Am J Otolaryngol 11:18L%190,1990
Facial Plastic Surgery in the Otolaryngology Training Program: An Update J.
REGAN THOMAS, MD, TAMARAK. EHLERT, MD, AND JEFFREYFENWICK, MD
In 1985, we demonstrated that, following the institution of a specific curriculum in facial plastic surgery, the number of cosmetic procedures generated and performed by residents rose dramatically. We have now demonstrated that this increase has been sustained in the 5 years since establishing the curriculum. We continue to maintain that the key to a successful curriculum in facial plastic surgery is the presence of at least one full-time staff member whose primary function is the practice and teaching of facial plastic surgery. AM J OTOLARYNGOL 11:188-190. 0 1990 by W.B. Saunders Company. Key words: facial plastic surgery, resident training.
the unique position of receiving at least 4 years of training specific to the head and neck. It is important that this training include specific instruction in the growing field of facial cosmetic surgery. In 1985, we reported the introduction of a specific facial plastic surgery curriculum3 for residents. A statistical analysis of the residentgenerated cosmetic surgery cases in the years immediately preceeding and following the introduction of this curriculum showed a significant increase in the number of facial plastic and reconstructive procedures performed by residents. Regular exposure to the techniques and concepts of aesthetic surgery through the teaching of a practicing staff member appointed for that purpose was felt to be the key element in the success of the program.* We returned in 1988 to reevaluate this program (Fig 1). It was our goal to determine whether, after 5 years, the initial interest in the program and increase in the number of aesthetic procedures had been maintained. We also wished to see if the addition of a fellow in facial plastic and reconstructive surgery at this institution had altered the results.
Facial plastic surgery, always within the domain of the otolaryngologist-head and neck surgeon, is no longer relegated to the last chapter of the text or last page of the residency curriculum. Recognizing the otolaryngologist’s unique understanding of head and neck anatomy and facility with soft tissue/reconstructive techniques, the medical community in general has come to recognize the key role played by the otolaryngologisthead and neck surgeon in the development of this challenging field. In its certification examinations, the American Board of Otolaryngology (ABO) requires a knowledge of “, . . the cognitive management (of) aesthetic, plastic and reconstructive surgery of the face, head and neck.“l The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), in response to the need for guidelines in establishing core curricula in plastic surgery, developed a comprehensive handbook’ outlining the essential abilities required of all otolaryngology residents preparatory to practice in this area. The AAFPRS, along with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), supports many programs, workshops, and conferences covering all aspects of facial plastic surgery, and maintains an impressive list of books, videotapes, and monographs available for the instruction of residents and practitioners. The otolaryngologist is in
METHODS Case numbers were identified and listed for the lyear period from July 1, 1987, to June 30, 1988. Only cases generated and performed solely by resident physicians in that period were counted, excluding all pro-
Received November 3,1968, from the Department of Otolaryngology, Washington University School of Medicine, St Louis, MO 63110. Accepted for publication November 20, 1989. Address correspondence and reprint requests to J. Regan Thomas, MD, #l Barnes Plaza, St Louis, MO 63110. 0 1990 by W.B. Saunders Company. 0196-0709/90/1103-0006$5.00/O
cedures performed by the attending staff or by the fellow in facial plastic surgery. Although residents in the Washington University Otolaryngology program rotate to several hospitals, only cases performed at Barnes Hospital (St Louis) on the resident clinic service was subjected to analysis. These data were compared with 188
THOMAS
ET AL
Figure 1. Percentage of total cases by categories (resident service).
