Path to becoming a Plastic Surgeon

[Will Hunting]

I'm curious as to the process of becoming a plastic surgeon. Do you go through GS residency and then a Plast surg residency?

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[TheThroat]

It depends on the type of plastic surgery that you want to do. Cosmetics? Reconstructive? Whole body or just face? There are many roads to the self-imposed title, but purists will tell you that a plastic and reconstructive surgery residency is the only way to be a REAL plastic surgeon.

 

[Spiff]

In the past it was usually 5 yrs of general surgery (most common) or other surgical specialty like ENT, Orthopedics, Neurosurg, or Urology with a 2 year plastics fellowship with some going even further for hand or craniofacial work. Nowdays there are 5 and 6 year integrated plastics residencies -- these spots are typically highly competitive. As for which route is "best," it depends on who you ask. A lot of the old school people think that the integrated programs aren't going to put out as good a surgeon as in times past. And there is something to be said for the versatility that comes with being double boarded at the cost of only 1 more year. But a lot of the integrated places seem to be doing just fine as well. The time saved is also an incentive to do other sub-sub specialty stuff too. I guess time will tell.

.... there are also other niche things like doing a facial plastics fellowship with ENT or an Ortho hand fellowship or an Oculoplastics fellowship from ophtho. Probably more things I am not thinking of too.

 

[Will Hunting]

In the past it was usually 5 yrs of general surgery (most common) or other surgical specialty like ENT, Orthopedics, Neurosurg, or Urology with a 2 year plastics fellowship with some going even further for hand or craniofacial work. Nowdays there are 5 and 6 year integrated plastics residencies -- these spots are typically highly competitive. As for which route is "best," it depends on who you ask. A lot of the old school people think that the integrated programs aren't going to put out as good a surgeon as in times past. And there is something to be said for the versatility that comes with being double boarded at the cost of only 1 more year. But a lot of the integrated places seem to be doing just fine as well. The time saved is also an incentive to do other sub-sub specialty stuff too. I guess time will tell.

.... there are also other niche things like doing a facial plastics fellowship with ENT or an Ortho hand fellowship or an Oculoplastics fellowship from ophtho. Probably more things I am not thinking of too.

thanks for the replies.

 

[novacek88]

Regarding the integrated spots above, you would be lucky to even match in one of these spots. To heck with what some old guys think. No one in their right mind would pass up one of these positions if they were lucky enough to match into of them considering these positions are even more difficult to come by than derm spots. That's right, integrated plastic surgery positions are the most difficult to match of all residencies at the moment. They are so competitive that it's thought you need serious connections in addition to AOA and 240 Step I to even be considered.

Or you can do a general surgery residency and then do a one or two year cosmetic surgery fellowship. Sure, you might not be a "true" plastic surgeon but you will still be able to do all the lucrative cosmetic procedures which is the reason 90% of general surgeons probably pursue a PRS fellowship in the first place.

 

[toofache32]

Or you can do a general surgery residency and then do a one or two year cosmetic surgery fellowship. Sure, you might not be a "true" plastic surgeon but you will still be able to do all the lucrative cosmetic procedures which is the reason 90% of general surgeons probably pursue a PRS fellowship in the first place.

This is a good point. The more I think about it, this is probably the best route for doing cosmetics. You can either spend 2 years doing free flaps, hand surgery, burn reconstruction, craniofacial, and varying degrees of cosmetics...or you could spend one year doing nothing but cosmetics. Unless you're interested in the other stuff, the former route is probably a waste of time as long as you're already trained as a surgeon in a primary discipline. In the old days that's all there was, but now other alternatives exist.

 

[mcindoe]

Or you can do a general surgery residency and then do a one or two year cosmetic surgery fellowship.

I don't think this is true. Cosmetic surgery is a specialty within plastic surgery; you can't just bypass the minimum 2 year plastic surgery fellowship after you finish general surgery and jump right into a cosmetics fellowship. After all, cosmetic surgery requires a solid understanding of flaps, angiosomes, soft tissue reconstruction--all the fundamentals you learn in plastic surgery. I'm sure if you did an ENT residency then you could then do a facial cosmetics fellowship, though most ENTs who do cosmetic surgery did fellowships in plastics. Likewise, ophthalmology residents could probably apply for fellowships in periocular cosmetic surgery. But if you want to be a board certified plastic surgeon, you have to do a plastic surgery fellowship.

