Residency training in plastic surgery: a survey of educational goals

With the advent of integrative plastic surgical training programs, requirements for earlier specialization decisions, and an increasing subspecialization within the practice of plastic surgery, the educational goals of residency training may have changed. The duration and extent of training required are also currently being questioned. This study was performed to better understand the necessary roles of plastic surgery residencies and to determine how these demands might optimally be met. Of 151 practicing plastic surgeons in the Ontario, Canada, region, 81 (53.6 percent) responded to a survey. General agreement was that 2 years was an optimal length of time for core surgical training, which should then be followed by at least 3 years of plastic surgical training. Opinions on the ideal length of time training in specific medical and surgical disciplines are discussed. Overall, respondents thought that two thirds of training should occur in tertiary care centers, with the remaining time spent at smaller community centers and private clinics. Nearly half of respondents thought that research training should be a mandatory part of the residency, although the amount of protected time for this activity varied substantially. Most thought that unrestricted elective time should also be available. Academic plastic surgeons rated the importance of research training (p < 0.01), critical appraisal skills (p < 0.05), and teaching skills (p < 0.05) as significantly more important than did their nonacademic colleagues. The authors present results from the Ontario region and a template for determining optimal characteristics for training programs. Further investigation may be of timely importance during a foreseeable future transition from traditional to integrative plastic surgery residency training.     

Selection and care of cardiac patients for plastic surgery

A major operation after successful coronary artery bypass surgery has been proved as safe as an operation for a patient free from coronary artery disease. Most patients with angina who demonstrate an operable coronary lesion should usually be scheduled for coronary artery bypass before undergoing nonemergency surgery. It is advisable to postpone elective plastic surgery for 6 weeks to 3 months after coronary bypass and 6 months after myocardial infarction. The life expectancy of cardiac patients must be carefully considered before elective plastic surgery, because performing an operation on a patient who cannot live to enjoy the benefits is unwise. Working together, cardiac surgeons, cardiologists, and plastic surgeons can now prolong the quantity of life and enrich its quality in properly selected and carefully managed patients.     

Managed care's attempts to capture aesthetic surgery

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.     

Surgeon perspectives on surgical options for early-stage breast cancer

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.     

Victor von Bruns (1812-1883) and his contributions to plastic and reconstructive surgery

Victor von Bruns was an active surgeon in Germany during the nineteenth century. His work is accompanied by many illustrations, and a selected few are presented in this survey. His original contributions to plastic and reconstructive surgery are notable, mainly in lip and cheek reconstruction. These are still valid today and have been adopted by many plastic surgeons. His books dealt not only with plastic surgery, but with almost every surgical event, such as amputation, larynx surgery, galvanosurgery, and war surgery. His publications and illustrations give an excellent picture of the advances made by him and other plastic surgeons during the second half of the nineteenth century, thus making him an important contributor to the renaissance of plastic surgery.     

Reconstructive breast surgery: referring physician knowledge and learning needs

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.     

Discount cosmetic surgery: industry trends and strategies for success

Discount cosmetic surgery is a topic of interest to plastic surgeons. To understand this trend and its effects on plastic surgeons, it is necessary to review the economics of cosmetic surgery, plastic surgery's practice environment, and the broader business principles of service industries.Recent work looked at the economics of the plastic surgery market. This analysis demonstrated that increased local density of plastic surgeons was associated with lower adjusted fees for cosmetic procedures. A survey of plastic surgeons about their practice environment revealed that 93 percent categorized the majority of their patients as very or moderately price-sensitive. Fully 98 percent described their business climate as very or moderately competitive and most plastic surgeons thought they lost a sizable number of cosmetic patients within the last year for reasons of price.A standard industry analysis, when applied to cosmetic surgery, reveals the following: an increased number of surgeons leads to lower fees (reducing their bargaining power as suppliers), patients are price-sensitive (increasing their bargaining power as buyers), and there are few barriers to entry among providers (allowing potential new entrants into the market). Such a situation is conducive to discounting taking hold-and even becoming the industry norm.In this environment, business strategy dictates there are three protocols for success: discounting, differentiation, and focus. Discounting joins the trend toward cutting fees. Success comes from increasing volume and efficiency and thus preserving profits. Differentiation creates an industrywide perception of uniqueness; this requires broadly positioning plastic surgeons as holders of a distinct brand identity separate from other "cosmetic surgeons." The final strategy is to focus on a particular buyer group to develop a market niche, such as establishing a "Park Avenue" practice catering to patients who demand a prestigious surgeon, although this is likely a small segment of the overall patient population. Plastic surgeons that buck the trend toward discount cosmetic surgery must take concrete and potentially costly steps to implement a plausible strategy for distinguishing their practices within the crowded cosmetic surgery market.     

The financial environment of aesthetic surgery: results of a survey of plastic surgeons

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.     

