Plastic Surgery Resident, Summer 2016 by PlasticSurgeryNews

ISSUE 3 | SUMMER 2016

From the publishers of Plastic Surgery News

» Man on a mission How a plastic surgery resident at Penn balances the rigors of training with a passion for humanitarian surgery trips

page 24

DURING The hidden (and unavoidable) pressures of raising a family page ## during plastic surgery training IN THIS ISSUE » Pediatric mandible fracture ......... p.10 » 10 key rhinoplasty papers to help navigate nasal anatomy ............... p.18 » To PhD, or not to PhD? ................. p.29 AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005

Shaping the standards of breast reconstruction For more information call: 800-433-6576

Plastic Surgery Resident | Summer 2016

A note from the editor

elcome to the summer 2016 edition of Plastic Surgery Resident magazine. Our aim is to keep the publication fresh and entertaining, so we will continue to cultivate some new recurring sections over the next few editions. For this issue, we ofer new installments of “Journal Club,” “Consult Corner” and “In-Service Insights” – and continue to expand our world view by sharing the plastic surgery perspectives of our international colleagues.

Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh

I’d also like to take this opportunity to preview a new plastic surgerythemed advice column beginning next issue afectionately titled “Dear Abbe.” With this column, we hope to address diicult decisions or situations commonly encountered during residency, but not often addressed – and we invite you to conidentially share your dilemmas. All questions will be de-identiied by the Plastic Surgery Resident editorial staf before being forwarded to a program director for his or her response and advice. he inaugural column will feature responses from Joseph Losee, MD, executive vice chair of the University of Pittsburgh’s Department of Plastic Surgery. Questions may be submitted to DearAbbe@ plasticsurgery.org. We hope that you enjoy this edition of Plastic Surgery Resident, and we look forward to getting feedback from our readership during the Senior Residents Conference (Sept. 20-21) and Residents Day (Sept. 22-23) programming leading into Plastic Surgery he Meeting in Los Angeles (visit PlasticSurgeryheMeeting.com and click on “Residents” for more information about these programs, Residents Bowl and the Senior Residents Coding Course). As always, I would like to thank our physician editors and ASPS production staf for another great issue of Plastic Surgery Resident. And don’t forget to look for our Annual Meeting edition in September! |

Plastic Surgery Resident | Summer 2016

Table of

Contents Parenting and plastic surgery residency: Tips and challenges..... 6 The most diicult aspect of parenting during residency may be asking for help.

Plastic Surgery Resident | Summer 2016 | Vol.3 No.1 he mission of the American Society of Plastic Surgeons is to support its members in their eforts to provide the highest quality patient care and maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities.

Textbook Review Comprehensive Cleft Care ........... 9

A SPS PR E SI DE N T

Second edition features 16 new chapters and includes DVD and online video.

EDITOR

Consult Corner Pediatric mandible fracture ..........10

ASSOCI ATE EDITOR

The most common facial fracture among kids presents crucial diferences in diagnoses.

RESIDENT EDITORS

Crossword ...................................... 13 Challenge your plastic surgery vocabulary.

In-Service Insights Thumb hypoplasia .........................14

Michael Costelloe | mcostelloe@plasticsurgery.org

Recognition and diagnosis of speciﬁc thumb abnormalities is a common exam topic.

Gina McClure | gmcclure@plasticsurgery.org

Journal Club: Rhinoplasty.............18

Mike Stokes | mstokes@plasticsurgery.org

These 10 articles will help prepare residents for the complex anatomy of the nose.

SE N IOR GR A PH IC DE SIGN ER

Non-U.S. craniofacial training .....21

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

Peruvian plastic surgeon shares experience from training in Taiwan and The Netherlands.

Faculty Focus Simon Talbot, MD ........................ 22 Brigham and Women’s Hospital plastic surgeon discusses his career path.

Resident Spotlight Fares Samra, MD........................... 24 University of Pennsylvania resident balances training with humanitarian eforts.

Industry Insider ............................ 27 Tips for navigating disability coverage from an insurance industry specialist.

STAFF V P/PROGR A MS A ND DEV ELOPMENT PUBLICATIONS DIRECTOR /M A NAGING EDITOR

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

Kendra Y. Mims | kmims@plasticsurgery.org A DV ERTISING SALES

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

To PhD, or Not to PhD? ............... 29

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

European plastic surgeon shares cultural diferences that impact quest for PhD.

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.

Calendar ........................................ 30 Upcoming meetings and missions.

ASPS Home Page: www.plasticsurgery.org 4

Plastic Surgery Resident | Summer 2016

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DURING

The hidden (and unavoidable) pressures of motherhood and medicine

“here are many ways to measure success; not the least of which is the way your child describes you when talking to a friend.” –Anonymous Sue Jordan, MD, PhD ight years ago this month, I became a mom. I was in the midst of graduate school, wondering if my research would ever meet the standards of graduation so that I could get on with my life. My inicky experiments, medical school and residency – 10 years, according to my math – stood between me and the family that I had always desired. I was 27 and had been married for just over three years. It may seem silly, but I still recall the moment – while standing in the sunlit hallway outside of the lab – that I realized no MD, PhD or board certiication were required to have a child. I had a supportive husband, income and determination. With that in mind, I took the leap into parenthood, which is life-changing on a scale that few realize until it happens. I’m now the mother of 8-year-old Linus and 2-year-old Harriet, and I’m about to enter my seventh year of an integrated plastic surgery residency. I’m often asked: “How do you have two kids during a surgical residency?” he short answer: I do the best I can for my children, one day at a time. Daily life is somewhat like an 6

Plastic Surgery Resident | Summer 2016

egg-and-spoon race. Some days, the egg is perfectly balanced in the spoon, and I glide efortlessly to the inish line. More often than not, there are toys to trip over, pager bombs going of and more projects being stufed into my oversized mom bag. All one can hope for is a bigger spoon, a soft landing or a partner to walk alongside to hold the egg on the spoon. No one ever said parenthood was easy. No one ever said building a career in academic surgery was easy, either. he web is overlowing with parenting advice, sites about pregnancy and homemade baby food (yes, I roasted and pureed my own organic vegetables) and even blogs speciic to pregnancy and parenting during graduate medical education. Simply put, being a mom is hard, and everyone has an experience to share. his is mine – reality, struggles, logistics and personal lessons to date. Frankly, there’s never a good time to become a parent. Plastic surgery residents are highly motivated individuals, and there’s always another project or career move to consider. here are, however, better and worse times (e.g., research year versus intern year, mid-winter versus 6

trauma season). Nonetheless, no one can completely plan for the unpredictability that is human reproduction and independent-thinking children. I was fortunate in that I penciled-in a six-month “optimal window” for delivery and got it. With my son, I was writing my thesis in a less physically demanding environment during late pregnancy, and he was 9 months old by the time I started on the wards as an M3. With my second child, I aimed for delivery toward the middle of my research year (PGY4) so that I would have time to get my research established on the front end, as well as some lexible time with my daughter before heading back on service at her 5-month mark. As a side note on pregnancy, the physiologic demands of pregnancy are real and should be acknowledged. While we’re used to compromising on our own health for the sake of residency, for nine months we have the utmost reason to eat lunch, stay hydrated – and request the hand case so you can simply sit for two hours of tourniquet time. No one will care, or remember, that you peed three times during rounds, scrubbed out to vomit or asked for help transferring a patient. Furthermore, postpartum recovery should not be underestimated. Hormonal and cardiovascular shifts and breast discomfort – not to mention sleep deprivation and the baby itself – necessitate honest maternity leave. I will admit to delusions of catching up on writing and being productive with my “time of.” Newborns neither know nor care what an h-index is. Know your maternity-leave policies and plan early. I truly cannot even remember the irst 10 weeks of postpartum. On breastfeeding, nursing is not about pumping in the supply closet between cases or carrying the tell-tale breast pump bag. It’s not even about nutrition or immunoglobulins. It is, however, about waking up an hour earlier and staying up late

to bond physically and emotionally with your baby. No one else can provide the comfort and security that breastfeeding delivers, and there’s no reward greater than the peace and love of a solaced child. To that end, there’s no shame in supplementing with formula if the demands of residency don’t allow for the hydration, nutrition or time needed to sustain gallons of milk production. he reality is that residency dictates that I will never be the organic yoga mom with the running stroller and perfect hair. I’m not June Cleaver or Martha Stewart. My house is not tidy, and we spend a lot on prepared foods. I will never be president of the PTA. I will rarely chaperone ield trips, and I will not make it to every parent open house. In fact, I had my name erased from a “Dear Mom & Dad” back-to-school night letter one year. I’m that parent who shows up late with her pager on vibrate during piano recitals. I make deals for extra call to attend the school holiday show in the middle of the workweek, and I freely admit that my husband is the primary caregiver. But at the end of the day, my children are healthy, well-adjusted and I’m a great Mom. Logistically, both kids started in daycare around 5 months old, and we have been pleased with the socialization. If one parent works from home, it’s doable to keep the baby while working – until he or she starts to crawl. Currently, my 8-year-old attends public (i.e., free) elementary school, and my 2-year-old attends the hospital-ailiated daycare. Typical daycare hours run from 6:30 a.m.-6 p.m., which is not ideal for residents. Fortunately, my husband is able to drop the kids of around 8 a.m. and pick them up at 3:45 p.m. and 6 p.m., respectively. We aim for dinner by 7 p.m., with homework immediately after, followed by bath time by 9 p.m. and bedtime by 10 p.m. Somewhere in the mix, we it in Chutes & Ladders, twirling in circles until we fall down and impromptu talks about religion and coyotes. hen, we start the egg race all over again. PPlastic Surger Surgery Resident ident | Summer mer 20 2016

Finding time requires lexibility and creativity, to say the least. I keep a physical checklist of concrete tasks that can be accomplished in 10 minutes, in order to minimize lead time (e.g., pulling papers, call schedules, administrative emails, editing) for those gaps between cases, immediately before or after conferences or while walking home, which can be productive. I save objectives that require more focus, such as preparing for cases and writing, for between 9 p.m. and midnight. (It is 1 a.m. as I write this article.) As for backup plans – because fevers happen – my husband’s schedule is reasonably lexible, and the grandparents are a short light away when one of us is out of town. Plus, I’m lucky to have supportive co-residents and attendings who have met my children, know their names and can act as local emergency contacts. It’s impossible to avoid guilt over always being behind, not publishing or reading enough, and not spending enough time with the kids, but I have yet to meet one working mom or dad who does not struggle with this perpetual guilt. Selishly, I would hate to look back and have missed the childhood of my children, but there are choices to be made – and it’s important for them to know that I work because I want to. Being a role model of hard work and accomplishment is a personal parenting priority. hat said, my children come irst, and I’m there for them when it counts. I will drop everything if they need me, and we will work out the rest. It can be diicult to accept that I’m doing the best I can. After all, there’s that persistent guilt. I still fall into the absurd belief that I need to be a more-perfect resident because I have children, and that I have something to prove for all working women (never leave early, never seem tired). One year, I resisted an unsolicited ofer from a senior resident to round for me on Christmas, until my husband stepped in and pointed out my irrationality. I nearly missed pure, innocent, childhood joy on Christmas morning for the perceived “weakness” of allowing someone to help me.

