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Table of
Contents Low cost of living, high income – The benefits of a rural practice ................................... 6 There may not be the bustle of an urban practice, but plastic surgery in the country has considerable up-sides.
Program Peek: University of California-Los Angeles ......................... 8 An intimate look at plastic surgery residency at this venerated Southern California institution.
Faculty Focus: Kodi Azari, MD .............................................................. 10 This UCLA Health System professor and microvascular/ reconstructive surgery specialist discusses his career choices.
ASMS resident representatives: A changing of the young guard ................................ 12 2017 representative Fan Liang, MD; sums up her past year; 2018 representative Navid Pourtaheri, MD, discusses what lies ahead.
PlastyPAC and residents: The Next Generation ................................................... 14 The political advocacy arm of ASPS creates a place for the Society’s residents on its Board of Governors.
Consult Corner: Pressure wounds and paraplegia ............................. 15 This relatively rare patient cohort will bring new variables – some easily manageable, others totally unanticipated.
InService Insights: Lower-extremity trauma ............................................. 18 Considered an overlooked portion of the hand section, this subset will likely make an appearance on the test – so be ready.
What I learned during my ‘micro’ Fellowship At Chang Gung Memorial Hospital ..........................20 Shan Shan Qui, MD, trained beside the legendary Fu-Chan Wei, MD, and absorbed a once-in-a-lifetime opportunity.
Journal Club..................................................................22 Ten articles on lower-extremity trauma, from the pages of respected surgical journals.
#TheTrend .....................................................................26 Jacob Grow, MD, and James Vargo, MD, introduce “Touch Surgery,” an interactive, surgical simulation app for trainees.
Residents Bowl 2017 winner: University of Washington ...........................................27 Bragging rights move to the Pacific Northwest after UWash defeats the University of California-San Francisco.
Crossword .....................................................................28 Word up – and word down – for this edition of the Resident Crossword.
On the cover: Alexey Markelov, MD (left) and Garrett Vangelisti, MD, at Sunset Beach State Park – a 10-minute drive from the North Bend (Ore.) Medical Center, where they practice.
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Plastic Surgery Resident | Winter 2017
Plastic Surgery Resident | Winter 2017 | Vol. 1 No. 9 he mission of the American Society of Plastic Surgeons is to support its members in their eforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR ESI DEN T Jefrey Janis, MD | Jefrey.Janis@osumc.edu EDITOR Alex Spiess, MD | amspiess@msn.com ASSOCI ATE EDITORS Mohammed Alghoul, MD | mo.alghoul@gmail.com Sanjay Naran, MD | sanjaynaran@hotmail.com INTER NATIONA L EDITOR Johan Sandberg, MD | ljsandbrg@gmail.com ASSOCI ATE INTER NATIONA L EDITOR Melissa Roy, MD | melissa.roy@mail.utoronto.ca R ESIDENT EDITORS Jacob Grow, MD | jgrow2@kumc.edu Kavitha Ranganathan, MD | krangana@med.umich.edu Deana Shenaq, MD | dshenaq@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org SENIOR DIR ECTOR OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org S TA F F W R I T E R Kendra Y. Mims | kmims@plasticsurgery.org GR A PHIC DESIGN ER Anna Abbinante A DV ERTISING SA LES Connor Winther (215) 521-8797 Wolters Kluwer Health
Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005. POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005 Postage paid at Arlington Heights, IL, and at additional mailing oices. he views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily relect the opinions of ASPS. Acceptance of advertisements for PSR is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised. ASPS Home Page: www.plasticsurgery.org
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CONSULT CORNER / continued from page 17
INSERVICE INSIGHTS / continued from page 19
all social and medical factors that may be contributing to delayed wound-healing. Making sure the patient has a robust multidisciplinary team is key. Adequate debridement and a good wound-care regimen are essential to successful stabilization of the wound, and reconstruction of the wound is only indicated after medical optimization and elimination of infection. |
‘TO AMPUTATE, OR NOT TO AMPUTATE’ his issue is perhaps the most debated topic in lowerextremity trauma. As a result, there have been a slew of questions covering it on the exam from year to year, with seemingly conlicting answers. Classically, any injury involving transection of the tibial nerve was an absolute indication for revision amputation. However, more recent data suggest that this is no longer the case. Furthermore, Higgin’s LEAP trial from 2010 highlights the unreliability of scoring systems in determining whether or not a limb can be salvaged. his makes it a diicult topic for formulating questions – and the most likely reason that amputation hasn’t come up on the In-Service in the last couple of years. However, this doesn’t mean the topic isn’t fair game. he following is a list of factors that should alert you to revision amputation being a plausible option for management. he more of these that are present, the more likely revision amputation is indicated.
