Plastic Surgery Resident, Fall 2019

ISSUE 16 | FALL 2019

From the publishers of Plastic Surgery News

Is taking a research year – or two – a desirable career path for you?

Most residents look to practice right away, but a research year can bring benefits that far surpass the costs of delay

'Cat bite fever' When your pager says 'hand infection' caused by a feline's teeth page 12

Are you coming to San Diego?

Plastic Surgery The Meeting is bursting with stuff for residents page 30

IN THIS ISSUE » ASPS president goes on the record for plastic surgery residents .............. p. 10 » Program Peek: UC San Diego Plastic Surgery ............p. 14 » InService Insight: Transgender Surgery ....................... p. 20

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ALLODERM SELECT™ RTM should be hydrated and moist when the package is opened. DO NOT use if this product is dry. Use of this product is limited to specific health professionals (e.g., physicians, dentists, and/or podiatrists). Certain considerations should be made to reduce the risk of adverse events when performing surgical procedures using a tissue graft. Please see the Instructions for Use (IFU) for more information on patient/product selection and surgical procedures involving tissue implantation before using ALLODERM SELECT™ RTM. ADVERSE EVENTS The most commonly reported adverse events associated with the implant of a tissue graft include, but are not limited to the following: wound or systemic infection; seroma; dehiscence; hypersensitive, allergic or other immune response; and sloughing or failure of the graft.

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References: 1. Wainwright DJ. Use of an acellular allograft matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995;21(4):243-248. 2. Data on file, Allergan. 2018. Sales Data. 3. AlloDerm Regenerative Tissue Matrix Instructions for Use, 2017.

A note from the editor

W

elcome to the Fall 2019 issue of Plastic Surgery Resident (PSR).

In this issue, we invite our plastic surgery Fellows, residents and medical students to San Diego for Plastic Surgery The Meeting – the annual scientific meeting of ASPS/PSF/ASMS, slated for Sept. 20-23. We also highlight the plastic surgery training program at the University of California San Diego, with its residents providing a fun list of destinations for the free time you may have in town during the annual meeting.

This may include gathering in the San Diego Convention Center’s Exhibit Hall to witness the 2019 edition of the Residents Bowl – on Friday, Sept. 20, and Saturday, Sept. 21 – as UT Health San Antonio seeks to defend its crown.

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

Our cover story, “Should I Take a Research Year – or Two?,” delves into subject matter surrounding the decision to take (or not) additional time to pursue research during residency training. This is a question faced by most residents – and we hope this article sheds more light on the pros and cons of that additional year (or two) of training.

As well as many of our recurring sections, this issue also includes a special feature in which ASPS President Alan Matarasso, MD, shares his unique career path and provides valuable advice for this community of young plastic surgeons.

Christopher Forrest, MD, chair of the Division of Plastic and Reconstructive Surgery at the University of Toronto, reflects on his career and reveals some of the things he knows now that he wish he knew at the beginning. We also feature another installment of our new Resident Perspectives series on family, the pursuit of pregnancy and plastic surgery by Dorothy Bird, MD, MS. The American Society of Maxillofacial Surgeons is soliciting applications for new ASMS Resident Ambassador positions. For those interested, be sure to submit your application by the Oct. 4 deadline. (See article on page 31.)

I’d like to send my thanks to our team of editors and the ASPS production staff for all of their hard work in bringing each quarterly of PSR to fruition. We hope you enjoy this issue – and see you in San Diego! |

2020 RESEARCH GRANT OPPORTUNITIES AVAILABLE The 2020 PSF Investigator-Initiated Grants Cycle is now open. A variety of grants are available – including combined grants supported by collaborations with sister societies – that address specialty areas of research in hand surgery, peripheral nerve, maxillofacial, reconstructive, microsurgery, pediatric plastic surgery, education and more. Combined grants supported by The PSF and the following organizations – AAHS, AAPPS, AAPS, ACAPS, ASMS, ASPN, ASRM, PSRC and ASE – are available.

New opportunities being offered include grants up to $100,000 on allograft tissue research (funded by MTF Biologics) and The PSF Translational Research Grant.

The PSF also continues to offer a variety of research and training grant opportunities, such as a pilot research grant, National Endowment for Plastic Surgery (NEPS) grants and Research Fellowship Grants. Applications for the 2020 cycle are due by Tuesday, Dec. 3. For more information and to apply, visit thepsf.org/research/grants-program.

Plastic Surgery Resident | Fall 2019

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Table of

Contents After the sleepless nights and high expectations, you must decide: Take a research year or not?...................6 Motherhood and residency: When nature wins..................9

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.

How to determine your career path: Advice from the ASPS president......................................... 10

A SPS PR ESI DEN T Alan Matarasso, MD | amatarasso@drmatarasso.com

Consult Corner: Treating an infected cat bite................... 12

ASSOCI ATE EDITOR Russell Ettinger, MD | retting@uw.edu

The “escalating arms race of academia” is moving more residents to delay practice in exchange for research.

She fought hard in her fertility battle – and overcame challenges both expected and surprising – but some things are beyond reach.

ASPS President Alan Matarasso, MD, talks about the path that began in residency and brought him to his presidency.

The timing of the bite, courses of action taken prior to E.D. arrival and the patient’s history should guide your treatment course.

Program Peek: University of California-San Diego...................................... 14 The Division of Plastic Surgery, founded in 1975 by Jack Fisher, MD, contains the nation’s oldest resident aesthetic clinic.

Message from the Director: Amanda Gosman, MD............................................................ 15

The University of California-San Diego residency program director lists the factors that make this institution great – including location.

Faculty Focus: Samuel Lance, MD....................................... 16 This University of California-San Diego plastic surgery leader’s credentials range from craniomaxillofacial surgery to sleep disorders.

24 Hours In: San Diego.......................................................... 18 Its world-class zoo and golf courses, popular beaches, stunning cliffs, food and Gaslamp Quarter are just the beginning.

InService Insights: Transgender surgery.......................... 20 The procedures related to the growing cohort of gender-affirmation patients are becoming more popular and numerous.

Journal Club: Acute peripheral nerve injury..................... 22 These injuries can have deep implications, and the authors want to familiarize residents with them – and how to manage them.

Advocacy summit: Residents join Society members in D.C............................ 24 “Ensuring Smiles,” and funding residency positions nationwide, were among the top items addressed by residents in Washington.

What I Know Now: Christopher R. Forrest, MD, MSc........................................ 26 After more than 10 years in practice, Dr. Forrest has learned much – including to when to watch, ask questions and embrace leadership.

Crossword: Potpourri in plastic surgery............................ 28 Are you informed on rhinoplasty arteries? What about carbon dioxide laser complications? Do you know your upper-lip muscles?

Senior Residents Conference, Residents Day: Plastic Surgery The Meeting stuff for residents.............. 30 Residents Day is free, but preregistration is required; SRC attendees will gain myriad perspectives, from business to the personal.

ASMS ambassador positions open; residents wanted to fill new seats....................................... 31 The Society is asking PGY 1-4 residents interested in pediatric or adult craniofacial surgery – or facial aesthetic surgery – to apply.

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Plastic Surgery Resident | Fall 2019 | Vol.3 No.3

Plastic Surgery Resident | Fall 2019

EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com

INTER NATIONA L EDITOR Johan Sandberg, MD | ljsandbrg@gmail.com 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 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 Elena Bragg 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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Life After Residency

SHOULD I TAKE A RESEARCH YEAR – OR TWO?

By Zeshaan Maan, MD, MSc, & Clifford Sheckter, MD Plastic surgery residency is six years of intense training packed with 80-hour weeks, sleepless nights and high expectations. This follows an already lengthy journey of at least eight years of undergraduate study and medical school. But you’re now considering adding another year? Or two?! While few residency programs across the United States require a year of research, others provide the option – and the escalating arms race of academia makes the research-year question highly relevant for plastic surgery trainees across the country.

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Plastic Surgery Resident | Fall 2019

FIRST, SOME BACKGROUND

Mastering surgical technique and developing impeccable clinical judgment are essential to the practice of surgery, but advancing the field of surgery requires the ability to question current practices and discover new knowledge. Historically, plastic surgery has been defined by its innovative approach. The specialty was founded by surgeons such as Sir Harold Gillies and Sir Archibald McIndoe, who explored new ideas and techniques to tackle poorly treated medical problems – thereby establishing a foundation of surgical principles taught to the most capable trainees.

Joseph Murray, MD, an American plastic surgeon, was awarded the Nobel Prize in Physiology or Medicine for performing the first human kidney transplant. Plastic surgeons are increasingly at the forefront of regenerative medicine research – a field that complements the reconstructive and restorative nature of our clinical practice.

In medicine (and most other industries), specialization has resulted in increased efficiency and the successful execution of desired objectives, calling into question the role of a surgeon-scientist.

However, traditional scientists are rarely exposed to the diagnosis and management of surgical disease, and they typically lack the perspective to translate an understanding of biology into effective clinical therapeutics. Though the role of the surgeonscientist has largely evolved toward working in multidisciplinary teams of investigators, a dedicated period of research training remains essential to success.

DOES IT HAVE TO BE RESEARCH?

While the need clearly exists for young, aspiring surgeon-scientists, the path that leads there isn’t for everyone – nor should it be. At Stanford University, we have established a non-traditional professional development year, which is analogous to the sabbatical model for tenure-track faculty. Trainees are encouraged to seek a variety of experiences outside of plastic surgery to stimulate both personal and professional growth. Our residents have engaged in diverse endeavors, including medical device innovation, health-services research, design consulting and international surgical outreach, in addition to basic and translational science research.

This period of cognitive independence provides residents with a welcome break from their structured clinical training and an opportunity to cleanse their intellectual palette.

While the need clearly exists for young, aspiring surgeon-scientists, the path that leads there isn’t for everyone – nor should it be.

BENEFIT VS. DRAWBACKS

When considering whether to take a research year, the benefits should be considered in light of the potential drawbacks, depending on career goals.

Most obviously, a research year benefits a budding surgeon-scientist by refining their academic niche; augmenting their resume; building extra-clinical relationships with mentors; and garnering national exposure through participation in meetings. More subtle benefits include fewer clinical obligations and greater discretionary time to allow for personal wellbeing and accomplishments, such as getting married or having children.

While these benefits are attractive, the extra time (one to two years) necessarily increases the duration of training. Pay during the year is either similar to resident salary or, potentially, lower. This represents an opportunity cost given the delay in earning an attending salary. For most residents with substantial student debt, this is a serious consideration.

Additional limitations include the risk of not achieving anticipated productivity during the year and disappointing mentors.

HOW TO MAKE THE MOST OF IT

In order to make the most of your research year, you must know your career goals. For those interested in a private practice, a non-traditional year may make more sense than a year in a research laboratory. If you’ve chosen your subspecialty, you can tailor your research and other experiences toward it.

As someone interested in academic hand surgery, I spent most of my research year developing a peripheral-nerve interface for upper-extremity neuroprostheses, while my co-resident, who plans to pursue global surgical outreach, chose the Laub Fellowship – which involved three to four months of mission trips and research on building surgical capacity in developing countries. In addition to the

continued on page 8 Plastic Surgery Resident | Fall 2019

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TAKE A RESEARCH YEAR / continued from page 7 experience itself, consider the benefits of a higher degree, such as an MPH, PhD or MBA, depending on your prospective career path.

CHOOSING THE RIGHT MENTOR

Your research experience will be heavily defined by your choice of mentor, making the identification of your mentor both difficult and critical. Choose a mentor who works in either a clinical or research area you are interested in – ideally both. Though choosing a prominent and well-connected mentor has value, as she or he should also be committed to your career development and available to provide mentorship and sponsorship.

Consider having more than one mentor if appropriate – for example, you might have a clinical mentor in your chosen subspecialty and a research mentor in your area of investigative interest. In addition, the mentor-mentee relationship must be maintained and nourished to be fruitful.

WHAT IF YOUR PROGRAM DOESN’T OFFER ONE?

As any resident or program director can attest, scheduling in residency is quite difficult. Plastic surgery programs are small relative to other specialties, so there’s little to no redundancy. If your program doesn’t routinely offer a dedicated research year, electing to take one will likely put significant strain on your co-residents. This should not preclude a well-considered year of enlightenment, but it does mean you should plan at least a year in advance (if not two), to allow your program the opportunity to fill your spot with an independent resident.