 

[TheThroat]

I don't think this is true. Cosmetic surgery is a specialty within plastic surgery; you can't just bypass the minimum 2 year plastic surgery fellowship after you finish general surgery and jump right into a cosmetics fellowship. After all, cosmetic surgery requires a solid understanding of flaps, angiosomes, soft tissue reconstruction--all the fundamentals you learn in plastic surgery. I'm sure if you did an ENT residency then you could then do a facial cosmetics fellowship, though most ENTs who do cosmetic surgery did fellowships in plastics. Likewise, ophthalmology residents could probably apply for fellowships in periocular cosmetic surgery. But if you want to be a board certified plastic surgeon, you have to do a plastic surgery fellowship.

A few points:

"Cosmetic surgery is a specialty within plastic surgery; "--actually, cosmetic surgery is not a real specialty, but a self-applied term that applies to any surgeon who does cosmetic procedures, including some plastic surgeons, otolaryngologists, dermatologists, ophthalmologists, etc.

"cosmetic surgery requires a solid understanding of flaps, angiosomes, soft tissue reconstruction--all the fundamentals you learn in plastic surgery."--I agree that you would learn this in a plastic surgery residency or fellowship, but we also get plenty of this in Oto as well. In fact, one fifth of our inservice and board tests concentrate on facial plastic surgery.


"though most ENTs who do cosmetic surgery did fellowships in plastics."--Not be arguementative, but this is incorrect. Almost all oto's who do "cosmetic" surgery have done a facial plastic surgery fellowship, not a true plastic surgery fellowships.


"But if you want to be a board certified plastic surgeon, you have to do a plastic surgery fellowship"--True, or a plastic surgery residency.

 

[droliver]

Almost all oto's who do "cosmetic" surgery have done a facial plastic surgery fellowship, not a true plastic surgery fellowships

I suspect there's more ENT's doing cosmetic procedures who aren't Facial Plastic Surgeons then those that are in this era.

The Facial Plastics board does not in fact require that you've ever done any post-residency fellowship training (you can look at http://www.abfprs.org/applying/index.cfm for the full list of prerequisites). Basically you can collect non-proctored cases if you're an ENT in practice & sit for the exam.

The standards and practices for this board are less then the Amer. Board of Plastic Surgery for what it requires for accredited training. Its one of the reasons Plastic Surgeons look at that certificate as a joke.

 

[TheThroat]

I have mixed feelings about the ABFPRS. I think that otolaryngologists who are well-trained in rhinoplasty, for example, should be able to do that procedure without further training, and should be able to market themselves as someone who does facial plastic surgery of the nose. In addition, otolaryngology residency training differs from program to program, and some do not have the facial plastics experience that other's have. The ABFPRS doesn't want to ostracize surgeons who have undergone a good residency training in plastic and reconstructive surgery. At the same time, I think that MOST otolaryngologists need fellowship training if they want to do facelifts, browlifts, hair transplants, skin resurfacing, etc.

So should the ABFPRS require a fellowship in facial plastic surgery? Probably, if they want to be more rigorous. But will they ostracize both oto and plastic surgeons if they do? Definitely.

 

[droliver]

I don't think it's really an issue of whether ENT's are qualified to do cosmetic surgery of the head & neck without a fellowship tacked on. Most trainees, even if their dedicated cosmetic training was modest, have extensive enough surgical experience to muddle thru the learning phase of becoming a good cosmetic surgeon.

What jerks the chain of the Plastic Surgery community is the deliberate obfuscation by the ABFPRS (and the other groups of cosmetic surgery boards) about who is and is not (in layman's terms) a Plastic Surgeon. You can imagine how confusing it is for patients trying to sift thru the yellow pages when under the "Physicians-Plastic Surgeons" listings you have ENT's, Dermatologists, General Surgeons, Vein Clinics, doc in the box types, and OBGYN's proclaiming themselves to be board-certified in this area.

