ISSUE 8 | FALL 2017
From the publishers of Plastic Surgery News
» Living on the leading edge
I found my thrill on Capitol Hill
Leadership roles can feed the need beyond the O.R.
page 18
» It’s OK to request personal time Chiefs will understand – they’ve been there, too
Society’s open invitation to residents brings 18 to D.C. for ASPS political advocacy event
page 30 IN THIS ISSUE » Dear Abbe: My attending is out to get me – what should I do? ........................................ p. 20 » Carpal tunnel syndrome: Our must-read articles .............................. p. 24 » International Pearls: Axillary lymph node dissection from Norway ............................................... p. 34
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A note from the editor
W
elcome to our Fall 2017 edition of Plastic Surgery Resident. Over the past two years, we’ve introduced our readers to numerous and recurring sections such as In-Service Insight, Consult Corner, PSR Journal Club, Program Peek, Faculty Focus and PSR Crossword. In this edition, we bring fresh content to each of these sections: his installment of Faculty Focus highlights one of our associate editors, Mo Alghoul, MD, from Northwestern University, while Program Peek takes a look at University of Michigan’s program – following-up on our Summer 2017 Faculty Focus feature on UM’s Jennifer Waljee, MD.
We also rolled-out another new section this year – #heTrend – which highlights the latest in plastic surgery technology, education and practice management. his month’s contribution is a review of the PRS Residents’ Gateway – the Plastic and Reconstructive Surgery journal’s foray online resource for residents, which features journal articles and video content relating to speciic subjects.
Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh
We hope that you enjoy this issue, and please feel free to give us feedback at the upcoming Plastic Surgery he Meeting (PSTM). As always, I would like to thank our physician editorial board and our production staf at ASPS. Of note, our resident editors’ terms are coming to a conclusion with PSTM, slated for Oct. 6-10 in Orlando. herefore, we’re taking online applications for our next group (three) of resident editors. Read the brief item below for additional details and instructions. I look forward to seeing all at Plastic Surgery he Meeting! |
ISSUE 5 | WINTER 2016
PSR seeks 3 resident editors; apply by Nov. 1
From the publishers of Plastic Surgery News
h bu
O.R. ergonomics: Avoid the chronic physical efects of long operations
ISSUE 6 | SPRING 2017
From the publishers of Plastic Surgery News
IN THIS » Pearls from » Rectus abd The must» Getting in is easy – a
» Using a Compass for clinical decision-making
AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005
When precision is crucial in reconstruction, this device can lead surgeons to the correct path
Stress relief: How I joined a b d dl d
page 16
» How to crush your grant proposal he pursuit of funding requires a good coach – and persistence
page 28 IN THIS ISSUE » InService Insights: Odontogenic cysts and tumors ................ p. 18 » Craniofacial surgery: The must-read articles
From the publishers of Plastic Surgery News
» Resident prep he attending’s incapacitated and you must inish the case – can you do it?
page 10
» he far side of the world A view of U.S. training, from an Australian plastic surgery Fellow
page 21
Value-added: Earning electives by going global IN THIS ISSUE » Pursuing a microsurgical fellowship: Three questions .......................................... p. 18 » Program Peek: Washington University .............................. p. 22
Resident editors report directly to the magazine’s Editor-in-Chief (Alex Spiess, MD) and collaborate on all editorial content to be published. As an editor, you’ll help develop content ideas, contribute editorial copy and solicit your coresidents and faculty to contribute content. Furthermore, you’ll provide a critical level of review to ensure that articles are well written, logically structured and in line with the magazine’s style guidelines and its mission.
............................. p. 22
» TheTrend looks at a bony-trauma app ..... p. 27 AM 444 AR
ISSUE 7 | SUMMER 2017
Plastic Surgery Resident magazine is inviting residents to apply for one of three positions as Resident Editor; these are one-year terms. Plastic Surgery Resident is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs.
We will accept applications from those who are in their senior years of residency (PGY-4, 5 or 6). To apply, please complete the application form that can be found by going to plasticsurgery.org and clicking on “Resources and Education” followed by “Publications” – and then on “Plastic Surgery Resident.” Look to the Related Links to find “PSResident Editor Application.” Please complete and submit the application by Nov. 1 to PSN Managing Editor Paul Snyder at psnyder@ plasticsurgery.org. Those selected will be notified by Dec. 1. |
» Drawing digitally – and artistically ......... p. 30 AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005
Plastic Surgery Resident | Fall 2017
3
Table of
Contents On behalf of the Society – and for the greater good .............................................. 6 Residents gain an education on politics and government during an eye-opening excursion to Washington, D.C.
Faculty Focus: Mo Alghoul, MD ................................ 10 The Northwestern University professor of plastic surgery was ready to settle into cosmetic surgery, until two ASPS leaders showed him a diferent path.
Consult Corner: Acute facial nerve lacerations ................................... 12 The “intimate relationships” between the diferent tissues requires the surgeon to approach them with great deliberation and patience.
Program Peek: University of Michigan................................................ 16 An up-close and personal look at plastic surgery residency at this Ann Arbor institution.
Why I take a leading role with young plastic surgeons .............................................. 18 Raman Mahabir, MD, used the positive changes within the ASPS leadership structure to help those just starting out.
Crossword .................................................................... 19 So you think your plastic surgery vocabulary is strong?
Dear Abbe ....................................................................20 What to do when your attending is against you; complaints about a colleague come to you – where do you go?
InService Insights .......................................................22 Vascular tumors with their confusing nature and low frequency in infants – perfect for the examination.
Journal Club .................................................................24 Ten articles on carpal tunnel syndrome, from the pages of respected journals.
New grants join existing grants that await your application ........................................28 The PSF 2018 Grants Cycle is underway, with a Dec. 1 deadline and an abundance of funding opportunities.
Senior Residents Conference ...................................29 ASPS supplies answers to the Top 7 questions residents ask about this annual meeting event.
Things I wish I knew when I was a plastic surgery resident ................................30 Henry Hsia, MD, reveals his reticence to ask for time of – as well as his chief’s understanding and blessing.
#TheTrend ....................................................................32 James Vargo, MD, and Jacob Grow, MD, take a deep-dive into the PRS Resident Reader and its quick, comprehensive article access.
Pearls from the Masters – International Edition ...................................................34 Hans Petter Gullestad, MD, plastic and reconstructive surgery chief at The Norwegian Cancer Institute, lends his expertise on complete axillary lymph node dissection.
On the cover: ASPS Active members and residents – including 18 of our young surgeons – converged on Washington, D.C., to promote the specialty’s agenda and educate federal lawmakers.
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Plastic Surgery Resident | Fall 2017
Plastic Surgery Resident | Fall 2017 | Vol.1 No. 8 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 to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR ESIDEN T 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 INTER NATIONA L EDITOR Johan Sandberg, MD | ljsandbrg@gmail.com R ESIDENT EDITORS Jacob Grow, MD | jgrow2@kumc.edu Kavitha Ranganathan, MD | krangana@med.umich.edu Deana Shenaq, MD | dshenaq@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org SENIOR DIR ECTOR OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org S TA F F W R I T E R Kendra Y. Mims | kmims@plasticsurgery.org GR A PHIC DESIGN ER Anna Abbinante A DV ERTISING SA LES 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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THE RISING HEGEMON OF RESIDENT ADVOCACY
How the Growing Army of Plastic Surgery Residents Can Change Medicine By Debra Bourne, MD, and Alex Spiess, MD
T
he life of a plastic surgery resident is profoundly demanding – educational and research demands, duty hours, night call and family considerations ill the days and nights, leaving us with little to no free time. his reality makes a resident’s decision on whether to enter the realm of politics and political advocacy particularly thorny.
Nevertheless, the potential payof of such a decision can be huge: changing health-care policy at the national and state levels, with results reaching into the O.R. and clinic, and directly to patients. What’s become crystal clear over the past few months, if not years, is that the U.S. health-care system is in dire need of informed reform – and the decisions required of our political leaders will carry consequences that couldn’t be higher for medicine and patients. So while residents may feel that their time allotment couldn’t be any more constricted, they can take solace in the fact that any efort they put forth for advocacy activities can have a positive, profound and enduring impact upon the specialty. Several plastic surgery residents recently stepped into the advocacy arena to educate and inform legislators – and to add to the health-care debate the voice of young plastic surgeons – at the inaugural ASPS Advocacy Summit held June 27-29 in Washington, D.C. he result was not only a greater number of plastic surgeons who’ve gained the tools to change the healthcare landscape, but also freshly enlightened lawmakers who’ve promised to cast votes that will change medicine. he summit serendipitously fell on what became a dynamic week on Capitol Hill – which made the event incredibly timely and salient. Plastic surgery residents Lee Squitiere, MD (left), and Gabrielle Davis, MD, share a moment on the steps of the Capitol Building.
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Plastic Surgery Resident | Fall 2017
Only weeks before this convergence in D.C., the U.S. House passed the American Health Care Act – its efort to repeal and replace the Afordable Care Act (ACA). he Senate was poised to vote on its version, known as the Better Care Reconciliation Act, the week of the arrival of the plastic surgeons. However, on the Advocacy Summit’s opening day, Senate Majority Leader Mitch McConnell (R-Ky.) delivered the stunning announcement that the Senate did not have the votes to move that bill forward.
Advocacy redefined in an uncertain future With the health-care environment in transition, a critical period has arrived for physicians to be informed on policy, and to advocate for patients and the profession. As both stakeholders and constituents, our voices carry enormous weight in crafting future policy that potentially will exert a direct impact on how we practice – and on the care that our patients receive.
Rep. Mike Doyle (far left, D-Pa.); Plastic Surgery Resident magazine editor Alex Spiess, MD (5th from left); residents; and ASPS representative Jessica Frasco (center) in Rep. Doyle’s oice. ASPS member Steve Bonawitz, MD, can be seen at Dr. Spiess’s right.
In years past, the ASPS Executive Oice had coordinated Regional Advocacy Fly-In events, which allowed plastic surgeons to spend one day in Washington to meet with their respective senators, congressmen and congresswomen, and educate these policymakers about issues of interest and importance to patients and practices. hese previous ly-in events were coordinated by geographic region, with plastic surgeons from predetermined, multistate regions spending a few days in our nation’s capitol at difering times of the year. At these functions, policy such as the Breast Cancer Patient Education Act and the Children’s Access to Reconstructive Evaluation and Surgery Act were among the issues ASPS advocated to Congress – and these important bills were later signed into law. his year, ASPS decided that one summit could replace these regional gatherings. he 2017 ASPS Advocacy Summit not only coordinated all regions of the country into one “ly in,” but also incorporated a didactic component dedicated to education and the discussion of current and pertinent Societyrelated legislative issues. In medical school, our immersion into health-care policy was a single lecture on the ACA; no formal instruction regarding policy or advocacy was folded into our resident training. I learned the majority of what I know about our legislative system in high school. Despite – or perhaps because of – this background, I wanted to attend the Advocacy Summit. I felt the need to become more informed and involved in healthcare policy in general and as it pertains to our specialty. Other residents must have experienced a similar desire, as 18 of us gathered in Washington, D.C.
Gaining steam he event kicked-of on June 27 with the Advocacy Summit Welcome Reception at the Washington Court Hotel – likely the only hotel in the world with the entire First Amendment to the U.S. Constitution engraved on its front façade. his gathering was led by Sen. Bill Cassidy, MD (R-La.), a practicing gastroenterologist before he entered the political realm, whose contributions to ACA-reform eforts included the Graham-Cassidy amendment. he measure would keep in place most taxes from the ACA and send the money back to the states in the form of block grants, with the states then using these block grants to create their own speciic systems for providing health insurance. Dr. Cassidy has long-supported relief for physicians. “Doctors spend billions of dollars on extraneous tests and healthcare services because they rightly feel they need to protect themselves from frivolous litigation,” he said. “America needs tort reform so that we can reduce health-care costs.” he following morning, Mara Liasson, a national political correspondent and analyst for both NPR and Fox News – and an expert on elections, national policy and relations between the White House and Congress – provided incisive perspectives and recommendations that launched a fruitful day of presentations, panels and discussion on the future of the ACA, the plastic surgery-related implications of the Medicare Access and CHIP Reauthorization Act, and ASPS advocacy priorities. According to Liasson, Republicans in both chambers spent years demonizing the ACA and blaming health-care laws on the law itself – which severely restricted their options when
they came into power, as the proposals they’ve put forth thus far would have worsened that landscape. Liasson also noted that American politics is becoming reality-resistant, which she attributed to the proliferation of information and information sources – and how that allows people to avoid perspectives that difer from their own.
