Impact of Gender Trends on Plastic Surgery Fellowship Match: Implications for Surgical Education

Abstract

Background:

No prior study has evaluated gender trends within the plastic surgery subspecialty fellowship match. The purpose of this study is to examine gender trends across fellowship trainee demographics to assess and characterize existing disparities between male and female plastic surgeon counterparts.

Methods:

A review of the new board diplomates listed in the annual newsletter to diplomates of the American Board of Plastic Surgery from 2015 to 2019 was used to identify physicians who pursued various plastic surgery subspecialties. Fellowship match data, including sex, practice type, and prior residency training, were obtained from publicly accessible institutional and private practice websites, social media, and online reports. Additionally, data on current practice type stratified by sex were collected.

Results:

From 2015 to 2019, 60.2% of all board-certified plastic surgeons pursued fellowship training or research fellowships. Female trainees were significantly more likely to pursue breast reconstruction fellowship than males (12.1% female versus 4.3% male). There were no significant gender differences among other fellowship subspecialties or practice types (academic, community, or private). Our data showed that plastic surgeons who completed an integrated residency program were more likely to pursue a fellowship (69.7%) compared with those who completed independent plastic surgery training (50.1%), but no significant gender differences were found within either training type.

Conclusions:

A significant gender difference remains among newly board-certified plastic surgeons; however, the ratio of male-to-female trainees across most fellowship subspecialties is equivocal, except for breast reconstruction being predominantly female.

Takeaways

Question: Do gender disparities exist in subspecialty fellowship training among newly board-certified plastic surgeons?

Findings: In this retrospective review of 984 diplomates (2015–2019), 60.2% pursued fellowship training. Gender differences were minimal across most subspecialties, except breast reconstruction, where women were more than 3 times as likely to specialize. Fellowship completion was more common among integrated residency graduates and was associated with working in academic or private practice settings.

Meaning: Gender representation in most plastic surgery fellowships is approaching parity, suggesting progress toward equity in surgical subspecialty training.

INTRODUCTION

Historically, gender disparities have been prevalent within surgical subspecialties. Societal pressures concerning assigned gender roles, such as fertility, child care, familial responsibility, and underrepresentation, have factored into women’s abilities to receive equal opportunity within the field.¹ In plastic surgery specifically, gender disparities are reinforced through unequal compensation, with female plastic surgeons earning $3473.21 less per year than their male colleagues.² Likewise, a survey of American Society of Plastic Surgeons members found that men were significantly more likely than women to earn salaries over $400,000 per year, even after accounting for board-certification year.³ Although maternity leave factors into this decreased compensation, female plastic surgeons have truncated maternity leave, as 40% take fewer than the minimum 6 weeks recommended by the American College of Obstetrics and Gynecologists.⁴

Gender disparities have also extended into academic pursuits, as female plastic surgeons have significantly fewer publications than their male counterparts.⁵ This pattern has been reflected at plastic surgery conferences, as women comprised a significant minority of keynote responsibilities (eg, instructors, moderators, panelists) from 2014 to 2018.⁶ Underrepresentation has also historically extended into leadership roles, with women holding only 12.5% of fellowship director positions across major plastic surgery subspecialities.⁷ Furthermore, inequities persist within the training environment, as national survey data demonstrate that female trainees are significantly more likely than male trainees to experience microaggressions.⁸

Plastic surgery residency programs have been diligently working toward decreasing the gender gap among residents within the past decade. According to the 2023 Report on Residents of the Association of American Medical Colleges, American and Canadian women made up 46.3% of active integrated plastic surgery residents, where men made up 48%, revealing a fairly equal level of representation among integrated residency programs.⁹ A study by Di Chiaro et al¹⁰ demonstrated that there has been an upward trend of women matching into plastic surgery residency; from 2021 through 2024, more women have matched into integrated plastic surgery residency than men. Although there are studies in the literature that exemplify the progress of gender equity through analyzing plastic surgery residency match trends, there is a gap in the literature regarding the gender analysis of fellowship match data for plastic surgery subspecialties. In this study, we conduct a comprehensive analysis across distinct plastic surgery subspecialty fellowships, with the aim of elucidating potential differences in fellowship participation between male and female surgeons. We further investigate gender trends among residency training pathways and various practice settings to assess how gender influences professional development within the field of plastic surgery.

