Plastic Surgery Resident, Fall 2016

ISSUE 4 | FALL 2016

Integrating professionalism into plastic surgery training

From the publishers of Plastic Surgery News

» Surviving residency A plastic surgeon new to practice ofers tips to prepare for life as a resident

page 30

» Get funded he PSF is now accepting grant applications for a wide range of projects

page 22 IN THIS ISSUE » Be prepared for a nasal trauma consult in the E.D. ........... p.13 » The must-read articles on flexor tendon repair ...................... p.16 » What to do when duty hours become excesssive ......................... p.10

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A note from the editor

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t is with great pleasure that I introduce the 2016 annual meeting edition of Plastic Surgery Resident magazine. Over the past year, we have been introducing our readers to a number of recurring features, and for this issue, we bring back favorites, such as “Consult Corner,” “CPT 101” and “Journal Club.”

Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh

In addition, we introduce readers to a new section, “Program Peek,” which provides a glimpse into a day in the life of a plastic surgery residency program, beginning with the “town-and-gown” training at the University of Pittsburgh. his dovetails nicely into “Faculty Focus,” which highlights Vu Nguyen, MD, who was recently elevated to plastic surgery residency program director at Pitt. We also bring irst-year residents and medical students the irst installment of a new series, “hings I Wish I Had Known Before Residency,” which ofers practical survival tips designed to help prepare new plastic surgery residents for the challenges that lie ahead – and how to navigate them. I hope you’ll ind the series to be both useful and a fun read. Finally, this issue marks the debut of a residency-themed advice column, “Dear Abbe,” which will tackle any questions and concerns posed by residents. Joseph Losee, MD, executive vice chair of the University of Pittsburgh’s Department of Plastic Surgery, takes on the role of advice columnist to share his experience and wisdom. I encourage any resident facing a diicult dilemma to submit it – all names will be kept conidential – to DearAbbe@plasticsurgery.org. I hope that you enjoy this issue of PSR, and please feel free to give me feedback during Plastic Surgery he Meeting, Senior Residents Conference, Residents Day or Medical Students Day in Los Angeles. As always, I would like to thank our physician editorial board and our editorial staf at ASPS for their help in making another issue of PSR a reality. I look forward to seeing you all at the annual meeting! |

Plastic Surgery Resident | Fall 2016

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Table of

Contents Integrating professionalism into plastic surgery training .................. 6 Three essays written by residents address the importance of professionalism.

Dear Abbe ......................................10 New advice column for residents tackles the problem of working excessive duty hours.

Consult Corner Nasal trauma .................................. 13 The face can be partitioned into subparts to better characterize and treat injuries.

Journal Club Flexor tendon .................................16 Ten articles to help residents navigate the abundant literature on hand surgery.

PSF research grants available..... 22 The 2017 research grant cycle has started, and residents are encouraged to apply.

Plastic Surgery Resident | Fall 2016 | Vol.4 No.1 he mission of the American Society of Plastic Surgeons is to support its members in their eforts to provide the highest quality patient care and maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR E SI DE N T

David Song, MD, MBA | dsong@surgery.bsd.uchicago.edu EDITOR

Alex Spiess, MD | amspiess@msn.com ASSOCI ATE EDITOR

Mohammed Alghoul, MD | mo.alghoul@gmail.com RESIDENT EDITORS

Sanjay Naran, MD | narans@upmc.edu Chad Purnell, MD | cpurne@gmail.com Sameer Shakir, MD | sameer.shakir@uphs.upenn.com E X EC U T I V E V ICE PR E SI DEN T

Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V P/PROGR A MS A ND DEV ELOPMENT

Gina McClure | gmcclure@plasticsurgery.org PUBLICATIONS DIRECTOR /M A NAGING EDITOR

Mike Stokes | mstokes@plasticsurgery.org

Crossword ..................................... 24

SEN IOR GR A PH IC DE SIGN ER

Challenge your plastic surgery vocabulary.

Jim Andrews | jandrews@plasticsurgery.org

Program Peek University of Pittsburgh............... 26

GR A PHIC DESIGN ER

New series ofers an inside look at plastic surgery residency programs.

Anna Abbinante A S S I S TA N T E D I T O R

Jim Leonardo | jleonardo@plasticsurgery.org S TA F F W R I T E R

Faculty Focus Vu Nguyen, MD ............................ 28

Kendra Y. Mims | kmims@plasticsurgery.org

University of Pittsburgh residency program director discusses his career path.

Brian Parker (215) 521-8969 Wolters Kluwer Health

If I knew then what I know now .. 30

Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005.

Plastic surgeon ofers tips for transitioning from medical student to resident.

CPT 101 Proper billing for Xiaflex® ............. 32

A DV ERTISING SA LES

Calendar ........................................ 38

POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005

Upcoming meetings and missions.

Postage paid at Arlington Heights, IL, and at additional mailing oices.

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he views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily relect the opinions of ASPS. Acceptance of advertisements for PSR is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised. ASPS Home Page: www.plasticsurgery.org 4

Plastic Surgery Resident | Fall 2016

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ESSAYS

Integrating professionalism into plastic surgery training AN ONLINE SURVEY of more than 800 plastic surgeons both in practice and in training conducted by the Women Plastic Surgeons (WPS) Steering Committee in 2014 revealed that more than 25 percent of respondents have been personally subjected to bias and/or harassment (“Survey reveals specialty’s ‘professionalism’ issues,” PSN September 2014). Verbal and physical harassment, as well as unprofessional statements related to gender, religion, age, culture, race, disability and sexual orientation were reported – all of which can negatively impact communication, teamwork and, ultimately, patient safety. To stimulate discussion on this critical issue, the ASPS Professionalism Task Force invited residents to submit essays on topics relating to professionalism and ethics in plastic surgery. Twenty-four essays were submitted, and the winning paper, “A Soldier’s Perspective on Professionalism in Plastic Surgery Training” by Anthony Braswell, MD, has been submitted for publication in Plastic and Reconstructive Surgery. he committee also recognized three additional papers as runners-up, which Plastic Surgery Resident is proud to present: “Osler’s Ideals as a Model for Professionalism in Plastic Surgery” by Kristopher Day, MD; “Professionalism of Interprofessionality” by Chris Reid, MD; and “Teaching Medical Professionalism in Residency” by Collier Pace, MD. 6

Plastic Surgery Resident | Fall 2016

Osler’s Ideals as a Model for Professionalism in Plastic Surgery By Kristopher Day, MD, he University of Tennessee

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o other ield of surgical practice relies more heavily on the ideals of professionalism than plastic surgery. his becomes apparent when one considers the internal fortitude that the plastic surgery patient demonstrates when she or he requests a consultation. Seeking elective plastic surgery is an exercise in humility in which patients must irst consider themselves in the mirror and confront what may be one of the most distressing aspects of their appearance. What follows is then a frank discussion – in most cases – with a stranger to “bare” not only their body but their feelings as to how that physical component impacts their self-image or identity. his chore is often made evermore harrowing by the fact that this body part is often ultimately private, the problem is embarrassing and, sometimes, one they would not reveal without great trepidation to their family or closest friends. Unfortunately, for many patients, this personal, Herculean task is undertaken despite inancial constraints or the threat of social stigma. What element of character, in the initial moments of interaction with a provider in whom so much faith has been placed, could be more important than professionalism? Professionalism comes in many forms, but some run deeper than others. As opposed to a job, in which one simply performs certain tasks for a prescribed duration in exchange for a wage, Webster’s deines a profession more as “a calling.” he word is derived from the Latin professio, meaning “to profess,” which introduces the concept of intellectual commitment in the true professional. John

Racy captures the notion of the professional as someone who performs a role greater than oneself when he describes a “profession (as) a socially sanctioned activity whose primary object is the well-being of others above the professional’s personal gain.”1 From this perspective it becomes clear that the professional habits that produce a well-groomed appearance, respectful demeanor, timeliness and the avoidance of unscrupulous medical practices are all selfevident – but are not suicient to explain the qualities of an authentic professional. To truly understand the bedrock of professionalism, one must appreciate the principles that form its foundation. Sir William Osler has been called the “Father of Modern Medicine,” and it would be challenging to ind a better exemplar of professional values. In his most celebrated essay, “Aequanimitas,” Osler challenges us to recognize what he considers to be the underpinnings of genuine professionalism: “Acquire the Art of Detachment, the Virtue of Method, the Quality of horoughness, and above all the Grace of Humility.”2 If these ideals were internalized as a mantra and practiced in concert, one can only imagine that genuine professionalism would emerge as the fruit of the process. he everyday practice of plastic surgery provides many opportunities for us to see how these ideals may be integrated into the routine practice of our craft.

Art of detachment he Art of Detachment may at irst sound counterintuitive to being a professional, but it proves to be essential in maintaining empathy with patients alicted by surgical ailments without becoming consumed by them. he potential misunderstanding of this intellectual posture by the laity was clearly understood by Osler. No one who has dedicated their life to healing would encourage conscious indiference on the part of their surgeon. Osler’s Detachment implies calm, and perhaps resolute, acceptance of what “comes to pass” as the physician maintains the presence of mind to devise a solution to complicated problems. he complex wound consult comes to mind to illustrate the importance of the Art of Detachment. hese patients often sufer from malnutrition, various comorbidities, synchronous acute illnesses, poor compliance and perhaps a litany of other social reasons to fall short of ideal candidacy for a complex wound management scheme. However, this does not diminish the importance of optimal wound management, possibly requiring sophisticated plastic surgical planning. Without artful detachment, such a clinical challenge may become overwhelming and negatively impact the clinical professional’s ability to develop a comprehensive treatment strategy.

Virtue and quality he Virtue of Method often comes naturally to many plastic surgeons, as it often goes hand-in-hand with the meticulous and algorithmic manner in which plastic surgeons commonly analyze problems. Of the many examples that might illustrate this point, the management of pan-facial trauma ofers, perhaps, one of the most potent. After a high-energy impact with fractures throughout portions of the lower, middle and upper face, one must assess each injury both individually and in combination with each other. A process must then be employed to coordinate the repair of these injuries in a sequence that yields the goal outcome of reduction and ixation, which is usually some form of “stable-to-unstable” surgical planning. Whether the approach progresses from “top-down,” “bottom-up” or some other variation, the tactic of methodical surgical planning and execution is exemplary of the efective plastic surgery professional’s approach. he value in cultivating a Quality of horoughness reveals itself in the attentive surgeon’s capacity to ofer patients treatment not only for the reason they present, but also for other identiied ailments of which the patient may not have been aware. I recently participated in the care of multiple patients consulted for reconstructive breast surgery who were concomitantly diagnosed and treated for melanoma, spinal stenosis, thyroid disease and a number of other maladies simply by listening and attending to the entire patient in a thorough manner. Given the fact that a signiicant degree of inirmity is inherent in patients who present for reconstructive plastic surgery, it should come as no surprise that such complex patients are often alicted by multiple other conditions. his presents professional plastic surgeons with a unique opportunity to reach beyond the presenting issue, exercise the experience inherent in our training, and make a positive impact on the “whole” patient by simply being thorough.

