EP 7: How Facial Plastic Surgery Training Actually Works | DEEP FOCUS

Facial plastic surgery training is often misunderstood and board certification can add even more confusion. In this episode, Dr. Chesnut walks through his exact training pathway, explaining how he became a facial plastic surgeon and why he is not board certified in plastic surgery. Learn the key differences in training routes, what credentials actually mean, and how to evaluate a provider based on true expertise, not just titles.
 
CONNECT WITH HOST 
Website: https://clinic5c.com/ 
Instagram: https://www.instagram.com/chesnut.md/ 
YouTube: https://www.youtube.com/@chesnutMD 
LinkedIn: https://www.linkedin.com/in/cameron-chesnut-a6910baa/ 
 
WAYS TO WATCH/LISTEN 
YouTube: https://www.youtube.com/@5CodesPodcast 
Spotify: https://open.spotify.com/show/1FZ7vpmq21iA1noPcFhixb?si=992ef6c8d859463f 
Apple: https://podcasts.apple.com/us/podcast/5-codes-podcast/id1866214238 
Instagram: https://www.instagram.com/5codespodcast/ 
 
TIMESTAMPS 
00:00 - Intro
00:25 - History of Plastic Surgery
01:32 - Core 4 Cosmetic Specialties
02:19 - Results vs Titles
03:01 - My Training Pathway
05:47 - My Practice Over 12 Years
06:55 - Collaboration Is Key
07:23 - T-Shaped Thinking
10:34 - Iteration and Innovation
11:40 - Patient Perspectives
12:45 - Turf Wars
15:25 - History of Procedures
17:00 - Cross Pollination
18:14 - Outro

ABOUT HOST 
Dr. Cameron Chesnut is the host of the 5 Codes podcast and the founder of Clinic 5C, where he leads a team dedicated to integrative cosmetic surgery, regenerative medicine, and functional health. An internationally recognized facial plastic surgeon, Dr. Chesnut is known for producing natural, refined results that enhance rather than alter one’s appearance. His approach blends surgical precision with biological optimization and disciplined restraint, drawing patients from around the world who value excellence, longevity, and holistic care. On 5 Codes, Dr. Chesnut uncovers the mindsets and evidence-backed strategies he lives by, helping high performers perform better, recover smarter, and feel their best in every area of life. 
 
DISCLAIMER 
The views shared on this podcast are my own and are not associated with, affiliated with, or representative of my clinical teaching role at the University of Washington School of Medicine. This content is for general educational purposes only and should not be considered individualized medical advice.

