Certification and Accreditation in Plastic Surgery Subspecialty Training

Summary:

There are multiple subspecialties that residents can pursue after core plastic surgery training, including 5 major fellowship categories: aesthetic, burn, craniofacial, hand, and microsurgery. Hand surgery remains the only plastic surgery subspecialty to date, with a formal accreditation process following fellowship. The purpose of this study was to review the literature regarding the accreditation and match process of plastic surgery fellowship programs, the process of hand surgery certification, and future directions pertaining to certification in other plastic surgery subspecialties.

INTRODUCTION

The training path for a plastic surgeon is lengthy, with integrated programs requiring a minimum of 6 years of training and independent programs requiring completion of prerequisite training in several surgical specialties followed by an additional 3 years of plastic surgery training. The breadth of skills learned in plastic surgery training is extensive, as the American Council of Graduate Medical Education (ACGME) requires minimum operative cases in all subspecialties of plastic surgery. After core plastic surgery training, trainees have the option to pursue further subspecialty fellowship training in aesthetic, burn, craniofacial, hand, and/or microsurgery. Some programs may be uniquely tailored as a combination of 2 or more subspecialties.

The specifics of each fellowship program vary, but the length of most programs is 1 year following plastic surgery residency training. From 2014 to 2016, 62% of integrated resident graduates and 50% of independent resident graduates chose to seek fellowship training.¹ Fellowship training provides trainees an opportunity to further refine their knowledge and operative skills by experiencing increased number of operative cases and increased case complexity in their respective choice of subspecialty. However, unlike plastic surgery residency, which is highly regulated by the ACGME, the vast majority of plastic surgery subspecialty fellowships are not accredited by the ACGME. To date, craniofacial surgery and hand surgery are the only 2 ACGME-accredited plastic surgery subspecialties, with hand surgery being the only subspecialty with a formal, standardized certification process.¹ The purpose of this study was to review the literature regarding the accreditation and match process of plastic surgery fellowship programs, the process of hand surgery certification, and future directions pertaining to accreditation and certification in other plastic surgery subspecialties.

PLASTIC SURGERY FELLOWSHIP SUBSPECIALTIES AND ACCREDITATION

Subspecialty training following plastic surgery residency can be categorized into 5 major fellowship categories. On its website, the American Council of Academic Plastic Surgeons lists 25 aesthetic (including breast), 52 burn, 35 craniofacial, 82 hand (of these, 17 are plastic surgery hand fellowships), and 41 microsurgery fellowship programs.² Both hand and craniofacial fellowships are recognized as plastic surgery subspecialties by the ACGME; nearly all hand surgery fellowships are ACGME-accredited, while only 8 craniofacial fellowships are ACGME-accredited (Fig. 1).³ Aesthetic surgery, microsurgery, and craniofacial surgery applicants participate in the San Francisco Match (SF Match), while the hand surgery match occurs through the National Resident Matching Program (NRMP) (Table 1).^4–7 Burn fellowships and any other subspecialty fellowship not participating in the SF or NRMP Match require separate applications and direct contact with the fellowship program.⁹

Fig. 1.

Plastic surgery fellowships per ACAPS (American Council of Academic Plastic Surgeons) listings.

Table 1.

Subspecialties and Fellowship Match^7,8

Subspecialty	Year Match Established	Sponsoring Match Organization	Match Month	No. Programs (Positions)	No. ACGME Accredited
Craniofacial surgery	1995	San Francisco Match	November	29 (32)	8
Microsurgery	2010	San Francisco Match	July	23 (41)	0
Aesthetic plastic surgery	2018	San Francisco Match	March	Not available	0
Hand surgery	NA	National Resident Matching Program	May	83 (177)	82

Some discrepancies exist between the listings on the American Council of Academic Plastic Surgeons website and each fellowship’s individual overseeing organization. The American Society of Aesthetic Plastic Surgery’s endorsed fellowship list consisted of 24 aesthetic fellowships, which participated in the SF Match; there were 4 other aesthetic fellowships that were not formally endorsed by the organization and did not participate in the SF Match.^4,7 The American Burn Association website lists 19 burn fellowships.⁹ The American Society of Craniofacial Surgeons lists 30 craniofacial fellowships; in 2018, there were 29 participating craniofacial fellowship programs in the SF Match and 32 positions offered.^5,7 The American Society of Reconstructive Microsurgery website lists 30 microsurgery fellowships; in the 2018 SF Match, there were 23 participating microsurgery fellowship programs and 41 positions offered.^6,7 Finally, there are 90 hand fellowships listed on the American Society for Surgery of the Hand (ASSH) website, which is more than the 83 programs that participated in the NRMP match.¹⁰