Plastic Surgery Resident | Summer 2016

Perversely, even with the additional obligations, I thought there was such a thing as a resident or a mom who was well-rested. It turns out that stress about perceptions of performance by peers and faculty after pregnancy is a common concern. Interestingly, in a survey of general surgery program directors published in JACS, fewer than 10 percent believed that pregnancy negatively afected a female resident’s scholarly activities, clinical abilities, dedication to patient care or timeliness.1 A study from the radiation oncology literature found equal academic productivity between residents who were mothers and their male and nonparent cohorts.2 hrough anecdotal observation, I have come to believe similarly that a resident’s work ethic stays the same after having a child. I have enough to worry about and no time to worry anyhow, so I keep moving. Residency is hard. Being a mom is hard. Yet here I stand, a normal person – not Superwoman and not a workaholic – and I would not trade my crazy life for any amount of money, accolade or sleep. My goofy, nerdy son and my take-charge toddler are ever unpredictable and precious. here’s no shortage of laughter in our household. Moreover, motherhood brings a diferent perspective on life and doctoring. I am inspired by my own working mom and by the strong women around me. Pregnancy during residency is a real issue, but parenting is the true challenge. Residency is a selish time, and realistic expectations should be kept for yourself, your spouse and your children. Protect yourself emotionally, even if it means taking the same week of every year in order to be home for dinner on your son’s birthday. Children will not let you stop being a mom, even for a minute, so you have no choice but to keep moving and ind a system that works. here will be imperfections and improvisations. For me, the unifying theme is the unremitting partnership with my husband and the purposefulness to be a role model to my children. |

References 1

Sandler B.J., Tackett J.J., & Longo W.E., Yoo P.S. “Pregnancy and parenthood among surgery residents: results of the irst nationwide survey of general surgery residency program directors. J Am Coll Surg 2016;-: 1e7. 2

Holliday E.B., Ahmed A.A., Jagsi R., Stentz N.C., Woodward W.A., Fuller C.D., & homas Jr C.R. “Pregnancy and parenthood in radiation oncology, views and experiences survey (PROVES): results of a blinded prospective trainee parenting and career development assessment.” Int J Radiation Oncol Biol Phys 2015. 92(3): 516-524.

COMPREHENSIVE CLEF T C A RE, SECOND EDITION

By Sanjay Naran, MD

lastic surgeons who endeavor to build their own libraries should consider the importance of identifying resources that possess utility that will evolve along with them. If someone purchases a book that’s too basic, it’s quickly outgrown. If they purchase a book that’s too advanced, they may ind, depending upon one’s eventual specialty interest, that they rarely reference it again. No matter one’s eventual focus, as we move through residency, ideally we will acquire at least one comprehensive text in each of the subspecialties of plastic surgery to which we may turn should we need to. In the specialty of cleft care, Comprehensive Cleft Care, Second Edition provides that resource. his second edition is a dramatic step forward from the previous one. Authored by internationally renowned experts, it includes the most current clinical perspectives on cleft care, designed to speed clinical decision-making and optimize patient care and outcomes. he new edition features 16 new chapters as well as a thorough update of previous chapters. Comprehensive Cleft Care, Second Edition is now divided into two volumes: the irst addressing nonsurgical topics, including fundamentals, embryology, anatomy, classiication, epidemiology, genetics, cleft palate speech and velopharyngeal dysfunction; and otologic, audiologic and airway assessment and management. he second volume addresses surgical solutions and examines primary cleft lip and palate repair, including various techniques for the diferent types of clefts. The authors also discuss secondary cleft surgery and dental, orthodontic and prosthetic management, and the management of skeletal deformities. The surgical technique chapters are often atlas-like, with detailed technical narratives provided for a wide range of cleft surgeries. A particular bonus to residents is the inclusion of two DVDs/online videos covering topics ranging from anatomy and embryology to detailed videos of more than 15 key surgical procedures. Overall, this book provides a contemporary, comprehensive and multidisciplinary reference for cleft care – and it’s a valuable resource to all students of plastic surgery. |

Plastic Surgery Resident | Summer 2016

Pediatric mandible fracture

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

By Jennifer McGrath, MD

andible fractures are the most common facial fracture in the pediatric population, accounting for roughly 20-50 percent of all facial fractures.1,2,3,4 While most residents frequently encounter adult mandible fractures while on call, the pediatric population presents several crucial diferences in diagnosis and management. he following case-based review aims to highlight features unique to the pediatric mandible fracture.

MESSAGE ON YOUR PAGER: CHILDREN’S E.R.: MANDIBLE FX S/P FALL FROM BICYCLE As you return the page, consider asking yourself and the E.R. staf the following: • Age of the child (dentition) • Mechanism (anticipation of defect) • LOC (extramandibular trauma, C-spine, concussion, etc.) • Broken or missing teeth • Lacerations (cutaneous or intraoral) (open fracture, access for ORIF) • Imaging (if they are planning a CT – can combine) PERTINENT HISTORY: While a consultant to the E.R. will have a speciic agenda, plastic surgery residents must remember that maxillofacial trauma patients are trauma patients. Do not miss concomitant injuries such as airway, cervical spine and intracranial injuries. Airway compromise 10

Plastic Surgery Resident | Summer 2016

may occur due to level of consciousness, edema or loss of anterior tongue support, so begin with the basics.5 As in the adult population, the examiner must have a high index of suspicion for cervical spine injuries when evaluating children with facial fractures, including mandible fractures. Pediatric patients have similar percentages of concomitant cervical spine fractures as the adult population, roughly 3.5 percent.6 As in many pediatric consultations, history may be limited by patient age or anxiety. Additionally, the nature of the injury itself may limit history even in older, cooperative children. Eliciting details from the patient or family regarding the mechanism, change in occlusion, missing or loose teeth and pain will help guide the physical exam. PHYSICAL EX AM: Patient evaluation should include inspection of the face, noting swelling, asymmetry, ecchymosis and lacerations. Chin lacerations are commonly caused at the impact site in falls. Preauricular swelling may suggest condylar fracture. Palpation may reveal bony step-ofs, instability or crepitus. Sensation should be noted, especially in the mental distribution. he patient’s maximal incisal opening should be assessed and is often limited due to pain, swelling or trismus. Note the excursion on opening and closing, looking for deviation, splaying or premature contact. Intraoral examination should look for ecchymosis, intraoral lacerations and discontinuity in the mandibular arch. Dental evaluation must assess occlusion in addition to missing, broken or mobile teeth. ADDITIONAL TESTING/IMAGING: If no imaging has been obtained prior to consultation, Panorex ilms are a good starting point. However, if positioning is substandard, these ilms may not adequately visualize the condyles, which are commonly involved in pediatric

GURE 1

mandible fracture patterns. CT imaging is often utilized for its higher sensitivity and for surgical planning. Ideally, maxillofacial CT and intracranial head CT will be performed simultaneous to minimize ionizing radiation. When reading imaging, maintain a high level of suspicion for multiple fractures, particularly condylar fractures, as about half of patients have multiple fracture sites.1,5 MANAGEMENT STR ATEGIES: he irst decisionpoint for management involves separating the subset of fractures that can be managed nonsurgically. Pediatric patients have a higher capacity for remodeling than adults. Patients with normal occlusions and favorable fractures, such as greenstick, high condylar, coronoid or simple nondisplaced body fractures, have satisfactory outcomes with conservative management alone.1 Soft diet and pain control are the mainstays of treatment. Displaced fractures, multiple fractures or unfavorable fracture patterns will typically require surgical intervention. For surgical reduction, a normal occlusion must be established and secured. Traditional teaching discourages the use of arch bars for maxillomandibular ixation in children in primary or mixed dentition. Deciduous and erupting permanent teeth are less-stable bases for securing arch bars or wires and are at increased risk of avulsion. Similarly, IMF screws risk damage to maxillary tooth buds; therefore, most practitioners avoid use of these in younger patients and rather rely on alternative MMF techniques, such as circumandibular and maxillary drop wiring or interdental wiring to the most secure teeth.2 Still, several surgeons have published on the safe and efective use of arch bars in the pediatric population. In their series of 48 fractures treated with arch bars in primary or mixed dentition, Naran et al. (2014), did not

FIGURE 3

report any tooth avulsions or damage to permanent teeth, and complication rates were no diferent when arch bars were used compared to all patients treated in primary or mixed dentition.7 Splints can also be fabricated and used to establish occlusion and MMF in very young patients without stable dentition. Most isolated mandible fractures do not require ORIF. he most common fracture site is the condyle, and many unilateral condylar fractures can be managed conservatively if there’s no malocclusion, especially in younger patients. If not, MMF is recommended; open treatment is rarely needed and only indicated with condyle displacement into the middle cranial fossa or dislocation interfering with jaw range of motion. Isolated, minimally displaced fractures of the body or angle that do not disrupt the pre-injury occlusion can also be treated conservatively. Displaced fractures or complex fractures will often require open treatment, with or without MMF. Most cases of multiple fractures will require open treatment of at least one fracture site. ORIF is usually accomplished with titanium plates and screws. Resorbable plates are an attractive alternative, but limitations in their biomechanical properties compared to titanium may limit their use. A titanium plate of equal size will be substantially stronger and more stable. Mixed dentition complicates open treatment of pediatric mandible fractures, due to the presence of the tooth buds within the body of the mandible. Placement of plates and screws should be planned to avoid the developing teeth and should be placed along the inferior border. Monocortical screws may be used, and care should be taken to avoid superior trajectories. Older children with permanent dentition can Plastic Surgery Resident | Summer 2016

essentially be treated as adults with standard techniques of arch mar MMF, IMF screws and open reduction, and internal ixation with titanium plates and screws.

there are no loose, mobile or broken teeth. here is pain and swelling bilaterally in the preauricular region. Trauma evaluation including cervical spine radiographs was negative.

he duration of MMF is shorter in pediatric patients, with two to three weeks usually adequate. Shorter periods of immobilization limit the risk of ankylosis – a devastating complication. Mandibular physical therapy is also an important factor to avoid ankylosis.

