Assessing the Value of a Multimedia-Based Aesthetic Curriculum in Plastic Surgery Residency: A Single-Center Pilot Study

Assessing the Value of a Multimedia-Based Aesthetic Curriculum in Plastic Surgery Residency: A... Abstract Background Although global demand for cosmetic surgery continues to rise, plastic surgery residents feel that current models of aesthetic training are inadequate in preparing them for future practice. Digital learning resources offer promising educational possibilities, yet there are no formal studies investigating the integration of these technologies into the aesthetic curriculum. Objectives Here, we review the current state of aesthetic training for plastic surgery residents and present a pilot study investigating the value of a dedicated multimedia-based aesthetic curriculum at a single, large academic program. Methods Twenty plastic surgery residents participated in an 8-week curriculum consisting of weekly multimedia-based modules covering a specific aesthetic topic. Participants completed pre- and post-intervention surveys at 0 and 10 weeks, respectively. Surveys evaluated resident perspectives of the current state of aesthetic training, confidence in performing surgical and non-surgical aesthetic procedures, perceived efficacy of multimedia interventions for learning, and preferences for inclusion of such approaches in future curricula. Results 16.7% of participants planned on entering an aesthetic fellowship following residency. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months. Resident confidence level in performing a particular aesthetic procedure significantly increased in 6/14 modules. More than 90% of residents were interested in incorporating the modules into residency. Conclusions Technology-based aesthetic training is critical for producing the finest future practitioners and leaders of this specialty. Here, we show that plastic surgery residents can benefit from a multimedia-based aesthetic curriculum, even if they do not plan on pursuing a career devoted to cosmetic surgery. The establishment of plastic surgery as a distinct specialty is rooted in aesthetics. In the late 1930s, pleas by Vilray Blair to the American Board of Surgery called for inclusion of a “group that is seeking ... to bring order into the restoring or the changing of surface or contour that might be done purely for the sake of appearance.” These efforts culminated in the formation of the American Board of Plastic Surgery (ABPS), and, ultimately, a standardized training program for plastic surgery residents.1 Since then, plastic surgery has rapidly expanded into a diverse specialty, encompassing both aesthetic and reconstructive domains. However, despite an increasing array of opportunities for sub-specialization in areas such as microvascular, craniofacial, and hand surgery, many plastic surgeons maintain a partial or full aesthetic focus of their practices. In 2010, half of all respondents in the Plastic Surgeons’ Plastic Surgery Workforce Task Force study reported that 75% or more of all procedures performed in their practices were cosmetic in nature.2 More recently, the majority of examinees for the ABPS maintenance of certification (MOC) exam opted for the cosmetic module.3 These findings likely reflect shifts in the plastic surgery landscape that include both increased global demand for cosmetic surgery and diminishing reimbursement rates for non-elective procedures.4,5 Consequently, there has been a vast expansion of the number of practitioners outside the field of plastic surgery who offer and perform aesthetic services in specialties such as dermatology, ophthalmology, general and maxillofacial surgery, otolaryngology, and gynecology. These realities are not unnoticed by plastic surgery residents, who have become increasingly concerned with gaining exposure to and developing skills in cosmetic surgery during their training.6 However, recent reports indicate that many trainees, both nationally and internationally, feel that aesthetic procedures are underrepresented in their residency training relative to reconstructive procedures, and that the current aesthetic training model is inadequate in preparing them for future practice.7-11 The field of plastic surgery has always been responsive to data-driven needed changes, particularly at the educational level. Advances in technology provide promising educational alternatives and adjuncts to resident training in the form of digital learning resources. To date, however, there is a lack of formal studies investigating the efficacy of integrating these technologies into the aesthetic curriculum, a shift that will be critical for producing the finest future practitioners and leaders of this specialty. Here, we review the current state of aesthetic training for plastic surgery residents at our institution, and present a pilot study investigating the efficacy of a dedicated aesthetic curriculum integrating digital resources in residency training. METHODS Approval was granted by the Office of Science and Research Institutional Review Board at the New York University (NYU) Langone Medical Center (Study # S17-00302). All current residents of the NYU Hansjörg Wyss Department of Plastic Surgery residency program (PGY 1-6, N = 20), excluding the senior author (SS), were invited to participate in the study, occurring at the end of the academic year (April through May 2017). The study consisted of pre- and post-intervention surveys administered at 0- and 10-week time points, respectively. The intervention was an 8-week aesthetic curriculum curated by this study’s senior investigators (a chief resident and the program director), which included weekly modules featuring a video and accompanying texts covering a specific aesthetic topic (eg, rhinoplasty, face lift). The weekly media-based component derived primarily from interactive surgical training videos from the Baker-Gordon videos accessible on the RADAR Resource and Plastic and Reconstructive Surgery journal’s website. The weekly text-based component was comprised of 3 to 4 focused review articles from peer-reviewed online sources or journals selected by the lead author. We expected that these activities would require approximately one hour of extra study per week. Survey criteria included: resident perspectives of the current state of aesthetic training in residency, current confidence in performing various aesthetic surgical and non-surgical procedures, perceived efficacy of various multimedia modules/interventions (ie, video, article, etc.) for learning, and resident preferences for inclusion of such multimedia-based approaches in future curricula. De-identified survey responses were analyzed using SPSSv24.0 (IBM Analytics; Armonk, NY) software for statistical analysis. Wilcoxon exact signed rank tests were performed to determine significant rank increases or decreases post-instruction. Two-sided testing was performed, with P < 0.05 considered statistically significant. RESULTS Twenty plastic surgery residents were included in the study, and their demographics are presented in Table 1. All residents in our program participated in the study, excluding the senior author (SS), a PGY-6 resident. The majority of residents (80%) was in the integrated/combined program, followed by 20% in the independent pathway. Ninety percent of residents planned on pursuing a subspecialty, with the majority selecting microsurgery (61.1%), followed by craniofacial surgery and aesthetic surgery (16.7%), and hand surgery (11.1%). When queried as to their future goals, 50% of residents responded that they planned to pursue a career in an academic practice, 10% a group private practice, and 5% (1 resident) solo private practice. Eight residents (40%) were undecided regarding their future goals. Table 1. Resident Demographics Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) View Large Table 1. Resident Demographics Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) View Large Table 2 displays the objective and subjective experiences of residents with cosmetic surgery at our institution. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months (range, 0 to 6 months). Eighteen residents (90%) indicated that they would find a structured aesthetic curriculum valuable. When asked to rank their satisfaction with the current aesthetic curriculum (1 to 6; 1 = not satisfied at all, 6 = most satisfied), the mean of all responses was 3.1 (range, 1 to 6). When asked how well prepared they felt performing cosmetic surgery procedures in general (1 to 6; 1 = not prepared at all, 6 = very prepared), the mean response of all residents was 2.7 (range, 1 to 6). Table 2. Resident Cosmetic Experience Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 View Large Table 2. Resident Cosmetic Experience Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 View Large Table 3 illustrates procedural experience of residents. For each aesthetic category, residents reported the number of cases in which they participated (0, 1 to 5, 6 to 10, or 10+ cases). Aesthetic categories included abdominoplasty, upper blepharoplasty, lower blepharoplasty, body contouring, breast augmentation, breast reduction, brow lift, face/neck lift, fillers, mastopexy, neuromodulators, rhinoplasty, chemical skin resurfacing, and laser skin resurfacing. In all categories, the most frequent response was “0 prior cases.” The categories with the greatest resident exposure were breast reduction and abdominoplasty, and the categories with the lowest resident exposure were skin resurfacing (both chemical and laser) and brow lift. As displayed in Figure 1A, when stratified by PGY level, there was a significant positive correlation between aesthetic exposure and confidence in performing aesthetic procedures as residents progressed through their training (Pearson coefficient = 0.94, P = 0.0061). Additionally, in comparison to residents who were in their “core surgery” rotations (PGY 1-3), residents in dedicated plastic surgery rotations (PGY4-6) had both significantly increased procedural experience (P = 0.0002) and confidence (P = 0.0007) in performing aesthetic procedures (Figure 1B, C). Table 3. Resident Procedural Experience Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 View Large Table 3. Resident Procedural Experience Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 View Large Figure 1. View largeDownload slide (A) Resident PGY level, (B) exposure, and (C) confidence. Figure 1. View largeDownload slide (A) Resident PGY level, (B) exposure, and (C) confidence. Residents were also asked to rank various learning methods from most preferred to least preferred (Table 4). The four options were resident cosmetic clinics, assisting attendings in the operating room, books/journal, or highly edited surgical videos. 78.9% of residents ranked resident cosmetic clinics as their most preferred method of learning. 73.7% of residents ranked assisting an attending as their second most preferred method of learning. 94.7% of residents ranked highly edited surgical videos as their third most preferred method of learning. Books/journals were the least preferred method of learning for all respondents. Table 4. Preferred Delivery Mode of Instruction Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 View Large Table 4. Preferred Delivery Mode of Instruction Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 View Large Post-interventional outcomes are displayed in Figure 2, which shows the change in confidence that residents experienced in performing a particular procedure. A significant subjective increase in confidence was determined in 6/14 modules. No significant improvement was seen in 3 of the categories. Of note, data were unable to be analyzed in 5 of the categories. Overall resident satisfaction with the multimedia-based aesthetic curriculum is displayed in Table 5. 93.8% of residents found the modules helpful, and 93.3% said they would be interested in incorporating them into residency. Residents were also asked to rank the usefulness of the modules. On a scale of 1 (most useful) to 5 (least useful), all modules received a score between 2 and 3. Table 5. Training Satisfaction Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) View Large Table 5. Training Satisfaction Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) View Large Figure 2. View largeDownload slide Pre- and post-module changes in performing procedure. Figure 2. View largeDownload slide Pre- and post-module changes in performing procedure. DISCUSSION It is imperative that plastic surgery residents are experienced and confident in performing aesthetic surgery, for both continued advancement and innovation in the field, and to ensure patient safety. However, there is evidence to suggest that this objective is not being adequately met. In 1996, Linder et al reported that more than half of recent plastic surgery graduates felt that their exposure to aesthetic procedures was insufficient.12 A decade later, Morrison et al found that half of graduating plastic surgery residents still felt inadequately prepared to integrate cosmetic surgery into their future practice.9 This sentiment is not unique to plastic surgery residents in the United States; similar views have been expressed by residents in Canada, Europe, and India.8,13-15 Subsequent re-evaluation of the aesthetic training paradigm resulted in significant changes, such as the addition of one year to residency training, increases in the minimum cosmetic case number for residents, and the establishment of a standardized curriculum for post-residency aesthetic fellowships. However, despite promising reports of increasing resident confidence in performing aesthetic procedures—suggestive of improved training—from 2008 to 2011, subsequent studies suggest that this rise has plateaued.3,10,16 Given the inherent limitations to resident exposure to aesthetic procedures, such as the relatively small volume at most academic centers, some have advocated for the incorporation of cosmetic surgery modules and other digital alternatives—such as web-based and video resources—into training programs to address this challenge. Integration of these modalities into resident training has been slow, and there is a lack of prospective studies evaluating the efficacy of digital educational alternatives. In this study, we assessed resident experiences and attitudes towards our pilot aesthetic surgery curriculum at our institution, and evaluated an 8-week aesthetic pilot curriculum consisting of surgical videos and accompanying focused articles. Clearly, the Halstedian model of direct exposure to—and involvement in—actual aesthetic surgical procedures is the most effective way to educate trainees and help them achieve competence in the surgical domain.12,17 This has been validated as superior to classroom-based education, and importantly, it has been shown that practice-based methods of resident training, such as educational aesthetic surgeries and Resident Aesthetic Clinics (RACs), increase resident preparedness and confidence for practice, do not adversely affect long-term surgical outcomes or major complication rates when compared to national outcomes, and furthermore, can improve patient quality of life despite variations in program structure, and across both surgical and non-surgical procedures.17-22 At our institution, residents receive 3 months of dedicated aesthetic training in our resident cosmetic clinic during both PGY 5 and 6. Prior to this, the majority of aesthetic education occurs via traditional self-learning (eg, textbooks, journals), studying for board exams, or at conferences. It is perhaps unsurprising then, that the vast majority (78.9%) of residents in our study ranked cosmetic resident clinics as their preferred mode of education. Although we did not specifically ask residents whether this assertion was based on a general perception of RACs or experience with our aesthetic clinic, the significant increases observed in both resident exposure and confidence as training progressed—particularly during these final 2 years—reiterates the significance of direct operative experience in resident education. However, while this may be a realistic training method at certain programs, practical issues relating to funding, geography, sufficient faculty oversight, and patient population, as well as issues related to liability and malpractice, unfortunately