Grace of humility he Grace of Humility may often go neglected, but when witnessed, its importance to the plastic surgery professional becomes obvious. While arrogance and self-importance alienate more fellow health-care providers than they impress, the simple display of humility can quickly become a beacon for cooperation, collegiality and the eicient delivery of highquality medical care. We all love to work alongside intelligent and skillful individuals who take pride in their craft. Too few of us consider, however, that those with such talents are often aforded options in life and typically choose to gravitate toward pleasant company. A particular hand surgeon at our institution regularly treats all staf members with whom he works with professional equity. Clearly, he understands that the individual who continued on page 34 Plastic Surgery Resident | Fall 2016

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ESSAYS

Professionalism of Interprofessionality By Chris Reid, MD, and Marek Dobke, MD UC San Diego Medical Center

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egardless of how professionalism is deined, its importance is uncontested. As it pertains to plastic surgery, professionalism has a heightened importance due to the fact that signiicant portions of plastic surgery are based on subjective rather than objective norms. Moreover, some have said the domain of cosmetic surgery does not fall into the same domain of medicine “as a profession dedicated to saving lives, healing and promoting health.”1

Many others have previously delineated the complexities of professionalism and ethics in plastic surgery.2-6 ACAPS, ABPS, ASPS and PSRC recognize the importance and have initiated a joint committee aimed at curriculum development in ethics and professionalism in plastic surgery graduate and postgraduate education. However, there is currently no formalized curriculum. And still to be shown is to what degree professionalism can be taught – and if it can be, at all.7

“Undoubtedly, in medicine leaders are a necessity, and as plastic surgeons, that is the role we will occupy. However, what is perpetuating deiciencies in ‘interprofessionality’ is the culture of domination.” Interprofessionality One facet of professionalism is how professionals occupying diferent stations in a hierarchy interact. As a surgeon, one is expected to be leader and decision-maker in and out of the O.R. A surgeon’s eforts are often carried out autonomously without collective input from others. However, there is growing evidence for, and acceptance in, shifting toward team-oriented patient care. Paige describes:

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Plastic Surgery Resident | Fall 2016

“(How the) physician’s role has transformed from the sole practitioner overseeing all aspects of a patient’s care to the leader of a team of health care professionals, each contributing their expertise in their scope of practice to help patients on their journey to health. his situation is especially true for surgeons who, thanks to advances in critical care, surgical equipment and techniques, pharmacology, anesthesia, and physical and occupational therapy, are now taking care of more and more challenging patients. As such, the contemporary surgeon must act more like a collaborative team coach than the autonomous captain of a ship.” 8 Scenarios requiring multispecialty team efort seem to grow by the month. One of the most recent incarnations recognizable by plastic surgeons relates to the complexity of the decisionmaking process in breast cancer treatment, which emphasizes “shared decision-making.” Another familiar example is that of cleft care, wherein medical, surgical, dental and allied health disciplines work in an interdisciplinary and coordinated system centered to optimize the outcome for the child and their family. In fact, the multidisciplinary unit with a foundation in diferent professionals deliberatively working together is standardized and required by the American Cleft Palate Craniofacial Association.9 his modern concept of delivering patient care is termed “interprofessionality” (IP), and it encompasses a manner of caring for patients in which professionals practice in an integrated and cohesive manner. his framework is not mutually exclusive with structured hierarchy, but rather suggests “continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation.”10 Support for this modern approach to health-care delivery has been sponsored by the Institute of Medicine15 and World Health Organization. 12 Moreover, there is data to support the implementation of IP education resulting in improved health outcomes.13-15 Additionally, the adoption of IP in the O.R. has been supported by the American College of Surgeons16 as well as shown to have a positive impact in trauma17 and cardiac surgery.18 And as mentioned previously, it is a constituent of the standard of care in cleft and craniofacial surgery. 9

Deiciencies in IP he O.R. serves a prime example of IP deiciency. It is illed continued on page 34

Teaching Medical Professionalism in Residency By Collier Pace, MD, Virginia Commonwealth University

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eaching professionalism is a growing concern within graduate medical education. In response to this movement, the training of medical and surgical residents, including those within the ield of plastic and reconstructive surgery, is evolving. While professionalism has traditionally been passed on informally through experiential learning, the current focus is integrating it into a formal curriculum. here is a push to evaluate resident professionalism objectively, so that progress can be documented and measured in response to the various eforts to teach this concept. he evolution of the way we measure and teach medical professionalism is indicative of the need to protect and advance the integrity of our ield. It is imperative that we do not allow the core values of medicine to deteriorate in the face of political and economic changes that inluence the way we practice, and any efort to this end should be applauded. However, professionalism is a complex entity that is not easily deined, measured or taught. If we are going to advance our understanding and implementation of this concept, we must attempt to clarify what it means to us. If we are going to try to measure one’s professionalism objectively, we must ensure those measurements are valid, accurate and reproducible. Furthermore, it is crucial that we do not marginalize rolemodeling or experiential learning when teaching residents professional standards. We may ind that it is the best way to truly communicate what it means to be a professional. In order to clarify what it means to act professionally, it is prudent to identify what constitutes a profession. Merriam-Webster deines a profession as “a calling requiring specialized knowledge and often long and intensive academic preparation” and “a principal calling, vocation or employment.” Practically, this deinition is too broad and misrepresents how the term is currently applied. Freidson distinguishes medicine from other occupations based on its autonomy from external regulation and oversight. He suggests that a profession’s autonomy and protection from outside inluence depends upon the following: (a) the skill and knowledge of members of a profession are so advanced that they cannot be justiiably evaluated or controlled by outsiders, (b) members of professions are responsible and can be trusted to work without supervision and (c) the profession as a whole has the willingness and capacity to take appropriate self-regulatory action regarding members who do not adhere

to technical or ethical standards.1 According to this view, if a profession were to lose the trust of society, that profession would, therefore, lose autonomy and no longer exist. More recently, Cruess and Cruess have summarized a list of 10 characteristics of a profession, which include the moral and ethical obligations to perform a public service.2 While there appear to be generally agreed-upon characteristics of a profession, the deinition is not straightforward. Professionalism is deined as the conduct, aims or qualities that characterize or mark a profession. However, if we are unable to succinctly deine a profession, then we will obviously be challenged to clearly state what professionalism means. Swick describes medical professionalism as a set of behaviors that demonstrate why physicians are deserving of the trust bestowed upon them by their patients, and the general public3 (see box on page 36). he importance of “trust” is in concordance with Freidson’s view. Additionally, punctuality, personal hygiene and appearance have been identiied as important professional characteristics.4 Our own professional society, ASPS, has a Code of Ethics that lists general and speciic principles as guidelines for the behavior of its members. In addition to previously mentioned values of altruism, excellence, duty and integrity, the ASPS Code of Ethics includes directives related to inances and advertising.5 One could extrapolate from this that the breadth of behaviors encompassed by the term “professionalism” is changing in the modern healthcare climate, making it increasingly diicult to deine what it means to be a professional. continued on page 36 Plastic Surgery Resident | Fall 2016

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Culture and professionalism clash with excessive duty hours Dear Abbe, I’m over my duty hours and have not had a day of service for more than three weeks. My chief resident makes no efort to excuse me from service for a free day or to make sure we have adequate time of between shifts. I feel my program director expects me to lie about my reported hours. What do I do? Sincerely, Tired and Confused Dear Tired and Confused, You describe a serious, complex and even controversial situation facing residency training programs. You certainly are not alone. It’s one of many tough situations I suspect you have been in and most certainly will encounter moving forward in your professional career. I think there are two issues at play here: 1) your responsibility as a resident to manage your time and duty hours = professionalism; and 2) your program’s attitude to duty hour requirements, including the culture set by the program director and the adherence by the chief residents. Personal responsibility = professionalism Duty hours are a very personal thing. It is impossible for the program director or chief residents to track every single resident’s hours on a daily basis. Residents must take personal responsibility and embrace the professional obligation to fully understand and adhere to the duty hour regulations – this also includes speaking up to remind everyone (even if it is an uncomfortable thing to do).

Lying about duty hours is never an option – it breaches all codes of professionalism, and it has the potential of putting your entire program in jeopardy. Anticipating a potential problem and reporting issues or concerns before they occur is expected and appreciated. While doing so, it is important for you to embrace and project a “lifestyle and attitude of an incredibly hard working team player” and not a “shift worker.” Yes, these two seemingly competing forces can make it challenging – some residents struggle to do this while others seem to do it efortlessly. It’s all in the attitude! You must assure that you are perceived as the hard-working team player while you keep your duty hours. It is diicult for some to strike a balance, but no one said all of this would be easy all the time. Your collective program’s attitude to duty hours Certainly, it is a lot easier when you have a team (i.e., chief, program director and chief resident) that is very vocal and proactive with maintaining duty hours. For the most part, I suspect the majority of chiefs and program directors understand the reality of duty hours and the seriousness of non-adherence; however, that doesn’t mean they champion the cause. Despite what they might personally feel about the rules, it would be rare that a program director is not “on board” and supportive of adherence. here are few senior residents and attendings who think speciically about your duty hours. hey have other things going on and expect you to do that (and they may even mumble and grumble when you bring up the issue).

By and large, they know the rules and that you are doing the right thing. Even if your program director appears to dislike duty hour rules, he or she is well-aware of how important it is to adhere to the rules. It is the program director’s responsibility 10

Plastic Surgery Resident | Fall 2016

EDITOR’S NOTE: “Dear Abbe” – named in honor of plastic surgery pioneer Robert Abbe, MD – ofers plastic surgery residents an opportunity to anonymously share concerns and seek advice from a highly respected senior-level faculty member. Joseph Losee, MD, vice chair of the University of Pittsburgh Department of Plastic Surgery, takes on the role of advice columnist for this inaugural edition. he views expressed in this column are those of the author and should not be considered legal advice. Residents and Fellows are encouraged to submit their questions to DearAbbe@plasticsurgery.org. Names will be withheld.

to create an environment where the rules are followed, as well as “set you up for success” and ensure that there are no built in roadblocks to successfully comply with the duty hours. As with most things in life, there are “average program directors” and then there are “good program directors.” A “good” program director will create an environment of approachability so that residents feel invited to have a discussion about such things with them. Be the solution I suggest that you establish yourself as a selless, essential and completely dedicated team player, as well as the hardest-working resident in the program. Directly approach your chief resident and program director as a professional. You should identify the “problem” and also give them the solution by presenting one or more logical and “do-able” initiatives. Ofer to lead the cooperative efort to ix the problem and implement the solutions. here are creative ways to follow the “letter of the duty hour law,” while taking full advantage of the “at home call” and “senior resident status” from which plastic surgery residents beneit. It will not be easy, but then again, most things important in life are not. After all, plastic surgeons are problem solvers!

If you have reason to believe your program director expects you to lie about your duty hours, then it is a signiicant continued on page 38

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Plastic Surgery Resident | Fall 2016

Nasal trauma

“Consult Corner” addresses a consult commonly encountered by an on-call resident. he column begins with the reason for consult and assesses questions that might go through a resident’s mind as he or she heads to the emergency department to see the patient. Key aspects of the history and physical, as well as additional testing that should be obtained, are also presented. Finally, a review of the decision-making process will present possible management strategies, all of which are synthesized into the context of an actual case.

A multifaceted approach to an E.D. call for consult By J. Thomas Paliga, MD

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ome of the busiest days for plastic surgery residents occur when they cover facial trauma at the children’s hospital and/or Level 1 trauma center. Patients will present to the E.D. with injuries involving a variety of facial structures sufered from myriad mechanisms. Perhaps the most eicacious residents will partition the face into its subparts in their studies and assessment, to better characterize injuries and provide primary interventions when necessary. In the following discussion, a particularly enigmatic structure for junior residents is addressed – as the anatomy, assessment and management of nasal soft tissue trauma is reviewed.