On message While lawmakers in D.C. deal with their legislative priorities, ASPS has developed its list of issues that demand attention. For 2017, the Society identiied graduate medical education as one of its top-priority policy items. Most of our salaries are funded through Medicare; however, the number of government-funded residency positions has been capped since the Balanced Budget Act in 1997. As the United States population ages, the demand for physicians to provide care to this expanding population increases. Nevertheless, the number of residency positions has not increased to keep up with the expanding need for primary care and specialty physicians. Estimates hold that by 2030, there will be a shortage of more than 100,000 physicians – among them nearly 30,000 specialists. Residents Kavitha Vakharia, MD (left); Debra Bourne, MD; and Bharat Ranganath, MD; on a break in Washington, D.C.
With our mission in this regard clear, we spoke with our respective representatives about the importance of expanding the number of Medicare-funded residency spots – not only for primary-care training, but also for training specialists such as plastic surgeons – and we asked that they cosponsor and pass the Resident Physician Shortage Reduction Act (H.R.2267/S.1301). Residents are relatively protected from medical malpractice suits and our malpractice insurance is covered through our residency program. However, the vast majority of plastic surgeons will be involved in a malpractice claim during their career. hat’s why we’ve placed such a strong emphasis on capping noneconomic damages and establishing a reasonable statute of limitations on claims ilings, which can help protect physicians from inappropriate litigation and excessive liability premiums.
Brass tacks It’s diicult to describe the feeling that accompanies success in an endeavor that’s required so much patience and persistence, but we were thrilled by the news that the House had passed H.R. 1215, the “Protecting Access to Care Act,” while plastic surgery residents walked the halls of Congress in June. his piece of legislation includes a three-year statute of limitations from the date of injury or one year following the date of discovery, caps noneconomic damages at $250,000 and limits attorney-contingency fees. Nirav Patel, MD, MS, JD (left); George Varkarakis, MD; and Wilton Triggs, MD; discuss strategy in the Rayburn House Oice Building on Capitol Hill. 8
Plastic Surgery Resident | Fall 2017
Far from being a one- or two-topic specialty, Advocacy Summit attendees also took up the mantle of ensuring network adequacy for patients; the repeal of the Independent continued on page 38
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Q&A WITH MOHAMMED ALGHOUL
By Kendra Y. Mims Plastic Surgery Resident strives to provide readers with career advice to help them advance in their profession after residency by sharing insights on how to create their desired career path. In this issue, we present ASPS member Mohammed Alghoul, MD, assistant professor of surgery at the Northwestern University Feinberg School of Medicine in Chicago, where he teaches surgical residents and students. Dr. Alghoul obtained his medical degree from the University of Jordan and his residency training in both general and plastic surgery at Cleveland Clinic. He completed fellowships in microsurgery and breast reconstruction, as well as a fellowship in aesthetic and oculoplastic surgery with Mark Codner, MD. Dr. Alghoul’s irst fellowship led to his special interest in breast reconstruction and a commitment to natural body restoration of each breast cancer patient. His study in oculoplastic surgery allows him to ofer specialized techniques for eyelid procedures – and he combines his knowledge and training in microsurgery with his cosmetic background to perform complex facial aesthetic reconstruction after cancer resection or trauma. Dr. Alghoul discusses his career in plastic surgery and oculoplastic surgery, teaching and work/life balance with PSR.
PSR: HOW DID YOU PREPARE YOURSELF DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Alghoul: I didn’t have that much time to prepare, because I did an independent-track plastic surgery fellowship after general surgery. However, I worked really hard in residency, and I left a favorable impression on my attendings who never hesitated to pick up the phone and provide a strong 10
Plastic Surgery Resident | Fall 2017
recommendation on my behalf. I also worked in both the animal and cadaver labs during residency and presented my research at national meetings of such organizations as ASAPS and PSRC. his provided me with an opportunity to meet people and network with other plastic surgeons who ultimately became my fellowship mentors.
PSR: HOW DID YOU CHOOSE YOUR SPECIALTY? Dr. Alghoul: I was always fascinated by microsurgery, so this was an easy and logical choice. For a long time, however, I debated if I needed to do a cosmetic fellowship. I had an excellent cosmetic experience during residency, and there were limited cosmetic fellowships available at the time. I was introduced to oculoplastic surgery from attending talks and courses by Glenn Jelks, MD, and Mark Codner, MD. I immediately fell in love with eyelid surgery and decided to pursue a fellowship. To my surprise, the skills needed for microsurgery and oculoplastic surgery were extremely similar, so in hindsight, it made a lot of sense to specialize in both.
PSR: WHAT IMPACT HAS YOUR FELLOWSHIP HAD ON THE ADVANCEMENT OF YOUR CAREER? Dr. Alghoul: My career is deined by my fellowship training, which has had a tremendous impact. It’s hard to get into academic practice without it. When I irst interviewed for my current job, they were searching for a breast microsurgeon, so my fellowship training was my way in. However, having an additional subspecialty in aesthetic and oculoplastic surgery made me a more attractive candidate. From the career perspective, being a microsurgeon deinitely helped me build a breast reconstructive practice at my current institution and expand the use of perforator laps. On the other hand, the eyelid background gave me more of an edge and opened the door to a new world of complex reconstructive eyelid cases that are usually referred to oculoplastic surgeons. I’m currently in my ifth year in practice, and I ind myself now focusing my research eforts on the periorbital area. My hope is to help advance the ield of cosmetic and reconstructive eyelid surgery through innovative approaches.
PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Alghoul: Having a mentor is important for early clinical and academic success. However, it’s not easy to ind a mentor in your practice who has the same clinical interest and is willing to take you under his or her wing and help advance your career. I believe most people keep in touch with their residency and fellowship mentors unless they get hired at their training institutions. Practice is not residency; it’s a new path, so guidance is needed. From the clinical standpoint, I still call my mentors when I have a challenging case. I sought advice from my partners who are experienced breast, aesthetic and microsurgeons. hey provided me with excellent mentoring over the years. his is one of the advantages of joining an academic practice.
PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Alghoul: I’m fortunate to have been involved in several ASPS committees. I love the networking aspect of it – meeting other plastic surgeons, bouncing ideas of one another, working on projects and, most importantly, giving back to the Society. It’s been a great learning experience for me personally, whether I’m helping on a project with the Young Plastic Surgeons Forum, working on a resident curriculum with PSEN or being an associate editor for this great magazine.
From the career perspective, being a microsurgeon deinitely helped me build a breast reconstructive practice at my current institution and expand the use of perforator laps. PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Alghoul: Work ethic and passion deine a successful resident. Like any other ield, if you are passionate about something, it means you care and put forth your best efort to succeed. Having a strong work ethic is equally important, and with that comes professionalism, hard work and dedication.
PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Alghoul: his is always the biggest challenge. My wife and I had our irst child one month before I started practice and the second child 18 months later. We have two little boys, age 3½ and 5, and like any parent, you want to give them all the time and attention they need. We do our best to organize our week, and we have our family time when we put everything else aside
every weekend. I try to dedicate a few hours on the weekend to work – and I usually squeeze an hour of work out in the morning before I start my day at the hospital.
PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Alghoul: I enjoy the creativity aspect of it, as well as seeing new problems every day and trying to come up with the best solution. Finding a solution to any given problem, in my opinion, is not satisfying enough, but inding the best solution is very gratifying.
PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Alghoul: It’s diicult to ind time to work on research when I don’t have dedicated time in a busy clinical practice. Getting referrals for reconstructive eyelid cases is somewhat a struggle, especially early-on when you don’t have an ophthalmology background. Finally, building a cosmetic practice – although not impossible in an academic setting – is much easier in private practice. hose of us who have mixed interest in cosmetic and reconstructive surgery or have a “hybrid” training background face the challenge of inding and achieving the right balance. I believe it’s an evolving process, but to become an expert, it’s better to specialize and focus on one area. However, when you like and enjoy both, this is easier said than done.
PSR: WHAT ROLE DOES TEACHING PLAY IN YOUR SCHEDULE? Dr. Alghoul: I love and enjoy teaching in the O.R., clinic and residents’ curriculum conferences. I like to teach technique more than didactics, but I also enjoy teaching the residents about facial anatomy and topography. I believe it’s the key to success in both cosmetic and reconstructive facial surgery. I’m also the medical student clerkship director, and I often have third-year medical students shadow me for one month at a time during their plastic surgery rotation. Generally, when I show up to clinic or the O.R., there’s always a resident or student eager to learn something about plastic surgery that day. I always keep that in mind, because as we get really busy, we tend to forget our teaching responsibilities as academic plastic surgeons.
PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Alghoul: On a professional level, ind what you are most passionate about in plastic surgery, ind a mentor and start building your expertise. It’s never too early. On a personal level, take care of yourself and your wellness – and don’t get too consumed by residency training.
PSR: PLEASE COMPLETE THIS SENTENCE: I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN … Dr. Alghoul: I sewed up a lip laceration in the E.R. I loved it! | Plastic Surgery Resident | Fall 2017
11
Management of acute facial nerve lacerations
“Consult Corner” addresses a consult commonly encountered by an on-call resident. he column begins with the reason for consult and assesses questions that might go through a resident’s mind as he or she heads to the emergency department to see the patient. Key aspects of the history and physical, as well as additional testing that should be obtained, are also presented. Finally, a review of the decision-making process will present possible management strategies, all of which are synthesized into the context of an actual case.
Facial lacerations require care, caution – and a methodical approach By Ali A. Qureshi, MD MESSAGE ON YOUR PAGE: E.D. CALL: FACIAL LACERATION, CAN T MOVE BROW
Y
ou are just inishing up closing the abdomen after a long microvascular free lap case for breast reconstruction when you receive the following page from the E.D.: “40 y/o M with laceration to the right face, unable to move right brow.” As you break scrub, you think about what you might see in the E.D. and how you will evaluate it.
interconnections between branches of the facial nerve exist with the exception of the frontal and marginal mandibular nerves (Figure 2). he frontal branch has an intimate relationship with the zygomatic arch (Figure 3). Hence injuries to these branches of the facial nerve can have major consequences if not identiied and addressed.
ANATOMY OF THE FACIAL NERVE he facial nerve is divided into three major segments: intracranial, intratemporal and extratemporal. he extratemporal segment begins where the facial nerve leaves the stylomastoid foramen and travels across the posterior belly of the digastric muscle towards the parotid. he nerve begins to branch within the parotid into irst the superior and inferior divisions. In turn, the nerve branches further into ive major branches: temporal, zygomatic, buccal, marginal mandibular and cervical (Figure 1). As it travels from the parotid towards the target muscles in the face, it is deep to the subcutaneous musculoaponeurotic system (SMAS). Figure 1: Anatomy of the facial nerve he facial nerve has variable branching patterns and many 12
Plastic Surgery Resident | Fall 2017
FIGURE 1: Derby BM, Codner MA. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 2017 Jan;139(1):151e-167e.
Figure 2: Anatomy of frontal branch of the facial
Figure 3: Relationship of the frontal branch of the facial nerve to the zygomatic arch
FIGURE 2: Derby BM, Codner MA. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 2017 Jan;139(1):151e-167e.
FIGURE 3: Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical Considerations to Prevent Facial Nerve Injury. Plast Reconstr Surg. 2015 May;135(5):1318-27.
PERTINENT HISTORY AND EXAM Any patient with trauma to the face should be examined using the principles of trauma evaluation including airway, breathing and circulation. Once patients have had a primary and secondary survey and are deemed stable for further evaluation, a pertinent history and focused physical examination should be performed. For injuries to the face, C-spine evaluation by the trauma services is critical prior to starting any manipulation of the head and neck for evaluation or procedural purposes.
to gently open the eye, to test the muscle against resistance. Asking the patient to smile and puf out their cheeks can be used to test zygomatic and buccal branches. he marginal mandibular can be tested by asking the patient to pout their lower lip. he cervical branch can be tested by asking patients to clench their teeth down and move their face forward while tightening their neck muscles to activate the platysma.
Mechanism of injury is always a key component. Patients should be asked if the traumatic laceration was the result of a sharp object or blunt trauma with shearing force. In the case of violence, patients should also be asked if they feel safe and appropriate involvement of social workers can assist in ensuring patient safety. Patients should be asked about any previous history of facial trauma, surgery or the use of neurotoxins for cosmetic or functional purposes. It is also important to obtain a history of any ocular problems, Bell’s palsy, or prior stroke.