The ABFPRS could do alot to up their credibility by standardizing their field's training criteria & realy coming down on its members who clearly practice outside the scope of their training

 

[Will Hunting]

I've learned much more than I imagined from this thread. Many questions that I had were answered. In the yellow pages I'd always wondered when I'd see dermatologists advertising as plastic surgeons.

 

[TheThroat]

I don't think it's really an issue of whether ENT's are qualified to do cosmetic surgery of the head & neck without a fellowship tacked on. Most trainees, even if their dedicated cosmetic training was modest, have extensive enough surgical experience to muddle thru the learning phase of becoming a good cosmetic surgeon.

What jerks the chain of the Plastic Surgery community is the deliberate obfuscation by the ABFPRS (and the other groups of cosmetic surgery boards) about who is and is not (in layman's terms) a Plastic Surgeon. You can imagine how confusing it is for patients trying to sift thru the yellow pages when under the "Physicians-Plastic Surgeons" listings you have ENT's, Dermatologists, General Surgeons, Vein Clinics, doc in the box types, and OBGYN's proclaiming themselves to be board-certified in this area.

The ABFPRS could do alot to up their credibility by standardizing their field's training criteria & realy coming down on its members who clearly practice outside the scope of their training

I really like the word obfuscation.

On another note, I agree that the ABFPRS should be more rigorous, but remember, only oto's or plastic surgeons can be ABFPRS certified. Even if the ABFPRS made it so that you had to have fellowship training, there still would be "Dermatologists, General Surgeons, Vein Clinics, doc in the box types, and OBGYN's" claiming to be board-certified.

 

[CTSballer11]

I really like the word obfuscation.

On another note, I agree that the ABFPRS should be more rigorous, but remember, only oto's or plastic surgeons can be ABFPRS certified. Even if the ABFPRS made it so that you had to have fellowship training, there still would be "Dermatologists, General Surgeons, Vein Clinics, doc in the box types, and OBGYN's" claiming to be board-certified.

This stuff seems to be getting out of hand. I was watching a special on TV and this board certified cardiothoracic surgeon lost his job and then started a plastic surgery practice, without any training in plastic surgery.

 

[TheThroat]

This stuff seems to be getting out of hand. I was watching a special on TV and this board certified cardiothoracic surgeon lost his job and then started a plastic surgery practice, without any training in plastic surgery.

I's just kiddin', man. Like I said, anyone can market themselves as a
"plastic surgeon" or a "cosmetic surgeon." Its caveat emptor as far as I am concerned. Since the vast majority of cosmetic surgery is self-pay, the patients need to research their surgeon. If they think that a cardiothoracic surgeon can do their plastic surgery and are willing to pay for it, then so be it.

 

[CTSballer11]

I's just kiddin', man. Like I said, anyone can market themselves as a
"plastic surgeon" or a "cosmetic surgeon." Its caveat emptor as far as I am concerned. Since the vast majority of cosmetic surgery is self-pay, the patients need to research their surgeon. If they think that a cardiothoracic surgeon can do their plastic surgery and are willing to pay for it, then so be it.

I agree with you 100 percent. The CT surgeon did not market himself as a Ct surgeon doing plastic surgery, he marketed himself as board certified in surgery but was not specific as to which specialty.

 

[RajMahal]

Regarding the integrated spots above, you would be lucky to even match in one of these spots. To heck with what some old guys think. No one in their right mind would pass up one of these positions if they were lucky enough to match into of them considering these positions are even more difficult to come by than derm spots. That's right, integrated plastic surgery positions are the most difficult to match of all residencies at the moment. They are so competitive that it's thought you need serious connections in addition to AOA and 240 Step I to even be considered.

Or you can do a general surgery residency and then do a one or two year cosmetic surgery fellowship. Sure, you might not be a "true" plastic surgeon but you will still be able to do all the lucrative cosmetic procedures which is the reason 90% of general surgeons probably pursue a PRS fellowship in the first place.

does anyone know how many plastics/cosmetics fellowships are out there, and how competetive THOSE are?

