Plastic Surgery Resident, Spring 2016

ISSUE 2 | SPRING 2016

From the publishers of Plastic Surgery News

» Facing Fellowship As the end of residency looms large, a craniofacial fellowship may be just what the doctor ordered

page 9

» Resident Iron Man he training schedule of Northwestern plastic surgery resident pushes the limits of possibility

page 20

Plastic surgery training in the USA A Scandinavian perspective page 6 IN THIS ISSUE » Journal Club: 10 facial anatomy articles for a solid foundation ...... p.18 » Hernia repair pearls ...................... p.28 » In-Service Exam insights ............... p.10 AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005

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A note from the editor

L

ast fall, the editors and production staf of Plastic Surgery News and Young Plastic Surgeons Perspective brought you the inaugural edition of Plastic Surgery Resident (PSR). he articles culled for that issue represented the combined eforts of members of the Plastic and Reconstructive Surgery editorial board, the chair of the ASPS Coding and Payment Policy Committee, faculty from the ASPS Oral and Written Board Preparation Course and many others.

Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh

As the title implies, the mission of Plastic Surgery Resident is to serve the needs and whims of residents in this specialty. Our goal is to ofer a publication that serves as both a residency reference and a source of news and entertainment.

As a means to this end, the editors of Plastic Surgery Resident are pleased to introduce in this edition several recurring sections that we anticipate readers will ind engaging and useful. Some of these sections include “CPT 101,” an in-depth look at procedural coding; “Consult Corner,” a presentation of an interesting case with management pearls and pitfalls; and “In-Service Insights,” which features selected In-Service Exam topics with analysis of a question and its potential answers.

We have also added sections that will give us an opportunity to highlight the lives of various attendings and residents outside of medicine, as well as a section (“Facing Fellowship”) designed to ofer tips to guide you along the interview trail. Over the course of the next few issues, I will introduce you to some of our international contributors, who have an interest in the U.S. methods of graduate medical education and surgical technique, as well as in introducing us to theirs. Finally, we are proud to ofer a new installment of the popular “Journal Club” feature that focuses on facial anatomy. his publication is distributed at no charge to members of the ASPS Residents and Fellows Forum, as well as to plastic surgery training programs in the United States. It can also be accessed worldwide at plasticsurgery.org/residents, through the PRS Residents Gateway (prsjournal.com) – and through the Plastic Surgery News app on the iPad. For more information or to receive a free subscription, contact ASPS Member Services directly at 847-228-9900.

I would like to thank PSR Associate Editor Mohammed Alghoul, MD, and our team of resident editors – Sanjay Naran, MD, Chad Purnell, MD, and Sameer Shakir, MD – without whom we would not have been able to bring this information-packed ofering to press.

Finally, I would like to thank the readers of Plastic Surgery Resident for your interest in this magazine and our wonderful specialty. We hope that you enjoy this publication, and I wish you the best in your career. |

Plastic Surgery Resident | Spring 2016

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Table of

Contents Plastic Surgery Training in the USA: View from Norway ................ 6

Plastic Surgery Resident | Spring 2016 | Vol.1 No.2

Advice for making your foray into the world as a practicing plastic surgeon

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.

Facing Fellowship .......................... 9

A SPS PR E SI DE N T

A craniofacial Fellow shares her thought process on selecting a program

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

In-Service Insights: Parotid Tumors...............................10 Be prepared to answer common questions about a not-so-common condition

Consult Corner Dog Bite to the Nose.....................12

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

When you get paged for a dog-bite consult, be prepared to act quickly and decisively

E X EC U T I V E V ICE PR E SI DEN T

PSR Crossword .............................15

STAFF V P/PROGR A MS A ND DEV ELOPMENT

Test your plastic surgical vocabulary with this challenging word puzzle

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

Mike Stokes | mstokes@plasticsurgery.org

Journal Club: Facial Anatomy ......18

SEN IOR GR A PH IC DE SIGN ER

10 important articles that will help lay a solid foundation for facial surgery knowledge

Jim Andrews | jandrews@plasticsurgery.org

Resident Spotlight Ironman Michael Gart, MD .......... 20

Jim Leonardo | jleonardo@plasticsurgery.org

Northwestern resident balances rigorous specialty training with grueling competition

Kendra Y. Mims | kmims@plasticsurgery.org

Calendar of Upcoming Events .... 23 Schedule of upcoming symposia and surgical mission trips abroad

Faculty Focus Amir Dorafshar, MD ..................... 24 Johns Hopkins faculty member ofers tips for a successful residency and fellowship

CPT 101 Billing and Coding ....................... 26 A primer on the codes that young plastic surgeons will see early and often

Pearls from the Masters Hernia Repair................................. 28 Experts in the ield share their wisdom and techniques for a successful procedure

A S S I S TA N T E D I T O R S TA F F W R I T E R A DV ERTISING SA LES

Brian Parker (215) 521-8969 Wolters Kluwer Health 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.

POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005 Postage paid at Arlington Heights, IL, and at additional mailing oices. 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

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Plastic Surgery Resident | Spring 2016

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Plastic surgery training in the USA: A Scandinavian surgeon’s perspective

By Johan Sandberg, MD uring my residency and fellowship training in the United States, I was often asked why I left Norway, one of the wealthiest countries in the world – as well as the nation with the highest quality of life – to train in the United States.

D

he answer, of course, is complex and multifaceted, but my primary motivation was the well-reputed quality of U.S. plastic surgery training and a wish to explore the land of opportunity. he hardest-working and most innovative of all European forefathers completed the same journey across the Atlantic Ocean in the 1800s, and the hardships of that era were certainly quite diferent in comparison to those I faced. In my case, one of my greatest diiculties was inding very few resources other than online chat groups and information from the Educational Commission for Foreign Medical Graduates (ECFMG) to help me in my quest. No other MDs in Norway had any advice to ofer me, except that I should let go of my dream because it was not considered a realistic goal.

Without any U.S. connections or the possibility of doing electives, an integrated plastic surgery position was out of the question for me, as it is for most foreign medical graduates. I decided to apply for a categorical position in general surgery – the common opinion on online chats recommended this option. Despite my strong U.S. Medical Licensing Examination (USMLE) scores (93rd and 99th percentiles), I was still considered a wild card.

In Scandinavia, medical school is based on pass-orfail results – the socialist concept promotes an equality approach. he dean of my university had never seen nor heard about me, or any other students for that matter. And even if I could get a letter of recommendation from the dean, it would be highly generic.

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Plastic Surgery Resident | Spring 2016

I knew I had to force the proverbial square peg through the round hole by interviewing well and making a good impression with my USMLE scores. Ultimately, I was able to get a ive-year position at a university-ailiated program in Philadelphia, and the ECFMG helped me obtain a J-1 visa for non-immigrants to participate in work- and studybased exchange visitor programs (the choice of an H-1 visa carried the risk that I would not be able to do a consecutive plastic surgery residency if that program did not want to sponsor me). I had to apply for a new visa every year, and an extension beyond seven years required a massive efort.

However, I am happy that I chose a J-1 visa.

I continued to score above the 90th percentile on my ABSITEs, took any research projects I could get my hands on, and I attended all the ASPS annual meetings.

I eventually secured a two-year position in a fantastic plastic surgery residency program in Houston through the San Francisco match program. From there I continued to do the fellowship of my dreams in microsurgery, still in Houston, through the microsurgery match.

CHALLENGE OF RETURNING HOME I returned to Norway eight years after my departure. Foreign graduates who train in the United States and aspire to go back to their home countries should realize this often requires extensive paperwork and cultural re-orientation.

Foreign education is often looked at with skepticism in Norway, but I was fortunate to obtain positions at hospitals where the chiefs had experience from the United States. To be recognized as a Norwegian general surgeon and plastic surgeon, I had to send 11.7 kg of paperwork to the Health Directorate, which, eventually, after roughly nine months, recognized my education from the United States.

Dr. Sandberg (right) in the O.R. in Telemark, Norway

In America, I learned that all “ patients deserve equal respect, but they are also all unique individuals with diferent problems that demand and deserve special considerations and continuity of care.

”

here are many diferences between American and Norwegian medical training, in my opinion. My Norwegian experience consists mainly of general surgery training and 10 months of plastic surgery residency training. In Norway, there is less focus placed on interactive or case-based teaching. Weekly lectures held by residents are common.

Some obligatory courses with written exams have to be passed, but yearly exams to monitor progression are not held.

Many rotations in plastic surgery have to be speciically applied for, and training is not part of a true program. No structured mentoring in the American sense exists. A chief-resident system is not used and progression is often unstructured. Residents are often left to passively assist during elective procedures in the O.R.

“On-call procedures” are often actively taught, but many surgeons will only begin to get training in elective procedures once they are recognized as “specialists” (attendings who have inished residency training). he term “specialist” is not to be confused with “board certiied” in the American sense as no exams or tests are held to obtain “specialist” status.

Specialists are then selected by faculty to be further trained in either general plastics or one subspecialty. It is rare to have a wide range of procedural knowledge such as that seen in the United States, and there are often more surgeons than procedures performed (this secures that call schedules are covered). Many attending surgeons operate together in teams when a larger procedure is performed.

No surgeons are on call for their own patients – shared call activity is the rule. Work hours are 40 hours per week with some added on-call activity.

