Research

Aesthetic Surgery Journal

Trends in Aesthetic Surgery Fellowship 2024, Vol 44(1) 95–101

© The Author(s) 2023. Published by
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Training: An Analysis of Supply and Demand Aesthetic Society. All rights reserved.
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https://doi.org/10.1093/asj/sjad208
www.aestheticsurgeryjournal.com
Isaac James, MD; Andrew Kochuba, MD, FACS; Jacob N. Grow, MD;
Isabel Ho, BA ; M. Bradley Calobrace, MD, FACS; Kiya Movassaghi, MD;
and James E. Zins, MD

Abstract
Background: Aesthetic surgery fellowship applications were consolidated under the San Francisco Match in 2018. The im­
pact of these changes on aesthetic program and applicant numbers had not yet been investigated.
Objectives: In this study we sought to evaluate changes in programs, positions, applications, match rates, and fill rates
since aesthetic surgery joined the San Francisco Match. We also aimed to compare these trends to craniofacial surgery,
microsurgery, and hand surgery fellowships over this same time period.
Methods: San Francisco and National Resident Matching Program (NRMP) match data for aesthetic, craniofacial, microsur­
gery, and hand fellowships were obtained from 2018 to 2022, and the number of applications, positions, programs, and
successful matches were evaluated.
Results: The number of aesthetic fellowship positions increased from 17 to 41 (141%) over the period studied. This resulted
in increased match rates and more unfilled positions. Over the same period, fellowship positions for craniofacial, hand, and
microsurgery increased by 3.4%, 6%, and 2.5% respectively. There was no increase in applications to any postgraduate
subspecialty, nor was there any change in the number of residents pursuing fellowship. Similarly, there was no change
in the percentage of fellowship-bound residents applying to any given discipline.
Conclusions: The increase in aesthetic fellowship programs and positions did not generate an increase in applications.
Applications to other plastic surgery subspecialties also failed to increase. Unlike aesthetic fellowships, their program num­
bers have remained stable. Given the limited fellowship applicant pool, our focus should be on enhancing the quality of
existing aesthetic programs rather than continuing to increase the number of aesthetic positions.

Level of Evidence: 3

Editorial Decision date: June 26, 2023; online publish-ahead-of-print July 11, 2023. Diagnostic

Science University, Division of Plastic Surgery, Eugene, OR, USA.

