Choosing Plastic Surgery
Plastic surgery is poorly understood by laypeople, medical students, physicians, and other surgeons. The most visible component of our specialty is aesthetic or cosmetic surgery, but plastic surgery is a broad specialty in which we operate on nearly every part of the body, on patients of all ages. We aren't confined to any organ system. While we specialize in soft tissue, hand and craniofacial surgeons very adept at manipulating and reconstructing bone as well. We treat patients with diseases ranging from congenital anomalies, to cancer, trauma, and degenerative/inflammatory disorders.
Plastic surgery training encompasses:
- Fundaments of surgery (wound healing, nutrition, intensive care)
- Fundamentals of plastic surgery (wound care, flaps, implants/biomaterials, lasers)
- Pediatric/Craniofacial surgery
- Hand surgery, upper and lower extremity reconstruction, peripheral nerve surgery
- Breast surgery (aesthetic and reconstructive)
- Trunk reconstruction including complex hernias, chest wall, and genital reconstruction
- Cosmetic/Aesthetic surgery including lasers and injectables and minimally invasive techniques
- Emerging areas (hand and face transplant immunology)
Plastic surgery is technically demanding, inherently creative, and rapidly changing. Plastic surgery is a relatively young specialty, having its modern origin during and after WW2. But it continues to reinvent itself. While reconstruction is at the heart of what we do, plastic surgeons are at the forefront of transplantation and tissue regeneration research. Additionally, we often work in teams, not only with other plastic surgeons, but frequently alongside orthopedic surgeons, neurosurgeons, otolaryngologists and surgical oncologists to perform complex reconstructions of the head and neck, spine, extremities, chest and abdomen.
Much of medicine and surgery has become formulaic. Very few specialties of medicine and surgery offer the chance to be truly creative. We do it every day. At your disposal to close a wound could be a VAC device, primary closure, a graft, several local or regional flaps, or a free flap. And that's just a wound.
The training is a minimum 6 years (or more, depending on the pathway chosen; more on this later). The training is rigorous. Once you finish training, expect long hours and hard work. We do not work shifts. We take call. We reattach fingers, arms, ears and various other parts in the middle of the night. If you seek a specialty with a high income, predictable sleep pattern, and easy hours, then plastic surgery is not for you.
If you're in your first or second year of medical school, try to get some exposure to plastic surgery. Spending some time with individual surgeons is valuable, but realize that each surgeon typically operates within a niche. In order to get a more complete perspective, ask if you can sit in on one of the resident teaching conferences (where an array of cases is usually presented and discussed), or try to spend a couple afternoons in the OR with different surgeons at your institution.
If you're in your third of fourth year of medical school, spend a month on a plastic surgery clerkship. It changed my life.
What is plastic surgery residency like?
There are two pathways to plastic surgery, the integrated (where you match straight from medical school) and the independent, where you first complete a residency in (typically) general surgery, otolaryngology/ENT, or oral surgery. The ACGME has a good précis on Pathways into Plastic Surgery:
It's important that anyone considering training in any specialty understands (and enjoys) the sort of patients we see, the sort of problems we handle, and the techniques and technology we have at our disposal.
In short, residency is hard work. It takes long hours and a great deal of practice to develop the manual skills to perform delicate microsurgery, the perspective to design a complex reconstruction, and the knowledge base in the various subspecialties of plastic surgery. The "10,000 hours of practice" concept likely applies to surgery. Depending on the rotation, you will wake up between 0430 and 0530. Your shortest day will usually be at least 12 hours. You will work many weekends and holidays. The ACGME work hour rules are observed, but 80 hours/week is still a lot.
For the integrated/combined route,
PGY-1 - surgical internship is spent learning the basics of patient management, fundamental surgical techniques. You will usually rotate through various surgical sub-specialties but home base is usually general surgery. You'll take the ABSITE and plastic surgery in-service exams. Completing surgical internship is a right of passage.
PGY-2 - the rotations you complete depend a lot on your program. There is a move toward less and less general surgery and more plastic surgery, though many programs still require 2 (or even 3) full years of general surgery training. The PGY2 job is tough. The PGY2 resident mostly sees consults, rotates in the ED and ICU, and does somewhat less operating, except at night. You'll still probably take the ABSITE and plastic surgery in-service.
PGY-3 - again, this year differs greatly depending on your program. At some programs you will be doing full-time plastic surgery, as a junior on the service, meaning you'll be doing a mix of consults and operating most days. Operations at this level include tissue expander/implant based breast reconstruction, breast reductions, hand trauma, abdominoplasties/ panniculectomies, resecting/reconstructing skin cancers, ED hand/face trauma, burn reconstruction, and lots more. You will be the junior assistant in bigger cases. You will often have a half-day of clinic and some time set aside for didactics, teaching conferences, grand rounds, and M&M. Residents typically start attending small surgical conferences. Time to start doing better on the plastic surgery in-service.
(in some programs there is a mandatory research year thrown in here)
PGY 4-6 - full time plastic surgery. You will be operating every day, seeing consults, and have graded responsibility for taking call and running the service. Larger cases, such as any microsurgery (free flaps, extremity reconstruction, peripheral nerve work), aesthetic surgery, and craniofacial operations will typically be done by the more senior/chief residents. In addition, you will typically do your pediatric/craniofacial rotations as a PGY4-6. As a senior resident and Chief, some programs offer the opportunity to participate in electives, attend a surgical mission trip, and attend national surgical meetings.
How much do plastic surgeons make?
The national average in 2017, according to salary.com was $364,233. This depends on a lot of factors including the style of practice (private, semi-private, academic), scope of practice (reconstructive, micro, hand, cosmetic, etc), where you practice, and how hard you work.
The AAMC also has a brief precis on plastic surgeon salaries.
How much do residents make?
Enough to live comfortably. Salaries are usually competitive between programs and often adjusted to the local cost of living. Your salary usually increases as you advance through residency. Many residency programs or hospitals publish this data online.
One of my surgical mentors told me to think about my career in stages. When you're young, you'll be interested in doing a variety of large, complex reconstructive cases. You'll enjoy taking lots of call because of the role it plays in building your practice as a young surgeon. But consider your priorities as a surgeon in his/her 50s, 60s, and beyond. Do you still want to be getting called about the Vioptix signal on your custom lower extremity VRAM free flap at 3am? Plastic surgery offers the flexibility to more toward a more comfortable office-based practice (such as in hand or aesthetic surgery) as you desire a more predictable schedule or simply want to slow down and enjoy life outside the hospital. Again, word to the wise, you can't build a successful practice straight out of residency without years of hard work and long hours.