Craniofacial surgery

[5150]

I'm a bit curious as to what the pros and cons are of doing craniofacial reconstruction through ENT versus plastics. Is the fellowship for craniofacial reconstruction right after the regular ENT residency? Can anyone shed some light on this for me? Is one pathway faster than the other? Training better in other versus the other?

Any information would be helpful, thanks.

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[naegleria brain]

plastics - expect a lot of touch ups and cosmetics.
ENT - expect more reconstructive

craniofacial fellowship trained ENT's are the ones that work with neurosurgeons to fix craniosynostosis (sp?) ie. tower skull, scaphocephaly etc. i've seen only one plastics guy called, and that's because the neurosurgeons were screwing with him. the ent replaced him halfway through

essentially it comes down to your bread-and-butter. do you want to excise acoustic neuromas or boob jobs?

 

[Jocomama]

I know ENT does facial trauma, but I was not aware of any ENT post-residency fellowships in pediatric craniofacial surgery. Is there a site that lists the programs?
Interesting

I'm a bit curious as to what the pros and cons are of doing craniofacial reconstruction through ENT versus plastics. Is the fellowship for craniofacial reconstruction right after the regular ENT residency? Can anyone shed some light on this for me? Is one pathway faster than the other? Training better in other versus the other?

Any information would be helpful, thanks.

 

[neutropeniaboy]

There's a little bit of misinformation here.

Let's agree that someone who does craniofacial surgery is someone who does reconstruction of the midface and cranial vault for genetic malformations or acquired malformations. Most typically these surgeons have backgrounds in oromaxillofacial surgery or plastic surgery. I know a handful of ENT guys who are craniofacial surgeons; however, these guys did a general plastics fellowship after ENT and then a craniofacial fellowship. I don't know of any fellowship that accepts ENT grads out of residency to do a craniofacial fellowship, and frankly I would be a little surprised (I've been surprised before) if there were.

Facial trauma is a mixed bag. There are some ENT folks who've done a lot of it, and some who have done very little of it. Generally speaking, if the bones are broken and there's not much of a defect, most ENT guys can do it. If there are significant soft tissue or bony defects, it's better that a microvascular surgeon or craniofacial surgeon deals with it.

 

[shigaT]

There are some cleft/craniofacial centers that have ENT/facial plastics trained people as their reconstructive surgeons. However, most are general plastics trained. While most ENT facial plastics fellowships are geared toward cosmetics and post H&N cancer or trauma reconstruction, there are a few that provide subspecialty training in pediatric cleft and craniofacial surgery - U. of Minnesota, SUNY Syracuse, and UC Davis are the ones I know of.

 

[chirurgino]

I'm a bit curious as to what the pros and cons are of doing craniofacial reconstruction through ENT versus plastics. Is the fellowship for craniofacial reconstruction right after the regular ENT residency? Can anyone shed some light on this for me? Is one pathway faster than the other? Training better in other versus the other?

Any information would be helpful, thanks.

Bottom line is that if you are really serious about peds craniofacial, you should be doing the 3 yrs of plastic surgery at some point. You can look up multiple examples of this, including John Meara, new chief of plastic surgery (and busy peds craniofacial practice) at Children's Boston, who did ENT at MEEI first and then went back to do plastics. Also, one of the ENT chiefs this past year at Iowa is going to do the 3 yrs of plastics for the same reason. There are many other examples. Why plastics controls peds craniofacial (including cleft lip/palate at most institutions) instead of ENT never made sense to me, but they do.

 

[5150]

Hmm... thanks for the clarification. Another semi-related question: What are the advantages of doing facial plastics and reconstruction through ENT versus doing it after a plastic surgery fellowing following gen surg?

Thanks again guys.

 

[resxn]

Hmm... thanks for the clarification. Another semi-related question: What are the advantages of doing facial plastics and reconstruction through ENT versus doing it after a plastic surgery fellowing following gen surg?

Thanks again guys.

This one I can chime in on, unlike the craniofacial question above.

I think that when speaking of facial plastics alone, ENT training rather than general surgery training is far, far better. The amount of head and neck surgery you do as well as nasal surgery is exponentially more in both volume and I'd argue undeniably in quality. You will know head and neck as well as general facial anatomy exceptionally better with an ENT residency. That point simply cannot be argued. Additionally, in ENT you will have a reasonable exposure to plastics cases (probably more than general surgery for facial plastics) and will be fully prepared for fellowship without doubt. Every residency has varying amounts of Plastics and that is one of the weakest parts of most ENT residencies, but there is some.

I can't tell you how easy a rhytidectomy is after doing parotid surgery. I can't tell you how much easier a rhinoplasty is after having done hundreds of septoplasties and multiple reconstructions of noses. I can't tell you how much easier it is to understand major flaps, whether pedicled or free, after doing a couple hundred in residency.

In general surgery, you will know many of the surgical techniques. In ENT, you will know the techniques, the anatomy, many of the procedures, and be much better prepared, at least in regard to facial plastics.

As for the rest of the plastics, well, that depends on what type your considering. You'll certainly be more prepared for breast augmentations by doing general surgery. Liposuction? Well, I've done plenty for fat harvesting with liposuction as well as submental procedures so I don't see an advantage in either residency there. Abdominoplasty? It's a face lift on the belly.

 

[5150]

Thanks again. I find reconstructive surgery in the head and neck to be really interesting. Most of my interest was sparked by gross anatomy initially... something about the anatomy in the head and neck that really appealed to me. Craniofacial surgery seemed like it would be interesting but I wouldn't exactly be enthused with doing a general surgery residency and plastics fellowship, just so I can finally get to work on craniofacial reconstruction. The head and neck is where my interests lie and I'd prefer to spend most of my time training on procedures involving that area.

