 or even 3 years @ a number of places (Emory,Duke,...) , not one year. The recent popularity of the Facial Plastics fellowships for ENT is related to the interest in cosmetic surgery as the other traditional ENT procedures have seen reimbursements slashed & most Facial Plastics fellowships traditionally have been cosmetic oriented with little reconstructive emphasis. Exposure to the most complex craniofacial reconstruction problems during those fellowships would be the extreme exception to the rule for most of these. Quite the opposite is true for Plastic Surgery Training which is traditionally much heavier on the reconstructive work & advanced techniques including free-tissue transfer.

In practice, it seems few Facial Plastic ENT's or Plastic Surgeons have much interest in reconstruction these days. The money's just too good for the aesthetic work in comparision to the insured procedures reimbursements and headaches involved. It's ironic that most of the names you see on the major Plastic Surgery texts & who have pioneered many of the advances in reconstruction over the last 25 years do NO reconstructive surgery anymore.

As for OMFS doing the major reconstructive work. There are a few pockets around without strong Plastic Surgery coverage that are covered by Oral Surgeons, but that is the exception rather then the rule. There just aren't that many places where they can get the training for it & (talking to my OMFS friends) there is little incentive for them financially to do it as it cuts down on their office based procedures that bring home the $$$$

 

[wheewer]

I was glad to see that someone posted about the facial plastics fellowship following an ENT residency. Could anyone offer their insight to a medical student now in 2016 possibly looking to pursue this path? Could anyone comment on the competitiveness, length in years, and number of facial plastics fellowship out there? What is payscale like for an attending who took this path? Thanks in advance for sharing your wisdom.

 

[Fah-Q]

^^^ Is this the biggest bump in SDN history?

 

[wheewer]

Thanks, I was hoping someone would appreciate that! Same questions 13 years later...

 

[Winged Scapula]

^^^ Is this the biggest bump in SDN history?

Almost.

I once saw a bump from 1999!

 

[Fah-Q]

I was glad to see that someone posted about the facial plastics fellowship following an ENT residency. Could anyone offer their insight to a medical student now in 2016 possibly looking to pursue this path? Could anyone comment on the competitiveness, length in years, and number of facial plastics fellowship out there? What is payscale like for an attending who took this path? Thanks in advance for sharing your wisdom.

I think it's very hard while still in medical school to know what kind of practice you want. I never considered plastics when I was a medical student. I wanted to be an ear surgeon and so I went into ENT. I liked head and neck surgery and free flaps during residency. I did a fellowship that was heavy on reconstruction (100+ free flaps). Now I don't do any free flaps at all. Your interests will likely evolve as time goes on so don't think you have to nail this decision right now. ENT and plastics are both very competitive and the facial plastics fellowships after ENT residency are very competitive. ENT is 5 years and most facial plastics fellowships are 1 year. I don't know for sure the number of fellowship spots available but there are far more applicants than spots every year. Salary is always difficult to say because there are so many variables. Most surgeons pursuing a cosmetics practice don't do very well at all for the first several years. But it gets better each year and the potential upside to a cosmetic practice is far better than just about any other specialty.

ENT is a great field because there is so much variety in the procedures you do and conditions you treat. If you like surgery but are still unsure what kind of surgeon you want to be (cancer, micro, minimally invasive, reconstructive, etc) then you can pick a field like ENT and find something in that field you really enjoy.

 

[inge1]

Hi! does anyone knows what is the average salary of an ENT facial plastic and reconstructive surgeon?

 

[Moose A Moose]

Regarding oculoplastics, I may be biased, but I feel they are much more competent in dealing with eyelid/orbital surgery than the general plastic surgery trained surgeon. The amount of exposure they get concentrated to that area is much much more than what 2 years of PRS fellowship can provide. Out of the whole 2 year fellowship, how much is devoted to lids/orbits, etc.

As an example, all of the plastic surgeons I know repair ptosis by doing blepharoplasties. Blephs should only be done when the problem is due to redundant skin, which, in many cases, it is not. In these cases, the typical blepharoplasties are then doomed to fail. The proper procedure would be ptosis repair, which your friendly neighborhood oculoplastics guy should be able to do. This would involve accurately diagnosing the etiology of the ptosis and fixing it accordingly. I hate to say it, but I'm sure most plastics guys are not very comfortable dealing the levators, Mullers muscle, etc. Heck, I'd be surprised if they knew what Herring's law of equal innervation was. Instead, they will want to do your simple blepharoplasty.

Don't get me wrong, I have nothing but respect for plastic surgeons. However, there is no way that in 2 or even 3 years of doing TRAM flaps, breast augmentations and reductions, etc, they would be as well trained as someone dedicating 2 full years after a full ophtho residency in dealing with periorbital stuff. However, as was said in previous posts, the general public or even most docs aren't aware of this. So they will go to the person who does the best marketing.

This is truth.

 

[plasticscf]

This is truth.

A few things:

1. Plastic surgery training is not two years anywhere in the United States. It is a minimum of three years for people who are already full trained surgeons (e.g. completed residency in general surgery, ENT, OMFS, etc.). For integrated residents, nearly all programs are 6 years with the vast majority having 1-2 years of general surgery followed by 4-5 years of plastics training. This is plenty of time to learn how to do orbital and eyelid surgery and, frankly, a multiple longer than an oculoplastics fellowship.

2. No one knows the answer to "how many of procedure X does one need to do to be competent?" The "more is better" argument is critically flawed. One only needs to do enough to perform the procedure safely, competently, with a predictable result for the patient and skill to handle complications that may arise. Once this goal is achieved, theoretically any procedure performed beyond that, in the context of a time-limited training period, is a missed opportunity to learn something else. So, how many procedures does one have to do to meet this for eyelid or orbital surgery? I have no idea. But I can tell you that, in my plastics training, which was three years, I did over 50 ptosis repairs and more orbital fracture ORIFs than the oculoplastics fellows at the same institution. I'm not sure I would say I'm more qualified to do these procedure than said fellows, but I can definitely do these procedures safely, competently, and can manage the complications, should they occur. There's a reason we have board certification and procedure minimums in programs.

3. No reasonable plastic surgeon or facial plastic surgeon is making the argument that oculoplastic surgeons shouldn't do orbital or eyelid surgery. They are, perhaps, as you suggest, better suited to do these procedures. However, where do you draw the line? Should they be doing facelifts? Because many are. This is where PRS/FPRS begin to groan. I'm not saying they shouldn't, but you should be aware that this goes both ways.

4. Finally, your statement in bold. The 2014 In Service Examination in Plastic Surgery had a question directly asking about Hering's Law. While PRS residents may not think about it everyday, I guarantee you that the vast majority know what it is. Below is the reference from the answer key (I can't post the question because it's protected content).

Parsa FD, Wolff DR, Parsa NN, et al. Upper eyelid ptosis repair after cataract extraction and the importance of Hering’s test. Plast Reconstr Surg. 2001 Nov;108(6):1527-1536.