Plastic, Aesthetic and Craniofacial Surgery

[deleted144060]

Greetings all,

I am a boarded general surgeon, BE plastic surgeon and now doing a craniofacial fellowship. I also have a PhD (med school combined). I will try to answer what I can about surgery in general along with questions pertaining to academic surgery and plastic surgery.

Because this is a moderated forum (by me and another plastic surgeon), your posts will not appear until approved. For the most part, the original post will be deleted but it will be quoted it the reply. Please be patient as some of the questions may take some time to answer. And please remember, any adivce given here is just the opinion of a few. It's not the gospel, but hopefully it will help.

--Moravian

Questions for Residents, Physicians, and other Professional Mentors
1. What do you enjoy most about your specialty?
I can and frequently do operate on many different areas of the body, perform everything from excisions of benigh skin lesions to microvascular free flaps, have both an adult and pediatric patients, and I'm never bored.

2. Is there anything you dislike about your specialty?
There is nothing I dislike about what I do. My only complaints are with the medical system as a separate entity.

3. How many years of post-graduate training does your specialty require?
If you can get into a combined plastic surgery program, it will take 5 to 6 years depending on where you train. Any additional training (hand, micro, pediatric, craniofacial, reconstructive, aesthetic) is generally an addition year for each. There are some 6 month aesthetic fellowhsips.

4. What is a typical schedule like for your specialty? Are the hours/shifts flexible?
Surgery in general is a busy specialty. That being said, your schedule will depend on what kind of practice you choose. If you decide to be in a solo provate practice, you will find yourself with very little free time. Joining a group (single or multispecialty) decreases the amount of call and office managment. Academics probably provides the most flexibility as far as hours are concerned.

5. Where do you see your specialty going in five years?
Plastic surgery is still one of those specialties that provides a means for private practice in that cosmetic surgery is is straight fee for service. That being said, I believe more individuals will forego solo practice for single specialty or hospital employed positions in the future for both economic and lifestyle reasons.

Questions for Members of Admissions Committees
1. What is the one thing you wish students planning to enter (medicine, pharmacy, dentistry) knew?
If they were only looking for a way to have decent income, they should find something else to do.

2. What are the three top characteristics you like to see in an applicant?
Stellar Step I and II scores
Ability to work well with others
Life experience outside of medicine

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[deleted144060]

This is from my response to an earlier private message concerning board scores.


In answer to your question, board scores are very important for getting an interview for the combined or integrated plastic surgery programs. You probably already know how competitive the combined plastic surgery match is and there are lots of applicants. Many of not most of the programs will use scores as an initial weeding out element (along with other things) to decide who to invite for an interview.

During the last round of interviews at my program, the majority of our invitees had Step I and II scores over 90 and many of them were in the 95 to 99 range. I think the lowest score was an 85, but that might be too low for some programs. Having been around the block a few times myself, I know that board scores aren't a reliable indicator of who will match, or who will even succeed, but it gets you in the door.

We also had a couple of applicants that took Step I a second time because they didn't do well the first time. I certainly didn't penalize them for that, and they even went up a bit on my scorecard for going through it a second time, but I wouldn't expect everyone to react that way.

As for studying, I can really only speak for step I. Because I was an MD/PhD, the time difference between steps I, II, and III was 11 years. Some states will not give you a license if the gap is larger than 7 years. For my current fellowship, I had to retake step I again, and let me tell you I was not happy about it.

I did every question in the Kaplan Q bank and read the First Aid series cover to cover. I actually did pretty well, but I don't know if it was the studying or just accumulated knowledge. Anyway, a lot of the material on the exam seemed to be covered on the Q bank or First Aid. I also know that Kaplan offers a course but I didn't have the time to take it. I did teach MCAT for them a long time ago, and I would tell you that the biggest asset they have is the practice tests. Test taking is a skill that can be learned for those of us that it doesn't come to naturally.

--M

 

[deleted144060]

"I like to watch the TV show Dr. 90210, and it seems most of their cosmetic cases are breast. If that's where the money is, these days, how does that justify the "best of the best" fighting for the priviledge of 7+ years residency (with the pressures of publishing, teaching, acquiring a fellowship, the "I'm academic medicine all the way" facade)"

Let me address the 90210 issue first, although I need to be somewhat careful. There is currently a well publicized lawsuit involving use of the internet to defame a plastic surgeon (not the 90210 guy, but I don't want to start one).

I can say that the surgoen from 90210 is NOT well respected by the vast majority of plastic surgeons. I have worked with people familiar with him and found out he is also not very well liked. Additionally, he is not board certified (and from what I hear, he never will be). The idea that his show represents plastic surgery is like thinking the Real World has something to do with reality.

The most performed cosmetic procedures are breast (both augmentation and reduction) and liposuction. Note the word "cosmetic." The field of plastic surgery is so much larger in scope of practice. My typical week might consist of doing some clefts, facial fractures, hand trauma, breast reconstruction, cancer excision with flap coverage, sentinel nodes, and a vascular malformation or two. On a cosmetic day, I might do augments, eyelid surgery, abdominoplasties, etc. One of the reasons I went into plastic surgery was because of it's extremely wide area of application. Check out plasticsurgery.org for more information on this.

I said I didn't really like that "best of the best" comment. But now that it's out there, let's examine the economics of the situation. In the late 80s and into the early 1990s, orthopaedic surgery and cardiothoracic surgery were highly sought after (along with a few others) because they were extremely well reimbursed (i.e. you made a lot of money). Those guys still make the big bucks, but it has been declining due to reductions in payments (CT surgery has some other issues as well). In fact, everyone is making less that they were 10 years ago, except for those specialties where people pay cash for services like plastic surgery, dermatology, and others who do cosmetic or fee for service based procedures. (As an aside, the top two grads of my med school did dermatology....no emergencies, no call, and nice reimbursements for the time spent. Number three did ophthalmology).

Plastics is becoming one of the few specialties where you can still afford to have your own practice and have a nice lifestyle. My friends who are in other surgical subspecialties are slowly going into hospital based, single specialty group or multispecialty group practices because they can't clear their overhead anymore without working themselves crazy. And these are people used to working long days.

So you see where this is going. The best med students, for the most part, gravitate to the more desirable specialties.

As you may have read from my introductory post, I am first and foremost a reconstructive surgeon. That's what I like to do. Will I do cosmetic procedures to pay the bills? Yes, especially if I don't stay in academics. It's just the economics of the situation.

--M

 

[deleted144060]

"My second question, relating to the first -- what are fellowships (and integrated programs) looking to produce? Academic plastic surgeons? Private practice cosmetic guys? What do the residents/fellows themselves want these days?"

This is actually an interesting question and relates to what I call the training paradox.

Academic programs want to train academic surgeons. 90% of surgery goes on in non-academic institutions. We all know this but the game goes on. During interviews, I hear many applicants say they want a career in academics, and maybe at that time they do because that's the only life they know. Maybe they think that's what they really want. Maybe they think that's what we want to hear.

In reality, while most are going to be private practice guys, everyone gets trained (generally speaking) as if they're going to be academic surgeons. You learn all types of procedures, become a master of anatomy and an expert with the literature. While we know that most are going out to the community, we also that they are going with a solid knowledge base and a vast array of skills so they can give the best care to their patients. And maybe, one will stay in the University system to pass on that knowledge to others. At least that's the way I see it.

I had a urology attending once tell me that people stay in a particular place because the s**t tastes like pineapple. When it starts to taste like s**t, they go somewhere else. While I think that he was a bitter old guy, he did have a point. Some residents in the Big U may have thought about academics, but then they see the downsides. I have seen those (and I've been there myself) that get tired of the politics, issues with the dean, decisions being made at higher levels that you have no control over, and the like. It's not that private practice is that much greener, I think it just depends on your taste.

--M

 

[deleted144060]

"I am beginning medical school (osteopathic) this august😀 , and I am very interested in plastic surgery in the future. Can you tell me about the expected timeline to becoming a plastic surgeon post-graduation? Plus, maybe some info regarding competition, necessary scores, and/or anything else you find important?"

Let me start with the bad news.

As a D.O., you are going to find it very difficult, if not impossible, to get a combined/integrated plastic surgery spot out of medical school. For reasons that I still don’t understand, The D.O.s are subject to prejudicial attitudes by some residency programs. The applicant pool is very competitive. The combined programs get flooded with applicants from the top twenty medical schools that have boards scores in the 90s, research publications, and letters of recommendation from the people that write the plastic surgery textbooks. While I dislike the phrase, “the best of the best,” that’s certainly what you’ll be going up against, at least on paper.

Now for the not so bad news.