Imaging obtained by the E.R. includes an axial maxillofacial CT that reveals bilateral subcondylar fractures, as well as a right parasymphyseal fracture. here’s no comminution or displacement. he condyles are displaced medially at roughly 90 degrees by the pull of the lateral pterygoid muscles (igure 2). he parasymphyseal fracture involves the tooth bud of the permanent right lateral incisor (tooth No. 26), as well as the primary right lateral incisor (tooth Q ).

COMPLICATIONS: he most frequent complications include dental trauma and temporomandibular joint clicking. Malocclusion can be a diicult complication to assess. Malocclusion is more common in fractures treated openly; however, this is confounded by the severity of fractures necessitating open treatment. In addition, preinjury occlusions are more diicult to determine in pediatric patients, and it may be diicult to determine if subsequent malocclusion is secondary to the trauma. Growth is a unique concern. Fractures, especially of the condyles, are known to inluence subsequent mandibular growth. A recent series did not show diferences in growth on cephalograms when comparing the injured to uninjured hemimandible in individuals, or when comparing to ageand sex-matched controls.1 Range-of-motion limitation has been associated with growth disturbances as well. Plates can be clinically noted to migrate as the patient grows, though there’s a lack of conclusive data that permanent plates and screws limit or disrupt growth. Plates are, therefore, not routinely removed in the absence of exposure or infection. PATIENT CASE: he patient is a 7-year-old, otherwise healthy female who presents to the E.R. with her parents following a fall from her bicycle. She was thrown forward over her handlebars, striking the inferior aspect of her chin on the pavement. On presentation, she has pain and swelling of the symphyseal region of her jaw. On examination, she has a decrease in her incisional opening, limited by pain and swelling. She has a 3 cm submandibular transverse laceration with no exposed bone. here are no obvious intra-oral lacerations. She has an anterior open bite of 2 cm (igure 1). he patient is in mixed dentition, but

he patient’s family is counseled regarding the need for surgical intervention given multiple fractures. he submental laceration is irrigated and closed. he patient is discharged from the E.R. on PO antibiotics, pain control and a soft diet with follow-up for ORIF several days later, allowing for reduction of acute swelling. In the O.R., ORIF is planned. Maxillomandibular ixation is necessary to establish her occlusion. Due to the patient’s mixed dentition, it’s advisable to avoid IMF screws. Instead, piriform aperture and circumandibular wires are used for intermaxillary ixation. An upper buccal sulcus incision is used for placement of the piriform aperture wires. A small hole is drilled at the lateral piriform aperture bilaterally and a 26-gauge wire is passed through. he wire then punctures the gingiva inferior to the access incision and is twisted to create a loop for MMF. With the occlusion stabilized, attention is paid to open reduction of the parasymphyseal fracture. Once reduced, the parasymphyseal fracture is plated with a four hole, 1.5-mm thickness titanium plate at the inferior border, inferior to the tooth buds. he wound is then irrigated copiously with antibiotic irrigation and closed with resorbable suture. Radiographs conirm appropriate occlusion and plate placement (igure 3). Note the plate placement inferior to the tooth buds at the inferior border. MMF is maintained for a brief period in children, typically two to three weeks. Suspension wires can be removed in the O.R. under a short general anesthetic. |

References: 1

Smith D.M., Bykowski M.R., Cray J.J., Naran S., Rottgers S.A., Shakir S., et al. “215 mandible fractures in 120 children: demographics, treatment, outcomes, and early growth data.” Plastic and Reconstructive Surgery. 2013;131(6): 1348-58.

Siegel M.B., Wetmore R.F., Potsic W.P., Handler S.D., & Tom L.W. “Mandibular fractures in the pediatric patient.” Archives of Otolaryngology - Head & Neck Surgery. 1991;117(5): 533-6.

Smartt J.M., Jr., Low D.W., & Bartlett S.P. “he pediatric mandible: II. Management of traumatic injury or fracture.” Plastic and Reconstructive Surgery. 2005;116(2): 28e-41e.

Halsey J.N., Hoppe I.C., Marano A.A., Kordahi A.M., Lee E.S., & Granick M.S. “Characteristics of cervical spine injury in pediatric patients with facial fractures.” he Journal of Craniofacial Surgery. 2016;27(1): 109-11.

Grunwaldt L., Smith D.M., Zuckerbraun N.S., Naran S., Rottgers S.A., Bykowski M., et al. “Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients.” Plastic and Reconstructive Surgery. 2011;128(6): 1263-71.

haller S.R., & Huang V. “Midfacial fractures in the pediatric population.” Annals of Plastic Surgery. 1992;29(4): 348-52.

Plastic Surgery Resident | Summer 2016

Naran S., Keating J., Natali M., Bykowski M., Smith D., Martin B., et al. “he safe and eicacious use of arch bars in patients during primary and mixed dentition: a challenge to conventional teaching.” Plastic and Reconstructive Surgery. 2014;133(2): 364-6.

Put your plastic surgical vocabulary skills to the test! By Sanjay Naran, MD

ACROSS 3. Muscles used to construct the sphincter during a sphincter pharyngoplasty for the treatment of velopharyngeal insuiciency. 5. Nerve whose speciic distribution maps the progression of facial atrophy of ParryRomberg syndrome. 7. Procedure most likely to result in hypertrophic scarring, at a reported rate of 40%. 9. Indicated procedure for a patient presenting with a circumferential electrical injury to the forearm consistent with compartment syndrome. 12. General sensation of the anterior two-thirds of the tongue is supplied by this nerve. 13. he only muscle of facial expression that compresses the cheeks. 17. A permanent, biosynthetic, bilayered living construct of cultured foreskin-derived neonatal human keratinocytes and ibroblasts. 18. Sign observed on MRI consistent with intracapsular silicone prosthesis rupture, representing the prosthesis shell loating in free silicone gel. 19. Branches of the lateral femoral circumlex artery whose perforators are most likely to be the dominant vascular supply for an anterolateral thigh lap. 21. Syndrome resulting in cold intolerance, thin ingers with shiny skin, and ulcers on the tips of the index and long ingers bilaterally. 22. Vector of commissure movement in a free gracilis muscle lap for facial reanimation should simulate the pull of this facial muscle. 24. Dermal appendages located in the groin and axillae, and implicated in the disease process of hidradenitis suppurativa. 25. he efect of nicotine on cutaneous blood vessels, resulting in decreased tissue oxygenation.

Answer key on page 26

DOWN 1. “Great” nerve most likely injured during rhytidectomy. 2. Most appropriate initial therapy for epithelioid sarcomas, as it will help decrease tumor size and local recurrence rates. 4. Ingestion of this herbal supplement may increase the risk of intraoperative or postsurgical bleeding secondary to its platelet inhibitor activity or its role as a stimulator of ibrinolytic activity. 6. he external branch of the anterior nerve emerges between the nasal bone and the upper lateral nasal cartilage to supply sensation to the skin, the dorsum of the lower nose, and tip. 8. he scapholunate and this ligament must be ruptured for a perilunate dislocation to occur. 10. Acidic component of Jessner solution. 11. Deiciency of which may result in Wernicke-Korsakof encephalopathy, which is often observed in massive weight-loss patients sufering from malnutrition. 14. Tooth with the longest root extending onto the maxillary wall near the piriform rim. 15. Anesthetic most frequently observed to induce hyperkalemia in patients with large burns who have also had long hospitalizations. 16. Abnormally elevated rheologic factors associated with hematologic disorders such as sickle cell disease can seriously compromise perfusion by causing this. 20. Dermoids of this region are the key clinical inding that distinguishes Goldenhar syndrome from hemifacial microsomia. 23. Associated with the use of textured prostheses when compared with smooth prostheses. Plastic Surgery Resident | Summer 2016

humb duplication & thumb hypoplasia By Lauren Mioton, MD

ecognition and diagnosis of speciic thumb abnormalities, along with their associated standard treatments, is oft-questioned on the In-Service Exam. Two categories of thumb abnormalities, thumb duplication and thumb hypoplasia, will be highlighted in this review. he main focus will be on the key diferentiating factors between the subtypes of hypoplasia and duplication – and the important factors for treatment.

THUMB HYPOPL ASIA Type I: Mild Hypoplasia: his is the most common type of thumb hypoplasia, in which the thumb appears slender and slightly shorter than a normal irst digit. While the phalanges and metacarpal may be thinner than normal, the scaphoid and trapezium are present. he radius and styloid process are unafected. he IP, MP and CMC joints are stable. Intrinsic muscles including the AbPB, OP and lateral head of the FPB are present but hypoplastic. All other structures are normal. here may be some narrowing of the irst web space. Type II: Moderate Hypoplasia: Similar to Type I, the metacarpal and phalanges are present but small. In these cases the trapezium, trapezoid, scaphoid and lunate may be smaller. he irst web space is deinitely narrowed, keeping the thumb abducted (pollex abductus deformity). If the abducted thumb abnormality is seen, look for abnormalities in the FPL. he ulnar collateral ligament at the MP joint is lax and median innervated muscles (OP, possibly FPB) are underdeveloped. Type III: Severe Hypoplasia: he carpal bones may be so hypoplastic or aplastic that the wrist is radially deviated.

