Plastic Surgery News, Winter 2016

ISSUE 5 | WINTER 2016

From the publishers of Plastic Surgery News

» Eat, play, love – and never be late

O.R. ergonomics: Avoid the chronic physical efects of long operations

here’s no ‘right way’ to be a resident, but these tips will keep you on course

page 11

» Plastic surgeon as artist Embrace your artistic talents during surgical training page 12

IN THIS ISSUE » Pearls from the Masters: DIEP flap ............ p.18 » Rectus abdominis flaps: The must-read articles .................................. p.22 » Getting involved in organized plastic surgery is easy – and completely worthwhile ...........p.28 AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005

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A note from the editor

I

t has been an exciting and productive irst year for Plastic Surgery Resident magazine. he publication has really taken on a unique identity – one that, based on feedback I’ve received at the Plastic Surgery he Meeting in Los Angeles, relects the personality of its readership.

Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh

his has genuinely become a publication written by and for its readers. his Winter edition is our last for 2016, and over the past few issues, we’ve been introducing our readers to several recurring sections. For this edition, we bring back some favorites such as In-service Insight; Crossword; Journal Club; Pearls from the Masters; and Faculty Focus.

We’ve also rolled-out for our readers a couple of new sections, including Resident as Artist, in which we highlight (and welcome) artistic works of the plastic surgery resident community. We’ve also put together a collection of reviews of our favorite plastic surgery companion books.

We hope that you enjoy this issue. As always, I would like to thank our physician editorial board and our production staf at ASPS. Best wishes for a safe and prosperous holiday season – and I look forward to seeing you all in 2017. |

Plastic Surgery Resident | Winter 2016

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Table of

Contents Ergonomics in the O.R. .................. 6

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.

Things I wish I knew when I was a plastic surgery resident ..............11

A SPS PR E SI DE N T

B. Aviva Preminger, MD, looks back at her years in training – and ofers her tips for residents to survive and thrive.

Plastic surgeons as artists............12 Alex Kaminsky, MD, addresses the idea that plastic surgeons are a natural blend of surgical technician and working artist.

In-Service Insights .........................14 Soft-tissue illers: Classiications, properties, complications, management and “illers of interest” are laid-out for consumption.

Debra Johnson, MD | johnson@pscmail.com EDITOR

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

Mohammed Alghoul, MD | mo.alghoul@gmail.com Sanjay Naran, MD | sanjaynaran@hotmail.com RESIDENT EDITORS

Alexander Kaminsky, MD, MPH | alexkaminsky@gmail.com Kavitha Ranganathan, MD | krangana@med.umich.edu Deana Shenaq, MD | dshenaq@gmail.com E X EC U T I V E V ICE PR E SI DEN T

Michael Costelloe | mcostelloe@plasticsurgery.org

Pearls from the Masters................18

SENIOR DIRECTOR OF COMMU NICATIONS

Chad Teven, MD, draws upon the expertise of David Song, MD, MBA, to convey novel approaches to DIEP lap reconstruction.

Mike Stokes | mstokes@plasticsurgery.org

Crossword ..................................... 20 Challenge your plastic surgery vocabulary.

Journal Club .................................. 22 Eleven articles to help residents understand the evidence behind abdominally based autologous breast reconstruction.

Residents’ abstracts honored ..... 25 Residents earned honors for outstanding presentations in seven categories at Plastic Surgery The Meeting in Los Angeles.

Faculty Focus: Michelle Roughton, MD ............... 26 UNC program director discusses challenges, her immediate love of breast recon and the need for resilience during tough times.

How to get involved in organized plastic surgery ........ 28 Ash Patel, MD, details his path to committee work, and how it was easier to get involved than he originally thought.

Book reviews ................................. 29 A look at two texts that will keep residents prepared for virtually any situation.

Calendar 4

Plastic Surgery Resident | Winter 2016 | Vol.1 No.5

Ex-college football player sees parallels between a career spent in the O.R. and concussion and injuries on the gridiron.

......................................31

Plastic Surgery Resident | Winter 2016

SEN IOR GR A PH IC DE SIGN ER

Jim Andrews | jandrews@plasticsurgery.org GR A PHIC DESIGN ER

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

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

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

Connor Winther (215) 521-8797 Wolters Kluwer Health Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005.

POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005 Postage paid at Arlington Heights, IL, and at additional mailing oices. he views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily relect the opinions of ASPS. Acceptance of advertisements for PSR is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised.

ASPS Home Page: www.plasticsurgery.org

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Ergonomics and Health in the O.R.: A Parallel to Injury and Concussion Prevention in College Football

By Sean Fisher, BSc, and David Song, MD, MBA

At the age of 27, I should be in the physical prime of my adulthood.

However, my experience thus far has been a departure from the golden 20s promised to most. Instead, there’s a body that feels aged beyond its reported model year; a fractured leg, ruptured deltoid ligament and dislocated ankle ensure that each day begins with stifness that feels more consistent with that of a 50-year-old; scars litter my body, as evidence of years of physical battery, and lower back pain serves as a constant reminder of the heavy weight frequently forced upon my back.

Football is integrally woven into the fabric of our modern culture.

Turn on the television on any given fall Saturday, and you’re sure to be met with a barrage of clashing helmets, cheering fans and NCAA emblems. Rinse and repeat on Sunday, with substitution of the NFL for the NCAA. While rivalries, salaries and Hail Mary passes dominate the conversation surrounding the topic of football, a darker side looms in the future for many of the game’s ex-participants.

However, the most alarming memento from my college football career – which now is an aspiring plastic surgery career – is the frequent, cervical neck pain that has resulted from the constant utilization of my head as a weapon.

When coupled with a 6-foot 5-inch frame, and assessing the spinal health of many career surgeons, the writing on the wall is clear. For myself, the conversation of ergonomics and health awareness for the surgical trainee is not simply a topic of interest. Rather, its emphasis is imperative for avoiding the degenerative spinal injuries that are too frequently acquired over many years in this physically demanding ield.

Much more to do

While studies in the ield of O.R. ergonomics and preventative health for surgeons have reported on the frequency of chronic pain and have illustrated the poor biomechanics that are too often present in the O.R.1–5, little has been done to promote the meaningful change that must occur to ensure longevity for those entering this profession. In assessing the severity of this problem – and in considering solutions – one must only look to the football stadiums throughout this country, which can provide relatable parallels upon which to draw.

Since the irst report of chronic traumatic encephalopathy (CTE)

by Bennet Omalu, MD, MBA, MPH, et al., in 2005, an increasing burden of evidence has suggested a seemingly obvious principle in the game of football6. hat is, longterm exposure to repeated traumatic events results in lasting physical harm. While this premise is not revolutionary, the tangible efects of CTE are. (Coincidentally, on the day this article came across the PSR editor’s desk, the AMA announced that it would honor Dr. Omalu on Nov. 12 with its Distinguished Service Award “ for his work discovering CTE in former American football players.”)

In recent years, a palpable shift has occurred in the public’s willingness to accept the risks associated with the game of football, as a growing number of ex-participants has begun to exhibit signs of this disease. In its wake, society has begun asking the question of how to more accurately monitor and protect football players from the dangers of traumatic injuries. hrough the application of prophylactic measures in every aspect of the game, an injuryprevention paradigm shift has begun to take hold. Using early education, technology and common sense physicaltraining strategies, the next generation of football player is being taught to take the threat of chronic injuries more seriously while being provided the tools necessary to help minimize the risk of such outcomes.

No collisions, but damaging still

Despite the fact that there have been no such revolutionary conclusions reached regarding physical harm in the ield of surgery, it’s abundantly clear that there are many long-term physical stressors imposed on aesthetic and reconstructive surgeons during the course of a long career. he National Institute of Occupational Safety and Health noted that static loads, extreme working postures and high levels of static contraction increase the occurrence of musculoskeletal defects Plastic Surgery Resident | Winter 2016

7

Ergonomics and Health in the O.R. '/. as evidenced by reports of chronic neck and back pain in up to 75 percent of surgeons1, it’s my belief that some of the same principles and technologies being applied to injury prevention in football warrant discussion in the context of tomorrow’s plastic surgeon. In doing so, we may begin to facilitate the usheringin of a new paradigm similar to that observed in the game of football, with the ultimate hope of protecting future generations of surgeons.

Physical preparedness

of the neck7, with other reports also noting the efect played by mental strain on these same symptoms8.

While the all-too-common 15-hour surgery does not elicit the same degree of shock as a violent collision on the football ield, it nonetheless wears upon the parties involved. And just as a football collision, taken in isolation it has a seemingly benign consequence – the isolated, long O.R. case is not threatening to the surgical trainee’s health. However, this isn’t to say that these events don’t pose long-term threats.

During my time playing football, the rush of the game and the pressure to succeed made it easy to brush-of the likely concussion, sprained ankle or ailing muscle. However, years later the physical manifestations of these decisions have begun to crystalize.

In keeping with this same logic, the pressures and demands of the academic environment for surgical trainees and young surgeons often push them to ignore any consideration of the surgery lifestyle outcome (if left unopposed).

While the profession of plastic surgery is, to a degree, unavoidably demanding, 8

Plastic Surgery Resident | Winter 2016

For anyone who has trained for a marathon, played a sport or set a weight-loss goal, it’s known that the “main event” is but a fraction of the work and energy put into the overall process. In order to safely complete a marathon, one does not simply decide to run 26.2 miles. Rather, such a task requires dedication to physical health in a holistic sense. his concept was interwoven throughout collegiate athletics with frequent weightlifting and cardiovascular exercise, diet implementation, mandatory injury rehab and frequent stretching and recovery sessions.

In much the same way, the demanding nature of the surgical O.R. warrants the application of these same principals, as it has been established that both the static and dynamic postural stresses experienced in the O.R. can result in fatigue and disability2. With periods of prolonged standing and retracting, and the constant maintenance of contoured body positions, trainees are subjected to atypical forms of physical exertion that are taxing beyond their apparent face value. his is evidenced by both reports of increased cardiovascular demand during surgery2, as well as abundant long-term musculoskeletal complaints from career surgeons3,5,9.