If you’re set on plastic surgery as a career, you can get there by doing a general surgery residency. Again, as a D.O., you’’ll get some discrimination, but not nearly as bad. This is actually the path I took because I didn’t get into a combined program. I worked hard, accumulated some teaching awards, had great inservice scores, etc. If you go this route, try to find someplace that has a plastic surgery residency. This will enable you to make some connections (probably the most important thing), maybe do some research in a plastic surgery lab, publish something, impress people and the like.

A possible additional benefit is that you never know what will happen. For instance, there was this combined program that I really wanted to get into out of medical school. I didn’t match and went elsewhere for general surgery. They took someone who ended up quitting in at the end of their intern year. They ended up filling that spot with someone else who happened to be in town at another general surgery program. I also know someone very well who’s name I won’t mention (because he’s well known) that came to the U.S. as a foreign medical grad, got a prelim spot at a big University program, then managed to wrangle a categorical general surgery spot and eventually got into their plastic surgery program. He’s now a very successful academic plastic surgeon.

Let’s say you try all this and are still unsuccessful. There is always the option of doing a hand, burn or microsurgery fellowship and then reapplying. With the additional training, you become a much more valuable asset to the program.

With all this, you’re looking at 5-6 years of training for a combined slot, 7 years (maybe 1 or two extra if you decide to do some research) for the general surgery route, and addition year or two if do any additional training.

Then there is still the real possibility that, after all this, you still don’t get a spot. I certainly thought this might happen to me. The bottom line is that I love surgery. I thoroughly enjoy patients coming to me with a problem that I can fix and, in the process make their lives better. I would have been happy as a general surgeon and the question you need to answer is whether you will be happy as well.

I will post a separate reply about board scores from an earlier query.

--M

Just to add to your answer from the D.O. interested in plastics, there are a few (4 I think) D.O. plastic surgery fellowships. The fellowship directors like to see people as early as their 4th year of med school start to show interest and form relationships. The next step is to become a very strong, well-recommended general surgery resident who is bright, well-liked by others, and for the most part spend occasional free time scrubbing with the plastic surgeons' cases. Also one must do an elective rotation around 4th year of surgery residency to 'audition'. These are my--a DO surgery intern--observations.

Thank you for the information. I might add that the audition can be a two edged sword. In one case, my program took someone for our combined program who did an "audition" rotation and was clearly one of the best med students we ever had. On the other hand, there was a person in my med school class, another MD/PhD, who was great on paper. He was really annoying in person but he was clueless about it. He really wanted to go to program A over program B. Against everyones advice, he rotated at program A and they hated him. He graduated from the residency at program B.

--M

 

[plasticdraper]

Hello everybody,

I graduated from combined general surgery/plastic surgery (3+3) residency in '06 and am graduating from hand fellowship this year. Starting this summer, I will be an aesthetics fellow. I am happy to give advice regarding plastics residency, hand and aesthetics fellowships.

1. What do you enjoy most about your specialty?
I enjoy the breadth of plastic surgery, the wide range of applications and the diversity of operations available to us. It's tough to get bored with aesthetic surgery, burns, hand, craniofacial and reconstructive surgery (both micro and non-micro).

2. Is there anything you dislike about your specialty?
What I dislike about our specialty is the intense competition required to be successful in private practice. There are many plastic surgeons and non-plastic surgeons who in particular, compete for aesthetic surgery. This has made competition somewhat cutthroat. Also, the general public has some misconceptions about plastic surgery which are perpetuated by a few media-hungry individuals.

3. How many years of post-graduate training does your specialty require?
The length of postgraduate training is 6-7 years for plastic surgery + 1 year per fellowship. For example, I trained 6 years for my plastic surgery residency + 1 year hand fellowship + 1 year aesthetic surgery fellowship for a total of 8 years of post-graduate training.

4. What is a typical schedule like for your specialty? Are the hours/shifts flexible?
The hours in private practice vs. academics vary. I'd guess an average of 50-70 hrs for the former and 60-100 hrs for the latter.

5. Where do you see your specialty going in five years?
In 5 years, I see the competition for aesthetic surgery becoming more intense, and the focus of more plastic surgeons into this area. Eventually, this will level off so that reconstruction will come back in popularity within 10 years or so. Unfortunately, hand surgery is becoming less important and I predict that within 25 years, very few plastic surgeons will be doing high-quality hand surgery.

 

[deleted144060]

Hi. Obviously Plastics is one of the most competitive programs out there. I was looking at the NRMP published data and it seemed that a lot of people with very great qualifications like extremely high scores or numerous publications did not match. I know that there are a lot of factors involved in the match process but I was curious to know about factors that are specially important for landing a Plastics spot. You said that you were a MD/PhD applicant. I'm sure that must have helped but can you expand on how helpful it was to you in the application process? Would taking a year of to do research somewhat level the playing field between a regular applicant vs a MD/PhD applicant? Thanks.

You are correct in that there are well qualified applicants that do not match into the combined programs. It’s a capricious process that seems to resemble T.V.s “Wheel of Fortune,” except that there are many more “lose your turn” possibilities.

In order to get an interview, all of the following are essential to increasing your chances to get in the door:

1. I can’t stress enough the importance of your Step I and Step II scores. Because of the number of applicants, the more desirable programs use these as a way to cull the applicant pool. This in not to say that someone with, say an 80, might not have an otherwise outstanding application, but it may not get looked at if a particular program has a “cut-off” score. Remember that you’re going up against a large applicant pool with scores in the 90-99 range.

2. I get asked a lot about research experience. In my case, I don’t think the Ph.D. helped me very much, and it may have hurt. I got the impression that surgeons want to train surgeons, not scientists. If you want to do internal medicine, heme/onc, etc., the Ph.D. can be more helpful. Again, I can only speak from my own experience here. As far as leveling the playing field with an M.D./Ph.D., I don’t really think it matters. If you think you need to take a year to do research you improve your chances, I don’t think it will be wasted because you will learn things.

Research is more one of those hoops you need to jump through. It shows that you’re motivated and willing to do the extra work to get a spot. There are other benefits as well, like learning to critically evaluate what you read in the journals, but the immediate benefit is getting an interview because everyone is doing it. We did interview one or two people who did not have research experience, but they had great scores and great letters of recommendation. When we asked them about it, they explained that there was limited opportunity for research where they come from, or that they spent their time doing other extra activities.

If you have the chance, research in a plastics lab is a bonus, especially because you’ll get a good letter of recommendation from plastic surgery people (assuming you did a good job and were well liked). More about letters below.

A word of caution. If you do have research experience, be prepared to discuss it at your interview. I have had, on more than one occasion, someone show up with a copy of their published research, but couldn’t discuss the methodology, conclusions, or anything else in the paper. For me, this is a sure fire way to get bumped right off the match list. If you don’t have publications, don’t worry. Just be prepared to discuss what you did.

3. We look at extra-curricular activities as well. I’m not talking about kayaking or playing an instrument (unless you went to the olympics or played at Carnegie Hall), but volunteer work, participation on committees, medical missions, etc. By the way, I have heard about people who put guitar playing on their application only to be handed a guitar at their interview to see if they could really play. NEVER put anything on your application that’s not true. You might get away with it, but if you’re found out, you’re finished.

4. How important are awards, such as AOA? There are some programs that only interview AOA applicants. I personally don’t really care about this because I know the process for being AOA is somewhat political as well as scholastic. I would rather see a teaching award, funded research proposal, or something involving the community. This area is one of those intangibles that may not be necessary for an interview, but it can only help.

5. Letters of recommendation, while not a complete “make or break” item for an interview, need to be strong. In other words, if a program is sitting on the fence with your scores, research experience, and extra-curricular activities, a really good letter may enough to push you on to the “invite” list. The converse is also true.

--M

 

[deleted144060]

You talked about the importance of the Step I scores. Is there a certain score level that above it the difference becomes nominal? And please talk about any other factors that you think weigh heavily in matching into Plastics.

Briefly, I don't think there is much of a difference between 95 and 99 on the board. But, as previously stated, if you're in the less than 85, it might become an issue.

--M

 

[deleted144060]

Just a quick question: I'm assuming all the advice you're mentioning here applies to the other uber-competitive surgical subspecialties (ortho, uro). Are there any major differences in what those fields look for in applicants versus plastics?

The better you look on paper and your ability to interview well will be advantageous for any of the subspecialties. Specifically, plastics is much more competitive than the others you mentioned. The are people who didn't match in plastics that most likely would have made it into ortho. This is not to say the ortho candidates aren't as good, it's just the reality about the competitiveness, the number of slots, the average boards scores, etc. between plastic surgery and other specialties.

Since I can't speak directly to how the interview process works for orthopaedics or urology (although I suspect it's similar), you should direct this question to someone in that field. We currently don't have any Orthopods or Urons as mentors that I'm aware of but there is a Urology and Orthopaedic discussion thread at http://forums.studentdoctor.net/forumdisplay.php?f=40

--M

 

[deleted144060]

O.K., you’ve scored 98 on Step I and II. Your up for AOA, an Albert Schweitzer award, and have more publications that your attendings. You’ve secured a good number of interviews and feel that you’re going to match in the combined program of your choice. NOT so fast...