Thanks.
rpm

 

[Radpimp]

Just want to add that both the primary ABMS boards of Otolaryngology and Plastic Surgery share the same subspecialty certificate of Plastic Surgery within the Head and Neck. It is incorrect to say that the board of Plastic surgery is the only ABMS board to certify physicians in the field of plastic surgery.

In a 2 year plastics fellowship, the fellow may spend 6 months or so on the head and neck. Otolaryngologists spend 4 years after their general surgery training in broad based head and neck surgery which includes facial plastic surgery. Otos will do way more parotid resections and lifting flaps for head and neck cancer which is directly applicable to performing facelifts. I would also add that most Otolaryngology residencies allow for more experience in rhinoplasty than a plastic surgery residency. At most good ENT programs, the residents will get exposure to head and neck/microvascular reconstruction with variety of rotational and free tissue flaps.

What bothers me is that most Plastic surgeons who may have done less than 10 rhinoplasties during there training feel that they are more qualified than an Otolaryngologist to perform a rhinoplasty or any facial plastic surgery procedure. ENTs have every right to call themselves facial plastic surgeons. ABMS have recognized this fact with the subspecialty certificate of Plastic Surgery within the Head and Neck. I mean really, what should ENTs call themselves who specialize in such? Its all a matter of semantics.

 

[droliver]

It is incorrect to say that the board of Plastic surgery is the only ABMS board to certify physicians in the field of plastic surgery.

Otolaryngologists spend 4 years after their general surgery training in broad based head and neck surgery which includes facial plastic surgery. Otos will do way more parotid resections and lifting flaps for head and neck cancer which is directly applicable to performing facelifts. I would also add that most Otolaryngology residencies allow for more experience in rhinoplasty than a plastic surgery residency.

What bothers me is that most Plastic surgeons who may have done less than 10 rhinoplasties during there training feel that they are more qualified than an Otolaryngologist to perform a rhinoplasty or any facial plastic surgery procedure. ENTs have every right to call themselves facial plastic surgeons.Its all a matter of semantics.

It is still incorrect to identify facial plastic surgeons as Plastic Surgeons, and the semantics come down to this. Plastic Surgery is a discipline & not a cluster of techniques. An ENT who does facial plastic surgery does not a Plastic Surgeon make. To minimize the difference b/w specialties is what above all irritates Plastic Surgeons, including those who come from ENT backgrounds. Look at the ads in your yellow pages & you can see that ENT's & other Cosmetic surgeons try to blur this distinction purposefully.

As has been pointed out before, to be a Facial Plastic Surgeon includes large #'s of practicioners who's additional training may merely include submitting cases for review & taking a test. The lack of standardized training undercuts the legitamacy of the discipline when you try to equate it to Plastic Surgery. *** THIS IN NO WAY MEANS THAT A facial plastic surgeon IS INHERENTLY A POORER SURGEON OR GETS LESSER RESULTS *** . It just means that they have different levels and scope of training.

As I understand it many of the fellowships available are often more appropriately identified as cosmetic surgery apprenticeships rather then comprehensive training in head and neck plastic surgery. That's neither good nor bad, its just the way things are. Within ENT fellowships, traditional overlap with head and neck plastic surgery is now carved up into various ENT subspecialties - pediatric, microsurgery, cosmetic, oncology - rather then taught as a unified discipline, another important distinction between facial plastic surgery & Plastic Surgery

No sensible person quibbles with ENT's doing rhinoplasty, but having done both a number of facelifts & parotids the overlap on the two procedures is less then you'd think unless you're into extended deep-plane face lifts (a very small minority) and into prodding the facial nerve branches.

To equate in part junior level ENT residency (PGY 2-3) to what's often post-graduate level Plastic surgery training (to what's often board certified Surgeons or ENT's) is dimissing the clear distinction in preliminary versus advanced training. Fully trained ENT's bring a lot to the table & its a great background for pursuing Plastic Surgery training. It has its own strengths and weakness as compared to General Surgery trained Plastic Surgeons as well the new breed of Integrated Plastic Surgeons

 

[toofache32]

To equate in part junior level ENT residency (PGY 2-3) to what's often post-graduate level Plastic surgery training (to what's often board certified Surgeons or ENT's) is dimissing the clear distinction in preliminary versus advanced training.