HOW TO REEMERGE

Many struggle with the transition back to clinical residency after they’ve completed their research year. This includes challenges in resuming the full-time resident schedule, relearning technical skills and building research momentum. Regarding clinical skills, 8

Plastic Surgery Resident | Fall 2019

the adage that “it’s like learning to ride a bike” is applicable, in the sense that resident life restarts with little lag, given years of prior training. Most faculty are understanding of the transition back to residency and anticipate rusty hands in the first few days to weeks back.

However, maintaining research momentum is a different beast. Time is a precious and limited resource during residency, and continuing a full-time research schedule while obtaining sufficient sleep is impossible. However, it’s still possible to remain productive by mentoring the lab member who’s continuing your project from research year(s); by contributing to dry lab aspects of ongoing projects; and by writing and editing manuscripts. Turnover between cases, waiting for flap checks and any personal study-time built into the week are obvious time periods in which residents can work on their research.

Impeccable time-management and a disciplined approach are critical for this strategy to be successful. Weekends and evenings are discretionary time

banks that residents may use to continue scholarly work, but these should be balanced by well-being activities and time with friends and family. Many residency programs don’t have research years, yet they graduate residents with impressive research accomplishments – proof that it’s possible to be productive without dedicated research time.

CONCLUSION

The factors involved in deciding whether to take a research year are numerous and complex. Ultimately, this can be a rewarding time of intellectual independence to grow professionally as well as personally, but these consideration must be weighed against the impact of lengthening training on an individual basis. |

Dr. Maan is a PGY-5 resident, and Dr. Sheckter is a PGY-7 resident, within the Integrated Plastic Surgery Residency Program in Stanford University Medical Center’s Division of Plastic and Reconstructive Surgery.

PSR NEWS NEW, ENHANCED RESIDENT EDUCATION CENTER LAUNCHED The ASPS Resident Education Center (REC) was launched July 1 on the Society’s new, enhanced-learning management system known as the ASPS Education Network (ASPS EdNet), with the new offering replacing PSENetwork. By employing this newly developed REC offering, residents will be able to view their institution, curriculum, progress and reporting.

However, the institution’s dashboard on plasticsurgery.org will not change.

Please note that the REC on the former www.PSENetwork.org platform was shut down and completely discontinued July 1. The new REC platform includes added functionality – such as a communications center; an assignment center; a grade book; a modern look and feel; enhanced analytics; and more.

The log-in information supplied by users to access the REC will not change, so please log-in to ednet.plasticsurgery.org by using existing PSEN usernames and passwords.

Those with any questions or concerns should feel free to contact the REC team at onlineeducation@plasticsurgery.org.

Striving for motherhood in residency

She tried everything – but nature had other plans

By Dorothy Bird, MD, MS Prior to completing plastic surgery training, I had completed a general surgery residency and worked as a trauma surgeon, so I consider myself really tough. However, infertility knocked me to my knees in a way that I never expected. I’m not complaining; my hope for this article is to share my story and prepare the next wave of trainees for some of the realities of family planning.

ADOPTING MACHISMO

I began my general surgery internship in 2006, just two years after the ACGME-imposed work-hour restrictions – which were basically considered a joke in the program. Not that I minded: I loved surgery and was pathologically determined to be a good resident. Working 110-120 hours weekly was typical. I adopted the machismo of the guys in bragging about how long I could work in one stretch like it was no big deal (which was a complete lie; I came home and cried routinely).

There were a few women in the program. There were a few female faculty who were divided into two camps: single battleaxes and married-with-kids- ightweights. During my intern year, one of the fourth-year residents became pregnant. Her husband was one of the chief residents. When the pregnancy was announced, she was immediately and mercilessly scorned. “How stupid could she be?” was the reaction from another resident that I remember the most clearly. No one mentioned Dad’s involvement in the decision. She was completely and utterly miserable. They divorced a few years later.

I got married to a nice, mild attorney, two weeks before starting residency. We were both pretty career-focused and weren’t sure about kids – not dead-set against them, but having them wasn’t assumed, either. We would wait and see how things went and figure it out later. We were 28 years old. After witnessing the reaction to my senior resident’s pregnancy, I firmly deferred any further childbearing plans until after residency; I wasn’t that stupid, after all. I covered extra call, cases, busy services, M&M’s and other resident duties for no less than four, two-week paternity leaves of my male co-residents.

Five years later, I was a senior resident. The leadership of my program had turned over – and with the new administration came a kinder culture. Making the program “woman-friendly” became a priority. My junior residents got pregnant left and

right. My husband and I decided to give kids a try. I thought I was so smart to create a “gap year” for childbearing between general surgery and plastic surgery residencies. I timed everything perfectly – I would be pregnant but not showing for plastics interviews, then deliver right after graduation and work locums jobs until starting a plastics residency the following year.

Brilliant.

THE BEST-LAID PLANS…

We tried for six months without success. I was 32. I met an OB-GYN (because, of course, I didn’t have any regular doctors during my residency) and we started the work-up. She prescribed egg-stimulating medication and I mentally prepared for twins.

Still no luck. More blood work and ultrasounds. She referred me to a reproductive endocrinologist. Things were becoming disruptive. “Sorry Dr. Whatever, I can’t scrub for the entire Whipple because I need to have a transvaginal ultrasound at 11 a.m.” Not cool, even in the most reformed program.

I began IVF during my “gap year.” Hundreds of injections.

Dozens of ultrasounds. Hours of acupuncture. No vacations.

Hopes up. (“Three terrific embryos transferred!”) Hopes down. (“Your pregnancy test was negative again.”) Seven unsuccessful cycles. It was emotionally exhausting. I worked full-time as a trauma surgeon during that period. Maybe that was part of my problem. My fertility doctor’s parting advice was: “Go to Dr. Rosenwacks at Cornell. He got Celine Dion pregnant. He’s the Godfather of IVF.” Fortunately, my plastics residency was close enough to New York to do this. Six months into my new program, I approached my PD with my plan. I did two cycles before calling it. Taking the 4:30 a.m. train to New York to get to the IVF clinic by 7 a.m., and back home for cases and afternoon rounds/call, was unsustainable. My husband and I spent tens of thousands of dollars for medications and procedures. My lower abdomen was a living pin cushion. The added emotional roller-coaster on top of the hopelessness of being a first-year, independent resident was too much. I gave up. I never give up, but I gave up.

RECONCILING WITH REALITY

The worst end of it was how my failure affected the people I loved the most. My husband would never be a father. My parents would never be grandparents. My in-laws would never see their son become a father. Our nieces and nephews wouldn’t have cousins. It was devastating.

It has taken a few years to really accept the outcome and move forward. Adoption and surrogacy weren’t for me. I stopped blaming myself for being selfishly career-minded and started enjoying the freedom of childlessness – such as spoiling my dog, travelling as much as possible and taking on challenging, all-night free flaps. I love being a plastic surgeon and, in reality, wouldn’t have done anything differently.

Dr. Bird is an instructor of Surgery at Cooper Medical School at Rowan University, Camden, N.J. Plastic Surgery Resident | Fall 2019

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DR AWING A ROADMAP FOR A UNIQUE CAREER PATH

Q&A WITH ASPS PRESIDENT ALAN MATARASSO, MD For a plastic surgeon who chose to go into solo, aesthetic practice, ASPS President Alan Matarasso, MD, New York, fashioned a career that still leaned heavily on involvement in organized plastic surgery and academic work, from research and writing, to lecturing to continuing to work with residents throughout his career.

Another important factor to consider: There isn’t anyone out there who’s successful in our world that won’t tell you they’ve devoted an inordinate amount of their time, energy and sacrifice to their career. We are the epitome of delayed gratification. Time is like a rubber band; it stretches to accommodate things, but it can also break. So prioritize your needs, your health and your family.

As his presidential term comes to a close, the Plastic Surgery Resident editorial board put forth questions to Dr. Matarasso about his unique career path, as well as advice for young plastic surgeons who might like the variety – albeit with a very heavy workload – that his career has offered.

I recognize that each of us defines success differently, but it doesn’t do any good to have all the success in the world if your health or family suffer as a result. No matter what type of practice you choose, it requires early-career planning, constant focus and a commitment to maintaining a healthy lifestyle, as well as your family and personal satisfaction.

Begin saving and financial planning early.

PSR: WHAT ADVICE WOULD YOU GIVE FOR EARLY CAREER SUCCESS AND DEVELOPMENT TO A YOUNG PLASTIC SURGEON COMING OUT OF RESIDENCY? Dr. Matarasso: Try to decide as early as possible what type of career you want in plastic surgery, and align that with the research you engage in and in your Fellowship training – which I consider invaluable in your career trajectory. The old saying is that residency is where you learn to bake the cake, Fellowship is where you learn to put icing on the cake and practice is where you learn to run a bakery. Envision from the beginning what you want your practice and your life to be like 10 years from now – and then, as best as possible, implement the plans necessary to fulfill your expectations.

The years disappear in the blink of an eye, and all of a sudden, you are what you did or didn’t plan.

I advise residents to practice where they want to live.

Ideally you want your success to correlate with geographic satisfaction. Nevertheless, you have to recognize that where you choose to live may change your career path. You might not be able to have things you want in one particular city, and careers in academic medicine can require relocating numerous times, so there’s going to be a give and take.

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Plastic Surgery Resident | Fall 2019

PSR: WHAT DO YOU CONSIDER TO BE THE MOST EXCITING, NEW FRONTIER OF OUR SPECIALTY THAT WE SHOULD BE PAYING CLOSE ATTENTION TO DURING OUR TRAINING? Dr. Matarasso: Plastic surgeons are – above and beyond anything else – innovators. There have been several dramatic changes over the course of my career. For example, breast reconstruction has changed significantly – from a submuscular procedure that required removing the nipple, to a prepectoral, nipple-sparing procedure. In aesthetic surgery, there’s been a paradigm change in terms of nonsurgical or minimally invasive surgery, which provides incredible new opportunities and challenges.

In addition to this specialty’s capability to produce so much innovation, we now also have outside, uncontrollable market forces that will drive new tools, techniques, procedures and demands. The best way to stay on top of all of this is to pay close attention to your area of interest, be well-versed in the latest knowledge and go to meetings. It’s very easy to finish residency and get into your own niche, but people have to

work to avoid being only as good as their training – plastic surgery is a lifelong journey. When I look at the operations I learned in training, I’m doing things very differently now – which can be said about so many facets of plastic surgery.

PSR: WHAT ADVICE CAN YOU LEND WITH REGARD TO JUGGLING AND MAINTAINING A BUSY CLINICAL PRACTICE WHILE STILL BEING DEEPLY INVOLVED IN ORGANIZED PLASTIC SURGERY? Dr. Matarasso: I had an idea of the type of career I wanted by my third year of medical school. I subscribed to PRS, procured the first issue of Annals of Plastic Surgery and attended Plastic Surgery The Meeting in medical school before medical students were indoctrinated to that. During residency, I enjoyed craniofacial surgery and I liked hand surgery – as a matter of fact, I was admitted to a hand surgery Fellowship in the middle of general surgery training.

As my career developed in aesthetic surgery, I continued to pursue academic endeavors. I had a solo private practice with a strong focus on education, and I was involved in organized plastic surgery. In addition to the Fellowship at Manhattan Eye, Ear & Throat Hospital, I’ve been at some point involved with all the training programs in Manhattan and a full professor at two medical schools. From them I’ve learned more than I’ve taught.

Mentors and role models are important in any career; life is too short to learn everything on your own. Early on, one of my mentors, Melvin Spira, MD, DDS, told me: “You’ll get all the fancy accoutrements one day, but it’s what you contribute that will endure.” I met Dr. Spira when he interviewed me during my general surgery internship year. When I didn’t move there, I recommended a classmate and close friend of mine from medical school, who was accepted to the training program; I remained close to him and his family. And now, I will be giving Dr. Spira, the former chief of Plastic Surgery at Baylor University, the ASPS Lifetime Achievement Award at Plastic Surgery The Meeting 2019 in San Diego.

PSR: WHAT LED YOU TO PURSUE A CAREER IN AESTHETIC PLASTIC SURGERY? WHAT WAS MOST APPEALING; WHAT WAS LEAST APPEALING TO YOU? Dr. Matarasso: The appealing part about cosmetic surgery was that you could endeavor to make something “perfect.” We are taking normal structures and making them better.

As appealing as that is, it’s also a difficult standard to achieve due to people’s perception of what a good result actually means to them, their vanity and so forth. What constitutes a good result to us and to the patient can be two very different things – and that can be hard to reconcile. For aesthetic surgery, there’s no measurable endpoint that defines a successful result other than the patient’s satisfaction, which is influenced by myriad unknown factors. Consequently, I spend more of my time now explaining to people what surgery won’t do, rather what it will do – because patients already know

what they want the procedure to do. And, as the famous expression in our world goes, “Beforehand, it’s an explanation; afterward, it’s an excuse.”

