Cosmetic Surgeon vs. Plastic Surgeon

There is a growing “turf war” between plastic surgeons and cosmetic surgeons regarding who is qualified to perform cosmetic surgery.  Central to this battle are issues of safety, ego and greed.  Cosmetic surgery is a rare area in medicine where earnings are not effected by government and insurance reimbursements.  As a result, there is a growing number of physicians performing cosmetic surgery procedures.

What is the difference between a plastic surgeon and a cosmetic surgeon?

To receive the title plastic surgeon one must complete an ACGME approved plastic surgery residency program.  This requires a minumim of 36 months of plastic surgery training after prerequisite training.   All prerequisite residency education must be taken within programs accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada (RCPSC), or the American Dental Association.  A summary of these requirements can be found here.

A “cosmetic surgeon” is a general term used by physicians (and some non-physicians) doing cosmetic surgery without having completed a plastic surgery (or other “core”) residency program.   There is not an ACGME approved training program to become a “cosmetic surgeon”.  Most “cosmetic surgeons” have their residency training in Family practice, Otolaryngology, OB/GYN, Oral Surgery, or Ophthalmology.

Who is qualified to do cosmetic surgery?

This is where it gets tricky.  Many plastic surgeons feel that only plastic surgery trained physicians are qualified to do cosmetic surgery.  The argument is that the only ACGME approved residency program that trains and prepares a surgeon to perform full body and facial cosmetic surgery is a plastic surgery residency program.

On the other hand, many cosmetic surgeons would suggest that plastic surgeons are trained to do reconstructive surgery primarily and that non-plastic surgeon cosmetic surgeons are just as qualified to do cosmetic surgery as plastic surgeons.

I actually believe there is a little bit of truth and inaccuracy on both sides of this argument.  I personally don’t believe that only plastic surgeons are qualified to do cosmetic surgery but there needs to be minimal training standards to assure patient safety.   In my own practice for example, good fortune and a busy schedule has afforded me the opportunity to have a boutique practice and am currently accepting primarily cosmetic surgery patients of the breast and body.   I am referring almost all of my facial plastic surgery patients to my business partner, Dr. John Bitner, who is a board certified otolaryngologist with additional training and certification in facial plastic surgery.  I, like many plastic surgeons, would consider facial plastic surgery a “core” cosmetic surgery specialty.

What are the “core” cosmetic surgery training programs?

The generally recognized “core” training programs for cosmetic surgery with a summary of the training involved are:

  1. Plastic surgeon – Prerequisite training (most commonly 3-5 years of general surgery) + 36 months of plastic surgery training.  Generally recognized as qualified to perform cosmetic surgery of the face and body.
  2. Facial plastic surgeon – Prerequisite training (most commonly 5 years otolaryngology) +  12 months of facial plastic surgery training.  Generally recognized as qualified to perform cosmetic surgery of the face
  3. Oculoplastic surgeon – Prerequisite training (most commonly 4 years opthamology) + 12 months oculoplastic training.  Generally recognized as qualified to perform cosmetic surgery of the face with a specific focus on eyelid surgery.

What are the training requirements for “cosmetic surgeons”?

Generally speaking, those physicians who are not “core” surgeons are self proclaimed “cosmetic surgeons”.  There are NO training requirements to call oneself a cosmetic surgeon.  For those who have additional cosmetic surgery training, it is not through an ACGME approved training program and is variable in length, intensity and responsibility.  There are many cosmetic surgeons with training consisting of observing a similarly trained surgeon do a few procedures.

 Which specialty is “best” at cosmetic surgery?

As a board certified plastic surgeon my answer to this question is admittedly biased.  The amount of time and intensity a plastic surgeon spends in plastic surgery training is generally triple that of the other specialties and most plastic surgeons finish their residency programs very well prepared.  That said, the field of plastic surgery is very broad including surgery of the face, surgery of the body and reconstructive surgery.  Depending on the nature of the specific training program, many facial plastic or oculoplastic training programs graduates may have as much experience with cosmetic surgery of the face.  All in all I think there is a lot that we as surgeons can learn from each other, particularly in facial surgery.