PLASTIC SURGERY IN SOCIALIZED MEDICINE Delivery of care is quite different in Norway, which has a socialized care system with insurance that covers all inhabitants of the country. Treatment committees consisting of chiefs from all major plastic surgery centers in Norway gather annually to decide on the recommendations and indications for socialized treatment. The decisions are based on a combination of science and budgets. Some differences from the United States health-care system in regard to plastic surgical procedures include: Patients can be on a long waiting list to have their surgery performed. Previously, the waiting list for breast reconstruction was up to six years. his has changed lately; after considerable protests by breast cancer patients, more funds were allocated for breast reconstruction. continued on pg.8 Plastic Surgery Resident | Spring 2016

7

Dr. Sandberg (second from right) celebrates graduation with colleagues (from left) Roman Skoracki, MD, Matthew Hanasono, MD, and Taiba Alrasheed, MD, in Houston in 2013.

be forever grateful “for ImywillUnited States training.

responsibility for patient care. Because all patients are evaluated according to similar “cookie-cutter” principles, and all surgeons in their subspecialty are considered equal, patients may be evaluated by one surgeon, operated on by a second and seen postoperatively by many other surgeons without any continuity. No personalized referrals are usually possible.

It was well worth the blood,

UNIQUENESS OF PATIENTS

”

sweat and tears.

Post-bariatric contouring surgery is covered under most circumstances in Norway; a functional indication and an upper limit of BMI are among the limiting factors.

No speciic amount of tissue has to be removed during a breast reduction; however, there has to be a non-cosmetic indication.

Surgical care for malignant melanoma is also a plastic surgical ield in Norway.

Private practice for cosmetic treatment exists, but the oices are mainly operated and owned by health-care companies that hire plastic surgeons and train them to practice in a “cookiecutter” fashion. Less focus is on the surgeon and his or her speciic training, while more focus is on the brand of the health-care company.

Many patient-care decisions are made collectively in groups by all MDs during morning meetings or rounds at the departments. In my opinion, this “shared” collective responsibility can sometimes translate into a lack of speciic 8

Plastic Surgery Resident | Spring 2016

In America, I learned that all patients deserve equal respect, but they are also all unique individuals with diferent problems that demand and deserve special considerations and continuity of care. he government and some surgeons in Norway still struggle with this concept, but the patients easily adapt to it. he great trend toward personalized healthcare globally is challenging the socialized medicine concept in its old format. Socialist systems have stopped innovating and changing with the world and science. A great deal of change is needed to modernize the socialist concepts, but a new wave of plastic surgery is already on the way.

I am truly blessed to work in a department with a system that is heavily inluenced by the American way, with modern and lexible management. his provides me with an opportunity to follow an American practice pattern in many ways.

I will be forever grateful for my United States training. It was well worth the blood, sweat and tears. |

FACING

Craniofacial Considerations

A

g trainees. Applyi l ng for a fellowship may a be the right decision for individuals who demonstrate a particular area of interest, seek the increased conidence that additional training afor f ds, or are preparing to work in a particular envi n ronment, such as academics.

As with fellowships in hand, microsurgery or aesthetics, the reasons for pursuing a craniofacial fellowship can vary. y Some residents may a have a developed a passion for craniofacial surgery through their training and wish to gain the expertise to perfor f m cranial vault operations and complex facial reconstructions. Some have a a passion for treating children with deformities, ranging from cleft f lip and palate to complex craniofacial syndromes. Others are more interested in adult facial reconstruction, facial transplantation and complex facial trauma reconstruction.

Whatever the inspiration, craniofacial fellowship training can beneit any n surgeon seeking to gain conidence and experience operating on the craniofacial skeleton.

y

,p

y

g

Fellowship is an exciting year. It is a unique opportunity to narrow your clinical focus and research interests, and the learning curve is tremendous. In August of your fellowship year, you will reconvene with your colleagues at craniofacial Fellow “Boot Camp.” Here, leaders in the ield teach the most current craniofacial techniques on cadave a rs in a smallgroup, hands-on setting. he fellowship year will ly by quickly, l and searching for a job in the midst of it creates an additional challenge. While craniofacial Fellows are ofte f n concerned about the relative dearth of academic craniofacial job opportunities available, the skills gained during your fellowship will prepare you to capitalize on whatever opportunity presents itself. f A variety of practice models will beneit greatly l from the unique skill – set gained during your craniofacial fellowship, whether in a large academic institution with a well-established craniofacial center, a smaller academic envi n ronment, group practice or private practice. | Plastic Surgery Resident | Spring 2016

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Parotid tumors are rare in clinic, but common on the ISE

By Wesley Sivak, MD, PhD

P

arotid tumors are rare in the clinical setting, representing just 2-3 percent of all head and neck tumors. However, they frequently appear on the In-Service Examination, so be familiar with the common benign and malignant variants, as well as their described histologic appearance – it can easily help you correctly answer a question or two on the test.

Approximately 80 percent of salivary gland tumors originate in the parotid gland, and roughly 80 percent of parotid gland tumors are benign. Facial paralysis is associated with malignant tumors and is a sign of neural invasion. Malignant tumors of the parotid can also metastasize to the regional lymph nodes and to distant sites, and they are staged according to the TNM classiication system (primary tumor (T), the amount of spread to nearby lymph nodes (N), presence of metastasis (M)).

Knowing the staging system may also get you another correct answer on the In-Service Exam.

Pleomorphic adenoma (a.k.a. benign mixed tumor) is the most common benign tumor of the parotid gland. It is histologically characterized by epithelial and connective tissue elements, with stellate and spindle cells interspersed with a myxoid background. he tumor is usually solitary and presents as a mobile, slow growing, painless-but-irm single nodular mass.

Warthin tumor (papillary cystadenoma lymphomatosum) is the next-most common tumor of the parotid gland; it is also benign and the only tumor virtually restricted to the parotid gland.

Warthin tumors predominantly occur in males and are bilateral 10-15 percent of the time. Histologically papillary cysts, they are characterized by mucoid luid and nodules of lymphoid tissue.

Warthin’s tumors primarily afect older individuals (age 60-70 years). he tumor is slow growing, painless and usually appears at the tail of the parotid gland near the angle of the mandible.

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Plastic Surgery Resident | Spring 2016

Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland (it is the second-most common malignancy of the submandibular and minor salivary glands).

Mucoepidermoid carcinomas contain two major elements: mucus-producing cells, and epithelial cells of the epidermoid variety. Low-grade tumors are associated with a predominance of mucus-secreting cells lining cysts and intervening nests of well-diferentiated epidermoid cells. High-grade tumors show few or no mucus-producing cells and the epidermoid cells are poorly diferentiated. Postoperative radiation therapy is generally recommended for higher-grade mucoepidermoid cancers.

Adenoid cystic carcinoma is the second-most common malignant tumor of the parotid gland (it is the most common malignant tumor of the submandibular, sublingual and minor salivary glands). It is more common in females and typically afects patients between 30-70 years old with a peak incidence in patients between 40-60 years. here are three histologic subtypes: cribriform, tubular and solid. he cribriform pattern has a classic “Swiss cheese” appearance with cells arranged in nests separated by round or oval spaces. he tubular pattern has a glandular architecture, while the solid (or basaloid) pattern has sheets of cells with little or no luminal spaces. Adenoid cystic carcinoma usually exhibits a protracted course characterized by indolent growth and a propensity for perineural invasion, reported to occur in 20-80 percent of patients. Patients may survive for years with metastases because the adenoid cystic carcinoma tumor is generally well-diferentiated and slow growing (survival rate is 89 percent at 5 years but only 40 percent at 15 years). Distant metastases, most frequently to the lung, are not uncommon.

Hemangiomas are the most common salivary gland tumors found in children, and usually involve the parotid gland. Like other hemangiomas, they are benign and characterized by

a rapid growth phase around the age of one to six months, followed by gradual involution over one to 12 years.

Histologically, the tumors are composed of capillaries lined by proliferative endothelial cells.

Squamous cell carcinoma is a malignant tumor that rarely involves the parotid gland, in comparison with the skin and aerodigestive tract. When squamous cell cancers occur in the parotid gland, they are usually of metastatic origin, although primary squamous cancers of the salivary glands do occur. hey are histologically identical to squamous cell cancers arising from other sites with epithelial cells that form sheets or compact masses that invade adjacent connective tissue.

Round nodules of keratinized squamous cells, known as “keratinous pearls,” are the hallmark of well-diferentiated squamous cell carcinoma. |

JW Marriot t | Washing ton, DC

CO-CHAIRS: Amy Alderman, MD | Bahman Guyuron, MD | Maurice Nahabedian, MD

References: Bell R.B., Dierks E.J., Homer L., et al. “Management and outcome of patients with malignant salivary gland tumors.” J Oral Maxillofac Surg. 2005 Jul; 63(7): 917-928.

Adelstein D.J., Koyfman S.A., El-Naggar A.K., et al. “Biology and management of salivary gland cancers.” Semin Radiat Oncol.

2012 Jul; 22(3): 245-253.

Co-Chairs Amy Alderman, MD, Bahman Guyuron, MD, and Maurice Nahabedian, MD, assembled a stellar faculty for Aesthetica

Deadline to submit resident abstracts for Plastic Surgery he Meeting is May 25 Plastic surgery residents are invited to submit scientiic abstracts for Plastic Surgery he Meeting in Los Angeles, by May 25. he selected abstracts, which will be included in the 2016 Plastic Surgery Senior Residents Conference and Residents Day programming during the ASPS/PSF/ASMS annual scientiic meeting, will be presented Saturday, Sept. 24. Abstracts will be accepted only in paper form and on the following topics: Aesthetic, Breast Reconstruction, Hand, Maxillofacial, Pediatric, Reconstruction/Burn/Microsurgery and Research.

Abstracts must present the author’s original clinical and/or basic science works. All plastic surgery residents and senior residents are invited to submit an abstract for consideration; non-residents and Fellows are not eligible for Residents Day abstract consideration, but they may submit abstracts to Plastic Surgery he Meeting at asps.confex.com/asps/2016am/cfp.cgi.

Additional criteria and restrictions apply. For information on criteria or to submit an abstract, go to plasticsurgery.org/meetings, click “Plastic Surgery he Meeting 2016” followed by “Submit a Resident Abstract." For more information, contact Mary Ellen Bogucki at mboguki@plasticsurgery.org.

