Plastics vs Cosmetics?

[dr.evil]

Please don't flame me on this. I'm a board certified general surgeon so I'm not totally naive.

I don't really enjoy hand surgery, burns, crazy flaps or most of "plastic" surgery per se. I do enjoy the craniofacial work (esp. cleft lips/palates) and most of the cosmetics (abdominoplasty, augmentation/reduction, etc).

Is it really unreasonable to do an isolated 1 year of fellowship/training in cosmetic surgery without the 2 years of plastic surgery? I know I wouldn't be board certified in plastics but that's not the point.

I would like to add the cosmetic procedures to my practice but continue to do much of my general surgery.

This may get nailed to the wall on this forum as it is likely mostly a turf battle and a reputation issue.

I would simply like to be additionally trained in a certain area and I know some ENTs (and DDS!) who have done this.

What's your opinion of this? Would I not be phenomenally trained if I did nothing for one year but cosmetics? That's a lot more than most plastic surgery fellowships give you, right?

Any comments or opinions?

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[maxheadroom]

You're asking plastic surgery residents and attendings if we think that it's OK for you to take some of our better elective surgery without doing some of the more difficult work, too? Really? You think you're going to be validated in your pursuit of this?

You want to do the nice, profitable cosmetic cases without doing the tough reconstructive work that is often the foundation of the techniques used in cosmetic surgery?

No.

 

[Moravian]

Where I did my plastics fellowship, there was a general surgeon in a small outside hospital that did the occasional abdominoplasty. And we had an oral surgeon that billed himself as a cosmetic surgeon because of some course he took. So it's out there and it happens.

The DDS couldn't get admitting privileges or OR privileges at the main hospitals for things other than oral surgery so he had to open his own "cosmetic surgery center." This went over so well that the plastic surgeons joined the ophthalmologists in petitioning the state government to limit scope of practice. The ophtho guys were going after optometrists who were wanting to do laser surgery.

The rest of it, as alluded to by Max, is political/financial. I am a boarded GS as well, but there is no way I could practice at a big hospital (i.e., anything other than small town) if I started doing my own mastectomies along with breast reconstruction. Or if I started doing hernias. Or thyroids. Or lap chole's (which I really enjoy) Or just about anything else I can do that a general surgeon could do, especially if it was on a paying patient (one with good insurance). Not only would I have the same problems as the DDS guy (issues with privileges depending on who was on the credentialing committee), but the general surgeons in town would shut down my referrals.

There are some similar issues with ENT. If plastics is strong at a particular institution, they may try to limit their scope. Some feel that since ENT guys spend 5 years doing head/neck, it's OK as long as they stick with facial plastic surgery.

This biggest issue for me is that although I'm early in my career (albeit more senior in years), I have taken care of complications from non-plastic surgeons doing plastic procedures. I'm more of the bent that you shouldn't be doing something if you can't fix it when it goes wrong. Or at least know how to fix it given that your patient might be mad enough to want to go somewhere else (or the complication might be one that you want to bring in an expert).

An example would be the good old lap chole. When I was the chief resident, I used to take interns and second years thru the procedure. Given that the junior had the requisite skills, they could usually get fairly proficient at a non-complicated, elective, non-obese, gallbladder relatively quickly. Does that mean they were ready to hit the streets at the end of their first year doing bile sacks? Not really. What happens if there is bleeding, a duodenal perf, bowel injury, duct stone, porcelain gall bladder, CBD injury, or the myriad of other things that can go wrong? Is the intern going to be able to fix it?

The other reason I used lap chole for an example is that there are papers that say if you injure the CBD, you should refer that patient to someone who does those repairs on a fairly frequent basis because the outcomes are better (unless you are the local hepatobiliary guy). This is just in case you come back me about the statement concerning of not operating if you can't fix it. I agree there are exceptions, but for the most part, I stand by it.

Lastly, there are the medical-legal reasons. Even though I'm a craniofacial guy, I will still scrub on adult recon cases. If we get a complicated abdominal hernia repair from GS, we always invite them in for the lysis of adhesions. Can we do it? sure we can. But besides having the general surgeon scrub and keep the referral source, it's an out for us in case of a bowel injury. I think we'd both agree that LOA is generally not too big a deal (although it can be), but it's a lot easier protecting your position when it's something you do every day vs. a couple of times a year. I can just see it now...

"So, Dr. Moravian...how was it that you did not recognize a bowel injury at the time of surgery and my client went on to have an ileus and abscess that severely affected their quality of life?"

"Oh, you did recognize it and tried to repair it, but evidently botched it?"

"Do you do abdominal surgery as a regular part of your practice?"

"In retrospect, don't you think it would have been good clinical judgement to have a general surgeon present at the time of surgery instead of consulting them after my client ended up in the ICU?"

You get my drift.

--M

 

[Pir8DeacDoc]

There are some similar issues with ENT. If plastics is strong at a particular institution, they may try to limit their scope. Some feel that since ENT guys spend 5 years doing head/neck, it's OK as long as they stick with facial plastic surgery.

Do you have any specific/personal thoughts on this yourself? FPRS is something I'm considering and curious what the PRS world thinks. I feel as ENT's we have a pretty good grasp on H&N stuff. As long as we keep it above the clavicles all should be fine?? Here our H&N guys will walk the plastics residents through harvesting and in-setting a fibula. Just curious what you or others think.

 

[dr.evil]

I knew this could be a flame war and I understand the "stealing our good cases" concept. Lord knows the general surgeons have had many cases taken away by subspecialists.

I wasn't looking for anyone's approval. Just opinions. I'm certain that if I trained in nothing but cosmetics for 1 year that I could well take care of the complications (or at least 98% of them).

