Plastic Surgery News, Summer 2017 by PlasticSurgeryNews

ISSUE 7 | SUMMER 2017

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 in St. Louis ......... p. 22 » Drawing digitally – and artistically ......... p. 30 AMERICAN SOCIETY OF PLASTIC SURGEONS 444 E. ALGONQUIN ROAD ARLINGTON HEIGHTS, IL 60005

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A note from the editor

t’s hard to believe we’re already halfway through 2017! June brings with it some warmer weather and, of course, another edition of Plastic Surgery Resident. In this edition, we bring you fresh submissions of InService Insight, Consult Corner, PSR Journal Club and the PSR Crossword. Our international footprint continues to expand, with two new submissions in this edition – including our cover piece, which examines the pursuit of global health electives in plastic surgery, as well as an interesting, inside look into an American fellowship from an Australian perspective.

Alex Spiess, MD Chief Medical Editor Plastic Surgery Resident Pittsburgh

With our Program Peek section, we take great pleasure in highlighting the plastic surgery program at Washington University in St. Louis. It’s an excellent read that pays homage to an elite program. In this installment of Faulty Focus, we head to Ann Arbor, Mich., to meet Jennifer Waljee, MD, and learn about some of her professional accomplishments as faculty at the University of Michigan. Finally, Matt Hanasono, MD, provides a nice overview of the nuances of pursuing a microsurgery fellowship. We continue to solicit content and submissions for our Resident as an Artist (residentart@plasticsurgery.org) and Dear Abbe (dearabbe@plasticsurgery.org) sections. he future ofering of Dear Abbe will be moderated by Ben Chang, MD, at Penn – so submit your questions for Dr. Chang today. Look for responses to those questions in our September (Plastic Surgery he Meeting) edition! We hope that you enjoy the summer edition of Plastic Surgery Resident. As always, I would like to thank our physician editorial board and our production staf at ASPS. We hope that you enjoy the issue – and look for us again in September for our fall annual meeting edition. |

Plastic Surgery Resident | Summer 2017

Table of

Contents Going global ................................... 6

Plastic Surgery Resident | Summer 2017 | Vol.1 No.7

Three plastic surgeons discuss unexpected gifts derived from international electives.

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.

Things I wish I knew when I was a plastic surgery resident .............. 10

Debra Johnson, MD | johnson@pscmail.com

Consult Corner: Eyelid laceration .......................... 12

ASSOCI ATE EDITORS

Function, anatomy and aesthetics are inseparable when treating this facial trauma.

Crossword .....................................15 Challenge your plastic surgery vocabulary.

Faculty Focus: Jennifer Waljee, MD .................... 16

EDITOR

Alex Spiess, MD | amspiess@msn.com 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

Assistant professor of plastic, reconstructive surgery at U-M, Ann Arbor, discusses her mentors, passion and personal balance.

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

Reconstructive microsurgery ..... 18

Mike Stokes | mstokes@plasticsurgery.org

Matthew Hanasono, MD, answers three questions that may alter your career arc.

Paul Snyder | psnyder@plasticsurgery.org

An Australian on a U.S. fellowship gets more than she expected ..... 21 Sydney Ch’ng, MD, arrived in Texas unsure of how her “bold and daring” move would end.

Michael Costelloe | mcostelloe@plasticsurgery.org SENIOR DIR ECTOR OF COMMU NICATIONS M A NAGING EDITOR SEN IOR GR A PH IC DE SIGN ER

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

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

Program Peek: Washington University ............... 22

Jim Leonardo | jleonardo@plasticsurgery.org

A close look at plastic surgery residency training at this St. Louis teaching institution.

Kendra Y. Mims | kmims@plasticsurgery.org

Journal Club ................................ 24

Connor Winther, Wolters Kluwer Health (215) 521-8797

Ten articles on mandible fractures (plus a bonus), for a headstart on the most common reason for surgery in facial skeletal trauma.

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.

InService Insights ....................... 28 Though the incidence of bone tumors of the hand is low, their identification still will be addressed in the annual In-Service exam.

Oral and Written Board Exam ... 29 Highly rated and interactive, comprehensive prep course will be held Aug. 17-19.

Illustrating on a ‘tablet’ ............... 30 James Vargo, MD, uses digital artistry to create vivid bone, soft tissue and more. 4

A SPS PR E SI DEN T

Devra Becker, MD, details the mindset residents should embrace as they prepare for an upcoming case.

Plastic Surgery Resident | Summer 2017

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

POSTMASTER: Send address changes to Plastic Surgery Resident c/o ASPS Membership Department 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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PERSPECTIVES ON INTERNATIONAL ELECTIVES

TRAVELING THE GLOBE LOBE TO ENRICH THE PLASTIC SURGERY URGERY EDUCATION N RIENCE R IENCE BY DEANA SHENAQ, MD

ross-cultural competency is an increasingly important tenet of surgical education in today’s global landscape. Many plastic surgery training programs ofer opportunities for residents to pursue international experiences, whether in the form of a formal clinical elective or as part of a mission trip. hese global experiences foster a greater understanding of diferent health-care systems and promote intercultural exchange of ideas and philosophies. hey may also allow clinical exposure to an area of plastic surgery that might not otherwise be possible at one’s home institution. International electives can also be rooted in volunteerism. Plastic surgery as a specialty has a historically strong tradition of international service, and various programs are currently available to residents interested in participating in global mission trips with established organizations (including ReSurge International – formally Interplast – and the Operational Smile Regan Fellowship). Operating in a setting with fewer resources can encourage the development of systems-based skills and foster an appreciation of our own health-care system. Diverse opportunities exist for plastic surgery training abroad; however, arranging these international experiences as a resident can be diicult or daunting. In order to provide difering perspectives on the global-elective experience and bring awareness to international elective opportunities, Plastic Surgery Resident spoke with three former plastic

Plastic Surgery Resident | Summer 2017

surgery residents about their time rotating abroad during their inal year of training. he following is a loosely edited transcript of those conversations. Rebecca Garza, MD, who completed the Stanford University (Calif.) Integrated Plastic & Reconstructive Surgery Program in 2016, is a microsurgery Fellow at he University of Chicago. Anaeze Ofodile, MD, is a 2016 graduate of the Lahey Clinic Plastic & Reconstructive Surgery Residency in Burlington, Mass. He’s completing a Master of Public Health degree in Health Policy and Systems at Johns Hopkins Bloomberg School of Public Health, and he will begin a microsurgery fellowship at MD Anderson Cancer Center in July. Lee Alkureishi, MD, began his residency training in Glasgow, Scotland, and graduated from he University of Chicago Plastic & Reconstructive Surgery Program in 2015. He recently completed a fellowship in Pediatric Craniofacial Surgery at Northshore University and Shriner’s Hospitals, Chicago.

>> WHERE DID YOU GO FOR YOUR ELECTIVE AND HOW DID YOU SET IT UP? Dr. Garza: I went to he University of Tokyo Hospital and visited Isao Koshima, MD, in the Department of Plastic, Reconstructive and Aesthetic Surgery. What brought me there was my interest in observing a large amount of

supermicrosurgery and lymphedema surgery. he University of Tokyo is known for excellence in clinical plastic surgery and research, and I had particular interest in meeting Dr. Koshima after he came to Stanford University as a visiting professor. During his visit, Dr. Koshima performed a cadaver dissection with a focus on perforator laps – and he shared with us some of the multitude of his cases. hat was my introduction to supermicrosurgery – and I was interested in learning more. he elective was funded by my residency program as part of the Stanford microsurgery curriculum. As residents, we were able to spend one to two weeks at an international center that specialized in microsurgery or supermicrosurgery. While in Tokyo, I stayed in a hotel in Shinjuku and traveled to the hospital (located in the Bunkyo-ku ward) by subway. Dr. Ofodile: I went to Taiwan (Chang Gung Memorial Hospital) and Asuncion-Paraguay (Operation Smile mission trip) in September and October 2015 for six weeks total. Lifei Guo, MD, my department chief at Lahey, helped to facilitate the Chang Gung experience, which was largely self-funded (travel, lodging, meals). Dormitory-style accommodations on the medical campus in Linkou are provided to visiting observers, but I chose to live in Taipei and to commute.

world-class, high-volume center for complex reconstruction. Its didactic curriculum (journal club, grand rounds, morbidity and mortality conference), renowned faculty and established history of hosting international observers as well as clinical Fellows, were obvious draws. he Operation Smile placement in Paraguay presented a valuable opportunity for surgical volunteerism and humanitarian work – and the clinical insights that I gained, in conjunction with a renewed perspective on life and career, will certainly stay with me for a very long time. Dr. Alkureishi: I traveled to Mexico City for one month and rotated at Hospital General Dr. Manuel Gea González at the program built by Ortiz Monasterio, MD. Most of my time was spent with Eric Santamaría, MD, at the main hospital, but I also traveled to his private clinic and a few private hospitals throughout Mexico City and the suburbs. I was introduced to Dr. Santamaría by our program director, who knew him through the American Society of Reconstructive Microsurgeons. Our residency program ofers a one-month elective in the chief year – and my goal was to go abroad to improve my medical Spanish. he residency program reimbursed part of my travel and housing expenses, with the remainder being self-funded. In terms of lodging, Dr. Santamaría recommended hotels close to the main hospital, but these turned out to be quite costly; I opted for a cheaper option further away.

>> WHAT WERE SOME THINGS THAT YOU WERE EXPOSED TO OVERSEAS THAT YOU FELT YOU DIDN’T GET DURING RESIDENCY TRAINING?

Dr. Garza (center) with Isao Koshima, MD (right), and a plastic and reconstructive surgery resident at he University of Tokyo Hospitals.

I also applied to the Resident Leadership Program in Operation Smile, which is completely underwritten by Stryker Corp. (travel, room/board, transportation). My subsequent placement in Paraguay (a truly wonderful experience) was almost entirely due to the availability of a mission trip during my elective rotation block. I chose Taiwan because the Chang Gung Memorial Hospital Department of Plastic Surgery is universally regarded as a

Dr. Garza: I observed unique cases in the treatment of lymphedema – including lymphovenous bypass performed in the extremities and also intra-abdominally. In addition to lymphedema treatment, I was able to witness a whole range of microsurgery, including genital, breast, and head and neck reconstruction. Observing patients undergo supermicrosurgery during lymphovenous bypass procedures fully awake was interesting – as was learning about the training program and plastic surgery in Tokyo.

