Being at the end of my plastics rotations, I am starting to really appreciate assisting to some reconstructive procedures of the trunk such as DIEP and TRAM flaps, abdominoplasty, etc.
Does anyone ever heard of a GS performing DIEP procedures? I know it involves mastering microsurgical techniques, but I am pretty sure it would be acquired in a reasonable amount of time during fellowship. It would also implies cohabitation with plastic surgeons in order to do them, but I know quite of them who really hate microsurgery and would be willing to refer these procedures to someone else.
Kimberli, any take on this?
(PS: I will be practicing in Canada so the pro-litigation atmosphere you suffer in US won't apply in my situation, I know a handful of general surgeons performing procedures usually within the realm of PRS without being bothered, but none of them learnt how to do DIEP)
My sentiments echo those of
@LucidSplash and
@droliver above.
I am somewhat confused about what you are proposing. General Surgery residencies don't have any training in the micro vascular techniques need for DIEP flaps; as LS notes you would get this is PRS training. Are you considering further training in PRS or simply a short course in microvascular techniques? I'm confused about how you would get the training with doing a full PRS residency.
In summary, here's my take:
1) I don't know any general surgeons or breast surgeons doing their own flap reconstruction in the US who don't have additional training in PRS
2) outside of litigation issues, I don't know any US hospitals which will give you PRS privileges to do flaps (these are not considered part of GS core skills) without evidence of additional training in PRS;
3) in the US, as droliver points out, it doesn't make financial sense. As you add procedures on, each one is reimbursed at a lower rate. This is why some surgeons won't do bilateral mastectomies or nipple reconstruction at the same time as the primary surgery. This may not be the case in Canada, but here there is great disincentive to spend several more hours for very little extra money.
4) I also don't know many PRS guys in PP doing DIEPs; we had one local guy here doing them right out of training, on a salary guarantee. As expected, once he became fee for service I've not heard of him doing any; why would you spend several hours doing that when the reimbursement is so poor? These *tend* to be things more feasible in an academic environment. YMMV.
5) The major issue I have with GS doing PRS work without the additional residency training is the same issue we have with proceduralists: who is going to fix it when you have a complication? For example, I've assisted on many many reconstructions over the last few years and I'm fairly certain I could put in a tissue expander or implant, even some Alloderm. But what if there was a complication - not a post op hematoma but capsular contraction, lateralization of the implant, what if I made the pocket too big or violated the sternal attachment etc? I could probably fix those but not as well as a fully trained plastic surgeon could. Even more importantly, what if your DIEP died? Are you going to find a local PRS guy who's going to bail you out and help reconstruct this woman's chest now that her flap has failed?
6) Politics. When you go stepping on others territory they don't appreciate it. Like the CR surgeon doing screening colonoscopies and losing referrals from GI, a GS doing his own reconstructions even if the local guys don't like DIEPs, runs the risk of alienating your PRS colleagues. They already have enough grief trying to deal with non surgeons doing aesthetic procedures and injectables. You should be working with them. I actually get a fair bit of referrals from local PRS colleagues: they'll do a redux and find atypical cells or malignancy in the specimen, or they'll see a High Risk patient who comes in for an aesthetic consult or perhaps even a prophylactic surgery consult but hasn't yet seen (or didn't realize they needed to see) a GS, etc. So I wouldn't dream of stepping on their toes.
At the end of the day, your plan just doesn't make much sense to me unless you are planning on doing a PRS residency.
