Plastic Surgery Resident, Summer 2019

From the publishers of Plastic Surgery News

ISSUE 15 | SUMMER 2019

Pursue a career – or start a family?

How one plastic surgeon maintained reproductive autonomy during training

»»'Filler complication – come evaluate!'

The message on your pager only hints at the minefield that an injection can present page 10

»»What women want

(their supervisors to know) Mothers who are plastic surgeons occasionally want to yell: 'Hey, li'l help?!' page 9

IN THIS ISSUE » InService Insight: Nerve and tendon transfers ........ p. 14 » Program Peek: University of Kansas ........................... p. 16 » 24 Hours In: Kansas City ..................................................p. 20

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

A note from the editor

W

elcome to our Summer 2019 issue of Plastic Surgery Resident.

In this issue of PSR, we again feature some of our recurring sections, such as InService Insight, Consult Corner, PRS Journal Club and #TheTrend. Also featured are the plastic surgery training program at the University of Kansas – and thoughts from the leadership of that program and institution.

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

The March 2019 issue of Plastic Surgery News featured a YPS Perspective on the challenges of starting a family while in training. We build upon this important topic by highlighting a piece by Wendy Chen, MD, MS, on preserving female reproductive potential while in training. This article will mark the beginning of new recurring column featuring resident perspectives on starting and raising a family while in training. We encourage you to share your story. (Submit your story to PSN Managing Editor Paul Snyder at psnyder@plasticsurgery.org).

We continue to seek applications for new Resident Editors; if you’re interested, be sure to apply – also send your applications to Paul at psnyder@plasticsurgery.org.

I would like to again thank our team of editors and the ASPS production staff for all of their hard work in bringing each quarterly of PSR to fruition. Enjoy the read, and have great summer! |

PSR seeks 3 resident editors; apply by Aug. 31 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 coresidents and faculty to contribute content. 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 Aug. 31 to PSN Managing Editor Paul Snyder at psnyder@plasticsurgery.org. Those selected will be notified after the conclusion of Plastic Surgery The Meeting, slated for Sept. 20-23. |

Plastic Surgery Resident | Summer 2019

3

Table of

Contents Chief resident opts for future reproductive potential via oocyte cryopreservation......................... 6 Wendy Chen, MD, MS, was well-aware of her biological clock as she advanced through her medical career – but she still was jolted by the choices she recently faced.

Consult Corner: Nasolabial injections gone wrong............................. 10 Sending instructions ahead, as well as not taking certain actions, can be as important as treatment upon arrival at the E.D, when facial injections are the cause.

InService Insights: Nerve and tendon transfers........................................ 14 Nerve transfers can preserve and restore function after injury, but tendon transfers become necessary in the presence of prolonged denervation.

Program Peek: University of Kansas.................................................... 16

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

The Department of Plastic Surgery was established in 1905, followed in 1943 by its residency program – and throughout, it has created leaders in the field.

R ESIDENT EDITORS Jacob Grow, MD | jgrow2@kumc.edu Kavitha Ranganathan, MD | krangana@med.umich.edu

Message from the Director: James Butterworth, MD...............................................17

E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org

The University of Kansas Plastic Surgery residency program director cites evolving leadership, progressive changes and an inviting culture as among elements of KU’s success.

STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org

Faculty Focus: Richard Korentager, MD.............................................. 18 The University of Kansas Department of Plastic Surgery chair and Integrated Residency Program director urges passion for the specialty and appreciation of family.

24 Hours In: Kansas City, Kan...........................................................20 Sleeping late or early latte, professional sports teams and stadia, plenty of public golf courses, a surfeit of bistros both casual and classy, and BBQ: What’s not to like about K.C.?

PlastyPAC Ambassador update: JT Stranix, MD...............................................................24 The resident ambassador to the PlastyPAC Board of Governors says a recent focus-group conference call involving residents will help advance PAC and resident goals.

Journal Club: Facelifts, Part II.............................................................26 Michael Chiodo, MD, and Jordan D. Frey, MD, in the second of this two-part series on facelifts bring relevant articles on techniques, complications and outcomes.

#TheTrend: Problems in Periorbital Surgery.................................28 James Vargo, MD, and Jacob Grow, MD, set aside their app “jones” and focus instead on a new, comprehensive book that describes feared, periobital surgical complications.

Crossword: Cleft, Craniofacial Surgery..........................................29 How well do you know Binder syndrome nasal structure? What about Apert syndrome orbital deformity? What’s the “suture” associated with harlequin’s deformity?