Although surgical training necessitates that a large amount of time and energy must be focused on the care of patients, it’s nonetheless important to maintain a degree of personal itness throughout this long process. In addition to

achieving the CDC’s recommended weekly amount of exercise, for obvious health beneits10, other forms of activity and training should be incorporated that relect the unique physical stresses placed on surgeons. his premise was frequently utilized in football training, as a heavy emphasis was placed upon exercises that targeted vulnerable areas. Frequent attention was paid to muscles charged with stabilizing the neck, as head-to-head collisions frequently resulted in neck ailments. In much the same way, trainees should consider prophylactic neck-strengthening exercises in an attempt to bolster their cervical column, given the frequent strain placed on this aspect of the body. his targeted strength training has the potential to increase the compensatory threshold against the forces that promote cervical hyperlexion – ultimately minimizing the negative efects of headgear, eyewear and poor posture that are staples of the operating environment.

While residents’ schedules often do not permit frequent trips to the gym, alternative at-home options such as yoga or Pilates may be considered to further tailor individual itnesstraining. By focusing on core strength, these practices may help in injury prevention during times of prolonged contoured posturing. Further, daily stretching should be considered, as it can easily be incorporated into any morning routine.

While it’s easy to neglect one’s personal itness, considering the extended hours frequently worked during surgical training, it’s also important to recognize that such actions have long-term ramiications on one’s ability to practice efectively. With previous studies demonstrating a reduced negative impact on practicing habits in surgeons who were noted to incorporate frequent exercise and stretching into their schedule8, it follows that surgeons at every level should strive to make exercise an integral part of their day.

Equipment

In addition to aspects of injury prevention that can only be improved through the actions of the trainee, we must also look to the surgical environment for additional areas to improve upon. Given the fact that loupes and headlamps make up such an integral part of the plastic surgeon’s armamentarium, the efects they have upon posture and long-term spinal health warrant discussion.

While it’s easy to consider these to be trivial components of the O.R. environment, it has previously been noted that the utilization of both loupes and headlamps may contribute to microsurgeons spending as much as 85 percent of operating time with asymmetric head-neck posturing4. And while it’s diicult to determine a causal relationship between this abnormal posturing and long-term degenerative spinal changes, studies have noted that up to 70 percent of surgeons and dentists who frequently use loupe technology report some degree of neck pain3,9.

Additionally, Sahni, et al., demonstrated that spinal surgeons who reported the frequent use of both loupes and headgear had an increase in both frequency and severity of neck-related symptoms during their years in practice3. While there are currently no studies that evaluate the correlation between headgear or loupe usage and neck pain in plastic surgeons, it’s reasonable to suspect outcomes similar to those of previous studies based on comparable rates of equipment utilization. As such, careful consideration is needed in the selection of appropriate eyewear, as well as the frequency of headlamp use.

When selecting loupes for training and beyond, residents should consider overall design, comfort, depth of ield and the required ield of view for their anticipated usage3. Additionally, special consideration must be given to both the declination angle as well as the working distance of lenses. Both of these factors play a critical

role in maintaining a healthy operating posture, as they contribute to the line of sight of the surgeon3.

If angulation in excess of 25 degrees is frequently sustained, a lexed position is established that can result in a large amount of torsional stress being placed on the cervical spine3. Similarly, this posturing can result with lenses that have an inadequate working distance, as surgeons are forced to manually adjust to ensure proper sight. he summation of these small diferences among currently available products can equate to a very tangible diference in overall outcome, as it has been noted that increasing the lexion angle of the spine from 15-30 degrees results in an additional 13-pound load being placed on the cervical spine11. his strain is further exaggerated by the weight of both loupes and headlamps, as burdensome products may increase this torsional stress to a degree that exceeds the compensatory limits of neck musculature3.

technologies, it’s not unreasonable to consider their potential efects on ergonomics and health safety in the O.R. While constant feedback and development often occur between surgeons and equipment suppliers to improve instrumentation, there are few examples of revolutionary developments with respect to the concept of O.R. ergonomics. he da Vinci robot system (Intuitive Surgical, Sunnyvale, Calif.) is one such example, as it has resulted in improved ergonomics by allowing surgeons to operate in a fundamentally diferent manner. his system allows surgeons to remove themselves from the patient’s side and operate in a more comfortable sitting position. While this allows for improvement in physical positioning, its use falls into a niche (i.e., laparoscopic surgery) that’s rarely occupied by plastic surgeons. As such, an emphasis should be placed not only on therapy-speciic technologies, such as the da Vinci robot system, but also

While the all-too-common 15-hour surgery does not elicit the same degree of shock as a violent collision on the football field, it nonetheless wears upon the parties involved.

While some degree of neck lexion is necessary for improving surgeons’ sight and reducing eyestrain, these beneits must be weighed against the cost of sustained hyperlexion of long duration.

By selecting appropriately suited loupes, trainees can reduce the amount of time spent in these extreme positions – thus minimizing some of the long-term stress placed on the surgeon’s cervical spine.

Additionally, judicious use of headlamps should be considered depending on the procedure being performed, in an attempt to further minimize this stress.

Technologic advances: wearable devices

As technology continues to rapidly develop, we have seen its adoption across various aspects of medicine.

While patient care is the most intuitive application of many newly developed

on broadly applicable concepts that beneit surgeons across all ields.

While there’s a paucity of evidence substantiating its use, wearable technology has the potential for this type of broad application in the O.R. his rapidly expanding ield is currently being adopted across various aspects of our technologically minded culture.

Fitness bands are now a common site on the wrists of many individuals – and within the realm of football, players are being itted with impact-sensing chinstraps that indicate when a player has been subjected to a dangerous amount of force. In much the same way, wearable technology in the O.R. has the potential to provide continuous monitoring as well as real-time feedback regarding the presence of abnormal body posturing.

Products such as ALEX (Nomu, Seoul, Plastic Surgery Resident | Winter 2016

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Ergonomics and Health in the O.R. '/.

South Korea) and LUMOback (Lumo Bodytech, Mountain View, Calif.) are two such examples that may ind utility in this theoretical domain of real-time injury monitoring and prevention. hese products advertise themselves as cervical neck- and lumbar-position monitoring systems, respectively, and while they haven’t been validated in human studies, products such as these may ofer an afordable and discrete means of protection against the longterm efects of poor body posture.

Changing perception

Proper equipment selection, health awareness and technologic advancements all have the potential to result in a degree of change in the prevention of chronic, degenerative conditions for future surgeons.

However, a truly meaningful paradigm shift is only possible if the mindset of those in training and beyond begins to adapt, as well. Historically, the culture of surgical training discouraged reports of stress and fatigue, ultimately facilitating an environment that promoted chronic musculoskeletal problems. While there have been a variety of policy changes enacted to help combat this dogma, the “strong man” mentality still prevails to a degree in the O.R. Certainly, the history of reported toughness in the surgical arena results in some degree of social conditioning for those currently in training.

However, we must also recognize that the apprentice model frequently utilized by training programs promotes a degree of apprehension and compliance in residents. While this isn’t to say that the onus of change is focused solely on those at the attending level, we must recognize that a top-down approach to the topic of injury prevention is necessary to truly facilitate lasting change.

During my time playing college football, I witnessed a similar culture that gloriied misplaced resilience and ignored the ramiications of such 10

Plastic Surgery Resident | Winter 2016

actions. It was only when the tone of the conversation changed that players began to think diferently about concussions and injury prevention. Simply stated, trainees must feel comfortable in asking for an opportunity to adjust positions, take the occasional break or ask for a sitting stool during times of exceptional strain.

In spending time operating with the co-author of this article, I can attest that these seemingly diicult requests become a natural component of the O.R. dynamic when posed by the senior surgeon. By maintaining a vested interest in not only their own health but also the health of trainees, those who oversee the curriculum for plastic surgery residents have the ability to set the path from an early point in their future careers.

Final thoughts

he careers of plastic surgeons and college football players are categorically diferent. here’s almost no risk of sustaining a fracture or concussion while spending time in the O.R. However, the physical risks associated with the environment of a surgeon are nonetheless important to consider for anyone entering the specialty of plastic surgery. Given the duration of training associated with becoming a boardcertiied plastic surgeon, individuals must seriously consider the controllable risks that may substantially shorten one’s career.

While cervical degeneration and peripheral neuropathies may seem inconsequential to the general public, such impairment is detrimental to a surgeon. As such, residents should begin to consider – at an early point in training – the physical manifestations of years of poor operating posture and health negligence.

To facilitate such a change requires a drastic shift in the thinking of those in training and beyond. While there are seemingly few things connecting the game of football and surgical training, we should take pause to evaluate how

concussion prevention is becoming a central focus of the NFL, NCAA and even Pee-Wee Football. In doing so, our hope is that adequate steps will be initiated to re-shape both people’s thinking and their actions regarding long-term health maintenance among current and future surgeons.

For just as people are beginning to seriously consider the ramiications of repeatedly running into someone with their head, we should also critically evaluate why such an alarming proportion of surgeons report some degree of musculoskeletal problems of the neck and spine. Change is only facilitated by the efort and actions of many, and it’s our hope that we begin to give this issue the attention it deserves both for the protection of today – and for tomorrow’s plastic surgeon. | Sean Fisher played linebacker for Nebraska University from 2009-12. He’s currently a fourth-year medical student at the University of Chicago School of Medicine.

References 1. Babar-Craig, H., Banfield, G. & Knight, J. Prevalence of back and neck pain amongst ENT consultants: national survey. J. Laryngol. Otol. 117, 979–982 (2003).

2. Berguer R. Surgery and ergonomics. Arch. Surg. 134, 1011–1016 (1999).

3. Kevin B. James, D. S., Stephanie Holloway, J. H. & Marco, R. A. W. Is there an Increased Incidence of Cervical Degenerative Disease in Surgeons who use Loupes and a Headlight? J. Spine 04, (2015).

4. Nimbarte, A. D., Sivak-Callcott, J. A., Zreiqat, M. & Chapman, M. Neck Postures and Cervical Spine Loading Among Microsurgeons Operating with Loupes and Headlamp. IIE Trans. Occup. Ergon. Hum. Factors 1, 215–223 (2013).

5. Auerbach, J. D., Weidner, Z. D., Milby, A. H., Diab, M. & Lonner, B. S. Musculoskeletal Disorders Among Spine Surgeons: Results of a Survey of the Scoliosis Research Society Membership. Spine 36, E1715–E1721 (2011).

6. Omalu, B. I. et al. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery 57, 128–134; discussion 128–134 (2005).

7. Bernard BP. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati: NIOSH, 1997;97–141.

8. Sivak-Callcott, J. A. et al. A Survey Study of Occupational Pain and Injury in Ophthalmic Plastic Surgeons: Ophthal. Plast.

Reconstr. Surg. 27, 28–32 (2011).

