Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices Abstract Background The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. Objectives The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. Methods A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. Results Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. Conclusions The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy. Providing training in aesthetic surgery is one of the central goals of any plastic surgery residency program. However, several program directors have described the challenge of providing sufficient exposure to cosmetic surgery in the teaching hospital setting.1-3 Resident-directed aesthetic surgery clinics have emerged as a promising solution to this problem. A number of surveys have explored the quality of cosmetic training in plastic surgery residency. In 2010, Neaman et al found that the majority of residency programs were associated with a resident clinic.1 A comprehensive survey of 95 program directors by Hashem et al in 2017 observed that resident-directed clinics were considered the best modality for cosmetic surgery training by both program directors and current residents.4 Moreover, surgical outcomes of resident-directed clinics have been shown to be comparable with national outcomes.2,3 Participation in resident aesthetic surgery clinics is an effective training method for the development of both surgical technique and operative autonomy. The value of these clinics in enhancing the diversity of residency training is especially significant in recent years, in light of the increased minimum aesthetic surgery requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). The authors sought to evaluate current practices of resident aesthetic surgery clinics by conducting a comprehensive survey of all plastic surgery training programs in the country. METHODS A survey examining specific aspects of resident aesthetic surgery clinics was distributed to 70 plastic surgery resident program directors in the United States. Surveys were administered in a single mailing via the American Council of Academic Plastic Surgeons (ACAPS) listserv of all program directors. No reminders were sent to unresponsive participants. Surveys were sent in August 2017 and responses were collected through September 2017. Thirty-five total questions sought to delineate: (1) each clinic’s structure; (2) procedures and services offered; (3) financial cost to the patient; and (4) satisfaction and educational benefit derived from the experience (Appendix A). The survey was designed by the senior author (P.J.T.). Questions comprised a variety of response formats, including yes/no, multiple choice, and free text. The collected answers were entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA) for qualitative and statistical analysis. Partially completed surveys were included in the final analysis to the greatest extent possible. For questions with free text responses, equivalent phrases were identified within the body of the response and equivalent answers were counted as the same answer in order to simplify quantification of our results. Statistical analysis was performed using Microsoft Excel. Responses were summarized using frequencies and percentages. This survey was conducted through ACAPS, a professional society whose membership are all involved directly in resident education. Hence, this study did not require approval by an Institutional Review Board (IRB). The ethical principles established by the Declaration of Helsinki were followed in order to protect the life, health, privacy, and dignity of all human subjects. Participation was voluntary, the privacy of the participants was protected, and the confidentiality of individual responses was maintained. RESULTS A total of 52 questionnaires were returned, a 74.2% response rate from the 70 plastic surgery programs. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. Clinic Structure This portion of the survey sought to address the overall clinic setup, methodology for patient recruiting, and scheduling of operations. Regarding availability and patient volume, a large percentage of programs (n = 23) indicated that a resident aesthetic surgery clinic is scheduled once per week. A few programs reported having clinic more frequently (Supplemental Figure 1). Twenty-seven programs reported seeing 1 to 5 new aesthetic consults per clinic session, and only two see more than 10 (Figure 1). Figure 1. View largeDownload slide Average number of new aesthetic consultations per clinic day. Figure 1. View largeDownload slide Average number of new aesthetic consultations per clinic day. To attract new patients, most aesthetic clinics advertise for their services (n = 28). However, word of mouth was considered the main way patients became aware of the clinic (n = 29), followed by digital advertising outside the institution (n = 5), print advertising inside the institution (n = 3), digital advertising inside the institution (n = 2), and print advertising outside the institution (n = 1). When queried about clinic leadership, thirty-four program directors indicated the chief resident was responsible for directing the clinic. Nine programs included senior residents (PSY 4 and 5) in the clinic leadership, and one program also included junior residents (PSY 2 and 3). In four programs, fellows participated in running the clinic, of which half were aesthetic fellows (n = 2). One program also included a physician assistant in running the clinic. Twenty-nine (56%) programs reported there was an attending present during clinic hours. When asked which providers and/or residents participate in the clinic, thirty-two program directors reported the chief resident participated, fifteen reported participation of senior residents in clinic, and three indicated junior residents participated in clinic. No programs reported the participation of interns in the resident clinic. Questions regarding equipment and support staff showed most clinics have an assistant for billing, booking, etc. (Supplemental Figure 2). Thirteen programs (25%) with a resident aesthetic surgery clinic report having dedicated operative block time. Of these, most programs had dedicated operating room (OR) time once per week (Figure 2). Other programs make the procedures part of the attending physician block schedule. One program reported having a weekly block for both trauma and aesthetic patients. Figure 2. View