I find it interesting that an ENT can do one year of PRS of the head and neck and that's o.k., but a general surgeon, who has 5 years of training in abdominal and breast operations (and everything subcutaneous under the moon), can't do an augmentation or abdominoplasty without the plastic guys getting their feathers ruffled. That seems a bit off to me.

The bottom line is that it's a turf war, a money issue and an ego issue. I was just looking for anyone who had taken this route or had experience with someone who had. I'm definitely not looking for approval.

Many of the general surgeons in my area will do augmentations and abdominoplasties without any extra training except for the small amount of cosmetics they had in residency. Although I could go do a workshop and do breast augmentation, I thought it may be better to get additional training for a year instead of a few days prior to doing that.

Hell, maybe I'll just forget the extra year and do them anyway.
Thanks

 

[Fah-Q]

I find it interesting that an ENT can do one year of PRS of the head and neck and that's o.k., but a general surgeon, who has 5 years of training in abdominal and breast operations (and everything subcutaneous under the moon), can't do an augmentation or abdominoplasty without the plastic guys getting their feathers ruffled. That seems a bit off to me.

I sorta agree with you about GS not being able to do some basic body contouring-type work. The big problem with your argument about ENT doing facial plastics is that general ENT training includes facial plastics. In fact, it's about 25% of our boards. The FPRS fellowships are really for people who want advanced training because they want to do facial plastics exclusively. Simple things like functional rhinos, local flaps, blephs, fillers, etc. comes with good, general ENT training. If a GS is getting abdominoplasty and breast recon/augs as part of their general training, then great...do what you're trained to do comfortably. But I'm guessing that kind of training in GS is rare.

 

[droliver]

Being a general surgeon followed by Plastic Surgery followed by a fellowship in aesthetics/breast, I can tell you that I really don't think you have the full perspective of some of these operations trying to do shortcuts.

I have great respect for what a general surgeon can do (having trained in it), but I'd be reluctant to personally endorse you doing surgical procedures except for body contouring (abdominoplasty & liposuction). I think those areas translate well to your core surgical training and the kinds of catastrophies you can cause should be managable to you.

For the breast & face, you really have no background in the management of complications or revisional surgery specific to this. That is not the type of experience or cases you encounter in volume doing some preceptorship in cosmetic surgery. If you're not comfortable doing flap based breast procedures (to move the nipple or reduce the breast), tissue expansion principles, and capsular breast work, you're going to run into a lot of real problems quickly on the cosmetic breast group that will torture you (they torture me and I know what I'm doing ). Keep in mind that reoperations on primary breast augmenation even in plastic surgeons hands are 10-20%+ in the FDA data.

On a more practical level, you may have trouble finding insurance coverage for these surgeries, you will have trouble getting hospital privledges to do them, and will expose yourself to a great deal of liability when complications occur. You will also get beat over the head relentlessly with your lack of credentials by a plaintiff's attorney (fair or not) and you will have board-certified plastic surgeons testifying pro bono that you've violated the standard of care for whatever. I remain convinced that at some point, liability issues are going to establish scope of practice battles long before state medical boards get around to it.

Don't you think Jan Adams & Rob Rey aren't wishing they could have gotten their boards ticket punched about right now? (neither sat for or passed their general or plastic surgery boards after their training). There's going to be more fallout both on scope of practice, board-certification, and office-based surgery after several higly publicized deaths in the last few years.

 

[Pir8DeacDoc]

dr oliver..


I'd much appreciate if you could address my post above if you get a chance. Thanks!

 

[Leforte]

We have had the plastic residents (our institution have a combined program) come into our facial plastics ORs to observe rhinoplasty, rhytidectomy, blephs, etc as their training does not fully encompass the aesthetic portion. Yes, they meet RRC minimums, but that's about it.

The facial plastics guys say that for these procedure, one is equipped to practice these following a ENT residency without an FP fellowship. Moreover, if one is so inclined, they can sit the FP boards after having completed so many cases, without the fellowship.

Personally, I have zero interest in aesthetics, nor will I do them in practice. Sure I may take down someones dorsal hump or throw in a few spreader grafts if asked when performing a septoplasty, but that's about it. The cosmetic patient is too much of a PITA. In addition, it takes years to establish a cosmetic practice.

Also, if plastics wants the cosmetic work - they can start buy taking all the facial trauma as a sign of good faith.

 

[maxheadroom]

At my place ENT does almost no facial cosmetics and does smaller H&N recon, but they won't do fibulas or other exotic flaps (they'll do a radial forearm or a pec and that's about it). We have a pretty good working relationship with them for that kind of thing.

As far as facial aesthetics goes, I think that an ENT who's had appropriate training can do most of those procedures without a problem. I don't like the fact that they can sit for the facial plastics boards without additional training. I think that if you're looking to add a certificate to your wall, you should train in a supervised setting that is regulated by an accrediting agency.

I get pissed about non-PRS surgeons doing breast & body contouring because I've seen some pretty f*cked up patients in my clinic who've had major complications that appear to be from a lack of knowledge on the surgeon's part and a lack of understanding how to deal with the complications early on. I had one patient who DIED from complications from a belt lipectomy done by a general surgeon who made some critical errors that set off an ultimately lethal chain of events.

 

[Moravian]

I completely agree with droliver's comments.

At my GS residency program, there were only GS residents so we rotated thru all the subspecialties (ENT, Gyn, Uro, Ortho, Neuro and Plastics). When I got to my plastic fellowship, it was quite the surprise. I was nearly overwhelmed by the amount of stuff I needed to learn. Like one of my earlier mentors said, "you don't know what you don't know."

