The Coronavirus Disease 2019 Impact on Plastic Surgery Training: A 9-year National Analysis of Case Log Disruptions and Recovery

Abstract

Background:

The coronavirus disease 2019 (COVID-19) pandemic disrupted surgical education, yet its impact on plastic surgery training remains incompletely understood. This study evaluates national trends in plastic surgery case volumes for residents graduating before, during, and after the academic year (AY) associated with the COVID-19 pandemic.

Methods:

This retrospective cohort study used Accreditation Council for Graduate Medical Education case logs of all graduating residents in Accreditation Council for Graduate Medical Education–accredited plastic surgery residency programs in the United States from 2014 to 2023. Primary variables of interest included case volumes of residents graduating before the COVID-19 AY (prepandemic), during the pandemic AY (2020–2021), and after the pandemic AY (postpandemic).

Results:

A total of 1902 graduates (859 independent, 1043 integrated) were included. Average total operative volume for plastic surgery residents remained stable during the COVID-19 AY and postpandemic compared with the prepandemic period (P = 0.591). Graduating plastic surgery trainees logged 2245 cases prepandemic, 2337 cases during the pandemic year, and 2421 cases postpandemic. Residents performed more breast cases during and after the pandemic year compared with the prepandemic period, whereas operative volumes remained stable for aesthetic, craniofacial/head and neck, hand/nerve, and “other” categories across all timepoints.

Conclusions:

Despite significant disruption to surgical services during the COVID-19 pandemic, plastic surgery residents maintained their operative exposure when graduating during and after the pandemic year compared with the prepandemic period.

Takeaways

Question: Were graduating plastic surgery resident case volumes affected by the coronavirus disease 2019 (COVID-19) pandemic?

Findings: Average total operative volume for plastic surgery residents remained stable during the COVID-19 academic year and postpandemic compared with the prepandemic period. Residents performed more breast cases during and after the pandemic year compared with the prepandemic period, whereas operative volumes remained stable for aesthetic, craniofacial/head and neck, hand/nerve, and “other” categories across all timepoints.

Meaning: Despite significant disruption to surgical services during the COVID-19 pandemic, plastic surgery residents did not see a decrease in their operative experience during or after the pandemic year.

INTRODUCTION

Although often described as a “black swan” event in medical history, the coronavirus disease 2019 (COVID-19) pandemic is not without precedent. Historical events such as the 1918 influenza pandemic,¹ the HIV/AIDS epidemic,² and more recent outbreaks such as severe acute respiratory syndrome³ have each placed strain on global health systems. Nevertheless, the COVID-19 pandemic proved uniquely disruptive in its scale and duration, challenging medical infrastructure, personnel, and training systems worldwide.

First reported in December 2019 in Wuhan, China, COVID-19 reached pandemic status by March 11, 2020.⁴ As of June 2025, the World Health Organization has documented 778.2 million cases⁵ and 7.1 million deaths⁶ globally. The scale of this disruption necessitated cancellation of elective procedures during the acute phase of the disease, widespread reallocation of healthcare resources, and restructuring of clinical workflows.^7–11 Although much of the literature has focused on the impact of these shifts on patient care, fewer studies have examined how the pandemic affected medical education—particularly the surgical trainee.^12,13

Operative case volume is essential to the development of competent surgeons.^14,15 Although the pandemic’s impact on case volumes has been examined in other surgical specialties such as otolaryngology,¹⁶ ophthalmology,¹⁷ and vascular surgery,¹⁸ its impact on plastic surgery remains underexplored in the literature. Current studies within plastic surgery have primarily focused on survey-based assessments of the COVID-19 pandemic and changes in trainee operative exposure, which have been limited by short-term outcomes or analysis of only a single training pathway.^{7–10,19–22} Therefore, a significant gap remains in the literature that analyzes objective, nationwide case volume data for graduating plastic surgery residents both during the COVID-19 pandemic year and in the postpandemic era. Understanding how operative exposure was affected during the pandemic year and whether volumes returned to prepandemic levels is crucial for assessing the long-term impact on resident training and for understanding how future disruptions may influence surgical training.

METHODS

Study Design

An ecological study was performed by obtaining case logs from the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is an independent not-for-profit organization that sets and monitors professional educational standards for physicians in training and oversees the accreditation of residency and fellowship programs in the United States.²³ Independent plastic surgery residents were defined as individuals who completed a prior ACGME-accredited categorical residency before entering 3 years of categorical plastic surgery training, whereas integrated residents matriculate directly from medical school into a 6-year ACGME-accredited plastic surgery residency. Residents are required to log every operative experience throughout the entirety of their training via the ACGME Case Log System.^24,25 As such, the ACGME maintains operative records, including case category, case year, and demographics for all trainees. The ACGME has a plenary institutional review board exemption (EX00705) for database studies through the American Institute for Research; thus, this study was exempt from institutional review board approval.

