what all cases do plastic surgeons typically do?

[maverick_pkg]

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Does any one have a list

 

[Pir8DeacDoc]

I did a fair amount of plastic surgery stuff in medical school and a rotation as an intern so take that for what it's worth..


Typical stuff I saw a lot for general PRS guys in academic centers:

- abdominoplasty
- breast reduction
- breast recon of all varieties after mastectomy
- a variety of flaps done for other services (ENT, ortho)
- scar revisions



sure there are more but these are the first things that came to mind.

Can't believe I left off hand stuff and facial fractures. But glad to see someone else already addressed that.

 

[deleted144060]

I printed out my index case log from fellowship, minus the numbers. This should give you some idea. What it doesn't show is all the "miscellanous" things that aren't considered index cases.

--M

Breast
Reduction
Augmentation
Reconstruction With Implant or Tissue Expander
Reconstruction - Myocutaneous Flap
Reconstruction - Free Tissue
Reconstruction - Nipple/Areola
Reconstruction - Secondary Breast Procedures
Gynecomastia
Other (Breast)

Burns
Nonoperative
Operative Treatment
Reconstruction

Congenital Defects of the Head and Neck
Cleft Lip Repair - Primary, unilateral repair
Cleft Lip Repair - Primary, bilateral repair
Cleft Lip - Secondary repairs
Cleft Lip Nasal Deformity
Cleft Palate - Unilateral Primary Repair
Cleft Palate - Bilateral Primary Repair
Cleft Palate - Secondary Repairs
Otoplasty
Reconstruction of Ear
Cysts, Sinuses, Angiomas and Hygromas
Craniomaxillofacial - Mandible
Craniomaxillofacial - Maxilla
Craniomaxillofacial - Major Craniofacial Reconstru
Other (Congenital Defects of H&N)

Cosmetic
Brow Lift
Face Lift
Blepharoplasty
Rhinoplasty
Suction Lipectomy
Skin Resurfacing
Abdominoplasty-Contouring
Other (Cosmetic

Head and Neck Trauma
Soft Tissue, Acute Repair
Eyelid
Facial Nerve
Soft Tissue - Scar Revision ( including Dermabrasion)
Soft Tissue Revision or Reconstruction - Grafts
Soft Tissue Revision or Reconstruction - Eyelid
Facial Bone Fractures - Nasal
Facial Bone Fractures - Maxillary/Midface
Facial Bone Fractures - Frontal Sinus/Nasoethmoid
Facial Bone Fractures - Zygoma-Orbi
Facial Bone Fractures - Mandible-Alveolar Ridge
Soft Tissue - Lymph Node Resection



Head and Neck Neoplasms
Resection - Lip
Resection - Other (Exclude Skin Cancer)
Resection - Lymph Node Resection
Resection - Endoscopy
Reconstruction - Flap, Skin
Reconstruction - Flap, Multiple Tissue
Reconstruction - Free Tissue Transfer
Reconstruction - Eyelid
Reconstruction - Nose
Other (Head and Neck Neoplasms)

Upper Extremity
Fingertip Injuries and Reconstruction
Tendon Repair - Flexor
Tendon Repair - Extensor
Tendon Repair - Tendon Transfer
Nerve Repair - Major
Nerve Repair
Decompresion (Nerves)
Fractures and Dislocations
Skin Repair
Contracture Release
Dupuytren
Tumors - Benign
Tumors - Malignant
Replant, Revascularization, Free Transfer
Amputation
Congenital
Arterial Repair - Digital
Other (Upper Extremity)

Lower Extremity
Flap
Other (lower extremity)

Skin and Soft Tissue Neoplasm
Benign
Malignant

Trunk-Genitalia
Pressure Sore - Debridement
Pressure Sore - Direct Repair
Pressure Sore - Flap
Thoracic-Abdominal Defects - Debridement
Thoracic-Abdominal Defects - Repair, Direct
Thoracic-Abdominal Defects - Repair, Flap
Male/Female Genitalia - Vaginal Reconstruction
Hidradenitis
Other (Trunk-Genitalia)

 

[dilated]

I printed out my index case log from fellowship, minus the numbers. This should give you some idea. What it doesn't show is all the "miscellanous" things that aren't considered index cases.