Dr James is an aesthetic surgery fellow, Cleveland Clinic, Department
of Plastic Surgery, Cleveland, OH, USA. Dr Kochuba is a plastic
surgeon in private practice in Reston, VA, USA. Dr Grow is a plastic
surgeon in private practice in Columbus, IN, USA and a Facial Surgery
contributing editor for ASJ Open Forum. Ms Ho is a medical student,
Case Western Reserve University School of Medicine and Cleveland
Clinic Foundation, Department of Plastic Surgery, Cleveland, OH, USA.
Dr Calobrace is a plastic surgeon in private practice in Northfield, KY,
USA and a clinical editor for Aesthetic Surgery Journal. Dr Movassaghi
is a clinical assistant professor of plastic surgery, Oregon Health and
Dr Zins is a professor of plastic surgery, Cleveland Clinic, Department
of Plastic Surgery, Cleveland, OH, USA and Facial Surgery section
coeditor for Aesthetic Surgery Journal.
Corresponding Author:
Dr James Zins, Department of Plastic Surgery, 9500 Euclid Avenue,
Suite A-60, Cleveland, OH 44195, USA.
E-mail: zinsj@ccf.org
96
Postgraduate fellowships in aesthetic plastic surgery offer
advanced training in surgical and nonsurgical aesthetic
procedures and unique mentorship opportunities.1 This
training provides a focused experience in aesthetic medi­
cine and surgery that allows fellows to significantly in­
crease their fund of knowledge and surgical skills. In the
2017-2018 application cycle, aesthetic plastic surgery fel­
lowships joined the San Francisco Match. This effort was
initiated by The Aesthetic Society to make application
more user friendly by simplifying, organizing, and centraliz­
ing the process. To participate programs must agree to
comply with rules that are identical to the current plastic
surgery resident match.
The present study was undertaken to evaluate the cur­
rent state of aesthetic fellowships and to analyze them in
the context of the other major plastic surgery postgraduate
opportunities. Specifically, we evaluated trends in the num­
ber of applications, available positions, match rates, and fill
rates since the match was initiated. In addition, we com­
pared these findings with similar data from the other major
postgraduate plastic surgery fellowships including hand,
craniofacial, and microsurgery programs during the same
time period. We hypothesized that the initiation of the
match, an increasingly competitive marketplace, and
growth of The Aesthetic Society–endorsed programs
would have led to an increase in applications to aesthetic
fellowships during the study time period.
METHODS
This cross-sectional retrospective review of prospectively
collected data was approved by the Cleveland Clinic
Institutional Review Board (IRB 22-365). Funding for this
study was provided by the Aesthetic Surgery Education
and Research Foundation (ASERF) under grant 2021-Q2C.
Data Collection
San Francisco Match (SF Match) and National Resident
Matching Program (NRMP) data for all United States post­
graduate aesthetic plastic surgery, craniofacial surgery, mi­
crosurgery, and hand surgery fellowships were obtained
for 2018 through 2022. SF Match and NRMP data included
the number of applications, programs, available positions,
applicant match rates, and position fill rates.2-6 Program in­
clusion was based on participation in the SF Match or
NRMP, regardless of whether or not fellowships were ap­
proved by the Accreditation Council for Graduate Medical
Education (ACGME). Consequently, all aesthetic fellow­
ships included in the present study had obtained The
Aesthetic Society–endorsed status. The hand fellowship
cohort was comprised of both orthopedic surgery and plas­
tic surgery programs and applicants. Applications and
Aesthetic Surgery Journal 44(1)
programs outside of the SF Match or NRMP were excluded,
as were incomplete and unsubmitted applications. Data
collected included number of applicants, number of fellow­
ship programs, number of fellowship positions, and number
of positions filled. Data regarding graduating residents was
collected from the annually published ACGME Data
Resource Book from 2017 to 2022.7-11
Statistics
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Data were managed and analyzed with R, version 4.2
(RStudio, Boston, MA). Descriptive analysis was performed
with standard statistical procedures. Multivariate general­
ized linear models with Poisson regression were per­
formed to compare changes in applications and positions
between specialties. Multivariate generalized linear mod­
els with logistic regression compared trends in match per­
centages between specialties. A 2-sided α of less than 0.05
was considered statistically significant for this study
(P ≤ .05).
RESULTS
Positions, Programs, Applicants
Aesthetic Surgery
Since the first year of the aesthetic plastic surgery match,
the number of aesthetic fellowship programs has increased
from 14 programs in 2018 to 34 in 2022 (143%). Aesthetic
fellowship positions increased from 17 to 41 (141%) over