9. Rundcrantz, B. L., Johnsson, B. & Moritz, U. Cervical pain and discomfort among dentists. Epidemiological, clinical and therapeutic aspects. Part 1. A survey of pain and discomfort.

Swed. Dent. J. 14, 71–80 (1990).

10.Shanafelt, T. D. et al. Avoiding Burnout: he Personal Health Habits and Wellness Practices of US Surgeons. Ann. Surg. 255, 625–633 (2012).

11. Hansraj, K. K. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg. Technol. Int. 25, 277–279 (2014).

Things I wish I had known residency

By B. Aviva Preminger, MD, MPH Beginning a residency requires a lot of preparation, thoughtfulness in one’s choice of clothing, staying involved in the activities that bring pleasure and the realization that there will be no “right” time to date, marry or have a family.

Accept these truths and “Just do it” – here are some tips residents might consider to make their lives just a little easier. he irst night of my internship was my husband’s last. I was on call, wearing three pagers and feeling nervous, eager and vigilant, set upon making sure that nothing bad would go down on my watch. he very same evening, I found my husband, well, wasted – and physically ill in my apartment. As drinking heavily was unusual for him, I wondered what might be coming down the pipeline for me that could require such physical catharsis, and how I could possibly prepare myself for it.

To begin with, there are the obvious things that can be done – such as setting two alarm clocks. here’s no worse way to start a new rotation than being late. As the saying goes, “You never get a second chance to make a irst impression.” On the subject of being late, you don’t ever want to be late for rounds, and you don’t ever want to walk into an O.R. after your attending. Your chances of getting to actively participate in a case increase exponentially if the attending believes you are prepared, and that begins by preparing the patient and setting up the room.

When it’s a plastic surgery case, it never hurts to ask if you can mark the patient. For some cases, the markings are half of the actual operation. Facing a patient holding a marking pen for the irst time can be daunting, but it’s best to clear that hurdle early on. As Einstein once said: “Education is not the learning of facts, but the training of the mind to think.”

Part of learning is making mistakes. And when you do make a mistake – because you will – you should own-up to it. Learn from your errors and, most importantly, be honest about them with yourself, your colleagues and your patients.

Preparation isn’t just academic. One of the best pieces of advice I ever received was to “Always make sure to eat, sleep and pee when you can.” Never start a day on an empty stomach, and keep some snacks readily available. I’ve always had a personal preference for chocolate – you can’t beat the sugar and cafeine rush. Eat a real breakfast if you can manage it. Protein and breakfast bars lose their taste after a while.

Do not underestimate the fatigue that comes with residency.

Learn to be aware of it and to know your own limits. I once came home to ind my husband passed out in bed post-call.

An empty frying pan was on a lit burner and all he could say was, “so hungry, so tired.” Sleep when and where you can. I can admit to sleeping in a recovery room on a stretcher next to a fresh transplant patient I was concerned about. hat said, don’t spend all of your time outside the hospital sleeping. For example, when on night loat, make sure you venture into the outside world for at least a few hours.

Good clothing choices and good manners hink about how you present yourself to patients and your colleagues. Tom Ford once said that “Dressing (well) is a form of good manners.” Wash your white coat and don’t overill the pockets. (It’s better to stock a patient’s bedside with dressings, than to serve as a human supply closet.) Doing laundry during residency can be a challenge, and scrubs are easy. hat said, they can be sloppy, not to mention dirty. Being physically puttogether gives others the impression that you have it together… even if you don’t quite yet.

However, comfort and practicality is key. Make sure you have comfortable O.R. shoes. I’ve always had a preference for Danskos, though they have gotten some bad press of late for a lack of ankle support. On the topic of support, the most valuable piece of information I learned on my vascular rotation was to wear compression stockings. Not only do they prevent varicosities, but they actually diminish fatigue and continued on page 30

Prepare for the good – and the bad Speaking of preparation, I cannot say enough about reading and preparing for cases. his doesn’t just make you look good, it also allows you to actually learn. In fact, if you’re allowed, ask to draft the operative report. his reinforces what you have done and conirms that you understood it. It also helps to ask your fellow residents and attendings what sources to read to prepare, which these days can range from book chapters to journal articles to PRS videos and the content available on PSEN (psenetwork.org).

Plastic Surgery Resident | Winter 2016

11

Plastic surgeon and artist: One doesn’t exist without the other

By Alexander J. Kaminsky, MD, MPH

A

s plastic surgeons in training, we’re all too familiar with the discordance in perception between our daily professional lives and the breadth of topics to master, versus what our families, patients, the public and even colleagues in other disciplines envision we do. While we may dismiss many of these outlandish stereotypes, there is a common perception that is overlooked but harbors elements of truth: the notion of the plastic surgeon as an artist.

Among applicants on the interview trail to secure a residency in plastic and reconstructive surgery, the story is often shared of a candidate entering a room where one is asked to sculpt or draw on command. Whether individual programs use this artistic ability to truly assess the candidate or are judging the stress response to the situation is beyond the scope of this article.

In a survey sent to members of the American Association of Plastic Surgeons to rank desirable characteristics of plastic surgery applicants, artistic sense actually ranked second to last (just above “letter of recommendation from unknown surgeon”)1. Although future U.S. plastic surgeons aren’t necessarily selected for artistic sense, overwhelmingly it’s still Camera: Canon D30 Tripod: yes Lens: 28-135mm IS Focal length: 28mm Aperture: f18 Shutter speed: 1/30,1/125,1/500 (2-stop bracket) ISO: 400 Processing software: Photomatrix HDR

an associated attribute. Furthermore, the perception of the plastic surgeon as an artist isn’t just Americentric. A survey from Cambridge of plastic surgery training representatives showed that 15 of 24 agreed that artistic skills are important in plastic surgery, with only six strongly disagreeing2.

With a simple PubMed search of “plastic surgeon and artist,” one can ind many editorials and articles including a PRS letter to the editor in 2003 by Robert Goldwyn, MD3. While acknowledging the perceived artistic abilities of plastic surgeons, which he personally dispelled, he brought up an anecdote of an anonymous colleague driven by such strong patient perceptions that he displayed a disingenuous veneer of artistry with unsigned sketches and sculptures in his oice that had been created by others.

Feature your artwork in an upcoming issue of PSR – submit to ResidentArt@plasticsurgery.org.

Two subsequent replies4,5 emphasized the plastic and reconstructive surgeon as primarily being a scientist/surgeon, with one reply stating that the myth of the surgeon as an artist is a disfavor by emphasizing the artistry rather than the surgical virtues of technical ability judgment and knowledge.

(Above) During my general surgery training at Inova Fairfax in northern Virginia, just outside Washington, D.C., one of the staf colorectal surgeons and I formed an unoficial photography enthusiast club – with one of our goals to shoot the D.C. monuments at night. While we were starting to set up our planned vantages for the Capitol Building, there was an eerie absence of activity and the overcast sky was being pierced occasional streaks of warm August sunlight. As the saying goes, luck favors the well-prepared… I had my tripod-mounted dSLR camera out and ready to capture this image.

12

Plastic Surgery Resident | Winter 2016

Rod Rohrich, MD, posed the question “so you want to be like Leonardo da Vinci or Michelangelo? Which one are you?”6, based on traits including learning styles, abilities and temperaments of these masters. While his conclusion of “be yourself” within the context of striving for excellence in training in medicine, anatomy, surgical skills and scientiic experimentation techniques highlights the commonly echoed theme of emphasizing the primary virtues of a sound surgeon, his editorial highlights and inluences trainees’ perception of intertwining the plastic and reconstructive surgeon with the artist.

More recently, Eric Swanson, MD,7 clariied a fundamental diference of the purest form of artist-versus-scientist with a divergence in the core principles of an artist using a medium for self-expression, contrasting with a scientist who uncovers knowledge to describe what already exists while not imparting his or her own subjectivity. He poses the question: Would a patient want to be a medium by continued on page 30

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Martin JB, Moore R, Paydar KZ, Wirth GA. Use of fenestrations in acellular dermal allograt in two-stage tissue expander/implant breast reconstruction. Plast Reconstr Surg. 2014 Nov;134(5):901-4.

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Wirth GA, Mowlds DS, Guidoti P, Salibian AA, Nguyen A, Paydar KZ. Acellular dermal matrix fenestrations and their effect on breast shape. Eur J Plast Surg. 2015;38:267272. Epub 2015 May 06.

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Mowlds DS, Salibian AA, Scholz T, Paydar KZ, Wirth GA. Capsular contracture in implant based reconstruction: Examining the role of acellular dermal matrix fenestrations.

Plast Reconstr Surg. 2015 Oct;136(4):629-35.

commercially marketed as an FDA-approved injectable for soft-tissue augmentation. At one point, it was considered the “gold standard” until it was supplanted by HA. Because of its high allergic reaction, skin testing was advised at least four weeks prior to injection with observation of any adverse efects. Hypersensitivity was deined as onset of erythema, induration or swelling at the test site. As such, palpable margins were noted due to the chronic foreign body reaction.

Human collagen hey are bioengineered human dermal tissue that do not require pretreatment skin test. hey are designed to replace lost collagen with a similar 3-D scafold structure that allows in-growth of the recipient’s living dermal ibroblasts.

Eventually, there is reabsorption of the iller by the body, thus leading to living human dermal tissue.

Hyaluronic acid HA is a naturally occurring polysaccharide unit consisting glycosaminoglycan compound with repeating N-acetylglucosamine and D-glucuronic acid. It’s a normal component of the ground substance that helps maintain proper tissue structure and function, such as protecting and lubricating joints and tendons. Its hydrophilicity is what helps maintain dermal volume and viscoelasticity. Since its FDA approval in 2003, it has supplanted collagen as the “gold standard” as the biologic iller of choice.

Depending on its mechanical properties, the level of dermal injection are based on its varying mechanical properties.

In general, greater elasticity and viscosity allows for less spreading of the iller, but it’s also much irmer, thus allowing for more lift. As such, Perlane, Juverderm Ultra Plus XC, which have the largest HA particles, should be injected in the deepest layers. Restylane and Juverderm Ultra XC are midsized and should be placed in middle of dermis, while Restylane Fine Lines contain the smallest particles and should be injected at the dermal-epidermal junction.

Location and anatomy is also important. For instance, when correcting tear-trough abnormalities, the iller should be injected at the level of periosteum. his also improves longevity of the iller, as the level is placed in tissue where it is immobile. In addition, this negates the break-down of the product from normal facial animation.