The ACGME provided access to the de-identified aggregated case logs of all graduating plastic surgery residents in ACGME-accredited plastic surgery training programs in the United States during a 9-year period from 2014 to 2023. This dataset included program-level information (program location, program size, independent versus integrated track, total number of programs, and graduate academic year [AY]), aggregated case log information (case category), and trainee demographic information (self-identified sex, race/ethnicity). All plastic surgery graduates (integrated postgraduate year [PGY]6 and independent PY3) between 2014 and 2023 from an ACGME-accredited plastic surgery residency program were included. No additional exclusion criteria were applied.

The primary variable of interest was cumulative plastic surgery case volumes of residents who graduated before the COVID-19 pandemic year (prepandemic), during the pandemic year (AY 2020/2021), and after the pandemic year (postpandemic). Prepandemic included AYs 2014/2015 through 2019/2020, the COVID-19 pandemic year included AY 2020/2021, and postpandemic included AYs 2021/2022 and 2022/2023. The AY was defined as July 1 to June 30. Strata timepoints were selected based on the implementation of emergency training modification orders by the ACGME and their subsequent removal by sponsoring institutions during the COVID-19 pandemic. Methods of analysis were modeled after similar studies conducted in other specialties evaluating case logs during the pandemic period.^26,27 Case categories were further grouped into the following subspecialty domains: breast, craniofacial/head and neck, hand/nerve, aesthetic, and other (Table 1). Subanalyses were conducted to determine whether there were significant differences in case volume by program track and subspecialty domain.

Table 1.

Categorization of Individual Case Types Into Larger Subspecialty Domains

Breast	Hand/Nerve	Craniofacial/Head and Neck	Aesthetic	Other
Absent breast	Nerve injury	Head and neck aesthetic deformity	Laser	Lower extremity wounds and deformities
Breast ptosis	Nerve compression	Head and neck congenital defects	Suction-assisted lipoplasty	Microvascular/free tissue transfer
Breast macromastia	Dupuytren contracture	Head and neck neoplasms	Use of injectables	Wounds or deformities of trunk
Breast micromastia	Fracture or dislocation	Head and neck trauma	Trunk/extremity aesthetic deformities	Integument burns
Breast and oncological surgery	Hand and upper extremity wound requiring reconstruction			Alimentary tract/abdominal surgery
	Nerve compression			Trauma/critical care/anesthesia
	Tendon (extensor or flexor)			Tissue expansion
	Arterial insufficiency or amputation of digit, hand, or upper extremity			Other deformity or disease process

Statistical Analyses

ACGME data were provided as aggregations. Total case volume across subspecialty domains was calculated by pooling across strata. To compare case logs across groups, we used weighted least squares regression, weighting each observation by the number of hospitals contributing data to better account for heterogeneity in variances. Group-specific point estimates, 95% confidence intervals, and P values were obtained directly from the fitted model. Overall group differences were evaluated using an F test comparing nested weighted least squares models. Statistical analyses were performed using R version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria). A P value of less than 0.05 was considered statistically significant.

RESULTS

A total of 1902 plastic surgery graduates (859 independent and 1043 integrated residents) were included. Plastic surgery trainees maintained their cumulative operative case volumes across the prepandemic, pandemic, and postpandemic periods. Graduating residents performed an average of 2245 cases in the prepandemic group, 2337 cases in the COVID-19 AY, and 2421 cases in the postpandemic group (P = 0.591) (Fig. 1). Total case volumes among integrated-only and independent-only residents did not significantly differ across time periods. Integrated prepandemic graduating residents logged an average of 2559 cases, COVID-19 pandemic year graduates logged 2457 cases, and postpandemic graduates logged 2584 cases (P = 0.293, Table 2, Fig. 2). Independent graduating residents logged an average of 1967 cases when graduating during the prepandemic period, 2103 cases during the COVID-19 pandemic year, and 2027 cases during the postpandemic period (P = 0.067, Table 2, Fig. 2). Residents in both integrated and independent training pathways met overall case minima set forth by the ACGME.

Fig. 1.

Average overall plastic surgery case logs stratified by timepoint.