A dynamic, three-day Super Symposium with a completely unique concept. One registration fee lets you move from room to room – topic to topic – easily switching in and out of the presentations. Plus, the smaller meeting size gives you more interaction with faculty and time with colleagues to discuss the material presented — making it a truly exceptional use of your time and money.

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Plastic Surgery Resident | Spring 2016

11

Dog bite to the nose “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 in the context of an actual case.

By Stephanie Dreifuss, MD

T

he concept of dog being man’s best friend is highly debatable for the plastic surgeons routinely called on to repair the traumatic injuries resulting from dog bites. According to the American Veterinary Medical Association, more than 4.5 million people in the United States are bitten by dogs each year. Twenty percent of those bites require medical attention – and roughly 27,000 dog bites will require reconstructive surgery. he following case explores this all-too-common trauma.

MESSAGE ON YOUR PAGER: DOG BITE TO THE NOSE Considerations as you walk to the E.D.: What is the defect?

What subunits are involved? What structures (skin, cartilage, lining) are missing? What was the mechanism? What is the quality of the remaining tissue? Is the missing tissue available and, if so, how is it preserved? What supplies might you need (nasal speculum and penlight for intranasal exam, camera) for documentation of defect?

PERTINENT HISTORY: It is irst critical to determine whether the patient is stable. Airway compromise or active bleeding necessitates urgent attention prior to reconstructive evaluation. he next step is to determine when the injury occurred and other information surrounding the incident, including the type of dog and vaccination status of both the dog and patient (i.e., rabies, tetanus). As always, the history should include the patient’s medical comorbidities, particularly disorders that would afect wound healing (diabetes, connective tissue disease, immunosuppression) or that would impact the 12

Plastic Surgery Resident | Spring 2016

patient’s candidacy for anesthesia and surgery (such as cardiac or pulmonary disease).

PHYSICAL EX AM: Assessment of the defect should include evaluation of the involved nasal subunits and structures (lining, cartilage, soft tissue/skin). Examine the wound edges to determine their quality and viability. If the missing tissue is available, verify that it was appropriately preserved (wrapped in saline soaked gauze, in a plastic bag, submerged in ice). he degree of damage and contamination to the tissue should also be assessed. A full facial examination should be performed in case of other injuries or, in some situations, to determine the availability of local tissue for reconstruction.

ADDITIONAL TESTING: When indicated, a maxillofacial CT scan can provide information about concomitant bony injuries. Preoperative workup, including an EKG, chest X-ray or routine laboratory testing, may also be necessary in certain cases.

MANAGEMENT STR ATEGIES: he simplest of defects may be amenable to healing by secondary intention. An abrasion or supericial laceration can be thoroughly washed out and treated with local wound care to achieve an optimal outcome. However, in larger defects or on convex surfaces, contraction may result in poor scarring or contour deformities. A deeper laceration with no associated tissue defect can be primarily repaired, especially in the upper two-thirds of the nose where the tissue is more lax. Skin grafts may also be employed; however, mismatches in color and texture limit their use.

A wound with associated tissue loss requires a more complex reconstruction. If only skin is missing, a local tissue lap can be used for reconstruction. hese provide a better color and texture match versus the aforementioned skin graft. he lap depends upon the involved subunit.

Bilobed laps, banner laps and dorsal nasal laps can be used for the sidewall and dorsum where there is more redundant soft tissue. Extensive defects involving soft tissue in addition to cartilage support or lining might require nasolabial or forehead laps, as well as cartilage grafts and lining laps. However, these strategies are generally not used in the acute setting. More often, the wound is temporized by debriding nonviable tissue, controlling infection and returning any remaining normal tissue to its anatomic position. herefore, in the acute setting, initial management most often involves primary closure where possible, antibiotics and application of a dressing. Multiple studies have demonstrated that antibiotics are indicated in dog bite wounds to prevent infection.1,2,3 In some cases, when missing tissue is available and appropriately preserved, it can be used as a full-thickness skin graft (if only skin is missing) or a composite tissue graft (if a combination of skin, cartilage and lining is missing). Not only does this serve as a biological dressing, it also replaces like with like – reconstructing the nasal lining, support and soft tissue.

If a composite tissue graft is used, multiple strategies to optimize graft-take can be efectively implemented.4 here is some evidence that hyperbaric oxygen therapy might aid in graft survival by increasing tissue oxygenation in the absence of a blood supply.5,6,7 Some animal studies have shown that steroids also improve composite tissue graft survival, although the mechanism is uncertain. 8,9 Additionally, postoperative cooling protocols are thought to improve graft-take by reducing metabolic demands.10,11,12 Still, incomplete graft-take is an expected outcome, especially in larger wounds. However, the goal in these cases is to reduce the size of the ultimate defect and, therefore, allow for a less extensive deinitive reconstruction. Prior to embarking on this reconstructive venture, these considerations, including postoperative care and risk of failure, must be discussed with the patient to obtain informed consent.

Following any of these initial management strategies, secondary reconstructions are the rule. Wounds that heal secondarily or are primarily closed might ultimately result in unattractive scarring or contour deformities requiring revision. Skin grafts might also leave obvious scars or mismatches in texture or color. In the case of a composite tissue graft, incomplete graft-take might result in a residual defect requiring reconstruction of lining, cartilage or soft tissue.

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

FIGURE 8

PATIENT CASE: he patient is a 64-year-old, healthy male whose dog bit him two hours prior to presentation. he dog was of unknown breed and obtained from a shelter several years prior. Both the patient and his dog are up-to-date with all vaccinations, including tetanus and rabies.

On examination, the patient has a defect involving a majority of the nasal tip and left ala measuring 3x2 centimeters (see igures 1, 2, 3). Skin, cartilage and lining are all absent. he wound is without gross contamination, there is no active bleeding, and the edges appear viable. he patient brings with him the avulsed tissue continued on pg.14 Plastic Surgery Resident | Spring 2016

13

wrapped in saline-soaked gauze in a plastic bag atop ice. his tissue includes lining, cartilage and skin (igures 4, 5). It is without any gross contamination. he remainder of the facial examination is within normal limits.

Management options are discussed with the patient, including dressing changes and, ultimately, forehead lap reconstruction versus composite tissue grafting with the avulsed part. He is counseled that the latter might result in a more aesthetic outcome given that it would use the original tissue. However, this strategy would involve hospitalization for intravenous antibiotics and steroids, twice daily hyperbaric oxygen therapy and a tissue hypothermia protocol. he patient is also informed that only partial graft-take is the expected outcome and that secondary reconstruction would be required. he patient provides his consent and is taken to the O.R. for replantation of the avulsed tissue. he wound and the avulsed segment are copiously irrigated and the tissue is replaced in layers (lining, cartilage and skin; igures 6, 7, 8).

Postoperatively, the patient begins an iced gauze cooling protocol to reduce tissue metabolism in the setting of absent blood supply and given intravenous corticosteroids and antibiotics. Hyperbaric oxygen therapy is also initiated for two hours, twice-a-day for 10 days.

FIGURE 10

he patient is seen in clinic postoperatively and noted to have a large eschar overlying the composite tissue graft. his eschar remains in place as a biological dressing until it spontaneously detaches from the underlying wound bed about eight weeks later. Ultimately, though the composite graft does not result in 100-percent take, it does result in a smaller defect measuring 1.5x1.5 centimeters, making it amenable to a second composite tissue graft from the conchal bowl (igures 9, 10, 11). | FIGURE 11

References: 1

Tabaka M.E., Quinn J.V., Kohn M.A., & Polevoi S.K. “Predictors of infection from dog bite wounds: which patients may beneit from prophylactic antibiotics.” Emerg Med J. 2015; 32(11): 860-3.

7

2

8

Cummings P. “Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials.” Ann Emerg Med. 1994; 23(3): 535-40.

3

Callaham M. “Prophylactic antibiotics in common dog bite wounds: a controlled study.” Ann Emerg Med. 1980; 9(8): 410-4.

4 Harbison J.M., Kriet J.D., & Humphrey C.D. “Improving outcomes for composite grafts in nasal reconstruction.”Curr Opin Otolaryngol Head Neck Surg. 2012; 20(4): 267-73.

5

McClane S.D., Renner G., Bell P.L., et al. “Pilot study to evaluate the eicacy of hyperbaric oxygen therapy in improving the survival of reattached auricular composite grafts in the New Zealand White Rabbit.” Otolaryngol Head Neck Surg. 2000; 123: 539-42.

6

Renner G., McClane S.D., Early E., et al. “Enhancement of auricular composite graft survival with hyperbaric oxygen therapy.” Arch Facial Plast Surg. 2002; 4:102-4.

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Plastic Surgery Resident | Spring 2016

Lewis D., Goldztein H., & Deschler D. “Use of hyperbaric oxygen to enhance auricular composite graft survival in the rabbit model.” Arch Facial Plast Surg. 2006; 8: 310-3.

Hartman D.F., & Goode R.L. “Pharmacologic enhancement of composite graft survival.” Ann Surg. 1987; 113: 720-3.

9

Aden K.K., & Biel M.A. “he evaluation of pharmacologic agents on composite graft survival.” Arch Otolaryngol Head Neck Surg. 1992; 118: 175-8.

10

Conley J.J., Vonfrankel P.H. “he principle of cooling as applied to the composite graft in the nose.” Plast Reconstr Surg. 1958; 17: 444-51.

11

Hirase Y. “Postoperative cooling enhances composite graft survival in nasal alar and ingertip reconstruction.” Br J Plast Surg. 1993; 46: 707-11.

12

Chandrawarkar R.Y., Cervino A.L., Wells M.D. “Reconstruction of nasal defects using modified composite grafts.” Br J Plast Surgy.

