Aesthetic fellowships in Sweden: Comparisons and Contrasts

Plastic surgery is one of the world's most competitive medical specialties. From its application in different specialty programs, outstanding results are required throughout the different evaluations of practicing plastic surgery – and the journey continues throughout one's career. The requirement of each program highlights the importance of comprehensive training for residents in all scenarios.

The vast majority of training centers tend to concentrate resources on the needs of each medical institution, where reconstructive procedures tend to dominate. As a result, this can limit practice in aesthetic procedures, which yields a challenge for programs in providing quality exposure during residency – similar to other subspecialties such as oncologic reconstruction, pediatric plastic surgery, microsurgery and craniofacial and hand surgery.

The solution to this educational gap lies in fellowships. These programs promote education to increase levels of proficiency in the aesthetic field, allowing residents to immerse themselves in a more-focused approach and preparing them for the challenges and demands ahead.

Leaving the comfort zone

Plastic surgery residents typically pursue aesthetic fellowships within their own country – or at least on the same continent (e.g., Americans within North America, Europeans within Europe, etc.), which creates homogeneity and training centered on similar ideology and vision. After venturing out of my comfort zone and progressing through several interviews and demanding processes, I was accepted into an aesthetic fellowship at VictoriaKliniken in Stockholm, Sweden, led by Charles Randquist, MD, PhD, Jessica Gahm, MD, PhD, and Marie Jaeger, MD, PhD, which sparked a 360-degree turn in my own training as a resident.

During this three-month experience (with an option of six months' duration), I was exposed to countless procedures that encompass a variety of fields, including facial surgery (rhinoplasty, blepharoplasty, face and neck lift), primary and secondary breast surgery, body contouring and hair transplantation. I also received training in minimally invasive aesthetic procedures such as botulinum toxin and fillers.

In the aesthetic surgery environment, all patients expect optimal results in their outcomes; to get there as a plastic surgery resident, the following are the pearls I learned along the way.

A place for the plastic surgeon

The patient experience with a plastic surgeon begins with the first step inside the clinic. "Patient satisfaction does not only depend on the post-surgical result; it is all about the journey." Every detail of this step is a direct reflection of the surgeon's personality, care, mission and vision. The staff should make the patient feel comfortable, inspiring peace and confidence from all senses – smell via natural flowers and relaxing aromas, sight via neutral colors and clean corners, taste through freshly prepared coffee or tea and chocolate, sound via calm music, and so forth. The patient should intrinsically feel that they're in an environment that prioritizes their safety and comfort.

First consultation and patient education

The first consultation is the first step for a successful procedure. Punctuality and strong patient-doctor communication should always be the objective. Comprehensive communication forges a bond of trust and loyalty between the patient and surgeon. An exhaustive medical history must be sought, as well as taking the time to understand the patient's motivations, desires and expectations. The doctor-patient dialogue must establish clear goals, limitations for each patient and individualized risk assessment while prioritizing patient safety.

Easy access to online information and the prevalence of social media often create unrealistic expectations and deliver misinformation for prospective patients. All doubts, concerns and post-surgical complications must be clarified and explained beforehand and in detail, through numbers and specific percentages.

Physical examination and anthropometric assessment

The simple act of removing clothing puts the patient in a vulnerable position. The conditions and the physical space in which the physical examination is carried out must afford the patient privacy in a respectful environment that limits discomfort.

For plastic surgery residents, the experience can play a counterproductive role, so all physical examination and anthropometric measurement processes must be deployed through standardized and validated tools. This will diminish bias in patient selection, establish the characteristics of each patient and allow the evaluation of therapeutic options and limitations on an individual basis.

Preoperative planning

A detailed and comprehensive surgical plan, including a checklist of equipment and material required during surgery, are crucial steps in any aesthetic procedure. A correct anamnesis, judicious measurement of physical anthropometry and pursual of results that maintain harmony in the patient's proportions should always be a priority.

The day of surgery: the five P's

Up to 99 percent of the success of surgery is determined by the five "P's" of best practice principles: patient selection, preoperative planning, proportional thinking, performance and postoperative care with long-term follow-up.

The entire process and duration of the surgery must be constantly evaluated, and the resident must understand that there's no room for improvisation during the transoperative period, as it can lead not only to post-surgical complications but also surgical failure as a result of poor planning and prolonged surgical times.

Plastic surgery residents are often bombarded with new papers that highlight innovative procedures and extraordinary results. Just follow the "KISS" principle: "Keep it simple and safe." Master the basic techniques, understand your surgical skills and limitations, and then progress to more complex procedures – all without ever compromising patient safety.

Postoperative care with long-term follow-up

Residents also must understand postsurgical complications. No procedure should be underestimated in the aesthetic field, no matter how small or short it might be. Post-surgical assessment should focus on ruling-out complications associated with the procedure.

Prescriptions and indications at the point of hospital discharge must be clear and precise. The patient must understand what he or she can and cannot do. At this point, doctor-patient communication is again crucial.

One of the most marked differences in the European vision is the long-term, post-surgical follow-up period. After initial, early and regular follow-ups, the common long-range period for American plastic surgery is a one-year – or two-year, at the most – follow-up after the procedure. One of the great teachings I picked up in Europe is to follow our patients even up to 10 years, as it allows us to know the durability and validity of our techniques and results in a more complete way.

Measure and judge your results constantly

This long-term follow-up provides the necessary tools to make a complete judgment and evaluation of our own surgical techniques. Once again, the plastic surgery resident must promote their practice through standardized processes. If we don't know our preoperative assessment in detail – or our surgical steps and postoperative care – we will not find the breakpoint to improve our results and patient satisfaction.

Opportunities and options

Aesthetic surgery training is an integral part of becoming a plastic surgeon, and fellowships are key to achieving this. Among the innumerable options for fellowships, the opportunities available in Europe add great value to our training, which focus on a scrub-in and hands-on experience that incorporates the resident throughout the entire journey.

I don't have the space to adequately express my thanks to Drs. Randquist, Gahm and Jagaer for their warm welcome, exhaustive desire to teach and, above all, for making me feel like a member of their team and family. I am forever in their debt.

Dr. De Luna Gallardo is chief resident and PGY-4 at Hospital Central Sur de Alta Especialidad de Petróleos Mexicanos, México City.