Craniofacial Surgery

[Cranial]

i am currently a third year dental student wishing to pursue a career in craniofacial surgery (complex craniomaxillofacial trauma, congenital malformations/syndromes, cleft lip/palate, craniosynostosis, reconstruction, orthognathic, ...). my questions revolve around attaining that goal. is is better to go through a combined certificate/MD OMFS program, and then do a craniofacial fellowship (i know few fellowships of that route); or is it better to go through a combined certificate/MD OMFS program, go through plastic surgery, and then do a craniofacial fellowship? other routes?

i can't help but notice that all the craniofacial teams/centers (that i know of) in the states are directed by plastic surgeons. is there anything in the training of the plastic surgeon that makes him/her more proficient in craniofacial surgery?

ps i posted this same message on www.dentaltown.com

thank you in advance

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[maxheadroom]

If you want to do the full range of craniofacial stuff, you'd be best served by getting an MD and doing a plastics residency. Long road, but I haven't heard of OMFS guys doing stuff like craniosynostosis and the like. Good luck.

 

[droliver]

Originally posted by Cranial
is there anything in the training of the plastic surgeon that makes him/her more proficient in craniofacial surgery?

The background and breath of experience is what really stands out. Oral Surgery is just a very limited field (I don't mean that negatively BTW) with the way you get trained. Your surgical "vocabulary" is just much more advanced with the perspective you get from Plastic Surgery training. There are a # of really outstanding Plastic Surgeons with OMFS backgrounds who get just scary good with craniofacial work

 

[Cranial]

hey thanks for the replies. so you guys suggest that i go right into an MD and plastics, and not start off with an OMFS residency? or do both?

do you know the names of those plastic surgeons with OMS background that do a great job in craniofacial. dr. posnick?

 

[droliver]

Nic Georgeiade MD @ Duke was the former chairman there & an MD-DDS
Barry Zide @ NYU is very well known
Kevin Kelley @ Vanderbilt is very good by reputation in this region
Stephen Colen @ NYU

These are the ones I'm thinking of off the top of my head as well as 2 of our more talented clinical faculty here in Louisville were also OMFS first.

Oral Surgery is a very good background to go on & do Plastic surgery & craniofacial after. The problem is that it is now very,very hard to secure a training position with the traditional Plastic Surgery fellowships with that background. Last years match rate was in the 30's% overall with an overwhelming (>>95% of the successful applicants) preference for 5 years (or more) trained general surgeons. If you know that's what your goal is, you're likely better off going to med school and doing an integreated plastics or general surgery-> plastics model.

 

[Cranial]

this is very informative, thanx alot everybody...

ok, how about MD/OMFS, 1-2 years of general surgery, and then a craniofacial fellowship. i realize the majority of these fellowships are open to plastic surgeons, but they are also open to "other appropriately qualified surgeons" (whatever that means). would you think that route of training provides enough knowledge and skill to treat craniofacial patients ethically? how about the politics of the matter? would it be really hard to get referrals from PCP's and pediatricians if one weren't a plastic surgeon?

i actually know of one recent MGH OMFS graduate who matched at a craniofacial fellowship within a plastic surgery program.

 

[maxheadroom]

Sorry, but that's way beyond anything that I can help you with. Not sure what the best options are for you, but I'd recommend the previously mentioned routes as most reliable to get you where you want to go. Good luck.

 

[droliver]

Originally posted by Cranial
i actually know of one recent MGH OMFS graduate who matched at a craniofacial fellowship within a plastic surgery program.

It depends on where he matched as to what to read into that. Craniofacial is not a very popular fellowship for a number of reasons & there are usually a number of positions that fail to fill. Most of the better fellowships would likely not consider an application from somone who had not done PRS prior & they put that on their application info most of the time

 

[maxheadroom]

The other point is that just because someone can get into a C/F fellowship doesn't mean that they're going to be able to practice without further training. Unless this OMFS/Craniofacial guy was able to find a very focused job, he'll have a hard time selling himself. i.e., most craniofacial surgeons are plastic surgeons at tertiary care centers who do c/f work along with general plastics.