I still think you could do some plastics stuff depending on how big your town was where you practiced, I would just be careful about what services you decide to offer. Remember that the idea is to do no harm.

As for Pir8DeacDoc, I don't have a problem with ENT and facial plastics as long as they've had the appropriate training. As Max inferred, training can be highly variable depending on location. In my plastics fellowship, we did the fibula harvests and flap insets. They did more cosmetic rhinoplasties (non-cleft) than us. We both split the facial trauma along with OMFS and we did a lot. That kind of thing does make you comfortable around the face, but I certainly don't advocate people doing procedures on the face (or anywhere for that matter) where their training might have been deficient.

--M

 

[dr.evil]

I think dr.oliver's comments are well thought out and probably more along the line of what I was looking for. I appreciate those, thanks.

I guess at some point I need to just say I'm going to do general surgery or I'm going to do plastics. I know there are things in all specialties you're not going to like. I've always thought it would be great to do Operation Smile and do cleft lips/palates for those kids. I also like the aesthetics and the lifestyle of a plastic surgeon better than a general surgeon. I'm just not sure if I would enjoy hand, microvascular work, free flaps, etc.

It's just a dilemna that I'll have to deal with. My perfect world would be non-cardiac thoracic cases, advanced laparoscopy, cosmetics, and craniofacial. Odd combination I know but definitely the things I enjoy the most.

It's odd how things work out because 3 years ago I would have told you I was going to shoot for a cardiothoracic fellowship.

One of my colleagues practice GS for 3 years then went back and did Plastics. He has always said he would do that again and again and has really guided me to think about this a lot.

Thanks for all of your replies. My heart and soul tells me to be a board certified plastic surgeon prior to doing cosmetics.

 

[TheThroat]

The problem with many ENT residencies is that they don't really provide the skill set for a lot of FPRS (rhytidectomies, laser resurfacing) and really just prepare us for septorhinos,etc. The "powers that be" make FPRS 25 % of our boards more to fend off the argument that all ENT's shouldn't be doing FPRS.

I agree with the above posts that if an ENT program trains its residents to do FPRS, then they should be able to do it. I have little desire to do cosmetics, mainly bc/ I just haven't set up my practice for it.

 

[GSresident]

I'm just not sure if I would enjoy hand, microvascular work, free flaps, etc.

There is a simple solution to that dilemma - just don't do it. Just because you are trained to do something doesn't mean you have to do it. I am in my last 6 months of a PRS fellowship now. I'm in the process of setting up my practice. I have hand training with K&K in Louisville but I have no interest in hand because I hate being up in the middle of the night. As a result I'm not even signing up for hand privileges.

I really enjoy microvascular work and free flaps but it is going to be just me in the practice. I won't have a partner or residents to help me. Not to mention I have no desire to do a 12 hour procedure with a $700 reimbursement. With all the post op care I would have to do I would go in the hole if I did a free flap. As a result I'm not going to offer free flaps as part of my practice. I was gung ho about free flaps when I started. Its really nice to talk about doing free flaps but I have bills to pay, salaries to meet etc. Reality is a big kick in the arse.

If I were you I would do a PRS fellowship and then just limit the scope of your practice when you finish. Its only an extra year. If you do a cosmetic fellowship and then start taking cosmetic patients you will be a pariah. Why put yourself in that situation?

 

[dr.evil]

As usual, most of the advice on here is pretty good, simple, straight-forward, and no-nonsense. Sometimes you just need to hear it from colleagues.

I guess what happens in my brain is that plastics would be like general surgery and I would get roped into a lot of things that I CAN do but just don't enjoy. Unfortunately in my current environment, you just don't want to say no to a referral for the fear of losing more referrals.

I've agonized over this for several months now and will continue to agonize over it until next year but I'm strongly leaning towards leaving my practice and pursuing a PRS fellowship. I had a long talk with one of my best friends who is in PRS fellowship and that seemed to have tipped me toward going for it.

I'll discuss this with my friend also but do you guys have opinions on some of the better independent fellowships for craniofacial training? I'm definitely not into the name or how academic it is. I would also prefer to avoid the East/West Coast (family issues).

Thanks again for helping me "see the light".

 

[GSresident]

I guess what happens in my brain is that plastics would be like general surgery and I would get roped into a lot of things that I CAN do but just don't enjoy. Unfortunately in my current environment, you just don't want to say no to a referral for the fear of losing more referrals.

I wouldn't worry too much about building a referral based practice in PRS, especially if the stuff you are interested in is cosmetics. No FP will ever send you a breast aug so when he sends you the public aid smoking diabetic decub with nec fasc you can say no if you don't want it.

Craniofacial, on the other hand, is a different bird. Likely you will have to do a craniofacial fellowship on top of your PRS fellowship and then join some sort of academic center. That is an extremely referral based business and craniofacial guys tend to be very territorial.

Best of luck.

 

[maxheadroom]

Craniofacial definitely requires fellowship training and a focus on a academic career. There are some places where the academic part isn't necessary, but there are lots of people who do Craniofacial fellowships and there just aren't enough funny looking kids to go around. Likewise, fewer and fewer plastic surgeons are doing cleft work because it's becoming something of a focused specialty -- you won't get a cleft referral unless you're one of the peds plastic surgeons at tertiary referral center X.

GSresident -- I'd argue that you SHOULD do that ducub. If it's nec fasc, you really shouldn't push it off on someone else while the patient gets more and more septic. If everybody did their fair share of public aid decubs and the like, no one would be overburdened by them. One of the biggest problems in plastic surgery today is everyone's pursuit of the purely elective, cash up front practice. There should be some sense of duty to the society that has funded our residency/fellowship training programs through CMS to give back and take care of the Medicaid patients and the other less-desirable consults as well.

