Surg onc vs Plastics

[petabread4]

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I was wondering if anyone could give insight on the types of onc related cases that a plastics would take vs a surg onc? How much onc volume do you get in plastics, and can you tailor your career path to focus more on onc cases?

 

[hamilton_ss]

Plastic surgeons can manage any cutaneous malignancies (basal, squamous, melanoma, merkel, etc), provided there is no evidence of mets, in which case they would likely refer or collaborate with the needed specialists.

Plastic surgeons do not manage viscus malignancies (i.e. renal cell, pancreatic, etc) or soft tissue sarcomas. An exception might be hand surgeons, who may manage hand/upper extremity sarcomas, nerve/bone/etc tumors.

Surg oncs generally specialize (i.e. hepatobiliarry). Sarcomas are often managed by orthopedic oncologists at many academic centers.

I'm still in training and can't accurately comment on career stuff.

 

[droliver]

Plastic surgeons can manage any cutaneous malignancies (basal, squamous, melanoma, merkel, etc), provided there is no evidence of mets, in which case they would likely refer or collaborate with the needed specialists.

Plastic surgeons do not manage viscus malignancies (i.e. renal cell, pancreatic, etc) or soft tissue sarcomas. An exception might be hand surgeons, who may manage hand/upper extremity sarcomas, nerve/bone/etc tumors.

That's kind of overgeneralizing things. I have no problem doing the occasional lipo or myosarcoma and nodal dissections of the axilla, neck, or groin for breast and cutaneous malignancies. Those are all kind of simple cases, particularly if you did a traditional pathway (Surgery before plastics) where you did a lot of oncology. The resections on the trunk and extremities are really not different from a lot of the muscle harvests you do on flap cases, and if you know your anatomy it's not very intimidating. My partner who came through an integrated program OTOH did almost no oncology (just the recons) and would never in a million years try to do some of the more extensive resections.

 

[caffeinemia]

That's kind of overgeneralizing things. I have no problem doing the occasional lipo or myosarcoma and nodal dissections of the axilla, neck, or groin for breast and cutaneous malignancies. Those are all kind of simple cases, particularly if you did a traditional pathway (Surgery before plastics) where you did a lot of oncology. The resections on the trunk and extremities are really not different from a lot of the muscle harvests you do on flap cases, and if you know your anatomy it's not very intimidating. My partner who came through an integrated program OTOH did almost no oncology (just the recons) and would never in a million years try to do some of the more extensive resections.

You would want to manage the oncological surveillence, adjuvant bs, etc etc? Sound's like a hassle. Must be because I'm of the integrated pathway and am narrow-minded, but no thank you. I'll drop whatever free flap in for you, but goodness, no lymph nodes and lymphedema for me please.

 

[MediCane2006]

....and thats a pretty nice summation of the differences between traditional and integrated program grads... 😉

To the OP, if you are double-boarded in gen and plastic surgery you can do as much onc as you want although it would be pretty unusual for a plastic surgeon to operate on visceral malignancies unless you're in a tiny remote hospital where you are providing gen surg coverage as well.

More commonly, plastic surgeons deal with cutaneous and connective tissue malignancies as well as some bony tumors (particularly in the hand). We also work closely with the surgical oncologists in reconstruction and, in complicated cases, are often helping out with the resection as well as the reconstruction.

 

[droliver]

You would want to manage the oncological surveillence, adjuvant bs, etc etc? Sound's like a hassle. Must be because I'm of the integrated pathway and am narrow-minded, but no thank you. I'll drop whatever free flap in for you, but goodness, no lymph nodes and lymphedema for me please.

While it really came about after I finished, there's a actually a lot of lymphatic work going on in microsurgery these days. It's really the only new types of procedures in reconstructive microsurgery (nodal transplants, DIEPS with node basins attached, lympatico-venous anastamosis and the like) in the last 10-15 years. That's a growth industry in microsurgery these days.

As to passing on oncology surveillance, what exactly do you think already you do in practice to varying degree for every breast cancer, breast implant, and skin cancers? Pretty much every breast recon you do sees you periodically with the caveat to call in between if there's changes on exam.

 

[caffeinemia]

While it really came about after I finished, there's a actually a lot of lymphatic work going on in microsurgery these days. It's really the only new types of procedures in reconstructive microsurgery (nodal transplants, DIEPS with node basins attached, lympatico-venous anastamosis and the like) in the last 10-15 years. That's a growth industry in microsurgery these days.

