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From the publishers of Plastic Surgery News

ISSUE 13 | WINTER 2018 From the publishers of Plastic Surgery News

»»Things I wish I had known back then

Don’t put too much emphasis on your first stop in practice

page 22

»»Building a program from scratch

How Hofstra’s plastic surgery program grew into a major regional force

page 12

A new training paradigm emerges It’s what you know – not when – in competency-based residency IN THIS ISSUE » Consult Corner:

Cover-toc to come: »» 'Snakebites' on your pager .................. p. 8 Head .. ............................................................. p. xx

» Resident Ambassador on the successes of 2018 – and what lies ahead ........ p. 20 » #TheTrend: This new app tracks drain data for patients, docs .......... p. 25

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A note from the editor

appy Holidays! It’s December, and for many of us, that means breaking out the parkas and shovels. That also means another edition of Plastic Surgery Resident magazine, and this edition brings you fresh content for InService Insight, Consult Corner and PSR Crossword. For this edition’s Program Peek, we highlight the 2018 ASPS Resident Bowl Champion program: The University of Texas Health San Antonio. With its emergence, Texas has arrived as a real state powerhouse when it comes to training plastic surgery residents. Associate Program Director Amita Shah, MD, PhD, is highlighted in the Faculty Focus – and under her leadership, the program was well-positioned to win this year’s ASPS Residents Bowl.

Alex Spiess, MD

Chief Medical Editor Plastic Surgery Resident Pittsburgh

This issue’s installment of #TheTrend highlights another entry in the pipeline of plastic surgery technology apps. The Drain IQ is an app designed to simplify the process of tracking postsurgical drain output. We also bring back Things, Secrets and Tips I Wish I Had Known Before Residency, by Umbareen Mahmood, MD, a young plastic surgeon with a practice in New York. Finally, our cover piece gives us an inside look at an emerging model of plastic surgery residency: competency-based plastic surgery training. We hope that you enjoy this edition – my last as editor. It's hard to believe three years have already come and gone. It’s been an honor being asked to serve as the inaugural editor of Plastic Surgery Resident. I believe we’ve developed an outstanding publication, one which has remained true to its core design mantra: “By the residents, for the residents.” As always, I would like to thank our physician Editorial Board and the ASPS staff; without their tireless efforts, we wouldn’t have seen the success we have over the past three years. With that, I pass the pen – and I look forward to the outstanding content that I’m sure lies ahead. |

2019

WHAT WILL YOU PRESENT? Submit Your Abstract for #PSTM19 Submit your abstract for Plastic Surgery The Meeting 2019 now through Feb. 25, 2019: PlasticSurgeryTheMeeting.com/SubmitAbstract

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If accepted, your abstract could be displayed at #PSTM19 and published in the annual supplement to the journal of Plastic and Reconstructive Surgery.

Plastic Surgery Resident | Winter 2018

Table of

Contents Competency-based plastic surgery training: It’s about talent, not time ..............6 The training model at UPMC and Johns Hopkins is only months old, but residents and directors already see its value.

Consult Corner: Snakebites .......................................................8 Docs in old Western movies who bark orders to “cut the wound and suck-out the venom” would be surprised at how treatment has changed.

The mission of the American Society of Plastic Surgeons is to support its members in their efforts 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 Alan Matarasso, MD | amatarasso@drmatarasso.com EDITOR Alex Spiess, MD | amspiess@msn.com

InService Insights: Rhinoplasty, Part II ....................................... 10

ASSOCI ATE EDITORS Sanjay Naran, MD | sanjaynaran@hotmail.com

Get on “board” with this installment on cosmetic rhinoplasty, beginning with assessment of nasofacial proportions and nasal analysis.

INTER NATIONA L EDITOR Johan Sandberg, MD | ljsandbrg@gmail.com

Building a program from the ground up ............................................... 12 Armen Kasabian, MD, brought know-how and enthusiasm to Northwell Health/Hofstra Medical School – and built a renowned residency program.

Program Peek: University of Texas at San Antonio ........... 14 Long known for its excellence in reconstructive surgery, this plastic surgery program has earned plaudits for its service to children, veterans – and residents.

Faculty Focus: Amita Shah, MD, PhD .................................. 16 Associate Residency Program Director, Professor in the Department of Surgery, Division of Plastic & Reconstructive Surgery, at UT Health San Antonio, edifies readers on her institution.

24 Hours In: San Antonio .................................................. 18 Learn the sordid story behind “The Three Emmas,” walk for miles along the famed Riverwalk and bask in the glory of the recent 2018 Resident Bowl victory.

PlastyPAC Ambassador update: JT Stranix, MD, looks ahead ...................... 20 The resident representative to the PlastyPAC Board of Governors looks back at 2018’s advocacy successes – and to what’s in store for 2019.

Things I wish I knew when I was a plastic surgery resident .................22 Umbareen Mahmood, MD, shares her memories of life as a resident and how life might have been a bit easier if she had known certain concepts sooner.

Crossword: Hand and Wrist ............................................ 24 So, you think you know your “hand and wrist” terms and minutiae?

#TheTrend: Drain IQ ................................... 25 James Vargo, MD, and Jacob Grow, MD, bring tech-savvy residents to a new app called Drain IQ, designed to help patients monitor their flap-drainage. 4

Plastic Surgery Resident | Winter 2018 | Vol.2 No.4

Plastic Surgery Resident | Winter 2018

ASSOCI ATE INTER NATIONA L EDITOR Mélissa Roy, MD | melissa.roy@mail.utoronto.ca R ESIDENT EDITORS Jacob Grow, MD | jgrow2@kumc.edu Kavitha Ranganathan, MD | krangana@med.umich.edu Russell Ettinger, MD | retting@med.umich.edu E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT 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 A S S O C I AT E E D I T O R Kendra Y. Mims | kmims@plasticsurgery.org GR A PHIC DESIGN ER S Steven Lindsey; Jun Magat A DV ERTISING SA LES Joe Anzuena (215) 521-8532 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 offices. The views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily reflect 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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Will 'how well' replace 'how long'? Residents shine first light on competency-based plastic surgery training By Jim Leonardo & Paul Snyder

Plastic surgeons have long been at the forefront of innovation, and they’re continuing that history on the educational front with a possibility of disrupting the specialty’s training process through Competency-Based Plastic Surgery Training (CBPST).

The CBPST program launched July 1 at Baylor Scott & White (BSW) Health and the University of Pittsburgh Medical Center (UPMC) – with The Johns Hopkins/ University of Maryland and the University of Michigan (UM) programs set to premiere in mid-2019. The initiative was approved by the American Board of Plastic Surgery and the Resident Review Committee after four years of analysis and input from program directors at the four institutions. The argument behind CBPST is that time itself should not determine a training plastic surgeon’s competency, but rather proof of proficiency – which could arrive in Year 5, 6 or beyond. “The goal of CBPST isn’t to train residents in a shorter period of time,” says Robert Weber, MD, who helped developed the program at BSW. “The goal is for a resident to train for as long as she or he needs – until they’re done.” Dr. Weber notes, however, that studies have revealed that reaching competency can be reached in five years rather than six. Even with that statistic in mind, UPMC Program Director Vu Nguyen, MD, says quality will supersede duration in this new module. “We’re not focusing on accelerated graduation,” he says. “The goal is to bring the residents to similar levels of competency while understanding that each achieves that competency somewhat differently. A more-focused program allows directors to identify those who learn more quickly or are more technically competent, and potentially shorten their training. “Those who need more time will have that, too,” adds Dr. Nguyen, who developed the UPMC program with

Joseph Losee, MD. “That doesn’t make them ‘bad’ or ‘failing’ residents – we’ll be able to determine who’s who earlier, determine where they need help and then provide focus in those specific areas.” CBPST program stewards Scott Lifchez, MD, at Johns Hopkins, and Steven Kasten, MD, at UM, have been deep in preparations designed to launch their respective programs later in 2019. Dr. Kasten published an article on the concept in PRS in 2009. Although the program itself is still too new to yield statistically relevant data or conclusions, residents involved in the programs decided to talk with PSR about how these programs are shaping up, what they’ve encountered thus far and how the training module could be a way forward for the specialty.

COMPETENCY, NOT TIME, IS THE FUTURE OF SURGICAL TRAINING Howard Wang, MD PGY-5 Johns Hopkins/University of Maryland I joined the Johns Hopkins/University of Maryland (JH/ UM) Plastic and Reconstructive Surgery Department’s Program Evaluation Committee in 2017 because of my growing interest in issues related to resident and medical education. Having viewed CBPST from the inside, I believe it represents the next step in the evolution of surgical training. Two components will be essential to the success of CBPST: an accurate and rigorous assessment tool, and a clear definition of objectives to achieve competency. Milemarker, a web-based tool employed in our program to provide

continued on page 26

Plastic Surgery Resident | Winter 2018

Treating a snakebite “Consult Corner” addresses a consult commonly encountered by an on-call resident. The 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.

Rattlesnake envenomation of the hand: a potential surgical emergency By Abigail Rodriguez, MD MESSAGE ON YOUR PAGER: E.D. CALL: PATIENT WITH COMPARTMENT SYNDROME FROM SNAKEBITE TO FINGER As you’re finishing up a laceration repair on a patient, your pager goes off. You return the page and speak to an E.D. resident who explains, “This patient was bitten by a rattlesnake on the finger. I really think he has compartment syndrome and needs to go to the O.R., now!”

A SNAKEBITE?! Venomous snakes in North America belong to one of two subfamilies: Crotalinae (crotalids or pit vipers) and Elapidae (elapids).1 Crotalids, including rattlesnakes, cottonmouths and copperheads, are found in Southern and Eastern United States, and they are responsible for the vast majority of snakebites in the country.1,2 Elapids such as coral snakes, found in the South/Southwest, are less common and responsible for only 2 percent of venomous snakebites each year.1,2 8

Plastic Surgery Resident | Winter 2018

Approximately 7,000-8,000 people are bitten by venomous snakes in the United States annually, and this results in about five deaths per year.2 Snakebite victims tend to be male and from 17-27 years of age.3 Bites are more common in the summer months, and 75 percent are on the upper extremity.3,4 If prompt, appropriate treatment is not provided, the morbidity of snakebites to the hand can be permanent and severe.

ALL SNAKEBITES ARE NOT EQUAL Importantly, not all venomous snakes inject venom with each bite. Envenomation (the process of venom being injected) occurs in most crotalid bites (75 percent) and about 40-50 percent of elapid bites.3,4 The remainder of bites lack venom, and thus are described as “dry bites.” The lower risk of envenomation with elapids may be attributable to shorter fangs that require a longer bite-time to inject venom.4 Envenomation results in different clinical manifestations, depending upon the type of snake involved.