 

[droliver]

I'd argue that you SHOULD do that ducub. If it's nec fasc, you really shouldn't push it off on someone else while the patient gets more and more septic. If everybody did their fair share of public aid decubs and the like, no one would be overburdened by them.

As someone who treats (way too many) pressure sores I disagree somewhat. You do not need to make yourself the debridement doctor to the community, or you'll be drowning in them. I'm getting ready to just start defering these patients altogether to the general surgeons, particularly in the nursing home group (who are the large majority I see).

I'm nearly 3 years out & I don't think I've seen one DU in the non-ambulatory group whom I though was a candidate for surgical closure who wasn't a high function paragplegic in their 20's or 30's. The failure rate of flap-based surgery is staggering when you look at medicare data. It just doesn't work when you scrutinize results and costs more money in surgery & hospitalizations then indefinate wound care after debridement. The only elderly/infirmed who do well are those that have temporary conditions that led to the DU (ie. a hip fracture) and are able to position themselves rather then rely on indefinate nursing care to prevent recurrence

 

[GSresident]

There should be some sense of duty to the society that has funded our residency/fellowship training programs through CMS to give back and take care of the Medicaid patients and the other less-desirable consults as well.

So I guess I don't get credit for the 7 years of indentured servitude that I did? I'm on call today and tomorrow, hand and face call. I've been on call for the last 7 Christmas Eve and Christmas days. As far as I am concerned that debt has been payed in full by both me and by my family. Why doesn't my family count as part of "society?" You talk about me as if I haven't payed taxes to "fund our residency/fellowship training programs." I'll probably pay more in taxes to "fund our residency/fellowship training programs" in my first 5 years of practice than the average person does in his entire life. As such you can argue that I should jump on the cross but I'm not going to.

 

[maxheadroom]

Ollie,

Don't get me wrong, I'm not saying that you need to flap them. I don't plan on flapping many decubs out in practice. I do plan on doing my part to take care of wound patients. I'm not going to give my practice over to them, but I think there is a responsibility to do things that your community needs.

GSresident, I'm glad to hear that you're doing your part now, when you're required. The bigger question, though, is are you going to be part of the solution when you get out in practice? You don't have to go out and save the whole world, but doing your small part makes your community a better place. It's part of what you signed up for when you went into surgery.

 

[droliver]

Max,

The problem is that when you make yourself available to do this, you end up being a dumping ground for every one of them. We get calls for transfers from good-sized cities less then an hour away with good sized numbers of plastic surgeons in them trying to dump these.

On a practical level the primary debridement codes pay poorly, while the preparation & flap codes actually pay OK (for what passes for the pay scale of reconstructive surgery). If more of these patients were flap candidates, it would be more attractive to do more of them. Like I said, since nearly none of them are and nearly all of them are medicare for their primary insurer, you will be floundering doing this.

As your elective schedule gets busy and you bounce around multiple hospitals & offices (as most of us do) the idea of working on add-on debridment cases into the night on patients who will never be reconstructive candidates isn't something I want to do regularly. Palliative debridements are an appropriate procedure to defer to general surgeons who usually aren't stretched between facilities like we are.

 

[GSresident]

Ollie,
I do plan on doing my part to take care of wound patients. I'm not going to give my practice over to them, but I think there is a responsibility to do things that your community needs.

GSresident, I'm glad to hear that you're doing your part now, when you're required. The bigger question, though, is are you going to be part of the solution when you get out in practice? You don't have to go out and save the whole world, but doing your small part makes your community a better place. It's part of what you signed up for when you went into surgery.

In the post above Droliver gives very good practical reasons why accepting dumps doesn't get you anywhere. He has more real world experience with that sort of thing than I do but just looking at the numbers of practice startup and overhead costs I can safely rule out decubs for practical reasons of my own.

I object to the concepts of 'duty' and 'responsibility' being used to force me to work for free or to work for less than what I think the service is worth. Imagine that. People reading this will think I am a radical or a caveman when I say that I don't want to work for free.

There very well may be a need for services that I can provide in the community and I would argue that there is plenty of money in the healthcare system to compensate me at what I consider a fair rate to perform those services. But instead of paying my fee, the insurance companies have decided to pay hundreds of millions of dollars to their CEO's and to build towering palaces of granite and glass. All the while they are using words like 'duty' and 'responsibility' to justify stealing from me. The only way they have power over me is if I accept the idea that I should sacrifice myself. I reject that notion. I refuse to use words like 'duty' and 'responsibility' to describe what I do and I am suspicious of anyone who does. Get those chains away from me!

If you really want to serve your community and make the healthcare system better in your community then you should fight for fair compensation. Unfortunately most insurance companies are loathe to negotiate fair fees with physicians. Therefore they leave only one option - don't take insurance.

 

[VoiceofReason]

As someone who treats (way too many) pressure sores I disagree somewhat. You do not need to make yourself the debridement doctor to the community, or you'll be drowning in them. I'm getting ready to just start defering these patients altogether to the general surgeons, particularly in the nursing home group (who are the large majority I see).

I'm nearly 3 years out & I don't think I've seen one DU in the non-ambulatory group whom I though was a candidate for surgical closure who wasn't a high function paragplegic in their 20's or 30's. The failure rate of flap-based surgery is staggering when you look at medicare data. It just doesn't work when you scrutinize results and costs more money in surgery & hospitalizations then indefinate wound care after debridement. The only elderly/infirmed who do well are those that have temporary conditions that led to the DU (ie. a hip fracture) and are able to position themselves rather then rely on indefinate nursing care to prevent recurrence

Are you saying that flaps in general don't work well? Or only certain types of flaps? Or the success rate is dependent on a number of patient factors?