MESSAGE ON YOUR PAGER: E.D. CALL: TRAUMA PATIENT WITH INJURY TO NOSE As you return the page, some of the initial information you need to consider includes the following: • Age of the patient: May impact expected outcome of reconstruction and desired complexity of repair • Comorbidities: Factors that may contribute to poor wound healing, poor surgical candidacy • Mechanism: Dog bite, MVC, broken glass-abrasion vs. laceration vs. avulsion • Timing: Degree of wound contracture and secondary healing

• Additional facial injury: Extent of trauma, anticipation of defect, don’t want to miss fractures • Surgical history: Compromise to nasal blood supply or limitation of local lap options As you conirm with the E.D. physician that you’ll be there to see the facial trauma patient promptly, also execute a quick review of the anatomy of the nose – this will be helpful. RELEVANT ANATOMY Tissue layers: external skin and nasalis muscle create a soft tissue envelope overlying a framework of bone and cartilage with an internal mucosal lining consisting of largely mucoperichondrium. STRUCTURAL THIRDS Upper: Overlying nasal bones1-3 Middle: Overlying lateral cartilages Lower: Nasal tip with paired ala over membranous septum and columella supported by medial crura of alar cartilage Aesthetic sub-units: Dorsum, tip, columella, side-walls, alae and soft triangles Function: Dominant central facial feature requiring proper position, dimension and symmetry to fulill its role in facial aesthetic function, while maintaining adequate and unobstructed passage of air for nasal breathing as its major structural function. Plastic Surgery Resident | Fall 2016

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PERTINENT HISTORY AND PHYSICAL EXAM: Patient goals for wound management and appearance can determine appropriate complexity of repair and staging of multiple procedures. Symptoms of nasal airway obstruction? Nasal deformity concerning for nasal bone fracture? Rule out septal hematoma and obtain hemostasis by nasal packing if necessary (need for nasal packing to resolve epistaxis should increase your concern for nasal bone fracture). Intranasal evaluation will require a speculum and adequate lighting to fully and adequately evaluate the mucosal surfaces.3,4 Is there localized edema or was local anesthesia administered that may distort the wound appearance? LOCAL ANESTHESIA: Local anesthesia is often required in order to properly assess, irrigate and explore the wound. his can be achieved by supraorbital/supratrochlear/ infratrochlear and infraorbital nerve blocks with 1-2 percent lidocaine to prevent distortion of the nasal tissues. CHARACTERIZATION OF THE WOUND Location: Localized to a structural third? Are one or more subunits involved? Size: Overall tissue loss will dictate reconstructive options. What percentage of the subunit has tissue loss? < 1.5 cm considered a small defect >= 1.5cm considered a large defect Depth: What tissue layers are involved? Is the nasal lining intact?

AVULSIONS Small, supericial defects: <1.5 cm with well-perfused subcutaneous tissue at base.1-3,4 Secondary healing: Limit this option for wounds <6mm in diameter and localized only to the glabella, medial canthus, alar crease and dorsum or sidewalls. Larger wounds or involvement of the major landmarks or subunits increase the risk of excessive wound contracture and subsequent distortion. Primary closure: <6mm defects of the dorsum or sidewall can often be repaired primarily as the skin is mobile and allows for undermining. Grafting: Small defects of the lower third involving the dorsum, tip and ala are not good candidates for healing by secondary intention due to distortion or primary closure because of the densely adherent tissues. Full thickness skin grafting from the forehead or retroauricular area may be more appropriate to match skin color and thickness at these sites while preventing distortion during healing. Local laps: A variety of local lap options exist for small defects. hese laps are better performed in a controlled setting and not primarily in the emergency department.

Supericial: healthy subcutaneous tissue lies at the base of the wound

Single-lobe transposition lap (Banner lap) – Small defects in the upper third

Deep: Periosteum or perichondrium is exposed or violated

Bilobed lap – Small defects in the thicker skin of the tip or ala

Wound condition: Contamination, clean margins, devitalized tissues, granulation tissue, early scar formation MANAGEMENT STRATEGIES: he main principle of treating soft tissue injuries of the nose is to reestablish baseline nasal appearance without causing airway obstruction.1-3 ABRASIONS Mainstays in treatment of abrasive soft-tissue injuries include thorough irrigation and cleaning of the wound to remove foreign particles that may result in tattooing. Conservative debridement is appropriate, noting a better cosmetic outcome will result via secondary revision rather than extensive primary intervention.3 LACERATIONS Simple lacerations to the nose can be repaired primarily when there’s no extensive soft-tissue loss. hese repairs should follow the principle of closing mucosa irst, followed by approximation of cartilaginous structures and inally the overlying muscle and skin. Mucosa should be closed with 5-0 gut suture with the knots kept within the nasal cavity. Cartilage can be repaired with 5-0 absorbable suture after ensuring reduction and proper anatomical alignment. When 14

closing the skin of the nose, the irst sutures should be placed at key landmarks to ensure anatomical alignment. he skin can be closed with either 5-0 or 6-0 fast-absorbing or nylon suture in patients who can tolerate removal.3

Plastic Surgery Resident | Fall 2016

Dorsal nasal lap – Caudal dorsum and tip defects requiring resurfacing One stage nasolabial lap – Small lateral defects within the ala or sidewall Large or deep defects: >=1.5cm or partial/full thickness defect.1-3,4 Composite chondrocutaneous grafts: Small defects (<1.5cm) with loss of cartilaginous tissue at the alar rim and columella can be repaired with composite cartilage grafts harvested from the helix, rim or ear lobe. Two-stage nasolabial lap: Paired with primary cartilage graft for framework support, this can be used to reconstruct the entire alar subunit. Forehead lap: Full tip/lobule subunit, subtotal and total nasal reconstruction can be performed in conjunction with extensive cartilage grafts to provide midline and alar support. his is typically performed in two or three stages, but it may require a four-stage technique with a radial forearm lap to provide intranasal lining.5

DISCUSSION: When evaluating soft-tissue trauma to the nose, the consult resident should apply his or her knowledge of the local anatomy and ultimate functional goals to aid in his or her characterization of the injury and planned intervention. General principles of soft-tissue injury management apply, and all wounds should be irrigated. Debris should also be removed and debridement kept to a minimum to improve the cosmetic result.

Patient case: he patient is a 52-year-old male who sufered traumatic injuries during a motor vehicle collision in which his face hit the windshield. In addition to multiple abrasions on the nose and forehead, the patient sufered a minimally displaced nasal bone fracture. Septal hematoma was ruled out. In evaluating the soft tissues of the nose, he was found to have a partial avulsion of the skin on the dorsum of the nose near the junction of the glabella. here was healthy subcutaneous tissue at the base of the wound and no exposed cartilage or bone. he wounds were all copiously irrigated and scrubbed to remove any foreign materials. he partially avulsed segment of dorsal skin was sutured in its native position using nylon under minimal tension, and no additional tissue was debrided. His follow-up at four weeks showed the abrasions are healing well, and the avulsed segment of skin has remained viable. At six months following the injury, the wounds have all efectively healed without the need for additional revision. Standard topical scar therapies were applied.

he mainstay of intervention in the E.D. setting is to suture avulsed or lacerated tissues as best as possible in their native positions and allow wound healing to take place. Over time, the wound may contract and become more manageable – or more complex reconstructive eforts can be planned. In cases of large areas of soft tissue loss, a planned reconstruction in the O.R. may take place within a day or two, while smaller wounds may be allowed to heal over a longer time span with interval clinic visits. Special consideration can be given to avulsed nasal segments, utilizing the saved tissue as a biological dressing or full thickness graft. his is particularly desirable in the pediatric population where dressings and visible defects are less tolerable to the patient and families. Finally, consideration must be given with regard to the need for antibiotics, tailoring the recommendation to the depth of the defect for possible cartilaginous involvement. In the past, nasal reconstruction was argued to follow a conceptual framework based on aesthetic subunits.6 While this remains a valuable tool, others have leaned in favor of conserving as much native tissue as possible and focusing the reconstruction on the defect, and not on the subunit.2,7-8 In a similar shift, some have even argued for immediate nasal reconstruction as opposed to taking a delayed approach.9 Perhaps, the trained plastic surgeon will be able to identify wounds that will not heal favorably over time and require more emergent intervention to prevent a poor outcome. |

References 1. horne, C.H., Grabb and Smith’s Plastic Surgery. 2013: Wolters Kluwer Health. 2. Fadi, C.C. and A.C. Melissa, Nasal Reconstruction, in Essentials of Plastic Surgery, Second Edition. 2014, CRC Press. p. 403-419. 3. Mueller, R., Facial Trauma: Soft tissue injuries, in Plastic Surgery, P.C. Neligan, Editor. 2012, Elsevier Health Sciences: London. 4. Ramachandra, T. and W.R. Ries, Management of Nasal and Perinasal Soft Tissue Injuries. Facial Plast Surg, 2015. 31(3): p. 194-200. 5. Menick, F.J., A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg, 2002. 109(6): p. 1839-55; discussion 1856-61. 6. Burget, G.C. and F.J. Menick, he subunit principle in nasal reconstruction. Plast Reconstr Surg, 1985. 76(2): p. 239-47. 7. Singh, D.J. and S.P. Bartlett, Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg, 2003. 111(2): p. 639-48; discussion 649-51. 8. Rohrich, R.J., et al., Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg, 2004. 114(6): p. 1405-16; discussion 1417-9. 9. Ferreira, S., et al., he primary closure approach of dog bite injuries of the nose. J Craniofac Surg, 2014. 25(3): p. e216-8.

Plastic Surgery Resident | Fall 2016

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Journal Club; 2016 Fall; (4)

his paper also contains very helpful illustrations to demonstrate the concepts of “grasping” and “locking,” which can be confusing to diferentiate to the beginner. Be sure to read the section titled “internal vs external” as it cites the advantage of an internal knot and describes the opposing interplay between strength and gliding resistance. his article serves well as an introduction to the current principles used to evaluate the various repair techniques.

2. Flexor tendon injuries: II. Operative technique. Strickland JW. J / Am Acad Orthop Surg. 1995;3:55-62.

» he second of Dr. Strickland’s two-part series is a masterful

JOURNAL ARTICLES ON

FLEXOR TENDON REPAIR

EVERY PLASTIC SURGERY RESIDENT

SHOULD READ By M. Asher Schusterman II, MD

F

lexor tendon repair is a technically challenging area of hand surgery and one of the more researched and published topics in the ield. Over the past 50 years, diferent repair techniques and postoperative rehabilitation protocols have been thoroughly studied in the pursuit of the perfect outcome. Residents often ind it diicult to sift through the volumes of suture techniques and treatment regimens, but the following 10 articles highlight the principles and techniques that will enable any young plastic surgeon to tackle these challenging cases.

1. Suture techniques for tendon repair; a comparative review. Rawson S, Cartmell S, Wong J. / Muscles Ligaments Tendons J. 2013;3:220-228.

» his recent review article not only opens with an eloquent history on the evolution of the principles of primary lexor tendon repair, but it also educates the reader on the several speciic repair techniques that have been described throughout the years. Instead of sifting through stacks of literature from the past ive decades, residents should use this article as a reference for the various methods that they will be exposed to throughout their training. 16

Plastic Surgery Resident | Fall 2016

narrative of the operative treatment of lexor tendon injuries. He begins by reminding us of the principles set forth by Sterling Bunnell, MD, who used a meticulous surgical technique that minimizes trauma to the tendon, as this will result in better outcomes. Loupes and a bloodless ield are absolutely necessary. he surgical narrative that follows gives the reader an easily understandable picture of the operative course in repairing zone 1 and 2. Using the accompanying photos, the reader will feel as if he or she is watching Dr. Strickland perform the procedure himself. He also describes his method of primary tendon repair with illustrations, which is known as the “Indiana” repair. his technique utilizes the Tajima version of the Kessler repair with a horizontal mattress to create a 4-strand repair. he inal step is a running-locking epitendinous suture, making sure that all knots are buried. his is a great article for residents to read when they are preparing the night before encountering their irst lexor tendon repair. Read the irst of Dr. Strickland’s series for a more in-depth look at the science behind our understanding of lexor tendon anatomy and multi-factorial healing response.

3. MOC-PS CME article: Treatment of lexor tendon laceration. Lehfeldt M, Ray E, Sherman R. / Plast Reconstr Surg. 2008;121:1-12.

» While this CME article is efective in teaching several aspects of lexor tendon repair, the physical exam tutorial is particularly useful to beginners learning the basics of a hand exam. he authors review the lexor zones of the hand and discuss the standard of care for injuries at each level. he authors also demonstrate the proper techniques for testing the lexor digitorum supericialis and profundus using helpful photos. Residents of all levels will beneit from the discussion on incision choice, as this is very important to know while on a hand rotation. he article also includes brief discussion on proper treatment of partial lacerations and tendon sheath repair, and includes a helpful illustration of the 4-strand cruciate repair, which is a popular tendon repair technique. he section on complications is extremely thorough and reminds residents of the importance of proper tourniquet application and use. his article stands as an all-encompassing tutorial for surgeons of all levels.