Calcium hydroxylapatite CaHA is dispensed in microspheres in a carboxymethylcellulose resorbable aqueous gel carrier. It promotes natural collagen in-growth with the spheres acting as a scafold, while the gel is reabsorbed. he spheres are slowly dissolved into calcium and phosphate ions through normal metabolic processes.

Poly-L-lactic acid PLLA most commonly used as a volume enhancer. It consists of PLLA microspheres in sodium carboxymehtylcellulose matrix similar to CaHA. Long-term illing efects are from in-growth of type I collagen, as PLLA is metabolized to carbon dioxide and water. It’s currently FDA approved in

patients with HIV retroviral drug-related lipoatrophy. It’s well-documented of nodule formation in dynamic portions of the face, such as lip and eye.

C O M P L I C AT I O N S A N D M A N A G E M E N T Complications can be categorized into immediate, intermediate and delayed onset.

Immediate-onset complications are deined as occurring between the time of injections up until two days. Such complications include overcorrection, undercorrection, erythema, swelling, edema, tenderness and ecchymosis. he most severe complication is soft-tissue necrosis, whereby the injection leads to the disruption of adequate vascular supply to the afected region. Diagnosis is usually through physical exam, whereby the afected area will display marked swelling and violaceous or blanching discoloration, depending on the etiology.

Direct injury of the vessel from cannulation or intra-vascular obstruction by inadvertent injection of the iller can cause arterial injury, leading to the familiar blanching. On the other hand, compression of vessel – usually venous compromise from excess amount of iller volume – would result in a purplish hue. he most commonly reported area of complication is the glabellar region. Be mindful of alar necrosis as a possible complication when injecting into the nasolabial fold.

Tyndall efect is another immediate-onset complication associated most commonly with HA. When placed too supericially and in an excessive amount, a bluish discoloration is noted. his bluish discoloration is caused by blue light, much more than other wavelengths, being scattered by the particles.

Serial injections of HA until the improvement of tissue compromise can reverse unwanted HA injections. Application of nitropaste for its vasodilation properties is an option, with close monitoring of possible tissue loss. As such, a warm compress is also recommended, while a cold application could potentially worsen compromised blood low.

Hyperbaric oxygen treatment remains controversial. Proper techniques, such as intermittent aspiration and prudent cannulation combined with intimate, three-dimensional knowledge of anatomy of facial vessels, are important preventive measures that one should take.

Intermediate-onset complication is deined as an adverse event that occurs three to 14 days after the injections. hey usually involve angioedema and nodule formation. Sculptra and Radiesse have been known to cause inlammatory nodules, and thought to be most likely due to supericial injections. In fact, it’s possible to have skin discoloration, and nodules should be quite supericial. As such, they usually occur in areas of thin soft-tissue coverage such as the eyelids, lips and nasiolabial region.

Nodules from Radiesse are commonly associated with lips, where such rates have been reported as high as 20 percent. Strategic massaging can prevent most nodular continued on page 30 Plastic Surgery Resident | Winter 2016

15

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17

PEARLS from the

MASTERS DIEP FLAP “Pearls from the Masters” highlights a technique from a master of plastic surgery, as told by one of his or her students. In this edition, Chad M. Teven, MD, PGY-4, describes the DIEP lap techniques for breast reconstruction employed

by ASPS immediate-past President David Song, MD, MBA, chief of the Plastic and Reconstructive Surgery Section at the University of Chicago.

By Chad Teven, MD avid Song, MD, MBA, has amassed a wealth of knowledge and experience through performing perforator breast reconstruction over the last 15 years – and as a result, he’s acquired speciic expertise in deep inferior epigastric artery perforator (DIEP) and supericial inferior epigastric artery (SIEA) lap reconstruction. Owing to the unique apprenticeship-based model of our residency program, I’ve had the opportunity to learn from – and perform numerous breast reconstructions with – Dr. Song and will share his technique for delayed autologous reconstruction.

D

Preoperatively, the patient is evaluated and marked in the standing position. he midline, inframammary fold and presumed breast mound are noted. he superior, inferior and lateral margins of the planned abdominal incision are also highlighted. Superior to the upper abdominal incision, a dotted line denotes adipose tissue (but not skin) that will be included as part of the lap if a larger lap is desired (igure 1). Perioperative antibiotics, subcutaneous heparin, a Foley catheter and general endotracheal tube intubation are used.

Preoperative imaging is not routinely employed by Dr. Song.

Initially, the mastectomy site is opened and the scar is excised. Skin is elevated of the pectoralis major muscle to the extent of the preoperative marks. Unless precluded by patient anatomy, a rib-sparing technique is used to isolate the internal mammary artery and vein. his is performed in the 18

Plastic Surgery Resident | Winter 2016

third or fourth intercostal space. Dr. Song excises a piece of pectoralis major in an efort to prevent undue compression on the pedicle after inset (igure 2).

Attention is then turned to the abdominal laps. Dr. Song irst attempts to identify the supericial inferior epigastric artery and vein. If these vessels are of adequate caliber (≥ 1 mm) and the artery has a palpable pulse, he will proceed with elevation of an SIEA perforator lap (igure 3). However, the majority of cases require elevation based on the deep inferior epigastric system.

FIGURE 1

FIGURE 2

FIGURE 3

When the decision has been made to use the deep system, dissection of the lap proceeds from lateral to medial, taking care to preserve the underlying rectus sheath. he lateral row is irst identiied and assessed. If the perforating vessel or vessels are deemed suicient (i.e., ≥ 1 mm and palpable pulse), the perforator can be dissected down through the rectus muscle to the main vascular pedicle. Care is taken to avoid injury to the muscle and its associated nerves. When the lateral row is insuicient, lap elevation is based on medial row perforators (igure 4). he pedicle is dissected so that it has adequate length. Flaps are allowed to perfuse while de-epithelialization occurs in situ of tissue that’s to be buried beneath the mastectomy laps. A hand-held Doppler is used to identify audible signals on the lap surface, which are marked with permanent suture for postoperative monitoring.

Flaps may be used for ipsilateral or contralateral reconstruction, depending on the shape and size of the defect and the reconstructive needs. At this point, the operating microscope is brought into the ield, and donor and recipient vessels are prepared for anastomosis. An anastomotic coupler is used to anastomose the larger of the donor venae comitantes (if division has occurred proximal to where the two venae coalesce) to the medial internal mammary vein (in most cases). It’s ideal to use a coupler ≥ 1.5 mm in diameter.

Occasionally, especially in the case of a large lap, a second venous anastomosis is performed to the lateral internal mammary vein (if present) or in retrograde fashion to the distal cut end of the medial vein. he arterial anastomosis is then performed using 9-0 nylon suture in interrupted fashion.

Dr. Song’s preference is to hold straight jeweler’s forceps in both hands, to start with the posterior wall, and to perform the anastomosis without a double-opposing Acland clamp.

After the microsurgical portion is complete, the pedicle is inspecting to ensure that FIGURE 4 it’s not kinked, twisted or otherwise compromised (igure 5).

he lap is then inset and further de-epithelialized to it the defect. One 15-French Jackson-Pratt drain is used per breast.

Interrupted 3-0 Vicryl® suture is buried in the deep dermis to approximate the edges, which are then closed with a running, subcuticular 3-0 V-Loc™ suture. Prineo® tape is placed on the skin surface.

Attention is then turned back to the abdomen, where the fasciotomies are closed with a running buried 0 Prolene® suture over a pain catheter pump. he pain catheter continuously delivers a 0.25 percent bupivacaine solution and is removed prior to discharge. he abdominal lap is then raised to the xiphoid process in the midline and to the lower boarder of the ribs laterally. Patients are placed in semiFowler’s position to facilitate abdominal closure. Buried, interrupted 2-0 Vicryl is used to approximate Scarpa’s fascia over one 19-French Jackson-Pratt abdominal drain. he skin is then closed with 3-0 V-Loc and Prineo tape. At this point, the umbilicus is delivered to its new position in the midline through an elliptical incision. his incision is closed in multiple layers with interrupted 4-0 Vicryl, subcuticular 5-0 Caprosyn™ and Prineo tape.

Clinical examination, an external Doppler system and measurement of tissue oximetry using ViOptix are employed for postoperative lap monitoring (igure 6).

Patients receive 24 hours of perioperative antibiotics, and prophylactic subcutaneous heparin for the duration of their hospitalization. If there are no complications at postoperative Day 1, patients can eat; strict bed-rest restrictions are lifted; and the Foley catheter is removed. In general, patients are discharged on postoperative Day 3, and a decision about whether to ofer postoperative thromboembolism prophylaxis is made in accordance with the ASPS “Venous hromboembolism Awareness Campaign” guidelines available in the “For Medical Professionals” section of plasticsurgery.org/VTE-Awareness. |

FIGURE 6

FIGURE 5

Disclosure: Dr. Teven and Dr. Song have no commercial association or inancial disclosure that might pose or create a conlict of interest with information presented in the above article.

Plastic Surgery Resident | Winter 2016

19

Put your plastic surgical vocabulary skills to the test!

1

By Deana Shenaq, MD

2 4

3 5 7

6

9

8

10

11 12 13 15

14

16 17

18

19

ACROSS 5. Type of blood supply to Moberg lap

20

8. Agent derived from medicinal leeches that inhibits thrombin 10. Congenital facial syndrome characterized by lat nose and midface retrusion 11. Total absence of mammary breast tissue with normal nipple and areola 13. Gene mutation associated with Saethre-Chotzen syndrome

DOWN 1. Most common non-epithelial breast tumor associated with Li-Fraumeni syndrome 2. Mammogram view necessary if breast implants present

14. Arterial supply to medial femoral condyle lap

3. Most common cause of lymphedema worldwide

17. Preferred plane for mesh during ventral hernia repair

6. Structure most commonly afected in hemifacial microsomia

4. First line therapy for macrocystic lymphatic malformations

18. Treatment for systemic lidocaine toxicity

7. Graft used to correct pinched nasal deformity

19. Radial volar deformity of little inger distal phalanx

12. Most common complication of cartilage grafting

20. Earliest visible carpal bone on radiographs

9. Treatment for Type IIIB hypoplastic thumb 15. Ideal shape of male nipple 16. Most common location for encephalocele in U.S.

Answer key on page 31

#PRSJournalClub

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

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ANATOMY 1. hree- and four-dimensional computed tomography angiographic studies of commonly used abdominal laps in breast reconstruction.

