Introduction | Description of Plastic Surgery | Plastic Surgery's Two Components | Certification | Models of Training | Training of a Plastic Surgeon | Delineation of Clinical Privileges | Summary Statements
As the American health care delivery system becomes more complex and the trend toward increased specialization advances, the lines that define various surgical specialties often blur. However, the training and skills of the various surgical specialists remain distinctly different. To ensure patient safety, promote quality of care and appropriately grant plastic surgery privileges, it is important to appreciate these training differences. As in all specialties, appropriate training, proficiency and experience are attributes that plastic surgeons must possess. This booklet has been prepared by the American Society of Plastic Surgeons™ (ASPS™) as a reference to help one understand the training and potential roles of a plastic surgeon. The material included in the booklet is intended to:
- Describe the scope of plastic surgery;
- Explain the significance of Board Certification;
- Provide an overview of plastic surgery training models;
- Illustrate the unique qualifications of Board Certified plastic surgeons;
- Describe procedures commonly performed by Board Certified Plastic Surgeons;
- Provide a platform upon which to base plastic surgery privileges.
Description of Plastic Surgery
Plastic Surgery includes 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 or cosmetic enhancement to these areas of the body. Cosmetic surgery is an essential component of plastic surgery. The plastic surgeon uses cosmetic surgical procedures both to improve overall appearance and to optimize the outcome of reconstructive procedures.1 Competency in plastic surgery implies an amalgam of basic medical and surgical knowledge, operative judgement, technical expertise, ethical behavior and interpersonal skills to achieve problem resolution and patient satisfaction.1
Plastic surgery procedures generally fall into one of two categories: reconstructive or cosmetic.
Plastic Surgery's Two Components:
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 appearance2.
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance.
Special knowledge and skill in the design and execution of grafts, flaps, free tissue transfer and replantation is necessary. Competence in the management of complex wounds, the use of implantable materials, and in the performance of tumor surgery is required. Plastic surgeons have been prominent in the development of innovative techniques such as microvascular and cranio-maxillofacial surgery, liposuction, and tissue transfer. Anatomy, physiology, pathology and other basic sciences are fundamental to the specialty.1
Significance of Board Certification
Medical specialty certification in the United States is a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board certification demonstrates a physican's exceptional expertise in a particular specialty and/or subspecialty of medical practice.3
Certification by an American Board of Medical Specialties (ABMS) board includes initial specialty and subspecialty certification and maintenance of certification throughout the physician's career. The intent of both the initial certification of physicians and the maintenance of certification is to provide assurance to the public that a physician specialist certified by a Member Board of the ABMS has successfully completed an approved educational program and evaluation process which includes components designed to assess the medical knowledge, judgement, professionalism and clinical communication skills required to provide quality patient care in the specialty.3
The American Board of Plastic Surgery, Inc.
An important qualifier for granting plastic surgery privileges is that the surgeon seeking privileges be certified by the American Board of Plastic Surgery (ABPS) or admissible to the ABPS examination process. ABPS is one of only 24 accredited specialty boards recognized by the ABMS. Surgeons who meet the requirements of the ABPS:
- 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.1
- To conduct examinations of approved candidates who seek certification by the Board.1
- To issue certificates to those who meet the Board's requirements and pass the respective examinations.1
- To do and engage in any and all lawful activities that may be incidental or reasonably related to any of the foregoing purposes.1
The ABPS 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.1
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.
Sub-certification in Surgery of the Hand (SOTH)
Subspecialty Certification in Surgery of the Hand (formerly called Certificates of Added Qualification or CAQ), provides board certified surgeons a way to highlight their interest in hand surgery. Currently, hand surgery is the only area in which plastic surgeons certified by the ABPS may obtain a subspecialty certificate. Treatment and management of hand diseases and trauma are an integral part of the core curriculum in plastic surgery residency training. There is no requirement or necessity for a diplomate of The ABPS Inc. to hold a Certificate in the Subspecialty of Surgery of the Hand in order to be considered qualified to include hand surgery within the practice of plastic surgery. Under no circumstances should a diplomate be considered not qualified to practice within an area of a subspecialty solely because of lack of subspecialty certification.