237
RESULTS A slight decrease was noted in the number of resident cases overall, from 271 in 1984 to 240 in 1988. The number of procedures performed in 1988 was closer to the figure for 1983 (237). Among specific categories, a large relative gain was noted in the number of head and neck procedures, with most other categories showing slight reductions (Fig 2).The number of plastic and reconstructive procedures remained statistically unchanged from 1984 to 1988. A significant increase was noted in the number of plastic procedures performed; 36% for 1988 versus 13% for 1983. The number of cosmetic surgery cases was compared, in both analyses, to that of two routine otolaryngologic procedures not expected to fluctuate greatly over this 5-year time period: tympanomastoidectomy and tonsillectomy (Fig 3). Tympanomastoidectomy showed a slight, steady increase over the period studied, while the incidence of tonsillectomy declined by 55%. Cosmetic surgery showed a dramatic increase from the 1983-1984
$
100
2 ”
80
60
2
40
Z
Cases
period, growing from seven cases to 75. This was maintained in 1988 with 68 cosmetic procedures performed. In both 1984 and 1988, cosmetic procedures outnumbered any other category in the resident experience, a significant change from the 1982-1983 period, before the introduction of a facial plastic surgery curriculum. In the specific analysis of different cosmetic procedures, it is important to note that dermabrasion and submental liposuction were not represented in the two earlier study periods. The number of browlifts, facelifts, and otoplasties dropped slightly in the most recent study period, while the number of rhinoplasties, blepharoplasties, and chin implants remained roughly the same [Fig 4). It should be emphasized that the cases under analysis represent only those generated and performed by a resident-staffed clinic. Residents in the Barnes Hospital program are also exposed to facial plastic surgery by assisting both full-time and part-time staff, and through rotations to the Veteran’s Administration Hospital, Children’s Hospital of St Louis, Jewish Hospital of St Louis, and the St Louis Regional Hospital rotation (city/ county hospital). This additional exposure to
z
60
2 v
50
mostoidectomy
B 40 PI kz 5 30
B “,
240
271 Cases
Cases
corresponding data gathered for our previous study of the years immediately preceeding and following the introduction of the plastic surgery curriculum (the academic years 1982-1983 and 1983-1984).
1987 -1988
1983 -1984
1982-1983
z 20
10 t-hod and Neck
Otologlc
Figure 2. Comparison vice by categories.
Plastic and Reconstructive
Endoscopic
of cases performed
GWlWOl
by the resident ser-
1982 - 1983
Figure 3. Cosmetic panomastoidectomy
1983 - 1984
1987 - 1988
surgery cases by year compared with tymand tonsillectomy.
190
FACIAL PLASTIC SURGERY
20
Figure 4. Comparison of cosmetic surgery cases by year (resident service).
0
1982
- 1983
H
1983
1984
q
1987-
1988
10 8
Blephoroplorty
Browlift
Chinlmplont
plastic surgery is enhanced by the concentrated teaching provided during the Barnes Hospital rotations. DISCUSSION Increased awareness of and demand for cosmetic surgery has brought about an increase in competition within this field. By virtue of their training, otolaryngologists-head and neck surgeons are uniquely qualified to perform these procedures. Therefore, it is imperative that residency training include instruction in aesthetic facial plastic surgery. Residents gain experience with plastic surgery techniques in a variety of ways. Constant work in and around the face with emphasis on regional anatomy and good soft tissue technique provides an excellent foundation for further training in aesthetic facial surgery. Our investigations indicate that increased exposure to these procedures and improved instruction in the selection and management of cosmetic surgery patients result in an increase in resident-generated cases of this type. Furthermore, no decrease in the number of resident cases has resulted from the presence of a
Rhytidectomy
Rhinoplasty
Otoplorty
Dermobrosion
Submental Lipoructlon
M&C
fellow in facial plastic surgery. On the contrary, this appointment provides both increased exposure to plastic surgery and an additional teaching resource to the residents in our program. Other resources include regular conferences and didactic sessions, books, videotapes, and workshops. The organizations that guide resident instruction have recognized the important role to be played by the otolaryngologist-head and neck surgeon in the growing field of facial plastic surgery. We are encouraged by the results of our program and are confident that similar curricula in facial plastic surgery can be profitably instituted elsewhere. References 1. The American Board of Otolaryngology, Booklet of Information. July 1988 2. Jafek BW: Essentials in Plastic and Reconstructive Surgery of the Head and Neck Region for the Resident in Otolaryngology. Washington, DC, Education Committee of the American Academy of Facial Plastic and Reconstructive Surgery, 1987 3. Thomas JR, Graboyes JH: A specific curriculum in facial plastic surgery. Arch Otolaryngol 1986; 11270-72 4. Thomas JR: Aesthetic surgery in the otolaryngology training program: A commentary. Arch Otolaryngol 1985;111:141
Facial Plastic Surgery in the Otolaryngology Training Program: An Update J.