Asymmetries and lacerations in the area of the involved muscles that may be afected should raise suspicion for possible nerve injury. here are some important caveats that should be considered. For example, asymmetry of smile or inability to puf out the cheeks in the case of a facial laceration may be present because of swelling. A laceration that goes through subcutaneous tissue and into muscle can cause direct damage to the muscles as well and should be considered. However, certain danger zones exist especially in the area of the zygomatic arch and lower border of the mandible where the frontal nerve and marginal mandibular nerves may be susceptible to injury.
A detailed and focused exam of the face should be performed. To test the facial nerve, a systematic approach is best and can be done by testing relevant muscles for each branch. To test the frontal branch, patients should be asked to raise their eyebrows. he zygomatic branch can be tested by asking patients to close their eyes tightly and the examiner trying
You go to the E.R. and see the patient. He has already had a primary and secondary survey by the trauma surgery team. he patient’s exam is notable for a 5 cm sharp, linear vertical laceration over the right zygomatic arch and extending over to the temple. here is no arterial bleeding or debris in the wound. No visible muscle is cut. he patient is unable to raise the right Plastic Surgery Resident | Fall 2017
13
eyebrow however he can close his eyes, smile symmetrically, pout his lower lips, and activate his platysma. You’re attending happens to call you and ask you what you want to do next.
MANAGEMENT AND PROCEDURAL PRINCIPLES Acute management of facial nerve lacerations involves a high index of suspicion. Careful physical examination can help diferentiate facial nerve injuries from injury of the muscle, however both can also happen together. Lacerations of the facial nerve that occur medial to the lateral canthus are not explored or repaired. Medial to the lateral canthus the branches of the facial nerve have signiicant arborization and this cross over allows injuries to the zygomatic and buccal branches to potentially be recoverable with time. However, more peripheral injuries like over the parotid, angle of mandible and temple area for example warrant exploration as these injuries are unlikely to recover without intervention. Depending on the location and extent of the laceration, the parotid duct can also be lacerated and would require evaluation by an experienced team. As with any other peripheral nerve injury, time is of the essence! Wounds with concern for traumatic laceration to nerves should be explored within 72 hours from the time of injury, not necessary the time the patient was seen in the E.R. his is because motor nerves can be stimulated for up to 72 hours after injury. he nerve can be repair directly or with a nerve graft or nerve transfer. he nerve repair should be tension free. he more proximal the injury, the greater the risk for synkinesis. Nerve graft options include the sural and medial and lateral antebrachial nerves. You tell your attending that you are concerned that the patient has a traumatic sharp laceration to the right frontal branch of the facial nerve and that it needs exploration and possible repair. You book the patient for the operating room and obtain consent for the procedure.
ACUTE STABILIZATION For traumatic lacerations immediately going to the operating room, the wound can be dressing with a moist occlusive dressing. In this case the patient is going to the operating room for exploration and possible repair. However, there may be instances where the patient is not going to the O.R. immediately but still will go within 72 hours. In these cases, the wound should be irrigated and cleansed and loosely approximated with removable sutures. Tight
closure can cause skin necrosis as swelling is likely to ensue. Depending on the extent and branches of the facial nerve that may be damaged, speciic considerations for the eyes must be made. Routine administration of antibiotics for clean wounds in the face are not indicated beyond what may be given for perioperative antibiotics. If there is concern for damage to the zygomatic branch of the facial nerve, the globe is at risk for problems because of impaired closure of the orbicularis and can dry out. Proper lubrication with artiicial tears or ointment is necessary. In severe cases, the eye may need to be patched shut to prevent desiccation of the globe and corneal irritation. Patients with damage to the buccal branches and injury to the muscles that move the mouth should be cautioned about liquids and possible diiculty eating. Patients may have diiculty sucking from a straw. Additionally, they should be cautioned about hot or cold foods as they may also have impaired sensation if there is concomitant damage to branches of the trigeminal nerve.
DELAYED RECONSTRUCTION For patients with missed injuries to the facial nerve or delayed presentation, options for restoration of function exist depending on which branches are injured. Facial reanimation surgery seeks to restore function and appearance of the face and are often options for zygomatic, buccal and marginal mandibular nerve injuries. Restoration of corneal protection with ocular competence is important for long-term vision and reduction in ocular problems. Oral competence is also critical for reducing in problems with eating and drinking. Smile restoration is important for facial expression and symmetry. A number of surgical options including both dynamic and static options for restoration of function exist and including microvascular free functional muscle transfers and temporalis and masseter transfer among others. Cross-face nerve grafting and nerve transfers from ipsilateral donors are also options. In this speciic case, if the patient presented in the delayed fashion outside the window for acute exploration and repair the brow can still be addressed with static procedures. Balancing procedures can be performed with a browlift procedure, either with direct excision or through an alternative approach. Additionally, neurotoxin to the contralateral frontalis can help restore symmetry. Dynamic procedures are not typically used for the brow as static procedures often lead to good, symmetric and aesthetically pleasing results.
CONCLUSION Evaluating acute facial nerve injuries in the E.D. requires a high index of suspicion. Asymmetries can be from soft tissue swelling or direct muscle injury as well. Making sure a patient has had an appropriate trauma workup including C-spine evaluation is critical before manipulation of the head and neck for repair and exploration. While acute facial nerve injuries are stabilized in the E.D., they will often require exploration within 72 hours. Delayed presentation or missed injuries still have options for repair. |
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Plastic Surgery Resident | Fall 2017
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A wellspring of plastic surgery leadership, research and innovation at the University of Michigan Section of Plastic Surgery By Katelyn Bennett, MD History • Established in 1964 by Reed O. Dingman, MD, DDS • One of the irst integrated plastic surgery programs in the country • Second chair of the section was William C. Grabb, MD (as in the Grabb and Smith textbook) Leadership • Paul S. Cederna, MD; Robert Oneal Collegiate Professor of Plastic Surgery; Section Head of Plastic Surgery • Adeyiza O. Momoh, MD; Clinical Associate Professor; Program Director of Integrated Plastic Surgery Residency Program National Leadership • Past-Presidents of he Plastic Surgery Foundation (PSF): William M. Kuzon, MD; Kevin C. Chung, MD • Current he PSF President: Paul S. Cederna, MD
• Past-Chairmen of the Plastic Surgery Research Council (PSRC): Paul S. Cederna, MD; Steven R. Buchman, MD • Past-President of the American Society of Maxillofacial Surgery (ASMS): Steven R. Buchman, MD • President-Elect of the American Society for Peripheral Nerve (ASPN): David L. Brown, MD • Past-Presidents of the ASPN: Paul S. Cederna, MD; William M. Kuzon, MD • Ethics Chair of the American Craniofacial-Cleft Palate Association (ACPA): Christian J. Vercler, MD • Seven faculty serve as American Board of Plastic Surgery (ABPS) oral examiners • American Board of Plastic Surgery Directors: William M. Kuzon, MD, PhD; Kevin Chung, MD; Paul S. Cederna, MD • Vice-Chairman of the ABPS: Paul S. Cederna, MD Clinical Experience • Training sites include the University Hospital; C.S. Mott
he University of Michigan Section of Plastic Surgery, led by Section Head and he PSF President Paul Cederna, MD (front row, third from left), and Integrated Plastic Surgery Residency Program Director Adeyiza Momoh, MD (front row, fourth from left).
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Plastic Surgery Resident | Fall 2017
• • • • •
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Children’s Hospital; the Frankel Cardiovascular Center; the Ann Arbor Veterans Afairs Hospital; East Ann Arbor Ambulatory Surgery; Livonia Center for Specialty Care and St. Joseph Mercy Hospital 16 full-time clinical faculty with an additional four clinical faculty at St. Joseph Mercy Hospital 27 residents, including those currently in academic development Craniofacial fellowship (1 Fellow/year) and hand surgery fellowship (2 Fellows/year) 30,000 clinic visits per year, 4,000 major operations per year, 80 operations per week Six months of plastic surgery rotations during intern year, four months during second year, nine months during third year, 10 months during fourth year, 12 months during ifth and sixth years Of-service rotations during the third and fourth years include head and neck reconstruction with otolaryngology; facial aesthetic surgery with otolaryngology; surgical oncology; oculoplastic surgery; and oral surgery Comprehensive training in microsurgery; body contouring; aesthetic surgery; burn reconstruction; hand surgery; gender-airmation surgery; and cleft/craniofacial surgery
Educational Curriculum • Monday “indications conference” in which patient photographs are displayed and relevant anatomy, reconstructive goals, patient preferences and operative plans are discussed • hursday morning core conferences with 45 minutes of didactics and 45 minutes of cases • Monday morning hand conferences for the hand service and orthopedic residents • Wednesday evening core craniofacial conferences and hursday morning craniofacial indications conference for the craniofacial service • Microsurgery skills lab • Annual cadaver dissections with varying content from year to year (rhinoplasty, aesthetic eye surgery, hand surgery and workhorse laps) • Monthly journal clubs to discuss current research within plastic surgery from any relevant journal Research • hree federally funded basic science labs related to craniofacial bone healing (Steven R. Buchman, continued on page 33
A message from the program director, Adeyiza O. Momoh, MD
W
ith a pioneering history as one the first integrated plastic surgery residency programs (one of three) in the United States, training at the University of Michigan (UM), Ann Arbor, continues to push boundaries in providing the best training possible to trainees. The early years of training in plastic surgery in the Ann Arbor area occurred in collaboration between the UM Hospital and St. Joseph’s Mercy Hospital, a private hospital in town under the guidance of Reed O. Dingman, MD. This relationship has been maintained over time, with residents rotating at both hospitals, and it provides a broad exposure to varying practice models in the training of our residents. The size of the faculty group and resident complement over the years has grown to meet evolving clinical and educational needs. There are currently 16 full-time academic faculty at the University and four clinical faculty at St. Joseph’s Mercy Hospital. The training program welcomes four new residents each year, with a total of 27 residents (23 in clinical training and four in academic development time). Early exposure Residents are exposed from early in their training to a high volume of the full breadth of plastic surgery. Included in this exposure is hand surgery and pediatric/craniofacial surgery, complex reconstructive microsurgery and cosmetics. The practice environment at UM is such that there are no “private practices” where cases are performed without residents. Consequently, all surgical cases are performed with residents – and by graduation, our residents average well over 2,500 cases. This is made possible with an internationally recognized faculty that presents expertise in all fields of our specialty. With the ultimate of goal of training well-rounded surgeons with stellar clinical and technical abilities – who are also innovative, who push the boundaries of our understanding through research and who lead our specialty forward – our training program invests extensively in all aspects of resident development. Residents have the opportunity to spend dedicated time pursuing diverse academic and research interests which could include the acquisition of advanced degrees. Mentored by the best They are mentored by the leaders of our specialty – the current The PSF president, two past The PSF presidents, two past presidents of the Plastic Surgery Research Council, a past president of the American Society of Maxillofacial Surgeons, two past presidents of the American Society for Peripheral Nerve and three ABPS Directors, to name a few. With these rich experiences, residents regularly achieve astounding accomplishments, successfully compete for grants, win numerous national awards, serve on national committees – and secure highly coveted fellowship positions and the best academic jobs nationwide. We are quite proud of the opportunity we have to train individuals who will lead our specialty forward. |
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The ‘why’ of leadership What matters to residents – and why residents matter By Raman C. Mahabir, MD
I
had just inished teaching a session of ASPS’s Essentials of Leadership (EOL) program, the Society’s efort to imbue up-and-coming plastic surgery leaders with some of the skills required to advance their careers. hree of us, good friends as well as EOL instructors, were passengers in an Uber ride as we traveled to O’Hare International Airport from the nearby ASPS Executive Oice in Arlington Heights, Ill. Without warning, one of my friends turned to me and asked: “Why do you do this?” Since this question is so fundamental, I sincerely hope the answer that follows will prompt you to ask the follow-up question: “How do I get involved?” his is my hope, as the Society will be so much stronger with you as an active participant in it. Participation in ASPS has the potential to ofer so much more than merely the actions of paying membership dues and attending meetings to fulill CME requirements. I joined ASPS as a resident more than a decade ago, but at that time the only portal to the committee structure for me was the Young Plastic Surgeon (YPS) Steering Committee. herefore, I signed up and became part of the groundswell of enthusiasm for young plastic surgeons to play a larger role in the Society. Simultaneously and coincidentally, an organizational restructure led to two important developments: Instead of one Vice President, there are now six – and instead of one committee for YPS, there’s now a standing position on every
committee for a resident, and most committees have YPS representation. his has created an unprecedented opportunity to be involved – which I genuinely hope you do. One of my reasons for involvement is personal: I like my colleagues and my specialty. Whether it’s the enormous annual meeting or an interactive local meeting, I’m eager to catch up with friends and fellow plastic surgeons. We belong to such a small community of such gifted individuals that it’s a delight to see what remarkable work people are doing in all aspects of their lives. As you live the life of a resident (operate, clinic, study, sleep, repeat), it can be easy to forget that you’re part of something vast. Take a quick look at the history of our specialty and our organization – you’ll see what we have achieved during the past decades. And you’ll appreciate the progress we have realized through the involvement of people like you!
