Board-certified Plastic Surgeons Receive the Least Training in Aesthetic Surgery!

Providing adequate training in plastic and reconstructive surgery is fraught with several challenges and this survey was performed to investigate the various shortcomings in training perceived by the trainees.

When plastic surgery residents were asked to specify specialties they were least trained in; aesthetic surgery was the most commonly reported specialty (53.7%) followed by burn surgery (45.4%) (see Fig. 7).

Reference: Asra Hashmi et al: A Survey of Current State of Training of Plastic Surgery Residents. BMC Research Notes. 2017 10:234

A large percentage of plastic surgeons feel inadequately prepared to perform aesthetic surgery

Aesthetic surgery training remains uniquely challenging for plastic surgery residents.

High-demanding patients and limited aesthetic surgery volume at academic medical centers restrict the aesthetic experience of many residents.

A large percentage of plastic surgery residents feel inadequately prepared to perform aesthetic surgery upon graduation.

Reference: Jason Silvestre, BS Joseph M. Serletti, MD, FACS Benjamin Chang, MD, FACS: Disparities in Aesthetic Procedures Performed by Plastic Surgery Residents. Aesthetic Surgery Journal, Volume 37, Issue 5, 1 May 2017, Pages 582–587.

If you are looking for the most-qualified and experienced surgeon for liposuction and/or autologous fat grafting surgeries, you have come to the right place! Not all plastic surgeons are created equal. Every surgeon has his own area of expertise which he is most passionate about. If you wish to get liposuction done, you do not want to go to a surgeon who is good at rhinoplasty, but performs only a handful of liposuction surgeries annually, and vice versa. You do not want to look for a surgeon who is the jack of all trades. You want to look for the master of a specific surgery!

Surgeon Who Specializes in Only One Particular Surgery Could be Best for the Job

A new retrospective analysis shows that the best surgeon for the job is one who specializes in that particular operation.

More than 695,000 operations performed by 25,152 surgeons were analyzed for the study, published in the July 2016 issue of the British Medical Journal.

The study authors say their results suggest that a surgeon who performs only a particular surgery 20 times day in and day out but no other surgery, may end up with better outcomes than a surgeon who does the same surgery 40 times among a mix of 60 other types of surgeries.

If the same surgeon who performs your blepharoplasty tells you that he can also do rhinoplasty, otoplasty, surgical face lift, breast implants, autologous fat grafting, liposuction and buttocks augmentation for you with equivalently good results and confidence, RUN! 🙂

Reference: British Medical Journal. 2016 Jul 21; 354:i3571

There is a misconception that plastic surgery is identical to cosmetic surgery. Cosmetic surgery is but one very small component (less than 5%) of plastic surgery training. The term “plastic surgery” and “cosmetic/aesthetic surgery” cannot and should not be used interchangeably. As a matter of fact, a board-certified plastic surgeon may not even have the necessary exposure and training to be a good cosmetic surgeon. A good plastic surgeon may not have the aesthetic sense to be a good cosmetic surgeon. Cosmetic surgery goes beyond technical skill. It is an art. It requires the vision of an artist. What many patients do not know is that adequate cosmetic surgery experience is usually gained only during post-residency fellowship training AFTER one has become a plastic surgeon! And not all plastic surgeons enroll in cosmetic surgery fellowship programs, because they may not have interest in cosmetic surgeries, or they may not be able to even get a fellowship position, as it is extremely popular and competitive! A typical plastic surgery residency program takes 3 to 4 years to complete, after which, one, upon passing examinations, becomes full-fledged plastic surgeon. Let us take a look at a typical plastic surgery training program. This is one from UCSD School of Medicine: 2015-2016 Independent Rotation Schedule. Let us count how many months a plastic surgery resident spends his time training in cosmetic surgery. During Year 1, one month is dedicated to basic aesthetic surgery training. In Year 2, another one month is spent in basic aesthetic surgery. In Year 3, one month each is spent in both basic and advanced aesthetic surgery. So, the total amount of time a resident spends in aesthetic training are just 4 months! Now, if you break down aesthetic surgeries into different anatomical regions and types of surgeries, you will realize that even a board-certified plastic surgeon may not have adequate exposure and experience to be an expert in any particular surgery, especially cosmetic surgeries in just 4-month time! Take liposuction surgery for an example. As a matter of fact, most plastic surgeons fresh out of residency training, have performed only less than 10 liposuction surgeries! Unless a plastic surgeon specializes in liposuction surgery, most plastic surgeons perform an average of ONLY 1 liposuction surgery every 2 months!

Plastic Surgeons Feel Most Uncomfortable with Facial Aesthetic and Liposuction Procedures

Training in cosmetic surgery is especially challenging to implement for many programs due to the lack of patient volume or staff support to train plastic surgery residents.

Furthermore, many residents do not get aesthetic exposure until the end of their training. Even in the senior levels [postgraduate year (PGY) 5 and PGY6], the exposure to cosmetic surgery is limited with regard to the breadth of procedures performed and the time spent on dedicated cosmetic surgery rotations.

Studies analyzing the quality of aesthetic surgery training have shown deficits in training satisfaction and low confidence in performing common cosmetic procedures upon graduation. This is not only limited to the United States but also Europe and Canada.

Although in recent year there is an increase in dedicated cosmetic surgery rotations, the comfort level of performing facial aesthetic and body contouring (liposuction) procedures remains low particularly among independent residents.

