ortho to plastics

[tcar18]

Anyone know people who did ortho residency then plastics?

Do you have to complete the full 5yrs ortho?

Would the scope of your practice be limited to hand?

checked a few other posts most along the lines of plastics hand fellowship after ortho residency.

thanks.

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[2nd year]

You can complete a 5 year Ortho residency and then go on to a 2 year Plastics fellowship. You will then be board certified in both. Hand is a logical fit, but you certainly are not limited to hand. You will be trained to practice in any area of Ortho or Plastics when you're done. I believe the University of Rochester has a couple of physicians on staff you are dual-boarded in Ortho and Plastics and their residents rotate with then for a couple of months on what is considered an "ortho-plastics" rotation.

 

[pagemmapants]

Dr. L. Scott Levin - 2 years general surgery residency, 4 years orthopedics residency, 3 years plastic surgery fellowship.

Now the Chief of Plastic & Recon and Residency Director here & Duke. Runs 3 ORs on his operating days, is the director of the Human Cadaver Research Lab, is an attending at 3 different hospitals, co-director of the wound care center, and is still active in research. . .

Is nuts.

 

[maxheadroom]

I agree. Levin is nuts.

 

[Tired]

You can complete a 5 year Ortho residency and then go on to a 2 year Plastics fellowship. You will then be board certified in both. Hand is a logical fit, but you certainly are not limited to hand. You will be trained to practice in any area of Ortho or Plastics when you're done. I believe the University of Rochester has a couple of physicians on staff you are dual-boarded in Ortho and Plastics and their residents rotate with then for a couple of months on what is considered an "ortho-plastics" rotation.

I love this pathway, and I'm giving serious thought to it (though I have quite a ways to go).

My understanding is that the fellowship was 3 years?

 

[maxheadroom]

All Independent pathway Plastics Residencies (occasionally incorrectly called fellowships) will have to be three years in length effective either in 2009 or 2010.

While I would have done five years of Ortho over five years of GenSurg (personal preference), the match statistics suggest that the best pathway outside of the Integrated/Combined model is complete GenSurg.

As always, I'll add my caveat: if you want to do plastics and you're a med student, apply to the Integrated programs. You never know how things will change in the five to seven years that it takes to complete GenSurg. And you'll never take out a colon as a Plastic Surgeon.

 

[Tired]

While I would have done five years of Ortho over five years of GenSurg (personal preference), the match statistics suggest that the best pathway outside of the Integrated/Combined model is complete GenSurg.

If I do it, I'll be independently funded (military). I understand that makes matching quite a bit easier . . .

 

[Pir8DeacDoc]

do you think funding is really that big of an issue?

I wouldn't have thought it would matter as the money comes out of the hospital "pool" and not actually out of the department funding. Curious to haer thoughts on this....

 

[maxheadroom]

I've never heard the faculty talk about funding for residents as an issue. If they're approved for X residents, the hospital usually is able to secure funding for X residents. I wouldn't look to the military as being a bonus for you. I had a classmate who was military who felt that she was at a significant disadvantage because the Air Force didn't really want her to do Plastics. Be careful of the military -- they'll lure you in with promises that you can do whatever you want, but the caveat is that you might not get your first choice of training options. They made her go GenSurg first (said "no" to Integrated altogether).

 

[beastmaster]

All Independent pathway Plastics Residencies (occasionally incorrectly called fellowships) will have to be three years in length effective either in 2009 or 2010.

What's your opinion on why this change has been suggested?

 

[maxheadroom]

I talked to a few people at the ASPS meeting in Baltimore. The overwhelming concern is that there is simply too much to learn in two years. I know that lots of very smart, capable, and successful people have done it in two years, but the Board thinks that more training is probably necessary.

 

[VoiceofReason]

Will a person boarded in ortho and plastics have a realistic opportunity to create some kind of ortho-plastic hybrid practice? Or asked another way: are there unique positions available for people who are boarded in both plastics and ortho, or will such people generally have to focus on either plastics or ortho?

This is interesting, I had heard of getting into independent plastics programs after completing ortho and neuro but I always thought that meant the people in ortho or neuro just decided they would rather do plastics, not both. What's the deal with these?