Plastic Surgery Resident | Summer Fall 2015 2016

he trapezoid is small and the scaphoid is frequently absent. he distal radius is small and styloid process is absent. Varying involvement of the metacarpals allows for subdivision of this group: • Type IIIA: Full-length metacarpal and intact CMC joint • Type IIIB: Tapered irst metacarpal and no CMC joint • Type IIIC: humb containing on the metacarpal, no muscles or tendons All extrinsic and intrinsic anatomic variations seen in Type II hypoplasia are present but more severe. Type IV: Floating humb (Pouce lottant): he small thumb is attached to the radial midaxial border of the distal palm by a small soft-tissue pedicle containing a neurovascular bundle. It contains two small phalanges and there is no metacarpal present. he trapezium is often missing and, at times, so is the scaphoid. Distal radius is normal in these patients. Type V: Aplasia: he thumb is absent. Half of these patients will have a normal radius and demonstrate “auto pollicization” due to a widened and pronated index inger that lays in an abducted position. In the other half of patients, the radius is deicient and the index inger is stifer and shorter.

T R E AT M E N T Surgical correction of thumb hypoplasia is most often addressed between 10-18 months in age. For Type-I hypoplasia, there are often no functional deicits and surgery is not warranted. Surgical treatment of Type II, as well as Type IIIA, thumb hypoplasia aims to improve the narrowed web

space, MP joint stability, palmar abduction, IP joint lexion and abducted thumb position with irst webspace release, opponensplasty and tenolysis. Pollicization has proven to be the standard of care for type IIIB, IIIC, IV and V thumb hypoplasia cases (when there is not an intact CMC joint).

T H U M B D U P L I C AT I O N A condition known as radial or preaxial duplication, thumb duplication is classiied using the Wassel classiication system, which is based on the level of bony duplication. Type I is a biid distal phalanx, Type II is duplicated distal to the IPJ, Type III is a biid proximal phalanx, Type IV is duplicated distal to the MCPJ, Type V is a biid metacarpal, Type VI is duplicated distal to the CMCJ. Type VII thumb duplication involves any patient with a triphalangeal duplicated segment. he most common types of thumb duplication are Wassel type IV, comprosing 50 percent, followed by Wassel type II (20 percent) and Wassel type VII (12 percent). he overall goals of thumb reconstruction are to: • Preserve all tendons and collateral ligaments and realign them to balance the reconstructed thumb • Align the articular surfaces as best as possible in an axial pattern using osteotomies if need be • Provide appropriate skin coverage. Details of treatment are rarely tested, but included below for completeness In treatment of Wassel Type II duplication cases, there may be unequal duplication, allowing for easy selection of the

thumb to be excised. A dorsal zig-zag incision in the skin is performed and the nail and nail bed are removed from the smaller thumb. he radial collateral ligament just distal to the IPJ is dissected out with a small piece of periosteum. During inspection of the IPJ, the FPL tendon is identiied and preserved, releasing it as distally as possible. he cartilage can be cut intraarticularly at the junction when excising the extra phalanx and a longitudinal wedge of cartilage is removed along the proximal phalanx on the side of the excised distal phalanx. he smaller portion of the lexor of the retained proximal phalanx is excised at the junction of the remaining lexor tendon. he smaller extensor tendon can be preserved to augment extensor function of the remaining thumb. he collateral ligament is then reattached to the retained distal phalanx and the skin trimmed and reapproximated. Patients with Wassel type IV duplication often exhibit a smaller duplicated thumb on the radial side. he surgical steps for correction are similar to aforementioned techniques in treatment of Type II duplications with a focus on the MCPJ. he broad metacarpal is treated in the same manner as the broad proximal phalanx in Type II correction. |

References: Light TR, Gaffey JL. Reconstruction of the hypoplastic thumb. J Hand Surg AM. 2010 Mar;35(3):474-479. Tonkin MA. Thumb duplication: Concepts and techniques. Clin Orthop Surg. 2012 Mar;4(1):1-17.

Medical Student’s Day A lifetime specialty in eight hours SEPTEMBER 23-27, 2016

By Sanjay Naran, MD Each year at Plastic Surgery he Meeting – the ASPS/PSF/ASMS annual scientiic meeting – a full-length program is dedicated to teaching medical students about plastic surgery. he popular Medical Student’s Day is slated to return Saturday, Sept. 24, in Los Angeles from 8 a.m.-3:45 p.m., providing an opportunity for physicians in training to meet directly with chairmen, program directors, residents and other leaders in plastic surgery. he program is designed to provide practical knowledge of the diferent types of training program pathways – as well as give an inside look at the path to becoming a resident in plastic surgery. Medical students interested in pursuing the specialty of plastic surgery are also invited to join the ASPS Medical Student Forum, which is open to medical students enrolled in an accredited program in the U.S. or Canada. Beneits include the following: • Electronic subscription to Plastic Surgery News • Access to members-only online resources including the Plastic Surgery Education Network (PSEN) • Free admission to the ASPS annual scientiic meeting, including the Medical Student’s Day program • Free admission to the Breakfast with Champions mentoring event • Access to information on he Plastic Surgery Foundation’s grants and scholarship programs • Optional subscription to the journal Plastic and Reconstructive Surgery at a reduced rate. he cost of membership is $25 per year; applications are available on the ASPS website. For information, go to plasticsurgery.org/joinasps, and click on “Medical Students.”

Plastic Surgery Resident | Summer 2016

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Journal Club; 2016 Smr; (3)

insight on creating a pleasing nasal proile. Follow the steps outlined in this article and mentally apply them to your nasal analysis. Using and understanding the soft-tissue cephalometrics will be critical to making a preoperative plan and executing an artistic vision.

2 Frequently used grafts in rhinoplasty: Nomenclature and analysis. Gunter JP, Landecker A, Cochran CS. / Plast Reconstr Surg. 2006 Jul;118(1):14e-29e.

» Authored by one of the forefathers of rhinoplasty, this review

RHINOPLASTY ARTICLES

EVERY PLASTIC SURGERY RESIDENT

SHOULD READ By Walter Sweeny, MD

article should slowly be committed to memory to grasp the basics of cartilage grafting. Grafting has become more commonplace, as the philosophy of structural rhinoplasty has expanded. his article reviews the most common cartilage grafts used for each nasal region and gives the reader straightforward details on placement, design and the type of cartilage that should be used for each graft. To enhance practical understanding of these grafts, it would be advisable to read the citations for the most popular grafts, to get an idea of graft size and methods of carving. I recommend paying particular attention to diferent types of columellar strut grafts, lateral crural grafts and tip grafts. Upon completion, the reader will be able to understand when and how to use these common cartilage grafts.

Four common anatomic variants that predispose to unfavorable rhinoplasty results: A study based on 150 consecutive secondary rhinoplasties. Constantian MB. / Plast Reconstr Surg. 2000 Jan;105(1): 316-31; discussion 332-3.

» In his superb textbook, Rhinoplasty: Craft and Magic, Dr. hinoplasty is by far the most diicult procedure to understand in plastic surgery. he anatomy is complex and variable, and the results are unpredictable. he available reading material on this topic, as well as the diferent approaches and philosophies, are extensive. It’s very common for a plastic surgery resident to read a textbook or a chapter on rhinoplasty to understand the principles and techniques. However, this approach usually provides only the perspective of one surgeon at a time on this complex procedure.

his edition of “Journal Club” presents 10 carefully chosen articles on rhinoplasty, which we believe will help lay a solid knowledge foundation. his list is by no means inclusive of all the excellent rhinoplasty papers, but nonetheless it’s a good place for residents to start.

Precision rhinoplasty, part I: he role of life-size photographs and soft-tissue cephalometric analysis. Guyuron B. / Plast Reconstr Surg. 1988 Apr;81(4):489-99

» his was one of the irst papers to signify the start of modern rhinoplasty, as plastic surgeons began to focus on quantitatively deining aesthetic goals. Granted, the actual methods of creating templates or using acetate tracings may be antiquated, but the thought process is quite valid. Delving into this paper will provide the reader with greater Plastic Surgery Resident | Summer 2016

Constantian devotes an entire chapter to detailing all of the aspects within this article. he name of this chapter is “Four Critical Anatomic Variants and the Secret of Everything,” which indicates how important this paper is to Dr. Constantian’s philosophy on rhinoplasty. he four anatomic variants are narrow middle vault; alar cartilage cephalic malposition; low radix or low dorsum; and inadequate tip projection. hese four anatomic variants arose from Dr. Constantian’s vast rhinoplasty experience, wherein he noticed a common theme to the problems he was seeing in almost every patient requesting primary or secondary rhinoplasty. hese anatomic variants link both function and aesthetics – and failure to address them will increase the likelihood of an unhappy patient or surgical failure. he article explains that on the anterior view, it’s the width of the middle vault and the alar cartilage positioning that are of tantamount importance; while the lateral view is a relection of dorsal/radix height and tip projection. Pay close attention to Dr. Constantian’s explanation of how nasal function and aesthetics come to a crossroads, as he regularly says that “all patients should breathe better after rhinoplasty.” he reader should also memorize Dr. Constantian’s most common false assumptions made by rhinoplasty surgeons, which are mentioned in this article:

» Soft tissue has the ininite ability to retract over the reduced skeletal framework.

» Each nasal region functions independently. Read this article and the accompanying book chapter to gain insight into Dr. Constantian’s approach to endonasal rhinoplasty.

4. he relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Constantian MB, Clardy RB. / Plast Reconstr Surg. 1996 Jul;98(1):38-54; discussion 55-8.