PSR: IF YOU COULD GO BACK IN TIME TO YOUR RESIDENCY TRAINING, WHAT WOULD YOU WANT TO CHANGE OR APPROACH DIFFERENTLY AND WHY? Dr. Matarasso: Residency training has evolved to the level I would’ve liked it to have been at the time I was training, which was to have an early focus on plastic surgery. Many of us did a rigorous, full general-surgery residency and two years of plastic surgery, which could total seven, eight or nine years. Now, many combined and integrated programs are initiating plastic surgery training right from the beginning – and functioning in a way that’s a better utilization of the residents’ time and more practical to their careers.

PSR: WHAT HAVE BEEN YOUR BIGGEST REGRETS IN YOUR CAREER; CHOICES OR MISTAKES THAT YOU MADE? Dr. Matarasso: That’s difficult. I’ve truly had a fulfilling career, which has culminated in becoming ASPS president.

I’ve had excellent trainees over the years, I’ve had wonderful patients and I’ve been in great institutions with terrific colleagues. If you’re in a fully academic career, you might get to move around more. I’m not sure that I would have enjoyed living elsewhere, but who knows if I could have had the same type of practice and career?

As a solo practitioner, you’re on a treadmill from day one and you never really take a break. Every day is stressful. You’re the chief cook and bottle washer, and your foot is always on the gas pedal. Some advice that I would give to people who are looking at private practice is to consider more of a group model. Aesthetic surgery has changed significantly.

In an optimal setting, a variety of equipment is necessary, and similar to just one person using an O.R., it isn’t efficient for a solo practitioner. Some people may prefer practicing alone, but having a group can favorably change your lifestyle and finances. While there are certainly compromises to groups and partnerships, the advantages might outweigh the disadvantages.

PS2 Practice Management, which happens to be a subsidiary of ASPS, is a wonderful, new resource for starting and managing a practice – particularly for plastic surgeons just entering practice out of training. If you need information on this, email Jennifer Cross, PS2’s chief operating officer, at jcross@ps2pm.com.

Enjoy the ride! |

Plastic Surgery Resident | Fall 2019

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Cat bite to the index finger

“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.

Though quite small, a cat’s tooth can create big problems

By Olivia Means, MD MESSAGE ON YOUR PAGER: HAND INFECTION, POSSIBLE ABSCESS, PLEASE CALL BACK.

Your pager displays this message from the E.D.: “Hand infection, possible abscess, please call back.” You get on the phone with the E.D. physician and receive the following information: “A 38-year-old male was bitten by his cat three days ago. He reports increased swelling and pain in the affected digit. Requesting evaluation by hand surgery.”

IMPORTANT CONSIDERATIONS Mechanism: For a hand infection that presents to the E.D., there’s usually a history of trauma in the form of a bite (human or animal), foreign body (splinter/nail) or minor, penetrating injury. A clear timeline of the inciting event and the following course(s) of action can give you an idea of how extensive the injury is. For example, while a cat bite and a human bite are likely to cause infection, a human bite also presents with the additional risk of tendon injury.

Prior interventions: It’s important to ask what, if any, form of treatment has been tried by the patient prior to his arrival. Has the patient been seen at an urgent-care center and placed on oral 12

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antibiotics? Has the patient tried to open the abscess by himself at home, by using a hot needle? (Yes, this does happen.) Has tetanus been updated?

Patient history: With any hand infection, the history should include hand dominance; the patient’s occupation; previous injury or surgery; smoking history and systemic disease – particularly, a history of diabetes; rheumatologic disease; chronic steroid use; and immunosuppressive conditions that could affect wound-healing and overall morbidity.

Imaging: At minimum, obtain radiographs of the affected hand to rule-out acute bony injury and assess for foreign bodies.

Cellulitis – or something worse? A cat bite often presents as cellulitis without an easily palpable abscess. However, incision at the puncture wound of a cat bite is usually beneficial, because the long, thin teeth of a cat can often inoculate a deeper, closed space – thus leading to worsening pain, decreased range of motion and blunted improvement on antibiotics alone. While you suspect an abscess with surrounding cellulitis, it’s critical to evaluate and rule out other, more aggressive hand infections, especially flexor tenosynovitis. The cardinal signs of flexor tenosynovitis – an abscess within the flexor tendon sheath – are pain on passive extension, fusiform swelling of the digit, tenderness of the flexor tendon sheath and a digit held in flexed position.

HISTORY AND PHYSICAL EXAM Now back to the E.D. and our patient: A 38-year-old male with a past medical history of congestive heart failure, no handrelated surgeries and presenting with right index-finger cellulitis secondary to a cat bite sustained three days prior. Immediately following the bite, he washed the finger in warm water. He reports taking some amoxicillin that he had in his medicine cabinet. He continued to have worsening redness, pain and swelling with resulting decreased range of motion, so he decided to come to the E.D. He denies any fevers, chills or purulent drainage from the puncture wounds. The patient is right-hand dominant, works at a factory and denies any current or past history of smoking.

On physical exam of the right upper-extremity, the patient has two-plus radial and ulnar pulses. Sensation is intact in radial, median and ulnar nerve distributions. There’s erythema of the right index finger extending proximally to the MCP joint, with two small puncture wounds at the ulnar aspect of the middle phalanx near the DIP joint. He’s mildly tender to palpation near the puncture wounds. There’s no pain on passive extension, no fusiform swelling of the digit, no tenderness of the flexor tendon sheath, and the digit is not held in a flexed position at rest. There’s no streaking extending proximally to the forearm.

Sensation and range of motion are normal at the wrist, elbow and shoulder. Compartments are soft.

Additional workup showed no skeletal injury or foreign body on X-ray. CBC showed mild leukocytosis with WBCs at 11.04; CRP at 18.2; and sed rate at 20. CMP was unremarkable.

Patient was afebrile. Prior to hand-surgery evaluation, he was given one dose of IV Unasyn and tetanus updated.

BEDSIDE INCISION AND DRAINAGE MATERIALS • • • • • • • • • •

Alcohol wipes (used to clean the area prior to administering local anesthetic) 10cc syringe; 18-gauge needle (to draw-up local); 27-gauge needle (to administer local) Local anesthetic: 1 percent lidocaine with epinephrine 1:100,000 Betadine prep Sterile gloves and towels 11-blade Culture swab Laceration tray with appropriate tools to spread tissue Sterile saline Dressing: xeroform, kerlix, tape

BEDSIDE INCISION AND DRAINAGE When the determination is made to proceed with incision and drainage of the affected digit, the process begins by obtaining informed consent, and by reviewing the risks, benefits, alternatives and complications of the procedure. Once these are completed, the procedure begins with achieving appropriate anesthesia. An alcohol wipe is used to cleanse the area to be injected. Local anesthetic (1 percent lidocaine with epinephrine

Pre-op (left) and post-op (right) treatment of a cat bite. Photos courtesy of James Yuen, MD, and Maximillian Malotky, MD.

1:100,000) is used to perform a digital nerve block. The entire hand is prepped with betadine solution, and a sterile field is created with sterile towels.

Use an 11-blade to make a Brunner-style incision along the volar, ulnar aspect of the middle phalanx. If there’s a palpable fluid collection, the incision can be made directly over the area of most fluctuance – taking care not to make any longitudinal incisions across a flexion crease or incising too deep in an area near the digital neurovascular bundle.

Following the incision, the patient described had immediate release of purulent fluid. Obtain cultures. Use a hemostat to probe the abscess via blunt dissection, in order to break up any septations and release additional fluid. Irrigate the wound with large amounts of sterile saline. The wound is left open.

A wick or small piece of a penrose drain can be placed within the wound to keep it open. A loose dressing of xeroform and kerlix is applied. Fluid cultures should be sent for gram stain, anaerobic, fungal and AFB.

POST-PROCEDURE CARE The patient is instructed to elevate the affected hand above his heart for as long as possible. Instructions for hand soaks include flexion/extension of the hand in warm, soapy water (baby shampoo, CHG or hibiclens) for 15 minutes, three times per day; and reapplication of the loose dressing following each soak.

FOLLOW-UP Patient is discharged from the E.D. on seven days Augmentin with follow-up in one week. Make sure to follow-up on fluid cultures to ensure patient is on appropriate antibiotics. |

Dr. Means is PGY-2 at Spectrum Health/Michigan State University, Grand Rapids, Mich.

REFERENCES

Raval P, Khan W, Haddad B, Mahapatra AN. Bite injuries to the hand – review of the literature. The Open Orthopaedics Journal, 2014;8,204-208.

Draeger RW, Bynum DK Jr. Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg. 2012;20(6):373-82.

Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. RadioGraphics.

2014;34(7):1968-86.

Plastic Surgery Resident | Fall 2019

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University of California - San Diego

By Anthony M. Kordahi, MD

History • UCSD Division of Plastic Surgery was founded in 1975 by Emeritus Professor Jack C. Fisher, MD, who’s still very active in the program providing lectures, education and mentorship • First U.S. application of principles of internal fixation using AO/ASIF technique for craniomaxillofacial surgery • Oldest and longest-running resident aesthetic clinic in the United States, since 1975 Leadership • Amanda Gosman, MD, Professor and Chief of Plastic Surgery UCSD; Plastic Surgery Program Director UCSD; Craniofacial Fellowship Director UCSD; Chief of Plastic Surgery Rady Children’s Hospital San Diego • Marek Dobke, MD PhD, Professor of Surgery UCSD • Mark Rechnic, MD, Associate Professor of Surgery UCSD • Ahmed Suliman, MD, Associate Professor of Surgery UCSD; Section Chief of the Division of Plastic and Reconstructive Surgery Veterans Administration San Diego • Samuel Lance, MD, Assistant Professor UCSD; Associate Plastic Surgery Residency Program Director UCSD • Frederic Kolb, MD, Professor of Surgery UCSD • Christopher Reid, MD, Assistant Professor UCSD; Director of Plastic Surgery Medical Student Education, Plastic Surgeon Division of Plastic and Reconstructive Surgery Veterans Administration San Diego 14

Plastic Surgery Resident | Fall 2019

National Leadership • Division members have held leadership roles in ASPS; reviewers for the journal Plastic and Reconstructive Surgery; Board Examiners for the American Board of Plastic Surgery; American Association of Plastic Surgeons; American Council of Academic Plastic Surgeons; American Society of Maxillofacial Surgeons; The PSF; Plastic Surgery Education Network; California Society of Plastic Surgeons; and others Clinical Experience • Rotations through four hospitals: o Rady Children’s Hospital: The largest children’s hospital in the state of California. Experience includes cleft lip and palate, craniosynostosis, microtia and management of craniofacial syndromes o San Diego Veterans Administrations Hospital: One of the largest VA hospitals in the country, serving a wide area of VA patients. Includes head and neck microvascular reconstruction, hand surgery and breast reconstruction.

Patients travel from as far as Las Vegas to receive microsurgery here o Jacobs Medical Center: Located in La Jolla, this site serves as our main exposure to general surgery in our first few years of training, which includes surgical oncology, vascular surgery and transplant surgery. In PGY years 3-6, we perform most of our cosmetic surgery, microvascular reconstruction, breast reconstruction and outpatient hand surgery at this location o Hillcrest County Hospital: One of two Level 1 trauma centers in San Diego, with a large catchment area extending all the way to the Mexican border. Also includes the Regional Burn Center for the Southernmost part of California.

At this site, we perform acute facial and hand trauma repair, burn surgery and intensive-care unit rotations. We split facial trauma call with the head and neck service every other night. We also split

hand call with the orthopedics service, taking one-third of the month.