largeDownload slide Frequency of operative block time. Figure 2. View largeDownload slide Frequency of operative block time. Five program directors noted which other specialties also possessed a resident clinic at their institution. Among the most common were otolaryngology (n = 4), followed by dermatology (n = 3) and ophthalmology (n = 1). Procedures and Services Offered Resident aesthetic surgery clinics offer a range of surgical procedures. Most clinics also offer a variety of invasive and noninvasive aesthetic procedures. When asked to rank the three most common procedures performed, abdominoplasty, breast augmentation, and liposuction were reported to be the most common trio of procedures performed in any individual clinic (n = 5), as well as the most commonly performed procedures overall (Figure 3). Figure 3. View largeDownload slide Most commonly performed procedures. Figure 3. View largeDownload slide Most commonly performed procedures. Regarding the availability of noninvasive procedures, most clinics offer neuromodulators and injectable fillers (Figure 4). The most common neuromodulators used are Botox (n = 28) and Dysport (n = 7). Juvederm (n = 28) was the most commonly available filler, followed by Restylane (n = 20), Perlane (n = 6), and Sculptra (n = 4). One program director indicated all injectable filler products are available at their resident clinic. A number of clinics also offer chemical peels, such as trichloroacetic acid peels (n = 16) and phenol peels (n = 5). Figure 4. View largeDownload slide Services available in resident clinic. Figure 4. View largeDownload slide Services available in resident clinic. Financial Cost to the Patient Although most resident aesthetic surgery clinics offer services at a reduced cost, survey respondents described substantial variation in consultation fees and billing. Many clinics offer a free consult (n = 12). One program has implemented a system where patients are vetted by the practice manager prior to their first appointment, and the number of new patients seen is limited. Other programs have consultation fees ranging from $25 to $250 (Figure 5). Of these, two clinics offered to apply the consultation fee to the surgery if scheduled. The resident aesthetic surgery clinic charging $250 for the initial consult was inclusive of all subsequent preoperative consults. Figure 5. View largeDownload slide Consultation fees. Figure 5. View largeDownload slide Consultation fees. Across clinics billing structures varied. Many clinics offer a per cent discount on the procedure (n = 11). Others offer a tiered pricing structure depending on the length and complexity of the procedure (n = 7). A smaller number of clinics offer a flat surgeon’s fee (n = 3). Most clinics charged additionally for anesthesia and facility fees, at standard, set prices (n = 13). Supplemental Table 1 shows the specific responses by program directors when asked how the procedures were billed to the patients. The most popular billing method used was a 50% discount on the attending surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees (n = 6). Some program directors provided information regarding payment options offered to patients. Three program directors indicated the procedures must be paid prior to surgery and one indicated they offer a payment plan. Additionally, one clinic offered free neurotoxin and/or filler for first time patients. Satisfaction and Educational Benefit Derived From the Experience Most program directors felt satisfied or very satisfied with the aesthetic resident clinic in their institution (n = 26), while three respondents reported being unsatisfied or very unsatisfied with the resident clinic (Figure 6). The majority of clinics track outcomes through the division/department morbidity and mortality conference (n = 28). Others held a dedicated aesthetic conference (n = 6), one used oral presentations to track outcomes, and four respondents reported outcomes are not tracked. Only three clinics handle complications for free, most charge for OR and anesthesia (Supplemental Figure 3). Figure 6. View largeDownload slide Program director satisfaction with resident clinic. Figure 6. View largeDownload slide Program director satisfaction with resident clinic. Supplemental Table 2 shows individual answers to the question “is there anything you would want more for the clinic?” Four program directors replied they would like more patients for the clinic, three would like to add lasers to their services, and one would like dedicated OR time. One respondent argued the overall value of the clinic was questionable, and worried that patients were being treated by less experienced practitioners. DISCUSSION Quality training in aesthetic surgery is a pillar of the plastic surgery residency framework. The Plastic Surgery Residency Review Committee of the ACGME recently increased the minimum case numbers for aesthetic procedures, setting a new standard for required resident exposure to cosmetic cases. Minimum case numbers for less invasive cosmetic procedures such as botulinum toxin and filler injections were also introduced. In light of these new core requirements, we sought to characterize the current state of resident clinics, determine the particular strengths, and identify possible areas for growth. The renewed focus on aesthetic surgery training underscores the invaluable role of resident aesthetic clinics in supporting the development of operative confidence and independent clinical decision making. Several studies have observed that resident clinics are a very effective educational method to achieve these goals, citing the high value, resident satisfaction, and excellent patient outcomes associated with the clinics.2,5,6 Sixty-three per cent of our survey respondents reported incorporating a resident clinic into their training programs, in concordance with previous reports that the rate of cosmetic clinics at plastic surgery residency programs remains stable at approximately 60%. In 2016, Hashem et al conducted a survey on perceptions by residents and program directors of aesthetic training during plastic surgery residency.4 They found residents were most confident with abdominoplasties, breast reductions, and augmentation mammaplasty. Facial aesthetic procedures such as rhinoplasties and facelifts were perceived as more challenging. In a recent publication Weissler et al assess the value of resident-run aesthetic clinics in plastic surgery