make this method of resident education an unrealistic first-line option in many cases.23-25 As such, the number of cosmetic resident clinics has not significantly increased over the past 8 years (present at 60% to 70% of centers), and these centers are rare outside the United States.3,6,17 Residents in our study also favored learning through assisting attending’s in the operating room, but limitations on resident work hours, combined with a healthcare landscape increasingly driven towards cost effectiveness, will undoubtedly continue to limit direct operative experience.26 Furthermore, there can exist significant variability in aesthetic operative experience among residents even within the same program, as was found in our study. This can be attributed to the training structure at most integrated programs, in which residents spend the preliminary years of residency completing “core surgery” rotations, as recommended by Plastic Surgery Residency Review Committee (RRC), in which operative exposure to plastic surgery—and particularly aesthetic surgery—is limited, if not absent. This likely explains the significant positive correlation we found between aesthetic exposure and perceived procedural confidence as residents progress along their training. Cadavers are another popular mode of education, but availability and cost limit widespread use among programs.3 Live animal models, while important for basic science research of aesthetic materials and technical principles, are not realistic substitutes for direct operative experience. More traditional modes of education, such as books or journals, certainly have value and are excellent means of obtaining foundational knowledge in a topic and tracking the latest advances and trends. Notably, 60% of plastic surgery residents continue to use physical textbooks on a weekly basis.27 However, the residents in our study unanimously ranked this method as their least preferred method of learning, perhaps reflective of the transformation from a knowledge-based to competency-based model of residency training.28,29 At the regulatory level, the Accreditation Council for Graduate Medical Education (ACGME) has developed core competencies and milestones emphasizing outcomes-based education, and the aesthetic topics tested on recent Plastic Surgery In-Service Training Exams (PSITE) favor decision making and outcomes over anatomy and diagnosis.30,31 In our study, only 16.7% of residents expressed a desire to pursue an aesthetic fellowship, which is lower than that seen in other studies, but consistent with recent evidence that fewer residents feel they need a fellowship to practice cosmetic surgery.3,16 Furthermore, 60% of our cohort expressed interest in pursuing careers in academic medicine, which inherently possess less of an aesthetic focus as compared to solo or group private practices. Thus, it is interesting, and encouraging that 90% of our cohort nonetheless saw value in a structured aesthetic curriculum, suggesting an appreciation by residents for education in all aspects of the field. While our cohort did include a majority of residents from combined plastic surgery tracks, prior studies have not found differences among residents in combined, independent, or integrated programs.11 Consistent with the aforementioned literature, we found that resident satisfaction with their current aesthetic training was low (15%), as was confidence level across many surgical and nonsurgical procedures. Of course, not all aesthetic procedures are comparable, and multiple studies have shown that residents find facial procedures more difficult than cosmetic breast and body contouring procedures.3,8,11 Notably, of the 5 surgical procedures in which residents experienced statistically significant increases in confidence following participation in the modules, 4 of them (lower blepharoplasty, brow lift, face/neck lift, and rhinoplasty) involved the face. Furthermore, many believe that the future of cosmetic surgery depends on the ability of surgeons to adapt and meet the demand for non-surgical procedures.32,33 However, deficiencies in the training of non-surgical aesthetic procedures have been demonstrated in residents both domestically and abroad, and it is difficult for residents to reach minimum case requirements in neuromodulators and dermal fillers.11,26,34 Modules in our study not only increased resident confidence in surgical procedures, but also in the use of fillers, an increasingly popular non-surgical procedure, and a core competency requirement for plastic surgery residents. Thus, we believe newer technologies may be able to address gaps in exposure to more complex and uncommon procedures. Technology-based education has been adopted across all of medicine. In surgery specifically, Khansa and Janis review a number of technological resources that have been incorporated into plastic surgery residency training.35 These include curriculum-based resources—such as the Plastic Surgery Education Network (PSEN)—as well as decision-making applications, surgical simulators and modules, video analysis, and other computer-based tools. They divide these into 3 types: those that help acquire new knowledge; those that help teach basic surgical planning, anatomy, and concepts; and those that help develop, improve, and refine surgical technique. Evidence of the efficacy of surgical education interventions such as these is promising. A meta-analysis by McGaghie et al examining the effects of technological integration in surgical resident education found simulation-based education to be more effective at teaching new skills as compared to traditional educational models.36 Surgical simulators have been developed for craniofacial, cleft, and breast surgery, and exhibit educational efficacy in domains such as skill assessment and decision making.37-39 With increasing affordability and accessibility, 3D printing represents an effective educational tool that exhibits improved patient and surgical outcomes as compared to traditional methods.40 However, despite the fact that many of these technology-based resources already exist, awareness and implementation unfortunately remain an obstacle. For example, 78% of plastic surgery residents were not aware of, nor had ever used, RADAR, the readily available digital aesthetic resource.27 Thus, formal integration into residency curriculum may ultimately be necessary for proper utilization. Since most of these technologies are easily accessible via computer or smartphone, they can be readily integrated into the teaching curriculum or as part of required preparation for surgery. iPads have been successfully integrated into plastic surgery training and were shown to improve not only resident education, but also clinical efficiency and HIPAA compliance.41 Technology has also demonstrated value as a feedback tool and can enrich communication between residents and faculty.42,43 As active resident participation is critical to successful integration of technology, it is encouraging that more than 90% of our residents found the modules helpful and were interested in incorporating them into their residency curriculums. As the majority of current faculty and program directors were trained in environments without the use of these newer technologies, resident participation and active engagement will be necessary for effective integration. In this study, our primary outcomes of interest were value and subjective resident perceptions of an integrated aesthetic curriculum in plastic surgery residency training as an adjunct to routine clinical and educational responsibilities. As such, there are several notable limitations to our study. First, our study was limited to a single academic institution and thus, in addition to a small sample size and an inability to account for potential covariates, does not account for variation in residency program size, exposure, volume, or location, thereby limiting generalizability.44 Similarly, while we attempted to account for prior resident engagement or interest in aesthetic surgery by querying expected fellowship and career plans in the pre-survey, our study does not directly account for this factor. Furthermore, aesthetic principles