• Resident aesthetic clinic during PGY years 4-6. This is an all-encompassing aesthetic clinic with graduated resident experience. Residents will perform their own botox, fillers and surgical cases including breast, body and facial aesthetics • Private practice elective rotations in San Diego and Los Angeles. An opportunity to spend time both in the office and in cases with multiple well-established private practice plastic surgeons • ConnectMed International: A 501(c)(3) non-profit organization founded by Dr. Gosman that improves access to surgical care in underserved communities and supports sustainable healthcare through education, partnerships, telemedicine and research. Enables residents with the opportunity to travel to Mexico, Vietnam and Africa to learn from international surgeons and provide care and education to underserved areas • Fresh Start Surgical Gifts: A non-profit organization founded by program graduate Dennis Nigro, MD, providing charity surgery for children based out of San Diego at Rady Children’s Hospital. Allows residents the opportunity to contribute to the surgical care of hundreds of patients that travel to San Diego throughout the year for complex surgical management Education and Research • Curriculum o Monday afternoon resident-led didactics o Wednesday morning research meetings and afternoon Grand Rounds o While on dedicated hand rotations, weekly anatomy dissection and journal clubs are held o Monthly M&M and Journal Club o Quarterly Mock Oral Examinations and microsurgery labs in UCSD’s state-ofthe-art Center for the Future of Surgery o Quarterly Multidisciplinary Team Meetings:

» Comprehensive Breast Cancer Care – Plastic Surgery, Breast Oncology, Radiation Oncology » Facial Trauma – Plastic Surgery, Head and Neck Surgery » Lower Extremity Reconstruction – Plastic Surgery, Orthopedic Surgery o Visiting Professors from ASPS, ASAPS, ASMS, ASRM, The PSF, CSPS • All residents are expected to publish at least once during every academic year • Funding for one yearly national or international meeting, or multiple if presenting • Our residents have protected research time while on specific rotations every year • Basic science and animal lab research available at the Altman Clinical and Translational Research Institute of UCSD • West Coast site for ASPS/ ACAPS Annual Plastic Surgery Intern Boot Camp • Current 2019 California Society of Plastic Surgeons Resident Bowl Champions Fellowship Training • 2013 – Micro, UTSW • 2014 – Hand, UTSW • 2015 – Aesthetics, San Diego • 2016 – Aesthetics, Cleveland Clinic • 2017 – Aesthetics, HunstadKortesis Center, Charlotte, N.C. • 2018 – Micro, UCLA • 2019 – Craniofacial, Ohio State • 2020 – Aesthetics, LSU Resident Benefits • Membership to San Diego Plastic Surgery Society, CSPS and ASPS • Meal money and annual housing stipend • Yearly embroidered team jackets • Yearly educational fund • Yearly AO Facial and Hand Trauma Courses in San Diego • Summer Welcome Pool Party, Winter Holiday Party • Follow us on Instagram at @ucsdplasticsurgery. | Dr. Kordahi is PGY-4 at University of California-San Diego Division of Plastic Surgery.

A Message From the Program Director, Amanda Gosman, MD

L

iving in San Diego is like winning the lottery.

I grew up in Toledo, Ohio – a wonderful and wholesome place to develop a deep understanding of the cold and gray, which now helps me appreciate my amazing surroundings. Aside from the nearly perfect weather – every day – San Diego has incredible resources that make it an excellent training environment for the next generation of plastic surgeons.

Amanda Gosman, MD

The University of California-San Diego (UCSD) is a hub of innovation for basic science research, biotechnology, engineering and education.

The cross-fertilization of ideas between the School of Medicine and the other schools at UCSD creates a truly unique learning experience for residents, who share rotations with engineering students. Relatively speaking, UCSD is a young medical school that celebrates its 51st year in 2019. In the spirit of youth, there’s still an invigorating aura of the Wild West, that anything is possible and that hope springs eternal from its energetic and trailblazing faculty, residents and students.

The UCSD plastic surgery program started in 1975, under the leadership of Jack Fisher, MD. I’ve served as program director since 2009, and we launched our Integrated Plastic Surgery Program in 2016. There have been exciting changes in the past decade. The San Diego community, our health system and our residency have gone through a tremendous growth spurt recently. It’s an exciting time of expansion for our plastic surgery division to keep pace with the busy clinical volume at our four primary hospitals. UCSD Health system has two campuses: In Hillcrest, we have a busy Level I trauma center with the regional burn unit – and in La Jolla, we have Jacobs Medical Center, new state-of-the-art tertiary care hospital-complex that includes the regional cancer center.

Across the interstate from the Jacobs Medical Center is our VA Hospital, which provides robust clinical and research opportunities for trainees. Rady Children’s Hospital San Diego is the largest children’s hospital in California – and it provides the full spectrum of pediatric plastic surgery and multidisciplinary craniofacial care. Our craniofacial center works in collaboration with the Fresh Start Surgical Gifts Program, which allows us to provide free, reconstructive surgical care to patients from all around the world.

One of the most amazing aspects of living, working and training in San Diego is our proximity to the Mexican border. The international health opportunities could not be better for seasoned global-health enthusiasts or those who are newly interested in virtually exploring this exciting realm of plastic surgery – by joining one of our international health telemedicine conferences. Residents have endless opportunities for international outreach involving clinical care, education and research in Mexico and around the world through ConnectMed International, a nonprofit organization I founded in 2010.

My passion for global health is what initially drew me into plastic surgery and subsequently to the opportunity at UCSD in 2006. I know this isn't everyone’s passion, but as I reflect on my training and career, my greatest hope is that we can provide opportunities for all of our trainees to find what they are most passionate about in plastic surgery. We have flexibility and opportunities for early independence in our curriculum, to allow trainees to customize their training experience so they can explore their interests and reach their full potential. The amazing thing about plastic surgeons is that most of us really love what we do – and that’s an incredible gift I hope share with all of our residents at UCSD. |

Plastic Surgery Resident | Fall 2019

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Q&A WITH SAMUEL LANCE, MD

By Kendra Y. Mims Plastic Surgery Resident strives to provide readers with career advice designed to aid them in their professional advance after residency – by sharing insights that may help them create their own, desired path.

In this installment of Faculty Focus, we present ASPS member Samuel Lance, MD, assistant professor of surgery, assistant clinical professor of plastic and craniofacial surgery, associate director of the residency program and director of adult craniomaxillofacial surgery at the University of California-San Diego School of Medicine’s Division of Plastic Surgery, as well as a member of the Rady Children’s Hospital complex sleep-disorder team.

In addition to specializing in reconstructive and aesthetic plastic surgery, Dr. Lance is trained in craniofacial and pediatric plastic surgery. His research endeavors are focused primarily on complex craniofacial disorders in pediatric patients and adults, including cleft palate and craniosynostosis. His breast research focuses primarily on the timing of breast reconstruction and ocoplastic approaches to early breast cancer – and he’s also involved in research targeting pediatric breast-reconstruction for asymmetry, as well as abnormally large adolescent-breast conditions.

Dr. Lance says balancing one’s life as a plastic surgeon should include an extended effort to break free from the specialty’s orbit, in order to connect – or reconnect – with people and things that are far removed from it; that perspective can keep one grounded. Dr. Lance also has relied upon mentors and senior colleague for a wider and deeper understanding of the specialty; therefore, he endeavors to spread his knowledge in that manner to junior surgeons, whenever possible. He believes that the pursuit of excellence should be a resident’s primary objective during training (as opposed to the absolute mastery of any particular procedure), and that compassion is the greatest attribute that a plastic surgery resident can possess.

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PSR: WHAT DREW YOU TO PLASTIC SURGERY? Dr. Lance: While I’ve always been drawn to the technical and manual aspects of surgery, I also have a fondness for design and artistry. Throughout my childhood and teen years, I was constantly building or creating my next structural masterpiece, either as a treehouse in our backyard – or a new house during my time as a construction worker. Furthermore, I was steeped in the arts, from playing music to drawing and photography.

As cliché as it may sound, plastic surgery presented the perfect combination of these two seemingly divergent concepts within the practice of medicine. I recall a lecture by a plastic surgeon that I witnessed during my second year of medical school, in which he described his study of facial mimetic muscles, bone structure and facial proportions – he then proceeded to show how these concepts directed his practice of traumatic facial reconstruction. The moment I saw that lecture, I thought: “This is it; this is what I want to do for the rest of my life.”

PSR: HOW SHOULD RESIDENTS PREPARE THEMSELVES FOR A FELLOWSHIP? Dr. Lance: Residency can be such a grueling experience; the last thing on the forefront of most minds is the next fellowship or subspecialty training. However, the foundation of a good fellowship application is simply excellence in achieving the goals of a residency. If you can dive into your residency with passion and dedication, the results will be twofold. First, you will garner the respect of your mentors and peers, leading to strong letters of recommendations. Second, you will develop an inclination toward innovation and a greater understanding of the specialty, leading to publications and vast improvements in knowledge.

We often look at the fellowship application process as a checklist that needs to be mastered. While items such as high In-Service Examination scores and publications are a necessary part of becoming competitive, a passion for the specialty and a genuine sense of care in one’s work will inevitably lead a resident to achieve these – and much more – with greater ease and satisfaction. Every fellowship director is ultimately looking for a person who will be respected by

patients and colleagues, and who will perpetuate the best image of their training program.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER ADVANCEMENT? Dr. Lance: The specialty of craniofacial surgery carries a long legacy of innovation and of pressing the boundaries of surgical treatment. Many of the outcomes of craniofacial surgery are measured in lifetimes on the constantly changing landscape of growing children. Fellowship training allowed me the opportunity to absorb decades of outcomes and practice changes by studying the successes and failures of my mentors.

It’s one thing to possess knowledge of a specialty; it’s another thing entirely to garnish wisdom in clinical practice. I owe the initial and continued success of my career to mentors who were willing to candidly share their practice and wisdom with me. Furthermore, fellowship allowed me the opportunity to meet and collaborate with others in this small, but tightly knit, community of surgeons.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS? Dr. Lance: Having a trusted mentor is critical to developing confidence and maintaining professional support in the early years, and I would argue, throughout the entirety of one’s practice. I often counsel our students to seek residency programs with faculty who are trusted by residents and who will build lasting mentorship relationships with their trainees.

The practice of medicine is exactly that – a practice. Even as we leave residency with knowledge and technical skills, we must continue to exist as a community of surgeons constantly looking to refine and sharpen each other throughout our career. To this day, I remain in close contact with my mentors from training. They are a source of wisdom, strength and friendship that shapes my practice and personal growth as a surgeon.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Lance: Societies and leadership in societies through committees is yet another avenue to maintain the needed relationships with other surgeons in our specialty. As previously mentioned, isolation often stifles the growth of a surgeon due to an absence of critical feedback and exchange of ideas. Societies and leadership involvement on committees helped me break away from the digital bubble that encompasses most of our medical learning in today’s world.

They allow me to interact directly with my peers and lead me to a deeper understanding of the complexities that exist in the advancement of medical practice.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Lance: Compassion. True compassion is only born out of a genuine sense of honor in one’s work and humility toward the monumental privilege of being a physician. Compassion recognizes the frailty of humanity found also in ourselves.

It acknowledges the struggle of human illness and the dedication required to overcome even a portion of this suffering through medical practice. A resident who demonstrates compassion in his or her practice will be a success. Their compassion will drive them to perform well and learn for the sake of their patients. It will transform their career from simply another job to a calling with the passion to succeed.

PSR: HOW DO YOU BALANCE TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Lance: Being married to a ballet dancer has given me a genuine appreciation for balance – in both a literal and figurative sense. Just as balance is fundamental to walking, so is it crucial in creating a lasting, successful career as a surgeon.

I often read this quote by Sir William Osler as a reminder to seek balance.

“While medicine is to be your vocation or calling, see to it that you have also an avocation – some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters. Begin at once the cultivation of some interest other than the purely professional.”

Learning to balance takes years of practice and constant refinement as the landscape of medicine changes. I’m far from mastering this skill, but I’m constantly looking to improve. Prioritizing family and personal life is a key element to wellbeing and professional success – especially during the early years of a career. The life of a surgeon is one of near-monasticism and can become all-consuming if not for dedicated efforts enhancing the connection to our humanity and personal growth. I try each day to spend at least 45-50 minutes to reconnect with my family, free from work concerns.

Waking up even 10-15 minutes earlier each day to spend in self-reflection, exercise or music has been equally rewarding.

I find that my hobbies and family time enlighten both my drive to succeed and my spark for innovation. Some of my most productive research ideas have come after a period of reflection and repose from the rigors of surgical practice.

PSR: WHAT WAS YOUR GREATEST NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE THAT? Dr. Lance: I found interacting with non-medical friends during residency to be quite challenging. I became so steeped in medical lore that staying in touch with the world around me was difficult. Few jobs in the professional marketplace are as consuming or time-demanding as residency. The dichotomy between the lifestyle of a resident compared to the lifestyle of friends who worked in other professions made friendships difficult at times. The tension of these contrasting lifestyles was overcome by dedicating what time I had to building strong relationships with non-medical peers and family.