 

[maxheadroom]

While it is possible to do plastics after NSG, I do not know of any people who have done that. All of the people that I know of who have gone from Ortho to Plastics primarily practice Plastic Surgery. I don't think that there is a special hybrid practice. Similarly, all of the ENTs that I know who have gone through Plastic Surgery training primarily practice Plastic Surgery and do not do things like BMETs, tonsils, and the like.

 

[droliver]

I've never heard the faculty talk about funding for residents as an issue. If they're approved for X residents, the hospital usually is able to secure funding for X residents.

Actually, there is something to this. I remember having this discussion during ranking meetings during residency. A military funded resident somehow gets the program some extra cash apparently was the way I heard it.

 

[PediBoneDoc]

Actually, there is something to this. I remember having this discussion during ranking meetings during residency. A military funded resident somehow gets the program some extra cash apparently was the way I heard it.

funding usually is an issue. each resident only has a certain number of years of GME (CMS) funding. once the resident has exceeded that time period, the program has to cover the resident's cost. that being said, it is usually not a problem for most orthopaedic or plastics programs.

I am not sure why you would go through both residencies. i guess it depends on you plans. there are hand surgery fellowships (ortho) that get training in flaps (both rotational and free). i guess it depends on what your future plans are.

 

[MattD]

I've been somewhat interested in this path myself, and would appreciate some input on the practice scope possibilities.

My real interest lies in things like reconstruction, trauma and deformity repair, that sort of thing. Ortho+plastics seems like a natural route as you would get training in ortho trauma, MSK deformity correction, replants, as well as the types of issues plastics folks deal with like cleft repairs and soft tissue reconstruction. I guess my question is, is there really an avenue for practice that would allow you to be involved in this wide a variety of conditions? Or would doing the plastics fellowship after ortho tend to push you into having a more purely 'traditional' plastics practice?

 

[Pir8DeacDoc]

In my somewhat limited experience, you won't be doing clefts and hand replants as part of the same practice. Someone who does clefts will be part of a multipseciality group of providers who will have fellowship training in craniofacial surgery. Their scope of practice would be a lot of congential stuff like Treacher-Collins/Pierre Robin and cleft lips/palates. Replants will be handled by someone with at least a hand fellowship and probably a microvascular one as well.

 

[maxheadroom]

I actually know a guy who is the "cleft guy" who also takes hand call and does replants and all that stuff. He did both a peds plastics fellowship and a hand fellowship. BTW, a hand fellowship is all that you need to do a replant -- you should get plenty of micro experience with a combination of plastics residency and hand fellowship.

 

[Moravian]

I actually know a guy who is the "cleft guy" who also takes hand call and does replants and all that stuff. He did both a peds plastics fellowship and a hand fellowship. BTW, a hand fellowship is all that you need to do a replant -- you should get plenty of micro experience with a combination of plastics residency and hand fellowship.

From another cleft guy....

You can do replants without a hand fellowship. Both of the job offers I'm considering (peds plastics/craniofacial) both have hand/micro call as part of the deal. In deference to all you hand guys out there, it's painful, it's usually at night, but putting fingers back on is a doable procedure for a non-hand fellowship plastic surgeon, especially if these were done in residency. I don't however, go past the metacarpals or do distal radius. Even with all the hand trauma I got during my fellowship, I never got any wrist experience. Thankfully the indications for replants (except in kids) are fairly stringent and unless you're at a major center, not that common.

--M

 

[-Goose-]

From another cleft guy....

You can do replants without a hand fellowship. Both of the job offers I'm considering (peds plastics/craniofacial) both have hand/micro call as part of the deal. In deference to all you hand guys out there, it's painful, it's usually at night, but putting fingers back on is a doable procedure for a non-hand fellowship plastic surgeon, especially if these were done in residency. I don't however, go past the metacarpals or do distal radius. Even with all the hand trauma I got during my fellowship, I never got any wrist experience. Thankfully the indications for replants (except in kids) are fairly stringent and unless you're at a major center, not that common.

--M

But it would be reasonable to expect a hand-fellowship trained plastic surgeon to be able to do distal radius fractures, right?

 

[Moravian]

But it would be reasonable to expect a hand-fellowship trained plastic surgeon to be able to do distal radius fractures, right?

I can't tell if that was sarcasm, but yes, it would be reasonable to expect a hand fellow/fellowship trained surgeon to take care of distal radius and wrist. That being said, the place I'm doing my craniofacial fellowship is so hand heavy that the plastic residents are doing some wrist and distal radius. As I mentioned, where I did my plastics, even though about 35% of what I did was hand, I maybe saw one wrist scope and never fixed a distal radius. I think my experience is probably more common.

