question

[ashahdc]

I'm in the process of scheduling electives and thinking about specialties. I'd like to know opinions on where the line is drawn between Plastics vs. ENT vs. OMFS. There seems to be such a huge variability - and it depends on the program. Some programs don't do squat and make me feel like damn I shoulda done dental then maxillofacial. I'm definitely into operating. Not trying to flame, but would love to hear some opinions.

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[resxn]

I'm in the process of scheduling electives and thinking about specialties. I'd like to know opinions on where the line is drawn between Plastics vs. ENT vs. OMFS. There seems to be such a huge variability - and it depends on the program. Some programs don't do squat and make me feel like damn I shoulda done dental then maxillofacial. I'm definitely into operating. Not trying to flame, but would love to hear some opinions.

kind of a broad question to answer with any distinct clarity, so I'll paint broad strokes.

Indeed, between the 3 there is enormous overlap, but I'll try to break it down from an ENT perspective:

Otology - neither of the other two do any otology except in the rare case of cancer and that usually is only for skin neoplasms involving the auricle.

Rhinology - neither of the other two do sinus work. However, a rare OMFS, and frequently plastics will deal with functional operations for breathing improvement (septoplasties, alar work, mid-vault work, turbinate reductions, etc.)

Laryngology - neither of the other two do any significant laryngology except in the relatively infrequent (but increasing) case of the OMFS who does a lot of H&N. The airway below the glottis is often exclusive to ENT among the 3, but there is overlap with thoracic surgeons and to a smaller degree with pulmonologists here.

Plastics - this is obviously the realm of the plastics, but both ENT and to a lesser extent OMFS do quite a bit of plastics depending on the particular surgeon's interest and experience.
Reconstructive plastics - broad overlap with all 3 services often having similar amounts of treatment for reconstructive procedures. In some centers plastics do more, in some ENT do more.

Trauma - nearly identical to reconstructive trends. OMFS often will get more mandible work simply because that's their baby.

Oncology - ENT probably dominates this area except in primary neoplasms of the mandible where OMFS does quite a bit. Plastics in this category tends to focus on skin lesions or reconstruction and rarely if ever delves into extirpation of HNSCCa. There are also a significant number of OMFS guys getting into skull base and primary HNSCCa in the last decade, however. That's not where they get paid, though, so it's not like the trend will continue to the point where they equal ENT.

Pediatrics - obviously wide overlap

General - ENT's probably do more with OSA than the others, followed by OMFS, and then plastics, but there are some exceptions. T&A's, tubes, parotids, thyroids, parathyroids, esophageal stuff (e.g. Zenker's), and deep neck space infections are usually ENT among the 3, but again some of these areas overlap with oher surgical fields like endocrine and general surgery. The infectious stuff can run together with OMFS often secondary to dental etiology.

Unfortunately, or fortunately, depending on your perspective, I don't think there are any distinct lines any more. Even derm is creeping in and doing more and more in the head and neck area. The derm guy, of all people, in my facility does forehead flaps for nasal reconstructions. We usually will work together on those, but still, the lines are blurred.

You are right though, in general, an OMFS guy can make more than the ENT. But so can plastics and any other specialty who collects money up front out of pocket instead of from a 3rd party payer.

 

[toofache32]

That's good info from Resxn, but I would emphasize the variability, depending on where you train. I'll give you the perspective from my institution as a 5th-year OMFS resident. We share a clinic with ENT at our county hospital and get to know those guys pretty well. Interestingly, OMFS & Plastics rotate onto ENT, but ENT doesn't rotate to OMFS or Plastics. I think all 3 specialties would benefit from rotations on the other 2.

My OMFS program does a very small amount of aerodigestive malignancy. Definately not enough neck dissections to feel comfortable doing it without a fellowship. It's otherwise completely dominated by ENT. We do a ton of skin cancer. The Moh's people basically split the face up evenly by all three services, except lips/perioral come to us while ears go to plastics. We also have Derms who do their own paramedian forehead flaps on occasion. OMFS does several of our own skin cancer excisions & reconstructions each week at one of our county hospitals where there are no Mohs surgeons. All salivary gland problems go to ENT, except one hospital where we only spend about 6-9 months.

Trauma- Face call is split every 3rd night, except OMFS does all mandibles all 7 days per week. And OMFS does all trauma at our VA (which is very little) We end up doing a fair amount more than the other services because of the mandible thing. If we have a mandible while ENT/Plastics has the midface on the same patient, they usually just give the whole case to us since we always love that stuff (ENT/Plastics interest is variable depending on the chief, faculty, etc).

OSA- None by plastics here. ENT does all of the trachs & UPPPs. OMFS does virtually all the noses, all maxillomandibular advancements, LAUPs and very rarely UPPP. Both do hypomandibular surgery for OSA.

Plastics- Interestingly, none of the 3 services do a ton, but it's probably pretty even. Plastics does a little more cosmetics, even though ENT/OMFS spend more overall time on the face.

Thyroids, parathyroids are all done by general surgery here. ENT really got rooked out on that one, especially for being such a "strong" department clinically and politically. Infections go to whoever is on face call, unless it's odontogenic it goes to OMFS.

No larynogology, sinus, skull base (except trauma), otology by OMFS here (or Plastics as far as I know). Just ENT. ENT does all their own free flaps here, but they occasionally toss a fibula to Plastics. OMFS doesn't do any free flaps.

Craniofacial- This is split between OMFS/Plastics at our children's hospital. Both services are scrubbed in on most bony reconstructions (i.e. cranial vault remodeling) while plastics does most of the primary lip/palates. OMFS does all the bone grafting and orthognathics. We do 2-5 orthognathic cases per week.

Anesthesia- OMFS residents do about 6 months of anesthesia, functioning as an anesthesia resident and running our own ORs. This allows us to do our own deep sedations and general anesthetics in our clinics for dentoalveoloar, implants, cosmetics, bone grafting, and some orthognathics.

More than anything, it sounds like you need to figure out which specialty you want. Then pick programs that will give you the exposure you're looking for. There are ways into OMFS with an MD degree, but it's not too common. Especially since most med students get almost zero exposure to OMFS. Good luck.

 

[resxn]

thanks for another perspective. I was hoping someone would post more than just what my experience has been--sounds like it is reasonably close, however.

 

[scalpel2008]

although there is a fair amount of overlap in the training as toofache and rsxn have so eloquently elaborated, the bread and butter stuff done in private practice is quite different between the 3 fields. So, it also depends on what you want to do after your training ie private practice (where the 3 are quite different) or fellowships/academics (where the overlap increases). That being said, its very difficult to make that decision before starting residency. Hell, I did dental school thinking i'll be done in four years and practice w/o call and that all changed when I came across OMS.