Plastic Surgeon: Friend or Foe?

[nacholibre]

So I'm on a month of plastics right now, and of course they all ask me what I want to go into and when I say ENT to some of my attendings they all give me a hard time about it. Most are jking, but a couple have gone on to give me a sermon on why because I mentioned the word "reconstruction" in my explanation of why I like ENT it means that I actually want to be a plastic surgeon, and then go on to explain to me that ENTs do their patients a disservice by not having plastic surgery raise their flaps for them, because ENTs "really don't understand flap physiology they just know how to raise the flap and so they do it" (not even kidding I got this from 2 different people).

And while on other services they've joked about snot and trachs, I have consistently got this serious ENTs steal our work vibe with comments like "Facial Plastics is not F-ing plastic surgery so why does that a-hole have plastic surgery on his card."

I know that there is some tension in our program because OHNS simply doesn't work with plastics despite several big attempts by plastics to get in on the H&N action, but is this the same everywhere? It seems like the fields really complement each other and could benefit one another

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[Leforte]

I'm sorry - I can't resist responding to this one.

How can plastics benefit ENT?

Seriously - if you were a patient, would you rather have a ENT trained microvascular surgeon, who fully understands to functional anatomy of their extirpation and reconstruction, who will follow the patient for the next 5 years, evaluating the outcomes, both oncological as well as functional outcomes, such as speech, swallowing, etc OR would you rather have a plastics reconstruction that - well - yes the flap has taken (as it has for the ENT attending) - and well, after that - see you later.

I have seen many outside institutions where plastics performs the flaps. Yes the flap is fine. But there is huge mass above the laryngectomy stoma that obstructs the airway (from a lateral thigh flap) - there is too much tissue in the mouth (from a fibula flap) to swallow - etc, etc, etc. They view the flap as viable - the patient feels otherwise.

The plastics teams, in general, do not follow these patients beyond confirming flap viability. Once the flap is good - the cancer surveillance and follow up is left to the primary team - they do not see the long term implications of their work.

Our H&N microvascular specialists follow them for life.

ENT Microvascular specialists do not claim to be plastic surgeons. Similarly, Facial plastics ENT do not claim to be Plastic surgeons. No ENT, that I know of, who has not done a plastics fellowship claims to carry a "plastic surgery card".

 

[OtoHNS]

Sounds like there's some bad blood between the departments at your program which is probably the underlying reason for most of the comments you're hearing.

During the first 2 years of my residency, we had plastics do our flaps and then hired our own microvascular guy for my last 2 years. We still had a collegial relationship with them and the plastics attending would frequently help our guy out with flaps.

I agree with Leforte's comments. I definitely remember a few cases where we had to go back later and debulk an excessively large flap that plastics had done because it was causing functional problems.

 

[Maybeknot]

You should mention rhinoplasty and see what they say.....

 

[nacholibre]

I'm sorry - I can't resist responding to this one.

How can plastics benefit ENT?

I just mean, academically speaking 2 fields that are doing so much research in microvascular technique should complement each other if anything. But in my naive state of mind, I of course had not thought about all of the potential pitfalls.

And yes Rhinoplasty has come up as well. I didn't know that they don't get any training with functional rhinoplasty (at least not at this program) and yet they put up such a fuss about the turf battle.

 

[Pir8DeacDoc]

My program did most of our own flaps. Sometimes we would have staffing issues and would involve the plastic surgeons. They are great at moving meat but don't have a great idea about the functional aspects of the flap for head and neck recon. They were very helpful for the immediate post op period but as mentioned above that was often as much as their care extended. Their extirpative surgeon should be the one to follow them up for recurrence. I wouldn't want a plastic surgeon scoping me. Overall we had a great group of plastic surgeon and one guy who was ENT/plastics so that worked well. We would do a lot of trauma with whichever service had a free attending.

 

[neutropeniaboy]

... and then go on to explain to me that ENTs do their patients a disservice by not having plastic surgery raise their flaps for them, because ENTs "really don't understand flap physiology they just know how to raise the flap and so they do it" (not even kidding I got this from 2 different people).

They say this to you because you're a medical student. They realize that you won't have any serious retort, so they feel uninhibited to say such things.

Of course what they say is nonsense. I'm sure my H&N colleagues would have a mouthful of compelling responses to those assertions.

This sort of tension occurs naturally when one field encroaches upon another.

I don't think you can draw broad conclusions like this. I've worked with a lot of plastic surgeons and ent plastics before. Some are better than others on both sides of the streets.

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[Fah-Q]

Epic turf battle that has been going on now for decades that the plastic surgeons are losing and they don't like it. It breeds resentment and results in the ridiculous things you have heard.

Imagine your girlfriend left you for a another dude? If someone asked you what you thought of that guy, would you praise him or would you trash him?

 

[Germanada]

Would just like to add at this point that (if I recall correctly) the first microvascular reconstructive surgery / free flaps were done by ENTs, namely at McGill University in Montreal and then at the University of Toronto way back in the day (at least according to a presentation given at the Triological Society Combined Sections Meeting this year).