Planning and scheduling activities with friends served to continued on page 29 Plastic Surgery Resident | Fall 2019

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San Diego

By Jiwon Sarah Crowley, MD, & Sean Li, MD

W

elcome to beautiful, sunny San Diego.

Perhaps the biggest issue you’ll encounter here is the overwhelming amount of activities to do, places to see and food to eat – all without a sufficient number of hours in the day in which to partake. The good news is: You’ll be visiting in September, well past the dreary days of “May gray and June gloom;” the ocean is still warm; and many of the tourists have gone back to work and school. There’s something for everyone, whether you’re visiting solo or with friends, family or co-workers – and these choices run the full spectrum of the exhilarating and adventurous to the “chill” and relaxing.

For those of you visiting for the first time, there are a few quintessential experiences to consider. First, the San Diego Zoo is one of the best zoos in the world. You could easily spend an entire day there and still not see every exhibit. Some zoos can feel a bit like a concrete prison for depressed animals, but the San Diego Zoo has some of the most elaborate and natural enclosures for families of primates, big cats, elephants and more; you’ll actually start to feel a little jealous you can’t join them.

If you’ve been to the zoo already, consider taking the 30-minute drive to the Safari Park in Escondido, where you can reserve your own private expedition into an 1,800-acre savannah that’s filled with rhinos, giraffes, zebras, antelopes – and even the rare Sumatran tiger!

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Plastic Surgery Resident | Fall 2019

Next door to the zoo is Balboa Park, the No. 1-rated park in San Diego. It offers a beautiful campus of Spanish-Renaissance architecture and filled with museums (including the museums of Art, Natural History, Man, and Air and Space); theaters; restaurants; street performers; and botanical and Japanese tea gardens. There’s also a world-class disc golf course (Frisbee golf) within the park, and this activity should be a priority if you’re an enthusiast or simply looking to try it out for the first time.

Speaking of golf, if you’re a golfer and want to play at one of the best public golf courses in the world, keep in mind that Torrey Pines is just 20 minutes from downtown. Its south course is on the bucket list for all serious golfers, and the newly re-designed North course has some of the most dramatic ocean views you can imagine. Reservations for non-residents can be made online up to 90 days in advance, but a last-minute cancellation system is in operation – so keep trying, right up until your visit.

BEACHES

San Diego is home to so many distinct types of oceanfront communities that it’s probably worth mentioning some of the more defining characteristics around the area to help you decide which beach you would enjoy visiting the most.

Coronado – When you see postcards of pristine, expansive San Diego beaches for as far as the eye can see, you’re probably looking at pictures of Coronado Island. This is home to the Hotel Del

Coronado, which is a classic 19th-century hotel on the beach, and has been a National Historic Landmark since 1977 (and it made the Travel Channel’s list of most-haunted hotels). It’s worth a visit, even if you aren’t staying there. The beaches are huge and clean, with lifesized sand castles. The surrounding area is filled with restaurants and art shops on cobbled streets of classic Spanish architecture.

Another way to enjoy Coronado is to head down to the Coronado Ferry Landing. Here you can spend hours enjoying the San Diego Skyline view – cruising on bikes or scooters, dining at several great restaurants, or chartering a sailboat out of the marina for an hour or two.

Sunset cliffs in Point Loma – This area features cliffs with coves of secluded beaches. The harbor side of Point Loma is home to an awesome, multi-use campus called Liberty Station – old military barracks that have been converted into restaurants, cafes, funky art shops and huge open fields, right on the water. Stone Brewing Company has a gastropub here which would be a great option for lunch or dinner. It’s right by the airport – and an easy way to spend the morning or afternoon before flying home.

La Jolla Shores – This is a perfect spot for families looking to relax and sunbathe, considering the mile-long stretch of beach, volleyball nets and fire pits. You can easily rent snorkel gear or embark upon guided kayak tours to see leopard sharks and turtles that migrate in the thousands to La Jolla Shores through December. La Jolla Cove is great for kelp-forest scuba diving. The Children’s Pool is famous for walking out on a jetty sea wall and beaches that are covered by seals and sea lions.

Honorable mentions – Pacific Beach and Ocean Beach have reputations for offering more of a “college” scene, but it’s great for surfing. Ocean Beach has a dog beach – which is great if you’re traveling with your furry four-legged companion. For other water activities, head over to Mission Bay and rent jet skis, a pontoon boat, Hobie cats or stand-up paddleboards in Sail Bay. For a more relaxing day on the water, take a guided tour of San Diego Bay by hooking-up with Hornblower Cruises & Events.

The neighborhood of Hillcrest has many eateries with delicious wares to sample. Try Snooze, “an A.M. Eatery,” for the best pancakes and French toast, and Hash House a Go Go for generous portions of delectable farm-style meals. Near the Hillcrest neighborhood in North Park is another prime location for food and brunch. Breakfast Republic specializes only in brunch and is one of the top places in the city for the most important meal of the day.

MEXICAN FOOD

San Diego’s southern expanse pushes up against the Mexican border, so it shouldn’t surprise that it offers some of the best Mexican food in the country. You can find delicious tacos, burritos, churros and everything between, almost anywhere in the city. Our favorites include City Tacos in North Park; Tacos El Gordo in Chula Vista (which some argue has the best tacos in the city); Oscar’s Mexican Seafood in Pacific Beach; and The Taco Stand in La Jolla. If you’re more of a burrito person, be sure to check out Lucha Libre (featured on Food Network) in North Park or Mission Hills.

BARS & BREWERIES

For beer lovers, San Diego is home to original craft breweries such as Stone and Ballast Point. Some other great microbreweries include Belching Beaver, Karl Strauss, Modern Times and Green Flash. If you’re more into trying liquor drinks in an offthe-beaten-path fashion, head to Mahalat Spirits Co., La Jolla, for tastings of handcrafted rum and whiskey. If you’re a fan of speakeasies and fancy cocktails with live music, check out Seven Grand and Prohibition Lounge.

DINNER OPTIONS

If you want to enjoy ocean or harbor views while eating, head to Tom Ham’s Lighthouse to have dinner at one of San Diego’s architectural landmarks, featuring USCG Beacon No. 9 – the only USCG-maintained and -operated lighthouse that’s attached to a restaurant. Other restaurants with amazing waterfront views include Coasterra (very close to the airport); Tidal in Mission Bay, diners can watch rays, leopard sharks and even moray eels; and The Marine Room in La Jolla, where waves crash against the window during high tide. If sitting by the water

BRUNCH

There are seemingly countless places ready to serve a scrumptious brunch in San Diego. If you’re in La Jolla, check out The Cottage, a quaint, little restaurant with killer French toast and fruit compote. The wait can be up to an hour, but don’t waste time inside the establishment – give them your name,

then head out to the adjacent La Jolla Cove and walk along the beach – or just relax on the grassy bluffs and watch the street performers. Herringbone is also a great brunch spot in La Jolla, offering the unique decor of indoor, giant 100-year-old trees.

Ocean Beach

continued on page 29 Plastic Surgery Resident | Fall 2019

19

Transgender Surgery

By Andrew Hollins, MD; Rachel Hein, MD; & Kristen Rezak, MD

W

ith more than 1.4 million people in the United States now identifying as transgender, it’s no surprise that the demand for gender-affirmation surgery continues to grow. This represents a unique at risk medical population with barriers to healthcare and higher incidence of anxiety and depression. Gender dysphoria is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a person whose gender at birth is incongruent with gender identity.

Plastic surgeons play an essential role in the comprehensive approach to patients diagnosed with gender dysphoria, as genderaffirmation surgery is often the last step in the treatment process.

This article aims to provide an overview regarding preoperative assessment and the surgical options for these patients.

PREOPERATIVE ASSESSMENT

Preoperative assessment of these patients requires an interdisciplinary team and an individualized approach regarding their expectations and personal goals. The World Professional Association for Transgender Health (WPATH) has developed recommendations and treatment guidelines for transgender patients. All patients who present for surgery must have the capacity to make fully informed consent. The age of consent for all gender-affirmation surgeries is age 18 in the United States. However, an underage patient who desires female-tomale (FtM) mastectomy can undergo surgery if they have a consenting guardian, have lived in the congruent gender identity for at least one year and completed one year of continuous testosterone therapy.

All patients who present for surgery must have a referral from a mental-health professional that documents persistent gender dysphoria, with one referral required for chest reconstruction and two separate referrals for genital reconstruction. Patients seeking 20

Plastic Surgery Resident | Fall 2019

surgery should have well-controlled comorbidities, as well as be up-to-date with any recommended gender-related health screening and routine cancer screening.

Hormone therapy is not required for chest gender-affirmation surgery. However, for patients undergoing male-to-female (MtF) chest reconstruction, 12 months of hormone therapy is recommended to allow for breast-tissue growth and better aesthetic outcomes. Hormone therapy is required for 12 continuous months prior to any genital-reconstruction surgery. In addition, patients must have lived 12 months continuously in the gender role congruent with their respective identity.

CHEST/BREAST

FACIAL OR OTHER GENDER AFFIRMATION SURGERY

One referral

Two referrals

Not required

Capacity of informed consent

Required

Required

Required

Age of consent

>18*

>18 only

>18 or guardian consent

Hormone therapy

Not Required

Required 12 Continuous Months

Not Required

Living in congruence with gender identity

Not Required

Required 12 Continuous Months

Not Required

WPATH

TARGET

REQUIREMENTS

FUNCTION

Documented referral of gender dysphoria from mental health provider

* Age of majority in a given country for under age 18. This is reflected by the country's standard. It's recommended that the patient will have stopped developing prior to undergoing transitioning surgery.

MALE-TO-FEMALE SURGERY

Male-to-female (MtF) patients represent the largest proportion of the transgender population, with implant-based breast augmentation being the most common MtF chest surgery.

Although hormone therapy isn't required for surgery, estrogen hormone therapy is recommended prior to surgery, to allow for breast-tissue growth and improved cosmetic surgical results. Fat grafting can be utilized as an alternative. Breast augmentation in the MtF population is similar to the approach in the cis patients.

The male chest is slightly wider than the female chest and could result in widened cleavage or laterally displaced nipple-areolar complex (NAC). The preference of perioareolar, axillary or inframammary approach and prepectoral verus subpectoral placement of the implants are surgeon- and patient-dependent.

The complications of breast augmentation are similar to the general population and include capsular contracture, hematoma and prosthesis rupture. Post-gender affirmation patients should undergo breast-mammography screening every two years starting at the age of 50, or after five to 10 years of feminizing hormone.

The goals of MtF genital reconstruction are sexual sensation, a functional vagina and acceptable cosmesis. Penile-inversion vaginoplasty is the gold standard for genital reconstruction in the MtF population. Inversion vaginoplasty includes performing scrotal excision; high-end ligation orchiectomy; dissection of the penis; creation of a neovagina in the pre-rectal space; and the creation a neoclitoris by utilizing the glans penis and a neourethra anastomosis. Urologic dysfunction is the mostcommon, long-term complication and occurs in 10-40 percent of patients, who may experience meatal stenosis or splayed urinary stream. It’s recommended that these patients continue the same prostate screening as cisgender men.

FEMALE-TO-MALE SURGERY

Subcutaneous mastectomy is performed in FtM patients who desire a male-chest contour. The goals of surgery include a male-chest contour, acceptable positioning of NAC and minimal scarring. This population is often more difficult than the male gynecomastia population, due to larger breast size and excess skin. Breast size and skin elasticity are the most important factors when planning surgical incisions.

For patients with small breasts or Grade I ptosis, liposuction alone can be performed only – or a semicircular or transareolar incision approach can be utilized. For medium-sized breasts or grade II ptosis, a concentric circular or extended concentric incision yields the best results. For large or grade III ptosis breasts, a free-nipple graft is the best available surgical option for patients. Nipple necrosis and hematoma are the most common surgical complications. Post-chest reconstruction FtM patients should continue cisgender-woman screening guidelines for breast cancer if no mastectomy or only a breast reduction is performed.

The goals of FtM genital reconstruction are to create an aesthetically pleasing neophallus that has intact tactile and erogenous sensation; that provides standing urination; and that imparts minimal donor-site morbidity. There are three surgical techniques in FtM genital reconstruction: metoidioplasty; pedicled phalloplasty with an anterolateral thigh (ALT) flap; and phalloplasty with a radial forearm free flap (RFFF). For all these reconstructive options, urologic dysfunction – including urethral strictures and fistulae – are the most common complications.

