Oral and maxillofacial surgeon Manolis G Manolakakis, D.M.D., thought that while his residency training provided the basics for specializing in facial cosmetic surgery, it wasn’t enough to make him a cosmetic surgery expert. So, he completed a fellowship in facial cosmetic surgery. Today, he trains fellows in his specialty who want to hone their facial cosmetic surgery skills.
Cosmetic surgery fellowships weren’t popular decades ago. But now that so many different specialties want to get a piece of the aesthetic pie, there’s more pressure for residents to do the extra training to better prepare for careers in cosmetic medicine and surgery, Dr. Manolakakis says.
“If you want to practice in a particular area of expertise, such as head and neck surgery, cosmetic surgery or TMJ surgery, [the American Association of Oral and Maxillofacial Surgeons] has set in place fellowships. The reason… is that people really do want to become subspecialists. After a residency, you’re more a jack-of-all-trades,” Dr. Manolakakis says.
After completing a dermatology residency at New-York Presbyterian Hospital, Weill Cornell, Isabela T. Jones, M.D., decided to do a year-long cosmetic dermatologic surgery fellowship, accredited through the American Society for Dermatologic Surgery (ASDS), with Mitchel P. Goldman, M.D., in San Diego. She’ll have completed that July 31, 2017, then will join a dermatology practice in McLean, Va.
“I decided to pursue [a] fellowship for many reasons, but I would say the primary driver was to become a true expert in aesthetic dermatology. I want to offer my patients the best possible results, and I felt like I would not be able to do that with only the skills I learned in residency,” Dr. Jones says.
Despite the potential need for more training, pursuing fellowship training in cosmetic surgery isn’t common practice. Dr. Manolakakis estimates about 3% to 5% of maxillofacial surgeons are fellowship trained in facial cosmetic surgery. It’s unlikely that physicians who have established practices will take a year or more off, as well as a pay cut (fellows’ salaries usually range between $50,000 and $75,000), he says.
But fellowship training is important, he says, because of all the different specialties that are offering medical and surgical cosmetic options, including oral and maxillofacial surgery, otolaryngology, dermatology, ophthalmology, plastic surgery and others.
“All these specialties have the general knowledge of what they learn. Then, to focus on cosmetic, they all offer fellowships in their respective fields. In plastics, they would do a full body aesthetic fellowship, including body and face. For ear nose and throat (ENT), it becomes a facial plastic and reconstructive fellowship. For oral and maxillofacial surgery, we focus on the face, so we’re very similar to ENT…,” he says. “Then, there is the American Academy of Cosmetic Surgery (AACS), which is a multispecialty group that offers fellowships. I recently took AACS’s oral and written board certification to become board certified in facial cosmetic surgery.”
The Aesthetics Melting Pot
Fellowship training in cosmetic surgery is complicated because there are different groups vying for ownership of aesthetics in medicine.
“It’s multispecialty — everybody has their hands in it,” Dr. Manolakakis says.
While there are no published studies that prove fellowship trained cosmetic surgeons provide better care, Dr. Manolakakis contends more training can’t hurt.
Even plastic surgeons can benefit from fellowship training. Morrison et al. surveyed plastic surgery program directors and senior plastic surgery residents about what they thought of the quality of cosmetic surgery resident training. According to the study published in 2008, trainees reported concerns, including that they lacked confidence in their abilities to perform rhinoplasty, facelifts, body contouring and more. More than a third of the residents felt they needed more training before being prepared to integrate cosmetic surgery into their practices upon graduation.
In other research, authors reviewed general cosmetic surgery training in fellowship programs by the American Academy of Cosmetic Surgery. They not only evaluated the operative experience of surgeons completing AACS post-residency fellowship, but also compared AACS fellowship training to other surgical residency and fellowship programs in the U.S.
In the 39 one-year general cosmetic surgery fellowship case logs they reviewed from 2007 to 2012, fellows completed an average 687 procedures, including an average 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations and 189 liposuctions. Minimum cosmetic surgery requirements in otolaryngology residency was 35 procedures; 20 for oral maxillofacial surgery, 28 for ophthalmology and 20 for dermatology. Minimum fellowship requirements for cosmetic surgery procedures were 300 for an AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and zero for Mohs dermatology, according to the review.
