Aesthetic vs Plastics

[desimd77]

I'm coming to the end of the GS residency and can't figure out what fellowship to go into. A friend of mine going into plastics and suggested i look into an Aesthetic fellowship. I am not really intested in doing TRAMs or big flaps, but I do like the idea of being able to do some cosmetic surgery in addition to GS if i wanted. I also like the plastics side because of the technical skills needed. Also I don't think i can take another 3 year fellowship after GS.

What kind of opportunities are out there? Do people prefer not to go to someone certified in Aesthetic surgery vs. plastics? Is it difficult to find a practice to join, because you are not really a gs and you are not really a plastics guy?

thanks in advace

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[Winged Scapula]

I'm coming to the end of the GS residency and can't figure out what fellowship to go into. A friend of mine going into plastics and suggested i look into an Aesthetic fellowship. I am not really intested in doing TRAMs or big flaps, but I do like the idea of being able to do some cosmetic surgery in addition to GS if i wanted. I also like the plastics side because of the technical skills needed. Also I don't think i can take another 3 year fellowship after GS.

What kind of opportunities are out there? Do people prefer not to go to someone certified in Aesthetic surgery vs. plastics?

There is no Board Certification for Aesthetic Surgery, at least not one that is a member of the ABMS. As to whether people "prefer", it depends on the knowledge of your customer base. Many people don't know the difference between an aesthetic/cosmetic surgeon and a plastic surgeon, and those are the patients you will get. Those that know the difference will go to a Plastic Surgeon.

I won't ask if you truly feel qualified to do even basic aesthetics with only 1 year of training - only you can answer that; I only know of 1 breast aesthetic fellowship that is open to general surgeons - located in Westchester, NY. All others require PRS training.

Is it difficult to find a practice to join, because you are not really a gs and you are not really a plastics guy?

Probably, if you are not going to be doing GS or taking GS call. You can't take plastics call, you might not be able to get hospital privileges or malpractice coverage to do aesthetics (my company requires a special rider for cosmetics and bariatrics), so what incentive is there for the group to take you on?

If you did GS AND aesthetics, that's a different story, and I'll let the PRS guys comment, but it appears to be the same issue as with Hand. You can't do Ortho, or Plastics.

There are other 1 year fellowships out there that ARE marketable - Breast for example (2 years in some places). MIS. Burns (although small market). Trauma/CC.

 

[deleted144060]

Part of my time is spent at a private hospitals outside the University system and I can tell you that you will most likely NOT get privileges to do aesthetic procedures. The plastic surgeons are VERY active in keeping out anyone who hasn't been through PRS or ENT w/ facial plastics. Occasionally an OMFS person will try to get facelift privileges and they get shot down every time. I'm not saying that it's right or wrong, it just is.

I know there are general surgeons doing lipo, abominoplasties and breast reduction/augs in their offices because we sometimes see their complications. Plastics folks get complications too, but we can admit them to the hospital and take care of it ourselves (because we have privileges).

Just something to think about.

--M

p.s. In my plastics training, I didn't want to do big tram flaps either, but it was necessary to get to where I wanted to be.

 

[Winged Scapula]

Part of my time is spent at a private hospitals outside the University system and I can tell you that you will most likely NOT get privileges to do aesthetic procedures. The plastic surgeons are VERY active in keeping out anyone who hasn't been through PRS or ENT w/ facial plastics. Occasionally an OMFS person will try to get facelift privileges and they get shot down every time. I'm not saying that it's right or wrong, it just is.

I know there are general surgeons doing lipo, abominoplasties and breast reduction/augs in their offices because we sometimes see their complications. Plastics folks get complications too, but we can admit them to the hospital and take care of it ourselves (because we have privileges).

Just something to think about.

--M

p.s. In my plastics training, I didn't want to do big tram flaps either, but it was necessary to get to where I wanted to be.

Good point. The non-PRS and ENT guys I see do aesthetics are doing them in their offices or little surgery centers where they are part owner.

Of course, it doesn't sound like the OP wants to be doing big cases so could possibly make it work in such an arena where he wouldn't necessarily need hospital privileges for aesthetics. Practically though - unless he were in BFE, could he even get the patient referrals?

We were discussing this today in the OR - a couple of local guy's names came up. One is ENT and built his plastics practice doing facial procedures. Fine...except now he's branched out into doing body sculpting, adominoplasties, etc. Stuff he never did in ENT training. The gas guys and nurses definitely know who's doing stuff they shouldn't be doing (and share that information, gossipy little bunch they are). Trouble is, this guy is Chief of Surgery at the hospital so I'm sure getting privileges was a little easier for him (although he still does a lot in his office...matter of fact, I've never seen him on the OR schedule).