education.7 They surveyed physicians who graduated from the plastic and reconstructive surgery program at their institution between 2009 and 2016. The authors found participants overwhelmingly agreed that their experience at the clinic was useful and helped them meet graduation requirements. All participants expressed strong support for the clinic and they believed there was not enough time dedicated to it. Furthermore, their study found the number of procedures performed in clinic to be significantly associated with the participants’ self-reported confidence in performing those procedures. Respondents reported being most comfortable with breast procedures such as augmentation mammaplasties and mastopexies, as well as body/truck procedures such as abdominoplasty and liposuction. They felt least comfortable with face/neck procedures such as rhinoplasties and neck lifts. Although Weissler’s survey shows that rhytidectomies are among the most common facial procedures, they constitute a small portion of the procedures performed. The present survey supports previous findings indicating that abdominoplasty and breast augmentation are the most commonly performed procedures in resident-run plastic surgery clinics.7 However, few respondents reported mastopexy among the most commonly performed procedures, and breast reductions were not mentioned. This could be explained by a distinction made by the respondents who did not consider breast reduction an aesthetic procedure. Additionally, breast reductions are often covered by health insurance, so patients are less likely to search for affordable options. Interestingly, three respondents reported facelifts as one of the most performed procedures in contrast to previous research. Hashem et al also reported a decrease in hands on training on minimally invasive procedures.4 In our survey, some respondents expressed an interest in offering more noninvasive cosmetic services in the clinic, particularly laser resurfacing. The ACAPS aesthetic surgery task force published recommendations for resident-run clinics in 2015, discouraging the implementation of nonsurgical facial rejuvenation procedures in favor of surgical procedures.8 However, the present study shows that most clinics are preforming these procedures and five respondents listed minimally invasive procedures among the most common procedures performed through the clinic. This may represent the beginning of a paradigm shift in resident clinic focus as the popularity of minimally invasive techniques increases. Over 14 million cosmetic minimally invasive procedures were performed in 2015. The popularity of these procedures is understandable, given their relatively lower risk, shorter duration, and quicker recovery period. Soft tissue fillers and chemical peels have risen 6% and 5%, respectively, in popularity in the last year alone. The substantial increase in the number of FDA-approved fillers highlights the rapidly growing popularity of these minimally invasive procedures. Meanwhile, a study published in 2016 shows that up to 10% of graduating residents in plastic surgery did not meet the case minimums for injectable procedures.9 Although ideally resident-run cosmetic clinics would have enough patient volume for chief and senior residents to acquire operative experience, a number of our survey participants reported low patient volume as a key issue. Offering fillers, peels, and lasers in the resident clinic may attract new patients, thereby boosting clinic volume and providing valuable experience in what could otherwise be an educational deficit. Additionally, clinics can be an appropriate environment for junior residents to acquire experience with these procedures. Qureshi et al demonstrated that nonsurgical facial rejuvenation procedures such as neuromodulators and soft tissue fillers can be performed by supervised residents as early as their second year of training with excellent patient reported outcomes. Furthermore, none of the 45 patients who completed their study suffered from complications during the one month follow up.10 These procedures may also serve as a strategy for programs without dedicated OR time or staffing to increase familiarity with common, minimally invasive cosmetic procedures. Practice management is another central component of the ACGME’s Core Competencies for plastic surgery training. In the authors’ opinion, resident clinics are invaluable for trainees to gain experience with the particulars of independent practice. Neaman et al sought to characterize the educational utility of chief resident clinics.1 The authors concluded that the chief clinic model provides a suitable environment for enhancing knowledge in systems-based practice, professionalism, patient care, and interpersonal and communication skills. Resident clinics are routinely cited as providing enough patient volume to greatly exceed the ACGME requirements for aesthetic procedures.1,11 Nearly half of our respondents reported receiving 3 to 5 new aesthetic consultations per clinic day, and the vast majority host clinic at least once per week. Eighty per cent of respondents reported advertising for the chief clinic. However, 74% then observed that word of mouth remains the primary mechanism by which patients become aware of the resident clinic. A possible suggestion to address this discrepancy would be encouraging residents to fully embrace the full spectrum of simulating independent practice by designing marketing and advertising materials and promoting their clinics on social media to engage additional patients. This will be an increasingly valuable practice as the role of social media in plastic surgery grows.12 Despite the clear educational advantages offered by resident clinics, programs can be limited by funding, lack of supervising faculty and support staff, and/or adequate dedicated OR time. The present results indicate that while the vast majority of program directors feel satisfied or very satisfied with their established resident clinic, ongoing challenges cited include the lack of dedicated OR time and support staff as well as low patient volume. One program director questioned the net value of the clinic, stating that higher risk patients are being treated by “the least experienced practitioner.” However, studies have demonstrated that resident-run cosmetic clinics have complication rates comparable to national outcomes.2,3 Resident-directed aesthetic surgery clinics also provide a valuable