Cosmetic procedures have been increasing in popularity, and the vast majority of the growth has been in the minimally invasive arena. In 2017, dermatologic surgeons surveyed by the American Society for Dermatologic Surgery (ASDS) reported performing an estimated 8 million cosmetic procedures.1 Since the inception of cosmetic medicine, innovative dermatologists have been at the forefront of this movement, having pioneered many of the devices and techniques that are now part of the standard practice including lasers, tumescent liposuction, neuromodulators, fillers, chemical peels, and fat reduction/body contouring.2,3
The Importance of Teaching Aesthetic Dermatology
Dermatologists are perceived by the public as well as our fellow physicians to be experts in cosmetic procedures. A 2012 survey revealed that primary care physicians perceive dermatologists as the most qualified specialists to perform neuromodulator, filler, and laser procedures.4 And a 2018 ASDS Consumer Survey also found dermatologists to be the most influential in their decision on whether to undergo a cosmetic procedure.5 In order to maintain the collective expertise and reputation of our specialty in aesthetic medicine, we must continue to uphold high standards in resident education.
It appears that a large portion of dermatology residents in the United States plan to incorporate cosmetics into their practices to some degree; surveys of US dermatology residents have reported that 75% to 99% of residents plan to include cosmetic procedures in their practice.6-8 Because most residents do not pursue cosmetic fellowships, the skills and knowledge gained during residency become the foundation upon which future expertise is built.
Most importantly, we owe it to our patients to train our residents to ensure that they have the knowledge and skill to safely and competently perform these procedures. We must ensure that residents are receiving accurate and unbiased information, especially because much of the post-residency cosmetic training is industry-sponsored. Just as importantly, they should also know their limitations as well as how to manage potential complications. Even residents who do not plan to perform any aesthetic procedures should still have enough familiarity with the procedures, the indications, contraindications, and potential complications to properly counsel and refer patients to the appropriate providers.
Currently, the Accreditation Council for Graduate Medical Education (ACGME) requires dermatology residents to demonstrate knowledge of the indications, contraindications, complications, and basic techniques of elective cosmetic procedures including botulinum toxin injection, fillers, laser and other energy-based devices, chemical peels, dermabrasion, hair transplantation, invasive vein therapies, liposuction, scar revision, and sclerotherapy.9 Education regarding these topics may be via didactic sessions such as lectures or video instruction. Currently, the ACGME also requires that residents either perform or observe 10 neuromodulator procedures, five filler procedures, and 15 laser procedures. Each resident must maintain a case log of these procedures and review the documentation with a faculty member in their program. Currently, the ACGME Dermatology Residency Review Committee is reviewing a proposal to increase the required number of cases for neuromodulators, fillers, laser procedures, and chemical peels and to require that the resident perform the procedures as the primary surgeon rather than as an observer.
Sources of Cosmetic Education
In the United States, most dermatology residents receive their cosmetic education through a variety of modalities, including lectures/didactics, textbooks, journals articles, observation in faculty clinics, and hands-on workshops.6-8 Additional sources of cosmetic education available to residents include local, regional, and national courses and conferences; industry-driven education sessions; online resources including those available through national societies such as the ASDS; social media; and online forums/discussion groups.
All ACGME-accredited dermatology residency programs are required to provide didactics, either by core or adjunct faculty. Most programs also provide hands-on workshops for residents to develop their procedural skills, as shown by surveys of residency program directors and residents.6-8,10 Some programs begin hands-on training during their first year of dermatology training, while others incorporate it later in residency. A 2012 survey of third-year residents demonstrated that earlier exposure to cosmetic procedures resulted in more familiarity with that particular procedure.6 Residents have the opportunity for hands-on training most commonly with lasers and injectable procedures (neuromodulators, fillers, sclerotherapy), while exposure to procedures such as liposuction and hair transplantation typically occurs through didactics.11
From a resident perspective, most residents report that they want more cosmetic training during residency, and most prefer active learning techniques such as hands-on training over lectures or assigned reading.6-8 Among dermatology residents surveyed in 2018, the vast majority reported that hands-on training was most helpful (89%) compared with assigned reading (4%), assisting (3%), conference attendance, or lectures (each 2%).7 Over the past several years, resident expectation for developing competence in cosmetic procedures during the course of their residency has also increased.8
A 2012 survey of third-year residents revealed that the use of virtual reality simulator models was not associated with familiarity of any cosmetic procedures, but the apprenticeship model (observing and assisting a faculty member performing the procedure) was more helpful.6