Do I personally care if a plastic surgeon or ENT raises a flap if I were a patient? No, all I care about is that whoever does it has been adequately trained and been keeping up with that skill (with consistent, good results).

Do I think it's highly unprofessional to bash a specialty to an impressionable young medical student for doing something they are adequately trained to do just because the basher wants to be the only player in the field and doesn't like competition by the bashee? Most certainly.

Just my $0.02

 

[Diezel69x]

Would just like to add at this point that (if I recall correctly) the first microvascular reconstructive surgery / free flaps were done by ENTs, namely at McGill University in Montreal and then at the University of Toronto way back in the day (at least according to a presentation given at the Triological Society Combined Sections Meeting this year).

Do I personally care if a plastic surgeon or ENT raises a flap if I were a patient? No, all I care about is that whoever does it has been adequately trained and been keeping up with that skill (with consistent, good results).

Do I think it's highly unprofessional to bash a specialty to an impressionable young medical student for doing something they are adequately trained to do just because the basher wants to be the only player in the field and doesn't like competition by the bashee? Most certainly.

Just my $0.02

Just to add a bit more fire to the discussion the father of plastic surgery in america was an Oral Surgeon, then only a dentist, Varaztad Kazanjian, and in Europe an Otolaryngologist Gillies... So what do people say about OMFS doing flaps???

 

[Pir8DeacDoc]

Never heard of or seen an oral surgeon doing flaps. Most aren't interested in cancer surgery. They want to yank thirds all day and do implants and make 900k for 30 hours a week of work. Good for them I guess.

 

[Diezel69x]

Never heard of or seen an oral surgeon doing flaps. Most aren't interested in cancer surgery. They want to yank thirds all day and do implants and make 900k for 30 hours a week of work. Good for them I guess.

You will be surprised there are growing amount of fellowships emerging for OMFS to do H&N oncology and reconstruction. While what you said is true for the majority, (except the 900K), some actually choose to do cancer and make only 300K

 

[Leforte]

Never heard of or seen an oral surgeon doing flaps. Most aren't interested in cancer surgery. They want to yank thirds all day and do implants and make 900k for 30 hours a week of work. Good for them I guess.

There was an OMFS trained microvascular at one of the hospitals I was privileged at. He did the extirpation and reconstruction. He had good outcomes and followed his own patients for life.

He was also fired when he was found by his wife (an orthopod) to have pictures of a naked dental school applicant to the residency program - the pictures were taken in his office while she was on an away rotation. She reported it to the Chief of Staff and he was immediately escorted off the hospital. He maintained his license and is now in PP making close to the high figure you suggested from the low figure you quoted in academics. Pretty amazing to watch someone do something so ethically wrong and triple their income in the process.

Regardless - I think that if a well trained OMFS trained person who does a H&N microvascular fellowship gets good results, follows their patients, etc. - then I do not see an issue. I assume they are also considering functional outcomes, etc.

 

[Pir8DeacDoc]

There was an OMFS trained microvascular at one of the hospitals I was privileged at. He did the extirpation and reconstruction. He had good outcomes and followed his own patients for life.

He was also fired when he was found by his wife (an orthopod) to have pictures of a naked dental school applicant to the residency program - the pictures were taken in his office while she was on an away rotation. She reported it to the Chief of Staff and he was immediately escorted off the hospital. He maintained his license and is now in PP making close to the high figure you suggested from the low figure you quoted in academics. Pretty amazing to watch someone do something so ethically wrong and triple their income in the process.

Regardless - I think that if a well trained OMFS trained person who does a H&N microvascular fellowship gets good results, follows their patients, etc. - then I do not see an issue. I assume they are also considering functional outcomes, etc.

I agree with you. No problem with them doing it. Just not common in my experience.

 

[maxheadroom]

I think most Plastic Surgeons are happy with H&N Recon being more of an ENT thing now. There are lots of academic guys who moan that loss, but there are even more folks who are happy that we aren't dealing with the fistulas/carotid blow-outs.

I've seen great reconstructions by ENT-Microsurgeons. I've seen great reconstructions by Plastics guys. I've also seen really terrible results/complications from both sides, too. I think that the high-volume folks from both sides tend to get very good results. The key aspect, from what I've seen, is a good team of extirpative surgeons and reconstructive surgeons.

 

[OtoHNS]

I've seen great reconstructions by ENT-Microsurgeons. I've seen great reconstructions by Plastics guys. I've also seen really terrible results/complications from both sides, too. I think that the high-volume folks from both sides tend to get very good results. The key aspect, from what I've seen, is a good team of extirpative surgeons and reconstructive surgeons.

High volume is key- centers where they are doing multiple free flaps every week tend to have the >95% success rates that are quoted in the literature. The fewer flaps that are done, the higher the complications in my experience.

 

[neutropeniaboy]

That was some serious emphasis!

 

[OtoHNS]

that was some serious emphasis!

Haha, yep!