In plastic surgery training, you get a lot of experience sewing nerves and vessels so finger replants are more or less (probably more on the "more" side) an extension of that. For upper arm/wrist, I would get the hand/orthopods involved.

--M

 

[-Goose-]

I can't tell if that was sarcasm, but yes, it would be reasonable to expect a hand fellow/fellowship trained surgeon to take care of distal radius and wrist. That being said, the place I'm doing my craniofacial fellowship is so hand heavy that the plastic residents are doing some wrist and distal radius. As I mentioned, where I did my plastics, even though about 35% of what I did was hand, I maybe saw one wrist scope and never fixed a distal radius. I think my experience is probably more common.

In plastic surgery training, you get a lot of experience sewing nerves and vessels so finger replants are more or less (probably more on the "more" side) an extension of that. For upper arm/wrist, I would get the hand/orthopods involved.

--M

No sarcasm intended. Thanks for the reply.

I want to do hand (including radial fractures) and I am going back and forth between Plastics & Ortho. If your end goal is to be a hand surgeon (one surgeon told said to me, "you must not like sleep, son"), which route would you suggest?

 

[Moravian]

If your end goal is to be a hand surgeon (one surgeon told said to me, "you must not like sleep, son"), which route would you suggest?

I would suggest that you pick the route that you enjoy the most. I personally only know one hand surgeon who does nothing but hand. He's an ortho guy who has been doing it a long time and has a pretty sweet practice. You need insurance, workmans comp, or $500 just to get in his door. He has a fellow that takes care of all the ER stuff. I don't know how common this type of practice is because he the only one I know.

The rest of the mortals however, tend to do other things along with hand. For instance, where I am now, there are 5 hand fellowship trained plastic surgeons that all have both cosmetic and reconstructive patients. At my plastics fellowship, the plastic surgery hand guy had a big cosmetic practice and the ortho hand guys all did general ortho stuff and trauma. That's what I mean by picking what you'd think you'd enjoy doing along with having a hand practice.

The other thing to consider is that ortho is a little easier to get into than plastics. There is also the option of doing general surgery. I know a few general surgeons who are hand trained along with one CT surgeon that burned out and did a hand fellowship. I'm not sure what he's doing now, but I'm assuming he's not doing a mix of hearts and hand. Or maybe he has the market cornered on patients that have an MI after they hurt their hand.

Anyway, as you can see there is more than one way to get to where you want to be. But I would ask yourself what you would like to do on any particular day if you weren't doing hand. Not to mention that it's going to take you five years of residency to get to a hand fellowship, so you might as well pick something you like (I don't recommend cardiothoracic, though).

--M

 

[maxheadroom]

I debated Ortho vs Plastics, also. I made the decision based on two things. First, I much prefer plastics cases to total joints. Second, I just seemed to "fit" more with the plasticians than the orthopods. It seems as though most of the people from my medschool class who were torn between two specialties often found "their people" on one side or the other.

 

[-Goose-]

I debated Ortho vs Plastics, also. I made the decision based on two things. First, I much prefer plastics cases to total joints. Second, I just seemed to "fit" more with the plasticians than the orthopods. It seems as though most of the people from my medschool class who were torn between two specialties often found "their people" on one side or the other.

I also feel like I fit less with the orthopods, which is one of the biggest reasons why I am considering plastics (although, 'on paper' I should: athlete, tall, etc etc). I do enjoy some aspects of orthopedic trauma. Joints don't bother me either. For some reason though, I really don't enjoy sports / scopes. Admittedly, I need more exposure to plastics.

Thank you both for your responses.

 

[VoiceofReason]

I also feel like I fit less with the orthopods, which is one of the biggest reasons why I am considering plastics (although, 'on paper' I should: athlete, tall, etc etc). I do enjoy some aspects of orthopedic trauma. Joints don't bother me either. For some reason though, I really don't enjoy sports / scopes. Admittedly, I need more exposure to plastics.

Thank you both for your responses.

This is one of the things i need to see as well. I'm also a relatively tall football and lacrosse player and I have a "dude-bro" sense of humor, too, so I figure that I'll probably fit in best with the orthos even though I'm really more interested in plastic procedures. Time will tell I guess.

