Revision Rates in Cosmetic Plastic Surgery with and without Resident Involvement

Abstract

Background:

Changes in surgical education have caused concern over residents’ preparedness for independent practice. As the field of otolaryngology requires such a wide breadth of expertise, ill preparation becomes especially costly. This study explores how the presence and participation of a postgraduate year 3 (PGY3) otolaryngology resident in surgery impacts revision rates and operating time as gauges for the resident competency and indirect training costs.

Methods:

A retrospective chart analysis of patients who underwent cosmetic plastic surgery at sites for PGY3 otolaryngology residents’ facial plastic surgery rotations was conducted. Residents performed one side of bilateral procedures (eg, blepharoplasties) and approximately 50% of midline procedures (eg, rhinoplasties). Chi-squared testing and odds/risk ratios were done to assess the effect of resident involvement on revision rates. Operating time was compared using t tests.

Results:

When a resident was involved in cosmetic surgery, the revision rate was 22.2% compared with 3.6% without. The likelihood of a future revision surgery was 7.57 times higher when a resident participated in the original operation. Resident involvement was not a statistically significant predictor of exceeding the allotted operating time.

Conclusions:

The revision rate of cosmetic surgery was much higher when a resident was involved. Otolaryngology residents would benefit from increased facial plastic and reconstructive surgery training. As a response to this analytical study, this clinical rotation was moved to be offered at a later stage of postgraduate surgical training to allow residents to gain more experience and be better set up for success in the rotation.

Takeaways

Question: How does resident involvement affect revision rates and operating times for cosmetic procedures as a gauge for resident competency?

Findings: When a resident was involved in cosmetic surgery, the revision rate was 22.2% compared with 3.6% with the attending physician alone. The odds of needing a future revision surgery were 7.57 times higher when a resident is participating in the original operation.

Meaning: Otolaryngology residents would benefit from increased facial plastics and reconstruction training, soft-tissue handling training, and increased operating room time.

BACKGROUND AND RATIONALE

Surgical training has steadily progressed in the direction of competency-based training, as evidenced by the adoption of the six clinical competencies, as well as case log requirements, by the Accreditation Council for Graduate Medical Education (ACGME).¹ This movement away from apprentice to well-rounded surgeon is not without its corresponding sacrifices. With increasing clinic hours and decreasing operating room hours with delayed autonomy for the next generation of surgeons, this shift is made more acute. While some advocate for chief resident clinics at later stages of residency,² others stress the importance of learning under an attending with direct supervision to promote gradual autonomy and to avoid unnecessary complications or compromises to the patient–physician relationship.^3–6 In theory, a surgical resident should at least begin by assisting the attending both in surgery and clinic. At the same time, the attending’s first priority is preserving patient safety and outcomes; teaching the resident then becomes secondary. In plastic surgery, those concerns are paired with aesthetic outcomes for the patient and financial concerns for the practice, as revisions are commonly at reduced or no cost; in essence, a teaching tax.

Due to the elective nature of cosmetic surgery, patients tend to have high expectations for postoperative outcomes with little tolerance for imperfection. This is the perfect recipe leading to the limitation of hands-on surgical and preoperative planning experience for residents.⁷ Cosmetic surgery revisions are not uncommon, often resulting from unexpected healing outcomes, miscommunications in consults, nonadherence to postoperative instructions, or unclear or unmet expectations.⁸ Another potential reason for cosmetic revisions is technical shortcomings during surgery, which thus-far has been largely ignored in the literature. The importance of surgical experience has not yet been quantitatively evaluated. Revision rates are an indicator of surgical skill, training, and experience, and ultimately patient satisfaction.^3,9

