Plastic surgeon vs Maxillofacial surgeon for stitches on the face

February 28, 2013 2:15 PM

if you get a cut on your face that requires stitches and you go to the ER is it better to ask for a plastic surgeon or a maxillofacial to stitch you up? And is the hospital required to give you one if you ask for it?
posted by john123357 to Health & Fitness (31 answers total)

Response by poster: maxillofacial surgeon I meant
posted by john123357 at 2:18 PM on February 28, 2013

It's better to let the emergency physician do it. We typically know what we're doing and will consult the appropriate speciality if the laceration looks too complicated.

There will always be a scar. Always. Be. A. Scar. (Unless you're a child.)
posted by gramcracker at 2:26 PM on February 28, 2013 [6 favorites]

It's the ER. You're not going to have that option. They don't keep a roster of surgeons in the back. The ER doc on duty knows how to stitch.
posted by cosmicbandito at 2:29 PM on February 28, 2013 [1 favorite]

cosmicbandito, not always. Friend of mine's kid took a hockey skate to the face, and the ER doc called in a plastics guy to do the suturing.
posted by KathrynT at 2:32 PM on February 28, 2013

They can bring in a plastic surgeon. I know people who had this done. I donʻt think the ER is required to get you one. But from my experience, they will do it.
posted by fifilaru at 2:44 PM on February 28, 2013

They do have a surgeon. Surgery, as well as other basic specialties, has to be available, either in-house or on call.

Plastic surgery is another matter. It requires a hospital of a certain size to offer that service as a consulting service. As gram said, it will be a matter of judgment for the ER physician. In a close situation, she should give you the choice.
posted by yclipse at 2:47 PM on February 28, 2013

The difference between an ER doctor's stitching and someone who has had plastics training is going to be extraordinarily obvious on the face, which has a lot looser skin and contour lines than other areas of the body.

A general surgeon would call in plastics if aesthetics mattered, and if cost were no object. That said this will not happen a majority of the time because it's not their kid's face.

Once you've seen the difference between an actual trained plastic surgery fellow and everybody else it's not even close.
posted by hobo gitano de queretaro at 3:16 PM on February 28, 2013 [1 favorite]

Rereading the question I see that I did not answer it.

Someone who has training in dentistry and surgery and specializes in maxillofacial is not going to be nearly as concerned with the skin and wouldn't be involved in a facial cut unless it was deep enough to really mess up the jaw. Still plastics.
posted by hobo gitano de queretaro at 3:19 PM on February 28, 2013 [1 favorite]

Response by poster: don't maxillofacial surgeons do operations to repair broken cheekbones and orbital bones that would require cutting and stitching the face ?
posted by john123357 at 3:34 PM on February 28, 2013

You can always get the scar revised by a plastic surgeon later, if you can't get stitched up by one in the ED.
posted by Argyle_Sock_Puppet at 3:35 PM on February 28, 2013 [1 favorite]

While a max-fac might stitch the face up in the course of their duties, if you try to call one up in the middle of the night for a simple facial laceration they will laugh and hang up. Their main concern is what's under the skin on the face. It's not their job.

Most of the time whoever is on in emergency would do it, depending on how extensive the wound is. If it was very deep and complicated a surgeon would. I'd say you'd have to kick up a stink to get an actual plastic surgeon in unless it was a doozy.

(Australia)
posted by chiquitita at 3:44 PM on February 28, 2013 [1 favorite]

When I was a nursing student I saw one guy in the ER with what was either a dog bite or a knife wound (he couldn't remember, bad sign, and it was surprisingly hard to tell) to his cheek. Plastic surgery came down and sewed him up (and did a really nice job).

Every other time it's been the ER doc. I haven't seen too many crazy facial lacerations. If it's nice and clean they often times will glue the wound (dermabond, which is medical crazy glue).

I can say that I think there would be a huge HUGE difference between a dog biting the face of a 14 year old girl (god forbid) and a drunk 50 year old who got punched in the face or fell on something sharp (quite a bit more common thankfully). In the former, the parents are going to be going apeshit, and if it's a small hospital without plastics I imagine the pt is going to get transferred somewhere else. In the latter, the doctor will get to it when they have time.

I'm not a doctor. I'm not anybody! I made this all up. I have nothing to tell you!!!
posted by sully75 at 3:54 PM on February 28, 2013

Response by poster: I'm in the US and when I was a kid a had a deep forehead gash and my mom asked for a plastic surgeon or a maxillofacial surgeon to stitch it up. The ER decided to call in a maxillofacial surgeon.
posted by john123357 at 3:55 PM on February 28, 2013

If it's a scheduled maxilofacial surgery like I had (see my jaw surgery Flickr set), the surgeons can go in via your mouth and kinda peel your face back to get at the bones, so, a plastic surgeon would probably have more skill/experience with stitching up the skin. In an unplanned surgery like putting someone back together after a car crash, they would probably bring in multiple specialists.
posted by oh yeah! at 4:18 PM on February 28, 2013

When I split my lip open as a child, a plastic surgeon stitched it up. (I was three or four. Thirty years later, there's still a scar. There will always be a scar.)
posted by Ruki at 4:26 PM on February 28, 2013

Response by poster: why did the ER call in a maxilofacial guy then rather than a plastic surgeon?

