Many plastic surgeons choose to pursue additional training upon completing a plastic surgical residency. Microsurgery fellowships are quite popular, as are hand surgery fellowships. There are also programs in craniofacial surgery, aesthetic surgery, pediatric plastic surgery, and burn surgery. Most fellowships last 1 year, although they can be as short as 2 months or as long as 2 years or more.
Aesthetic, or cosmetic, surgery involves the manipulation of tissues to enhance appearance. Common aesthetic procedures performed by plastic surgeons include rhinoplasty (reshaping of the nose), facelift, aesthetic eyelid surgery, laser skin resurfacing, botulinum toxin injection, breast augmentation, liposuction, and body lifts.
The field of cosmetic surgery is unique among surgical disciplines. First, aesthetic operations are performed on an elective basis for no truly functional purpose (although it has been argued that the function of the face, eg, is to “look good”). In other words, patients are subjected to all the risks of anesthesia and surgery despite their being physiologically healthy. These patients can suffer all types of complications that are possible with other types of surgery, including nerve damage, hematomas, infections, skin loss, significant scarring, myocardial infarctions, and even death. The aesthetic surgeon must be comfortable knowing that these adverse events will doubtlessly occur at some point despite even the most careful patient selection, perfect surgical technique, and smooth anesthesia.
Aesthetic surgeons must enjoy participating in detailed discussions with their patients about their aesthetic issues and the surgical plan. Honest two-way communication is essential to be sure that patients' aesthetic expectations are realistic. They require much more question-and-answer time than reconstructive patients do. Careful patient selection is critical. Usually, however, the expectations of the aesthetic patient are reasonable, and their response to cosmetic surgery is predictable.
Cosmetic surgery is unlike other fields within plastic surgery because of economic issues. There are no laws dictating the price of a facelift or blepharoplasty. Therefore, surgical fees are determined by supply and demand, and often these fees can be very high—on the order of $10,000 to $25,000 for a facelift alone, not including anesthetic expenses. Not surprisingly, other practitioners with varying degrees of training are performing cosmetic procedures. For example, dermatologists, dentists, oral surgeons, otolaryngologists, and even some ophthalmologists perform facial aesthetic surgery. Likewise, some obstetricians and general surgeons have performed breast augmentation and liposuction. Some states have passed laws preventing nonsurgeons from performing cosmetic surgery.
For those with artistic abilities, aesthetic surgery offers a means of sculpting the human body into living art. And the results can be truly impressive! Patients with facial aging can often be made to look literally decades younger and more energetic. Likewise, a woman who has had multiple pregnancies resulting in abdominal wall laxity and breast involutional ptosis can be made to look like she has the body of a 20-year-old. A young, otherwise beautiful girl who happens to have a prominent nose or ears can be given more harmonious features. It can be quite gratifying indeed to provide joy to a patient who has been concerned with a cosmetic deformity for years.
Most aesthetic fellowships last 6 months and tend to focus on a specific region—facial aesthetic surgery or body contouring surgery. There is currently no certificate of added qualification (CAQ) or universally accepted board examination for aesthetic surgery.
One-year fellowships are available to those seeking advanced training in burn critical care, acute surgery, and burn reconstruction. Plastic surgeons often head burn units in North America and elsewhere, although general surgeons also play a major role in burn care. Burn surgeons treat patients with thermal injury, electrical injury, chemical injury, immune-mediated burn-like injuries including Stevens-Johnson syndrome, and cold-related injury. Plastic surgeons often focus on burn reconstruction rather than acute burn care. The care of these patients can be quite challenging and highly rewarding. Much of burn reconstruction requires the use of local flaps, skin grafts, and tissue expansion. However, many cases require multiple stages, strategic planning, and advanced techniques.
Craniofacial surgeons treat diseases of the bones and soft tissues of the face and skull. They often work with children, treating such conditions as craniosynostosis (premature fusion of the sutures of the skull), cleft palate, hemifacial microsomia (delayed growth of one side of the face), and conditions such as Apert, Crouzon, Treacher-Collins, and Pfeiffer syndromes. They can also work with adults, treating patients with untreated congenital anomalies, craniofacial trauma, and tumors of the skull base, as well as orthognathic deformities.