Dr. Ofodile: he breadth of clinical pathology (intra-oral malignancies in Taiwan and untreated cleft deformities in Paraguay) is the irst thing that comes to mind. Additionally, the operational aspects and culture around surgical-care delivery in both environments were refreshing to see irsthand and learn from, lending credence to the age-old saying “here are many ways to do same thing.”

Plastic Surgery Resident | Summer 2017

PERSPECTIVES ON INTERNATIONAL ELECTIVES Dr. Alkureishi: he main thing I took from the elective was getting a lavor for how things work in another country and health-care system. I had the opportunity to work with fantastic Mexican surgeons, particularly Dr. Santamaría and Alexander Cardenas, MD. Observing the similarities and diferences in their residency training, as well as the diferent hospital systems, was very beneicial. When I started my medical training in Glasgow, the program would not allow residents to graduate until they had spent at least six months (usually a year) elsewhere to broaden their educational experience. I totally agree with that philosophy.

Wednesday morning; and outpatient clinic was held on Friday. On most O.R. days, I saw one microsurgery case (from incision to closure – or, at the very least, lap inset) but occasionally I moved about multiple rooms to get a feel for the variety of complex wounds and the reconstructive approaches in place. here were ample opportunities to scrub in, but instead I chose to take photos and make notes. By design, the bulk of my exposure entailed free-tissue transfer. Case examples included osteoseptocutaneous free ibula laps for composite mandible defects; ALT for loor of mouth defects; medial sural-artery perforator lap for total nasal reconstruction; and a free gracilis transfer for traumatic brachial plexus injury.

>> WHAT WAS YOUR SCHEDULE LIKE, AND WHAT TYPES OF CASES WHERE YOU EXPOSED TO?

In Paraguay, the entire Operation Smile team of surgeons, anesthesiologists, pediatricians, nurses and I spent the irst two days after arrival evaluating patients (approximately 260 total) in preoperative clinic. he remainder of the work week was spent in the O.R. Days were long but incredibly fulilling, and they often were bookended by team meals. I participated in roughly 30 cases – the bulk of which were primary cleft lips (bilateral and unilateral) and revision palates (istulas, pharyngeal laps for VPI).

Dr. Garza: I was on hand for several surgical cases almost every day during the week. Following the O.R., I attended educational conferences that mostly focused on case discussions. One day per week was dedicated to clinic, where I was able to see patients in follow-up who had undergone lymphedema surgery. In the evening after clinic, we attended a journal club and took ward rounds, where we saw both pre- and postoperative patients. he preoperative patients underwent ICG imaging, and surgical plans were formulated. I was able to observe lymphovenous bypass with several bypasses done simultaneously; vascularized lymphnode transfer; breast reconstruction with DIEP laps; lowerextremity reconstruction with SCIP laps; head and neck reconstruction; and several lap revisions. Dr. Ofodile: Typically, each Tuesday morning in Taiwan a journal club was held; faculty lectures were delivered

Dr. Alkureishi: I was given free rein to choose which cases I wanted to be involved with, with any of the attendings in the program. here were generally three O.R.s running everyday, and I had the choice of scrubbing the cases, or going back and forth between rooms. he elective was very much geared toward making sure I had the best, individualized experience possible. One-and-a-half days per week were spent in Dr. Santamaría’s private oice/clinic, seeing a mix of new and established patients.

>> WHAT WAS THE BEST PART OF THE ELECTIVE? Dr. Garza: he department surgeons and staf were very welcoming, and they involved me in their daily rounds, educational conferences and surgical cases. he service was busy, and I was able to see quite a bit in my limited time there. What I gained most was an appreciation for innovation through surgical techniques. It’s an exciting place – and it made me feel like a part of the international microsurgery community.

Dr. Ofodile (center) enjoys lunch with Fu Chan Wei, MD (left), and one of the residents at Chang Gung Memorial Hospital at a restaurant in Tapei, Taiwan.

Plastic Surgery Resident | Summer 2017

Dr. Ofodile: he best part for me was the ability to expand my professional and social network, international travel and the concomitant cultural immersion that comes with it. Both Taiwan and Paraguay were uniquely beautiful places to visit and work.

Dr. Alkureishi: he best part was interacting with the trainees at Hospital Manuel Gea Gonzalez every day. he residents of the program are among the best in the country, and the program consistently turns out world-class surgeons. hey welcomed me into their program from the irst day and went out of their way to make sure I was having a great experience. In particular, Dr. Santamaría’s microsurgery Fellows – Jonathan Figueroa, MD, and Diana Correa Bernal, MD – pretty much ferried me around for the entire month. hey also were great to work and socialize with.

>> WHAT WERE YOUR FAVORITE SOCIAL ACTIVITIES? Dr. Garza: he University of Tokyo has a beautiful campus, and the hospital is situated within the university gates. I spent my evenings and the weekend exploring Tokyo. he city is Dr. Alkureishi (center, right) with Dr. Santamaría and his team in Mexico City. expansive, and there are many diferent districts to visit. I enjoyed delicious Japanese cuisine, >> WHAT ADVICE DO YOU HAVE FOR OTHER RESIDENTS shopping in Ginza and Omotesando, and visiting the Meiji TRYING TO SET UP INTERNATIONAL ELECTIVES? Shrine and Imperial Palace. You can easily access all parts of the city by subway – and just walking around Shinjuku, Dr. Garza: Be sure to immerse yourself in the experience, Akihabara and Harajuku at night was amazing. I also made and spend time with the trainees to get a real sense of the it to the Tsukiji ish market very early Saturday morning for program. Make sure your visit coincides with a time that’s breakfast. If I had more time, I would have visited more Tokyo clinically busy. neighborhoods and some of the nearby regions by train. Dr. Ofodile: Start early – and have a contingency plan Dr. Ofodile: Taipei is a major cosmopolitan city, so the (domestic and international) for your elective experience in social activities were in line with most world capitals – case things fall through. Have clear professional objectives dining, arts, movies, etc. Unique are the cultural and social for your time (surgical techniques, cultivating a mentor or entities of natural hot springs and “night markets” – they research collaborator). Be respectful of the work culture are not to be missed. Regarding the latter, everyone has a wherever you go, and seek cues from the residents. Most favorite, and mine was the Shilin night market. I also made a importantly, have fun. quick, 90-minute trip to Hong Kong while there. Dr. Alkureishi: If you have the opportunity, go for it! It’s a Asuncion had a fair bit of colonial architecture in the great experience. historic center, which I particularly enjoyed. It’s the capital of Paraguay and had the aforementioned assortment of social activities. My workdays were often longer on the Operation >> ANYTHING ELSE YOU WOULD LIKE TO SHARE? Smile trip, so I barely indulged. he people in both places Dr. Garza: I would encourage all residents to spend time at were welcoming and incredibly friendly. an international program that focuses on an aspect of plastic surgery that’s of particular interest to you. My trip was Dr. Alkureishi: Jonathan and Diana (the microsurgery educational and inspiring – and I’m very grateful to have had Fellows) were more than happy to show me the local this experience during my training. | sights and hang out in the evenings. I tried some fantastic restaurants that were of the beaten path, but my favorite activity was visiting the Museo Nacional de Antropología in Mexico City. It was great to learn more about the history of the city and the country, and all of the cultures that comprise Dr. Shenaq is a PGY-6 plastic and reconstructive surgery resident at he University of Chicago Medicine and Biological Sciences. its makeup.

Plastic Surgery Resident | Summer 2017

Things, secrets and tips I wish I had known residency Methods behind the best resident-case preparation By Devra Becker, MD

y residents often ask me: “How should I prepare for the upcoming case?”

“Prepare,” I respond, “as though I’m going to drop dead at the start of the case – and you will have to inish it.” Traditional surgical teaching is based on bounded freedom – residents are given minor responsibilities in the O.R., and upon successful completion of the task they are given more. Slowly, through the course of years, they progress from closing incisions to independently performing the majority of cases. he challenge of this model is that surgical residents are often passive actors. Residents have been socialized to wait until they are asked to perform a task, and often view being asked to do that task as a reward for correctly answering questions. Often, they fall into a trap of preparing by trying to anticipate the questions they will be asked – rather than by trying to think about the case holistically. he result is a detailed understanding of facts of a case, but a jejune understanding of the entirety of the case arc. he best residents strive to understand the case as if they were the attendings. Get a notebook Get a solid, well-constructed notebook. Make a page for preoperative and perioperative management. Write notes on the appropriate lab studies to order, and the types of studies that need to be reviewed before any surgery. (You may choose to write on the front sides of the pages only, which helps optically when you’re forced to lip through the notebook in search of something speciic. Writing on the backs of the pages can cause bleed-through – and it’s also quite visually “busy” if both facing pages are illed by notes.) If you are doing a breast case, know whether a preoperative mammogram is indicated, follow-up on whether it’s been done and note what the results are. Know the current recommendations for pre-op laboratory studies, and deepvenous thrombosis prophylaxis. Go through your own checklist for each patient of what should be done and whether it has been done. Never assume the attending surgeon has done it. 10

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Discuss which journal articles and book chapters the attending thinks are useful before the case he attending was once where you are now. He or she has insight into which material is the most useful to know. he key here, however, is to start the discussion with some ideas of your own. he resident who says, “I was planning on reading Green’s Operative Hand Surgery and the 2012 Plastic and Reconstructive Surgery review article for this case. Do you have any other suggestions?” leaves a very diferent impression than the resident who says “What should I do to prepare for this case?” Create a running, annotated bibliography in your notebook. Write down the steps for every case Synthesize information on the operative steps that you’ve gleaned from textbooks, journal articles and old operative notes – and write down, in excruciating detail, the steps of the case. Be as speciic as possible. he operative steps should read like a detailed recipe; imagine that the O.R. will set up the case using only the information in your operative steps, and pull only those instruments and sutures that you’ve noted. In my O.R., I encourage the residents to write-out those detailed steps and place photocopies on the wall during the case. I even have them annotate anatomy drawings and put those on the wall. Before the case, I review the steps with them. he circulator and scrub can also see those steps, and it helps them plan. Before every case, I review the case with the operative team. I talk about how long I anticipate each part of the operation will take, what I will need to complete the case and the nuances of the case that may not be on their notes in the pick list. I often write down those steps and what I will need on the white board in the O.R.; this helps the circulators and scrub nurses plan, and it makes team changes easier. Look at old operative notes Compare your notes with operative notes from prior cases. Ask attendings for a copy of an operative report. his will help deine not only the steps, but also the type of information the attending thought important to dictate. It will help you to understand the low of the case. he more you read operative notes, the better you will become at dictating operative reports, as well. Continued on page 20

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Management of eyelid 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.