Crotalid venom is known to cause: • Local tissue destruction – Erythema, edema, ecchymosis, bullae and tissue necrosis can occur, usually starting within 10 minutes (see Figure 1).1,4 The severity is variable and can escalate to auto-amputation.1 • Hematologic toxicity – Crotalid venom is thought to cause platelet destruction via phospholipases, as well as fibrinolysis.1 The resultant coagulopathy can arise acutely – but it also can develop from two to seven days later.1,5 Coagulopathy can also resolve and then recur.5 In severe cases, DIC can develop.1 Systemic toxicity usually involves nausea, vomiting and diaphoresid; it rarely escalates to significant hypotension, tachycardia, respiratory distress, angioedema and cardiovascular collapse.1 Elapid venom is known to cause: • Minimal local tissue damage3 • Neuromuscular blockade – The venom’s neurotoxic polypeptide competitively blocks acetylcholine

FIGURE 1

• Degree of pain with movement and palpation • Compressibility of all compartments • Capillary refill • Distal pulses • Sensation • Skin changes • Any cardiovascular, pulmonary, and neurologic changes3

COMPARTMENT SYNDROME IN SNAKEBITES In cases of snakebites to the upper extremity, plastic surgeons are consulted to monitor for and manage the feared development of compartment syndrome. The six “Ps” of compartment Figure 1. Significant soft tissue changes after envenomation syndrome can aid in diagnosis: from a crotalid (Courtesy Corbett B, Clark RF. North pain, paresthesia, pallor, American Snake Envenomation. Emerg Med Clin N paralysis/paresis, poikilothermia Am. 2017;35:339-354) and pulselessness.5 Intracompartmental pressure receptors and can result in cranial measurements above of 30 mmHg or nerve palsies, ptosis, dysarthria and within 30 mmHg of the diastolic pressure dysphagia.4 In severe cases, respiratory are generally diagnostic and warrant paralysis and death can occur. fasciotomy.4,5 Envenomation from an elapid is more likely to have delayed manifestation of symptoms, up to 12 hours from the time of the bite.3

HISTORY AND PHYSICAL A focused history for a snakebite patient should include: • Time of injury • Type and size of snake, if known • Handedness • Occupation • Prior treatments or interventions • Co-morbidities • Prior injuries or surgeries • Smoking status • Tetanus status • Allergies, especially to horse/sheep3 Next, a thorough exam should be performed and the following specifically noted: • Bite location • Range of motion

The incidence of compartment syndrome after envenomation has been found to be 0.20-1.36 percent.5 It has been documented to develop anywhere between 1.4 and 39.7 hours after presentation to the E.D.3 Children are at higher risk of deep-tissue necrosis and increased intra-compartmental pressure.4 The elevated compartment pressures after crotalid envenomation are thought to be due to venom-induced myonecrosis.1 Many of the anticipated local changes after envenomation can mimic compartment syndrome, increasing reliance on intra-compartmental pressure-monitoring for diagnosis.4 Even still, most studies agree that antivenom should first be administered for increased intra-compartmental pressures, and fasciotomy should be performed only if there’s inadequate response.4

STUDIES Coagulopathy can be manifested by low fibrinogen, prolonged prothrombin time (PT), decreased activated partial thromboplastin time (A-PTT) or platelet-count less than 20,000/mm3.3 Of these, thrombocytopenia is the most common in patients with crotalid bites.1 CBC, coagulation profile, CMP, CK and UA should all be ordered and EKG considered.3 No specific imaging is recommended, though a standard radiograph would be part of a thorough work-up. MANAGEMENT First and foremost, the ABCs of trauma should be addressed. Then, attention can be turned to the affected extremity. The E.D. Resident asks if they should extract the venom; excise the bite site; or apply a tourniquet. Would these interventions help prevent compartment syndrome? • No. There’s no good evidence showing these non-pharmacologic interventions help curb progression of the envenomation, nor have they been shown to prevent compartment syndrome.1 In fact, tourniquets can exacerbate local tissue-damage after crotalid envenomation – by decreasing perfusion and trapping venom locally.4 In theory, severe elapid envenomation may be curtailed with tourniquet application by slowing the systemic spread of the neurotoxin, though this is not generally recommended.4 All tourniquets, rings, watches and constrictive clothing should be removed from the affected extremity.3 The leading edge of erythema or edema should be marked, and the extremity elevated.3 It’s recommended that all snakebite patients be admitted for observation, as late manifestations of envenomation may arise.1,3 Antibiotics are not routinely recommended, as cellulitis occurs in less than 3 percent of cases.4 In general, blood products are not indicated in snakebite

continued on page 28 Plastic Surgery Resident | Winter 2018

Rhinoplasty Part II: A Focus on Cosmetic Rhinoplasty Maximize your In-Service Examination score by revisiting those embryology lessons learned early in your career as a physician, while embracing the opportunity to know more stuff about embryology.

Part I of “Rhinoplasty,” which appeared in the Fall 2018 issue of PSR, focused on nasal anatomy, as well as closed and open approaches for a functional rhinoplasty. By Rachel Hein MD, & Jeffrey Marcus, MD

osmetic rhinoplasty begins with assessment of nasofacial proportions and nasal analysis. As you may be aware, the face can be divided into vertical fifths and horizontal thirds. The nose should also be evaluated for deviation, bony width, alar base width (this should be approximately the intercanthal distance), dorsal aesthetic lines and tip-defining landmarks or deformities.

CORRECTION OF NASAL DORSUM

After evaluation, if change in the nasal dorsum is desired, it’s addressed with either reduction or augmentation. When hump reduction is planned, it’s done prior to any septal resection (septoplasty). Septal resection is done to remove deviated portions of the septum, but 10-15mm of septal “L” strut must be left to provide support to the nose. There are numerous

Plastic Surgery Resident | Winter 2018

methods to reduce dorsal prominence, including rasp or powered instrument. When a hump is reduced, the mucosal lining of the midvault must be preserved and protected. If it isn’t, an “open roof ” results. The upper lateral cartilages are attached to the nasal bones; if they aren’t supported after hump reduction, then the midvault will be narrower than the upper vault. This is called “inverted V deformity.” This may be treated by spreader grafts. Augmentation may be performed with septal, auricular, costal cartilage, diced cartilage (Turkish delight) grafts or cadaveric/ synthetic implants. Dorsal-onlay grafts improve contour, and radix grafts raise the nasofrontal angle. An increasingly popular augmentation technique includes filler placement in the subperichondrial plane.

CORRECTION OF BONY ABNORMALITIES

Surgeons differ in sequencing osteotomies. Lateral osteotomies are the most common. After a hump has been resected, they serve as “closing wedge” osteotomies to narrow the upper vault. If the upper vault must be narrowed with minimal or no resection of the osseous hump, it isn’t possible to simply perform lateral osteotomies alone; the intervening bone medially blocks the movement and forces the greenstick portion of the fracture to occur more distally. The upper portion remains wide. This can result in the “rocker deformity,”

where the upper-most portion of the nasal bones (the thickest portion) cannot be moved medially. Medial osteotomies (medial oblique or paramedian) are used in that setting in conjunction with the lateral osteotomies to allow the upper portion of the nasal bones to move medially.

NASAL BASE

If the ala themselves are relatively normal but the nasal floor is wide, then the floor can be reduced via excision. If the ala themselves are excessive, then alar wedge excisions (in some form) can be performed. In the setting of external nasal valve collapse, lateral crural struts are the correct option to provide support. A lateral crural strut is a long graft place over or under the lateral crus, which extends all the way to the piriform to provide support. A batten graft is a shorter graft that supports the lateral crus and can be helpful in the setting of weakness.

Examination of the nasal tip may also reveal a deformity. Below are some common nasal deformities and techniques for treatment. Deformity

Description

Correction

Pinched Nasal Tip

Decreased interdomal distances

Subdomal graft (bar-shaped graft under domes); reconstruction (overlay) or replacement of the lateral crurae/domes

Pollybeak Deformity

A secondary deformity resulting from failure to provide tip support. Fullness of supratip due to under-projection of nasal tip

Provide intrinsic or extrinsic support to the tip to bring the projection of the domes 5-7mm above the level of the anterior dorsum

Boxy Tip

Wide angle of divergence

Create aesthetic domes/genu on each side typically with intradomal sutures, bring the two domes into proximity with interdomal suture, correcting the angle of divergence, and treat residual lateral crus convexities which are common in this condition

Parenthesis Tip

Vertical orientation of LLC

Re-orient the axis of the lateral crurae, using inferiorly laced lateral crural struts

Bulbous Tip

Wide lateral crurae (cephalo-caudal)

Cephalic trim or other maneuvers to reduce cephalic excess

Alar rim grafts (also called alar contour grafts) are placed along the rims in narrow pockets to create straight appearing ala from below and to help prevent retraction of the ala.

CORRECTION OF NASAL TIP DEFORMITIES

Finally, the nasal tip is addressed. Tip projection is dependent on the inherent characteristics of the medial, middle and lateral crurae of the LLC; the caudal septum prominences; and suspensory ligaments. Projection can be adjusted by altering these in strategic fashion. The lateral crurae and the combined paired medial crurae form legs of a tripod which supports the tip. Tip projection can be decreased by shortening the legs of the tripod. A number of techniques allow this. If increased nasal tip projection is desired, extrinsic support must be provided to the tip. All of the following contribute extrinsic support to the paired medial crurae, which together form the anterior leg of the supportive tripod: columellar strut grafts, septal extension graft and crural-septal sutures. Cephalic trim may also increase tip projection or rotation. Interdomal Sutures

Also called “Dome Binding Sutures.” Placed between domes of the LLC to bring them together

Transdomal Sutures

Can refer to suture placed between domes posterior to the genu

Medial Crural Sutures

Placed between medial crura, often to secure a columellar strut or septal extension

Crural-Septal Suture

A suture placed from the medial crurae to the septum

Columellar Strut Graft

Placed between the medial crura for extrinsic support

Onlay Tip Graft

Cartilage graft placed over the domes which provides projection and shape

Shield Graft

Cartilage graft placed along the infratip lobule extending anteriorly above the natural level of the dome peaks, to provide projection and tip definition

