Welcome to our next installment in the So You Want to Be. In this series, we highlight a specific specialty within medicine, such as plastic surgery, and help you decide if it’s a good fit for you. You can find the entire list on our So You Want to Be playlist. A lot of you asked for plastic surgery in the last video, so that’s what we’re covering here.
So you want to be a plastic surgeon. Maybe you like the idea of making millions, working with celebrities, doing boob jobs and facelifts – not so fast. We’re going to debunk the public perception myths of what it means to be a plastic surgeon, and give it to you straight. This is the reality plastic surgery, and we’ll help you decide if it’s a good field for you.
What is Plastic Surgery?
Plastic surgery is all about using plastic to make people look pretty, right? No, and never repeat those words. The word plastic comes from the Greek word “plastikos“, meaning “to mold”, a reference to how plastic surgery is involved in the reshaping and manipulation of tissues. Generally speaking, plastic surgeons focus on soft tissue, such as skin, muscle, and fat, rather than bones, which are in the territory of orthopedic surgeons.
Plastic surgery is far more diverse than what you probably expect. The public is most familiar with aesthetic, or cosmetic, plastic surgery that has been popularized by celebrities and showbiz, but the overwhelming majority of actual surgical procedures in plastic surgery are reconstructive in nature. In 2018, there were 5.8 million reconstructive surgical procedures in the U.S., compared to only 1.8 million cosmetic surgical procedures. That being said, nonsurgical minimally invasive cosmetic procedures, like botox or fillers, are extremely popular. In 2018 alone, there were 15.9 million nonsurgical cosmetic procedures.
So what’s the difference between cosmetic and reconstructive plastic surgery? Cosmetic plastic surgery includes procedures involved with enhancing one’s appearance. The most popular cosmetic surgical procedures include breast augmentation or “boob job”, liposuction, rhinoplasty or “nose reshaping”, blepharoplasty or “eyelid surgery”, and abdominoplasty or “tummy tuck”. The most popular cosmetic nonsurgical procedures include botox injections, soft tissue fillers, chemical peels, laser hair removal, and microdermabrasion.
Reconstructive plastic surgery (recon) is highly diverse, and in my personal opinion, far more fascinating. Recon includes surgical procedures to correct facial and body abnormalities that can be caused by birth defects (like cleft lip or cleft palate), injury (like soft tissue reconstruction for severe traumatic injuries), disease (like breast reconstruction after mastectomy for breast cancer), or aging. Plastic surgery is on the cutting edge of innovation in medicine, with radical procedures like face and hand transplants, or even gender reassignment surgeries that are so convincing you wouldn’t believe it.
The first surgical case I saw was an animated latissimus dorsi transfer where we created a makeshift bicep, or rather elbow flexor, out of a patient’s lat muscle in their back. With the beauty of neuroplasticity in the brain, the patient was able to train themself to bend the elbow by focusing on activating their latissimus dorsi muscle. I talk more about this first case and how I fell in love with plastic surgery on my YouTube channel Kevin Jubbal, M.D.
Another one of my favorites was doing a nerve graft to treat Bell’s palsy hemifacial paralysis. In short, one side of the patient’s face was paralyzed, so we harvested the sural nerve from her leg and using microsurgical techniques, grafted it to their face to reanimate the paralyzed side. I know. Straight science fiction.
Between cosmetic and reconstructive practices, one isn’t necessarily better than the other, but there are pros and cons which we’ll get to shortly. I was obviously enamored by the complex recon, and would sometimes tease my cosmetics-focused colleague that I’m at least helping the world and not just trying to make a quick buck. To which they responded, “we’re also making the world a better place, one pair of breasts at a time.”
In the hospital, we call plastic surgeons the “surgeon’s surgeon”, as they are the most relied upon by other surgical specialists. Any time a neurosurgeon, urologist, general surgeon, orthopedic surgeon, otolaryngologist, or any other surgeon needs help with complex coverage and reconstruction, they call in the plastic surgeons. Unlike any other surgical specialty, plastic surgery is unrestricted by body part. They work on any part of the body, from head to toe, hands to feet, eyelids to genitalia.
How to Become a Plastic Surgeon
To become a plastic surgeon, there are two paths of training after completing medical school. First is called the Integrated Path, whereby you complete 6 years of plastic surgery residency, and this is the path I took. This is consistently the number 1 or number 2 most competitive specialty to match into. To give you a sense of how competitive it is, one of my colleagues went into neurosurgery, another competitive field, because he said plastics was too competitive.
If the Integrated Path is out of reach, all hope is not lost. There is also the Independent Path, whereby you first complete 5 years of general surgery residency, and then apply for an additional 3 years of independent plastic surgery residency, for a total of 8 years. This route is best suited for those who either did not know they wanted to go into plastic surgery when they were applying to residency or those who were unable to match into the Integrated Path.
Sub-specialization within Plastic Surgery
After completing residency, you can practice as a plastic surgeon, or choose to sub-specialize further with 1 to 2 years of fellowship. These are the main pockets of sub-specialization you can choose from:
Plastic surgeons specializing in breast obviously do breast augmentation, but also a major part of their practice includes breast cancer reconstruction. After the general surgeon removes the tumor, the plastic surgeon comes in with a variety of techniques and procedures to restore a woman’s anatomy. Breast surgeons also do breast reductions and lifts, among other procedures.
