cosmetics after GS?

[Dissonance]

I've noticed that 2 pgy-5 GS residents from the program here are moving on to 'cosmetic surgery' 1 year fellowships. I haven't had a chance to talk to them.
I've noticed a discernable negative reaction from posters about cosmetics and especially toward these type of fellowships. I also realize cosmetics is not the same as PRS and is governed by a different board.
I also noticed that many do not sit for boards or become board certified.

What are the negatives of these types of fellowships? Is being BC from the 'american board of cosmetic surgery' legit? do you think a 1 year fellowship is able to train you to do breast, abdominoplasty, blephs etc post doing a GS res? lastly, is doing cosmetics without a plastics background prone to litigation?

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[maxheadroom]

I've noticed that 2 pgy-5 GS residents from the program here are moving on to 'cosmetic surgery' 1 year fellowships. I haven't had a chance to talk to them.
I've noticed a discernable negative reaction from posters about cosmetics and especially toward these type of fellowships. I also realize cosmetics is not the same as PRS and is governed by a different board.
I also noticed that many do not sit for boards or become board certified.

What are the negatives of these types of fellowships? Is being BC from the 'american board of cosmetic surgery' legit? do you think a 1 year fellowship is able to train you to do breast, abdominoplasty, blephs etc post doing a GS res? lastly, is doing cosmetics without a plastics background prone to litigation?

The American Board of Cosmetic Surgery is nothing more than a sham. There are no training standards. There is no oversight. It is simply an organization based around making money. You will see very, very few Plastic Surgeons who will have anything to do with that organization. They are not recognized by the ABMS (American Board of Medical Specialties), although they continuously seek recognition as an equivalent.

 

[Moravian]

Max is very blunt, but he's absolutely right. The Cosmetic Surgery Board is not recognized by the American Board of Medical Specialties. As much as they try to get recognized, it's never going to happen.

All specialties that are recognized have training programs that are certified by the ACGME. That means there are rules, regulations, and more importantly standards concerning the training received. There are no standards for cosmetic surgery.

 

[Winged Scapula]

Being certified by the American Board of Cosmetic Surgery is only legit in the eyes of those who don't know better. That would be naive patients and medical colleagues who don't do their homework.

You will not be respected by your knowledgeable colleagues for it and some of those in the know may scoff at your training and "certification". I have no problem with someone who wants an aesthetics practice. I am surrounded by them here and know many professionally and socially. Its the first thing I look at when I see ads in the local magazines.

However, I am general surgery trained and would not consider having any aesthetic work done by someone who is not PRS or ENT/facial PRS trained. *Maybe* if you spent an entire year just learning cosmetics on ONE body part (ie, the aesthetic breast fellowships), I might consider it, but the skill in tissue handling, managing complications and training required to do the wide variety of procedures you've listed cannot be truly mastered in a year long fellowship and are not offered in a typical general surgery residency, IMHO.

 

[Dissonance]

So the training received at these fellowships must be extremely variable and most likely inadequate. I'm assuming it is possible for someone trained in these fellowships to open up an aesthetics practice and bill in cash. However, this seems like taking a large risk, since logically being bc in something that is not recognized by the ABMS could mean that you get lit up in court if you were to get sued?

It seems that there would be a reasonably fullfilling component to performing aesthetic reconstructions and implants post breast onc sx., as opposed to purely cosmetics. I'm assuming 'lifestyle' of these are good, hence possibly making aesthetic breast fellowships more competitive?

 

[rongeur]

It seems that there would be a reasonably fullfilling component to performing aesthetic reconstructions and implants post breast onc sx., as opposed to purely cosmetics. I'm assuming 'lifestyle' of these are good, hence possibly making aesthetic breast fellowships more competitive?