Wong C, Saint-Cyr M, Arbique G, Becker S, Brown S, Myers S, Rohrich RJ. / Plast Reconstr Surg. 2009;124:18-27.

» Wong, et al., simulate the perfusion of pedicled TRAMs,

JOURNAL ARTICLES ON

ABDOMINALLY BASED AUTOLOGOUS BREAST RECON

EVERY PLASTIC SURGERY RESIDENT

SHOULD READ

By Kavitha Ranganathan, MD

O

f the 20,325 autologous breast reconstructions performed last year in the United States, the vast majority involved abdominal donor sites.

Abdominal-based free laps are the most commonly performed procedures for autologous breast reconstruction and are widely taught in plastic surgery residency programs. he complex anatomy of these laps and the superiority of one type over the other have been the subjects of debate in numerous publications. Some surgeons are irm believers in performing DIEP laps to preserve the abdominal wall musculature and minimize donor site morbidity, while others believe that muscle sparing TRAMs have superior blood supply and do not increase abdominal wall morbidity. On the other hand, pedicled TRAM laps are still performed, although they’ve been shown to be associated with higher rates of fat necrosis and abdominal wall morbidity. he purpose of this Journal Club is to introduce the residents to what we consider as key articles on the anatomy of rectus abdominis-based perforator laps and outcomes of abdominally based autologous breast reconstruction.

22

Plastic Surgery Resident | Winter 2016

free TRAMs, muscle-sparing TRAMs, DIEPs and supericial inferior epigastric artery laps using dynamic computed-tomographic scanning to examine the main vascular pedicle of each lap (superior epigastric artery, deep inferior epigastric artery, medial/lateral row of deep inferior epigastric arteries and medial/lateral perforator vessels, and supericial inferior epigastric artery, respectively). Although perfusion studies in cadavers commonly underestimate clinically the true extent of the vascular territory, this article was selected given the importance of its application in predicting complication rates, including partial lap loss and fat necrosis based on pedicle type. An understanding of anatomic variations based on selection of the vascular pedicle will minimize the likelihood of postoperative complications and allow for selection of the abdominally based perforator that’s most suitable for each individual patient at hand. For example, if a large lap is needed, consider harvesting a medial row-based perforator DIEP or muscle-sparing TRAM lap to minimize donor site morbidity while also maximizing perfusion to the lap. On the other hand, if a small lap is needed, consider an SIEA or lateral row perforator DIEP lap instead.

2. Perforasomes of the DIEP lap: vascular anatomy of the lateral versus medial row perforators and clinical implications.

Wong C, Saint-Cyr M, Mojallal A, Schaub T, Bailey SH, Myers S, Brown S, Rohrich RJ. / Plast Reconstr Surg.

2010;125:772-782.

» Wong, et al., elaborate on the indings above to next deine the zones of perfusion of DIEP laps unique to each type of perforator (medial or lateral) using similar methodologies.

Traditionally, two classiication systems are used to describe perfusion to each zone of a lap. In this study, the authors ind that the vascular territory perfused by dominant medial perforators is signiicantly larger than that perfused by dominant lateral perforators. While medial row perforators correlated with Hartrampf ’s deinition of lap zones with perfusion crossing the midline irst, lateral row perforators followed Holm’s zones with perfusion proceeding laterally irst. hese indings can once again be used when making judgments about lap design and perforator selection. his article was included within this list because it uniies the diferences between the Hartrampf and Holm zones of perfusion. Additionally, the diferences in perfusion between dominant lateral and medial row perforators should be used during the process of lap tailoring. For example, when

Summary of vascular territory according to flap type

Average percentage of paddle (SD)

Pedicled TRAM

Full-width TRAM

32.6 (13.1)

48.4 (12.6)

Muscle-sparing Muscle-sparing TRAM (domiTRAM (dominant medial row) nant lateral row) 43.2 (7.9)

basing the lap on a lateral perforator, consider tailoring the lap based on Holm’s zones of perfusion; conversely, in the setting of a dominant medial perforator, tailor the lap according to Hartrampf ’s zones of perfusion, given the greater extent of perfusion across the midline.

3. he venous anatomy of the anterior abdominal wall: An anatomical and clinical study.

Rozen WM, Pan W, Le Roux CM, Taylor GI, Ashton MW / Plast Reconstr Surg. 2009;124:848-853.

» Rozen, et al., study the venous anatomy of DIEP laps by performing direct catheter venography to map the supericial and deep venous systems of the anterior abdominal wall of cadavers and within a cohort of patients using preoperative CTA. he SIEV was consistently located supericial to Scarpa’s fascia with an average diameter of 2.3 mm. he vena comitantes of the DIEA consistently ran alongside the major branches of the DIEA within or deep to the rectus abdominis muscle. his article is critically important, as venous congestion is the most common complication leading to lap loss. herefore, understanding the venous anatomy and diferences in location between the deep and supericial inferior epigastric venous systems as presented in this article will optimize eiciency during perforator dissection. his article distinguishes itself as a result of its anatomic depictions of the supericial and deep venous systems important for abdominally based free lap harvest.

4. Avoiding denervation of rectus abdominis in DIEP lap harvest: he importance of medial row perforators.

Rozen WM, Ashton MW, Murray ACA, Taylor GI. / Plast Reconstr Surg. 2008;122:710-716.

» Using 20 hemi-abdominal walls from cadavers, Rozen, et al., map the course of the thoracolumbar nerves to the rectus abdominis in an efort to avoid denervation of the abdominal wall. he thoracolumbar nerves travel from the costal margin, behind the internal oblique muscle, and enter the rectus sheath laterally alongside the lateral row arterial perforators. Importantly, these nerve plexuses travel with the lateral DIEA perforator, and not alongside the medial perforators. As denervation of the abdominal wall is hypothesized to be one potential source of abdominal wall weakness postoperatively, the authors recommend careful dissection around the laterally located thoracolumbar nerves, and prefer medial row perforator harvest. Although the debate continues as to which factors are most important in avoiding abdominal donor site

45.7 (5.3)

DIEP (dominant lateral perforator)

DIEP (dominant medial perforator)

SIEA

32.9 (2.9)

44.6 (11.0)

33.3 (6.7)

morbidity, avoiding denervation of the abdominal wall by understanding the anatomic topography unique to neural innervation as presented in this article represents a low-cost, high-potential beneit option; therefore, this article and its depiction of thoracolumbar nerve anatomy make it an important component of resident education.

IMAGING 5. Computed tomographic angiography (CTA) in planning abdomen-based microsurgical breast reconstruction: A comparison with color duplex ultrasound.

Scott JR, Liu D, Said H, Neligan PC, Mathes DW / Plast Reconstr Surg. 2010;125:446-453.

» By comparing CTA with color duplex ultrasound among 22 consecutive patients undergoing abdominally based microsurgical breast reconstruction, Scott, et al., demonstrate that ultrasound identiies only 66 percent of the perforators identiied by CTA. herefore, although duplex ultrasound is noninvasive, lower in cost and performed without contrast, it’s associated with a false negative rate of 33.7 percent. hus, CTA ofers more accurate information in terms of the number, caliber and anatomic orientation of perforators in the setting of abdominally based microsurgical breast reconstruction. his study was designed to include side-by-side comparisons of color duplex ultrasound and CTA performed on each patient, and it’s an important reference for insurance companies to demonstrate the superiority of CTA over ultrasound imaging in the setting of abdominally based, free lap breast reconstruction.

6. Advancing deep inferior epigastric artery perforator lap breast reconstruction through multidetector row computed tomography: An evolution in preoperative imaging.

Hijjawi JB, Blondeel PN / J Reconstr Microsurg. 2010; 26:011-020.

» his article written by Drs. Hijjawi and Blondeel beautifully depicts the historical progression of imaging used in the setting of free lap breast reconstruction, beginning with unidirectional Doppler imaging and concluding with a discussion on the superiority of multidetector row-computed tomography. his article reviews the pros and cons of each imaging modality, acknowledging the high false-positive rates and inaccuracies of ultrasound Plastic Surgery Resident | Winter 2016

23

in contrast to the superior accuracy of multidetector row CT imaging in its ability to depict branching patterns, vessel caliber and perforator orientation relative to the rectus sheath. his article is a must read for its step-bystep discussion of suprafascial and subfascial perforator dissection based on in vivo anatomy and imaging. his article also is formatted in such a way that it has the feel of a personal tutorial with an experienced teacher. If you don’t have time to read the whole article, however, speciically focus on the section “MDCT in the Planning of DIEAP Flaps: he Fog Lifts.” For residents approaching their irst DIEP lap, this is a well-organized, focused and detailed resource that will allow you to gain experience in deining perforators and identifying clinically relevant anatomy before even stepping into the O.R.

OUTCOMES 7.Quality of life and patient-reported outcomes in breast cancer survivors: A multicenter comparison of four abdominally based autologous reconstruction methods.

Macadam SA, Zhong T, Weichman K, Papsdorf M, Lennox PA, Hazen A, Matros E, Disa J, Mehrara B, Pusic AL. / Plast Reconstr Surg. 2016;137:758-771.

» In this multicenter study, women who underwent abdominally based breast reconstruction were recruited to compare health-related quality of life outcomes and complications among patients who underwent DIEP, muscle-sparing free TRAM, free TRAM and pedicled TRAM. Among the 1,790 patients analyzed, patientreported outcomes on the Physical Well-being Abdomen portion of the BREAST-Q® were signiicantly higher among patients who underwent DIEP reconstruction compared to pedicled TRAM. Interestingly, scores were not signiicantly diferent between DIEP, muscle-sparing TRAM or free TRAM. Satisfaction with breasts and psychosocial well-being were similar between all groups.

Not surprisingly, complications related to abdominal wall morbidity were signiicantly higher among patients who underwent pedicled TRAM reconstruction versus all other laps. he study design and breadth of indings make this article another must read. he multicenter design of the study promotes generalizability, while the presentation of both patient-reported outcomes and objective complication rates demonstrate the comprehensiveness with which the authors constructed this manuscript.

8. Donor-site hernia repair in abdominal lap breast reconstruction: A population-based cohort study of 7,929 patients.

Mennie JC, Mohanna P, O’Donoghue JM, Rainsbury R, Cromwell DA. / Plast Reconstr Surg. 2015;136:1-9.