A team approach is used in the workup, management, and follow-up of children with craniofacial anomalies. Craniofacial surgeons work closely with neurosurgeons, dentists, speech pathologists, social workers, and pediatricians to plan craniofacial and orthognathic (jaw correcting) procedures. Craniofacial surgeons usually practice within a large tertiary care medical center to generate the case volume necessary for sustaining a standing craniofacial anomalies program. However, many craniofacially trained plastic surgeons find that the volume of craniofacial cases in their practice is less than desired.
Hand and Upper Extremity Surgery
Hand surgeons treat a variety of conditions of the hand and upper extremity, including fractures, tendon lacerations, traumatic amputations/devascularizations, rheumatoid arthritis, nerve entrapment syndromes, tumors, and congenital anomalies. In a single day, a hand surgeon may perform a replantation from an industrial accident, see a newborn with complete syndactyly, and perform implant arthroplasties to restore function in a patient with rheumatoid arthritis. Restoring pain-free function is the top priority in hand surgery. Cosmesis is also a secondary goal once pain and function have been addressed.
Worldwide, most hand surgeons are initially trained in plastic surgery. In the United States, however, plastic surgeons represent only one-third of hand surgeons, with the balance coming mainly from orthopedics. Passing a qualifying examination earns the physician a CAQ, which some centers may require in order to be on call. Hand fellowships are often combined with microsurgical fellowships (“hand–micro” fellowships). There is significant crossover between hand surgery and microvascular surgery training; both usually involve advanced microvascular and microneural techniques specific to the upper extremity. Because hand surgeons often perform procedures involving small vessels and nerves of the upper extremity, a strong microsurgical background is critical. There is currently great demand for hand surgeons, especially those with a plastic surgery background, in both private and academic practice.
Microsurgeons are trained to manipulate tissues by creating microvascular anastomoses and microneural coaptations. They can, for example, replant a severed digit or extremity by repairing the vessels and nerves under the operating microscope. Microsurgical techniques are also used to perform free tissue transfers (free flaps). For example, if a woman has a mastectomy for cancer and desires an autologous (from her own tissue) reconstruction, then an excellent option is a flap reconstruction in which skin and fat are removed from the abdomen and placed on the chest wall to reconstruct the breast. Similarly, in cases of congenital facial paralysis, the gracilis muscle can be transferred to the face to make facial expression possible.
The microsurgical revolution occurred in the 1970s and 1980s. Demand for surgeons who have completed microvascular fellowships remains high, although perhaps not as high as during the past 20 years. Many plastic surgery programs provide extensive microvascular experience, and many plastic surgeons find that they are able to perform the more routine free tissue transfers without the need for further training. However, for complex reconstructive problems, especially those involving the head and neck and the extremities, advanced microvascular training is valuable.
Pediatric Plastic Surgery
Pediatric plastic surgeons address the specialized plastic surgical needs of children, analogous to the way in which pediatric general surgeons address the general surgical needs of children. Pediatric plastic surgeons are usually based in children's hospitals and are university affiliated. Conditions treated by pediatric plastic surgeons include certain craniofacial anomalies, including cleft lip and palate and velopharyngeal insufficiency (nasal speech); separation of conjoined twins; congenital anomalies affecting the face, ears, hands and upper extremities, trunk, and chest wall; and vascular anomalies including hemangiomas and vascular malformations. In addition, pediatric plastic surgery encompasses pediatric burn reconstruction, soft tissue tumors, and traumatic reconstruction, particularly of the face, hands, and lower extremity. There are several craniofacial fellowships that include aspects of pediatric plastic surgery. However, there are very few fellowships that encompass the entire breadth of pediatric plastic surgery. Most of these last 12 to 24 months.
|Plastic and Reconstructive Surgery 2011 Match Statistics|
- Number of positions available: 108
- 175 US seniors and 36 independent applicants ranked at least one plastic surgery program
- 100% of all positions were filled in the initial Match
- The successful applicants: 91.6% US seniors, 0.1% foreign-trained physicians, and 0.1% osteopathic graduates
- Mean USMLE Step I score: 249
- Unmatched rate for US seniors applying only to plastic surgery: 24.6%