» Any surgeon performing rhinoplasty should have a basic understanding of not only nasal physiology, but also the functional airway, which is Dr. Constantian’s focus in this article. he common answer to protecting the airway is to place spreader grafts, and this classic article quantitates the impact of spreader grafts and other surgical interventions on the various sites of nasal obstruction (external, internal and septal). It also attempts to answer critical clinical questions, such as: Are spreader grafts more efective than dorsal augmentation when addressing internal valve obstruction through an endonasal approach? In using rhinometry, Dr. Constantian sheds light on these topics within this breakthrough paper. If scrutinizing all the data within a functional rhinoplasty article is not for you, then I recommend looking at the four tables within the paper, as they do an excellent job of underscoring the important points. While this is a must-have within any rhinoplasty library, Dr. Constantian performed all of these rhinoplasties endonasally, and the rhinometric values could vary with the more commonly performed open rhinoplasty approach.

Broad nasal bone reduction: an algorithm for osteotomies. Gruber R, Chang TN, Kahn D, Sullivan P. / Plast Reconstr Surg. 2007 Mar;119(3):1044-53.

» One of the most diicult things to grasp for someone learning rhinoplasty is how to approach osteotomies, as well as the indications for diferent types of osteotomies. his part of the rhinoplasty procedure is usually done by feel and is mostly blind. Choosing the type of osteotomy relies on the shape of the nasal bones, the width of the nasal bones and the bony nasal contours – and this is where Dr. Gruber’s article is incredibly helpful for the beginner. he underlying theme of the manuscript is appropriate use of the medial oblique osteotomy and its value in narrowing the broad dorsum, but there’s more educational value contained in this article. By categorizing nasal bones into three basic types – isolated broad base, broad base and dorsum and isolated broad dorsum – the reader is given a foundation to understand and apply common osteotomies. he article should not be treated as an all-encompassing, thorough review; this paper focuses on the low-to-low osteotomy for the narrowing nasal base, which should be cautioned against in any patient with a narrow nasal passage. Even with these and other limitations, the cadaver pictures and illustrations make this a great starting point.

6. Dynamic interplays during rhinoplasty. Guyuron B. / Clin Plast Surg. 1996 Apr;23(2):223-31. Review.

» Dr. Guyuron tackles one of the most complex and critical aspects of rhinoplasty: the surgical feedback loop. Each surgical maneuver in rhinoplasty results in nasal and facial aesthetic changes. Understanding and anticipating these changes is one of the most diicult things for the resident to grasp during surgery. his article gives an outline of how dorsal augmentation afects the illusion of intercanthal distance, how raising the nasion gives the appearance of a longer nose and how losing tip support can widen the alar base. While this is a must-read, you may have to memorize the principles before you actually understand them or can accurately predict compensatory changes following surgical maneuvers. Take a look at the textbook Dallas Rhinoplasty and Dr. Guyuron’s textbook, Rhinoplasty, for an updated in-depth description of the dynamic interplays in rhinoplasty.

Rhinoplasty. Rohrich RJ, Ahmad J. / Plast Reconstr Surg. 2011 Aug;128(2):49e-73e. Review.

» his paper is a magnum opus to rhinoplasty review articles, giving the reader a solid overview to many aspects of rhinoplasty. Accompanying videos that detail nasal analysis, opening the nose, tip grafting and tipshaping are must-watch. While this is a review article, it lays out a systematic approach to analysis, standardized photography, pros and cons of open versus closed approach to rhinoplasty, and managing common complications. One of the many strengths of this article is the straightforward algorithms that can be used to understand complex techniques. here’s a wealth of information within this article that will take time to get through, but the easily digestible format makes it a great article for the start of a comprehensive rhinoplasty overview.

New concepts in nasal tip contouring. Toriumi DM. / Arch Facial Plast Surg. 2006 May-Jun;8(3):156-85.

» his has been one of the most – if not the most – impactful articles on my understanding of rhinoplasty. It is often noted that “as the tip goes, so does the rhinoplasty,” and this article underscores the accuracy of this quotation. Readers will walk away from this article with an understanding of how rhinoplasty is an evolving operation and that its results are best measured over decades rather than a single, one-year followup. Aggressive resection can result in narrowing or pinching of the nose, which won’t be fully appreciated in the early postoperative period. Additionally, this paper does a fantastic job of introducing structural rhinoplasty, the underpinning of Dr. Toriumi’s rhinoplasty approach. It does, however, primarily focus the reader’s attention on creating pleasing contours of the tip by balancing the tip with dorsal aesthetic lines; on creating favorable orientation of the lower lateral cartilages; and on utilizing structural tip support to prevent polly beak deformities. Among dozens of papers, Dr. Toriumi recognizes this as one of his most pivotal. Take your time with this article, because there’s quite a bit of information to digest, and it will take several reads to grasp all of the details. Plastic Surgery Resident | Summer 2016

9. Lateral crural repositioning for treatment of cephalic malposition. Toriumi DM, Asher SA. / Facial Plast Surg Clin North Am. 2015 Feb;23(1):55-71. Review.

» Listed within the suggested readings is Dr. Toriumi’s article dedicated to structural rhinoplasty; the previously mentioned article is in some ways similar to this one and implements changes that Dr. Toriumi has made over the years. Lateral crural positioning is one of the most powerful techniques within rhinoplasty and can almost be thought of as a Swiss army knife. Lateral crural strut grafting can address cephalic malposition, retracted alae, pinched nasal tip, asymmetries of the nasal base, tip rotation, tip projection and external valve weakness. he article contains detailed illustrations and descriptions of how to apply this technique – and when to apply it. In addition, there are many pearls, such as how to vary your trans-columellar incision when changing tip projection, and how to accurately perform base reductions. When asked in a published panel discussion what Dr. Toriumi considers among his most important technical changes within the last ive years, he mentioned repositioning of the lateral crura. his highlights the importance of the technique of lateral crural repositioning.

he plunging tip: Analysis and surgical treatment.

A DDI T ION A L R E A DI NG

» Toriumi DM. Structure approach in rhinoplasty. Facial Plast Surg Clin North Am. 2002 Feb;10(1):1-22.

» Toriumi DM, Rosenberger E. Rhinoplasty of the Aging Nose. Facial Plast Surg. 2016 Feb;32(1):59-69. doi: 10.1055/s-0035-1570126. Epub 2016 Feb 10.

» Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010 Apr;37(2):335-52. doi: 10.1016/j. cps.2009.12.008.

» Guyuron B, Uzzo CD, Scull H. A practical classiication of septonasal deviation and an efective guide to septal surgery. Plast Reconstr Surg. 1999 Dec;104(7):2202-9; discussion 2210-2.

» Constantian MB. Difering characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg. 2002 May;109(6):2097-111.

» Rohrich, Rod J, Liu, Jerome H. Deining the infratip lobule in rhinoplasty: Anatomy, pathogenesis of abnormalities, and correction using an algorithmic approach. Plast Reconstr Surg. 2012 Nov.;130(5):1148-1158. |

Kosins AM, Lambros V, Daniel RK. / Aesthet Surg J. 2015 May;35(4):367-77.

» A common complaint prior to primary rhinoplasty is dissatisfaction with nasal appearance animation, commonly referred to as a plunging tip. his paper examines the several factors that contribute to this, such as poor projection, acute nasolabial angle, long lateral crura and overactive nasal musculature within the columellar base. his paper is the irst prospective scientiic study to quantitatively examine the plunging tip and describe its illusory components. he measurements performed in the paper demonstrate that nasal tip moves less than 1 mm and changes position less than 1 degree. he appearance of the plunging tip has more to do with the position of the alar crease, which is classiied into three diferent types. If you’ve previously associated the majority of all dynamic nasal tip plunging to the depressor septi nasi, then prepare yourself for a very educational read. his paper is a prime example of the principle that a problem can be properly addressed only after a thorough understanding of the etiology is reached.

» Dr. Sweeny is a PGY-4 resident at Northwestern University Feinberg School of Medicine, Chicago.

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

“I love the PRS journal podcasts,” says Australian plastic surgeon Damian Marucci, MBBS, PhD. “The March group, in which David Song, MD, moderated two of the papers was simply awesome.” Catch up on previous Journal Clubs on the PRS Resident Chronicles blog (prsresidentchronicles.wordpress.com/) and join #PRSJournalClub each month for a discussion with authors on a new topic.

Plastic Surgery Resident | Summer 2016

FACING FELLOWSHIP and aesthetic surgery. Despite this large scope, the fellowship timetable is well-structured but lexible, with the Fellow attending diferent teams such as trauma, orthognathic surgery, clefts, ear and obstructive sleep apnea.

Non-U.S. craniofacial surgery fellowships By Alberto Cordova-Aguilar, MD, MPH saw many cases involving children with birth defects, particularly craniofacial malformations, during my plastic surgery training in Peru. Despite the help that the Peruvian medical profession receives from diferent organizations, there are still children who don’t receive timely treatment. herefore, I’ve decided to pursue a craniofacial surgery fellowship to decrease my learning curve and bring better patient care to my home country.

