When traveling around the country lecturing and visiting plastic surgery training programs, I’m often asked why the University of Texas Southwestern Medical Center’s plastic surgery residency training program places an emphasis on teaching cosmetic surgery. My response is that equal emphasis is placed on cosmetic and reconstructive surgery, using a balanced approach to teach the goals and principles of each discipline within the core training of plastic surgery. As do most plastic surgery training programs, ours has a strong tradition of training all aspects of reconstructive plastic surgery. However, over the past decade and particularly over the past 5 years in the changing marketplace, our program has refined its focus on cosmetic plastic surgery, obviating, it is hoped, the need for doing a fellowship or for additional training to learn the principles of aesthetic plastic surgery. Can we succeed in accomplishing this? Can programs continue to provide adequate training to plastic surgery residents on the principles of cosmetic surgery, working within the confines of a core residency into the 21st century? Let’s examine how plastic surgery has dealt historically with internal subspecialization. With regard to hand surgery, we now require a Certificate of Added Qualification, with 1 year of fellowship in formal hand training. We also require a 1-year fellowship for craniofacial surgery. So what should we do with cosmetic surgery training? Should we require an extra year of training in addition to the core plastic surgery training program? It would be optimal not to do so, because every time we carve out another fellowship, we are reducing the scope and practice of plastic surgery as we know it. The overall experience of the hand surgery model has limited the scope of the practice of those completing plastic, general, and orthopedic surgery training programs, especially in large metropolitan areas. What have we learned from these experiences? Perhaps we should consider retaining the basic elements of both cosmetic and reconstructive surgery within an expanded corpus of the plastic surgery training program. What we really need is more emphasis and time spent on core plastic surgery training so that, within a 5-year integrated program, 3 to 4 years are spent exclusively in plastic surgery, with only 1 to 2 years spent in general surgery training. In many cases, learning the principles and refinements of cosmetic surgery can be more difficult than learning those of reconstructive surgery. There is a natural balance in the philosophy of teaching cosmetic surgery and reconstructive surgery simultaneously, as the principles and goals of performing both arts are similar. The similarities end quickly, however. In reconstructive plastic surgery, one is restoring a defect to a more normal appearance. In critical analysis, the end point is less than ideal because of the challenge of the particular deformity. Appropriately, the expectations of the reconstructive patient and often the surgeon are not as high as in cosmetic surgery. In contrast, cosmetic surgery enhances the normal appearance of the patient who comes to us without substantial physical disfigurement. The expectations of the cosmetic surgery patient are often much greater than those of the reconstructive surgery patient. The surgeon’s expectations are also higher, and there is more pressure to produce consistently excellent results. Managing cosmetic surgery patients preoperatively and postoperatively assumes a high level of interpersonal communication skills, which can be acquired by concentrated training in this arena. Plastic surgeons make their living through the dexterity of their hands, but they must also be able to communicate with their patients in an efficient manner. This is done by being physicians first. But how do we do this? We learn that the perfect result is elusive. We learn to choose our patients carefully. We learn to be constructively self-critical of our results. We learn to get better at what we do—the artistry and sculpting of the face and body. Dare to say “no” when patients are unrealistic or when you cannot deliver the results they desire. Treat your patients as you want to be treated. Don’t perform surgery on patients with whom you have trouble communicating. When in doubt, don’t. We teach these essential principles to our residents from their first day and hope that they propagate them throughout their residency and their careers. Cosmetic surgery is an art as much as a science. Can we meet the challenge of adequately training cosmetic surgeons in our present training framework? With the rapid evolution of aesthetic surgery and technology, cosmetic surgery education becomes even more important. It is essential to enhance our continued prosperity as a plastic surgery specialty. In the face of an unregulated growth of cosmetic surgery performed by nonplastic surgeons, we must be able to train future cosmetic surgeons equally well in reconstructive surgery as they are educated within our core plastic surgery training programs. If we don’t accept these challenges, the uniqueness of plastic surgery as a reconstructive and cosmetic specialty of the entire body will disappear. However, I don’t think this will happen, because plastic surgeons have always risen to the occasion when challenged. We are stimulated to provide better care through the development of innovative techniques that will keep us in the forefront of all aspects of reconstructive and cosmetic surgery. In the 21st century, we cannot continue to teach the expanding scope of cosmetic plastic surgery to our residents adequately within the realm of a core, 2-year training program. Therefore, what changes can we make? What are our options? Lengthen our training program? This may not be possible within the curriculum or because of financial constraints. Change our program content and emphasis? This is essential to the evolution of plastic surgery training with expansion of the plastic surgery knowledge base, especially in cosmetic surgery. Add a fellowship training year? This may not be practical because of financial constraints. How will you be recognized for this effort? The most practical way to change our program content is by adding a core year of specialty training that is tailored to the specific resident interest within our plastic surgery residency training programs, such as: hand/micro training, breast/cosmetic training, or pediatric/craniofacial training. To remain competitive and to stay one step ahead of nonplastic surgeons who are performing plastic and cosmetic surgery today, we must act now! Look at the definition of plastic surgery—to restore, to remake, to mold. That is what we do as both cosmetic and reconstructive plastic surgeons. Our specialty can prosper if we recognize that cosmetic plastic surgery should be and is a significant and integrated part of our plastic surgery training programs. We must give it the same attention and respect that we have given reconstructive surgery in the past.
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Rod J. Rohrich (2000) studied this question.