COMPLICATIONS

Complications of rhinoplasty are rare and are most commonly aesthetic in nature, but other, more significant complications may arise. Bleeding is next most-common and usually related to turbinate treatment, septal tears or osteotomies. Septal hematoma occurs with bleeding between the two leaves of septal mucosa. Septal hematoma can lead to loss of integrity of the septal L strut, particularly if accompanied by infection. The end result here is saddle nose deformity. Fortunately, infection is rare, with MRSA being the most common pathogen. The most-dreaded complication is a CSF leak, caused by disruption of the perpendicular plate-attachment at the cribriform during septal harvest. Confirmatory testing for beta-2-transferrin can aid the diagnosis. Clinically, symptoms include headache and watery rhinorrhea. Septal perforation can occur in the setting of bilateral adjacent mucosal tears. Patients will typically complain of crusting, whistling and bleeding. This complication is difficult to correct, but depending on the size, it may be treated with either local flaps or allograft. | Dr. Hein is a PGY-4 resident at Duke University Medical Center, Durham, N.C.; Dr. Marcus is Division of Plastic Surgery chief at Duke University Medical Center and president of the Rhinoplasty Society. Plastic Surgery Resident | Winter 2018

From the beginning

Hofstra/Northwell residency: How to build a program By Jim Leonardo Armen Kasabian, MD, doesn’t take “No” for an answer – particularly where residency training is concerned. As system chief of plastic surgery at Northwell Health and residency program director at the Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Dr. Kasabian has been the driving force behind the “disruption” of residency training, while nearly singlehandedly constructing the program at his institution. The Hofstra/Northwell residency program involves three major institutions: North Shore University Hospital in Manhasset, Long Island; Long Island Jewish Medical Center in New Hyde Park, Long Island; and Lenox Hill Hospital, which merged with Manhattan Eye and Ear Hospital, in Manhattan. Dr. Kasabian was a 17-year veteran of the New York University (NYU) School of Medicine, where he served as chief of microsurgery, and assistant chief of plastic surgery at Bellevue Hospital (both in Manhattan) when he decided to follow a senior colleague to Staten Island University Hospital, and to a new division of plastic surgery. “Being new, there wasn’t that much to the new division,” he says. “However, SUNY Downstate Medical Center in Brooklyn asked to send a resident to Staten Island. The residents liked it so much that after a year, Downstate sent two. But then that program closed.” As with many things, timing is everything. Around this time, Staten 12

Plastic Surgery Resident | Winter 2018

Island Hospital merged with North Shore-Long Island Jewish Medical Center (NSLIJ), and the chief of surgery named Dr. Kasabian chief of the plastic surgery system. “I thought: This is a good time to start a new residency program; we’re integrated with these other big hospitals,” he says. “I came back to NSLIJ and started work on the program in October 2010; by May 2011, I’d submitted an application for the residency program. By August, we had our site visited – and by October 2011 we received approval. Today, when you count all the medical residents, pediatric residents, OB/GYN and plastic surgery, we’re the second- or third-largest medical education program in the country.”

A REMARKABLE TURNAROUND

By any measure, the timing of this turnaround was extremely rapid, Dr. Kasabian notes. But circumstances helped create a favorable environment. “It was almost an ideal situation to set something up – there was such a large clinical volume,” he says. “At that time, we had 17 hospitals with no plastic surgery residency, which didn’t make any sense. NSLIJ (which has become part of and renamed Northwell Health) includes 23 hospitals, the Zuker school and The Feinstein Institute for Medical Research. “When I first came here, everyone told me I’d never be able to start a residency here; I was told that it’s too hard and there’s not enough interest,” Dr. Kasabian adds. “I thought: ‘This doesn’t make any sense.’ During my 17 years at NYU, residents were the most important part

Armen Kasabian, MD

of a plastic surgery department. It was important for teaching and research, for satisfaction for the faculty – and it was good for patient care. How could anyone say that a program wouldn’t work at NSLIJ? They said, ‘You’ll see, you won’t be able to do it.’ ” Time often separates fact from fiction – which, in this case, means Dr. Kasabian’s analysis was the correct one. “Now that the program’s here, if one of the staff in an affiliated hospital doesn’t have a resident, I get a phone call: ‘Where’s my resident?’ Now they look for residents to help them with a case or take care of a patient.” What Dr. Kasabian has done at Hofstra/ Northwell is nothing short of remarkable, according to Associate Program Director Neil Tanna, MD, “considering that the area already has traditional programs such as NYU, New York Presbyterian (Cornell-Columbia), Montefiore and Mount Sinai. Adding this program

and showing the justification by demonstrating the opportunities present in this geographic location – and then putting together faculty that are committed to the education of these residents – is an incredible feat,” he says. “It’s a testament to his character in the pursuit of education.” ASPS President Alan Matarasso, MD, clinical professor of plastic surgery and private practitioner who works with Hofstra/Northwell residents, says the program’s unique not only for the rapidity and efficacy with which it was created, but also because it provides for residents a wide clinical exposure – including a county-hospital rotation; access to a “bioskills” lab; comprehensive immersion into gender-reassignment surgery; and international mission trips that focus on cleft lip and palate repair. It also boasts a strong “visiting professors” program that attracts the brightest names among international plastic surgery, he says. According to Dr. Tanna, major strengths of the program lie in its incarnation as a high-volume program that gives residents wide exposure to clinical plastic surgery while maintaining a strong emphasis on education and learning. “We’re able to utilize those strengths through the strong, clinical exposure that results from the diversity of the faculty and of the training sites,” he says. “Each of the three different training sites presents a large number of faculty – there are several at each – and each site has a different clinical area of excellence. “So throughout these different training sites, we have different faculty and the residents are able to see the full breadth of plastic surgery – including microvascular, aesthetic, hand and pediatric craniofacial surgery,” Dr. Tanna notes. “The beautiful thing is, because there are different training sites, the residents who train at each see how things are done by different providers; they see different ways to perform microvascular breast reconstruction, head-and-neck recon, cleft palate and facelift, for instance. When you have diversity, you have more exposure; it’s

the numbers. Broader exposure – that’s where the clinical strength lies.” Its diversity isn’t limited to O.R. time, Dr. Matarasso notes. “If residents are interested in full-time academic career, they’ll have a lot of mentorship; if they’re interested in private practice, they’ll have a lot of mentorship. If they’re interested in research or publications, they have the exposure as well,” he says. “Dr. Kasabian’s trying to carve-out dedicated research time – which most programs don’t have, but some have a block of time for you to do research. Regardless, they’re getting academic and private practice exposure – and in all core areas of plastic surgery.”

RESIDENT APPRECIATION

Though the program is in its first year, residents already have opinions on its efficacy. Hofstra/Northwell PGY-4 resident Benjamin D. Schultz, MD, says the program has everything a well-rounded resident could ask for. “We do a lot of breast reconstruction microsurgery, and we’re one of the few centers where the plastic surgeons still do all of the major head and neck reconstruction,” he says. “At least twice per week we do mandible reconstruction with free fibulas, and tongue and pharyngeal reconstruction with radial forearms and ALT flaps. Not many other programs have plastic surgeons doing the reconstructions; we do it every week.” He also lauds residents’ exposure to aesthetic and cosmetic surgery. “We work at Lenox Hill-Manhattan Eye and Ear, which is renowned as a major center for aesthetic surgery in the country,” Dr. Schultz says. “We work with many of the big names in plastic surgery, who take the time to teach us their techniques. We spend a full calendar year – though spread over three years – doing cosmetic surgery nearly exclusively that whole time. It’s a fantastic training ground.” Hofstra/Northwell PGY-5 resident Mark Fisher, MD, says the depth – and balance – of the program is, nationally, second to none. “This is a program where we get all the best of both worlds, in a sense. On one hand, we are immersed in extremely strong clinical training, during

which we’re exposure to world-class faculty – from both private practice and academic backgrounds and experience,” he says. “On the other, we’re exposed to microsurgical reconstruction from the experts – and they often come from different parts of the world through the visiting professor program, which broadens our exposure as residents. And, we’re surrounded by co-residents who are more friends and family than they are coworkers – which makes going to work fun. Finally, we’re in New York City; what could be better for young plastic surgeons?”

HELPING THE LESS FORTUNATE

In addition to producing highly trained plastic surgeons, the Hofstra/Northwell program has the added benefit of reaching part of the less-fortunate population that otherwise might not have access to medical care – and residents who might not have access to cases. “Some of the patients are clinic patients and may not have the insurance to see a private physician,” Dr. Kasabian says. “We have a significantly sized, full-time faculty and we see everybody now; we don’t turn anybody down. Unfortunately, there still are patients who we can’t get to, because we don’t have enough residents. “However, being able to help this much wasn’t possible before,” he adds. “When the main concern is paying the bills, some plastic surgeons will say: ‘I can’t see the patient; they don’t have insurance.’ But we take care of it. It’s that much more rewarding for faculty because we’re teaching residents while helping an underserved population. “Taken together, our program has made a great impact on patient care – and on the faculty, in addition to the residents,” Dr. Kasabian says. “I’ve always thought residents stimulate things, ask you questions – and by teaching them, we continue to learn. It’s good for patients, for faculty and for training the next generation of plastic surgeons.” |

Plastic Surgery Resident | Winter 2018

University of Texas Health San Antonio: A long tradition of excellence in reconstruction, paired with exceptional opportunities for residents By Efstathios Karamanos, MD; Julie Ferrauiola, MD; & Kelly Kafka, MD History • The Division of Plastic and Reconstructive Surgery at UT Health San Antonio has a long tradition of excellence in reconstruction following oncologic resection and traumatic injuries. The division has been accredited since 1998. • It is the only plastic surgery residency program in San Antonio (seventhlargest city in the United States) and has referrals coming from all of South Texas. • It is an independent residency program accepting two residents per year. • 35 residents have graduated and are currently in practice around the United States, both in academic and private practice. • It has successfully placed former residents in outstanding fellowships – such as microsurgery at UT MD Anderson, and craniofacial at UCLA. Leadership • Howard T. Wang, MD, Professor of Plastic Surgery and Otolaryngology, Division Chief and Program Director of Plastic Surgery Residency • Amita Shah, MD, PhD, Assistant Professor of Plastic Surgery, Associate Program Director • Peter T. H. Wang, DMD, MD, Director of Center for Reconstructive Pediatrics • Robert C. Lyons, MD, Chief of Surgery, Chief of Plastic Surgery at South Texas Audie Murphy Veterans Hospital