It was a standard gash on forehead, no broken facial bones or anything.
posted by john123357 at 4:26 PM on February 28, 2013

Do they even do stitches on the face anymore? The last 2 facial-injury patients I sent to ER from work got surgical glue instead. Very nice, minimal scarring. I suppose it depends on the extent of the injury though.
posted by Mary Ellen Carter at 4:33 PM on February 28, 2013

john123357, I think your experience was idiosyncratic. Maybe the ER doc called maxillofacial surgeon rather than plastic surgeon because the plastics fellow on call was terrible with kids, or because the maxillofacial surgeon was great with kids, or because the maxillofacial surgeon had a new technique they wanted to try out in an ER setting, or the plastics fellow stole the ER doc's dog, who knows?

But ordinarily the ER doc will triage each situation based on which expertise is needed, and usually they do their own glue/suturing unless it's a clear case for plastic surgery. They're not going to call in a maxillofacial surgeon unless there's bone injury.

Perhaps your mum has magical powers? Or strong powers of persuasion? When I got a cut on my face, the doc sewed it up with thick black sutures, which I thought was awesome because I was six and looking like Frankenstein was coolio.
posted by Sidhedevil at 4:49 PM on February 28, 2013 [1 favorite]

In my experience (a dog attack that caused me to end up with ~30 stitches in my ear), they brought in a plastic surgeon without asking for that part because it was so bad.
posted by asphericalcow at 4:53 PM on February 28, 2013

Response by poster: Also when they call in a plastic surgeon to stitch up your face is it usually a resident or a full doctor? (I think the technical term is a board certified plastic surgeon.) Can you request that it not be a resident?
posted by john123357 at 5:10 PM on February 28, 2013

Residents are doctors. But you would probably get a plastic surgery fellow (doing a specialty fellowship after completing residency) on call for the ER at most large hospitals. You can't request a particular surgeon, or a surgeon with a particular set of certifications or number of years of experience, in an emergency situation at any hospital I'm aware of.
posted by Sidhedevil at 5:43 PM on February 28, 2013

Someone who sees you in a non teaching hospital is going to be a full fledged plastic surgeon, or worst case, it's going to be someone who did the full general surgery residency (5-7 years) and is specializing ("fellowship") in plastic surgery (additional 1-3 years).

There are a lot of people out there calling themselves aestheticians and all sorts of nonsense, and when you press them on the details say yes, I'm a doctor. When their credentials are questionable at best.

You are completely entitled to request no students, no residents, MD only, but how that request is going to be received is entirely dependent on the psychological health of the environment of that particular hospital during that shift.

For the record I don't really think going back in later to 'fix' a scar works. Once it begins healing and forming tissue that cake is baked.

Long story short, anyone can do stitches. But it takes special training, years of practice, and a bit of luck to ensure that it will look pretty when it heals.
posted by hobo gitano de queretaro at 5:46 PM on February 28, 2013

Maybe when you were a kid the ER just called an ER surgeon and said 'hey the mom's freaking out, tell her you're a maxillofacial guy'.
posted by jacalata at 5:47 PM on February 28, 2013 [2 favorites]

Argyle_Sock_Puppet: You can always get the scar revised by a plastic surgeon later, if you can't get stitched up by one in the ED.
posted b

Human skin is not like steel, that can be rewelded and buffed back to hide the work again and again if necessary. Some unreparable damage is done every time the skin is torn. So, yes, you can always get the scar revised - but it will not look as good as if it were done by the best possible surgeon in the first place.
posted by IAmBroom at 5:48 PM on February 28, 2013

Response by poster: The hospital I usually go to has a medical school so who would likely show up, a resident, a fellow or a "full" plastic surgeon?
posted by john123357 at 6:02 PM on February 28, 2013

This all varies widely by the hospital, but if your regular hospital is a level one trauma center, there is a facial trauma call schedule. At my institution, "face call" is covered by plastics, ENT and OMFS (oral/maxillofacial surgery). Which one you get depends on who is on-call.

Just because it's on your face doesn't mean you need one of these specialists. In my experience, ED doctors are more than qualified to close the vast majority of facial wounds and can achieve aesthetically excellent results. If they feel out of their league, they will call whoever is on call. You will get either a resident or a fellow depending on the service covering.

