Plastics Lifestyle

[FourthTime]

Hello. First time posting in Plastics. I'm doing a rotation right now and am becoming interested in this field. I have 2 questions. What is the lifestyle like? Is it controllable or are the hours more fixed. Also, I really LOVE the outcomes of the surgeries, but do find some of them (TRAMS) long and tedious. Does that mean I shouldn't consider the field...how do you decide?

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[droliver]

Lifestyle is relative. IF you have a successful aesthetic practice, the money is very good. Keep in mind that the competition for cosmetic surgery is cutthroat & there is a big difference in salary b/w the have & have not's in most communities. Reconstructive surgery & hand surgery pay very little & a # of plastic surgeons now refuse to do them at all. Most of the very successful ones I know work very long hours (60-70 week), albeit with less nightime call involved. If you do not like long operations, you will not like a good bit of plastic surgery procedures (both reconstructive & cosmetic) as many will last hours & hours.

 

[supahfresh]

Totally depends on what you want. The field is quite diverse. I unfortunately (or fortunately) despise cosmetics.

Burn, hand, and peds are much more interesting. Not sure if there's any money there, but they are awesome. You could always swing a faculty position somehwhere and work and do research and make less money. Or maybe you could be part of a startup biotech company designing skin substitutes.

Overall, you should do it because you love it. If you find yourself being bored by flap cases and long craniofacial cases then proceed with caution. Cosmetics is infinitely more boring.

 

[maxheadroom]

There's tons of money in burns. Not many people interested in it and the compensation is quite good. Of course, it can be pretty gruesome. If you have a good burn unit, you can do very little work besides the grafting and make a very nice living.

 

[droliver]

Max,

the money situation for burns is kind of like the finances for the emergency room. IF you're in a location that gets a lot of funded patients (worker's comp for burns) the math works. If not you end up with VERY expensive & labor intensive charity work. The profitability of burn units & surgeries varies tremendously depending on this. Plastic Surgeons that do burns (really do burns, not just post burn reconstruction or contracture releases) usually end up pretty involved in the global patient care for those patients which involves the critical care, the intricacies of the nutrition support, the complex rehab protacols, etc.... These systems are not the kind of things that can run on auto-pilot & as the contemporary burn unit has developed, fewer & fewer of them are directed by Plastic Surgeons (who by and large like to operate rather then fiddle over the critical care of large burns). It seems that more & more of the units are now directed by the trauma-critical care divisions in surgery

 

[maxheadroom]

OK, Ollie's got me. I'm thinking of smaller burn units. I've seen a few where plastics "runs" the patient, but farms out the critical care to an ICU attending.

I agree that the best burn units are run by General surgeons who have trained in surgical critical care and burns. They provide comprehensive care for the burned patient, running vents, pressors, nutrition, and doing the excision and grafting themselves.

 

[droliver]

Yeah Max, if you kind of follow the development of burn care over about the last 75 years you see a lot of seminal contributions by Plastic Surgeons, but the interest in the field has just dwindled as its gotten so super-specialized if you want to do it well in addition to collecting a pretty morbid group of patients which turns most people off. We've gotten to where we have picked up so many survivors of formerly lethal burns, that you now have a lot of patients with large burns whose total care is now predominately supportive/rehabilatative (after the initial resuscitation & coverage). I would hazzard to guess that most of the new integrated model PRS programs get even less training in Burns & recieve less critical care training,such that we get a self-fullfilling cycle where even fewer people will do this in plastics.

 

[maxheadroom]

Actually, a fairly large percentage of the integrated programs do a disproportionate amount of burns when compared to their general surgery colleagues. At most programs, PRS residents do between 3 and 9 months of burns in their first three years.

 

[droliver]

Max,

I've gotten the impression that a lot of the burn experience the integrated programs feature is pretty superficial & almost entirely confined to the junior years. This would vary depending on whether the burn unit featured a Plastic Surgeon directing (not consulting) the global care. I know @ the University of KY in Lexington, that they (the integrated residents) run the whole show with little General Surgery support for the burn unit, but this is becoming more rare I think @ any burn unit of substancial size.

 

[maxheadroom]

True, the PRS seniors (PGY4-6) have very little contact with the burn unit. They take backup call when the burn fellow is unavailable and help out with excision and grafting when things are really busy. Otherwise, the unit belongs to the fellow and the junior.

 

[droliver]

Yeah, that arrangement @ your program seems pretty typical & maybe even more involved then many programs. As a surgery resident I did burns extensively as part of our trauma service & spent over a year doing it. As a Plastics Resident now @ the same program I do almost 0% except for the hand burns (required by the plastics RRC) & some consulting on face burns (which rarely need grafting). Burns is just so low on the totem pole now for priority by the ASPS that it is recieving less and less attention now. I don't mind it one bit as I'm already "burned out" with it, but it can be a pretty big hole in your training if you end up practicing outside of larger metro areas where you might end up being expected to take care of some of the medium sized burns.