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• David Person, MD, Hand Center of San Antonio and Fellowship Program Director for the Hand Fellowship for UT Health San Antonio National Leadership • Division members, under the leadership of Dr. Howard Wang, have held numerous positions in several plastic surgery associations. Dr. Wang has held in recent past the co-chair position of the ACAPS/ASPS Curriculum Development Subcommittee for the Plastic Surgery Educational Network and is chair of The PSF Visiting Professor Subcommittee. Clinical Experience • The division is dedicated to providing the best educational experience possible in the art and science of plastic surgery. • The ethos of the program is to produce caring, competent and well-educated practitioners to advance the art of plastic surgery in the academic and private-practice setting. • We utilize multiple sites to achieve the widest exposure possible to the entire scope of plastic surgery. The flagship of the program is the University Hospital in San Antonio, a Level I Trauma Center. The full range of plastic surgery is performed in this hospital, with particular emphasis on reconstructive surgery of oncologic defect and traumatic injuries. UT Health San Antonio Plastic and Reconstructive Surgery Residency performs a significant amount of microsurgical reconstruction, including head and neck surgery; neuro; lower-extremity reconstruction; and reconstruction of

the breast. A significant amount of orthoplastic surgery is performed here, with emphasis on soft-tissue coverage of the upper- and lower-extremity, nerve transfer and repair, as well as treatment of tendon injuries and hand fractures. • The Children’s Hospital of Methodist provides a myriad of craniofacial surgery. Cleft lip and palate surgery, congenital anomalies, pediatric craniofacial surgery and cosmetic surgery is performed here under the direction of Dr. Peter Wang. • The Audie L. Murphy Memorial Veterans Hospital serves the veterans of the South Texas. A multitude of general plastic surgery and dermatology reconstruction is performed here. • The Hand Center of San Antonio provides the residents with a comprehensive experience in hand surgery. • The cosmetic rotation during the chief year of residency offers residents the opportunity to perform a large amount of cosmetic surgeries with private practice surgeons from around the city. Residents graduate with a wide range of cosmetic experience, including facelifts and blepharoplasties. Educational Curriculum • Core curriculum: The didactic component of the training program is designed around a three-year rotating schedule, based on the Comprehensive Plastic Surgery Curriculum. Clinically related cases are also thoroughly discussed for illustrative purposes in a format to help prepare for the ABPS Oral Board Examination.

A Message From Program Director Howard Wang, MD The Plastic Surgery Residency Program at University of Texas Health San Antonio this year turned 20 years old. I have been fortunate to be the program director for the last 11 and division chief for the last 10. What makes our program exciting and unique is that despite being a young program, we’re the only plastic surgery residency program in the seventh-largest city in the country. We’re an independent program that graduates two residents a year for a total complement of six residents. We offer a wealth of training and research opportunities; clinically, our residents experience an impressive depth and breadth of cases and they rotate at a wide-ranging variety of sites, including a Level 1 University Hospital Trauma Center; the Audie L. Murphy Veterans Administration hospital; and at private-practice settings. We have collaborated on research projects with the U.S. • Conferences: A weekly case management conference, plastic surgery grand rounds, a monthly morbidity and mortality conference, monthly mock orals, and weekly hospitalward teaching rounds are held for the residents. • Journal Club/other conferences: Additional conferences are held throughout the year, such as Journal Club and the multidisciplinary hand, breast, craniofacial, tumor and burn conferences, and interactive clinical sessions. • Gross anatomy dissections: Conducted in collaboration with the Department of Anatomy, with specific emphasis on surgical approaches and planning. • Microsurgery: In addition to the scheduled conferences and didactic sessions, residents are provided with an annual microsurgical-training course. This “hands-on” course teaches the basics of microsurgery and allows the residents unencumbered practice sessions. Formal evaluation and instructions are provided. The microsurgery lab is available at any time.

Army Institute of Surgical Research, The University of Texas at San Antonio and multiple departments within our institution. Our graduates have gone on to careers at academic centers such as University of California-Davis, University of Kansas and Oregon Health & Science University. Being in San Antonio, we’ve had the privilege of training military plastic surgeons. Three out of four of the current complement of plastic surgeons at Brooke Army Medical Center have graduated from our program.

We’ve also trained one of the leading plastic surgeons in the nation in the field of transgender surgery. Our nursing staff, advanced practice providers, faculty, staff and residents are a family – and this tight bond was what allowed our program to succeed, for example, in this year’s Residents Bowl held during Plastic Surgery The Meeting in Chicago. I look forward with optimism as we go forward in developing a world-class center of excellence in plastic surgery. |

• Hand conference: Held in the UT Health San Antonio Long School of Medicine every Tuesday morning under the direction of David P. Green, MD. • Travel to local and national meetings: Residents are provided an opportunity and encouraged to participate and present at local and national meetings. For example, our residents recently won the ASPS Resident Bowl at the 2018 ASPS/ PSF/ASMS Annual Meeting. Participation in leadership development is encouraged and supported. Research • Research is considered one of the three pillars of the residency program, along with patient care and development of surgical skills. Residents are encouraged to become involved in research at all phases of their residency. A faculty member will become his/her mentor early in the residency, and help plan and initiate a project. This team will then see the project through the initial stages; the funding aspects; the procurement of data; the interpretation of results; and, finally, the presentation and submission of a manuscript.

• In the division, residents continually submit multiple abstracts and papers to different national meetings and journals. Dr. Shah has protected research time for both clinical and basic-science projects. Dr. Howard Wang had previously worked in basicscience research as well – through which he’s received grants from NEPS/PSF – and he has published in journals such as Tissue Engineering. The division continues to emphasize research as a cornerstone of academic development – and it encourages all residents to participate, regardless of future plans. | Dr. Karamanos is a PGY-6 resident, and Dr. Ferrauiola and Dr. Kafka are PGY-8 residents, in the University of Texas Health San Antonio Division of Plastic Surgery.

Plastic Surgery Resident | Winter 2018

Q&A WITH AMITA SHAH, MD, PHD Plastic Surgery Resident strives to provide readers with career advice to help them advance in their profession after residency by sharing insights on how to create their desired career path.

In this installment of Faculty Focus, we present ASPS member Amita Shah, MD, PhD, San Antonio, assistant professor in the Department of Surgery, Division of Plastic & Reconstructive Surgery, at UT Health San Antonio; and associate program director and the medical director for the UT Health Plastic Surgery Outpatient Clinics. Dr. Shah, who’s deeply interested in breast reconstruction and reconstruction-related microsurgery, completed her MD and general surgery residency at UT Health San Antonio, and her plastic surgery residency at the University of North Carolina Chapel Hill. She also has earned a Doctor of Philosophy degree in biomedical engineering at the University of Texas at San Antonio. Dr. Shah’s research focus is engineering and regenerative medicine, with emphasis in biomaterials – and she’s striving to improve the quality of decision-making by patients undergoing breast surgery, in addition to other breast-cancer patient advocacy. Dr. Shah says she values the help and guidance that her mentors provided her during her training years, and strives to provide that to the young plastic surgeons with whom she comes in contact. In this Faculty Focus, she tells residents of the work she puts into carving-out time each day for herself and for her family – a very important goal, and one not to be overlooked, she maintains – and how organizational work with ASPS broadens her horizons in the specialty.

PSR: HOW DID YOU PREPARE YOURSELF TO GET INTO A COMPETITIVE RESIDENCY? Dr. Shah: I didn’t do anything specifically to get into a competitive residency; I just did what I thought was fun and interesting, and those activities ended up helping me get to where I wanted to be. I spent three years between my PGY-2 and PGY-3 years in general surgery – doing research at UT Health San Antonio and the U.S. Army Institute of Surgical Research, in the field of tissue engineering and regenerative medicine. Eventually, I earned my PhD in biomedical engineering. I also created and ran a pre-clerkship surgery course for second-year medical students during that time, which was very rewarding and educational for me.

PSR: HOW DID YOU CHOOSE THIS SPECIALTY? Dr. Shah: I’ve always known what interests me, but I didn’t know that it fit with plastic surgery – until I conducted research during general surgery residency. The plastic surgeons utilized the scaffold we developed, and seeing the potential applications of my research in plastic surgery piqued my interest. I subsequently spent time with them clinically and enjoyed the creativity and innovation that plastic surgery allows us.

PSR: CAN YOU CITE SPECIFIC WAYS YOUR RESIDENCY HAS IMPACTED YOUR CAREER? Dr. Shah: During my plastic surgery residency, I was taught process-improvement, administration, leadership, how to be a surgeon-scientist and plastic surgery, as well as the business of medicine. Because of this training, I’ve been able to work as the medical director for our clinics; build and work with multidisciplinary teams; institute new programs and services in the hospital and clinic; revamp our academic conferences; execute personnel management; improve our inpatient and outpatient workflows; and start building our plastic surgery research program at UT.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Shah: Mentors are very important! My mentors helped me not only with difficult clinical cases, they’ve also helped me with difficult leadership situations that I had no idea I would encounter as an attending. Having the ability to talk to a 16

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person who’s been through similar situations – and has seen the light at the end – is invaluable. Mentors also help guide me as I build my research lab.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Shah: My involvement with these societies and committees has given me the opportunity to meet other plastic surgeons I wouldn’t have met otherwise. Their different perspectives and ideas have inspired and informed me as we work to grow our division. It’s also given me unique opportunities – such as when I participated in the PRS Facebook Journal Club as one of the authors of the featured manuscript.

I had to go on medical leave during my chief year of general surgery. My attendings, co-residents and their families helped me and my family through that difficult time. PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Shah: Work ethic and a growth mindset. When a resident has a love of learning and the grit to back it up, I have yet to find their limit.

PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Shah: I have to work at – and be deliberate about – balancing my time every day. I get up early in the morning and work when my family’s asleep, so at the end of the day I can spend time with them. My son is 8 years old, and we like to play piano duets and board games together. My husband and I make it a point to spend time with each other and talk every night, even if I get home late. During weekends when I’m not on call, I play piano at my church for the worship service. I’ve been playing piano there for 20 years, so they’re like my family and they help keep me grounded.