 

[Cranial]

its seems like a plastic surgery residency is going to be necessary. i'll have to give the whole idea more thought

do you guys know prominent academic plastic surgeons at MGH, Penn, and/or Georgetown? it is just that i have access to those facilities and would like to look more into it.

thanx

 

[idoc]

Jim May @ the Harvard-MGH Program
Scott Spear @ Georgetown
Linton Whitaker @ Penn

 

[aphistis]

Originally posted by droliver
It depends on where he matched as to what to read into that. Craniofacial is not a very popular fellowship for a number of reasons & there are usually a number of positions that fail to fill. Most of the better fellowships would likely not consider an application from somone who had not done PRS prior & they put that on their application info most of the time

What are some of these reasons? It's a field I'm looking at closely as well.

 

[maxheadroom]

Mostly for 2 reasons . . .

1. There isn't much demand for craniofacial-fellowship trained surgeons. There just aren't that many Treacher-Collins/FLKs going around and people tend to desire a high-volume practitioner.

2. There isn't a whole lotta money in it. Lots of people go into PRS saying that they'll do craniofacial or hand/micro and in the end they get sick of the Medicaid $0.20 on the dollar billed and go into private practice with a leading towards cosmo.

 

[droliver]

That's pretty much it in a nutshell.

The craniofacial business has become more & more concentrated in fewer surgeons due to the maturation of integrated craniofacial teams (surgeon, neurosurgeon, orthodontist, speech tx.) thru the various state crippled children agencies. You can't just get a referral & do a cleft anymore in many places, but rather you must commit to the beurocracy of it all. This has made it less attractive for people who don't do a large volume of it or unless they have some endowed salary for it. The HUGE reduction in fees for it has also made the majority of practicing surgeons avoid it in droves. People usually do it b/c they love it or they have some foundation or charity organization that is subsidizing their fees (a la a number of the people @ NYU I'm told).

As Max also pointed out, there is still a good deal many more plastic surgeons around who have been trained to do them then there are patients requiring operations. A number of the craniofacial fellowships have retooled to have more focus on cosmetic surgery to remain relavent for applicants

 

[Cranial]

my impression is that many of those craniofacial teams meet about 40-60 times a year (about once a week) as a team and discuss new cases and major follow-ups amongst each other. and they probably see only about 50 new cases a year. with the rest of their time they practice other facets within their subspecialties. this, to me, makes the field attractive if one truly enjoys craniofacial surgery.

i do realize that some of these patients require complicated tx plans, but the fellow/residents would probably pick most of the work-up anyway.

moreover, most of the follow-up visits take place outside the craniofacial team with the pt?s pediatric dentist, orthodontist, pediatrician, and so forth. these providers would then report back to the craniofacial team.

somebody correct me if otherwise.

thanx

 

[maxheadroom]

The craniofacial teams that I've worked with have always had a multi-disciplinary clinic once a week, where PRS, NSG, orthodontist, and speech path were all present. True, residents and fellows are involved in the care, but craniofacial tends to require a very involved attending staff. These kids are young and require very focused care. Sure, the specialties will continue to work in their general fields, but at most institutions, their craniofacial job makes up about half of their schedule.

Sounds like you're trying to talk yourself into taking the road less-travelled. That's fine, but it's less-travelled for a reason -- its success is far from guaranteed.

If you want to do craniofacial surgery, in the developing medical environment of focused sub-specialization, you would be well-advised to get an MD and do a traditional PRS residency. Sure, you're other plan could work, but are you willing to be your career?

 

[Energon]

If you are a dual degree OMS, I think there are 2 avenues into craniofacial surgery. 1). Upon completion of OMS residency you have to do one extra year of gen surg (PGY-2) and do 2 more years of plastics. 2). Do an AAOMS accredited craniofacial/plastics fellowship which is usually 1year long. How you run your practice is a whole other ball game. It's best to start a full scope OMFS practice: dentoalveolar (apectomies, preprosthetic etc), implants, orthognathic, TMJ, trauma (w/ open/ closed reductions etc) exodontia and craniofacial (clefts & other congenital reconstructive surgeries) as well as cosmetic. Then as your practice grows, you can afford to just concentrate on whatever you want (craniofacial in this case).