Avoiding the squeeze of aesthetics, function and anatomy By Michael Sorkin, MD

acial trauma cases are consistently among the most diicult to prepare for as an intern. Given the complex and critical anatomic features, functional implications and aesthetic ramiications of such injuries, proper initial repair forms the crux of care for patients presenting with such injuries. his article will provide a brief overview of how to initially evaluate and treat eyelid injuries in the E.D.

MESSAGE ON YOUR PAGER: E.D. CALL: STELLATE LACERATION, RIGHT EYELID You are just about to sit down and eat your midnight snack when you receive the following page from the E.D.: “25 y/o male with stellate laceration of the right eyelid after assault, needs plastics closure.” As you hastily inish the snack on the way to the E.D., you contemplate what you’ll encounter when you meet the patient. ANATOMY OF THE EYELID: As with most of plastic surgery, a good understanding of the underlying anatomy is the foundation for a successful reconstruction. he eyelid is a critical anatomical structure that protects the globe – it’s responsible for voluntary and relex mediated blinking, and it prevents desiccation of the cornea by distributing a tear ilm over the eye (Fig. 1). For a better surgical approach, the eyelid can be divided into 12

Plastic Surgery Resident | Summer 2017

anterior and posterior lamellae which are relevant for an anatomically correct repair. • Anterior lamella – Skin – Orbicularis muscle (pretarsal/preseptal) • Posterior lamella – Septum – Retractors/levator – Orbital septum – Tarsus – Palpebral conjunctiva LID MARGIN: he lid margin is 2mm wide and is formed by the palpebral conjunctiva posteriorly that transitions into keratinized epithelium at the mucocutaneous junction. he Meibomian gland oriices are located just anterior to this – followed by the gray line, which is formed by insertions of the muscle of Riolan (pretarsal orbicularis). he lash line forms the anterior border of the lid margin (Fig 1). LACRIMAL SYSTEM he lacrimal system is responsible for constant tear production, distribution and elimination to prevent corneal desiccation. he trilaminar tear ilm is produced by the lacrimal gland and accessory glands. he puncta represent the starting point of the lacrimal drainage system and are located

for evaluating under direct visualization which structures are involved. Furthermore, luorescein staining can help determine whether a corneal injury is present. • If there’s any concern for lacrimal duct injury, probing of the superior and inferior punctum and canalicular system should be performed. his speciically applies to all lacerations medial to the punctum.

Fig. 1: Anatomy of an upper and lower eyelidm (B.M. Zide and G.W. Jelks, Surgical Anatomy of the Orbit, Raven Press, 1985)

5-7 mm lateral to the medial canthal angle. he tears pass through the upper and lower canaliculi which are 8mm long, and travel into the combined ampulla and into the lacrimal sac located in the lacrimal fossa. From there, the tear ilm drains through the nasolacrimal duct into the inferior meatus of the nasal cavity (Fig. 2). PERTINENT HISTORY AND EXAM • As with any patient seen in the E.D., it’s important to obtain a focused history. Relevant medical problems, prior surgeries, medications, smoking status, mechanism of injury (blunt vs. penetrating trauma), vision changes (blurry vision, double vision), wearing glasses or contacts, etc., can all contribute to making the correct diagnosis.

Tip: Lacrimal probes come in diferent sizes. It should be inserted perpendicular to the lid margin for 1-2 mm, then a sharp turn medially while retracting/pulling the eyelid laterally and slowly advancing the probe until bone of the lacrimal fossa is felt as a “hard stop.” A “soft stop” may indicate that soft tissue is trapped; forcefully advancing the probe may result in further injury. If the probe does not advance or becomes visible within the laceration, then a canalicular laceration is present and requires repair over silastic tubing (see below). ANESTHESIA AND PREP When performing procedures around the eye, it’s critical to achieve excellent anesthesia and patient comfort, as any sudden movements in response to pain may not only interfere with the attempted repair, it also could result in an iatrogenic injury. For smaller lacerations, a local ield-block or targeted nerve-block may be suicient – while more complex lacerations requiring a canalicular exploration may best be done under general anesthesia. Keep in mind that many patients will still feel tarsal sutures despite local anesthesia. If performing the laceration repair under local, Tetracaine eye drops may be helpful for corneal anesthesia. A 1:1 Betadine ophthalmic (Betadine 5%) should be used to prep the site and to rinse the wound.

• When evaluating patients in the E.D., it’s tempting to focus on the presenting laceration. However, performing a systematic trauma exam is critical, in order not to miss any associated injuries that may not be apparent on initial exam. • A detailed ocular exam should include visual acuity, extraocular muscle movement, pupil reactivity and overall assessment for traumatic globe indings including hyphema and retinal detachment. If there is any concern for globe injury, ophthalmology should be consulted and treatment of these injuries prioritized. • A slit lamp exam, if available, can be very helpful in evaluating the laceration under magniication and

Fig. 2: Lacrimal system anatomy (Gray’s Anatomy, 40th Edition)

Plastic Surgery Resident | Summer 2017

be required – especially in pediatric cases. Injecting the upper or lower intact canaliculus with luid or dye (methylene blue) may assist in identifying the proximal cut end. First, the lacrimal probe should be advanced though the punctum, both ends of the canaliculus and into the lacrimal fossa, in order to ensure free passage with a “hard stop.” A punctal dilator can now be used to widen the punctum and allow for the silastic tube to be threaded through. Fig. 3: Schematic of an eyelid margin repair (Nelson, Management of Eyelid Trauma, Australian and New Zealand Journal of Ophthalmology, 1991)

PROCEDURAL PRINCIPLES Facial tissues are privileged with regard to blood perfusion, and only minimal and absolutely necessary debridement should be performed in order to preserve eyelid tissue. he wound should be thoroughly clean of all dirt and foreign bodies to avoid dermal tattooing. Simple lacerations not involving the lid margin should be repaired in layers. Careful approximation of the tarsus, orbicularis muscle and skin should always be attempted to achieve optimal results. Meticulous technique with closure under no tension will help to avoid complications. If needed, careful undermining and myocutaneous lap advancement can achieve primary closure in smaller avulsions. LID MARGIN REPAIR: Repair of the lid margin is accomplished with a vertical mattress suture of 6-0 silk on a cutting needle in a “nearnear-far-far” fashion (Fig. 3). he suture is placed along the grey line anterior to the Meibomian glands, 2-4 mm away from the cut edge and 2-4 mm deep. Avoid posterior placement, as this may violate the tarsal conjunctiva and irritate the cornea. Good apposition with slight margin elevation should be the goal and shelving should be avoided. Next, a simple interrupted suture is placed more anterior just along the lash line, and the tails of the vertical mattress suture are incorporated and directed anteriorly as to avoid corneal irritation. Now additional buried sutures of 6-0 silk can be placed in tarsus, followed by 6-0 silk or monoilament for skin. CANALICULAR REPAIR: If a canalicular laceration is identiied, repair should not be delayed more than 24-48 hours, as edema and scar formation make it more diicult to ind the proximal cut end. Repairing a canaliculus may be quite challenging, and assistance of loop magniication or even an operative microscope may

Plastic Surgery Resident | Summer 2017

Once the silastic tube is passed, the canalicular ends should be approximated with interrupted sutures of 7-0 Vicryl if technically feasible. Either monocanalicular or bicanallicular (Crawford) stents are commonly used and remain in place for three to six months. RECONSTRUCTION OF COMPLEX INJURIES: Complex injuries of the eyelid often result in signiicant tissue loss that cannot be easily repaired in a primary closure. he management of these injuries will frequently require a morecomplex reconstructive approach that includes local skin laps and skin grafts. While a detailed discussion is beyond the scope of this article, some elements may be useful to the evaluating resident. A primary closure of a lid margin avulsion is commonly possible in defects up to 25 percent of the lid width. Further tissue can be recruited through the use of a Tenzel lap or lateral canthotomies to provide more laxity. For larger defects, it’s critical to reconstruct the posterior and anterior lamellae of the eyelid. Required tissue can often be borrowed from the unafected eyelid (Hughes lap and Cutler-Beard lap). Full-thickness skin grafts harvested from the auricular region can be useful to provide coverage of the anterior lamella, while auricular cartilage grafts can provide support if tarsal plate is missing. CONCLUSION Evaluating facial trauma patients in the E.D. in the middle of the night always generated a high level of “sphincter tone” during my irst year as the consult resident. Aside complex aspects of anatomy that are not easily understood, the implications of a poor laceration repair or missed skeletal injury can have signiicant efects on the patient’s outcome. Particularly where injuries to the eyelid are involved, a thorough exam and appropriate treatment of associated lacrimal duct or lid margin injuries can prevent detrimental complications down the road. | Dr. Sorkin is a PGY-4 plastic surgery resident at the University of Michigan.

Put your plastic surgical vocabulary skills to the test! By Nicholas Berlin 1

2 5

7 9

12 13

15 16

17 18 19

ACROSS

1. Level of evidence for case series 2. Widely used to scale responses in survey research 5. Level of evidence for prospective cohort study

8. Cancer Risk After Fat Transfer registry 10. Best approach to reduce bias 12. Number of patients enrolled

DOWN

14. Validated survey to measure patient reported outcomes for breast surgery

1. Graphical display of results from multiple studies

15. Probability of rejecting a false null hypothesis 16. he Venous hromboembolism Prevention study 17. Bias in choosing patients for a study 19. Used to for time to event analyses 20. Variable associated with exposure of interest and is potential cause of outcome 21. hreshold for signiicance

3. Ethical basis for randomized controlled trials 4. Probability of rejecting a true null hypothesis 6. Measure of association in logistic regression 7. Patients with and without an outcome are compared to identify risk factors 9. General Registry of Autologous Fat Transfer 11. When data does not it a normal distribution

23. Probability of assignment to treatment given observed covariates

13. Bias in assessing an outcome of interest 15. Bias when study outcome afects the decision to publish indings

24. Used to detect heterogeneity or publication bias

18. Replacing missing data with substituted values

22. Variable with limited number of possible values

Answer key on page 31

Q&A WITH JENNIFER WALJEE, MD

By Kendra Y. Mims Plastic Surgery Resident aims to provide readers with career advice to help them advance in their profession after residency by sharing insights on how to create their desired career path. In this issue, we present ASPS member Jennifer Waljee, MD, MS, assistant professor in the Section of Plastic and Reconstructive Surgery at the University of Michigan (UM) School of Medicine, Ann Arbor.

