Plastic Surgery Independent Model: How to Navigate Your First Year of Residency

by Christopher Homsy, MD
Tulane University, New Orleans, Louisiana

The independent plastic surgery pathway is a three-year fellowship that follows a completed general surgery or ENT residency. First-year independent residents face multiple challenges. From day one, they are expected to “get into the plastic surgery mindset” fairly quickly. This can be difficult for those who have spent at least five years immersed in another surgical specialty. As fully trained surgeons, most independent plastic surgery residents are already technically proficient and comfortable with managing critically ill and complex patients. However, are they ready to tackle a new specialty?

Here is a checklist for a successful debut in plastic surgery training.

A (very) steep learning curve: Read. Every. Single. Day.

Start by knowing anatomy cold. There is no other way around it. Focus on the musculoskeletal and the neurovascular anatomy, head-to-toe. For many incoming independent plastic surgery residents, one of most challenging areas to master is the Hand and Upper Extremity. Textbooks such as Green’s Operative Hand Surgery can provide a comprehensive overview. The ASSH Manual of Hand Surgery is similarly useful and is available in both hardcopy and electronic versions. For more focused problem-based learning, however, an online resource such as is available for free. “Orthobullets” is frequently used by orthopedic surgery residents and can be downloaded as an app on any smartphone making it especially helpful for management of hand consults in the emergency room. Craniofacial surgery is another area in which many general surgery-trained residents, particularly those with limited exposure to ENT or Head and Neck surgery, struggle to catch up to their integrated peers. Plastic Surgery: Volume 3: Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery edited by Drs. Rodriguez, Losee, and Neligan, is perhaps one of the most comprehensive textbooks for this subspecialty.

Photography 101.

In this day and age, smartphones deliver high-quality – sometimes equivalent digital images, and are often more convenient to carry than a camera. A recent survey showed that about 72% of patients felt that using smartphones for photography was acceptable1. However, one should keep in mind that patients’ photographs are considered to be an integral part of their medical record and should be protected under the same HIPAA regulations, and must be securely stored, with private, identifying information protected2. If your institution does not allow the use of phones for medical photography, you should consider getting a Digital-SLR type camera. Photographic documentation is essential in plastic surgery. and adhering to the rules published by the American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Foundation (PSF) is key. A recent review of plastic surgeons’ websites, showed that only 66% of images were adherent to the published standards3. “Photographic Standards in Plastic Surgery” brochure published by the American Society of Plastic Surgeons (ASPS) is an easy-to-read quick guide to correct photographic documentation.

Unleash the artist in you: Learn to draw your operative plan.

Practice makes perfect, so start early. Drawing is especially relevant in flap design and in operative planning for procedures such as rhinoplasty and cleft lip and palate repair. Putting in the extra effort to draw out your operative plan ahead of time will help you consolidate your knowledge of anatomy and surgical principles.

The In-Service Exam.

The Plastic Surgery In-Service exam is administered every year, around the month of March. For a first-year independent plastic surgery resident, this leaves less than a year to prepare. For maximum-efficiency studying, every time you learn a specific subject, consider reviewing that same topic in “Essentials of Plastic Surgery” by Dr. Jeffrey Janis. This textbook may be the single most helpful resource for the In-service exam.Another helpful resource is the “Plastic Surgery Education Network (PSEN)”. PSEN is an online learning center developed by the ASPS. It offers a Resident Curriculum with more than 80 modules grouped into eight general sections. Each section starts with a “pre-test” section, followed by a Slideshow presentation. Residents are then directed to “must-read” course articles relevant to each topic. Finally, each module presents one or more board cases, and ends with a review of the “pre-test” questions with elaborated answers and explanations. Residents may access PSEN on, the American Council of Academic Plastic Surgeons (ACAPS) publishes all the previous in-service exams with answers and explanations on its website This is truly an excellent resource to review several months prior to the in-service exam. While questions rarely repeat year-to-year, going over previous exams will put you in the “exam mindset” and help you review high-yield topics for the test.

Evidence-based Plastic Surgery.

Once you have a good grasp of the plastic surgery principles and core subjects, you should make it a habit to read journal articles to keep up with the latest developments and research.Plastic and Reconstructive Surgery (PRS) journal is the plastic surgery journal with the highest impact factor (3.784 as of June 2018). PRS provides the latest research and evidence-based articles, videos, and podcasts. The PRS website offers a Residents section with a collection of articles that every resident should read.

Don’t quit.

“The single most important thing is to never quit. There will be failures and setbacks. People will tell you that you cannot do it. Don’t quit. Believe in yourself and great things will happen.” –Rod J. Rohrich4

Colleagues, the first year in plastic surgery residency is extremely demanding, and the learning curve is very steep, so work hard, stay humble, keep reading… but most importantly, enjoy and love what you do!

  1. Nair, A. G., Potdar, N. A., Dadia, S., Aulakh, S., Ali, M. J., & Shinde, C. A. (2018). Patient perceptions regarding the use of smart devices for medical photography: results of a patient-based survey. International Ophthalmology
  2. S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule. Available at: http://www.hhs. gov/ocr/privacy/hipaa/understanding/summary
  3. Adherence to Photographic Standards:A Review of ASPS and ASAPS Member Surgeons’ Websites. (2016). Adherence to Photographic Standards:A Review of ASPS and ASAPS Member Surgeons’ Websites, 2(2).
  4. Rohrich, R. J. (2018). So, You Want to Be a Success? Aspire, Inspire, and Perspire-A Lot! Plastic and Reconstructive Surgery, 141(3), 819–820.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s