LAUSR

Aesthetic surgery education is a core part of plastic surgery training with increasing competition from other specialties with an interest in aesthetic surgery of the body and face. In their article, Silvestre et al assess variability of aesthetic surgery experience during plastic surgery residency.1 The authors analyzed case logs of 818 residents in either independent/combined or integrated plastic surgery residency programs from 2011 to 2015. Silvestre et al use the Accreditation Council for Graduate Medical Education (ACGME) case minimums as a proxy for baseline level of competency. Fold differences between the bottom and top 10th percentiles were calculated and used as a measurement of variability between training models by year. Specifically in aesthetic craniofacial surgery, browlift procedures were identified as having the greatest variability while breast procedures had the least variability. They also identify that in 2015, the bottom 10th percentile of both integrated and independent/combined residents failed to achieve the minimums for neurotoxin and soft tissue filler injections. The authors posit that the variability in volume is multifactorial and may be due to resident motivation, lacked of uniform curriculum across residency programs, and variable models of aesthetic surgery education in academic or private practice settings. The authors should be congratulated on their contribution to aesthetic surgery education and raising awareness about the procedural variability in aesthetic surgery training and education. It would have been useful for the authors to more directly compare integrated vs independent/combined plastic surgery residency programs to answer whether or not variability is changing as a result of shifting models of training. This is important as combined plastic surgery program are being phased out and more programs are transitioning to integrated formats based on recommendations by the American Board of Plastic Surgery (ABPS).2 The methodology heightens the need for more uniformity of aesthetic surgery education and notes that nonsurgical aesthetic procedures like neurotoxin and soft tissue filler injections are an area that may require more attention by educators. The study falls short of identifying specific and correctable causes for variability in aesthetic surgery training. We agree with the authors that resident motivation is a possible explanation for variability between graduating classes. In our experience, residents with strong interests in aesthetic surgery for example are more likely to seek out opportunities to participate in aesthetic surgery cases. Over the course of six years of training, this can lead to variability among residents in case logs. The ACGME attempts to reduce variations in training among residents graduating from the same program by giving major citations to programs in which residents have greater than 50% difference in total number of cases per category. How resident motivation affects variability between individual graduating residents was not assessed in the present study, and is perhaps the most difficult to study. When comparing variability by general categories, it is not surprising that aesthetic facial procedures had the most variability as