Metoidioplasty involves the creation of a neophallus from a hypertrophied clitoris. The clitoris is dissected with detachment of clitoral ligament and division of urethral plate with urethroplasty to increase neophallus length. The advantage of this approach is the principle of like-with-like reconstruction utilizing the glans and allowing for erectile rigidity without a prosthesis. The drawback of metoidoplasty is a shorter neophallus (5-7cm). The pedicled ALT flap can be used for a “tube-withina-tube” flap design for neourethral formation. This flap provides a reliable vascular supply with a discrete donor site. Difficulties of this option for genital reconstruction include a thick, subcutaneous layer that limits tube formation, and the need for a prosthesis for erectile rigidity.

Finally, the RFFF creates an aesthetic neophallus with adequate length for standing urination. Neurorrhaphy between donor antebrachial cutaneous nerves to the dorsal clitoral and/or ilioinguinal nerves provides tactile and erogenous sensation.

Disadvantages with use of this flap include donor site morbidity.

Most patients will undergo TAHBSO prior to phalloplasty, but they’ll need to continue to follow screening for cervical cancer after genital reconstruction.

CONCLUSION

Gender affirmation continues to be an evolving field within plastic surgery. Studies have demonstrated that patients who undergo gender-affirmation surgery have significant benefits of mental and psychosocial health with an extremely low rate of regret (2 percent). Thus, a comprehensive, multidisciplinary, preoperative assessment is vital for treatment of these patients.

Each patient presents with different individual goals that can be addressed through the many potential treatment options. | Dr. Rezak is an associate professor of plastic surgery; Dr. Hein is PGY-5; and Dr. Hollins is PGY-2; at Duke University Division of Plastic Surgery, Durham, N.C. REFERENCES

Coleman, E., et al. The standards of care of the world professional association for transgender health, 7th version. Int J Transgenderism 13 (2011):165-232 James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. A. (2016). The report of the 2015 US transgender survey. Washington, D.C.: National Center for Transgender Equality Weyers, S. et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. The Journal of Sexual Medicine 6, 3 (Mar. 2009), 752-60 Claes, K. et al. Chest surgery for transgender and gender nonconforming individuals. Clinical Plastic Surgery Jul 2018;45(3):369-380 Monstrey, S. et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plastic Reconstr Surg 121, 3 (Mar. 2008), 849–59 Buncamper, M. et al. Surgical Outcome after Penile Inversion Vaginoplasty. Plastic Reconstr Surg 138, 5 (2016), 999-1007 Morrison, S.D. et al. Phalloplasty: A Review of Techniques and Outcomes. Plastic Reconstr Surg 138, 3 (Sept 2016), 594-615 Frey, J.D. et al. An Update on Genital Reconstruction Options for the Female-toMale Transgender Patient: A Review of the Literature. Plastic Reconstr Surg 139, 3 (Mar. 2017), 728-737 Massie, J.P. et al. Predictors of Patient Satisfaction and Postoperative Complications in Penile Inversion Vaginoplasty. Plastic Reconstr Surg 141, 6 (June 2018), 911e–921e

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Journal Club; 2019 Fall; (16)

this retrospective review entails 53 patients with MRI and US studies, 46 of whom had nerve injury identified by surgery or clinic/electrodiagnostic testing. Ultrasound was found to have increased sensitivity and equal specificity when compared to MRI (sensitivity US 93 percent vs MRI 67 percent; specificity 86 percent for US and MRI). This study challenges the historical view that MRI is superior.

2. Timing and Appropriate Use of Electrodiagnostic Studies.

Bergquist, ER., Hammert, WC. Hand Clinics. 2013; 29 (3), 363-370

JOURNAL ARTICLES ON

ACUTE PERIPHERAL NERVE INJURY

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Nichole Joslyn; MD, Benjamin Timmins, MD; & Michael Schmitt, MD

A

cute peripheral nerve injuries (PNIs) have many implications within the plastic and reconstructive surgery. From facial nerve lacerations to an upperextremity gunshot wound, it’s imperative that young plastic surgeons are familiar with acute PNIs and how to manage them.

In this installment of Journal Club, we discuss diagnostic methods, classifications, treatment principles and postoperative optimization of acute PNIs.

DIAGNOSING NERVE INJURIES 1. Detection of Peripheral Nerve Pathology: Comparison of Ultrasound and MRI.

Zaidman, C.M. Neurology. 2013; 80 (18), 1634-1640 Before we discuss this article, it’s important to note that ultrasound (US) vs MRI is highly controversial. With that caveat,

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Plastic Surgery Resident | Fall 2019

Nerve conduction studies (NCS) and electromyography (EMG) are arguably the second-best method of evaluating nerves (behind clinical examination). NCS directly examines motor and sensory function, while EMG examines the motor unit, action and spontaneous potentials in muscles. The authors discuss what physicians would expect to see in electrodiagnositc studies for neuropraxia vs axonotmesis and neurotmesis – and how these findings change with time from injury. It’s important to not only understand what the test reveals, but also to recognize how the timing of the study can play into it.

CLASSIFICATION OF NERVE INJURIES 3. A Classification of Nerve Injuries.

Seddon, HJ. British Medical Journal. 1942; (2) 4260, 237-239 Seddon introduced classification of nerve injuries, and here he’s divided injuries into neurotmesis (complete transection of a nerve); axonotemesis (lesion in continuity, the axon is damaged but the connective tissue around the nerve survives to some extent); and neurapraxia (transient block, or the nerve is intact but not transmitting impulses).

4. A Classification of Peripheral Nerve Injuries Producing Loss of Function.

Sunderland, S. Brain. 1951; 74, (4) 491-516

Sunderland acknowledges the Seddon classification, but goes on to subdivide axonotmesis into three types with differing degrees of disruption (see table below). It’s important to note that more recent papers argue for a 6th degree of injury, or a mixed type of injury. Understanding this classification is important to guide treatment.

SEDDON

PROCESS

SUNDERLAND

Neurapraxia

Segmental demyelination

1st degree

Axonotmesis

Axon injured, endoneurium intact

2nd degree

Axonotmesis

Axon and endoneurial injury; perinerium intact

3rd degree

Axonotmesis

Axon, endoneurial and perineum injured; epineurium intact (i.e., neuroma in continuity)

4th degree

Neurotmesis

Nerve transection

5th degree

POST-OP CARE

TREATING NERVE INJURIES 5. Management of Nerve Gaps: Autografts, Allografts, Nerve Transfers and End-to-Side Neurorrhaphy.

Ray WZ, Mackinnon SE. Experimental Neurology. 2010; 223(1), 77

9. Evidence and Techniques in Rehabilitation Following Nerve Injuries.

Novak CB,et al. Hand Clinics. 2013 Aug; 29(3):383-92 This article highlights the importance of rehabilitation in optimizing sensorimotor outcome after nerve injury. The time of immobilization following repair varies. Arguments for early range of motion suggest decreased scarring and increased neural mobility, while those for longer periods of immobilization hypothesize an increase in scar at the coaptation site. The ideal balance should therefore protect the coaptation site, yet promote neural mobility.

This idyllic time period remains to be established, but this article does offer some general guidance in the decision-making. The authors also briefly discuss the role of electrical stimulation and sensory reeducation.

1 -3 degree injuries will often recover without surgery, whereas 4th-5th degrees require operative intervention. When tension-free primary repair is not possible, alternatives include autogenous nerve grafts; nerve transfers; end-to-side coaptation; nerve conduits; and nerve allografts. Nerve topography is critical for any successful nerve repair. Improper alignment could result in poor functional recovery. Lastly, rehabilitation rounds-off what is a great general overview on managing nerve gaps. st

rd

6. Processed Nerve Allografts for Peripheral Nerve Reconstruction: A Multicenter Study of Utilization and Outcomes in Sensory, Mixed and Motor Nerve Reconstructions.

Brooks DN, et al. Microsurgery. 2012; 32.1:1-14

10.State-of-the-Art Techniques in Treating Peripheral Nerve Injury.

Kubiak CA, et al. Plast Reconstr Surg. 2018; 141.3: 702-710

While the benefits of autograft are acknowledged, the donor site morbidity shouldn’t be overlooked. This paper from the RANGER research program (A Registry Study of Avance® Nerve Graft Evaluating Outcomes in Nerve Repair) employed multicenter, retrospective data to evaluate outcomes of a processed human-nerve allograft. They found that these allografts performed well, and were safe and effective in sensory, mixed and motor-nerve defects between 5-50 mm. The allografts compare favorably to those reported in the literature for nerve autograft and are better than those reported for nerve conduits.

Optimizing post-injury recovery is critical, and yet there’s much within the field of neuroscience that’s still unknown. This article summarizes background information on four newer techniques that these scientists believe to have the most promise in improving functional recovery: Electroceuticals have been around since the 1950s, and there are some promising studies suggesting a positive effect of brief, low-frequency electrical stimulation on nerve regeneration; nerve guidance conduits have been around since the late 1800s, but they’re constantly evolving; the regenerative benefits of autogenous fat-grafting are unclear, but some early studies are promising; and optogenics (the use of light to control proteins that regulate axonal regeneration) is a state-of-the-art technology that’s very early in investigation. More research is needed.

7. A Systematic Review on the Use of Fibrin Glue For Peripheral Nerve Repair.

Sameem M, et al. Plast Reconstr Surg. 2011; 127, 6:2381-2390

You’ve identified a peripheral nerve laceration and are about to repair it primarily; now what? Sutures, fibrin glue or a combination of both? This paper reviews the literature on these repair methods.

Those in support of fibrin glue argue that it’s faster, technically easier and avoids suture granuloma and scar formation. However, critics cite gapping and failure when fibrin glue is used in isolation.

8. Optimal Timing For Repair of Peripheral Nerve Injuries.

Wang E, et al. Trauma Acute Care Surg. 2017; 5:875-881 Optimal timing of nerve repair is up for debate. Cambell argues sharp injuries should be repaired within three days. Seddon argues that if you wait three weeks, fibrosis helps in your ability to perform coaptation. This is a retrospective study examining the timing of repair and the specific factors that impact motor-sensory outcomes after peripheral-nerve injury. Those repaired within 24 hours did not have improved outcomes when compared with those repaired later. Ultimately, this study found that outcomes were primarily affected by patient characteristics and injury level rather than timing. Remember that early repair within 72 hours allows for nerve stimulation to identify cut distal nerve endings. This is especially important in injuries to facial nerves or nerves with topographic considerations.

ADDITIONAL READING • • • • • • • • • •

Pathophysiology of Peripheral Nerve Injury: A Brief Review. Burnett MG, et al. Neurosurgical Focus. 2004; 16(5), 1-7 The Surgical Management of Facial Nerve Injury. Rovak JM, et al.

Seminars in Plastic Surgery. 2004; 18(1), 23-30 Functional Outcome Following Nerve Repair in the Upper Extremity Using Processed Nerve Allograft. Cho MS, et al. The Journal of Hand Surgery. 2012; 2340–2349 Nerves and Nerve Injuries. Sunderland, S. E&S Livingstone Ltd, Edinburgh. 1968.

New Directions in Peripheral Nerve Surgery. Mackinnon SE. Annals of Plastic Surgery. 1989; 257-273 Facial Nerve Trauma: Clinical Evaluation and Management Strategies.

Brown S, et al. Plast Reconstr Surg. 2019; 143 (5), 1498-1512 The Treatment of Brachial Plexus Injuries. Narakas AO. International Orthopaedics. 1985; 9 (1), 29-36 Peripheral Nerves of the Extremities: Imaging with US. Fornage BD. Radiology. 1988; 167 (1), 179-182 Evaluation and Management of Peripheral Nerve Inury. Campbell WW. Clinical Neurophysiology. 2008; 119 (9), 1951-1965 https://surgicaleducation.wustl.edu/ |

Dr. Joslyn is PGY-6; and Drs. Timmins and Schmitt are each PGY4; at Oregon Health & Science University Division of Plastic and Reconstructive Surgery, Portland.

Plastic Surgery Resident | Fall 2019

23

ASPS ADVOCACY SUMMIT

Call for engagement: Recap of D.C. efforts Sixty ASPS members and 18 plastic surgery residents took part in the ASPS Advocacy Summit held June 17-19 in Washington, D.C., during which more than 100 meetings were held between ASPS members and residents, and members of Congress or their staff. Among the participants was Alicia Billington, MD, PhD, who was chosen as one of 10 residents to receive a scholarship that allowed her to attend. These are her thoughts and perspectives on the Summit.

By Alicia Billington, MD, PhD

T

here was no shortage of issues for which to advocate in Washington, D.C. But for me, the Resident Physician Shortage Reduction Act (S.348/H.R.1763) was crucial: Ensuring enough doctors are available to meet the nation’s medical needs in light of an impending physician-shortage crisis is something in which I’ve been personally invested over the last 10 years.