2003; 56: 26-32. Prior to embarking on this reconstructive venture, these considerations, including postoperative care and risk of failure, must be discussed with the patient to obtain informed consent.

Put your plastic surgical vocabulary skills to the test!

By Sanjay Naran, MD

1

3

Answer key on page 23

2

4 5

6

7 8 10

9

11

12 13

14 15

17 16

18

19

20 21

22

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ACROSS 1. Bone substitute with the capacity for osteoconduction and osseointegration.

3. Joint type of the metacarpophalangeal joint of the thumb.

5. Increased levels of which causes gynocomastia in men taking anabolic steroids.

7. Eruption of which timing of initiation of palatal expansion should be based upon.

10. Abbreviation for which the intercartilaginous incision in rhinoplasty follows the caudal border of.

11. Cancer associated with a mutation in the breast cancersusceptibility genes types 1 and 2.

13. Donor nerve most preferred for microneurovascular transfer with a muscle lap for cases of Mobius syndrome.

15. Reduction mammaplasty pedicle with the greatest risk of altered nipple sensation.

18. Anesthetic agent that may be safely used in patients with suspected diagnosis of malignant hyperthermia.

19. Arterial pedicle for the reverse sural fasciocutaneous lap.

21. Ligament whose injury, in conjunction with that of the central tendon, results in a Boutonniere deformity.

22. Deformity of multiple cranial sutures.

23. Incision correlated with increased risk of nipple-areola complex necrosis in nipple-sparing mastectomies with immediate reconstruction.

DOWN 2. Artery through which blood supply is preserved with placement of an implant in the subpectoral space versus the subglandular space.

4. Arterial pedicle for the medial femoral condyle free vascularized osseous corticoperiosteal free lap.

6. Bone in which isolated orbital fractures most commonly occur.

8. Gland in which approximately 80% of salivary tumors originate.

9. First line treatment for symptomatic venous malformations.

12. Acid whose prophylactic administration in the setting of wrist fractures is most likely to decrease the risk of subsequent development of complex regional pain syndrome.

14. Bone autograft material most likely to provide osteogenesis.

15. Tumor location that is a relative contraindication of nipplesparing mastectomy.

16. Adverse efect most likely to be observed with treatment of a hemangioma with propranolol.

17. Nerve innervating the extracanthal orbicular, injury of which results in diiculty with eyelid closure, voluntary squinting and animation.

20. Topical agent that increases turnover of follicular epithelial cells and helps prevent collagen loss.

Plastic Surgery Resident | Spring 2016

15

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Journal Club; 2016 Spr; (2)

1. he relationship of the supericial and deep facial fascias: Relevance to rhytidectomy and aging | Stuzin JM, Baker TJ, Gordon HL. | Plast Reconstr Surg. 1992 Mar;89(3):441-9; discussion 450-1.

» his is one of my favorite articles and an all-time classic.

James Stuzin, MD, et al., beautifully describes facial anatomy pertinent to facelift and facial aging through the dissection of 14 hemifaces. his article describes all of the basic anatomy of SMAS, fascial planes, muscles of facial expression and facial nerve branches. In addition, this article also describes the retaining ligaments of the face, which, at the time, was a relatively new concept.

2. he retaining ligaments of the cheek | Furnas DW. | Plast Reconstr Surg. 1989 Jan;83(1):11-6.

FACIAL ANATOMY ARTICLES

EVERY PLASTIC SURGERY RESIDENT

SHOULD READ

By Mohammed Alghoul, MD

K

nowledge of facial anatomy is extremely important for both cosmetic and reconstructive surgery. Our understanding of facial anatomy has expanded over the past three decades thanks to the contributions of plastic surgeons who published excellent anatomic studies. Several cadaver studies, published primarily in Plastic and Reconstructive Surgery, were performed by cosmetic plastic surgeons to improve their understanding of facial aging and their ability to safely execute facial rejuvenation procedures. his edition of “Journal Club” is dedicated to facial anatomy and features key articles that will enhance plastic surgery residents’ understanding of this important topic. he list is obviously not inclusive of all the important articles, but it is deinitely a good start to establish a solid foundation on which residents can further build. his section will cover facial anatomy as it relates to facial and periorbital rejuvenation. he eyelid, ear and nose anatomy will not be covered in this issue. It is recommended that these papers be read in chronological order.

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Plastic Surgery Resident | Spring 2016

» his article by David Furnas, MD, preceded Dr. Stuzin’s article noted above and focuses mainly on the anatomy and clinical importance of the retaining ligaments of the face.

Dr. Furnas was the irst to coin that term and describe the location of the main ligaments with a high level of accuracy. he importance of this article is that it paved the way to several important anatomic studies detailing these retaining ligaments.

3. Anatomy of the frontal branch of the facial nerve: he signiicance of the temporal fat pad | Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. | Plast Reconstr Surg. 1989 Feb;83(2):265-71.

» his is another classic article by Dr. Stuzin, et al., this time focusing on anatomy of the temporal area. he authors dissected 12 hemifaces and described the fascial layers of the temporal area and fat pads in addition to the location and course of the frontal branch of the facial nerve. Notice that what Dr. Stuzin describes as the “supericial fat pad” is indeed the intermediate fat pad. here is another fat pad in the subgaleal plane that is more supericial, as described in more recent publications.

4. An anatomically based study of the mechanism of eyebrow ptosis | David M. Knize | Plast Reconstr Surg.

1996 June;97 (7):1321-1333

» David Knize, MD, is credited with the detailed description of the forehead and temporal anatomy. I recommend reading all his articles for an in-depth understanding of the complex anatomy of that region in the context of brow ptosis. In this classic article, he dissected 40 hemi-heads and described in details the diferent fascial layers, zones of adhesions and gliding planes to help us better understand the mechanism of eyebrow ptosis. his includes descriptions of Zones A and B in the forehead and the galeal fat pad, in addition to the orbital ligament and the course of the supraorbital nerve.

A fascinating anatomic study with histologic analysis, this article may leave you somewhat confused for the level of its complexity, but nonetheless more knowledgeable about the forehead and brow anatomy. A more recent article by Dr. Knize, “Anatomic concepts for brow lift procedures,” which was published in PRS in 2009 (see “additional reading” on next page), is easier to read, has better, color igures and summarizes the indings of this article.

5. New perspectives on the surgical anatomy and nomenclature of the temporal region: Literature review and dissection study | O’Brien JX, Ashton MW, Rozen WM, Ross R, Mendelson BC. | Plast Reconstr Surg. 2013 Mar;131(3):510-22. » his is one of many great anatomic papers by Bryan Mendelson, MD, who has done a tremendous work in the ield of facial surgical anatomy. His original article on anatomy of the temporal region, “Surgical anatomy of the ligamentous attachments in the temple and periorbital regions,” was published in PRS in April 2000. In this original article, Dr. Mendelson describes for the irst time the diferent morphologies of the retaining structures of the periorbital area and classiies them into ligaments, septa and adhesions. His descriptions were completely diferent from those by Dr. Knize, which created a great deal of confusion among plastic surgeons. he locations of the areas of adhesions were similar but the extent, nature and nomenclature were diferent. he reason why I recommended reading the more recent version above is that it details what was previously described in the original article from 2000, and it also contains excellent anatomic igures.

6. Surgical anatomy of the midcheek and malar mounds | Mendelson BC, Muzafar AR, Adams WP Jr. | Plast Reconstr Surg. 2002 Sep 1;110(3):885-96; discussion 897-911.

» Get ready for high-level surgical anatomy in Dr. Mendelson’s most advanced anatomic paper. It may be diicult for the novice reader to fully understand – I read this article several times during residency, and each time I took away a bit more. In this study Dr. Mendelson details for the irst time the anatomy of what he describes as the premaxillary space with its boundaries. he concept of an anatomic space was relatively new in facial anatomy and in this instance the theory was that laxity and descent of the roof of the premaxillary space was responsible for the appearance of malar mounds. In addition to delineating the relationship of the orbicularis retaining ligament and the zygomatic cutaneous ligaments to the space, this article describes in detail the spatial relationship of the diferent zygomatic facial nerve branches to the premaxillary space. Another recent article by Dr. Mendelson and Chin-Ho Wong, MD, titled “Facial soft-tissue spaces and retaining ligaments of the midcheek: Deining the premaxillary space” published in PRS in July 2013 describes the prezygomatic space and introduces the premaxillary space in the medial cheek.

7. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus | Muzafar AR, Mendelson BC, Adams WP Jr. | Plast Reconstr Surg. 2002 Sep 1;110(3):87384; discussion 897-911. » his article was published at the same time as the previous paper using the same cadaver dissection (six cadaver heads). his is the irst time the term “orbicularis retaining ligament” was used to describe the ligament that was known as the “orbitomalar ligament.” he orbicularis retaining ligament anatomy along with the lateral orbital thickening and surrounding fat compartments are described in detail. A more recent article by Drs. Mendelson and Wong titled “he tear trough ligament: Anatomical basis for the tear trough deformity” published in PRS in June 2012, revisits this topic and focuses on the description of the medial segment of the orbicularis retaining ligament, which was named “the tear-trough ligament.”

8. he fat compartments of the face: Anatomy and clinical implications for cosmetic surgery | Rohrich RJ, Pessa JE. | Plast Reconstr Surg. 2007 Jun;119(7):2219-27; discussion 2228-31. » his paper changed our perception of the anatomy of the facial subcutaneous fat suggesting that it is compartmentalized. Using methylene blue dye injection techniques in the subcutaneous layer, Rod Rohrich, MD, and Joel Pessa, MD, were able to show supericial fat compartments with distinct boundaries. In a follow-up article, “he retaining system of the face: Histologic evaluation of the septal boundaries of the subcutaneous fat compartments,” the authors conirm their injection studies and histologically showed that the boundaries between the supericial fat compartments are actual septae that connect the supericial fascia to dermis. his further enhanced our understanding of the retaining ligaments and their supericial extension as septa creating the “retaining system of the face.”

