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From the publishers of Plastic Surgery News

ISSUE 14 | SPRING 2019 From the publishers of Plastic Surgery News

»»'Hand trauma' on your pager

First, do no harm – by gathering the right information

page 8

»»The next 'great house' found in this app

Authors of #theTrend swear by new MedOne Plastic Surgery app

page 24

Mission trips: food for the soul Treating the underserved abroad will change lives – the patient's and the resident's IN THIS ISSUE » InService Insight:

Cover-toc to come: »» Cleft lip reconstruction .................... p. 10 Head .. ............................................................. p. xx

» Program Peek: Johns Hopkins/U. Maryland ............ p. 12

» 24 Hours In: Baltimore, a.k.a. 'Charm City' ......... p. 16

ARLINGTON HEIGHTS, IL 60005 444 E. ALGONQUIN ROAD AMERICAN SOCIETY OF PLASTIC SURGEONS

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ALLODERM™ IS THE MOST-USED AND MOST-STUDIED ADM, TRUSTED BY MORE PLASTIC SURGEONS.2,3 Not actual patients. Individual results may vary.

Learn more at the Allergan booth at Plastic Surgery The Meeting 2018.

INDICATIONS ALLODERM SELECT™ Regenerative Tissue Matrix (ALLODERM SELECT™ RTM refers to both ALLODERM SELECT™ RTM and ALLODERM SELECT RESTORE™ RTM products) is intended to be used for repair or replacement of damaged or inadequate integumental tissue or for other homologous uses of human integument. This product is intended for single patient one-time use only. ALLODERM SELECT™ RTM is not indicated for use as a dural substitute or intended for use in veterinary applications. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS ALLODERM SELECT™ RTM should not be used in patients with a known sensitivity to any of the antibiotics listed on the package and/or Polysorbate 20. WARNINGS Processing of the tissue, laboratory testing, and careful donor screening minimize the risk of the donor tissue transmitting disease to the recipient patient. As with any processed donor tissue, ALLODERM SELECT™ RTM is not guaranteed to be free of all pathogens. No long-term studies have been conducted to evaluate the carcinogenic or mutagenic potential or reproductive impact of the clinical application of ALLODERM SELECT™ RTM. DO NOT re-sterilize ALLODERM SELECT™ RTM. DO NOT reuse once the tissue graft has been removed from the packaging and/or is in contact with a patient. Discard all open and unused portions of the product in accordance with standard medical practice and institutional protocols for disposal of human tissue. Once a package or container seal has been compromised, the tissue shall be either transplanted, if appropriate, or otherwise discarded. DO NOT use if the foil pouch is opened or damaged. DO NOT use if the seal is broken or compromised. DO NOT use if the temperature monitoring device does not display “OK.” DO NOT use after the expiration date noted on the label. Transfer ALLODERM SELECT™ RTM from the foil pouch aseptically. DO NOT place the foil pouch in the sterile field. PRECAUTIONS Poor general medical condition or any pathology that would limit the blood supply and compromise healing should be considered when selecting patients for implanting ALLODERM SELECT™ RTM as such conditions may compromise successful clinical outcome. Whenever clinical circumstances

require implantation in a site that is contaminated or infected, appropriate local and/or systemic anti-infective measures should be taken. ALLODERM SELECT™ RTM has a distinct basement membrane (upper) and dermal surface (lower). When applied as an implant, it is recommended that the dermal side be placed against the most vascular tissue. Soak the tissue for a minimum of 2 minutes using a sterile basin and room temperature sterile saline or room temperature sterile lactated Ringer’s solution to cover the tissue. If any hair is visible, remove using aseptic technique before implantation. 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. ALLODERM SELECT™ RTM is available by prescription only. For more information, please see the Instructions for Use (IFU) for ALLODERM SELECT™ RTM available at www.allergan.com/AlloDermIFU or call 1.800.678.1605. To report an adverse reaction, please call Allergan at 1.800.433.8871. References: 1. Data on file, Allergan. 2018. Sales Data. 2. Data on file, Allergan. March 12, 2018. Breast Reconstruction Market Metrics. 3. Data on file, Allergan. PubMed search performed in January 2018. Tissue Reinforcement: Breast Reconstruction Entries. Allergan® and its design are trademarks of Allergan, Inc. ALLODERM™ and its design and ALLODERM SELECT™ are trademarks of LifeCell Corporation, an Allergan affiliate. © 2018 Allergan. All rights reserved. ALS116515 08/18

A note from the editor

elcome to the Spring 2019 issue of Plastic Surgery Resident. As the incoming chief medical editor, I would like to acknowledge our outgoing editor, Alex Spiess, MD, Pittsburgh, who served as shepherd for our publication over the past three years. In the process, Dr. Spiess transformed PSR into a publication truly for residents, by residents. We thank him for his hard work, skill and leadership.

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

In this issue of PSR, we feature many of our recurring sections such as InService Insight, Consult Corner, PRS Journal Club and #TheTrend. In time for the American Association of Plastic Surgeons annual meeting slated for April 6-9 (visit aaps1921.org) and Plastic Surgery Research Council annual meeting slated for May 2-5 (visit ps-rc.org), with both being held in Baltimore, we highlight the combined training program at Johns Hopkins/University of Maryland – the residents of which have provided a packed and exciting list of things to do in “24 Hours in Baltimore.” Our cover story highlights the profound and lasting impact of volunteering – on the life of the patients treated, as well as the surgeons who treat them. I would like to thank our team of editors and the ASPS production staff for all of their hard work in bringing each quarterly issue of PSR to fruition. In fact, we’re seeking applications for new resident editors, and we encourage all who are interested to apply. See the information provided in the box below. I hope you enjoy this issue of PSR – and I’m excited to serve you, our resident readership, as its new chief medical editor. |

PSR seeks 3 resident editors; apply by June 1 Plastic Surgery Resident (PSR) magazine is inviting residents to apply for one of three positions as Resident Editor; these are one-year terms. PSR is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs.

Resident editors report directly to the magazine’s Chief Medical Editor (Sanjay Naran, MD) and collaborate on all editorial content to be published. As an editor, you’ll help develop content ideas, contribute editorial copy and solicit your co-residents and faculty to contribute content. Furthermore, you’ll provide a critical level of review to ensure that articles are well written, logically structured and in line with the magazine’s style guidelines and its mission.

We will accept applications from those who are in their senior years of residency (PGY-4, 5 or 6). To apply, please complete the application form that can be found by going to plasticsurgery.org and clicking on “Surgeon Community” followed by “Resident & Fellow Forum.” Look to the Table of Contents to find “PSResident Editor Application.” Please complete and submit the application by June 1 to PSN Managing Editor Paul Snyder at psnyder@plasticsurgery.org. Those selected will be notified by Sept. 1. |

Plastic Surgery Resident | Spring 2019

Table of

Contents The value of medical mission trips extends far beyond the O.R. .......................................6 Michael Lypka, MD, DMD, witnessed how patients, physicians and entire communities have been changed through cleft lip and palate surgery.

Consult Corner: Fractures of the hand ....................................8 Hand and upper-extremity fractures can require quick thinking and fast responses, but “information” is where it all begins.

InService Insights: Cleft lip ........................................................... 10 Treatment of bilateral and unilateral cleft lip may be difficult to visualize, but a quick refresher in embryology and abnormal physiology can bring clarity.

Program Peek: Johns Hopkins/University of Maryland .... 12 This combined program, formed in 1989 by two plastic surgery pioneers, has been ranked as the top residency program for 21 consecutive years.

Message from the Director: Scott Lifchez, MD ......................................... 13 Plastic Surgery Residency Program director at Johns Hopkins, University of Maryland highlights the challenges met – and skills acquired – by its residents.

Faculty Focus: Oluseyi Aliu, MD ........................................... 14 Assistant Professor of Plastic and Reconstructive Surgery reveals his parents’ roles in bringing him to the United States – and to the specialty.

24 Hours In: Baltimore ....................................................... 16 The charm of this historical port city is highlighted by young plastic surgeons eager to share their favorite restaurants, neighborhoods and activities.

PlastyPAC Ambassador update: JT Stranix, MD .............................................. 19 The resident representative to the PlastyPAC Board of Governors says advocacy efforts on the Society’s behalf is strongest when residents participate.

From the Resident Representative: Kavitha Ranganathan, MD .......................... 21 The resident representative to the ASPS Board of Directors will work to broaden the reach of residents in the Society and to recruit mentors.

Journal Club: Facelifts .........................................................22 Jordan D. Frey, MD, understands the daunting yet exciting milieu of facelifts, and in Part I of this Journal Club he contributes five articles to foster understanding.

#TheTrend: MedOne Plastic Surgery ....... 24 James Vargo, MD, and Jacob Grow, MD, shine their tech light on the newest app from Thieme – and describe an all-inclusive, slam-dunk digital database.

Crossword: Plastic Surgery Potpourri ........................... 25 From rhytidectomy complications to medial femoral circumflex arterial supply, your knowledge of anatomy and surgery will be tested in this installment.

Plastic Surgery Resident | Spring 2019

Plastic Surgery Resident | Spring 2019 | Vol.3 No.1 The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR ESI DEN T Alan Matarasso, MD | amatarasso@drmatarasso.com EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com ASSOCI ATE EDITOR Russell Ettinger, MD | retting@uw.edu 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 S Steven Lindsey; Jun Magat A DV ERTISING SA LES Joe Anzuena (215) 521-8532 Wolters Kluwer Health

Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005. POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005 Postage paid at Arlington Heights, IL, and at additional mailing offices. The views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily reflect the opinions of ASPS. Acceptance of advertisements for PSR is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised. ASPS Home Page: www.plasticsurgery.org

On The Cover: Michael Lypka, MD, and John McFate, MD, repair a cleft lip in Armenia, Colombia.

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The Medical Mission Trips That Forever Alter the Local Landscape – and the Lives of Plastic Surgery Residents

By Michael Lypka, MD, DMD

In the current era of medicine, where physicians are more often employed by hospitals – and less regarded than ever before by patients and hospital personnel – one highlight for me (and I’m certain for the residents who attend each year) is a week in Latin America, where we perform cleft lip and palate surgery.

Plastic Surgery Resident | Spring 2019

Dr. Lypka, the director of Operation San Jose, with a 14-year-old primary cleft lip repair patient in Villahermosa, Mexico.