“In residency programs, when we’re doing our general training, there are so many different facets to what we have to learn that it’s impossible to just focus in on cosmetic surgery,” Dr. Manolakakis says. “The reality is everyone comes to the cosmetic world with their own background, training and expertise. The cosmetic world is like the central meeting ground.”
Dr. Jones says the first thing she gained from her fellowship is clinical experience.
“During fellowship, I worked with five leaders in cosmetic dermatology — all who practice in slightly different ways. I have been able to refine my skills in facial assessment, dermal fillers, neurotoxins and lasers. Not only am I now able to perform these procedures more efficiently, safely, and for a wider range of indications, but I also feel more comfortable dealing with any complications which may arise,” Dr. Jones says. “… I have learned procedures which I never did in residency, including ablative laser resurfacing, skin tightening and tumescent liposculpture, among others. Second, I have spent about half of my time performing clinical research. As fellows, we are involved in every aspect of clinical trials, from coming up with ideas to writing protocols, to actually performing the study procedures and assessments and writing manuscripts. I have been able to publish multiple papers this year.”
And that’s not all. Dr. Jones says she learned a tremendous amount about the ins and outs of running a private practice.
NEXT: Advice to Future Fellows
Advice to Future Fellows
Fellowship training generally occurs after residency training. Doctors interested in fellowships might start looking in their second or third year of residency for what their appropriate specialty societies offer or at what’s available through the AACS, according to Dr. Manolakakis.
Not all fellowships are the same. Some fellowships are accredited; some are not. It’s best to find a fellowship program that is accredited because the fellowship has to fulfill certain guidelines, according to Dr. Manolakakis. The tricky part about accreditation in cosmetic surgery is that the Accreditation Council for Graduate Medical Education (ACGME) does not view cosmetic surgery as an accredited specialty. Rather, the individual societies offer accredited fellowship programs that have to meet certain standards and are reviewed, he says.
When picking a fellowship, there are a couple of things to consider — aside from location, according to Dr. Jones. Future fellows should look at how much hands on experience they’ll get.
“A fellowship that involves mostly shadowing will not be able to prepare you for the real world,” Dr. Jones says.
Another question to ask yourself: How enthusiastic are the physicians who will be training and mentoring you?
“Some programs may only want a fellow in order for them to have extra hands to help,” Dr. Jones says. “I would look for a program that is truly interested in developing you.”
Doctors interested in pursuing fellowships should also ask what percentage of time will be dedicated to research (if any). Those interested in research might want to find a more suitable program. And, finally, what are previous fellows doing now?
“This will give you a better idea of the overall feel of the program,” Dr. Jones says.
Identifying a potential fellowship program is the beginning. The next step is to make sure it’s a good match. In a one-on-one interview with the fellowship director, the resident can get a feel for the program’s quality and expectations, and the director can better understand if that fellow is a good match for his or her practice.
Fellowships are typically 12 months. During that time, fellows are co-surgeons to the director. The aim should to be learn how to run a cosmetic practice; evaluate patients; assess treatment options, from surgical to nonsurgical; use multimodalities to achieve desired outcomes; and manage postoperative patient care and complications, according to Dr. Manolakakis.
“The real issue with cosmetic surgery is that we want to make sure that it’s provided safely. Coming out of a residency, you have limited access to all of this because you’re pulled from one place to another. We don’t have the ability to really follow through with patients and see their whole process from start to finish. That’s an important part of fellowships,” he says.
At-a-click cosmetic surgery fellowships
American Academy of Facial Plastic and Reconstructive Surgery (ASAPS) offers generalized and focused registered fellowships.
The American Academy of Facial Plastic and Reconstructive Surgery offers 12-month fellowships. To be eligible, applicants must have completed a residency in otolaryngology or plastic surgery that is approved by the Accreditation Council for Graduate Medical Education or be board-certified by the American Board of Otolaryngology or the American Board of Plastic Surgery.
The American Society for Dermatologic Surgery (ASDS) offers accredited cosmetic dermatologic surgery fellowships.
American Association of Oral and Maxillofacial Surgeons (AAOMS) offers facial cosmetic fellowships.
The American Society of Ophthalmic Plastic and Reconstructive Surgery offers one- and two-year accredited fellowships.