I'm just curious because flap surgery sounds really cool to me as far as advanced wound care and reconstruction goes.

 

[plastikosmd]

flaps in general are cool, flaps that are insensate that cover an area subject to high pressure that is also insensate do not work out well. recurrance is close to 100%. prevention is the key when it comes to DU.

 

[droliver]

Are you saying that flaps in general don't work well? Or only certain types of flaps? Or the success rate is dependent on a number of patient factors?

Flaps for decubitus ulcers (DU) in non-ambulatory patients do not work.

High functioning, younger paraplegics can do enough self-positioning to make them last awhile, but they all fail over time(ie. you get recurrent DU). If you can get closure of their wound for several years before breakdown, that's generally thought to be acceptable.

Flaps for DU on the obese, malnurished, non-compliant paraplegics, or nursing home patient population is a waste of everyone's time and resources. These patients are better served (unfortunately) by long term palliative wound care and secondary healing IMO. The failure rate of flap closure for DU at 10 months out in some medicare data approaches 90% if I remember correctly.

So personally, if they don't have a condition that was temporary that led to the DU (ie. bedrest after a hip fracture or fall), I'm a pessimist (with the data on my side)

 

[VoiceofReason]

Flaps for decubitus ulcers (DU) in non-ambulatory patients do not work.

High functioning, younger paraplegics can do enough self-positioning to make them last awhile, but they all fail over time(ie. you get recurrent DU). If you can get closure of their wound for several years before breakdown, that's generally thought to be acceptable.

Flaps for DU on the obese, malnurished, non-compliant paraplegics, or nursing home patient population is a waste of everyone's time and resources. These patients are better served (unfortunately) by long term palliative wound care and secondary healing IMO. The failure rate of flap closure for DU at 10 months out in some medicare data approaches 90% if I remember correctly.

So personally, if they don't have a condition that was temporary that led to the DU (ie. bedrest after a hip fracture or fall), I'm a pessimist (with the data on my side)

Much clearer, thank you. I'm not well versed in medicine yet, much less plastics. But now I understand.

I have another question now, though. From the brief reading I did it seems that flap surgery is indicated for many different kinds of wounds involving tissue loss -- how is the overall success rate of flap surgery when the wound does not result from a DU (meaning the recovery conditions are much closer to optimal)? I'm assuming it's much better or we'd probably be trying to find a different way to treat these things..

Thanks for bothering with my newbie questions

 

[curiousgeorge09]

Hi! I'm a first timer and I had some questions.

Can scars on the face be removed if caused by a scratch a finger nail?
If so how?
how much would this cost?

 

[Dr.Millisevert]

There are some similar issues with ENT. If plastics is strong at a particular institution, they may try to limit their scope. Some feel that since ENT guys spend 5 years doing head/neck, it's OK as long as they stick with facial plastic surgery. --M

Both ENT and OMFS spend 4-6 years on nothing but the the H/N.. many of which log many more related procedures than plastics in these areas (cosmetic as well as reconstructive). If they do a 1-2 year fellowship on top of this, i don't see how you can say that either is not qualified to do some simple lower blephs, sub mandibular lipo, or inject a little botox.

 

[Dr.Millisevert]

I feel as ENT's we have a pretty good grasp on H&N stuff. As long as we keep it above the clavicles all should be fine?? Here our H&N guys will walk the plastics residents through harvesting and in-setting a fibula. Just curious what you or others think.

agreed

 

[Dr.Millisevert]

Craniofacial definitely requires fellowship training and a focus on a academic career. There are some places where the academic part isn't necessary, but there are lots of people who do Craniofacial fellowships and there just aren't enough funny looking kids to go around. Likewise, fewer and fewer plastic surgeons are doing cleft work because it's becoming something of a focused specialty

One of the biggest problems in plastic surgery today is everyone's pursuit of the purely elective, cash up front practice. There should be some sense of duty to the society that has funded our residency/fellowship training programs through CMS to give back and take care of the Medicaid patients and the other less-desirable consults as well.

i do agree with everything you've said here.

 

[Moravian]

Both ENT and OMFS spend 4-6 years on nothing but the the H/N.. many of which log many more related procedures than plastics in these areas (cosmetic as well as reconstructive). If they do a 1-2 year fellowship on top of this, i don't see how you can say that either is not qualified to do some simple lower blephs, sub mandibular lipo, or inject a little botox.

Dr. Millisevert,

I believe you took what I said out of context. I never said that I, Moravian, personally feel that ENT and OMFS with the proper training shouldn't be able to do the above mentioned procedures. I was merely relating my experience with how different institutions deal with these specialties. In places where plastics is strong, they go out of there way to limit scope of ENT and OMFS. Where I did my fellowship, ENT and OMFS were stronger politically than plastics and did what they wanted. I have also seen this in private practice as well, depending on which groups have the largest market share. It doesn't have anything to do with qualifications, only competition.

I have always been an advocate of first do no harm, whether you're practicing in the U.S. or on a mission trip to another country. If you have the training, by then all means have at it...if not, you shouldn't experiment on people just for the reimbursement.

In fact, in a later post (http://forums.studentdoctor.net/showpost.php?p=5993341&postcount=11) I said:

"I don't have a problem with ENT and facial plastics as long as they've had the appropriate training. As Max inferred, training can be highly variable depending on location. In my plastics fellowship, we did the fibula harvests and flap insets. They did more cosmetic rhinoplasties (non-cleft) than us. We both split the facial trauma along with OMFS and we did a lot. That kind of thing does make you comfortable around the face, but I certainly don't advocate people doing procedures on the face (or anywhere for that matter) where their training might have been deficient."