» Mennie, et al., use a database comprosed of all reconstructive procedures performed in English National 24

Plastic Surgery Resident | Winter 2016

Health Service Hospitals to demonstrate that abdomenbased breast reconstruction increases the rate of hernias requiring repair (2.45 percent) compared to patients who underwent mastectomy alone (0.28). Rates after DIEP, free TRAM, and pedicled TRAM were 1.65 percent, 3.18 percent and 4.91 percent, respectively. Relative to DIEP laps, free TRAM laps had an adjusted hazard ratio of 1.81, and pedicled TRAMs had an adjusted hazard ratio of 2.89 for hernias requiring repair.

9. Using propensity score analysis to compare major complications between DIEP and free musclesparing TRAM lap breast reconstructions.

Zhong T, Novak CB, Bagher S, Maass S WMC, Zhang J, Arad U, O’Neill AC, Metcalfe KA, Hofer SOP. / Plast Reconstr Surg. 2014;133:774-782.

» Propensity score analysis is a method of adjusting for confounding factors such as the indication for intervention or treatment selection. It difers from multivariable regression, which controls for confounders that may afect a particular outcome but does not adjust for indication bias.

In this study, Zhong, et al., retrospectively evaluate 292 women who underwent 428 abdominally based free lap breast reconstructions from 2009-2012. he adjusted odds of abdominal complications (hernia/bulge) after musclesparing TRAM were 2.73 times higher than after DIEP reconstruction. here was no signiicant diference in odds of developing a breast complication between these two methods. his article was selected as an important read for two reasons.

First, the statistical methods used in this study are important to understand, as propensity score analysis is a method that matches groups of patients to minimize confounding factors while maximizing the ability to detect a true efect. Second, this paper elucidates the diference between breast and abdominal donor site-related complications. Although many published studies in the past demonstrated no diference in overall complication rates, the lack of clear deinitions between donor and recipient site complications limits the true application of such indings. herefore, the thoughtful statistical methodology and clear deinition of outcomes are what make this article a worthwhile read.

10. Abdominal wall following free TRAM or DIEP lap reconstruction: A meta-analysis and critical review.

Man LX, Selber JC, Serletti JM. / Plast Reconstr Surg.

2009;124:752-764.

» Man, et al., perform a meta-analysis to compare complications after DIEP and free TRAM reconstructions.

In this study, the authors ind an increased risk of fat necrosis (relative risk, 1.94; 95 percent CI 1.28-2.93) and lap loss (relative risk, 2.05; 95 percent CI 0.47-1.78) in DIEP lap reconstruction compared to free TRAM. Patients that received DIEP laps had a lower risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28-0.86). Importantly, however, keep in mind that the generalizability of meta-analyses and systematic

reviews is limited by the quality of studies included. For this reason, it’s critical to follow PRISMA guidelines when conducting a meta-analysis or systematic review. his article distinguishes itself by its comprehensive bibliography on abdominal-wall morbidity unique to any meta-analysis or systematic review. Use this manuscript as a reference to most easily search for articles focused on abdominal donor site morbidity following free TRAM or DIEP lap reconstruction.

Bonus Article A prospective study comparing the functional impact of SIEA, DIEP and muscle-sparing free TRAM laps on the abdominal wall: Part I. Unilateral reconstruction.

Selber JC, Nelson J, Fosnot J, Goldstein J, Bergey M, Sonnad SS, Serletti JM. / Plast Reconstr Surg.

2010;126:1142-1153.

» In this blinded, prospective, cohort study, Selber, et al., examine functional abdominal-strength outcomes among patients who’ve undergone abdomen-based free lap breast reconstruction. Among the 157 patients included in the study, there was no statistical diference in abdominal strength when measured at the same time point between free TRAM, DIEP and SIEA reconstructions. Although there was an initial decline in abdominal wall-strength among all groups at early time points, this improved with time. his study was followed by Part II (see additional reading) and addressed bilateral reconstruction.

ADDITIONAL READING 1. Schaverien M, Saint-Cyr M, Arbique G, Brown SA. “Arterial and venous anatomies of the deep inferior epigastric perforator and supericial inferior epigastric artery laps.” Plast Reconstr Surg. 2008;121:1909-1919.

2. Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, Taylor GI. “Avoiding denervation of rectus abdominis in DIEP lap harvest II: An intraoperative assessment of the nerves to rectus.” Plast Reconstr Surg.

2008;122:1321-1325.

3. Garvey PB, Buchel EW, Pockaj BA, Casey WJ III, Gray RJ, Hernández JL, Samson TD. “DIEP and pedicled TRAM laps: A comparison of outcomes.” Plast Reconstr Surg. 2006;117:1711-1719.

4. Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, Serletti JM. “A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM laps on the abdominal wall: Part II. Bilateral reconstruction.” Plast Reconstr Surg. 2010;126:1438-1453.

5. Yueh JH, Slavin SA, Adesiyun T, Nyame TT, Gautam S, Morris DJ, Tobias AM, Lee BT. “Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus lap, and implant techniques.” Plast Reconstr Surg. 2010;125:1585-1595.

Top resident abstracts honored in Los Angeles The top abstracts written and presented by plastic surgery residents were also recognized during Plastic Surgery The Meeting in Los Angeles. More than 150 residents submitted abstracts in seven categories presented in nine sessions.

The following were honored as the outstanding resident presentations: Aesthetic Is Cosmetic Surgery Tourism Worth It? A Cost Analysis of Nontuberculous Mycobacterium Surgical Site Infections Contracted Abroad James Lee, MD; New York-Presbyterian/Weill Cornell & Columbia University Medical Centers Breast Reconstruction I Impact of Anti-Estrogen Therapy on Random Pattern Skin Flap Survival: A Pilot Study Emily Wirtz, MD; University of North Carolina Hospitals Breast Reconstruction II Lateral Thigh Perforator Flap: An Alternative for Autologous Breast Reconstruction Marco Maricevich, MD; University of Pittsburgh Hand Severe Hand Injuries from Fireworks: Injury Patterns, Treatment, and Fireworks Types Brinkley Sandvall, MD; University of Washington Maxillofacial Repeal of Universal Helmet Laws: Efects on the Incidence and Pattern of Craniomaxillofacial Trauma in the State of Michigan Nicholas Adams, MD; Michigan State University, Grand Rapids Medical Education Partners Pediatric Changes on Polysomnography Following Sphincter Pharyngoplasty – Does It Worsen Sleep Apnea in Children?

Christina Busuito, MD; Wayne State University Reconstruction/Burn/Microsurgery I Panniculectomy in Renal Transplant Candidates: A High Complication Rate Yields a Higher Reward Chad Bailey, MD; University of California Davis Medical Center Reconstruction/Burn/Microsurgery II Wound Morbidity in Minimally-Invasive Anterior Component Separation Compared to Transversus Abdominis Release Brodie Parent, MD; University of Washington Research Here Comes More Sun Shine: Industry’s Payments to Plastic Surgeons Rizwan Ahmed, MD; Duke University Medical Center Moderators for the sessions were Lynn Damitz, MD, and Josef Hadeed, MD (Aesthetic); Bruce Mast, MD, and Smita Ramanadham, MD (Breast Reconstruction I); Donald Buck, MD, and Kent Higdon, MD (Breast Reconstruction II); Brent Egeland, MD, and Sonu Jain, MD (Hand); Peter Taub, MD, and Christian Vercler, MD (Maxillofacial); Seun Adetayo, MD, and Robert Havlik, MD (Pediatric); Victor Hassid, MD, and Ivo Pestana, MD (Reconstruction/Burn/ Microsurgery I); Scott Hollenbeck, MD, and Eamon O’Reilly, MD (Reconstruction/ Burn/Microsurgery II); David Mathes, MD, and Jon Ver Halen, MD (Research). Support for the resident abstract presentations was provided by AirXpanders, Inc.; LifeCell, an Acelity Company; Mentor Worldwide LLC; Merz North America; The Doctors Company; ViOptix, Inc. Plastic Surgery Resident | Winter 2016

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Q&A WITH MICHELLE ROUGHTON, MD

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

In this installment of “Faculty Focus,” we present ASPS member Michelle Roughton, MD, Chapel Hill, N.C., program director, assistant professor and director of microsurgery of the Division of Plastic and Reconstructive Surgery at the UNC Department of Surgery.

Dr. Roughton received her medical degree at UNC and completed a combined plastic surgery residency and general surgery residency in 2011 at the University of Chicago. She specializes in breast reconstruction, both implant-based and autologous; microsurgery, including DIEP laps; breast reduction and augmentation; and oncoplastic breast surgery.

Taking some time from the challenges of balancing motherhood and work as a plastic surgery resident – and advancing in her career without fellowship training – Dr. Roughton shares her professional journey with PSR.

PSR: HOW DID YOU CHOOSE YOUR SPECIALTY? Dr. Roughton: I’ve always wanted to do breast reconstruction. hat’s what brought me into plastic surgery when I was a medical student. I enjoy getting to know the patients and being a happy blip in their cancer journey.

PSR: HOW HAS YOUR DECISION TO FORGO FELLOWSHIP TRAINING IMPACTED YOUR CAREER? Dr. Roughton: I think I would be more competitive. For example, if I wanted to apply to become chair of one of the top ive plastic surgery departments without a fellowship, I would be less competitive on paper for that. But I think it really depends on what your goals are. You don’t need to do a fellowship to do microsurgery.

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Plastic Surgery Resident | Winter 2016

At some point in your career, where you train and whether you’ve graduated with honors becomes less important – it’s more about what you’ve accomplished in your current position. I don’t think your residency training matters much when you’re age 50. What you’ve done as a plastic surgeon matters more. As you become more senior, residency training matters less and less.

Fellowships are great – everyone gets something out of training. he longer you train, the more you know when you inish. However, you’re still never going to know everything when you inish. At some point, you have to cut the cord and go igure it out. he less training you have in a given procedure does make performing it more challenging, but it’s not a hard stop. You may have to work a little harder, ind a mentor or expand your geographic preferences, but you can certainly pursue most things. You’ll get there. You just have to be lexible.