and procedures are relevant to all residents and plastic surgeons, not just those for whom it dominates their fellowship training or future practice. Therefore, while we believe that a structured curriculum, particularly in the early stages of residency, would augment the education of residents, regardless of prior engagement, this is an interesting avenue of future research that we hope to include in future studies. Additionally, while we show that perceived pre-curriculum confidence in performing aesthetic procedures is significantly associated with prior case exposure, we did not include an objective metric for measuring post-module competency in our study, as there currently exist no validated measuring tools for assessing pre- and post-intervention competency of aesthetic topics in residents, particularly across various levels of training. It is unlikely that board-like exam questions alone are the optimal method for assessing surgical competency, and further studies are required to determine how to most accurately measure aesthetic and non-aesthetic competency and confidence, and whether non-operative exposure or subjective perceptions translate into operative competency or performance. Time allotment is another factor we did not study, but would be an important consideration for any standardized curriculum given the variations in workload and responsibility across PGY or rotations. Finally, the modules themselves were selected subjectively by the senior authors and consisted of a series of readings and accompanying surgical videos that were not standardized across different procedure types. Larger, multi-program studies incorporating greater numbers of residents, and approved, standardized proficiency metrics are warranted in order to minimize bias and increase power. Such initiatives will be critical for assessing the efficacy of these technologies across the spectrum of plastic surgery residency education. CONCLUSION In this study, we show that plastic surgery residents are willing to participate in a structured aesthetic curriculum incorporating digital resources—even if they do not plan on focusing on cosmetic surgery in their careers. Furthermore, we demonstrate that such a curriculum can efficiently increase resident confidence in both surgical and nonsurgical aesthetic procedures, and may be particularly valuable in the early years of residency, or in programs in which operative exposure to aesthetic surgery is minimal or absent. It is imperative that the field of plastic surgery embraces the advantages of the currently available—and increasingly affordable and accessible—technologically based educational alternatives in order to address the current challenges of aesthetic surgery training. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Mackay DR , Johnson S . The origins and current state of plastic surgery residency in the United States . J Craniofac Surg . 2015 ; 26 ( 8 ): 2251 - 2253 . 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The quality of aesthetic surgery training in plastic surgery residency: a survey among residents in Germany . Ann Plast Surg . 2013 ; 70 ( 6 ): 704 - 708 . Google Scholar Crossref Search ADS PubMed 15. Khare N , Puri V . Education in plastic surgery: are we headed in the right direction ? Indian J Plast Surg . 2014 ; 47 ( 1 ): 109 - 115 . Google Scholar Crossref Search ADS PubMed 16. McNichols CHL , Diaconu S , Alfadil S , et al. Cosmetic surgery training in plastic surgery residency programs . Plast Reconstr Surg Glob Open . 2017 ; 5 ( 9 ): e1491 . Google Scholar Crossref Search ADS PubMed 17. Koulaxouzidis G , Momeni A , Simunovic F , Lampert F , Bannasch H , Stark GB . Aesthetic surgery performed by plastic surgery residents: an analysis of safety and patient satisfaction . Ann Plast Surg . 2014 ; 73 ( 6 ): 696 - 700 . Google Scholar Crossref Search ADS PubMed 18. Sterodimas A , Boriani F , Bogetti P , Radwanski HN , Bruschi S , Pitanguy I . Junior plastic surgeon’s confidence in aesthetic surgery practice: a comparison of two didactic systems . J Plast Reconstr Aesthet Surg . 2010 ; 63 ( 8 ): 1335 - 1337 . Google Scholar Crossref Search ADS PubMed 19. Qureshi AA , Parikh RP , Myckatyn TM , Tenenbaum MM . Resident cosmetic clinic: practice patterns, safety, and outcomes at an academic plastic surgery institution . Aesthet Surg J . 2016 ; 36 ( 9 ): NP273 - NP280 . Google Scholar Crossref Search ADS PubMed 20. Qureshi AA , Parikh RP , Sharma K , Myckatyn TM , Tenenbaum MM . Nonsurgical facial rejuvenation: outcomes and safety of neuromodulator and soft-tissue filler procedures performed in a resident cosmetic clinic . Aesthetic Plast Surg . 2017 ; 41 ( 5 ): 1177 - 1183 . Google Scholar Crossref Search ADS PubMed 21. Weissler JM , Carney MJ , Yan C , Percec I . The value of a resident aesthetic clinic: a 7-year institutional review and survey of the chief resident experience . Aesthet Surg J . 2017 ; 37 ( 10 ): 1188 - 1198 . Google Scholar Crossref Search ADS PubMed 22. Ingargiola MJ , Molina Burbano F , Yao A , et al. Plastic surgery resident-run cosmetic clinics: a survey of current practices . Aesthet Surg J . 2018 ;doi: 10.1093/asj/sjy065 . 23. Cueva-Galárraga M , Cárdenas-Camarena L , Boquín M , Robles-Cervantes JA , Guerrerosantos J . Aesthetic plastic surgery training at the Jalisco plastic and reconstructive surgery institute: a 20-year review . Plast Reconstr Surg . 2011 ; 127 ( 3 ): 1346 - 1351 . Google Scholar Crossref Search ADS PubMed 24. Pu LL , Thornton BP , Vasconez HC . The educational value of a resident aesthetic surgery clinic: a 10-year review . Aesthet Surg J . 2006 ; 26 ( 1 ): 41 - 44 . Google Scholar Crossref Search ADS PubMed 25. Hultman CS , Wu C , Bentz ML , et al. Identification of best practices for resident aesthetic clinics in plastic surgery training: the ACAPS National Survey . Plast Reconstr Surg Glob Open . 2015 ; 3 ( 3 ): e370 . Google Scholar Crossref Search ADS PubMed 26. Silvestre J , Serletti JM , Chang B . Disparities in aesthetic procedures performed by plastic surgery residents . Aesthet Surg J . 2017 ; 37 ( 5 ): 582 - 587 . Google Scholar PubMed 27. Waltzman JT , Tadisina KK , Zins JE . The rise of technology in plastic surgery education: is the textbook dead on arrival (DOA) ? Aesthet Surg J . 2016 ; 36 ( 2 ): 237 - 243 . Google Scholar Crossref Search ADS PubMed 28. Bancroft GN , Basu CB , Leong M , Mateo C , Hollier LH Jr , Stal S . Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery . Plast Reconstr Surg . 2008 ; 121 ( 6 ): 441e - 448e . Google Scholar Crossref Search ADS PubMed 29. Knox AD , Gilardino MS , Kasten SJ , Warren RJ , Anastakis DJ . Competency-based medical education for plastic surgery: where do we begin ? Plast Reconstr Surg . 2014 ; 133 ( 5 ): 702e - 710e . Google Scholar Crossref Search ADS PubMed 30. Silvestre J , Taglienti AJ , Serletti JM , Chang B . Analysis of cosmetic topics on the plastic surgery in-service training exam . Aesthet Surg J . 2015 ; 35 ( 6 ): 739 - 745 . Google Scholar Crossref Search ADS PubMed 31. Motakef S , Campwala I , Gupta S . Establishing milestones for facial injectables in plastic surgery residency training: four-year follow-up . Aesthet Surg J . 2017 ; 37 ( 10 ): NP140 - NP141 . Google Scholar Crossref Search ADS PubMed 32. Liu TS , Miller TA . Economic analysis of the future growth of cosmetic surgery procedures . Plast Reconstr Surg . 2008 ; 121 ( 6 ): 404e - 412e . Google Scholar Crossref Search ADS PubMed 33. D’Amico RA , Saltz R , Rohrich RJ , et al. Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: future demand, consumer preferences, and trends in practitioners’ services . Plast Reconstr Surg . 2008 ; 121 ( 5 ): 1787 - 1792 . Google Scholar Crossref Search ADS PubMed 34. Ferron CE , Lemaine V , Leblanc B , Nikolis A , Brutus JP . Recent Canadian plastic surgery graduates: are they prepared for the real world ? Plast Reconstr Surg . 2010 ; 125 ( 3 ): 1031 - 1036 . Google Scholar Crossref Search ADS PubMed 35. Khansa I , Janis JE . Maximizing technological resources in plastic surgery resident education . J Craniofac Surg . 2015 ; 26 ( 8 ): 2264 - 2269 . Google Scholar Crossref Search ADS PubMed 36. McGaghie WC , Issenberg SB , Cohen ER , Barsuk JH , Wayne DB . Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence . Acad Med . 2011 ; 86 ( 6 ): 706 - 711 . Google Scholar Crossref Search ADS PubMed 37. Diaz-Siso JR , Plana NM , Stranix JT , Cutting CB , McCarthy JG , Flores RL . Computer simulation and digital resources for plastic surgery psychomotor education . Plast Reconstr Surg . 2016 ; 138 ( 4 ): 730e - 738e . Google Scholar Crossref Search ADS PubMed 38. Johnston MJ , Paige JT , Aggarwal R , et al. ; Association for Surgical Education Simulation Committee . An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains . Am J Surg . 2016 ; 211 ( 1 ): 214 - 225 . Google Scholar Crossref Search ADS PubMed 39. Kazan R , Viezel-Mathieu A , Cyr S , Hemmerling TM , Gilardino MS . The Montreal Augmentation Mammoplasty Operation (MAMO) simulator: an alternative method to train and assess competence in breast augmentation procedures . Aesthet Surg J . 2018 ;doi: 10.1093/asj/sjx267 . 40. Langridge B , Momin S , Coumbe B , Woin E , Griffin M , Butler P . Systematic review of the use of 3-dimensional printing in surgical teaching and assessment . J Surg Educ . 2018 ; 75 ( 1 ): 209 - 221 . Google Scholar Crossref Search ADS PubMed 41. Gerstle T , Hassanein AH , Eriksson E . iPad integration in plastic surgical training: optimizing clinical efficiency, education, and compliance with the health insurance portability and accountability act . Plast Reconstr Surg . 2015 ; 135 ( 1 ): 223e - 225e . Google Scholar Crossref Search ADS PubMed 42. Connolly KA , Azouz SM , Smith AA . Feedback in plastic and reconstructive surgery education: past, present, and future . J Craniofac Surg . 2015 ; 26 ( 8 ): 2261 - 2263 . Google Scholar Crossref Search ADS PubMed 43. Kobraei EM , Bohnen JD , George BC , et al. Uniting evidence-based evaluation with the ACGME plastic surgery milestones: a simple and reliable assessment of resident operative performance . Plast Reconstr Surg . 2016 ; 138 ( 2 ): 349e - 357e . Google Scholar Crossref Search ADS PubMed 44. Janis JE , Vedder NB , Reid CM , Gosman A , Mann K . Validated assessment tools and maintenance of certification in plastic surgery: current status, challenges, and future possibilities . Plast Reconstr Surg . 2016 ; 137 ( 4 ): 1327 - 1333 . Google Scholar Crossref Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Assessing the Value of a Multimedia-Based Aesthetic Curriculum in Plastic Surgery Residency: A Single-Center Pilot Study

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Oxford University Press
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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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1527-330X
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10.1093/asj/sjy110
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Abstract

Abstract Background Although global demand for cosmetic surgery continues to rise, plastic surgery residents feel that current models of aesthetic training are inadequate in preparing them for future practice. Digital learning resources offer promising educational possibilities, yet there are no formal studies investigating the integration of these technologies into the aesthetic curriculum. Objectives Here, we review the current state of aesthetic training for plastic surgery residents and present a pilot study investigating the value of a dedicated multimedia-based aesthetic curriculum at a single, large academic program. Methods Twenty plastic surgery residents participated in an 8-week curriculum consisting of weekly multimedia-based modules covering a specific aesthetic topic. Participants completed pre- and post-intervention surveys at 0 and 10 weeks, respectively. Surveys evaluated resident perspectives of the current state of aesthetic training, confidence in performing surgical and non-surgical aesthetic procedures, perceived efficacy of multimedia interventions for learning, and preferences for inclusion of such approaches in future curricula. Results 16.7% of participants planned on entering an aesthetic fellowship following residency. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months. Resident confidence level in performing a particular aesthetic procedure significantly increased in 6/14 modules. More than 90% of residents were interested in incorporating the modules into residency. Conclusions Technology-based aesthetic training is critical for producing the finest future practitioners and leaders of this specialty. Here, we show that plastic surgery residents can benefit from a multimedia-based aesthetic curriculum, even if they do not plan on pursuing a career devoted to cosmetic surgery. The establishment of plastic surgery as a distinct specialty is rooted in aesthetics. In the late 1930s, pleas by Vilray Blair to the American Board of Surgery called for inclusion of a “group that is seeking ... to bring order into the restoring or the changing of surface or contour that might be done purely for the sake of appearance.” These efforts culminated in the formation of the American Board of Plastic Surgery (ABPS), and, ultimately, a standardized training program for plastic surgery residents.1 Since then, plastic surgery has rapidly expanded into a diverse specialty, encompassing both aesthetic and reconstructive domains. However, despite an increasing array of opportunities for sub-specialization in areas such as microvascular, craniofacial, and hand surgery, many plastic surgeons maintain a partial or full aesthetic focus of their practices. In 2010, half of all respondents in the Plastic Surgeons’ Plastic Surgery Workforce Task Force study reported that 75% or more of all procedures performed in their practices were cosmetic in nature.2 More recently, the majority of examinees for the ABPS maintenance of certification (MOC) exam opted for the cosmetic module.3 These findings likely reflect shifts in the plastic surgery landscape that include both increased global demand for cosmetic surgery and diminishing reimbursement rates for non-elective procedures.4,5 Consequently, there has been a vast expansion of the number of practitioners outside the field of plastic surgery who offer and perform aesthetic services in specialties such as dermatology, ophthalmology, general and maxillofacial surgery, otolaryngology, and gynecology. These realities are not unnoticed by plastic surgery residents, who have become increasingly concerned with gaining exposure to and developing skills in cosmetic surgery during their training.6 However, recent reports indicate that many trainees, both nationally and internationally, feel that aesthetic procedures are underrepresented in their residency training relative to reconstructive procedures, and that the current aesthetic training model is inadequate in preparing them for future practice.7-11 The field of plastic surgery has always been responsive to data-driven needed changes, particularly at the educational level. Advances in technology provide promising educational alternatives and adjuncts to resident training in the form of digital learning resources. To date, however, there is a lack of formal studies investigating the efficacy of integrating these technologies into the aesthetic curriculum, a shift that will be critical for producing the finest future practitioners and leaders of this specialty. Here, we review the current state of aesthetic training for plastic surgery residents at our institution, and present a pilot study investigating the efficacy of a dedicated aesthetic curriculum integrating digital resources in residency training. METHODS Approval was granted by the Office of Science and Research Institutional Review Board at the New York University (NYU) Langone Medical Center (Study # S17-00302). All current residents of the NYU Hansjörg Wyss Department of Plastic Surgery residency program (PGY 1-6, N = 20), excluding the senior author (SS), were invited to participate in the study, occurring at the end of the academic year (April through May 2017). The study consisted of pre- and post-intervention surveys administered at 0- and 10-week time points, respectively. The intervention was an 8-week aesthetic curriculum curated by this