The past two years, my program did NOT take the biggest board scorer, publisher or humanitarian. Who we took depended a lot on the interview process. Below is Moravian’s guide on what I look for in an interviewee. Granted, this will be somewhat different from person to person, but I think that the basics will hold true no matter where you interview.

1. Be on time. Enough said.

2. Dress conservatively. Do not wear wacky ties or bright suits. This goes for men and women. Make sure your shoes are shined and you have a recent haircut/style. You might think that this would be a good time to show your individuality by wearing big hoop earrings, combat boots or your favorite muppet tie, but nothing could hurt your cause any worse. We don’t want to see oddballs, we want uniformity and normality. Your appearance is the first impression you make. If it’s a bad one, it’s going to be a tough hole to climb out of.

3. Some programs have an informal get together with the applicants and the current residents the night before the interview. The above rules on normality apply here as well. I would add that you do not want to try to impress the residents by name dropping or touting your CV. You’d be surprised how many people do this and it’s a huge mistake.

4. Don’t drink too much coffee. You might be asked to throw a few stitches (my old program director would make you use 6-0). You may also find yourself needing to go to the restroom at the most inopportune times.

5. I have discussed elsewhere the need for honesty and for being prepared to discuss your research (if you have done any). This also includes anything else on your CV. Don’t put down anything that’s not true. For example, I interviewed a candidate that said he did research on facial fractures. After some questioning, it became apparent that he didn’t know anything about facial fractures. I had another hand me a reprint of a paper listing him as second author. The subject was something I was familiar with, and as it turned out, I was a lot more familiar with his research than he was.

6. Relax. I know that’s easier said than done, but it’s like the advertisement says, “Never let them see you sweat.” If you don’t think you interview well, ask some of your faculty to do mock interviews with you and give feedback on your performance. I can tell you that from getting into med school all the way to my current fellowship, I was accepted at those places where I thought I managed to relax and enjoy myself.

So you go through the process and you feel good about your interview. Now, you might ask, how does the selection process work? I can only tell you how things work at my program, but I suspect that it may be similar elsewhere (except at those places where the Chair makes the decision independently).

We (the faculty, fellows, and residents who participated) sit down at the end of the day and go over each applicant separately. We each assign a point value on a scale from 1 to 3 (three is best). The points are added up giving a rough idea of the ranklist. Then the fun starts.

If there is anyone in particular that we couldn’t stand, they get blacklisted. This usually happens to 3 or 4 of the applicants and can be for various reasons. The residents could really like someone, but one of the faculty might not based on whatever they saw during the the interview. Or the residents might say there is no way they can see themselves working with a particular individual. This happened to one person this past year that had 99 scores, great publications, and letters from the top guys in plastic surgery but who managed to annoy everyone, and I mean everyone...even the other applicants. This person never made it on the match list.

The reality is that we try to pick someone we think would be a good fit for our program. Someone who we feel may not be good for us maybe a top pick elsewhere, and vice versa. In the end, you have to realize that it really can be an arbitrary process, subject to whims based on initial impressions, geographic bias, and those intangibles that can work for or against you. There is nothing you can do if you remind an attending of his ex-wife, or look like the guy who ran over his dog. And there is the number of really good applicants...when there only one or two spots per program, not everyone is going to find a home. All you can do is your best, maximize your chances, and keep swinging if you don’t get in the first time.

--M

 

[deleted144060]

I've got a random question: a lot of residents in plastic surgery stress that private practice plastic surgery is not how it is all cracked up to be on TV (dr. 90210, etc). I was just wondering, what is it that differentiates the young men and women that open up their own practices and succeed in areas like miami, new york and L.A. from those who don't succeed? Are there people out there who have tried to hang their own shingle, but soon failed due to having no customers? After looking at probably 50 different resumes of different successful plastic surgeons, its surely not about training, nor is it about prior experience as an academic surgeon, as most of them began practicing immediately after residency. Is it simply a combination of good marketing skills, excellent results and a lot of luck? Or is there more/less to it?

I know this was directed to Plasticdraper, but I'll take a swing at it as well.

The question you ask is a complex one that touches on several issues. The first and foremost is that there is essentially no one teaching how to set up a practice, the different types of practice models, reimbursements, and the other necessary evils for survival after residency. There is beginning to be more resident education in this area at the big national meetings, but it's taking it's time making it into the curriculum of teaching programs.

Plastic surgery is still one of those few specialties where you can hang up a shingle and make a living going solo, mostly because the cosmetic procedures are prepaid. In the cities you mentioned, it would be very difficult to start a purely cosmetic practice from start because of the saturation factor. Success encompasses but is certainly NOT limited to:

1. Competition. If you go to New York City planning to be the next Dan Baker, you're going to have a problem because there already is a Dan Baker, (and a Sherrell Aston, an Alan Matarasso, and a whole bunch of other really good surgeons). At the hospitals I'm familiar with, the attendings do their own consults as they are all scrambling for business. I have also found a lack of collegiality in that some younger attendings will badmouth others, especially if they're competing for the same cases.

2. Motivation. In a saturated market, you're going to have to do what it takes to get started. This means ER consults, bedsore sore consults, and the rest of the cases no one wants to do. It also means being on every insurance plan so you can trying to get by on what reimbursement there is for your reconstructive cases until you can get a referral base going. And there is the actual running of your practice (see below). If you thought you worked like a dog in residency...

3. Business sense. Let's face it...some people, including myself, are business idiots. We are not trained to run a business, we're trained to take care of patients. Your solo practice will involve facility expenses, staff management, billing, collections, dealing with insurance companies, etc. There are ways of dealing with some of this, like getting an outside agency to do your billing (for a slice of the pie, of course), and being guaranteed a salary by a hospital for one or two years. One of the problems with the latter is that after your guarantee is over, are you going to be left with a bunch of medicare/caid patients that aren't going to be enough to keep your practice running? An issue with the outside billing agency bit is that they can drop the ball. A very good friend of mine who's a private practice gyn/onc surgeon lost 200K in profit when his company didn't file his claims. The billing company is being sued, but he'll never recover all his of income.

4. Personality and talent. You can get by with less than stellar results (to a certain degree) if your patients like you. But you can be the most talented guy in the world and, if you're a putz, patients usually won't fork out 10K for you to do their facelift, especially if there is another surgeon down the street who gets good results and is a likable person.

I realize that this really on scratches the surface, but I hope it helps in some way. No matter what your profession will be, there are many ways to practice and get paid. It would certainly behoove anyone to do their homework before making a big decision such as how/where to work after residency.

--M

 

[deleted144060]

hello,

i will be starting medical school this august. although i am not absolutely certain, i am looking at plastic surgery for residency and training. so far, the people i have asked advice from have just said to relax and not worry about residency, but given the competition for plastic surgery, i would like to know what you suggest i can do early on if in fact i do pursue it (grand rounds, meeting residents and faculty, research btw MSI and II, etc.,)

I asked Plasticdraper for his input, and here's what he had to say:

At this early point in your career, it is important to keep your options open and certainly plastic surgery has become a popular choice for many medical students. For year one, I would recommend focusing and mastering your grades since high grades are the single most important thing you can achieve to keep yourself in the running for plastic surgery. If you can do this and find you have time or the ambition to do more, I would seek out an academic plastic surgeon and see if you can watch some cases to see what plastic surgery's all about. If you're lucky, you can parley this into a clinical or basic science project which you can sustain for x amount of years and culminate in a letter of recommendation. Again, scholastic excellence is the most important thing at this point and will help you do well on Step I, which is often a cutoff used by some integrated/combined programs.

From Moravian:

I couldn't agree more. Spend the first two years (and ideally the rest of your career) learning as much as you can. You will be exposed to a great deal of information and it's too early for you to know what's important and what isn't. Remember, what you don't know will, at some time in your future (plastic surgery or not), hurt your patients. And, in a selfish sort of way, you'll need to know all you can in order to do well on Step I and II.
If you manage to hook up with a plastic surgeon try to read about any case you might scrub in on ahead of time in case you're asked questions.