Plastic Surgery Training Models: Based Upon the ACGME Program Requirements for Graduate Medical Education in Plastic Surgery5
The Accreditation Council of Graduate Medical Education (ACGME), an independent, non-governmental accreditation body for graduate medical education, recognizes two training models: independent and integrated. Both the integrated and the independent models require a minimum of six years of clinical surgical education in which a minimum of three years are concentrated in plastic surgery education.
The primary difference between the integrated and the independent models is where the prerequisite training takes place. In the independent model, residents complete the prerequisite training outside of the plastic surgery residency process in a surgical program accreddited by the Accreditation Council of Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada (RCPSC), or the American Dental Association (see below). In the integrated model, residents complete core surgical training and the plastic surgery-specific training under the authority and the direction of the plastic surgery program director.
In the independent model of training, the residents complete the prerequisite training outside of the plastic surgery residency process followed by three years of concentrated plastic surgery training, with no less than 12 months of senior/chief responsibility in plastic surgery after successful completion of one of the following prerequisite curricula:
a) Complete an ACGME-accredited residency in general surgery, including vascular surgery, neurological surgery, orthopedic surgery, otolaryngology, thoracic or urology;
b) Satisfactory completion of a residency program in Oral and Maxillofacial surgery approved by the ADA is an alternate pathway for prerequisite training prior to a plastic surgery residency. This pathway is available only to those individuals holding a 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.
In the integrated model, residents complete 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.6
a) The integrated curriculum must contain six years of clinical surgical training under the authority and direction of the plastic surgery program director.
b) Of these, 36 months must be concentrated plastic surgery training with no less than 12 months of senior/chief responsibility on the clinical service of plastic surgery. Residents must complete the last 36 months of their education in the same plastic surgery program.
c) The curriculum includes the basic experience in clinical general surgery. Additional clinical experiences appropriate to the training of a plastic surgeon should be provided in alimentary tract surgery, abdominal surgery, breast surgery, emergency medicine, pediatric surgery, surgical critical care, surgical oncology, transplant, trauma management and vascular surgery.
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 12 months in duration, and may take place in either an institutional setting or with an individual preceptor.
Continuing Medical Education
ASPS requires that 150 hours of Continuing Medical Education (CME) must be earned during a consecutive three-year period. 150 hours, no less than 60 must be in category 1, with a minimum of 50 of the 150 hours earned in plastic surgery activities. This is required of all Candidates for Membership and Active Members, as well as the Maintenance of Certification Process of the Board.
Maintenance of Certification in Plastic Surgery Program (MOC-PS®).
Effective 1995, certificates issued by the Board are dated and will be valid for ten years but subject to participation in MOC-PS®. Certificates issued prior to 1995 are valid indefinitely.
The key components of the MOC-PS® Program include evidence of 1) professional standing; 2) lifelong learning; 3) successful completion of cognitive examination; and 4) practice profile assessment with tracer case. The Maintenance of Certification Booklet of Information and the information posted on the Board's website is the source for all information relevant to MOC-PS®. Online participation of Maintenance of Certification Activities is required throughout the 10-year certification cycle. The Professional Standing update and a Practice Assessment in Plastic Surgery (PA-PS) module is required in years three, six and nine of the 10-year MOC-PS® cycle.
The Maintenance of Certification Program of the Board includes these requirements:
In each of years 3, 6 AND 9, complete:
1. One Practice ssessment in Plastic Surgery (PA-PS) Module which requires the diplomate to:
a) Select one of 20 tracer procedures available.
b) Enter data online from 10 consecutive cases of a single tracer procedure such as breast reduction or carpal tunnel syndrome.
c) Review benchmarking report.
d) Complete one MOC-approved edcational activity aligned with the tracer procedure such as an online CME article or one of the MOC courses held at the national meetings.
e) Complete the Action Plan for Improvement.