 

[GTFOOMICT]

The plastic surgeons are VERY active in keeping out anyone who hasn't been through PRS or ENT w/ facial plastics. Occasionally an OMFS person will try to get facelift privileges and they get shot down every time. I'm not saying that it's right or wrong, it just is.

I'm in OMS and appreciate some of your discussions on your forum.

In CA there are some OMFS who completed fellowships and have log numbers to back it up. They do 100% of their cases in private practice in surgery centers as you suggest. The 2 I know well attempted to get privileges so they could manage their own complications. They were denied initially despite having adequate training. It was obvious politics. They didn't really care because they were happy in their well equipped center. They just wanted to be prepared.

They had a hematoma following a facelift on a patient and wanted hospital based OR and nursing support but they had to refer to the prs at the hospital. Patient complained and armed with that complaint and privileging information at similar hospitals the pair was given privileges.

I 100% agree that those without training shouldn't be given privileges. But why put up that wall when the private practice world is so unregulated?

Do you feel all those practitioners who were shot down were in fact I'll-equipped or do you feel those that are trained are still turned down?

Thanks for your input. I'm naive on this.

 

[deleted144060]

Do you feel all those practitioners who were shot down were in fact I'll-equipped or do you feel those that are trained are still turned down?

Both. Unfortunate but true. It can be very political and is something you should consider when looking for a job.

Best,

--M

 

[droliver]

Do you feel all those practitioners who were shot down were in fact I'll-equipped or do you feel those that are trained are still turned down?

Both. A facelift is outside the scope of an oral surgeon's practice

 

[maxheadroom]

The big question that I have for these "Cosmetic Surgeons" is why they don't broadcast what their board certification really is?

If you're an OMFS doing facelifts, do you actually tell your patient that you're OMFS? Or do you come up with some BS Cosmetic Surgeon title?

 

[DREDAY]

The big question that I have for these "Cosmetic Surgeons" is why they don't broadcast what their board certification really is?

If you're an OMFS doing facelifts, do you actually tell your patient that you're OMFS? Or do you come up with some BS Cosmetic Surgeon title?

We proudly broadcast as OMFS, and patients happily come to us. Our results speak for itself.

 

[DREDAY]

Both. A facelift is outside the scope of an oral surgeon's practice

Why don't you say that to my attendings who are doing rhinos, septos, ABBE flaps, MOHs, ottos, face lifts at 3 different hospitals.

 

[DREDAY]

Both. A facelift is outside the scope of an oral surgeon's practice

oh i forgot.. pectoralis flaps too.

 

[Exodontist]

The big question that I have for these "Cosmetic Surgeons" is why they don't broadcast what their board certification really is?

If you're an OMFS doing facelifts, do you actually tell your patient that you're OMFS? Or do you come up with some BS Cosmetic Surgeon title?

That's where the maxillofacial part comes in. There's really no point arguing about OMFS's scope, some are trained to be more competent than others. What you need to understand is that our scope is not just extractions and dental impants.

To Dreday: let not get defensive, these are the M.Ds that need to be educated on our field so they dont get flamming on some of the "crazy" stuffs we do.

 

[armorshell]

Both. A facelift is outside the scope of an oral surgeon's practice

Would you still define it as outside of scope if said OMS was trained to perform facelifts in their residency, with procedural numbers comparable for credentialing of a PRS?

 

[Fah-Q]

I wondered how long it would take for the dentists to object to the above statement. There was quite the thread on the scope of oral surgery in the otolaryngology forum a few months ago.

This might get nasty again.

 

[GTFOOMICT]

Those Oral Maxillofacial Surgeons with medical licenses are protected twice over.

The dental practice acts allows them to do facelifts, facial implants, botox, fillers etc. You can disagree with that law but it's there.

The full medical license allows them to do all of the above again.

The 'fake boards' previously mentioned may be a large problem within medicine. A quick google search and I found a cosmetic surgeon with quite the list of board certifications. One of them he was the founder, president, and sole member! Quite exclusive and only the best of the best?? I'm gonna see if I can join as a medical student of course.

I have been told by a PRS that historically the skills needed to safely perform and care for cosmetic surgery of the face was limited to plastic surgeons. It was part of their/your training and VERY FEW other individuals within all the specialties had any form of exposure. The scope of plastic surgery at that time was also not as broad (although still impressive) and cosmetics could be more prominent in some programs. All his opinion, not mine.