SO, WHY WOULD YOU WANT TO?
Participation in ASPS has the potential to ofer so much more than merely the actions of paying membership dues and attending meetings to fulill CME requirements. Another reason is my passion. You know in your heart that there’s more to being a plastic surgeon than surgery, and ASPS can provide you with the opportunity to pursue some of your passions. I’ve been a member of more than a dozen diferent committees over the years and that gave me the opportunity to explore diverse interests. For example, the ASPS Development Committee revealed to me the complexities of the philanthropic side of ASPS and gave me the opportunity to develop a skillset that, until then, I didn’t realize that I had. continued on page 21
Plastic Surgery Resident | Fall 2017
Put your plastic surgical vocabulary skills to the test! By Jef Lisiecki, MD 1 2 3 4 5 6 8
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ACROSS
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4. “Je le pansai, Dieu le guérit”
1. Developed sodium hypochlorite and boric acid solution for wound care
5. Dealer of trauma surgery papyrus
2. Calavarial bone graft discoverer
8. His patients in WW2 called themselves the “Guinea Pig Club” 10. First described benign juvenile melanoma
3. Komatsu and ___________, irst digit replant 6. DIEP pioneer
12. Gillies’ hospital
7. World War I veteran and hand surgery pioneer
13. With Gillies, wrote “he Principles and Art of Plastic Surgery” 14. Nineteenth century father of aesthetic surgery
9. Female French facelift pioneer who operated from her home 10. Famous for his Samhita
17. French eugenicist, who described acrocephaly with syndactyly
11. Classical Athenian politician who likely had sagittal synostosis
18. Plastic surgeon recipient of Nobel Prize
14. Invented mouth gag for cleft surgery 15. Corrected prominent ear deformity in 1881 16. Italian father-and-son pioneers of nasal reconstruction
Answer key on page 31
hey complain about my co-resident Dear Abbe, I’ve overhead multiple complaints about one of my co-residents. Should I approach them directly about what I’m hearing, or should I inform my program director of these complaints? Sincerely, Unsure of My Options
Dear Unsure, It depends. If the resident is your junior – especially one for whom you have direct supervisory responsibility – I’d set up a private feedback session and review the things the resident is doing well and those that need improvement, including the complaints you overheard. It’s best to present the complaints as hearsay and ask the resident for his or her side of the story before ofering a critique. If the resident is at your same level of training and he or she is a friend, a friendly “heads-up” in private may be appropriate. If the resident isn’t a close friend or is above your level of training, I would recommend to the people making the complaints that they approach the resident directly. For any issues that have substantial impact on patient or staf safety, such as coming to work drunk or abusive behavior, go to your program director.
My attending is out to get me Dear Abbe, I feel the attending with whom I work really dislikes me and is constantly degrading me both personally and professionally. Other attendings on service tell me I’m doing a great job and have no complaints. I really feel this attending is out to get me. What should I do – if anything? Sincerely, Worried For My Job
Dear Worried, If you have an attending mentor who you trust, I would discuss your concerns with this mentor as a irst step. If not, you should record speciic examples of the concerning behavior and report these to your program director. If you feel that your program director is unwilling or unable to help you, I would bump this up to the chief of your service or to the hospital ombudsman. | 20
Plastic Surgery Resident | Fall 2017
EDITOR’S NOTE: “Dear Abbe” – named in honor of plastic surgery pioneer Robert Abbe, MD – ofers plastic surgery residents an opportunity to anonymously sly share concerns and seek advice from a highly respected senior-level faculty member. Benjamin Chang, MD, associate professor of Clinical Surgery, and program director and associate chief of Penn Plastic Surgery, Philadelphia, steps into Dr. Abbe’s shoes for this installment. he views expressed in this column are those of the author and should not be considered legal advice. Residents and Fellows are encouraged to submit their questions to DearAbbe@ plasticsurgery.org. Names will be withheld.
THE ‘WHY’ OF LEADERSHIP / continued from page 18 Over time, I turned my interest to education and advocacy – and then I honed those skills with the Society’s guidance. No one is born a leader, but through the use of your talents and accepting responsibility you can become one. his certainly occurred in my case: As I served, I learned and grew into leadership – and in the upcoming year I will serve as the chair of the PSEN and join the PlastyPAC Board of Governors. My inal reason centers around emotion, as I found that doing work on behalf of the Society ofers dual rewards – with the Volunteers in Plastic Surgery (VIPS) program and advocacy eforts serving as great examples. By taking part in volunteer surgery missions, you can give children a chance at a life and happiness that they otherwise would never have; by giving of your time and expertise in a short visit to Washington, D.C. (or wherever the call takes us), you can help legislators understand the signiicance of what you’re presenting and thereby inluence legislation that afects medicine. Your contribution to the patient and the community can be transformational – and at the same time, you can derive immense personal satisfaction. he increase in diversity, the growing public awareness, the focus on synergy with sister societies and the innovation within our specialty are creating exceptional and unprecedented opportunities for young plastic surgeons to be fullyy engaged g g with their Society. y Whether the ield is education, advocacy or research, when you use your talents and desires to drive the future of ASPS, ou can advance the qualit of care for lastic sur er i nts. Regardless e us or area of interest ou c to ursu s our car as t e ave een or m ne.
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Plastic Surgery Resident | Fall 2017
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Vascular tumors Confusing classification, its infantile frequency make this perfect for the In-Service Exam By Tulsi Roy, MD
V
ascular tumors are neoplasms characterized by endothelial hyperplasia. Confusing classiication systems and relative infantile frequency make them ideal subject matter for the In-Service Examination. hough vascular tumors are very rarely malignant, they can be disiguring, locally destructive or life-threatening. Identifying the role of medical or surgical management versus observation and reassurance is key to managing this disease process.
INFANTILE HEMANGIOMA (IH) IH is one of the most frequent benign tumors of infancy, afecting up to 10 percent of Caucasian infants, more commonly in females and preterm infants. Twenty percent of IH are multifocal in nature, and a majority of these lesions involve the head and neck. Classically, IH demonstrates a three-stage cycle of rapid postnatal growth during the irst year of life (proliferation phase); slow regression from age 1-4 (involution phase); and quiescence after age 4 (involuted phase), in which lesions are replaced by ibrofatty tissue. Lesions typically irst appear at 2 weeks of age and achieve 80 percent of their size by age 3-4 months, during which time they transition from small, cutaneous macules to larger, bulkier bright red, well-demarcated lesions. IH lesions are associated with increased expression of GLUT-1, a glucose transporter protein that diferentiates them from normal endothelium. Of relevance to the In-Service Exam, though IH is rarely 22
Plastic Surgery Resident | Fall 2017
hereditary, patients with PHACES syndrome (posterior fossa malformations/hemangiomas/arterial anomalies/cardiac defects/eye abnormalities/sternal cleft and supraumbilical raphe) account for 3 percent of patients presenting with IH. Ultrasound is a noninvasive, well-tolerated radiographic study to obtain to distinguish hemangiomas from vascular or lymphatic malformations. MRI with contrast is the gold standard imaging-modality, but frequently requires sedation for patients of this age. MRI typically will demonstrate enhancement of a vascular tumor during its proliferative phase, with prominent low-voids in the peripheral tissues around the tumor. While many hemangiomas resolve with observation and parental reassurance, patients with involuted IHs can be left with skin atrophy, pallor, telangectiasias or residual ibrofatty bulk. Ulceration is a frequent complication of IH as a result of rapid growth that results in pain, hemorrhage, scarring and
not insigniicant amounts of parental stress. Most of the time, ulceration can be managed conservatively with local wound care with topical antibiotic ointment and petroleum jelly. Location of these lesions is also of key importance in stratifying management. Hemangiomas of the periorbital region can result in complications in ophthalmologic development, including strabismus, amblyopia and astigmatism. Hemangiomas over the chin and neck may be associated with airway involvement, which may cause life threatening airway obstruction. Difuse hemangiomatosis is described as the presence of at least ive cutaneous lesions. his condition increases the risk of internal hemangiomas, particularly those involving the liver. hese hepatic lesions can be large and associated with highlow states resulting in premature high-output congestive heart failure. Infantile hemangiomatosis is characterized by a classic triad of anemia, CHF and hepatomegaly.
(NICH) and rapidly involuting congenital hemangiomas (RICH). Regression of RICH lesions typically completes by 6 months to 1 year of age, whereas NICH lesions grow proportionately to the infant. Indications for excision are similar to those for IH.
KAPOSIFORM HEMANGIOENDOTHELIOMA (KHE) Kaposiform hemangioendothelioma is a locally aggressive vascular tumor. hese tumors are frequently associated with an overlying vascular birthmark and can vary in size. KHE is of clinical relevance particularly due to its association with Kasabach-Merritt phenomenon (KMP), a profound thrombocytopenia resulting from platelet trapping within vascular tumors. In cases where tumors are amenable to surgical resection, complete surgical excision is curative. For those tumors where surgical excision cannot be carried out safely, vincristine and sirolimus therapy has shown excellent rates of KHE regression.
Tumors in non-signiicant anatomic locations can be observed. While topical steroids are inefective for IH, intralesional steroids can be helpful for small, localized tumors in high-risk anatomic locations such as the airway, periorbital region and nose. Systemic prednisone therapy and propanolol have been shown to be efective for tumors larger than 3 cm, though regression takes place over the course of months. Embolization of intrahepatic or high-low regions is recommended for the treatment of cardiac shunt. While operative intervention is most favorable in the involuted stage of IH, surgery during proliferation and involution is recommended for tumors that threaten anatomically sensitive areas such as the eyes, failure of medical management, necessity for staged reconstruction, or are well-localized in an anatomically favorable area.
CONGENITAL HEMANGIOMA Congenital hemangiomas are frequently confused with IH, but they are, in fact, a separate subset of vascular tumors. hey are comparatively much more rare and they do not demonstrate a cycle of growth. Instead, they present fully grown at birth, with no period of subsequent proliferation. As such, they do not express GLUT-1. Additionally, they, too, can cause physiologic shunting and result in high-output congestive heart failure. Congenital hemangiomas are classiied into non-involuting congenital hemangiomas
PYOGENIC GRANULOMA Pyogenic granulomas, also known as lobular capillary hemangiomas, are relatively common, bright-red, small vascular tumors that typically present in children, young adults and pregnant women. hey present with a period of rapid proliferation over several weeks, sometimes associated with a history of trauma to the area. hey frequently present on the head and neck, particularly along the gingival and oral mucosa. If presenting during pregnancy, pyogenic granulomas may resolve on their own. Recurrent bleeding, however, usually drives intervention. Curettage, shave excision and electrodessication are nonoperative strategies for management; however, fullthickness surgical excision has the lowest rate of recurrence. Tulsi Roy, MD, is a PGY-3 at University of Chicago. | Plastic Surgery Resident | Fall 2017
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Journal Club; 2017 Fall; (8)
For the more contentious topics, two (or more) articles have been chosen in order to provide a balanced view. While this adds up to more than 10 journal articles, these articles have been carefully chosen with brevity in mind, and the savvy reader should glean the take-home points reasonably quickly.