But all you're going to be able to offer after a one year "cosmetic breast" fellowship is expander/implant. No breast onc guys are going to refer to you if you're not even qualified to do a pedicled TRAM for patients who need it, much less a free TRAM or DIEP. The unrecognized cosmetic fellowships are for pulling people in off the street who don't know or don't care about ABMS. Any doctor who had to go through the pain of board certification in any specialty is not usually a huge fan of this.

 

[Winged Scapula]

But all you're going to be able to offer after a one year "cosmetic breast" fellowship is expander/implant. No breast onc guys are going to refer to you if you're not even qualified to do a pedicled TRAM for patients who need it, much less a free TRAM or DIEP. The unrecognized cosmetic fellowships are for pulling people in off the street who don't know or don't care about ABMS. Any doctor who had to go through the pain of board certification in any specialty is not usually a huge fan of this.

Me thinks you are overstating the case.

Now, I agree with you that the 1 year aesthetic breast fellowships are not going to give you the same experience as a plastic surgery trained physician. However, there are aesthetic breast fellowships which DO offer tissue transfer techniques. I am only aware of 1 that takes general surgeons however; there are clearly many more which are only open to PRS surgeons. There clearly isn't the broad based experience you would get in a plastics residency.

Secondly, no patient NEEDS a TRAM. The vast majority of oncologic reconstruction that takes place in this country is with tissue expanders and implants.

You are probably training at an academic medical center and see more TRAMs, DIEPs, etc. This is not typical of what happens in the community where most breast cancer is taken care of. These are complicated procedures, with little to no more reimbursement than the implants and with a lot of potential complications.

I am always happy to have a patient consider this option (as long as they aren't a smoker, etc.) with their plastic surgeon but most patients, especially older ones, are not interested in the additional complications, recovery, etc. and opt for expanders/implants.

Oncologic reconstruction reimbursement sucks. I can understand why most plastic surgeons recommend the easiest, shortest procedure with the fewest complications to their patients.

Finally, in terms of malpractice liability: it depends on your insurer. Mine does not allow me to do plastic surgery procedures outside of local tissue rearrangement and advancement flaps without additional training and cost. A few years ago when the market was strong, many plastic surgeons approached my partner and I to see if we wanted them to teach us how to do the expanders/implants. We were definitely interested but decided that all we needed was one complication that we hadn't been trained to handle to have the plantiff's attorney ask us where we did our plastic surgery training. We figured it wasn't worth it...now with the economic changes, we have more than enough plastic surgeons willing to do our reconstruction. They do a great job, so they should do it.

 

[droliver]

I'm assuming 'lifestyle' of these are good, hence possibly making aesthetic breast fellowships more competitive?

Well coming from someone who actually did a fellowship in breast surgery, it would be difficult to be very comfortable or proficient with most advanced techniques if you don't have the "vocabulary" you get from plastic surgery training beforehand. It's not hard to do breast augmentation, but it's very hard to do it with low reoperation rates. Redo surgeries and reconstruction are even trickier still.

I cannot imagine someone wanting to stick their neck out liability wise to do this surgery without proper credentials (plastic surgery training in the case of breast). It's something you'll be clubbed over the head with in any lawsuit

 

[maxheadroom]

Well coming from someone who actually did a fellowship in breast surgery, it would be difficult to be very comfortable or proficient with most advanced techniques if you don't have the "vocabulary" you get from plastic surgery training beforehand. It's not hard to do breast augmentation, but it's very hard to do it with low reoperation rates. Redo surgeries and reconstruction are even trickier still.

I cannot imagine someone wanting to stick their neck out liability wise to do this surgery without proper credentials (plastic surgery training in the case of breast). It's something you'll be clubbed over the head with in any lawsuit

. . . And there will be a long line of Board-Certified Plastic Surgeons who are happy to provide expert witness testimony with the fully support of the Plastic Surgery community.

 

[rongeur]

Secondly, no patient NEEDS a TRAM. The vast majority of oncologic reconstruction that takes place in this country is with tissue expanders and implants.