PSR: WHAT WAS YOUR GREATEST NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE IT? Dr. Shah: I had to go on medical leave during my chief year of general surgery. My attendings, co-residents and their families helped get me and my family through that difficult time. They covered call, visited me in the hospital and at home, encouraged me, made sure I was OK when I came back to work, and never once made me feel like I was burdening them. I will always remember and treasure the camaraderie and support I received during my general surgery residency.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Shah: As a reconstructive surgeon, it’s rewarding to see my patients get back to the lives they desire. I love talking with my patients and their families, and having continuity of care with them. I think San Antonio has the best patients – they make me feel like part of their family. I also enjoy that plastic surgery cases are not cookie-cutter, and that my patients participate in their plans of care.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Shah: Our team is challenged daily by inefficiencies we see in the inpatient and outpatient settings, but fortunately, I find it fun to implement process-improvement projects and see the results. For example, we’ve implemented a system which has cut in half the time to surgery for our trauma patients. We’ve adjusted the clinic templates and workflow to improve patient access while cutting wait times. A current project we’re working on is the utilization of mobile technologies for inpatient workflow, to cut down on redundancy and improve efficiency and communication. There’s always another project to do, so I’m also trying to learn when to say “no” and delegate more often, so I don’t overload myself.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Shah: I enjoy working with residents to come up with new and interactive sessions for our weekly academic conferences. We’ve done nipple-tattoo workshops; wellness activities at the batting cages and bowling alley; art class; microsurgery workshops; quiz bowl sessions with the “Eggspert;” and we’ll soon launch a plastic surgery Spanish class for our conferences. We held our first Breast Reconstruction Awareness Day event this year – and, of course, we sent our residents to the 2018 ASPS Residents Bowl this year for the first time. (Editor’s note: They won.)

The other part I like about working closely with the residents: I get to know them well. We develop our educational programs based on helping each resident develop their own interests and build on their strengths. I tell them that if they think research is boring, it’s because they haven’t yet researched a question that interests them.

PSR: WHAT’S YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Shah: Go to clinic! There’s so much to learn there. I was given this advice when I was interviewing for residency, and I’m glad that I listened to it.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN …” Dr. Shah: I saw the picture of the mouse with a tissueengineered ear on its back. |

Plastic Surgery Resident | Winter 2018

SanAntonio Where Past Meets Present – And Food, Drink And Entertainment Abound By Victor Stams, MD, & Julie Ferrauiola, MD

an Antonio is commonly referred to as the Alamo City, and its known as the nation’s seventh largest city. It’s also known as the home of the NBA World Champion San Antonio Spurs – and, since the close of Plastic Surgery The Meeting held Sept. 28-Oct. 1 in Chicago, as home of the 2018 National Plastic Surgery Resident Bowl champions UT Health San Antonio! As one of the largest cities in Texas, San Antonio serves as the destination for a wide array of tourists during the year. On the surface, the most common attractions include the River Walk, The Alamo, and Sea World, but a deeper look reveals the city has a hearty number of fun diversions – and quite a few little-known facts. 18

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THE PEARL DISTRICT

The Pearl Brewery District is a rehabbed area of downtown San Antonio bursting with (relatively new) shops, eateries and entertainment options. Those who develop an appetite while walking about will find themselves facing plenty of hunger-slaying options: For adventurous eaters and Instagram-worthy scenery, Cured is the place. For excellent Mexican fare, find a table at La Gloria. Steak and steakhouse lovers can steer themselves to the Boiler House, while anyone with a hankerin’ for “a simple, noodle-focused menu” will find that at Tenko Ramen. Swing by The Modernist for a drink. Jerry and Olaf are two of the best cocktail artists in the city, and they opened this mid-century modern bar – reminiscent of your parent’s basement – with some

of the best offerings in the city. Just tell them your poison, and they’ll make you a custom cocktail to suit your tastes. Finish the night with a view of the San Antonio skyline at Paramour – a great rooftop bar with snack options from chef Jason Dady (an Iron Chef Gauntlet contestant and local culinary master). If you have a good part of the day and want some culture: • Grab breakfast at Bakery Lorraine at the Pearl – and then go visit the farmer’s market that sets up shop every Saturday and Sunday year-round. • Head over to the San Antonio Botanical Gardens. They just did a major renovation and added more beautiful exhibits, with a bonus: They have a life-sized chess board!

• Grab some lunch at WD Deli (their BLT is magic). • The McNay Art Museum (also known simply as “The McNay”) is the home of Ohio-born heiress Marion KooglerMcNay, the first collector of modern art in South Texas. This eclectic collection includes more than 20,000 works. • If you need a place to recharge after all this, or you figure that a little “Zen” might be good for your mood, visit The Japanese Tea Garden, which came into being after philanthropist George W. Brackenridge donated money to convert a rock quarry – and so did Emma Koehler! Who is Emma Koehler, you may ask?

A STORIED HOTEL

If you stop for a drink at the Hotel Emma bar and order a “3 Emmas,” make sure you learn the story behind the hotel and how mistresses, murder and beer shaped one of San Antonio’s mostpopular downtown destinations. For those who won’t be in San Antonio anytime soon but still want to know the story, the legend goes:

First, and most prominent, is Emma Koehler, who took over Pearl’s Brewhouse after her husband, Otto, was killed in 1914. She successfully led employees through the Prohibition Era before passing away in 1947, according to Hotel Emma’s website. Employees at Hotel Emma, named after Koehler, honored her (in 2017) during Dia de Los Muertos. An altar at the hotel for her is full of flowers, candles, photos and skulls. “Gone but not forgotten,” reads a Facebook post from the hotel. But there are also two other Emmas in this story… Four years before she took the reins of the brewery over, Koehler was in a car accident and required full-time care at home. Her husband, Otto, hired a home nurse, who was also named Emma. This Emma, however, went by Emmi, according to the website.

Otto Koehler struck up an affair with Emmi and her friend, the third Emma. This Emma was tall and blonde, according to legend. Otto set up the pair of Emmas in a house on the city’s South Side. But not everything was paradise. On Nov. 12, 1914, Otto visited the house and some sort of argument occurred. The taller, blonde Emma shot him dead, according to the hotel’s historian. “I’m sorry, but I had to kill him,” she told police. She was charged with murder, but fled to Europe to help as a WWI nurse. Four years later, the tall Emma returned to the Alamo City and was found not guilty by an all-male jury, according to the legend. Later, she married one of the jurors. As for nurse Emma? She got married and wasn’t heard from again. Hotel Emma was named after Emma Koehler before opening in November 2015. – From mysanantonio.com

THE RIVERWALK/DOWNTOWN EXPERIENCE

The Alamo is one of those “must-see” tourist attractions that, while perhaps not visually breathtaking, people will endeavor to visit (if, for no other reason than to render moot the inevitable and

continued on page 29 Plastic Surgery Resident | Winter 2018

We don’t plan to rest on the advocacy laurels of 2018 By JT Stranix, MD Resident Ambassador, PlastyPAC Board of Governors

WHILE THE 2018 MIDTERMS DID NOT BRING THE “BLUE WAVE” SOME analysts expected, the power dynamics in Washington, D.C., definitely shifted for the 116th Congress. Throughout the election, with the congressional majority at stake, a number of candidates resorted to personal attacks on their competition, which generated a negative atmosphere in advance of the Nov. 6 election. Considering the recently contentious political environment, I thought it would be a good time to reflect on the positive impact exerted over the past year by the congressional advocacy efforts of ASPS and PlastyPAC. • We conducted the second annual ASPS Advocacy Summit, where 75 physician members joined more than 13 additional stakeholders in Washington, D.C., for political- and policyfocused programming, networking and a day on Capitol Hill advocating for the specialty in 83 congressional meetings. • Our members urged Congress to advance a measure that would repeal the Independent Payment Advisory Board (IPAB), which would have had unprecedented power to cut Medicare spending. Following the advocacy efforts of the House of Medicine, President Trump in February signed the repeal of IPAB. • We worked closely with Sen. Tammy Baldwin (D-Wis.) prior to her introduction of the Ensuring Lasting Smiles Act, which would require coverage of congenital anomalies from birth. Sen. Baldwin was committed to introducing the bill with bipartisan support, and ASPS helped secure Sen. Joni Ernst (R-Iowa) as the Republican lead sponsor of the bill. 20

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• Our efforts increased bipartisan support and co-sponsorships for an increase of Medicare-funded, graduate medical-education residency slots. • We advocated for the passage of the Ambulatory Surgical Center (ASC) Quality and Access Act, which would provide higher Medicare reimbursement to ASCs. • We worked with the Health Coalition on Liability and Access (HCLA) to advocate for passage of the Good Samaritan Health Professionals Act, which would extend liability standards under the Volunteer Protection Act of 1997 to licensed health professionals who volunteer in another state during a disaster. • We advocated for the passage of the MISSION ZERO Act, which would provide grants to civilian hospitals to hire activeduty military trauma surgeons to help fill a gap in care identified by the National Academies of Sciences, Engineering and Medicine. We’ve been able to make favorable progress over the past year – and we will continue to advocate for our specialty’s best interests in a positive and productive manner through any type of political atmosphere. Having noted that, it seems appropriate now to bring some of our primary advocacy areas of interest for the upcoming year. In 2019, we will: • Focus on building federal support for stronger health insurancenetwork standards and work to shape congressional education surrounding out-of-network reimbursement. • Advocate passage of legislation that will require insurance coverage of congenital anomalies. • Seek to provide Medicare beneficiaries with the choice to privately contract with physicians. • Advance additional medical-liability reform measures that will protect physicians who volunteer during disasters, and will cap noneconomic damages. • Continue to push for increased GME slots and funding for specialists. • Ensure that ASCs remain a viable alternative to hospital outpatient departments by championing policies that implement adequate reimbursement for these cost-effective facilities. I hope you exercised your right to vote by casting a ballot Nov. 6. Please feel free to contact me with comments, questions or additional areas of interest for our future advocacy efforts. | Dr. Stranix is Chief Resident in New York University Langone Health’s Wyss Department of Plastic Surgery. He can be reached at jtstranixmd@gmail.com.

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Things, secrets and tips I wish I had known residency

BEFORE

Three questions you should tackle By Umbareen Mahmood, MD

felt confident in my technical and leadership capabilities, and I looked forward to the approaching year as the time for me to refine my skills.

Questions unasked – and unanswered

However, chief year was not the glorified year of cherry-picked cases and leaving the hospital early to make it to the gym or dinner with friends; rather, it was a time of trying to manage residents, attendings, patients and multiple hospital services – and of trying to make sure everyone was happy and taken care of (I blame this mentality on being female and a perfectionist).

he day was Thursday, March 18, 2010, and I stood with an envelope in my hands – in front of my entire Dartmouth medical school class, professors, attendings, residents, staff and countless other spectators – wondering who came up with the horrible idea of having to discover your fate with an audience to witness your elation or despair. My hands mechanically took over, and I somehow managed to utter “University of South Florida, Plastic and Reconstructive Surgery” into the microphone. The months after were a blur, and the next thing I knew, it was 2 a.m. Saturday at Tampa General Hospital, and a nurse on the floor was paging me to ask what I wanted to give the 63-yearold male one day status post-APR for pain (of course, I had to look up what “APR” stood for, followed by consulting Epocrates for medication dosages). Somehow, intern year came and went, and the process of being an effective and knowledgeable resident became increasingly fluid. There were times it felt like the five years to make it to the sixth year of residency felt impossibly far away – but the next thing I knew, I was a chief resident entering my final year. I

Plastic Surgery Resident | Winter 2018

The one monumental question that had always lingered in the shadows of my mind but had been ignored – as I was too busy trying to be a good resident and learn as much as possible – was: “What happens after residency?” This is the question I was largely unprepared to answer – and arguably one of the most important. After having talked to many others in my shoes then, and who reflect on their past experiences now, many (including myself) had very little instruction on how to prepare for life after residency. During my chief year, I had received pearls of advice that I often repeat to myself to this day. Now, they've become my 2 cents for soon-to-be grads.