Reference: Colton H. L. McNichols et al: Cosmetic Surgery Training in Plastic Surgery Residency Program. . 2017 Sep; 5(9): e1491. Published online 2017 Sep 26. doi:  [10.1097/GOX.0000000000001491]

Plastic surgeons believe they need to perform only 4-7 liposuction surgeries to achieve competency

In a study done in 2014, senior plastic surgery residents across United States were surveyed and asked the question, “How many liposuction surgeries do you think you need to perform as a primary surgeon during your residency training in order to achieve competency?” Majority answered, “Four to seven surgeries“!

Caveat emptor: When a plastic surgeon tells you that he has spent 4 years training in a plastic surgery residency training, he does not mean 4 years training to perform one particular surgery. That is 4 years performing 1001 different kinds of surgeries! The surgeon whom you are going for your liposuction may have performed only 4 liposuction surgeries throughout his entire career! The first 1,000 patients whom Dr Arthur Tjandra performed liposuction on, never returned to him for a second session, for very obvious reason. 🙂

Reference: Arash Momeni, Rebecca Y. Kim, Derrick C. Wan, Ali Izadpanah, and Gordon K. Lee: Aesthetic Surgery Training during Residency in the United States: A Comparison of the Integrated, Combined, and Independent Training Models. Plastic Surgery International. Volume 2014 (2014), Article ID 281923. 

To make matter worse, many aesthetic/cosmetic surgeries, including liposuction, are non-claimable from medical insurers/Medicare/Medicaid/Medisave/ObamaCare/ government subsidies. Hence, if a patient wishes to have aesthetic surgery done, they have to pay in full, in cash! Now, if you had to pay for a surgery yourself, would you want a trainee surgeon/resident operate on you? One is only willing to do that if one does not have to pay for the surgery, or one is paying subsidized rates. But, having said that, how many patients are willing to have cosmetic surgery performed on their faces or bodies by a surgeon who is still training, knowing that they may end up with botched surgeries which have life-long effect? Many patients willingly allow trainee doctors treat their diabetes, hypertension, heart attack, take out their appendixes, fix bone fractures, etc, but when it comes to cosmetic surgery, they only want the senior consultants (the attending) to perform the surgeries! In this case, when do trainee surgeons get the opportunity to practice? It is a sad fact of life! If you are poor and you cannot afford to pay, you have to go to a public or teaching hospital to give trainee doctors opportunity to practice on you in return for free or subsidized treatments. But, unfortunately with cosmetic surgery, even if you are willing to be practiced on by trainee surgeons, you still have to pay for it! Hence, when you have to pay for it, you will want to make sure that no trainee touches you! As a matter of fact, during residency training, most residents only get the opportunity to become assistants/second surgeons, and not the main surgeons, because full-fee-paying patients have the rights to demand for a specialist consultant or senior consultant to perform the surgery for them. And since most patients go to established surgeons in private practice for their cosmetic surgeries, instead of teaching hospitals, the volume of cosmetic surgery cases  in teaching hospitals are notably low! In fact, in some countries, liposuction is not required in the core curriculum of plastic surgery training in order for one to “graduate” as a plastic surgeon! We know of quite a number of plastic surgeons who have not performed a single liposuction surgery on their own, as the main surgeons, throughout their entire residency training! That is why a plastic surgeon who wishes to offer cosmetic surgeries in his practice, usually spends another 1 to 2 years in fellowship training in specific cosmetic surgery procedures. One to two years are definitely still not enough time to equip one with the skill to perform cosmetic surgeries from head to toes, so they have to choose to train in very specific procedures. You must have thought that they get to perform surgeries as the main surgeons while training as fellows? Wrong! Fellows usually only get the roles as assistants, and many, depending on the volume of cases, only get to watch! But, at least they get to spend the full one to two years learning, assisting, and watching cosmetic surgeries being performed. Without fellowship training, the 3-4 months plastic surgeons spend in aesthetic surgery during plastic surgery residency, is grossly inadequate to equip them with the skill and expertise to perform cosmetic surgeries in their own practice later on in their career. In countries where cosmetic surgeries are not allowed to be performed on people with certain belief, such as in the Middle East and the Gulf, or in countries which adopt religion-based law, such as Brunei and countries in the Middle East and the Gulf, do you think residents in-training would ever get enough exposure to such surgeries? The trainers themselves, may not have performed those surgeries, let alone the trainees! Therefore, it is very important to note that plastic surgery is not identical to cosmetic/aesthetic surgery, and even a plastic surgeon who has passed plastic surgery board examinations and become “accredited” may not be equipped with the skill and expertise to perform cosmetic/aesthetic surgeries, unless he has taken a one or two-year post-graduate fellowship in cosmetic/aesthetic surgeries after he becomes qualified as a plastic surgeon! As fellowship positions are very limited, especially in cosmetic/aesthetic surgeries where it is very competitive (because this is where the money is!), most surgeons will have to seek their own training in cosmetic/aesthetic surgeries by attending courses.

Majority of plastic surgery senior residents lack confidence in performing cosmetic surgeries

In a survey of cosmetic surgery training in plastic surgery training programs in the United States where 89 plastic surgery programs were canvassed, researchers find that majority of senior plastic surgery residents lack confidence in performing rhinoplasty, face lift, endoscopic and body contouring (liposuction) surgeries.

Reference: Morrison CM, Rotemberg SC, Moreira-Gonzalez A, Zins JE: A survey of cosmetic surgery training in plastic surgery programs in the United States. Plast Reconstr Surg. 2008 Nov;122(5):1570-8.

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