REGAN THOMAS, MD, TAMARAK. EHLERT, MD, AND JEFFREYFENWICK, MD
In 1985, we demonstrated that, following the institution of a specific curriculum in facial plastic surgery, the number of cosmetic procedures generated and performed by residents rose dramatically. We have now demonstrated that this increase has been sustained in the 5 years since establishing the curriculum. We continue to maintain that the key to a successful curriculum in facial plastic surgery is the presence of at least one full-time staff member whose primary function is the practice and teaching of facial plastic surgery. AM J OTOLARYNGOL 11:188-190. 0 1990 by W.B. Saunders Company. Key words: facial plastic surgery, resident training.
the unique position of receiving at least 4 years of training specific to the head and neck. It is important that this training include specific instruction in the growing field of facial cosmetic surgery. In 1985, we reported the introduction of a specific facial plastic surgery curriculum3 for residents. A statistical analysis of the residentgenerated cosmetic surgery cases in the years immediately preceeding and following the introduction of this curriculum showed a significant increase in the number of facial plastic and reconstructive procedures performed by residents. Regular exposure to the techniques and concepts of aesthetic surgery through the teaching of a practicing staff member appointed for that purpose was felt to be the key element in the success of the program.* We returned in 1988 to reevaluate this program (Fig 1). It was our goal to determine whether, after 5 years, the initial interest in the program and increase in the number of aesthetic procedures had been maintained. We also wished to see if the addition of a fellow in facial plastic and reconstructive surgery at this institution had altered the results.
Facial plastic surgery, always within the domain of the otolaryngologist-head and neck surgeon, is no longer relegated to the last chapter of the text or last page of the residency curriculum. Recognizing the otolaryngologist’s unique understanding of head and neck anatomy and facility with soft tissue/reconstructive techniques, the medical community in general has come to recognize the key role played by the otolaryngologisthead and neck surgeon in the development of this challenging field. In its certification examinations, the American Board of Otolaryngology (ABO) requires a knowledge of “, . . the cognitive management (of) aesthetic, plastic and reconstructive surgery of the face, head and neck.“l The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), in response to the need for guidelines in establishing core curricula in plastic surgery, developed a comprehensive handbook’ outlining the essential abilities required of all otolaryngology residents preparatory to practice in this area. The AAFPRS, along with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), supports many programs, workshops, and conferences covering all aspects of facial plastic surgery, and maintains an impressive list of books, videotapes, and monographs available for the instruction of residents and practitioners. The otolaryngologist is in
METHODS Case numbers were identified and listed for the lyear period from July 1, 1987, to June 30, 1988. Only cases generated and performed solely by resident physicians in that period were counted, excluding all pro-
Received November 3,1968, from the Department of Otolaryngology, Washington University School of Medicine, St Louis, MO 63110. Accepted for publication November 20, 1989. Address correspondence and reprint requests to J. Regan Thomas, MD, #l Barnes Plaza, St Louis, MO 63110. 0 1990 by W.B. Saunders Company. 0196-0709/90/1103-0006$5.00/O
cedures performed by the attending staff or by the fellow in facial plastic surgery. Although residents in the Washington University Otolaryngology program rotate to several hospitals, only cases performed at Barnes Hospital (St Louis) on the resident clinic service was subjected to analysis. These data were compared with 188
THOMAS
ET AL
Figure 1. Percentage of total cases by categories (resident service).