Creating long-term benefits in cleft lip and palate volunteer missions

The authors present their experience with 15 years of organizing cleft lip and palate surgical volunteer missions in Latin America. The history, basic principles, and objectives of Operation San Jose, a volunteer goodwill program from Christus St.Joseph Hospital in Houston, Texas, are covered. This report addresses the different problems encountered and solutions found. Following the principles set by Operation San Jose, CIRPLAST is a Peruvian foundation for plastic surgery that travels to remote areas in Peru, operating on patients with cleft lip and palate deformities. This report highlights the importance of working with local plastic surgeons and their residents, and emphasizes that the program should be organized by and the operations performed by accredited plastic surgeons and with the auspices and support of the national plastic surgery society and the local medical board. Operation San Jose promotes the creation of long-term benefits by offering a program to teach local surgeons cleft lip and palate repair techniques and to set up guidelines to organize local surgeons so that they can continue this effort by treating their own patients in their own countries.     

Certificate-of-Need regulation in outpatient surgery and specialty care: implications for plastic surgeons

For plastic surgeons, independent development of outpatient surgical centers and specialty facilities is becoming increasingly common. These facilities serve as important avenues not only for increasing access and efficiency but in maintaining a sustainable, competitive specialty advantage. Certificate of Need regulation represents a major hurdle to plastic surgeons who attempt to create autonomy in this fashion. At the state level, Certificate of Need programs were initially established in an effort to reduce health care costs by preventing unnecessary capital outlays for facility expansion (i.e., managing supply of health care resources) in addition to assisting with patient safety and access to care. The purpose of this study was to examine the effect of Certificate of Need regulations on health care costs, patient safety, and access to care and to discuss specific implications of these regulations for plastic surgeons. Within Certificate of Need states, these regulations have done little, if anything, to control health care costs or affect patient safety. Presently, Certificate of Need effects coupled with recent provisions in the Medicare Modernization Act banning development of specialty hospitals may restrict patient access to ambulatory surgical and specialty care. For the plastic surgeon, these effects not only act as an economic barrier to entry but can threaten the efficiencies gained from providing surgical care in an ambulatory setting. An appreciation of these effects is critical to maintaining specialty autonomy and access to fiscal policy.     

Large-volume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the quality improvement process

Large-volume liposuction can be associated rarely with major medical complications and death. The case of exsanguinating retroperitoneal hemorrhage that led to cardiopulmonary arrest in an obese 47-year-old woman who underwent large-volume liposuction is described. Extensive liposuction is not a minor procedure. Performance in an ambulatory setting should be monitored carefully, if it is performed at all. Reporting of adverse events associated with outpatient procedures performed by plastic surgeons should be mandated. Hemodynamic instability in the early postoperative period in an otherwise healthy patient may be due to fluid overload, lidocaine toxicity, or to hemorrhagic shock and must be recognized and treated aggressively. Guidelines for the safe practice of large-volume liposuction need to be established.     

When an adult female seeks ritual genital alteration: ethics, law, and the parameters of participation

Ritual genital cutting for women, a common practice in Africa and elsewhere around the world, remains dangerous and controversial. In recent years, a 14-year-old girl living in Sierra Leone exsanguinated and died following a ritualistic genital cutting. Hoping to avoid that fate, women with backgrounds that accept ritual genital cutting may, when they reach majority age, ask plastic surgeons to perform genital alterations for cultural reasons. Although plastic surgeons routinely perform cosmetic procedures, unique ethical and legal concerns arise when an adult female patient asks a surgeon to spare her the tribal elder's knife and alter her genitalia according to tradition and custom. Misinformation and confusion about this issue exist. This article explores the ethical and legal issues relevant to this situation and explains how the thoughtful surgeon should proceed.     

Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation

There has been little discussion in the published literature regarding breast shape preferences. This study was conducted to ascertain previously undocumented differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation, with respect to upper-pole contour. Sixty-six respondents, grouped into three cohort categories (plastic surgeons, breast augmentation patients, and lay people), were asked to evaluate a series of 12 nonptotic breast profiles representing a range of upper-pole contours. Five profiles exhibited convex upper-pole contours, five exhibited concave contours, and two exhibited upper poles with flat slopes. A five-point Likert-type scale was used to rate attractiveness, naturalness, how close the shape was to each respondent's personal ideal, and how close the shape was to what the respondent believed was our society's ideal. Statistical comparisons were made among the three cohorts. The plastic surgeon cohort (n = 11) rated concave upper-pole contours significantly higher than did the patient cohort (n = 13) for attractiveness, naturalness, and personal ideal (p < 0.01). For convex contours, the plastic surgeon cohort gave significantly lower scores than did the patient cohort (p < 0.01). The lay category (n = 42) demonstrated preferences intermediate between those of the other groups. There are no known studies in the literature documenting the breast shape preferences of plastic surgeons and their patients. This study suggests that plastic surgeons and patients seeking breast augmentation may have drastically different images in mind regarding what constitutes an attractive, natural, and ideal breast shape. These findings have potential implications for patient treatment and satisfaction.     