this same time period. When compared with other plastic
surgery subspecialties, aesthetic fellowship positions
significantly increased over time (incidence rate ratio
[IRR] = 1.23, P < .001; Figure 1). However, application num­
bers showed no change from 2018 to 2022 (Figure 2).
Detailed yearly data for all 4 subspecialty fellowships are
provided in Table 1.
Other Plastic Surgery Subspecialties
Craniofacial, microsurgery, and hand fellowship application
and program trends were also evaluated. Similar to aes­
thetics, these fellowships did not see a change in applicant
numbers (Table 1, Figure 2). However, unlike aesthetic fel­
lowships there were no significant changes in the number
of programs, positions, or match rates (Table 1, Figure 1).
Match Rates and Unfilled Positions
Aesthetic Surgery
Due to an increase in positions without an increase in appli­
cations, the likelihood of successfully matching into an
aesthetic fellowship position increased significantly from
60.7% to 89.0% during the study period (IRR = 1.23,
James et al
Figure 1. A plot of the available positions each year from 2018
to 2022. Statistical significance was determined with
multivariate generalized linear models (P ≤ .05). * P ≤ .05.
P < .001). The number of unfilled positions also increased
from 0 in 2018 to 16 in 2022.
Other Plastic Surgery Subspecialties
Unlike aesthetic surgery, the other plastic surgery fellow­
ships analyzed saw no significant change in match or fill
rate over the study period. Match rates are shown in
Figure 3. Raw data are shown in Table 1.
Competition Between Plastic Surgery
Subspecialties
When subspecialty matches were compared with one an­
other, the relative percentage of applicants applying to
each program did not change over time (Figure 4). There
was no change in relative interest in aesthetic surgery de­
spite the increased supply of positions.
Graduating Plastic Surgery Residents
The number of graduating plastic surgery residents in­
creased from 192 in 2018 to 221 in 2022 (Figure 5).
Therefore, because the number of applicants was flat, the
percentage of graduating residents applying to fellowships
actually decreased (Figure 4). There was also a decided in­
crease in the number of residents graduating from integrat­
ed plastic surgery programs from 2018 to 2022. In 2018,
there were 81 integrated track and 111 independent track
graduates. In 2022, the balance of graduating residents
had shifted to 145 integrated and 47 independent. This rep­
resents an increase in integrated residents from 42% to
66% of the graduating class over the course of the study.
DISCUSSION
In 2017 The Aesthetic Society joined the other major plastic
surgery subspecialties and instituted a match for its
97
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Figure 2. A plot of the submitted applications each year from
2018 to 2022. Statistical significance was determined with
multivariate generalized linear models (P ≤ .05).
endorsed fellowships. Before 2017 postgraduate plastic
surgery training appeared to be increasing across all plas­
tic surgery subspecialties. The 2007 survey data collected
by Rohrich et al found that 24% of graduating residents
planned to pursue fellowships the following year.12
Herrera et al found a significantly higher percentage of res­
idents choosing to do a fellowship in the 2005 to 2010
study period (41%).13 Similarly, Silvestre et al reported that
45% of residents graduating between 2014 and 2016
sought a fellowship.14 Our data are consistent with these
more recent numbers. We found that approximately 50%
of graduating residents pursued fellowship training.
Given recent changes, including an easier application
process, an increase in aesthetic fellowship positions, ef­
forts to increase program quality, and greater competition
in the marketplace we hypothesized that there would
have been an increase in aesthetic fellowship applications
during our period of study. However, this does not appear
to have been the case. Although the reasons applications
did not increase commensurate with available positions re­
main unclear, we suspect that this discrepancy between
supply and demand is due to multiple contributing factors,
discussed below.
Small Sample Size
Although this lack of increase in applications may initially
seem surprising, a careful look at the numbers may explain
this discrepancy. In 2022, there were 221 plastic surgery
graduates. Of those, approximately 48% pursued a fellow­
ship, yielding 106 fellowship-bound residents.7 If we were
to arbitrarily distribute these residents evenly between
hand, craniofacial, microsurgery, and aesthetics, there
would be approximately 26 fellows for each specialty.
This is very close to the average of 29 aesthetic fellowship
applicants during each year studied. If aesthetic fellowship
applicants are to increase either fellowship interest must
98 Aesthetic Surgery Journal 44(1)