Transcript

0:00

Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level, through optimizing the way you look, move, perform, feel, and connect. Today on the Five Codes Podcast, we are going to dive deep into plastic surgery, the history of plastic surgery, training around plastic surgery, and what the current landscape looks like, especially when it comes to plastic surgery on the face. Plastic surgery comes from a root word in Greek, plasticos, which means to shape or mold, which makes sense when you think about other types of plastics. So at its root, plastic surgery is really a philosophy applied to human anatomy, changing, reshaping, and that comes from reconstructive surgery primarily, and has evolved now into cosmetics. If we look at the true history of plastic surgery going back, it branched out a general surgery around the time of World War I, really focused on reconstructing soldiers who were being gruesomely injured in war, really. And for about three or four decades, plastic surgery continued with no formal recognition as to what it was, and around World War II, it really started taking shape. The first board in plastic surgery came around then 30 years later, and it was recognized by the American Board of Medical Specialties about 10 years after that. So now, you know, 30, 40 years after the initiation of plastic surgery, a lot of time on grade, a lot of procedures before it officially became recognized as a plastic surgery specialty, as a sub-specialty. When we look at the current plastic surgery landscape, specifically plastic surgery on the face, we talk about the core four cosmetic specialties, and there's been a lot of turf war in here. One of those core four cosmetic specialties, general plastic surgery, does not require a fellowship training. It comes out of a residency training. The other three all require a very specific fellowship training in facial plastic surgery, ocular plastic surgery, ocular facial plastic surgery, whatever you want to call it, that comes from another base sub-specialty. One of those is ear, nose, and throat into fellowship. Second one is ophthalmology, and the third one is dermatology. All three of those require a specific sub-specialty training to be in the landscape of facial plastic surgery. One thing I found is that surgeons approach this core four conversation very differently, depending on how they built their practice. At the top, the best results, the surgeons that are leading the field, they are very focused on their results and their outcomes and innovating. Others are heavily focused on training pathways and titles. And the surgeons that I respect, and the surgeons who tend to respect each other in this field, are very focused on their results, and their long-term outcomes, and they spend very little time talking about training backgrounds and titles. There's a spirit of collaboration at this highest level. We could describe this as game-recognized game, as they say in the NBA. My training fits into the most recent end of this core four landscape, with my core four board certification being in dermatology, and my following fellowship being very focused on the face, with the full integration of general plastic surgery, facial plastic surgery, and ocular plastic surgery. That training pathway is structurally very similar to facial plastic surgery and ocular plastic surgery with the base training followed by the very in-depth fellowship. And I am very grateful for the structure of that fellowship training for me, because it turned me into an alloy. An alloy is a combination of different elements, where the final product is stronger, performs better, and is more resilient than any of the base products. And that's always how I've wanted to view my end product of my training. I wanted to take a very wide breath from all of those other core four specialties and create my very unique perspective and depth. So I'm very fortunate that I was able to do that. My fellowship was very focused, very in-depth, very high quality, and also very high volume at the same time. Newmarically, if we wanted to get quantitative with that, looking at my ACGME case log from that year, my fellowship training included 190 cosmetic facial procedures, that is eyelid surgeries and facelifts. That's in addition to all the reconstructive work. That is a very, very high volume of training. As a reference point, general plastic surgery at the time that I was training needed 50 cosmetic procedures over a five-year period. And they could be in any part of the body didn't necessarily have to be specifically the face to achieve the ACGME requirements to move past residency. So that's 10 procedures a year over five years in any area versus something like 190 procedures in one year. So there's no question that fellowship training, whether you're coming from ear nose and throat, ophthalmology, dermatology, or some general plastic surgeons who also go on to do fellowship, is a highly concentrated and highly important year for the depth of your subspecialty training leading into your future career. That fellowship training for me allowed me to have my second board certification and to become a member of the American Academy of Facial Plastic and Reconstructive Surgery. This is the only biggest, most respected professional society for facial plastic surgery. And I'm very grateful to be heavily involved, teaching and learning in that facial plastic surgery society. Speaking from my experience coming from dermatology and watching my co-fellows in ear nose and throat, ophthalmology and general plastic surgery go through their fellowship training. There is a very high volume and very deep depth that comes with those fellowship cases, what you get to do. And that ultimately determines the entire path of your career afterwards, leading to those high level results and outcomes that we all know and appreciate, coming when somebody is highly, highly sub-specialized and obsessed with that process that they're doing. And that word obsession defines my practice very well. Over the past 12 years, I focused exclusively on the face and I have built my practice solely on results. The quality and the durability of the outcomes that my patients are getting. Almost every day I receive requests from my colleagues in the core four cosmetic specialties, ocular plastics, facial plastics and general plastics to come into my OR and learn from me. And this is how we cross pollinate. And this is how we build and this is how we support each other. I'm also very fortunate to have created great relationships and taught alongside some of the best in ocular plastic surgery. I'm looking at you, Guy Mastery and Flora and