Craniofacial trained plastic surgeons specialize in soft tissue reconstruction of the head and face. Their bread-and-butter includes pathologies like cleft lip and cleft palate, craniosynostosis whereby sutures in the skull fuse prematurely resulting in abnormal head shapes in babies, and they’ll even fix your broken jaw.
Microsurgery is the most innovative and sci-fi sub-specialization within plastic surgery. The “micro” in microsurgery refers to the microscopes used when connecting blood vessels or nerves together. This allows for moving tissues around the body, like the nerve graft for facial reanimation in Bell’s palsy. Microsurgical cases are some of the longest, with some lasting over 24 hours, and it also comes with challenging call. For that reason, we say microsurgery is a young man’s sport. It’s probably not the ideal lifestyle for future 50-year-old you with a family and kids.
Hand was what I fell in love with and was planning on specializing in. The hand has some of the most complex, intricate, and beautiful anatomy in the entire human body. Hand surgery includes pathologies like carpal tunnel, fractures, contractures, and tumor resections and reconstruction.
Burn is the black sheep of the family, and is not nearly as precise, meticulous, or fun as the rest of plastic surgery. That being said, it’s incredibly important as burn victims are in great need.
And last, aesthetic plastic surgery, which is what you’re likely most familiar with. Breast augmentation, rhinoplasty, abdominoplasty, and liposuction are some of the most common procedures performed.
Things I Love About Plastic Surgery
If you couldn’t already tell, I’m enamored with plastic surgery. The diversity and variety you’ll experience in plastics are second to none. Additionally, it’s the most innovative field in medicine. Period. Much of it seems to be science fiction.
If you like precision, meticulousness, and obsession with details, plastic surgery may be a good fit. No other specialty obsesses over the most precise way to close an incision to optimize healing and minimize scarring. In medical school, I found myself reading books on how to suture or tie better knots while everyone else was more concerned with their shelf exams. If you’re the type of person to take interest in such detail, plastics is probably for you.
Pay is more variable than other specialties, and no, you aren’t guaranteed to be driving around in a Ferrari or Lambo. Recon, especially in academic settings, doesn’t pay nearly as well as aesthetic practices. That being said, you’ll still have quite a good lifestyle, as compensation is above average, most surgeries are not urgent, and call isn’t so bad. However, if you do choose microsurgery or handle face trauma, your call will be far more taxing.
Lastly, changes in healthcare and reimbursement are worrisome to attending physicians of all specialties. Luckily for plastic surgeons, they always have the option of going to a cash-based aesthetic practice, thus granting them immunity to possible decreases in reimbursement on a systemic scale.
Things I Don’t Love About Plastic Surgery
No specialty is perfect, and plastic surgery is no exception.
In terms of personalities, plastic surgery is a mixed bag. While it’s a diverse field, the prospect of making millions as an aesthetic surgeon attracts a small number of trainees who are more concerned with money and appearances than actual substance.
I’m going to teach you something that most doctors don’t even know. There’s a great deal of confusion with plastic surgeons versus cosmetic surgeons, and this isn’t so much a problem with plastics as it is a problem with branding. If you wanted to get cosmetic work done, you should go to a board-certified plastic surgeon. Plastic surgeons are the masters of all cosmetic procedures, as they’ve gone through at minimum 6 to 8 years to earn their distinction of being board certified in plastic surgery. Cosmetic surgeons, on the other hand, do not have rigorous standards for training. I’ve seen non-surgical doctors of various specialties, from OB-GYN to anesthesia, emergency medicine to primary care, and more touting themselves as cosmetic surgeons after completing a weekend course on how to do botox. They obviously have no business doing any cosmetic procedures, but greed is a powerful force. It’s dangerous quackery like this that gives cosmetic surgery a bad wrap and results in the horror stories of patients have severe complications or even dying.
There’s also a common misconception that plastic surgery is a highly creative and artistic field. Don’t get me wrong, compared to anything else in medicine, it definitely is, especially if you go into aesthetics. You are incorporating the art and science of beauty into your surgical treatment. That being said, it’s not like you can go in and creatively wing it and do something new. For any defect or goal in treatment, there are only a few standards of care to choose from that have tolerable risk profiles and high rates of success.
Who Should Become a Plastic Surgeon?
Plastic surgery isn’t for everyone, but how can you know if it’s right for you?
First, make sure you actually enjoy the bulk of plastic surgery. I wasn’t personally in love with burn, but everything else was so incredibly innovative and cool. Shadow more than just one plastic surgeon, as the field is so diverse and varied. Scrubbing into a microsurgical case will feel entirely different than doing aesthetics or even craniofacial.
In terms of personality, you should be comfortable with almost painfully precise attention to detail and meticulousness. If the thought of mastering the art of suturing bores you, or you prefer to use staples in closures – which is blasphemy to a plastic surgeon – then look elsewhere.
Lastly, you have to be willing to work your tail off. Plastic surgery is so insanely competitive that if you’re allergic to hard work, you might as well look elsewhere. That doesn’t just mean top grades in class, but also crushing your standardized tests, having multiple publications, a strong personal statement, and killer interview skills. But you don’t have to go at it alone. Med School Insiders is here to help you.
What type of surgeon should I cover in the next So You Want to Be video? Let me know with a comment down below. As always, thank you all so much for watching. Much love to you all, and I will see you guys in that next one.