2. Professional Standing Update which requires the diplomate to:
a) List Medical license, hospital privileges, outpatient facilities, advertising material, society membership and peer evaluations. See info on "Selected for Audit" as needed.
b) Upload CME summary report(s) for the current and previous CME cycles from the ASPS website, or upload CME documentation confirming at least 150 CMEs from the last three years.
In year 7, 8 OR 9:
3. Finalize the online application with required documentation.
4. Submit the six month case list on the Board's Clinical Case Log website.
In year 8, 9 OR 10:
5. Successfully complete the 200-question computer based exam. The MOC-PS® Study Guide produced by ASPS, available at www.psenetwork.org, is an excellent reference for exam preparation.
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)
- Breast augmentation
Treatment of Facial Diseases and Injuries Including Maxillofacial Structures
- Facial fractures including the mandible
- Acquired or congenital deformities of the nose, ear, jaw, eyelid, lips, palate
- Craniofacial surgery
- Skull base surgery
- Facial deformity and wound treatment
- Tumors of the head and neck
Surgery of the Hand and Extremities
- Soft-tissue wounds and congenital abnormalities of the hand and upper extremity fractures and congenital abnormalities of the bones of the hand, wrist and distal forearm.
- Carpal tunnel syndrome (endoscopic and open)
- Dupuytren's contracture
- Surgery for rheumatoid arthritis
- Tumors of the bones and soft tissues
- Microvascular flaps and grafts
- Replantation and revascularization of the upper and lower extremities and digits
- Reconstruction of peripheral nerve injuries
Reconstruction of Congenital and Acquired Defects of the Trunk and Genitalia
- Vaginal reconstruction
- Repair of penis deformities
- Gender reassignment
- Chest and abdominal wall reconstruction (e.g. abdominal wall reconstruction)
Complex Wound Healing and Burn Treatment
- Initial burn management
- Acute and reconstructive burn treatment
- Body contouring
- Facial contouring
- Breast augmentation
- Breast lift (mastopexy)
- Cosmetic rhytidectomy
- Cosmetic rhinoplasty
- Cosmetic blepharoplasty
- Subcutaneous injections/Botox/filler material
- Skin peeling and dermabrasion
- Vein injection sclerotherapy
- Endoscopic cosmetic surgery
- Laser therapy for vascular and cutaneous lesions
- Chemical peel
- Laser skin resurfacing
- Mechanical dermabrasion
Plastic surgeons who are certified by the ABPS, Inc. and who are members of the ASPS have undergone rigorous training and have been evaluated by their peers on their practice of plastic surgery, from both the technical and ethical perspectives, in written and oral formats. Board certified plastic surgeons should be eligible for consideration to perform the above procedures by virtue of their plastic surgery training and certification process.
Plastic surgeons certified by ABPS, Inc. should be eligible for consideration for clinical privileges at all hospitals, clinics, 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 ASPS 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
- The American Board of Plastic Surgery, Inc.
- Seven Penn Center
- Suite 400
- 1635 Market Street
- Philadelphia, PA 19103
- Phone: (215) 587-9322
- FAX: (215) 587-9622
American Council of Academic Plastic Surgeons
- 4900 "B" South 31st Street
- Arlington, VA 22206
- Phone: (703) 820-7400
- FAX: (703) 931-4520
- Published by: The American Society of Plastic Surgeons, October 2011
- 1. The American Board of Plastic Surgery, Ind., Booklet of Information, July1, 2011 - June 30, 2012.
- 2. The American Medical Association, Policy Compendium, 1999, p. 673.
- 3. American Board of Medical Specialities; "What Board Certification Means." www.abms.org. Accessed December 2010.
- 4. The American Board of Plastic Surgery, Inc., 2011 Certification in the Subspecialty of Surgery Of The Hand (SOTH). https://www.abplsurg.org/documents/SOTH_2010_BOI.pdf Accessed January 2011.
- 5. ACGME Program Requirements for Graduate Medical Education in Plastic Surgery, Effective July 1, 2009.
- http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/360_plastic_surgery_07012009_f07012012.pdf. Accessed January 2011.