 

[Moravian]

Hey, you are making it sound like we have no sense of humor. What do think we are? Neurosurgeons?

--M

 

[VoiceofReason]

Hey, you are making it sound like we have no sense of humor. What do think we are? Neurosurgeons?

--M

Haha the craziest dude I know is a neurosurgeon. He used to scream at us and his son at our high school lacrosse games back in the day ... "You *******! my daughter hits harder than you! Hit him! Put that ******* in the hospital!!" I'm dead serious he was hilarious at those games. He's still crazy.

 

[Pir8DeacDoc]

He's still crazy.

Of course he is, he's a neurosurgeon.

 

[NNavy21]

I looked into the ortho--> plastics route a few years back. I was told that the reason so few people go this route is the relatively small discrepancy in salary between a general orthopod and new plastics staff....why complete 2 or 3 additional years when you can start building a practice sooner and make almost the same amount? (I realize the ceiling for plastics is much higher given the cosmetic stuff)

He also said that he thought most programs looked just as favorably at the ortho/ENT trained guys as the general surgery people. When it comes down to it...how much of a general surgery residency even carries over to plastics training now a days? I've seen few GS programs that offer much plastics/reconstructive training beyond the early junior years.

 

[pagemmapants]

So for those of you who were choosing between ortho and plastics - I seem to be having the same dilemma myself - what were the deciding factors for you in particular?

I've done 2 weeks on Ortho, 2 weeks on Plastics and I'm currently doing a 2 week stint on our ENT service and I really don't know what else to do to help me decide. I like craniofacial recon, I love hand, I like joint replacements, I like flaps (free or otherwise) and Mohs recons, I love spine, I like ORIFs. . . but I hate scopes and breast and belly. I haven't had much exposure to aesthetics at all (since our institution doesn't DO much of it) but I get the feeling I'd like blephs/rhinos but hate abdominoplasties. The one panniculectomy I was in was plenty, thanks.

As far as finding "my people" I guess I feel like I get along better with the plastics guys than the ortho guys so far, but that may have something to do with the more pervasive frat mentality of bones or the fact that I'm 5'2". . . but I got along really well with the "hand weenies" as they say.

Next year I'm doing a year of research in our plastic surgery lab here, but the project involves compression plates and implant-associated infection so I'm keeping both doors open. I don't think I would do PRS if I *had to* do general surgery first, but the 6-year integrated programs keep this option wide open.

Any other suggestions as to what I should think about while making this decision? Is there some big factor I'm missing on either side? Or will I just have to spend next year seeing everything I can of both and hope that the gods of the OR bestow some wisdom upon me?

 

[Moravian]

I don't think I would do PRS if I *had to* do general surgery first, but the 6-year integrated programs keep this option wide open.

I think you've answered your own question. Based on what you've posted, I would suggest that you apply for the integrated/combined plastic surgery residency and use ortho as a back up plan. If you end up having to do five years of something before you can get into plastics, it sounds like you would like ortho better. You would certainly get hand experience.

I also think one of the reasons that there aren't as many ortho trained plastic surgeons doesn't have to do with salary. It has more to do with what you enjoy doing. Most of the orthopods I know really love their jobs (although I must admit the reason escapes me and never wanted to do plastics. While money can be a strong motivator, for me enjoying my work is as, if not more important. I just turned down two job offers making significantly more money to take one that will let me do what I want.

--M

 

[Pir8DeacDoc]

I think you've answered your own question. Based on what you've posted, I would suggest that you apply for the integrated/combined plastic surgery residency and use ortho as a back up plan. If you end up having to do five years of something before you can get into plastics, it sounds like you would like ortho better. You would certainly get hand experience.

I also think one of the reasons that there aren't as many ortho trained plastic surgeons doesn't have to do with salary. It has more to do with what you enjoy doing. Most of the orthopods I know really love their jobs (although I must admit the reason escapes me and never wanted to do plastics. While money can be a strong motivator, for me enjoying my work is as, if not more important. I just turned down two job offers making significantly more money to take one that will let me do what I want.

--M

I'm sure you are aware, as is the med student poster, but trying to match intergrated plastics with ortho as a back up is a tall order. Both are super competitive with PRS being the most competitive match. I could imagine a situation where a well-qualified applicant doesn't match PRS (because it just happens) and their application screams plastics and not ortho (which pisses off the orthopods) thereby making the match into ortho harder than it already is.