This bill would fund 3,000 residency positions annually for five years, with 50 percent of the new GME spots going to primary care and 50 percent going to specialty-care shortage positions.

States have responded by opening up more medical schools and expanding existing programs, but Medicare funding of residency programs has remained capped since the Balanced Budget Act of 1997. This bill is important because it affects not only all medical students and residents, but also every American – because all patients need doctors.

PlastyPAC leaders chose the Ensuring Lasting Smiles Act (ELSA) (S.560/H.R.1379) as the Society’s White Hat topic to bring before the respective congressional delegates during the Summit. ELSA would require all insurance plans to cover care for patients with congenital differences and allow

24

Plastic Surgery Resident | Fall 2019

for treatment for the normal functioning or replacement of missing or abnormal body parts, including teeth. It would not cover cosmetic procedures for normal body parts for aesthetic purposes.

Sen. Tammy Baldwin (D-Wis.) sponsored this bill after meeting a young boy named Aidan Abbott, who was born with ectodermal dysplasia. I happened to be rotating through our craniofacial children’s program in June and experienced firsthand the challenges confronting many patients with facial clefts, such as finding good dental coverage for their dental anomalies. While posting about ELSA on Instagram, I gained a new follower known as @rarewashwoman – who I later learned was Aidan’s mother. Stories like this show that one voice can make a difference!

WHY SHOULD THEY CARE?

I was extremely fortunate to not only receive a scholarship from ASPS, but also the blessing of my program director, Michael Harrington, MD, to attend this event. Educating residents involves far more than what’s covered on the In-Service Examination and in the O.R. We have a duty to our profession to ensure our patients get the best care. When we became

HOW DO I GET INVOLVED IN ADVOCACY?

Perhaps you’re wondering: Where do I start? I became interested in health policy as a first-year medical student. I was completely overwhelmed and didn’t know anything about legislation or health care. Over the next few years, I reached out to leaders at my school and found my passion for ensuring all patients have access to doctors. I started frequently visiting Washington and my state capitol in Tallahassee to advocate for the doctor shortage. Fast-forward to my Match Day, where Rep. Kathy Castor (D-Fla.) announced her “Creating Access to Residency Education (CARE) Act of 2014” to specifically address this problem.

Residents who traveled to the advocacy summit include (top row, left) Bharat Ranganath, MD, and David Nash, MD; (second row, left) Benjamin Schultz, MD; Bianca Molina, MD; George Kamel, MD; and Sterling Braun, MD; (third row, left) Kavitha Ranganathan, MD; Mohammed Al-Rakan, MD; and Spencer Anderson, MD; (fourth row, left) Vinod Chopra, MD; and Christopher Stewart, MD; (fifth row, left) Travis Miller, MD; and David Kurlander, MD; and (front row, left) medical student Ariel Wampler; Julie Ferrauiola, MD; and Ashley Thorburn, MD. Not pictured are Alicia Billington, MD, PhD; Justin McKinney, MD; and John "JT" Stranix, MD.

So how do you do this? My first recommendation is to find a good mentor. Reach out to leaders you admire and ask them how to become involved. Second, join an organized medicine group. I became actively involved in my local, state and the national American Medical Association as a medical student.

Now that I’m a resident, I’m also a member of the ASPS. I encourage you to become involved in both groups so that you can bring important plastic surgery issues to colleagues in other fields.

The ASPS Advocacy Summit is a great introduction to health policy. In fact, 50 percent of this year’s attendees were there for the first time. A great feature of the Summit are the break-away sessions, where teams meet to discuss topics in small groups and go over techniques for meeting with members of Congress.

Third, become a member of PlastyPAC. It costs only $25 for residents, and it allows our profession to continue educating members of Congress on behalf of the specialty. Plastic surgeons meet with their members of Congress to discuss such topics as scope of practice, out-of-network billing, FDA panels hearings on BIA-ALCL and more.

The Florida delegation meets with Rep. Cathy Castor (right, D-Fla.) at the ASPS Advocacy Summit, held June 17-19 in Washington, D.C., to discuss her continued engagement in fixing the resident physician shortage. Pictured are (from left) Alicia Billington, MD, PhD; Andrew Rosenthal, MD; Christian Laatsch; Raj Sawh-Martinez, MD, MHS; and George Varkarakis, MD.

doctors, we took an oath to “do no harm,” but I believe that also includes the responsibility of standing up to do the right thing.

In order for plastic surgeons to maintain the standards of our profession, we must have a voice – and using that voice must start early, in residency.

I challenge each residency program to find one attending and one resident over the next year who can teach, engage and promote health policy in plastic surgery.

Fourth, stay up-to-date on important topics in plastic surgery and medicine. I like to use social media to help keep abreast of hot topics. I follow the New England Journal of Medicine and the journal PRS, and I receive policy updates that are emailed weekly to my account from various policy sites. For those of you on social medial, you can follow me @medicaladvocacy on Instagram and Facebook, where I post interesting articles that can get you started and engaged.

Finally, continue the relationships you make through advocacy.

I can’t tell you how nervous I was the first time I knocked on a lawmaker's door. A decade later, I can’t wait for it to swing open to see someone with whom I’ve developed a friendship with over the years.

Thank you again to ASPS for this incredible opportunity – I look forward to participating in the ASPS Advocacy Summit for years to come. I hope to see you there! |

Dr. Billington is PGY-5 at the University of South Florida Morani College of Medicine, Tampa.

Plastic Surgery Resident | Fall 2019

25

WHAT I KNOW NOW

That I WISH I KNEW then

By Christopher R. Forrest, MD, MSc

It’s been a minute…

– Drake, “From Time”

This Drake lyric is a good reminder of how quickly it all goes by, and that you should enjoy the journey and not focus on the destination. I was really fortunate as a resident to have the benefit of great teachers, a wealth of clinical material, excellent co-residents (well, except for maybe one) and a program that seemed to care about my well-being and success.

That being said, there are several things that would have been nice to know before I started my surgical training. It has been a while, but the feeling never goes away – and I still occasionally have nightmares where I awaken and wonder if I really did pass my final exam.

The journey to surgical excellence never really ends. There are moments when you feel you’ve hit a home run and done something amazing, but just around the corner is an unexplained and unexpected complication. That’s when the surgical gods decide to deflate your ego a little. Still, I would emphasize that during residency, it’s crucial to learn the skills for survival and health that will last your career – and also facilitate your evolution and maturation as a surgeon.

WATCH, LEARN – AND ASK

Know when to ask for help – then do it. It took me a while to realize that it wasn’t always on my shoulders. Surgery is a cooperative, team sport – and it was important that I understood I wasn’t expected to know everything. It speaks to the importance of mentorship and collegiality: Having a guide to take you through the nuances of all aspects of surgical training is incredibly beneficial.

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Plastic Surgery Resident | Fall 2019

Watch experienced surgeons negotiate the traps and challenges of dealing with ED referrals, case preparation, staff idiosyncracies and even hospital parking are some examples where a mentor can be a huge advantage. A program and surgical residency should foster cooperation and community, not competition.

Never underestimate your influence as a surgical leader. It doesn’t matter if you’re in your first week of residency – as a surgeon, the team will look to you for direction and leadership.

Well, as a PGY-1, the hardened and battle-worn O.R. nurses may not take you quite so seriously until you’ve proven yourself, but the impact you will have on medical students can be profound. Always act professionally. You never know who’s watching.

The business of surgical practice is much neglected during most residency programs, and mine was no different. I wish I had spent more time learning from my staff (i.e., attendings) about the challenges and hurdles they encountered once they had started their own practices. I also wish I had taken the time to ask my staff what their lives were really like. I have a scheduled tennis lesson at 1:30 p.m. each Thursday, because I believe it’s an important component of balancing my week. If people ask when they see me leave the hospital, I’m happy to tell them where I’m going. When I was a resident, I really had little idea what the extracurricular lives of my staff were like.

Be kind to yourself. This is huge – and as Type A personalities, most surgical residents probably don’t do enough to promote health, both mental and physical. It’s okay to have a life beyond residency; make sure that you carve out a little bit in an appropriate way. Exercise, spend some time with family, do something every week that you look forward to and learn how to “turn off.”

RANDOM THOUGHTS

Support your attending. Know their patients better than they do, check their schedule, anticipate what they need – and that will translate into a better educational experience for you.

It’s easy to have strong opinions as a trainee, and while there are many ways things can be done, keep an open mind. Even if you disagree with the way a staff person does something and think to yourself: “This must be crazy,” you can always learn from an experience – even if it’s how not to do something.

Keep a record of all the people you work with and all the cases you do. As grapes grow and soak up the terroir of the land to make a great wine, so will you become the sum of the parts of all your teachers – and it’s nice to know where you acquired certain traits from, before you evolve into your own being.

As staff, we want you to succeed; it’s our greatest source of educational satisfaction. Challenge and engage your staff person. Suck the information from them until they are dry.

There are no “small” operations; you can learn from them all. Even if you’re lost in the crowd during a major operation and feel the chances of doing a fronto-facial mono-bloc advancement are slim to none after graduation, you can always engage in the anatomics. That’s the common language we have as surgeons – and there’s no part of the body that, as plastic surgeons, we wouldn’t touch. Understanding the anatomy is always a great default.

Spend time in clinic. It’s easy to get lost in the O.R., but if you don’t see your patients before and after surgery, you’ll never know what to operate on – and what’s happened as a result.

See as many complications as you can and track them – the only way not to get complications is not to operate. Looking after them is the hardest thing we do.

Talk to the “elders” at conferences. When I was attending national meetings as a resident and even as junior staff, I would always be nervous about approaching a plastic surgery icon to ask a question. Now that I’ve reached senior status, one of the biggest joys of attending meetings or doing a visiting professorship is talking to you guys – the next generation of surgeons. It keeps me in touch with what’s going on. So, to me it’s a win-win.

Be confident. There are many types of cases in our world of plastic and reconstructive surgery, and it’s impossible to see them all during your training. Be confident in the skills that you acquire, that you’ll be able to adapt them to whatever type of case falls in your lap.

Okay, that’s enough to fill your brains for now. Being a surgical resident is a privileged time. You have the best of all worlds available to you, but it’s easy to lose perspective when you’ve been up all night and have rounds to organize the next morning. There’s an old Hollywood movie with James Stewart that could sum-up a career in plastic and reconstructive surgery: “It’s a Wonderful Life.” It will be – just make sure you don’t lose sight of that in the deep, dark recesses of residency training. |

Dr. Forrest is chair of the Division of Plastic and Reconstructive Surgery at the University of Toronto, and medical director of The Centre for Craniofacial Care and Research.

Plastic Surgery Resident | Fall 2019

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Put your plastic surgical vocabulary skills to the test!

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By Rami Sherif, MD ACROSS

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Muscle that is critical to controlling neck contour in a neck lift

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Area where upper and lower lateral cartilages meet

5.

9.

Substance used to reverse nodules, asymmetries, or vascular compromise caused by injection of hyaluronic acid fillers Artery divided during incision for open rhinoplasty

Medication that is an absolute contraindication to CO2 laser for facial rejuvenation if used within 6-12 months of lasering

12. The most common complication of blepharoplasty 15. Most commonly injured branch of the facial nerve during facelift 16. Most common adverse effect of CO2 laser

17. This layer of the face, continuous with the platysma, temporoparietal fascia, and galea, is manipulated during a facelift

19. Muscle that causes horizontal rhytids of the glabellar region and is also a common target of Botox therapy 20. “____” line describes a straight plane that connects the most prominent portions of the upper lip and lower lip 22. Most common complication of facelift

23. Injection of hyaluronic acid fillers too superficially can lead to this effect of bluish discoloration 24. Type of graft placed between the upper lateral cartilage and septum to widen the internal nasal valve 28

Plastic Surgery Resident | Fall 2019

3.

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Most commonly injured muscle in blepharoplasty (two words) What nerve, when injured, can lead to sympathetic reinnervation of facial skin causing gustatory sweating (Frey's Syndrome)?

A hematoma in this space after blepharoplasty is exceedingly rare but can be devastating, leading to blindness Muscle that shortens the upper lip and decreases tip projection when fired (two words)

10. Physical exam test performed to evaluate collapse of the internal nasal valve 11. Bony structure in nostril that humidifies, warms, and filters air 13. In-office test to evaluate tear production.

