Abstract
Background:
Congenital craniofacial anomalies represent a critical domain in plastic surgery training, requiring technical expertise, multidisciplinary collaboration, and exposure to specialized congenital cases. Although the Accreditation Council for Graduate Medical Education mandates pediatric plastic surgery experience, variability in training opportunities exists across programs. Understanding how factors such as program size, training pathway, geographic region, resident demographics, and the COVID-19 pandemic impact surgical exposure is essential for ensuring equitable and comprehensive education.
Methods:
A retrospective cohort study was conducted using Accreditation Council for Graduate Medical Education case log data from graduating US plastic surgery residents between 2014/2015 and 2022/2023. All accredited integrated and independent programs were included. Variables assessed included resident gender, underrepresented minority status, training pathway, program size, geographic region, and COVID-19 era.
Results:
A total of 1902 residents (1043 integrated; 859 independent) were included. The overall mean case volume was 115.3 ± 52.5. Integrated residents logged significantly more cases than independent residents (122.2 ± 57.3 versus 106.8 ± 46.0, P < 0.001). No significant differences were observed by gender or underrepresented minority status. Independent residents from larger programs completed more cases than those from smaller programs (119.5 ± 51.1 versus 102.2 ± 43.0, P < 0.001). Regionally, residents in Western programs performed significantly more cases than peers in other regions (P < 0.001). Case volumes remained stable over time, with no significant impact of COVID-19.
Conclusions:
Exposure to congenital craniofacial surgery has remained stable nationally, even through the COVID-19 pandemic, although significant differences exist by training pathway, program size, and geography.
Takeaways
Question: How do congenital craniofacial surgical case volumes vary among plastic surgery residents in the United States?
Findings: In this 9-year national study of 1902 graduating plastic surgery residents, integrated residents performed significantly more congenital craniofacial cases than independent residents. No significant differences were observed by gender or underrepresented minority status. Independent residents from larger programs recorded higher case volumes than those from smaller programs, and residents from Western programs logged the most cases across all pathways.
Meaning: Congenital craniofacial exposure has remained unaffected by demographic factors or the COVID-19 pandemic. However, training pathway, program size, and regional differences continue to shape operative experience.
INTRODUCTION
Congenital craniofacial anomalies represent a complex and vital subset of conditions treated by plastic surgeons, often requiring nuanced surgical intervention and multidisciplinary coordination with many medical and surgical specialities.1,2 Training in the operative management of these conditions is a key component of plastic surgery residency as it not only teaches residents how to provide care for vulnerable pediatric patients, but also instills important physicians skills such as teamwork and coordination between the different treating teams.
The Accreditation Council for Graduate Medical Education (ACGME) requires exposure to pediatric plastic surgery as part of residency training, underscoring its relevance to clinical proficiency. Moreover, the majority of congenital craniofacial care is offered at specific pediatric tertiary centers which might not be available at every training institution. Little is known about the national trends in congenital craniofacial exposure among graduating plastic surgery residents and how this exposure is distributed across different training pathways, program sizes, geographic regions, and demographic factors such as gender and race/ethnicity. Previous studies have found disparities across these aforementioned factors in other specialities.3–5 Moreover, with increasing attention to equity in surgical education and the impact of external pressures like the COVID-19 pandemic, it is important to assess how case volume and distribution have evolved over time. Furthermore, previous literature has showed that there has been a decline in the incidence of congenital craniofacial anomalies requiring surgical repairs.6 This raises critical questions about whether surgical exposure in residency programs is declining accordingly, and if not, what factors might be preserving training opportunities in this domain.
The goal of this study was to assess case volumes of congenital craniofacial cases performed by graduating US plastic surgery residents over a 9-year period, and how it is impacted by program size, training pathway, geographic region, trainee demographics, and the COVID-19 pandemic. Through this national analysis of ACGME case log data, we seek to identify patterns and disparities in training exposure and offer insights into the evolving landscape of congenital craniofacial education in plastic surgery residency.
METHODS
A retrospective cohort study was conducted to assess the volume and distribution of congenital craniofacial surgical cases logged by graduating plastic surgery residents in the United States over a 9-year period (2014/2015–2022/2023). The most comprehensive database of surgical case logs by ACGME plastic surgery residents was used to minimize selection bias. All the data were deidentified and coded.
Data Source
The ACGME provided access to an extensive dataset encompassing all graduating plastic surgery residents in accredited training programs across the United States. This dataset included congenital craniofacial surgical cases logged by graduating residents as well as their demographic information. Given its breadth and accuracy, this database served as the most objective, reliable resource for evaluating trends in surgical training.