Rob. Oculoplastics is a specialty that we are so lucky to have in the facial plastic surgery atmosphere and I'll get to learn from. Sometimes it's teaching at the highest level, getting to lead the eyelid surgery section at the AAFPRS National Meeting, something that Mike Niac invited me to do and told me. He knew he'd catch some heat for it, but he also knew that my different perspective and my results would help create a meaningful conversation around it and he was right about both of those things. And what Mike demonstrated there was an example of that growth mindset of collaborating and making things better for all of our patients. My good friend Ben Talley has talked about that exact idea when it comes to results, highlighting specifically that surgeons from different training backgrounds, including dermatology, can become very fast-ciled at these procedures with the right training and the right experience and ultimately everything boiling down to the results that we are achieving. This environment of collaboration is how we get better. It is beautiful and it reminds me this idea of T-shape thinking from James Clear, who's the author of Atomic Habits a book worth checking out. In T-shape thinking, the vertical part of the T, this is our craft, our sub-specialty, how we affect the world, what drills down. This is how we make an effect. This is our plastic surgical specialty, if you will. The top part of the T, the horizontal part, is the breadth of your experience, what's your pulling in? Early on in my surgical training, I called this cross-pollinating, that horizontal part of my T was my integration with facial plastic surgery, ocular plastic surgery, and general plastic surgery. I borrowed that term cross-pollinating from our chief of plastic surgery at UCLA, somebody that I was very fortunate to get to work with and know over my four years there, and he was referring to me specifically. We were in the operating room and he was giving me a compliment saying, you are really cross-pollinating, you're training by doing this. As I matured in my practice, that part of the T got wider. It got wider into areas like functional and regenerative medicine focused on preparing for and recovering from surgery. It branched into areas like neurobiology, understanding how we interpret faces, and even into anesthesia, having strong anesthesia preferences for this very narrow niche of the vertical part of my T, how I liked it to go. So I developed opinions around all those things pulling in from other specialties. And as you reach levels of mastery, start to look at virtuosos in other fields altogether. For me, that was something like surfing, looking at layered Hamilton. Somebody that I'm very fortunate to call a friend and that I consider a mentor who took a landscape like surfing that was very broad, worldwide, and he pulled in ideas from completely different areas that others didn't have. And in that process, did things that others did not think were possible. That includes writing massive unbelievably large waves, using strategies and tools that he built that did not exist prior. So he really took a broad T and drove a vertical part into changing the world of surfing altogether. That's something I draw a lot of inspiration from. And as my T gets more vertical, as I'm affecting the world more, I'm also realizing how important the base of that T is. For me, this is what I'll call the roots. This is taking, I guess, a level beyond what James Claire was even talking about, the roots of a lot of this for me, it took maturity in my practice to understand what those are. I've had a standard of excellence for myself in that vertical part forever. But at the root of it really sits the relationships that I'm creating with my patients. That's what's holding everything up. And that really drove me towards this idea of quality relationships, quality procedures, more than quantity. I'm not doing multiple surgeries a day. I'm really focused on the ones that I'm doing the relationships that I'm creating. And how powerful that vertical part of my T is, well, really enjoying the horizontal part of my T, pulling things in from the outside world and drawing inspiration from completely other fields altogether at this point. And for me, this speaks to my 12 years of deep focus on the face being very different. It has not been the same thing over and over again for 12 years. There's been constant iteration, constant innovation focusing on my results. It's been a very deliberate process to get better. This is my obsession. This is my standard for excellence for myself. And that looks like a very detailed journaling process that I do after every single procedure, making notes to myself. Because I know that months down the road, I'll get to see the results and go cross reference with the journal that I took for myself and learn and iterate and get better. So it's a very deliberate, in-depth process that has been going on constantly over 12 years, whether it's focusing on my results, focusing on my personal state of peak performance and flow state, being ready for every single surgery. My life at this point essentially revolves around being ready for surgery in this way. And that is unique to my entire training process. And that probably pulls from that horizontal part of my T from my athletic background quite a bit, being peaked and being primed and being ready to perform on my best every time I step in the operating room. And this is what I think patients see too. Just like it is with other providers and other surgeons, some get their identities very tied into their titles, and less so into their results. But patients fall into those categories too. Some can get very anchored to what the training background and title is of their surgeon and others tend to focus more on a broad landscape that includes primarily the results and the experience of that process altogether. And so I'm very fortunate at this point in my practice that I get to choose very carefully who I work with, which is a lot of very high performing people. And they tend to see that broad landscape very well. What the surgeons doing, what their results look like, how long they last afterwards, what the entire process, landscape, what the innovation, what the iteration look like. So I'm very fortunate to work with people who appreciate the alloy that I am and what I get to bring to the table, which ultimately boils down to our long term results together. And within those turf wars of facial plastic surgery that are ongoing, it can be very difficult as a patient to sort things out as to what's happening. When I mentioned these turf wars, these are relatively recent, over