PATIENTS AND METHODS

Study Design

A retrospective review of the new board diplomates listed in the American Board of Plastic Surgery annual newsletter to diplomates from 2015 to 2019 was performed.¹¹ Data, including educational backgrounds and practice type (private, academic, or community), were publicly accessible information obtained from institutional websites, private practice websites, and online platforms, including LinkedIn and Doximity.

Study Participants and Eligibility Criteria

Electronic newsletters listing newly certified board diplomates of the American Board of Plastic Surgery were used to obtain physician identities. Physicians lacking sufficient data and those who had pursued fellowships outside of the field of plastic surgery were excluded. Individuals were categorized as male or female according to website photographs, naming conventions, biographies, and listed pronouns. Information obtained included fellowship subspecialty (microsurgery, craniofacial, hand/peripheral nerve reconstruction, cosmetic/aesthetic, pediatric, burn, breast reconstruction, oculoplastics, research, or “other.” The “other” category included gender-affirming surgery; trauma/surgical critical care; wound healing; ear, nose, and throat; head/neck; body contouring; and palliative care. Physicians who completed combined fellowship programs were documented as having multiple subspecialty fellowship types. Practice settings (private, academic, or community) were collected. Academic practices were defined as those affiliated with a Liaison Committee on Medical Education–accredited medical school or an established residency program in any specialty.¹² The data also accounted for physicians working in more than 1 practice setting category. Additionally, we documented whether plastic surgeons completed an integrated plastic surgery residency program or pursued an independent plastic surgery program. If an individual transferred from a general surgery program to an integrated program, they were classified as having attended only the integrated residency.

Statistical Analysis

Distributions of overall fellowship, fellowship subspecialty type, practice type, and residency training by sex are summarized as frequencies and percentages for the combined years of 2015 to 2019 and similarly for each year individually. Differences between female and male genders were assessed via Fisher exact test. Logistic models were then fit to estimate the odds of being a woman and entering each fellowship subspecialty. Odds ratios (ORs) greater than 1 indicate an increased likelihood of female surgeons, whereas ORs less than 1 indicate decreased odds of female surgeons. Year was included as another covariate in these models. The Firth correction was used in models with outcomes having scarce responses in 1 sex. Results were summarized as ORs, along with their 95% confidence intervals (CIs) and P values, with statistical significance defined as a P value less than 0.05.

RESULTS

Characteristics

A total of 984 new American Board of Plastic Surgery diplomates were included in this study, of which 73.8% (N = 726) were men and 26.2% (N = 258) were women (Table 1). A total of 592 (60.2%) of all board-certified plastic surgeons pursued fellowship training or a research position, with approximately equivalent proportions for each sex (61.0% [n = 443] of all men and 57.8% [n = 149] of all women). Across the 5-year span, significantly more men entered fellowship or research positions in total. In 2015, of the 176 fellowship or research positions allotted, 142 (80.7%) were filled by men (P < 0.0001) (Table 2). Data by fellowship type (microsurgery, craniofacial, hand/peripheral nerve reconstruction, cosmetic/aesthetic, pediatric, burn, breast reconstruction, oculoplastics, research, and other) did not yield significant gender differences, except for women in breast reconstruction (12.1% of breast fellows were women in comparison to 4.3% of breast fellows who were men, P = 0.001).

Table 1.