PSR: HOW DID YOU PREPARE YOURSELF DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Waljee: I developed an interest in research during residency, and after spending time in the Robert Wood Johnson Clinical Scholars Program, I wanted to be an academic surgeon. With that in mind, I sought-out mentors during residency who had similar career paths and trajectories to what I hoped to achieve, and tried to look for opportunities to accumulate the tools and skills that would be valuable for me in the long-term. PSR: HOW DID YOU CHOOSE YOUR SPECIALTY?

Dr. Waljee received her Bachelor of Science degree in Biology, and earned a Master of Public Health Degree in Epidemiology degree at UM. She completed medical school at Emory University, Atlanta, and returned to the University of Michigan for her surgical training. Dr. Waljee completed her general surgery residency training in 2009 and spent an additional two years completing training in plastic and reconstructive surgery at UM. She completed a fellowship in Hand Surgery and joined the faculty in July 2012. Dr. Waljee is clinically focused on the treatment and reconstruction of upper-extremity conditions and burn injuries. During residency training, she completed a twoyear fellowship through the Robert Wood Johnson Clinical Scholars Program at UM and obtained a Master of Science degree in Health Services Research. Her current research interests include the development and implementation of patient-reported outcomes as quality measures, and understanding variations in care in reconstructive procedures and hand surgery. Dr. Waljee discusses work/life balance, mentorship and her professional journey with PSR.

Plastic Surgery Resident | Summer 2017

Dr. Waljee: In medical school, I really enjoyed my time on my surgery rotations. I didn’t have a lot of exposure to plastic surgery, but knew I wanted to become a surgeon. I was thrilled to match at the University of Michigan in general surgery, and over time I had more exposure to plastic surgery and reconstructive procedures. I really enjoyed the anatomical challenge and the creative approach that plastic surgery ofered, and I had the opportunity to work with fantastic mentors in plastic surgery – including Amy Alderman, MD, and Kevin Chung, MD. When I inished general surgery, I was fortunate to have the opportunity to join the integrated program at the University of Michigan. PSR: WHAT IMPACT HAS YOUR FELLOWSHIP HAD ON THE ADVANCEMENT OF YOUR CAREER? Dr. Waljee: My residency training and fellowship gave me the tools I needed to begin a career in academic practice. I not only received outstanding clinical training, but I also had practical experience in the nuts and bolts of research, including writing manuscripts and grants. Most importantly, my mentors helped instill in me a drive to constantly assess the way we practice and ind opportunities to improve. My training also gave me the perspective to

step back and think about the research questions I wanted to answer and how those answers could provide the greatest impact on our ield. PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Waljee: It’s absolutely critical. I’ve been extremely fortunate to have multiple individuals in my life who have served as mentors in diferent regards. For example, there are those who can counsel you on certain aspects of your clinical practice; of your academic work; and of more mundane issues, such as how to eiciently structure your time and worklow. here may be others you turn to for work/life balance advice, or how to handle challenging situations. My mentors have been critical to my development – and I ind it essential to have a trusted group I can lean on and turn to for advice on a daily basis. PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Waljee: It’s been fantastic to get involved in our professional societies and gain a broader perspective on hand surgery and plastic surgery on a national level. Although we all have diferent practice cultures and stresses, there are many issues that are common to all of us. I really enjoy connecting and collaborating with others who are in a similar place, in terms of years in practice and learning from one another. It’s also been very valuable to meet senior surgeons at other institutions who have served as mentors to me and hear their perspectives on a lifelong career in plastic surgery. PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Waljee: I believe it’s essential to be passionate about plastic surgery. he years in training are short but tremendously busy and stressful. here’s a lot to learn in a short period of time. It’s hard to maintain perspective at times, especially during long hours and challenging cases, but it’s worth it. Keeping your focus on what excites you about plastic surgery will make even the hardest days enjoyable. PSR: WHAT WAS THE BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE IT? Dr. Waljee: Returning to residency after I had my irst child was challenging, and it was hard to ind balance between the demands of residency training, my spouse’s residency training and, of course, the demands of parenting. PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIFE? Dr. Waljee: Every day is diferent. We have two girls, ages 4 and 10, and my husband and I try to coordinate our schedules as much as we can, in order to be there for them. Although it’s gotten easier over time, our girls understand

I really enjoyed the anatomical challenge and the creative approach that plastic surgery ofered, and I had the opportunity to work with fantastic mentors in plastic surgery. we have unpredictable schedules. We try to be there when it counts, like for recitals, games and plays, but they also know there are times when our patients need us as well. I try not to work too much at home when they’re awake, but they do see us preparing for cases and working on research projects. hey understand it’s something we love doing, and all four of us like sharing the stories about our day in the evening when we see each other. here’s never a dull moment! PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Waljee: I love taking care of patients and having the opportunity to work with students, residents and Fellows every day. It’s an absolute privilege. PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Waljee: here are always clinical challenges, which are inherent to plastic surgery, but they keep it interesting and fun. It’s also a challenge to ind enough hours in the day to accomplish everything I want to get done – that’s deinitely the biggest challenge. PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Waljee: I’m very fortunate to work at the University of Michigan, and I have an opportunity to teach and mentor lots of students, residents and Fellows every day, both in and out of the O.R. and clinic. It’s an incredibly rewarding experience – their energy, enthusiasm and desire to learn and care for patients remind me that I have an amazing job every day. PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Waljee: Enjoy every moment, because it goes quickly. PSR: FILL IN THE BLANK: I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN ___ Dr. Waljee: I realized the ininite reconstructive possibilities through constant anatomical principles. | Plastic Surgery Resident | Summer 2017

Pursuing a fellowship in reconstructive microsurgery By Matthew Hanasono, MD

o those of you who are considering a reconstructive microsurgery fellowship, I would like to pose three questions: Why pursue a reconstructive microsurgery fellowship? What do fellowship programs look for in potential Fellows? What should you look for in a fellowship? Consider that microvascular free-tissue transfer is one of the most powerful techniques of any type of surgery. Also consider that microsurgeons aren’t just surgeons who performed microvascular free laps – they’re also experts who perform complex surgeries using pedicled laps, local laps, grafts and implants to treat a very broad range of oncologic, traumatic and congenital reconstructive problems. It’s from this perspective that I endeavor to answer those three, important questions. I must add that the views expressed in this article are entirely my own and don’t necessarily represent the views of all programs – or even my own program. WHY RECONSTRUCTIVE MICROSURGERY? For applicants who’ve trained in a residency program that ofers limited microvascular surgery experience, the reason for doing a reconstructive microsurgery fellowship is obvious: to obtained the knowledge and skills necessary to competently perform free-lap surgery. However, if you’re an applicant who’s trained in a program with substantial microsurgical experience, a microsurgical fellowship can still provide very important experience and details. It can provide greater comfort with microsurgery, thus allowing you to treat more-complex surgical challenges and broaden the range of conditions you feel secure treating. While an inherently talented and self-motivated surgeon can no doubt acquire advanced microvascular skills by themselves in practice – and by less-formal routes, such as course work and observerships – a focused fellowship experience in reconstructive microsurgery will jump-start your practice by years. Moreover, a fellowship will mean to your colleagues and to your patients that you’re not just a plastic surgeon who can do microsurgery – rather, that you’re an expert in microsurgery, even though you may be in the early years of your independent practice. Another reason for pursuing a fellowship in any subspecialty is to develop relationships with faculty who are leaders in the ield and can serve as mentors, even after

Plastic Surgery Resident | Summer 2017

you complete the fellowship. It’s been my great pleasure as a faculty member to stay in contact with many prior Fellows, providing career advice and discussing challenging cases, as well as to enjoy long-term friendships as colleagues. If the fellowship includes a research component, there is the opportunity to develop research skills and publish, which is important if you are planning to pursue an academic career. In some fellowships, there is also a large network of alumni who can be a valuable resource when looking for job opportunities. Occasionally, training at a particular fellowship program may lead to a faculty job there as well. A MATTER OF TRUST First and foremost, fellowship programs look for Fellows that they can trust to take care of their patients. Hard work, reliability, attention to detail and a willingness to put the patient’s needs irst are inarguably the most important qualities required to be a good physician and surgeon. Salvage of failing free laps requires early diagnosis and quick action, so it is absolutely critical that a Fellow is the kind of person who will come in, at the irst sign of lap compromise even in the middle of the night. Following these qualities are an enthusiasm for the ield and a willingness to learn. As in any training situation, fellowship faculty members want to work with Fellows who are open-minded and a joy to teach. In a large fellowship such as the one we have at MD Anderson Cancer Center, which currently has eight to nine Fellows per year, we also look for individuals who will work well together as part of a team.

expertise, that a fellowship program may consider part of their mission. To a large extent, what to look for in a program depends on your future goals and your learning style. Programs difer to some extent on the quantity of microsurgery you will be exposed to, types of surgery you will help perform, and supervision you will receive, as well as other speciics that may be important to some applicants, such as the opportunity to pursue research and on-call responsibilities. KNOW WHAT YOU WANT – AND NEED A given training program may also have speciic faculty who are particularly well known for their surgical or teaching skills that applicants may also take into consideration when choosing a fellowship. Some microsurgery fellowships focus primarily on breast reconstruction or hand reconstruction and the applicant should be aware of this and will need to have his or her career goals in line with this type of practice. In some fellowships, residents may take center stage in the surgery and in the after care, which can be arduous but also an important learning experience. Fellows in such programs are expected to have already mastered the basics of microsurgery and, therefore, may have less opportunity to practice manual skills. Instead, they may be more involved in supervision and teaching of residents.

Hard work, reliability, attention to detail and a willingness to put the patient’s needs first are inarguably the most important qualities required to be a good physician and surgeon.