For breast and body surgery, no training program comes close to the length and intensity of a plastic surgery residency program.  There are very few facial plastic surgeons or oculoplastic surgeons attempting breast and body surgery.  Regarding “cosmetic surgeons”, doing breast and body surgery, most have a year or less experience in the principles of general surgery of the body.  In my opinion this is FAR too little experience to prepare oneself for the specifics risks of this kind of surgery.

Who should be doing cosmetic surgery? (my opinion)

I personally don’t think the turf battle should be about who is best.  As long as surgery is done safely without human experimentation who am I to say who’s results are best.  That judgement is best left to the patient.  Safety is the issue!  There should be safeguards for the patient to assure that their surgeon is adequately trained to safely and effectively perform the procedure.  Currently there are few scope of practice laws in cosmetic surgery and anyone with an M.D. or D.O behind their name can legally perform cosmetic surgery in their own office.   In my opinion these safeguards should include:

Minimal training requirements

  • The “core” specialties listed above have specific prerequisite and training requirements preparing them for a career in cosmetic surgery limited to their scope of training.
  • The route for “cosmetic surgeons” to receive training in plastic surgery already exist in these “core” ACGME accredited training programs.  These training programs are difficult to get into and rigorous to complete.  All “cosmetic surgeons” have the ability to apply for and complete one of these training programs and in my opinion anything less is a short cut.
  • It is my opinion that all surgeons with certification to do plastic surgery of the breast and body should have a minimum of THREE years of training in plastic surgery of the body.  This training prepares the surgeon to handle the unexpected and gives one a respect for the risks of these kinds of procedures.  Most plastic surgeons have 6 years or more and my opinion is that anything less than three is completely inadequate.
  • A physicians practice should be limited to the scope of their primary training.  I am a plastic surgeon who did my residency training in plastic surgery…. I should not be delivering babies, removing wisdom teeth, removing tonsils, and so forth…  even if I CAN do these things I do not have the background training to do them with the  maximal degree of aptitude or safety.

Hospital privileges

Without scope of practice laws, the “police” for who should or who shouldn’t be performing specific procedures is hospital credentialing.  These committees look closely at the training and certification of the surgeon before granting privileges.  They do not grant privileges for cosmetic surgery procedures except when training for those procedures was part of an ACGME accredited training program.

As a plastic surgeon, I cannot do heart surgery because I do not have privileges to do so in the hospital.  However, if I wanted to do heart surgery in my office operating room I legally could.  In my opinion, there should be legislation that prohibits surgeons from doing office surgical procedures that they don’t have hospital privileges for.  One would be surprised how many cosmetic surgeons do not.

This becomes an issue of patient safety if there were to arise a problem during an office surgery that would require transfer to a hospital.

 Truth in advertising

Although I don’t believe that only plastic surgeons are qualified to perform cosmetic surgery it should be clear to the patient what kind of physician they are seeing.  ”Plastic surgeon” is a term reserved only for surgeons trained through a plastic surgery residency program.  I would never refer to myself as a “oculoplastic surgeon”, “otolaryngologist”, “oral surgeon”, etc.   I find it shameful when a patient tells me they have seen a cosmetic surgeon who referred to themselves as a plastic surgeon (and this happens all the time).

Code of ethics

There should be a governing body ensuring ethical standards.

Facility accreditation

Office cosmetic surgery should only be performed in accredited facilities to assure minimal safety standards.  Procedures should be done with qualified ancillary staff, particularly anesthesia.  Patients should have adequate monitoring.  Complications should be reported.

In conclusion, choosing a physician to do your cosmetic surgery can be tricky.  Although there are never guarantees in outcomes, choosing a board certified plastic surgeon assures your surgeon is adequately trained and follows strict safety and ethical standards.