A Plastic Surgery Resident's View of Aesthetic Training and the Future

Every June, another group of senior plastic surgery residents reaches an important milestone that marks the completion of their training in plastic and reconstructive surgery. Leading up to this point, program directors must ensure that all residents have met the Accreditation Council for Graduate Medical Education core procedural minimums.1 This past year, we have seen a remarkable change in the case requirements for plastic surgical residents. Minimal requirements for reconstructive surgery will rise from 850 to 1000 cases, while the aesthetic requirements will triple from 50 to 150 cases. These changes, which will be implemented over the next 2 years,2 make sense. Not only have we added an extra year of training, but our specialty has changed markedly in the past 20 years. According to the 2013 statistics from the American Society of Plastic Surgeons, 5.7 million reconstructive procedures and 15.1 million cosmetic procedures (1.7 million cosmetic surgical procedures) were performed.3 On the surface, it appears that the number of cosmetic surgical procedures comprises 23% of the total “invasive” surgical procedures performed in the United States for 2013. However, 4.4 million of the reconstructive procedures are listed as “tumor removal (including skin cancer).” If you eliminate these procedures, the cosmetic surgical numbers are in fact larger than the reconstructive numbers. There were 3 times as many breast augmentations as breast reconstructive procedures. This underscores how important cosmetic surgery is to the practicing plastic surgeon. Forty-three percent of board-certified plastic surgeons who maintain certification through the Maintenance of Certification program choose the aesthetic track.4 As demonstrated by the American Society of Plastic Surgeons’ Plastic Surgery Workforce Task Force Study, half of its respondents declared that over 75% of their practice is dedicated to cosmetic surgery.5 This underscores how important cosmetic surgery training is to the practicing plastic surgeon in an increasingly competitive marketplace. To further assess what residents-in-training were exposed to and interested in, a survey of current plastic surgical trainees was conducted to assess both their interest and exposure to aesthetic surgery. An online survey was emailed to 475 of the plastic surgery trainees who are enrolled into the American Society for Aesthetic Plastic Surgery’s (ASAPS) Resident Program (Table 1). The survey was sent by email twice to the 475 trainees. A total of 75 residents responded for a 16% response rate. Of these respondents, 92% are planning to perform aesthetic surgery upon completion of training, with 81% dedicating a significant portion of their practice to aesthetic surgery (Figures 1 and 2). Despite the significant interest in aesthetic surgery among this group of respondents, 32% stated that they have minimal training in aesthetic surgery (Figure 3). Many would argue that the best preparation for an aesthetic practice comes from the hands-on approach that is typically provided through a dedicated resident cosmetic surgery clinic. We were happy to see that over two-thirds of the programs did in fact have a resident cosmetic clinic where they evaluated and treated patients. This survey underscores how important cosmetic surgery training is to plastic surgery residents. Given the changes in the requirements put forth by the Residency Review Committee (RRC), it is our hope that many programs will be evolving and making changes in their cosmetic surgical education and training. Survey Distributed to 475 of the Plastic Surgery Trainees Enrolled Into the American Society for Aesthetic Plastic Surgery’s Resident Program What year in residency or fellowship are you in? Integrated: R1 Integrated: R2 Integrated: R3 Integrated: R4 Integrated: R5 Integrated: R6 Integrated: R7 Traditional/combined: R1 Traditional/combined: R2 Traditional/combined: R3 Fellow: Aesthetic Fellow: Craniofacial Fellow: Hand Fellow: Microsurgery Other How much of your residency training is/was devoted to aesthetic surgery? None Minimal Average Average above Intensive Do you (or did you) have your own resident cosmetic surgery clinic? Yes No How often do you research an aesthetic subject? 0-1×/month 2×/month 1×/week 2-3×/week >3×/week Are you planning on performing aesthetic surgery upon completion of training? Yes No How much of your practice would be aesthetic surgery based ideally? None Minimal Moderate Mostly All When researching an aesthetic subject, what journal(s) do you use most often? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other When publishing an aesthetic paper, what is your journal of choice? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other What journals are reviewed for journal club at your institution? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other No journal club at my institution After completion of training, will you subscribe to ASJ? Yes No Which journal’s website have you found to be the most user-friendly? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery How well does ASJ meet your educational needs as a resource for aesthetic surgery? 1 2 3 4 5 If you could only have access to one journal for your aesthetic needs, which journal would you pick? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other Are there any additional educational resources you would like to see ASJ provide? Yes No If yes, what are the additional educational resources you would like to see ASJ provide? What year in residency or fellowship are you in? Integrated: R1 Integrated: R2 Integrated: R3 Integrated: R4 Integrated: R5 Integrated: R6 Integrated: R7 Traditional/combined: R1 Traditional/combined: R2 Traditional/combined: R3 Fellow: Aesthetic Fellow: Craniofacial Fellow: Hand Fellow: Microsurgery Other How much of your residency training is/was devoted to aesthetic surgery? None Minimal Average Average above Intensive Do you (or did you) have your own resident cosmetic surgery clinic? Yes No How often do you research an aesthetic subject? 0-1×/month 2×/month 1×/week 2-3×/week >3×/week Are you planning on performing aesthetic surgery upon completion of training? Yes No How much of your practice would be aesthetic surgery based ideally? None Minimal Moderate Mostly All When researching an aesthetic subject, what journal(s) do you use most often? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other When publishing an aesthetic paper, what is your journal of choice? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other What journals are reviewed for journal club at your institution? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other No journal club at my institution After completion of training, will you subscribe to ASJ? Yes No Which journal’s website have you found to be the most user-friendly? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery How well does ASJ meet your educational needs as a resource for aesthetic surgery? 1 2 3 4 5 If you could only have access to one journal for your aesthetic needs, which journal would you pick? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other Are there any additional educational resources you would like to see ASJ provide? Yes No If yes, what are the additional educational resources you would like to see ASJ provide? 1 = Never, 2 = Below Average, 3 = Average, 4 = Above Average, 5 = Best Survey Distributed to 475 of the Plastic Surgery Trainees Enrolled Into the American Society for Aesthetic Plastic Surgery’s Resident Program What year in residency or fellowship are you in? Integrated: R1 Integrated: R2 Integrated: R3 Integrated: R4 Integrated: R5 Integrated: R6 Integrated: R7 Traditional/combined: R1 Traditional/combined: R2 Traditional/combined: R3 Fellow: Aesthetic Fellow: Craniofacial Fellow: Hand Fellow: Microsurgery Other How much of your residency training is/was devoted to aesthetic surgery? None Minimal Average Average above Intensive Do you (or did you) have your own resident cosmetic surgery clinic? Yes No How often do you research an aesthetic subject? 0-1×/month 2×/month 1×/week 2-3×/week >3×/week Are you planning on performing aesthetic surgery upon completion of training? Yes No How much of your practice would be aesthetic surgery based ideally? None Minimal Moderate Mostly All When researching an aesthetic subject, what journal(s) do you use most often? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other When publishing an aesthetic paper, what is your journal of choice? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other What journals are reviewed for journal club at your institution? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other No journal club at my institution After completion of training, will you subscribe to ASJ? Yes No Which journal’s website have you found to be the most user-friendly? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery How well does ASJ meet your educational needs as a resource for aesthetic surgery? 1 2 3 4 5 If you could only have access to one journal for your aesthetic needs, which journal would you pick? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other Are there any additional educational resources you would like to see ASJ provide? Yes No If yes, what are the additional educational resources you would like to see ASJ provide? What year in residency or fellowship are you in? Integrated: R1 Integrated: R2 Integrated: R3 Integrated: R4 Integrated: R5 Integrated: R6 Integrated: R7 Traditional/combined: R1 Traditional/combined: R2 Traditional/combined: R3 Fellow: Aesthetic Fellow: Craniofacial Fellow: Hand Fellow: Microsurgery Other How much of your residency training is/was devoted to aesthetic surgery? None Minimal Average Average above Intensive Do you (or did you) have your own resident cosmetic surgery clinic? Yes No How often do you research an aesthetic subject? 