Gender Differences Within Fellowship, Practice Type, and Residency Training

Characteristic		Male, N = 726*	Female, N = 258*	P
Fellowship: yes versus no				0.375
Fellowship		443 (61.02)	149 (57.75)
No fellowship		283 (38.98)	109 (42.25)
Fellowship type
Microsurgery		171 (38.60)	56 (37.58)	0.846
Craniofacial		97 (21.90)	31 (20.81)	0.819
Hand surgery/peripheral nerve reconstruction		148 (33.41)	38 (25.50)	0.083
Cosmetic/aesthetic		77 (17.38)	28 (18.79)	0.711
Pediatrics		36 (8.13)	20 (13.42)	0.074
Burn		25 (5.64)	3 (2.01)	0.077
Breast reconstruction		19 (4.29)	18 (12.08)	0.001
Oculoplastics		5 (1.13)	1 (0.67)	>0.999
Other		21 (4.74)	5 (3.36)	0.645
Research		21 (4.74)	9 (6.04)	0.521
Practice type
Private practice		384 (52.97)	124 (48.06)	0.192
Academic practice		282 (38.90)	109 (42.25)	0.374
Community practice		98 (13.52)	30 (11.63)	0.518
Residency training
General surgery + plastics	Overall, N = 479*	Male, N = 382*	Female, N = 97*	P †
Fellowship	240 (50.10)	195 (51.05)	45 (46.39)	0.428
Integrated plastics	Overall, N = 505*	Male, N = 344*	Female, N = 161*	P †
Fellowship	352 (69.70)	248 (72.09)	104 (64.60)	0.097

^*n (%).

^†Fisher exact test.

Table 2.

Overall Proportions of Male-to-Female Fellowship Match by Year

Year	Male	Female	P *
2015, N = 176†	142 (80.68)	34 (19.32)	<0.0001
2016, N = 202†	145 (71.78)	57 (28.22)	<0.0001
2017, N = 190†	133 (70.00)	57 (30.00)	<0.0001
2018, N = 210†	156 (74.29)	54 (25.71)	<0.0001
2019, N = 206†	150 (72.82)	56 (27.18)	<0.0001

^*Fisher exact test.

^†n (%).

There were also no statistically significant gender differences based on practice type (academic, private, or community). Regarding plastic surgery training, more plastic surgeons who completed their training at an integrated residency program entered fellowship (69.7%) than those who completed an independent program (50.1%), but gender differences were not observed within either training type (Table 1).

Sex as a Predictor of Fellowship Type

After adjusting for year in logistic models, women were more than 3 times as likely as men to enter breast reconstruction (OR, 3.19; 95% CI, 1.60–6.34; P < 0.001), with 2015 alone showing that women had 7.58 times greater odds (95% CI, 1.82–33.8; P = 0.005). (See table, Supplemental Digital Content 1, which details gender differences in fellowship type, https://links.lww.com/PRSGO/E771.) Women also had marginally increased odds of pursuing a pediatric plastic surgery fellowship, although this was not found to be statistically significant (OR, 1.72; 95% CI, 0.94–3.06; P = 0.070). No associations were observed across the 5-year span for many fellowship subspecialties. Women were 3.33 times as likely as men to enter a cosmetic/aesthetics fellowship in 2018 (95% CI, 1.12–10.0; P = 0.029), but approximately equivalent or lower odds were observed across all other years. Similarly, women had more than 5 times greater odds of pursuing research in 2015 alone (OR, 5.29; 95% CI, 1.04–26.9; P = 0.045), but odds varied between genders from 2016 through 2019.

Overall, women had marginally decreased odds of entering hand/peripheral nerve reconstruction (OR, 0.70; 95% CI, 0.45–1.05; P = 0.092) and burn fellowships (OR, 0.32; 95% CI, 0.08–0.95; P = 0.069). No consistent patterns were observed for the following fellowship subspecialties: microsurgery, craniofacial, cosmetic/aesthetic, other, and research (Supplemental Digital Content 1, https://links.lww.com/PRSGO/E771).

Fellowship as a Predictor of Academic, Private, or Community Practice Type

Logistic models indicate that those in academic practice are nearly twice as likely to have completed a fellowship (OR, 1.99; 95% CI, 1.37–2.89; P < 0.001) compared with those in community practice for all years combined (Table 3). Increased odds for academic versus community practice were also observed in 2016 and 2017 (OR, 2.81; 95% CI, 1.28–6.45; P = 0.012 and OR, 4.74; 95% CI, 1.35–22.3; P = 0.025, respectively). Those in private practice are 4 times more likely to have completed a fellowship compared with those in community practice for 2017 (95% CI, 1.16–18.9; P = 0.042), but were marginally less likely in 2018 (OR, 0.51; 95% CI, 0.23–1.09; P = 0.083). These results held true when sex was included as a predictor in the models (Table 3).

Table 3.