1. he anatomical course of the palmar cutaneous branch of the median nerve, including a description of its own unique tunnel Naf N, Dellon AL, Mackinnon SE / Journal of Hand Surgery (Edinburgh, Scotland). 1993;18(3):316-7
» Dr. Naf and colleagues investigated the course of the palmar
JOURNAL ARTICLES ON
CARPAL TUNNEL SYNDROME
EVERY PLASTIC SURGERY RESIDENT
SHOULD READ
branch of the median nerve with the aim of conirming the existence of a separate tunnel for this nerve outside of the carpal tunnel. In 20 forearms from 12 cadavers, they found the palmar sensory branch arising from the median nerve at a mean of 5.7cm and a maximum of 11cm proximal to the wrist crease. Distally, they determined that it runs next to or in the FCR sheath until ~1.5cm proximal to the tubercle of the scaphoid, where it enters a distinct tunnel in the supericial layers of the transverse carpal ligament – where is stays for 3cm and then exits to innervate the palmar skin. hese indings can help guide incision planning for CTR, as well as describe another possible nerve-compression site in the wrist.
2. Anatomical variations of the median nerve in the carpal tunnel Lanz U / he Journal of Hand Surgery. 1977;2(1):44-53
By Sergey Turin, MD
C
arpal tunnel syndrome (CTS) is the most-common peripheral compression neuropathy1, with an estimated prevalence of ~3.7 percent2, and carpal tunnel release (CTR) is the most-frequently performed surgery of the hand. he volume of literature published on the subject is astounding, with a PubMed search for “carpal tunnel syndrome” returning 8,115 English-language articles as of this writing. Frustratingly, electronic versions of many of the articles that appear on the “most-cited” lists3-5 can often be diicult or impossible to ind (e.g., Phalen’s seminal work “he Carpal Tunnel Syndrome – 17 Years Experience in Diagnosis and Treatment of 654 Hands” published in 1966). Moreover, there are few double-blinded RCTs addressing the points of contention in the diagnosis and treatment of carpal tunnel syndrome, with a plethora of conlicting evidence to be found. With these points in mind, the articles presented in this edition of Journal Club include classic studies – which may be diicult to obtain – paired with a more-recent article on the same topic, and that the resident reader should be able to more-easily access. 24
Plastic Surgery Resident | Fall 2017
Variations in the course of the thenar motor branch of the median nerve and their relationship to the hypertrophic muscle overlying the transverse carpal ligament Al-Qattan MM / he Journal of Hand Surgery. 2010;35(11):1820-4
» While injury to the palmar cutaneous branch can lead to anesthesia of the palm and a painful neuroma, injury to the recurrent motor branch of the median nerve is far more morbid – which thus has earned it the “million-dollar nerve” moniker, inspired by high damages awarded to patients with iatrogenic injuries of this nerve. Poisel described the three courses the motor branch can take – trans-, extra- or sub-ligamentous – in his 1974 study.6 Lenz then prospectively examined in 1977 the course of this branch during open surgery in 246 hands, and Al-Qattan repeated the study in 2010 with 100 hands. he most common path was extraligamentous (46 percent vs 56 percent), followed by subligamentous (31 percent vs 34 percent) and transligamentous (23 percent vs 9 percent) variations in the Lenz and Al-Qattan series, respectively. Notably, Al-Qattan did ind one case of a pre-ligamentous branch arising proximal to the transverse carpal ligament (TCL) and running supericial to it, and Al-Qattan comments on the important inding that all the subligamentous branches in their series were
associated with a purely ligamentous TCL, whereas all the transligamentous and preligamentous branches were associated with a hypertrophic muscle overlying the TCL. he strong relationship can be used intraoperatively, should there be concern regarding the course of this branch. Ng and Talwalkar have recently published a short article with high quality images of the three classic motor branch patterns, which the reader may ind useful, since the motor branch is rarely seen in routine carpal tunnel surgery..7
3. Long-term outcomes of carpal tunnel release: a critical review of the literature Louie D, Earp B, Blazar P / Hand (New York, N.Y.). 2012;7(3):242-6
» Dr. Louie and colleagues analyzed the outcomes of carpal tunnel release surgery at two years of follow-up or later. Some of the longer-term issues includes paresthesias lasting nine months or longer after CTR, abnormal latencies on electromyography (EMG) testing for up to three years or longer, and recurrence of CTS. he authors summarized the results of 13 studies, which showed a clinical success rate of 7590 percent and a recurrence rate of 4-57 percent at a minimum of two years’ follow-up. Notably, the rate of recurrence was 4-15 percent for seven studies and 67 percent in the eighth study that speciically reported recurrence. he authors suggested the wide variation in recurrence rates may have been due to inconsistent deinitions of “recurrence” – e.g., recurrence of any preoperative symptoms vs. need for reoperation. Until more series with long-term follow-up are published, these data are useful in counseling patients and setting their expectations.
4. Correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls Luchetti R, Schoenhuber R, Nathan P / Journal of Hand Surgery (Edinburgh, Scotland). 1998;23(5):598-602
Median nerve compression in the carpal tunnel – functional response to experimentally induced controlled pressure Lundborg G, Gelberman RH, Minteer-Convery M, Lee YF, Hargens AR / he Journal of Hand Surgery. 1982;7(3):252-9
» he initial work by Gelberman, et al.,8 set out to study pressure within the carpal tunnel in various wrist positions in patients with CTS compared to controls. heir data showed pressures were elevated in patients with CTS vs. the controls, with a mean of 32 mmHg, increasing to 94 mmHg with 90˚ of wrist lexion, and higher still to 110 mmHg with wrist extension. Controls had a mean pressure of 2.5 mm Hg in neutral rising to 31 and 30 mmHg with wrist lexion and extension, respectively. Luchetti, et al., later went on to summarize 11 studies besides their own for a total of 115 controls and 339 patients showing carpal tunnel pressures at 7.4, 30.8 and 59.0 mmHg in control subjects for neutral, lexed and extended wrist positions, with corresponding measurements in patients with CTS being 24.4, 68.9 and 89.6 mmHg.
hese numbers become meaningful when viewed in the context of the study by Lundborg, et al., which exposed 16 healthy volunteers to increased pressure within the carpal tunnel, inding that paresthesias were induced at 30 mmHg and complete motor-then-sensory blockade was induced at both 60 and 90 mmHg.
5. Carpal tunnel syndrome and computer exposure at work in two large complementary cohorts Mediouni Z, Bodin J, Dale AM, et al. / BMJ Open. 2015;5(9):e008156
Computer use and carpal tunnel syndrome: A meta-analysis Shiri R, Falah-Hassani K. / Journal of the Neurological Sciences. 2015;349(1-2):15-9
» he relationship between occupational activities (vibration or impact exposure in manual labor and computer use in oice work) and development of carpal tunnel syndrome is still a hotly debated topic. One of the reasons for this: he number of confounding factors is so large (comorbidities, age, sex, occupation, hobbies, speciic tasks at work and their frequency, ergonomics of the workspace, etc.) that it’s essentially impossible to completely control for all of them to obtain high-quality data. he two cited articles represent this well. Dr. Mediouni, et al., prospectively examined cohorts of patients in France (1,551 patients from a representative sample of the French population) and in the U.S. (711 patients from clerical, service and construction industries) over a three- to ive-year follow-up period. Diagnosis was based on history and exam in the French cohort; and history and Nerve Conduction Studies in the U.S. cohort. he French cohort saw 2.3 percent diagnosed with CTS with an odds ratio (OR) of 0.39 (0.17; 0.89) for the group with the highest exposure to computer use (disc by questionnaire). U.S. cohort had a 4.3 percent rate of new CTS diagnosis, with computer-use exposure estimated by job description. he U.S. cohort OR for CTS in patients with presumed highest computer-use exposure was 0.16 (0.05; 0.59). Dr. Shiri conducted a meta-analysis of six studies (n=4964) comparing computer workers to the general population and six studies (n=5202) comparing computer workers to other oice workers. When compared to the general population, computer or typewriter use actually appeared to be associated with a lower risk of CTS (OR=0.72). However, when only oice workers were analyzed, the opposite was found: computer or typewriter use overall had a higher risk for CTS (OR=1.34). Speciically, mouse use (OR=1.93), frequency of mouse or computer use (OR=1.84 and 1.89, respectively) and number of years of computer work (OR=1.92) were associated with higher rates of CTS, whereas keyboard use was not. One likely explanation: Manual laborers may have a higher rate of CTS than oice workers due to exposure to vibrating machinery and repetitive motion – invalidating the assumption that both groups are at equal risk for CTS at the beginning of the study. While this data is by no means Plastic Surgery Resident | Fall 2017
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Read the Plastic and Reconstructive Surgery Carpal Tunnel Syndrome articles listed at the bottom of page 27 ( Additional Reading ) on the PRS website for free through Dec. 1. Visit the PRS home page at PRSJournal.com; click on Residents; and scroll down until you !nd the Plastic Surgery Resident logo and Carpal Tunnel Syndrome Articles Every Resident Should Read.
satisfaction with symptom relief in the CSI group, compared to 34 percent in the placebo group. At this time, overall good evidence exists that CSI is an efective temporary treatment of CSI, but more data is needed before drawing conclusions regard the long-term results.
7. Splinting vs. surgery in the treatment of carpal tunnel syndrome – A randomized controlled trial Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM / JAMA. 2002;288(10):1245–1251
» his is the irst RCT to provide Level I evidence showing deinitive, this study does show that computer and mouse use may have a positive association with development of CTS symptoms.
6. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial Dammers JW, Veering MM, Vermeulen M. / BMJ (Clinical research ed). 1999;319(7214):884-6
Carpal-tunnel syndrome. Results of a prospective trial of steroid injection and splinting Gelberman RH, Aronson D, Weisman MH / he Journal of Bone and Joint Surgery, American Volume. 1980;62(7):1181-4
» he early evidence comes from the prospective study by Gelberman, et al., of 50 hands in 41 patients. he follow-up was variable from six to 26 months, with only 22 percent of hands free of symptoms at the end of the follow-up period. However, the authors found that patients with mild symptoms (duration one year, normal sensation and strength, and less-pronounced EMG changes) “had the most satisfactory responses to injections and splinting,” as well as a lower rate of relapse compared to the more severely symptomatic patients. More recently, Dammers, et al., conducted a double-blind randomized controlled trial (RCT) that provides some of the best evidence for corticosteroid injection (CSI) treatment of CTS. he authors randomized 60 patients with a history of CTS conirmed by NCS to receive either 10ml of lidocaine or 10ml of lidocaine + 40mg methylprednisone. At one month, 77 percent of the patients in the intervention group had improved vs. only 20 percent in the control group. At this point, the patients in the control group not showing improvement were transferred for non-blinded treatment, thus ending the double-blind RCT. his is the underlying reason why CSI is only considered proven to be superior to placebo until at one month. However, at one year follow up, 15 of the 30 patients randomized to CSI did not need a second treatment (CSI or CTR), compared to only two of the 30 control patients. he control patients that crossed over to receive CSI also showed similar eicacy, with 86 percent showing improvement after CSI. he other Level I study by Armstrong, et al.,9 unblinded the participants at two weeks, and thus also does not give high level evidence for longerterm efect, although they did show 70 percent patient 26
Plastic Surgery Resident | Fall 2017
superiority of surgery vs. conservative treatment (i.e., splinting) for CTS. his was conducted as an intention-totreat study, which is to say that the outcomes were analyzed based on initial treatment assignment, ignoring noncompliance, protocol deviation and crossover. Eighty-seven patients were randomized to the surgery cohort and 89 to the splinting cohort. Only 73 of the 87 patients randomized to the surgical arms underwent surgery, whereas 32 of the 89 patients randomized to the splinting arm underwent surgery later in the study. Patients in the surgery group had a better rate of improvement than the splinting group at three months (80 percent vs 54 percent) and at 18 months (90 percent vs 75 percent). It should be noted that the splinting group analysis at 18 months does include the 32 patients who had received carpal tunnel surgery although they were initially randomized to the non-surgical group. While the methodology may appear complex at irst, it is a validated method of compensating for some of the laws frequently found in RCTs. For further reading, a very concise summary of the intentionto-treat concept is available.10
8. Carpal tunnel syndrome despite negative neurophysiological studies Kitsis CK, Savvidou O, Alam A, Cherry RJ / Acta Orthopaedica Belgica. 2002;68(2):135
Carpal tunnel decompression in spite of normal electromyography Grundberg AB / J Hand Surg Am. 1983;8:348–9
» EMGs are a routine part of peripheral nerve compression workup at most institutions, and are often ordered to obtain insurance preauthorization for surgery. Dr. Grundberg demonstrated in this article that although EMG testing is useful, the surgeon must ultimately rely on his or her exam and judgment, and discount negative study results when they don’t it the clinical picture. He described 26 patients who presented with normal EMG results, yet all had the classic paresthesias and night pain of CTS, with a combination of other positive history and physical exam indings. All patients underwent open carpal tunnel release on the grounds of clinical suspicion of CTS and 30 of 32 hands were “considered to be cured of their carpal tunnel syndrome”, thereby conirming the diagnosis post factum. Kitsis, et al., published a more recent study demonstrating
the same principle. hey examined a group of 125 patients presenting with clinical diagnoses of CTS and normal EMG results. he decision for surgery vs. conservative management was made on a case-by-case basis with no randomization, so there’s a large amount of bias in the study. Ninety-six of 125 patients did undergo surgery, with 90 percent of them having a good or excellent outcome at one year, with only 24 percent of the nonoperative group showing the same results. Although there’s no high-quality data regarding the outcomes in cases where NCS and the clinical presentation are discordant, it does appear at this time that the surgeon’s clinical judgment and exam is the gold standard for CTS diagnosis.