service to patients who may not otherwise have access to an appropriately trained cosmetic surgeon. Surveys of patients who had a gastric bypass show most patients would like to have body contouring surgery after their massive weight loss. It was found the main reason why only a minority of patients undergo the procedure was due to cost.13 Furthermore, millions of patients travel abroad every year to seek medical care, with many traveling in search of affordable cosmetic surgery. Treatment for complications from procedures performed abroad cost millions of dollars every year and most of that cost is assumed by Medicare. Even if we assume a similar complication rate for procedures performed abroad, patients would benefit from the continuity of care they would receive by having their procedure in the United States.14 This study has a number of strengths. The high survey response rate (72.4%) establishes that the responses are representative of the vast majority of training programs. This is the highest response rate to date compared to prior surveys investigating the status of resident clinics, including the American Society of Plastic Surgeons 2008 survey of residents and program directors (64% response rate).15 Our findings expand on the body of research that demonstrates the utility of resident-run cosmetic clinics. Moreover, few studies to date have characterized the structure of resident aesthetic clinics and the services offered. Our survey is the most comprehensive and current update on the status of resident-run clinics in the country. The authors advocate the incorporation of resident-run cosmetic clinics to enhance aesthetic surgery training and address the disparities in aesthetic training that currently exist. By presenting a detailed view of the structure of existing clinics and the challenges these clinics face, we hope to facilitate the incorporation of resident-run cosmetic in programs across the United States. There are limitations to this current report. The survey used was not validated or pretested before distribution. Additionally, several questions were designed to be answered in a free text format to allow for candid responses, which limited the capacity to directly compare answers. This was addressed to a certain extent by identifying common phrases in each free text response. Though this free text response format is by default not a validated tool, we feel that allowing for open responses enabled us to obtain a diverse range of answers unencumbered by premade options. Furthermore, the data presented in this study are self-reported, which raises the possibility of inaccuracies. However, in this study the authors chose to survey only program directors of accredited training programs, with all responses submitted anonymously. Given that program directors are intimately associated with resident training and thereby the resident clinic, we feel that the answers provided are authentic and constructive. Finally, it is possible that program directors with a resident-run cosmetic clinic at their institution were more likely to respond to this, and other surveys on the same subject, leading to an overestimation of the number of programs that have implemented resident clinics. The present survey was administered only to program directors and did not include plastic surgery residents or fellows. This is due to the fact that the primary objective of this study was to describe the current state of resident aesthetic clinics. The authors may perform a subsequent survey of residents in the future to assess resident perception and educational benefit of aesthetic clinics. CONCLUSION Resident aesthetic surgery clinics are evolving alongside the growing demand for and range of cosmetic procedures available. Practices vary greatly across these clinics. However, these clinics were employed by the majority of the plastic surgery programs surveyed. The role of resident-directed clinics will likely continue to grow to fill the need for high quality, lower cost aesthetic surgery while strengthening resident aesthetic training and autonomy. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. 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. Neaman KC , Hill BC , Ebner B , Ford RD . Plastic surgery chief resident clinics: the current state of affairs . Plast Reconstr Surg . 2010 ; 126 ( 2 ): 626 - 633 . Google Scholar CrossRef Search ADS PubMed 2. Pyle JW , Angobaldo JO , Bryant AK , Marks MW , David LR . Outcomes analysis of a resident cosmetic clinic: safety and feasibility after 7 years . Ann Plast Surg . 2010 ; 64 ( 3 ): 270 - 274 . Google Scholar CrossRef Search ADS PubMed 3. 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 4. Hashem AM , Waltzman JT , D’Souza GF , et al. Resident and program director perceptions of aesthetic training in plastic surgery residency: an update . Aesthet Surg J . 2017 ; 37 ( 7 ): 837 - 846 . Google Scholar CrossRef Search ADS PubMed 5. 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 6. Linder SA , Mele JA 3rd , Capozzi A . Teaching aesthetic surgery at the resident level . Aesthetic Plast Surg . 1996 ; 20 ( 4 ): 351 - 354 . Google Scholar CrossRef Search ADS PubMed 7. 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 8. 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 9. 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 10. 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 11. 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 12. Branford OA , Kamali P , Rohrich RJ , et al. #PlasticSurgery . Plast Reconstr Surg . 2016 ; 138 ( 6 ): 1354 - 1365 . Google Scholar CrossRef Search ADS PubMed 13. Azin A , Zhou C , Jackson T , Cassin S , Sockalingam S , Hawa R . Body contouring surgery after bariatric surgery: a study of cost as a barrier and impact on psychological well-being . Plast Reconstr Surg . 2014 ; 133 ( 6 ): 776e - 782e . Google Scholar CrossRef Search ADS PubMed 14. Adabi K , Stern CS , Weichman KE , et al. Population health implications of medical tourism . Plast Reconstr Surg . 2017 ; 140 ( 1 ): 66 - 74 . Google Scholar CrossRef Search ADS PubMed 15. Morrison CM , Rotemberg SC , Moreira-Gonzalez A , Zins JE . A survey of cosmetic surgery training in plastic surgery programs in the United States . Plast Reconstr Surg . 2008 ; 122 ( 5 ): 1570 - 1578 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. 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Abstract

