gregoryhouse

Head of the Department of Diagnostic Medicine
5+ Year Member
Nov 6, 2013
333
259
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Medical Student
Hi guys,

So I know this is a fairly dumb question that is personal to each individual but I'm hoping to at least hear some opinions from people out of residency.

I am in my 2nd year of Ophthalmology and for the first year I was very sure about wanting to do plastics. However, as I have started gaining more experience with cataract surgery, I am finding it very enjoyable and not so sure anymore that I would like to give it up or if its worth doing an additional two years of training for plastics.

I still really enjoy plastics. I have done a lot of primary plastic cases and orbit cases and I would like to continue to do them in my career. However, I am worried about giving up cataract surgery and also worried about the outlook of plastics and being pigeonholed into doing a large amount of cosmetic work. What I enjoy most about plastics is the functional aspect (bleph, ectropion, entropion, ptosis, etc) and reconstruction (skin cancer repair, etc). I feel like I have done enough primary functional cases to feel comfortable doing blephs, ectropion, and ptosis out of residency. I also feel like I would be comfortable doing biopsies and small reconstructions. I am not sure how that would actually play out once I'm actually in a practice but if allowed I would certainly feel okay doing those procedures.

So I am just hoping to hear from some people outside of residency and in private practice on their thoughts regarding this and whether ASOPRS fellowship is necessary. I do want to learn more oculoplastics specific things such as more orbital surgery but I am worried about doing 2 years of fellowship, losing my cataract experience and then being pigeonholed into either academia to continue to do orbit cases or have to supplement with cosmetics in private practice.
 

mjohnsonets

2+ Year Member
Feb 28, 2017
20
5
Roanoke, VA
www.etsvision.com
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Non-Student
On the job front for private practices:

There are practices where you can do both but typically these plastics docs have completed a one year fellowship in plastics. Some of it will depend on where you want to practice and how saturated the plastics market is there.

In general but not always: if you want to live in a big city doing both will be hard. You will likely not get many plastics referrals, unless it's internal referrals, if there are ASOPRS surgeons around. If you end up in a medium or smaller city then you certainly could do both with ease. Basically the more ASOPRS surgeons there are in the vicinity you're practicing in, the less plastics you will likely be doing or getting referrals for.
 

Equality

10+ Year Member
May 7, 2009
258
25
Status
Fellow [Any Field]
Most post-ASOPRS people practice only plastics--some in academia, many in private practice, with or without cosmetic component, with or without orbit component.

If you really like plastics, you will want to be good at it, which requires that you do plastics 100%. Usually to be able to do 100% plastics and get hired, you will want ASOPRS. Orbital surgery is not something to be dabbled with because it comes with risk of vision loss, and as a referring physician, I would want to make sure that the plastics person I'm referring my orbit patient to has orbit training, and ASOPRS label will most likely certify this.

There's a practical aspect also: there are very few, if at all, one-year plastics fellowships left due to ASOPRS crackdown of non-ASOPRS (aka 1 year) fellowships. You would be lucky if you can find one to apply to.

If you feel comfortable doing blephs and ptosis out of residency, and if that's all you want to do to add to comprehensive practice, you may not need any plastics fellowship.
 
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TheLesPaul

10+ Year Member
Aug 20, 2007
748
85
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Attending Physician
this is a fairly dumb question
You're right!

I have done a lot of primary plastic cases and orbit cases
I doubt you have done primary orbit cases as a 2nd year resident. A lacrimal gland biopsy is not true orbital surgery, and being alone in the orbit is different from being hand-held. I can have a resident "do a decompression" with me telling them what to do but of course they couldn't do it on their own.

I feel like I have done enough primary functional cases to feel comfortable doing blephs, ectropion, and ptosis out of residency
Unlike cataract surgery, most of the skill of plastics is not in the mechanics of the surgery. Anyone can cut skin and stitch it together.

I do want to learn more oculoplastics specific things such as more orbital surgery
The worst screw-ups I see are from people who practice out of their skill set. You are not doing your patients or yourself any good by pretending to be good at orbital surgery. You can seriously maim or kill people in orbital surgery!