Three main questions

One of the best pieces of advice I received from a highly respected and successful mentor was: In order to help sortout life after residency, you need to ask yourself three main questions: Where do you want to be? What do you want to be doing (i.e., hand, craniofacial, cosmetic, reconstruction)? Finally, how do you want to be doing it (i.e., academic, private practice, hospital employed, VA, etc.)? I had several appealing options in Florida and drove myself (and my family, especially my tough-love orthopedic surgeon brother)

There’s a good chance your first post-grad job might not be your last. The goal is to learn as much as you can and come out relatively unscathed, if things don’t work out. crazy trying to figure out what I should do. I then realized that none of the options under consideration aligned with the first question: Where did I want to be? For me, that was unequivocally back home in New York. Unfortunately, no one in my Florida network had any real connections in New York, nor did they know the medical landscape there. So I scoured online job postings, the ASPS JOB Board and the classifieds in Plastic Surgery News; I googled practices in New York; and I sent countless emails and cold-called countless practices to ask if they were looking to hire a soon-to-be freshly minted plastic surgeon. The stress mounted with the feeling that I had to make the “right decision” – to which I would be held forever. However, several veteran surgeons one night during dinner all began sharing horror stories of their first experience out of residency – and their subsequent experiences, as well. And I suddenly felt a huge relief in realizing that for better or worse, there’s a good chance the first post-grad job might not be the last. The goal is to learn as much as you can and come out relatively unscathed, if things don’t work out (this is where I emphasize that having a medical attorney read your contract, and look over such items as a non-compete, is absolutely crucial).

As a recent graduate only two years out of training, it’s true what everyone says – you learn a tremendous amount about how to really be a surgeon (no more cutting on lines carefully drawn by your attending!); how to manage patients the way you want; and how to carve-out a career that fits your life, the latter of which especially is a constantly evolving process.

Things I wish I could tell my chief-resident self: •R elax and take a deep breath. No one has it totally figured out – not even surgeons who’ve been practicing for 20 years. •Y ou are your best champion and advocate. You cannot expect anyone to help you figure out your future, you have to take a proactive role in finding opportunities – and determine what is best for you. •T alk to everyone. I have learned something from every single person I have spoken to: surgeons, attorneys, accountants, reps, HR, office managers, secondary providers, the list is endless… •E ducate yourself. Start understanding what different types of malpractice are; what a “non-compete vs. restrictive covenant” is and how that will affect you; what comes after a fellowship that you may gain; insurance 101; etc. • Th e dreaded Boards are manageable. This is particularly true if you have a solid study plan for the Written Boards and structure your time as you juggle post-grad life, including a new job and a possible cross-country move. Also, start thinking early about where your cases will come from, as you concurrently collect for the Oral Boards. In the end, the best-laid plans may not work out initially – there undeniably will be ups and downs, successes and failures – but at the end of the day, you are a well-trained plastic surgeon. And if you can make it through that, you can tackle anything. Dr. Mahmood is in private practice in New York. She can be reached at DrUMahmood@gmail.com. |

Plastic Surgery Resident | Winter 2018

Put your plastic surgical vocabulary skills to the test! Hand and Wrist

By Steven D. Kozusko, MD, MEd 1

11 12

14 15 16

ACROSS

3. Eponym for the axial flap used to treat volar oblique thumb tip injuries with exposed bone 5. Infection risk with leech therapy 6. Most commonly fractured carpal bone 7. Forced flexion of a finger held in extension results in this injury to the finger 8. Expansile and locally destructive chondrogenic tumors arising from aberrant cartilaginous foci within the medullary canal 9. What sort of finger fracture pattern results from torsion 11. Eponym for the test used to detect De Quervain’s tenosynovitis 13. Treatment for amputation of the thumb at the CMC joint 14. Most common indication for treatment of a metacarpal neck fracture 16. The principal pathologic feature in rheumatoid arthritis 17. Most important structure to repair in finger replantation for survival 18. Eponym for intra-articular fracture of the first metacarpal base 24

Plastic Surgery Resident | Winter 2018

DOWN

1. Benign NV tumor found most commonly in the fingertip with cold intolerance 2. Eponym for the flap used to treat dorsal oblique and transverse fingertip amputations 3. Lateral antebrachial cutaneous nerve branches off of this nerve 4. Treatment for a subungual hematoma 9. Hand anomaly most associated with Apert syndrome 10. An appropriate treatment for gouty tophi 12. Eponym for an atretic FPL tendon rupture due to a scaphoid osteophyte 15. Most common benign tumor in the thenar eminence

Answer key on page 31

#TheTrend

Drain IQ

A simple – and clean – way to track post-op drain output #TheTrend is a column new to the pages of Plastic Surgery Resident. Plastic surgery residents Jacob Grow, MD, and James Vargo, MD, are “tekkies” who are immersed in trending resources and tech (apps, websites, etc.) available to the plastic surgery community. Through #TheTrend, they will endeavor to spotlight resources with the highest value and greatest potential to plastic surgery residents, that they can help protect a resident’s most valuable commodity: time. These reviews will be specific to plastic surgery – and unbiased, as the authors are free from financial disclosures... “unfortunately,” they say. |

By James Vargo, MD, & Jacob Grow, MD In our last 2018 installment of #TheTrend, we test-drove iFlap, perhaps the most premium smartphone application available to plastic surgery residents. For this issue, we’ve decided to switch gears and focus on Drain IQ – an app that we consider more of a daily driver than a Ferrari or a Lamborghini. It may not have the panache of other apps we’ve reviewed in the past, but it’s certainly practical and carries the potential to boost patient satisfaction (think of it as a nice, reliable 2012 Honda Accord with backup camera and XM radio). Drain IQ is for patients, and designed to simplify the process of tracking post-surgical drain output. The real beauty of Drain IQ lies in its simplistic and user-friendly layout. Patients begin by listing each surgical drain, including a drain label (i.e., drain number), as well as a drain location. The procedure date is also included for each drain log, which allows output to be tracked based on postoperative day. After creating the profile for each drain, users will record the output based on volume (ml), which is auto-timestamped by the app. Times can also be adjusted if recording is delayed. During the recovery period, each drain can be selected with totaled outputs for each day. There is also a free text/notes option for each recorded output to allow documentation of output characteristics such as color,

consistency or odor… God forbid. Drains can also be easily deleted from the log when they are removed from the patient, if done so sequentially. Finally, there’s also a slick “Share My Report” feature that formats the drain-output data in a table which can then be sent via email or text message, if desired, to keep the surgery office up-to-date on the output progress. Of note, there are no identifying features within the table, keeping it HIPAA compliant. Gone are the days of handling crumpled and stained drain sheets that look like ancient hieroglyphics from an Indiana Jones adventure. Our only qualm with the app is that it’s only available for Apple (sorry Android users!), and it also necessitates that your patients actually have a smartphone. On the flipside, it’s completely free and has a clean, intuitive design that requires minimal teaching prior to implementation. Overall, this may not be the sexiest app out there, but it certainly serves a very practical role and gets our stamp of approval here at #TheTrend. Go give it a try! | Dr. Vargo and Dr. Grow are PGY-5 residents at the University of Kansas Medical Center, Kansas City.

Plastic Surgery Resident | Winter 2018

COMPETENCY-BASED TRAINING: A MATTER OF PROFICIENCY / continued from page 7 feedback to the trainee from the attending on operative performance after each individual operative case, has been in use for several years. It tracks the trainee’s progress and will play an important role in resident assessment in the CBPST model. Developing objectives for competency is a challenging task in a specialty as broad as plastic surgery, but this is also underway in conjunction with other institutions.

The general tone of this year is different than I expected. Instead of the intern year being something to “slog through,” it’s obvious that each rotation is carefully selected to advance the end goal of creating competency in plastic surgery. – Elizabeth Moroni, MD PGY-1 UPMC

CBPST has the potential to create a learner-centric training environment with increased transparency, where both trainees and program directors can better-monitor acquisition of clinical knowledge and operative skills. As a trainee, I believe CBPST can provide additional motivation and direction to focus on specific areas of competency while also addressing areas of weakness. The potential to shorten the duration of training will be a strong incentive for trainees, and with modifications to the curriculum, this should be achievable for many trainees – particularly since our colleagues in Canada have been successfully training plastic surgeons in five years rather than six.

Furthermore, the frequent assessments that are part and parcel of CBPST should allow for custom tailoring of curriculum to individual trainees – based on potential deficiencies or to augment specific areas of interest once core-competencies have been attained. There may be challenges during the implementation of CBPST, but this exciting new model is undoubtedly the future of surgical training.

TAILORED TRAINING, INCENTIVIZED EDUCATORS: A RECIPE FOR SUCCESS Elizabeth Moroni, MD PGY-1, UPMC On Feb. 12, 2018, just nine days before rank lists were due, I received an email from UPMC’s Department of Plastic Surgery announcing that the RRC had approved Pitt (as well as BSW, Michigan and the Johns Hopkins programs) to pilot CBPST. 26

Plastic Surgery Resident | Winter 2018

By the time I received this e-mail, my rank list was essentially set. I spent months interviewing and researching programs; I made dozens of pro/con lists; and I was ready for the grueling application process to be over. Having completed all that, this news brought both excitement and concern: If I were to match at Pitt, could I really complete residency training in five years? How will this change the fellowship-application timeline? How will the department support me when the initiative inevitably encounters hurdles over the years of my training? After some in-depth contemplation, I signed the informedconsent document to become a study participant in this pilot program – if I matched. In my opinion, being a part of the CBPST inaugural cohort gives Pitt even more incentive to train me to the best of its ability, since I will now be studied throughout residency (and beyond) to ensure that I become a competent plastic surgeon. Even in the “worst-case scenario,” I still get the status quo six-year training at a well-regarded institution. As an intern, everything is new to me – so it’s difficult to appreciate differences between my intern year in CBPST from the intern year that my upper-level resident-colleagues experienced. Overall, it’s probably pretty similar – we spend a few months on plastic surgery services with the majority of rotations off-service, ranging from anesthesia to neurosurgery to ICU months. However, the general tone of this year is different than I expected. Instead of the intern year being something to “slog through,” it’s obvious that each rotation is carefully selected to advance the end goal of creating competency in plastic surgery. At my regular check-in meetings with Dr. Nguyen, we discuss my progression as we move through the year, as well as what I’ve learned and what I need to focus on for continued improvement. He also takes feedback on my experience and makes changes to rotations, so that my co-interns benefit from my experience – and vice versa. As we advance in training, these meetings will help highlight specific deficiencies/weaknesses, and craft individualized schedules aimed at improving upon those weaknesses. This will likely be a logistical challenge, but it’s one that Pitt believes it can take on while still providing adequate resident coverage to all of our operative services. Being a part of change can be challenging, and CBPST is so new that it’s impossible to predict the shape the program will take in the coming years. As Dr. Nguyen likes to say: “We’re building the plane as we fly it.” Maybe I’ll be ready to graduate in five years; maybe I won’t. At the end of the day, though, I’m excited to be a part of a program that’s introspective – and constantly looking to improve and innovate. Dr. Moroni is one of three CBPST residents at UPMC.