Abstract Background The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. Objectives The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. Methods A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. Results Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. Conclusions The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy. Providing training in aesthetic surgery is one of the central goals of any plastic surgery residency program. However, several program directors have described the challenge of providing sufficient exposure to cosmetic surgery in the teaching hospital setting.1-3 Resident-directed aesthetic surgery clinics have emerged as a promising solution to this problem. A number of surveys have explored the quality of cosmetic training in plastic surgery residency. In 2010, Neaman et al found that the majority of residency programs were associated with a resident clinic.1 A comprehensive survey of 95 program directors by Hashem et al in 2017 observed that resident-directed clinics were considered the best modality for cosmetic surgery training by both program directors and current residents.4 Moreover, surgical outcomes of resident-directed clinics have been shown to be comparable with national outcomes.2,3 Participation in resident aesthetic surgery clinics is an effective training method for the development of both surgical technique and operative autonomy. The value of these clinics in enhancing the diversity of residency training is especially significant in recent years, in light of the increased minimum aesthetic surgery requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). The authors sought to evaluate current practices of resident aesthetic surgery clinics by conducting a comprehensive survey of all plastic surgery training programs in the country. METHODS A survey examining specific aspects of resident aesthetic surgery clinics was distributed to 70 plastic surgery resident program directors in the United States. Surveys were administered in a single mailing via the American Council of Academic Plastic Surgeons (ACAPS) listserv of all program directors. No reminders were sent to unresponsive participants. Surveys were sent in August 2017 and responses were collected through September 2017. Thirty-five total questions sought to delineate: (1) each clinic’s structure; (2) procedures and services offered; (3) financial cost to the patient; and (4) satisfaction and educational benefit derived from the experience (Appendix A). The survey was designed by the senior author (P.J.T.). Questions comprised a variety of response formats, including yes/no, multiple choice, and free text. The collected answers were entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA) for qualitative and statistical analysis. Partially completed surveys were included in the final analysis to the greatest extent possible. For questions with free text responses, equivalent phrases were identified within the body of the response and equivalent answers were counted as the same answer in order to simplify quantification of our results. Statistical analysis was performed using Microsoft Excel. Responses were summarized using frequencies and percentages. This survey was conducted through ACAPS, a professional society whose membership are all involved directly in resident education. Hence, this study did not require approval by an Institutional Review Board (IRB). The ethical principles established by the Declaration of Helsinki were followed in order to protect the life, health, privacy, and dignity of all human subjects. Participation was voluntary, the privacy of the participants was protected, and the confidentiality of individual responses was maintained. RESULTS A total of 52 questionnaires were returned, a 74.2% response rate from the 70 plastic surgery programs. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. Clinic Structure This portion of the survey sought to address the overall clinic setup, methodology for patient recruiting, and scheduling of operations. Regarding availability and patient volume, a large percentage of programs (n = 23) indicated that a resident aesthetic surgery clinic is scheduled once per week. A few programs reported having clinic more frequently (Supplemental Figure 1). Twenty-seven programs reported seeing 1 to 5 new aesthetic consults per clinic session, and only two see more than 10 (Figure 1). Figure 1. View largeDownload slide Average number of new aesthetic consultations per clinic day. Figure 1. View largeDownload slide Average number of new aesthetic consultations per clinic day. To attract new patients, most aesthetic clinics advertise for their services (n = 28). However, word of mouth was considered the main way patients became aware of the clinic (n = 29), followed by digital advertising outside the institution (n = 5), print advertising inside the institution (n = 3), digital advertising inside the institution (n = 2), and print advertising outside the institution (n = 1). When queried about clinic leadership, thirty-four program directors indicated the chief resident was responsible for directing the clinic. Nine programs included senior residents (PSY 4 and 5) in the clinic leadership, and one program also included junior residents (PSY 2 and 3). In four programs, fellows participated in running the clinic, of which half were aesthetic fellows (n = 2). One program also included a physician assistant in running the clinic. Twenty-nine (56%) programs reported there was an attending present during clinic hours. When asked which providers and/or residents participate in the clinic, thirty-two program directors reported the chief resident participated, fifteen reported participation of senior residents in clinic, and three indicated junior residents participated in clinic. No programs reported the participation of interns in the resident clinic. Questions regarding equipment and support staff showed most clinics have an assistant for billing, booking, etc. (Supplemental Figure 2). Thirteen programs (25%) with a resident aesthetic surgery clinic report having dedicated operative block time. Of these, most programs had dedicated operating room (OR) time once per week (Figure 2). Other programs make the procedures part of the attending physician block schedule. One program reported having a weekly block for both trauma and aesthetic patients. Figure 2. View largeDownload slide Frequency of operative block time. Figure 2. View largeDownload slide