Following the Keogh report earlier this year into the quality of cosmetic surgery in the UK, surgical training in cosmetic surgery is high on the agenda. A Cosmetic Surgery Interspecialty Committee at the Royal College of Surgeons is currently discussing this issue, although formulating specific guidelines for training and validation of ‘cosmetic surgeons’ will be a challenge for those of us representing our specialties.

Currently in the UK, the specialties of ENT, plastic surgery and oral and maxillofacial surgery (OMFS) have facial plastic surgery on their curriculum, and trainees are examined in this subject in their exit exams prior to obtaining a Certificate of Completion of Training (CCT). In reality the training received is very variable.

 

 

 A nasal reconstruction using a melolabial flap.

 

A framework of autogenous rib to be used for ear reconstruction in congenital microtia. 

 

A revision open septorhinoplasty with weak irregular lower lateral cartilages.

 

ENT trainees are trained to perform septorhinoplasty because there are currently sufficient numbers of funded trauma and ‘functional’ rhinoplasty cases. Trainees in plastic surgery and OFMS are unfortunately seeing fewer rhinoplasties in many regions due to funding restrictions. All three specialties train their registrars in facial skin cancer excision and reconstruction, though again the quality of this training is very variable. A number of plastic surgery trainees have an aesthetic surgery attachment as part of their registrar training, though because this is generally in the private sector the opportunities to gain surgical experience are limited. I am aware of schemes to allow trainees to perform facial plastic surgery for private patients under supervision, but these are few and far between in the UK.

So where does this leave trainees who wish to gain expertise in facial plastic surgery, either for specialist NHS or private work? In reality additional training to that obtained on a general training programme is required, and this is a challenge. There are a number of options, of which the best is a specialist fellowship. First of all the trainee must decide the type of expertise they wish to gain and tailor their training accordingly. In addition to formal fellowship training, there are other opportunities for training in facial plastic surgery, including courses and conferences. Visits to experts in the field are particularly productive.

The Training Interface Group into Reconstructive Cosmetic Surgery chaired by Paul Johnson offers a number of short Cosmetic Surgery Fellowships each year. These are for pre CCT trainees and offer an ideal opportunity for specialist registrars to gain an intensive exposure to cosmetic surgery with a number of trainers from different specialties. The fellow is encouraged to seek out training opportunities depending upon their clinical interest and although there is an initial learning agreement, the timetable is flexible. Several interface fellows have joined me for both NHS and private nasal plastic surgery cases, and I am always impressed by their enthusiasm. Of course these fellowships do not qualify an individual to set up in private practice, but they are a good start.

The European Academy of Facial Plastic Surgery (EAFPS) has a well established fellowship programme currently led by Alwyn D’Souza. The Academy offers three funded and a number of unfunded fellowships each year in various centres throughout Europe. Fellows are also encouraged to visit other units outside of Europe. The fellowships are open to trainees who have completed four years of registrar training and have passed their exit examination. The fellow is expected to sit the EAFPS board exam, and passing this exam is a requirement for successful completion of the fellowship. The closing date for these fellowships is December each year and details are available on the Academy website.

There are also several fellowships available in the UK offering specialist training in facial plastic surgery. These are usually linked to other areas of specialist surgery such as rhinology and head and neck surgery with specialty specific on-call commitments, and they offer a variable amount of facial plastic surgery experience. The fellowship I run in Manchester with my colleague Raj Bhalla is for one year and gives training in advanced endoscopic and anterior skull base surgery with Raj and rhinoplasty and nasal and ear reconstruction with myself.

There are only a few of these fellowships, generally for one year and their scarcity ensures they are competitive with UK and overseas applicants. They offer the opportunity for post CCT specialist hands on training, making the individual competitive for an NHS consultant post.

I always stress to my fellows that they should regard their fellowship as only the beginning and not the completion of their training in facial plastic surgery. Training should continue after appointment as a consultant, and speaking personally, most of my specialist skills have been learned since I became a consultant. This is a career long process, and patience is required to gain experience, and build a successful practice. I continue to learn from experienced colleagues, and indeed from my trainees.

 

Useful Resources The Interface Group

http://www.jcst.org/training_interface_groups/
cosmetic_surgery/index_html
Application information for the Interface fellowship

http://www.severndeanery.nhs.uk/recruitment/
vacancies/show/reconstructive-cosmetic-surgery-3/
The European Academy of Facial Plastic Surgery

https://www.eafps.org/
International Federation of Facial Plastic Surgery Societies

http://www.iffpss.org/
American Academy of Facial Plastic and Reconstructive Surgery

http://www.aafprs.org/
European Society of Plastic, Reconstructive and Aesthetic Surgery

http://www.espras.org/

Declaration of Competing Interests: None declared.


Fellowship Experience
Ofer Gluck, Consultant Otolaryngologist, Edith Woflson Medical Centre, Tel Aviv, Israel.
I came as an overseas fellow for an eight month clinical training programme, as a fellow training in advanced rhinology and reconstructive facial plastic surgery, at the Manchester Royal Infirmary Hospital, under the supervision of Mr Tim Woolford and Mr Raj Bhalla.
In reconstructive facial plastic surgery, led by Tim Woolford, I gained excellent experience of rhinoplasty and reconstructive nasal and ear surgery. The majority of reconstructive cases were patients diagnosed with skin malignancy who had undergone Mohs surgery the day before the reconstruction. With Raj Bhalla I gained wide experience of endoscopic sinus surgery, including advanced procedures such as orbital decompression, median drainage procedures and endoscopic anterior skull base surgery.
I gained experience in rhinoplasty and revision rhinoplasty from both Mr Woolford and Mr Bhalla. On my return to Israel I began to work as a consultant, building my own service treating a large spectrum of patients using the knowledge and techniques I learned during my stay in Manchester. I would recommend this fellowship programme to any otolaryngologist who wants to gain experience in the fields of rhinology, reconstructive facial plastics and rhinoplasty.
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CONTRIBUTOR
Tim Woolford (Prof)

Department of Otolaryngology - Head and Neck Surgery, Manchester Royal Infirmary; Honorary Clinical Professor, Edge Hill University, UK.

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CONTRIBUTOR
Ofer Gluck

Edith Woflson Medical Centre, Tel Aviv, Israel.

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CONTRIBUTOR
Paula Bradley

BA (Hons), MRCS, DOHNS, Cumberland Royal Infirmary, Northern Deanery, UK.

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