study’s senior investigators (a chief resident and the program director), which included weekly modules featuring a video and accompanying texts covering a specific aesthetic topic (eg, rhinoplasty, face lift). The weekly media-based component derived primarily from interactive surgical training videos from the Baker-Gordon videos accessible on the RADAR Resource and Plastic and Reconstructive Surgery journal’s website. The weekly text-based component was comprised of 3 to 4 focused review articles from peer-reviewed online sources or journals selected by the lead author. We expected that these activities would require approximately one hour of extra study per week. Survey criteria included: resident perspectives of the current state of aesthetic training in residency, current confidence in performing various aesthetic surgical and non-surgical procedures, perceived efficacy of various multimedia modules/interventions (ie, video, article, etc.) for learning, and resident preferences for inclusion of such multimedia-based approaches in future curricula. De-identified survey responses were analyzed using SPSSv24.0 (IBM Analytics; Armonk, NY) software for statistical analysis. Wilcoxon exact signed rank tests were performed to determine significant rank increases or decreases post-instruction. Two-sided testing was performed, with P < 0.05 considered statistically significant. RESULTS Twenty plastic surgery residents were included in the study, and their demographics are presented in Table 1. All residents in our program participated in the study, excluding the senior author (SS), a PGY-6 resident. The majority of residents (80%) was in the integrated/combined program, followed by 20% in the independent pathway. Ninety percent of residents planned on pursuing a subspecialty, with the majority selecting microsurgery (61.1%), followed by craniofacial surgery and aesthetic surgery (16.7%), and hand surgery (11.1%). When queried as to their future goals, 50% of residents responded that they planned to pursue a career in an academic practice, 10% a group private practice, and 5% (1 resident) solo private practice. Eight residents (40%) were undecided regarding their future goals. Table 1. Resident Demographics Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) View Large Table 1. Resident Demographics Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) Variable/statistic Study cohort (n = 20) PGY level, n (%)  1 3 (15%)  2 3 (15%)  3 3 (15%)  4 4 (20%)  5 4 (20%)  6 3 (15%) Program type, n (%)  Integrated/combined 16 (80%)  Independent 4 (20%) Planning on pursuing a subspecialty, n (%) 18 (90%)  Microsurgery 11 (61.1%)  Aesthetics 3 (16.7%)  Craniofacial 3 (16.7%)  Hand 2 (11.1%) Future goals, n (%)  Academic practice 10 (50.0%)  Undecided 8 (40.0%)  Group private practice 2 (10.0%)  Solo private practice 1 (5.0%) View Large Table 2 displays the objective and subjective experiences of residents with cosmetic surgery at our institution. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months (range, 0 to 6 months). Eighteen residents (90%) indicated that they would find a structured aesthetic curriculum valuable. When asked to rank their satisfaction with the current aesthetic curriculum (1 to 6; 1 = not satisfied at all, 6 = most satisfied), the mean of all responses was 3.1 (range, 1 to 6). When asked how well prepared they felt performing cosmetic surgery procedures in general (1 to 6; 1 = not prepared at all, 6 = very prepared), the mean response of all residents was 2.7 (range, 1 to 6). Table 2. Resident Cosmetic Experience Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 View Large Table 2. Resident Cosmetic Experience Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 Variable/statistic Study cohort (n = 20) Number of designated cosmetic surgery months  Mean (SD) 1.65 (2.43)  Median 0  Range 0-6 Agree with value in a structured curriculum, n (%) 18 (90%) Satisfied with current aesthetic training (1 = not satisfied, 6 = satisfied)  Mean (SD) 3.1 (1.47)  Median 3  Range 1-6 How well prepared are you for cosmetic surgery (1 = not at all, 6 = very prepared)  Mean (SD) 2.7 (1.46)  Median 2.5  Range 1-6 View Large Table 3 illustrates procedural experience of residents. For each aesthetic category, residents reported the number of cases in which they participated (0, 1 to 5, 6 to 10, or 10+ cases). Aesthetic categories included abdominoplasty, upper blepharoplasty, lower blepharoplasty, body contouring, breast augmentation, breast reduction, brow lift, face/neck lift, fillers, mastopexy, neuromodulators, rhinoplasty, chemical skin resurfacing, and laser skin resurfacing. In all categories, the most frequent response was “0 prior cases.” The categories with the greatest resident exposure were breast reduction and abdominoplasty, and the categories with the lowest resident exposure were skin resurfacing (both chemical and laser) and brow lift. As displayed in Figure 1A, when stratified by PGY level, there was a significant positive correlation between aesthetic exposure and confidence in performing aesthetic procedures as residents progressed through their training (Pearson coefficient = 0.94, P = 0.0061). Additionally, in comparison to residents who were in their “core surgery” rotations (PGY 1-3), residents in dedicated plastic surgery rotations (PGY4-6) had both significantly increased procedural experience (P = 0.0002) and confidence (P = 0.0007) in performing aesthetic procedures (Figure 1B, C). Table 3. Resident Procedural Experience Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 View Large Table 3. Resident Procedural Experience Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 Number of prior cases Procedure 0 1-5 6-10 10+ Abdominoplasty 10 (52.6%) 2 (10.5%) 1 (5.3%) 6 (31.6%) Blepharoplasty upper 13 (68.4%) 1 (5.3%) 3 (15.8%) 2 (10.5%) Blepharoplasty lower 13 (68.4%) 2 (10.5%) 2 (10.5%) 2 (10.5%) Body contouring 11 (57.9%) 2 (10.5%) 3 (15.8%) 3 (15.8%) Breast augmentation 11 (57.9%) 4 (21.1%) 3 (15.8%) 1 (5.3%) Breast reduction 9 (47.4%) 1 (5.3%) 3 (15.8%) 6 (31.6%) Brow lift 14 (77.8%) 4 (21.1%) 0 0 Face/neck lift 12 (66.7%) 1 (5.6%) 3 (16.7%) 2 (11.1%) Fillers 12 (63.2%) 3 (15.8%) 2 (10.5%) 2 (10.5%) Mastopexy 10 (52.6%) 2 (10.5%) 4 (21.1%) 3 (15.8%) Neuromodulators 11 (61.1%) 4 (22.2%) 1 (5.6%) 2 (11.1%) Rhinoplasty 12 (66.7%) 0 2 (11.1%) 4 (22.2%) Skin resurfacing (chemical) 14 (77.8%) 2 (11.1%) 1 (5.6%) 1 (5.6%) Skin resurfacing (laser) 13 (72.2%) 3 (16.7%) 2 (11.1%) 0 View Large Figure 1. View largeDownload slide (A) Resident PGY level, (B) exposure, and (C) confidence. Figure 1. View largeDownload slide (A) Resident PGY level, (B) exposure, and (C) confidence. Residents were also asked to rank various learning methods from most preferred to least preferred (Table 4). The four options were resident cosmetic clinics, assisting attendings in the operating room, books/journal, or highly edited surgical videos. 78.9% of residents ranked resident cosmetic clinics as their most preferred method of learning. 73.7% of residents ranked assisting an attending as their second most preferred method of learning. 94.7% of residents ranked highly edited surgical videos as their third most preferred method of learning. Books/journals were the least preferred method of learning for all respondents. Table 4. Preferred Delivery Mode of Instruction Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 View Large Table 4. Preferred Delivery Mode of Instruction Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 Delivery mode Benefit from learning Median 1 (best) 2 (2nd best) 3 (3rd best) 4 (worst) Resident cosmetic clinic 15 (78.9%) 4 (21.1%) 0 0 1 Assisting attending 4 (21.1%) 14 (73.7%) 1 (5.3%) 0 2 Books/journal 0 0 0 19 (100%) 4 Highly edited surgical videos 0 1 (5.3%) 18 (94.7%) 0 3 View Large Post-interventional outcomes are displayed in Figure 2, which shows the change in confidence that residents experienced in performing a particular procedure. A significant subjective increase in confidence was determined in 6/14 modules. No significant improvement was seen in 3 of the categories. Of note, data were unable to be analyzed in 5 of the categories. Overall resident satisfaction with the multimedia-based aesthetic curriculum is displayed in Table 5. 