Frequency of operative block time. Five program directors noted which other specialties also possessed a resident clinic at their institution. Among the most common were otolaryngology (n = 4), followed by dermatology (n = 3) and ophthalmology (n = 1). Procedures and Services Offered Resident aesthetic surgery clinics offer a range of surgical procedures. Most clinics also offer a variety of invasive and noninvasive aesthetic procedures. When asked to rank the three most common procedures performed, abdominoplasty, breast augmentation, and liposuction were reported to be the most common trio of procedures performed in any individual clinic (n = 5), as well as the most commonly performed procedures overall (Figure 3). Figure 3. View largeDownload slide Most commonly performed procedures. Figure 3. View largeDownload slide Most commonly performed procedures. Regarding the availability of noninvasive procedures, most clinics offer neuromodulators and injectable fillers (Figure 4). The most common neuromodulators used are Botox (n = 28) and Dysport (n = 7). Juvederm (n = 28) was the most commonly available filler, followed by Restylane (n = 20), Perlane (n = 6), and Sculptra (n = 4). One program director indicated all injectable filler products are available at their resident clinic. A number of clinics also offer chemical peels, such as trichloroacetic acid peels (n = 16) and phenol peels (n = 5). Figure 4. View largeDownload slide Services available in resident clinic. Figure 4. View largeDownload slide Services available in resident clinic. Financial Cost to the Patient Although most resident aesthetic surgery clinics offer services at a reduced cost, survey respondents described substantial variation in consultation fees and billing. Many clinics offer a free consult (n = 12). One program has implemented a system where patients are vetted by the practice manager prior to their first appointment, and the number of new patients seen is limited. Other programs have consultation fees ranging from $25 to $250 (Figure 5). Of these, two clinics offered to apply the consultation fee to the surgery if scheduled. The resident aesthetic surgery clinic charging $250 for the initial consult was inclusive of all subsequent preoperative consults. Figure 5. View largeDownload slide Consultation fees. Figure 5. View largeDownload slide Consultation fees. Across clinics billing structures varied. Many clinics offer a per cent discount on the procedure (n = 11). Others offer a tiered pricing structure depending on the length and complexity of the procedure (n = 7). A smaller number of clinics offer a flat surgeon’s fee (n = 3). Most clinics charged additionally for anesthesia and facility fees, at standard, set prices (n = 13). Supplemental Table 1 shows the specific responses by program directors when asked how the procedures were billed to the patients. The most popular billing method used was a 50% discount on the attending surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees (n = 6). Some program directors provided information regarding payment options offered to patients. Three program directors indicated the procedures must be paid prior to surgery and one indicated they offer a payment plan. Additionally, one clinic offered free neurotoxin and/or filler for first time patients. Satisfaction and Educational Benefit Derived From the Experience Most program directors felt satisfied or very satisfied with the aesthetic resident clinic in their institution (n = 26), while three respondents reported being unsatisfied or very unsatisfied with the resident clinic (Figure 6). The majority of clinics track outcomes through the division/department morbidity and mortality conference (n = 28). Others held a dedicated aesthetic conference (n = 6), one used oral presentations to track outcomes, and four respondents reported outcomes are not tracked. Only three clinics handle complications for free, most charge for OR and anesthesia (Supplemental Figure 3). Figure 6. View largeDownload slide Program director satisfaction with resident clinic. Figure 6. View largeDownload slide Program director satisfaction with resident clinic. Supplemental Table 2 shows individual answers to the question “is there anything you would want more for the clinic?” Four program directors replied they would like more patients for the clinic, three would like to add lasers to their services, and one would like dedicated OR time. One respondent argued the overall value of the clinic was questionable, and worried that patients were being treated by less experienced practitioners. DISCUSSION Quality training in aesthetic surgery is a pillar of the plastic surgery residency framework. The Plastic Surgery Residency Review Committee of the ACGME recently increased the minimum case numbers for aesthetic procedures, setting a new standard for required resident exposure to cosmetic cases. Minimum case numbers for less invasive cosmetic procedures such as botulinum toxin and filler injections were also introduced. In light of these new core requirements, we sought to characterize the current state of resident clinics, determine the particular strengths, and identify possible areas for growth. The renewed focus on aesthetic surgery training underscores the invaluable role of resident aesthetic clinics in supporting the development of operative confidence and independent clinical decision making. Several studies have observed that resident clinics are a very effective educational method to achieve these goals, citing the high value, resident satisfaction, and excellent patient outcomes associated with the clinics.2,5,6 Sixty-three per cent of our survey respondents reported incorporating a resident clinic into their training programs, in concordance with previous reports that the rate of cosmetic clinics at plastic surgery residency programs remains stable at approximately 60%. In 2016, Hashem et al conducted a survey on perceptions by residents and program directors of aesthetic training during plastic surgery residency.4 They found residents were most confident with abdominoplasties, breast reductions, and augmentation mammaplasty. Facial aesthetic procedures such as rhinoplasties and facelifts were perceived as more challenging. In a recent publication Weissler et al assess the value of resident-run aesthetic clinics in plastic surgery education.7 They surveyed physicians who graduated from the plastic and reconstructive surgery