Plastic Surgery Clinical Privileges

Introduction | The Scope of Plastic Surgery | Plastic Surgery's Two Components | Training of a Plastic Surgeon | Scope of Training | Training of a Plastic Surgeon | Delineation of Clinical Privileges | Summary Statements

Introduction:

As the health care delivery system in this country evolves, the lines that define various medical specialties and distinguish the differences between primary care physicians and specialists have begun to blur, although the training and skills of medical specialists and surgical specialists remain distinctly different. Medical practitioners and health care professionals are encouraged to use this booklet as a reference on the role and training of a plastic surgeon.

In the United States, physicians are generally licensed as "medical practitioners" by state licensing boards. Federal laws do not govern the quality of specialty training or dictate the procedures a physician may aspire to perform. In effect, a medical school graduate can legally claim to be a specialist of his or her own choosing, with or without residency training in that specialty.

Managed care executives, medical directors, credentialing committees and hospital administrators have a responsibility to help ensure that patients are treated by qualified surgeons. The granting of clinical privileges to physicians by verification of credentials allows a hospital or health plan to assure its patients and members of the training of its physicians. This booklet has been prepared by the American Society of Plastic Surgeons to provide:

• Health care policy makers with an understanding upon which to base decisions on plastic surgical services
• Credentialing committees with guidelines that will enable them to protect patients and members of their respective hospitals and health plans from
  unqualified surgeons
• The medical community with a clearer delineation of procedure specific medical expertise where specialist roles now overlap.

This booklet serves as an information resource on granting clinical privileges for plastic surgery services based on the realities of medical practice and education of the specialist. Factors considered include the scope of plastic surgery, the defined educational pathways that qualify candidates for examination by the American Board of Plastic Surgery, and issues related to the delineation of clinical privileges for plastic surgeons.

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The Scope of Plastic Surgery

General Description

Plastic Surgery deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, cranio-maxillofacial structures, hand, extremities, breast and trunk, and external genitalia. It uses aesthetic surgical principles not only to improve undesirable qualities of normal structures but in all reconstructive procedures as well.

Special knowledge and skill in the design and surgery of grafts, flaps, free tissue transfer and replantation is necessary. Competence in the management of complex wounds, the use of implantable materials, and in tumor surgery is required. Plastic Surgery has been prominent in the development of innovative techniques such as microvascular and cranio-maxillofacial surgery, liposuction, and tissue transfer. The foundation of surgical anatomy, physiology, pathology, and other basic sciences is fundamental to this specialty.

Competency in plastic surgery implies a special combination of basic knowledge, surgical judgement, technical expertise, ethics, and interpersonal skills in order to achieve satisfactory patient relationships and problem resolution.

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Plastic Surgery's Two Components:

Reconstructive and Cosmetic (Aesthetic) Surgery

Plastic surgery procedures generally fall into one of two categories - Reconstructive or Cosmetic.

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Reconstructive procedures commonly performed by plastic surgeons include:

• Correction of Congenital Anomalies (such as cleft lip and palate)
• Maxillofacial and Craniofacial Surgery
• Hand Surgery
• Breast Reconstruction following Mastectomy
• Breast Reduction for Hyperplasia
• Burn care
• Trauma care (such as repair of lacerations and facial fractures)
• Excision of tumors and reconstruction following various types of cancer treatment

Commonly performed cosmetic procedures include:

• Face lifts
• Eyelid lifts
• Breast enlargement
• Some nasal surgery
• Body contouring
• Liposuction

Sometimes the overlap between reconstructive and cosmetic surgery leads to confusion. For example, similar techniques may be utilized for reconstruction of nasal deformity after trauma (reconstructive rhinoplasty) as well as for cosmetic alteration of a normal nose (cosmetic rhinoplasty). The technique and procedural coding may be the same, but the reason for surgery is the key factor to be considered in determining whether the procedure is reconstructive or cosmetic.

A number of position papers identifying criteria for determining coverage of various procedures are available from the American Society of Plastic Surgeons. Additionally, the society has developed clinical guidelines for a number of plastic surgery procedures. Contact the American Society of Plastic Surgeons at 1-800-766-4955.