Working with a population of patients desperately in need – and also truly grateful for the care they receive – can be a relief from the daily routines endured by a hospitalist. Operation San Jose (funded by the CHRISTUS Foundation, a Catholic charity in Houston) is an annual, cleft medical-mission trip that typically travels to Mexico or Central/South America. With a core group of nurses, anesthesiologists and plastic surgeons, the group works with local surgeons and hospitals to provide high-quality cleft care to as many patients as possible.

Thanks to rotations at Texas Children’s Hospital (Baylor program), Hermann Children’s Hospital (University of Texas Houston program), Shriner’s Hospital (UTMB) and St Joseph Hospital (Methodist program), residents obtain a broad view of techniques performed in cleft surgery. As is typical at most institutions where the resident isn’t the primary surgeon, especially for primary cleft lip surgery, a mission trip such as Operation San Jose is where a resident truly can bring his or her acquired knowledge and skill to the forefront as the operating surgeon. Residents are supervised carefully by plastic surgery faculty, who themselves regularly perform cleft lip surgery. As the week progresses, confidence grows – and the competence level in performing the surgery is typically superb.

Two plastic surgery residents participate each year, and while residents often just “tag along” for the ride, the residents who make this trip are the primary surgeons – and they are assisted and directed by the faculty. My first experience with Operation San Jose came in 2009 as a chief resident in plastic surgery at the Methodist LOGISTICAL Hospital program, CONSIDERATIONS formerly the St. Joseph A few logistical issues exist Hospital program. I had for the resident going on the opportunity to travel a medical mission. In the to Villahermosa, Mexico, past, cases on a cleft mission with the group – and it was trip couldn’t be officially an experience that would logged by the resident; but have a huge impact on my now, when the necessary career and perspective as a paperwork is established practicing plastic surgeon. Dr. Lypka (center, dark blue scrubs) and the rest of the surgical team by the residency program take a moment for a photo in Puebla, Mexico. and sponsoring institution, RESIDENT FOCUS these cases can be counted. Nearly 10 years later, and now as director of Operation San Unfortunately, since Operation San Jose typically rotates Jose, I’ve seen the evolution of the program and the truly great among a few locations, getting official paperwork from the things that it does, both for patients who receive care and hosting institutions each year has been difficult, thus making the volunteers – particularly plastic surgery residents – who official case counting impossible. participate each year. Since it isn’t an official rotation recognized by the Methodist A unique experience of the Methodist Hospital plastic surgery hospital residency, residents on this trip must use vacation program is the opportunity to participate in Operation San time to attend. The hospital turns a” blind eye” to the trip and Jose. Two residents per year travel with the group (all expenses therefore assumes no liability. While liability was not on my paid) for the 10-day trip during their chief year. When a radar as director, recent residents have expressed concern about Methodist Hospital program resident isn’t available (regardless this; one decided not to attend for this reason. Unfortunately of the reason), a University of Texas Medical Branch resident – and probably not necessary, in my opinion – Operation has substituted. At the Methodist residency program, the continued on page 27 craniofacial/pediatric plastic surgery experience is varied.

Plastic Surgery Resident | Spring 2019

“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.

Hand and Upper Extremity Fractures By Morgan Brgoch, MD MESSAGE ON YOUR PAGER:

You’ve finally made it to bed and slipped into a deep sleep, but at 2 a.m., this reverie is shattered by an initial page from the E.R.: 34-year-old female with an isolated injury to her right hand. Field bandage not removed, EMS reports exposed bone with uncontrolled hemorrhage. Tourniquet placed en route to the hospital one hour ago.

FIRST MOVES: DAMAGE CONTROL AND DIRECTION Well-meaning providers may inadvertently compound a simple fracture into a debilitating injury with simple lack of awareness or delay in the initial treatment. As you drive into the hospital, you’re hoping for an efficient evaluation and initiation of treatment by the E.R./ trauma team, which is critical. Upon arrival, you:

• Remove any tourniquets, jewelry, clothing, etc. Provide hemostasis with local pressure only; prolonged tourniquet time (unfortunately, common in hospital transfers or transport) only serves to worsen

Plastic Surgery Resident | Spring 2019

neurovascular injury and predispose to reperfusion injury and compartment syndrome.

• Three-view the X-ray. One view is no view. If initial X-rays from the trauma bay are inadequate, they must be repeated. Include one joint above and one joint below the injury.

• Start antibiotics. Open fractures should be treated with antibiotics – in addition to irrigation and debridement. If no allergies are present, delayed treatment of open fractures, grossly contaminated fractures or immunocompromised host should be treated with a third-generation cephalosporin +/- an aminoglycoside for crush injuries. A penicillin derivative should be added for farm injuries and bite wounds (fight bite). Ensure tetanus prophylaxis. • Assess for occult injuries. Concomitant injuries may often be overlooked during the initial assessment – or hidden by distracting injuries such as open fractures.

HISTORY AND PHYSICAL In addition to standard H&P specifics, focused questions to elicit valuable, perioperative details are imperative: • Age • Handedness • Occupation • Smoking status • Mechanism of injury (crush, twist, avulsion, etc.) • Timing of the injury • Last meal (and timing thereof) • Allergies • Co-morbidities • Previous injuries or surgeries

A detailed and comprehensive physical exam is indispensable and will ultimately guide the overall management of the injury.

• Neurovascular status: Assess perfusion via color, capillary refill, turgor or even temporary use of digital pulse oximetry. Assess radial and ulnar proper digital nerves to each digit with two-point discrimination. Thumbs up, OK sign, and cross fingers to test radial, AIN

34-year-old female with open comminuted intra-articular fracture of the right thumb proximal phalanx. Imaging shows injury pre-reduction plain films (on left) and post-reduction fluoroscopy (on right). Bedside washout, reduction, closure and thumb-spica splinting performed acutely (images courtesy of Dr. Brgoch).

and ulnar nerves, respectively. Evaluate the carpal tunnel/median nerve for acute carpal tunnel syndrome promptly and maintain high index of suspicion in high energy wrist trauma, displaced distal radius fractures, peri-lunate dislocations, etc. Perform an Allen’s test to assess for competent arch/ collateral perfusion.

• Anatomy of the injury: Assess the exact bones involved, potential arthrotomy or tendon laceration, and presences of shortening or malrotation. Simple versus comminuted, reducibility, and stability if reduced.

–– Assess the viability and availability of the surrounding soft tissue for potential closure. Assess nail beds for subungual hematomas and evaluate for potential Seymour fracture in skeletally immature patients.

• Passive and active range of motion, and stability at each joint.

STUDIES • Three-view X-ray: PA, lateral and oblique views to adequately assess fracture.

• Critical considerations: Potential operative indications and operative planning depend upon the specifics of the fracture pattern and location.

–– Open versus closed

–– Comminuted versus simple

–– Intra-articular versus extra-articular –– Digit involved: thumb, index, long, ring, small (avoid referring to digits as 1, 2, 3, etc.) –– Bone involved and the location of the fracture Carpal, metacarpal, proximal phalanx (P1), middle phalanx (P2), distal phalanx (P3)

Base, shaft, neck, head, tuft, etc.

–– Fracture pattern: transverse (usually unstable), longitudinal, oblique, spiral –– Angulation and direction (i.e., apex dorsal)

–– Malrotation or shortening

• Consider CT scan for mangling injuries or highly comminuted fractures (i.e., comminuted intra-articular distal radius fractures) to guide operative planning. • Fluoroscopy: Invaluable for initial reduction, splinting and assessment of fracture stability once reduced and the patient performs ROM exercises.

MANAGEMENT While the timing of definitive intervention is highly variable based on surgeon preference, most (vascularly intact) injuries can be managed successfully at the bedside. Initial management should focus on thorough irrigation and debridement of all open injuries; fracture reduction; adequate softtissue coverage; and splinting. Tips and improvisations passed from one resident generation to the next allow for efficient acute-management at the bedside without compromising patient care. • Anesthesia: After determined to be neurovascularly intact, anesthesia is best obtained with local anesthetic administration with epinephrine to aid in hemostasis. This may be administered as a hematoma block, wrist block or digital block as appropriate. Despite the medical school dogma, epinephrine has ultimately been proven safe in the digits.

• Irrigation: Copious saline irrigation of all wounds (minimum of 3L often employed) is the single-best method to prevent infection. A 16-gauge needle may be used to punch small holes in the top of a saline bottle as an improvised shower head.

continued on page 29 Plastic Surgery Resident | Spring 2019

Cleft Lip Unilateral and Bilateral Cleft Lip Reconstruction Maximize your In-Service Examination score by revisiting lessons learned early in your career as a physician. To provide an assist with meeting this goal, “Cleft Lip” endeavors to provide residents with a renewed understanding of the condition, which in turn should result in a greater understanding of the methods deployed in its repair. By Eric Maiorino, MD

he cleft lip reconstruction can initially seem difficult to conceptualize. However, with an understanding of the embryology and abnormal anatomy, the repair is easier to understand. In this installment of InService Insights, we review the commonly tested aspects of unilateral and bilateral cleft lip reconstruction.

DEMOGRAPHICS

Cleft lip is the most common facial birth defect in the world, with males twice as likely to be affected as females. There’s also a variation in incidence among races: Asian and Native Americans have rates as high as 1:450, whereas it occurs in 1:1,000 Caucasians and 1:2,000 African Americans. A left unilateral cleft is the most-common configuration – it’s nine times more common than a bilateral cleft.

Plastic Surgery Resident | Spring 2019

EMBRYOLOGY AND ETIOLOGY

Lip formation begins around the fourth week of gestation, and is usually completed by the seventh week with the fusion of the maxillary prominences with the medial nasal prominences. A failure of fusion of the medial nasal prominence with the maxillary process results in a cleft lip. Approximately 10 percent of infants with cleft lip will have an associated syndrome, with Van der Woude (due to an autosomal dominant IFR6 gene mutation) being the most common – accounting for 2 percent of cases. A positive family history of cleft lip increases the likelihood of recurrence, as seen in Table 1. Environmental factors such as exposure to anticonvulsants or smoking during the first trimester have increased risk of cleft lip/palate, with phenytoin increasing the rate tenfold, while folic acid is thought to play a protective role.