--M

 

[Dr.Millisevert]

Dr. Millisevert,

I believe you took what I said out of context. I never said that I, Moravian, personally feel that ENT and OMFS with the proper training shouldn't be able to do the above mentioned procedures. I was merely relating my experience with how different institutions deal with these specialties. In places where plastics is strong, they go out of there way to limit scope of ENT and OMFS. Where I did my fellowship, ENT and OMFS were stronger politically than plastics and did what they wanted. I have also seen this in private practice as well, depending on which groups have the largest market share. It doesn't have anything to do with qualifications, only competition.

I have always been an advocate of first do no harm, whether you're practicing in the U.S. or on a mission trip to another country. If you have the training, by then all means have at it...if not, you shouldn't experiment on people just for the reimbursement.

In fact, in a later post (http://forums.studentdoctor.net/showpost.php?p=5993341&postcount=11) I said:

"I don't have a problem with ENT and facial plastics as long as they've had the appropriate training. As Max inferred, training can be highly variable depending on location. In my plastics fellowship, we did the fibula harvests and flap insets. They did more cosmetic rhinoplasties (non-cleft) than us. We both split the facial trauma along with OMFS and we did a lot. That kind of thing does make you comfortable around the face, but I certainly don't advocate people doing procedures on the face (or anywhere for that matter) where their training might have been deficient."

--M

I completely agree. Thanks for the reply!

 

[PRS Man]

I completely agree. Thanks for the reply!

I am new to this site but I must say that this discussion initiated by Doc Evil is very interesting. I am a plastics chief and will be doing a cosmetic fellowship next year. I feel very comfotable doing faces and noses but I still want more training. I have no doubt that an ENT surgeon doing partotids, necks, and fibulas would have the technical expertise and knowldege of the anatomy to pull off an extended smas with minimal complications and a good aesthetic result, but is he trully the best man for the job? Has he evaluated enough patients preop/postop, has he seen and done the various different techniques (ie MACS, SMASectomy, SMAS plication, ect) to know what works best in his hands, has he read the literature, has he been to the meetings, and does he do enough each year to keep his skills up? If the answer to all of these questions is yes, than in my opinion he has done the appropriate training and while he may be taking business away from my specialty, he is doing no harm and has a right to do these cases. However, the dermatologists, family practice docs, and anyone else who may have stayed at a holiday inn last night should not. As for Dr. Olivers response regarding the general surgeon doing cosmetic surgery without a fellowship, I couldn't agree more. The general surgeon has the training in ventral hernia repairs and fascial work to be able to plicate the rectus and get a nice aestheic result after abdominoplasty. However, would he feel comfortable doing an aug/masto, resuspending the IMF, or doing lateral capsule work, based on his mastectomy experience...probably not.

 

[Pir8DeacDoc]

I have no doubt that an ENT surgeon doing partotids, necks, and fibulas would have the technical expertise and knowldege of the anatomy to pull off an extended smas with minimal complications and a good aesthetic result, but is he trully the best man for the job? Has he evaluated enough patients preop/postop, has he seen and done the various different techniques (ie MACS, SMASectomy, SMAS plication, ect) to know what works best in his hands, has he read the literature, has he been to the meetings, and does he do enough each year to keep his skills up?

You are probably not overly familiar with the curriculum in ENT training but face lift isn't one of the standard procedures that we roll out of residency and throw into a general practice. A general ENT isn't going to have a practice doing tonsils, tubes, parotids, sinuses, and throw in a face lift for good measure. An ENT who is interested enough in facial recon will have most likely done a FPRS fellowship and will most certainly have done all of the above things that you mentioned. Chances are very good that they would be doing a cosmetics only practice.

 

[macpyra85]

Also, if plastics wants the cosmetic work - they can start buy taking all the facial trauma as a sign of good faith.

no, don't give facial trauma to the plastics guys... leave that to the OMFS! lol

 

[Fah-Q]

I have no doubt that an ENT surgeon doing partotids, necks, and fibulas would have the technical expertise and knowldege of the anatomy to pull off an extended smas with minimal complications and a good aesthetic result, but is he trully the best man for the job? Has he evaluated enough patients preop/postop, has he seen and done the various different techniques (ie MACS, SMASectomy, SMAS plication, ect) to know what works best in his hands, has he read the literature, has he been to the meetings, and does he do enough each year to keep his skills up?

It is only fair to ask the same of a general plastic surgeon wanting to do aging face. Just because the diploma on the wall says "plastic surgery" doesn't make a surgeon any more competent to do facial cosmetics. The general public may never understand that but we as surgeons should.

I think everyone would agree that a general ENT and a general plastic surgeon probably need additional training to do quality facial cosmetic work.

 

[maxheadroom]

What's this "General Plastic Surgeon" of which you speak? My program is called "Plastic Surgery". There's no General anywhere in it, but we do sometimes salute the boss.

I know that there are some ENT programs where the residents get significant aesthetic surgery exposure, but I also know lots of places where they don't. At my place, the closest the ENT residents get to aesthetic cases is a one month observership with some private practice ENT-Facial Plastics guy in another town.

Surgeons need to know their boundaries and do what is safe. I would never do a neck dissection on a H&N Cancer patient, but I feel prepared to do a free flap reconstruction on one. Both are big, complex Head & Neck cases. Both are done by ENTs and Plastic Surgeons in many communities. I know a Plastic Surgeon who does big H&N Cancer whacks (not very common these days). I know several ENTs who do major H&N Recon.