9. Surgical anatomy of the lower face: he premasseter space, the jowl, and the labiomandibular fold | Mendelson BC, Freeman ME, Wu W, Huggins RJ. | Aesth Plast Surg 2008; 32:185-195 » In this paper, Dr. Mendelson and colleagues describe the “premasseter space” for the irst time, as well as its boundaries and relationship to the retaining ligaments, platysma and masseter muscles and facial nerve branches. he authors describe the central role of the premasseter space in the aging process and the development of the jowl and the labiomandibular fold.

10. Retaining ligaments of the face: review of anatomy and clinical applications | Alghoul M, Codner MA. | Aesthet Surg J. 2013 Aug; 33(6):769-82.

» his is a review article that summarizes the indings of most of the above-mentioned articles in the context of the retaining ligaments of the face. As the title suggests, it reviews the anatomy of all previously described retaining ligaments, their classiication, location and clinical signiicance. he article also contains illustrations that show the relationship of the supericial and deep retaining system of the face to the fat compartments, and the relationship of the retaining ligaments of the face to the facial muscles and facial nerve branches.

A DDIT ION A L R E A DI NG » Knize DM. Anatomic concepts for brow lift procedures.

Plast Reconstr Surg. 2009;124(6):2118-26. » Moss CJ1, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions.

Plast Reconstr Surg. 2000;105(4):1475-90; discussion 1491-8. » Wong CH1, Mendelson B. Facial soft-tissue spaces and retaining ligaments of the midcheek: deining the premaxillary space. Plast Reconstr Surg. 2013;132(1):49-56. » Wong CH, Hsieh MK, Mendelson B. he tear trough ligament: Anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012;129(6):1392-402. » Rohrich RJ1, Pessa JE. he retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg.

2008;121(5):1804-9. | Plastic Surgery Resident | Spring 2016

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Resident Spotlight: Michael Gart, MD

“Resident Spotlight” showcases a plastic surgery resident or Fellow whose life outside of the hospital is (almost) as interesting as his or her work. Michael Gart, MD, a sixthyear resident in Northwestern’s seven-year Integrated Plastic Surgery Program, has completed three Ironman Triathlons (and two “ half Ironmans”) since his residency began. PSR sat down with Dr. Gart to learn what it takes to tackle these challenging races during a rigorous plastic surgery training program.

Plastic surgery's resident Iron Man in training

By Chad Purnell, MD PSR: For those who don’t already know, what is an Ironman?

Dr. Gart: An Ironman is a 140.6-mile triathlon, consisting of a 2.4-mile swim, 112-mile bike ride and a full marathon (26.2 miles), raced in that order without breaks.

PSR: When did you become interested in competing in an Ironman?

Dr. Gart: During one of my general surgery rotations during intern and second year, I carpooled with a vascular surgery resident who had completed several Ironman races in college and medical school. I remember asking her about the race and thinking, “I can do that.” She swore never to do one again, but over the course of the next year, I was able to break her down and we signed up together for Ironman Madison (Wis.) in 2013. I didn’t know exactly what I was getting myself into, but I am so thankful she joined me – I would not have made it through the process without her.

PSR: How much experience with each of the three race components did you have before you started?

Dr. Gart: he Ironman in Madison was my irst triathlon and my irst organized marathon. I’ve been running recreationally for about 18 years, so I knew that was not going to be a problem for me. At the time I signed 20

Plastic Surgery Resident | Spring 2016

up, the longest organized run I had completed was a halfmarathon, but I had been on some recreational runs of 2025 miles. As far as the bike and swim, I had absolutely zero experience at the time I signed up for the race. I had not been open-water swimming in almost a decade, and I hadn’t been on a bicycle since I was about 10 years old.

PSR: What did you do to prepare?

Dr. Gart: I started of in pretty good shape from running and weight training, so my training plan was not as lengthy as some. I’d say I trained speciically for the race beginning in April or May, so ive or six months.

Having grown up in Florida, I assumed that I knew how to swim, but after a few sessions in the pool, I quickly learned that I knew nothing whatsoever about swimming. In April, I signed up for one-on-one beginner swim lessons, which was humbling and embarrassing – mostly because there were groups of children learning with me in the facility, seemingly at the same swimming level – but also great.

I asked the coach to treat me like a child and teach me everything from the basics. We worked hard to break bad habits and before long, I was doing something that more closely resembled swimming. I had to lie to my coach and tell him I was doing a sprint triathlon because I don’t think he would have continued to work with me if he knew I was preparing for a 2.4-mile open water race just ive months later. My irst open-water swim was two months before race day. Fortunately, I lived right of Lake Michigan, so I was able to practice nearly every day.

I purchased my bike in the winter and bought an indoor bike trainer to get in some miles during the cold weather. Once it warmed up, I began riding outside, irst with 30-40 mile rides and then gradually increasing to 100+ mile rides. he irst time I rode my bike outdoors was three months before race day. It was diicult to learn so quickly, but the time pressure deinitely pushed me.

As far as running and overall health, I focused on increasing my running distances, taking care not to increase too quickly and risk injury. I kept weight-training to maintain my body weight as best I could. Once I had all three sports down, it was time to focus on linking them together into sessions we call “bricks” – following a long swim with a bike ride, or a long bike ride with a run.

PSR: How did you fit in all of this training while in residency?

Dr. Gart: All I really did during that time was work and train during the week – with some time to go on dates with my (now) wife on the weekends. I would get up at 3:30 or 4 a.m. to do one to one-and-a-half hours biking on my indoor trainer or swim one or two miles in Lake Michigan before work. After work, it was weight training, eating, preparing for cases, sleep. It was diicult. Fortunately, I began my research year a couple of months before the actual race, which is when the training volume really picks up. My work hours were much more forgiving in the lab.

Dr. Gart completes an Ironman triathlon

I reserved my “golden” weekends for very long training days, usually a two- or three-mile swim followed by a 70-80 mile bike and a 10-15 mile run. You don’t want to do a whole lot after one of those days but eat and sleep. I drove to Madison often with my training partner to bike the course and familiarize myself with the challenging terrain.

PSR: What was the week like leading up to the race? Did you change your routine?

Dr. Gart: he week leading up is a diicult time for all of us.

It’s a time where everyone says you should – and you really should – slow down and give your body a rest; to trust in your training and believe you are prepared, and allow yourself time to heal from the punishment you’ve been dealing out on a daily basis. hat’s diicult to do because not only are you illed with self-doubt, particularly before your irst Ironman (and if you were/are terriied of the swim, like me), but you also have just come of of your peak training months, where you were logging hundreds of miles per week. It’s diicult to shut that of and believe it will all just come back to you on race day.

In terms of nutrition, I was eating an incredible amount of food, probably around 8,000 calories/day during the peak training weeks to maintain my weight. Conventional wisdom says to eat up to 70-80 percent of all of your calories in carbohydrates, so you can binge on things you might otherwise avoid. And calories are no issue – my typical expenditure for a full Ironman race is near 15,000 calories. he day before, I usually drink at continued on pg.22 Plastic Surgery Resident | Spring 2016

21

least two gallons of water, and the night before, I try to keep it simple – grilled chicken and pasta early (before 7 p.m.) and very little afterward. he morning of the event is always the same: a peanut butter-and-banana sandwich on a wholewheat bagel, protein shake and a cup of bad hotel cofee.

PSR: What was race day like? How did you feel at the end of each section of the race?

Dr. Gart: Race day is crazy. he swim terriied me (and still does), but what’s more is that the Madison Ironman has a “mass start” swim. What that means is everyone is treading water at the start line, waiting for the cannon to go of. hey call it the “human washing machine,” and that’s no understatement. Immediately after the cannon went of, I got kicked in the face twice and nearly panicked. he water was very rough that day, making for an extra tough swim, but I had prepared as best I could and inished in the time I expected.

For me, the swim is the whole race. Once I get out of the water, the day is mine. I know I can inish the bike and the run, so I am always my happiest at the swim-to-bike transition knowing that the rest of the day is for me to enjoy the experience. he Madison bike portion of the Ironman is particularly challenging and technical, but beautiful. he spectators at the race are incredible – someone in a chicken suit slapped my butt as I was crawling to the top of a large hill on my bike. After 112 miles on your bike, you will do anything to get of of it, so I was just happy to be done. I biked the course several times during my preparation, so I had accurately estimated my bike time as well. he run is my biggest strength, so I was happy to start but surprised at how exhausted my legs were after the bike ride. he run took about an hour longer than I expected but I still inished in great time. Finishing the run is truly a special experience.

PSR: What was your first thought when you crossed the finish line?

Dr. Gart: Coming down the inisher chute of an Ironman – especially your irst – is an absolutely surreal experience.

You want to laugh, cry, collapse, scream, eat, sleep, lie down and do back-lips all at once. All I remember thinking was “I did it!” Immediately afterward, there are food tents for the participants, so I ate four slices of pizza, a few large cookies, some fruit and pretzels and lots of chocolate milk… and I think a sub sandwich. My wife tells me I fell asleep on the loor of our hotel room a couple of hours later.

PSR: What advice do you have for someone – particularly a fellow resident – who wants to train for an Ironman?

Dr. Gart: I would say that it’s not as crazy as it sounds, and it’s an incredible journey that teaches you so much about yourself and how to handle fear, anxiety and adversity. I would recommend it to anyone who has a good baseline level of itness and interest in completing one. Nobody says you have to start with a full Ironman, either – in fact, most people at the race thought I was nuts to start of that way, but that’s how it all worked out.