ANATOMY

The cleft lip can be classified into complete versus incomplete – and then further into unilateral versus bilateral. A complete cleft extends through the lip into the nasal floor, whereas an incomplete cleft has an intact nasal sill. A microform cleft (also known as forme fruste) has a small notch in the vermillion, a vertical scar from vermillion to nostril sill and minimal nasal deformity.

In the complete unilateral cleft lip, the anatomical deformity results from the abnormal attachments of the separated orbicularis oris muscle. On the non-cleft side, the muscle inserts into the anterior nasal spine, resulting in deviation of the caudal cartilaginous nasal septum away from the cleft. The maxilla is similarly rotated outward and away from the cleft, due to the pull of the muscle. On the cleft side, the orbicularis oris abnormally inserts into the alar base, resulting in lateralization and flattening of the cleft side lowerlateral cartilage. The cleft side maxilla is also displaced, in a posterior, inferior and lateral position, due to the forces of the malpositioned muscle. In the complete bilateral cleft lip, two clefts separate the prolabium – derived from the frontonasal process – from the

TABLE 1 RISK OF FAMILIAL RECURRENCE IN CLEFT LIP1 Affected family member(s)

Percent risk

1 affected parent

3-5

1 affected child

2 affected children

Affected parent and child

Monozygotic twins

40-50

Dizygotic twins

Affected niece/nephew

Affected cousin

0.5

TABLE 2 KEY POINTS AND FLAPS 1

Low point of Cupid’s bow

Peak of Cupid’s bow (non-cleft side)

Peak of Cupid’s bow (cleft side)

Noordhoff’s point (vermillion-cutaneous junction; where the vermillion begins to fuse)

Alar base (cleft side)

Alar base (non-cleft side)

Lip-nasal sill-orbicularis junction

Midpoint of the columella

Mucosal (M) flap

Used to line gingivobuccal sulcus

Columella (C) flap

Used to close nasal sill or lengthen columella

Lateral (L) flap

Mucosa; used to line lateral nasal vestibule

Advancement flap

Rotation flap

FIGURE 1 paired lateral maxillary shelves. The prolabium has no Cupid’s bow, philtrum or columns and no orbicularis muscle, and often has an indistinct white roll. Because the premaxilla lacks the posterior force of a normal orbicularis muscle, it can be anteriorly projected out of the normal maxillary arch, and even into a “fly away” position above the nasal tip. The orbicularis oris muscle fibers abnormally terminate in the lateral alar bases, resulting lower lateral nasal cartilages that are flattened and widened bilaterally. PREOPERATIVE EVALUATION

Most cleft lips are now identified prenatally with ultrasound, while isolated cleft palates are generally diagnosed after delivery. Patients should be evaluated shortly after birth by a multidisciplinary team of audiologists, geneticists, otolaryngologists, pediatricians, plastic surgeons, speechlanguage pathologists and dentists, in order to identify and treat any associated syndromes or comorbidities. Evaluation of the cleft type and degree should be assessed. Parent education should be provided, especially in regard to feeding. While some infants with an incomplete cleft lip may be successful with breastfeeding, most infants with cleft lip and palate require specialized bottles/nipples.

TREATMENT

Advances in intrauterine repair have been made over the last decade, but there continues to be a major risk of preterm labor – therefore, prenatal cleft lip repair is not currently the standard of care. After delivery and prior to definitive repair, patients with a complete cleft lip may require nasoalveolar molding (NAM) or a lip adhesion to bring the alveolar segments closer together. While NAM can help close the alveolar space, correct malposition of nasal cartilage and elongate the columella, it requires frequent adjustments of the molding plates – and it’s not tolerated by all infants. Lip adhesions, on the other hand, are performed at age 1-2 months and surgically convert a complete cleft lip into an incomplete cleft lip. The pressure from a closed lip can collapse the alveolar segments closer

continued on page 28

Plastic Surgery Resident | Spring 2019

Johns Hopkins/University of Maryland: Where tradition meets innovation By Howard Wang, MD; Joseph Lopez, MD; & Keli Kolegraff, MD

History • Founded in 1889, Johns Hopkins Hospital is the birthplace of surgical residency training in the United States. Johns Hopkins Hospital was ranked No. 1 overall by U.S. News and World Report for 22 years – including 21 consecutive years. • University of Maryland School of Medicine is the oldest public medical school in the nation and the fifth-oldest medical school overall. • The combined Johns Hopkins/ University of Maryland Plastic Surgery Residency program was formed in 1989 under the leadership of Jack Hoopes, MD, at Johns Hopkins and Nelson Goldberg, MD, at University of Maryland. • Today, the Johns Hopkins/University of Maryland combined program consists of a seven-year integrated program with four residents per year, and a three-year independent program with one resident per year – for a total complement of 31 residents. Leadership • Richard Redett, MD, Professor and Interim Director of Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital

Plastic Surgery Resident | Spring 2019

• Sheri Slezak, MD, Professor and Chief of Division of Plastic and Reconstructive Surgery, University of Maryland Medical Center • Michael Grant, MD, PhD, Professor and Chief of Division of Plastic, Maxillofacial and Reconstructive Surgery, R Adams Cowley Shock Trauma Center • Scott Lifchez, MD, Associate Professor and Program Director • Damon Cooney, MD, PhD, Associate Professor and Assistant Program Director • Yvonne Rasko, MD, Assistant Professor and Assistant Program Director National Leadership • Faculties in the program have held or hold leadership roles in nearly every national plastic surgery associations, including the Plastic Surgery Research Council (Justin Sacks, MD – President); The PSF (Scott Hultman, MD – President Elect); ASPS (Michelle Manahan, MD – Chair of Patient Safety Subcommittee); American Association of Plastic Surgeons; American Board of Plastic Surgery; American Society of Maxillofacial Surgeons; and American Cleft-Palate Craniofacial Association. Clinical Experience • The Johns Hopkins/University of Maryland program is a city-wide program that incorporates three primary sites and multiple additional training sites, providing in-depth

exposure to the entire spectrum of plastic and reconstructive surgery. • The integrated residents spend six months of intern year on general surgery rotations and begin dedicated plastic surgery training in the first year. One year for academic enrichment is scheduled between the second and third clinical years for research, advanced degrees or other academic pursuits. • Johns Hopkins Hospital consists of two clinical services: the Edgerton service, which focuses on pediatric plastic surgery, craniofacial surgery and gender-affirmation surgery; and the Hoopes service, which focuses

on microsurgical reconstruction, breast reconstruction and general reconstruction. • University of Maryland/Shock Trauma Center/Baltimore VA is another primary site that focuses on facial trauma, lower-extremity trauma reconstruction, breast surgery and general reconstruction. • Johns Hopkins Bayview Medical Center is its other primary site,

with focuses on hand surgery, body contouring, breast reconstruction and burn surgery. • Other clinical rotations include the Curtis National Hand Center; Wellspan Health; Dellon Institute of Peripheral Nerve Surgery; Walter Reed National Military Medical Center; chief resident cosmetic clinic; and cosmetic rotations in private practices in Baltimore and near Washington, D.C. • There is one month of elective time in the PGY-5 year and two in the PGY-6 year. Previous residents have used this time for various local, national and international rotations. • There are 23 full-time clinical faculties at the three primary training sites, with one craniofacial Fellow, one microsurgery Fellow, one hand Fellow and three burn Fellows. Educational Curriculum • Weekly Thursday grand rounds and protected resident-education time for activities that include anatomy lab, journal club, indication club, microsurgery training or the Weekly Tuesday Core Conference • Dedicated monthly craniofacial conference, monthly microsurgery journal club, bi-monthly JHH hand surgery conference, monthly Curtis hand journal club, and quarterly aesthetic journal club hosted by various private practice faculties • Quarterly business of medicine curriculum • Twice annual mock oral exams Research • There are many research opportunities available to residents during the research year and clinical years. • Basic science and translational options include: vascularized composite allotransplantation lab with Gerald Brandacher, MD; tissue engineering lab with Dr. Sacks and Hai Quan Mao, MD; material tissue-engineering lab with Devin O’Brien-Coon, MD; and peripheral nerve research lab with Sami Tuffaha, MD. • Clinical research options are available

A Message From Program Director Scott Lifchez, MD The plastic surgery residency program at Johns Hopkins School of Medicine began training its residents 70 years ago. Beginning with our first graduate, Plastic Surgery Research Council founding President Milton Edgerton, MD, our program has sought to train plastic surgeons who are excellent clinicians and researchers – and the future leaders of our specialty. We have graduated more than 100 residents since that time.

In 1989, under the leadership of John Hoopes, MD, chief of plastic surgery at Johns Hopkins, and Nelson Goldberg, MD, chief of plastic surgery at University of Maryland, the plastic surgery residency programs of the two institutions combined to create one, city-wide plastic surgery training program for Baltimore.

In the 1990s, we began our Integrated plastic surgery residency. We continue to have both the Integrated and Independent models of training, and we graduate five residents per year between the two programs. Residents in both programs rotate at hospitals and practices across the city of Baltimore and outside of Maryland – including the Johns Hopkins and the University of Maryland/Shock Trauma main teaching hospitals, as well as community hospitals in Maryland, Pennsylvania and the Washington, D.C., region. Our elective rotation in the pre-chief year allows residents to spend a month anywhere in the world to learn about plastic surgery. Our integrated residents spend a year between the PG-2 and PG-3 clinical years immersed in an intellectual enrichment program. Some have chosen to use the year performing basic science and/or clinical research, and some have used the year exploring international health policy, biomedical engineering and even the development of the devices and inventions that will help future plastic surgeons care for their patients. We’re very proud of the residents we work with every day. Their talent, creativity and dedication gives great care to our patients – and it reminds us of all of the reasons we, as their faculty, love this field. |

at Johns Hopkins, University of Maryland and Shock Trauma Center, covering the full range of plastic surgery topics. • Innovation and entrepreneurship are important aspects of the program, with multiple residents and former residents holding patents and/or creating start-up companies from work performed during residency. Some examples of companies include Life Sprout (Sashank Reddy, MD, and Dr. Sacks), ReconstratA (Angelo Leto Barone, MD) and Sonavex (Dr. O’Brien-Coon).