Unless you can evaluate manage the face as a whole (brows, axial globe position, bony anatomy, midface, jowls, neck), your work is going to be overwhelmingly mediocre and you should probably stick to VA blephs and entropion repairs. You can always open a med spa and hire aestheticians, although that is a very different marketplace. I was in your shoes too - you love cataract surgery because it is your first true surgical experience. If you really are meant for plastics though, you don't miss intraocular surgery at all by the end of fellowship.
 

Dusn

7+ Year Member
Mar 19, 2011
279
65
Status
Attending Physician
Cataract surgeons are a dime-a-dozen and the reimbursements for it get cut nearly every year. You will have no leverage with any future employer if that is the only skill you have.

Plastics supplements their income with cosmetics. In a lot of private practices, cataract surgeons need to supplement their income with "premium IOLs" and convincing people with 20/20 vision to get their 1+NSC removed. It's an entirely different experience than in residency where you're removing real cataracts.
 

orbitsurgMD

Senior Member
10+ Year Member
Dec 27, 2005
1,962
92
Status
Attending Physician
Hi guys,

So I know this is a fairly dumb question that is personal to each individual but I'm hoping to at least hear some opinions from people out of residency.

I am in my 2nd year of Ophthalmology and for the first year I was very sure about wanting to do plastics. However, as I have started gaining more experience with cataract surgery, I am finding it very enjoyable and not so sure anymore that I would like to give it up or if its worth doing an additional two years of training for plastics.

I still really enjoy plastics. I have done a lot of primary plastic cases and orbit cases and I would like to continue to do them in my career. However, I am worried about giving up cataract surgery and also worried about the outlook of plastics and being pigeonholed into doing a large amount of cosmetic work. What I enjoy most about plastics is the functional aspect (bleph, ectropion, entropion, ptosis, etc) and reconstruction (skin cancer repair, etc). I feel like I have done enough primary functional cases to feel comfortable doing blephs, ectropion, and ptosis out of residency. I also feel like I would be comfortable doing biopsies and small reconstructions. I am not sure how that would actually play out once I'm actually in a practice but if allowed I would certainly feel okay doing those procedures.

So I am just hoping to hear from some people outside of residency and in private practice on their thoughts regarding this and whether ASOPRS fellowship is necessary. I do want to learn more oculoplastics specific things such as more orbital surgery but I am worried about doing 2 years of fellowship, losing my cataract experience and then being pigeonholed into either academia to continue to do orbit cases or have to supplement with cosmetics in private practice.

If you want to develop a referral practice in plastics, you will need to do a fellowship. There is really no other option. If you choose to practice in an area where there are no fellowship-trained oculoplastics specialists, you might get some referrals from optometrists, but you won't get referrals from other ophthalmologists or likely from dermatologists and ENT either. Mohs surgeons will want to send patients to either an oculoplastics specialist or to a general plastic surgeon, but usually not to a general ophthalmologist who likes to do plastic cases. You might be able to capture some of your own practice's plastic cases, but you will have to produce results at least as good as those of available subspecialists to justify not referring.

Cataract surgery really has enough of its own demands that it would be difficult to maintain the type of cataract volume needed to both keep and refine your cataract skills and also do enough plastics to do as well at that as a subspecialist. Despite having a positive and confidence-enhancing experience as a resident, there really are a lot of subtleties to even seemingly simple "functional" procedures that you develop an appreciation for only having done many cases and having followed many postoperative patients, more that even the experience in a surgically robust residency program can give you. Doing a bleph well can be satisfying, but the real work and the real mastery is how you do with those cases that don't initially come out well, how you handle complications, both of others and your own. Reconstructions can also be challenging and very satisfying, but your skill will come from having dealt with a large census of different reconstructive problems and having developed an understanding of how various approaches to particular problems work and, in turn, don't work. That takes time and case volume that I don't know how you would get as anything other than a plastics subspecialist.

[I did a general surgery internship and did rotations in general plastic surgery (which I liked very much, having had similar positive experiences as a medical student) and had the opportunity to work closely with several oculoplastics-trained mentors in residency before doing an oculoplastics fellowship.]
 

hello lady!