Inclusion and Exclusion Criteria
All ACGME-accredited plastic surgery residency programs were included in this study. Residents who completed their training between 2014/2015 and 2022/2023 were eligible for inclusion. No additional exclusion criteria were applied, ensuring a comprehensive analysis of surgical case logs across all plastic surgery residents in accredited programs.
Variables and Case Categorization
The primary outcome of this study was the total number of congenital craniofacial procedures logged by graduating residents. This included primary cleft lip repair, primary cleft palate repair, secondary cleft lip or palate repair, cleft lip nasal deformity repair, craniomaxillofacial reconstruction, vascular malformation, and other head and neck congenital defect procedures. Independent variables assessed included residents’ gender, whether residents were self-described as underrepresented minority (URM), program size, training pathway, program geographic location, and the effect of COVID-19. Gender was categorized as male or female. Program size was categorized as small (defined as <3 residents per cohort) or large (defined as ≥3 residents per cohort). Training pathway was categorized as independent or integrated. Geographic location was categorized as Central, Western, Northeastern and Southern based on the Association of American Medical Colleges geographic definitions.7 The Northeast included programs in Connecticut, District of Columbia, Maine, Massachusetts, New Hampshire, New Jersey, Maryland, New York, Pennsylvania, Rhode Island, and Vermont. The South included Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Puerto Rico. The Central region included Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. The West included Arizona, California, Colorado, Hawaii, Nevada, New Mexico, Oregon, Utah, and Washington. Academic years 2014/2015–2019/2020 were grouped as the pre-COVID group, 2020/2021 was labeled as the COVID group, whereas 2021/2022–2022/2023 were grouped as the post-COVID group.
Statistical Methods
Descriptive statistics were used to summarize the demographics of the plastic surgery residents included. Total case volume across program type was calculated by pooling across strata. To test for differences while accounting for heterogeneity, we used a weighted least squares regression, weighting each observation by the number of contributing hospitals. In the cases where only one summary estimate was available, model estimates were saturated, and an analysis of variance procedure derived from standard formulas was used to test for differences instead. Statistical analyses were performed using R (v4.4.1, R Foundation for Statistical Computing, Vienna, Austria). A P value of less than 0.05 was considered statistically significant
Ethical Considerations
This study utilized deidentified secondary data and did not involve direct interaction with human participants. The ACGME has plenary institutional review board exemption (EX00705) for database studies from the American Institute for Research, thus this study was exempt from institutional review board approval.
RESULTS
A total of 1043 integrated and 859 independent plastic surgery residents graduated between the 2014/2015 and 2022/2023 academic years and were included in this analysis. The overall mean number of congenital craniofacial cases performed during residency was 115.3 ± 52.5. Integrated residents completed significantly more cases than independent residents (122.2 ± 57.3; 95% CI [119.2, 125.3] versus 106.8 ± 46.0; 95% CI [103.5, 110.2]; P < 0.001). The number of integrated graduates increased from 62 in 2015 to 165 in 2023, whereas the number of independent graduates decreased from 130 to 65 over the same period. Case volume for integrated residents remained stable, and there was no significant change, with 123.6 ± 55.9 (95% CI [109.7, 137.5]) in 2014/2015 and 120.3 ± 59.2 (95% CI [111.3, 129.3]) in 2022/2023. Similarly, no significant trend was observed among independent residents, whose case numbers changed from 108.0 ± 47.6 (95% CI [99.8, 116.2]) to 105.7 ± 42.0 (95% CI [95.5, 115.9]) (Fig. 1).
Fig. 1.
Number of congenital craniofacial surgical cases performed by integrated and independent graduating residents over 9-year span.
Gender-based Differences
Among integrated programs, 630 male and 413 female residents graduated during the study period. Female residents recorded an average of 122.9 ± 60.1 (95% CI [116.0, 129.8]) cases, whereas male residents logged 121.8 ± 55.1 (95% CI [116.2, 127.4]) cases, with no statistically significant difference (P = 0.796). In independent programs, 626 male and 233 female residents graduated. Female residents performed 108.9 ± 43.8 (95% CI [103.1, 114.8]) cases compared to 106.1 ± 46.8 (95% CI [102.5, 109.6]) performed by male residents; the difference was not statistically significant (P = 0.394) (Fig. 2).
Fig. 2.
Number of cases performed by independent and integrated male residents vs female graduating residents.