PSR: HOW IMPORTANT IS IT TO HAVE A MENTOR DURING EARLY YEARS OF PRACTICE? Dr. Roughton: It’s invaluable. I can’t imagine doing it without a mentor or sounding board around you. When I irst came out of training, I joined a practice of four; certainly, the senior partner as well as my junior colleagues were an invaluable part of that early practice. I also stayed close to my mentors during my training. hey were never too far from an e-mail or a phone call.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED ADVANCE YOUR CAREER? Dr. Roughton: he importance of this is a hidden gem that I didn’t discover in training. I was selected to the Essentials of Leadership course last year. It’s sponsored by ASPS, and it was the most meaningful professional development activity I’ve ever done – by far. In addition to learning leadership skills, I met all of these wonderful people. I’m highly extroverted and I get a lot of energy from interacting with others. Other plastic surgeons in similar situations are

an invaluable resource – whether I’m learning about their training program, what they do clinically or how they balance their family.

article? How do you make that down-time eicient? When you talk to highly successful people, they’re doing something productive during that time.

he Young Plastic Surgeons (YPS) Forum is a terriic group of people and embodies this camaraderie. I would strongly suggest that everyone get involved with YPS early-on – and apply for the Essentials of Leadership course sometime later.

Another challenge in my practice is being a residency program director. It has a lot of rewards, but it’s also a lot of work. his is something I had zero perspective on as a resident. I had no idea what my program director was doing behind the scenes. I was just trying to learn the material.

It’s exciting to be a part of organized plastic surgery because you know that you’re now purposefully aware of issues afecting plastic surgeons and your peers’ clinical practice. It’s hard to put into words how meaningful it is to be involved and network with other people in similar positions.

PSR: IS THERE ANYTHING YOU WOULD DO DIFFERENTLY? Dr. Roughton: Not ofhand, because you can’t know how things would turn out if you changed anything. I’m very happy with my current situation. I wouldn’t change a thing.

PSR: WHAT WAS THE BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY AND HOW DID YOU HANDLE IT? Dr. Roughton: My job search was really hard for me. I was married when I came to residency, and I’m still married to my wonderful husband, who’s a lawyer. Law jobs are fairly hard to come by – and to practice in diferent states, attorneys must take that state’s bar exam. My husband had already moved once for my job and was not keen to relocate for a single year. here weren’t any microsurgery fellowships in Chicago. Somehow, despite this, I was ofered an amazing job at University of Michigan in 2011. I turned it down because he couldn’t ind a job in either Ann Arbor or Detroit. In that instance, I had to put my family irst. I turned that job down and found a very unique, high-volume, reconstruction- and microsurgery-heavy private practice job in Chicago. Two years later, I was recruited back to academics in our home state of North Carolina, where I currently practice.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Roughton: Juggling elective cases with urgent and emergent ones, while being productive in both research and education. Scheduling is a huge issue. If your elective practice is solidly booked, how do you ind time to take care of unexpected complications or trauma patients? I think it’s an ongoing challenge for everyone. I don’t have all the answers, but certainly a big part of managing your schedule is eiciency. If your breast surgeon is doing a mastectomy, what are you doing during that time? When you’re waiting for a case to start, what are you doing? Sitting on a stool; looking at Facebook? Or putting that time to use by reviewing an

PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Roughton: What I think is helpful – and I’m not always able to do it well – is maintaining work-life balance through alignment. If I can align the same people and they can overlap, it’s terriic. For example, I had to do an event to recruit medical students into the UNC School of Medicine.

It was on a Saturday, and I really wanted to spend time with my kids, ages 1 and 3, because I hadn’t had a chance to see them much during the week. After some brainstorming, I brought my 3-year-old, and she sat on the panel with me. hat accomplished a lot. I got to spend time with her, and she got to go to work with mommy and was very excited about it.

She packed her little doctor bag. he incoming students and trainees who attended realized: “Look, there’s a mom. She’s somehow able to make this work.”

During the holidays I try to have the residents come over and I have my family there, too, and they all interact with each other. It’s a nice way to have everyone together. When you’re able to align those things, it’s very helpful. It’s not always possible, but when it works, it’s a wonderful thing.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Roughton: Teaching is bundled in the day, so every clinic and every case is another opportunity.

PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Roughton: You’re in the greatest ield of medicine. You’ve already made it. You just need to be resilient enough to inish your training. Stay positive. Residency seems like it’s going to last for the rest of your life, but it’s such a small amount of time.

It just doesn’t seem that way when you’re in the middle of it.

You’re going to miss it, believe it or not. It takes a while to miss it, but you will. Stay strong. Finish strong. And enjoy it.

PSR: HOW WOULD YOU COMPLETE THIS SENTENCE? ‘I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN…’ Dr. Roughton: ...I saw my irst pedicled TRAM lap. |

Plastic Surgery Resident | Winter 2016

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TAKE IT FROM A YOUNG ASPS MEMBER –

Committee involvement is easier than you think

By Ash Patel, MD

Every one of you reading this has spent countless hours working to get to where you are today, but your professional development isn’t limited to what you learn in residency or fellowship – and it doesn’t end when you enter practice. Being involved in one of our many plastic surgery societies – be it local, regional or national – isn’t simply a space iller on your CV. Involvement in organized medicine is an essential part of your ongoing professional development.

When I entered practice, I had no idea how to begin to get involved with our societies. Like many, I thought there were a number of barriers to this involvement, but my colleague, Malcolm Roth, MD, opened my eyes to the importance of being involved in ASPS. I learned that my prejudices about who was able to be involved in the Society were unfounded, and during my irst year of practice, I applied for, and was appointed to, the Young Plastic Surgeons Steering Committee.

ASPS, which represents more than 94 percent of boardcertiied plastic surgeons, has a mission to maintain high standards of training, ethics and research in plastic surgery. he Society does this in part by providing education, advocacy and practice support. While it employs an executive director and a number of staf members, the activities of the Society could not be performed without the large number of our colleagues who volunteer to serve our specialty.

THE BENEFITS ARE CLEAR Over the past several years, the personal beneits of committee service have become truly apparent to me. One such beneit is networking with colleagues. As a surgeon in academic practice, 28

Plastic Surgery Resident | Winter 2016

not only have I met other young faculty members from across the country, but I’ve also gotten to know more senior colleagues. his has proven to be an invaluable experience, and it’s enabled me to help my medical student mentees; to assist with resident recruitment; and to aid in helping our residents and Fellows ind fellowship or faculty positions.

Perhaps more importantly, I’ve been able to meet colleagues in other practice settings – which has helped me better understand the challenges that all plastic surgeons face. For the young surgeon, the unparalleled networking opportunities allow for professional mentorship from leaders in our ield. his isn’t merely limited to clinical experts – it includes experts in practice management, ethics, legislative advocacy, and health policy and research, and it allows for the acquisition of new skills and knowledge. hrough my involvement in the Quality and Performance Measurement Committee, for instance, I’ve learned how to critically appraise Clinical Practice Guidelines and evaluate quality measures.

Initially with the New York State Society of Plastic Surgeons, and more recently with ASPS, I’ve learned how to be efective in legislative advocacy. Both of these diferent skillsets have undoubtedly made me a better and more complete plastic surgeon.

THE BENEFITS GO BOTH WAYS Resident involvement in our organizations is crucial to ensure that future plastic surgeons are properly represented. here are tremendous personal beneits to being involved, and early involvement will allow you to showcase your abilities and ind your passion – which will pay dividends for you in the future, as well as provide leadership to the Society from the important cohort of young plastic surgeons. And the breadth of activities also means there’s likely to be something of interest to everyone. | Dr. Patel is Associate Professor and Program Director at Albany Medical Center in New York. He serves as chair of the ASPS Public Education Committee, the Breast Reconstruction Awareness Fund Appropriations and Review Committee, and he is vice chair of the YPS Steering Committee. Dr. Patel can be contacted at patela6@mail.amc.edu.

For information on ASPS committees, please visit the “For Medical Professionals” section of plasticsurgery.org, and click on “Surgeon Community.”

Plastic Surgery Emergencies: Principles and Techniques

By Naikhoba C.O. Munabi, MD It’s one of your irst nights on call as a junior resident. Suddenly, the quiet you’re enjoying is interrupted by your pager. You’re being summoned to the E.D. to treat an injury you’ve never seen before. What do you do?

You grab your copy of Plastic Surgery Emergencies.

At 250 pages, this pocket guide is a highly portable resource and a great irst stop in understanding how to manage hand and craniofacial consults (although other frequent categories such as burns, pressure sores and aesthetic surgery complications are included). he book tends to gloss-over anatomy but does provide a fairly comprehensive review of critical physical exam indings, with diagrams, radiographs and photographs judiciously used to help conirm diagnoses.

Written using a combination of short paragraphs and bullet points, the book systematically details plans for acute management of plastic surgery emergencies in the E.D. Considering its 21 chapters – organized based on type of injury or problem – and the comprehensive, 50-page index,

it won’t take you long to ind (and read) the most applicable section of the book as you’re en route to the patient. he book’s most useful aspect is its step-by-step instructions (with illustrations) on how to perform procedures. Such actions as administering local blocks, and information on the type and size of suture to use for diferent facial lacerations and splinting for hand injuries, are clearly described. Even less common procedures such as performing a lateral canthotomy are included among the potential tasks you could have to do late at night.

In no way is this a comprehensive text for preparing for O.R. service or the In-Service Examination (for that, turn to Essentials of Plastic Surgery and the major plastic surgery textbooks). But as a irst stop on those late nights, Plastic Surgery Emergencies is easy to carry – and an accessible read. And when you have to wake up your chief resident or attending, it will be clear that you’ve done a comprehensive evaluation of the patient and have an appropriate plan.

Plastic Surgery Emergencies: Principles and Techniques. Bullocks J.M., Hsu P.W., Izaddoost S.A., Hollier L.H., Stal S. New York: hieme, 2008.

Essentials of Plastic Surgery: A UT Southwestern Medical Center Handbook

By Wendy Chen, MD, MS his handbook is likely to be one of the irst books encountered by students of plastic surgery. But rather than eventually being set aside, Essentials of Plastic Surgery remains a concise resource for students as they advance, as it both highlights key points relevant to clinical service and serves as a study guide for the InService Examination. he topics addressed range widely – and expanded in the second edition to now cover basic principles, allotransplantation, skin and soft tissue, congenital craniofacial deformities, facial trauma, acquired deformities of the head and neck, breast reconstruction, trunk and lower-extremity reconstruction, as well as hand, wrist, upper extremity and aesthetic surgery.

Sections and chapters are organized logically with a clinical relevance to plastic surgeons, with an introduction to embryology, anatomy, physiology, how to evaluate the patient (focused history and physical), and clear indications and lists of reconstructive options and approaches. Also included are relevant classiication systems, technical points, high-yield diagrams, and information on postoperative care and common complications.

High-yield “tips” are scattered throughout the chapter – and at the end of each, a box of key points lists high-

yield pearls, and the references often contain important historical articles. For the student and junior resident, this handbook provides an excellent foundation and introduction to any topic. For the senior resident, it also may also serve as a concise reminder of forgotten details.