Logistic Models: Fellowship as a Predictor of Practice Type

Characteristic	N	OR	95% CI	P
Academic versus community practice	980	1.99	1.37–2.89	<0.001
Private versus community practice	980	0.94	0.66–1.35	0.75
Academic versus community practice: 2015	176	1.94	0.86–4.50	0.11
Private versus community practice: 2015	176	1.30	0.60–2.86	0.50
Academic versus community practice: 2016	202	2.81	1.28–6.45	0.012
Private versus community practice: 2016	202	0.63	0.32–1.21	0.17
Academic versus community practice: 2017	189	4.74	1.35–22.3	0.025
Private versus community practice: 2017	189	4.05	1.16–18.9	0.042
Academic versus community practice: 2018	210	1.48	0.66–3.27	0.33
Private versus community practice: 2018	210	0.51	0.23–1.09	0.083
Academic versus community practice: 2019	203	2.38	0.82–7.47	0.12
Private versus community practice: 2019	203	1.09	0.38–3.43	0.87
Sex	980
Male		—	—
Female		0.84	0.63–1.13	0.25
Academic versus community practice	980	2.00	1.38–2.90	<0.001
Private versus community practice	980	0.94	0.66–1.35	0.73
Sex	176
Male		—	—
Female		0.63	0.29–1.40	0.25
Academic versus community practice: 2015	176	2.09	0.92–4.90	0.084
Private versus community practice: 2015	176	1.34	0.61–2.94	0.47
Sex	202
Male		—	—
Female		0.63	0.33–1.19	0.15
Academic versus community practice: 2016	202	2.77	1.26–6.40	0.013
Private versus community practice: 2016	202	0.62	0.32–1.20	0.16
Sex	189
Male		—	—
Female		1.11	0.58–2.14	0.76
Academic versus community practice: 2017	189	4.75	1.35–22.3	0.024
Private versus community practice: 2017	189	4.09	1.17–19.1	0.041
Sex	210
Male		—	—
Female		1.09	0.57–2.10	0.79
Academic versus community practice: 2018	210	1.48	0.66–3.27	0.33
Private versus community practice: 2018	210	0.51	0.23–1.09	0.084
Sex	203
Male		—	—
Female		0.95	0.49–1.83	0.87
Academic versus community practice: 2019	203	2.36	0.81–7.44	0.12
Private versus community practice: 2019	203	1.08	0.37–3.41	0.88

Residency Training Type as a Predictor of Fellowship

When determining the likelihood of plastic surgeons having a fellowship based on residency training type (either integrated or independent), those who completed an integrated residency were 2.29 times as likely to have a fellowship for all combined years (OR, 2.29; 95% CI, 1.77–2.98; P < 0.001) (Table 4). This was also true for each year individually from 2016 to 2019, with increased odds ranging from 2 to 3 times as likely, except for 2015, which had had only marginally greater odds (OR, 1.74; 95% CI, 0.93–3.31; P = 0.087). When sex was included as a predictor in the models, these trends held true. Additionally, although not statistically significant, women were less likely to have a fellowship in models in 2015 (OR, 0.64; 95% CI, 0.29–1.42; P = 0.26) and marginally so in 2016 (OR, 0.53; 95% CI, 0.27–1.00; P = 0.052) (Table 4).

Table 4.

Logistic Models: Residency Training (Integrated Versus Independent) as a Predictor of Fellowship

Characteristic	N	OR	95% CI	P
Integrated plastics versus general surgery	984	2.29	1.77–2.98	<0.001
Integrated plastics versus general surgery: 2015	176	1.74	0.93–3.31	0.087
Integrated plastics versus general surgery: 2016	202	2.40	1.36–4.28	0.003
Integrated plastics versus general surgery: 2017	190	2.28	1.27–4.16	0.006
Integrated plastics versus general surgery: 2018	210	3.05	1.73–5.50	<0.001
Integrated plastics versus general surgery: 2019	206	2.19	1.24–3.91	0.007
Sex	984
Male		—	—
Female		0.76	0.56–1.02	0.070
Integrated plastics versus general surgery	984	2.37	1.82–3.10	<0.001
Sex	176
Male		—	—
Female		0.64	0.29–1.42	0.26
Integrated plastics versus general surgery: 2015	176	1.83	0.97–3.52	0.066
Sex	202
Male		—	—
Female		0.53	0.27–1.00	0.052
Integrated plastics versus general surgery: 2016	202	2.64	1.47–4.80	0.001
Sex	190
Male		—	—
Female		0.95	0.49–1.85	0.88
Integrated plastics versus general surgery: 2017	190	2.30	1.27–4.24	0.007
Sex	210
Male		—	—
Female		1.08	0.57–2.10	0.81
Integrated plastics versus general surgery: 2018	210	3.04	1.72–5.49	<0.001
Sex	206
Male		—	—
Female		0.77	0.40–1.49	0.44
Integrated plastics versus general surgery: 2019	206	2.29	1.28–4.15	0.006