93.8% of residents found the modules helpful, and 93.3% said they would be interested in incorporating them into residency. Residents were also asked to rank the usefulness of the modules. On a scale of 1 (most useful) to 5 (least useful), all modules received a score between 2 and 3. Table 5. Training Satisfaction Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) View Large Table 5. Training Satisfaction Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) Variable/statistic Did you find the modules helpful? n (%)  Yes 15 (93.8%) Would you be interested in incorporating them into residency? n (%)  Yes 14 (93.3%) Usefulness of the modules on a scale of 1 (most useful) to 5 (least useful) Median (IQR)  Face/neck lift 2 (1-4)  Rhinoplasty 3 (1-3)  Breast augmentation 3 (2-3.75)  Mastopexy 3 (2-4)  Blepharoplasty 2.5 (1.25-4)  Nonsurgical 3 (2.25-3.75)  Abdominoplasty 2.5 (1-3)  Brow lift 2 (1.25-3) View Large Figure 2. View largeDownload slide Pre- and post-module changes in performing procedure. Figure 2. View largeDownload slide Pre- and post-module changes in performing procedure. DISCUSSION It is imperative that plastic surgery residents are experienced and confident in performing aesthetic surgery, for both continued advancement and innovation in the field, and to ensure patient safety. However, there is evidence to suggest that this objective is not being adequately met. In 1996, Linder et al reported that more than half of recent plastic surgery graduates felt that their exposure to aesthetic procedures was insufficient.12 A decade later, Morrison et al found that half of graduating plastic surgery residents still felt inadequately prepared to integrate cosmetic surgery into their future practice.9 This sentiment is not unique to plastic surgery residents in the United States; similar views have been expressed by residents in Canada, Europe, and India.8,13-15 Subsequent re-evaluation of the aesthetic training paradigm resulted in significant changes, such as the addition of one year to residency training, increases in the minimum cosmetic case number for residents, and the establishment of a standardized curriculum for post-residency aesthetic fellowships. However, despite promising reports of increasing resident confidence in performing aesthetic procedures—suggestive of improved training—from 2008 to 2011, subsequent studies suggest that this rise has plateaued.3,10,16 Given the inherent limitations to resident exposure to aesthetic procedures, such as the relatively small volume at most academic centers, some have advocated for the incorporation of cosmetic surgery modules and other digital alternatives—such as web-based and video resources—into training programs to address this challenge. Integration of these modalities into resident training has been slow, and there is a lack of prospective studies evaluating the efficacy of digital educational alternatives. In this study, we assessed resident experiences and attitudes towards our pilot aesthetic surgery curriculum at our institution, and evaluated an 8-week aesthetic pilot curriculum consisting of surgical videos and accompanying focused articles. Clearly, the Halstedian model of direct exposure to—and involvement in—actual aesthetic surgical procedures is the most effective way to educate trainees and help them achieve competence in the surgical domain.12,17 This has been validated as superior to classroom-based education, and importantly, it has been shown that practice-based methods of resident training, such as educational aesthetic surgeries and Resident Aesthetic Clinics (RACs), increase resident preparedness and confidence for practice, do not adversely affect long-term surgical outcomes or major complication rates when compared to national outcomes, and furthermore, can improve patient quality of life despite variations in program structure, and across both surgical and non-surgical procedures.17-22 At our institution, residents receive 3 months of dedicated aesthetic training in our resident cosmetic clinic during both PGY 5 and 6. Prior to this, the majority of aesthetic education occurs via traditional self-learning (eg, textbooks, journals), studying for board exams, or at conferences. It is perhaps unsurprising then, that the vast majority (78.9%) of residents in our study ranked cosmetic resident clinics as their preferred mode of education. Although we did not specifically ask residents whether this assertion was based on a general perception of RACs or experience with our aesthetic clinic, the significant increases observed in both resident exposure and confidence as training progressed—particularly during these final 2 years—reiterates the significance of direct operative experience in resident education. However, while this may be a realistic training method at certain programs, practical issues relating to funding, geography, sufficient faculty oversight, and patient population, as well as issues related to liability and malpractice, unfortunately make this method of resident education an unrealistic first-line option in many cases.23-25 As such, the number of cosmetic resident clinics has not significantly increased over the past 8 years (present at 60% to 70% of centers), and these centers are rare outside the United States.3,6,17 Residents in our study also favored learning through assisting attending’s in the operating room, but limitations on resident work hours, combined with a healthcare landscape increasingly driven towards cost effectiveness, will undoubtedly continue to limit direct operative experience.26 Furthermore, there can exist significant variability in aesthetic operative experience among residents even within the same program, as was found in our study. This can be attributed to the training structure at most integrated programs, in which residents spend the preliminary years of residency completing “core surgery” rotations, as recommended by Plastic Surgery Residency Review Committee (RRC), in which operative exposure to plastic surgery—and particularly aesthetic surgery—is limited, if not absent. This likely explains the significant positive correlation we found between aesthetic exposure and perceived procedural confidence as residents progress along their training. Cadavers are another popular mode of education, but availability and cost limit widespread use among programs.3 Live animal models, while important for basic science research of aesthetic materials and technical principles, are not realistic substitutes for direct operative experience. More traditional modes of education, such as books or journals, certainly have value and are excellent means of obtaining foundational knowledge in a topic and tracking the latest advances and trends. Notably, 60% of plastic surgery residents continue to use physical textbooks on a weekly basis.27 However, the residents in our study unanimously ranked this method as their least preferred method of learning, perhaps reflective of the transformation from a knowledge-based to competency-based model of residency training.28,29 At the regulatory level, the Accreditation Council for Graduate Medical Education (ACGME) has developed core competencies and milestones emphasizing outcomes-based education, and the aesthetic topics tested on recent Plastic Surgery In-Service Training Exams (PSITE) favor decision making and outcomes over anatomy and diagnosis.30,31 In our study, only 16.7% of residents expressed a desire to pursue an aesthetic fellowship, which is lower than that seen in other studies, but consistent with recent evidence that fewer residents feel they need a fellowship to practice cosmetic surgery.3,16 Furthermore, 60% of our cohort expressed interest in pursuing careers in academic medicine, which inherently possess less of an aesthetic focus as compared to solo or group private practices. Thus, it is interesting, and encouraging that 90% of our cohort nonetheless saw value in a structured aesthetic curriculum, suggesting an appreciation by residents for education in all aspects of the field. While our cohort did include a majority of residents from combined plastic surgery