4. he efect of epitendinous suture technique on gliding resistance during cyclic motion after lexor tendon repair: A cadaveric study. Moriya T, Zaho C, An KN, Amadio PC. / J Hand Surg. 2010;35:552-558.

» Placement of an epitendinous suture is, in most instances, a vital adjunct to lexor tendon repairs and helps in tidying the tendon ends after core repair, reducing the incidence of triggering and allowing for better tendon gliding. his study not only introduces the reader to ive common designs of epitendinous suture repair, but it tests those methods in an elegant cadaveric study. he results demonstrate the importance of a buried knot coniguration, as this signiicantly decreases gliding resistance even when using a 6-0 prolene suture. Furthermore, the authors mention in the discussion that if a knot cannot be buried, it should be placed on the lateral aspect of the tendon as opposed to the volar surface. his principle is also important for core suture repair and is evident in the evolution from the tradition grasping technique reported by Isidor Kessler, MD, (see additional reading) to the modiied Kessler method, which allows for an internal knot.

5.Digital function following lexor tendon repair in Zone II. A comparison of immobilization and controlled passive motion techniques. Strickland JW, Glogovac SV. / J Hand Surg. 1980;5:537-543.

» his early contribution from Drs. Strickland and Glogovac was the irst paper to directly compare immobilization and early passive motion protocols, showing that early motion was not only safe, but it actually produced better results than immobilization after primary tendon repair. his paper corroborated another famous article published three years earlier by Graham Lister, MD, Harold Kleinert, MD, Joseph Kutz, MD, and Erdogan Atasoy, MD, (see “Additional Reading”), which initially set forth this protocol of immediate postoperative mobilization. Prior to this, many postoperative protocols were driven by studies showing that the tendon repair site was weakest in the irst three weeks after surgery. herefore, to prevent high rupture rates, many surgeons would immobilize these patients for several weeks. As one would imagine, this only resulted in decreased range of motion primarily due to joint stifness and tendon adhesions. Although there was some evidence of this prior to its publication, this paper was essentially the “nail in the coin” for immobilization protocols. his paper also deines the total active motion (TAM) formula, which has been used by many in subsequent studies to measure the degree of postoperative lexion.

6.Indications, methods, postoperative motion outcome evaluation of primary lexor tendon repairs in Zone II. Tang JB. / J Hand Surg Eur. Vol. 2007;32:118-129.

» Flexor tendon lacerations in zone 2, known as “no man’s land,” continue to be a primary focus of research in lexor

tendon repair, given the complex anatomy and relatively poor outcomes seen with injuries at this level. In his personal review, Dr. Tang educates the reader about the concepts that he gained from more than 20 plus years of experience and how they continue to guide his treatment of these complicated injuries, from initial assessment through postoperative rehab protocol. he most educational section of this article, in my opinion, is his opening discussion on the indications for primary repair of zone 2 injuries. It is important to remember that the early recommendation for these injuries, given the variable outcomes, was tendon grafting (see Dr. Bunnell’s classic report in 1918). hus, it is vital to know when the situation is right for primary repair and when tendon reconstruction is the better option. Dr. Tang describes several clear scenarios and diferent subtleties that make primary repair favorable or not. Furthermore, his rule for delaying primary repair up to seven days, until an experienced surgeon can perform the repair, is poignant and important for residents to understand when faced with what may appear to be a simple, clean tendon laceration that seems ixable in the emergency room or clinic. he reader should also pay close attention to his treatment of the pulley system, namely A2 and A4, as his explanation gives the reader great insight into the function of these structures. his article has helped greatly in shaping the current standard of care for lexor tendon injuries in zone 2.

7.Development of lexor tendon surgery: Twenty-ive years of progress. Strickland JW. / J Hand Surg. 2000;25:214-235.

» In his masterpiece article, Dr. Strickland uses an unmatched literature review to provide us with a true “tour de force” of primary lexor tendon repair. He begins with a brilliant, thorough review of the basic science that has shaped our understanding of the anatomy, morphology, nutrition and biomechanics of lexor tendons that every surgeon must know prior to tackling cases. he tutorial on the biochemical mechanisms of tendon healing also stands out in this paper, as his describing the intrinsic and extrinsic healing processes and how they guide our understanding of adhesion formation and prevention. Along with illustrating several repair techniques, Dr. Strickland shows the results of experiments analyzing the strength of 2-, 4- and 6-strand repairs, how suture material afects outcomes and inishes with complications, postop protocols and tendon grafting. his paper is a lot to digest in one sitting, but the reader stands to gain a wealth of information upon completion.

8.Secondary lexor tendon reconstruction: A review. Freilich AM, Chhabra AB. / J Hand Surg Am. 2007;32

» Despite the shift to primary repair over the past century, secondary tendon repair and reconstruction is still indicated in patients presenting either in a delayed fashion or with segmental tendon loss.hese complex cases present a unique challenge to even the most capable hand surgeons.his Plastic Surgery Resident | Fall 2016

17

review article out of the University of Virginia uses a wealth of historical knowledge and evidence to educate the reader on delayed tendon repair, as well as one- and two-stage tendon reconstruction, providing current indications for each operative pearls for success. Namely, the discussion on two-stage reconstruction gives the reader a clear, step-by-step process of how to reconstruct the sheath and pulley system in stage 1 and subsequently reconstruct the lexor tendon using an autograft in stage 2. Pay close attention to the section on rehab protocols, as they difer from primary repair regimens.he article also discusses injuries in zones 3, 4 and 5, and the proper treatment of these diicult cases in the pediatric population.

9. Complications after lexor tendon repair: A systematic review and meta-analysis. Dy CJ, Hernandez-Soria A, May Y, Roberts TR, Daluiski A. / J Hand Surg Am. 2012;37:543-551.

» his meta-analysis out of the Hospital for Special Surgery in New York delivers the most current, reliable complication rates after primary repair.he paper reports rates of rupture of 4 percent, adhesion of 4 percent and reoperation of 6 percent. Furthermore, the analysis also shows that those rates have not signiicantly changed since 2000. Interestingly, the authors mention that signiicantly fewer adhesions were seen when a modiied Kessler repair is utilized, which is interesting because the 2-strand repair, when used alone, is not as strong as the other 4 and 6-strand repairs that have been described. Nevertheless, residents can feel conident using this article to quote complication rates to patients who are considering repair.

10. Flexor tendon repair, rehabilitation and reconstruction. Sandvall BK, Wood KK, Recor C, Friedrich JB. / Plast Reconstr Surg. 2013;132:1493-1503.

» his recipient of PRS’s Best Hand Paper in 2014 is a complete and up-to-date overview of the current standards of care for lexor tendon repair. Intended speciically for plastic surgeons, this article follows the entire timeline of treatment of lexor tendon laceration beginning with preoperative evaluation and continuing through long-term complications, giving the reader a stage-by-stage description of the current options at each step. he authors discuss several topics including the diferent options for anesthesia (wide-awake tendon repair), suture materials, tendon reconstruction, pediatric tendon repair and a variety of rehabilitation protocols. he authors even mention several new products that have been studied with a high level of evidence and show promise for primary tendon repair. While basic, this paper gives the reader a complete understanding of the treatment process, enabling any plastic surgeon to handle these cases and directs them on where to look for more detailed articles on any topic. 18

Plastic Surgery Resident | Fall 2016

ADDITIONAL READING 1. he zig-zag volar incision for lexor-tendon surgery. Bruner JM. Plast Reconstr Surg. 1967;40:571-574. 2. Primary repair without immobilization of lexor tendon division within the digital sheath: an experimental and clinical study. Acta Orthop Scandinav. 1969;40:587-601. 3. Primary lexor tendon repair followed by immediate controlled mobilization. Lister GD, Kleinert HE, Kutz JE, Atasoy E. J Hand Surg. 1977;2:441-451. 4. Flexor tendon: I. Foundations of treatment. Strickland JW. J Am Acad Orthop Surg. 1995;3:44-54. 5. Core strength purchase afects strength of tendon repairs. Tang JB, Zhang Y, Cao Y, Xie RG. J Hand Surg. 2005;30:1262-1266. 6. Gliding characteristics and gap formation for locking and grasping tendon repairs: A biomechanical study in a human cadaver model. Tanaka T, Amadio PC, Zhao C, Zobitz ME, Yang C, An KN. J Hand Surg. 2004;29:6-14. 7. Flexor tendon repair rehabilitation protocols: A systematic review. Starr HM, Snoddy M, Hammond KE, Seiler JG. J Hand Surg. 2013;38:1712-1717. 8. Flexor-tendon reconstruction of severely damaged hands: A two-stage procedure using a silicone-dacron reinforced gliding prosthesis prior to tendon grafting. Hunter JM, Salisbury RE. J Bone Joint Surg Am. 1971;53:829-858. 9. Factors that inluence the outcome of Zone I and Zone II lexor tendon repairs in children. Elhassan B, Moran SL, Bravo C, Amadio P. J Hand Surg Am. 2006;31:1661-1666. 10. An evidence-based approach to lexor tendon laceration repair. Lalonde DH. Plast Reconstr Surg. 2011;127:885-890.

Join the PRS Journal Club discussion on social media Join #PRSJournalClub to discuss, debate and digest the latest plastic surgery research with colleagues from around the world. With each issue of PRS, read 3 discussion-worthy articles, each paired with three classic papers (including one classic CME); listen to the journal’s new podcast featuring special guests and Resident Ambassadors (via PRSJournal. com, iTunes, or YouTube.com/PRSJournal), and discuss with the authors live on Twitter (@PRSJournal) in a monthly moderated Q&A session (#PRSJournalClub). The PRS Journal Club has been attracting readers, listeners and participants from around the world:

“I love the PRS journal podcasts,” says Australian plastic surgeon Damian Marucci, MBBS, PhD. “The March group, in which David Song, MD, moderated two of the papers was simply awesome.” Catch up on previous Journal Clubs on the PRS Resident Chronicles blog (prsresidentchronicles.wordpress.com/) and join #PRSJournalClub live in June for a discussion with authors on the topic of “Full and Short Scar Face Lit Incision Techniques in Four Sets of Identical Twins & One Set of Identical Triplets.”