Times are different. Training dictates scope. Accept it. And OMS has their own "underdogs" taking their $$$ procedures away from them as well. Laws will never limit cosmetic procedures to just plastic surgeons. Speaking of $$$, OMS make way more pulling teeth and putting in implants so saying it's a money grab is useless.

Any OMS who tells patients he/she is a plastic surgeon is a lier. If they say there are a cosmetic surgeon, I'm fine with that. If they say they are performing plastic surgery of the face....not sure what I think about that. I do understand the confusion from the public though.

 

[Mohab]

Both. A facelift is outside the scope of an oral surgeon's practice

If you had said "A facelift IN MY OPINION SHOULD BE CONSIDERED outside the scope of an oral surgeon's practice", I would have no problem with your statement. You are definitely entitled to have such beliefs.
But to try to present it as if a fact (when it is obviously false) is exactly the reason why so many people -both patients and other healthcare professionals- are confused about our specialty. Are you suggesting all OMS's performing facelifts are breaking the law? Why don't you just accept that there are many surgical specialties and that a lot of overlap exists in their scope of practice. Trying to argue otherwise won't change anything.

 

[droliver]

If you had said " You are definitely entitled to have such beliefs.
But to try to present it as if a fact (when it is obviously false) is exactly the reason why so many people -both patients and other healthcare professionals- are confused about our specialty. Are you suggesting all OMS's performing facelifts are breaking the law?

Well 18 national specialty organizations, including the AMA, the American College of Surgeons, the American Society of Plastic Surgeon, The American Society of Aesthetic Plastic Surgery, and 12 state medical societies filed affidavits with the state of California opposing expansion of Oral Surgeons scope of practice to include facial cosmetic surgery when this was being litigated in 2006. Despite widespread opposition, Gov. Schwarzenegger went on to sign a bill that expanded the practice of oral surgeons in that state.

This issue of oral surgery scope of practice has been contested in many states

EX:Tennessee Medical Association v. Tennessee Board of Dentistry 2001
The Tennessee Medical Association sued the Tennessee Board of Dentistry in a scope of practice dispute. The dentistry board tried to allow maxillofacial surgeons to perform examinations and procedures that exceed the statutory mandate of caring for “teeth…jaws or associated structures.” The board allowed dentists to perform aesthetic and reconstructive surgery on all parts of the head and neck, including on the eyelids, nose, and ears. TMA won in the trial court, whereupon the case was appealed by later upheld by The Tennessee Supreme Court.

FWIW, the AMA is on record as recently as 2009 (see AMA publication “Scope of Practice Data Series on Oral and Maxillofacial Surgery.”) reinforcing the notion that oral surgeons performing cosmetic facial surgery represents an unwarranted expansion of traditional practice. So long story short, NO it's not just my personal opinion that this practice is inappropriate. As oral surgery is an approved pathway for plastic surgery residency training, I'd encourage those oral surgeons interested in plastic surgery of the head and neck to apply.

 

[armorshell]

Well 18 national specialty organizations, including the AMA, the American College of Surgeons, the American Society of Plastic Surgeon, The American Society of Aesthetic Plastic Surgery, and 12 state medical societies filed affidavits with the state of California opposing expansion of Oral Surgeons scope of practice to include facial cosmetic surgery when this was being litigated in 2006. Despite widespread opposition, Gov. Schwarzenegger went on to sign a bill that expanded the practice of oral surgeons in that state.

This issue of oral surgery scope of practice has been contested in many states

EX:Tennessee Medical Association v. Tennessee Board of Dentistry 2001
The Tennessee Medical Association sued the Tennessee Board of Dentistry in a scope of practice dispute. The dentistry board tried to allow maxillofacial surgeons to perform examinations and procedures that exceed the statutory mandate of caring for “teeth…jaws or associated structures.” The board allowed dentists to perform aesthetic and reconstructive surgery on all parts of the head and neck, including on the eyelids, nose, and ears. TMA won in the trial court, whereupon the case was appealed by later upheld by The Tennessee Supreme Court.

FWIW, the AMA is on record as recently as 2009 (see AMA publication “Scope of Practice Data Series on Oral and Maxillofacial Surgery.”) reinforcing the notion that oral surgeons performing cosmetic facial surgery represents an unwarranted expansion of traditional practice. So long story short, NO it's not just my personal opinion that this practice is inappropriate. As oral surgery is an approved pathway for plastic surgery residency training, I'd encourage those oral surgeons interested in plastic surgery of the head and neck to apply.