--M

 

[deleted144060]

I'm still in school but I'm extremely passionate about medicine and surgery in particular! I have spent over 100 hours in theatre already, as well observing doctors in their rooms and learning as much anatomy as I can. The surgical specialties which I have seen (and assisted in) so far have been orthopedics and ENT. I have also watched some general surgery. I'm from South Africa, so I realise things are quite different here to what they are in the US, but surgery is surgery none-the-less.
I believe medicine is my calling, so nothing else will do, and I have had my heart set on orthopedics. Recently, however, I have started noticing that I really like the "smaller surgery" like in otorhinolaryngology. I dont like the ear ops though 🙂
I know I have plenty of time to think about my surgical specialty with 9 years of study ahead, but I like to aim for something anyway. I have thought about Neurosurgery (which I still need to observe) and I'm still open to orthopedics BUT I have become very interested in plastics. The only thing which puts me off is the cosmetic surgery (you know, tummy tucks, breast augmentation, face lifts etc) I want to be a doctor, not a beautician for dissatisfied rich women.
I will probably land up working in a state hospital after graduating which does involve more re constructive surgery than cosmetic (as you know, SA is renowned for its violent crime

) but I wanted to ask whether it is possible to do plastic surgery and stay relatively clear of the cosmetic stuff when working in private practice? I really couldn't care whether I earn less for avoiding cosmetics.

I have also considered Maxillofacial surgery and then subspecialising in craniofacial surgery, which would mean that I would have to study dentistry (a negative factor) and I am going to observe some surgery soon. Do you have any advice for me on this? Have you found Plastic surgery to be an enjoyable specialty? And how do you feel about cosmetic surgery?

First of all, sorry for the delay. I've just started my craniofacial fellowship in a new place and I've been kind of running around like an idiot figuring out the new system.

As for your question(s), it sounds like you've certainly thought about this quite a bit. I think you've made the first couple of really major decisions...namely that you really want to be in medicine and surgery is your calling. I have also been following the posts on the plastic surgery section as well. Dr. Millisevert, Plasticdraper and others have already posted some fine advice about plastics and OMFS. Plasticdraper also had a fine post in the thread "plastic surgeons don't save lives" concerning cosmetic surgery. If you haven't read that post, you should.

For me, cosmetic surgery was a way to operate on normal anatomy so I would know what needed to be restored in a trauma situation. I was just never interested in anything beyond that. You mentioned taking care of dissatisfied rich women. I'm sure there is some of that, but I'll tell you that during the time I spent doing cosmetics in NYC, I found that if I liked the patient (and I did most of the time), I wanted to help them, whether it was a facelift, a bleph, or just a little botox. They were happy and grateful. Granted, there were the occasional patients who thought that a breast aug was going to get their boyfriend back, and those I steered clear of.

As for why I like doing what I do (and I do truly love my job), I'm not sure I can put it into words. It's why some people like fixing broken bones, others like reading MRIs, etc. It's just what turns me on. I like to make the broken thing as normal and as functional as possible. I like the face because it's complicated and challenging. I like kids because they're honest and generally don't ask for the stuff that happens to them. It may sound trite, but hardly a day goes by that I'm not truly grateful that I've been able to go as far with my training as I have and do the things that I can do.

If I were truly honest, I could also say that if I hadn't gotten a plastic fellowship, I would have been happy as a general surgeon. If I hadn't gotten a craniofacial fellowship, I would have been as happy as a plastic surgeon. For me, it really is about taking care of people. It's just that much better for me that I can do that in my current field.

Yes, you can make a living doing reconstructive surgery. As far as being in a solo private practice, you may have some financial trouble with just doing the reconstructive stuff. There are however, more and more hospital employed positions that pay quite nicely for someone who wants to do mainly reconstructive work. And you may find (as I did) that you won't mind the occasional cosmetic patient. You'll fix some little girl's face in the ER after a dogbite, and her mother will like the result and ask if you would fix her eyelids. And then she refers some friends and so on. It's already happened to me.

As has been posted, you can get to craniofacial through either plastics or OMFS. There are pluses and minuses to both which have been discussed elsewhere. And if you think all ENT does is myringotomies, you need to see a neck dissection along with a mandible resection followed by a pectoralis flap. Those guys do some big whacks.

When I was trying to find my way, an old surgery graybeard asked me what I saw myself doing everyday. And doing everyday for the next 30 years. In my heart I knew the answer and was lucky enough to get there. I wish the same for you.

--M

 

[deleted144060]

The thread "Surgery and Surgical Subspecialties" is being split into "General Surgery" and "Plastic/Aesthetic/Craniofacial. Vandysurgeon will be the mentor for the general surgery portion. Plasticdraper and I will continue to mentor the plastic surgery thread.

--Moravian

 

[deleted144060]

Hello,
I have always been a gifted sculptor and musician. So far as I can tell, my talents would fit best in plastic surgery. The musical performance aspect seems similar to practicing surgery and the artistic eye I am guessing would help give me an advantage in terms of aesthetic discernment? Does this sound like good reasoning to those w/experience? What are the more important attributes of a good plastic surgeon?

In my book, the most important attribute of a plastic surgeon (or any type of doctor for that matter), is that you care about your patients. And I don't just mean being able to empathize. This includes continuing your education through your lifetime, constantly evaluating your results and striving for improvement, staying current with literature, doing the right operation, and referring your patients elsewhere for things that you might not do very well instead of doing a suboptimal job just to get the payment. You should always strive to give your best care, even to those patients that you can't stand (and this WILL happen) so you’re able to make the best decisions.

I had one of my general surgery attendings tell me that he could train a monkey to operate, but he couldn’t teach someone how to care. While I believe the second part, I have seen residents that really didn’t have the hands for the job.

Plastic surgery, more so than most other surgical subspecialties, is technique driven. Many of the people I know in the field have hobbies that involve using their hands. For example: A hand surgeon who is a sculptor, a cosmetic surgeon who does some really fine oil painting, a few musicians, and my boss who loves to work on car engines (expensive car engines). I play classical guitar. I also thoroughly enjoy whitewater kayaking and bicycling which have nothing to do with the arts. I also know plastic surgeons who don’t do any of this stuff. While I think that having that “artistic sense” is beneficial, appreciation of proportion and aesthetics can be taught.

However, operating is only about 40% of the ball game. It’s the decision making that goes into whether or not to operate, what operation is needed, how to handle postoperative complications, when to re-operate, when to wait, when to refer, etc. that make up the bulk of the job. I’m not sure about how playing at Carnegie Hall matters in that regard.

In the end, I think that people tend to gravitate to what they enjoy. If plastic surgery is it, then best of luck to you.

--M

 

[deleted144060]

I'm considering applying to integrated Plastics programs, as well as to General Surgery as a back-up. However, I was told (by the Chair of Plastics, no less) that General Surgery programs would be unlikely to accept me if they knew I was planning on doing Plastics. How true is this? I'm just afraid that I won't match.

This really isn't the case, although I'm sure there might be a few curmudgeons out there that may hold it against you. Most program directors know how competitive plastic surgery is (i.e., I think the match rate is less than 40%), and if you're competitive for plastics, you're going to be competitive for general surgery as well. Maybe even more so.

You can't jump ship anymore and move to another program if a plastic spot should open up. As of 2008, all training for integrated/combined plastic programs must be done at the same institution. I suppose you could fill an open spot at a program that had both general and plastics if, by some miracle, a spot should open right after your third year of GS training. This still happens, although it is becoming increasingly rare.

The bottom line is that you want to be a surgeon (I know I did), and most PDs know this as well. If I hadn't gotten a plastics fellowship, I would have been a content general surgeon. It's not a question between say, surgery and radiology. Surgery programs generally lose about 10-30% of their residents through attrition anyway. Some leave, some go to anesthesia, some get fired, etc. If I were in charge of the match list, I would have no problem with matching someone who was applying to my program as a back-up because I would know that they were motivated to finish. And, as I said, most plastic surgery applicants are more qualified (generally speaking by board scores, research, publications) than a fair number (certainly not all) of the general surgery applicants. This is not to upset the GS guys, but it is true nonetheless.

You're Chair might be right about the attitude at your institution, but I see a fair number of letters of recommendation from general surgeons who say that they wish their plastics applicant would consider their program for GS if they don't match in plastics.

Everyone is doing it (you'd be stupid not to), we all know it, so just be honest about your motivation.

--Moravian

 

[deleted144060]

Hi,

I am an MS4+. I deferred after graduation to pursue a research fellowship. I'm doing work in the immunology of melanoma in a basic science dermatology lab. I'm doing dermatology work because I had been setting myself up for a dermatology residency and hoping to subsequently do a Moh's fellowship. I had the opportunity to observe some moh's surgeons doing repair of facial defects and was really excited about it. At this late date, though, I've realized that I don't want to be restricted to little flaps and tiny grafts under local anesthesia. What excited me was always the plastics work, and not the derm. I recently went to derm grand rounds with a sense of dread, never wanting to see another rash.

So...I'm intending on applying for plastics this year. I loved my surgery rotation and think I can get a letter from an old attending (the chief of trauma), and hopefully the chair. My PI from this year will definitely give me a letter (although it seems of limited utility since he is a dermatologist).

My question is: what should I do? Should I apply general and then hope for a fellowship? Should I apply for a prelim to get some good letters, and then apply to integrated programs? I just don't really believe that I'm that competitive for plastics right now, without a single plastic surgeon letter.