Before signing up, the best advice is to honestly evaluate your current personal situation, and be sure you have the time, money and dedication to complete the task at hand. You’ll want to make sure your friends and spouse/signiicant other are on board because it will consume a lot of your free time, and you won’t always be the most pleasant version of yourself when you’re burning the candle at both ends. With that being said, if you’ve decided to accept the challenge, talk to people who have completed one or more, analyze your strengths and weaknesses, don’t be afraid to ask for help or admit you can’t swim, and make a realistic training plan that you can adhere to.

For a resident, I would say this is simply a diferent application of the same drive and dedication that helped you to earn your spot in your residency program. We are all driven and goal-oriented people by nature. If you plan and prepare appropriately, you can accomplish whatever you want.

PSR: What races do you have planned for the future?

Dr. Gart: I am preparing for Ironman Chattanooga in September, and I am considering doing a half-distance Ironman race in late summer. I have a couple of 10-mile running races and the Chicago Marathon this fall. I’m not sure after that, but I think I owe it to my wife and my future co-Fellows to maybe take a year of.

PSR: You also run for charity.

Dr. Gart: I began running the Chicago Marathon for Team Bright Pink (BrightPink.org) in 2014, after several close friends and family members were diagnosed with BRCArelated cancers. I feel a particular draw to this organization as a plastic surgery resident because I often see young women – sometimes as young as 16 years old – diagnosed with BRCArelated breast cancers, undergoing bilateral mastectomy before they even have their driver’s license. Bright Pink focuses on prevention and early detection eforts for BRCA-related breast and ovarian cancers. |

PSR: Did you ever think you’d do it again?

Dr. Gart: As soon as I inished, I knew I would do it at least once more. It is a very signiicant training burden on an already limited amount of free time, so I knew that inding the time would be an issue. Fortunately, my wife is wonderfully patient and able to tolerate my schedule, for which I am ever grateful to her.

22

Plastic Surgery Resident | Spring 2016

Is there a resident in your program who deserves to be in the Resident Spotlight?

Email us at psn@plasticsurgery.org

UPCOMING MEETINGS & SURGICAL TRIPS APRIL

JUNE

4/3 – 4/7 Rotaplast (San Francisco) Iasi, Romania (415) 252.1111 rotaplast.org

6/5 – 6/19 Rotaplast (San Francisco) Arusha, Tanzania (415) 252.1111 rotaplast.org

4/15 – 4/29 Alliance for Smiles (San Francisco) Changzhi, China (415) 647-4481 allianceforsmiles.org

6/10 – 6/12 New England Society of Plastic and Reconstructive Surgeons Bretton Woods, N.H. (603) 880-4385 neplasticsurgery.org

4/16 New York Regional Society of Plastic Surgeons Spring Meeting New York (212) 620-5653 plasticsurgeryny.org

6/10 – 6/25 Alliance for Smiles (San Francisco) Beira, Mozambique 415) 647-4481 allianceforsmiles.org

MAY 5/1 – 5/8 Rotaplast (San Francisco) Pereira, Colombia Contact: (415) 252.1111 rotaplast.org 5/21 – 6/4 Alliance for Smiles (San Francisco) Guizhou Province, China 415) 647-4481 allianceforsmiles.org 5/15 – 5/29 Rotaplast (San Francisco) Lima, Peru (415) 252.1111 rotaplast.org 5/19 – 5/22 AAPS & PSRC Joint Meeting New York (978) 927-8330 meeting.aaps1921.org 5/27– 5/30 California Society of Plastic Surgeons Annual Meeting Santa Monica, Calif.

(510) 243-1662 californiaplasticsurgeons.org

6/11 – 6/15 Southeastern Society of Plastic and Reconstructive Surgeons Annual Scientiic Meeting Orlando, Fla. (435) 901-2544 sesprs.org Endorsed by ASPS 6/11 – 6/18 Austin Smiles (Texas) San Salvador, El Salvador (512) 451-9300 austinsmiles.org 6/18– 6/25

Bridges of Hope (Indiana) Guatemala City, Guatemala Contact: (317) 581-9559 bridgesofhopeinternational.org 6/23– 6/25

ASPS Aesthetica Super Symposium Washington, D.C. (800) 766-4955 Sponsored by ASPS

JULY

AUGUST

SEPTEMBER

8/5 – 8/7 ASMS Basic Maxillofacial Principles and Techniques Course Chicago (978) 927-8330 maxface.org Jointly provided by ASPS & ASMS 8/7 –8/21 Rotaplast (San Francisco) Maypyidaw, Myanmar Contact: (415) 252-1111 rotaplast.org 8/18 – 8/20 Oral & Written Board Preparation Course Chicago (800) 766-4955 Sponsored by ASPS

9/4 – 9/11 Rotaplast (San Francisco) Iasi, Romania (415) 252-1111 rotaplast.org 9/18 – 10/2 Rotaplast (San Francisco) Cumana, Venezuela (415) 252-1111 rotaplast.org 9/22 – 9/23 Plastic Surgery Senior Residents Conference & Residents Day Los Angeles (800) 766-4955 plasticsurgerythemeeting.org Sponsored by ASPS, ACAPS and YPS

8/25 – 8/27 Breast Surgery & Body Contouring Symposium Santa Fe, N.M. (800) 766-4955 Sponsored by ASPS 8/27 – 9/3 Bridges of Hope (Indiana) Panama City, Panama Contact: (317) 581-9559 bridgesofhopeinternational. org 8/27 – 9/10 Alliance for Smiles (San Francisco) Ordos, China Contact: (415) 647-4481 allianceforsmiles.org

9/22 ASMS Pre-Conference Symposium at Plastic Surgery he Meeting Los Angeles Contact: (978) 927-8330 plasticsurgerythemeeting.org Jointly provided by ASPS & ASMS 9/23– 9/27 Plastic Surgery he Meeting Los Angeles (800) 766-4955 plasticsurgerythemeeting.org Sponsored by ASPS, he PSF and ASMS

8/28 – 9/11 Rotaplast (San Francisco) Barquisimeto, Venezuela Contact: (415) 252-1111 rotaplast.org

Answer key

7/16 – 7/17 ASPS Plastic Surgery Coding Workshop Chicago (800) 766-4955 Sponsored by ASPS 6/16 – 6/30 Austin Smiles (Texas) Chifeng, China (512) 451-9300 austinsmiles.org 7/30 – 8/6 Bridges of Hope (Indiana) Santo Domingo, Dominican Republic (317) 581-9559 bridgesofhopeinternational.org

Plastic Surgery Resident | Spring 2016

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Q&A with Amir Dorafshar, MD

By Kendra Y. Mims Plastic Surgery Resident aims to provide readers with career advice to help them advance in their profession after residency by sharing insights on how to create their desired career path.

In this issue, we present ASPS member Amir Dorafshar, MD, Baltimore, associate professor of Plastic and Reconstructive Surgery and clinical co-director of the Face Transplant Program at the Johns Hopkins University School of Medicine.

Dr. Dorafshar completed his general surgery residency and plastic surgery residency at the University of Chicago's Pritzker School of Medicine. He also completed his research fellowship at UCLA School of Medicine and his craniofacial/ microsurgical fellowship at the Johns Hopkins Medical Institute in 2010. Dr. Dorafshar specializes in adult and pediatric craniofacial surgery following congenital, oncological or traumatic conditions.

From his fellowship at Johns Hopkins to tips for maintaining work-life balance, Dr. Dorafshar shares highlights from his career journey with PSR. PSR: How did you prepare yourself as a resident to get into a competitive fellowship?

Dr. Dorafshar: I really enjoyed residency. I worked hard.

I tried to learn as much as I could and do as many cases as possible. We didn’t get an extra year to do research in my program, but research was highly encouraged.

Research was the key to preparing myself to get into a competitive fellowship. Every opportunity that I could get, I would jump on a research project. While doing clinical research, you gain insight from the attendings you work with, and learn how they think. You go to the literature and you read the background of what you are investigating, and this helps you to improve your basic knowledge of plastic surgery. I would also try to get into the research lab and practice microsurgery during any free time I had on 24

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translational research projects that we were running. he combination of doing clinical research and translational research was critical in helping me develop my fount of knowledge and my operative skills during residency. It also helped me to understand what’s new, what’s out there and what our philosophy was at the University of Chicago. I was able to present and publish those indings on a national stage, and was, therefore, exposed to the world of academic plastic surgery at an early stage in my career.

Lastly, and perhaps most importantly, the mentoring I received in my training program, without a doubt, helped me get into a competitive fellowship program. But you have to want it; you have to be determined, hard-working, enthusiastic, willing to learn and show yourself worthy of good mentorship.

PSR: How did you select your fellowship?

Dr. Dorafshar: We did a lot of microsurgical reconstruction at the University of Chicago. I fell in love with head and neck reconstructive microsurgery. Toward the end of my residency, I developed an interest in facial transplantation as a method to improve our reconstruction of the head and neck area. I knew Eduardo Rodriguez, MD, was interested in performing a face transplant in Baltimore. I also knew Baltimore has a steep history in craniofacial reconstruction, particularly in traumatic facial reconstruction. I wanted to learn something that would complement the things that I learned in my residency with respect to head and neck microsurgery.

Microvascular surgery is generally about moving tissue from one region of the body to another region, but to do craniofacial surgery, one must have a deeper understanding of the craniofacial skeleton and how to manipulate it surgically. I thought craniofacial surgery would complement my training in head and neck microsurgery.

PSR: What impact has your fellowship had on the advancement of your career?

Dr. Dorafshar: My fellowship laid the foundation to the rest of my career. I was fortunate to be at the right place at the right time. During my fellowship year I was able to help with some of the foundational work for the facial transplantation project that we completed in Baltimore. My

PSR: How does teaching play a role in your schedule?