Contrast this with the program @ Indiana where the first year residents (pgy-6's) spend 4 months of their first year (of a 2 year program) as THE burn doctor: do all the excisions & grafting, every other night first call (backing up a pgy 1 or 2 the other night), directing all the critical care, etc.... It's insane! I can't believe they've never been spiked for this when they get reviewed, even if their total #'s of index cases turn out ok. Spending more then 15% (1/6 th) of a 2 year program doing exclusively burns.....ugggggh!

 

[Mariah246]

Totally depends on what you want. The field is quite diverse. I unfortunately (or fortunately) despise cosmetics.

Burn, hand, and peds are much more interesting. Not sure if there's any money there, but they are awesome. You could always swing a faculty position somehwhere and work and do research and make less money. Or maybe you could be part of a startup biotech company designing skin substitutes.

Overall, you should do it because you love it. If you find yourself being bored by flap cases and long craniofacial cases then proceed with caution. Cosmetics is infinitely more boring.

Sorry to revive an old thread but could anyone post regarding common procedures in plastic surgery and how long (average range) they take?

I ask because I missed out on the plastics sub-rotation during my surgery rotation (lottery system) and am fairly curious.

Regarding general surgery, I found myself pretty turned off by the longer surgeries. I remember seeing a 1 hr mastectomy and then following it up the next day with a 3 hr mastectomy. The difference in dexterity was shocking between the two attendings. (Unfortunately, I was booted out of the OR during the reconstruction portion as the other student who did nab the plastics spot had to scrub in to watch)

I also witnessed a 6 hour lap colectomy that really left me questioning whether I could stomach such long surgeries. Just wanted to see if they were commonplace in plastics or not. (Offhand, I'd guess yes. The other student told me the TRAM breast reconstruction took a fairly long time as well)

 

[GSresident]

Here are some times for various procedures based on what I am seeing in my training:

Primary simple Breast augmentation - 45 minutes to an hour
facelift - 2 1/2 hours to 5 hours (deep plane)
blepharoplasty - 15 minutes per lid
endo brow lift - ~1 1/2 to 2 hours depending
Abdominoplasty with liposuction of the flanks - 3 hours
breast reduction 2 to 3 hours depending
closed rhinoplasty - 1/2 hour
open rhinoplasty 2 to 3 hours
gastroc flap for reconstruction of knee/upper tibia defect - 1 1/2 hours
lat dorsi flap for breast reconstruction - 2 1/2 hours to 3
Tram flap for breast reconstruction 2 1/2 to 3 hours
Arch bars and IMF for mandible fracture - 45 minutes to 1 1/2 hours
plating of mandible after arch bars - 1 to 2 hours, depending
ZMC reduction/plating - 1/2 to 3 hours depending
orbital floor plating - 1/2 to 2 hours depending
Panfacial fracture including mandible - 4 to 8 hours depending
Free Fibula for oral reconstruction - 8 to 12 hours depending

 

[Plastikos]

There was an article in PRS recently about the lifestyle of 50+ yo plastic surgeons, and in comparison to quite a few different fields. PRS averaged something like 52.5h/wk, which was one of the lowest of all fields polled. Course, 50 is a ways away for most and the groundwork had already been laid.

 

[Pir8DeacDoc]

Here are some times for various procedures based on what I am seeing in my training:

Free Fibula for oral reconstruction - 8 to 12 hours depending

Thanks for sharing, that's very useful.

Does the time for your fibula include harvesting and in-setting? Interestingly enough at my program our ENT attending will often walk the PRS resident through a fibula and it doesn't seem to take quite that long. Although admittedly I'm normally more focused on the resection while they are harvesting so I haven't really timed it out.

 

[GSresident]

8 to 12 is for everything - my total involvement in the case.

It takes me about an hour and a half to 2 hours to harvest the fibula graft. It takes on average another 45 minutes or so to shape the graft exactly like you will need it (osteotomies etc). The ENT team here prebends the plate and pre-drills for us which is really nice. If no vein graft is required the micro takes me 45 minutes. If a vein graft is required it takes me about 20 minutes to harvest the vein. Doing the vein graft adds two anastamoses so the total for micro then becomes an hour and a half. Once the micro is done it takes an hour or so to inset the flap and close up there. The leg donor site takes an hour or so to close. Lots of times there will be an ENT resident around who wants to do plastics so the leg sometimes takes care of itself. If vein was harvested it takes a half hour to close the vein donor site. Add in a 15 minute break or so before the micro and another at least 1 hour for delays waiting for suture, for the scope to work, etc. Also the needle count will be off, so add an hour waiting for xray. At our institution the resident has to stay in the room and accompany the patient to the PACU so that adds another hour.

I've done free fibulas in as little as 5 but usually it takes the whole 8 hours, especially if I am walking someone else through the harvest or the micro.

 

[Pir8DeacDoc]

Thanks...Now I can see how it would probably take that long. I assumed that once you had harvested and were under the scope that someone would be around to close the leg for you. If you have to do that yourself and then wait around for the entirety of the case then the meter runs up pretty quickly.