A number of factors have likely contributed to these shifts, including one-resident per case surgical operating room requirements, lack or delay in autonomy in the operating room, and lack of targeted feedback in the operating room, all of which may possibly stunt early surgical skill acquisition. This shift was made even more apparent in the aftermath of the COVID-19 pandemic, when a decline in cosmetic or elective cases and the reassigning of surgical residents to treat COVID-19 patients negatively impacted the training curriculum.^2,10,11 This has been quantified in plastic surgery and operationalized as preparedness and confidence.^12,13 Even before COVID-19, questions about adequate preparation for independent practice of recent residency graduates have been raised especially given overall resident autonomy has decreased over time.^12,14,15 Major deficiencies in the domains of independent practice ability, patient responsibility, and some motor skills, all fundamental elements of patient care are seen throughout surgical residents. These factors help explain the unprecedented high demand by residents to invest in additional training and specialization, including specialized fellowships, after general surgery residency. It is reported that greater than 80% of chief residents proceed to 1- or 2-year fellowships in various subspecialties, and a recent survey of surgical residents has revealed that nearly 40% of residents lack confidence in their skills after 5 years of training, including 23% of graduating chief residents.^12,16

Proposed by Malcom Gladwell, the 10,000 hour rule describes the large number of hours it takes to become an expert in a field.¹⁷ And although this is true, it is not simply the time or repetition that makes you an expert, but the opportunity to assess and modify your technique to excel. The amount of time to effectively achieve this goal is no longer mathematically possible in a 5- or 6-year surgical residency.¹⁸ In a study by Smith looking at resident duty hours in head and neck endocrine surgery, less time to develop competence may have led to increased rates of recurrent laryngeal nerve and accidental injuries at leading hospitals.¹⁹ As less time during otolaryngology residency is spent in general surgery and modifications to internship schedules include new night shifts and floats, soft tissue management skills are not emphasized as they once were.

Although resident revision rates have been studied in many fields of medicine, we sought to determine the revision rates in cosmetic plastic surgery with and without resident involvement as a way to better inform the curriculum of postgraduate Otolaryngology training. We not only investigated revision rates, but also the operating time for procedures including residents on the surgical team as an additional measure for the efficacy and preparedness of surgical residents.

STUDY DESIGN AND METHODS

This study is a retrospective chart review of cosmetic plastic surgery procedures performed at an ambulatory surgery center or community hospital from January 1, 2014 to July 1, 2017, the last 2.5 years of a clinical rotation site. This site was a clinical rotation in plastic surgery with a specific focus on wound closure, soft-tissue handling, and facial plastic surgery for postgraduate year 3 (PGY3) otolaryngology residents. Residents were in their third postgraduate year and were supervised by the primary investigator, who is triple board certified in otolaryngology, plastic surgery, and facial plastics with over 20 years of academic teaching experience. All patients were from a single plastic surgery practice and were granted medical clearances by outside practitioners to undergo cosmetic plastic surgery.

Patients were excluded from this study if other concomitant noncosmetic procedures occurred in the same surgical setting. Patients were also excluded if the revision was a result of abnormal surgical findings, such as abnormal breast tissue pathology; if the patient was of Asian or African descent and had a documented history of keloid scarring, and the revision was due to keloid scarring; if the patient sought their original surgery as a correction of a cosmetic surgery from another surgeon; or if the patient consistently underwent revision surgery against the advisement of the surgeon’s judgment. The average patient was American Society of Anesthesiologists (ASA) classification 2 or less, and all included patients were nonsmokers. Patients with significant comorbidities, including healing compromise (ie, prior radiation) were not included in this study. All procedures were supervised from start to finish by one attending physician, who is triple board certified in plastic surgery, otolaryngology, and facial plastics and a full clinical professor in plastic surgery and ear, nose, and throat.

Cosmetic revisions included but were not limited to scar revisions, touch-up liposuction and fat grafting, correction of asymmetries, and dorsal rasping in rhinoplasties, all administered at the patient’s convenience once it was determined that there was appreciable healing from the original surgery. The outcomes of interest included actual versus scheduled times of surgery and likelihood of revision after surgery. Sidedness of cosmetic defects in bilateral procedures with attendings and residents was also evaluated to exclude bias associated with attending compensation of outcomes. Standard practice for cases including a resident are defined as follows: For bilateral cases, the supervising surgeon performed the right side and the resident the left, and the opposite was performed for body cases. For midline procedures, the resident performed 50% or more of the operation from the patient’s right side. The lead attending surgeon was present for the entirety of the surgical case.