The effect of increased plastic surgeon supply on fees for aesthetic surgery: an economic analysis

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.     

Vilray P. Blair, his surgical descendants, and their roles in plastic surgical development.

Perhaps one of the most historically well-known plastic surgeons is Vilray P. Blair. As commander of the U.S. Army corps of head and neck surgeons during World War I, he became well known for his work in posttraumatic reconstruction. Blair's efforts in the early part of this century helped to develop plastic surgery as a distinct surgical subspecialty in the United States. His prowess as a surgeon allowed him to build one of the largest plastic surgery centers in the country and to train many of the top young American surgeons. Blair excelled as a teacher. He produced academic surgeons such as James Barrett Brown and Bradford Cannon, who took the lead in the care of wartime injuries during World War II. At Valley Forge General Hospital, Blair's trainees dedicated themselves to the reconstruction of injured patients and trained other young plastic surgeons in the care of postwar trauma. This exceptional level of patient care resulted in the U.S. government recognizing plastic surgery as a subspecialty following World War II. Since that time, Blair's surgical descendants at Washington University have led the country in the development of new training concepts and ideals and have gone on to become leaders in plastic surgery worldwide.     

Fatal outcomes from liposuction: census survey of cosmetic surgeons

Troubling reports of adverse outcomes after liposuction prompted a census survey of aesthetic plastic surgeons. All 1200 actively practicing North American board-certified ASAPS members were polled by facsimile, then mail, regarding deaths after liposuction. Patient initials together with case summaries precluded data replication yet assured patient anonymity and preserved surgeon privacy. Incomplete returns or ambiguous findings were authenticated, where feasible, by direct follow-up. Total number of lipoplasties performed by plastic surgeons was interpolated from the ASPRS procedure database for the survey time frame of 1994 to mid-1998. Lacking reliable annual case volume estimates, deaths from lipoplasties performed by non-ABPS surgeons were excluded from the actual mortality rate computation but were included in cause-of-death ranking statistics. Responding aesthetic plastic surgeons (917 of 1200) reported 95 uniquely authenticated fatalities in 496,245 lipoplasties. In this census survey, the mortality rate computed to 1 in 5224, or 19.1 per 100,000. A virtually identical 20.3 per 100,000 mortality rate was obtained in a 1997 random survey commissioned by the parent society. Pulmonary thromboembolism remains as the major killer (23.4+/-2.6 percent); lacking consistent medical examiners' toxicology data, the putative role of high-dose lidocaine cardiotoxicity could not be ascertained. Where so stated, many deaths occurred during the first night after discharge home; prudence suggests vigilant observation for residual "hangover" from sedative/anesthetic drugs after lengthy procedures. Taken together, these two independent surveys peg the late 1990s mortality rate from liposuction at about 20 per 100,000, or 1 in every 5000 procedures. Set beside the 16.4 per 100,000 fatality rates of U.S. motor vehicle accidents, liposuction is not an altogether benign procedure. We do not have comparable mortality data for lipoplasties performed by non-ABPS-certified physicians.     

The effect of increased consumer demand on fees for aesthetic surgery: an economic analysis

Economic theory dictates that changes in consumer demand have predictable effects on prices. Demographics represents an important component of demand for aesthetic surgery. Between the years of 1997 and 2010, the U.S. population is projected to increase by 12 percent. The population increase will be skewed such that those groups undergoing the most aesthetic surgery will see the largest increase. Accounting for the age-specific frequencies of aesthetic surgery and the population increase yields an estimate that the overall market for aesthetic surgery will increase by 19 percent. Barring unforeseen changes in general economic conditions or consumer tastes, demand should increase by an analogous amount. An economic demonstration shows the effects of increasing demand for aesthetic surgery on its fees. Between the years of 1992 and 1997, there was an increase in demand for breast augmentation as fears of associated autoimmune disorders subsided. Similarly, there was increased male acceptance of aesthetic surgery. The number of breast augmentations and procedures to treat male pattern baldness, plastic surgeons, and fees for the procedures were tracked. During the study period, the supply of surgeons and consumer demand increased for both of these procedures. Volume of breast augmentation increased by 275 percent, whereas real fees remained stable. Volume of treatment for male pattern baldness increased by 107 percent, and the fees increased by 29 percent. Ordinarily, an increase in supply leads to a decrease in prices. This did not occur during the study period. Economic analysis demonstrates that the increased supply of surgeons performing breast augmentation was offset by increased consumer demand for the procedure. For this reason, fees were not lowered. Similarly, increased demand for treatment of male pattern baldness more than offset the increased supply of surgeons performing it. The result was higher fees. Emphasis should be placed on using these economic relationships to expand the demand for aesthetic surgery.     

Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time.     

Subcutaneous mastectomy data: a preliminary report.

This is a preliminary report on data accumulated in the first 12 months by the Subcutaneous Mastectomy Data Evaluation Center at Saint Francis Memorial Hospital in San Francisco, California. We present some statistics on 419 subcutaneous mastectomies performed by 105 plastic surgeons.