he later articles by Drs. Deune, Mackinnon and Nagle are well-written introductions to the open vs. endoscopic debate that continues to this day. Dr. Nagle cited evidence for both the Agee single-portal and the revised (extra-bursal) Chow two-portal techniques and supported the advantages of both, including faster return to work, less impairment and quicker recovery of grip and pinch strength, improved postoperative pain and lack of a palmar scar. Drs. Deune and MacKinnon conirmed the statistics put forth regarding ECTR leading to less pain in the acute postoperative period and faster return to work, before pointing out that the Workers’ Compensation cohort didn’t seem to demonstrate the drastically reduced time away from work compared to the rest of the patients, obviously raising the question of secondary gain. hey detailed how the narrow viewing ield in ECTR does not allow the surgeon to examine or manipulate any of the carpal tunnel contents and thus predisposes to inadvertent laceration of tendons, nerves and vascular structures, with examples provided. According to the review conducted by Drs. Deune and Mackinnon, the overall rate for laceration of a nerve, tendon or vascular structure is approximately 0.45 percent (16 per 3,204 patients) for ECTR and 0.67 percent (2 per 304 patients) for OCTR.
9. A primer for workers’ compensation Bible JE, Spengler DM, Mir HR / he Spine Journal: Oicial Journal of the North American Spine Society. 2014;14(7):1325-31
» Many patients presenting with hand complaints will have sustained them in the course of their employment, and are thus eligible for treatment and therapy via worker’s compensation. Dr. Bible, et al., outlined the background and basic structure of the Workers’ Compensation system and framed the surgeon’s role in it. Residents will encounter these patients and their case workers in clinic – and this is a short and very worthwhile read to gain familiarity with the process.
More recent evidence has not signiicantly shifted the landscape of this debate. A recent Cochrane review12 found that there appears to be no diference between the techniques in major complications, or short- or long-term eicacy. However, weak evidence exists that ECTR is associated with a lower minor-complication rate (RR 0.55; 95 percent CI 0.38 to 0.81), better grip strength (mean diference of 11 kg; 95 percent CI 6.2 to 18.81), and a faster return to work (mean diference 8.10 days; 95 percent CI -14.28 to -1.92 days). Overall, the quality of the evidence is deemed quite low and thus no strong recommendations can be made at this time.
10. Endoscopic carpal tunnel release using the single proximal incision technique Agee JM, McCarroll HR, North ER / Hand Clinics. 1994;10(4):647-59
Endoscopic carpal tunnel release. he voice of polite dissent Deune EG, Mackinnon SE / Clinics in Plastic Surgery. 1996;23(3):487-505
Endoscopic carpal tunnel release. In favor Nagle DJ / Clinics in Plastic Surgery. 1996;23(3):477-86
» his is an elegant re-introduction of the single-portal technique for endoscopic carpal tunnel release (ECTR), which was revised using a diferent instrument design to allow visualization of the blade’s point-of-entry into the transverse carpal ligament. he salient points include the importance of staying in the extra-synovial plane to allow clear visualization of the TCL; passing the instrument down the ulnar side of the tunnel; hugging the hook of the hamate; and alignment with the ring-inger ray. he indings of Dr. Agee’s 1992 RCT (11) of 122 patients (65 OCTR hands and 82 ECTR hands) were reiterated, with the focus on decreased time until return to work (46.5 vs. 25.0 days), which was even more dramatic (45.5 vs. 16.5 days) once the 21 Workers’ Compensation patients were removed from the analysis. here was also less loss of pinch and grip strength in the ECTR cohort. he technical aspects and pearls of the single-portal ECTR technique are readily available from a number of sources at this point, but this article sets the background for the technique at the time it was introduced.
I would like to thank Jason Ko, MD; homas Wiedrich, MD; and Gregory Dumanian MD; for their mentorship and guidance in compiling this list. Dr. Turin is a PGY-4 plastic surgery resident in the Division of Plastic Surgery at Northwestern Feinberg School of Medicine, Evanston, Ill.
ADDITIONAL READING AND REFERENCES 1.
Hermiz, Steven J., Kalliainen, Loree K. Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome. Plast Reconstr Surg. 2017;140(1):120e-129e.
2.
Wessel, Lauren E., Fufa, Duretti T., Canham, R. Bruce. Outcomes following Peripheral Nerve Decompression with and without Associated Double Crush Syndrome: A Case Control Study. Plast Reconstr Surg. 2017; 139(1):119-127.
3.
Soltani, Ali M., Allan, Bassan J., Best, Matthew J. A Systematic Review of the Literature on the Outcomes of Treatment for Recurrent and Persistent Carpal Tunnel Syndrome. Plast Reconstr Surg. 2013; 132(1):114-121.
4.
Lalonde, Don H. Evidence-based Medicine: Carpal Tunnel Syndrome. Plast Reconstr Surg. 2014;133(5):1234-1240.
continued on page 38 Plastic Surgery Resident | Fall 2017
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he PSF research grants – and the help to secure them – are now available Apply for new or existing grants by Dec. 1
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esidents, take note: ASPS has announced the launch of he PSF 2018 Grants Cycle – and some new programs this year that will ofer valuable opportunities to enhance plastic surgery training. here should be grant programs available for young plastic surgeons in nearly every corner of the specialty. he deadline to submit applications is Dec. 1. Obtain a helping hand with your application by checking out the Foundation’s “Grant Writing Resources,” which can be found in the “Our Grants Program” section under he PSF’s “Research” tab.
he Scott Spear Research Innovation in Breast Reconstruction Fellowship grant was developed and is being ofered this year in memory of ASPS Past President and Georgetown University Hospital Department of Plastic Surgery Department Founding Chair, Scott Spear, MD, in holding with the Spear family’s desire to nurture and grow the training and expertise of young academicians who consider a career in breast reconstruction and patient care. Available to residents and Fellows, this grant provides salary support to undertake a research project under the guidance of an experienced mentor. he application must describe a structured research-training plan for a project focused on breast cancer or breast reconstruction. Funding for this new program comes from the Allergan Foundation. Another program new this year is he PSF Translational Research Grant. he goal of this program is to accelerate the translation of scientiic discoveries and technical developments into practical solutions that improve human health through innovation funding, and to encourage collaborative, transdisciplinary work to accelerate the translation of medical discoveries into improved health. hese seed grants will be awarded in therapeutics, medical technology, diagnostics, population health sciences and community engagement. Examples include (but are not limited to) prototype device development, preclinical studies and pilot clinical studies. Two new scholarship programs are also being ofered: he PSF Graduate Research Scholarship and the Clinical Research Leadership Scholarship. he PSF Graduate Research Scholarship is designed to provide tuition support to a plastic surgeon in his or her pursuit of an advanced degree in research (Master of Science, Epidemiology/Biostatistics, etc.) An award not to exceed $25,000 will be given to an ASPS Candidate member, plastic surgery resident or Fellow ailiated with an accredited plastic surgery program, and who has demonstrated 28
Plastic Surgery Resident | Fall 2017
a commitment to advancing the public health through their pursuit of an advanced research degree (i.e., MPH, MS or PhD). he new he PSF Clinical Research Leadership Scholarship will provide funding to support the participation of plastic surgeon-scientists to attend select clinical research-training and development programs to enhance skills in outcomes, translational or clinical research. Applications will be accepted on a continuous basis and reviewed quarterly. For more details on both of these programs, including applications and guidelines, please visit https://www.thepsf. org/research/psf-grant-funding.htm. he PSF also ofers a Research Fellowship (in addition to the new Spear Fellowship) to provide salary support to residents, in order to aid their development as future researchers; Pilot Grants to provide seed funding to allow investigators to begin work on preliminary research projects related to the plastic surgery sciences; and Combined Pilot Grants that address specialty areas of research supported through collaborations with sister societies, to address specialty areas such as hand surgery, peripheral nerve, maxillofacial, reconstructive microsurgery, education and more. he following are grants programs being ofered by he PSF: • ASE/PSF Combined Research Grant • Combined Pilot Research Grant • Pilot Research Grant • National Endowment for Plastic Surgery Grant • PSF/MTF Allograft Tissue Research Grant • Research Fellowship
GRANT APPLICATION SUBMISSION INFORMATION All applications for he PSF Investigator-Initiated Grant Program must be submitted online by Dec. 1, 2017, through proposalCENTRAL (proposalcentral.altum.com), the online grant management system used by he PSF. Only applications submitted through proposalCENTRAL will be eligible for scientiic review and considered for funding. Funding for awarded projects begins in July 2018. For information on the programs and application process, go to thepsf.org and click on Research followed by “Our Grant Program,” or send e-mail to research@plasticsurgery.org. |
TOP 7
QUESTIONS ASKED BY RESIDENTS AT PLASTIC SURGERY THE MEETING
Q
WHAT’S WITH ALL THOSE RIBBONS ON PEOPLE’S BADGES?
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WHAT DO I WEAR TO PLASTIC SURGERY THE MEETING?
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ARE THERE NETWORKING OPPORTUNITIES FOR RESIDENTS?
[A] Ribbons identify an attendee’s role at the annual meeting or their contribution to he Plastic Surgery Foundation (he PSF) or to PlastyPAC, the Society’s political action committee. hey also represent the special recognition bestowed upon our leadership and honorary members. All residents should receive a “Resident” ribbon when they exchange their ribbon voucher at the ribbon desk, located at Attendee Registration – located on the main loor of the OCCC.
[A] “Business casual attire” is appropriate for PSTM. Please keep in mind that temperature luctuations in convention centers are common, so please dress in layered clothing that can be easily added or removed throughout the OCCC and the hotels.
[A] Yes, Senior Residents are encouraged to attend the SRC Welcome Reception from 6-7:30 p.m. Wednesday, Oct. 4, at the Hilton Orlando Hotel. All residents are invited to the network with peers and members of the ASPS Young Plastic Surgeons Forum at the Residents Networking and Mentorship Reception from 6-7 p.m. hursday, Oct. 5, at the Hilton Orlando Hotel.
One way to network is to watch the Residents Bowl, hosted in the Exhibit Hall of the OCCC.
PSTM REGISTRATION HOURS Orange County Convention Center (OCCC), South Concourse Thursday, Oct. 5 . . . . . 6:30 a.m. – 6 p.m. Friday, Oct. 6 . . . . . . . . 6:30 a.m. – 6 p.m. Saturday, Oct. 7 . . . . . . 6:30 a.m. – 5:30 p.m. Sunday, Oct. 8 . . . . . . . 6:30 a.m. – 5:30 p.m. Monday, Oct. 9 . . . . . . 6:30 a.m. – 5 p.m. Tuesday, Oct. 10 . . . . . 7:30 a.m. – 1 p.m.
The hours are: Saturday, Oct. 7: Opening Round One . . . . . . . . . . . . . . . . Opening Round Two . . . . . . . . . . . . . . . . Sunday, Oct. 8: Second Round . . . . . . . . . . . . . . . . . . . . . Finals . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9:30-11 a.m. 3-4:30 p.m. 9-10:15 a.m 3-4 p.m.
Q
WHO CAN ATTEND RESIDENTS DAY, AND WHAT DO I NEED TO DO?
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HOW DO RESIDENTS GET INTO THE INSTRUCTIONAL COURSES?
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THIS IS REALLY IMPORTANT: WILL COFFEE BE AVAILABLE – IF SO, WHERE?