Resident Benefits • ASPS membership • Meal cards • Camera and loupes fund • Conference attendance fund for chief residents • Four weeks of vacation per year We welcome you to learn more about us at https://www.hopkinsmedicine.org/ plastic_reconstructive_surgery/education/ residency_programs/index.html and follow us on Instagram @hopkinsplasticsurgery. |

Plastic Surgery Resident | Spring 2019

Q&A WITH OLUSEYI 'SEYI' ALIU, MD Plastic Surgery Resident strives to provide readers with career advice designed to aid them in their professional advance after residency by sharing insights to help them create their desired path.

In this installment of Faculty Focus, we present ASPS member Oluseyi “Seyi” Aliu, MD, Johns Hopkins Medicine assistant professor of pastic and reconstructive surgery, Baltimore. Dr. Aliu completed his plastic surgery residency at the University of Michigan (UM), Ann Arbor. During his residency, he earned a Master of Science degree in Health and Healthcare Research and completed a fellowship in health services research as a Robert Wood Johnson Foundation Clinical Scholar (2011-13). Dr. Aliu also completed a fellowship in microsurgery at Albany (N.Y.) Medical Center in 2016, and he’s currently on the plastic surgery faculty at the Johns Hopkins Hospital in Baltimore. Dr. Aliu’s upbringing has informed a great deal of his personal and professional lives, and his gratitude for the opportunities with which he’s been presented is evident in the path he has chosen in plastic surgery – as well as in his dedication and desire to give back to the specialty, to young plastic surgeons and to his patients. His advice to plastic surgery residents is to be, above all, conscientious. PSR: WHAT FACTORS PLAYED A ROLE IN CHOOSING PLASTIC SURGERY AS YOUR SPECIALTY? Dr. Aliu: It works differently for everyone, I think. For some it’s inspiration by something witnessed; for others, it’s the influence from someone admired, or a response to incidences in one’s life. For me, I think it was intuition: There was no “come to Jesus” moment, per se. I simply wanted to do something with my life that I knew I’d be dedicated to spending the time and effort required to be very good – and something that would perpetually interest me. I knowingly gave myself the opportunity to experience a very wide range of specialties inside and outside surgical disciplines and trusted intuition to do the rest. Plastic surgery won out in the end. 14

Plastic Surgery Resident | Spring 2019

As for what I appreciate most about plastic surgery: There is a daily promise of variance in the surgical challenges that are my job to solve. I thoroughly enjoy that daily freshness of purpose.

PSR: HOW DID YOU PREPARE YOURSELF DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Aliu: Like most endeavors, getting into a fellowship requires an application and an interview. It goes without saying that those of us who successfully get into a plastic surgery residency have impressive resumes that make for a good application. Generally, we also interview well. Something that makes a big difference in getting into your fellowship of choice is being able to distinguish yourself by what those who have worked with and trained you say about you. Plastic surgery is a small specialty – and the subspecialties within plastic surgery are even smaller; hence, these opinions are heavily weighted. Have a track record of being what people desire most in a colleague: be dependable, be knowledgeable and capable in the discipline you want to be an expert, be agreeable. Don’t discount the heft of a good word said in your favor.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON THE ADVANCEMENT OF YOUR CAREER? Dr. Aliu: I did a microsurgery fellowship with a wide range of exposure to oncologic and trauma reconstruction for breast, head and neck and lower-extremity problems. The fellowship undoubtedly gave me options in order to choose the right fit from whence to properly launch my career. My training in fellowship left me able to offer a panoply of reconstructive options to a wide range of patients, which made it easier to fit the needs/requirement of the places in which I was interested in starting my career.

My academic interest is in health policy, which somewhat focused my options to places where I could find mentors to guide me properly in a field in which there aren’t too many surgeons. It certainly did help to have a versatile set of skills, gained from fellowship, that made me a good fit to fill the needs in the places where I had the best chance of gaining early traction with my academic endeavors.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Aliu: Perhaps the most important extrinsic factor correlated with a successful career is proper mentorship. Intrinsically, all of us who’ve got to this point are highly motivated, industrious and ambitious. But that’s enough for only so much. Early on, most of us lack the nous to build our desired clinical practice successfully, to develop an impactful academic portfolio, or to do both and have a fulfilled personal life. The part of success that takes more wisdom than intelligence and drive is invariably supplied by proper mentorship.

One-hundred percent of the time, your decisions are directly consequential to the well-being of people who’ve come to you in a spell of vulnerability. Be conscientious.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Aliu: Assuming that the requisite qualities of reliability, intelligence, curiosity, and good personal and professional ethics are all present. I think understanding the substance and gravity of the job is an important attribute. “Conscientiousness,” to put it pithily. It’s a unique job in the sense that 100 percent of the time and 100 percent of your decisions impact the wellbeing of others – directly and in hugely consequential ways. If you truly get what that means, you are doing it right.

PSR: HOW DO YOU BALANCE TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIFE? Dr. Aliu: The most important word in this question is “time.” Time is finite and, in all honesty, this early in my career (2.5 years post-training), I’m not so sure I have the right professional/personal life balance at the moment. Recognizing the scarcity of time, I think the weight of my ambitions and the attendant anxieties about making the right moves to achieve my career goals occupy the lion share of my attentions – at this stage.

I think that professional and personal life balance is perhaps best measured longitudinally, over time – meaning that I’m currently certainly conscious of the need for this balance for the sake longevity and ultimate success in life and career. And, hopefully, if I turn my current anxieties into well-taken decisions this early on, I’ll give myself the space I need to achieve a healthy work/life balance. So, remaining conscious of the need for that balance is the best I can do – at the moment.

PSR: WHAT WAS THE BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE IT? Dr. Aliu: Properly maintaining relationships with family and friends. These relationships are very easy to take for granted, for several reasons. A few that readily come to mind are: You believe the bonds so tightly forged, especially with family, that they are too robust to being frayed, and you assume there’s always going to be forgiveness for negligence. Finally, it’s easy to get defensive because you feel like you deserve a pass – because the nature of the job is famously tasking, and you convince yourself everyone must see it that way and surely understand your absenteeism.

I took every opportunity to remind myself of the immense value of my family and friends in my life. Case in point, my family are emigres from Nigeria. My parents took a risk bringing five children to the United States with little prospects and no guarantees. Especially during the first five years here, my parents made innumerable sacrifices – many times at the expense of their well-being – for the welfare of myself and my siblings. Reminding myself of this quite rightly overwhelms me with gratitude – and it continues to be that no challenge in residency or life has proven a match for the effect of that gratitude.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Aliu: That I made the right choice. That I’m doing a job I unwaveringly have the drive to be better at doing, always.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU’VE ENCOUNTERED IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Aliu: My current challenges are typical of those one has early in practice: being efficient with time and getting the right partition between clinical responsibilities, academic interests and life. I suppose I could have better-learned time management during medical school and residency but, in practice, your responsibilities deepen and broaden so much that it takes a while to be become good at managing them properly.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Aliu: I work in an academic medical center, so you can say teaching is an embedded responsibility which, of course, is part of the reason one choses to work in such an environment. I have residents and medical students with me in the O.R., clinics and my research group. In essence, teaching is always in my schedule.

PSR: WHAT IS YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Aliu: One-hundred percent of the time, your decisions are directly consequential to the well-being of people who’ve come to you in a spell of vulnerability. Therefore, be conscientious. |

Plastic Surgery Resident | Spring 2019

Baltimore By Keli Kolegraff, MD; Howard Wang, MD; & Joseph Lopez, MD

elcome to Charm City! Baltimore is a historic port city situated on the Chesapeake Bay. It’s the largest city in Maryland (population: 612,000) and the economic center of the state. In addition to being the home of the world-renowned Johns Hopkins Hospital and the University of Maryland/ Shock Trauma Medical Center, which are our program’s flagship training hospitals, Baltimore is known for its history, museums, beautiful harbor and many neighborhoods that each add a unique flavor to the city as a whole. The vast majority of our program’s residents live within Baltimore proper, in neighborhoods such as Canton, Patterson Park, Fell’s Point, Harbor East, Mount Vernon and Federal Hill. We’ve asked our Hopkins/Maryland plastic surgery residents to weigh-in on the “Best of Baltimore in 24 hours” – and here’s what they recommend to check out in this city of charm.

7 A.M. – JUMPSTART YOUR DAY

Many of our residents like to get an early start on their day with a trip to their local gym, a yoga class at CorePower Yoga or a 16

Plastic Surgery Resident | Spring 2019

nice run along the Baltimore waterfront. Others recommend an early-morning trip to the neighborhood farmers’ market. Nick Calotta, MD, prefers to start his day at one of the many excellent, affordable public golf courses in the area – and he’s always looking for people to join him.

10 A.M. – PICK YOUR NEIGHBORHOOD AND MEET FOR BRUNCH

quirky and uniquely Baltimore breakfast atmosphere, the Papermoon Diner (Charles Village), which is covered from floor to ceiling with retro toys, does not disappoint.

1 P.M. – WHAT TO DO, WHAT TO DO Deciding how to spend the afternoon in Baltimore really depends on the season and your interests. Resident outdoor activities include hiking at Kilgore Falls, Prettyboy Reservoir, Gunpowder Falls State Park or Harpers Ferry National Historical Park. Phil Hanwright, MD, along with our research year residents Chris Frost, MD, Nima Khavanin, MD, and Franca Kraenzlin, MD, are likely to be found sailing around the Inner

There’s no doubt about it: Baltimore loves brunch! With most neighborhood restaurants offering weekend brunch specials, the most difficult decision is deciding where to go. The current resident favorites are the more “upscale” experiences at Woodberry Kitchen (Woodberry) and Cafe Mezze (Harbor East). Miss Shirley’s (Inner Harbor) and Blue Moon Cafe (Fell’s Point) are among other very popular brunch destinations, and both of these have been featured on the Food Network. We highly recommend the “Cap’n Crunch French Toast” or the “Sweet Baby Jesus” if you make it past the long lines at Blue Moon Cafe. If you prefer a more A view from the Baltimore waterfront.