Let me start by saying that Mohs surgery can be a challenging career. They usually act as their own pathologist and I have seen a few that did some outstanding work with facial flaps. But i do understand the thing about the rashes.

I don't think applying for a prelim position and hoping to get lucky is going to be a high yield proposition. Matching into plastics from a preliminary year means that you'd have to match into the program where you are doing your surgery year or get a spot at some program who doesn't know you as a PGY-1. It happens, it's just very rare. The downside is that, after your year is over, you might just be out of a job.

You have nothing to lose by applying for an integrated/combined program except for the money you'll spend getting to interviews. Your scores are respectable, you have research experience, and I'm assuming your letters will say good things about you. Your personal statement should reflect what you've stated about wanting to change from derm to plastics. As a back up, you should apply to general surgery programs and be thinking fellowship when you are finished. If you are at someplace that has a plastic program and a spot does open, all the better, but I wouldn't depend on this.

There has been some discussion about the possible future demise of the plastic fellowship (see http://forums.studentdoctor.net/showthread.php?t=429613). You may also find yourself doing a hand or micro fellowship after general surgery as a way into plastics. You need to ask yourself if you'd be happy being a general surgeon (or hand, burn, vascular, etc) in the event that you don't get into plastic surgery.

Another option that you might consider is the laboratory route. At Pittsburgh's program (at least when I was there in 2000), they took in someone from their lab every year (or every other year). I don't know if there is a plastic residency where you are now, but it is a consideration. I would however, consider matching directly into plastics followed by the general surgery route (unless you don't want to be a general surgeon) and then the lab.

Best,

--Moravian

 

[deleted144060]

Hi Moravian, thanks for answering these questions.

I am an MS2 right now, not really sure what I would like to do yet.
I first got interested in Neurosurgery and now I am doing a basic science project in spinal cord injury. However, recently I have read up on some plastics research and I found it really interesting; now I am interested in plastics in addition to neurosurgery.
I am in the top 5% of my class and learning my material well, but I worry since combined plastics is such a tough match that even with good board scores, grades, stellar clerkships, and AOA that if I decide to enter plastics that I won't have a chance of matching, especially considering 4-5 people in my class are already doing research with the chief of plastics at our school. An MS4 entering combined plastics told me that to match in combined plastics that you had to impress your home school's chief and do research otherwise you won't have any shot.
If this is true I am debating whether to try to do research in plastics as well. The reason I am hesitant is that I wonder if my time is better spent just focusing all my energies on my spinal cord injury project, since a good publication will benefit me even if I do apply for plastics. Should I just contact the chief and view cases? Research? Or stick to what I have now and then work with what I have if I decide to do plastics?

I can tell you that having a research project that is not plastics related is definitely not a show stopper. Research is a hoop that we’ve all jumped through, albeit some with a little more enthusiasm. The advantage you would have with working in plastics is that they get to know you which does help with your letters of recommendation. By no means do I advocate abandoning your neuro research. Having a good project is something to hang on to, but since you’re still fairly early in the process, it can’t hurt to see what’s available for you on the plastic side. Just be prepared to discuss why your focus has changed. If you really don’t have the time for two projects, you still need to become known to the plastic folks by shadowing, rotating, showing up at journal clubs, etc.

For me, having someone who can intelligently discuss their research is much more important than the subject. You’d be surprised the number of applicants I talk to that have no idea what the science is behind their project even-though they’re listed as an author. They automatically go into the round file.

That being said, any kind of research is still no guarantee. You really need to nail your boards, do some volunteering, and make connections within the plastic community. From what you’ve said, this part doesn’t sound like it’s going to be a problem.

I will also tell you that the person we took last year did not have a lot of research, What he did have was an outstanding MS4 audition rotation. He came to our program, worked hard, read before cases, knew everything about every patient on the service, was well liked, and was generally the best med student we ever had. He also had stellar board scores. While we had other applicants who looked better on paper, we went with what we knew (and we were fairly certain that were ranking this guy number one before we even interviewed anyone else). We actually had someone rotate before the above mentioned person who had good research and came from a big name place with big name letters of recommendation. We thought he would be our top pick before the other person (who was not from a big name place) showed up and completely blew him out of the water.

So the short answer is that I don’t think the project matters as long as you get in with the plastics crowd at some point and do all the other things you need to get an interview.

Best,

--Moravian

 

[deleted144060]

I am interested in PRS and have a third year elective slot which I am not sure how to use best. I don't have a home pRS program and all programs I have looked into, will not take an away rotator for a PRS elective until she or he has completed all core including general surgery. My elective is right before my two general surgery rotations - so that leaves me out of options in that sense. What is the best way to use that elective slot in a way that can maximize my efforts to match at a combined or integrated PRS program? thanks.

I’ve asked around and no one I know has heard of such a stipulation. I know where I did medical school, they used to recommend that general surgery be done first so you didn’t look like a complete idiot when you got to plastics.

PlastikosMD suggested to possibly set up an individual rotation with a preceptor. These rotations often 'fly under the radar,' as they are not set up through a department. This will often require, especially if they’re a high-power name, some sort of introduction.

Maxheadroom had a couple of other options as well. First, do something related like month of Burns or an Ortho Hand elective if it’s possible to do this without doing GS first. The other option might be to get a senior elective out of the way to clear their schedule in fourth year.

Hope this helps.

 

[deleted144060]

Quoting from the Careers in Medicine subsite of the official AAMC website:

"A plastic surgeon deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, head and facial structures, hand, extremities, breasts and trunk. A plastic surgeon uses aesthetic surgical principles not only to improve undesirable qualities of normal structures, but in all reconstructive procedures as well. "​

I think I understand what this means, but I'm wondering if you guys can help me clarify a little. Just going by this description, it seems that there would be a great deal of overlap between plastic surgery and orthopedic surgery.

And I have another question of a different nature: I read that orthopedic surgery, moreso than the others, is somewhat devoid of medicine -- that one's knowledge of medicine kind of atrophies a little as it doesn't get used. I'm wondering if there is any truth to this in orthopedics (if you have any insight, I know this is the plastics thread), but more importantly, how does plastic surgery fare in this department?

In answer to the first part of your question, generally there is very little overlap between orthopaedics and plastic surgery. There are some orthopods (and these are few) that will do local flaps for coverage of traumatic or oncologic wounds, but I haven't met one yet that did their own free flaps. In very simplistic terms, they tend to be the bone/joint/tendon docs and plastics are the soft tissue/reconstruction docs. The exception areas tend to be the hand where both ortho and plastics operate equally, and head/neck/craniofacial where plastics deals directly with bones in facial fractures, osteocutaneous flaps and reconstruction. This last is not the sole domain of plastics as OMFS and ENT do facial reconstruction/fractures as well.

This takes me to the second part of your question, which is something I've struggled with on and off since I began residency in 2000. What I've come to realize is that you can't be all things to all people. This is why we have specialties, subspecialties, and super subspecialties. The further you get along the path to super subspecialist, you will lose some of your medical skills. My feelings about this have changed as I've moved along my career path to where I now welcome the help of additional specialties in patient care.

For example, in my GS training, I had very extensive ICU experience. I had no problems running multiple drips, analyzing PA catheter data, doing my own bronchs, taking care of renal failure, heart failure, and general complex medical problems superimposed over surgical issues. We did not have any critical care fellows at my residency and I felt that I could provide better care to the surgical critical care patients than the medicine residents. We also had surgical attendings who were trauma/critical care fellowship trained that were great teachers.

After I moved on to a plastics fellowship, I realized the benefits of being the "consultant service." Sure, I could do everything I did in GS residency, but I didn't have the time. I kept on eye on the flaps, facial fractures, and other critical reconstruction patients, but it was easier, more time efficient, and SAFER to let the critical care team take care of the day to day stuff. For my floor patients who had other medical problems, if needed I'd get the appropriate medical services involved (i.e., infectious disease, nephro, cardio, etc.) to help with the management. This doesn't mean I'm less of a doctor, or that I got lazy...it's just a reflection that I needed to be in the OR, seeing consults, reading, or just generally learning my trade as a plastic surgeon. Part of being a good doctor also includes knowing when to get help as opposed to stubbornly trying to slog through it yourself. You won't be able to and it may not be the best thing for your patients.

For me, now that I'm on my way to being super subspecialist, my general medical base has certainly suffered. In order for me to do what I do, I came to realize that it really has to be that way. Can I do all the stuff I did in residency? Sure, but I'm pretty rusty and I'll miss things, but I don't need to be taking care of renal failure because that's not what I do anymore. So yes, there is a tradeoff, but it's not a bad thing. I do what I'm trained to do (operated on babies, kids, facial trauma, some hand) and let the other services take of the area in which they're the experts. And because I'm a super subspecialist, I work in centers where the other expertise is readily available.