Planned analyses included t test to determine if cases with or without residents were more likely to run over or under time; chi-square testing to determine if procedures with residents were associated with revisions; and odds/risk ratio of revisions without or without a resident assisting in the original operation. All statistical analyses were performed using SPSS (IBM, Armonk, N.Y.). This study used a significance level of 𝛼 = 0.05.

ETHICAL CONSIDERATIONS

All patients sign informed consents before surgery that detail the risks, including cosmetic irregularities associated with healing and potential for re-operation. All patients were aware of resident involvement in surgical care. All patients additionally sign forms detailing Health Insurance Portability and Accountability Act (HIPAA) policies and financial policies, including policies on revisions for the practice. All patients in this study were identified by patient number, and all identifying features were redacted before data entry and analysis. This study was approved by Biomedical Research Alliance of New York (BRANY) institutional review board (A-IRB00000080).

RESULTS

The retrospective chart review identified 1581 patients who underwent cosmetic surgery between January 1, 2014, and July 1, 2017. This group was predominantly female (n = 1357, 85.8%) and white (n = 1297, 80.9%). The mean age of patients was 47.6 years (SD = 7.07) and mean body mass index was 27.2 (SD = 4.58). Body procedures (n = 1084) were more common than facial procedures (n = 414). In 69.8% of these procedures, the operation was performed by the attending surgeon alone (n = 1103) and 30.2% (n = 478) of these cases involved a resident. Table 1 provides descriptive statistics for these groups.

Table 1.

Descriptive Statistics for the Sample and Groups of Interest, Procedures Performed with and without a Resident

		Overall		Without PGY3		With PGY-3
n		1581		1103	69.8%	478	30.02%
Sex
	Female	1357	85.8%	941	85.35	416	87.0%
	Male	224	14.2%	162	14.7%	62	13.0%
Age		47.6	7.07	48.0	6.95	47.2	7.21
BMI		27.2	4.58	27.1	4.33	27.3	4.82
Race
	White	1279	80.9%	894	81.1%	385	80.5%
	Black	168	10.6%	113	10.2%	55	11.5%
	Asian	101	6.39%	78	7.07%	23	4.81%
	Other	33	2.09%	18	1.63%	15	3.14%
Surgery type
	Facial	414	26.2%	293	26.6	121	25.3%
	Body	1084	68.6%	746	67.6%	338	70.7%
	Combination	83	5.25%	64	5.80%	19	3.97%

Of the 1581 patients who received surgery during the research period, 146 had a revision procedure performed before January 1, 2019 (Table 2). There were 106 revisions done on patients who had a resident involved in their initial surgery, and only 40 revisions completed for patients who were exclusively operated on by the attending surgeon. This translated to an overall revision rate of 9.2% (n = 146), and a revision rate of 22.2% (n = 106) in resident-involved cases versus 3.6% (n = 40) in attending-only cases. Levene test for normality was performed, and the samples follow a normal distribution and do not have unequal variance.

Table 2.

Descriptive Statistics for the Revision Sample and Groups of Interest, Procedures Performed with and without a Resident

		Overall		Without PGY3		With PGY3
n		146		40		106
Sex
	Female	120	82.2%	33	82.5%	87	82.1%
	Male	26	17.8%	7	17.5%	19	17.9%
Age		46.1	6.88	46.3	6.54	45.9	7.14
BMI		28.2	4.08	27.9	4.03	28.4	4.11
Race
	White	117	80.1	31	77.5%	86	81.1%
	Black	19	13.0%	5	12.5%	14	13.2%
	Asian	7	4.79%	4	10.0%	3	2.83%
	Other	3	2.05%	0	0.00%	3	2.83%
Surgery type
	Facial	38	26.0%	11	27.5%	27	25.5%
	Body	96	65.8%	27	67.5%	69	65.1%
	Combination	12	8.22%	2	5.00%	10	9.43%

Procedures with residents were significantly more likely to result in a subsequent revision procedure than those without (P < 0.001), based on chi-squared testing (x² = 136.89, df = 1). Resident involvement in a patient’s cosmetic surgery made them 7.57 times more likely to undergo a revision (confidence interval: 5.17, 11.1). The most common revision procedure was scar revision (n = 77, 52.7%) followed by nasal rasping (n = 14, 9.6%) and revisions because of functional compromise (n = 14, 9.6%). Examples of functional compromise included ectropion, nasal obstruction, pain at incision site, among others. In unilateral scar revisions (n = 58) following a bilateral procedure involving a resident (n = 79), 87.9% (n = 51) of the revisions occurred on the side completed by the resident.