Harbor – and maybe even Annapolis, if the winds are right. Brian Cho, MD, prefers to spend his time cycling on the Northern Central Railroad (NCR) Trail, which runs from Maryland to Pennsylvania. Alex Sun, MD, almost certainly can be found rock climbing in the area. In late April, the Sherwood Gardens are home to 80,000 tulips in bloom, and in late August, the numerous sunflower fields are in their full glory. Keli Kolegraff, MD, Amy Quan, MD, and Melanie Major, MD, highly recommend visiting the gardens if your trip allows. Local music festivals are also popular in the spring, summer and fall. Seasonal sporting events include the Baltimore Ravens’ NFL games at M&T Bank Stadium and the Baltimore Orioles’ MLB games at Camden Yards. Highly recommended family-friendly outings in Baltimore include the superb National Aquarium, Maryland Zoo, B&O Railroad Museum, Maryland Science Center, Irvine Nature Center and Patterson Park. Peabody Heights Brewery (Waverly/Charles Village), a family-friendly destination, also is very popular among residents. Baltimore is home to a number of museums, including the Baltimore Museum of Art (Charles Village), Walters Art Museum (Mount Vernon) and the American Visionary Art Museum (Federal Hill). These are always great options – particularly if the weather’s not cooperating with your outdoor plans.

5 P.M. – COFFEE PIT STOP

After a busy afternoon out and about, a coffee break is in order. Residents love Pitango Bakery + Cafe (Fell’s Point), Artifact Coffee (Woodberry) and Ceremony Coffee Roasters (Harbor Point).

7 P.M. – DINNER AT BALTIMORE’S BEST

10 P.M. – A NIGHT OUT IN FELL’S POINT

While Baltimore will always be known Each of the different Baltimore for its crab cakes and fresh seafood, the neighborhoods has a distinct feel to city’s culinary scene extends far beyond its nightlife. College kids tend to its waterfront. Baltimore is home to flock to Federal Hill, while the young, a number of award-winning chefs, professional crowd usually gravitates to such as Chef Cindy Wolf (Charleston, Fell’s Point, Harbor East and Canton. Cinghiale, Bar Vasquez) and Chef Spike While there certainly are great bars in Gjerde (Woodberry Kitchen), as well as all of Baltimore’s neighborhoods, our many other award-winning restaurants. residents love the Sagamore Pendry Our residents rank Charleston (Harbor (Fell’s Point), Barcocina (Fell’s Point), East), The Food Market (Hampden), Brewer’s Art (Mount Vernon) and the Woodberry Kitchen (Woodberry) and Thames Street Oyster House (Fell’s Point) as the best restaurants in Baltimore. For a particularly unique and delicious taste, try the Spicy Bird and Tofu Brah from Asian-fusion restaurant Ekiben (Fell’s Point). We all know it’s the absolute favorite restaurant in Baltimore for Akash Chandawarkar, MD. Offbeat shops are nestled within Baltimore’s Fell ’s Point. If seafood’s what you’re looking for, we highly recommend L.P. Bygone (Harbor East). MC Harlan Steamers (Locust Point), Loch Bar (Remington) and the Elk Room (Harbor (Harbor East) or Mama’s on the Half East) are both 1920s, speakeasy-style Shell (Canton). Nothing compares to cocktail bars that are always a lot of fun. the crab cakes at Faidley’s (Lexington Market) – but you’ll have to get there 2 A.M. AND BEYOND – before they close at 5 p.m. LATE NIGHT EATS If you’ve made it this far, you might as 8 P.M. – CATCH A SHOW well experience the absolute-best place There are a number of performing arts to grab late night food in Baltimore: theaters within the city, including our Jong Kak Korean Barbeque Restaurant residents’ favorite the Hippodrome (Station North). We highly recommend (Downtown), which is within walking any of the barbeque options, tofu soup distance of the University of Maryland/ and seafood pancake. Sit at the BBQ Shock Trauma. Baltimore Symphony table, if you can, and enjoy! Orchestra (Mount Vernon) and Peabody You will probably find it best to get some Conservatory (Mount Vernon) are also rest after this meal... Good night, and great options, and they offer weekly sleep well – we hope you’ve enjoyed your concerts. Major music concert venues time here. | in the city include Royal Farms Arena, Rams Head Live and Baltimore Soundstage. Plastic Surgery Resident | Spring 2019

Join the PlastyPAC Residents Club As a member of PlastyPAC’s Residents Club, your annual contribution of $25 allows us to connect with more members of Congress as we work to advance and protect the specialty and the patients we treat. MEMBER BENEFITS PROGRAM (1) ticket to the PlastyPAC social event at PSTM on Sunday, September 30 from 3-4:30pm

Quarterly PlastyPAC newsletter, with political updates and details on the PAC’s activities on the Hill

Present a PlastyPAC check to your member of Congress, coordinated by ASPS in your home or work district, should the PAC Board approve a disbursement

Recommend political disbursements to the PAC Board. Only PAC contributors can make recommendations to the Board!

Recognition at PSTM and within ASPS publications, including PSN, PlastyPAC.net, Advocacy Matters and the Resident’s Journal (recognized at the time of contribution)

As the largest advocacy group for reconstructive and cosmetic surgery, PlastyPAC has a record of fighting for plastic surgeons and patients for more than two decades, including: • Successfully repealing the Independent Payment Advisory Board, which threatened fair Medicare payment for providers • Passed the Breast Cancer Patient Education Act, offering greater awareness to breast cancer patients of their reconstructive options • Increasing the cap on Medicare-funded graduate medical education (GME) positions and increasing funding for additional specialty residency slots • Protecting patient safety through policies that prevent non-physicians from performing complex surgical procedures • Promoting insurance coverage for reconstructive surgical procedures

JOIN THE RESIDENTS CLUB FOR $25. Visit Booth #1255 to make your contribution today www.PlastyPAC.net 18

Plastic Surgery Resident | Spring 2019

Letting residents have their say in directing advocacy efforts By JT Stranix, MD Resident Ambassador, PlastyPAC Board of Governors

CAN YOU IMAGINE WHAT WOULD HAPPEN IF our healthcare system experienced a shutdown similar to the recent government debacle? This is now the second editorial in the past year that I have written in the midst of a government shutdown. That level of dysfunction can make it difficult to remain optimistic about our government and its lawmakers’ priorities. However, I would like to highlight two positive areas that we, as plastic surgeons in training, can focus on to brighten our political outlook.

As always, I encourage you to contact me with any comments, questions or concerns you may have regarding relevant issues in our specialty and also for healthcare in general. Your priorities are mine as well – and I want to make sure I address these issues by entertaining as many perspectives as possible. For additional information about PlastyPAC or to contribute, please visit our website at PlastyPAC.net. Your generosity, even at a resident amount, provides us with the resources needed to effect legislation in our favor. | Dr. Stranix is chief resident in the Hansjorg Wyss Department of Plastic Surgery at NYU Langone, New York. He can be reached at jtstranixmd@gmail.com.

Although the news tends to focus our attention on the contentious political atmosphere and legislative stalemates, PlastyPAC’s bipartisan efforts have continued to effect positive legislative actions. The Society's political advocacy has helped thwart scope-of-practice expansions to protect our interests and also stopped a federal cosmetic tax from being enacted. In the most recent example of this advocacy in action, the Medical Board of California was successfully educated by ASPS on why American Board of Cosmetic Surgery certifications are not equivalent to the level of training of American Board of Medical Specialties member boards, including ABPS. The plastic surgeons and Executive Office staff behind these ASPS political advocacy efforts are working diligently to protect our current and future interests as plastic surgeons, and PlastyPAC composes a significant component of that advocacy footprint. When we recently asked plastic surgery residents and Fellows about why they contribute to PlastyPAC, their responses were sincerely optimistic and enthusiastic about our field. Members of the Residents Club emphasized that the strength of a unified voice is critical to successful advocacy efforts – and they clearly recognize the importance of advocacy in protecting our future interests as plastic surgeons. We look forward to sharing these individual comments from residents and Fellows with you via email as the year progresses.

Kavita Vakharia, MD (far left); Bharat Ranganath, MD; Debra Bourne, MD; ASPS Advocacy Project Manager Jessica Frasco; and Steve Bonawitz, MD, in Washington, D.C. Plastic Surgery Resident | Spring 2019

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Plastic Surgery Resident | Spring 2019

New ASPS resident representative’s pledge:

Expand reach, cultivate mentors

By Kavitha Ranganathan, MD | Resident Representative, ASPS Board of Directors

SPS represents the largest body of organized plastic surgery in the world and has served as the foundation for collaboration between faculty, residents, and medical students throughout its rich history. I’m incredibly grateful for the opportunity to serve as the resident representative to the ASPS Board of Directors – and I hope to use this position to effectively represent my peers alongside the current leaders of our specialty.

EARLY, CRITICAL EXPOSURE For residents interested in experiencing the world of plastic surgery outside of the O.R., the resident representative position is a chance to gain exposure to organized plastic surgery early in our careers, to implement and develop programs that are uniquely important to residents, and to lead the Residents Council. Numerous past residents have made significant contributions to the ASPS through this position: Sanjay Naran, MD, helped created this Plastic Surgery Resident magazine; Deana Shenaq, MD, served as an editor of Essentials of Surgery, a plastic surgery-based textbook designed for medical students; and Russell Ettinger, MD, founded the Residents Council, composed of residents from programs around the country who aspire to be the future of the Young Plastic Surgeons Forum and ASPS. The immense support from ASPS leadership and staff for each of these initiatives has been unparalleled and certainly has fostered the successes of these programs. As this year’s resident representative, my goals are to design mentorship programs to align residents with both young and established faculty; and to broaden the role of the Residents Council within ASPS in the areas of social media,

advocacy and resident education, in order to augment the activities of ASPS by its next generation. One of the most important factors that contributes to our success is mentorship.

STANDARDIZING MENTORSHIP The availability of mentors within plastic surgery, however, is quite variable as a result of divergent experiences, interests and geography. To standardize the mentorship process and improve access to the immense resources of the ASPS, I plan to design mentorship teams that pair residents with faculty members that capitalize on shared experiences not only within the work place, but also outside. With an ever-increasing focus on work-life balance and physical and mental well-being alongside continued career advancement, such mentorship experiences are critical. As our generation challenges the traditional notion of what it means to successful, we must actively search for ways to optimize career longevity through work-life integration. To do this most effectively, we need to develop relationships with mentors who’ve already led by example – and ASPS serves as the perfect foundation for this initiative, given the eminence of the faculty and staff within its membership.