Assuming one does a facial plastics and reconstruction fellowship after ENT, is it reasonable that you would be able to fill up your days with procedures that aren't simple blepharoplasties and facelifts and other cosmetic surgeries of that nature? I like the idea of doing reconstruction post head and neck cancer, but I have no idea if the volume of cases is sufficient that you could fill your days with that. I have no real interest in doing rhinoplasties, etc.

 

[resxn]

Absolutely. There are a number of plastic surgeons I know who spend the majority of their time doing reconstruction, whether for trauma or oncology or congenital defects. However, it is certainly a niche area. You will need to be in a big city at a good tertiary or quaternary referral center to do this exclusively.

Many of the reconstructive plastics guys I know do supplement their income with everything from botox to breast augmentations for 2 reasons. First, the call of the cash cow is hard to resist. Two, it fill the gaps between big recons.

And, actually, there is one more altruistic reason. Doing septorhinos, blephs, brow lifts, etc. will actually prepare you to better handle reconstruction. It's good to mix it up a bit at least for the early part of one's career. At least, that's what I think. I know I'm a much better at fixing NOE fractures because I continue to do septorhinoplasties here and there.

 

[5150]

I'm a bit naive to the economics of medicine. Do the plastics who spend most of their time in payment up front cosmetic surgery tend to make more than reconstructive surgeons? I keep hearing about doctors who fill the gaps with cosmetic surgery, and I always wondered if this was simply because of volume issues or if it was because there is simply more money doing purely cosmetic surgery.

 

[resxn]

I'm a bit naive to the economics of medicine. Do the plastics who spend most of their time in payment up front cosmetic surgery tend to make more than reconstructive surgeons? I keep hearing about doctors who fill the gaps with cosmetic surgery, and I always wondered if this was simply because of volume issues or if it was because there is simply more money doing purely cosmetic surgery.

Ridiculously more money for cosmetics.

Ridiculously.

 

[toofache32]

Ridiculously more money for cosmetics.

Ridiculously.

Definately. I'm an oral surgery resident, and we have a guy on faculty that does head & neck cancer. After spending 12-15 hours in the OR doing a trach, bilateral neck dissections, glossectomy, mandible resection, fibula....then manage them in the ICU, then on the ward for a week or more......for all that he only gets about $3000. Then today he placed 8 maxillary implants in his private clinic at $2000 each. That was a $16,000 case that took him one hour. And the patient went back to work the next morning. Cash procedures are where it's at, regardless of specialty.

 

[courtyard]

Hi all,

I am an MS3 planning on going to ENT.
Reading this post was interesting, and after having read about discussions of various fellowships and subspecialty within ENT, I have a question - just about what kinds of procedure can an ENT doc who has freshly graduated from a residency perform without requiring further fellowship training?

I understand that easy answer is, depends on the program. But there must be a standardized expectations of procedures after completing an ENT residency.

Breaking down each field within ENT: Head and neck, craniofacial, plastic, and otology. Up to what extend within each of the field of ENT can a new ENT doc without fellowship realistically be work on?

Thanks!

C.

 

[Fah-Q]

It certainly does depend not only on the program but also on the surgeon. ENT has a huge amount of variety and some people just feel more comfortable with certain areas.

My opinion:

Head and Neck - partial and subtotal gloss with local flap and pec flap recon, total and partial laryngectomies, neck dissections, thyroids, parathyroids, parotids, any skin cancer, maxillectomies, endscopic laser resections of early laryngeal/pharyngeal tumors, mandibular resections that don't require free flaps, and most any other "lump" in the neck
Definitely need a fellowship for free flaps and any sort of anterior skull base resections

Pediatrics - tubes, tonsils, adenoids, trachs, neck masses
Probably need a fellowship for airway reconstruction and maybe for cochlear implants

Otology - tympanoplasties, mastoids
Maybe need a fellowship for stapedectomy, cochlear implants, labrynthectomy
Definitely need a fellowship for acoustic neuroma surgery, encephaloceles, and lateral skull base tumors

Craniofacial - probably need a fellowship for all of it as most ENT residencies don't do any and only a few do enough

Plastics - varies highly depending on where you train; functional rhinoplasty, blepharoplasty, brow lift, face lift, local flap recon of Moh's defects, Botox, laser/chemical resurfacing, dermabrasion, fillers (Restylane, Juvederm, etc.), facial nerve reanimation/rehabilitation surgery, midface and mandibular trauma
You might need a fellowship to do any of these if you train at a program weak in plastics but some programs would have you fully prepared to do all the above.

General - all of the above and endoscopic and open sinus surgery, septoplasty, wide variety of laryngology procedures, sleep apnea surgery

In other words, you would know plenty of procedures well.

 

[resxn]

Hi all,

I am an MS3 planning on going to ENT.
Reading this post was interesting, and after having read about discussions of various fellowships and subspecialty within ENT, I have a question - just about what kinds of procedure can an ENT doc who has freshly graduated from a residency perform without requiring further fellowship training?

I understand that easy answer is, depends on the program. But there must be a standardized expectations of procedures after completing an ENT residency.

Breaking down each field within ENT: Head and neck, craniofacial, plastic, and otology. Up to what extend within each of the field of ENT can a new ENT doc without fellowship realistically be work on?

Thanks!

C.

As a general ENT coming from a good program, I can handle about 98% of the stuff that walks in through my clinic doors. I choose to handle about 95% just because of practice preference.

I think most ENT's trained in the US would feel that way. The above post is a good breakdown of many of the things we do.