SUBSPECIALTY CERTIFICATION IN HAND SURGERY

The only fellowship subspecialty with formal subspecialty certification by the American Board of Medical Specialties is hand surgery, for which an individual may obtain the Subspecialty Certificate in Surgery of the Hand, also known as the Certification in the Subspecialty of the Hand (CSSH). Following the World War II, hand surgery developed from a general field of clinical interest into a defined surgical subspecialty involving surgeons from different training backgrounds.¹¹ Formal training programs were established that allowed residents in orthopedic surgery, plastic surgery, and general surgery to pursue additional training in hand surgery. The ASSH was established in 1946, and the first division of hand surgery was established in 1970.¹²

The first examination for the certificate of added qualification (CAQ) in hand surgery was held in 1989 and has been refined since. Today, the CSSH is a written test administered by the Joint Committee on Surgery of the Hand, from the American Boards of Orthopedic Surgery, Plastic Surgery, and Surgery. In 2013, the CSSH replaced the formerly used CAQ in Surgery of the Hand previously administered by the American Boards of Orthopedic Surgery, the CAQ in Surgery of the Hand previously administered by the ABPS, and the Surgery of the Hand Certification previously administered by the American Board of Surgery.¹³ Of note, the American Osteopathic Board of Surgery (AOBOS) administers its own version of the examination, which has different requirements, timing, and test administration.¹⁰

The CSSH is a written examination consisting of approximately 175 multiple-choice questions that need to be completed over the course of four 60-minute sessions, whose content breakdown is listed in Table 2.¹⁴ Though the CSSH itself is a written examination, there are multiple clinical prerequisite requirements that must be met before one may become eligible for the examination (Table 3).¹⁴ General prerequisites to taking the CSSH include adherence to ethical and professional standards, general active engagement in the practice of hand surgery, and general board certification and licensure in an appropriate surgical specialty. More specific requirements include completion of a 1-year ACGME-accredited fellowship in hand surgery, practicing hand surgery for at least 2 years in the same location, and submission of a case log. The case log must consist of at least 125 cases managed during a 12-month period within 2 years preceding application for CSSH; the minimum case number must be met for 6 of 9 categories (Table 4).¹⁵

Table 2.

Surgery of the Hand Examination Contents^14,15

Topic	Value, %
Bone/joint/ligament	27–54
Hand, forearm, carpal fractures/dislocations; malunion/nonunion; degenerative/posttraumatic/inflammatory arthritis; joint stiffness/contractures, ligament injury/instability, osteonecrosis/infection; anatomy, physiology, biomechanics
Muscle/tendon	8–18
Flexor/extensor tendon injuries and reconstruction; compartment syndrome/Volkmann ischemic contracture; tendinosis and tendinopathies; infection; anatomy, physiology, biomechanics
Nerve	10–20
Acute nerve injury; chronic nerve injury; radial, median, ulnar nerve tendon transfers; compression neuropathies; neuromuscular; brachial plexus; anatomy and physiology
Vascular	4–10
Revascularization and replantation; vasospastic disease and chronic ischemia; thrombosis, embolism, aneurysm; malformations; lymphedema; anatomy and physiology
Skin/fascia/nails	6–18
Fingertip/nailbed trauma/ amputations; soft-tissue coverage; infection including animal bites; frostbite/burns; injection/extravasation injuries; Dupuytren’s disease
General principles/miscellaneous	7–19
Cancer pathology; congenital anomalies; prosthetics, orthotics, rehabilitation; dystrophy/pain management; anesthetics; ethics/professionalism

Table 3.

Requirements to Take the CSSH Examination¹⁰

General certification by American Board of Orthopedic Surgery, American Board of Plastic Surgery, or American Board of Surgery

Active practice of surgery of the hand for at least 2 years, in the same location, following the completion of any formal education

Current, valid, registered, full, and unrestricted license to practice medicine in the United States and/or Canada

Completion of a 1-year ACGME-accredited fellowship in surgery of the hand

Submission of a list of hand-surgery cases managed during a consecutive 12-month period within the 2 years preceding application, in at least 6 of the 9 categories

Adherence to all other requirements as set forth by the applicant’s certifying board

Table 4.