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Training of a Plastic Surgeon

Significance of Board Certification

An important qualifier for physicians requesting plastic surgery privileges is that they are certified by the American Board of Plastic Surgery, a member board of the American Board of Medical Specialties. Surgeons who meet the requirements of the American Board of Plastic Surgery and are granted board certification are known as diplomates of The American Board of Plastic Surgery, Inc.

The intent of the certification process, as defined by the member boards of the American Board of Medical Specialties is:

To provide assurance that a certified medical specialist has successfully completed an approved educational program and an evaluation including an examination process designed to assess the knowledge, experience and skill requisite to the provision of high quality patient care in that specialty.

Purposes of the American Board of Plastic Surgery

The essential purposes of the American Board of Plastic Surgery are:

• To establish requirements for the qualifications of applicants who request a certificate of their ability in the field of plastic surgery in its broadest sense.
• To conduct examinations of approved candidates who seek certification by the Board.
• To issue certificates to those who meet the Board's requirements and pass the respective examinations.
• To do and engage in any and all lawful activities that may be incidental or reasonably related to any of the foregoing purposes.

The American Board of Plastic Surgery is not an educational institution, and certificates issued by the Board are not to be considered degrees. The certificate does not confer on any person legal qualifications, privileges, or license to practice medicine or the specialty of plastic surgery. Standards of certification are clearly distinct from those of licensure; possession of a Board certificate does not indicate total qualification for practice privileges, nor does it imply exclusion of others not so certified. The Board does not purport in any way to interfere with or limit the professional activities of any licensed physician nor does it desire to interfere with practitioners of medicine and any of their regular or legitimate activities.

It is not the intent nor has it been the function of the Board to define requirements for membership on the staff of hospitals, or to define who shall or shall not perform plastic surgical operations. The Board is not a primary source of censure or primary review of ethical problems.

The American Board of Plastic Surgery is one of only 24 accredited specialty boards recognized by the American Board of Specialties. The prestige associated with recognition from the American Board of Medical Specialties exists for two primary reasons:

• The American Board of Medical Specialties is expressly designed to provide public protection through quality control in medical education.
• Only through recognition by the American Board of Medical Specialties can a specialty board gain full access to resources of the entire spectrum of graduate medical education. The resources include such entities as the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, the National Resident Matching Program, and the National Board of Medical Examiners.

Any Diplomate of the American Board of Plastic Surgery, Inc., will have met the Board's educational and plastic surgery training requirements. Specific clinical training is provided in the following areas:

1. Congenital defects of the head and neck, including clefts of the lip and palate, and craniofacial surgery
2. Neoplasms of the head and neck, including the oropharynx and training in appropriate endoscopy
3. crania-maxillofacial trauma, including fractures of the mandible and maxilla
4. Aesthetic (cosmetic) surgery of the head and neck, trunk and extremities
5. Plastic surgery of the breast
6. Surgery of the hand/upper extremities
7. Plastic surgery of the lower extremities
8. Plastic surgery of congenital and acquired defects of the trunk and genitalia
9. Burn management, acute and reconstructive
10. Microsurgical techniques applicable to plastic surgery
11. Reconstruction by tissue transfer including flaps and grafts
12. Surgery of benign and malignant lesions of the skin and soft tissues.

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Scope of Training (including prerequisites)

Prerequisites

1. All prerequisite residency training must be taken within programs accredited by the following organizations: the Accreditation council for Graduate Medical Education, the Royal College of Physicians and Surgeons of Canada or the American Dental Association.
2. The curriculum for residency training in plastic surgery is two years. A program may be accredited for more than two years ( such as in the integrated model; or the independent model using a three-year format) when it is demonstrated that there is a clear educational rationale, consonant with the Special Requirements and the objectives for residency training, which cannot be met in a two-year curriculum, or when the program director has delineated a program with special goals that exceed those defined in the Special Requirements.

Training Models

The Residency Review Committee for Plastic Surgery recognizes two training models: Independent and Integrated.