--M

This is really neat. Is there any chance you could throw in percentages for some of the more common things? Actually, if you were doing a fellowship I guess it might be skewed, but if you were taking general attending call it would still be handy to see how much recon vs aesthetic was done, etc.

 

[deleted144060]

Is there any chance you could throw in percentages for some of the more common things?

The percentages, for the most part, are going to depend on where you train. About 30-35% of what I did was hand. The rest of it was mostly made up of trauma related stuff (face, lower extremity reconstruction), recon after cancer (head/neck and breast) and pediatric congenital. Very little of what I did could be considered cosmetic at my fellowship institution which is why I was sent to NYC for three months.

I saw another post where it was mentioned that they did 50% hand. Where I am at now, the residents are doing a lot more flaps and complex hand than I did in my fellowship, but they don't get as much pediatrics.

If you train at a place that has more guys doing cosmetic surgery, you'll undoubtedly get more cosmetic cases. The problem with the cosmetic stuff is that, depending on your attending, you really won't be doing anything since they are mostly private pay.

As far as practicing afterward, it will depend on what you like to do, where you want to live, how hard you want to work (see previous post at http://forums.studentdoctor.net/showthread.php?t=434161) and elsewhere.

--M

 

[droliver]

My residency was structured a little odd (in a good way)the way it was weighted. For comparison, during my residency I'd guess I did

<< 10% hand
<< 5% kids
~ 10% wound care and burns
~ 20% facial fractures & lower extremity trauma
~ 20 % general plastic and reconstructive surgery
~ 35 % cosmetic and post weight loss surgery

I think I did something like 30 non-hand micro cases for reconstruction. Residents 10-15 years ago would have likely done about 100 if that tells you anything about the economics of plastic surgery.

I followed this with a fellowship in cosmetic and breast surgery working with 4 surgeons in Nashville.

This kind of "imbalance" worked great for me as I did a lot of what I do now. Hand & pediatric surgery are wasted time for many people in 2007 the way the field has changed in a practical way. Out of close to 30 surgeons not in the university practice in my city, there are 2 that do any volume of hand surgery and one that does pediatric surgery.

 

[dilated]

This kind of "imbalance" worked great for me as I did a lot of what I do now. Hand & pediatric surgery are wasted time for many people in 2007 the way the field has changed in a practical way. Out of close to 30 surgeons not in the university practice in my city, there are 2 that do any volume of hand surgery and one that does pediatric surgery.

What call do you take, if any? If you had to take call for privileges, would you be able to take a different call than hand if you don't like it/don't feel comfortable with it?

 

[droliver]

I take plastic surgery call at 2 hospitals, but I get called rarely. There's about a dozen surgeons here who cross-cover weekend call over 5 ER's. I've had to go to in to sew someone up 3-4 times in a year. I cannot complain about my call burden.

I don't take any hand call. I didn't even request privledges nor do I schedule even simple hand cases (carpal tunnel, trigger fingers) just because I'm not interested in being forced to do hands at all

I don't work at the pediatric hospital.

There's a level one trauma center that takes almost all the major max-face trauma and crushed extremities kind of cases.

 

[beastmaster]

Hand is wasted time for many people in 2007 the way the field has changed in a practical way. Out of close to 30 surgeons not in the university practice in my city, there are 2 that do any volume of hand surgery

Can you elaborate on this a little more please?

 

[droliver]

Can you elaborate on this a little more please?