Table 2.

Average Number of Cases Logged Stratified by Program Track and Timepoint

	Prepandemic	COVID-19 Pandemic	Postpandemic	P *
Integrated
Mean	2559	2457	2584	P = 0.293
95% CI	2482.5–2636.3	2305.2–2607.9	2481.7–2686.9
Independent
Mean	1967	2103	2027	P = 0.067
95% CI	1926.7–2006.3	1986.5–2219.2	1939.7–2115.0

^*A P value of less than 0.05 was considered statistically significant.

Fig. 2.

Average plastic surgery case logs stratified by program track and timepoint.

A subanalysis of subspecialty domains demonstrated varying trends in average case volumes based on their relation to the COVID-19 AY. The average number of breast cases increased during the COVID-19 AY and in the postpandemic period. Specifically, breast case volumes increased from 492 during the prepandemic period to 560 during the COVID-19 year and 582 during the postpandemic period (P = 0.026; Table 3). There were no statistically significant detectable differences in average case volumes for graduating residents in aesthetic, hand/nerve, craniofacial/head and neck, and “other” categories across the 3 timepoints. Although case volumes increased over time, no evidence of a difference was seen when comparing average case volumes during the prepandemic period (244), during the pandemic year (258), and during the postpandemic period (267) for the aesthetic subcategory (P = 0.056, Table 3). No detectable significant differences were seen when comparing average case volumes during the prepandemic period (344), during the pandemic year (375), and during the postpandemic period (387) for hand/nerve (P = 0.378, Table 3). No detectable significant differences were seen when comparing average case volumes during the prepandemic period (564), during the pandemic year (558), and during the postpandemic period (574) for craniofacial/head and neck (P = 0.945, Table 3). Similarly, no detectable significant differences were seen when comparing average case volumes during the prepandemic period (602), during the pandemic year (585), and during the postpandemic period (611) for the “other” subcategory (P = 0.977, Table 3).

Table 3.

Average Number of Cases Stratified by Subspecialty Domain and Timepoint

Subspecialty	Timing	Mean	95% CI	P *
Aesthetic	Prepandemic	244	233.5–253.6	P = 0.056
	COVID-19 pandemic	258	234.3–281.2
	Postpandemic	267	250.2–283.0
Breast	Prepandemic	492	457.1–527.0	P = 0.026
	COVID-19 pandemic	560	478.6–641.9
	Postpandemic	582	525.1–639.5
Craniofacial/head and neck	Prepandemic	564	523.0–604.1	P = 0.945
	COVID-19 pandemic	558	463.5–653.0
	Postpandemic	574	507.7–640.5
Hand/nerve	Prepandemic	344	309.0–378.7	P = 0.378
	COVID-19 pandemic	375	293.4–456.3
	Postpandemic	387	329.4–443.6
Other	Prepandemic	602	513.0–690.3	P = 0.977
	COVID-19 pandemic	585	378.3–792.5
	Postpandemic	611	466.1–756.3

^*A P value of less than 0.05 was considered statistically significant.

DISCUSSION

This study addresses a critical gap in the literature by evaluating changes in plastic surgery graduating resident case logs before, during, and after the COVID-19 pandemic year. Case volumes remained steady during the study period for plastic surgery residents despite the COVID-19 pandemic, even when stratified by training pathway. Residents performed more breast cases when graduating during and after the COVID-19 pandemic year compared with before the pandemic year, with stable volumes of aesthetic, hand/nerve, craniofacial/head and neck, and “other” cases over time. Notably, residents in both training pathways met overall case minima set forth by the ACGME and exceeded their respective prepandemic case volumes when graduating in the postpandemic period.

No evidence of a difference was observed in total case volumes among graduating plastic surgery residents between the prepandemic, COVID-19 year, and postpandemic periods, suggesting that overall operative exposure was preserved despite significant disruptions to elective surgical care. These findings parallel observations in integrated vascular surgery, where Tolaymat et al¹⁸ reported no significant changes in total logged case volumes among graduating vascular residents across prepandemic and pandemic cohorts, except in 1 subcategory. Similarly, Loughran et al¹⁹ demonstrated that independent plastic surgery residents maintained average total case numbers in the year before the pandemic, 4 months into the pandemic, and 16 months thereafter. In contrast, other surgical specialties experienced more pronounced volume reductions, including otolaryngology, where Mann et al¹⁶ reported significant decreases in trainee operative volume across all subspecialties in the year following March 1, 2020, and ophthalmology, where Vongsachang et al¹⁷ observed significant declines in case volume across all procedural categories in 2020. Collectively, these comparisons suggest that certain specialties were more vulnerable to pandemic-related surgical disruptions than others. Plastic surgery training may have been buffered by the rapid recovery of elective volume, flexibility in case redistribution, and prioritization of graduating trainee cases following the resumption of elective procedures. These findings underscore the adaptability of plastic surgery training programs and reinforce the stability of operative exposure during the COVID-19 era.