program at their institution between 2009 and 2016. The authors found participants overwhelmingly agreed that their experience at the clinic was useful and helped them meet graduation requirements. All participants expressed strong support for the clinic and they believed there was not enough time dedicated to it. Furthermore, their study found the number of procedures performed in clinic to be significantly associated with the participants’ self-reported confidence in performing those procedures. Respondents reported being most comfortable with breast procedures such as augmentation mammaplasties and mastopexies, as well as body/truck procedures such as abdominoplasty and liposuction. They felt least comfortable with face/neck procedures such as rhinoplasties and neck lifts. Although Weissler’s survey shows that rhytidectomies are among the most common facial procedures, they constitute a small portion of the procedures performed. The present survey supports previous findings indicating that abdominoplasty and breast augmentation are the most commonly performed procedures in resident-run plastic surgery clinics.7 However, few respondents reported mastopexy among the most commonly performed procedures, and breast reductions were not mentioned. This could be explained by a distinction made by the respondents who did not consider breast reduction an aesthetic procedure. Additionally, breast reductions are often covered by health insurance, so patients are less likely to search for affordable options. Interestingly, three respondents reported facelifts as one of the most performed procedures in contrast to previous research. Hashem et al also reported a decrease in hands on training on minimally invasive procedures.4 In our survey, some respondents expressed an interest in offering more noninvasive cosmetic services in the clinic, particularly laser resurfacing. The ACAPS aesthetic surgery task force published recommendations for resident-run clinics in 2015, discouraging the implementation of nonsurgical facial rejuvenation procedures in favor of surgical procedures.8 However, the present study shows that most clinics are preforming these procedures and five respondents listed minimally invasive procedures among the most common procedures performed through the clinic. This may represent the beginning of a paradigm shift in resident clinic focus as the popularity of minimally invasive techniques increases. Over 14 million cosmetic minimally invasive procedures were performed in 2015. The popularity of these procedures is understandable, given their relatively lower risk, shorter duration, and quicker recovery period. Soft tissue fillers and chemical peels have risen 6% and 5%, respectively, in popularity in the last year alone. The substantial increase in the number of FDA-approved fillers highlights the rapidly growing popularity of these minimally invasive procedures. Meanwhile, a study published in 2016 shows that up to 10% of graduating residents in plastic surgery did not meet the case minimums for injectable procedures.9 Although ideally resident-run cosmetic clinics would have enough patient volume for chief and senior residents to acquire operative experience, a number of our survey participants reported low patient volume as a key issue. Offering fillers, peels, and lasers in the resident clinic may attract new patients, thereby boosting clinic volume and providing valuable experience in what could otherwise be an educational deficit. Additionally, clinics can be an appropriate environment for junior residents to acquire experience with these procedures. Qureshi et al demonstrated that nonsurgical facial rejuvenation procedures such as neuromodulators and soft tissue fillers can be performed by supervised residents as early as their second year of training with excellent patient reported outcomes. Furthermore, none of the 45 patients who completed their study suffered from complications during the one month follow up.10 These procedures may also serve as a strategy for programs without dedicated OR time or staffing to increase familiarity with common, minimally invasive cosmetic procedures. Practice management is another central component of the ACGME’s Core Competencies for plastic surgery training. In the authors’ opinion, resident clinics are invaluable for trainees to gain experience with the particulars of independent practice. Neaman et al sought to characterize the educational utility of chief resident clinics.1 The authors concluded that the chief clinic model provides a suitable environment for enhancing knowledge in systems-based practice, professionalism, patient care, and interpersonal and communication skills. Resident clinics are routinely cited as providing enough patient volume to greatly exceed the ACGME requirements for aesthetic procedures.1,11 Nearly half of our respondents reported receiving 3 to 5 new aesthetic consultations per clinic day, and the vast majority host clinic at least once per week. Eighty per cent of respondents reported advertising for the chief clinic. However, 74% then observed that word of mouth remains the primary mechanism by which patients become aware of the resident clinic. A possible suggestion to address this discrepancy would be encouraging residents to fully embrace the full spectrum of simulating independent practice by designing marketing and advertising materials and promoting their clinics on social media to engage additional patients. This will be an increasingly valuable practice as the role of social media in plastic surgery grows.12 Despite the clear educational advantages offered by resident clinics, programs can be limited by funding, lack of supervising faculty and support staff, and/or adequate dedicated OR time. The present results indicate that while the vast majority of program directors feel satisfied or very satisfied with their established resident clinic, ongoing challenges cited include the lack of dedicated OR time and support staff as well as low patient volume. One program director questioned the net value of the clinic, stating that higher risk patients are being treated by “the least experienced practitioner.” However, studies have demonstrated that resident-run cosmetic clinics have complication rates comparable to national outcomes.2,3 Resident-directed aesthetic surgery clinics also provide a valuable service to patients who may not otherwise have access to an appropriately trained