Your post is at best vague and at worst misleading, because you're ignoring a very important variable. All the litigation AND the SOP Series are explicitly focused on OMFS without a medical degree. In fact, in the SOP series it is the verbatim opinion of the AMA that MD bearing OMFS should have no limitation to their scope of practice such as they suggest for DDS-only OMFS

 

[droliver]

The "important variable" is merely that an MD degree exempts you from scope of practice legislation governing dental practice and lumps you with MD's. As states and state medical boards are traditionally loath to get into to restricting scope of practice of MD's, it is not specified as such in state law and it's basically an end-run around the debate rather then addressing the issue of competency. There has been some talk (in Georgia most recently) of state boards getting into more specifically limiting MD scope of practice after some recent disasters by providers doing surgery clearly outside of their scope of practice. The aforementioned organizations are still on the record about oral surgeons (DMD or no) and this issue.

 

[DREDAY]

So explain to me why OMFS can perform frontal sinus reconstruction, NOE fx, panfacial trauma, maxillectomy, mandibulectomy, and neck dissections but not cosmetics? If we are equally trained to perform cosmetics and the above surgeries, there shouldn't be restrictions. The issue here is not competence but rather money. Your arguments in support of patient safety is a facade and that is why it will never hold up.

OMFS can do reconstructions like this: http://abcnews.go.com/Nightline/chrissy-steltz-blinded-gunshot-prosthetic-face/story?id=11162243

but can't do cosmetics? hmmmmm

The "important variable" is merely that an MD degree exempts you from scope of practice legislation governing dental practice and lumps you with MD's. As states and state medical boards are traditionally loath to get into to restricting scope of practice of MD's, it is not specified as such in state law and it's basically an end-run around the debate rather then addressing the issue of competency. There has been some talk (in Georgia most recently) of state boards getting into more specifically limiting MD scope of practice after some recent disasters by providers doing surgery clearly outside of their scope of practice. The aforementioned organizations are still on the record about oral surgeons (DMD or no) and this issue.

 

[armorshell]

The "important variable" is merely that an MD degree exempts you from scope of practice legislation governing dental practice and lumps you with MD's. As states and state medical boards are traditionally loath to get into to restricting scope of practice of MD's, it is not specified as such in state law and it's basically an end-run around the debate rather then addressing the issue of competency. There has been some talk (in Georgia most recently) of state boards getting into more specifically limiting MD scope of practice after some recent disasters by providers doing surgery clearly outside of their scope of practice. The aforementioned organizations are still on the record about oral surgeons (DMD or no) and this issue.

We agree in the fact that there exists a complicated waltz around the real issues, but we disagree on exactly who it is doing the dancing. I'd uphold that telling an oral surgeon with residency training, a year long fellowship in facial cosmetics and a strong logbook of procedures to present to a hospital credentialing board that they are unqualified to perform these procedures because they don't have an MD an "end-run around the debate without addressing the issue of competency."

As far as I know, there's no evidence whether either specialty performs any procedure with any more skill or safety than another (Besides the quite "rigorous" Ladosci article). Debates are focused on anecdotes, legalese and semantics rather than patient care and surgical competence, which seems like a pragmatic way to handle the situation to me.

Am I crazy to think if a surgeon learns how to do a procedure in an academic setting that they should be able to do it in practice?

 

[armorshell]

Also, your post about the Tennessee decision is again, unclear at best. The outcome of the Tennessee decision is about blanket approval for OMFS to perform all cosmetic procedures under the dental practice act, which the court disagreed with. If you read the decision, they are comfortable with OMFS performing all the procedures mentioned but not as a de facto declaratory order.

We recognize that this is necessary and that an oral and maxillofacial surgeon may
perform some aspects of these cosmetic procedures in some instances. We hold merely that the
definition of dentistry contained in Tennessee Code Annotated § 63-5-108(a)(1) does not blanketly
authorize a dentist, even an oral and maxillofacial surgeon, to perform cosmetic procedures such as
face lifts and nose jobs.

I think most OMFS would agree with the decision of this case. Scope of practice should be determined by surgical training, not by legislation, which is what the board was trying to achieve here.

Also, as long as we're quoting case law here, why not mention MSV vs. Niamtu? Is it because it was thrown out?

 

[armorshell]

So explain to me why OMFS can perform frontal sinus reconstruction, NOE fx, panfacial trauma, maxillectomy, mandibulectomy, and neck dissections but not cosmetics?