Any fellowship starts with a wish, though planning is the bridge between a wish and reality. By deinition, a craniofacial surgery fellowship is a one-year clinical program; however, depending upon your educational background, a six-month period also could work. Many factors come into play when looking for a fellowship program outside the United States, but probably being a non-U.S. citizen is the irst one. After endless searching, I discovered that the Chang Gung Memorial Hospital, Taiwan, ofers an international fellowship in craniofacial surgery, and that was the beginning of my story. I decided to apply online – and a few months later, I was accepted for a one-year clinical fellowship. he hospital, through the Ministry of Health and Welfare of Taiwan, gave me all necessary documentation, including the visa permit. In retrospect, this fellowship was an incredible experience. To begin, the Taoyuan Craniofacial Center at Chang Gung Memorial Hospital is one of the largest craniofacial units in Asia, receiving referrals not only from throughout Taiwan, but also from Southeast Asia. he center is a unique blend of high patient-volume and a strong research base, which provides an ideal place for a hands-on experience covering all aspects of the craniofacial ield – such as congenital, reconstructive

Moreover, continuing medical education plays a vital role as a an educational resource and an essential part of any training program. Due to the focus on evidence-based medicine, every Fellow is required to carry out research projects. Each Monday and Tuesday morning in this center, Fellows participate in a comprehensive research conference and a craniofacial clinical-case session, respectively. hese usually involve excellent discussions in English about interesting topics and diicult cases. he clinic also gave me room to be involved in preoperative management and how to deal with diicult cases. hough all the medical staf speaks English, the clinics are basically held in Mandarin; however, professors usually make comments in English. During this year in Taiwan, I scrubbed-in as irst or second assistant in more than 320 cases. At Chang Gung Craniofacial Center, the incidence of craniosynostosis is very low compared to the large amount of clefts, orthognathic and microtia patients, so I decided to apply for another fellowship listed on the Dutch Association for Facial Plastic and Reconstructive Surgery (DAFPRS) website. My goal was to use a three-month period to learn more about craniosynostosis and to complete my facial aesthetic surgery experience in a “Western” nation. Six months later, I had been accepted at Erasmus Medical Center in Rotterdam (he Netherlands). he Rotterdam medical center had an atmosphere designed to make one feel at home and carry through the day-to-day activities. hroughout this fellowship, I had the opportunity to visit another craniofacial unit – the Necker Enfants-Malades Hospital in Paris, which also is a well-known European craniofacial center. he Chang Gung fellowship indeed exposed me to the broad spectrum of craniofacial cases and the various surgical techniques available. Perhaps, one of the most unique aspects of an international fellowship experience is the potential to meet diferent people and share your culture with other Fellows from all points on the globe. Life is about choices. As Robert Frost wrote in “he Road Not Taken,” Two roads diverged in a wood, and I – I took the one less traveled by, and that has made all the diference. It’s not so much which path you choose – it’s that you choose a path, and that you remain devoted to seeing it through to the end. An international fellowship is an efective and rewarding path along the goal of higher learning in plastic surgery. | Plastic Surgery Resident | Summer 2016

Q & A WITH S I M O N TA LB OT, M D

By Kendra Y. Mims PSR: HOW DID YOU SELECT YOUR FELLOWSHIP?

Plastic Surgery Resident seeks to provide readers with tips to help them advance in their careers after residency by sharing insights on how to create their desired career path. In this issue, we present Simon Talbot, MD, Boston, director of the Upper Extremity Transplant Program at Brigham and Women’s Hospital (BWH) and assistant professor of surgery at Harvard Medical School. Dr. Talbot, who specializes in hand and microvascular surgery, attended the University of Auckland School of Medicine in New Zealand and completed his plastic surgery residency at BWH through the Harvard Plastic Surgery Combined Residency program. He also completed a fellowship in hand and microvascular surgery at Beth Israel Deaconess Medical Center in Boston, and a research fellowship at Memorial Sloan-Kettering Cancer Center in New York. Dr. Talbot says he is grateful for the peers and mentors who have helped him get to where he is in his career today, as he shares his career path with Plastic Surgery Resident: PSR: AS A RESIDENT, HOW DID YOU PREPARE TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Talbot: To prepare yourself for a good fellowship, you need to always be the best resident you can be. Start to transition your thinking from being a resident to being an attending by transitioning toward independent decision making. I think you also need to solidify what you’re interested in because the only way you can immerse yourself in a fellowship is to be really excited about what you’re doing. Discovering what really makes you passionate and what subspecialty of plastic surgery you really love is key because the more interested you are in something, the harder you work at it, and the better you become. 22

Plastic Surgery Resident | Summer 2016

Dr. Talbot: I had been interested in hand surgery for a long time and was very interested in an apprenticeship model. I really wanted someone to teach me how to put together all the pieces of preoperative, intraoperative and postoperative management. Joseph Upton, MD, a phenomenal surgeon who works in Boston, was willing to take me on as a Fellow. Another aspect that was really important to me was to learn from a real master. Oftentimes in residency, you are trying to get a broad overview of how to take care of patients and how to work through a particular type of operation. But in fellowship, you are trying to master a more reined aspect of surgery. here are many facets to this process, and I wanted to (hopefully) pick up some of the things that a real expert had learned over an entire career. PSR: HOW IMPORTANT IS IT TO HAVE A MENTOR? Dr. Talbot: It’s absolutely essential to have at least one or even several mentors for a number of reasons. First, they can make sure you are on the right track, and they can help you avoid pitfalls and overcome obstacles. It’s hard doing what we do and going through years of training and fellowship and inding the right job. It is helpful to have someone you can bounce ideas of of. Second, from a practical point of view, it’s important to have someone who can give you advice about things you should do and shouldn’t do – and who has been through it before. Sometimes we can’t “see the wood for the trees” ourselves, and a mentor can help with this. hird, it’s very helpful from a personal point of view to have a support network when you need encouragement. Fourth, plastic surgery is a small world, and connections and introductions can be very helpful. I’ve had several mentors who have helped me at diferent stages of my career along the way, and they remain close friends. PSR: WHAT IMPACT HAS YOUR FELLOWSHIP HAD ON THE ADVANCEMENT OF YOUR CAREER? Dr. Talbot: Of course, my fellowship taught me many important and practical surgical skills – and patient management skills. However, it also enthused me about hand surgery. It put me in contact with many people – my co-fellows, teachers, mentors and Joe Upton, with whom

I did my fellowship, have become great, lifelong friends. It’s incredibly valuable and helpful in your career to have people around you who are your conidants, colleagues and friends. Sometimes this can be even more important than the practical skills you learn. PSR: BWH HAS A HISTORY OF SURGICAL MILESTONES, SUCH AS THE WORLD’S FIRST KIDNEY TRANSPLANT AND THE FIRST FULL FACE TRANSPLANT IN THE U.S. WHAT DOES THIS HISTORY MEAN FOR INCOMING RESIDENTS? Dr. Talbot: he history of BWH makes you feel like you are part of something bigger than yourself, and I think that is very important. he history encourages you to succeed. It shows how other people have been able to accomplish things that are similar to what you hope to do at some point. It shows you that your dreams are possible. PSR: HOW DOES THE SURGICAL PHILOSOPHY “SEE ONE, DO ONE, TEACH ONE” APPLY TO YOUR RESIDENT TEACHING? Dr. Talbot: his surgical mantra points out that one of the important things about learning is the ability to catch on quickly. As soon as you can teach it, you know you can do it. In our resident teaching, one of our goals is to take people who are totally unfamiliar with something to a level where they can pass on the knowledge to other people. PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Talbot: Teaching is a continuous, integrated part of my job in an academic medical center. I teach residents every day as part of surgery and clinics, and I teach lab fellows regularly in the research that I do. I also teach medical students regularly who rotate with us. I hope that this makes a diference for these students, residents and fellows so that they continue to move forward in plastic surgery. PSR: WHAT IS THE MOST IMPORTANT ATTRIBUTE TO BE A SUCCESSFUL RESIDENT? Dr. Talbot: I think there are several attributes: diligence and hard work; honesty and integrity, and strong ethics and morals. If you have these attributes, you can’t go wrong. PSR: WHAT WAS THE BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY, AND HOW DID YOU HANDLE IT? Dr. Talbot: I really haven’t had family around me, and I’m a long way from where I grew up and the place I previously considered home (New Zealand). I’ve handled it by surrounding myself with others who fulill this role. I’ve been in Boston for 12 years, and I feel like Boston is home now. PSR: WHAT DO YOU ENJOY THE MOST ABOUT YOUR WORK? Dr. Talbot: I have amazing partners. I love to work with them, and they are a group of people with wonderful talents. I have an incredible variety of patients with a lot of complex

Dr. Talbot demonstrates a procedure in the O.R. at BWH.

problems. I get unbelievable satisfaction out of the time I spend with my patients and the opportunities I have to make diferences in their lives. I have a drawer in my oice of thank you cards and photographs from patients, and whenever I am having a bad day, I go to my drawer and look at them. It makes you realize that in plastic surgery, we have a unique opportunity to incredibly change and inluence people’s lives at a moment when they’re going through a bad period. I think that is a privilege you can’t underestimate. PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Talbot: I think my biggest challenge right now is the change in the health-care system. I think we have less time to do more and more, and it’s a challenge in my life to be able to provide the care and teaching I want to give in the amount of time that is available to me. PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIFE? Dr. Talbot: I really try to maintain a work hard, play hard philosophy. When you’re at work, I think it’s very important to be completely committed to the patient in front of you and to give them the time they need. But I think it’s equally important to give your family and friends the time they need when you’re with them. Frankly, when you’re alone, you need to give yourself the space you need to relect. he most important thing is making sure that you are present wherever you are. PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Talbot: I try to tell all of the residents to work hard, stay enthusiastic and stay curious. If they maintain those values or attributes, they will enjoy their residency while learning how to be great plastic surgeons. | Plastic Surgery Resident | Summer 2016

Resident Spotlight: Fares Samra, MD

“Resident Spotlight” showcases a plastic surgery resident or Fellow whose life outside the hospital is (almost) as interesting as his or her work. Fares Samra, MD, a University of Pennsylvania Integrated PGY-4, discusses his outreach projects close to home in Philadelphia – and far abroad in the Middle East.

By Sameer Shakir, MD Fares Samra, MD, is a Syrian-American born and raised in New Jersey. He is the youngest of four sons in a family where the practice of medicine runs deep – both of his parents and two of his brothers are physicians. Dr. Samra attended the University of Pennsylvania as an undergraduate, during which time he spent a semester in Cairo while earning a degree in Near Eastern Languages and Civilizations. He would go on to medical school at NYU before making his way back to Penn, where he now balances a plastic surgery residency with his passion for humanitarian work.

PSR: You’re very involved with mission work; how did you irst become involved?

FS: I always knew I wanted to be involved with medical missions. I even wrote about it in my personal statement for medical school. When I was growing up, my family would make regular trips back to Syria to visit our relatives. My mom, a pediatrician, was regularly involved with charity work in Damascus, and I was exposed at a young age to the huge divide between socioeconomic classes in the hird World. She instilled in us a desire to help and protect the underserved, both at home and abroad.