You are probably training at an academic medical center and see more TRAMs, DIEPs, etc. This is not typical of what happens in the community where most breast cancer is taken care of. These are complicated procedures, with little to no more reimbursement than the implants and with a lot of potential complications.

I am always happy to have a patient consider this option (as long as they aren't a smoker, etc.) with their plastic surgeon but most patients, especially older ones, are not interested in the additional complications, recovery, etc. and opt for expanders/implants.

Oncologic reconstruction reimbursement sucks. I can understand why most plastic surgeons recommend the easiest, shortest procedure with the fewest complications to their patients.

This is all true, but wouldn't you want patients to at least have the option presented to them? Autologous recon isn't right for everyone or even most people, but the decision should be made based on whether it's right for the patient, not whether the surgeon only spent a year training and has zero training in relatively fundamental plastic surgery procedures like a pedicled TRAM. Would you refer to recon people who were only trained in expander/implant? (legitimate question)

 

[Winged Scapula]

This is all true, but wouldn't you want patients to at least have the option presented to them?

Obviously, this is why when I discuss recon with my patients, I mention and show pictures of every option. The decision is not mine. My role is to educate the patient.

Autologous recon isn't right for everyone or even most people, but the decision should be made based on whether it's right for the patient, not whether the surgeon only spent a year training and has zero training in relatively fundamental plastic surgery procedures like a pedicled TRAM.

Since I have the option of sending my patients to BC plastic surgeons who offer all forms of reconstruction, I have no interest in sending them to someone who has spent only a year in training, regardless of what form of reconstruction they choose. I think you are misinterpreting my words. My comment about autolgous recon was not based on whether or not patients should or shouldn't have it but in response to your comment that patients NEED it.

And I think it DOES make a difference if a patient wants autologous tissue recon that they go to someone with the training AND who does it frequently enough. Since I am the referral source for my patients, they are not going to be sent to someone without the training and experience. Local PRS realize this which is why they market themselves to me and not PCPs if they are interested in doing cancer reconstruction (which most PRS in this area are not).

Would you refer to recon people who were only trained in expander/implant? (legitimate question)

It would depend on the patient and the person. But at this point, probably not because the patient will also often want nipple reconstruction and/or reduction for symmetry and other plastic procedures which the person you mention trained in aesthetic breast surgery may or may not have. But if they were and they were good, I would consider it.

Look, if its a surgeon I know and trust and whom doesn't try and hoodwink the public with the BC American Board of Cosmetic Surgery crap, then sure, I'd consider them if they offered everything I think my patient would need. It doesn't make much sense to me to have one person do the expander/implant and then send them to someone else for symmetry procedures and nipple/areolar reconstruction. So as long as they could do everything the cancer patient would need as well as some of the benign stuff I see, then I would consider using them.

If you are training in such a program, I think you have to realize that my opinion is commonplace amongst the medical profession. You will have a struggle in some parts of the country to market yourself. I wish you the best of luck.

 

[Dissonance]

. . . And there will be a long line of Board-Certified Plastic Surgeons who are happy to provide expert witness testimony with the fully support of the Plastic Surgery community.

Thats exactly what I thought would happen. It is obvious the backdoor to 'cosmetics' is fraught with peril. Why these GS residents from my program would consider doing these fellowships is beyond me.

 

[JackADeli]

The American Board of Cosmetic Surgery ...There are no training standards. There is no oversight. ...They are not recognized by the ABMS (American Board of Medical Specialties)...

So the training received at these fellowships must be extremely variable ...I'm assuming it is possible for someone trained in these fellowships to open up an aesthetics practice and bill in cash...

I am no expert on these types of training. Yet, I hear, however unethical one may feel, they can be lucrative. Further, we are specifically speaking of GenSurge trained MDs going into these. Unfortunately, I hear of too numerous non-surgeons going to these training. To my understanding, there are numerous family practice, dermatologists, and dentists to name a few that carry the "certification". I know of "aesthetic" centers & spas in more rural communities run by non "SURGEONS". Someone just the other day was telling me about the booming practice of office based abdomino-plasty being performed by the local "aesthetics" family practice doctor. Furthermore, this aesthetic FP's office/clinic is an integral component of the local FP residency training... i.e. a formal rotation!