[A] Residents Day is free to all residents and Fellows; advance registration is required. he program is from 7:30 a.m.-4:30 p.m. Friday, Oct. 6, in S330 A-D, located on Level 3 of the OCCC. Complimentary breakfast will be served from 7-7:30 a.m.; lunch is also included with registration.
[A] Residents who are registered for PSTM may add courses and events to their registration online prior to the start of the meeting; at the On-Site Registration desk located on Level 2; or at the Course Registration kiosk located on Level 2.
[A] Breakfast and lunch are included with the registration for the Senior Residents
Conference on hursday, Oct. 5, and the Residents Day Program on Friday, Oct. 6.
Q
IS REGISTRATION REQUIRED FOR THE SCIENTIFIC SESSIONS?
[A] No, registration is not required for the Scientiic Sessions. All registrants of PSTM have open access to these panel presentations. hese are also often referred to as the General Sessions. General Sessions for 2017 include: Session A – S331 (Level 3); Session B – S330 A-D (Level 3); Session C – S320 A-D (Level 3); Session D – S310 A-D (Level 3). Plastic Surgery Resident | Fall 2017
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Things I wish I had known residency Don’t be afraid to ask for personal time By Henry Hsia, MD
O
n my irst day of internship, I reported to the pediatric ward. My rotation was pediatric surgery, and I would be taking my very irst call as a resident later that evening. I was told pediatric surgery call was fairly brutal, and I’d been warned to brace myself for a long night that would be spent running all over the hospital dealing with sick kids and answering pages for everything from loor nurses calling for a Tylenol order to full trauma alerts in the E.D. I was told not to worry about inding the call room, since I’d probably be too busy to use it. When I began residency, I’d warned family and friends not to expect to see much of me. As a “resident” I expected to literally “reside” in the hospital – and that was ine with me. I wasn’t going to let anything get in the way of becoming a successful plastic surgeon and had prepared myself for the worst.
hen it was my turn to endure a long awkward silence. “But it’s more than six months away!” he inally said. I could feel the disappointment and hurt coming at me through the phone. After an awkward good-bye and hanging up the phone, I spent a long time thinking about how I had messed up that Plastic Surgery Resident | Fall 2017
No problem As bad and guilty as I felt, I was still hesitant to ask for the time of. I was afraid that asking for this just days into my internship would label me as “the resident who was less dedicated than everyone else” and put me on the fast track to nowhere as far as my career was concerned. I inally found the courage to approach my chief resident and told him about my friend’s wedding. Without batting on eye, he responded: “Six months? No problem. We’ll make sure you have that weekend of.”
As a “resident” I expected to literally “reside” in the hospital – and that was fine with me.
Go to a wedding – or to work? Not long after that irst pediatric surgery call (which lived very much up to its reputation), an old friend from college phoned to tell me he was getting married – and that he wanted me to be in his wedding party. After the initial back-and-forth of congratulations and good-natured disbelief, he said to me: “So you’re going to be there, right?” here followed a very long pause from me. I inally reminded him that as the low man on the totem pole in my hospital, I really didn’t know whether I could get the time of – and that he shouldn’t count on me being there.
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conversation. Instead of getting me to join him for one of the biggest moments of his life, my friend instead found out that he couldn’t count on me.
Looking back, I can’t believe that I had been so silly about it all, but it’s easy to lose perspective under the stresses of residency and fall into a “siege” mentality about your own life. In fact, those stresses make maintaining your social supports all the more important and necessary if you’re going to make it through residency and go on to a fulilling career over the long haul.
Keeping priorities straight True, you may need to make adjustments and be more proactive in organizing your personal life, but those eforts are more than worthwhile, if they help you keep your priorities straight during residency. After all, the process of becoming an outstanding and empathetic plastic surgeon is a long one – and it’s important not to spurn the support of the very people who are going to help you successfully inish that marathon. Dr. Hsia is an assistant professor of Surgery and founding director of the Yale Regenerative Wound Healing Center, Yale School of Medicine, New Haven, Conn. |
UPCOMING MEETINGS & SURGICAL TRIPS OCTOBER 10/7/17 10/14/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (317) 581-9569 healthtalents.org
10/14/17 10/22/17 Austin Smiles (Austin, Texas) Guatemala City, Guatemala (512) 451-9300 austinsmiles.org
NOVEMBER 11/11/17 11/18/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (317) 581-9569 healthtalents.org
11/9/17 11/11/17 ABPS Oral Examination Phoenix, Ariz. (215) 587-9322 abplasticsurgery.org
DECEMBER
JANUARY
12/7/17 12/10/17
1/10/18 1/13/18
ASPS Project Well Recharge Retreat La Quinta, Calif. (847) 981-5430 plasticsurgery.org
American Association for Hand Surgery Annual Meeting Fajardo, Puerto Rico (978) 927-8330 meeting.handsurgery.org
12/14/17 12/17/17 1/12/18 1/14/18
Florida Plastic Surgery Forum Palm Beach, Fla. (904) 693-1799 fsps.org/meetings
American Society for Peripheral Nerve Annual Meeting Fajardo, Puerto Rico (978) 927-8330 meeting.peripheralnerve.org
11/17/17 11/19/17 10/22/17 10/30/17 Plasticos Foundation (Newport Beach, Calif.) Cienfuegos, Cuba (949) 572-2942 plasticosfoundation.org
6th ISPRES Congress Dubai, UAE +971 4 4264 240 epsc-ispres2017.com
1/13/18 1/16/18 American Society for Reconstructive Microsurgery Annual Meeting Las Corabas, Puerto Rico (312) 456-9579 microsurg.org
11/30/17 12/3/17 15th IFATS Meeting Miami, Fla. (603) 643-2325 ifats.org
1/18/18 1/21/18 34th Annual Atlanta Breast Surgery Symposia Atlanta, Ga. (439) 901-2544 sesprs.org
1/20/18 1/27/18 Bridges of Hope International (Fishers, Ind.) Cartegena, Columbia (317) 581-9569 bridgesof hopeinternational. org
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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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PRS Resident Reader: Quick and comprehensive access to the articles you need right now By James Vargo, MD, and Jacob Grow, MD
#TheTrend #TheTrend is a column new to the pages of Plastic Surgery Resident. Plastic surgery residents Jacob Grow, MD, and James Vargo, MD, are “tekkies” who are immersed in trending resources and tech (apps, websites, etc.) available to the plastic surgery community. Through #TheTrend, they will endeavor to spotlight resources with the highest value and greatest potential to plastic surgery residents, that they can help protect a resident’s most valuable commodity: time. These reviews will be specific to plastic surgery – and unbiased, as the authors are free from financial disclosures... “unfortunately,” they say. |
Much to our surprise, #heTrend has been allowed back for its second installment. “Winter is coming,” and it’s the time of year when plastic surgery residents realize they’ve been spending more time watching Game of hrones than doing their “nightly reading.” For those who’ve kept the faith or are looking to get back to the grind, inding a single digital resource to help dig into a speciic topic can be daunting. We’ve all searched high and low on YouTube for quality surgical-technique videos, only to get stuck watching something narrated in French and seemingly ilmed by the same guy who shot he Blair Witch Project. Similarly, when searching for a quality CME article, PubMed is sometimes too broad, making a seminal paper harder to ind than xeroform on a medicine loor. If you’re looking for a source to remedy these frustrations, we’ve found a solution. Enter the PRS Resident Reader, part and parcel of the PRS Residents’ Gateway, at prsjournal.com. E- section just for trainees Resident Reader is a digital resource available through the Plastic and Reconstructive Surgery journal website – in a section created for current trainees called the Residents’ Gateway. his portal was designed and compiled by residents for residents. Main categories (Breast, Cosmetic Face, Cosmetic Breast, Cosmetic Body, Hand, Craniofacial, Reconstruction and Burn) are organized into relevant subcategories (Blepharoplasty, Rhinoplasty, Facelift, etc.) for easy navigation.
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Within each topic, users are presented a variety of high-yield articles and multimedia resources from within PRS. All journal articles are either seminal papers that every resident should read; evidence-based discussions by a master in that ield; or a CME article. his conveniently distills the massive volume of PRS publications into quintessential articles that provide a solid framework for further study. Additionally, a robust video archive has been compiled for each topic and includes keynote discussions, preoperative patient markings, intraoperative surgical techniques and/or conference lectures. his multimedia library is a “holy grail” of sorts, as high-quality, peer-reviewed video databases are almost non-existent in our highly visual ield – save perhaps the Plastic Surgery Education Network (PSENetwork.org). Great features Residents’ Gateway has many other great features. “PRS Resident Chronicles” is an award-winning, resident-produced and resident-edited blog site that encompasses just about everything – from posts about surviving the grind of residency to commentaries on hot-button topics within the ield. he Gateway also links to PRS Journal Club videos, the esteemed Plastic Surgery Resident magazine, PRS Grand Rounds and others.
PROGRAM PEEK / continued from page 17
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In our opinion, the PRS Residents’ Gateway and Resident Reader are an invaluable resource for case preparation, advancing knowledge on high-yield topics, and stepping into the massive world of peerreviewed articles. It serves both interns who are looking to identify the most clear and comprehensive review articles on major topics, as well as chief residents who are seeking a launch point for their literature review and critique of facelifting techniques. In addition, the video library attached to each topic truly solidiies the website as a resident favorite. Resources will be updated on a biennial basis to keep content relevant. Keep it coming, PRS! Our critiques are limited, but it would be great to continue to see the content grow and update over time. It should also be noted that only content from PRS is included, so if you’re searching for manuscripts published in other journals, you’ll need to look elsewhere. Overall, the combination of high-yield PRS articles and a large, peer-reviewed video library irmly places Resident Reader atop the “iron throne” of plastic surgery resident resources.
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MD), heterotopic ossiication (Ben Levi, MD) and regenerative peripheral nerve interfaces for neuroma treatment and control of prosthetic limbs (Paul S. Cederna, MD) hree federally funded outcomes/health services researchers (Kevin C. Chung, MD; Jennifer F. Waljee, MD; and Edwin G. Wilkins, MD) with projects on distal radius fracture treatment in the elderly; outcomes in rheumatoid hand; opioid-prescribing patterns in hand and plastic surgery; and outcomes in breast reconstruction More than 50 active grants Funded academic development time for all residents currently between PGY3 and PGY-4, or between PGY-4 and PGY-5; signiicant lexibility regarding time spent in the lab (1-3 years) depending on career goals, research interests and clinical resident complement Annual Reed O. Dingman Research Symposium in June; all residents PGY-2 and above required to present basic science or outcomes research
Resident Beneits • Membership to the House Oicers Association • Gas reimbursement when traveling ofsite for clinical duties (Livonia Center for Specialty Care) • $200 meal money/month at the University Hospital, C.S. Mott Children’s Hospital and the Frankel Cardiovascular Center • Residents all given $,1500 per academic meeting for three meetings per year, if presenting an abstract • Four weeks of vacation • Night loat resident during the week eliminates overnight call and allows residents assigned to clinical services to read, prep and sleep before cases • Annual resident retreat and monthly steering committees, where tangible change occurs in response to residents’ values and opinions Resident Camaraderie • Annual Plastic Surgery Roast: All residents collaborate on video skits to roast chiefs, attendings and other co-residents, which are then combined into a twohour video screened at Dr. Cederna’s house every June • WIPS (Women in Plastic Surgery): he female residents at Michigan have a long tradition of gathering socially to ofer mutual support throughout training Dr. Bennett is currently in academic development time as a plastic surgery resident PGY-5 at the University of Michigan. She hopes to complete a craniofacial fellowship after training at UM. |
Dr. Grow and Dr. Vargo are both PGY3 residents at the University of Kansas Medical Center, Kansas City. To contact Dr. Grow, submit email to jgrow@ topplasticsurgeryapps.com. |
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PEARLS from the
MASTERS INTERNATIONAL EDITION
COMPLETE A XILL ARY LYMPH NODE DISSECTION By Hans Petter Gullestad, MD
Hans Petter Gullestad, MD, a nestor (mentor) in Norwegian plastic surgery, is known for melanoma treatment and his dedication to quality improvement. He served from 1995-2015 as Chief of Plastic and Reconstructive Surgery at Radiumhospitalet (he Norwegian Cancer Institute) and he’s been involved since 1995 with melanoma treatment. Dr. Gullestad also is a member of the Norwegian Melanoma Council, and he’s spent considerable time abroad to stay abreast with international developments and research in the ield. – Johan Sandberg, MD, PSR International Editor
T
he axilla is a small space with important structures traversing it or outlining its boundaries. It therefore needs to be approached with care.