Fares Samra, MD, PGY4 at the University of Pennsylvania

Plastic Surgery Resident | Summer 2016

When the Syrian revolution began in 2011, my family and I immediately got involved in whatever capacity we could – and we continue that to this day. Whether it’s protesting in front of the United Nations building in New York, raising funds for charity, meeting with government oicials or just raising awareness, we continue to support increasing the freedom and rights of all Syrians. In 2013, my brother, Salem, a hand surgery Fellow at the time, led by example by traveling to Jordan to provide medical care to Syrian refugees. I was incredibly proud of him – and wished

Dr. Samra with the Syrian-American Medical Society during a mission to Jordan in April.

I could have been there to help, but I was an intern at the time and had no control over my own schedule. As a PGY-2, I have some control over when I take a vacation, and I was determined to go to Jordan. As a very junior resident, however, there was only so much knowledge and skill I had to ofer, and I would need to ind the right venue for helping.

overall. he orthopedist on our trip subspecialized in hand surgery, and a ton of complex hand and extremity reconstruction was performed. My dad and I did 18 cases, the majority of which were burn- or traumarelated. We also saw a large number of congenital deformities. It is, to date, the most meaningful and impactful surgical experience I’ve had in my life.

I searched everywhere for organizations that were providing relief, and ultimately I found LEAP Global Missions (leapmissions.org) – an awesome charity organization that sends plastic surgeons to postnatural disaster and war-torn areas for reconstructive mission work. After speaking with ASPS member Craig Hobar, MD, the founder of LEAP, I was given his blessing to join the January 2014 group, despite my junior resident status. I joined two other plastic surgeons, and we did our best to navigate the logistical and political hurdles to help as many people as possible. It was an incredibly powerful and humbling experience.

PSR: How does the schedule accommodate mission work? FS: It’s hard to plan too far ahead in residency. Mission

In April 2016, I went on my second mission, this time joined by my father, Said, also a plastic surgeon, and my wife, Aya, who served as a translator. We traveled with the Syrian American Medical Society (SAMS), a non-political, non-proit humanitarian organization and leading provider of health care for Syrians both within Syria and in neighboring countries (to learn more about SAMS, go to sams-usa.net). Our mission had more than 80 volunteers, including more than 60 medical providers with a wide range of specialties: internal medicine, pediatrics, emergency medicine, family medicine, neurology, medical and interventional cardiology, dermatology, general surgery, orthopedics and, of course, plastic surgery.

FS: Anyone who’s made it to a plastic surgery residency

Over the course of six days, our mission saw more than 6,000 patients, and our team of four performed 37 surgical procedures (18 were plastic) – as well as 39 cardiac catheterizations that were performed by all teams

work has to be taken as vacation time, and there is a pretty limited amount of that every year. I’m coming up on the time where I need to sort out away-rotations and applications for fellowship. Still, my hope is to go on a mission yearly, or at least biennially. I’m trying to convince some of our attendings at Penn to come with me next time. he O.R.s I worked in had 9-0 nylon on the shelf – they’ll feel right at home!

PSR: What words of wisdom would you provide to residents who want to get involved? knows all about hard work, perseverance and sacriice. Going on missions requires all of the above, but the amount of self-fulillment and the gratitude of your patients is exponentially greater than anything you’ve ever experienced in residency. It’s an incredibly humbling and rewarding experience. A word of caution: Don’t think that going on a mission gives carte blanche to pretend you’re an attending, or to try out something you’ve never done before. here’s a lot of controversy over surgical missions that involve traveling surgeons or trainees who perform procedures they haven’t mastered. As a resident, I would make sure you’re in an environment where you can work closely with an attending, assisting while having the appropriate amount of autonomy – just as you would at home.

Plastic Surgery Resident | Summer 2016

Residents, Fellows and attendings celebrate a successful Movember at the home of Joseph Serletti, MD, chief of the Division of Plastic Surgery at University of Pennsylvania, in November 2015.

PSR: Can you tell us about Penn’s “Movember” movement? hey say a picture speaks a thousands words.

FS: “Movember” is a movement to raise awareness and funds for men’s health issues. Participants grow mustaches throughout November, and thus become a walking billboard for the cause. I’m always looking for ways to bring the team together at Penn, and a friend of mine from another program told me about their experience doing this. It sounded awesome. I pitched it to my co-residents and our attendings, and before I knew it, there were 22 residents, Fellows and faculty growing out their mustaches. It was hilarious, and for a great cause! We raised $800 for the Movember Foundation and had a great time doing it.

PSR: Will this be a recurring event at Penn Plastic Surgery? FS: hat will have to be decided by the junior residents

Dr. Samra and his father, Said Samra, MD, during their latest SAMS mission trip in April, during which the duo performed 18 operations on Syrian refugees in Jordan.

myself. Asaad, Salem, and I have all followed in our father’s footsteps. Maher, afectionately referred to as “the smart one” in our family, is a banker. Asaad trained at Baylor and graduated in 2007; Salem trained at Yale and graduated residency in 2012, and hand fellowship in 2013. hey all are in practice together in the town in which I grew up: Holmdel, N.J.

PSR: Any parting thoughts before you get back to work? FS: he opportunity to become a plastic surgeon is an incredible gift. here’s something about taking the skills you learn and applying them to improve the lives of the underserved in the world’s poorest communities that simultaneously humbles and fulills you in ways that you can’t imagine. It pushes you to be better and to ind ways of giving more. |

in our program. One thing I know for sure: here are a lot of people who are hoping they will never see us with mustaches again…

PSR: You are among a long line of plastic surgeons named Dr. Samra. Can you elaborate?

FS: It’s pretty incredible. I’m the fourth Dr. Samra plastic surgeon in my immediate family. And it all happened by accident. My parents, Said A. Samra, MD, and Raja Barakat, MD, were born and raised in Damascus. After graduating medical school and getting married, they moved here to pursue their post-graduate training. My dad trained in general surgery and intended on moving back to Syria to practice. At the time, Syria was at war in Lebanon, and my grandfather urged my dad to stall for a couple of years and not return home, due to the risk of being drafted into the military. He just wanted to be a general surgeon, but to avoid conscription, he needed to ind a way to keep training. He always enjoyed his experience while rotating on plastic surgery, so he pursued fellowship training and ultimately became board-certiied in the specialty. My parents had four sons: Asaad, Salem, Maher and 26

Plastic Surgery Resident | Summer 2016

Answer key

By Amy Fuqua

lastic surgeons have invested greatly into their education, patients and specialty, and from those investments they nurtured their most valuable asset: their ability to earn an income. Income does a lot of things – it pays for oice operations, rent, fees, licenses, memberships, employees, a home mortgage, education expenses, child care, vacations and more. An income is absolutely worth protecting. But how would a young surgeon go about doing that? I believe that at the heart of every plastic surgeon is a researcher. hey don’t ask for the answer – they ask the right questions, gather accurate data and arrive at their own conclusions. Here are two key questions you should ask in order to protect your income. WHAT TYPE OF DISABILITY INSURANCE DO I NEED? here are two diferent policies that you should consider both as a surgeon and a business owner. he irst is personal disability coverage. his type of policy pays YOU in the event you become disabled. he second is a business overhead expense (or BOE) policy. his pays your PRACTICE in the event you become disabled. HOW DOES MY PRACTICE TYPE AFFECT MY CHOICE? Are you practicing in academic medicine or in private practice? here are diferent considerations for each situation.

PRIVATE PR ACTITIONERS Statistics abound regarding the costs of running a practice. Even if you are a solo practitioner with a spouse working as scheduler/oice manager/accountant, there will still be business

costs that must be paid regardless of whether or not you’re working. If you weren’t able to practice for a period of 90 days, who would continue to pay overhead expenses such as employee wages, location costs, utilities, business insurance premiums, etc.? A BOE policy would provide reimbursement or beneits for those expenses so that your business can continue to run. Premiums for a BOE policy are tax deductible as a business expense One thing a BOE will not pay is your salary. If you want to protect that investment, you’ll need personal disability coverage as well.

EMPLOYED PRACTITIONERS Practicing in an academic or employed setting (anything other than running your own private practice) makes the disability arena a little easier to navigate. A BOE is not necessary in most cases, so let’s look at what you need to ask about your group or individual disability coverage. he most important thing to remember here is that the way in which your disability premiums are paid will afect how the beneit will be paid. For example, a surgeon working for a hospital with a corporate long-term disability policy where premiums are paid by the corporation will typically have a beneit that is taxable. If the premiums going into the policy are not taxed, then the beneit itself will be taxable. To further this, the carrier many times will not withhold taxes from beneit payout, so you will be responsible for paying them come April 15. You may have the option to choose to have taxes withheld from the beneit. In addition, based on the deinition of disability on that group policy, you may consider a secondary personal policy.

Plastic Surgery Resident | Summer 2016

WHAT IS THE DEFINITION OF DISABILITY?

FUTURE INCREASE OPTION

his may be the most important question. he same way your specialty training separates you from a general surgeon, this deinition separates the tailored policy from the basic.

his rider will guarantee your insurability for a certain period of time, allowing you to increase your covered income – and, therefore, your maximum monthly beneit – regardless of any health changes. For example, you’ve just purchased a policy with a $5,000 maximum monthly beneit with an additional $10,000 of Future Increase Option. his would allow you to purchase up to $15,000 of beneit in the future without going through medical underwriting.

‘OWN OCCUPATION’ VS ‘ANY OCCUPATION’ “Own occupation” policies generally deine disability as the inability to perform the material and substantial duties of your own occupation, which will be shown on the application. Most physicians’ policies will have a “two-year own occupation” deinition, which means that for the irst two years, you qualify for beneits if your illness or injury prevents you from performing the duties of your own occupation. After that period, you may only qualify for beneits if your illness or injury prevents you from performing any occupation. here’s an “ownoccupation to age 65” beneit, which is a much better alternative. he appropriate “own occupation” – in some cases, “own specialty” – deinition will protect you as a surgeon, not just as an income earner.