Minimum Cases Required per Category¹⁵

Category	Cases
Bone and joint	20
Nerve	20
Tendon and muscle	20
Skin and wound problems	14
Contracture and joint stiffness	10
Tumor	10
Congenital	3
Microvascular	3
Nonoperative	4 (maximum 6)

According to the ASSH task report, between 2000 and 2010, there were 204 plastic surgeons who went through hand fellowship training. Of these plastic surgery graduates who pursued a fellowship, 111 (54%) acquired the CSSH. During the same time period, 50% of general surgery graduates and 59% of orthopedic surgery graduates obtained the CSSH. Acquiring the CSSH was not associated with the program type or size.¹³ One of the most common reasons cited for not obtaining the CSSH was not having enough cases to qualify.¹³

SUBSPECIALTY CERTIFICATION IN MICROSURGERY

There is currently no formal certification process for microsurgery, though a CAQ in microsurgery is an active topic of discussion. A review of the literature yields 2 articles, which broached the topic of implementing a formal certification in microsurgery.^16,17 Layliev et al¹⁶ surveyed microsurgery fellowship directors and residency program directors in the United States for whether or not there should be a CAQ in microsurgery. Seventy-three percent of surgeons responded to Layliev et al’s¹⁶ survey; 25% supported a CAQ in microsurgery and 75% did not. More specifically, the majority of residency program directors in the United States did not support a CAQ in microsurgery (17% versus 83%), while microsurgery fellowship directors were split 44% in favor of a CAQ and 56% against it.¹⁶ Similarly, Heidekrueger et al¹⁷ surveyed directors of microsurgery programs in Europe. Fifty-seven percent of those surveyed in the European study responded; 61% of respondents (range, 47%–100% depending on the country) supported a CAQ in microsurgery. In both studies, there was a statistically significant difference in support for a CAQ between those surgeons who had themselves completed a fellowship compared with those who had not.^16,17

Suggested options for eligibility criteria of a microsurgery CAQ include the following:¹⁶

1. Surgeons who have completed a 12-month microsurgery fellowship;

2. Surgeons who have completed a 12-month fellowship or those without a formal fellowship but who have independently performed a certain number of microsurgical cases; or

3. Surgeons who have completed a fellowship, or, until a selected date, those without fellowship training who have independently performed a certain number of microsurgical cases (the grandfather exemption).

In the United States, the survey options for CAQ eligibility referred to plastic surgeons specifically, while the European survey stated “surgeons” without specifying a plastic surgery background. Based on Layliev et al’s¹⁶ results, supporters of the CAQ believed that eligibility for a CAQ in microsurgery should include plastic surgeons who have completed a 12-month microsurgery fellowship or, until a selected date, plastic surgeons who have performed a certain number of microsurgical cases without formal fellowship training (grandfather exemption). In Europe, the survey was limited to the first 2 options for CAQ eligibility, with option 2 being more popular.¹⁷ Both articles concluded that an exploratory committee of executive members from respective medical boards and official societies is recommended to further explore the topic.^16,17

CRANIOFACIAL FELLOWSHIP CERTIFICATION STATUS

Craniofacial surgery is one of the 2 fellowships (the other being hand surgery) recognized as a subspecialty of plastic surgery by the ACGME. There are 8 craniofacial fellowships accredited by the ACGME and 29 programs that participate in the SF Match.³ Currently, there remains a significant variability among craniofacial fellowship training. Studies on case logs have shown 73% of programs focusing primarily on cleft/orthognathic surgery, 19% focusing on adult/trauma/reconstructive surgery, and 4% focusing on intracranial/orbital/midface surgery; 50% of craniofacial fellows believed that training could be improved by introducing minimum case requirements and by establishing core areas of exposure.¹⁸ There is no formal certification for craniofacial surgery; literature review yielded no articles regarding future directions in certification in craniofacial surgery.

IMPACT OF CERTIFICATION AND ACCREDITATION IN PLASTIC SURGERY

Although added qualification certificates are not intended to confer legal privileges, they may help distinguish practitioners with additional training in a particular field of interest. The aim of such a certificate would be to acknowledge those surgeons who have demonstrated qualifications in their surgical subspecialty beyond those expected of other plastic surgeons by virtue of additional training or a practice characterized by a majority of cases in that subspecialty surgery.¹⁶

The vast majority of plastic surgery subspecialty fellowships are not ACGME-accredited; in such programs, fellowship experience within the same subspecialty can vary immensely. Ultimately, microsurgery survey results suggest that the focus may not be on whether an individual has been fellowship-trained, but whether they are capable of performing a number of procedures within their subspecialty.^16,17 The appropriate overseeing societies for each subspecialty as well as the board of plastic surgery should be intimately involved to determine the appropriate quality standards for any certification process.¹⁷