 

[Cranial]

hi all

i am actually leaning towards the longer way: completing a 6-yr OMS programs, plastics, and then a craniofacial fellowship or two. i feel that thats only fair to the craniofacial patient. an in-depth understanding of occlusion and a prolonged experience in working with the skull is the way to go. it is my opinion that dentistry and OMS are essential to the craniofacial surgeon.

its also important to gain a broad surgical base through plastic surgery. the surgical management of the craniofacial patient is very demanding.

further, there isn't anything wrong with more education. especially relavant education.

thanx

 

[Energon]

Cranial you might want to check out the aaoms fellowship websites and do a little more research on it. If academic craniofacial surgery is truly what you want to do, check out the U-Pitt fellowship it may be the answer.

http://www.aaoms.org/Residency/PDF/Fellowships.pdf

 

[droliver]

Originally posted by Cranial
i am actually leaning towards the longer way: completing a 6-yr OMS programs, plastics, and then a craniofacial fellowship or two. i feel that thats only fair to the craniofacial patient. an in-depth understanding of occlusion and a prolonged experience in working with the skull is the way to go. it is my opinion that dentistry and OMS are essential to the craniofacial surgeon.

Be warned..... you could face signifigant difficulty trying to get a Plastic Surgery position after Oral Surgery and this is likely to get even harder in the future with the increasing number of applicants. The transition from that background to Plastic Surgery is also not the easy road, especially with the vascular, reconstructive, and patient care issues.

 

[Energon]

Droliver, the plastics residency that OMFS or ENT's do just prepare them to work on the facial structures right? or is it the entire body?

 

[maxheadroom]

Plastic surgery residency is the same for everybody. Some ENTs do "Facial Plastics", which does not qualify them to sit for the ABPS examination. They are ENTs who have fellowship training in facial plastics. Not the same as Plastic Surgery.

I know that those of you in OMFS/Dental school want to justify your educational choice in light of your career goals by looking to a route that is, quite frankly, probably not going to last much longer. The field of surgery is in the middle of a cultural revolution in which training programs are being encouraged to streamline their educational activities. While Ollie and I disagree on the best way to train a plastic surgeon, I think that we're going to see more and more programs switching to an integrated-type format. In turn, the remaining "fellowship" plastics positions are going to go to board-eligible General Surgeons and occaisional ENTs and orthopods.

If you are in school currently and you want to go into craniofacial surgery & plastics, I'd encourage you to consider getting an MD and pursuing the mainstream plastics training programs.

If you want to be a dentist/orthodontist/OMFS, you could certainly work with craniofacial surgeons (orthodontists are an essential part of a craniofacial team when it comes to the dental appliances required), but your chances of running a craniofacial program would be greatly diminished.

Not trying to start a flame war between MD and DDS/DMD, but you need to hear the realities from people who are already there. Best of luck.

 

[droliver]

Originally posted by maxheadroom
While Ollie and I disagree on the best way to train a plastic surgeon, I think that we're going to see more and more programs switching to an integrated-type format.

Max, I actually think there could be fewer integrated programs in the future as Gerneral Surgery moves to a 4+2 or 3 model for most of its specialty surgery training fields. It just seems logical to me (and a number of academics) that this dovetail arrangement would better then the a lot of the struggling integrated programs.

As for your other comments I think you're spot on!



AMMD- each of the respective background for training has its strengths & weaknesses. General Surgery just has much more broad-based training then others to allow an easier transition is the consensus. There are many examples of people from all these other disciplines who have been tremendous leaders & innovators though.

 

[Energon]

I know that those of you in OMFS/Dental school want to justify your educational choice in light of your career goals by looking to a route that is, quite frankly, probably not going to last much longer.

Max I really don?t know what you mean by this, the way I see it is that DDS/MD OMF surgeons are always going to be around because they have a lot on their plate that requires someone to have a background in dentistry? Although a 4yr OMS program might stop because hospitals will eventually require their oral surgeons to be MD?s with the General Surgery Experience.


As far as my question about the Facial Plastics program:
(I know your opinion about this Dr Oli) but the truth of the matter is that if an OMFS (I don?t know about ENTs) wants to get a good job @ hospital based or even a full scope private practice the employers require them to have experience with plastics so I think that a fellowship after residency is a good idea.