with Rebecca McGraw, MD, MFA

On the difficult ski slopes in Vail, Colo, accidents happen. The latest methods are often needed to make things right

When I was a plastic surgery resident, deciding where to set up my practice, one of my professors at the Columbia University College of Physicians and Surgeons (New York City) told me, “Go where you want. You can make it work anywhere.” I took this advice to heart and settled in Vail, Colo, a world-class ski-resort town that has only 4,500 full-time residents.

I opened this practice the old-fashioned way, as one of my mentors suggested. I picked a place where I wanted to be and obtained an office, a phone, and some stationery. I cannot think of anything much more daunting than opening a private practice in a small town, and it has been an overwhelming amount of work, but I cannot imagine doing it any other way.

The practice, a unique combination of small-town plastic surgery and an international clientele, has grown exponentially. Its mix varies with the seasons—from management of ski injuries in the winter when most locals are extremely busy with their own careers, to primarily aesthetic procedures in the “mud” seasons (spring thaw and rainy fall).

Many of my patients are vacationers or second-home owners, so I meet people from all around the globe. I perform breast-cancer reconstructive surgery year-round in conjunction with the local cancer center. Here’s a timeline of the first year of my life as a plastic surgeon in the Vail Valley.

Fall: Grand Opening

The practice opened during the fall. The first thing I did—even before I had my phone hooked up—was to buy numerous books: Opening a Medical Practice; Aesthetic Medicine: Practicing for Success; The Business of Medical Practice; Mastering the Re-imbursement Process; and many others. I read them diligently and tried to follow their advice.

I found that the common strain in each of these books—and the precept that has been the strongest building block of my practice—is developing trust. Once I got to know some of the other area physicians, I found that they were—and still are—my best referral sources. I learned that patients go to physicians they trust. Having patients trust you is one of the greatest honors and responsibilities of being a physician.

When patients get recommendations from their own physicians, they feel good and trust those referrals. I am extremely grateful for the support I received (and still receive) from other valley physicians. No matter how many advertising dollars I spend in the yellow pages or the local newspaper, the element that helped my practice most was people—physicians and my own patients. Word-of-mouth advertising takes the longest, but it is the most dependable way to build a practice.

One of my first patients was a woman who wanted body contouring (liposuction) before the ski season opened in full swing. She had her surgery in November and, 5 days later, she saw one of my staff members on the ski mountain. The patient had her snowboard in hand and said, “Don’t tell him [me] that you saw me here. He told me not to board for a week.”

That patient and several others had their elective aesthetic procedures before the busiest tourist season of the year. She fared well despite her hasty return to snowboarding. Since that first patient, I have learned that most of my patients ask me the same question: “When can I ski again?” Most of my injury and aesthetic-surgery patients are healthy and active, regardless of age. They are eager to return to an active lifestyle.

Winter: The Downside to Downhill

Soon after I opened the practice, millions of vacationing skiers came to try their luck on Vail Mountain, just as they do each winter. World-class alpine racers and snowboarders compete in Vail every year, some on the most difficult “black diamond” slopes. Locals ski during their lunch breaks and on weekends. I even try to get a few runs in before office hours on days when I can.

Kids as well as adults ski, snowboard, and sled routinely. Just as with any other sport, injuries occur—maybe more so. Here are the most common ski injuries I encounter, as well as their management and prevention strategies.

Trees: Head and Face Injuries

With all the media attention given to the tragic deaths of Sonny Bono and Michael Kennedy, many people think that trees are the number-one cause of serious skiing injuries. Well, I can confirm that. Trees not only add an extra challenge to the skills of skiers and snowboarders, they also pose a significant danger. The combination of high speeds, trees, and heads makes bone and soft-tissue facial damage the most common major skiing injury I see.

Facial fractures, such as tripod and various Lafort fractures, top the list (Figure 1). These fractures are accompanied by significant facial swelling. Initial management includes pain control and time to reduce the swelling. If there are open facial wounds, they must be closed first. They must also be explored for foreign bodies; Iusually find tree bark in these wounds.