cosmetic surgeon. Surveys of patients who had a gastric bypass show most patients would like to have body contouring surgery after their massive weight loss. It was found the main reason why only a minority of patients undergo the procedure was due to cost.13 Furthermore, millions of patients travel abroad every year to seek medical care, with many traveling in search of affordable cosmetic surgery. Treatment for complications from procedures performed abroad cost millions of dollars every year and most of that cost is assumed by Medicare. Even if we assume a similar complication rate for procedures performed abroad, patients would benefit from the continuity of care they would receive by having their procedure in the United States.14 This study has a number of strengths. The high survey response rate (72.4%) establishes that the responses are representative of the vast majority of training programs. This is the highest response rate to date compared to prior surveys investigating the status of resident clinics, including the American Society of Plastic Surgeons 2008 survey of residents and program directors (64% response rate).15 Our findings expand on the body of research that demonstrates the utility of resident-run cosmetic clinics. Moreover, few studies to date have characterized the structure of resident aesthetic clinics and the services offered. Our survey is the most comprehensive and current update on the status of resident-run clinics in the country. The authors advocate the incorporation of resident-run cosmetic clinics to enhance aesthetic surgery training and address the disparities in aesthetic training that currently exist. By presenting a detailed view of the structure of existing clinics and the challenges these clinics face, we hope to facilitate the incorporation of resident-run cosmetic in programs across the United States. There are limitations to this current report. The survey used was not validated or pretested before distribution. Additionally, several questions were designed to be answered in a free text format to allow for candid responses, which limited the capacity to directly compare answers. This was addressed to a certain extent by identifying common phrases in each free text response. Though this free text response format is by default not a validated tool, we feel that allowing for open responses enabled us to obtain a diverse range of answers unencumbered by premade options. Furthermore, the data presented in this study are self-reported, which raises the possibility of inaccuracies. However, in this study the authors chose to survey only program directors of accredited training programs, with all responses submitted anonymously. Given that program directors are intimately associated with resident training and thereby the resident clinic, we feel that the answers provided are authentic and constructive. Finally, it is possible that program directors with a resident-run cosmetic clinic at their institution were more likely to respond to this, and other surveys on the same subject, leading to an overestimation of the number of programs that have implemented resident clinics. The present survey was administered only to program directors and did not include plastic surgery residents or fellows. This is due to the fact that the primary objective of this study was to describe the current state of resident aesthetic clinics. The authors may perform a subsequent survey of residents in the future to assess resident perception and educational benefit of aesthetic clinics. CONCLUSION Resident aesthetic surgery clinics are evolving alongside the growing demand for and range of cosmetic procedures available. Practices vary greatly across these clinics. However, these clinics were employed by the majority of the plastic surgery programs surveyed. The role of resident-directed clinics will likely continue to grow to fill the need for high quality, lower cost aesthetic surgery while strengthening resident aesthetic training and autonomy. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. 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. Neaman KC , Hill BC , Ebner B , Ford RD . Plastic surgery chief resident clinics: the current state of affairs . Plast Reconstr Surg . 2010 ; 126 ( 2 ): 626 - 633 . Google Scholar CrossRef Search ADS PubMed 2. Pyle JW , Angobaldo JO , Bryant AK , Marks MW , David LR . Outcomes analysis of a resident cosmetic clinic: safety and feasibility after 7 years . Ann Plast Surg . 2010 ; 64 ( 3 ): 270 - 274 . Google Scholar CrossRef Search ADS PubMed 3. 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 4. Hashem AM , Waltzman JT , D’Souza GF , et al. Resident and program director perceptions of aesthetic training in plastic surgery residency: an update . Aesthet Surg J . 2017 ; 37 ( 7 ): 837 - 846 . Google Scholar CrossRef Search ADS PubMed 5. 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 6. Linder SA , Mele JA 3rd , Capozzi A . Teaching aesthetic surgery at the resident level . Aesthetic Plast Surg . 1996 ; 20 ( 4 ): 351 - 354 . Google Scholar CrossRef Search ADS PubMed 7. 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 8. 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 9. 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 10. 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 11. 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 12. Branford OA , Kamali P , Rohrich RJ , et al. #PlasticSurgery . Plast Reconstr Surg . 2016 ; 138 ( 6 ): 1354 - 1365 . Google Scholar CrossRef Search ADS PubMed 13. Azin A , Zhou C , Jackson T , Cassin S , Sockalingam S , Hawa R . Body contouring surgery after bariatric surgery: a study of cost as a barrier and impact on psychological well-being . Plast Reconstr Surg . 2014 ; 133 ( 6 ): 776e - 782e . Google Scholar CrossRef Search ADS PubMed 14. Adabi K , Stern CS , Weichman KE , et al. Population health implications of medical tourism . Plast Reconstr Surg . 2017 ; 140 ( 1 ): 66 - 74 . Google Scholar CrossRef Search ADS PubMed 15. Morrison CM , Rotemberg SC , Moreira-Gonzalez A , Zins JE . A survey of cosmetic surgery training in plastic surgery programs in the United States . Plast Reconstr Surg . 2008 ; 122 ( 5 ): 1570 - 1578 . 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)

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Aesthetic Surgery JournalOxford University Press

Published: Mar 14, 2018

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