Bread and Butter Procedures

[Dr.CCM]

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I'm just wondering what are the bread and butter procedures for a general plastics guy?

What do you typically see mostly during residency and such?

Thanks.

 

[maxheadroom]

Hard to answer as Plastics is so broad. My friends in private practice who are "generalists" do a fair bit of breast surgery (augs, reductions, implant recon), skin cancer excision/reconstruction (especially if they're friendly with the local MOHS guy), some basic hand (carpal tunnels, ganglion cysts, triggers), and a wide range of cosmetic (depending upon what you like to do, facelifts, noses, body contouring). Most general guys out in private practice don't really do facial trauma (fractures) and most try to avoid hand call.

It really depends upon two things:

1. What you like to do.
2. What the community needs.

 

[Dr.CCM]

Wow, that seems like such a wide, awesome variety. To that end, does fellowship training in a particular area help/hurt your marketability in others ie the guy who does an aesthetic fellowship, will he still be able to do hand surgery, breast recon, etc?

 

[maxheadroom]

The real answer to that is "it depends".

You get two things out of a fellowship:

1. Added knowledge/experience
2. A marketable credential

As the "new guy" in town (especially in this economy), even if you're fellowship-trained in aesthetics, you won't be getting a whole lot of aesthetic business at first. In some communities (especially in this economy) you need to be CAQ eligible or certified to take Hand call (especially in some major markets with lots of surgeons who are under financial pressure).

I have a couple of friends who finished PRS training with HUGE hand experience and are probably more competent at extremity trauma than lots of the guys who have a CAQ but haven't done hand trauma in a long time. Doesn't matter, they haven't been able to get on the on-call panel at their hospitals. Why? Because the older guys who used to do mostly cosmetic are suddenly scrambling to grab ER stuff. One guy that I know in a large midwestern city only gets called when the patient is Medicaid/self-pay. The insurance patients seem to mostly end up with the established guys.

Friends tell me that it's been a similar problem for breast recon. A couple of years ago it was hard to find a Plastic surgeon in lots of the major metro areas who would co-ordinate immediate recon with a mastectomy. If you were willing, you could be pretty busy. Now, my friends who are fresh out of residency are competing with the guys in their late forties who haven't put in an expander in ten years.

My recommendation on fellowships is to look at what you expect to gain from that extra year of training. If your interest is in Hand surgery, it's pretty much required these days to do a Hand fellowship to get the "good" cases from the workman's comp managers and to be accepted by the other Hand guys in a larger market. (I've only been in practice for four months and I've already received a few insured patients from other Hand guys in town who have complex problems that fall within my area of "special interest".)

I only recommend an Aesthetic fellowship if there's a skill that you really want to learn more that was deficient in residency. If you didn't get much complex breast, then go work with Hammond/Spear/Maxwell. If you want to be a nose ninja, do the UTSW aesthetic fellowship or work with Toriumi (he does take a Plastics person from time to time). Otherwise, a well-rounded Plastics residency should give you the fundamentals to start small and build.

 

[Dr.CCM]

So, barring a deficiency in a particular area, it's probably best to go with a hand fellowship simply because not only will you get the gamut of procedures, but you'll be more marketable since you'll be a hand guy too, correct?

 

[maxheadroom]

Only if you like doing Hand and want to focus on that. I think a fellowship year is a good investment for just about anyone -- you learn something new and you see different approaches to something that you thought you knew. I'm just wary of a lot of the cosmetic fellowships. Certain ones have a history of being low-operative and taking all of the after-hours & weekend calls. While you certainly learn a lot by seeing some of that, most of those guys have a pretty limited practice.