Dr. Kubiak is an Academic Development Time resident at the University of Michigan. She can be reached at kubiakc@med.umich.edu.
MICROSURGICAL FELLOWSHIP / continued from page 21 here were plenty of cases for everyone; what we did depended upon on our own motivation to remain in the theater even after inishing our own program to help others. hen, we might receive even more chances to operate there. My prevailing thoughts during these cases were: “his is a unique case; I can’t miss it,” or “I won’t see this case in Europe.” And these thoughts compelled me to stay, hours upon hours, operating.
Factors Supporting the Need for Revision Amputation • Tibial nerve transection • Warm ischemia time >6 hours
I once heard Dr. Wei say that one year operating in Chang Gung was comparable to ive years in any hospital in the rest of the world. I realized how wise was that statement, when I received my consultant position in Maastricht University Medical Center two years ago. Teamwork was essential. Long operations, complicated cases, large wounds to be closed – success in these was only possible because we had colleagues helping us, providing moral support, too, and with many cases that inished quite late. I still remember those nights after inishing a long surgery – a resident, some visitors and me, sitting at the McDonald’s in the hospital’s basement, having our late dinner… I really enjoyed these moments! I also fondly recall a speciic moment of collegiality, when one of my co-Fellows came along to our theater after inishing their own program. We took in the fresh Taipei air that made our next operations lighter. By the completion of my Fellowship at Chang Gung, microsurgery had become an operation in which I had conidence. My year there also taught me that, no matter what, with patience and teamwork, most problems can be solved. From a surgical standpoint, I’ve witnessed the improvement in patients’ quality of life through a free lap – and it’s enormous. here are still challenges that we face in order to get better outcomes for these patients, such as reducing operating time and the morbidity of the donor site, and minimizing side efects. My Fellowship has allowed microsurgical procedures, for me, to be quite straightforward and systematic. I enjoy operating, even in such long procedures. And it’s one of the main treasures that I cherish – and that I owe to my time at Chang Gung. | 30
Plastic Surgery Resident | Winter 2017
• Severe crush injury with extensive muscular and NV damage • Multi-level injury • Elderly patient with comorbidities • Failed revascularization
COMPARTMENT SYNDROME Compartment syndrome is not uncommon in the setting of lower-extremity trauma, especially when revascularization is required. As with the upper extremity, remember your ive P’s as indicators of compartment syndrome: Pain with passive movement out of proportion (most reliable test); paresthesias; pallor; pulselessness (late inding); and paralysis (late inding). Even in the setting of an open fracture, one cannot assume that all compartments are released from the injury alone. Fasciotomies are typically performed in the O.R. with delayed revascularization/replantation or secondarily when symptoms arise. Release may be achieved with two linear incisions. he lateral access point allows release of the anterior and lateral compartments, while the medial opens the posterior compartment. Furthermore, it’s imperative that both the supericial and deep posterior compartments are released, as the deep compartment is sometimes forgotten, resulting in signiicant functional deicits with prolonged ischemia and secondary contracture. A special thanks to Ryan Endress, MD, for his input in formulating this high-yield study resource. |
Dr. Grow is a PGY-3 resident at the University of Kansas Medical Center, Kansas City. He can be contacted at jgrow2@kumc.edu.