Dr. Dorafshar: Teaching is one of the best parts of my jobs and one that I probably enjoy the most. I try to teach at all levels including undergraduates, medical students, residents and Fellows. I give lectures and sometimes lead anatomical dissections focusing on craniofacial anatomy and exposures. I also help lead core curriculum at the Johns Hopkins downtown location, so I facilitate our residents to learn the basic concepts of plastic surgery. I also help with the Resident Cosmetic Clinic, in which our chief residents have more independence with ofering cosmetic surgery to our patients.

Dr. Dorafshar demonstrates a craniofacial surgical technique.

fellowship also helped me to become recruited as a junior faculty member at the Johns Hopkins Hospital and Shock Trauma. Staying in the same location helped me immensely, as I was familiar with my surroundings and I had excellent infrastructure around me to continue my research projects.

Right away, I was also exposed to complex cases and was able to have excellent mentoring to help me through them. his enabled me to write about my experiences, publish them and get more recognized in the ield.

PSR: How important is it to have a mentor?

Dr. Dorafshar: It’s by far the most important thing you can have. Good mentors are the absolute reason I am here today.

Without those people to guide you and help you along the way, there’s no way you can make it. Mentorship is the most valuable resource we have.

PSR: How do you start a craniofacial practice?

Dr. Dorafshar: Get good mentors to help you. Craniofacial surgery is a challenging specialty that requires a great deal of experience and skill. When you’re just starting out, you need someone to help you and guide you along the way. I think having good mentors are the most important and valuable assets that you can have when you start out in your career.

PSR: When did you publish your first paper?

Dr. Dorafshar: I’ve been writing papers since I was a medical student. I was still working on papers from the year that I spent in the lab during a research fellowship at UCLA, even during plastic surgery residency. I think the last one was published by the time I was a fourth-year plastic surgery resident. By the time I was a Fellow, I had a number of research projects that were in the process of getting published. I guess it’s built over many years. It doesn’t come overnight.

Plastic Surgery Resident | Spring 2016

PSR: What is the most important attribute to being a successful resident?

Dr. Dorafshar: I think there are several attributes to becoming a successful resident, which may be quite diferent from becoming a successful faculty member. he characteristics that come to mind are being motivated, driven and determined to succeed, with a humility and compassion for patient care. I also think it is important not just to accept the status quo, but also think how can we do things better through our work and research.

PSR: What was the biggest non-medical challenge of residency, and how did you handle it?

Dr. Dorafshar: I’m not sure I’ll ever manage the perfect work-life balance –that’s like most of the plastic surgeons I know. I think work-life balance is the hardest thing to maintain. It’s important to stay healthy, it and active, and not to get so involved that you forget to live the rest of your life. I try to stay it and active as much as I can by playing squash and doing yoga to maintain my work-life balance and keep things fun and exciting.

PSR: What do you enjoy the most about your work?

Dr. Dorafshar: I love craniofacial surgery. he face is so important because it’s right there in front of you and everyone sees it. People are stigmatized by it and socially conscious of their facial appearance. he face is so intrinsic to our daily lives, and restoring that sense of normalcy to people’s lives, that’s the most satisfying part for me. hat’s why I do craniofacial surgery, whether it’s cancer reconstruction, putting the broken bones of the patient’s face back together after a trauma or making children who are born with congenital diferences look close to normal.

I think the thing that I enjoy most is the feeling you get when you have just inished a craniofacial reconstruction on a child and you show their parents for the irst time what their son or daughter now looks like. hey are so happy and relieved that you have managed to help their child that it’s really just an amazing feeling.

PSR: Do you have any parting words of advice for plastic surgery residents?

Dr. Dorafshar: Work hard. Be determined. Don’t accept the status quo –and try to achieve excellence. |

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by Mark Villa, MD The process of how procedural codes are created and assigned values is one that profoundly affects physicians and their practices, but very few plastic surgeons know much about how codes are either created or valued. hen I say “code” in this article, I mean “current procedural terminology” (CPT) codes, not ICD10 codes. ICD-10 was created by the World Health Organization to allow the tracking of medical information. It was never intended as a means for medical coding for reimbursement purposes, though it is available and quite adaptable to this purpose.

W

he CPT coding system is proprietary.

It’s owned and maintained by the AMA, which created the system in the 1960s to provide standardized descriptions for the services provided by surgeons. Prior to that time, physicians described things as they saw it – and the descriptors for the same procedure could be quite diferent from physician to physician.

With the advent of CPT and its standardized terminology, reporting procedural services; tracking what was being done from the local to the national level; and communication between and among physicians as to what services they were providing and what those services entailed was all made easier. he CPT system has undergone many revisions and alterations over the years, and the scope of the described services 26

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has expanded markedly. One of the largest and most complex expansions involved the creation of the so-called evaluation and management (E&M) codes in the 1990s to describe standard oice visits for adult and pediatric populations. he Center for Medicare and Medicaid Services (CMS), the agency responsible for overseeing the health-care expenditures of the federal government, started using CPT coding as the exclusive means for reporting procedural services to the government in 1983. Private insurers followed suit – and at this time, CPT is the universal language of procedural coding for American medicine: All charges submitted to third-party payers, including insurance companies and the government, are communicated using CPT codes.

A new CPT code or a change in an extant CPT code may be proposed by virtually anyone, including medical specialty societies, individuals (including physicians), hospitals, third-party payers and representatives from industry. A form for submitting a proposal for a code is available on the AMA website. Once an individual submits an application,

AMA staf review it. If the issue has been previously submitted and adjudicated, the applicant is informed.

If the proposal is something novel, it is passed on to the CPT Advisory Committee. he CPT Advisory Committee consists of representatives from professional medical societies who review and assess the proposal. If the advisory committee decides the proposal lacks merit, then it will go no further. If they ind it worthwhile, it will be submitted to the CPT Editorial Panel. he editorial panel consists of 17 members and includes representatives of medical societies, insurance companies and CMS, among others. It is the sole body charged by the AMA with making any changes (additions, revisions or deletions) to CPT codes. he editorial panel members will then vote on the proposal. If they accept it, the result is a new code or a change in an existing code. hey can also reject the proposal, refer it to a subcommittee for more in-depth review, or they can defer it to a later meeting if additional material exists that they deem necessary to make a decision.

If they accept a code or a code change, that code must then be assigned a value in Relative Value Units (RVUs) to determine the reimbursement for that speciic service. he valuation of codes is carried out by another committee of the AMA: the AMA/Specialty Society Relative Value Scale Update Committee – or in common parlance, the RUC. he RUC is composed of 29 members, each of whom represents diferent professional societies which, taken

he reason this is called a “relative” value scale is because of the way the RBRVS is structured. A procedure requiring twice the time and/or practice resources of another procedure will have roughly twice as many RVUs. While the system may not always be exact, it is generally quite close. he practice expense (PE) component is determined by the professional society that uses the code most frequently. Its members create a list of every supply required to perform a service, including procedure

follow CMS’s lead and adopt the value that CMS assigns to a code.

CMS then uses a conversion factor of around $36 per RVU to determine actual reimbursement for the services represented by the code. his conversion amount is set by Congress and has nothing to do with the RUC. One of the overarching principles of the CPT and RUC processes is “budget neutrality.” his means there is a ixed sum of money that the government commits to

“he medical liability component is essentially an attempt to determine how much that individual procedure represents of a physician’s overall medical liability.” together, represent essentially all of medicine – with an even balance between cognitive and procedural physicians.

Assigning values to codes utilizes a highly technical methodology called the Resource Based Relative Value Scale (RBRVS), which values a code based on the resource costs needed to perform the service.

William Hsiao, PhD, an economist at the Harvard School of Public Health, created the RBRVS in the late 1980s. It breaks down the cost of performing a procedure into three components: “Physician Work” (48 percent), “Practice Expense” (48 percent) and “Medical Liability” (4 percent). Each of these components is determined in a diferent way.

To establish physician work, specialty societies send surveys to their members who perform the procedure under consideration to determine how much time a physician spends preparing for, performing and setting-up care after a procedure – including the number of oice visits required to adequately care for a patient in the postoperative period.

Procedures have a so-called “global period” of 0, 10, or 90 days, depending on their magnitude, and the cost of the postoperative visits is included in the payment for the procedure itself. As such, physicians may not submit additional charges for routine care related to the procedure during that time.

tables, lights, bandages, gauze pads, electricity, alcohol wipes, etc. – literally EVERYTHING needed for treatment. his list is then parsed to an extraordinary degree by the PE subcommittee of the RUC to ensure its validity – and that nobody tries to earn extra money by having too many or unnecessary supplies on hand. he medical liability component is essentially an attempt to determine how much that individual procedure represents of a physician’s overall medical liability.

It’s determined by another subcommittee of the RUC. Once all of these components have been determined, they are combined – which yields the overall number of RVUs for a procedure. his number of RVUs assigned by the RUC to a certain code using the RBRVS methodology is not binding in any way. It is submitted as a recommendation to CMS, which may accept the recommendation of the RUC or change it if it sees it (realistically, CMS will usually reduce the value).

After review, CMS publishes its recommendation each November in what is known as the “Final Rule.” hese changes in values then take efect on Jan. 1 of the following year. he government is the largest payer for health care in the United States, so essentially all third-party payers

health care each year, so the more RVUs that are created, the less reimbursement physicians will receive per RVU. he RBRVS is also not lexible; small, individual changes cannot be made to codes. If anything about a code needs to change, it must go through the entire process from soup to nuts. It’s a little like presidential approval of legislation: here is no line-item veto. You either accept the whole bill, or none of it.

With an increased desire to control health-care costs, a distinct downward pressure exists on code valuations. herefore, if an established code goes through a RUC survey and valuation, it will almost certainly come out with fewer RVUs than it had before going through the process.