It's irrelevant to compare Plastics guys who have also done 5 years of general surgery when the requirement is only 3. This is also the case with integrated programs. The first year of general surgery is the same as that done by ENT/everybody else, so no advantage there. It doesn't count anyway because there's very little true operating anyway that year. The 2nd and 3rd years of general surgery (at least at my institution) are spent as lower-levels doing pus, appys, and diabetic feet. I'm not sure how a couple of years of abdominal surgery with no facial involvement prepares you for delicate facial cosmetics more than people who spend ALL their time on the face...when the end result is the same number of years. I don't think general surgery is as relevant to facial cosmetics as some think it is. I could just as easily argue that my 4 years of fine hand-coordination skills developed in dental school would put me ahead, but I'm sure you guys would balk at that as well (even though there are no dexterity requirements for surgical residencies).

For some reason, general surgeons consider themselves to be the standard against which all others are measured, when in fact they just deal with the problems that specialty surgeons don't want to deal with. I've never understood why they have this mentality, but I suspect it's because of the defensiveness & aggression that's passed down from many of their faculty. They will fiercely argue "I'm right, you're wrong!!" to anyone who will listen. At least that's the atmosphere in the places I work.

 

[droliver]

For some reason, general surgeons consider themselves to be the standard against which all others are measured, when in fact they just deal with the problems that specialty surgeons don't want to deal with.

I'd agree with this 100% & I'll explain why. General surgery training is really a stagering discipline to do. I really don't think there's any other field with the breadth of material, intensity of the work, and global patient care you're forced deal with during residency. It's literally the Marine Corp of teaching hospitals. They do in fact end up with many of the problems other specialties can't/won't deal with, but for my money they are often the best doctors in the hospital.

Its clearly not the most focal path to doing facial cosmetic surgery, but to minimize what you learn from that background misunderstands the skill sets you need at the end of your training. The mature surgeon you end up with is why, all things being equal, most program directors would prefer that background prior to training in Plastic Surgery. But its an evolutionary period due to financial pressures of training program & ongoing expansion of the field such that the Integrated model is the future. Still the majority of Plastic Surgeons in practice were traditional model trainees & will be for some time so I think my point is valid. You do make good mention of this difference that will be uniform in the future (ie. less experienced residents during their Plastics training).

 

[Spiff]

It is still incorrect to identify facial plastic surgeons as Plastic Surgeons, and the semantics come down to this. Plastic Surgery is a discipline & not a cluster of techniques.

I think not understanding this is where people commonly get confused. As the name implies, ENT is an anatomically-defined specialty while Plastic Surgery is a discipline or procedure-defined specialty. Otolaryngologists get a significant amount of training in the discipline of plastic surgery of the head and neck...or at least they ought to be getting such training. Principles of wound care, trauma reconstruction, local and free tissue transfer are part and parcel of todays ENT training. Several ENT residency programs such as Mayo, train their residents (not just fellows) in microvascular reconstructive techniques. Of course, like most Plastics programs, the focus is more on reconstructive surgery than cosmetics.

However, the Otolaryngologist's plastics exposure is somewhat diluted by the necessity of learning all of the other aspects of the specialty. Otology/Neuro-otology, laryngology, Rhinology/Sinus, Allergy/Immunology, pediatric Otolaryngology are all in there as well. Craniofacial aspects of plastic surgery are also hit or miss and I dont think most Otos are qualified to do big-time cleft repairs. The general plastics resident's exposure head and neck plastics is also diluted by the incredible breadth of the rest of the specialty.

It will be interesting to see how things change in the future as more and more general plastic surgeons come from integrated programs. Currently a lot of plastic surgeons incorporate their dual training into their practices such as performing both the mastectomy and the reconstruction in breast cancer cases, or doing a H&N cancer resection and the reconstruction. I think this is a great advantage of being double-boarded. I also know of cases where general plastic surgeons who were not boarded as general surgeons or othopedists inadequately treated a breast or bone/soft tissue sarcoma and then threw flaps on when they should have waited with predictably disasterous results too.

An ENT who does facial plastic surgery does not a Plastic Surgeon make.