FOLLOWING PARADIGM SHIFTS Residency curricula are ever-changing in response to dynamic shifts in resident autonomy and clinical experiences. Accordingly, ASPS is at the forefront of these changes and effectively addressing these paradigm shifts and promoting resident education. As the resident liaison to ASPS, I have experienced firsthand the sincere commitment to resident education by this organization. This year,

resident groups have begun working with ASPS staff to identify ways to optimize the resources currently available to more readily fit within confines of residency training. As part of this process, residents will have the opportunity to edit online training videos and modules to optimize its practicality for their peers. Residents Council members have also begun augmenting the social media presence of ASPS, in preparation for Instagram Takeover days and posting highlights of the work of residents across the country. In addition, due to a growing interest in advocacy, ASPS staff have opened the Legislative Advocacy Committee to residents – consequently, residents are working to increase awareness of the ongoing initiatives within ASPS, including the Ensuring Lasting Smiles Act and other such legislation.

CONTRIBUTING – TOGETHER The honor of serving as the resident liaison to ASPS is unparalleled and has nurtured both my personal and professional development. For me, it’s a chance to learn from those more experienced and wise, and to contribute to the future of our field. In the midst of continued opportunity and a shared love for plastic surgery, I hope to share the privilege of serving as resident representative to ASPS with my fellow trainees, so that together, we may contribute to our field as the future generation of plastic surgery. | Dr. Ranganathan is a PGY-6 at the University of Michigan (Ann Arbor) Section of Plastic Surgery.

Plastic Surgery Resident | Spring 2019

Journal Club; 2019 Spring; (12)

acial aesthetic surgery can often be an exciting but daunting realm for plastic surgery residents. A sound and complete understanding of facial anatomy, a keen eye for individualized aesthetic ideals, procedural competence and precision with a number of technical variations – as well as consideration for pre-, intra- and postoperative management strategies – are all necessary to achieve a successful facelift result. A keenly executed facelift procedure can be one of the most fulfilling and altering procedures that plastic surgeons perform. In this first installment of a two-part review, five key and landmark articles related to facelifts – which should be read by all plastic surgery residents – are briefly reviewed and discussed.

ANATOMY 1. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad.

Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. / Plast Reconstr Surg. 1989 Feb;83(2):265-71.

JOURNAL ARTICLES ON

FACELIFTS

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

PART 1

In this landmark paper, the authors describe the course of the frontal branch of the facial nerve in relation to the fascial layers of the temporal region based on cadaver dissections. The frontal branch was found to travel consistently on the undersurface of the temporoparietal fascia and cross the zygomatic arch superficially. A safe place of dissection deep to the superficial leaf of the deep temporal fascia is described, which has utility in both aesthetic and reconstructive head and neck surgery. This paper was one of the first to describe facial nerve anatomy, which allowed for more precise and safer facelift dissection, especially when submusculoaponeurotic system (SMAS) dissection is employed.

By Jordan D. Frey, MD

he subspecialty focus on facelifts offers a treasure chest filled with information, differing approaches and emphases, data of myriad types and measures, and the experiences of the leaders in plastic surgery. Publications that target facelifts often delve into topics both wide-ranging and numerous; for that reason, while choosing 10 articles for Journal Club has been a relatively simple task, winnowing the pertinent information within to fit the space allotted here has proven difficult. So in order to properly present this review, we’ve divided it into two parts – the second of which will appear in the Summer edition of PSR magazine.

2. Anatomical considerations to prevent facial nerve injury. Roostaeian J, Rohrich RJ, Stuzin JM. Plast Reconstr Surg. 2015 May;135(5):1318-27.

This review of facial nerve anatomy is a must-read by all plastic surgery residents before performing a facelift. Each branch of the facial nerve is reviewed in terms of anatomy 22

Plastic Surgery Resident | Spring 2019

and, most importantly, specific strategies for avoiding injury during dissection are detailed in a straightforward, easyto-read manner, with attention paid to providing threedimensional landmarks. Facial nerve injuries in facelift surgery are rare; however, they can be devastating when they occur, and fear of injury often leads to suboptimal dissections. The authors note that there are regions where nerves become more superficial and can be distorted as they run adjacent to ligaments that can compress the soft tissues. These areas include (1) the superior aspect of the frontal nerve near the sentinel vein; (2) the area lateral to the zygomatic eminence at the upper masseteric retaining ligaments, where the lower zygomatic and buccal branches are more superficial; anterior to the mandibular tuberosity near the facial vessels; adjacent to the lower masseteric ligaments at the point where the marginal mandibular nerve is on a more superficial course; and approximately 1.5 to 2 cm below the mandibular angle, where the cervical nerve branches into the platysma, where there are dense attachments to the sternocleidomastoid fascia. It has been said that the key to facial aesthetic surgery is patience and anatomy. By reading this paper, residents will certainly know their facial nerve anatomy.

3. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.

Rohrich RJ, Pessa JE. Plast Reconstr Surg. 2007 Jun;119(7):2219-27; discussion 2228-31.

Early facelift procedures focused on the laxity and descent of the skin, as well as on tightening the investing SMAS layer, that produce the characteristics of facial aging. However, these techniques fail to address a paramount contributor to the stigma of the aged face: fat atrophy. In this key article, Drs. Rohrich and Pessa delineate the key fat compartments of the face, which form discrete anatomic subunits. The compartmental structures of forehead, periorbital, malar and jowl are meticulously outlined. By addressing deflation of these compartments in a thoughtful and individualized manner through autologous fat grafting at the time of a facelift, results can be enhanced greatly, as all components of the aging face are addressed.

PREOPERATIVE ASSESSMENT AND FACIAL AESTHETIC IDEALS 4. The individualized component facelift: developing a systematic approach to facial rejuvenation.

maneuvers according to patient needs as determined on preoperative evaluation. Also provided is a section specifically discussing facial analysis – it’s pointed, and clear. The authors assert that proper preoperative analysis must include facial height, facial width and overall distribution and location of facial fullness. In their review of more than 800 facelifts using this assessment method, they found that all patients had facial asymmetry, which they addressed by varying their operative technique. The importance of accurate preoperative assessment cannot be overstated.

FACELIFT TECHNIQUES 5. Facial Fat Grafting: Why, Where, How, and How Much.

Marten T, Elyassnia D. Aesthetic Plast Surg. 2018 Oct;42(5):1278-1297.

We have learned from the above articles that it’s important in facelift surgery to address all contributors to the aged face, with fat compartments being a critical component. This is a very detailed article that addresses all aspects of fat transfer related to facelifts. It begins with a philosophical discussion of why this practice is important, and then it evolves into a discussion of technical steps – including sequencing of when to inject fat, which is often overlooked. Moreover, a very helpful photograph/diagram is included to demonstrate the typical amounts of fat that are grafted to each area of the face, which provides an easy to reference guide to review before cases. After this, specific technical considerations applicable to each region of the face are reviewed. Importantly, the planes of injection of each region are clearly discussed, as this is often a point of consternation for beginners. For instance, injections of the lower lid and tear trough areas are reviewed. The author states that treatment of this area with fat grafting has completely changed management of the lower lid and should be done in a preperiosteal plane with approximately 1-3 cc for each infraorbital area, and 0.5-1.5 cc for each tear trough. | Dr. Frey is chief resident in the Hansjorg Wyss Department of Plastic Surgery at NYU Langone, New York.

(The remaining five Journal Club articles in the series on Facelifts – along with the listing of Additional Reading – will appear in the Summer 2019 edition of Plastic Surgery Resident magazine.)

Rohrich RJ, Ghavami A, Lemmon JA, Brown SA. Plast Reconstr Surg. 2009 Mar;123(3):1050-63.

Facial analysis must take place on an individualized patient basis and in a consistent manner. This can be challenging for residents who often haven’t as much exposure to the preoperative evaluation of facial rejuvenation patients. This article is all-around excellent and could fit into any of the categories within this review. However, one particular strength is its focus throughout on individualizing technical Plastic Surgery Resident | Spring 2019

#TheTrend

MedOne Plastic Surgery: The best resource we’ve reviewed to date By James Vargo, MD, & Jacob Grow, MD #TheTrend is a column new to the pages of Plastic Surgery Resident. Plastic surgery residents Jacob Grow, MD, and James Vargo, MD, are “tekkies” who are immersed in trending resources and tech (apps, websites, etc.) available to the plastic surgery community. Through #TheTrend, they will endeavor to spotlight resources with the highest value and greatest potential to plastic surgery residents, that they can help protect a resident’s most valuable commodity: time. These reviews will be specific to plastic surgery – and unbiased, as the authors are free from financial disclosures... “unfortunately,” they say. |

In the spirit of the eagerly anticipated final season of Game of Thrones, we at #TheTrend are always hunting for the next “great house” to stake claim for the Iron Throne of Plastic Surgery educational resources. We’ve had the chance to review many exceptional websites, apps and databases over the last few years, each providing firm justification to back their lineage. However, Thieme has truly broken the mold with its release of MedOne Plastic Surgery, which we had the pleasure to review. Winter has finally come – and it’s a force to be reckoned with. Thieme is a name we’ve come to know as plastic surgery trainees, as it touts one of the largest collections of classic and innovative textbooks in our field. In an effort to facilitate the integration of printed text with more contemporary methods of learning, developers at the company have released a truly allinclusive digital database that allows users to fully harness the power of the publisher’s library. Subscriber to MedOne Plastic Surgery are provided instant access to more than 140 plastic surgery textbooks directly through the website or via the companion smartphone app. All books are full-text and include supplemental videos, high-quality illustrations and photos. If a topic interests you, MedOne Plastic Surgery has a book that covers it. This may seem a bit overwhelming, but don’t worry – all resources are cataloged by subcategory (anatomy, aesthetics, facial, hand/wrist, etc.) and are fully searchable. For example, if you’re preparing for a nasal

Plastic Surgery Resident | Spring 2019

reconstruction case and search “forehead flap,” excerpts are pulled from 100 textbooks, 47 procedural links and 602 media sources – including four surgical videos. While reading through text, you can also take notes, bookmark key sections and highlight images as favorites that will then compose your own personal “My MedOne” page for later review. Such a robust database with searchable content is truly unparalleled, but MedOne Plastic Surgery doesn’t stop here. Under the “Procedures” tab, an additional searchable archive organizes top surgical videos for a given procedure while also pairing highyield book chapters to supplement the video – including supplemental sections for “surgical anatomy,” “surgical technique,” “complications” and others. This streamlined approach is incredibly valuable for expedited case prep or for taking a deep dive into your area of interest. MedOne then took this concept one step further by creating a “Learn from the Masters” section organized by names of prominent

continued on page 29

Put your plastic surgical vocabulary skills to the test! Plastic Surgery Potpourri