When analyzing case volume trends by subspecialty domain, notable increases were seen in breast surgery volume over time, specifically when graduating during the pandemic year and in the postpandemic period. Unlike aesthetic procedures, breast surgery often involves oncological reconstruction and, therefore, is not considered purely elective. American Society of Plastic Surgeons (ASPS) guidelines during the pandemic suggested that plastic surgeons use an individualized approach to immediate breast reconstruction, oncoplastic reconstruction, and contralateral balancing procedures.²⁸ It is important to note that while overall cancer screening and mastectomy rates declined during the pandemic, the proportion of mastectomies performed increased in 2020, as these procedures were deemed medically necessary.^29,30 Moreover, due to the pandemic, mastectomies for breast cancer shifted away from inpatient stays to outpatient centers with same-day discharge, thus necessitating changes to breast reconstruction protocols.^31–33 Reconstruction was adjusted to prioritize same-day mastectomy with immediate implant-based reconstruction when possible.³⁴ This approach aimed to prevent surgical backlogs in the postpandemic period and reduce the number of healthcare encounters required for breast cancer patients, potentially leading to an increase in breast surgery cases completed by plastic surgery trainees during and after the pandemic year.³⁵

Aesthetic case volumes remained stable throughout the COVID-19 AY and into the postpandemic period, with a nonsignificant upward trend during these time periods. At first, stable or increasing aesthetic case volumes may seem contradictory given the cancellation of elective procedures during the pandemic.¹⁹ However, a 2020 study analyzing queries for aesthetic surgery found that although searches for cosmetic and aesthetic surgery dropped during the initial emergency declaration of the COVID-19 pandemic in March 2020, search volumes quickly recovered and even surged just 6–8 weeks into the pandemic.³⁶ Further, an ASPS member survey in June 2020 showed that nearly two-thirds of plastic surgeons continued conducting visits during the pandemic via telemedicine and video and noted a sustained strong public interest in aesthetic plastic surgery procedures.³⁷ Similarly, the 2022 ASPS Procedural Statistics Report noted an increase in aesthetic demand when elective operations were resumed toward the end of the pandemic, potentially driven by increased discretionary income due to travel/entertainment restrictions and the flexibility of recovery while working from home during the pandemic.³⁸ These phenomena may also have been fueled by the “Zoom Boom,” where increased use of video communication created a larger emphasis on facial appearance and ultimately greater acceptance of aesthetic surgery.^39–42 Finally, for individuals who struggled with weight gain during the pandemic—often referred to as “COVID weight”—aesthetic plastic surgery was increasingly viewed as a solution for addressing body contouring concerns.³⁸ Notably, Chaker et al⁴³ reported an increase in abdominoplasties performed from 2020 to 2021, likely attributable to patients “wanting to feel good” during the postpandemic period. Together, these factors likely contributed to the stability in resident aesthetic case volumes during and after the COVID-19 pandemic year.

Hand/nerve case volumes remained steady for residents graduating during the COVID-19 AY and after the pandemic compared with prepandemic residents. Our findings are consistent with a study analyzing independent plastic surgery resident case logs in the peri-COVID period, where the authors noted no significant differences in the total number of hand and upper extremity procedures between prepandemic and pandemic years.¹⁹ Similarly, a study looking at orthopedic surgery resident case logs demonstrated maintenance of hand/finger cases before and after the COVID-19 pandemic.²⁶ The authors noted that although fewer people presented to US emergency departments with hand and finger injuries during 2020, those who did had significantly greater odds of hospitalization and, thus, potential conversion to inpatient surgery.^26,44 Further, Diamond et al⁴⁵ discussed trends in hand trauma at 2 level 1 trauma centers across the country during the pandemic, noting a rise in operative hand trauma cases such as high-energy fractures, nerve injuries, or revascularization/replantation. Similar findings were observed in studies published from Germany and Italy, whereby the nature of the trauma may have shifted during the COVID-19 pandemic but the rate of hand surgery increased.⁴⁶ Thus, these findings suggest that a shift toward more emergent inpatient hand surgery amid reductions in other elective plastic surgery procedures may have helped preserve resident operative exposure in hand surgery during the pandemic year.