Hand surgery remains the only plastic surgery subspecialty with a universally recognized certificate, though craniofacial surgery and microsurgery may also be on the path to formal certification. For hand surgery, the CSSH is a prerequisite for active membership in the ASSH; more importantly, certain hospital policies require physicians taking hand call to be CSSH-certified.¹⁰ The percentage of accredited fellowships in hand surgery exceeds those in microsurgery and craniofacial surgery, suggesting that added certification options are potential catalysts for the adoption of accreditation status.¹

There appears to be an increasing need to provide public accountability, and the rise in accredited fellowships may make formal certifications of subspecialties into a future reality.¹ Other arguments in favor of a certification process include standardization and improved quality of fellowship training, identification of those surgeons who have expertise and interest in their subspecialty, and stimulation of research and development of said field.¹⁶ There may be traction within the field for embracing these distinctions, as the previously mentioned surveys of both American and European microsurgeons revealed that a large proportion of respondents support the development of a CAQ in microsurgery, especially those who have obtained additional microsurgery fellowship training themselves.^1,16,17 The significance of these results could be that those who have completed additional fellowship training may have greater insight into the demands and requirements of the training and subspecialty. Conversely, it could indicate that those who have obtained additional training simply desire recognition for their efforts.¹⁶

Arguments against subspecialty certifications include the concept of certifications limit the practice of plastic surgeons who choose not to obtain available CAQs, surgeons being viewed as inadequate regardless of actual technical skill, and causing the different subspecialties (eg, microsurgery) to become clearly defined as highly specialized areas of plastic surgery rather than a core feature of the field. Like any other specialty, plastic surgery residency programs have minimum requirements for various types of procedures. Naturally, different institutions will have different trends and volume for different types of procedures. Historically, a universal concern has been the volume of cosmetic surgery training during plastic surgery residency. With the increase in integrated plastic surgery programs, an additional year of plastic surgery training, and an increase in dedicated cosmetic surgery rotations, trainees have become more comfortable with cosmetic surgery, are satisfied with their exposure to and autonomy with cosmetic cases, and fewer residents feel the need for fellowship training to practice cosmetic surgery.^19,20

Similarly, it has been implicated that deep inferior epigastric artery perforator flaps can be performed safely with acceptable morbidity with proper training during residency and without fellowship training.²¹ An increase in fellowship accreditation could also lead to a depreciation in value of fellowship training as more and more individuals become fellowship-trained, despite more than adequate residency training. The field of plastic surgery could become even more highly specialized, opening up the opportunity for surgeons of other subspecialties, such as general surgery, otolaryngology, neurosurgery, and orthopedics, to pursue CAQs; this would detract from plastic surgery’s identity as a specialty.¹⁶

There is already evidence of other specialties being eligible for plastic surgery fellowships. For example, while the prerequisite for the New York University microsurgery fellowship is completion of a plastic surgery residency program, it has been open to those trained in otolaryngology, orthopedics, and general surgeons in rare circumstances. Similarly, the microsurgery fellowship at MD Anderson trains those with an otolaryngology background.⁶ Alternatively, facial plastic surgery fellowships and oculofacial plastic surgery fellowships are overseen by the American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery, respectively.^22,23 These fellowships are dictated by their respective specialties and predominantly accept resident applicants from the fields of otolaryngology and ophthalmology, though according to the AAFPS website, plastic surgery residents are eligible to apply for facial plastic surgery fellowships.²³

This may be an age-old dilemma that our specialty will continue to face as medicine becomes increasingly subspecialized. As Drs. Mogelvang and McCormack stated so well, “Plastic Surgery [is] a highly individualistic specialty based on the surgical molding of tissues in so many areas of the body, but in the company of so many anatomically based specialties … [Plastic Surgery] must mold itself to change but at the same time must strive to maintain its identity and its quality.”²⁴ While it is for the benefit of the patient for different specialties to have open dialogue and joint conferencing, it is a fallacy to label 2 different specialties as identical in a given anatomic area.²⁴

CONCLUSIONS

The only plastic surgery subspecialty to date with a formal certification process after fellowship training continues to be hand surgery. Although craniofacial fellowships are ACGME-accredited as a subspecialty, there is a lack of a uniform certification process after training is completed. Similarly, the field of microsurgery has gained more attention and discussion regarding the need for both accreditation by the ACGME and a subsequent certification process. There continue to be factors pushing for and against formal subspecialty certification following fellowship training. The goal of certification is to ensure a high standard of practice and to recognize those surgeons who meet that standard while preserving the core definition of what it means to be a plastic surgeon. Fellowships in each subspecialty are rapidly changing and growing in number, while the literature on subspecialty accreditation remains scarce. Formal certification of plastic surgery subspecialties may be an inevitable result of modern medicine, though more updated research would help better assess current and future trends.