By Tyler A. Evans, MD

2 3 4

5 6

8 9

12 13

14 15

18 19

26 27

28 29

ACROSS

5. Ulcer from malignant degeneration of chronic wound or burn wound 7. Most common cause of eyelid ptosis in elderly patients resultin in elevated supratarsal crease 8. Nerve that innervates the levator palatine muscle 9. Most frequent rhytidectomy complication 11. Most common congenital nasal mass 14. Most common carpal fracture 16. Nevus in area of lateral brachiocutaneous and supraclaviuclar nerves 17. Syndrome associated with aberrant carotid arteries, VPI, and deletion of 22q11.2 18. Muscle flap with medial femoral circumflex arterial supply 19. Dermal matrix of bovine collagen and shark-derived chondroitin sulfate covered by silastic epidermis 21. Syndrome associated with multiple enchondromas with subcutaneous hemangiomas 23. Muscle that causes transverse rhytids at root of nose 25. Syndrome associated with gustatory sweating following parotid surgery 27. Nerve that supplies sensation to superomedial thigh and scrotum/ mons 29. Syndrome associated with progressive hemifacial atrophy often requiring fat grafting or parascapular flap for the deformity

Answer key on page 30

DOWN

1. Nerve that supplies sensation to concha and posterior EAC 2. Signs for diagnosis of flexor tenosynvitis 3. Nontraumatic flexion deformity of PIP of small fingers 4. Tooth with the longest root 6. Avascular necrosis of the lunate 10. First cranial suture to fuse in normal child 12. Contraindicated for 1 year before laser or dermabrasion due to risk of scarring and delayed healing 13. Bone growth into grafted material 14. Ear deformity with a third crus, antihelical flattening, scaphoid fossa deformity 15. Potentially serious complication with phenol peels 20. Syndrome associated with microtia, mandibular hypoplasia, preauricular pits, and hemifacial microsomia 22. Otoplasty technique using sutures spanning the concha to the mastoid 24. Eyelid cyst caused by inflammation from blocked meibomian gland 26. Otoplasty technique using mattress suture to bend the antihelix 28. Patients with this allergy/sensitivity should not receive Botox

Plastic Surgery Resident | Spring 2019

All insurance agents aren’t created equal – so ask the right questions By Lawrence B. Keller, CFP

nlike medicine, which has a standardized educational and training path, the insurance and financial services industry does not. In fact, for the most part, anyone can call himself or herself a “financial advisor.” Believe it or not, according to a study published in September 2011 by the Life Insurance and Market Research Association (LIMRA), the agent retention rate for 2010 was 11 percent. This number represents the percentage of agents who are still under contract through December of their fourth year after hire. What does this mean to you? It simply means that, if you’re a resident or Fellow and choose to work with a newly licensed insurance agent, the odds are good that by the time you complete your training, that agent or financial advisor is no longer working for the same company or is no longer in the profession.

THE CHECKLIST

Therefore, I would suggest that those in the market for an agent ask the individual under consideration about any professional designations and/ or certifications they’ve earned. Not only does this show a commitment to the industry, as certain experience requirements must be met, but these individuals should also have a good understanding of the financial planning process. You might also want to ask the following questions:

Plastic Surgery Resident | Spring 2019

What’s your educational background and area(s) of expertise? How long have you been in the industry? Which disability insurance companies do you recommend most often and why? Which life insurance companies do you recommend most often and why? How much experience do you have working with clients in my medical specialty? Do you have any affiliation with any specific insurance company? Beware agents who are “captive” and can only offer policies from one company or who may have a strong financial incentive to do so. Ideally, you want to purchase your policy from an agent who represents several insurance companies, provides you with illustrations of coverage from each and will review with you in detail the differences between them. This way, you can make a decision that best meets your needs, goals and budget.

SOONER, RATHER THAN LATER

The time to ask your questions is before you purchase any insurance products. All too often, I see physicians in situations that could have easily been avoided, had they

taken the time to really understand who they were working with and what they were purchasing, before they “signed on the dotted line.” Finally, remember: The contractual language and premium rates must be approved by the insurance department of each state before a policy can be approved for sale by a particular insurance company. Since the industry is heavily regulated, you will not be paying anything more by purchasing your policy from an “experienced” insurance agent than you would by purchasing your policy from a newly licensed or “inexperienced” insurance agent or broker. | Lawrence B. Keller is the founder of Physician Financial Services, a New York- based firm specializing in income protection and wealth accumulation strategies for physicians. He can be reached at (516) 677-6211 or by email to Lkeller@physicianfinancialservices. com.

continued from page 7

OPERATION SAN JOSE / continued from page 7

San Jose does not provide any liability insurance for any member of the trip. When traveling outside of the United States, a passport will be necessary. Work visas are not obtained and we enter the host country as “tourists.” The hosting hospital typically requires proof of medical licensure by the visiting physicians. Every trip is different, and the medical authority in each region/country requires different documentation. Safety when traveling to a developing country is of paramount concern. While nothing is a certainty, I have never felt unsafe except on one occasion – when I decided to leave the group to go for a jog solo in downtown Guayaquil, Ecuador. Most time is spent either in the hospital operating, or traveling to and from the hotel on a bus. If common-sense measures are practiced, despite what’s suggested on the news, safety is not a significant issue.

SCHEDULING ELEMENTS The exact schedule of each trip varies, but the structure follows a typical format. The first and last days are travel days, and the first working day is a clinic day, where patients (typically about 80-100) are evaluated. About 50 patients are selected for surgery, with some designated as unsuitable candidates due to medical conditions as identified by the team anesthesiologists and pediatrician – and others with problems too complex to be treated in this setting. Although many people think mission trips involve operating in a hut without proper equipment or monitoring, the trip (and I think most other trips), has evolved to performing operations in typically modernized operating theaters with all the necessary surgical instruments and suture materials, and with excellent postoperative monitoring. The second day of the trip offers the opportunity to experience the local culture and geography – including sightseeing. I vividly remember multiple excursions, most notably to Palenque;

Mayan ruins in Chiapas; colonial Antigua and Lake Atitlán in Guatemala; and the beautiful landscape in Armenia, Colombia. Operating begins the third day – typically on a Monday – and continues all day, every day, for five days. Some days require longer hours than others, and most last until late evening. Cases are typically limited to cleft lip and palate surgery, although occasionally other procedures, such as hand and burn cases, have been performed. The number of primary cleft-lip surgeries can range anywhere from five to 15, usually with a large number of primary and secondary cleft palate cases. There are many revisional cases, and cleft rhinoplasty is abundant. The final working day is a clinic day, where all postoperative patients are evaluated and appropriately scheduled for further follow-up. Abbe flaps have been performed on several occasions during this day, requiring separation three to four weeks later by the local participating surgeon. On all trips, local surgeons are included – and all commit to following the patients in the initial post-op period. This last working day without question is the most rewarding, where patients and families express their utter joy and appreciation for the care they’ve received.

AUSPICIOUS GENESIS Operation San Jose has been traveling to Latin America since the early 1980s, performing cleft lip and palate surgeries. Ernest Cronin, MD, the founder and director, led the group until his recent retirement from practice just a few years ago. A skilled cleft surgeon with an impressive pedigree, he’s the nephew of Thomas Cronin, MD, inventor of the breast implant and innovator of multiple techniques in plastic surgery – most notably in hand and cleft surgery. Dr. Ernest Cronin carried on this tradition of excellence in plastic surgery.

With his quiet nature, mild manner and superior technical skills in the O.R., he led by example and trained many residents over the years as faculty at the St. Joseph Hospital/Methodist Hospital Residency Program. Dr. Cronin trained both as an otolaryngologist and plastic surgeon, and he spent time with Paul Tessier, MD, after completion of his plastic surgery residency. In a world of social media, it’s interesting that Operation San Jose was ahead of the curve in the mission-trip milieu. A local Houston media star, Marvin Zindler (now deceased), often traveled with the group to chronicle the work that was being done by Dr. Cronin and Operation San Jose. After Dr. Cronin’s retirement, I took over as director, as I was already involved in the trip annually since I was a resident. I began my training in dentistry and specialized in oral and maxillofacial surgery before pursuing plastic surgery training. I completed the plastic surgery program at the Methodist Hospital and a craniofacial surgery fellowship at Children’s Hospital Los Angeles. I currently practice pediatric plastic surgery at Children’s Mercy Hospital in Kansas City. As director, I’m thankful to have an experienced coordinator who does all of the legwork in preparing for each trip.

DEPENDABLY SKILLED CARE Cleft medical-mission trips have been criticized by some who argue that inexperienced surgeons perform operations they usually don’t perform, resulting in poor outcomes or post-op problems, with local surgeons then forced to manage these complications. While this is true in certain situations, many patients who receive care on these trips often would not have received care otherwise. One could argue that significant complications after a cleft lip or palate repair are few, and that a poor repair is better than no repair.

continued on page 28 Plastic Surgery Resident | Spring 2019

OPERATION SAN JOSE / continued from page 27

INSERVICE INSIGHT / continued from page 11

In certain regions of the world, there’s a lack of skilled local surgeons to perform the operations. However, more often than not, there are local surgeons who can do the surgery – but there is a lack of resources to pay for the surgery. I believe the positives overwhelmingly outweigh the negatives. In addition, when an experienced team revisits the same location and develops relationships there, long-term follow-up is also possible.

together, thus helping to facilitate a secondary definitive closure of the cleft lip two to three months later. Scar formation can be an issue for subsequent repairs, and wound dehiscence is a common complication. Some surgeons elect to perform a gingivoperiosteoplasty (GPP) at the time of primary cleft lip repair in an attempt to obviate the need for secondary bonegrafting in the future.

IMMEASURABLY SATISFYING From a resident perspective, while the surgical experience is one of a kind, it’s the intangibles that can’t be overlooked. The confidence that grows with such an experience is invaluable. The sense of pride and joy that emerges from helping others less fortunate is immeasurable. I will never forget my first trip, repairing a 14-year-old girl’s cleft lip and palate – she was a patient who’d never received any previous treatment and lived a life of isolation and torment. Playing a role in helping this girl was something that was life-changing not only for her, but for me as well. Working intimately with a team of doctors and nurses truly builds a sense of worth and a renewed respect for others. In my view, this is an experience that indisputably validates the true reason we all became doctors: to help others in need.