For the ortho guys, I suspect it's the same. Everywhere I've been in my training, orthopaedics always seems to be the busiest surgical service, mostly because of trauma. Those guys are always in the OR doing what they've trained to do and let the other services take care of the remaining issues.

So why, you may ask, do we need to learn all this stuff in the first place if we are not going to be using it later in our careers? As I've said before, what you don't know can and will hurt your patients. You do retain enough knowledge to know when you need to call in other services to head problems off at the pass. You can intelligently discuss patient management with the consultant services. You know enough of what others bring to the table in order to optimize the outcome for your patients.

You also don't really know where your training might be going, either. I didn't match into a combined/integrated program, so there was a distinct possibility that no matter how hard I worked, I may not have gotten into a plastics fellowship. I needed to learn how to be the best general surgeon I could be in order to provide the best care to my patients. During my plastic fellowship, I lost some of my GS chops because I was elevating my game to be the best plastic surgeon I could be. Now that I'm finishing my craniofacial/pediatric plastic fellowship, I know that I've lost some of my PS skill as well. For instance, I don't do breast reconstruction anymore. I could if I wanted to, but I know that my results won't be as good as the people that do it all the time. And I'd rather be working on kids. It's the same reason why the breast reconstruction surgeons don't do clefts.

So, does this mean that this will happen to you? It depends on what you want and where you want to practice. One of the guys I graduated GS residency with practices in a smallish size city and he does everything....abdominal, colorectal, breast, thoracic, and endocrine. My fellow chief resident from plastics is in a similar situation (although his town is slightly bigger) and he operates on everything plastic except for kids. You can compare this with people who just do rhinoplasties, breast, or eyes. I think that both are needed, but it's going to depend on what you want. I have never met an uberdoctor, but that doesn't mean there isn't some out there. But I'm sure even they occasionally need help.

--Moravian

 

[deleted144060]

What is the general consensus on US IMG's trying to make it into Integrated/Combined spots? If board scores are great, and US Letters from plastic surgery faculty are equally as good, and research has been done in plastic surgery, is the application still "thrown" away in the trash, or is there some chance? Also, if you have plastic surgery research, but no publications, is this viewed very negatively?

As you may have guessed, the consensus is not good. None of the other people I've polled have ever personally known an IMG that matched into a plastic surgery residency. The reason for this most likely stems from the overwhelming large number of very qualified U.S. grads in the applicant pool. That being said, the sample size of my informal survey is relatively small, so I'm not going to say that it's beyond the realm of possibility.

For something like this to happen, you would need the following:

1. Board scores that put you in the top percentile

2. You mentioned research. I've never personally decided to not consider someone because they didn't have publications. I think it's more important (as do others), that you can intelligently discuss your research, its possible applications and future directions.

3. Community service

4. A champion. By this I mean someone who is going to make phone calls on your behalf. I think out of everything, this is probably the most important.

You mentioned in another message that you were doing research in the U.S. This has got to help as long as you're not annoying. If you're a hard worker, are well liked, getting someone to champion your cause may be that much easier. Without someone vouching for you, I would guess that your chances of matching are close to null. Still, this doesn't mean that it can't happen. You don't know until you try, but you just need to maintain some realism so you can plan accordingly.

Another option for you may be the "lab route." This is something I have personally witnessed so I know it's viable. Where I graduated from medical school, they would roll one of their lab guys into their program, sometimes on an every other year schedule. I don't know how common it is, but I'm sure it's still happening out there.

Best,

--M

 

[deleted144060]

i was wondering if the medical field had any language ideas,., I know it sounds absurd but like this(?)

Due to people speaking with their voice and not every body being able to learn everything taught,., facial plastic surgeons might have a better idea about the state of peoples thoughts and the health of their life based on their perception of people going back to their normal life after facial surgery🙄

Interesting question...and although I'm not entirely certain what you're driving at, I'll attempt a reply.

I think that the physicians ability to empathize and recognize "perception of self" issues lies more with the physician than the specialty. This is not to say that it's an independent variable, since training does play a role. It's almost a nature vs. nuture argument.

For example, I became much more sensitive to my craniofacial and reconstructive patients during my craniofacial fellowship. This result was not inherent in craniofacial training, but it was because my teacher made me aware. I had always considered myself an empathetic individual, but I realized, with my mentors guidance, that there was a level of both verbal and non-verbal subtlety that I was not seeing. The reason I don't think it's an inherent result of training is that I very recently dealt with a patient that was repaired by a "facial plastic surgeon" who obvious didn't care or didn't know about the emotional/psychological effects on his patient.

This subtext, while not immediately apparent to the uninitiated, extends to cleft patients and their families, those with syndromes, trauma/oncologic reconstructive and even cosmetic patients. I should also point out that the face is not the only part of the anatomy where this happens. Anything that affects your patients sense of self, well being or place in the world will have psychological effects which may be missed if you're not attuned. This is probably why most top notch trauma and craniofacial programs have access to a psychologist that make their living dealing with these issues.

I hope this gets close to the mark. If I completely missed the boat, let me know and I'll take another shot.

--M

 

[deleted144060]

I am very interested in plastic surgery, however I have severe back pain when standing for extremely long periods of time. What are the physical requirements of a typical day in residency/practice as a plastic surgeon?

The amount of standing I do depends on the case. For a hand case, it's common to sit. A breast reconstruction may take 4-6 hours. Skin lesions may be less than 30 minutes. Everything else sort of falls in between. During residency, especially when rotating through cardiothoracic, I can remember 12 hour cases. A whipple may go anywhere from 4 or 5 hours to all day if things aren't going well.

Early on, i.e., as a med student, I had some similar problems with my back and knees. I started wearing Dansko clogs and never went back. It was amazing what a difference changing footwear made. About every two to three years or so I need to get my left knee injected with some steroids, but I consider it a very small price in order to do my job.

I did get an MRI, but nothing showed up. You might consider the same if your problem persists. There might be something medical that can be taken care of. Also, if I know I'm going to be doing a big case, I'll take some Motrin prophylactically.

 

[deleted144060]

As way of background, I am a fully qualified dentist who is now studying graduate entry medicine in Australia. I have a great interest in OMFS and have assisted many surgeries with OMFS, and performed a few myself. However as a I progress through medicine I feel that perhaps plastics but more specifically craniofacial plastics may enable more scope of work and not "waste" my medical degree.

It appears that CFPS may enable me to do more facial reconstructive and aesthetic/cosmetic work than OMFS would? This is probably where I see myself in the future rather than pure OMFS (wisdom teeth, dental implants etc).

It also appears that plastics hold the political/hospital power over OMFS (at least in Australia) and in a way prevent OMFS from performing aesthetics of head and neck even though many OMFS are probably quite capable.

What advice could you give me as an aspiring OMFS or CFPS.

I realize that you used quotes when writing “waste my medical degree.” I sometimes thought that about doing cosmetic surgery until I actually did some and realized that no matter what your doing, if you’re taking care of your patients to the best of your ability, then there is no “waste.” For me, it was a matter of wanting something else, and I suspect that is your situation as well.

In the U.S., there are many oral surgeons in craniofacial surgery. A residency in OMFS is one way to get into a craniofacial fellowship. A plastic surgery residency (or, in my case, a plastic fellowship after general surgery) is the other option. Many OFMS docs do orthognathic surgery (sagittal splits and Lefort I) and facial trauma/reconstruction. They don’t do craniosynostosis or, to the best of my knowledge, Lefort III without the additional CF training (altough I guess there might be some OMFS people doing the latter, I just haven’t heard of it). We also have the occasional OMFS doing cosmetic surgery, but it really tends to get under the plastic surgeons skin. Some states are working on limiting scope of practice because of this, but that really doesn’t pertain to your question.

I’m not sure how the situation in Australia works. If you were in the U.S. and wanted to do plastic surgery and craniofacial surgery, you’d have to go the plastic residency route followed by a CF fellowship. If you weren’t interested in general plastic surgery, a CF fellowship followed by OMFS training would be the ticket. For some things, I think the OMFS guys have the advantage because plastic surgeons don’t usually do much orthognathic training (if at all). It’s an extra tool in the box when applying that experience to CF surgery, especially since that in the States, orthognathics is not a large part of most CF fellowships (but this is location dependent). On the other hand, because of my plastic training, I’m very comfortable doing a free fibula for facial reconstruction, or nerve grafts/flaps for facial reanimation, or performing facelifts.

As far as where the political power lies, it again depends on location. Where I did my plastics fellowship, ENT and OMFS were very strong. In fact, the OMFS chair was analogous to the 800lb. gorilla. Where I’m doing my CF fellowship, plastics runs the show. Then there’s private practice where all bets are off, although some hospitals may limit your privileges depending on your training. What you do in your private office, however, is up to you.