JAD

 

[Winged Scapula]

Unfortunately, I hear of too numerous non-surgeons going to these training. To my understanding, there are numerous family practice, dermatologists, and dentists to name a few that carry the "certification". I know of "aesthetic" centers & spas in more rural communities run by non "SURGEONS". Someone just the other day was telling me about the booming practice of office based abdomino-plasty being performed by the local "aesthetics" family practice doctor. Furthermore, this aesthetic FP's office/clinic is an integral component of the local FP residency training... i.e. a formal rotation!

JAD

WTF indeed.

I for one, cannot imagine:

1) "office based" abdominoplasty

2) a non-surgeon doing what is widely recognized as a surgical procedure.

Now, it reminds me of a conversation I was having with a GS friend of mine. She was disparaging non-surgeons doing aesthetic procedures.

We were NOT talking about anything involving cutting of skin - but rather Botox and other injectables, Laser hair removal, Dermbrasion, Accent cellulite removal, etc.

My point was that she didn't learn any of the above in residency and took the same darn weekend courses that the Ob-Gyns, Derms and FPs took, so why should she be any better. As long as you aren't doing surgery, does it matter who is doing these procedures?

Just wondering what the consensus is and what I *might* be missing.

 

[JackADeli]

... a non-surgeon doing what is widely recognized as a surgical procedure...

Let me throw another log in the fire....
But, this is what is happening out there.... especially in the cash for service practices... the uninsured select patient populations are paying dollars. In addition to office based abdomino-plasty..... apparently does primary repair, without mesh, inguinal hernias in the office. I guess that is the standard of care when it comes to hernia repair too!

...it is AMA policy that individual character, training, competence and judgment be the criteria for granting privileges in hospitals... physicians representing several specialties can and should be permitted to perform the same procedure if they meet this criteria...

...It is the position of the American Academy of Family Physicians that clinical privileges should be based on the individual physician's documented training and/or experience, demonstrated abilities and current competence. This general policy would of course apply to privileges in all areas. The Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association hold similar positions...

Gots to love the "of course"!!!

...The AAFP strongly believes that the granting of privileges for new procedures and techniques for all physicians should be made on the basis of each physician's documented training and/or experience, demonstrated abilities and current competence.

The AAFP further believes that courses to teach new procedures and techniques should be available to all physicians, regardless of specialty...

Gots to love "all physicians"!!!

So, what does it mean? Let's put it this way.... how many lap choles or inguinal hernias are you required to perform to be eligible for ABS certification? Some would argue that number is in conjunction with the broader experience and additional other cases. The counter argument that has been made.... "well, they are basic procedures and I'm not seeking ABS certification, just the right to perform a lap chole/lap appy/inguinal hernia". There in lies the rub. That is how you have dentists, derms, FPs out in the community collecting cash on the barrel for what we think should be the domain of a "fully trained surgeon".

Don't get me started on the privileging of ED docs and their positions....

JAD

 

[medhacker]

Is being BC from the 'american board of cosmetic surgery' legit?

California seems to think they are legit.

They won a court battle, in California, some years ago and they were given equal recognition, in what respects the ability to adverstise themselves as "board certified". They can now legally and openly advertise as "board certified" cosmetic surgeon.

Word has it they don't plan to stop with the Cali success...



_______________________________________________
Medhacker an FP doing cosmetic surgery, pissing off the plastics and the derms...and loving every single minute of it!

 

[Winged Scapula]

California seems to think they are legit.

They won a court battle, in California, some years ago and they were given equal recognition, in what respects the ability to adverstise themselves as "board certified". They can now legally and openly advertise as "board certified" cosmetic surgeon.