Both budget neutrality and the aforementioned downward pressure on the values of codes represent two reasons that professional societies need to very carefully consider either the establishment of new codes or the modiication of existing codes. | Mark Villa, MD, is an associate professor of Plastic Surgery at he University of Texas MD Anderson Cancer Center in Houston. He is chair of the ASPS Coding and Payment Policy Subcommittee.

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PEARLS from the

MASTERS HERNIA REPAIR “Pearls from the Masters” highlights a technique from a master of plastic surgery, as told by one of his or her students. In this edition, Jennifer Cheesborough, MD, PGY-6, describes the hernia repair technique of Gregory Dumanian, MD, chief of the Division of Plastic Surgery at Northwestern University’s Feinberg School of Medicine.

By Jennifer Cheesborough, MD r. Dumanian’s retrorectus direct-supported repair with components separation hernia technique is used to address wide midline incisional hernias.

His technique has evolved during the course of my residency, and I feel that I can conidently share his current technique having performed 30-plus of these cases with him.

D

Dr. Dumanian begins by performing a laparotomy, identifying the hernia sac and reducing the abdominal contents. He then begins to perform any necessary lysis of adhesions to clear the abdominal wall for safe placement of sutures. In patients without signiicant intra-abdominal scar tissue, a retrorectus plane will be developed. Any scar tissue at the medial borders of the rectus muscles will be removed to healthy bleeding tissue. he anterior rectus sheath is dissected away from the overlying subcutaneous fat for 4 cm in all directions. he posterior rectus sheath is then dissected away from the posterior rectus muscle for 4 cm, taking care not to damage the deep inferior epigastric vessels. At this time, an assessment is made whether the rectus muscles can be reapproximated with minimal tension – or if a components separation needs to be performed to further medialize the muscle.

For a components separation, bilateral 6-cm subcostal incisions are made transversely down the external oblique fascia.

Cautery is used to stimulate the underlying muscles to conirm that the visualized muscle is, in fact, external oblique and not the rectus muscle. he subcutaneous tissue is dissected bluntly 28

Plastic Surgery Resident | Spring 2016

away from the underlying fascia both up over the ribs and down to the iliac crest through this incision using a Deaver retractor for visualization. he external oblique fascia is incised just lateral to the rectus sheath. his incision is carried up over the ribs and down as far as possible. Inferiorly, the surgeon can pass his or her ingers through a small tunnel cranial to the inguinal ligament to hook the leading edge of the incised external oblique fascia, pull this edge into the visual ield and complete the release. Finally, and perhaps most importantly, the external oblique muscle is bluntly dissected away from the underlying internal oblique muscle along the length of its release. his allows for the maximal medialization of the rectus muscles.

Soft midweight uncoated polypropylene mesh is utilized for all clean cases and for select clean-contaminated cases. he mesh is soaked in bacitracin/gentamicin irrigation solution. he posterior sheath is closed using 2-0 PDS prior to introduction of the mesh into the now extra-abdominal ield. he mesh is cut down to a 7- or 7.5-cm width and the length necessary to reach from xiphoid to pubis (igure 1).

0-polypropylene pop-of sutures are then used to serially place sutures from the anterior rectus muscle 4 cm away from the edge, through the muscle, into the edge of the mesh, and back through the muscle no more than 1 cm away from the original bite (igure 2). he mesh is inset under tension so that there is no tension on the rectus in the midline after mesh inlay. One tip that helps make this possible is to place and snap ive to six sutures on each side before you tie them down, thus allowing access and a better estimation of the tension. Also, we leave the leading suture untied as the next series of sutures is placed to prevent diiculty accessing or visualizing the operative space. After the mesh is fully inset, the midline anterior rectus sheath (which should be lying together without separation) is closed using interrupted igure of eight 0-polypropylene sutures with 1-2 cm bites (igure 3). Any excess skin is removed to minimize the dead space and risk of seroma formation. Two 7-mm clotstop drains are left in the subcutaneous plane. he skin is then closed using a few sparing 2-0 vicryl sutures in Scarpa’s fascia, interrupted deep dermal sutures with 3-0 vicryl and either staples or a running 4-0 biosyn subcuticular sutures. |

A SECOND OPINION

By Stephen J. Kovach III, MD entral hernia repair and abdominal wall reconstruction are common clinical scenarios the reconstructive surgeon will encounter. hey represent an enormous clinical undertaking and cost to the U.S. healthcare system, both in delivery of care and in lost work days. It is not uncommon for reconstructive surgeons to see patients in consultation who have had multiple prior hernia repairs looking for a durable repair. he principles I outline below provide a more durable solution for abdominal wall reconstruction and ventral hernia repair.

V

First of, it's important to understand that "mesh" is not a dirty word. he reinforcement of a hernia repair with mesh has been shown to signiicantly reduce the recurrence rate in comparison to primary closure of the defect. Even with modern techniques of component separation of the abdominal wall and the ability to allow for primary closure of the autologous fascia in the midline, mesh should be used to reinforce the repair and could signiicantly reduce the risk of hernia recurrence. he placement of mesh within the anatomic planes of the abdominal wall is dependent on the quality of the surrounding abdominal wall, and the location and size of the defect. he anatomic plane of mesh placement directly relates to the risk of hernia recurrence.

Plastic Surgery Resident | Spring 2016

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In general, a retromuscular placement results in a lower recurrence rate in comparison to intraperitoneal underlay or onlay. It is our preferred approach to perform a retro-muscular sub-lay repair if anatomically feasible. his is true both for clean cases as well as contaminated cases. he inset of the mesh is crucial and needs to be set under physiologic tension to oload the autologous fascial closure if possible.

Not every case is a clean case. Many cases of abdominal wall reconstruction occur in the setting of concomitant intraabdominal procedures, chronic wounds or istulae. he degree of contamination will directly afect the recurrence rate as recurrence rates rise with increasing degrees of contamination.

Additionally, the degree of contamination will dictate the mesh choice, with most experienced abdominal wall surgeons trending toward either biologic mesh or bioabsorbable mesh in such cases. he anatomic plane of mesh placement, even with increasing degrees of contamination, remains important as retro-muscular placement of mesh in the setting of contamination has lower recurrence rates. his is why the posterior rectus sheath is the most expensive real estate in the entire abdominal wall.

Getting the autologous fascia closed in the midline is protective for hernia recurrence. Achieving autologous fascial closure overlying the mesh reconstruction is the primary focus of abdominal wall reconstruction. Abdominal wall component

separation techniques take advantage of the laminar structure of the abdominal wall to gain advancement of the autologous fascia toward the midline. his allows reapproximation of the functional rectus muscles in the midline if possible. Adjunctive maneuvers such as the traditional anterior component separation is crucial to allow reapproximation of the fascia in the midline. he addition of perforator-sparing anterior component separation has allowed for reduction of wound-healing issues in comparison to non-perforator sparing approaches. he transversus abdominis release (TAR) allows both advancement of the autologous abdominal wall toward the midline, and creation of a retro-muscular and preperitoneal plane that allows placement of a large piece of mesh without skin undermining. he primary closure of the autologous fascia in the midline over the mesh reconstruction is protective for hernia recurrence and signiicantly reduces the risk of hernia recurrence.

An ounce of prevention is worth a pound of cure. here are patient populations that are prone to develop midline ventral hernias after their index procedure and the laparotomy.

Identifying those subsets of patients that are at signiicant risk for developing a midline ventral hernia and reinforcing their primary closure with mesh may provide for prevention of development of a ventral hernia. With the advent of the bioabsorbable mesh products, this is an ongoing area of interest and research. |

AUGUST 25–27, 2016 SANTA FE CONVENTION CENTER

Program Chair: J. Peter Rubin, MD | Co-Chair: John Y. S. Kim, MD

Join us in Santa Fe and see what everybody’s talking about—the surgical pearls, the videos of procedures, the free instructional courses.

“Always one of the best, most relevant meetings of the year.” – 2015 ATTENDEE “All the times I’ve attended the Santa Fe meeting have been rewarding. Good value. I have always gone home with new information that was important.” – 2015 ATTENDEE In 2016, we’re excited to announce that John Y.S. Kim, MD will join J. Peter Rubin, MD as co-chair of the meeting.

Together, they’ll bring even more fresh faces and new ideas to the meeting that leads the way in aesthetic and reconstructive education.

S P O N S O R E D BY:

Early registration savings now through Thursday, July 7 Sientra

Register and learn more » PlasticSurgery.org/BreastandBody

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Plastic Surgery Resident | Spring 2016

Where the world of plastic surgery comes together Plastic Surgery The Meeting is the must-attend event for 3,200 plastic surgeons from more than 54 countries. Our seven content-specific tracks will help you personalize your educational experience and tailor it to what is most important to you.

Plan to join us in Los Angeles this September!

SEPTEMBER 23-27, 2016

Follow all the latest news and updates #PSTM16

This activity has been approved for AMA PRA Category 1 Credit™.

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Plastic Plastic Surgery Surgery Resident Resident || Spring Spring 2016 2016

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The only tissue expander which allows access to the periprosthetic space Allograft sling and tissue expander breast reconstruction is the most common method of breast reconstruction in the U.S. A recent Harvard study showed that seroma and infection are significantly higher when using an Allograt sling.* AlloX2 allows doctors to be prepared for these postoperative complications.

INTEGRAL DRAIN

PORT2

AlloX2’s additional port design (Port2), allows transdermal communication with the pocket around the implant; where these complications occur. Much like traditional breast expanders, the port can be located with a standard magnet.

Port2 facilitates seroma drainage, as well as diagnostic fluid sampling in order to identify bacteria and hone antibiotic treatment. *Chun YS, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications.

Plast Reconstr Surg. Feb 2010;125(2):429-36.

U.S. Patent 8,454,690 — Additional Patent Pending

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888.878.0811 32

Plastic Surgery Resident | Spring 2016