After these attributes, programs probably difer in what they’re looking for. Many academically oriented programs hope to attract individuals that are speciically interested in pursuing an academic career, with a proven track record of scholarly activity, primarily demonstrated by the presentation and publication of clinical and basic science research. My own desire is to recruit fellows who I believe will become future leaders in our ield in terms of research, teaching, and/or service in our national and international societies, regardless of whether they work in academics or private practice. While there are often many obstacles to overcome related to visa issues, language barriers and diferences in training for foreign nationals, there is also the positive aspect of helping other countries, which may be underserved with respect to microsurgical and advanced reconstructive

PRIOR EXPERIENCE COUNTS

For applicants with less prior microsurgical experience, such fellowships may not be an ideal it. Smaller fellowships may ofer the less experienced applicant closer, more intensive supervision. Larger fellowships may favor applicants who have already had considerable exposure to microsurgery during residency and have a higher degree of sophistication that is necessary to appreciate nuances present in diferent styles of surgical technique, preoperative decision-making and postoperative care practiced by multiple faculty surgeons. Finally, some programs are geared more toward training future academicians, while others train a mix of academic and community practice surgeons and this can often be gleaned from inding out what types of careers past Fellows have followed. | Dr. Hanasono is a professor and Reconstructive Microsurgery Program director at the University of Texas MD Anderson Cancer Center, Houston. Plastic Surgery Resident | Summer 2017

BEFORE RESIDENCY / continued from page 10 Determine what you need to know about the patient to do the operation – and take care of the patient after the case Memorizing the chart is one way to do this. But understanding why you need to know the history will help you remember it in a more meaningful way. A good resident knows that the patient has a history of cancer; a great resident knows that the patient has a history of cancer, and that he or she will consider DVT chemoprophylaxis – due to its efect on the patient’s Caprini score. Operate out loud Great residents talk while they operate. hey announce each step they’re about to perform, and they make explicit the pitfalls they’re trying to avoid. “After I’ve made my skin incision, I’m going to spread the subcutaneous fat with tenotomy scissors to identify and preserve the medial antebrachial cutaneous nerve branches that I expect to ind 1.5cm proximal to the medial epicondyle and 3.5-cm distal to it.” Not only is this reassuring to the attending, but it keeps the resident focused on the case.

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After each case, make epi-surgical notes Epi-surgical notes are indings in the O.R. that anatomy books don’t capture – those medial antebrachial cutaneous nerve branches that were thinner than you expected during the dissection, the tight, trampoline-like feel for the transverse carpal ligament, the shiny tendon compared to the opalescent nerve. It’s the “Wow, that was deeper than I expected,” and the “hose ibers are a deeper purple” of surgery. At some point during your training, an attending or a chief will say in the O.R: “Look at that!” When she or he does, make sure you understand what you are looking at. Ask for clariication. Review the O.R. ‘pick list’ after the case Why wait until you graduate to print-out the pick lists? After each case, look at what the O.R. staf pulled for the case. What was on the card? What did you use? his serves two purposes. First, it provides insight into how the O.R. is preparing for the case, which will help you communicate with the staf in the future. Second, it will help consolidate in your mind what instruments were important. Learn how to properly record important steps Your notebook will become your customized “Operative Techniques” textbook. As you ill the pages with notes and drawings, you will become more prepared for each case, and you will learn to be better prepared for new cases. hose notes of how you stayed out of trouble during the dissection for the cross-facial nerve graft as a PGY-4? hey will help you prepare for your facelift as a PGY-6. Knowing how to write down important steps for the entirety of the case is a skill that can be reined for any case. Soon your notebook will be full. Get a new notebook. |

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Plastic Surgery Resident | Summer 2017

Dr. Becker is the Plastic and Reconstructive Surgery program director at UH Cleveland Medical Center, and associate professor of plastic surgery at CWRU School of Medicine, Cleveland.

When pushing the envelope pays of

An Aussie’s perspective of an American plastic surgery fellowship By Sydney Ch’ng, MD

arrived in Houston for a microsurgery fellowship interview at the MD Anderson Cancer Center in the summer of 2012, and the city was exactly as I had pictured it in my mind – scorching, arid and barren. It didn’t help that the air conditioner in my hotel room (the only room available in the hotel) growled so loudly that it prevented any restful sleep. Plastic surgery training in Australia is long. I had taken time out during training to earn a PhD, and in the 18 months immediately prior to my U.S. arrival, I had also completed two fellowships – 12 months in head-and-neck surgery (Royal Prince Alfred Hospital, Sydney, Australia) and six months in adult craniomaxillofacial trauma (Chang Kung Hospital, Linkou and Keelung, Taiwan). he thought of a third fellowship – in Houston, no less – was therefore not very palatable. However, I knew two plastic surgeons from Sydney who went to MD Anderson for their fellowships (albeit, quite a few years before), and they were highly successful specialists. Admittedly, by then they were better-known as cosmetic than reconstructive plastic surgeons. At some stage, however, when they irst launched their careers, it would have been on the heels of having completed a highly reputable plastic surgery fellowship. With that thought as consolation, I arrived in Houston in July 2012 to commence 12 months of microsurgery fellowship at MD Anderson, alone and semi-depressed. My husband had stayed behind in our new home in Sydney.

Grueling – and worthwhile here were seven of us – keen and competitive Fellows. I wanted my experience there to justify the sacriice I was making. After a few trials, we managed to devise and agree upon a system of allocating microsurgical cases among us. I was used to having more autonomy as a Fellow in Australia – as a head-and-neck surgery Fellow, I had operated unsupervised with the consultant (“attending,” in the United States) being of-site and only nominally in charge. here was a lot more supervision at MD Anderson. he hours were grueling. I remember days where I would inish a free lap and be expected to help with back closures for spinal metastasectomy, and with abdominal wall reconstruction following multiple redo laparotomies. On top of that, we didn’t have in-house residents – so were responsible for completing in-patient drug charts, test orders and discharge summaries! In the last few months of our fellowship (in my opinion), the

seven of us were utterly burned-out. However, it would take me several years at my home institution to accumulate the same breadth of experience I gathered from the large variety of cases I was exposed to during my fellowship year. Daring to be bold Fellowship was a time to be bold and daring, a time of opportunity to challenge and test one’s technical limits under the security of attendings who assumed the ultimate responsibility. I remember the high-stake cases: perforator-toperforator anastomoses, the repair of a perforator that had been inadvertently divided, multiple free laps and the dissection of woody ibrotic necks of severe radionecrosis for recipient vessels. his experience contrasted sharply with that of my irst year as a junior consultant in Sydney only a few months later; my practice was mainstream and conservative, because I was building my reputation. At times, when the going gets tough in the midst of a complex case, I still (now in my fourth year as a consultant) draw strength from the sense of invincibility I had when I was a Fellow: Believe and plough on. Camaraderie forged by ire As the year wore on, real camaraderie developed among the Fellows. We had fun outside work – pedicure and manicure (for some of us), lunches and dinners, the cupcake-baking contest, and traveling together to conferences. he real challenge came toward the end as we tried to secure our irst jobs after fellowship. It was a unique experience, as much in being the person at the center of the process as being the one on the sideline looking at others. I had left Australia with the semi-promise upon my return of a job at Royal Prince Alfred Hospital in Sydney, where I would be jointly appointed to the Plastic Surgery, Head and Neck Surgery, and Melanoma and Surgical Oncology departments. It was my dream job – but until I inally signed the job contract four months after I returned to Australia, I would have the niggling worry that the stars might not align. My co-Fellows had to decide if they would accept appointments at an academic institution or go into private practice. Job interviews could get competitive and stressful – but it worked out for everyone in the end. he friendships that developed continue, long after the fellowship – we continue to share news of promotions, childbirth and weddings, as well as trials and tribulations. Equally, the bonds that formed between my mentors and me have stood the test of time; to this day, they are a source of wisdom and advice. I arrived in Houston as somewhat a reluctant Fellow, but I look back at my time with pride and gratitude. It was an eye-opening introduction to a very diferent health-care system, and it provided me with world-class microsurgery training. he standard of patient care and the expertise to which I was exposed serve as a yardstick against which future standards will be gauged. | Dr. Ch’ng is an associate professor of plastic surgery and associate professor of surgery at the Institute of Academic Surgery, University of Sydney, Australia, Plastic Surgery Resident | Summer 2017

Program Peek In-depth plastic surgery training undergoes continual evolution at Washington University, St. Louis By Dennis Nguyen, MD History

Leadership

• In 1925, plastic surgery pioneer Vilray P. Blair, MD, became the inaugural division chief. Dr. Blair, a pioneer in post-traumatic reconstruction, laid the foundation for the American Board of Plastic Surgery (ABPS)

• Susan E. Mackinnon, MD; Chief & Shoenberg Professor

• James Barrett Brown, MD, succeeded Dr. Blair in 1955. His many contributions included the development of the dermatome for split-thickness skin grafts, as well as cleftcraniofacial reconstructive techniques • Notable trainees include Frank McDowell, MD; Bernard Sarnat, MD; Bradford Cannon, MD; Peter Randall, MD; and Ralph Millard, MD

• Marissa M. Tenenbaum, MD; Program Director & Associate Professor • Keith E. Brandt, MD; Executive Director of the ABPS & William G. Hamm Professor Clinical Experience • Clinical training at Barnes Jewish Hospital (1,365 beds); St. Louis Children’s Hospital (280 beds); West County (77 beds); Christian Northeast (254 beds) • Full breadth and depth of training in aesthetic, breast,

Memorial Sloan Kettering Plastic & Reconstructive Surgical Service Chief and 2017 he PSF Visiting Professor Babak Mehrara, MD (in the back row, center, wearing a black shirt), residents and faculty enjoy a baseball game early in the 2017 season at Busch Stadium, home of the St. Louis Cardinals.

