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The study sites included 2 internal medicine clinics, 1 family practice clinic, and 1 pediatric clinic. Participants were given the survey as part of their intake paperwork for the clinic. Participation was voluntary and anonymous. Subjects younger than 18 years of age were excluded. Completed surveys were placed in a secured dropbox. Survey The survey study was conducted under approval from the University of California Los Angeles Institutional Review Board (IRB 124212B). Respondents were asked to provide standard demographic information on age, sex, household income, and marital status. In addition, they were questioned about their own history of plastic surgery performed or considered. Respondents were asked to identify training paths and specialties that could produce a cosmetic surgeon; options included surgeon, dentist, obstetrician/gynecologist, anesthesiologist, family practitioner, internist, and dermatologist. Subjects were then asked to identify the area of the body they would be most interested in having treatment for with plastic surgery, as well as the principal reason they would not have plastic surgery. Questions directed at surgeon selection included importance of advertisement, reputation, type of referral, board certification, surgeon age, training background, and quality of practice. For these questions, respondents were asked to rate the importance of each factor on a scale of 0 to 10, where 0 was least important and 10 was most important. Potential respondents were questioned on where they would prefer to undergo plastic surgery: at a private surgicenter, a community hospital, or a university medical center. Finally, respondents were asked to express their preference for a larger, more expensive procedure with longer lasting results or a shorter, less-expensive procedure with more temporary results. The full questionnaire is available in Appendix 1 at www.aestheticsurgeryjournal.com. Data Analysis Only responses with data available for all of the demographic variables were used; respondents who failed to choose at least 1 response for each question were excluded. Descriptive statistics were obtained for the demographic variables to describe the sample. Income was categorized in US dollars as $0 to 45 000 (low income), $45 000 to $100 000 (middle income), and >$100 000 (high income). An ordinal logistic regression model was then manually fit for the total for plastic surgery with age, sex, marital status, and income. Cross-tabulated frequencies were calculated and chi-square associations were computed among the association variables. A linear analysis of income was also employed to assess correlations with associated variables. Results Demographics Ninety-six subjects responded to the survey. Average respondent age was 34.5 years (range, 18-67 years). Eighty-one (84%) were women and 15 (16%) were men. Average annual household income of participants was $91 298 (range, $0 to $500 000). If we eliminated the participants who reported an annual income of $0, the average annual household income rose to $106 886 (±SE $9607). Forty-two participants were single and 54 (56.2%) were married. Sixteen respondents (16.7%) had previously undergone cosmetic surgery (Table 1). Defining a “Cosmetic” Surgeon Among participants, 32 (33.3%) did not draw a distinction between a plastic surgeon and a cosmetic surgeon (Figure 1A). Downloaded from https://academic.oup.com/asj/article/33/4/585/204723 by guest on 20 May 2021 Galanis et al 587 All respondents identified “surgeon” as a training path that could yield a cosmetic surgeon; 33 (34.4%) said that surgeon was the only training path that could yield a cosmetic surgeon. The remainder of subjects identified dermatologist (34%), dentist (22%), obstetrician/gynecologist (22%), anesthesiologist (12%), family practitioner (12%), and internist (10%) as training paths capable of yielding a cosmetic surgeon. Only 8 respondents (8.3%) selected all available training paths. There was no statistically significant correlation between these responses and age, sex, income, or marital status (Figure 1B). Interest in Plastic Surgery Nineteen subjects (19.8%) were considering cosmetic surgery at the time they completed the survey. Seventy-five subjects (78.1%) said they might consider cosmetic surgery in the future. (in the Emergency Department and Operating Room) of various body areas b. Skin grafting, rotational and free flap reconstruction for burn, traumatic, operative and other complex wounds in various body areas § Participate in the pre- and post-operative surgical management of patients before and after major head and neck and reconstructive Plastic Surgery; attend Plastic Surgery clinic at least once a week; participate on daily morning and afternoon patient rounds § Manage postoperative complications including wound