Word has it they don't plan to stop with the Cali success...



_______________________________________________
Medhacker an FP doing cosmetic surgery, pissing off the plastics and the derms...and loving every single minute of it!

But that doesn't make any difference. As long as a board exists, there is no fraud being committed by labeling oneself as "Board Certified".

Hell, I could create a Board of Breast Surgery tomorrow and call myself Board Certified and perhaps even get some state to ratify it. But as long as the certification is not recognized by the usual ABMS, then it isn't really BC, is it? Regardless of what California says.

 

[medhacker]

But that doesn't make any difference. As long as a board exists, there is no fraud being committed by labeling oneself as "Board Certified".

Hell, I could create a Board of Breast Surgery tomorrow and call myself Board Certified and perhaps even get some state to ratify it. But as long as the certification is not recognized by the usual ABMS, then it isn't really BC, is it? Regardless of what California says.

What goes in California is what the state of California says. California says, board certified by ABCS is equivalent to ABMS and that is the "law of the land" in Cali.

Some other states specifically state only ABMS is considered board certified by their board of medicine, and it's illegal for someone ABCS certified to advertise as "board certified" - not the case in Cali anymore.

The board of medicine, and the community at large in Cali must respect the decision of the court and thus consider ABCS members as legit "board certified" cosmetic surgeons.

 

[JaggerPlate]

What goes in California is what the state of California says. California says, board certified by ABCS is equivalent to ABMS and that is the "law of the land" in Cali.

Some other states specifically state only ABMS is considered board certified by their board of medicine, and it's illegal for someone ABCS certified to advertise as "board certified" - not the case in Cali anymore.

The board of medicine, and the community at large in Cali must respect the decision of the court and thus consider ABCS members as legit "board certified" cosmetic surgeons.

If it's any consolation, Cali is so stocked full of cosmetic surgeons, whether they be legit PRS guys who don't do recon anymore or GSurg -> 'cosmetic fellowship' etc, that people have a choice and are usually smart enough to chose the PRS guys. Most PRS surgeons have a little blurb on their site about being BC in PRS vs cosmetic surgery, etc. I say this because I have a family member in CA who went in for a cosmetic procedure and was told specifically from three separate friends (with no medical experience) to go to a BC PRS surgeon NOT a cosmetic surgeon.

 

[asmallchild]

Well coming from someone who actually did a fellowship in breast surgery, it would be difficult to be very comfortable or proficient with most advanced techniques if you don't have the "vocabulary" you get from plastic surgery training beforehand. It's not hard to do breast augmentation, but it's very hard to do it with low reoperation rates. Redo surgeries and reconstruction are even trickier still.

I cannot imagine someone wanting to stick their neck out liability wise to do this surgery without proper credentials (plastic surgery training in the case of breast). It's something you'll be clubbed over the head with in any lawsuit

 

[Winged Scapula]

If it's any consolation, Cali is so stocked full of cosmetic surgeons, whether they be legit PRS guys who don't do recon anymore or GSurg -> 'cosmetic fellowship' etc, that people have a choice and are usually smart enough to chose the PRS guys. Most PRS surgeons have a little blurb on their site about being BC in PRS vs cosmetic surgery, etc. I say this because I have a family member in CA who went in for a cosmetic procedure and was told specifically from three separate friends (with no medical experience) to go to a BC PRS surgeon NOT a cosmetic surgeon.

I HIGHLY doubt medhacker finds that consoling.

By his own admission, he's a Family Practitioner doing Cosmetic Surgery.

 

[beefballs]

forgive my ignorance, but shouldn't you be able to deal with the complications if you are gonna do a procedure, and based on anatomy alone, abdominoplasty by any non surgeon borders on negligence

 

[JaggerPlate]

I HIGHLY doubt medhacker finds that consoling.

By his own admission, he's a Family Practitioner doing Cosmetic Surgery.

Oh ... well, ummm sorry??? I had no idea. It's probably just Cali.