URM Versus Non-URM Residents
There were 151 URM and 892 non-URM graduates from integrated programs, and 179 URM and 680 non-URM graduates from independent programs. There was no significant difference in cases logged between the groups. Among integrated residents, URM individuals performed an average of 119.0 ± 52.9 (95% CI [107.8, 130.2]) cases, compared to 122.8 ± 57.8 (95% CI [118.2, 127.4]) by non-URM residents (P = 0.516). In independent programs, URM residents logged 106.0 ± 47.0 (95% CI [100.4, 111.6]) cases, versus 107.1 ± 45.9 (95% CI [104.2, 109.9]) among non-URMs (P = 0.713) (Fig. 3).
Fig. 3.
Number of cases performed by independent and integrated URM vs non-URM graduating residents.
Program Size
In integrated programs, 539 residents graduated from small programs (<3 residents/year), and 504 from large programs (≥3 residents/year). Case volumes were similar between the 2 groups (122.0 ± 57.8; 95% CI [116.7, 127.3] versus 122.5 ± 56.7; 95% CI [117.0, 128.0]; P = 0.894). In contrast, independent residents from large programs performed significantly more cases than those from small programs (119.5 ± 51.1; 95% CI [112.7, 126.4] versus 102.2 ± 43.0; 95% CI [98.1, 106.4]; P < 0.001) (Fig. 4).
Fig. 4.
Number of cases performed by independent and integrated graduating residents in small vs large programs.
Geographic Location
Among integrated residents, 295 graduated from Central programs, 293 from Northeastern, 259 from Southern, and 196 from Western programs. A significant regional difference was found (P < 0.001). Residents from Western programs reported the highest average case volume (149.5 ± 66.7; 95% CI [142.1, 156.9]), significantly exceeding that of Central (116.8 ± 50.0; 95% CI [110.8, 122.8]), Northeastern (117.3 ± 59.9; 95% CI [111.2, 123.3], and Southern programs (113.4 ± 48.3; 95% CI [107.0, 119.8]).
Among independent residents, 192 graduated from Central programs, 233 from Northeastern, 310 from Southern, and 124 from Western programs. A significant geographic disparity was also observed (P < 0.001). Western residents performed the most cases (124.0 ± 50.8; 95% CI [116.5, 131.5]), followed by Central residents (109.9 ± 43.8; 95% CI [103.9, 115.9]), Southern residents (107.9 ± 48.0; 95% CI [103.2, 112.6]), and Northeastern residents (93.7 ± 38.7; 95% CI [88.3, 99.2]) (Fig. 5).
Fig. 5.
Number of cases performed by independent and integrated graduating residents in different geographic locations.
Impact of the COVID-19 Pandemic
For integrated programs, 573 residents graduated during the pre-COVID era (2014/2015–2019/2020), 148 during the COVID-affected year (2020/2021), and 322 during the post-COVID period (2021/2022–2022/2023). No significant differences were observed across these groups (125.3 ± 59.4 (95% CI [121.4, 129.2]) versus 115.2 ± 52.5(95% CI [107.6, 122.8]) versus 120.0 ± 55.4 (95% CI [114.9, 125.2]); P = 0.054).
For independent programs, 649 graduated pre-COVID, 76 during COVID, and 134 post-COVID. Again, there were no statistically significant differences in case volumes between these groups (108.0 ± 47.5 (95% CI [104.4, 111.6]) versus 104.9 ± 44.3 (95% CI [94.4, 115.4]) versus 102.4 ± 38.6 (95% CI [94.5, 1003]); P = 0.330).
DISCUSSION
This national study presents the most comprehensive analysis to date of congenital craniofacial case exposure among graduating plastic surgery residents in the United States. Over a 9-year period, the average case volume remained stable, with integrated residents performing more cases than their independent counterparts. Gender and URM status had no effect on the number of cases logged by graduating residents. Moreover, graduating independent residents from larger programs, defined as having more than three residents per cohort, logged more cases than their counterparts graduating from smaller programs. This was not observed among integrated programs. Moreover, residents from Western programs logged in significantly more cases than any other geographic location across both independent and integrated pathways. Finally, the COVID-19 pandemic did not appear to disrupt training volume in this domain, suggesting a level of resiliency in residency education.