A lot of people just don't want to do hand surgery. It's becoming fairly marginalized in Plastic Surgery, even in many training programs. Most orthopedists I know want nothing beyond the simplest elective outpatient hand patients anymore either. There's a lot of potential exposure for ER call cases which is very disruptive to your practice and life. As the reimbursement has drifted down for all things insurance, people have just decided en mass that it's just not worth it on a time vs. money basis. That's my take on it.

 

[deleted144060]

A lot of people just don't want to do hand surgery. It's becoming fairly marginalized in Plastic Surgery, even in many training programs. Most orthopedists I know want nothing beyond the simplest elective outpatient hand patients anymore either. There's a lot of potential exposure for ER call cases which is very disruptive to your practice and life. As the reimbursement has drifted down for all things insurance, people have just decided en mass that it's just not worth it on a time vs. money basis. That's my take on it.

Not to disagree with Droliver, but I think that your hand experience is really going to depend on where you train. If you’re at a university program with a level one trauma center, you’re going to do hand. If there are CAQ hand surgeons on the faculty, you’re going to do a lot of hand. The residents at the program where I’’m doing my CF fellowship do so much hand that they joke they will either become hand surgeons or never do hand again. The ACGME also has rules dictating how many of certain cases that you need to graduate. Until the rules change, a certain degree of hand is a requirement.

Outside of the university, Droliver is right on concerning malpractice exposure from the trauma crowd and lack of reimbursements from the pool of non-insured and low income patients. This doesn’t mean that people with insurance don’t hurt their hands, you just usually won’t see them in a university ER. In my residency, I coded over 300 hand CPTs, and I only saw two patients with insurance. How they ended up with me is another story.

It was not uncommon for me to see a patient who had a hand injury that was closed in some outside ER and then told to see a hand surgeon. The hand surgeon would tell them that they either needed insurance or $500 just to be seen in the office. Eventually, sometimes weeks later, they would show up in the resident clinic or in the university ER. This kind of thing would drive me crazy because I knew these people who have had a better result had their injury been repaired earlier. But, for the reasons mentioned above, this is the reality of the situation. And it’s not just the repair. A great deal of the functional outcome depends on physical therapy. That’s a whole other set of issues.

From my training, I feel very comfortable taking care of most things distal to the carpal bones. However, if I were taking hand call in the community and was faced with a replant or a spaghetti wrist, I would most likely close and send it to a university center. It isn’t so much that I couldn’t do the case, it’s all the post op care, possible need for reoperation in the case of a replant, and the follow up with therapy that dictates most of the outcome. It’s also a good idea, in my book anyway, to refer the complex cases to someone who does that sort of thing for a living instead of a hobby. I had a hand surgeon once tell me that the most dangerous situation for a patient was to have a bad injury, have insurance and be in a community hospital.

 

[droliver]

Not to disagree with Droliver, but I think that your hand experience is really going to depend on where you train. If you’re at a university program with a level one trauma center, you’re going to do hand. If there are CAQ hand surgeons on the faculty, you’re going to do a lot of hand.

Well, I think you're missing some of the trends going on nationwide at some large teaching programs which reflect what's going on in private practice. While rotating as a fellow thru the Kleinert Institute in Louisville I got phone calls from Dallas, Birmingham, Nashville, Gainesville, Richmond, and New Orleans looking for someone to accept a replant because the plastic surgeon or orthopedist on call at the teaching hospital in their city/state would not take hands/replants. It was surprising to me at the time (but not now) as many of those cities actually have hand fellowships in them.

Outside of hand trauma, there are a number of programs I know of (via friends who trained there) which get very little exposure to elective hand surgery. This is getting more common in both academics and private practice as a number of surgeons just decline to do any hand surgery

 

[deleted144060]

Well, I think you're missing some of the trends going on nationwide at some large teaching programs which reflect what's going on in private practice.

Very interesting. I wonder how this is going to effect the ACGME requirements in the future. I also wonder if/when the state/federal government is going to get involved.

Thanks for your perspective.

--M