In your situation, I think you need to ask yourself what you really see yourself doing for a career and then take the necessary steps to get there. While I don’t know what this would entail in your country, I can look at the improbable nature of my own career path and tell you anything is possible. It also can't hurt to talk to the OMFS and plastics docs down under to get a homegrown perspective.

--M

 

[deleted144060]

You mentioned that, in broad terms, plastics is the "soft tissue/reconstruction" department -- but also that ortho is the bone, joint, tendon department -- since you didn't explicitly say so, does soft tissue include muscles? Who generally repairs and reconstructs muscles (ortho or plastics)?

I would put the repair of muscles along with soft tissue repair. The extremities are areas where there is some overlap, especially in the arm. Both ortho and plastic hand surgeons work on upper extremity for things like tendon/muscle transfers. That being said, as a general rule orthopods generally take care of humerus fractures and plastics stays down by the distal radius/ulna. If there is an upper extremity injury with bone, muscle, nerve and vessel injury, orthopaedics may take care of the bone and plastics everything else. For the lower extremity, the division of labor is a little more distinct. While ortho generally does the bone/joint component, plastics does the soft tissue reconstruction. There are, however, some (ortho oncology surgeons) that do their own reconstructions.

I noticed in my reading that some residencies (duke, for example) state that residents get training in "limb salvage." This sounds to me like something I would be very interested in, but other residency websites don't really mention it.

Limb salvage, or reconstuction of an extremity instead of amputation, is a common occurrence in the setting of lower extremity trauma. While I don't know for sure, Duke may be one of those centers that gets referrals from other places for that specific purpose. This would include reconstruction for trauma and after oncologic resection. Most university programs have level I/II trauma centers and plastic surgeons are intimately involved with soft tissue coverage of traumatic defects.

Also, when you take tissue in the form of a free flap and transplant it somewhere else, how does that effect the form and function of the donor region? Full recovery usually?

This really depends on where the tissue comes from and how it's harvested. For instance, using a free rectus muscle flap with a skin paddle has an affect on the structure of the abdominal wall. Patients will sometimes complain about a bulge from loss of the rectus muscle. This flap can also be taken as a perforator flap leaving the muscle intact. The dissection can be somewhat tedious and time consuming, but the incidence of a bulge is lower according to the literature because the muscle is left behind, hopefully with its innervation intact. There are many examples of other flaps as well that leave little or no functional deficits, as well as others that can cause more sequela. This where the decision making process becomes as important if not more so than your technical skill. If you're interested, I recommend "Reconstructive Surgery" by Mathes and Nahai.

And lastly, I'm sure you find plastics clinically rewarding (or you wouldn't be doing it), but do you ever find yourself envious of the outcomes in other specialties? I really like the idea of general reconstruction and wound healing, but sometimes I wonder if the technology just won't produce a satisfactory result for me. I wonder how often patients lose so much tissue that reconstruction becomes impossible, in other words. Do you find yourself amazed, satisfied, or unsatisfied most of the time with the extent to which you can reconstruct tissue loss?

I'm very appreciative of what other services and specialties can do. However, if I were envious, I would be in another specialty. As I've posted before, one person cannot perform every procedure and although I sometimes wish that I knew enough to do some of the things others can do, I have enough on my plate doing my own job.

It does happen that a particular defect cannot be reconstructed because to do so would cause even more harm. It's a sad situation, but you have to know when to stop. Sometimes it's better just to amputate the affected part and let the patient get on with their life rather than subjecting them to procedures with little benefit. It goes back to the decision making process and judgement that really makes the difference in taking care of your patients.

I am usually more amazed by other peoples work than my own. Sure, I can get a result that really makes me proud, but I'm very critical of myself. I can usually find something that I think could have been done better.

 

[deleted144060]

I am currently a NSG resident interested in pursuing craniofacial surgery training. How would I best proceed with this and what would this require (additional residency? fellowships?). I really have just started to learn more and would appreciate anyone's help!

The upfront bad news is that no one I've talked to, and I've talked to some people that have been around a long time, knows anyone who except for one notable exception that went from neurosurgery directly to a craniofacial fellowship. The exception in question happened a long time ago and that particular physician only does neurosurgery anyway. The problem is that the skill sets between plastics/CF and neurosurgery are not the same, but are more complimentary.

Additionally, the ACGME accredited craniofacial fellowships only take those who are board eligible in plastic surgery. There are non-ACGME fellowships available, and this is where the OMFS folks go for their CF training. The difference between the two approaches is that the ACGME fellowships have agreed upon rules and guidelines like all ACGME programs. The others do not and some are better than others. Even if you managed to get into a non-ACGME program, the consensus is that you would find your privileges extremely limited in the craniofacial area because you did not complete the approved plastic surgery training. The OMFS docs sometimes find themselves in the same position, but it really depends (for them) on where they trained and where they're practicing.

If you really want to be a craniofacial surgeon, you would need to do an accredited plastic surgery fellowship (2 years) followed by a craniofacial fellowship (1 year).

 

[deleted144060]

If someone, namely me in the future, is not able to match into an integrated plastic surgery residency, what do you think the benefits of the other surgical residencies are? Does general surgery definitely provide the most complimentary skill set prior to entering a plastics fellowship, or could ortho or neuro provide equally (or more) valuable skills to a future plastic surgeon?

Sorry for the delay in responding. I wanted to get some opinions other than just my own before attempting a reply.

The general feeling I get is that they all have their pluses and minuses. Perhaps in the past, general surgery might have given one a superior skill set. With the advent of minimally invasive approaches in general surgery training, the skill set may not be as applicable. I think having experience in breast surgery is helpful not so much in reconstruction, but in understanding what your patients are dealing with, having a better knowledge of the anatomy, having a grip on some of the complications, etc. You're experience is also going to be dependent on where you train. I was at a community program and as a PGY-4, we chiefed the subspecialty service. This meant I was doing urology, gyn, ENT, and plastics. Even then, I was still fairly overwhelmed when I started my plastics fellowship. There is a big difference between being able to technically do a breast reduction versus decideing which procdure to do, when to graft a nipple, dealing with asymmetry, fat necrosis, poorly positioned nipple, loss of nipples, infections, skin loss, and so on.

Plastikosmd says:

General surgery is exactly that..General. It is a field that is really good at teaching you how to be a doctor.
1st year = How to manage patients, attention to detail, etc.
2nd year = How to be a consultant, improving your surgical skills, etc.
3rd year = How to manage a service, operate and perfect your consultant skills
4-5 years = Chief experience and operate

Since it is general, i believe it is the easiest field to transition from to another, also why almost all surgical training starts there. You could easily go from a fully trained NS/ortho to plastic and it has been done before. I would think it would be up to the individual. If you want a more well rounded background, general surgery provides the best exposure. If you know you're going to be looking for something more specific ( say an interest in craniofacial, or hand) then a surgical subspecialty may be a better bet.

Maxheadroom says:

"I don't think that any surgical specialty really lends itself to training Plastic surgeons well. General is losing its relevance very quickly as minimally invasive surgery becomes more and more important in their training. When I was a junior resident, the Peds Surgeons always wanted the PRS residents for their cases because we knew how to handle soft tissues and dissect out small structures (as PGY-3s). Those are skills that are being lost by GS residents because of their focus on Endo-Surgery.

The only way that I see integrated PRS training changing is an eventual move to a 1+4 or 2+4 model with less and less GenSurg. The ABPS and RRC have already put out a list of required rotations for plastics residents, period (both independent and integrated pathways). Things like Ophtho, OMFS, and Derm aren't part of any GenSurg curriculum that I've seen and they're much more relevant to a PRS resident than lap choles and right colons."

The caveats that I might add is that you do learn how to use the instruments, deal with patients, and get experience running a service before you move on to a fellowship. But this can really be said about any surgical residency.

ENT would give you experience in head and neck which would be very helpful as a plastics fellow. You would get hand experience with ortho. I'm not sure neurosurgery really does anything for you except learing not to suck the brain (just kidding).

Another point of view is that of droliver who has posted this on the plastic surgery board:

http://forums.studentdoctor.net/showpost.php?p=6265251&postcount=36

And is it easier to get a plastics fellowship after general surgery than the other specialties?

There is a post on the plastic surgery forum here http://forums.studentdoctor.net/showpost.php?p=6250631&postcount=30 that puts forward the premise that most programs looked just as favorably at the ortho/ENT trained guys as the general surgery people.

Most of the people I know in plastics who did not do the combined route traditionally came from general surgery. I think this is still the most common route. It may because general surgery, while competitive, is not as bad as ortho, ENT or combined plastics. Some people may have decided later or changed their minds during residency. After all, general surgery has been the conventional gateway for vascular, cardiothoracic, breast (oncologic), bariatric, plastic and surgical oncology fellowships. For me, it was a matter of what I wanted to do if I didn't get into plastics. I never really got that excited about ortho or ENT and knew general surgery gave me a bit more flexibility. I'm pretty sure I would have been happy as a general surgeon, and I actually had a fellowship spot at NIH for surgical oncology as a back-up in case I failed in the SF match.