One of the more positive findings in this study is the lack of difference in surgical exposure between different genders, and residents of differing URM status. Increasing awareness, structured initiatives, and mentorship programs for women and URM trainees may have helped mitigate potential disparities in surgical exposure.8,9 Although prior studies have noted differential experiences in autonomy and mentorship, our findings suggest that case volume in the context of congenital craniofacial cases is not affected by demographic variables.10–12
The current study demonstrates that integrated residents performed significantly more congenital craniofacial procedures compared to independent residents. This finding probably reflects the difference in structure and duration of both training pathways. Integrated programs expose residents to six years of plastic surgery training, which allows residents early exposure to congenital craniofacial cases compared to their peers in independent programs.13 Integrated programs offer a continuous curriculum starting from medical school graduation, often enabling more consistent early exposure to complex pediatric cases. By contrast, independent residents typically enter plastic surgery training after completing a categorical surgery residency, which may delay or limit their exposure to subspecialty cases like congenital reconstruction.
Program size further influenced case exposure among independent residents. Independent residents graduating from large programs logged significantly more congenital craniofacial cases compared to those from smaller programs. This may be due to the increased likelihood of larger programs being affiliated with tertiary care centers, including high-volume pediatric hospitals or craniofacial units. Moreover, it has been previously shown that congenital disorders are better treated in larger volume centers, which causes smaller centers to receive less referrals.14 Smaller programs may therefore lack the dedicated pediatric infrastructure or referral volume necessary to maintain high case numbers in congenital surgery. It is important to note that the same finding was not found among integrated residents, which warrants future studying to clarify if there are any structural factors that buffer integrated residents from the variation seen in independent programs.
Our results have found that residents from Western programs had higher congenital craniofacial case volumes. This finding likely reflects several factors such as state-level referral patterns, institutional subspecialty presence, and the presence/absence of fellowship programs. Due to the ACGME data being aggregated, we were unable to directly assess these confounding factors that likely explain the higher case volumes found in Western programs.
Despite long-standing concerns that congenital anomalies requiring surgery are declining due to improved prenatal detection and increased pregnancy terminations,6 our analysis revealed stable case volumes across trainees over the study period. This may be due to centralization of care in specialized craniofacial centers, which allow for consistent surgical volume for trainees despite the possible declining incidence rates.
Interestingly, the COVID-19 pandemic did not significantly alter case exposure for congenital craniofacial procedures. This is encouraging, particularly given widespread concerns that elective and pediatric surgical services would have been disproportionately disrupted.15–17 Our data suggest that training programs may have effectively adapted during the pandemic to preserve critical surgical exposure in this essential domain. This likely reflects the urgent and time-sensitive nature of many congenital reconstructive procedures, which are often scheduled in early infancy and cannot be postponed indefinitely.18 It is also important to note that guidelines such as the Centers for Medicare and Medicaid Services report offered guidance to craniofacial surgeons on which cases should be postponed during the pandemic and have considered the time-sensitive nature for the many of these conditions.17
It is also important to note that many of the congenital craniofacial cases are considered advanced cases that require fellowship training and are not expected competencies for graduating residents. Residency is designed to provide foundational experience, whereas craniofacial fellowships offer advanced specialization. Regardless, our data show that residents surpassed the minimum mandatory case log requirements set by the ACGME.
This study has several limitations. First, the use of aggregate ACGME case log data limits granularity and relies on accurate and consistent resident self-reporting. Moreover, because analyses were performed using aggregated ACGME data, distributional assumptions could not be formally tested, and results should be interpreted as descriptive comparisons rather than causal estimates. Second, the analysis does not account for case complexity, autonomy levels, or the presence of dedicated craniofacial fellowships, which may influence resident experience. Third, regional differences may be influenced by unmeasured confounders such as institutional case mix, differences in state population demographics, program-specific rotation structures, and the presence of other learners such as fellows. Finally, although stable case volume is reassuring, it does not necessarily equate to competency, and further research into surgical outcomes and technical proficiency is warranted.
CONCLUSIONS
Congenital craniofacial exposure has remained stable over the past decade, despite evolving training structures and external pressures such as the COVID-19 pandemic. Integrated residents and those in larger independent programs had higher case volumes, whereas gender and URM status did not influence surgical exposure. These findings may inform efforts to standardize pediatric surgical training and ensure equitable exposure across all training environments, ultimately contributing to a more consistent and competent plastic surgery workforce.
DISCLOSURES
Dr. Janis receives royalties from Thieme Publishers and Springer Publishing. He is also a member of the Plastic Surgery Review Committee, ACGME. Dr. Sean Hogan, Dr. Chris Fox, and Dr. Yoon Soo Park are employees of the ACGME and any opinions expressed may not necessarily reflect the views, policies, or requirements of the ACGME. The other authors have no financial interest to declare in relation to the content of this article.
Footnotes
Published online 25 June 2026.
Disclosure statements are at the end of this article, following the correspondence information.
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