DISCUSSION

Our study found that despite the overall greater number of male board-certified plastic surgeons from 2015 to 2019, there were no significant gender biases among fellowship subspecialties apart from breast reconstruction, attracting predominantly female surgeons. We also observed variability from year to year in multiple subspecialties including microsurgery, craniofacial, cosmetic/aesthetic, other, and research, which may be attributed to varying interests and the relatively small size of the field of plastic surgery. This study also showed that fellowship training increases the odds of plastic surgeons practicing at an academic institution or private practice when compared with community practice, and that integrated residency training was a predictor of plastic surgeons entering fellowship. Both findings held true when sex was included as a predictor. This overarching trend may suggest progress toward gender equality within plastic surgery fellowship training, given that sex seemingly does not play a significant role across fellowship type or current practice setting in our data set.

A shift within plastic surgery has occurred during the past 10 years, from male predominance to female predominance among the residency match trends.^10,13,14 We are likely seeing this same trend among fellowship subspecialty data. Literature published before 2020 indicates that from 2010 to 2016, women constituted between 20% and 40% of plastic surgery residents.¹⁴ This is consistent with our findings that show that roughly 70%–80% of plastic surgery fellowship positions were held by men from 2015 to 2019. There is considerable research examining the gender shift to more women entering plastic surgery residency. Previous evidence from Shahriari et al¹³ revealed that 2022 marked the second consecutive year in which more women than men matched into a residency program. Their findings indicated a match rate of 56% for women in 2021 and 52% in 2022. Similarly, these data also correlate with findings from Di Chiaro et al¹⁰ that demonstrated a trend of increasing percentages of women matching into plastic surgery residency from 2019 to 2024. Most notably, from 2021 through 2024, more women matched into an integrated plastic surgery residency than men. Our study’s results mirror these previous findings, as we observed a promising trend toward gender equality in most plastic surgery fellowship types. The lack of significant gender disparities in our analysis further supports the notion that the field is moving toward greater gender balance.

The shift we are seeing may in part be attributed to a change in societal norms and evolving perceptions about gender roles when it comes to women pursuing careers in historically male-dominated fields. Before this shift, female plastic surgeon attendings faced unequal opportunities for advancement and, therefore, challenges in establishing merit that theoretically would have affected their competitiveness when applying for a subspecialty fellowship.^5,6 It should also be noted that with a higher number of women in plastic surgery in more recent years, fellowship choices may become more reflective of genuine interest and aptitude rather than gendered expectations and barriers. Our data, showing minimal gender differences in most fellowship types, suggest that women are likely choosing fellowships based on their interests and strengths, much like their male counterparts, though additional factors may also play a role.

Beyond these societal shifts, the increasing presence of women in plastic surgery has likely contributed to a growing number of visible female leaders and role models within the specialty. We suspect that observing other women succeed in these roles has influenced residents’ perceptions and aspirations, making them more likely to consider or pursue subspecialty fellowships.

The results of this study may also be explained by evolving structures within plastic surgery training. Over the past decade, plastic surgery has seen a substantial expansion of integrated residency programs, which now comprise the majority of training positions. Integrated programs provide earlier and more consistent exposure to plastic surgery compared with independent programs. Such early immersion may shape how trainees explore subspecialty interests and ultimately select fellowship pathways.

In addition, integrated programs offer sustained mentorship continuity, with residents spending 6 years within the same faculty environment. This long-term access to mentorship may meaningfully influence career development and help reduce barriers that have historically affected women more significantly. Taken together, the growth of integrated training and its structural advantages may help explain the more balanced fellowship outcomes observed in our study.