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he PSF Ofers Exciting Research Opportunities for Residents he Plastic Surgery Foundation (PSF) is pleased to announce the launch of he PSF 2017 Grants Cycle! he PSF Grant Program ofers valuable opportunities for plastic surgery residents as a way to enhance their training experience. here are a variety of funding mechanisms available such as he PSF Research Fellowship that provides salary support to residents to aid in their development as future researchers, as well as pilot grants that provide seed funding intended to allow investigators to begin work on preliminary research projects related to the plastic surgery sciences. he PSF also ofers combined pilot grants that address specialty areas of research supported through collaborations with sister societies to address specialty areas such as hand surgery, peripheral nerve, maxillofacial, reconstructive microsurgery, education and more! Following is a more detailed overview of funding opportunities available in the 2017 cycle and information on how to apply: • ASE/PSF Combined Research Grant • Combined Pilot Research Grant • Pilot Research Grant • National Endowment for Plastic Surgery Grant • PSF/ MTF Dermal Tissue Grant • Research Fellowship Grants ASE/PSF Combined Research Grant he Plastic Surgery Foundation (PSF) and the Association for Surgical Education (ASE) recognize the importance of fostering the development of surgeon scientists that yield improvements in patient care in surgery. he ASE/PSF Combined Research Grant is intended to fund a research project that will advance the scientiic knowledge and aim to develop and validate new methods of surgical care. Research projects that focus on surgical education and training in plastic surgery are encouraged. Combined Pilot Research Grant he PSF, along with AAHS, AAPS, ACAPS, ASMS, ASPN, ASRM and PSRC, recognize the importance of promoting innovative research in hand surgery, academic plastic surgery related to research, peripheral nerve research, microsurgery and stimulating fundamental research in plastic surgery. Together, these subspecialty organizations are dedicated to fostering the development of surgeon scientists and are committed to increasing the amount of research dollars available to fund pilot research studies that set the stage for investigators to apply to larger funding agencies. 22

Plastic Surgery Resident | Fall 2016

Pilot Research Grant he PSF Pilot Research Grant is intended to support residents and junior faculty in their eforts to address focused research questions, obtain preliminary data to support larger grant proposals in the future, and develop a line of research that can be carried forward into an academic career. his grant supports the preliminary or pilot phase of these research projects. Senior investigators are encouraged to use other funding mechanisms, but they may apply for this grant if they are proposing a new research concept or novel idea for which no prior funding has been obtained. Projects that are a prelude to the NIH or other external funding agencies are encouraged. National Endowment for Plastic Surgery Grant he National Endowment for Plastic Surgery Grant is intended to support research projects that translate clinical or basic science research indings into clinically relevant advancements or tools having a high likelihood of impacting daily practice and patient care within the next few years. Applications will be evaluated based upon the importance of the study question, soundness of study design, demonstration of study feasibility through preliminary/pilot data, the quality of the investigator team and the use of appropriate statistical and analytic methods. PSF/MTF Dermal Tissue Grant he PSF and the Musculoskeletal Transplant Foundation (MTF) will ofer research grants to investigators studying allograft tissue transplantation in plastic and reconstructive surgery. hese grants are intended to provide support for research projects focused on biologic reconstruction with a strong clinical translation component that utilize dermal, adipose, placental or other allograft transplant technologies. he PSF and MTF will ofer research grants for projects with a high likelihood of impact on scientiic discipline and/or on patient care. Examples of clinical technologies of interest include, but are not limited to, the use of allograft biologics in breast reconstruction, wound healing, nose reshaping, soft tissue defect illing and other applications of allograft tissue in plastic and reconstructive surgery. Research Fellowship Grants he PSF Research Grant and Fellowship Programs he PSF supports investigators from the beginning of their continued on page 38

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USBS/MG151/14-0001 6/2014

Put your plastic surgical vocabulary skills to the test! 1 2

By Sanjay Naran, MD

3 4 5 6

7

8

9 10

11

12 13

15

14

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17 18

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20 21 22

ACROSS 1. Technique that recreates the antihelical fold with a series of molding sutures on the posterior aspect of the ear cartilage. 2. his reconstruction involves taking a tarsoconjunctival lap from the upper eyelid, leaving 3 to 4 mm of the upper tarsus intact, and advancing the remaining tarsus and conjunctiva to the lower eyelid defect. 4. his ligament is a fascial thickening that supports the globe. 7. his auricular artery is the primary blood supply to the anterior surface of the ear. 8. Syndrome characterized by nasomaxillary hypoplasia. 9. Abbreviation for a hearing aid aixed in the mastoid region using an osseointegrated implant. 15. Ear deformity that is a complication of rhytidectomy. 16. his law describes equal innervation to the eyelids in that the signal to the levator is the same despite the potential need for each eyelid to work independently. 18. Maternal concentrations of this hormone are highest in the irst 3 days of life and begin to decrease thereafter. 20. Technique that relies on the excision of postauricular skin to achieve ear setback. 22. his nerve provides sensory innervation to the lateral fat pad of the lower eyelid.

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Plastic Surgery Resident | Fall 2016

DOWN 1. Hypoplastic condition of the ear which includes a spectrum from complete absence of the ear to a smaller than normal ear with normal morphology. 3. he antihelix and antitragus of the external ear arise from this brachial arch. 5. his technique corrects a prominent helical tail by ixation of the helical tail to the concha. 6. his gland’s secretions prevents evaporation of tear ilm over the eye. 10. Congenital anomaly in which the upper part of the retroauricular sulcus is absent or buried under the temporal skin. 11. his ligament is a condensation of the sheath overlying the anterior superior part of the levator muscle. 12. his technique applies the Gibson and Davis principle, which states that cartilage tends to curl away from a cut surface. 13. Syndrome describing a tetrad of indings including ptosis, telecanthus, epicanthus inversus, and decreased horizontal lid issure. 14. Congenital ocular defect of the eyelid, iris, retina, choroid, or optic disk, ranging in size from a small notch to a large structural cleft. 17. his phenomenon is an upward and outer movement of the eye when the eye is closed, and serves as a protective mechanism which keeps the cornea protected behind the upper eyelid. 19. Surgical techniques for correction of prominent ears that relies on placement of conchomastoid sutures. 21. Ear deformity featuring a third crus, a lat helix, and a malformed scaphoid fossa. Answer key on page 37

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Program Peek A look inside the “Town and Gown” practice of academic plastic surgery at the University of Pittsburgh By Sameer Shakir, MD “Program Peek” highlights the diverse practice of plastic surgery across the country one residency program at a time. We hope by describing various approaches to plastic surgery training that medical students, residents, and Fellows alike will critically appraise and consequently adopt meaningful changes at their home institutions. In our introductory article, we provide a glimpse into comprehensive academic plastic surgery and the innovative curriculum at the University of Pittsburgh.

Leadership • J. Peter Rubin, MD; UPMC Endowed Chairman in Plastic Surgery • Joseph E. Losee, MD; Ross H. Musgrave Professor in Pediatric Plastic Surgery, Executive Vice Chairman • Vu T. Nguyen, MD; Residency Program Director

History

Clinical Experience

• Established in the 1940s with four prior chairmen

• “Town and Gown” clinical training encompassing seven hospital sites throughout the city of Pittsburgh including the University of Pittsburgh, Medical Center, Children’s Hospital of Pittsburgh, Allegheny General, West Penn and Veterans Afairs Health Systems

• Achieved departmental status in July 2012 • 22 trained chairman in plastic surgery previously trained at Pitt • Site for the irst bilateral hand

26

transplant under former chairman W.P. Andrew Lee, MD, in 2009

Plastic Surgery Resident | Fall 2016

• 24 full-time and 11 volunteer clinical faculty, including three former chairs of Plastic Surgery • 28 surgical residents across PGY1 to PGY7 • Craniofacial, hand, microsurgery and body contouring fellowships • Extensive training in breast surgery, general reconstruction, head & neck, upper extremity, pediatric/ craniofacial, body contouring, aesthetic, burn and oral-maxillofacial surgery • Recognized as the single plastic surgery program in the country to perform 100 percent of head-andneck microsurgery and subsequently perform ~150-200 microsurgical reconstructions annually Residents bonding with visiting faculty during the annual “Resident Camaraderie Day” in Summer 2016.

• Beginning in 2016, Pitt now trials a “Milestones” approach to residency training involving measures of core clinical competencies rather than traditional post-graduate year to determine graduation eligibility Educational curriculum • Protected time including four hours per week of dedicated core curriculum, M&M and Grand Rounds • Weekly “Sunday School” at Allegheny General Hospital to discuss clinical indications, anatomy and surgical technique with senior Plastic Surgery attendings • Annual host to the ACAPS Plastic Surgery Intern Boot Camp initiated in 2015 to provide a weekend-long introductory primer to plastic surgery

Pitt Plastic Surgery residents pictured with Chair J. Peter Rubin, MD, at the Ohio Valley Society of Plastic Surgeons (OVSPS) Annual Scientiic Meeting. he OVSPS Cup, representing the teaching program with the best representation at the meeting, has remained in Pitt’s possession for more than a decade.

• Endowed Musgrave and Vecchione lectureships

A message from the program director, Vu T. Nguyen, MD

• Microsurgical, hand and craniofacial skills laboratories held annually • Monthly journal clubs highlighting relevant research from Plastic and Reconstructive Surgery Research • Four nationally funded basic science laboratories related to tissue engineering, transplant immunology, pediatric craniofacial biology and wound healing • Each laboratory is supervised by a surgeon and scientist to help bring advances from the bench to the bedside • Optional funded research year during PGY-4 • Annual Resident Research Day with basic science and clinical prizes awarded by nationally and internationally renowned visiting professors Resident beneits • $1,250 enrichment fund annually • Free hospital parking • hree weeks vacation plus ive days of holiday time annually • Meeting reimbursement if presenting • Moonlighting privileges during research year

At Pitt Plastic Surgery, we have a proud legacy of having recruited and trained generations of leaders in our ield. To date, there have been more than 300 plastic surgery residents and fellows who have trained here at Pitt. At last count, 22 alumni of Pitt’s plastic surgery residency program have served at one time as division chiefs or department chairs at nearly a quarter of the nation’s 90 plastic surgery programs. In addition, numerous leadership positions in local, regional, national and international organizations, in plastic surgery and surgery in general, have been held by Pitt alumni. herefore, for over a half-century, Pitt Plastic Surgery has been a leader in the ield and at the forefront of resident education. A critical factor in that equation, has been the citywide service that the residency program provides. Beginning in the 1970s, the two existing Pittsburgh residency programs in Plastic Surgery (UPMC and West Penn) combined, and have since collaborated to form a unique “town-and-gown” relationship; with rotations existing at UPMC, AGH, Mercy, and West Penn. his town-and-gown experience of Pitt Plastic Surgery has become one of the hallmarks of our program, and one for which we are nationally known. he “community” attending plastic surgeons at these non-university hospitals take this relationship very seriously and contribute to our residency program, often in a greater way than our full-time academic faculty. his includes attendance at our weekly, citywide grand rounds conferences and journal clubs, and participation in all academic and administrative events on the calendar (e.g., formal resident evaluations, residency interviews, resident research day, program evaluations/program director’s retreat, etc.). All of these non-UPMC attendings have appointments within the Department of Plastic Surgery and are registered as ACGME faculty for our residency programs. Due to the direct involvement of this large number of faculty members, situated in diverse clinical environments, and with difering practice patterns; the breadth and depth of surgical exposure and experience we provide for our residents is virtually unparalleled. his is a major factor not only in ongoing education, but in recruitment of top tier medical students and residents into our program. hese elements coalesce to produce the town-and-gown nature of our unique and nationally recognized combined residency program. In essence, this provides our residents with “several small residency programs” rolled up into a large, composite experience – including exposure to three prior chiefs of Plastic Surgery. | Plastic Surgery Resident | Fall 2016

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Q & A WITH V U N G U Y E N , M D

By Kendra Y. Mims Plastic Surgery Resident seeks to provide readers with tips to help them advance in their careers after residency by sharing insights on how to create their desired career path. In this issue, we present Vu Nguyen, MD, assistant professor in the University of Pittsburgh Department of Plastic Surgery and program director of the Plastic Surgery Residency Program. Dr. Nguyen completed a combined residency program in general and plastic surgery, in addition to a two-year research fellowship, at the University of Pittsburgh. Following residency, he completed a clinical fellowship in microsurgery, breast and aesthetic surgery at the University of Pennsylvania. he focus of Dr. Nguyen’s fellowship training centered on the spectrum of microsurgical techniques for breast reconstruction, as well as implant-based breast reconstruction and advanced aesthetic procedures. He specializes in microsurgery and breast reconstruction. Dr. Nguyen co-directed the inaugural ACAPS-sponsored Plastic Surgery Boot Camp in 2015, a three-day program to help facilitate the transition of integrated and independent residents into plastic surgery training. he University of Pittsburgh Medical Center hosted the event, which drew 45 irst-year plastic surgery residents from 22 plastic surgery programs across 15 states. Due to the program’s success, the Boot Camp expanded this year to three locations: Pittsburgh, Kansas City, Kansas, and Tampa, Fla., to include approximately 75 interns, representing 27 plastic surgery programs. Dr. Nguyen discusses his role as the chair of the Intern Boot Camp Task Force, as well as highlights from his career journey, with PSR below:

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Nguyen: I was proactive in diferent areas, both clinical and academic. I took two years of to work in the basic research lab and then continued with clinical projects as a resident. It’s also about being in the right place at the right time. PSR: HOW DID YOU SELECT YOUR FELLOWSHIP? Dr. Nguyen: I really wanted to have focused training on 28

Plastic Surgery Resident | Fall 2016

microsurgical breast reconstruction. I speciically chose the Penn fellowship because it was very focused on free-lap breast reconstruction during that time. I wanted that to be a major clinical element of my career. PSR: HOW IMPORTANT IS IT TO HAVE A MENTOR? Dr. Nguyen: I think it’s important to have a mentor at all stages of training and your professional life. It’s an essential component of growth that can change as you change or as your stages in life change. It’s also important to have mentors for diferent things, whether it’s personal or professional growth. Sometimes those areas can blend together or a person can fulill multiple roles, but it’s important to have mentorship in a number of critical areas. PSR: WHAT IMPACT HAS YOUR FELLOWSHIP HAD ON THE ADVANCEMENT OF YOUR CAREER? Dr. Nguyen: It was critical for me to be able to do what I wanted clinically and to also obtain the academic faculty position that I hold. Microsurgery fellowships are not only clinically important, but in this day and age they are increasingly important to being able to obtain more competitive and/or academic positions. PSR: WHAT IS THE MOST IMPORTANT ATTRIBUTE OF A SUCCESSFUL RESIDENT? Dr. Nguyen: You need to have persistence, as well as a strong work ethic. Let’s be honest, we’re not all gifted with a photographic memory and/or an intuitive set of hands. In residency and in life, hard work and persistence can often overcome brilliance, intellect or having a gifted set of hands. PSR: LOOKING BACK, IS THERE ANYTHING YOU WOULD HAVE DONE DIFFERENTLY? Dr. Nguyen: I would not have rushed to inish, and I would’ve considered completing additional training or an additional clinical fellowship. Once you are done with training and in practice, it becomes much more diicult to go back into fellowship. You’re in a diferent place from a learning point of view. My advice is to recognize that it’s more of a marathon than a sprint. I think many people today are doing multiple fellowships in order to pursue a particular

career focus or in order to become as well-trained as possible before they begin practice. PSR: WHAT DO YOU ENJOY THE MOST ABOUT YOUR WORK? Dr. Nguyen: I enjoy the teaching aspect and interacting with the residents and Fellows on a daily basis. here are opportunities in every situation to teach and to learn as you’re teaching. A lot of that depends upon inding some important lesson in whatever you do, whether that is operating or seeing patients at the bedside or clinic. To borrow a dictum from another educator, you should try and learn three things every day: something knowledge-based, something technical and something systems-based. PSR: HOW DID YOU COME TO SPEARHEAD THE PLASTIC SURGERY BOOT CAMP? Dr. Nguyen: he Boot Camp was created as an initiative by Jefrey Janis, MD, the ACAPS president at that time. We built a small task force to create a boot camp program for plastic surgery, and I was appointed to oversee the task force. We looked at funding options and decided to have the inaugural boot camp in Pittsburgh in 2015 because of the centralized location, in addition to having the logistical support and faculty who could support the program. We launched our second boot camp event in July and expanded it to three locations. It has been great to see the program grow to cover more residents, locations and times. PSR: DO YOU PLAN TO CONTINUE TO OFFER THIS PROGRAM EVERY YEAR? Dr. Nguyen: Yes, if we have stable support. We would ideally like to grow that support to encompass six regional centers across the United States that would cover the approximately 200 incoming plastic surgery interns every year and provide every participant with the opportunity to come to their regional boot camp. PSR: WHY IS THE PLASTIC SURGERY BOOT CAMP IMPORTANT TO THE SPECIALTY? Dr. Nguyen: he original notion was that there were residents transitioning to plastic surgery that could beneit

if we had some form of standardized education, where everyone would receive a working knowledge and critical skills before they transitioned from the position of a medical student to a surgical resident. here is a lot of key, baseline information to be transferred during the program and in a relatively short amount of time. herefore, we created an educational environment that was low-pressure and fun. We also had people transitioning from general surgery training into the independent track and wanted to integrate them into the program. Although they’re very skilled at being a resident, they don’t necessarily have the basic plastic surgery knowledge. he program was created to encompass both the integrated track and the independent track. PSR: WHAT WAS YOUR FAVORITE PART OF THE BOOT CAMP? Dr. Nguyen: It was really enjoyable to see interns come in and hear how excited they were about inally being a resident and/or inally being in plastic surgery. Many of these people knew each other from the interview trail, and now they’re on the other side of it – they’re matched and in programs. It was great to see them reconnect so soon after matching. here is a lot of camaraderie built through the program. he program itself was built around conceptually having short 15-minute lectures and then spending a lot of time doing practical, physical procedures, such as splinting, plates and screws, interviewing standardized patients. All of the activities can be fun and educational at the same time. PSR: WHAT CHALLENGES DO YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Nguyen: Having enough time for clinical care, administrative work, research output and teaching responsibilities. hose things are all good problems to have. It’s about inding that correct balance that its your professional life. PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIFE? Dr. Nguyen: You have to set priorities. You need to make personal time and family time a priority, just as you would an important meeting or case. It can be as logistically easy as putting family appointments on your Outlook calendar and mentally knowing that important things take time and commitment. Recognize that there’s a sacriice to all of those things, and it’s important to be happy with the sacriices that you make. PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Nguyen: Plastic surgery is such an incredible ield because of the diversity. he important thing within this ield is to discover the thing you really love to do, and to get good at it. And to be comfortable and happy with the sacriices it may take to do the thing you want to do. |

Dr. Nguyen with participants in the 2016 Plastic Surgery Residents Boot Camp session at the University of Pittsburgh. Plastic Surgery Resident | Fall 2016

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Things I wish I had known residency By Jacob Unger, MD To all of you bright-eyed and bushy-tailed medical students-soon-to-be-interns, CONGRATULATIONS!

E

njoy this time on top of the world, because you are about to be back on the bottom! Life is an exciting journey, but many of you, especially in medicine, have probably noticed a certain cycle in these early parts of the path to your careers. You start your freshman year of high school or college or your irst year of medical school scared, nervous and determined. You discover that you grow in knowledge, conidence and wisdom as you move through the ranks. And, at the pinnacle of your mastery of each given arena of education, you are thrust back down to the beginning all over again! No transition may be as nerve-racking as the transition from student-doctor to doctor. You may be the president of your medical school class or the person that all of the irst-year go-getters run to for advice on how to get their irst paper published or poster accepted, but you are about to have a “real job” where you will be responsible for peoples’ lives and wellbeing in a very real way, often in a new place and city.

While this experience is likely to frighten you, I encourage you to fully embrace it and approach it with great mindfulness. If your experience is anything like mine, this will be one of the most memorable and wonderful experiences you will ever have in your medical career. You will not be the most knowledgeable person in the room any longer, but I encourage you not to see this as a weakness. Harness its potential to help you grow exponentially as a physician, and use it as a strength. Here is some advice on how to do this: BE HUMBLE. It’s time to learn from your peers and upper-level residents. You will ascertain more experience, understanding and knowledge faster than you ever thought possible. BE EMPATHETIC. Not only to your patients, but also to your fellow interns. You will each bring certain strengths to the team. his is a time to work on fostering a team environment at the highest level. It is only through shared responsibility and excellent communication that your patients can receive the level of care they deserve. BE PREPARED. While mistakes are bound to be made, it is your duty to ight the inevitable to the best of your ability. Study your patients’ charts, read their medical histories the night before rounds and have a plan of attack for ensuring that you carry out the day’s tasks without letting anything fall through the cracks. BE FOCUSED. Work-life balance is important, and making new friends is a wonderful aspect of beginning residency, but always remember that your new job carries a great deal of responsibility. Ensure that you are ready to start each day with focus and purpose; it is a great privilege to be a physician. FINALLY, HAVE FUN! My wife and I always say life is not about the destination. It’s about the journey, so enjoy the ride! Residency is exhausting, physically and emotionally. You will spend more time with your co-residents than anyone else in your life during your training, and there will be tremendous highs and lows throughout these six-plus years. When times are tough, remember that these shall pass, and when there are moments of joy and triumph, you should take them in deeply, because these are also leeting. My recommendation is to savor the entirety of the experience. Remember, this is your only chance to train. his will be the foundation of your entire career. In many ways, I envy the complex and wonderful experience you are all about to embark on. Trust me when I say, it will be one of the most amazing and formative experiences of your life. I wish you all the best of luck, and to that end I remind you, in the words of Louis Pasteur, “chance [luck] favors only the prepared mind.” Godspeed. |

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Plastic Surgery Resident | Fall 2016

#PRSJou J rnal n Club l

A New Globally Interactive Journal Club, Podcast, and Live Discussion Series THREE WAYS TO JOIN: 1 l

2 l

3 l

Read Journal Club picks of the

Listen and learn as Resident

Discuss. Join our live Twitter

month. Each month, three articles

Ambassadors and a special Plastic

talk. Each month, the Resident

are selected, and paired with 2

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31

Coding for injectable treatment of Dupuytren’s contracture

D

upuytren’s disease is a benign, progressive ibroproliferative disorder afecting the palms of the hands. It is characterized by the formation of collagen-rich nodules and cords, which gradually contract by the action of myoibroblasts, resulting in joint contractures. Collagenase clostridium histolyticum (marketed as Xialex® in the United States) is a novel treatment for Dupuytren’s contracture, approved by the U.S. Food and Drug Administration in February 2010. Prior to its availability, percutaneous needle aponeurotomy or surgery were the only treatments for contractures related to this disorder. Intra-lesional use of clostridial collagenase can cause enzymatic disruption of these cords, and this was evaluated in a total of 1,082 patients receiving 2,630 injections during its clinical development, including two large prospective, randomized, double-blind, placebo-controlled trials: Collagenase Option for Reduction of Dupuytren’s (CORD) I and CORD II.

Both studies showed a statistically signiicant reduction in contracture compared to placebo (64.0 percent vs. 6.8 percent contracture resolution after treatment in CORD I; 44.4 percent vs. 4.8 percent contracture resolution in CORD II). Treatment was well-tolerated, with the majority of adverse events self-limited; serious adverse events related to collagenase treatment were rare (less than 2 percent). One recent study showed slightly worse correction of contracture at the MCP and PIP joints with use of collagenase as compared to surgery with limited fasciectomy, with residual contracture at 6-12 weeks of 13-degrees vs. 6-degrees for MCPs (p>0.05), and 25-degrees vs. 15-degrees for proximal interphalangeal (PIP) joints (p<0.05). However, there seem to be fewer adverse outcomes with collagenase and ive-year data show recurrence rates that are similar at 45-50 percent. Maximal improvement with use of collagenase is seen in patients with less severe contractures and with isolated contractures of the metacarpophalangeal (MCP) joint.

Photos: Dupuytren Foundation/dupuytrens.org

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Plastic Surgery Resident | Fall 2016

Current indications for intervention (surgery or collagenase injection) include MCP contractures of greater than 30-degrees and PIP contractures greater than 0-degrees and most literature shows limited collagenase eicacy if the PIP contracture is greater than 40-degrees. Manufacturer recommendations are for up to two cords in the same hand to be treated at one time.