As to passing on oncology surveillance, what exactly do you think already you do in practice to varying degree for every breast cancer, breast implant, and skin cancers? Pretty much every breast recon you do sees you periodically with the caveat to call in between if there's changes on exam.

It may be a regional difference (for some reason I think you're in the Southeast)... but as far I am concerned the surgical oncologist or breast surgeon will follow the patient for true breast recurrences -- at least in the two regions I've trained (Midwest and New York. Even if I suspect a recurrence or whatever, it'd be a "please follow up with your oncologist." Of course, I'll be around for assistance with reconstructive options in a recurrence, but I'm not ordering the mammography or biopsying the lesion or whatever, etc. The only caveat I see is this new ALCL crap, which we've known about for years and dealt with for years, but is now all the sudden is in the spotlight given the recent NY Times and FDA bulletin.

Regarding what you say about microsurgery, I think your view is a little narrow or are we just not talking about the same thing? Trends in microsurgery - in terms of growth and recent hot topics - include gender reassignment, lymphedema, facial/hand/soft tissue allo transplantation, robotic microsurgery (check out the recent PRS article). Not all of that has really panned out though. Despite all the buzz -- the face transplant patients have all had serious medical complications, including overwhelming infection and death. Lymphedema surgery hasn't really been proven on a large enough scale yet. Gender reassignment is still mired in insurance, social, ethical questions. Honestly, I'm a utilitarian and at the end of the day, and most people just want a decent pair of breasts, and a DIEP or MSFTRAM will do just fine for 90% of them.

 

[droliver]

.. but as far I am concerned the surgical oncologist or breast surgeon will follow the patient for true breast recurrences -- at least in the two regions I've trained (Midwest and New York. Even if I suspect a recurrence or whatever, it'd be a "please follow up with your oncologist." .

I don't know anyone who does a lot of recon who just dismisses the patients from follow up, and we're he best qualified to sort out these issues in reconstruction patients. Their PS is actually the one they often follow up with first as they see us MUCH more with these procedures then they do the breast surgeon after mastectomies are done (different story on BCT patients). Many general surgeons don't see them at all after mastectomy for check ups, but dismiss them to us and/or their oncologist for surveillance. That's particularly true of implant reconstruction, which are almost 90% of breast reconstruction in the United States. We ask to to come in annually and any time in between for changes on exam. That often avoids unnecessary imaging and workup by seeing us first.

 

[MediCane2006]

I don't know anyone who does a lot of recon who just dismisses the patients from follow up, and we're he best qualified to sort out these issues in reconstruction patients. Their PS is actually the one they often follow up with first as they see us MUCH more with these procedures then they do the breast surgeon after mastectomies are done (different story on BCT patients). Many general surgeons don't see them at all after mastectomy for check ups, but dismiss them to us and/or their oncologist for surveillance. That's particularly true of implant reconstruction, which are almost 90% of breast reconstruction in the United States. We ask to to come in annually and any time in between for changes on exam. That often avoids unnecessary imaging and workup by seeing us first.

Yeah, I see the breast recon patients both sooner and FAR more frequently than their breast surgeons do.... and of the very few recurrences I have had in reconstructed patients, all have been picked up in the plastic surgeon's office (or, once, in the OR going after that persistent "scar nodule")

 

[caffeinemia]

I don't know anyone who does a lot of recon who just dismisses the patients from follow up, and we're he best qualified to sort out these issues in reconstruction patients. Their PS is actually the one they often follow up with first as they see us MUCH more with these procedures then they do the breast surgeon after mastectomies are done (different story on BCT patients). Many general surgeons don't see them at all after mastectomy for check ups, but dismiss them to us and/or their oncologist for surveillance. That's particularly true of implant reconstruction, which are almost 90% of breast reconstruction in the United States. We ask to to come in annually and any time in between for changes on exam. That often avoids unnecessary imaging and workup by seeing us first.

While I respect your opinions as someone who's been in practice for a long time, I think you're selectively reading. Who said anything about dismissing people from follow up? I'm still going to follow up with patients for their reconstructive concerns/results, etc -- that can last a long time, especially if I put a nasty implant in them. But like I said, if I suspect a recurrence, I am definitely not the one managing it. It's definitely going to lead to follow up with their breast surgeon or surgical oncologist or medical oncologist. One caveat, as I mentioned before, is that we're always gonna watch for stupid ALCL now -- ugh. I also do agree that we see them a lot for the recon and the complications that invariably come with healing and foreign bodies and ****ty mastectomy flaps. But I am honestly not ever going to be responsible for dealing with breast cancer recurrences or skin cancer recurrences (except BCC, maybe).