The Business of Plastic Surgery

1 Beginnings

Chris Reid

Abstract

This chapter introduces the reader to the field of plastic surgery and to the pathways to become a plastic surgeon. Goals and objectives are outlined for the college/undergraduate, medical student, and resident to successfully navigate the course to becoming a board-certified plastic surgeon. Also included is discussion of fellowship choices in plastic surgery.

Keywords: plastic surgery residency, sub-internship, sub-Is, fellowship, board certification

1.1 Plastic Surgery: What Is It?

Welcome to the amazing field of plastic surgery. Within it lies incredible opportunity to help patients, tailor a practice to one's own personal interest, and allow for continued personal enrichment.

Plastic surgery is an evocative specialty. Just the words conjure Hollywood actors who have had work done, resulting in endless jokes for late night television. Plastic surgeons do perform facelifts and breast augmentation. And a plastic surgeon won a Nobel Prize for performing the first kidney transplant, and another started the subspecialty of hand surgery, treating war victims after the world wars of the 20th century. Plastic surgery is without a doubt the most diverse surgical discipline, spanning all age groups and organ systems, operating from the top of head to the tips of toes, and treating both cosmetic and reconstructive concerns. The public is most familiar with the aesthetic identity of plastic surgery, but the primary training of plastic surgeons is focused on the adage of restoring form and function. This collectively describes procedures that address structural or functional losses that may be the result of congenital, traumatic, oncologic, burn, degenerative, or other pathologic processes. Included within the discipline is also the practice of aesthetic surgery, which is directed at reversing the effects of aging and degeneration or enhancing aspects of one's appearance. Aesthetic surgery is most accurately a subdivision of plastic surgery, which focuses on restoration and reconstruction.1 Even during reconstructive procedures, plastic surgeons optimize the aesthetic aspects of reconstruction.

Many practicing plastic surgeons focus on aesthetic surgery, and even on particular areas, such as surgery of the nose or breast. Plastic surgeons often split their time, performing both cosmetic and reconstructive surgery. This division of time depends on market factors, the surgeon's interest, and often chance. Those plastic surgeons who focus entirely on reconstructive procedures are, as a rule, working in academic centers, which provides the insurance reimbursement patterns and infrastructure to perform complex reconstructive plastic surgical procedures (see Chapter 3). Those not in an academic practice are often hard pressed to not focus at least some practice time on aesthetic surgery, which has a significantly larger reimbursement-to-work ratio than reinsurance-based reconstructive cases. Although it is unrealistic for a single plastic surgeon to execute the entire breadth of the specialty, many surgeons do have diverse practices. An attractive aspect of the field is the ability to make of it what they want and serve patients in whatever capacity they wish.

Plastic surgeons are innovators, contributing to the exciting evolution of the specialty. Procedures and technologies in common practice now were unknown a few decades ago. Just as neuromodulators such as botulinum toxin were serendipitously found to improve wrinkles while being used to treat eyelid spasms, surgical treatment of migraine headaches was developed by a plastic surgeon observing patients in his aesthetic practice.2,3,4

The long and storied history of plastic surgery includes the development of skin grafting at the beginning of the 20th century following the severe injuries inflicted on the world's patients during World War I. In the 1930s, plastic surgeons were instrumental in pressing car companies to make shatterproof windshields; later they assisted in writing the language for the Flammable Fabrics Act for regulations with manufacturing of clothing such as children's pajamas. Microsurgery, craniofacial surgery, and the development of the Vacuum-Assisted Control (VAC) device to heal wounds have all been innovations by plastic surgeons.5

More recently, plastic surgeons have been responsible for developing and refining composite tissue transplantation such as face and hand transplants. Evolving technologies and newly defined anatomy have opened up the entirely new field of supermicro-surgery. The tiniest of lymphatic vessels, just 0.2 to 0.8 mm, can be reconnected. Many plastic surgeons in practice now never imagined that these feats were possible when they entered the field.

1.2 Am I a Good Fit for Plastic Surgery?

If you are interested in plastic surgery but have not yet started medical school, it is to your benefit to explore further. In addition to learning about plastic surgery, you will no doubt learn more about the medical field. Shadowing a surgeon in your community can be a great introduction to plastic surgery. Most practicing surgeons fondly recall this experience and without hesitation will often graciously open their doors so you can experience what it is that they do. These experiences allow you to see firsthand what the practice of plastic surgery is like and begin to assess your "fitness" for the specialty. While not all plastic surgeons share same interests, there are similarities that unite members of the field.

In addition to shadowing, pursuing humanitarian work via mission trips can be worthwhile and enlightening. Plastic surgeons tend to do more of this type of work than those in other medical disciplines, typically through programs providing service to the underserved, either globally or regionally. Becoming engaged in these groups can be particularly rewarding and can serve as the beginnings of a career of helping communities facing unimaginable challenges. For more information, contact the university affiliated plastic surgery groups in your area. Many people enjoy these opportunities so much that they continue them throughout their training and their careers.

1.2.1 Traits that Make a Good Plastic Surgeon

Problem Solver

In many fields of surgery, the goal is to learn the steps to making a diagnosis, executing a procedure, and then caring for the patient during recovery. One example is the treatment of appendicitis. Nearly all surgeons would approach and treat it in essentially the same manner with minimal variation. However, plastic surgeons focus more on principles and techniques that can be applied across a broad range of situations, sometimes not previously encountered. Many seasoned plastic surgeons will tell you that they learned more in their initial years of practice than during their residency, as they began to practice the skills and techniques they were equipped with during residency to new situations. Even the common plastic surgery equivalent procedures to appendectomy will have numerous ways to approach and treat; choosing the best approach boils down to solving the problem. For example, there are numerous variations in the common plastic surgical procedure of skin grafting in regard to harvesting technique, management of harvest site, dressing application, and adjunctive measures to promote healing.

Being a plastic surgeon requires being a good problem solver. If you are someone who likes to tackle challenges and explore new ways to find solutions, then you may be well suited for the field. In their role as problem-solvers, plastic surgeons fix the problems or complications that other surgeons encounter and cannot fix themselves. Surgeons from other specialties will call on plastic surgery, for example, for creative ways to close a wound. These roots in identifying and solving problems allow us to help others.

Determination

No doubt any person completing medical school and serving as a physician is intelligent and will contribute to this noble profession. According to National Residency Matching Program data, plastic surgery residency choice is consistently among the most competitive of all.6 Plastic surgery applicants rank highest or near the top of nearly all objective measures listed, including test scores, AOA, and research experiences. There are a comparatively small number of positions, and the competition for these spots is fierce. Further, because the field is challenging and broader than almost any other, training requires a longer-than-average residency, typically 6 years or more. The length and rigor of the training require intelligence and determination to complete successfully. Plastic surgery also offers the opportunity for potential independence from declining insurance reimbursement, something not afforded by many other fields. If you are someone who has done well scholastically early in life and had an aptitude and love for creative learning, then plastic surgery may be a good fit. However, given the hurdles posed by the competitive metrics used in selecting positions for training plastic surgeons, it may be particularly challenging for individuals who are slow learners or not good test takers.

Artist

We are a visual species, and much of the work plastic surgeons do is visible to the world. A patient does not generally see the tumor removed by a neurosurgeon, while a reconstructed breast or nose is visible every day. Decisions of timing the repair of a cleft lip and other congenital deformities are based on how humans appear to others because that impacts how they experience the world....