FEW RISKS, BUT PLENTY OF BENEFITS – AND MORE AS TIME PASSES Jordan Blough, MD PGY-1 BSW Health/Texas A&M College of Medicine CBPST represents a new mentality of surgical training – and it makes a lot of sense. It’s the belief in quality over quantity, and that you can be “ready” to operate and make decisions independently at the level of an attending surgeon before a pre-defined amount of time. In Canada, plastic surgeons require five years of training, while in the United States, the mainstream belief is that six years of integrated residency is necessary. There are many highly talented plastic surgeons who trained in Canada, so in theory the extra year is not, in fact, necessary – at least not for every individual. We’re all unique, we each have our own learning curves and we have different levels of commitment and stressors outside of residency. This is why it’s a logical next-step for residency programs to lessen the focus on time and embrace the belief in competency. Dr. Weber, in conjunction with other staff, believes in this route, and they have helped pioneer our class as the first year of CBPST training. Ultimately, the training itself isn’t much different. We still see the same cases – and many of them. The question really becomes: “How many cases are sufficient?,” with the response being: “As many as it takes to be competent.” So how do we know when we’ve become competent? Three words: Feedback, feedback, feedback. I think there are probably many residents who receive feedback only after their monthlong rotation concludes. CBPST entails more granular feedback at an immediate, case-by-case level. I would posit that because competency-focused training is more feedback-intensive, higher-quality training will result. The gain from a single case is likely magnified. I’ve already seen or experienced more rigorous and diligent preparation for each case; feedback during and immediately after every case; as well as self-reflection and study with a clear direction based on this feedback. This, in combination with the opportunity to potentially save a year of time, makes CBPST an attractive option. In addition to specific verbal feedback on each case, residents log each case on Milemarker – rating our level of performance from 1 (essentially assisting) to 5 (performing the case at the attending level, without requiring any direction by the supervising attending). The supervising attending then does the same, rating us from 1-5 for the case. In time, our

performance level and progression can be monitored quantitatively for each individual procedure type. Although we may excel in one area (e.g., breast reduction), we may struggle in another, making clear where we need to strengthen our focus. In fact, we may actually be assigned more case types at which we do not excel. As an intern with limited experience thus far (having recently completed just one of four months of plastic surgery), I’ve just started establishing my initial baseline – rating myself mostly 1s and 2s. We’re just starting to learn how to be surgeons, but I’m excited to track my progress over the next few years, and I’m optimistic that it will facilitate more meaningful and streamlined training. It’s also worth noting that the competency aspect of my training doesn’t necessarily apply to the general surgery rotations in which we participate, so in this respect, my training hasn’t yet differed greatly from standard training. I think the benefits of CBPST increase each year the resident progresses. I expect to truly begin reaping the benefits more next year – and certainly as a PGY-3 and -4. As an attending physician, I no longer will have the benefit of feedback in the O.R. However, I do believe the skills of self-reflection and self-study will have been firmly ingrained throughout the duration of my residency, thereby facilitating continued self-improvement as a practicing attending. I also anticipate that I will be motivated to employ the same teaching tactics and feedback implementation with the future residents I may teach.

LEARNING MORE QUICKLY WITH INDIVIDUALIZED ATTENTION Jesse Payton, MD PGY-1 BSW Health/Texas A&M College of Medicine Competency-based education was a popular idea at the University of Virginia, where I completed medical school training. The thought was that people differ in learning style and speed, and they progress more quickly if their education is individualized to suit their needs. Therefore, it excited me when Dr. Weber talked about changing the education paradigm for plastic surgery from time-based to competency-based. Plastic surgery training duration has ranged in the independent model, and we have very little data to suggest the optimal length for an integrated program. This is likely because operative volume and diversity – as well as individual resident

continued on page 30 Plastic Surgery Resident | Winter 2018

CONSULT CORNER / continued from page 9 patients with thrombocytopenia, unless DIC or bleeding are present.1 Serial exams are required to monitor for compartment syndrome. Again, fasciotomy is unlikely to be required, but a heightened suspicion should be maintained. Bullae can be lanced (but not unroofed) to minimize local inflammatory response and maximize range of motion. Wounds should be irrigated promptly; wet to dry dressings performed as needed; and debridement performed only after demarcation of viable tissue.4

ANTIVENOM Crotalidae polyvalent immune fab (CroFab®, BTF International Inc.) is commonly utilized to treat envenomation from crotalids by binding and neutralizing venom toxins. This is derived from immunized sheep and can halt progression of local tissuedamage and systemic effects, including coagulopathy.1,7 Both acute and delayed hypersensitivity reactions can occur, so concomitant treatment with antihistamines may be required.3 Indications for administration of antivenom are debated. A Snakebite Severity Score has been developed to facilitate decision-making (see Figure 2).9 Scores of 0-3 indicate minimal severity where no antivenom is indicated, though inpatient observation is required.9 Antivenom administration is indicated for scores ≥ 4, starting with four-six vials, ideally within six hours of envenomation.9 Hemotoxicity should be frequently reassessed, with repeat labs one hour after antivenom administration.1 The dose can be repeated within an hour, if initial control isn’t achieved.8 After initial control is established, additional two-vial doses every six hours for 18 hours can be given to limit the chance of recurrence, but this is not required.8 The cost of a single vial of CroFab is 3300 USD. Crotalidae Immune F(ab’)2 (Anavip®, Rare Disease Therapeutics, Inc.) is a new, equine-derived antivenom that may reduce late or recurrent coagulopathy effects of venom.10 North American Coral Snake Antivenin (Equine) (Pfizer, Inc.) is an antivenom for coral snake envenomation approved by the FDA that’s still available in areas, but it’s no longer manufactured.1 ®

RECURRENT COAGULOPATHY The cause of recurrent or rebound coagulopathy or thrombocytopenia is not entirely clear.1,7 Local tissue destruction tends to recur from six to 36 hours after initial improvement, while hemotoxicity tends to recur within two to seven days.1 Thus, while patients can typically be discharged once there’s stability of local changes and hematologic parameters, they must follow-up closely in about two to three days and five to seven days after discharge, for repeat exam and labs.7,8 Patients may require retreatment with antivenom if significant abnormalities are noted.

Plastic Surgery Resident | Winter 2018

FIGURE 2

Criteria Points Pulmonary system No symptoms/signs

Dyspnea, minimal chest tightness, mild or vague discomfort, or respirations of 20-25

Moderate respiratory distress (tachypnea, 26 to 40 breaths/minute; accessory muscle use) 2 Cyanosis, air hunger, extreme tachypnea, or respiratory insufficiency/failure

Cardiovascular system No symptoms/signs

Tachycardia (100 to 125 beats/minute), palpitations, generalized weakness, benign dysrhythmia, or hypertension

Tachycardia (126 to 175 beats/minute) or hypotension, with systolic blood pressure greater than 100 mm Hg

Extreme tachycardia (>175 beats/minute), hypotension with systolic blood pressure <100 mm Hg, malignant dysrhythmia, or cardiac arrest

Local wound No symptoms/signs

Pain, swelling, or ecchymosis within 5 to 7.5 cm of bite site

Pain, swelling, or ecchymosis involving less than half the extremity (7.5 to 50 cm from bite site)

Pain, swelling, or ecchymosis involving half to all of extremity (50 to 100 cm from bite site)

Pain, swelling, or ecchymosis extending beyond affected extremity (more than 100 cm from bite site)

Gastrointestinal system No symptoms/signs

Pain, tenesmus, or nausea

Vomiting or diarrhea

Repeated vomiting, diarrhea, hematemesis, or hematochezia

Hematologic symptoms No symptoms/signs

Coagulation parameters slightly abnormal: PT, <20 seconds; PTT, <50 seconds; platelets, 100,000 to 150,000/mL; or fibrinogen, 100 to 150 µg/mL

Coagulation parameters abnormal: PT, <20 to 50 seconds; PTT, <50 to 75 seconds; platelets, 50,000 to 100,000/mL; or fibrinogen, 50 to 100 µg/mL

Coagulation parameters abnormal: PT, <50 to 100 seconds; PTT, <75 to 100 seconds; platelets, 20,000 to 50,000/mL; or fibrinogen, <50 µg/mL

Coagulation parameters markedly abnormal, with serious bleeding or the threat of spontaneous bleeding: unmeasurable PT or PTT; platelets, <20,000 /mL; or undetectable fibrinogen; severe abnormalities of other laboratory values also fall into this category

Central nervous system No symptoms/signs

Minimal apprehension, headache, weakness, dizziness, chills, or paresthesia

Moderate apprehension, headache, weakness, dizziness, chills, paresthesia, confusion or fasciculation in area of bite site

Severe confusion, lethargy, seizures, coma, psychosis, or generalized fasciculation

PT, prothrombin time; PTT, partial thromboplastin time. Points are assessed on the basis of manifestations caused by the venom itself (antivenom reactions not included). Ranges given are for adults; appropriate compensation should be made for age.

Figure 2. The Snakebite Severity Score can guide clinical decision-making (Courtesy Dart RC, Hurlbut KM, Garcia R, Boren J. Validation of a severity score for the assessment of crotalid snakebite. Ann Emerg Med. 1996;27(3):321-326)

continued on page 30

24 HOURS IN SAN ANTONIO / continued from page 19 judgmental statement of incredulity: “You went to San Antonio, but DIDN’T visit the Alamo?!” For those who paid absolutely no attention during history and/or civics classes, or for visitors to the United States who’ve yet to research the history of the southern United States, the Alamo was a mission and the site of a battle (Feb. 23-March 6, 1836) between the U.S. Texian Army and Mexican Troops. A pivotal battle in the Texas Revolution, the defeat sparked massive volunteering for the newly created Texas Republic Army – and created myth and legend surrounding this modest facility.