Generally, surgery length did not considerably differ from the anticipated time needed to complete the procedure (P = 0.769), finishing, on average, 16 minutes before the scheduled end time (SD = 42 minutes). Procedures that ultimately required a subsequent revision did not differ between actual and anticipated length (P > 0.99). The presence of a resident was similarly not associated with a time discrepancy (P = 0.674). The Shapiro-Wilk test revealed no significant departures from normality in surgical run time (W = 0.964, P = 0.162).

DISCUSSION

It is not a revelation that cosmetic surgery has an inherent revision rate. In fact, the revision rate for rhinoplasty of 9% found in this study was consistent with that found in previous studies.⁸ More concerning is that cases involving a resident had a much higher probability of revision (22.2%) that those not involving a resident (3.6%), making for a risk ratio of 7.57 despite constant supervision. Previous studies have shown resident participation does not increase morbidity or mortality per se, but does increase technical specific injury, such as recurrent laryngeal nerve or accidental vessel injury.^10,19

The 80-hour limit has had minimal impact on residents’ operative experience, case number and variety, and residents’ perceptions of their educational experience, as well as no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units.^20,21 However, accuracy of case logs is inconsistent and has even been characterized as sometimes inaccurate.²²

When analyzing results for plastic surgery, there is a distinction to be made between a complication versus a revision. In this study, 10% of revisions were for functional concerns, such as ectropion, while the rest were driven by cosmetic or patient satisfaction demands. The implications for the patient and surgeon are unmet expectations, lost time, and financial burden to the practice.^23,24 This is in contrast to reconstructive surgery, in which an inherent revision rate is expected and remunerated. As such, it may be necessary to introduce more soft-tissue handling experience earlier and cosmetic surgery training later in the resident education curriculum to help mitigate any unexpected costs to the attending or instructor that could potentially prevent surgical residents from having hands-on training amidst the fiscal concerns of the practice.

Unlike Vieira, who found a greater than two-fold time to complete cases with residents, there was no statistically significant time difference in this study.²⁵ The assistance of a resident compensated for the time spent in teaching. Was this at the expense of quality? We were able to eliminate this as a possible confounding variable by further looking into the sidedness of revisions. When considering scar revisions, 89% were on the side where the residents consistently performed. Issues such as cutting on the scribed lines, matching tissue planes, compensating for incision length mismatch, and suture technique need to be carefully mastered. If the revision rate were a side-effect of the attending rushing to compensate, the sidedness of the revisions would have been more balanced. Direct reasons for increased revision rates include residents not cutting on the surgical marking due to moving counter traction in an upper blepharoplasty, where it is not possible to put back skin, and scar revisions related to incidence of “dog ears” at the end of incisions due to sewing mismatch or tissue height discrepancies in dermal closures.

The strength of this study is that it was completed on a controlled group with a narrowly defined subset, and all cases being fully supervised by a single attending surgeon. The criticism of whether the markedly higher revision rate is a student or teacher problem is why the study design is a comparison of revision rates with or without a resident, following the same attending with over two decades of surgical teaching experience after residency. The distribution in facial versus body procedures was equivalent between the groups. As elective cosmetic procedures, there were minimal confounding comorbidities, and given the 89% side dependence of revisions, any comorbidities did not affect the results as bilateral complications would have been expected. The inclusion of body cases is justified as this was a rotation with an emphasis on soft tissue handling, as it is paramount in achieving cosmetically pleasing results in surgery of any part of the body. Thus, this study gives important information about competency, not in individual procedures, but in a discipline. As a response to this analytical study, this clinical rotation was moved to be offered at a later stage of postgraduate surgical training, PGY5 year instead of PGY3, to allow residents to gain more experience and be better set up for success in the rotation.