CODING FOR XIAFLEX TREATMENT Xialex is only indicated for Dupuytren’s contractures: ICD10 code M72.0 (Palmar fascial ibromatosis [Dupuytren]), old ICD-9 code 728.6 (Contracture of palmar fascia). Treatment protocol consists of a two-day regimen. Day 1: Injection of a Dupuytren’s cord is coded with CPT 20527: “Injection, enzyme (e.g., collagenase), palmar fascial cord (i.e., Dupuytren’s contracture).” CPT J0775 is used to code for the medication: “Injection, collagenase, clostridium histolyticum, 0.01 mg.” As the billing unit is 0.01mg, but the recommended dose for each cord is 0.58 mg, CPT J0775 is coded 58 times. Each vial of Xialex contains 0.9 mg of lyophilized powder and any remaining reconstituted solution is to be discarded, so

CPT J0775 with a -JW modiier (“Drug amount discarded/not administered to any patient”) should be coded 32 times. If a second cord is injected, or one cord afecting two joints is injected twice, then CPT 20527 with a -51 modiier can be billed, and the appropriate units of Xialex billed with CPT J0775 and J0775-JW. Day 2: For the follow-up visit 24-72 hours later, when the cord is manipulated and contracture released, providers should code CPT 26341: “Manipulation, palmar fascial cord (i.e., Dupuytren’s cord), post enzyme injection (e.g., collagenase), single cord (10-day global).” If a splint is to be applied, bill CPT 29130: “Application of inger splint; static.” A second cord manipulation can be billed with CPT 26341-51 and 29130-51.

CONCLUSION Xialex is a irst-in-class biologic, injectable Collagenase clostridium histolyticum that is considered a safe, efective alternative to surgery for patients with Dupuytren’s contracture. Appropriate coding must be used to account for the amount of medication used and discarded, two separate days of treatment, and if more than one site is treated. |

Plastic Surgery Resident | Fall 2016

33

ESSAYS

Osler’s Ideals as a Model for Professionalism in Plastic Surgery / continued from page 7 aptly cleans the room after his cases and the manager who efectively creates the O.R. schedule deserve the same respect for their eforts. As a result, he enjoys some of the fastest room turnovers and surgical scrub help among any surgeons. Most team members would rather join forces with the humble practitioner who permits his or her skillset to speak for itself than those who feel compelled to tout their own gifts at the expense of others. Most of us have experienced daily events where the power of modesty is fully displayed. Whether it be in the operating room, a clinical oice, or even during a harried emergency room consultation, a humble, graceful attitude naturally recruits help both for the professional practitioner and, more importantly, the patient. After coming to appreciate the four qualities above that Osler considered indispensable to a true professional, it becomes clear how such a foundation should almost inevitably result in authentic professionalism. However, despite the high praise for these elements, Osler claims that “in the physician or surgeon no quality takes rank with Imperturbability.” By this he means “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, (and) impassiveness… without, at the same time, hardening ‘the human heart by which we live.’ ”3 Osler has, perhaps, distilled the concept of the “professional” to a single thought. Such lofty prose cannot be negated, but it also raises an important question: Who could possibly maintain such lawless practice? More to the point, who among those of us who fall short of professional perfection could hope to someday meet such colossal standards? For no matter how true the sentiment rings, it is the practice of professional tenets that helps patients and serves a societal purpose.

Lead and learn by example To fortify the plastic surgeon who might seek to enrich his

or her professional conduct, even more revered teachers’ wisdom than Osler’s may be sought. Since the days of Socrates, scholars have asked, “Can you tell me whether virtue is acquired by teaching or practice?”4 Aristotle later opined that “we learn by practice, and the best practice is to follow a model of the virtuous person.”5 Osler himself said that “we can only instill principles, put the student in the right path, give him method, teach him how to study, and early to discern between essentials and non-essentials.”6 Just as trainees learn the principles of surgery during an operation that supersede the rote performance of its technical steps and manual maneuvers, they also beneit from the examples of professional role models. hrough the careful appreciation of the practices of our predecessors, such as Osler and countless others, we may all hope to develop the underpinnings of true professionalism that matter most in plastic surgery. “he Art of Detachment, the Quality of horoughness, the Virtue of Method, and… the Grace of Humility,” culminating in “Imperturbability,” form the Oslerian mantra of the consummate professional. he apogee of these ideals provides an archetype to guide us all in the daily delivery of professional plastic surgical care. Far from a mandate to be enforced by punishment or sanction, Osler instead bestows plastic surgeons with an object for our aspiration to better ourselves and our profession. | References 1. Racy, J. Professionalism: sane and insane. J CIin Psych.1990;51: 138-140. 2. Flesch, R. he Book of Unusual Quotations. p 122. Harper: 1957. 3. Osler, W. “Aequanimitas,” Valedictory Address, University of Pennsylvania. Philadelphia, PN. May 1st, 1889. http://www.medicalarchives.jhmi.edu/osler/aequessay.htm. Accessed December 15th, 2015. 4. Jowett, B, translator. he Dialogues of Plato. Random House: New York, 1937:349. 5. Barnes, J, editor. he Complete Works of Aristotle: he Revised Oxford Translation, Vol II. Princeton University Press: Princeton, NJ, 1984. 6. Osler, W. “After Twenty Five Years,” an Address at McGill College, Montreal, Canada. 1899; published in Aequanimitas: With Other Addresses to Medical Students, Nurses and Practitioners of Medicine, p 210. H.K. Lewis: London, 1910.

Professionalism of Interprofessionality / continued from page 8 with multiple diferent professionals, each playing an integral part in providing high-quality care. However, what most commonly transpires is interdisciplinary interaction rather than interprofessional teamwork. Surgeons enjoy a privileged status, traditionally being thought of as the “most integral,” and sit atop the operational hierarchy. Mentors pass this ambience of interactions to trainees still today. Traditionally, surgeons are quite content with this structure19 and oblivious to the reality that team interaction in the O.R. is severely lacking.20 Worse still, others have previously investigated the negative efect that the traditional hierarchal structure, lacking IP, has on team members, communication and patient outcomes.19-27 34

Plastic Surgery Resident | Fall 2016

he source of these issues is thought to result from a culture of domination8,28 and involves hierarchies of control consisting of power over other team members. What can result frequently is lateral violence, bullying, disdain and fear of reporting safety issues or measures for quality improvement. As a result, patient care sufers. What is important to not confuse is that the inherency of hierarchy or structure being the driving force behind these issues, but rather the culture of the hierarchy: domination. On the opposite side of the spectrum are cultures of partnership with hierarchies of actualization at their core. his allows for care to be ofered to patients alongside other team

members while knowing more about others’ roles and learning from them. Undoubtedly, in medicine leaders are a necessity, and as plastic surgeons, that is the role we will occupy. However, what is perpetuating deiciencies in IP is the culture of domination. hose in leadership are the ones who most strongly can impact a system’s culture, and thus we are positioned to identify and sustain movement toward a culture of partnership. Leading by example, it is possible to integrate into health systems focus on increasing teamwork over simply interacting. For those surgeons currently in practice, making such a change would be the most dramatic. Not only personally, because it will involve a wholesale paradigm shift, but also globally because they occupy one of the most powerful leadership roles and have a potential to impact change on the largest number of people. Moreover, speciically important are plastic surgery faculty, because of the “hidden curriculum” wherein ideas of culture and IP are taught to trainees. How residents and students gain skills of ethics and professionalism is often through role modeling by their faculty. Trainees emulate their instructors, and although “role modeling can be a powerful teaching method, its value is dependent on what the person in charge is modeling.”29 Some may argue that IP jeopardizes accountability, and that this is easier to establish when leaders are dominating. If IP encourages a horizontal spread of responsibility, it may lead to situations wherein no one is accountable when something goes wrong.

In fact, the opposite may be true By fostering cohesion and partnerships in the care of patients, all participants can actualize a sense of responsibility. Rather than having those in non-leadership roles feel marginalized in a domination system and simply present to take instruction, IP allows them a personal sense of importance as a member of the team. And as a result, there is the ability to develop shared accountability associated with increasing participation. Moreover, as has been shown repeatedly, IP is associated with fewer safety issues, better communication and improved patient outcomes.13-18 As well, is seems logical that IP is essential in increasing globalization of plastic surgery care and arenas such as telemedicine. Worth mentioning is the importance of these concepts of IP and a culture of partnership with regard to the trainee. he practices adopted and modeled during training are likely to solidify in one’s career. Discussions with those physicians who graduated from medical schools where nursing rotations were obligatory, indicate that there is tremendous educational

value in positioning “captains” into roles of “board sailors” as part of their preparation for leadership roles. Currently, for trainees to gain this kind of insight, they are going to need exposure and curriculum relating to IP.8, 28 Additionally, the hidden curriculum and role modeling are not exclusive to faculty. In the same fashion that a resident learns from their faculty, so do junior residents from senior residents and students from their superiors. So if the perpetuation of domination is not disturbed early and across many levels, it will persist.

Conclusion As we move toward modern health systems, those in leadership roles, such as plastic surgeons, are obligated to improve and implement strategies directed at patient care and outcomes. We know that by changing health-care structures to be more focused on partnerships centered in IP that outcomes are improved and experiences are better. hese improvements in outcome are becoming expectations, and acceptance of the rigidity of tradition will not be practical in the near future. Concerns regarding diluting accountability by adopting a teamwork model are unfounded. Hopefully there will be encouragement and support for curriculum development and awareness of IP – and cultures of partnership in plastic surgery. | References 1. Miller FG, Brody H, Chung KC. Cosmetic surgery and the internal morality of medicine. Camb Q Healthc Ethics. 2000;9:353-364. 2. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61:270-271. 3. Rohrich RJ. Professionalism: he end product of the medical profession. Plast Reconstr Surg. 2006;118:1487-1488. 4. Rohrich RJ. he sandbox rules for plastic surgery. Plast Reconstr Surg. 2008;122:303-305. 5. Sterodimas A, Radwanski HN, Pitanguy I. Ethical issues in plastic and reconstructive surgery. Aesthetic Plast Surg. 2011;35:262-267. 6. Wray RC,Jr. On morality, ethics, and the american board of plastic surgery. Plast Reconstr Surg. 1994;93:1506-1507. 7. Levine RJ. Some reflections on postgraduate medical ethics education. Ethics Behav. 1997;7:15-26. 8. Paige JT, Garbee DD, Brown KM, Rojas JD. Using simulation in interprofessional education. Surg Clin North Am. 2015;95:751-766. 9. Team Standards, American Cleft Palate - Craniofacial Association. Available at: http://www.acpa-cpf. org/team_care/standards/. Accessed 01, 01, 2016. 10. D’Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. J Interprof Care. 2005;19 Suppl 1:8-20. 11. Greiner A, Knebel E, eds. Health professions education: a bridge to quality. . Institute of Medicine, Washington, DC: National Academies Press; 2003. 12. World Health Organization (WHO). Framework for action on interprofessional education and collaborative practice. Available at: http://www.who.int/hrh/resources/framework_action/en/. Accessed 01/01, 2016. 13. Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: Efects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(1):CD002213. 14. Reeves S, Zwarenstein M, Goldman J et al. Interprofessional education: Efects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008;(1):CD002213. doi:CD002213. 15. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: Efects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013;3:CD002213. 16. Seymour NE, Cooper JB, Farley DR et al. Best practices in interprofessional education and training in surgery: Experiences from american college of surgeons-accredited education institutes. Surgery. 2013;154:1-12. (Continued on next page)

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ESSAYS

17. Capella J, Smith S, Philp A et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010;67:439-443.

24. Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Attitudes to teamwork and safety in the operating theatre. Surgeon. 2006;4:145-151.

18. Stevens LM, Cooper JB, Raemer DB et al. Educational program in crisis management for cardiac surgery teams including high realism simulation. J horac Cardiovasc Surg. 2012;144:17-24.

25. Carney BT, West P, Neily J, Mills PD, Bagian JP. Diferences in nurse and surgeon perceptions of teamwork: Implications for use of a briefing checklist in the OR. AORN J. 2010;91:722-729.

19. Undre S, Sevdalis N, Healey AN, Darzi S, Vincent CA. Teamwork in the operating theatre: Cohesion or confusion?. J Eval Clin Pract. 2006;12:182-189.

26. Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203:96-105.