Our findings also carry important implications for surgical education. As gender distributions in fellowship training become more balanced, residency programs may need to evaluate whether their current structures equitably support subspecialty exploration and preparation for all trainees. Ensuring that residents have consistent and unbiased access to subspecialty rotations, procedural experiences, and research opportunities may help prevent inadvertent gender steering into or away from specific fellowships. Programs may also consider implementing formalized mentorship frameworks, particularly in smaller subspecialties where women have been historically underrepresented, to provide equitable guidance during fellowship selection. These educational strategies could help sustain momentum toward gender parity.

Investigating gender disparities is not only pertinent to physicians in training but also to the quality of patient care. Previous studies have demonstrated that having a diverse healthcare workforce enhances patient access to care, improves their perception of the care received, and increases ideal health outcomes.^15,16 Continued research to understand how these trends evolve over time will be essential to maintaining progress toward decreasing gender biases in the field of plastic surgery.

Limitations to our study include the use of the American Board of Plastic Surgery’s annual newsletter for the initial identification of our participants. This reliance on a single source may introduce selection bias, as it only captures board-certified plastic surgeons and therefore omits individuals who pursued fellowship training but did not complete board certification. Consequently, our dataset may exclude a subset of fellowship graduates and not reflect the true distribution of fellowship match outcomes. Additionally, because board certification occurs several years after the fellowship match, this limits our ability to interpret our findings as a direct or contemporaneous representation of fellowship match trends. Moreover, our method of data collection, which used publicly institutional and privately owned practice websites, could have compromised the accuracy of the data due to the unregulated and possibly outdated nature of online data. To mitigate this risk, participants were excluded when sufficient data could not be obtained. Furthermore, each participant was cross-verified, and multiple credible sources were used to optimize accuracy. Cross-verification and the use of various sources additionally allowed us to reduce bias that could have been inflicted by search algorithms that may prioritize certain sources over others. Our study also categorized participants into binary genders (female and male) due to the structure of available data. This study design limits our ability to generalize our findings to all gender identities. Additionally, a small sample size is a potential limitation. To address this, it would be beneficial to compare the current data with data from previous and subsequent years to analyze trends over time. Such longitudinal analysis could provide a more comprehensive understanding of evolving patterns and enhance the robustness of the findings.

Our study is the first to provide an in-depth analysis of gender trends across all plastic surgery subspecialty fellowships, residency training pathways, and practice settings. By analyzing data across numerous subspecialty fellowships, this study provides a novel perspective on the evolving role of sex within plastic surgery, highlighting areas of progress that can inform future efforts to promote diversity in the field. Additionally, our findings actively contribute new insight into how gender dynamics impact career outcomes within plastic surgery. Specifically, our review suggests that changes being made at the residency level of training may have had a positive impact on subspecialty training, potentially contributing to a more inclusive and diverse surgical subspecialty. It is our hope that this diversity will drive innovation, elevate the quality of patient care, and strengthen team dynamics within plastic surgery. Although our findings support a promising future for women in competitive surgical subspecialties such as plastic surgery, further qualitative, survey-based research aimed at understanding why plastic surgery residents chose specific subspecialty fellowships could be valuable. Furthermore, given the potential impact of the COVID-19 pandemic on training patterns and career choices, examining fellowship trends in the post-2020 era would be a valuable extension of this work.

CONCLUSIONS

Our study shows that although a significant gender difference was prominent among newly board-certified plastic surgeons from 2015 to 2019 overall, fellowship opportunities seem to be equivocal and not biased against women based on gender alone. Breast reconstruction and pediatric fellowship training seem to attract more female plastic surgeons overall, whereas hand/peripheral nerve reconstruction and burns seem to be male predominant. Prior fellowship training was more common for plastic surgeons in either academic or private practice compared with community practice, with sex included as a predictor. With recent residency match data trending toward female medical students entering plastic and reconstructive surgery residency, we anticipate that the pendulum may shift toward a more female-predominant fellowship match in the coming years. The equivocal match rates across various fellowship types of varying competitiveness are reassuring for the future of women pursuing competitive surgical subspecialties.

DISCLOSURE

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