With more demand in residency training in areas beyond critical surgical technique and skills, how does the resident training balance with patient outcomes? The 2014 ACGME case log requirement increase for aesthetic surgery training has had a positive effect on resident comfort with aesthetic procedures and their ability to incorporate them into future practice.¹ However, the literature reveals the infrastructure for cosmetic training of otolaryngology or plastic surgeons leaves something to be desired. Specifically, residents see low patient volumes and minimal staff support.^23,26 The problem is compounded in that the majority of cosmetic surgery takes place in private practice away from the academic training centers.⁷ It is easy to discount these findings as related to ear, nose, and throat residents in a plastics rotations, but we feel that they are much more symptomatic of a shift indicative of higher PGY levels lacking in surgical experience due to loss of double scrubbing and an overall lack of hands-on learning opportunities. These deficits are perceptible throughout surgical training, making this a difficult study to get published, as no one wants to see or extrapolate deficits in the existing training schema.

A key component of success in surgical training is being prepared, especially if clinical material is limited by mounting nonclinical responsibilities. Although there is increasing awareness of the shortcomings of surgical training, research presenting data in criticism of current practices is minimal. A survey of fellowship directories by Mattar in 2013 found that 28% of general surgery residents were unprepared despite duty hour changes for operations.¹² This is a responsibility of the training program, as well as the resident’s responsibility to be ready for the level of soft-tissue handling that performing in a cosmetic surgery rotation takes. This is especially important as increased revision rates have implications that extend far beyond the resident. Studies highlighting suboptimal performance in surgery can further open the conversation for improvement.

A stepwise solution needs to be implemented early in resident training. Intern level soft tissue handling courses, basic skills courses, and simulation models as well as second assisting responsibilities should be maximized. This may include seeking community-based experience, such as participation in resident aesthetic clinics which provide residents with further experience and competencies needed to perform cosmetic procedures, with safe and successful surgical results to patients.^2,7 Resident clinics also build comfort levels in performing key cosmetic surgery procedures.²⁷

Although increased autonomy and exposure are associated with increased confidence, it must be driven by resident interest.^6,28 As the real implication of early resident involvement, PGY3 involvement for the purposes of cosmetic training resulted in higher revision rates. Although deferring the exposure from PGY3 to a more senior level of resident who has likely had more soft-tissue experience might compensate for this, it is critically important that we improve at granting autonomy to residents and do so earlier in their training.²⁹

Even for more common surgical procedures, there can be limited repetition during training. Therefore, it is imperative to determine objectively whether residents are actually achieving basic competency in these operations and to address the large variations in experience between individuals in our residency system.³⁰

The surgery groups were equal in content of body and facial procedure mix, and procedures were used to evaluate soft-tissue handling. In these cases, residents were expected to handle soft tissue efficiently, not to know how to perform all of the steps of a cosmetic plastic surgery operation, which would be unexpected for the residents at this level.

CONCLUSIONS

This retrospective analysis shows that resident involvement in cosmetic surgery increases revision rates from 3.6% to 22.2%. When operating with a resident, the risk of revision surgery was 1.24 times, or 25% more per individual case, the risk of revision surgery without a resident. The odds of revision surgery when a resident assisted in the initial surgery were 7.57 times those of procedures without residents. The current model of show and supervise seems inadequate, and residents may require more or different education in the operating room. An attending in the operating room, potentially on the other side during closure may not be enough. For successful cosmetic surgery training of otolaryngology and other surgical residents to exist, it has to not only benefit residents, but maximize results and minimize secondary expenses. There needs to be thoughtful consideration of prerequisite training, soft-tissue handling skill, and timing of cosmetic surgery rotations. Mandatory clinical skill labs on cadavers or simulated training devices may be needed before stepping into the operating room for a cosmetic case. The changes that residency programs have been characterized and generated a positive trend in resident perception of their personal ability across most aesthetic procedures, though gaps in education still exist. These gaps remain under examination, and many residency programs continue to develop their own methodologies to improve resident training in aesthetic surgery.³¹ As technology constantly improves, the use of intraoperative training videos for cosmetic rotations may be one such solution.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article.