0-1×/month 2×/month 1×/week 2-3×/week >3×/week Are you planning on performing aesthetic surgery upon completion of training? Yes No How much of your practice would be aesthetic surgery based ideally? None Minimal Moderate Mostly All When researching an aesthetic subject, what journal(s) do you use most often? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other When publishing an aesthetic paper, what is your journal of choice? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other What journals are reviewed for journal club at your institution? (choose as many as you’d like) Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other No journal club at my institution After completion of training, will you subscribe to ASJ? Yes No Which journal’s website have you found to be the most user-friendly? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery How well does ASJ meet your educational needs as a resource for aesthetic surgery? 1 2 3 4 5 If you could only have access to one journal for your aesthetic needs, which journal would you pick? Aesthetic Plastic Surgery Aesthetic Surgery Journal Annals of Plastic Surgery Clinics in Plastic Surgery Journal of Plastic, Reconstructive & Aesthetic Surgery Plastic and Reconstructive Surgery Other Are there any additional educational resources you would like to see ASJ provide? Yes No If yes, what are the additional educational resources you would like to see ASJ provide? 1 = Never, 2 = Below Average, 3 = Average, 4 = Above Average, 5 = Best Response to question 5 (Are you planning on performing aesthetic surgery upon completion of training?) from the survey. Response to question 6 (How much of your practice would be aesthetic surgery based ideally?) from the survey. Response to question 2 (How much of your residency training is/was devoted to aesthetic surgery?) from the survey. As plastic surgeons, we always remain critical of what we do and constantly look for better ways to reach our goals. This is an exciting time in plastic surgery education, where we now have an extra year of training and new specific guidelines from the RRC as to what we should be accomplishing during those years of training. Our survey demonstrates that residents want more exposure to aesthetic surgical procedures, and we suspect that they will see this happen with the new changes in case requirements. Additionally, there are now more opportunities to extend one’s training as a fellow. The ASAPS-endorsed fellowship continues to grow. There are now nearly 15 endorsed fellowships that all share a similar curriculum and goals. As programs evolve toward the new requirements, postgraduate residents still have the opportunity to gain additional training in aesthetic surgery through the endorsed fellowship program. Recognition of the importance of both reconstructive and aesthetic principles is imperative as they lead to improved patient outcomes and satisfaction rates. An appropriate example is demonstrated in breast reduction surgery. The evolution from concentrating mainly on conservation of the nipple areolar complex and volume reduction to include aesthetic considerations led to the development of minimal scar techniques with improved shape and projection. We appreciate that our survey has an inherent bias built into it. While 475 residents are enrolled in the program, only 75 responded. Those 75 more than likely have a keen interest in pursuing an aesthetic plastic surgery practice. We are excited about the changes going on within the subspecialty of plastic surgery. Tripling the case requirements will certainly help fill any perceived void in training and help establish more stout training in aesthetic surgery. It is equally exciting to see that the ASAPS will be reaching out to program directors and offering to help them in any way possible via community faculty and educational tools. Ideally, a dedicated cosmetic surgery rotation with designated sites and a cosmetic surgical resident clinic for hands-on exposure would be a part of every training program. This sentiment is echoed in prior plastic surgery resident surveys performed in the United Kingdom, United States, and Canada.6-9 The ultimate goal of any training program should be for every graduating resident to feel well trained and comfortable with the breadth of plastic surgery, including the most common cosmetic procedures. We are pleased to see the changes in the RRC requirements and the support of the ASAPS through educational outreach and their endorsed fellowship program. As plastic surgeons, we should remain leaders in the field of aesthetic surgery. These types of changes will allow us to invest in our future and maintain our footprint in aesthetic plastic surgery.