Remember, primum non nocere. When you're thinking about doing something that pushes your scope of practice, ask yourself if you would do this to your best friend's mother. Do the right thing for the patients and you'll be busier than you want to be.

 

[Fah-Q]

What's this "General Plastic Surgeon" of which you speak? My program is called "Plastic Surgery". There's no General anywhere in it, but we do sometimes salute the boss.

I know that there are some ENT programs where the residents get significant aesthetic surgery exposure, but I also know lots of places where they don't. At my place, the closest the ENT residents get to aesthetic cases is a one month observership with some private practice ENT-Facial Plastics guy in another town.

Sorry, general plastics must be a local thing. They do hand, wounds and breast but don't really touch the face much. That is how is how plastic surgeons are referred to where I am because it is an ENT dominated health system.

I think cosmetic exposure is not hard to get, but hands-on cosmetic training is rare. That is why I made the comment that general plastics guys are no more qualified to do aging face than a general ENT. Both need additional training.

 

[GSresident]

I think cosmetic exposure is not hard to get, but hands-on cosmetic training is rare. That is why I made the comment that general plastics guys are no more qualified to do aging face than a general ENT. Both need additional training.

The point is there is no such thing as 'general plastic surgery.' There is plastic and reconstructive surgery which actually has a real board certificate issued by the real governing body of medical specialties. 25% of the official curriculum for plastic and reconstructive surgery is cosmetic surgery and 25% of our yearly in-service is focused on cosmetic surgery. I feel extremely comfortable doing face lifts and all other head and neck cosmetic procedures and I will be doing them when I open my practice in July. That being said I probably won't get much cosmetic business at the beginning and that is OK.

You're not going to get away with saying 'general plastic surgeon'. By saying that you are trying to say that 'facial plastic surgeons' are more qualified, which they aren't. There is one person who can call himself a plastic surgeon and that is the person who went through an accredited plastic and reconstructive surgery residency and is at least board eligible if not board certified.

 

[Pir8DeacDoc]

GS, you know I respect you/your opinions a lot but you can have the certificates and call yourself whatever you want. At the end of the day a facial plastic surgeon is at least as qualified as a plastic surgeon to work on the aging face. Either way, it's well within the scope of practice of both surgeons and at least in my limited experience there isn't a turf war. But my n=1.


Is anyone aware of combined practices where a PRS and a facial plastics guy have teamed up in practice? I am seriously thinking of doing this with one of my buddies from college.

 

[GSresident]

GS, you know I respect you/your opinions a lot but you can have the certificates and call yourself whatever you want. At the end of the day a facial plastic surgeon is at least as qualified as a plastic surgeon to work on the aging face. Either way, it's well within the scope of practice of both surgeons and at least in my limited experience there isn't a turf war. But my n=1.

Is anyone aware of combined practices where a PRS and a facial plastics guy have teamed up in practice? I am seriously thinking of doing this with one of my buddies from college.

Facial plastic surgeons very well may be as qualified as a plastic and reconstructive surgeon to deal with the aging face. I have never claimed otherwise. My issue is with Fah-Q stating that a plastic surgeon is not qualified to do so because they don't get training in the aging face. There is no distinction between 'general plastic surgery' and surgery of the aging face - they are in fact the same thing. Any board eligible or board certified plastic and reconstructive surgeon by definition has training in surgery of the aging face. We don't need to do a 'facial plastic surgery' fellowship because it would be redundant. If someone wants additional training in an area that he wants more experience that is fine but is not expected.

 

[Fah-Q]

The point is there is no such thing as 'general plastic surgery.' There is plastic and reconstructive surgery which actually has a real board certificate issued by the real governing body of medical specialties..

I guess I'll just try to apologize...again. I really touched a nerve didn't I?General plastics must be a local thing. By the way, what do you consider the AAFPRS and their fellowhsips and board certification? Is that not real?

25% of the official curriculum for plastic and reconstructive surgery is cosmetic surgery and 25% of our yearly in-service is focused on cosmetic surgery. I feel extremely comfortable doing face lifts and all other head and neck cosmetic procedures and I will be doing them when I open my practice in July

Getting a multiple choice question right doesn't make you competent. I'm just curious, how many "face lifts and all other head and neck cosmetic procedures" does it take to be "extremely comfortable" doing them?

You're not going to get away with saying 'general plastic surgeon'. By saying that you are trying to say that 'facial plastic surgeons' are more qualified, which they aren't. There is one person who can call himself a plastic surgeon and that is the person who went through an accredited plastic and reconstructive surgery residency and is at least board eligible if not board certified.

I actually never said who was better qualified. You seem to be so desperate to assert superiority...which always begs the question why?

My issue is with Fah-Q stating that a plastic surgeon is not qualified to do so because they don't get training in the aging face. There is no distinction between 'general plastic surgery' and surgery of the aging face - they are in fact the same thing. Any board eligible or board certified plastic and reconstructive surgeon by definition has training in surgery of the aging face.

I guess my personal experience is not the norm and I apologize for generalizing. I didn't realize PRS residents elsewhere were getting hundreds of facial cosmetics procedures as primary surgeon.

I will disagree with you that "any board eligible or board certified plastic and reconstructive surgeon by definition has training in surgery of the aging face" making them more qualified than facial plastic surgeons. Training, especially in cosmetics, is very program dependent. The PRS residents here just don't touch the face much at all, except when they are on one of our services. They are not more qualified than a general ENT, who operates on the face regularly, and they are certainly not more qualified than a fellowship trained facial plastic surgeon. Like I said before, the title of "plastic surgery" on the diploma has nothing to do with making one more competent to do facial plastics.