2+ Year Member
Dec 6, 2015
146
119
Status
Attending Physician
If you want to develop a referral practice in plastics, you will need to do a fellowship. There is really no other option. If you choose to practice in an area where there are no fellowship-trained oculoplastics specialists, you might get some referrals from optometrists, but you won't get referrals from other ophthalmologists or likely from dermatologists and ENT either. Mohs surgeons will want to send patients to either an oculoplastics specialist or to a general plastic surgeon, but usually not to a general ophthalmologist who likes to do plastic cases. You might be able to capture some of your own practice's plastic cases, but you will have to produce results at least as good as those of available subspecialists to justify not referring.

Cataract surgery really has enough of its own demands that it would be difficult to maintain the type of cataract volume needed to both keep and refine your cataract skills and also do enough plastics to do as well at that as a subspecialist. Despite having a positive and confidence-enhancing experience as a resident, there really are a lot of subtleties to even seemingly simple "functional" procedures that you develop an appreciation for only having done many cases and having followed many postoperative patients, more that even the experience in a surgically robust residency program can give you. Doing a bleph well can be satisfying, but the real work and the real mastery is how you do with those cases that don't initially come out well, how you handle complications, both of others and your own. Reconstructions can also be challenging and very satisfying, but your skill will come from having dealt with a large census of different reconstructive problems and having developed an understanding of how various approaches to particular problems work and, in turn, don't work. That takes time and case volume that I don't know how you would get as anything other than a plastics subspecialist.

[I did a general surgery internship and did rotations in general plastic surgery (which I liked very much, having had similar positive experiences as a medical student) and had the opportunity to work closely with several oculoplastics-trained mentors in residency before doing an oculoplastics fellowship.]
This is pretty spot on.
 

HaveAVision

2+ Year Member
Sep 12, 2016
5
0
Status
Medical Student
Hi guys,

So I know this is a fairly dumb question that is personal to each individual but I'm hoping to at least hear some opinions from people out of residency.

I am in my 2nd year of Ophthalmology and for the first year I was very sure about wanting to do plastics. However, as I have started gaining more experience with cataract surgery, I am finding it very enjoyable and not so sure anymore that I would like to give it up or if its worth doing an additional two years of training for plastics.

I still really enjoy plastics. I have done a lot of primary plastic cases and orbit cases and I would like to continue to do them in my career. However, I am worried about giving up cataract surgery and also worried about the outlook of plastics and being pigeonholed into doing a large amount of cosmetic work. What I enjoy most about plastics is the functional aspect (bleph, ectropion, entropion, ptosis, etc) and reconstruction (skin cancer repair, etc). I feel like I have done enough primary functional cases to feel comfortable doing blephs, ectropion, and ptosis out of residency. I also feel like I would be comfortable doing biopsies and small reconstructions. I am not sure how that would actually play out once I'm actually in a practice but if allowed I would certainly feel okay doing those procedures.

So I am just hoping to hear from some people outside of residency and in private practice on their thoughts regarding this and whether ASOPRS fellowship is necessary. I do want to learn more oculoplastics specific things such as more orbital surgery but I am worried about doing 2 years of fellowship, losing my cataract experience and then being pigeonholed into either academia to continue to do orbit cases or have to supplement with cosmetics in private practice.
Thanks for asking this question. I feel the same way! Very helpful!
 
Dec 10, 2019
7
2
Status
Attending Physician
You're right!



I doubt you have done primary orbit cases as a 2nd year resident. A lacrimal gland biopsy is not true orbital surgery, and being alone in the orbit is different from being hand-held. I can have a resident "do a decompression" with me telling them what to do but of course they couldn't do it on their own.


Unlike cataract surgery, most of the skill of plastics is not in the mechanics of the surgery. Anyone can cut skin and stitch it together.


The worst screw-ups I see are from people who practice out of their skill set. You are not doing your patients or yourself any good by pretending to be good at orbital surgery. You can seriously maim or kill people in orbital surgery!