Of course DRE, because those don't pay very well. If tomorrow Obama blows his magic pan flute and ripe medicaid dollars started flowing into the pockets of facial trauma surgeons, it'd only be a matter of days before this board is rife with threads about why OMFS shouldn't be mucking around with jaw fractures.

 

[DREDAY]

Well 18 national specialty organizations, including the AMA, the American College of Surgeons, the American Society of Plastic Surgeon, The American Society of Aesthetic Plastic Surgery, and 12 state medical societies filed affidavits with the state of California opposing expansion of Oral Surgeons scope of practice to include facial cosmetic surgery when this was being litigated in 2006. Despite widespread opposition, Gov. Schwarzenegger went on to sign a bill that expanded the practice of oral surgeons in that state.

This issue of oral surgery scope of practice has been contested in many states

EX:Tennessee Medical Association v. Tennessee Board of Dentistry 2001
The Tennessee Medical Association sued the Tennessee Board of Dentistry in a scope of practice dispute. The dentistry board tried to allow maxillofacial surgeons to perform examinations and procedures that exceed the statutory mandate of caring for "teeth…jaws or associated structures." The board allowed dentists to perform aesthetic and reconstructive surgery on all parts of the head and neck, including on the eyelids, nose, and ears. TMA won in the trial court, whereupon the case was appealed by later upheld by The Tennessee Supreme Court.

FWIW, the AMA is on record as recently as 2009 (see AMA publication "Scope of Practice Data Series on Oral and Maxillofacial Surgery.") reinforcing the notion that oral surgeons performing cosmetic facial surgery represents an unwarranted expansion of traditional practice. So long story short, NO it's not just my personal opinion that this practice is inappropriate. As oral surgery is an approved pathway for plastic surgery residency training, I'd encourage those oral surgeons interested in plastic surgery of the head and neck to apply.

Obviously this judgement against OMFS that you speak of did not hold up. Dr. William Hunter a DDS only OMFS, WHO WAS THE PLAINTIFF IN THE CASE YOU QUOTED, continues to practice cosmetic surgery in Tennessee. I'm sure that given the controversy, the state kept a close eye on him. For the past 10 years since the judgment, he continues to practice cosmetic surgery. He must be doing something right for his patients to continue to seek his services. Don't believe me? here is a link to his practice.


http://www.drhunteroms.com/

 

[GTFOOMICT]

The "important variable" is merely that an MD degree exempts you from scope of practice legislation governing dental practice and lumps you with MD's. As states and state medical boards are traditionally loath to get into to restricting scope of practice of MD's, it is not specified as such in state law and it's basically an end-run around the debate rather then addressing the issue of competency. There has been some talk (in Georgia most recently) of state boards getting into more specifically limiting MD scope of practice after some recent disasters by providers doing surgery clearly outside of their scope of practice. The aforementioned organizations are still on the record about oral surgeons (DMD or no) and this issue.

Good for them for being on the record. It's a shoddy report.

It's actually insulting that you think an individual who completed dental school at the top of their class, then med school, then 4 years of surgical residency, then completes a fellowship in facial cosmetic surgery is not competent to do facelifts.

And yes, thankfully for those who have the interest, an OMS with MD can apply and be a full PRS. I think that is a generous offer by your profession to be honest. But why would they if their sole interest is face? A waste of resources. Plenty of facial fellowships abound.

At the end of the day, an OMS can make way more money sticking to pulling teeth and placing implants. So it's not just a money grab. There has to be a level of enjoyment by the surgeon, and there has to be devotion there. It's a word-of-mouth business. You can't stay in business if you aren't doing a good job. Money is too easy to get in dentoalveolar procedures. A cosmetic surgery office has got to be many times more difficult to run and will only get more difficult to run as reimbursement for physicians continues to get disgustingly low. You'll have every surgeon and non-surgeon on your turf then.

But because you are an attending with assuming plenty of experience, why are some of the brand name universities like stanford, duke, etc changing their deparment names to Plastic, Maxillofacial, and Oral surgery and/or having fellowships in OMS and/or hiring OMS on staff?? Cuz at the end of the day, our training has something to offer. Training in OMS is very different depending on where you're at, so don't paint everyone with the just a dentist brush. We are not plastic surgeons and there is a plethora of things you can do that I can not and will not be able to do. But we do have a place, and our training is good.

http://plastic.surgery.duke.edu/
http://plasticsurgery.stanford.edu/patient_care/oral.html