Plastic Surgery Resident | Summer 2017

burn, craniomaxillofacial, general reconstruction, pediatric, peripheral nerve and upper/lower extremity

A message from the program director, Marissa M. Tenenbaum, MD

• 12 full-time faculty • 20 surgical residents across PGY-1 to PGY-6 • Fellowship positions in hand, peripheral nerve, microsurgery, breast and aesthetic surgery • Trainees develop autonomy on resident-run “Ward Service” for hand, general reconstructive and aesthetic surgery Educational curriculum • hree hours of protected time devoted to core curriculum, M&M, Grand Rounds, Hand/Reconstruction/Trauma conference weekly • Monthly journal club organized by residents • Host to annual visiting professors (ASPS, he PSF, ASMS) • Weekly cadaver dissection labs for upper-extremity and craniofacial • Joint hand and upper-extremity conference with Orthopedic Surgery • Biannual injection clinics proctored by Dr. Tenenbaum, and by Terence Myckatyn, MD (director of Aesthetic and Breast Fellowship) • Senior residents and all faculty dedicate two days annually to Mock Oral Boards Research • Continually funded (e.g., NIH, DOD, he PSF, industry) research laboratories in peripheral nerve, breast and pediatric-craniofacial surgery • Optional funded research time • Annual James Barrett Brown Research Day; awards for best basic science and clinical research, judged and presented by prominent visiting professors Resident beneits • Educational funding for national meetings • Each resident is individually paired with a faculty mentor • hree weeks of vacation and ive days of holiday time annually • Moonlighting privileges during research year • Intern “Welcome” BBQ , holiday party and graduation held at faculty homes

hank you for taking the time to learn about the Plastic Surgery Residency Program of the Division of Plastic and Reconstructive Surgery at Washington University in St. Louis. The faculty has worked hard to design a training program with complete, in-depth, didactic presentations and an extensive clinical experience. The program is continuously evaluated and updated to provide cutting-edge training that prepares residents and Fellows to be leaders in specialties of plastic and reconstructive surgery and hand surgery. Barnes-Jewish Hospital is the main teaching hospital for the residency program. U.S. News & World Report consistently includes BarnesJewish on its Honor Roll among the nation’s top hospitals. Barnes-Jewish is a state-of-the-art medical facility, with more than 70 operating rooms running at capacity every day. Outpatient clinics and ambulatory procedures are conducted at the Center for Advanced Medicine, a patient-friendly facility that allows expedited care of ambulatory patients. A significant portion of the training also takes place at St. Louis Children’s Hospital, located on the Barnes-Jewish Hospital and Washington University Medical Center campus. The Plastic Surgery Residency Program is associated with Washington University School of Medicine. The School of Medicine is one of the leading medical research, teaching and patientcare institutions in the nation – and it’s consistently ranked one of the top medical schools by U.S. News & World Report. Approximately 1,200 Washington University faculty members practice at either Barnes-Jewish Hospital or St. Louis Children’s Hospital. The most recent edition of The Best Doctors in America selected more than 390 Washington University faculty members as leading doctors – including approximately half those in the Division of Plastic and Reconstructive Surgery. |

Learn more about us at plasticsurgery.wustl.edu. | Plastic Surgery Resident | Summer 2017

Journal Club; 2017 Summer; (7) GENERAL PRINCIPLES 1. Mandibular osteosynthesis by miniature screwed plates via a buccal approach Champy M, Loddé JP, Schmitt R, et al. / J Maxillofac Surg. 1978;6:14–21

» Perhaps the most classic paper in craniomaxillofacial trauma

JOURNAL ARTICLES ON

MANDIBLE FRACTURES

EVERY PLASTIC SURGERY RESIDENT

SHOULD READ

literature, Champy’s miniplate investigation revolutionized the management of mandible fractures. he study evaluated 183 mandible fractures repaired with 226 miniplates using monocortical juxta-alveolar and sub-apical osteosynthesis, without compression and without intermaxillary ixation via an intraoral approach. Complication rates were considerably lower than previous studies, with malunion occurring at 0.5%, delayed union at 0.5%, and infection in 3.8% of cases. Of note, this method may be applied to all mandible fractures excluding those involving the condyles. he article also provides a detailed discussion of the mechanophysics of the mandible, which led Champy to describe his lines of osteosynthesis. he technical aspects have become a standard by which we practice today, requiring a single, posterior miniplate, or two miniplates anterior to the canines, with two screws over each side of the fracture, ixated along these lines of tension. Not only were the results and complication rates better than any established procedure at the time, the employed technique was easier and could be adopted by a more novice surgeon. his article is a must-read for all plastic surgery residents managing facial trauma, as it provides justiication for using miniplates and details the biomechanics at work in mandible fractures.

2. Fractures of the mandible: a technical perspective Ellis E III, Miles BA / Plast Reconstr Surg. 2007; 120: 76-89

» A personal commentary by the “Michael Jordan” of

By Jacob Grow, MD, and James Vargo, MD

andible fractures are the most common cause for operation in patients sustaining facial skeletal trauma, with more than 75,000 cases reported each year. Despite the high incidence, an evidence-based approach to treating these injuries is not as simple as one might think. Many topics are hotly debated in the literature, including ixation techniques; utility and duration of maxillomandibular ixation (MMF); the role of antibiotics; and management of the pediatric mandible. For plastic surgery residents taking craniomaxillofacial call, understanding the appropriate workup and management of this patient population will have great signiicance. With that in mind, we hope to shed light on these topics and others in this Journal Club installment by highlighting some key “jawdropping” articles in the literature on mandible fractures. 24

Plastic Surgery Resident | Summer 2017

mandible fractures, this article could be more appropriately titled “Fractures of the Mandible: How I Do It – Pearls from the Master.” In a hybrid mix of CME style and selfrealized anecdotes, Dr. Ellis describes his management of mandible fractures beginning with preoperative workup and imaging. His considerations regarding operative technique is the crux of the paper, as he discusses his approach in an algorithmic and logical manner. He includes both simple and comminuted fractures of the body, symphysis and angle, as condylar fractures are addressed in another paper. He does an excellent job detailing diferent methods of ixation as well as when certain techniques may be more appropriate than others. Beyond the intraoperative details, he also highlights the broad picture of repairing mandible fractures from a physiologic perspective, asserting that restoration of occlusion should be the primary goal. His rational is not without academic validity, as he does support his recommendations with current literature. For the young resident with little experience repairing mandible fractures, this is a great article to reference early and often.

SPECIFIC FRACTURE PATTERNS 3. A prospective study of 3 treatment methods for isolated fractures of the mandibular angle Ellis E III / J Oral Maxillofac Surg. 2010;68(11):2743-54.

» his study out of Parkland Hospital is a benchmark for well-designed and controlled-for prospective studies, comparing ixation techniques for isolated fractures of the mandibular angle. 185 patients with isolated angle fractures were treated with sequentially assigned techniques: 1) Non-rigid ixation with ive-six weeks of MMF; 2) non-rigid but functionally stable ixation with a single miniplates and no MMF; 3) rigid ixation with two miniplates and no MMF. Each of the techniques is well described and many variables are controlled for; something lacking in the mostly retrospective pool of literature. Dr. Ellis discusses that he prefers a trans-oral approach with a single 2.0-mm miniplate along the superior border as advocated by Champy (see above article). his is supported by his data, which shows that this method has the greatest ease of use for young surgeons; an equal rate of acceptable occlusion; and a signiicantly lower rate of wound complications relative to rigid ixation. his is interesting in that it’s in contradiction to dogma and prior biomechanical studies that suggest rigid ixation is superior and has fewer complications. Additionally, for cases of infection, Group 2 was superior in that the plate was more easily accessed and amenable to removal in clinic with local anesthesia, compared with under general in an O.R.

4. Treatment of mandibular condylar process fractures: biological considerations Ellis E III, hrockmorton GS / J Oral Maxillofac Surg. 2005;63(1):115-34

» Yet another contribution to the mandibular fracture literature from Dr. Ellis, this commentary attempts to explain the biological adaptations that occur within the masticatory system following condylar fractures. his topic is traditionally fraught with controversy between those advocating for non-operative management and those for open reduction. he three primary approaches include: a period of MMF followed by functional therapy; functional therapy without a period of MMF; open reduction with or without internal ixation. Dr Ellis eloquently walks the reader through TMJ biomechanics; adaptation of articulation following nonsurgical treatment; the requirement or lack thereof for MMF; and a biological basis for ORIF. He concludes that the ability of the jaw to adapt to a speciic fracture pattern should determine how a fracture is managed; unfortunately, sound data does not exist regarding which patterns the body can adapt to, and which it cannot. Second, open treatment of fractures not surprisingly require fewer biomechanical adaptations, but this feature must be weighed against the risk of iatrogenic

injury during the approach, as well as the risk of disrupting vascular supply to the condyle during ixation. Overall, this paper is an excellent resource for functional understanding of condyle fractures; it’s perfect for any resident ready to “take the red pill” from he Matrix and explore the depths of the rabbit hole of mandibular/TMJ biomechanics.

HARDWARE/MMF 5. Supplemental maxillomandibular ixation with miniplate osteosynthesis – required or not? Kumar I, Singh V, Bhagol et al. / J Oral Maxillofac Surg. 2011;15(1):27-30

» his manuscript attempts to address the need for MMF following single monocortical-miniplate ixation. A traditional belief exists that a brief period of MMF provides transient reinforcement of the tension band and allows re-attachment of the soft tissue with the patient held in occlusion. To address this, a retrospective review was performed using two matched groups, one with the use of postoperative MMF for ive days and one without MMF. he groups were then matched with respect to fracture location and plating scheme. he decision to use ive days of MMF was at the discretion of the surgeon. hey included 118 patients with 180 fractures. Results showed that there was no signiicant diference in overall complication rate, postoperative pain, malocclusion or wound infection. his is interesting and initially counterintuitive, as one would think that these rates would be higher in patients treated with MMF. As a result, the study provides rationale for immediate movement in patients plated via a singleminiplate approach.

6. Prospective randomized clinical trial comparing bite force in 2-mm locking plates versus 2-mm standard plates in treatment of mandible fractures Agarwal M, Mohammad S, Sing RK et al. / J Oral Maxillofac Surg. 2011;69(7):1995-2000

» To lock or not to lock? hat is the question addressed in this article from the Journal of Oral and Maxillofacial Surgery. Traditional miniplating systems with non-locking screws are limited by the requirement that plates must be perfectly adapted to underlying bone to prevent alterations in alignment and occlusion. With non-locking screws, the head of the screw compresses the plate against the bone to create stability. Locking screws, however, utilize threads on the screwhead to lock into the plate, which does not require intimate contact between the bone and the plate – thus allowing the plate to serve as an “internal ixator.” he theoretical advantages of locking screws are: less screw-loosening; greater stability across the fracture; lower precision required for plate adaptation; and less alteration in reduction with screw tightening. he pool of biomechanical literature on the stability of locking vs. non-locking is far Plastic Surgery Resident | Summer 2017

from unanimous. his study addressed postoperative bite force by performing a prospective, randomized controlled trial between two groups – one with 2-mm locking titanium miniplate ixation, the other with 2-mm non-locking titanium miniplates ixation. Patients underwent 7-10 days postoperative MMF with elastics. Twenty patients with 34 fractures were included. Results showed no signiicant diference between pain, swelling, infection, paresthesias, hardware failure and fracture segment mobility. hey did ind a signiicant diference in bite force, with the locking-screw group having signiicantly greater bite force at one, three and six weeks, as well as three months. his suggests that locking plates are capable of bearing the masticatory load during osteosynthesis, providing further rationale for their use.