You can request an attending but you are not guaranteed to get them to come in. If you don't want residents or fellows, go to a non-teaching hospital and you will get an attending every time. You will get good and bad surgeons amongst all the specialties but in general, plastics, ENT and OMFS are all equally trained in handling facial lacerations.
posted by karlos at 6:34 PM on February 28, 2013 [1 favorite]

Response by poster: if you go to a non-teaching hospital is it more likely that they will deny the request for a plastic surgeon because they dont have residents to hand it off to?
posted by john123357 at 6:42 PM on February 28, 2013

It makes no difference. I stiched on head and neck (and got complimented on it) when I was a med student rotating through ENT. They are absolutely not required to get plastics/ent/omf for a simple lac.
posted by a robot made out of meat at 7:08 PM on February 28, 2013

if you go to a non-teaching hospital is it more likely that they will deny the request for a plastic surgeon because they dont have residents to hand it off to?

It depends on the resources of the hospital and the severity of the wound. I doubt they will flat out deny the request, but if the wound is rather simple to fix and the plastic surgeon on call is unavailable at the moment (e.g., involved in another, more complicated case), they may advise you to let the ED take care of it. If you don't want to listen to their advice and would rather wait, that would be your call. But, if the plastics person is very busy, it may be awhile.
posted by bluefly at 5:59 AM on March 1, 2013

anecdata - I've had surgery above the neck twice. once by a plastic surgeon (20 yrs ago), and recently by an eent Dr. unless you knew where to look you wouldn't notice either and both occurred in highly visible locations.
posted by forforf at 10:59 AM on March 1, 2013

I'm an ER doctor and I can count on one hand the number of times I've gotten a plastics person simply because the patient requested it. It's usually overly worried parents. Here is a blog post that explains the thinking behind such an encounter better than I could in this space.

Most places I've worked don't have OMFS on call. I did work at one very large academic institution that had OMFS, but we would not call them unless they were legitimately needed for an OMF emergency.

You haven't clarified whether this is a simple wound that does not require a surgeon to repair it, or a more complex wound where there might be a legitimate question of whether a surgeon repairing it would be the better choice.

In the cases of simple wounds, it's easy - I basically never involve the surgeons (the cases above that I mentioned were during residency so it wasn't my call). The few times patients have asked me about a surgeon, I have been able to have a conversation such as the one described in the blog post and I have changed their mind, especially when I point out that I can fix this wound in 15 minutes, but if they want the surgeon, it's going to be a much longer wait - probably a few hours.

For one of the more complex wounds, I give my honest assessment of whether I could do the repair just as well and then if they still want me to, I will offer to call the surgeon but I make no promises about them coming in to do the repair. This assumes the surgeon is onsite and it is during daytime hours. If the surgeon is at home and would need to be called in (this would be in a community setting), I would suggest the patient go/transfer them to the nearest level 1 trauma center for the repair, usually. As the blog post notes, if I feel I cannot do the repair adequately myself then I can obligate the surgeon to come in for it using legislation called EMTALA.

If you typically go to an academic medical center, who you would get would vary.
- One academic center I've worked at had ENT, OMFS, and plastics alternating coverage for a 'facial trauma' service. Depending on the service and who was on call, you would get either a resident or a fellow - also, some locations have plastics residencies (integrated programs) where the same residents are in the plastics program for 5 6 years, and in those locations you'll get a resident, where in other locations there are separate surgical residencies and then plastics fellowships. You can definitely get medical students as well, especially in the months of July-Sept when they are doing their 'audition' rotations.
- In another academic center I worked at, we usually used plastics for these consultations unless it was a patient we were already consulting the trauma team on, in which case the trauma team would take care of the laceration repair(s) - this could be a surgical resident, emergency medicine resident, or medical student. It always cracked me up inside when parents would demand a plastic surgery consultation for their child and an emergency medicine resident covering the plastics service would come and do the repair.
- In the community hospitals where I've worked there has not been plastic surgery coverage. I would transfer any patient who needed plastics repair (which is very few people).

I've never worked at an academic center where you could get an attending plastic surgeon for a consult like the one you describe. Perhaps if there were no plastics rotation or residency, that could happen. But generally attendings work at academic centers in part because they get the benefit of not having to do silly consults like this, they can delegate it to the residents. You could request that you not get a resident to do your repair, but the attending surgeon is probably not available so you may or may not get the repair done if you do that. At a community place, yes, they're more likely to deny your request, because surgeons are busy people and they need to be doing things that actually require a surgeon to do.

Anyone considering demanding a plastics consult should recall that the longer it takes to close a wound, the greater the risk of infection is. Surgeons begin to balk at closing wounds at about 8 hours after the wound occurred.

I hope that answers some of your many questions about this scenario... but feel free to MeMail me if you want to know more! I'm glad you asked this because I think people really don't understand what they're asking for or why when they demand to be seen by a plastic surgeon.
posted by treehorn+bunny at 11:43 AM on March 1, 2013 [3 favorites]