14. Area where nasal bony vault meets upper lateral cartilages 18. Nerve that must be carefully avoided during genioplasty

21. A “___ - nose” deformity can occur if less than 1cm of septal L strut is preserved Answer key on page 31

FACULTY FOCUS / continued from page 17 express my dedication to our friendships and build a life outside of residency.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Lance: I enjoy the variety and breadth of plastic surgery.

This isn’t only anatomic variety, it’s also artistic variety. Many cases in plastic surgery require a vision of the final aesthetics to guide our surgical approach and clinical decisions. Refining this vision for each patient is a unique and rewarding challenge of plastic surgery. I also enjoy the regular interactions with a wide array of consulting services. Almost every surgical and even nonsurgical specialties collaborate with plastic surgery on a frequent basis. Some of my most trusted colleagues can be found in neighboring surgical services.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Lance: Effective delivery of care is perhaps the most significant challenge in academic medicine. We are often tasked with the care of underserved populations – which have their unique challenges in delivering effective care. No matter how skilled I become as a surgeon or physician, the care I offer is only as good as the communication and trust I can build with my patient. This includes communication of their personal needs and barriers to receiving care. I try my best to provide not only direct medical care but also resources for social services and clear information regarding their diagnosis and treatment.

A second challenge is growth as a clinical instructor. Each resident learns in unique ways requiring

specific teaching strategies both in the O.R. and in didactic sessions. Being able to identify education styles, grow in my knowledge of adult learning and effectively teach residents is a lifelong challenge. Instruction, however, is the core of my mission in academic medicine and is vital to the development of effective surgeons for the future.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Lance: I choose to remain in academic surgery primarily for the opportunity to teach residents and medical students. As associate residency program director, I make every effort to prioritize resident education even during a busy clinical schedule. Dedicated, didactic schedules allow for specific times of teaching but really serve to enhance a regular pattern of instruction and mentorship throughout my daily practice. I try to make the most of each clinical scenario as an opportunity to interact with residents, and build on their knowledge and skills, while adding direction toward resources for growth.

PSR: AS A SEASONED AND EXPERIENCED PLASTIC SURGEON, WHAT WOULD BE YOUR ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Lance: I’m not entirely sure I would classify myself as exceptionally “seasoned” or vastly “experienced.” Even years into my career, I recognize daily the immense breadth of knowledge and skill that is plastic surgery.

If I have any words of advice, they are to acknowledge and be humbled by the scale of plastic surgery. This will, in turn, drive you to continuous improvement and learning. |

24 HOURS / continued from page 19 isn’t a high priority, there are other delicious options – including Din Tai Fung for delicious soup dumplings at The Mall at University Town Center; Buona Forchetta in South Park for authentic Italian; and Sushi Ota for incredible fresh sushi. A Lion’s Share, situated in the heart of downtown, is a fantastic, little place with unique meats that inclue boar, rabbit and even camel.

SPORTS

San Diego has the Padres baseball team, Gulls minor league hockey and the Legion rugby team.

(The San Diego Chargers NFL team moved to Los Angeles only a couple of years ago.)

However, the biggest sport here is surfing. Swing over to any of the beaches for surf lessons with some of the best areas being Scripp’s Pier while grabbing breakfast at Caroline’s Seaside Cafe, Pipe’s Beach, Tourmaline Surfing Park, Silver Strand and more.

LIVE MUSIC

San Diego boasts a vibrant music scene with many big name artists “playing through” the city. Many big acts perform at Petco Park, Pechanga Arena and the North Island Credit Union Ampitheatre. If you’re into the local music scene and a more-intimate setting, you should check out House of Blues, The Observatory and Soda Bar.

NIGHTLIFE

The day isn’t over yet, so make your way to downtown’s Gaslamp Quarter – and become immersed in a nightlife scene that encompasses 16 blocks of bars, clubs and trendy restaurants.

The area also hosts many unique events, so do some homework before arriving. Other great areas for nightlife include the Pacific and Ocean beaches if you’re feeling young again (see page 19), and Hillcrest and North Park/Normal Heights if you’re into live music.

It's normal to feel a little overwhelmed when considering all the various options for activities and places to eat, but hopefully this article has helped narrow down some of your choices. Either way, please come visit us again soon! |

Dr. Crowley is PGY-7 and Dr. Li is PGY-4, both at the University of California-San Diego School of Medicine Division of Plastic Surgery.

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Senior Residents Conference and Residents Day await in San Diego

By Paris Butler, MD, MPH; Scott Hollenbeck, MD; Michelle Roughton, MD; and Ann Palzer

N

ew speakers and an everevolving program await at the Senior Residents Conference (SRC) and Residents Day events, slated to be held Thursday, Sept. 19, and Friday, Sept. 20, during the annual scientific meeting of ASPS/PSF/ASMS/ASPSP – the world’s largest plastic surgery meeting. We invite you to spend oneand-a-half days networking with your resident colleagues and current leaders in plastic surgery – and utilize a program built through a joint effort by ASPS, the ASPS Young Plastic Surgeons Steering Committee and the American Council of Academic Plastic Surgeons. This year’s co-chairs are Paris Butler, MD, MPH; Scott Hollenbeck, MD; and Michelle Roughton, MD. The resident program marks the unofficial kick-off of Plastic Surgery The Meeting, and we anticipate that nearly 300 residents will join us in the host city of San Diego to enjoy an energetic and entertaining resident-focused program.

TARGETED EDUCATION As you head toward the completion of residency, you likely have questions about topics not routinely covered in training.

We’ve done our best to put together 10 packed hours of pertinent information – broken into small, palatable segments most relevant to the seasoned resident.

The day begins with tips on building the practice you want in any setting: academic, employed or private. Although we wish you every success as you start out, we also recognize that it doesn’t always work out the first time. Listen to real-life stories of transitions from the people who made them.

The morning concludes with such insights as how to buy a practice; what machines are really useful for your office; setting your cosmetic fees; hiring your first employee; and straightforward advice on how to get a job. We’ll also discuss how 30

Plastic Surgery Resident | Fall 2019

RESIDENTS BOWL FRIDAY, SEPT. 20 & SATURDAY, SEPT. 21 SAN DIEGO CONVENTION CENTER For more information visit www.plasticsurgerythemeeting. com/residents/residents-bowl

to handle the unhappy patient. Speakers will be upfront and honest about their experiences. We’ll also explore the keys to a successful career – and provide guidance on the first financial steps a starting plastic surgeon should take.

Once in practice, becoming boardcertified is the next logical step. The afternoon kicks-off with information on preparation for both the ABPS Written and Oral examinations, to be followed later by important information from ABPS Executive Director Keith Brandt, MD. The afternoon will include discussions on how to deal with your first lawsuit, contract negotiations, how to get a fellowship and how to interpret profit and loss statements.

You’ll also learn what referring surgeons look for in their plastic surgeon.

Additionally, your career should be a marathon, not a sprint; for that reason, we’ve included lectures on surgeon longevity, staying healthy, ergonomics and injury avoidance.

Thursday concludes with an insightful presentation on starting a family while being a plastic surgeon, followed by

another prime opportunity to network over cocktails and appetizers – the Residents Day Reception.

ASPS thanks Mentor Worldwide LLC for sponsoring the Senior Residents Conference and is grateful for their generous support of its resident education programs. ASPS would also like to recognize and thank Allergan, Integra Life Sciences, MTF Biologics, Sientra, The Doctors Company, KCI, an Acelity Company, Plastic Surgery Match and Plastic Surgery Business Solutions for their support of the Resident Networking Reception and Residents Day program.

FIT FOR EVERYONE The program’s second day is offered to all residents. The morning is dedicated to fellowship matching and job-hunting techniques. In-practice plastic surgeons compare and contrast whether you need a fellowship in different practice settings, whether getting a job where you trained is a good idea and practicing in urban vs. rural settings. You’ll also gain insight on whether you should consider pursuing an MBA or other non-medical degree.

After the morning break, Rod Rohrich, MD, will share advice on how to get published in the journal PRS. Neal Reisman, MD, JD, is back with his fundamental risk-management talk. There will be a dynamic presentation on the importance of having a vision for your practice.

Leaders of the specialty will explain what the Society can do for you, and the many ways in which you can get involved.

ASPS immediate-past President Jeffrey Janis, MD, will provide useful tips to help you navigate Plastic Surgery The Meeting 2019 – and to close the Residents Day program, 2019 ACAPS Goldwyn Award Winner and The PSF past President Linda Phillips, MD, has been invited to speak to you. As a true mentor and leader in the specialty of plastic surgery,

APPLY BY OCT. 4

we know this will be the highlight of the program.

ABSTRACT PRESENTATION An integral part of both SRC and Residents Day is the opportunity to present your research during the Resident Scientific Sessions on Friday and Saturday.

Abstract submissions were accepted through May 1; best paper selections and resident author names will be announced in an issue of PSN later this year.

REGISTRATION For Senior Residents planning to attend Thursday’s SRC, registration is required ($475). Members of the Residents/ Fellows Forum save $100 ($375). The fee is necessary to cover the educational sessions, meals and the Resident Reception on Thursday. Your registration also includes complimentary admittance to the “Basics of Plastic Surgery Coding” Course taught by Scott Oates, MD. This instructional course will be held from 4-6 p.m. Sunday, Sept. 22. The Residents Day program is free to all residents and Fellows, but we do ask you to register in advance so we can be sure to have enough food and beverage for all.

On behalf of this year’s co-chairs, thank you for taking the time to read through this – and we look forward to seeing you in San Diego. For more information, to register or to keep up-to-date with deadlines and developments, go to plasticsurgerythemeeting.com and click on the “Residents” tab. |

Answer key from page 28

ASMS ANNOUNCES CREATION OF NEW RESIDENT AMBASSADOR POSITIONS

By Navid Pourtaheri, MD, PhD, ASMS Resident Representative Are you a plastic surgery resident interested in pediatric or adult craniofacial surgery, or facial aesthetic surgery?

The ASMS has several, new positions available for those seeking to become a Resident Ambassador.

WHAT IS AN ASMS RESIDENT AMBASSADOR? Resident Ambassadors assist the ASMS in spreading Society news and information to the public regarding the subspecialty of maxillofacial surgery.

They accomplish this by serving as liaisons for the ASMS in their local regions and by posting on social media content that’s geared toward updating surgeons and the public about ASMS initiatives.

WHO CAN APPLY? PGY1-4 residents at ACMGE-accredited, integrated plastic surgery programs are eligible to apply. If you are not already an ASMS resident member, you must also submit an application to become one – and membership is free. Lastly, you’re expected to have a working knowledge of our social media platforms: Instagram, Twitter and Facebook. Ambassadors will serve two-year terms and provide content at least twice per month.

HOW DO I APPLY? Send a copy of your current CV and a brief personal statement – at most, a half-page with single-spacing – describing your interests and plans for the position. Please include a signed letter of good standing from your residency program director.

Lastly, please post a sample of ASMS-related content to your social media page(s) and tag us, so that we may evaluate it.

EXAMPLES OF SAMPLE CONTENT • A photo of your group on an overseas cleft-surgery trip • A photo of you or other residents having fun or engaged in learning at an ASMS Basic Course • A photo of an ASMS Visiting Professor at the podium or socializing with residents • A photo from a presentation, course or social gathering of ASMS members or trainees at the combined ASPS/PSF/ASMS annual meeting • Historical photos of pioneers in craniofacial or facial plastic surgery • A screenshot of your favorite craniofacial or facial aesthetic journal article, and a sentence about its take-home message.

Complete all application materials by Oct. 4, and email to navidp@gmail.com.

Please feel free to follow, “like” and comment on our social media pages: Twitter: @facialartists Instagram: asms1947 Facebook group: ASMSPlasticSurgery Social media is a great way to stay connected with friends, colleagues and professional societies. Become an ASMS ambassador – and provide valuable information about maxillofacial surgery to other surgeons and the public. |

Plastic Surgery Resident | Fall 2019

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21. SADDLE

24. SPREADER

18. MENTAL

23. TYNDALL

14. KEYSTONE

22.HEMATOMA

13. SCHIRMER

20. RIEDELS

11. TURBINATE

19. PROCERUS

10. COTTLE

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16. HYPOPIGMENTATION 8. DEPRESSORSEPTI 7. RETROBULBAR

15. BUCCAL

6. AURICULOTEMPORAL

12. ASYMMETRY

4. SCROLL

9. ISOTRETINOIN

3. INFERIOROBLIQUE

5. COLUMELLAR

1. PLATYSMA

2. HYALURONIDASE

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