the recent decades, as to what's happened. The first of these, the strongest one of these, came from ear nose and throat surgery as they were starting to really focus on applying a plastic surgery principle to an area of anatomic expertise of theirs, the nose. So what that looked like is the ear nose and throat surgeons were really focusing on high level rhinoplasty techniques. Plastic surgery principles applied to their nose, the area that they were working on. And they started branching into other high level facial procedures, including facelifting. This was not well received by the plastic surgery world, the board certified plastic surgery world, who was constantly focusing on ENT to sort of crush that effort to grow, so not board certified. And what they're doing, they're not plastic surgeons. And that led to a very tooth and nail battle. I got to hear Galen McCulloch, one of the fathers of this process that was happening. I got to hear him speak about this process live. It's an interesting story. And he told it at the AAPRS annual meeting, and he told of how challenging it was for facial plastic surgery to establish itself from general plastic surgery under a lot of fire, even though they were doing really great procedures, they were innovating those things. And ultimately, it's those long term results that panned out to allow facial plastic surgery to become its own entity, to eventually achieve its own board certification, which is sort of a very similar part of history of how long it took plastic surgery from its inception to become recognized as a subspecialty. Aucuoplastic surgery went through a very similar path with their area of expertise being on the eye and the orbit. And even with that deep knowledge and subspecialization, all the training they're doing regarding the orbit and the eyelids, there is not a plastic surgery board certification for aucuoplastic surgery. It does not exist. The newest player in that world is certainly dermatology, which falls a very similar training path to ophthalmology and aucuoplastics and facial plastics coming from E&T. And it's the same story. And with really high in-depth training, really high quality, lots of subspecialization afterwards, that board certification does not exist in that space. Maybe I say yet, maybe I say ever, I'm not sure what's going to happen with oculoplastic surgery or dermatology into those spaces. But there are tens again. At the very high level, there tends to be a lot of collaboration across those specialties. And at other levels, there tends to be a lot of focus on who and what their training background is and what those titles are that go with it. If you scale that back to a procedure level and look at the different procedures that have benefited from this cross-pollination, things become really interesting. Something like blepharoplasty was the realm of general plastic surgery only until the oculoplastic surgeons really started owning and innovating in that space. The most prime example of this is something called a scarless or trans-conjunctival lower eyelid surgery. Lower eyelid blepharoplasty had been largely stagnant with not a lot of change happening in that space. An oculoplastic surgery came in and they owned this procedure and created an entirely different approach to it that is widely used and adopted today and is arguably, maybe not arguably, superior approach to go to the lower eyelid. I think it's also really cool that that procedure was innovated at UCLA. This is my chief of oculoplastic surgery who I got to work with so much and others in that UCLA space, so back at my home. That same idea of blepharoplasty being innovated by oculoplastic surgery carries into face lifting and maybe specifically deep plane face lifting between general plastic surgery and facial plastic surgery. For years, well, there was sort of some animosity between those spaces. These were progressing in parallel to diverging paths even with a lot of stones being thrown about the superiority of one technique to another as these sort of co-evolved in different directions a bit. That had gone on for decades in very recent history. Even over the last five to seven plus years, a lot of those walls have been broken down and those barriers have been jumped over and I have to give a shout out here to Ben Tallah and Ritu Chopra coming from facial plastic surgery and general plastic surgery who quite literally have broken down walls between themselves to cross pollinate and bring the best of these worlds together and essentially create a platform now where there's a lot more collaboration amongst these specialties that had been relatively bitter towards one another for many, many years. This changed the landscape of face lifting, no question. Face lifting in the last few years has progressed far beyond what it was doing for the decades prior and a lot of it has to do with that type of collaboration that's happening. That's like such a blatant illustration of how good it is to have high level people, those the best of them, ignoring training boundaries and collaborating on techniques and outcomes and being very patient centered and innovative, it highlights that so so well and I have to give those guys a big credit for that. I am so grateful to those surgeons, friends of mine, the surgeons that have supported me, those that have come to learn from me and grateful for my fellowship training. I am grateful for the facial plastic surgery world as a whole, whether that's coming from general plastics, facial plastics, ocular plastics. That level of cross pollination and where the field has gone as a whole has been incredible, those at the top of the field are going to continue to drive that and I cannot wait to see where the field goes as a whole. This is all good news for our patients and procedures getting better and better and outcomes getting better and better and ultimately that's what it all boils down to for me. If you have any questions or topics you would like me to explore further, please leave them in the comments. I read them all and they often help shape the future conversations here. If you would like to learn more about my surgical practice, you can visit clinic5c.com where you will find additional information on my approach to surgery, recovery and performance focus care. I also want to be clear that the views shared on this podcast are my own and are not associated with or representative of my clinical teaching affiliation with the University of Washington School of Medicine, nor should this be taken as individual medical advice. Thank you for spending your time with me. I appreciate you being here and I will see you on the next episode.