ANTIBIOTICS / INFECTION 7. Use of antibiotics in the treatment of mandible fractures: a systematic review

in the review, subdivided into those with isolated softtissue infection (n=18) and biopsy-proven osteomyelitis (n=26). All patients were treated with a consistent regimen of incision and drainage; tissue and bone culture with sensitivity testing; extraction of non-salvageable teeth; placement of MMF for one week; fracture reduction with bony debridement and decortication; rigid internal ixation of the mandible via an extraoral approach; and antibiotic therapy (PO x1 week for soft tissue alone, 4-6 weeks IV for osteomyelitis). his protocol was successful in all 18 patients (100%) with soft tissue infection and 24 of 26 (92%) patients with osteomyelitis, for an overall success rate of 95%. his data also provides evidence that the traditional, draconian approach of prolonged MMF in infected patients is unnecessary. he detail provided in the paper makes the approach highly reproducible, saving health-care costs by reducing unnecessary returns to the O.R. for delayed ixation. Overall, it sets a new standard for management of mandible fractures in the setting of infection.

Kyzas, PA / J Oral Maxillofac Surg. 2011; 69:1129-1145

» he mother of all mandible-fracture systematic reviews, this article attempts to inally put to rest the question of antibiotic use in this patient population. hirty-one studies were included, nine of which were randomized controlled trials, totaling 5,437 patients. Following a brutally honest critique of the literature, the results were inconclusive … at best. he percentage of postoperative infections ranged from 4.5% to 62% in studies not using antibiotics, as compared to 1.9% to 29.4% in studies using antibiotics. here was a suggestion across these studies that the use of prophylactic antibiotics is likely beneicial, although no quantitative synthesis of the data could be performed secondary the non-homogeneous patient populations, variable study designs, lack of critical information regarding antibiotics and overall poor study quality. In conclusion, despite the plethora of studies, the overall evidence for antibiotic use in these patients is poor. Although few would argue against using prophylactic antibiotics of some ilk, many important questions remain to be answered – including which antibiotics, in what dosage and for what duration postoperatively. For any resident looking for a quality reference on the topic, this is certainly the place to start, as it emphasizes the need for continued evaluation and improved data on a seemingly obvious treatment.

8. Rigid internal ixation of infected mandibular fractures Mehra P, Van Heukelom E, Cottrell DA / J Oral Maxillofac Surg. 2009; 67:1046-1051

» Infection is a common complication following surgical management of mandible fractures, as hardware is placed in a ield contaminated by oral lora in a patient population with historically poor compliance. In this highly powered retrospective review, a well-detailed algorithmic approach is taken to evaluate this complication with excellent outcomes after a single operation. Forty-four patients were included 26

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UNIQUE PATIENT POPULATIONS 9. he second Chalmers J Lyons Academy study of fractures of the edentulous mandible Bruce RA, Ellis E III / J Oral Maxillofac Surg. 1993; 51: 904-11.

» Management of mandible fractures in the edentulous patient has been and continues to be a contested topic in the literature. his landmark study surveyed 27 oral and maxillofacial surgeons, yielding data for 167 mandible fractures in 104 edentulous patients over a 12-year period. he mandibular body was the most commonly fractured site, both isolated or in combination with another region (78%), as this area experiences the greatest degree of bony resorption over time. Furthermore, 89% of fractures were signiicantly displaced, necessitating surgical intervention, as no patient was treated by observation alone. A variety of surgical techniques were employed, but most patients (81.5%) underwent ORIF with rigid plating from either an intraoral (14%) or extraoral (67%) approach. Comparing complications in healing, 27% of those treated with closed reduction had either delayed or ibrous union, compared to 13% in those treated with ORIF. Prior to this large, retrospective review, collective data was limited – most surgeons were managing this patient population based only on personal or anecdotal experience. he study subsequently established rigid ORIF as an acceptable standard of care for displaced fractures of the atrophic mandible, in a practice still advocated today by the AO Foundation.

10. he pediatric mandible: II. Management of traumatic injury of fracture Smartt JM, Low, DW, Bartlett SP / Plast Reconstr Surg. 2005;116(2):28e-41e.

» his article out of Children’s Hospital of Philadelphia is the second installation of a comprehensive, two-part series on pediatric mandible fractures. hough it won’t be

discussed here, Part I delves into growth and development of the pediatric mandible. Part II continues with an easy-to-read synthesis of the literature, combined with well-established anecdotal evidence for treating mandible fractures in children. he authors detail the data regarding epidemiology and etiology of fractures. hey also weigh the pros and cons of each type of pediatric ixation with respect to fracture location and patient age. he illustrations provide a nice resource for wiring techniques that residents may be less familiar with, as these are not employed in adult fractures. he inal “cherry on top” is the author’s comprehensive algorithm for management of the pediatric mandible, something all residents love. Overall, this article is a great “one-stop shop” reference for any resident looking for an evidence-based approach to the pediatric mandible.

BONUS CME

3. Valentino J, Marentette LJ. Supplemental maxillomandibular ixation with miniplate osteosynthesis. Otolaryngol Head Neck Surg. 1995;112(2):215-20. 4. Wilson IF, Lokeh A, Benjamin CI, et al. Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures. Plast Reconstr Surg. 2001;107:1369-1375. 5. Kaplan BA, Hoard MA, Park SS. Immediate mobilization following ixation of mandible fractures: a prospective randomized study. Laryngoscope. 2001;111(9):1520-4. 6. Abubaker AO, Rollert MK. Postoperative antibiotic prophylaxis in mandibular fractures: A preliminary randomized, doubleblind, and placebo-controlled clinical study. J Oral Maxillofac Surg. 2001;59(12):1415-9. 7. Bolourian R, Lazow S, Berger J. Transoral 2.0-mm miniplate ixation of mandibular fractures plus 2 weeks’ maxillomandibular ixation: a prospective study. J Oral Maxillofac Surg. 2002;60(2):167-70. 8.

Evidence-based medicine: mandible fractures Morrow BT, Samson TD, Schubert W, Mackay DR / Plast Reconstr Surg. 2014; 134: 1381-1390

» his CME in PRS from 2014 is an excellent starting point for those looking for a concise assessment of the current understanding of mandible fractures. All major topics are addressed with the highest level of evidence from the literature that currently supports our clinical decisions.hese include cause and epidemiology; preoperative imaging; timing of repair; antibiotic prophylaxis; and nuances of surgical management, such as ixation techniques, bone grafting and the edentulous mandible. Perhaps the most compelling conclusion is that the paper draws attention to the lack of high-level evidence that exists, despite there being enough papers in the literature to re-drape your living room walls. Of note, many of the articles referenced here are included in our formal “Top 10.” So, whether you choose to utilize this CME as a starting line or inish line in the race for an evidence-based understanding of mandible fractures, it’s an invaluable resident resource.

Chritah A, Lazow SK, Berger JR. Transoral 2.0-mm locking miniplate ixation of mandibular fractures plus 1 week of maxillomandibular ixation: a prospective study. J Oral Maxillofac Surg. 2005;63(12):1737-41.

Miles BA, Potter JK, Ellis E. he eicacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: a prospective randomized trial. J Oral Maxillofac Surg. 2006;64(4):576-82.

10. Benson PD, Marshall MK, Engelstad ME, Kushner GM, Alpert B. he use of immediate bone grafting in reconstruction of clinically infected mandibular fractures: Bone grafts in the presence of pus. J Oral Maxillofac Surg. 2006;64(1):122-6. 11. Czerwinski M, Parker WL, Correa JA, Williams HB. Efect of treatment delay on mandibular fracture infection rate. Plast Reconstr Surg. 2008;122:881-885. 12. Lovato C, Wagner JD. Infection rates following perioperative prophylactic antibiotics versus postoperative extended regimen prophylactic antibiotics in surgical management of mandibular fractures. J Oral Maxillofac Surg. 2009 Apr;67(4):827-32. 13. Sharif MO, Fedorowicz Z, Drews P, et al. Interventions for the treatment of fractures of the mandibular condyle. Cochrane Database Syst Rev. 2010;4:CD006538. |

ADDITIONAL READING 1. Chidyllo SA, Marschall MA. Teeth in the line of a mandible fracture: which should be performed irst, extraction or ixation? Plast Reconstr Surg. 1992;90(1):135-6. 2. Ellis E, haranon W. Facial width problems associated with rigid ixation of mandibular fractures: case reports. J Oral Maxillofac Surg. 1992;50(1):87-94.

Dr. Grow and Dr. Vargo are PGY-3 residents at the University of Kansas Medical Center, Kansas City.

On behalf of Rod J. Rohrich, MD, and the entire Editorial Board of Plastic and Reconstructive Surgery, the PRS articles highlighted in this article can be read for free through Sept. 1 by clicking “Residents” on PRSJournal.com: http://bit.ly/BestCranioPSR

Plastic Surgery Resident | Summer 2017

Bone tumors of the hand By Chad Teven, MD

espite the low incidence of bone tumors in the hand – 6 percent of all bone tumors are found in that extremity – we nevertheless must be able to identify these tumors for the annual In-Service Examination. Lesions of the hand tend to be problematic, given the functional use of the hand for nearly all daily activities. Interestingly, malignant tumors of the hand tend to behave less aggressively than their counterparts in the body, while benign hand tumors behave more aggressively. A thorough history and physical examination is key to the evaluation of a patient presenting with this disease process. Whether benign or malignant, tumors of the hand most often cause localized pain and swelling. Additional presenting symptoms may consist of deformity, skin changes, acute or chronic pain, and pathologic fracture. Initial diagnostic-imaging will generally include plain radiographs. Tumors with a benign appearance exhibit cortical expansion within a deined border. Oppositely, malignant tumors demonstrate cortical destruction, ill-deined borders and soft-tissue extension. his article will highlight the commonly tested bony hand tumors on the In-Service Examination. Soft-tissue tumors of the hand are outside the scope of the current article.