tracks, prior studies have not found differences among residents in combined, independent, or integrated programs.11 Consistent with the aforementioned literature, we found that resident satisfaction with their current aesthetic training was low (15%), as was confidence level across many surgical and nonsurgical procedures. Of course, not all aesthetic procedures are comparable, and multiple studies have shown that residents find facial procedures more difficult than cosmetic breast and body contouring procedures.3,8,11 Notably, of the 5 surgical procedures in which residents experienced statistically significant increases in confidence following participation in the modules, 4 of them (lower blepharoplasty, brow lift, face/neck lift, and rhinoplasty) involved the face. Furthermore, many believe that the future of cosmetic surgery depends on the ability of surgeons to adapt and meet the demand for non-surgical procedures.32,33 However, deficiencies in the training of non-surgical aesthetic procedures have been demonstrated in residents both domestically and abroad, and it is difficult for residents to reach minimum case requirements in neuromodulators and dermal fillers.11,26,34 Modules in our study not only increased resident confidence in surgical procedures, but also in the use of fillers, an increasingly popular non-surgical procedure, and a core competency requirement for plastic surgery residents. Thus, we believe newer technologies may be able to address gaps in exposure to more complex and uncommon procedures. Technology-based education has been adopted across all of medicine. In surgery specifically, Khansa and Janis review a number of technological resources that have been incorporated into plastic surgery residency training.35 These include curriculum-based resources—such as the Plastic Surgery Education Network (PSEN)—as well as decision-making applications, surgical simulators and modules, video analysis, and other computer-based tools. They divide these into 3 types: those that help acquire new knowledge; those that help teach basic surgical planning, anatomy, and concepts; and those that help develop, improve, and refine surgical technique. Evidence of the efficacy of surgical education interventions such as these is promising. A meta-analysis by McGaghie et al examining the effects of technological integration in surgical resident education found simulation-based education to be more effective at teaching new skills as compared to traditional educational models.36 Surgical simulators have been developed for craniofacial, cleft, and breast surgery, and exhibit educational efficacy in domains such as skill assessment and decision making.37-39 With increasing affordability and accessibility, 3D printing represents an effective educational tool that exhibits improved patient and surgical outcomes as compared to traditional methods.40 However, despite the fact that many of these technology-based resources already exist, awareness and implementation unfortunately remain an obstacle. For example, 78% of plastic surgery residents were not aware of, nor had ever used, RADAR, the readily available digital aesthetic resource.27 Thus, formal integration into residency curriculum may ultimately be necessary for proper utilization. Since most of these technologies are easily accessible via computer or smartphone, they can be readily integrated into the teaching curriculum or as part of required preparation for surgery. iPads have been successfully integrated into plastic surgery training and were shown to improve not only resident education, but also clinical efficiency and HIPAA compliance.41 Technology has also demonstrated value as a feedback tool and can enrich communication between residents and faculty.42,43 As active resident participation is critical to successful integration of technology, it is encouraging that more than 90% of our residents found the modules helpful and were interested in incorporating them into their residency curriculums. As the majority of current faculty and program directors were trained in environments without the use of these newer technologies, resident participation and active engagement will be necessary for effective integration. In this study, our primary outcomes of interest were value and subjective resident perceptions of an integrated aesthetic curriculum in plastic surgery residency training as an adjunct to routine clinical and educational responsibilities. As such, there are several notable limitations to our study. First, our study was limited to a single academic institution and thus, in addition to a small sample size and an inability to account for potential covariates, does not account for variation in residency program size, exposure, volume, or location, thereby limiting generalizability.44 Similarly, while we attempted to account for prior resident engagement or interest in aesthetic surgery by querying expected fellowship and career plans in the pre-survey, our study does not directly account for this factor. Furthermore, aesthetic principles and procedures are relevant to all residents and plastic surgeons, not just those for whom it dominates their fellowship training or future practice. Therefore, while we believe that a structured curriculum, particularly in the early stages of residency, would augment the education of residents, regardless of prior engagement, this is an interesting avenue of future research that we hope to include in future studies. Additionally, while we show that perceived pre-curriculum confidence in performing aesthetic procedures is significantly associated with prior case exposure, we did not include an objective metric for measuring post-module competency in our study, as there currently exist no validated measuring tools for assessing pre- and post-intervention competency of aesthetic topics in residents, particularly across various levels of training. It is unlikely that board-like exam questions alone are the optimal method for assessing surgical competency, and further studies are required to determine how to most accurately measure aesthetic and non-aesthetic competency and confidence, and whether non-operative exposure or subjective perceptions translate into operative competency or performance. Time allotment is another factor we did not study, but would be an important consideration for any standardized curriculum given the variations in workload and responsibility across PGY or rotations. Finally, the modules themselves were selected subjectively by the senior authors and consisted of a series of readings and accompanying surgical videos that were not standardized across different procedure types. Larger, multi-program studies incorporating greater numbers of residents, and approved, standardized proficiency metrics are warranted in order to minimize bias and increase power. Such initiatives will be critical for assessing the efficacy of these technologies across the spectrum of plastic surgery residency education. CONCLUSION In this study, we show that plastic surgery residents are willing to participate in a structured aesthetic curriculum incorporating digital resources—even if they do not plan on focusing on cosmetic surgery in their careers. Furthermore, we demonstrate that such a curriculum can efficiently increase resident confidence in both surgical and nonsurgical aesthetic procedures, and may be particularly valuable in the early years of residency, or in programs in which operative exposure to aesthetic surgery is minimal or absent. It is imperative that the field of plastic surgery embraces the advantages of the currently available—and increasingly affordable and accessible—technologically based educational alternatives in order to address the current challenges of aesthetic surgery training. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Mackay DR , Johnson S . The origins and current state of plastic surgery residency in the United States . J Craniofac Surg . 2015 ; 26 ( 8 ): 2251 - 2253 . 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Journal

Aesthetic Surgery JournalOxford University Press

Published: Nov 12, 2018

References

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