infection/dehiscence, bleeding, systemic complications related to injury, anesthesia, co-morbidities and other factors Medical Knowledge: Goals and Objectives: General § Discuss and compare skin and connective tissue according to: anatomy, histology, normal physiology and biochemistry; understand the pathophysiology of benign and malignant skin disorders and unique pathophysiology of connective tissue disorders and tumors. § Develop a fundamental knowledge of normal wound healing and factors that influence this process: diabetes, vascular insufficiency (arterial and venous), steroids and immunosuppressive medications, renal and hepatic failure, protein and calorie malnutrition, vitamin and trace element deficiencies, etc. § Explain the basic techniques for surgical repair of incisions and lacerations of the head, neck, trunk and extremities including the concepts of viability, perfusion, (lines of) tension, etc. § Understand the specific differences in healing of skin, connective tissue, tendons, bone (with and without periosteal coverage) and nerves § Describe the physiology and specific considerations for various techniques of skin and composite tissue transplantation with particular regard to component tissue (neo-) circulation: a. Skin grafts (split- vs. full- thickness) bone & cartilage grafts, composite grafts d. Skin flaps, muscle flaps, myocutaneous flaps, bone flaps, osteocutaneous flaps, myo-osseous flaps, neurocutaneous flaps j. Vascularized versus non-vascularized flaps § Discuss the pathophysiology of thermal, chemical, and electrical burns including consideration of systemic pathophysiology (cardiac, pulmonary, renal, immune system, etc. (see Medical Knowledge Competency Burn Rotation) § Explain considerations in the geriatric patient undergoing major reconstructive operation to include the implications of: a. Decreased functional physiologic reserve, multiple medical problems c. Altered wound healing; consider significance of: age, concomitant disease (diabetes, vascular disease, renal disease, etc.), (relative) malnutrition, medications; susceptibility for (nosocomial) infections d. Need for pre-operative evaluation, and intensive peri-operative monitoring § Define the tumor, node and metastases (TNM) classification system as used for neoplasms of skin, soft tissue and head and neck. § Develop an understanding of the relevant anatomy of specific body regions: a. Head and neck including functional skeletal units, vascular supply and lymphatic drainage, sensory and motor innervation b. Hand including neurovascular supply, compartments, etc. and upper extremity c. Foot and lower extremity d. Breast Trauma § Discuss the implications of different types of soft tissue injury (cut, blast, crush chemical and thermal burn) in terms of healing, considerations for reconstruction and potential complications; understand specific problems associated with prolonged exposure of bone, tendons, nerves and vasculature § Explain the assessment of facial skeletal trauma according to the following systems: a. LeFort I, II, and III classification of maxillary fractures b. Nasoethmoidal disruption classification c. Zygomatic, orbit and mandibular fractures d. Disruption classification § Understand the principles of repair of facial trauma: a. Consideration of functional and cosmetic units b. Options for bony reconstruction: temporary vs. permanent, sources for bone grafting c. Options for rotational and free flap soft tissue coverage § Discuss considerations in the (staged) repair for massive craniofacial trauma including temporary vs. permanent airway control, consideration of intracranial and other injuries in the overall planning of the facial reconstruction § Understand the comprehensive assessment (grade, extent, involvement of joints and other critical areas, circumferential burn, etc.) of burn injuries; summarize the options for surgical treatment (see Burns Goals and Objectives, including escharotomy, early vs. delayed grafting, conservative therapeutic adjuncts, etc.) § Describe the specific considerations for assessment of hand trauma (soft tissue injury with or without tissue loss, nerve and vascular injury, bony injury); describe the important functional units of the hand § Understand the major considerations in the decision-making for reconstruction vs. amputation in upper and lower mangled extremity injuries: a. Extent of tissue loss, extent of nerve and vascular damage b. Expected residual function c. Age and overall medical condition of the patient (acute and chronic) d. Available resources and overall cost of (multiple) operations Breast § Discuss the options for breast reconstruction after surgery for breast cancer: a. Immediate vs. delayed reconstruction b. TRAM or other flap reconstruction vs. the use of artificial implants c. Major (dis-)advantages of common types of implants d.
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