Independent model

In the independent model of training, residents complete two or three years of concentrated plastic surgery training, with no less than 12 months of senior/chief responsibility, after successful completion of one of the following prerequisite curricula:

1. A minimum of three years of clinical training with progressive responsibility in the same program in general surgery. Transitional year or rotating internships may not be used to fulfill this requirement.
2. A complete neurological surgery, orthopedic surgery, otolaryngology or urology residency.
3. Satisfactory completion of a residency program in Oral and Maxillofacial surgery approved by the American Dental Association is an alternate path way for prerequisite training prior to a plastic surgery residency. This pathway is available only to those individuals holding D.M.D./M.D. or D.D.S./M.D. degree. Training must also include a minimum of 24 months of progressive responsibility on surgical rotations under the direction of the general surgery program director after receipt of the M.D. degree. Rotations in general surgery during medical school, prior to the M.D. degree, will not be considered as fulfilling any part of the 24-month minimum requirement.

Integrated model

In the integrated model, residents complete five or six years of ACGME-accredited plastic surgery training following receipt of an M.D. or D.O. degree from an institution accredited by the Liaison Committee on Medical Education or the American Osteopathic Association.

1. The integrated curriculum must contain no less than five years of clinical surgical training under the authority and direction of the plastic surgery program director.
2. Of these, no less than 24 months must be concentrated plastic surgery training with no less than 12 months of senior/chief responsibility on the clinical service of plastic surgery.
3. Additional clinical experiences appropriate to the training if a plastic surgeon should be provided in anesthesiology, burn management, critical care medicine, emergency medicine, cardiothoracic surgery, general surgery, neurological surgery, orthopedic surgery, otolarynology, pediatric surgery and trauma management.

Please see attached diagram (page 11) outlining the path options and educational requirements for specialization in plastic surgery.

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Training of a Plastic Surgeon

Prerequisite for Plastic Surgery Residency

• Doctor of Medicine (M.D.) Or Osteopathy (D.O.)
• OR 3 years of clinical training in general surgery with progressive responsibility in the same program (this is a minimum requirement before entrance into plastic surgery residency)
• OR An accredited residency training program in neurological surgery, orthopaedic surgery, otolaryngology or urology.

• D.M.D. plus M.D. degree or D.D.S. plus M.D. degree
• OR Completion of residency program in Oral and Maxillofacial Surgery, approved by the American Dental Association (ADA).
  • Must include Doctor of Medicine degree (M.D.) and a minimum of 2 years post M.D. surgical rotations

• M.D. degree from outside of U.S. or Canada
• OR Satisfactory completion of accredited residency training in general surgery, orthopaedic surgery, otolaryngology or urology, including evidence of current admissibility to the respective specialty board's examination process in the United States required.

Required Graduate Education in Plastic Surgery

Training in an accredited 2 or 3 year plastic surgery program with the final year at senior level. Beginning on July 1, 1995, both years of a two (2) year program or the last two (2) years of a three year program must be completed in the same institution. In either instance, the final year must be completed at senior level.

Certification by the American Board of Plastic Surgery, Inc.

Must pass qualifying (written) exam, and certifying (oral) exam

Supplemental education

Certification by the American Board of Plastic Surgery, in and of itself, means that the plastic surgeon has completed the training and practice needed to perform the scope of the specialty of Plastic Surgery (see pages 9-10). However, some surgeons may choose to further explore their interests in one or more areas through additional clinical or academic experiences.

Fellowships

Fellowships in plastic surgery offer the surgeon an opportunity to pursue additional experiences in the basic science and clinical practice of plastic surgery. These fellowships cover a wide variety of topical areas. However, they are not required to follow any generally recognized format or any approved curriculum. Fellowship training experiences can be of variable lengths, ranging from three to twelve months in duration, and may take place in either an institutional setting or with an individual preceptor.

Certificates of added qualification

Certificates of added qualification, or CAQ, provide board certified surgeons a way to highlight their interest in a particular area. Currently, hand surgery is the only area in which plastic surgeons certified by the ABPS may obtain a CAQ. However, treatment and management of hand diseases and trauma are an integral part of the core curriculum in plastic surgery residency training.

All ABPS board certified plastic surgeons are qualified to treat the broad scope of hand diseases and upper extremity trauma.