237
RESULTS A slight decrease was noted in the number of resident cases overall, from 271 in 1984 to 240 in 1988. The number of procedures performed in 1988 was closer to the figure for 1983 (237). Among specific categories, a large relative gain was noted in the number of head and neck procedures, with most other categories showing slight reductions (Fig 2).The number of plastic and reconstructive procedures remained statistically unchanged from 1984 to 1988. A significant increase was noted in the number of plastic procedures performed; 36% for 1988 versus 13% for 1983. The number of cosmetic surgery cases was compared, in both analyses, to that of two routine otolaryngologic procedures not expected to fluctuate greatly over this 5-year time period: tympanomastoidectomy and tonsillectomy (Fig 3). Tympanomastoidectomy showed a slight, steady increase over the period studied, while the incidence of tonsillectomy declined by 55%. Cosmetic surgery showed a dramatic increase from the 1983-1984
$
100
2 ”
80
60
2
40
Z
Cases
period, growing from seven cases to 75. This was maintained in 1988 with 68 cosmetic procedures performed. In both 1984 and 1988, cosmetic procedures outnumbered any other category in the resident experience, a significant change from the 1982-1983 period, before the introduction of a facial plastic surgery curriculum. In the specific analysis of different cosmetic procedures, it is important to note that dermabrasion and submental liposuction were not represented in the two earlier study periods. The number of browlifts, facelifts, and otoplasties dropped slightly in the most recent study period, while the number of rhinoplasties, blepharoplasties, and chin implants remained roughly the same [Fig 4). It should be emphasized that the cases under analysis represent only those generated and performed by a resident-staffed clinic. Residents in the Barnes Hospital program are also exposed to facial plastic surgery by assisting both full-time and part-time staff, and through rotations to the Veteran’s Administration Hospital, Children’s Hospital of St Louis, Jewish Hospital of St Louis, and the St Louis Regional Hospital rotation (city/ county hospital). This additional exposure to
z
60
2 v
50
mostoidectomy
B 40 PI kz 5 30
B “,
240
271 Cases
Cases
corresponding data gathered for our previous study of the years immediately preceeding and following the introduction of the plastic surgery curriculum (the academic years 1982-1983 and 1983-1984).
1987 -1988
1983 -1984
1982-1983
z 20
10 t-hod and Neck
Otologlc
Figure 2. Comparison vice by categories.
Plastic and Reconstructive
Endoscopic
of cases performed
GWlWOl
by the resident ser-
1982 - 1983
Figure 3. Cosmetic panomastoidectomy
1983 - 1984
1987 - 1988
surgery cases by year compared with tymand tonsillectomy.
190
FACIAL PLASTIC SURGERY
20
Figure 4. Comparison of cosmetic surgery cases by year (resident service).
0
1982
- 1983
H
1983
1984
q
1987-
1988
10 8
Blephoroplorty
Browlift
Chinlmplont
plastic surgery is enhanced by the concentrated teaching provided during the Barnes Hospital rotations. DISCUSSION Increased awareness of and demand for cosmetic surgery has brought about an increase in competition within this field. By virtue of their training, otolaryngologists-head and neck surgeons are uniquely qualified to perform these procedures. Therefore, it is imperative that residency training include instruction in aesthetic facial plastic surgery. Residents gain experience with plastic surgery techniques in a variety of ways. Constant work in and around the face with emphasis on regional anatomy and good soft tissue technique provides an excellent foundation for further training in aesthetic facial surgery. Our investigations indicate that increased exposure to these procedures and improved instruction in the selection and management of cosmetic surgery patients result in an increase in resident-generated cases of this type. Furthermore, no decrease in the number of resident cases has resulted from the presence of a
Rhytidectomy
Rhinoplasty
Otoplorty
Dermobrosion
Submental Lipoructlon
M&C
fellow in facial plastic surgery. On the contrary, this appointment provides both increased exposure to plastic surgery and an additional teaching resource to the residents in our program. Other resources include regular conferences and didactic sessions, books, videotapes, and workshops. The organizations that guide resident instruction have recognized the important role to be played by the otolaryngologist-head and neck surgeon in the growing field of facial plastic surgery. We are encouraged by the results of our program and are confident that similar curricula in facial plastic surgery can be profitably instituted elsewhere. References 1. The American Board of Otolaryngology, Booklet of Information. July 1988 2. Jafek BW: Essentials in Plastic and Reconstructive Surgery of the Head and Neck Region for the Resident in Otolaryngology. Washington, DC, Education Committee of the American Academy of Facial Plastic and Reconstructive Surgery, 1987 3. Thomas JR, Graboyes JH: A specific curriculum in facial plastic surgery. Arch Otolaryngol 1986; 11270-72 4. Thomas JR: Aesthetic surgery in the otolaryngology training program: A commentary. Arch Otolaryngol 1985;111:141