ITINERARY: A DAY OF PAMPERING

To become steeped in Texas and U.S. history, to engage with historical (or simply downright interesting) memorabilia and to grab a drink, make your way to the Menger Hotel, where Teddy Roosevelt established the Rough Riders.

MUSIC, IN BRIEF

If you’ve had your fill of the past and are searching instead for quality repast, head over to the Esquire Tavern for some good bar food. The Esquire is the oldest bar on the San Antonio Riverwalk – and it boasts not only the longest wooden bartop in all of Texas, but it’s also the last place JFK was seen having a drink before he headed to Dallas. To neutralize all of those calories, you can take a leisurely stroll along the Riverwalk – and appreciate that it’s only about 3 feet deep, so there’s no worry about falling in. It is, however, five miles long at its downtown portion and 15 miles overall.

FAMILY FUN

• The DoSeum is great for kids and adults of all ages. There are a host of interactive displays – enough that everyone will be kept busy for a while. • The Witte Museum – “Where nature, science and culture meet” – just received a full makeover and has great exhibits that are geared toward South Texas History. Enter the world – and learn about the science and benefits – of pollination, visit wild Texas, get to know the “People of the Pecos,” stroll through a dinosaur gallery and become immersed in 300 years of San Antonio history. • Grab a hotdog at Pugel’s. As one diner put it, “Quick service, tasty hotdogs, great price, chill atmosphere – what’s not to love?” • Head to the San Antonio Zoo to say “Hi” to Timothy the Hippo, who’s been courting Fiona at the Cincinnati Zoo on social media. • Grab some of the best wings in town at Cullum’s Attagirl. • The best cocktail bar on the strip is TBA. It has a resident cat, PJ, who hangs at the bar • If you happen to be staying out late (after 10:30 p.m.), are on foot and want to sample wares at the best food truck in San Antonio, head over to Hardbodies parking lot (yes, it’s a male strip club) and indulge in street corn and tostados from Tacos el Regio – just make sure you get the green salsa.

• Th e Shops at La Cantera outdoor mall will supply visitors with a shopping extravaganza that can provide everything from Sephora and Neiman Marcus to Montblanc. • A day pass to Loma de Vida spa can be the ultimate way to decompress from such an intense shopping experience. • Once thusly refreshed and recharged, go to Sustenio restaurant at the Hotel Eilan, for dinner with a view. • Finally, after you’ve decided to concede the day, you can always stop for a nightcap at George’s Keep. •S aint Mary’s Strip, located just north of downtown San Antonio, has tons of music venues – all within walking distance. • J azz, TX (yes, that’s its name) in the Pearl District, always has some amazing live music, as well as refined Texan cuisine, craft cocktails and draft beer, according to its website.

FOR NBA FANS

The San Antonio Spurs have made the playoffs the last 24 out of 25 seasons – and who doesn’t love head coach Gregg Popovich? HEB offers fan zone tickets starting at $5.

HONORABLE MENTIONS

Sea World; Six Flags Fiesta Texas; tubing down the Guadalupe River (offered by several outfitters); a Missions (San Antonio’s Minor League Baseball team) baseball game; Poteet (“The Strawberry Capital of Texas!”) Strawberry Festival; Fredericksburg peaches (mid-May through early August); Texas Wine Country; Big Lou’s Pizza; Rudy’s Bar-B-Que; and Taco Taco (best tacos in the United States, per Food Network).

Victor Stams, MD; Meg Rajan, MD; Kelly Kafka, MD; UT Health Program Director Howard Wang, MD; and Julie Kim, MD.

HAIL CHAMPIONS!

At the end of the day, if nothing else has sufficiently impressed you, we recommend that you take a short trip to the University of Texas Health Science Center, where you can visit with the 2018 Resident Bowl championship-winning team! | Plastic Surgery Resident | Winter 2018

CONSULT CORNER / continued from page 28

EARLY RETURNS / continued from page 27

CONCLUSIONS & KEY POINTS • Hallmarks of crotalid envenomation are local-tissue destruction and coagulopathy, whereas minimal local-tissue damage with neuromuscular blockade can be seen with elapid envenomation. • Compartment syndrome is a significant but rare development after envenomation, noted in only about 0.20-1.36 percent of cases. • Fasciotomy is unlikely to be required after most envenomation cases. • Antivenom can reverse local effects so as to avoid the need for fasciotomy in some cases. • Antivenom administration, dosing and frequency can be guided by the Snakebite Severity Scale. • Close follow-up of snakebite patients is required, as recurrent or rebound coagulopathy can occur and require retreatment with antivenom. |

needs – vary considerably. As a result, there may not be an optimal, standardized residency length applicable to all people in all programs.

Dr. Rodriguez is PGY-5 at Baylor Scott & White, Division of Plastic Surgery in Temple, Texas

Although I have limited experience with the program thus far, Milemarker received quite a bit of attention – with residents evaluating themselves on a 1-5 scale for each procedure that they perform, followed by the attending physicians rating them and providing feedback in order to improve specific areas of the procedure. This is supplemented by regular, face-to-face performance evaluations.

References

1. Corbett B, Clark RF. North American Snake Envenomation. Emerg Med Clin N Am. 2017;35:339-354. 2. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health (NIOSH): Venomous Snakes. (2018, May 31). Retrieved from cdc.gov/niosh/topics/snakes/default.html 3. Gold BS, Barish RA, Dart RC. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin N Am. 2004:22:423-443. 4. Edgerton MT, Koepplinger ME. Management of Snakebites in the Upper Extremity. J Hand Surg Am. 2018; Epub ahead of print. 5. Hwang CW, Flach FE. Recurrent Coagulopathy after Rattlesnake Bite Requiring Continuous Intravenous Dosing of Antivenom. Case Reports in Emergency Medicine. 2015;719302:1-5. 6. Hsu C, Chuang J, Hsu Y, Wang S, Fu C, Yuan K, Chen C, Kang S, Liao C. Predictors of the development of post-snakebite compartment syndrome. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2015;23:97. 7. Witham WR, McNeill C, Patel S. Rebound Coagulopathy in Patients With Snakebite Presenting With Marked Initial Coagulopathy. Wilderness & Environmental Medicine. 2015;26:211-215. 8. CroFab® [package insert]. BTG International Inc. West Conshohocken, PA; March 2012. 9. Dart RC, Hurlbut KM, Garcia R, Boren J. Validation of a severity score for the assessment of crotalid snakebite. Ann Emerg Med. 1996;27(3):321-326. 10. Anavip® [package insert]. Rare Disease Therapeutics, Inc. Franklin, TN; 2015.

As an integrated plastic surgery applicant, the announcement of the CBPST program had potential and notable benefits. The most obvious was the potential to graduate in five years instead of six. Doing so would, hopefully, allow me to supplement my education with a fellowship a year earlier and diversify my eventual employment opportunities. The ability to move toward CBPST seemed, to me, like a marker of a good education. Only a program with good operative numbers and diversity of cases would be able to graduate residents in fewer years. I also hoped that CBPST would help me become a better surgeon faster, as the concept is established on frequent feedback and individualized education.

Another benefit that may hopefully be up for implementation is flexible block-scheduling later in residency. If a resident is doing very well in hand, for example, but feels less confident in craniofacial surgery, he or she may be able to forego a hand block – and instead do an additional craniofacial block, thus decreasing redundancy and addressing weaknesses more promptly. The greatest potential risk that I see with CBPST involves perception: If a resident graduates in five years, he or she might be viewed less favorably as would an applicant for fellowship positions and job postings – due to having one year less experience. Speaking to other plastic surgeons in the field, I’ve been assured that this is unlikely – but it’s still a potential risk of the system. Nevertheless, I’m excited to see what form CBPST will take. I’m sure the concept will continue to evolve – and should it prove promising, I imagine it will have a place in other specialties, as well. | Dr. Blough and Dr. Payton are PGY-1 residents – and two of four CBPST residents – in the Texas A&M at BSW Health Center’s Division of Plastic Surgery.

Plastic Surgery Resident | Winter 2018

UPCOMING MEETINGS & SURGICAL TRIPS JANUARY 1/16/19-1/16/19 Oculoplastic Symposium Atlanta (414) 901-2544 sesprs.org 1/17/19-1/19/19 Atlanta Breast Surgery Symposium Atlanta (414) 901-2544 sesprs.org 1/18/19-1/30/19 Mission to Kingston, Jamaica Newton Square, Pa. (610) 355-2003 globalhealthvolunteers.net

FEBRUARY

MARCH

APRIL/JUNE

2/14/19-2/23/19 Mission to The Philippines Irving, Texas (972) 253-1800 hhmm.org

3/7/19-3/7/19 In-Service Examination for Residents Online (847) 228-3340 plasticsurgery.org

4/9/19-4/12/19 American Burn Association Annual Meeting Las Vegas (312) 642-9260 ameriburn.org

2/23/19-3/2/19 Mission to Panama City, Panama Fishers, Ind. (317) 581-9589 bridgesofhopeinternational. org

3/8/19-3/16/19 Mission to Chiapas Copainala, Mexico Irving, Texas (972) 253-1800 hhmm.org

6/15/19-6/22/19 Mission to Panama City, Panama Fishers, Ind. (317) 581-9589 bridgesofhopeinternational. org

1/19/19-1/26/19 Mission to Guatemala City, Guatemala Fishers, Ind. (317) 581-9589 bridgesofhopeinternational. org

3/10/19-3/24/19 Mission to Luxor, Egypt San Francisco (415) 521-1111 rotaplast.org 3/14/19-3/16/19 ASPS Aesthetica 2019 Super Symposium Arlington Heights, Ill. (847) 228-3359 plasticsurgery.org

Answer Key / From Page 24 G 4 L T O R 5 A E R O M O N U P S H I 8 E N C H O N D A 10 11 F I C T O I 13 P O L L I C I C N H 15 L I 16 S Y N O V I P I O N M E A 1

M O B E R G U S C A P H O I D U L L E T O 9 S P I R A L C Y U T E I N 12 D M A A A N C N E O T A T I O N Y E U L R S Y F 17 V E I N L B E N N E T T

T I S M A L R

Z A T I O N K E L S R O M A A T A A S O Y 2

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

Plastic Surgery Resident | Winter 2018