Unless you can evaluate manage the face as a whole (brows, axial globe position, bony anatomy, midface, jowls, neck), your work is going to be overwhelmingly mediocre and you should probably stick to VA blephs and entropion repairs. You can always open a med spa and hire aestheticians, although that is a very different marketplace. I was in your shoes too - you love cataract surgery because it is your first true surgical experience. If you really are meant for plastics though, you don't miss intraocular surgery at all by the end of fellowship.


I could take a lot of what you say and apply it to some of my General ophth colleagues who "practice retina part time".......as in part time cataract surgeon and part time medical retina To be a truly good general ophthalmologist takes considerable dedication, especially if you are also a high volume guy/gal. The same applies to our subspecialties of ophthalmology. A lot about doing a fellowship is finding out what you really didn't know (but thought you did) and learning to do it correctly

I also loved cataract surgery during residency. It's a lot of fun and the patients are (generally) happy. But, I would not trade being a retina doctor at all. Keep an open mind about oculoplastics, and continue to explore its many facets. My friends, who are OP surgeons in PP, do practice 100% OP surgery and they are very glad they made the choice
 

CovFEFE

2+ Year Member
Jun 10, 2017
12
4
Status
Resident [Any Field]
First off, I think it's safe to say the phrasing of your question wasn't the most artful... Of course an ASOPRS fellowship is worth if you want to primarily do plastics.

I'll provide a little bit of a different perspective from someone who practices as a comprehensive doc, and does a fair amount of plastics, medical retina and glaucoma/MIGS, in addition to cataract surgery.

In residency, I loved cataract surgery, and I also really liked retina and plastics (I seriously considered doing a fellowship in one of the two during 1st year) but got hooked on cataract surgery and I knew that cataract surgery will have to be a core part of my future practice. Additionally, I knew before the end of residency that I wanted practice in a small to midsize city, and I also wanted to have a broad scope of practice.

My residency had 2 ASOPRS Attendings and we got a lot of plastics cases between the two of them, but I still had a healthy amount of trepidation about doing solo plastics cases. But honestly, I felt the same about my first few cataract cases in practice too, and I think it's good and healthy to have some trepidation as a new Attending as it checks one's hubris and overconfidence.

For plastics, I was interested in functional blephs, ptosis, ectropion, entropion repair and botox. Right after residency, I got a few oculoplastics books, and a video atlas (Bobby Korn) to brush up. I watched lots of youtube videos (guy massry, ric caesar etc) and richard allen (eyerounds), amongst others to learn surgical pearls from experts. I practiced lots of suturing at home (to be more efficient in the OR). I also discussed cases with mentors especially early on, shared preop and postop results to get feedback from former Attendings. These are some of the things I did to prepare myself, and it was tremendously helpful. This goes without saying, but you have to thoroughly know eyelid anatomy, surgical planes, potential complications relevant to the surgery you're doing otherwise you have no business doing that surgery.

In addition to the above, I'm very careful about patient selection/evaluation, and I do a thorough preop counseling/consenting. I don't do any cosmetic cases, and borderline functional cases I generally don't do either. Perfectionist patients with unrealistic expectations I screen out as well. It's critically important to be on the same page as the patient regarding the indications, goals and realistic expectations for surgery, otherwise you're asking for trouble and an unhappy patient.

Also, I think it's critically to be systematic in your patient evaluation, because not every droopy eyelid needs surgery. Just yesterday I had a ptosis consult, 49 yo, moderate LUL ptosis, moderately dilated L pupil, and normal motility; I sent him to the ER to r/o a pcom aneurysm as opposing to signing consents for surgery. You also want to r/o myasthenia, concurrent brow ptosis, Hering's law with cases of "unilateral" ptosis, as they may need a neurologist or different type of surgery as opposed to ptosis repair.

Also, I always hand patients a handheld mirror so they can see their face as I point out objectives of surgery (this is how skin that can be safely removed with your bleph, or this is the eyelid height I'm aiming to achieve with your ptosis repair) just to make sure we have common/shared goals of surgery.

Finally, I have a low threshold to refer patients to oculoplastics (closest one is 1.5hrs away) for anything orbit, cosmetic cases, reconstructions, 2nd opinions etc.

So, OP, it's definitely doable in the right location if you're willing to invest the time and effort it'll require to develop your skillset.
 
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