 

[GSresident]

By the way, what do you consider the AAFPRS and their fellowhsips and board certification? Is that not real?

Actually, the American Board of Facial Plastic Surgery, as I understand it, is not recognized by the American Board of Medical Specialties. Please verify that statement by looking here:
American BOard of Medical Specialties

The lack of recognition by the American Board of Medical Specialties puts the American Board of Facial Plastic Surgery on par with The American Board of Cosmetic Surgery.

The American Board of Plastic Surgery, which will certify me, is on the list of ABMS recognized specialties.

In order to apply for certification by the "American Board of Facial Plastic Surgery" you have to be boarded in either ENT or Plastic and Reconstructive Surgery, submit 100 op reports and pass a test. There are a few other requirements listed but there isn't a specific requirement to do a "facial plastic surgery fellowship." Again, please verify that statement by looking here:
American Board of Facial Plastic Surgery

PS - look at the post time. I'm up because I'm on call for face trauma. We split it up with ENT and OMFS. Geez, I hope a 'general plastic surgeon' can deal with operating on the face. LOL

 

[jdm51]

That's very interesting - I just most PRS boarded people don't feel the need to get this extra certification, especially when they're already 2 years out of practice like this Facial Board says you have to be.

Bascially it's a way for ENT trained surgeons to validate their facial plastic training it seems.

 

[GSresident]

That's very interesting - I just most PRS boarded people don't feel the need to get this extra certification, especially when they're already 2 years out of practice like this Facial Board says you have to be.

Bascially it's a way for ENT trained surgeons to validate their facial plastic training it seems.

I would be interested in finding out what percentage of the ABFS members are boarded in Plastic and Reconstructive Surgery.

 

[Pir8DeacDoc]

GS, appreciate your input as always...


I was discussing the AAFPS with my friend in plastics residency and he was surprised to find that there is no requirement for actual completion of a fellowship to be recognized by the AAFPS. I'm not exactly sure what that's about. I am told that about 25% of our ENT boards cover facial plastics. Maybe the board assumes that with proper interest and a good case load/exposure then that is adequate to fulfill technical proficiency. It seems a good way for a surgeon interested in doing these types of cases to hang a more specific shingle and market that to his community.

 

[GSresident]

GS, appreciate your input as always...


I was discussing the AAFPS with my friend in plastics residency and he was surprised to find that there is no requirement for actual completion of a fellowship to be recognized by the AAFPS. I'm not exactly sure what that's about. I am told that about 25% of our ENT boards cover facial plastics. Maybe the board assumes that with proper interest and a good case load/exposure then that is adequate to fulfill technical proficiency. It seems a good way for a surgeon interested in doing these types of cases to hang a more specific shingle and market that to his community.

The AAFPS also accepts plastic and reconstructive board certification as the pre-req for becoming a member. It is very interesting that on their website they are trying to make a distinction between 'general plastic surgery' and facial plastic surgery but they don't require a fellowship beyond your PRS training to become an AAFPS member.

By the way you weren't supposed to admit that it is a marketing scam.

 

[maxheadroom]

That's always been my argument with the FPS certification -- no additional training requirement. I don't like the idea that they encourage people to do cases that they may or may not be trained to do in order to become certified. That just seems bass-akwards to me. I have no problem with a FELLOWSHIP-TRAINED ENT doing aesthetic facial surgery and calling themselves a Facial Plastic Surgeon. The problem that I have is with people who do a weekend course and start doing breast augs and body liposuction.

 

[Fah-Q]

Actually, the American Board of Facial Plastic Surgery, as I understand it, is not recognized by the American Board of Medical Specialties.

Neither is hundreds of other boards. That doesn't make them marketing schemes. There are 24 boards recognized and the American Board of Otolaryngology is one of them. It certifies us to do general otolaryngology, not facial cosmetic surgery, even though it is part of our general training. The ABPS will certify you to do general plastic surgery, not facial cosmetic surgery, even though it is part of your general training. Additional training is not "redundant," it is prudent.

I'm still waiting for you to answer my question: How many "face lifts and all other head and neck cosmetic procedures" does it take for one to become "extremely comfortable?" Your fellowship must be top-notch for you to have already learned facial cosmetics, especially since you just started operating on the face 18 months ago. Would you qualify to become board certified by the ABFPRS?

PS - look at the post time. I'm up because I'm on call for face trauma. We split it up with ENT and OMFS. Geez, I hope a 'general plastic surgeon' can deal with operating on the face. LOL

Your arrogance is palpable. Operating on the face is a challenge that requires extensive knowledge and training. One day you might figure that out.

Maxheadroom - I agree with your assessment of the AAFPRS. The 100 case thing was developed to "grandfather" in all the guys that had been doing facial plastics for years but obviously couldn't stop their practices and do a year fellowship just to become board certified. This backdoor will soon be shut and all new AAFPRS members will be required to do one-year fellowships. I also agree that a general ENT wanting to do facial cosmetics needs more training. But I believe that the same should be expected of a general plastic surgeon...and it seems you guys disagree with that philosophy.

 

[maxheadroom]

But I believe that the same should be expected of a general plastic surgeon...and it seems you guys disagree with that philosophy.

Ouch! There's that nasty "General Plastic Surgeon" term again. We do have that regulated in our training -- the RRC sets numbers and reviews programs. Facial cosmetic surgery is an integral part of any plastic surgery training program. A program that is lacking in the didactics or numbers to safely train Plastic Surgeons should be cited by the RRC-PS. Between the reconstructive and cosmetic facial surgeries done in residency, the graduate of an accredited Plastic Surgery residency should be appropriately trained to operate on the face.