Not necessarily, but this is also a bit extreme too. Are you going to say that non-ortho boarded plastic surgeons who primarily do hand work arent "hand surgeons"? Of course not. By the same token, I submit that folks like John Conley, Ted Cook, and Richard Holt qualify as "plastic surgeons" in anyone's book.

Within ENT fellowships, traditional overlap with head and neck plastic surgery is now carved up into various ENT subspecialties - pediatric, microsurgery, cosmetic, oncology - rather then taught as a unified discipline, another important distinction between facial plastic surgery & Plastic Surgery

True, but I think this is how it functionally ends up with traditional plastic surgery as well despite all the rhetoric. There are very few renaissance types in the plastics world who feel equally comfortable doing cleft repairs, hand microsurgery, rhinoplasty, and soft tissue sarcoma resection/reconstruction... and those who do are usually double-boarded in another specialty like Gen Surg, Ortho, or ENT anyway. The reality is that in practice, most plastic surgeons fall into some sort of "box" just like everyone else.

 

[TheThroat]

It is still incorrect to identify facial plastic surgeons as Plastic Surgeons, and the semantics come down to this. Plastic Surgery is a discipline & not a cluster of techniques. An ENT who does facial plastic surgery does not a Plastic Surgeon make. To minimize the difference b/w specialties is what above all irritates Plastic Surgeons, including those who come from ENT backgrounds. Look at the ads in your yellow pages & you can see that ENT's & other Cosmetic surgeons try to blur this distinction purposefully.

While it would be nice to have clear distinctions between all the fields, it is a fantasy. The reason is that the field of plastic surgery, as the public understands it, is really cosmetic surgery. Cosmetic surgery is almost all self-pay, and thus is subject to marketing factors. It is poor marketing to label yourself an Otolaryngologist when really you want to be labelled a facial plastic surgeon, even if you are both. You have pointed out that the certificate of the ABFPRS is easy to get, BUT its only easy to get if you have completed an Oto or Plastics residency. Surgeons trained in ANY OTHER FIELD can't get the certificate. So you can look in your yellow pages and see alot of other docs claiming to be "cosmetic surgeons," but if you go to a Board Certified Facial Plastic surgeon, they will have either completed a plastics residency or an oto residency. I think that both residencies train people to do plastic surgery of the head and neck.

 

[PDT4CNV]

Just want to add that both the primary ABMS boards of Otolaryngology and Plastic Surgery share the same subspecialty certificate of Plastic Surgery within the Head and Neck. It is incorrect to say that the board of Plastic surgery is the only ABMS board to certify physicians in the field of plastic surgery.

In a 2 year plastics fellowship, the fellow may spend 6 months or so on the head and neck. Otolaryngologists spend 4 years after their general surgery training in broad based head and neck surgery which includes facial plastic surgery. Otos will do way more parotid resections and lifting flaps for head and neck cancer which is directly applicable to performing facelifts. I would also add that most Otolaryngology residencies allow for more experience in rhinoplasty than a plastic surgery residency. At most good ENT programs, the residents will get exposure to head and neck/microvascular reconstruction with variety of rotational and free tissue flaps.

What bothers me is that most Plastic surgeons who may have done less than 10 rhinoplasties during there training feel that they are more qualified than an Otolaryngologist to perform a rhinoplasty or any facial plastic surgery procedure. ENTs have every right to call themselves facial plastic surgeons. ABMS have recognized this fact with the subspecialty certificate of Plastic Surgery within the Head and Neck. I mean really, what should ENTs call themselves who specialize in such? Its all a matter of semantics.

There is a similar problem in the private practice ophthalmology community. Plastic surgeons at hospitals complain that only they are qualified to do these procedures...but at many ophtho programs, the residents will have done just as many if not more blephs, ptosis repairs, ectropion,entropion, tumor reconstructions involving the lids and periocular area than the plastics guys. Now there are a few ophthalmologists doing boob jobs, etc...but that is the exception, not the rule.

 

[ddmo]

but purists will tell you that a plastic and reconstructive surgery residency is the only way to be a REAL plastic surgeon.

Are you referring to an Integrated program? If so, I guess just about every chair of an academic plastics department isn't a "REAL plastic surgeon" based on your definition.