BENIGN BONE TUMORS OF THE HAND ENCHONDROMA Enchondromas are the most-common primary bony tumor of the hand, accounting for nearly 90 percent of all tumors. Although benign, they can be locally destructive and result in pathologic fractures. Enchondromas are often located in the proximal phalanx, middle phalanx or metacarpals of the ulnar digits. On X-ray, they appear as a well-circumscribed 28

Plastic Surgery Resident | Summer 2017

radiolucent lesion, with a popcorn-like or stripling appearance. hese can transform into malignant lesions, most commonly when seen in association with multiple endochondromatosis (e.g., Mafuci syndrome and Ollier disease). Small asymptomatic lesions may be observed over time; however, larger lesions that are symptomatic or suspicious should be excised in full. Bone grafting may be necessary to reconstruct the bony defect.

OSTEOID OSTEOMA he second-most common bony tumor of the hand is the osteoid osteoma, which comprises nearly 10 percent of hand bony tumors. hese are generally found in younger patients, often in the proximal phalanges, metacarpals and carpal bones. Swelling and nighttime pain relieved by nonsteroidal anti-inlammatory drugs (NSAIDs) are common. X-ray indings demonstrate a central radiolucent focus with surrounding sclerosis. hese osteoblastic tumors are nonprogressive, and conservative management is recommended initially. If unsuccessful, curettage or en bloc excision with or without bone grafting is ofered.

GIANT CELL TUMOR OF THE BONE Although benign, giant-cell tumors of the bone are locally aggressive and may metastasize to the lung. hey are noted for local recurrence and extension into surrounding tissues. hey are usually found in young adults, frequently in the phalanges, metacarpals, carpal bones or distal radius. Radiographically, these lesions are often juxta-articular, lytic and expansive. Campanacci developed a grading system to describe the radiographic features (Table 1). Any patient thought to have a giant-cell tumor of the bone should undergo chest-computed tomography to rule out pulmonary spread – as well as bone

TABLE 1. CAMPANACCI GRADING SYSTEM FOR GIANT CELL TUMORS OF BONE GRADE

I II III

DESCRIPTION

WELL-MARGINATED, INTACT CORTEX WELL-MARGINATED, EXPANDED CORTEX ILL-DEFINED, SOFT-TISSUE EXTENSION, CORTICAL DESTRUCTION

scans to elucidate bony architecture. Grades I and II lesions are often treated by curettage with or without bone grafting. Higher-grade lesions may require en bloc excision and bony reconstruction. hese lesions have a high rate of recurrence if tumor is left behind.

MALIGNANT BONE TUMORS OF THE HAND CHONDROSARCOMA Although relatively rare, chondrosarcomas are the mostcommon malignant bony tumor of the hand. hese cartilaginous lesions usually develop de novo, but they also can be associated with endochondromatosis. Chondrosarcomas are indolent in nature, with pain and swelling progressing over months to years. Radiographically, these lesions demonstrate cortical expansion, poor circumscription and soft-tissue extension. For aggressive lesions, treatment is wide excision or amputation. Recently, however, due to functional impairment with amputation, intralesional excision and close follow-up has been advocated for low-grade lesions.

present with acute pain and swelling of the proximal phalanges or metacarpals. Plain radiographs show a lytic lesion that’s expansile in nature and located centrally, juxtacortically or extraosseously, which can invade the surrounding soft tissues. Treatment includes wide excision or amputation. For high-grade tumors, neoadjuvant or adjuvant chemotherapy is ofered to decrease the risk of recurrence or metastasis.

EWING SARCOMA Ewing sarcoma rarely afects the hand – but when it does, it has a predilection for male patients in the irst and second decade of life. Generalized symptoms such as fever, pain, swelling and malaise may accompany a Ewing sarcoma, often delaying a correct diagnosis, as infection may instead be suspected. Radiography demonstrates bony destruction, softtissue extension and periosteal reaction. Treatment includes wide excision or amputation, as well as chemotherapy. In cases of positive margins, radiotherapy may be ofered. Patients should undergo evaluation for metastatic disease. | References 1. Henderson M, Neumeister MW, Bueno RA. Hand Tumors: II. Benign and Malignant Bone Tumors of the Hand. Plast Reconstr Surg. 2014:133:814e-821e. 2. Trumble TE, Budof JE. Hand Surgery Update IV. Chicago, IL: American Society for Surgery of the Hand; 2007. 3. Campanacci M, Baldini J, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am. 1987;69:106-114.

OSTEOSARCOMA Osteosarcomas are malignant osteoblastic-cell tumors that

Dr. Teven is PGY-4 resident at University of Chicago Medicine.

Oral and Written Board prep course coming to Westin O’Hare on Aug. 17-19 Plastic surgery residents who wish to leave no stone unturned in their eforts to become ABPS-certified plastic surgeons are encouraged to register for the 2017 ASPS Oral and Written Board Preparation Course, slated to be held Aug. 17-19 at the Westin O’Hare Hotel, Rosemont, Ill. The deadline for advance registration is Aug. 4. This interactive and comprehensive prep course will employ more than 100 plastic surgery cases to provide a thorough overview of plastic surgery principles and management problems. The course, which is appropriate and recommended for young plastic surgeons seeking a

review of clinical science and patient safety issues, will prove quite useful for those who plan to take the oral and written ABPS examinations – and it can serve as an educational resource for MOC eforts.

craniofacial/head and neck; and CPT coding. In addition, attendees will participate in complimentary, 45-minute case-book review sessions with our content expert faculty.

The course will address the ACGME/ABMS competencies of: • Professionalism • Patient care and procedural skills • Medical knowledge • Interpersonal and communication skills

Residents preparing for the Written Exam, and Oral Exam candidates, can benefit from this prep course’s high- yield review of core curriculum. This course has proven statisically popular – 97 percent of the 2016 responding participants noted that they would recommend this course to others.

The course will include topic modules in the areas of breast/aesthetic; hand/complex wounds/burns/scars;

This live activity is approved for AMA PRA Category 1 CreditTM – with three applicable to Patient Safety – are available.

Register by visiting PlasticSurgery.org/BoardPrep; by calling (800) 766-4955 or (847) 228-9900, or by sending e-mail to registration@plasticsurgery.org. Plastic Surgery Resident | Summer 2017

Digital artistry When necessity becomes the mother of invention By James Vargo, MD

started illustrating out of necessity in December 2015. he Department of Plastic Surgery at the University of Kansas (KU) Medical Center, Kansas City, was working on a paper for PRS describing patterns for anastomosis and inset of double tranverse upper-glacilis (TUG) laps. he primary author was trying to draw her own sketches and asked me for help, since I used to draw for fun in my free time. I drew for the paper three images in pencil that were nearly identical to one another, except for the diferent anastomotic patterns. I became frustrated with the idea of drawing the same image, multiple times, by hand, or having to make signiicant changes to a paper illustration. As a result, I bought a Wacom Intuos Pro drawing tablet and Corel Painter 2016 – and taught myself to draw digitally. I’ve never had any formal art training. Breaking the ‘rules’ of art he irst digital illustration I attempted was for another PRS paper from within our department (“Deep Pyriform Space: Anatomic Clariications and Clinical Implications”). A lot of efort was required for me to learn how to

draw digitally without looking at my hands, as well as to retrain my mind that I could break the rules of hand-drawn art. I’ve since done 20-plus illustrations for various departments within KU Medical Center as well as other institutions. I’ve had illustrations published in PRS, Aesthetic Surgery, Journal of Craniofacial Surgery, Radiology and a textbook, and I’ve designed multiple logos for various groups. For coloring and shading my “oil painting” illustrations, I use the art software Corel Painter 16. It allows me to use a wide variety of art media (such as pastel, chalk, watercolor, etc.) with extremely realistic properties. As I make brush strokes via the digital stylus on a tablet, the software reads the angle and pressure of the stylus and creates a realistic looking oil-brush stroke. It pulls and mixes with the colors I’ve already painted, and even gives a 3-D look – where some paint may be thicker or thinner, just as would be the case in a real oil painting. If the stroke becomes too long, though, the paint will thin-out and the color will fade away. his is an area in which I’m relatively inexperienced – but I’m exploring with “all of the free time” we have.

valuable. For example, it’s enhanced my understanding of detailed anatomy and structural relationships – and training as a surgical resident also has provided me with unique perspectives to the art, as I’ve seen the surgical anatomy and I understand how a surgeon thinks when they see an illustration. his has deinitely grown from something that was just a hobby to a full-side career that I hope to continue to expand.

Value in relaxation – and omprehension like that I can learn to oil paint ithout having to buy an easel and rushes, and I can sit outside at a cofee hop and draw. I couldn’t think of a etter way to get away from the daily rind of residency. And as far as a time ommitment, for me an illustration enerally takes about 10-20 hours to omplete, depending on its complexity. ve found that being a plastic surgeon/ medical illustrator has been extremely

I’m happy to be contacted with questions, concerns or suggestions on digital illustrations. Please send e-mail to james.d.vargo@gmail.com. | Dr. Vargo is a PGY-3 plastic surgery resident at the University of Kansas Medical Center, Kansas City.

Feature your artwork in an upcoming issue of PSR – submit to ResidentArt@plasticsurgery.org. 30

Plastic Surgery Resident | Summer 2017

UPCOMING MEETINGS & SURGICAL TRIPS JUNE

JULY

AUGUST

SEPTEMBER

6/10/17 – 6/17/16 Hope International (Fishers, Ind.) Guatemala City, Guatemala (317) 581-9569 hopeinternational.org

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

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

9/2/17 – 9/9/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

6/10/17 – 6/17/17 Austin Smiles (Austin, Texas) Veracruz, Mexico (512) 451-9300 austinsmiles.org

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

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

9/7/17 – 9/9/17 American Society for Surgery of the Hand Annual Meeting (San Francisco) (312) 880-1900 meetings@assh.org

6/14/17 – 6/17/17 World Society for Reconstructive Microsurgery 2017 World Congress Seoul, South Korea (312) 263-7150 wsrm2017.com

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

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

9/20/17 – 9/25/17 Health Talents International (Birmingham, Ala.) Guatemala City, Guatemala (205) 991-9939 healthtalents.org

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

Answer Key 1

2 5

7 9

12 13

15 16

17 18 19

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

Plastic Surgery Resident | Summer 2017

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