WHAT ARE MY EARNINGS AND MY MAXIMUM MONTHLY BENEFITS? How the carrier deines earnings will determine what beneit the policy will pay. Earnings are typically deined as salary from a speciic occupation, but be aware that some policies will include other income as earnings as well. he maximum monthly beneit is typically 60 percent of your monthly earnings. his beneit can be reduced by a number of things, including beneits that you may receive from other policies (such as group coverage or Social Security). Just because your policy says that it will pay 60 percent of your income does not mean that it will always pay the full 60 percent.

WHAT IS THE WAITING PERIOD? Every disability policy has a waiting period – the amount of time you must wait while maintaining the deinition of disability before your policy beneits will be paid. Waiting periods generally range from 30-120 days; the shorter the waiting period, the higher the base premium. Also, keep in mind that you typically won’t receive a payment until you are owed a month’s beneit, so your 90-day waiting period would mean you would go 120 days before receiving any beneit. Use this rule when calculating how much you should have in reserves.

WHAT HAPPENS AS I MAKE MORE MONEY? You’ve just purchased a policy with a certain beneit based on your current income. What happens when your income increases (and we know it will)? here are a few options (or riders) to consider adding when the policy is written.

COST OF LIVING ADJUSTMENT (COLA) his rider will only come into play if you meet the deinition of disability and beneits are paid (typically for more than one year). COLA will increase your monthly beneit each year based on the percentage you elected at the time of inception. Generally speaking, this rider is the most expensive of the three listed here.

RESIDUAL BENEFIT RIDER his rider provides a beneit when you sufer a loss of income of 15 percent or more (based solely on an injury or illness.) For example, let’s say that you’re partially disabled and receiving beneits under your own occupation policy. After recovery, you go back to work at your own occupation, but you’re earning less than 85 percent of your pre-disability earnings. his beneit would continue to pay.

CAN I WAIT TO PURCHASE COVERAGE LATER? As with most personal beneit policies, the cost of coverage is less expensive when you’re younger and increases as you age, as does your risk of needing the coverage. Given the fact that it’s likely that you’re currently the healthiest you will ever be, starting this uphill climb at the lowest possible price is advisable. No matter when you purchase your policy, keep in mind that the premium will be increased incrementally over time. Just over one in four of today’s 20-year-olds will become disabled at some point before reaching age 67, according to Social Security Basic Facts 2015.

WHO SHOULD I ASK THESE QUESTIONS OF? he short answer is a licensed insurance agent. To ind a licensed agent: • Ask a trusted friend or colleague for a recommendation • Search your state’s Department of Insurance website • Contact ASPS for recommendations Look for advanced designations such as Chartered Property Casualty Underwriter (CPCU), Certiied Insurance Counselor (CIC), Chartered Life Underwriter (CLU) or Accredited Adviser in Insurance (AAI). And don’t be afraid to interview agents and check their background. his list is not meant to be exhaustive; it is meant to give you a starting point for a conversation with your agent. No two disability policies read the same way, and each carrier has its own deinitions, riders, waiting periods and combinations of each. Each situation is unique, and with all of the policy options available, so is each solution. | amy.fuqua@usi.biz. his article is brought to you by CosmetAssure, which is a subsidiary of USI Insurance Services

TO PHD, OR NOT TO PHD? — that is the question Attitudes toward research and academic credentials differ across the globe By Johan Sandberg, MD

y American colleagues are often surprised to hear that I’m working on a PhD degree after having served for two years as an attending in Norway. In my experience, PhD titles are generally less common for MDs in the United States as compared to Norway, though academic productivity is much higher in the United States. Upon my return to Norway after eight years of training in Philadelphia and Houston, I was intrigued to learn how much weight was placed at home on a PhD as part of academic career progression. I was even more fascinated that there are virtually no requirements to publish once a PhD has been achieved, considering that “publish or perish” and “wer schreibt bleibt” (roughly translated as “Who writes, stays”) are expressions that describe academic requirements for surgeons in Europe. For a surgeon, PhD work combined with time away from clinical activities could be a double-edged sword, were his or her operative experience and progression as a surgeon begin to sufer. hree years of full-time research is the assigned period of time for a PhD in Norway; however, a 50-percent PhD position over six years can be obtained. Nevertheless, this could mean a critical loss of three important years during a crucial part of surgical development, detracting from the 10,000 hours needed to become a true specialist, according to Malcolm Gladwell. To obtain a PhD in Norway, a minimum of three papers on the same theme must be published over these three years. he PhD title is viewed by some as a necessary evil, often earned in a laboratory setting, to guarantee a position in an urban academic setting – thus avoiding work in rural Norway. My PhD existence translates into one designated research day every week, and one day dedicated to highly advanced surgical procedures related to my project. he other days are dedicated to regular clinical surgical activities. his is not very diferent from the everyday life of an assistant professor at an academic center in the United States. We Europeans are fascinated with history, tradition – and titles. A marginal increase in pay is also awarded to those who obtain a PhD. Some surgeons obtain a PhD in their late 50s without having published anything previously during their entire career – some to crown their career with a prestigious title, others to inally realize a project that has been in the making for many years. Research seems less associated with innovation and curiosity than with tradition and duty. A fair number of surgeons who earn their PhD title are never to publish again. In a socialist environment, a strong atmosphere of consensus-thinking runs the risk of stunting innovation. Repetitive research and noninnovative projects could be safe bets to be published, albeit in less prestigious forums, while still qualifying the author for a coveted PhD title. his could create an unfortunate, non-innovative, three-paperPlastic Surgery Resident | Summer 2016

progression up the career ladder. For those who conduct preclinical research in a laboratory and perform no clinical work, the PhD degree is a requirement. In my own quest to follow my scientiic curiosity, I soon realized that research in Norway outside of a PhD format is very rare – and funding is diicult to obtain. In my experience, residents and Fellows are taught statistics and research as part of their training in the United States. American residents are able to critically review scientiic papers better than Norwegian residents. Socialized medicine focuses on a cookie-cutter approach, and centralized protocols are advocated. his further removes socialized residents from critical scientiic review and guides them into a governmentally managed science that is accepted by “the consensus of the group.” However, I would be remiss if I didn’t quickly add that some excellent, groundbreaking research is produced in Norway. Some laboratories are very well organized and well funded, and put forth excellent results. With socialized medicine comes great databases; patients are eager to contribute to science and often diligent in their follow-up. Collaboration between diferent hospitals and groups is often possible. Government-structured support and funding has many advantages. In order for the Norwegian system to remain viable in the international community, it must be renewed and revitalized, particularly for physicians who perform clinical work and research concurrently. Maybe clinical researchers should have a diferent system that focuses less on PhDs and inds a more modern way to secure highly qualitative scientiic production. Inspiration from the United States can help improve our system. Earlier involvement of scientiic and critical thinking in basic education is crucial. he ideas of the young and inspired must be better-utilized. Research should not be restricted by requirements of a three-year, three-paper PhD format. Focus on scientiic production with rewards through pay per qualitative papers – instead of pay per PhD degree – would be more appropriate. Research should be performed parallel to clinical activities, not to stunt surgical progression. A radically diferent system for funding research with a possibility to get funding outside of the PhD format would be preferable.

Upcoming Surgery Trips & Meetings 9/3 – 9/10 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

9/21 – 9/26 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

9/4 – 9/11 Rotaplast (San Francisco) Iasi, Romania (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

9/8 – 9/11 LEAP Foundation (Dallas) Dominican Republic (972) 566-6550 leapmissions.org 9/8 – 9/11 LEAP Foundation (Dallas) Dominican Republic (972) 566-6550 leapmissions.org 9/10 – 9/18 Association of Baptists for World Evangelism (Harrisburg, Pa.) Moldova (717) 774-7000 abwe.org/serve/healthcare 9/16– 9/17 Chicago Breast & Lymphedema Symposium Chicago (773) 795-0333 cme.uchicago.edu/CBLS2016 9/17 – 9/25 CERT International (Crossville, Tenn.) Haiti (931) 707-9328 certinternational.org 9/17 – 9/24 Surgicorps International (Pittsburgh) Zambia (412) 322-9309 surgicorps.org/volunteer

and YPS

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 9/28 – 10/5 Mission of Hope (Cedar Park, Texas) Haiti (512) 256-0835 mohhaiti.org 9/29 – 10/1 ASSH Annual Meeting Austin, Texas (312) 880-1900 assh.org/annualmeeting 9/30 – 10/9 Hospital De La Familia (Berkeley, Calif.) Nuevo Progresso, Guatemala (510) 883-9064 hospitaldelafamilia.org

I am blessed to be working at a hospital that has been extremely supportive of my wishes for my research and my PhD work, which allows me to progress as a surgeon at the same time I obtain my degree. |

9/18 – 10/2 Rotaplast (San Francisco) Cumana, Venezuela (415) 252-1111 rotaplast.org

Lars Johan Sandberg, MD, trained at Mercy Catholic Medical Center and he Methodist Hospital, both Philadelphia, and MD Anderson Cancer Center, Houston.

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

Plastic Surgery Resident | Summer 2016

#PRSJou J rnal n Clu l b

A New Globallly Interac In nteracti tive v Journal Club, Podcast, and an Live Discussion ussi Series THREE WAYS TO JOIN: 1 l

2 l

3 l

Read Journal Club picks of the

Listen and learn as Resident

Discuss. Join our live Twitter

month. Each month, three articles are selected, and paired with 2

Ambassadors and a special Plastic S geon guest discuss the 3 Journall Sur

talk. Each month, the Resident Ambassadors moderate a discussion

classic articles and 1 classic CME.

Club ub picks p on the monthly l

with the authors. We invite YOU

This is a ready-made Journal Club Discussion for academic and clinical

Podcast dcast. Episodes Epis are available ournal.com, YouTube.com/ ouTube on PRSJournal.com,

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Plastic Surgery Resident | Summer 2016

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