I’ve been using this handbook since medical school. As a neophyte, I initially began using it as a reference and a dictionary for plastic surgery jargon, then as a road map to help navigate complicated, dense chapters in other specialized textbooks. As the years went on, I began to use the handbook as a way to organize pearls from any lecture I attended. During a morbidity and mortality conference, I added to the “complications” sections of relevant chapters and took note of landmark papers.

Because I carry this book with me everywhere, I also include in the blank pages general medicine clinical points (i.e., coagulation cascade) and art of medicine points (i.e., how to be a good doctor). In this way, I have used this book and its wide purview as a tool to keep me engaged in any didactic situation.

Without question, this is one of the best investments I have ever made. For a handbook focusing on aesthetic surgery, readers can look forward to Essentials of Aesthetic Surgery, slated to publish in Spring 2017.

Essentials of Plastic Surgery: A UT Southwestern Medical Center Handbook. CRC Press/Taylor & Francis Group, Boca Raton, Fla., 2014

Plastic Surgery Resident | Winter 2016

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THINGS I WISH I HAD KNOWN BEFORE RESIDENCY | continued from page 11 to how the residents interact with and support each other. leg cramping when standing in an O.R. for hours on end.

Also consider the external support systems you’ll have If you’ve always enjoyed a certain activity or outlet, ind a way available to you when choosing a residency program. Family to make time for it. If you don’t have one yet, I suggest you is key, especially if you plan to start a family during residency. ind one. Working long hours at a stretch with no downtime If you do have children, make sure to have trustworthy can take a real toll. child-care arrangements and a backup plan for when they fall through… because, one day, they will.

Speaking of time, there’s never a good time and never enough time for dating, marriage or having kids. So as Nike says, When you have free time, try to spend it with those who are “Just do it.” It doesn’t really get any easier later on, and the most important to you. Keep in mind that your hours, days responsibilities are actually greater. On a related note, be as and years may difer drastically from those of the people respectful as you can of your colleagues who enter this arena, around you. It’s diicult to describe the stresses involved, so and treat them as you would wish to be treated. try to be understanding of those who probably can’t relate.

Be – and seek – understanding Support systems are critical during residency and should be taken into account when choosing a program. Pay attention PLASTIC SURGEON AS ARTIST | continued from page 12 which the surgeon expresses his or her artistic ideal – or to adhere to established techniques that have been developed through scientiic methodology to rebuild, reshape or restore?

As with most subjects, the truth lies somewhere in between. here’s no denying that the plastic surgeon as artist is entrenched in the public psyche and perpetuated by the plastic and reconstructive community in our journals, and by the images we select for the covers and title pages in our textbooks, as well as by the logos for our societies and websites. While we embrace this role, individually deserved or not, it will be important to keep in mind our scientiic training and the years of hard work acquiring the requisite knowledge and skill to become a plastic and reconstructive surgeon, for the moment when we are (inevitably) challenged by a patient, friend, family member or colleague, with the question of “are you an artist?”

While we are taught the scientiic method and how to objectively analyze, plan for and execute surgical cases to extract experience and knowledge from each encounter, I believe there’s a role for artistry to make its way into the O.R. After all, how many times have the alcohol pads come out to erase and redraw the resident’s operative plan based on nothing more than “this looks better to me!”

Most importantly, keep in mind that this, too, shall pass; that it’s all a means to an end, and someday, in some weird way, you’ll actually miss your years in the trenches. |

For many of us, we were or are artists in the purest sense of expressing ourselves through a medium. We are obsessive with regard to details, as we know the efect of minutia can exert profound efects on our outcomes. When we strive to learn, revise and perfect our surgical skills, our judgment and our knowledge during residency, we often may lose sight of our other creative outlets.

I hope this column will serve as a forum to showcase some of the visual works of art by many of our talented residents. True to our form as scientist irst, I request that each submitted pieces, have an accompanying backstory as well as some of the objective speciications on how it was created (if you can recall). Please submit images 300dpi or larger to ResidentArt@plasticsurgery.org and a separate word document with the details. | References 1. Liang F., Rudnicki P.A., Prince N.H., Lipsitz S., May J.W. Jr., Guo L., An Evaluation of Plastic Surgery Resident Selection Factors. J Surg Educ. 2015;1:8-15. PMID: 25218369 2. Sepehripour S., Patel A.J., Art, Artistry, and Plastic Surgery. Plast Reconstr Surg. 2012;4:638e-640e.

PMID: 23018744 3. Goldwyn R.M., he Plastic Surgeon as Artist. Plast Reconstr Surg. 2003;1:327. PMID: 12832912 4. Cigna E., Medicine and Plastic Surgery: Science or Art? Plast Reconstr Surg. 2004;2:598-9. PMID: 15277844 5. Colon G.A., he Plastic Surgeon as an Artist. Plast Reconstr Surg. 2004;5:1513. PMID: 15060375 6. Rohrich R.J., Sullivan D., So you want to be like Leonardo da Vinci or Michelangelo? Which one are you? Plast Reconstr Surg. 2011;6:1309-11. PMID: 22094748 7. Swanson E., he Plastic Surgeon: Artist or Scientist? Plast Reconstr Surg. 2013;1:182-4. PMID: 23271529

IN-SERVICE INSIGHTS | continued from page 15

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formation. his may be performed in conjunction with dilute intralesional steroid injections. It should be noted that intralesional steroids can be efective in treating PLLA and PMMA; they are usually not as efective with CaHA. Should irregularities continue to persist, excision may be required, usually via needle disruption and unrooing.

collagen is the most common of illers to be associated with severe allergic reactions. It’s important to treat these in an appropriate manner, with either local steroid injections or systemic oral treatment. Failure to do so in a timely manner can result in unsightly scarring. |

Delayed-onset complications occur after two weeks. hese include persistent erythema, nodules, infection, granulomas, acneiform eruption, delayed immune-mediated hypsersentivitiy and telangiectasias. Hypersensitivity is relatively uncommon, ranging from 1-3 percent. Bovine

1. Alam M., Dover J.S. “Management of Complications and Sequelae with Temporary Injectable Fillers.”

Plast Reconstr Surg. 2007;120 (6 Suppl): 98S-105S. Review

Plastic Surgery Resident | Winter 2016

References

2. Broder K.W., Cohen S.R. “An Overview of Permanent and Semipermanent Fillers.” Plast Reconstr Surg.

2006;Sep:118 (3 Suppl): 7S-14S. Review.

3. Wilson A.J., Taglienti A.J., Chang C.S. ,et al. “Current Applications of Facial Volumization with Fillers.”

Plast Reconstr Surg. 2016;May:872e-89e.

UPCOMING MEETINGS & SURGICAL TRIPS MARCH

MAY

JULY

AUGUST

3/2/17 In-Service Exam for Residents Online (847) 228-9900 plasticsurgery.org

5/5/17 – 5/6/17 Plastic Surgery Coding Workshop (San Diego) (847) 228-9900 plasticsurgery.org/Coding

7/15/17 – 7/22/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

8/5/17 – 8/12/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

3/2/17-3/4/17 Aesthetica Super Symposium New Orleans, La. (847) 228-9900 aesthetica.plasticsurgery.org

5/6/17 – 5/13/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

7/15/17 – 7/22/17 Hope International (Fishers, Ind.) Cartegena, Columbia (317) 581-9569 hopeinternational.org

8/10/17 – 8/12/17 Breast Surgery & Body Contouring Symposium (San Diego) (847) 228-9900 plasticsurgery.org

5/19/17 – 5/27/17 Helping Hands (New Haven, Conn.)

Chiapas, Mexico (516) 900-4263 hhmm.org/volunteer

7/22/17 – 7/23/17 Plastic Surgery Coding Workshop (Chicago) (847) 228-9900 plasticsurgery.org

8/17/17 – 8/19/17 Oral & Written Board Preparation Course (Rosemont, Ill.) (847) 228-9900 plasticsurgery.org

3/11/17 – 3/18/17 Hope International (Fishers, Ind.) El Salvador (317) 581-9569 hopeinternational.org 3/11/17 – 3/18/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org 3/17/17 – 3/25/171 Helping Hands (New Haven, Conn.)

El Salvador (516) 900-4263 hhmm.org/volunteer 3/26/17 – 5/1/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

APRIL

JUNE 6/3/17 – 6/10/16 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

7/22/17 – 7/29/17 Hope International (Fishers, Ind.) Cartegena, Columbia (317) 581-9569 hopeinternational.org

6/3/17 - 6/16/17 Rotaplast (San Francisco) Arusha, Tanzania (415) 521-1111 rotaplast.org 6/10/17 - 6/17/17 Hope International (Fishers, Ind.) Guatemala City, Guatemala (317) 581-9569 hopeinternational.org

4/8/17 ASPS Essentials of Plastic Surgery Coding Workshop Arlington Heights, Ill. (847) 228-9900 plasticsurgery.org/Coding

Answer Key 1 2 3

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F A X I A L U L N A

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M A 9 P H I R U D I N I O D 11 L A M A Z I A S L B 13 L I T W I S T 14 S G E N I C U I 16 Z O A C T C 8

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I N T R A

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.

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S U

P H Y L L O

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B I N D E R E D S O 12 M W A A 15 L A R O V P I A 17 U N D E R L G

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S C L E R O T H E R A P A Y

L I P I D O P K I R N E R T T A T E L

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C A P

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Plastic Surgery Resident | Winter 2016

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Hemostasis for the Microsurgeon SuperFine MicroClip

Actual size of SuperFine MicroClip (1.5mm x 2.1mm)

GEM’s SuperFine MicroClip is one e off the smallest hemostasis clips available ab blle le on the market today.

Detail of Micro Tip

Non-Stick BiPolar Forceps GE GE GEM’s BiPolar Forceps are available in a variety of popular patterns for v mi mi microsurgical applications.

Disposable microvascular clamp

Rx Only. For safe and proper use of these devices, refer to the appropriate Instructions for Use for indications, warnings, precautions, side effects and contraindications.

800.510.3318 toll free The Gem logo, Global Excellence in Microsurgery and SuperFine are trademarks of Baxter International Inc., or its subsidiaries.

Biover logo is a trademark of Biover AG.

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205.941.0111 U.S.

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www.SynovisMicro.com

Plastic Surgery Resident | Fall 2016

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USBS/MG151/14-0001 6/2014