Many people ask why Plastic surgeons tend to gravitate to aesthetic surgery, when a large body of their training and knowledge was focused on reconstruction. There are a number of reasons, some personal, others financial. Both reconstruction and cosmetic surgery are extremely rewarding on a professional level. There is nothing quite like returning someone to a normal appearance after trauma, or cancer removal. On the other hand, cosmetic surgery has the benefit of allowing patient selection, and you are able to achieve stellar results that make you and your patient happy.
So why are so many surgeons moving from reconstruction to elective cosmetic procedures?
A large part of the equation is financial. Reconstruction is largely paid for by insurance. A study published in The Journal of Plastic Surgery in 2007 found that the average payment to the surgeon for a free flap reconstruction of the face was $2,300. These cases often take more than 5 hours, and require intensive inpatient follow-up. The surgeon is paid for the surgical service, and no more money can be billed for 90 days after the procedure. (The payment is capped.) The service is very profitable for the hospital, with an average profit of $18,000 per case. This creates a situation where surgeons are encouraged to do more flap surgeries, but this is at the expense of their ability to perform services that yield a higher wage. As an example, the revenue for a breast augmentation renders much more revenue than a flap, and takes less than an hour to complete. These patients are healthy, and go home the same day. As the hospital and surgeons are paid separately by the insurers, for most surgeons it is not financially viable to perform only reconstruction as a sole revenue source. Another paper published in 2016 confirmed the reimbursement discrepancy, with reconstructive cases resulting in a surgeon fee of approximately $254 +/- $199, whereas a straightforward, brief (23 minute) carpal tunnel release resulted in revenue of $785.27.
The result is most major reconstructions are limited to large tertiary care facilities, and a limited tenure among surgeons performing these long, demanding cases. I have personally witnessed this process, young surgeons spending long hours in the hospital, then transitioning to private practice. The lifestyle is more family friendly, and cosmetic surgery is very satisfying as you strive for perfection. I still perform reconstruction, but these activities are in part made possible by my cosmetic work, which pays the bills. It is tremendously rewarding to exercise skills perfected by the masters extending back generations, and not being limited to just a few treatments for the privileged ones among our society.
Plastic and Reconstructive Surgery 2016; Vol 137. Number 3: 980-984
Plastic and Reconstructive Surgery 2007; Vol 120:157-165