Table 1. Yearly Data Describing the Number of Positions, Program Applicants, and Unfilled Positions for the Major Plastic Surgery
Fellowships From 2018 to 2022

Specialty Data measured 2018 2019 2020 2021 2022 IRR (P value)

Aesthetic surgery Programs (n) 14 20 19 24 34 1.22 (.003)

Positions (n) 17 24 24 32 41 1.23 (<.001)

Applicants (n) 28 27 33 30 28 1.01 (.9)

Applicants Matched (n) 17 19 20 22 25 1.34 (.029)

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Unfilled Positions (n) 0 5 4 10 16 1.84 (<.001)

Craniofacial surgery Programs (n) 26 29 29 29 29 1.02 (.7)

Positions (n) 29 32 30 30 30 1.00 (>.9)

Applicants (n) 31 25 32 28 22 .95 (.4)

Applicants Matched (n) 24 21 26 21 16 .91 (.5)

Unfilled Positions (n) 5 11 4 9 14 1.21 (.087)

Hand surgery (orthopedic surgery and plastic surgery) Programs (n) 83 84 82 88 89 1.02 (.6)

Positions (n) 176 178 177 177 187 1.01 (.6)

Applicants (n) 188 198 188 187 195 1.00 (>.9)

Applicants Matched (n) 170 177 171 175 181 1.12 (.2)

Unfilled Positions (n) 6 1 6 6 6 1.02 (.9)

Microsurgery Programs (n) 23 23 27 30 28 1.07 (.3)

Positions (n) 40 41 45 48 46 1.04 (.4)

Applicants (n) 49 52 54 48 52 1.00 (>.9)

Applicants Matched (n) 34 35 43 39 40 1.14 (.2)

Unfilled Positions (n) 6 6 2 9 7 1.09 (.5)

P values reflect statistical significance compared with other groups utilizing generalized linear models. IRR, incidence rate ratio; n, number.