The temporal window for treating these facial fractures is 5–14 days. During this period, the swelling has usually subsided and the bones are still reducible for fixation. Not all facial fractures necessitate surgical repair. Surgical indications are functional problems such as double vision or malocclusion, a visible deformity, or the expectation of these conditions when edema subsides.

Many facial fractures can be treated conservatively. The temporal window is germane to my practice because it allows for patient convenience. Although I routinely perform facial surgeries on locals and vacationers alike, I can counsel those who strongly desire to return home for surgery for the sake of convenience.

My main recommendations for preventing tree-collision injuries are to always wear a helmet (with a face guard) and, of course, to avoid wooded areas. Skiers should know their abilities and stay within them, especially when skiing or snowboarding close to trees, other skiers, or obstacles. Skiers must be aware that areas with trees frequently have fallen trees, branches, and other obstacles just below the snow surface that can catch a ski or board and send the skier headlong into an upright tree.

Big Air: Hand Injuries

Vail’s annual “Big Air Competition”—which features an 80-foot jump at the base of the mountain—sees its share of not only air but emergency medical and plastic surgery services. Big air means big injuries—compression fractures and pelvic fractures, for instance.

From a plastic surgeon’s perspective, the injuries from this venue are predominantly to the hand and wrist from falls—metacarpal and phalangeal fractures, and carpal fractures and dislocations. These injuries are frequently open fractures or are associated with neuro-vascular compromise, and necessitate urgent surgical treatment.

How can these injuries be prevented? Once again, avoidance. Leave the 80-foot jumps to the professionals. As for the professionals themselves, very little can prevent injuries from a fall or an improper landing from that height. Proper protective equipment may decrease the risk of severe injuries.

Another hand injury is “skier’s thumb.” This is specifically an acute injury to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint.

Skier’s thumb is caused by falling onto a ski pole. Forceful abduction onto the pole causes a tear of the UCL. With complete tears, the result is usually a Stener lesion, which occurs when the adductor aponeurosis is interposed between the distally avulsed ligament and its insertion into the base of the proximal phalanx, preventing normal healing without surgical intervention.

Skier’s thumb is specifically an acute injury, as opposed to the chronic pathogenesis of the more common “gamekeeper’s thumb,” which is anatomically an injury to the same structure that occurs due to chronic stress. The treatment of the acute injury is the direct repair of the ligament avulsion, whereas the chronic injury requires more complex reconstruction, such as a free tendon graft or arthrodesis.

Ski-pole manufacturers have altered the poles’ handle designs in an attempt to prevent skier’s thumb. However, these alterations have had little, effect on decreasing the incidence of skier’s thumb.

Rails: Soft-Tissue Wounds

Rails, such as those found in terrain parks, cause perhaps the worst complex soft-tissue injuries I see. Like trees, rails can be approached by skiers at high speeds. A miscalculation can cause massive tissue trauma. Whereas tree-collision injuries are mostly to the face and head, rails and ramps more frequently affect the lower extremities and trunk (Figure 2, page 38).

On rare occasions, there is not enough viable tissue to close these wounds primarily, and flaps are indicated. Prevention of terrain-park injuries includes proper training, and again, the recognition of one’s limitations. Proper gear reduces the risk and severity of injuries.

The vast majority of skiing and snowboarding injuries are to the lower extremities. It is unusual for these injuries to include open fractures with complex soft-tissue injuries. These injuries are rare because of the low energies associated with most recreational skiing—in contrast to high-energy auto collisions. When these complex soft-tissue injuries do occur with open fractures, I manage the patients in conjunction with an orthopedist.

Lifts and Après Ski

Few plastic surgery articles would be complete without mentioning lifts. The lifts in question here are not surgical lifts, but ski lifts, which can contribute to the array of injuries mentioned previously. Impacts and falls from ski lifts can cause facial fractures, hand injuries, and complex soft-tissue wounds.

Fortunately, the development of high-speed, detachable lifts has significantly reduced the risk of ski-lift injuries. This new technology allows lift chairs to slow down as skiers board and exit the lifts. This has markedly improved the lift’s safety and has therefore prevented numerous injuries.