I'm not trying to be a debbie downer, just want to make sure that folks are aware how challenging this route could be. Good luck!

 

[Moravian]

I'm sure you are aware, as is the med student poster, but trying to match intergrated plastics with ortho as a back up is a tall order.

I completely agree it's a tall order, but I think it a much better option than not matching at all. I was one of those people that didn't match into the combined and didn't have a backup. I scrambled for a GS spot and I wouldn't wish that on anyone. It all worked out OK in the end (I was very happy with my residency) but it was not a fun experience at the time.

For the past three years, I have interviewed applicants and/or reviewed their applications for combined plastics. I am continually amazed at their caliber (at least on paper). And every year, there are very well qualified folks who don't match. I would take the chance on pissing off some of the orthopods just to have something to fall back on.

Of course, there's always the option of doing something else not as competitive, but a 5 year residency is a long time to do something you don't really like very much. And in the end, if you still can't get a spot, you're going to have some real issues. I guess a transitional year would be another option, albeit not very appetizing. Then there's always the chance of finding a spot in a plastics lab or a lab that has some connections, but that would be my last choice.

 

[pagemmapants]

It helps that our Division Chief is double-boarded ortho/plastics. . . and as mentioned my research is in the PRS lab but will primarily be on compression plates. Keeping my options open. Moravian - what you proposed is exactly what I have been thinking, and I think the main thing that will change my course will be if I don't do as well on Step 1 as is necessary for the integrated programs. Last I checked the average was a 241 or so (~233 for bones). The rest of my application should be sufficient, at least so I anticipate from my clinical clerkship grades and faculty support thus far (now if only I could get the surgery clerkship director to submit my grade officially I'd be much happier!), as well as the planned research year ahead.

Really, I think Moravian hit the nail on the head when he said that if I didn't match integrated I'd be much more happy with 5 years in bone than 5 years in general followed by another 3 years PRS. The unfortunate part is that this means applying to two of the most competitive matches out there, simultaneously. Let's just hope I'm up to the challenge!

 

[droliver]

I'd say that what you'd take technique, anatomy, science, and "discipline" -wise from general surgery is 1000X more relevant to your average plastic surgery practice then orthopedics. The only advantage of orthopedic training to me is in hand surgery, a discipline rapidly disappearing from the practice of most plastic surgeons (and most orthopedists too for that matter).

 

[VoiceofReason]

I'd say that what you'd take technique, anatomy, science, and "discipline" -wise from general surgery is 1000X more relevant to your average plastic surgery practice then orthopedics. The only advantage of orthopedic training to me is in hand surgery, a discipline rapidly disappearing from the practice of most plastic surgeons (and most orthopedists too for that matter).

is nobody doing it? or where are the hand cases going?

 

[eclcell]

Most or nearly all ortho programs are not going to be interested in someone who wants to ultimately do plastics. There are plenty of qualified people applying who just want to do ortho. So I think somehow you would have to hide all the plastics interest from your application because if it is in there your interviewers will ask. That would be a problem if all your research etc. is in plastics. Your much better off going all out for an integrated spot in plastics. Ortho back up is not all that realistic unless your super qualified for both.

 

[NNavy21]

I'd say that what you'd take technique, anatomy, science, and "discipline" -wise from general surgery is 1000X more relevant to your average plastic surgery practice then orthopedics.

All those nights in the SICU and days spent doing lap procedures, whipples and the like are going to do wonders for you....


What plastics-pertinent anatomy do you learn in a GS residency? breast?

 

[pagemmapants]

What plastics-pertinent anatomy do you learn in a GS residency? breast?

Don't forget the layers of the abdominal wall for those component separations.

Seriously, though, I would think that getting good experience with the vascular anatomy of the extremities would be v. helpful for a flap-heavy PRS training program; that would definitely be more of an ortho than a GSU thing. One could say that ENT-->H&N training wouldn't give you pertinent training for PRS but there are at least some ENT guys who follow up with PRS even though they haven't touched a belly in years (and they might be better at rhinos and blephs than the GSU-trained PRS fellows). Really to me it seems like none of the above give you "optimal" pre-fellowship experience for PRS because you're always missing something.