increase among residents not seeking postgraduate train­
ing, or fellowship-bound trainees would need to choose
aesthetic surgery over other competing fellowship options.
Yet our data show that the relative distribution of
fellowship-bound residents to the various plastic surgery
subspecialties remained unchanged from 2018 to 2022.
When examined in this context, the root cause of the mis­
match between supply and demand is revealed.
There is considerable variability in surgical experience
between aesthetic fellowships. Although diverse experi­
ence can be an attractive attribute, many aesthetic fellow­
ships are more heavily weighted toward breast and body
and less heavily weighted toward facial aesthetics.1
Numerous studies have demonstrated that residents feel
comparatively more comfortable with breast and body pro­
cedures, and what many seek from fellowship is nuanced
training in facial aesthetic surgery.15,16 Therefore, efforts
to increase facial aesthetics in our postgraduate fellow­
ships might increase training interest.
Other mitigating factors may also influence the choice of
one fellowship over another, including mentorship, length
of training, family responsibilities, and financial consider­
ations.17-19 Because busy aesthetic practices tend to be in
the private sector, residents may be less likely to be ex­
posed to practicing aesthetic surgeons and more likely to
be influenced by faculty with a reconstructive focus. Data
collected in 2020 by Egro et al demonstrated that 70.2%
of academic plastic surgeons are fellowship trained, with
hand (35.6%), craniofacial (32.0%), and microsurgery
(28.1%) most strongly represented.20 In contrast, aesthetic
surgeons represented only 6.9% of fellowship trained fac­
ulty. Bovill et al reported similar findings in 2022, with
74.5% of academic faculty members being fellowship
trained and aesthetic surgeons comprising only 3.3% of
James et al
Figure 3. The percentage of applicants that successfully
matched for each subspecialty in the 2018 to 2022 match
years.
that group.21 Therefore, resident experience in hand, mi­
crosurgery, and craniofacial surgery generally outpaces
aesthetic exposure. This is supported by numerous studies
suggesting that residents feel least prepared for aesthetic
surgery when compared with other plastic surgery subspe­
cialties.15,22-24
A number of factors have been documented to influence
a resident’s choice to pursue or not pursue a fellowship.
Greater time spent in training and having at least 1 child
at the time of graduation have been associated with forgo­
ing fellowship training.18,25 Numerous studies have demon­
strated that integrated residents are more likely to commit
to fellowship training when compared with independent
classmates. Independent residents are generally older,
suggesting that age and length of training may play a role
in fellowship decisions.13,14,18,19,25
Adding an additional year of training also comes with a
significant opportunity cost of both compensation and
time. Furthermore, interest on large student loans contin­
ues to accrue. Hashmi et al found that plastic surgery resi­
dents with more than $200,000 of debt were less likely to
pursue a fellowship when compared with residents who
owed less than $100,000.19 This might represent short-term
thinking if the opportunity cost of an extra year of training is
offset by greater long-term earnings. However, long-term fi­
nancial benefits of fellowship have not been well studied.
A number of other factors may well have affected fellow­
ship numbers and specific fellowship choices. This includ­
ed but was not limited to the COVID-19 pandemic and
economic changes during the time period studied. These
factors may have encouraged residents to choose careers
with a reconstructive rather than cosmetic focus. Previous
studies have demonstrated a relationship between eco­
nomic prosperity measured through stock market indices
for both hand and aesthetic surgery. In good times aesthet­
ic procedures increase, whereas in difficult economic times
hand surgery cases increase.26,27 Residents may well have
99
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Figure 4. The percentage of graduating residents who
matched into to each fellowship type. Of note, orthopedic
hand fellowships are not included in this figure.
taken this into consideration when making fellowship deci­
sions. Time will be required to better understand the specif­
ic impact the COVID-19 pandemic had on fellowship
choices.
Given the finite pool of fellowship applicants and the
number of graduate subspecialty opportunities, it is un­
likely that aesthetic fellowship applications will increase
substantially in the near future. Therefore, efforts might
best be focused on enhancing and standardizing the qual­
ity of existing programs rather than the creation of new
ones.
The Aesthetic Society Endorsed Fellowship Committee
is in the process of a wide range of quality initiatives. In
the past year, the committee has made a significant effort
to enhance program quality. The committee has estab­
lished operative minimums, initiated a formal webinar se­
ries, and initiated a fellowship survey through which
aesthetic fellows may anonymously voice their concerns
and provide constructive feedback. Most recently, the fel­
lowship steering committee has focused on furthering pro­
gram quality. Such initiatives under consideration include
the guarantee of uniform salary, the assurance of standard
vacation time, and a requirement that programs cover fel­
low attendance at The Aesthetic Society Annual Meeting.
Finally, efforts are underway to assure transparency of indi­
vidual fellowship experience by posting graduating aes­
thetic fellows’ operative logs on The Aesthetic Society
website. It is suggested that perhaps The Aesthetic
Society Endorsed Fellowship Steering Committee should
mirror the constructive oversight exemplified by the
Plastic Surgery Residency Review Committee (RRC) of
the ACGME. Although the Plastic Surgery RRC has a signifi­
cantly larger staff, perhaps some of the RRC high- and low-
quality indicators could be adapted by the endorsed fellow­
ship committee, enhancing fellowship quality. By requiring
stricter quality control, the discrepancy between applicant
and program numbers may self-correct.
100
Figure 5. The number of graduating plastic surgery residents
each year as well as which portion of each comes from
integrated vs independent tracks.
An important avenue for future study would be to evalu­
ate data specific to newly added programs. A comparison
between new and preexisting programs may help to better
understand the growing discrepancy between applications
and positions. It should be noted that the data available
through the SF Match and NRMP reports are limited, and
therefore the above data were not available for our review.
Further, although our paper addressed supply and de­
mand, it did not address program quality, postfellowship
performance, or practice success. Evaluation of these fac­
tors also calls for future study.
This study had several limitations. Due to the nature of
the study, we were unable to capture data from outside
the SF Match system. Aesthetic fellowship positions filled
outside the match were not included. Similarly, data were
not available regarding programs, applicants, and match
rates before the initiation of the centralized aesthetic match
in the 2017-2018 cycle. We were therefore unable to distin­
guish between truly new programs created after 2018 and
previously existing nonendorsed aesthetic fellowships that
became endorsed by The Aesthetic Society during the
course of the study. Because accurate aesthetic fellowship
data were only available with the initiation of the aesthetic
match, our sample size was limited to this 5-match cycle.
However, the data presented remain valuable because
they underscore the importance of efforts to close the
gap between applications and positions.
CONCLUSIONS
This study demonstrates that aesthetic fellowship applica­
tions have not increased despite the initiation of the match
process, improvement in fellowship quality, and a dramatic
increase in fellowship programs. Furthermore, this article
suggests that aesthetic fellowship applications are unlikely
to increase in the near future, and program numbers have
Aesthetic Surgery Journal 44(1)
not increased in other plastic surgery subspecialties. It is
suggested that further attempts to improve aesthetic fel­
lowship quality and value may be the best path forward.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
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Funding
Funding for this study was provided by the Aesthetic Surgery
Education and Research Foundation (ASERF; Garden Grove,
CA) under grant 2021-Q2C.
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