Similarly, craniofacial/head and neck surgery volumes remained stable across all 3 time periods. This is likely attributable to the time-sensitive nature of many pediatric craniofacial procedures. Although some procedures, including cleft lip and orthognathic repairs, were postponed during peak pandemic periods, others such as alveolar bone grafting saw no changes between prepandemic and pandemic case volumes.^28,47,48 Similarly, cleft palate repair was often prioritized due to evidence of worse speech outcomes when delayed beyond 12 months of age. Thus, the continuation of some craniofacial/cleft procedures despite broader elective surgery shutdowns may have resulted in relatively stable surgical rates overall, leading to no significant changes in plastic surgery trainee volumes during the pandemic year.

The results of this study offer important guidance for plastic surgery residency programs navigating periods of uncertainty or systemic disruption. The absence of differences in total resident case volumes across prepandemic, pandemic, and postpandemic cohorts suggests that overall operative exposure was maintained despite substantial changes to clinical practice during the COVID-19 era. Although case log totals alone do not fully capture trainee proficiency, our results demonstrate that the existing training system was sufficiently adaptable to preserve cumulative operative experience. In addition, changes to clinical practice offered trainees the opportunity to practice surgical skills outside the operating room, engage in cross-institutional virtual lectures, and participate in research during periods of surgical disruption, broadening trainee education.²² Moving forward, the incorporation of competency-based training models would assist programs in maintaining educational standards while remaining adaptable to fluctuations in operative volume caused by pandemics or institutional changes.

This study has several limitations. First, ACGME data were only available as aggregates at the year level, thus limiting the precision of our study timepoints. National emergency status during the pandemic was declared in March 2020, which affected 3 months of the 2019/2020 AY and a significant portion of the 2020/2021 AY.⁴⁹ As such, we selected AY 2020/2021 as the pandemic year, understanding that 3 months of the recognized pandemic period were included in the prepandemic strata. This may have potentially dampened the averages seen in the prepandemic period, whereas post-COVID resumption of cases may have inflated the volume seen during the COVID-19 AY. Second, although national status was declared in March 2020, the timeframe and degree of implementation (and resolution) were ultimately determined by each sponsoring institution, which may have resulted in some variability in resident case volumes across programs. Unfortunately, these data were not available and could not be taken into account for this analysis. Nonetheless, our study focused on assessing general trends of resident case logs; thus, the impact of this variability may be minimal. Third, this study analyzed the average of all graduating chief case logs, which comprised case logs from the entirety of one’s residency training. Graduating chiefs in AY 2021/2022 and AY 2022/2023 experienced the pandemic during their PGY5/PY2 and PGY4/PY1 years, respectively. Thus, due to aggregated data reported as averages, the direct effect of the COVID-19 pandemic on case volumes is not entirely clear, as year-to-year data were unavailable. Fourth, this study does not incorporate regional variability in the severity and timing of COVID-19 outbreaks, differences in institutional surgical case availability, or local variations in resident redeployment practices. Finally, this study is a retrospective analysis using self-reported ACGME case log data, which may be subject to underreporting, overreporting, or inconsistency and does not provide insight into the complexity of cases.

Future studies should consider stratifying data by trainee level to better capture the heterogeneous impact of the COVID-19 pandemic on plastic surgery training and explore how operative volume for specific resident PGY/PY levels was affected during the pandemic and beyond. Additionally, qualitative studies involving resident and program director perspectives may offer valuable insight into effective adaptations used during the pandemic and inform future strategies to safeguard surgical education during widespread healthcare disruptions.

CONCLUSIONS

The COVID-19 pandemic placed a significant strain on surgical training. This study demonstrates that despite significant disruption to elective cases, overall plastic surgery resident case volumes remained stable during the COVID-19 AY and into the postpandemic period. Subspecialty trends showed increases in breast surgery, with no detectable changes in aesthetic, hand/nerve, craniofacial/head and neck, and “other” volumes over time. Nevertheless, residents continued to exceed minimum total operative volume requirements outlined by the ACGME.

DISCLOSURES

Dr. Janis receives royalties from Thieme Medical Publishers and Springer Publishing. He is also a member of the Plastic Surgery Review Committee, ACGME. The other authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

Sean O. Hogan, Chris Fox, and Yoon Soo Park are employees of the ACGME, and any opinions expressed may not necessarily reflect the views, policies, or requirements of the ACGME.