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Delineation of Clinical Privileges

Specific procedures commonly performed by plastic surgeons include, but are not limited to:

Treatment of Skin Neoplasms, Diseases and Trauma

• Benign and malignant lesions of the skin and soft tissue
• Reconstructive grafts and flaps
• Scar revisions
• Laser therapy for vascular lesions

Surgery of the breast

• Breast reconstruction
• Breast reduction
• Breast biopsy
• Congenital anomalies
• Mastectomy (subcutaneous and simple)

Treatment of facial diseases and injuries including maxillofacial structures

• Facial fractures including the mandible
• Nose deformity
• Ear deformity
• Jaw deformity
• Eyelid deformity
• Cleft lip and palate deformity
• Craniofacial surgery
• Skull base surgery
• Facial deformity and wound treatment
• Tumors of the head and neck

Surgery of the hand and extremities

• Hand wounds
• Tendon injuries
• Fractures of the hand and wrist
• Carpal tunnel syndrome (endoscopic and open)
• Dupuytren's contracture
• Surgery for rheumatoid arthritis
• Congenital anomalies
• Tumors of the bones and soft tissues

Reconstructive microsurgery

• Microvascular flaps and grafts/free tissue transfer
• Replantation and revascularization of the upper and lower extremities and digits
• Reconstruction of peripheral nerve injury

Reconstruction of congenital and acquired defects of the trunk and genitalia

• Vaginal reconstruction
• Repair of penis deformities
• Gender reassignment
• Chest and abdominal wall reconstruction

Complex wound healing and burn treatment

• Initial burn management
• Acute and reconstructive burn treatment

Cosmetic surgery

• Body contouring
• Facial contouring
• Breast augmentation
• Breast lift (mastopexy)
• Cosmetic rhytidectomy
• Cosmetic rhinoplasty
• Cosmetic blepharoplasty
• Subcutaneous injections
• Skin peeling and dermabrasion
• Vein injection sclerotherapy
• Liposuction
• Endoscopic cosmetic surgery
• Laser therapy for vascular and cutaneous lesions

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Summary Statements

Plastic surgeons who are certified by the American Board of Plastic Surgery and who are members of the American Society of Plastic Surgeons have undergone rigorous training and have been evaluated by their peers on their practice of plastic surgery, from both the technical and ethical perspectives. Board certified plastic surgeons should be eligible for consideration to perform the above procedures by virtue of their plastic surgery training and certification process.

Continuing Medical Education is an important component of clinical competence for surgeons. Members of the American Society of Plastic Surgeons are required to obtain 150 hours of continuing medical; education within a 3 year period. A minimum of 50 out of the 150 hours must be specific to the practice of plastic surgery.

Plastic surgeons certified by the American board of Plastic Surgery should be eligible for consideration for clinical privileges at all hospitals, clinic, managed health care organizations, military service and third-party payment organizations created and operating within the United States of America and Canada.

It is not the intent of the American Society of Plastic Surgeons to define requirements for membership on hospital staffs or other health care entities, or to define who shall or shall not perform plastic surgical operations. The ASPS does not purport to limit the professional activities of any licensed physician or health practitioner, or to interfere with their legitimate and regular activities.

This booklet has been reviewed by the following organizations:

American Society of Plastic Surgeons

444 East Algonquin Road

Arlington Heights, IL 60005

Phone: (847) 228-9900

Fax: (847) 228-9131

American Association for Hand Surgery

444 East Algonquin Road

Arlington Heights, IL 60005

Phone: (847) 228-9758

Fax: (847) 228-6509

American Society of Plastic Surgery, Inc.

Seven Penn Center

Suite 400

1635 Market Street

Philadelphia, PA 19103

Phone: (215) 587-9322

American Society for Aesthetic Plastic Surgery, Inc.

3922 Atlantic Avenue

Long Beach, CA 90807

Phone: (310) 595-4275

American Society of Maxillofacial Surgeons

444 East Algonquin Road

Suite 120

Arlington Heights, IL 60005

Phone: (847) 228-3327

Fax: (847) 228-6509

American Society for Reconstructive Microsurgery

444 East Algonquin Road

Suite 120

Arlington Heights, IL 60005

Phone: (847) 228-9717

Fax: (847) 228-6509

Association of Academic Chairmen of Plastic Surgery

444 East Algonquin Road

Suite 120

Arlington Heights, IL 60005

Phone: (847) 228-8375

Fax: (847) 228-6509

Published by:

The American Society of Plastic Surgeons, October 1994

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