20. Makary MA, Sexton JB, Freischlag JA et al. Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg. 2006;202:746-752.

27. Mazzocco K, Petitti DB, Fong KT et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-685.

21. Lingard L, Espin S, Whyte S et al. Communication failures in the operating room: An observational classification of recurrent types and efects. Qual Saf Health Care. 2004;13:330-334.

28. Oehlert JK, Potter T. To move health care to health caring: A conversation with julie kennedy oehlert, DNP, RN. Creat Nurs. 2015;21:30-37.

22. Halverson AL, Casey JT, Andersson J et al. Communication failure in the operating room. Surgery. 2011;149:305-310.

29. Spike JP. Residency education in clinical ethics and professionalism: Not just what, but when, where, and how ought residents be taught?. Am J Bioeth. 2006;6:23-25.

23. Lingard L, Reznick R, DeVito I, Espin S. Forming professional identities on the health care team: Discursive constructions of the ‘other’ in the operating room. Med Educ. 2002;36:728-734.

Teaching Medical Professionalism in Residency / continued from page 9 A challenge to deine he challenges in deining medical professionalism naturally lead to diiculties in objectively measuring this important entity. Can we assign a number or grade to a resident’s professionalism that is valid, accurate and reproducible? An incredible number of instruments have been proposed in the literature to measure diferent aspects of professionalism; however, the validity of these instruments is frequently not addressed.6 hese instruments often involve a list of character traits, or professionalism domains, that are individually measured numerically. he numbers for each domain are then compiled into an overall score that is meant to represent the professionalism of the person being evaluated.7-8 However, there is no consensus regarding the professionalism domains that are measured.

Additionally, some professionalism evaluations are only performed by supervising faculty, whereas others are completed by faculty, peers, students and mid-level providers.

he evaluation of plastic surgery residents has been standardized in recent years in response to the joint initiative between the Accreditation Council for Graduate Medical Education (ACGME) and ABPS. he Plastic Surgery Milestone Project has provided a system to assess resident proiciency within core competencies, one of which being professionalism. Residents are graded on a scale of 1 to 5, with 4 marking the target level of competency for graduation. he beneits of a system such as this include a standard framework for the evaluation of residents across the specialty, as well as the fact that it forces those who are performing the evaluations to give feedback regarding a resident’s professional qualities. However, Swick’s Definition of Medical Professionalism based upon the discussion presented thus far in this article, there are inherent • Physicians subordinate their own interests to the interests of challenges in measuring the complex others concept of professionalism on a numerical scale. Undoubtedly, future research will • Physicians adhere to high ethical and moral standards examine the validity and predictive value of • Physicians respond to societal needs, and their behaviors reflect assessing professionalism in this way.

a social contract with the communities served

• Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others and trustworthiness • Physicians exercise accountability for themselves and for their colleagues • Physicians demonstrate a continuing commitment to excellence • Physicians exhibit a commitment to scholarship and to advancing their field • Physicians deal with high levels of complexity and uncertainty • Physicians reflect upon their actions and decisions 36

Plastic Surgery Resident | Fall 2016

Ultimately, the reason for examining the various interpretations and nuances of professionalism, and how it is quantiied, is to advance the professional behavior of the ield of medicine. Critical to this goal is the methodology for teaching professionalism to a new generation of physicians. Formal curriculum improvements and didactic teaching are important to this process and demonstrate that we, as a specialty, consider professionalism to be valuable. However, trying to communicate the essence of professionalism to residents with highly variable backgrounds is not an easy endeavor.

My role models I submit that role modeling, or experiential learning, is the most efective way to inluence the behavior of residents in training. I have seen this traditional modality – while near impossible to standardize, measure or communicate verbally – have a powerful inluence on my own behavior. Observing how my mentors behave in various clinical and interpersonal circumstances has clearly shaped the way I currently handle those same situations. Whether in the clinic, the O.R., or elsewhere, I encounter a scenario almost every day where I stop to consider how one of my mentors would respond. I have a mentor who has an unusual skill of being able to communicate very directly and conidently, without ever appearing harsh or abrupt. After spending time with this person, I ind myself adopting some of the same intonations and mannerisms that he uses.

truly means to us, as physicians and surgeons, and to adhere to those standards. Eforts to teach this complex concept through formal curricula, and providing objective feedback to residents, should continue to play an essential role in this process. However, we must not forget that role modeling is an extremely efective and powerful way to communicate and foster what it means to be a professional. | Acknowledgements: he author would like to thank Isaac L. Wornom III, MD, Austin I. Mehrhof Jr, MD, DDS, and Daniel P. Luppens, MD, for their contributions to the content of this article. References 1. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd and Meade, 1970 2. Cruess SR, and Cruess RL. Professionalism must be taught. BMJ. 1997;315:1674-7 3. Swick HM. Toward a normative definition of professionalism. Acad Med. 2000;75:612-6. 4. Gale-Grant O, Gatter M, Abel P. Developing ideas of professionalism. Clin Teach. 2013;10(3):165-9. 5. http://www.plasticsurgery.org/Documents/Governance/asps-code-of-ethics.pdf

ANSWER KEY

5

H U G H E

2

1

he way we treat patients is being inluenced by political and administrative changes. his represents deterioration of our autonomy and threatens our profession. While facing these challenges, it is important to clarify what professionalism

8. Reed DA, West CP, Mueller PS, Ficalora RD, Engstler GJ, Beckman TJ. Behaviors of highly professional resident physicians. JAMA. 2008;300(11):1326-33.

W E 8 B I S T 10 11 E C W R R H 15 16 H Y P I X I E 17 B P T 18 E S T R O G E N L O A 20 T L L U C K E I L 22 A Z Y G

It is critical that faculty who take on the responsibility of teaching residents realize that their behavior is shaping the future of our profession. Every resident I’ve ever interacted with, whether they’re willing to admit it or not, wants the approval of his or her mentors and emulates their behavior in some form. While observing how a mentor behaves in certain situations, and seeing their body language, choice of words, tone of voice, and ultimately their actions, the complex nature of professionalism can be elucidated. All residents consciously or subconsciously pattern their behavior and decision-making after their mentors to some degree, and eventually they will be in a position to inluence trainees in the same fashion.

7. Gauger PG, Gruppen LD, Minter RM, Colletti LM, Stern DT. Initial use of a novel instrument to measure professionalism in surgical residents. Am J Surg. 2005;189:479-487.

M U S T A R D E 3 I S 4 E L O C K W O O D C R 6 7 O P O S T E R I O R M T N D E R D I I 9 B A H A 12 O S 13 14 M T E R I N A R N N S T T 21 R S O M A T A M H L

A third faculty member whom I consider a role model has an amazing ability to be available and understanding irrespective of the time of day or night, and whether or not he is on call. I regularly notice that I am thinking about how he might respond, when I encounter similar situations.

6. Veloski JJ, Fields SK, Boex JR, Blank LL. Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med. 2005;80:366-370.

C B G O L L E 19 O P F B H U O R A M N R I C O F A C I A L S P H I M O S I S

Another faculty member I look up to has a way of allowing long, somewhat uncomfortable silence when I come to him with a question. his inevitably leads to me illing the silence with my own stream of consciousness. At the end of the conversation, all he really has to say is “now you’ve answered your own question,” and I usually walk away thinking about how wise he seems to be. I have discovered myself using this technique when discussing issues with patients and noted that it conveys a willingness to listen, which is always appreciated.

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Dear Abbe / continued from page 10 problem (it’s time for a new program director). Seriously, that posture will get a program director ired in today’s climate. If that is the case, there are many people to turn to, indeed. You may need to have a conidential discussion with your division chief and/or department chair. Maybe you, along with some of the other responsible residents in the program, band together and go as a team. hose higher on the food chain certainly “get it” and appreciate the ramiications of non-adherence, and even more importantly, dishonesty. Another option is to conidentially meet with someone in your institution’s GME oice, such as the designated institutional oicial (DIO). You and the other residents have an opportunity each year to conidentially ill out the ACGME Resident Survey. he ACGME and the Plastic Surgery – Residency Review Committee (RRC) review these data each year. his is a powerful way to report non-compliance and that will be “heard.” his maneuver should not be taken lightly. Finally, if all else fails, you can conidentially report all of this to the ACGME. hat will get someone’s attention for sure! |

he PSF Ofers Exciting Research Opportunities for Residents / continued from page 22 careers, during residency and as they advance to becoming experienced and well-established plastic surgeons. he purpose of the Research Fellowship Grant is to encourage research and academic career development in plastic surgery. his grant is for salary support only for a Resident or Fellow to obtain training and experience in research, under the guidance of an experienced mentor. he application must describe a structured research training plan, in addition to a research project. Only already funded research projects will be considered. Evaluation of the application will place emphasis on the research training experience, research project, applicant potential, mentor qualiications and commitment to mentoring. Research Fellowship grants must be used for salary support only. In 2016, he PSF awarded 36 investigator-initiated projects and nearly $800,000 in research funding. Grant application submission information Applications are currently being accepted via proposalCENTRAL (proposalcentral.altum.com) through Dec. 1, 2016. All applications for he PSF InvestigatorInitiated Grant Program must be submitted online through proposalCENTRAL, the online grant management system used by he PSF by Dec. 1, 2016. Only applications submitted through proposalCENTRAL will be eligible for scientiic review and considered for funding. Funding for awarded projects begins in July 2017. For further information on the programs and application process, please visit hePSF.org/grants or email research@plasticsurgery.org. | 38

Plastic Surgery Resident | Fall 2016

Upcoming Surgery Trips & Meetings 11/27 – 12/11 Rotaplast (San Francisco) Faridabad, India (415) 252-1111 rotaplast.org 11/30 – 12/7 Mission of Hope (Cedar Park, Texas) Haiti (512) 256-0835 mohhaiti.org 12/2 – 12/11 Association of Baptists for World Evangelism (Harrisburg, Pa.) North Africa (717) 774-7000 abwe.org/serve/healthcare 12/3 – 12/10 Mission of Hope (Cedar Park, Texas) Haiti (512) 256-0835 mohhaiti.org 12/26 – 1/2/17 CERT International (Crossville, Tenn.) Mexicali, Mexico (931) 707-9328 certinternational.org 12/31 – 1/7/17 CERT International (Crossville, Tenn.) Mexicali, Mexico (931) 707-9328 certinternational.org 1/8/17 – 1/22/17 Rotaplast (San Francisco) Chittagong, Bangladesh (415) 252-1111 rotaplast.org 1/14/17 – 1/21/17 Health Talents International (Birmingham, Ala.) Guatemala (205) 991-9939 healthtalents.org 1/16/17 – 1/19/17 Bridges of Hope (Fishers, Ind.) Cartagena, Colombia (317) 581-9569 bridgesofhopeinternational.org

1/20/17 – 1/22/17 Atlanta Breast Surgery Symposium Atlanta, Ga. (435) 901-2544 sesprs.org 1/21/17 – 1/28/17 Bridges of Hope (Fishers, Ind.) Cartagena, Colombia (317) 581-9569 rotaplast.org 1/26/17 – 2/1/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org 2/11/17 – 2/19/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org 2/16/17 – 2/25/17 Helping Hands (New Haven, Conn.) Tanauan-Batangas, Philippines (516) 900-4263 hhmm.org/volunteer 2/18/17– 2/25/17 Austin Smiles (Austin, Texas) San Salvador, El Salvador (512) 451-9300 austinsmiles.org 2/18/17– 2/25/17 Bridges of Hope International (Fishers, Ind.) Cartagena, Colombia (317) 581-9569 bridgesofhopeinternational.org 2/24/17 – 2/25/17 ASPS Plastic Surgery Coding Workshop Houston (847) 228-9900 plasticsurgery.org 3/2/17 In-Service Exam for Residents Online (847) 228-9900 plasticsurgery.org

For more surgical trips, visit the Volunteers in Plastic Surgery calendar at ThePSF.org; for additional meetings, visit the ASPS International Clearinghouse of Meetings calendar at plasticsurgery.org. |

OCTOBER 6-10

Plastic Surgery Resident | Fall 2016

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