Should Bariatric Surgeons Perform Plastic Surgery?

1. Titus D. Duncan, M.D.,FASMBS, FAACS Director of Bariatric Surgery Atlanta Medical Center & Morehouse School of Medicine Atlanta, Georgia Should Bariatric Surgeons Perform Plastic Surgery?

2. Disclosures • Fellowship grant and Speaker’s bureau Ethicon EndoSurgery

3. YES! Should Bariatric Surgeons Perform Plastic Surgery?

4. THE ENDTHANK YOU

5. History of Plastic/Cosmetic Surgery

6. Should Only Plastic Surgeons Perform Cosmetic Surgery on the Post Weight Loss Bariatric Patient?

7. History of Liposuction Patented liposuction tool

8. History of Cosmetic/Plastic Surgery • 1974 - Giorgio Fishcer - Gynecologist 1st devised body liposuction • 1978 - Illouz – French Plastic surgeon – 1st cosmetic use of liposuction technique • 1985 - Jeffrey Klein – dermatologist – introduced tumescent liposuction technique • The father of modern cosmetic nasal surgery was a Berlin orthopedic surgeon • The ASPRS was originally founded by oral surgeons and was called the American Society of Oral Surgeons until 1931

9. History of Abdominoplasty • 1st performed in 1890 by Drs. Demars and Marx in France • In U.S. 1stabdominoplasty performed at Johns Hopkins by gynecologist

10. Today’s Plastic Surgery Training Programs • Today’s programs work against the aspiring young cosmetic surgeon • The minimum requirement for plastic surgeons is only two years • There are 137 head-to-toe procedures that the ABPRS recognizes as within that specialty’s province • Residents aspiring to be cosmetic surgeons have inadequate training and little access to the cosmetic wing of plastic surgery • Today’s more sophisticated and well-informed patients are reluctant to have the procedures performed by novice surgeons in-training

11. Problems with Training in Plastic Surgery • The young graduate surgeon is often inadequately prepared to practice cosmetic surgery at the high level of expertise expected by today’s patient • Surgeons often learn cosmetic surgery “on the job” • Therefore uninformed, patients inadvertently become the teaching cases that should have been provided during the formal training period

12. Who Should Perform Cosmetic Surgery On Post Weight Loss Patients? • Numerous specialties include aesthetic surgery in their core curriculum • These procedures are taught in most residency programs to ophthalmologists, dermatologists, ENT docs, plastic surgeons, oral and maxillofacial surgeons and gynecologists • In most of these specialties, cosmetic surgery procedures are part of the resident’s training, they are part of the board exams for those specialties and they are covered under the malpractice policies for those specialties • Contemporary educators will freely admit that aesthetic surgery is well within the accepted scope of numerous specialties

13. The Cosmetic Surgery Paradigm • No single specialty owns the body or the face and each of these specialties have brought advancements to the collective table of aesthetic surgery • Dermatologists pioneered laser surgery and invented tumescent liposuction • The current American Society of Plastic and Reconstructive Surgeons were originally founded by oral surgeons and physicians and was called the American Society of Oral Surgeons until 1931 • One huge misconception is that “plastic surgery” is synonymous with cosmetic surgery

14. Typical 2 Year Plastic Surgery Training Program in Atlanta • Burn service VA • Pediatric service • Hand surgery service • Reconstructive oncology service • Trauma and maxillofacial service • Aesthetic service

15. How Surgeons Become Qualified • Training • Education • Experience

16. How Surgeons Become Qualified • Training • Education • Experience

17. Blood Supply of Abdominal Wall for Safe Abdominoplasty

19. Avoiding the Medial Brachial Cutaneous Nerve in Brachioplasty: An Anatomical Study SaeedChowdhry, MD, Joshua B. Elston, BA, Todd Lefkowitz, MD, and Bradon J. Wilhelmi, MD Objective: With more patients undergoing bariatric surgery procedures, there has been an increased demand on plastic surgeons to manage excess skin around the body from massive weight loss. The upper arm is one of the areas that require surgical attention. One of the complications of brachioplasty is injury to cutaneous nerves of the arm. We report our findings of the location of the medial brachial cutaneous nerve on the basis of anatomical landmarks to aid the reconstructive surgeon in planning his or her operative approach and procedure. Methods: Eight fresh cadaver arms were dissected under loupe magnification. The brachial plexus was dissected from proximal to distal to evaluate the branching points of the cutaneous nerves. Measurements were taken from the medial epicondyle to cutaneous branches off the main nerve. Results: At about 7 cm proximal to the medial epicondyle, there is an arborization of 2 to 3 cutaneous branches. This nerve sends 3 to 4 branches through the muscular fascia across the ulnar nerve to skin of the medial arm at about 15 cm proximal to the medial epicondyle. In most cadavers, this was found in the midportion of the arm. Conclusions: The plastic surgeon will be challenged to effectively manage excess skin from weight loss. Placing the incisions more posteriorly on the arm will help avoid morbidity associated with injury to these nerves, while still providing an acceptable aesthetic outcome. Knowledge of the anatomy of the course of the medial brachial cutaneous nerve can help the surgeon better plan his or her operative approach to maximize aesthetic benefit and limit nerve injury.

21. How Do Bariatric Surgeons Learn Cosmetic Surgery the Right Way? • Preceptorships • Residency • Courses • Post residency fellowships

22. What Are Our Goals? • Patient safety • Patient satisfaction • Quality Outcomes

26. Duration of Extra Training • Weekend courses • Mini-fellowships • 1 month, 3 months or 6 months? • 1- 2 year fellowship?

27. All Surgeons /Training Programs Are Not Created Equal Considerations • Volume, mentor expertise and academic content of the training program • Skill and acuity of the surgeon - in – training

28. Unqualified Cosmetic Surgeons • Entrance from another specialty without adequate “re-training” • Completion of an accredited residency training program that lacks specific training in cosmetic surgery

29. Should Bariatric Surgeons Perform Plastic Surgery?

30. Can Bariatric Surgeons Perform Cosmetic Surgery on Post Weight Loss Patients • Yes… • If they obtain: • Training by expert in the field • Focus on Education in the field, i.e. anatomy, potential complications, etc • Work to become Experienced