FIGURE 1
From a surgical point of view, the lymph nodes in the axilla are classiied according to their relationship to the pectoralis minor muscle (Figure 1). Lymph nodes located laterally, or below the lower margin of the pectoralis minor muscle, are classiied as Level 1. Lymph nodes located deep in relation to the pectoralis minor muscle constitute Level 2 nodes. Lymph nodes located medially or superiorly to the upper margin of the pectoralis minor muscle constitute Level 3 nodes. In breast cancer surgery, nodal dissection is a staging procedure and involves only Level 1 and Level 2. In a therapeutic/complete lymph dissection, nodes on all three Levels are to be removed. In the axilla, all nodes are located in the fatty tissue and surrounded by fascia (Figure 2). he axilla is shaped like a pyramid, with the top of the pyramid in the axillary apex. he fascia limitation of the pyramid is the clavipectoral fascia anteriorly; the serratus anterior or deep fascia medially; the axillary fascia inferiorly; and dorsally the fascia covering the latissimus and sub-scapular muscle. he removal of the nodes en bloc, including its fascial linings, is practical and follows oncologic principles. 34
Plastic Surgery Resident | Fall 2017
he clavipectoral fascia is a sheet of tissue that extends from the apex of the axilla, where it’s attached to the clavicle, to the base of the axilla, where it’s continuous with the axillary fascia. It encloses the pectoralis minor muscle. he pectoralis minor muscle is an expendable muscle and its removal allows for a safe en bloc lymph node dissection all the way up to the axillary vessels, brachial plexus and the apex of the axilla.
FIGURE 2
FIGURE 3
All photos and illustrations are courtesy of H Gullestad, MD, and HP Gullestad, MD
PREOPERATIVELY It’s mandatory to inform the patient about the risks and beneits of the procedure, such as seroma, lymphedema and numbness on the inside of the upper arm. General anesthesia with an endotracheal tube is preferable. Muscle relaxation is necessary to obtain proper visualization of the apex of the axilla.
POSITION AND INCISION Place the patient in a supine position on the operating table, with the arm of the afected side abducted to 90 degrees on an upper-extremity board. he arm is prepped to the elbow joint, and the remainder of the arm is sterilely wrapped so it can be manipulated freely in the operating ield. We use a Lazy-S incision from the edge of the pectorals major muscle, transversally crossing the axilla and down to the edge of the latissimus dorsi muscle. his approach allows good access and visibility. he scar is well-hidden and prevents contractures.
OPERATION
muscle are clearly visible. With careful dissection, you can now dissect the anterior surface of the pectoralis minor muscle free from the insertion at the third, fourth and ifth rib up to the coracoid process, and leave the pedicle and innervation of the pectoralis major muscle on the posterior surface of the muscle (Figure 4). It easily dissects of the pectoralis minor. Occasionally, a branch from the pectoralis major nerve may penetrate the pectoralis minor muscle. Dissect it free and you are now ready to divide the pectoralis minor muscle. Pay attention to any fatty tissue between the pectoral muscles; it may harbor additional lymph nodes. Include the fat on the pectoralis minor to ensure a complete en bloc resection. To keep the muscle in position when dividing it, release 2/3 medially, then incise the clavipectoral fascia laterally. he clavipectoral fascia above the pectoralis minor tendon is opened. Put a inger (Figure 5) underneath the tendon to protect the underlying brachial plexus and divide with Bovie using coag setting. continued on Page 37 FIGURE 4
Flaps are raised just below scarpas fascia, one supero-medial and the other latero-inferior, to identify the margins of the axilla. he laps are folded away from the incision and stapled to the skin to provide exposure and traction. he laps are covered with a moist gauze to prevent desiccation. he axillary tissue to be removed borders important motor nerves. By switching between Bovie and bipolar instruments, precision and speed can be accomplished without inducing muscular activity. We now proceed to ix the arm to a sling in an abducted and internally rotated position (Figure 3). his facilitates exposure to the Apex of the axilla and reduces the need for a second assistant. At the same time, rotate the operating table slightly away from you. When the pectoralis major muscle is retracteded, the clavipectoral fascia and the pectoralis minor Plastic Surgery Resident | Fall 2017
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FIGURE 5
and incise its fascia all the way up to the apex of the axilla. Using both medial and lateral dissection, the lymphatic chain can now be divided underneath the edge of the subclavian muscle. Keep the serratus anterior fascia with the specimen and dissect in the plane between the fascia and the thoracic wall. he tissue is now swept downward. At this stage the intercosto-brachial nerve will cross from the chest wall through the axillary fat to supply the skin of the upper axilla and inside of the upper arm. his nerve is sacriiced. With a sponge on a stick and gentle traction, the specimen can now be pulled downward in the axilla.
International Pearls / continued from Page 35 Finally, divide the remaining muscle medially and further divide the clavipectoral fascia up to apex of the axilla. he axilla is now widely exposed. From an oncological point of view, I prefer to dissect the axilla from above and down, disrupting any proximal lymph low irst. his also allows gravity to work to your advantage. With the clavipectoral fascia incised laterally, the fat pad overlying the brachial plexus can be dissected medially and the axillary vein will be exposed. Dissect careful along the vein and ligate carefully all its tributaries up to the subclavian muscle. Approach the serratus anterior from the medial side FIGURE 6-A
Remember that the long thoracic nerve is positioned on the serratus anterior fascia. By including the fascia in the specimen, you are lifting the nerve away from the thoracic wall. However, the nerve can easily be seen through the fascia. Open the fascia, dissect-out the nerve and release it all the way from where it enters the muscle and up underneath the axillary vein. Re-position the nerve onto the thoracic wall/ serratus muscle. When dissecting underneath and laterally along the axillary vein, the thoraco-dorsal nerve and artery will be exposed. Follow these structures laterally until they form a common trunk with the thoraco-dorsal vein. Paying attention to these two nerves, the specimen can now be dissected further down into the groove between the thoracic wall and the lateral subscapular and latissimus dorsi muscle. Preserve the subscapular vessels if possible. Pull the specimen laterally and dissect free all the adjacent tissue around the thoraco-dorsal vessels and nerve, down until just below where it turns into the muscle. Now you can free the specimen from the lateral edge of the latissimus dorsi muscle and remove it en bloc. FIGURE 6-B
In this way, the specimen is removed completely covered with fascia on both sides (Figure 6-A and Figure 6-B). A marking suture is placed at the apex. After meticulous hemostasis, a Jackson Pratt drain is placed, directed toward the top of the axilla. he skin is closed without tension, including scarpas fascia. he closure is performed in two layers. A slight compression can be applied to the dressing. |
Plastic Surgery Resident | Fall 2017
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RESIDENTS CHANGING MEDICINE / continued from page 8 Payment Advisory Board – which seats unelected members who aren’t permitted to actively practice medicine or hold any position that’s directly involved in the delivery of Medicare services – and improving reimbursement for procedures performed at ambulatory surgery centers. (More information is available on these topics at the ASPS website at plasticsurgery.org/for-medical-professionals/advocacy.)
government, issue brieings, talking points and, of course, a comprehensive agenda and itinerary that left no question unanswered and no activity unclear. hose who attend the next Advocacy Summit will, undoubtedly, be privy to the same level of attention and supplies, so “the fear of the unknown” will have no place in residents’ decisions as they contemplate participation amid their busy schedules.
he long-range and cumulative efects of the summit continue to be felt after our return home: An additional two senators and 11 representatives – Democrats and Republicans – have signed-on since the event’s conclusion as cosponsors of either IPAB repeal; the Resident Physician Shortage Reduction Act; the Ambulatory Surgical Center Quality and Access Act; or Protecting Seniors’ Access to Medicare Act.
his is the irst year scholarships were made available to support resident attendance. Twelve scholarships were accessible on a irst-come irst-served basis. Scholarship awardees received complimentary registration, hotel accommodations and meals. (Transportation to Washington, D.C., was not covered.) I’m conident that all 18 resident attendees would agree it was a stimulating and valuable experience – and those who wish to experience a similar sensation should keep an eye out in February 2018 for information about scholarship opportunities for next year’s Advocacy Summit.
‘Advocacy soup’ for the soul Attending the Advocacy Summit was not only an excellent opportunity to become more informed about health policy and network with like-minded physicians, it was a great chance to interact with ASPS leaders. Eighty-two plastic surgeons attended the Washington event – including seven ASPS Executive Board members and 31 physicians who play crucial roles on the ASPS Legislative Advocacy Committee. ASPS provided residents with a solid base of information, including a 55-page Advocacy Summit packet for physicians, replete with position statements, FAQs on several health policy-related programs administered by the federal
Next up he next Advocacy Summit is slated for June 2018. he dates will be conirmed after the congressional calendar is released at the end of November. Whether you want to learn more about speciic health-care policy, physicians’ roles in the legislative process, make a positive impact in health policy or simply get involved in ASPS, take advantage of the next Advocacy Summit. For some, it can be a career-changing – and time-altering – experience.
For more information on the Society’s advocacy priorities, visit plasticsurgery.org/for-medical-professionals/advocacy. Dr. Bourne is a PGY-6 resident in the Department of Plastic Surgery at the University of Pittsburgh Medical Center. Dr. Spiess is the editor of Plastic Surgery Resident and division chief of Hand in the Department of Plastic Surgery at Pitt. |
JOURNAL CLUB / continued from page 27 5.
Hentz, Vincent R., Lalonde, Don H. MOC-PS(SM) CME Article: SelfAssessment and Performance in Practice: he Carpal Tunnel. Plast Reconstr Surg. 2008;121(4):1-10.
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Henry, Steven L., Hubbard, Bradley A., Concannon, Matthew J. Splinting after Carpal Tunnel Release: Current Practice, Scientiic Evidence, and Trends. Plast Reconstr Surg. 2008;122(4):1095-1099.
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Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153-8. Papanicolaou GD, McCabe SJ, Firrell J. he prevalence and characteristics of nerve compression symptoms in the general population. he Journal of Hand Surgery. 2001;26(3):460-6. Joyce CW, Kelly JC, Carroll SM. he 100 top-cited classic papers in hand surgery. J Plast Surg Hand Surg. 2014;48(4):227-33.
10. Eberlin KR, Labow BI, Upton J III, Taghinia AH. High-impact articles in hand surgery. Hand (New York, N.Y.). 2012;7(2):157-62. 11. To P, Atkinson CT, Lee DH, Pappas ND. he most cited articles in hand surgery over the past 20-plus years: a modern-day reading list. he Journal of Hand Surgery. 2013;38(5):983-7.
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12. Poisel S. Ursprung und verlauf des ramus muscularis des nervus digitalis palmaris communis 1 (N. medianus). Chir Praxis. 1974;18:471-4. 13. Ng CY, Talwalkar SC. Clinical images of the recurrent motor branch of the median nerve. he Journal of Hand Surgery, European volume. 2012;37(3):284-5. 14. Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. he carpal tunnel syndrome. A study of carpal canal pressures. he Journal of Bone and Joint Surgery, American volume. 1981;63(3):380-3. 15. Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and efective for short-term management of carpal tunnel syndrome. Muscle & Nerve. 2004;29(1):82-8. 16. Gupta SK. Intention-to-treat concept: A review. Perspectives in Clinical Research. 2011;2(3):109-112. 17. Agee JM, McCarroll HR, Jr., Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. he Journal of Hand Surgery. 1992;17(6):987-95. 18. Vasiliadis H, Georgoulas P, Shrier I, Salanti G, Scholten R. Endoscopic release for carpal tunnel syndrome. Cochrane Database Of Systematic Reviews. 2014(1).
Join PlastyPAC’s Resident’s Club As a member of PlastyPAC s Resident s Club, your one-time contribution of $25 allows us to connect with more members of Congress as we work to advance and protect the specialty and the patients we treat.
As the largest advocacy group for reconstructive and cosmetic surgery, PlastyPAC has a record of ?ghting for plastic surgeons and patients for more than two decades, including: » Protecting patient safety through policies that prevent nonphysicians from performing complex surgical procedures » Ensuring that unquali?ed practitioners cannot advertise in a false or misleading way » Repealing the Independent Payment Advisory Board and/or any other mechanisms that erode transparency and fairness in Medicare payment policy development » Increasing the cap on Medicare-funded graduate medical education (GME) positions and increasing funding for those additional residency slots » Promoting insurance coverage for reconstructive surgical procedures
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