TAKE HOME Cleft missions such as the Operation San Jose experience present opportunities that should be sought by every resident, even if their interest is not cleft surgery. Residents can get involved with faculty at their institutions who embark upon such trips, or directly seek opportunities with organizations such as Operation Smile or Smile Train. The value of such trips cannot be overstated, both for the residents and thankful patients they serve. The technical experience is tremendous – but the sense of pride in helping others less fortunate is priceless. As plastic surgeons, we share a duty to use our specialized skills – skills that no other surgical specialty possess – for the betterment of others. A mission trip can provide such an experience and reinforce the reasons why we became physicians in the first place. It’s not only restorative for the patient, but also for the physician. | Dr. Lypka is associate professor of pediatric surgery at the University of Missouri-Kansas City School of Medicine.

There are several variations for definitive repair of the unilateral cleft lip, which include the Rose-Thompson straight line repair; the Randall-Tenison triangular flap repair, which uses a Z-plasty at the vermillion-cutaneous margin; and the Le-Mesurier quadrangular flap. However, the rotationadvancement flap introduced by cleft-repair innovator Ralph Millard, MD, is the most common. There are several key landmarks that are marked on the lip and nose to assist with creation of the advancement and rotation flaps, as shown in Figure 1 and Table 2. For the bilateral cleft lip repair, the philtral flap is created from the white roll and vermillion of the prolabium without orbicularis repair in the Modified Manchester repair. In the Millard or Mulliken repair, the central vermillion, white roll and orbicularis muscle are recruited from the lateral lip elements and covered with the central “tie” flap to recreate the philtral columns and Cupid’s bow.

COMPLICATIONS

Outside of normal surgical healing complications, there are several common secondary deformities after cleft lip repair. Imprecise lip markings may result in misalignment of the white roll or vermillion, which may require re-excision to correct. A widened lip-scar can be the result of inadequate orbicularis opposition or muscle dehiscence. A short lip deformity is more frequent with a Millard repair and is corrected by repeat rotation/advancement, whereas a long lip deformity seen in the triangular or quadrangular flaps usually requires full-thickness excision. A whistle deformity is a central vermillion defect more common after bilateral cleft repairs, with notching of the vermillion causing exposure of the central incisors in repose. This can be treated with V-Y advancements, fat grafting or Abbe flaps, in order to add additional tissue to the lip.|

References 1. Janis, J et al. Essentials of Plastic Surgery: Second Edition. 2017. Thieme Medical Publishers: p264-272 2. Murray, J et al. Folic Acid and Orofacial Clefts: A Review of the Evidence. Oral Dis. 2010;16(1): 11-19 3. Monson, L et al. Primary Repair of Cleft Lip and Nasal Deformity. PRSurg. 2013;132(6):1040e-1053e 4. Hopper, R et al. Cleft lip and Palate. Grabb and Smith’s Plastic Surgery, 6th edition. Chapter 23

Dr. Maiorino is plastic surgery Fellow at the University of Texas Houston Science Center. 28

Plastic Surgery Resident | Spring 2019

CONSULT CORNER / continued from page 9

#TheTrend / continued from page 24

• Hemostasis: Evaluation of the injury is best obtained with adequate hemostasis. The small finger of a size 6 glove may be cut and placed/rolled onto the injured digit, to both exsanguinate and provide a temporary tourniquet for any procedures on a digit. Tagging this “tourniquet” with a hemostat will ensure that it’s promptly removed at the end of the procedure and prevent iatrogenic injury (it’s hard to splint a fracture with a hemostat hanging off of the finger).

plastic surgeons who have published within Thieme. When selecting a surgeon, you are provided a photo, a brief biography and hyperlinks of practice websites, social media and other online resources. Also included are these surgeons’ surgical videos with their own narrations and corresponding linked citations from the video source textbook. To top it off, MedOne also provides full-text access to every e-journal published by Thieme, including the Journal of Reconstructive Microsurgery; Seminars in Plastic Surgery; Journal of Facial Plastic Surgery; and more. The archives of these journals date back many years and can be filtered for easy identification of review articles, editorials and more for specific topics.

• Fracture reduction: Adequate fracture reduction is usually best obtained with traction and manipulation under fluoroscopy. Specific maneuvers (i.e., Jahss for metacarpal head fractures) may be employed as needed. Once reduced, the stability of the fracture must be assessed with passive and active range of motion. • Closure: Adequate healthy soft-tissue coverage is imperative to bony healing. Complex closure in layers is also surprisingly helpful in maintaining fracture reduction (i.e., nailbed repair in distal phalanx or Seymour fractures). • Splinting: In general, adequate immobilization via splinting should be tailored to the location of the fracture and the fracture pattern. Avoid excessive immobilization which may ultimately cause stiffness. Broad guidelines: –– Distal radius – Sugar tong splint –– Carpal/metacarpal fracture – Volar-based intrinsic plus splint (wrist at 30 degrees extension, MCP at 90 degrees flexion), versus ulnar gutter splint for ring and small fingers –– Ulnar digits – Ulnar gutter splint versus buddy tapping –– Radial digits (index and long) – Volar-based intrinsic plus extended one joint above and below the fractured bone –– PIP fracture dislocation (“jammed finger”) – Extension blocking splint –– Thumb – In general, thumb spica splint • Operative Management: Subacute management with closed reduction and percutaneous pinning, versus open reduction and internal fixation, is advisable within one to two weeks as a balance between edema versus interval callus formation and stiffness. Beyond this time, reduction is exponentially more difficult to obtain. |

MedOne Plastic Surgery provides additional, personalized functionality to streamline its use. Users can create custom “playlists” of either full textbooks, specific chapters, videos or links to create unique study guides. These can be kept private or shared with other MedOne users. As a bonus, MedOne has even formatted the content from the Essentials of Surgery plastic surgery textbook and developed a 1,000-plus question bank that’s fully customizable based on specific topics. Answers can be reviewed and re-tested to maximize learning while progress is tracked through a statistics page. MedOne Plastic Surgery truly encompasses nearly every function plastic surgery residents desire in a resource. If you don’t believe us, you can request your own 14-day free trial from its website and decide for yourself. Our critiques are extremely limited. If you are an old soul and prefer the feel of a textbook in your hand or like to see a shelf full of books, accepting that your resources exist purely in a digital realm may be a deal-breaker. Also, unlike owning a textbook, purchasing a subscription to MedOne does not grant lifelong access to the content. Subscriptions are purchased year to year – and they’re certainly not cheap. However, institutional access is available for departmental purchase, which is likely the preferred route for most residents. Price notwithstanding, MedOne Plastic Surgery is handsdown the best resource for plastic surgery residents we’ve seen while writing for #TheTrend. It has a massive quantity of information, it’s extremely user-friendly and it contains all the bells and whistles every resident begs for in a study tool. Give it a try – we promise you won’t be disappointed. | Dr. Vargo and Dr. Grow are PGY-5 residents at the University of Kansas Medical Center, Kansas City.

Dr. Brgoch is chief plastic surgery resident at Penn State Health Milton S. Hersey Medical Center, Hershey, Penn.

Plastic Surgery Resident | Spring 2019

UPCOMING MEETINGS & SURGICAL TRIPS APRIL

MAY

JUNE

JULY/AUGUST

4/2/19-4/5/19 American Burn Association Annual Meeting Las Vegas (312) 642-9260 ameriburn.org

5/2/19-5/5/19 64th annual Plastic Surgery Research Council Baltimore (978) 927-8330 ps-rc.org

6/6/19-6/8/19 Abdominal Wall Reconstruction 2019 Washington, D.C. (202) 780-1655 awconference.com

7/18/19-7/20/19 Breast Surgery and Body Contouring Symposium Miami (847) 981-5410 plasticsurgery.org

4/6/19-4/9/19 American Association of Plastic Surgeons Annual Meeting Baltimore (978) 927-8330 aaps1921.org

5/18/19-5/25/19 Mission to Agra, India San Francisco (415) 252-1111 rotaplast.org

6/9/19-6/23/19 Mission to Arusha, Tanzania San Francisco (415) 252-1111 rotaplast.org

5/18/19-5/25/19 Mission to Guatemala City Franklin, Tenn. (615) 595-5857 theshalomfoundation.org

6/14/19-6/28/19 Mission to Chulucanas, Peru Newton Square, Pa. (610) 355-2003 globalhealthvolunteers.net

7/20/19 Gender-Affirming Breast, Chest & Body Master Class Miami (847) 228-9900 plasticsurgery.org

5/23/19-6/1/19 Mission to Puerto Escondido, Mexico Crossville, Tenn. 1-888-299-8502 certinternational.org

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

4/25/19-5/5/19 Mission to Liberia, West Africa Crossville, Tenn. 1-888-299-8502 certinternational.org

8/23/19-8/25/19 American Society of Maxillofacial Surgeons Summer Basic Course Philadelphia (978) 927-92608330 maxface.org

6/17/19-6/19/19 2019 Advocacy Summit Washington, D.C. (847) 981-5410 plasticsurgery.org

Answer Key / From Page 25 A R 2 N K 3 O C A 5 M A R J O L I N 6 D K M A 8 I P I L E V A G U S 9 10 E H E M A T O M A N O L E 12 B D T R M O I D 13 O A O O S C C P S A P H O I D 15 16 K T A T T I T O Y C R E R 17 V E L O C A R D I O F A C I A L Y H C T Y O R A C I L I S 19 20 T N I N T E G R A H D O O 23 24 M U L U C C I P R O C E R U S I C N D H 26 A T E A M Y 27 I L I O I N G U I N A L O H A S N A Z T R I A O R 28 N D E 29 R O M B E R G G 1

C A S E N I N 11 D E 4

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M A F F U 25 F R E N A S

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

Plastic Surgery Resident | Spring 2019

UPCOMING MEETINGS & SURGICAL TRIPS NEW FOR 2019! Masters Course

Expand your thinking. Advance your skills. JULY 18 -20, 2019 Program Chair: Karol Gutowski, MD Program Co-Chair: Caroline Glicksman, MD

34TH ANNUAL

Earn up to 21.50 AMA PRA Category 1 Credits™

10 Patient Safety Credits

PlasticSurgery.org/BSBC