That said - an add-on question to those of you kind enough to counsel a lowly MS2:

How well-trained/well-accepted are graduates from integrated and/or combined programs? Do they have any gaping holes in their education due to their shortened curriculum? Is there any bias against them with respect to fellowships or joining private practices?

Being a fully trained P&R surgeon at the age of 31 sounds too good to be true and I'm wondering what the catch might be.

 

[Moravian]

How well-trained/well-accepted are graduates from integrated and/or combined programs? Do they have any gaping holes in their education due to their shortened curriculum? Is there any bias against them with respect to fellowships or joining private practices?

I heard Dr. Kawamoto (craniofacial guru at UCLA) say the he would not take anyone into his craniofacial fellowship that did not do a full five years of general surgery. I have also had conversations with others (general surgery trained plastic surgeons) that didn't feel the combined residencies resulted in a better trained plastic surgeon. In the first case, Dr. Kawamoto, while certainly famous and an exceptional surgeon, is in his 70s and has an "old school" approach. I think this attitude, while pervasive several years ago, is beginning to fade (although some may argue this).

What am I basing this on, you may ask? Even if you weren't, here it is...

I trained at a plastics program that had an independent spot (after 5 years of general surgery) and a combined spot. I was initially concerned that there would be a training "mismatch" and that I'd be a co-resident with someone who didn't really know what they were doing. I was very pleasantly surprised. The reality was that we both knew things the other didn't. For instance, he knew a lot more plastic surgery than I did, even though I had more than the average exposure to plastics in my GS training. I attributed this to my needing to learn how to be a general surgeon in case I didn't get a fellowship, and him always knowing he was going into plastics and spending his time studying/reading for that outcome. On the other hand, there were some aspects of patient care and management that he missed because he didn't have the extra two years, had never been chief of a service, etc. Technique-wise, there really was no difference. At the end of two years, I believe we came out fairly even.

I really think it's the part about patient care/management/ and the extra two years of experience that gave the impression that the combined programs weren't as good. This doesn't mean that these skills aren't learned, only that they had to be "taught" in a combined setting where it had previously been taken for granted, if that's making any sense. As the combined model evolves, I see this becoming less pertinent. Plastic training is going to be extended to three years (instead of two) and in some programs, four years. And as the independent slots slowly disappear (emphasize slowly), and the teaching faculty become populated with graduates of combined programs, it won't make any difference anymore.

 

[pagemmapants]

Thanks for your extensive response, Moravian. I know I have plenty of time to figure this out, but it's still nice to get some more experienced perspectives to work from.

Anyone else have input?

 

[Vibez]

I'm having the same dilemma. Just talked with an advisor who suggested that i limit my career choices. About to finish my MSIII year ... STEP 1 is 254, honor'd surgery among a few others in clerkship. Not AOA, but close, top 20% of class. Research for 3 yrs in college in Immunology, 1 published paper, nothing in ortho/plastics. Planning on taking two electives in ortho, two in plastics to solidify my decision in 4th yr, w/ one away rotation in each.

Here's the thing. Applying to integrated/combined plastics w/ a backup in ortho sounds ridiculous, almost cocky. Should i have another backup? Radiology? Worst nightware is to scramble. Will I match into something? I'm at the point where i'd really just like to know what i'm doing with life. You tell me saucier, i'll start stirring the pot.

Also, I was thinking about taking some art classes to pump up my plastics app. Sounds corny, i know, but i haven't used that part of my brain for a while now. Worth it?

 

[PRS Man]

Vibez...You have to figure out why you want to go into plastics or ortho. Unless you love hand or maybe craniofacial, there is very little overlap. One is heavy lifting surgery, while the other is finesse. If you are looking for a backup, doing a nonoperative specialty simply because it is prestigious or financially rewarding will leave you unsatisfied. With a 254 on your boards, if you are honest and humble on your interviews, you should get a spot. Gen Surg seems like a good backup for plastics, because it allows you to attain your goal, albeit by a slightly more circuitous route. Unfortunately, there is no other way to fulfill your ortho goal, short of doing a transitional year. Only take art classes if they interest you. The best bang for your buck for a third year to prepare for a plastic surgery residency is to learn Plastic Surgery Secrets cover to cover, scrub as many cases as possible, start and finish some plastic surgery research, find a mentor that will vouch for you as a person, and do several away rotations...be the first to arrive and the last to leave, do more than your asked, and always be in the middle of everything.