I recently posted that I thought one of the reasons that there aren't as many ortho trained plastic surgeons doesn't have to do with salary or opportunity for plastic surgery fellowships. It really has more to do with what you enjoy doing. Most of the orthopods I know really love their jobs (although I must admit the reason escapes me 🙂 and never wanted to do plastics. While money can be a strong motivator, for me enjoying my work is as, if not more important.

Do you think there would ever be an integrated program through ortho in the future?

Maxie says "I don't see any sort of Ortho-Plastics integrated pathway developing. While Ortho is much more relevant to us from an anatomic view, there are some pretty huge differences in approach to patient care."

I agree.

--M

 

[deleted144060]

This is a partial repost of a thread I started in the plastic surgery section. It's an abstract from an article recently published in PRS that tried to answer the questions of what qualities in an applicant program directors found most desirable. I don't think it tells us anything we didn't already know, but it's always nice to see something in print. I also found it interesting that interest in academics was a consideration even though the majority of graduates go into private practice.

--Moravian


Selection Criteria for the Integrated Model of Plastic Surgery Residency

Jeffrey R. LaGrasso, M.D.
Debbie A. Kennedy, M.D.
James G. Hoehn, M.D.
Salmon Ashruf, M.D.
Adrian M. Przybyla, M.D.
Albany, N.Y.

Background: The purpose of this study was to identify those qualities and characteristics of fourth-year medical students applying for the Integrated Model of Plastic Surgery residency training that will make a successful plastic surgery resident.

Methods: A three-part questionnaire was distributed to the training program directors of the 20 Integrated Model of Plastic Surgery programs accredited by the Residency Review Committee for Plastic Surgery by the Accreditation Council on Graduate Medical Education. The first section focused on 19 objective characteristics that directors use to evaluate applicants (e.g., Alpha Omega Alpha Honor Society membership, United States Medical Licensing Examination scores). The second section consisted of 20 subjective characteristics commonly used to evaluate applicants during the interview process. The third section consisted of reasons why, if any, residents failed to successfully complete the training program.

Results: Fifteen of the 20 program directors responded to the questionnaire. The results showed that they considered membership in the Alpha Omega Alpha Honor Society to be the most important objective criterion, followed by publications in peer-reviewed journals and letters of recommendation from plastic surgeons known to the director. Leadership capabilities were considered the most important subjective criterion, followed by maturity and interest in academics. Reasons residents failed to complete the training program included illness or death, academic inadequacies, and family demands.

Conclusions: The authors conclude that applicants who have achieved high academic honors and demonstrate leadership ability with interest in academics were viewed most likely to succeed as plastic surgery residents by program directors of Integrated Model of Plastic Surgery residencies.

(Plast. Reconstr. Surg. 121: 121e, 2008.)

 

[deleted144060]

Do you know if there is an official deadline for the remaining 5 year programs to go to 6 years? If interviewing for spots next fall (for Jul '10), would there still be 5 year positions or will it all be 6?

I talked to a couple of program directors about what's been going on at the meetings concering a consensus on plastic surgery training. The news is that there really isn't a consensus. The place where there is some agreement is that for the independent pathway (i.e., after a full residency in general surgery, ENT, OMFS, etc.) the training period should be three years of plastics. I believe this change from 2 to 3 years will be happening fairly soon.

As far as the integrated/combined programs are concerned, there really isn't any cohesive plan. There are some that still feel that all plastic surgery trainees should have 5 years of general surgery and the combined programs are producing inferior surgeons. Granted this opinion is mostly from the "old guard," but they're still around and still carry some weight. This is primarily the reason way I don't think the independent pathway is going away soon.

The integrated programs are a little different in that you're a plastic surgery resident from day 1. This basically means that the rotations are geared more towards plastic surgery and include dermatology/Mohs, ENT, OMFS, orthopaedics/hand, and the like. Since you would be getting this training prior to your formal plastics training, some feel that you only need two years of plastics.

The combined programs, where you basically belong to general surgery for 3 years, don't always have the flexibility in rotations that you would get in an integrated setting. This will, however, vary on where you train. At my old program, the combined residents had the same rotations you would get at an integrated program. At others, you end up being the red-headed step child of general surgery. So the question is whether this means that you should do three years of plastic surgery after three years of general surgery.

In short, for the independent pathway, the fellowship in plastics (or residency as it's called by the ACGME) will be 3 years. The future of the integrated/combined programs is still in flux and probably will be for some time. Some will be 5 years, some will be 6, some will have a lab component, some may go to two years of general surgery and three years of plastics. The bottom line is that you should try to get in where you can regardless of the number of training years. One year is NOT a long time (and believe me, I should know).

--M

 

[deleted144060]

I apologize to Dre for taking so long to get his post up for viewing. THe whole "getting a real job" deal put me behind on a couple of different things. Anyway, this is his response to my reponse about the upcoming program changes. For more discussion please see the following thread:

http://forums.studentdoctor.net/showthread.php? t=547758

I looked into this issue on the interview trail (more as a matter of curiosity, because I was going to go where someone was willing to train me in plastic surgery and I didn't care if it was 5 years or 8). The most common model for the integrated programs is 3 years of general with about 6 months of plastics rotations during those general surgery years, followed by 3 years of plastics (usually with 6 months of research built into the 4th year--the amount of research time varied from program to program).

There are some exceptions (when I interviewed, UC-Davis, Oklahoma, Ohio State, Michigan State, Utah, and UT-SW were all 5 year programs. The rest were 6 years) but of the ~45 or 50 so-called integrated or combined programs, the model I described is the most common.

The word from PD's that I got when I asked this question was that integrated programs would not be affected by the switch to 3 years, because: integrated programs already provide 3 years of dedicated plastics programs (notable exceptions being Nevada-Las Vegas and UTSW; Nevada has a 4th year entirely dedicated to research followed by 2 years plastics, and UTSW is a straight 3+2 model) and technically integrated plastics residents are plastics residents for the entire duration of their residency, which apparently provides a bit of a sidestep for those PD's.

For combined/coordinated programs, the story differs: because residents in these programs are technically general surgery residents for their first three years, the switch to plastics constitutes a new residency and residents in these programs would have to do an additional year of plastics.

There are other programs (USF, Pitt) that intimated that they would be switching to a 2+4 model in the near future, but I've been told that under the current ACGME guidelines, this format would not provide the prerequisite general surgery training required by the ACGME--this from the PD at Wake Forest and the chairman at my med school (which only has an independent 2 year residency). So who really knows?

I don't know what the future holds for the education of plastic surgeons, and I don't know how the ACGME/RRC/AACPS would react to my comments, but I'm reporting what the integrated interviewees are being told.

Thanks Dre. Sorry again for the delay.

 

[Dr.Millisevert]

As way of background, I am a fully qualified dentist who is now studying graduate entry medicine in Australia. I have a great interest in OMFS and have assisted many surgeries with OMFS, and performed a few myself. However as a I progress through medicine I feel that perhaps plastics but more specifically craniofacial plastics may enable more scope of work and not "waste" my medical degree.

It appears that CFPS may enable me to do more facial reconstructive and aesthetic/cosmetic work than OMFS would? This is probably where I see myself in the future rather than pure OMFS (wisdom teeth, dental implants etc).

It also appears that plastics hold the political/hospital power over OMFS (at least in Australia) and in a way prevent OMFS from performing aesthetics of head and neck even though many OMFS are probably quite capable.

What advice could you give me as an aspiring OMFS or CFPS.

I would agree with Moravian in that if I were you.. I would base my decision on what you enjoy more.. General Plastics or General OMFS. At the end of the day, there are only so many cleft/cranio kids to go around and you have to be happy with what you're doing outside of Craniofacial surgery. i.e.: your bread and butter work.

It is 100% possible to complete a craniofacial surgery fellowship post OMFS, and it is 100% possible to practice as a craniofacial fellowship trained OMFS in Australia. PM me and I'd be happy to help put you in contact with some people who might be able to help you further. 👍

 

[Bdog]

Hi there,

Excellent thread. It's been very useful as I determine my career path. You alluded to a difference in approach to patient care between ortho and plastics. Can you elaborate on this? Thanks very much!

 

[Samron 1010]

Hi Im a pre-dental student and I hope to become a Cranio-Maxillo- Facial surgeon in the future. My main question is I want to achieve this goal by going through dental school rather than med school. The main reason being I can get done with dental school in six years rather than eight. How much more fellowships will I need in order to become a complete facial reconstruction surgeon thank you