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Blasted ENT Attending
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Feb 11, 2002
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Before recently, I never really questioned that those doing the regular plastics route would be better doing facial plastic surgery.

But, more recently, I have to ask the question why a general surgeon who does a general plastics fellowship would be better equipped to do facial plastic surgery than an ENT (or OMFS) who does a facial plastics fellowship as well.

And I'm being serious. Forget about this issue of board certification. Forget about ENT/PS docs having to assure their patients that they are "pastic surgeons."

Here are my thoughts: ENT residents routinely lift flaps used in facelifts (especially doing parotids). We do septoplasties all the time. Occasionally we do rhinoplasties. We do flaps of all kinds when we resect facial skin cancers. BoTox is a no-brainer. We do blephs occasionally. So, we have at least a rudimentary foundation in facial cosmetics before we get to a fellowship.

Do general surgery residents get similar experiences? How often do you guys do plastics rotations during residency or get these kinds of referrals?

I don't know. I think I'd go to a general plastic surgeon, but I'm not sure I know why.


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A little perspective after 8 months of this: the only things I feel like a fully trained ENT would have any substancial advantage over my background would be with rhinoplasties (and even some ENT programs do few aesthtic rhinoplasties during training) & the initial comfort level with facial fracture ORIF (its a pretty quick learning curve though). Most other things have been a pretty simple transition. Having done a fair amount of head & neck CA procedures & exposures during my surgery training, I don't really feel that its a good proxy for how comfortable you'll be doing facelifts, the similarities are superficial between it & a parotidectomy flap exposure as to what is the real key points of a good outcome.

I fully agree that ENT's are certainly trained enough (even without a fellowship in facial plastics) to perform head & neck aesthetics. ENT is a great background if you really want to limit yourself to the head & neck. A good deal of this is also going to depend upon your experience during training. Some programs in ENT do a LOT of aesthetic surgery, but in others its just a modest component. Being an assistant & watching someone do these cases is NOT the same thing as saying you have good training in aesthetic surgery, and I think that's the case at a lot of programs nowadays.

Here's why I think it's a mistake to go the facial plastics route:

-In most markets you're going to be outcompeted by Plastic Surgeons.

-its a self-limited training. I meet about half a dozen ENT/facial plastic trained interviewees who were applying for Plastic Surgery during my cycle. The common refrain was how handicapped they felt in practice by their training & that if they could do it again they wouldn't have wasted a year. One of the Plastics Residents here had done that when I was an intern years ago & he said the same thing. He also felt that the level of understanding you get from the reconstructive operations was so valuable to the aesthetic procedures & that he just had no/little background in it after ENT/FPS. BTW he had trained in one of the top ENT programs & had done what I'm told is one of the better FPS fellowships.

-you leave a lot of money on the table when you can't offer the other aesthetic procedures to your patients

-the % of patients that are asking for facial aethetic procedures is a small part of the overall customer base that exists for cosmetic surgery in 2004+ & you're going to be scrapping it out with evryone for those. I have heard this argument verbatim from half a dozen plastic surgeons with ENT backgrounds in private practice. While they all prefer facial aesthetic cases, the other procedures make up large components of their practices

-the growth area in cosmetic surgery currently is body contouring
& this figures to increase rapidly with the bariatric surgery craze. You will have limited yourself out of this and breast augmentation which outnumber the major facial cases many times over.

-many traditional head & neck cosmetic procedures are being chipped away by a combination of injectable fillers, skin care products,peels,BOTOX, & externally delivered energy (lasers,RFA, IPL, etc..) that can all be delivered by non-surgeons. Again, if all you have to offer is a limited palate of procedure, you are going to be outcompeted by your peers.

Just something to think about...
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A couple of senior plastic surgeons (both former ASPS presidents) speak regularly about the sequence of events with cosmetic patients. First, they come in for something small (excise a mole). They're testing you to see if they like you. Then they come in for something more significant (liposuction of abdomen or thigh), but still fairly "minor" -- something covered by clothing. When they get a good result from this, they move on to being ready to have you work on their face, which can't be covered. It's fairly well documented. Patients will work their way up to the bigger procedures and test you to make sure that you are: competent, compassionate, attentive, and committed to taking care of their pain (if a patient hurts a lot after a procedure, you can be guaranteed that your chance of another case is small).

Point is, if you can't do the other "lesser" procedures in the build up, you have a smaller chance of doing the facelift. Rhinos are a bit different, because they tend to be performed on young people.

Ollie is quite right about the overall numbers, though. Body contouring and breast surgery by far (maybe a power of 10) outnumber cosmetic facial surgeries.

It's also a question of what you want to do. Me? I like hand surgery, craniofacial stuff, breast surgery, and complex "shark bite" reconstruction. Not sure how much of that I'll actually see when I get out, but I'll have the option to do a full range of procedures. I really don't care to do H&N cancer, tubes, tonsils, and the other ENT stuff. So PRS fits me best. But I won't object if you do a few facelifts. Just send them to me for their abdominoplasty. ;-)
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quick off topic question - i know the ENT residencies are 4-5 years - are the plastics residencies a general surgery residency followed up by fellowship??? any help is appreciated - thanks

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Originally posted by Ratch
quick off topic question - i know the ENT residencies are 4-5 years - are the plastics residencies a general surgery residency followed up by fellowship??? any help is appreciated - thanks

Currently two accepted routes to PRS:

1) the traditional, Independent Model wherein you complete at least 3 years of General Surgery (although be warned that currently almost all successful applicants have completed the full 5+ years of Gen Surg) and apply for further training in PRS


2) the Integrated Model which you match into as a 4th year medical student; programs may be 3+3 or 4+2 generally (ie, gen surg years plus PRS years).
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