One of the benefits of working in a ski-resort community is that emergencies usually happen late in the afternoon, just as my office hours are winding down. Seldom do injuries occur that interrupt my office hours—or a good night’s rest.

In late afternoon, skiers are most fatigued and therefore most injury-prone. Another explanation: My patients often tell me that by the end of the day, they finally build up enough courage to try the maneuver that caused the injury.

Occasionally, injuries occur during late-evening hours due to après-ski activities that affect balance and coordination on icy sidewalks and steps. However, late-night injuries are the exception rather than the rule.

Spring and Summer

Along with the spring thaw, known by locals as “mud” season, comes a relative rush of aesthetic consultations to our office. The mountain closes for skiing in April, and by then I notice that a considerable number of patients call to make appointments for late April and May.

Second-home owners say that they would like to have their aesthetic procedures done before they head out of town. Local patients say that their workloads at their own seasonal jobs slow down enough so that they can afford to take the time off for the aesthetic procedure they had been wanting.

The spring and summer seasons are a mixed bag of plastic surgery work for me. I see plenty of mountain-biking accidents, and they fall into the same categories as the ski injuries in the winter—face, hand, and complex soft-tissue wounds.

I have another increase in aesthetic surgery consultations in the summer. I am fortunate to have had some out-of-town patients come to have their surgery in the seclusion of the mountains.

This does not happen automatically, as—I must admit—I thought it might. I had hoped that I could just put myself on the map and expect that people would want to come to Vail to have their plastic surgery. But people have to trust. People have to have heard about me from someone they know—the old-fashioned referral.

The active mountain lifestyle leaves patients not only with injuries, but, of course, with scars from them. Some of my local patients with scars from old athletic injuries have asked for scar revisions, even when I run into them outside the office.

One man asked me, “You’re a plastic surgeon, right?” In a public setting, he immediately showed me a scar on his shoulder from an old ski-racing injury and said, “Can you fix this?” I recommended scar revision using a subcission with a diamond wire and fat grafting.

Another patient had a remote history of compartment syndrome due to an intense workout of pushups. He had lived with fasciotomy scars for years. His scars were so contracted that he couldn’t even raise his arm up normally to brush his own hair. I performed scar revision and restored the man’s function.

Regardless of the season, I also continually perform breast-cancer reconstruction on patients referred to me from the cancer center. Performing this surgery is one of the most rewarding aspects of my job. The cancer center is one of the strongest reasons that I came to Vail Valley—it allows me to work as a cancer-team member with physicians from other specialties.

A Final Downside

It is both my good fortune and my misfortune that many of my patients are outdoor and ski enthusiasts who visit Vail from countries all around the globe. Certainly, interacting with people of so many different nationalities gives me great pride and lends my practice a prestigious international flair.

The downside of this, however, is that sometimes I don’t get to see the results of my reconstructive efforts. Telephone follow-ups and photos sent by many patients tend to reduce the impact of this downside, however.

Ski injuries are just one aspect of mountain plastic surgery. My practice runs the plastic surgery gamut, and I suspect this is the norm for any small-town plastic surgery practice. I always need to be prepared for anything. I frequently bounce clinical ideas off local surgeons in other specialties—general surgery, oral and maxillofacial surgery, otolaryngology, and orthopedics.

Starting a plastic surgery practice in Vail has been a difficult endeavor from the clinical and the business standpoint, but I do not regret that I did it. Although there are probably more ups and downs (up the lift, down the mountain; reconstructive in winter, aesthetic in summer) for a practice in Vail than would be expected in most other places, it is fortunate for most skiers—myself included—that skiing injuries are relatively rare. PSP

Jeffrey N. Thaxton, MD, is a plastic surgeon in private practice in Vail, Colo. He is on the medical staff at Vail Valley Medical Center and Shaw Regional Cancer Center. His wife, Rebecca McGraw, MD, MFA, is a general practitioner who performs medical reviews for an insurance company. She has also been an associate editor for the journal Disability Medicine. They can be reached at (970) 476-2777 or [email protected].