4

Plastic Surgery Resident | Summer 2019 | Vol.3 No.2

Plastic Surgery Resident | Summer 2019

M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org A S S O C I AT E E D I T O R Kendra Y. Mims | kmims@plasticsurgery.org GR A PHIC DESIGN ER Elena Bragg A DV ERTISING SA LES Joe Anzuena (215) 521-8532 Wolters Kluwer Health

Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005.

POSTMASTER: Send address changes to ASPS Membership Department Plastic Surgery Resident 444 E. Algonquin Road Arlington Heights, IL 60005 Postage paid at Arlington Heights, IL, and at additional mailing offices.

The views expressed in articles, editorials, letters and other publications published by Plastic Surgery Resident (PSR) are those of the authors and do not necessarily reflect the opinions of ASPS. Acceptance of advertisements for PSR is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised.

ASPS Home Page: www.plasticsurgery.org

ASSI Instruments Are Like Diamonds... ... ®

Needle Holders For

Supermicrosurgery

ASSI •B188.1 Curved Jaw, 0.1mm Dia.

ASSI •BT188.1 Titanium, Curved Jaw, 0.1mm Dia.

®

ACCURATE SURGICAL & SCIENTIFIC INSTRUMENTS ®

For diamond perfect performance®

accurate surgical & scientific instruments corporation 800.645.3569 516.333.2570 fax: 516.997.4948

west coast: 800.255.9378

www.accuratesurgical.com

Not all ASSI products shown in our literature or on our website are available for sale in Canada

Preserving fertility

One plastic surgeon’s journey to safeguard a childbearing future

T

he average age of women giving birth in the United States has been rising for decades. While many factors play a role in advancing this trend, women’s access to education – and the arrival of a critical period for career advancement during peak years of reproductive potential – are among the most significant.

By Wendy Chen, MD, MS Contributors: Rachel Beverley, MD, Fellow, and Sunita Katari, MD

6

Increasing age is accompanied by the decreasing quantity and quality of oocytes, as well as the increased risk of miscarriage or fetal anomalies related to chromosomal abnormalities. When women seek fertility at later ages, the likelihood increases that oocyte quality/quantity will be compromised, and that the patient will potentially need an oocyte donor to achieve her reproductive goals. Planned oocyte cryopreservation (OC) is an option for women who desire to preserve future reproductive potential.

Plastic Surgery Resident | Summer 2019

As I chose medicine and then surgery as a career, planned OC had always been considered in the back of my mind. As each year passed and I approached 35, I still had a lot of excuses for avoiding it: “I’m still young;” “It’s going to be too expensive, anyway;” “I’ll never have time to do it;” “It’s too complicated.” In reality, there was probably also a component of denial, because proceeding with “freezing my eggs” would also come with the acknowledgement that I was getting older; that I had to face the possibility of being diagnosed with reduced fertility; with the gravity of a maternity; and with a commitment to the idea of starting a family.

In a recent survey of plastic surgery trainees, 5 percent of female plastic surgery trainees reported that they had opted for oocyte cryopreservation. Undergoing this procedure was significantly correlated with older age

(p=0.030). Sixty-three percent reported cost as a significant barrier to oocyte cryopreservation. The most common reason reported by females undergoing this procedure was “completion of my education” (38.9 percent). Other reasons included “stability and/or advancement of career goals” (16.7 percent), “time needed to find a suitable long-term partner” (16.7 percent), and “need to achieve financial stability” (16.7 percent).

At our department’s inaugural women surgeons’ meeting, a colleague told her ongoing story of struggling for nearly a decade to get pregnant and wishing she hadn’t put off pursuing her reproductive life. Even now, an unsupportive environment is not uncommon (Bourne D, accepted Jan 2019, Plast Reconstr Surg). Her story galvanized me to move from contemplating oocyte cryopreservation to making an appointment. “It doesn’t hurt to just get information about the process,” I figured.

“It’s just one appointment.”

THE FIRST APPOINTMENT

It took a couple of weeks to get into the reproductive endocrinology clinic. I was on my body-contouring rotation, and I left our clinic a little early to go across the street to my own appointment. The co-pay was $40.

At my first appointment, I felt encouraged and validated. The first thing my doctor said to me was: “I’m so glad you’re here.” As a relatively normal, healthy, non-tobacco-using 33-year-old woman undergoing this process, there’s no greater “modifiable risk factor” than age.

I met with the financial advisor that day, we went through the numbers, and I decided to proceed with the next step: assessing my ovarian reserve, which would cost $300-400. I reasoned that if my fertility was poor, it would be a life-changing revelation – it would change whether I wanted to proceed immediately with OC; whether to consider single motherhood by choice (“SMBC”); whether to potentially change the type of plastic surgery I would want to practice; whether I would

pursue a fellowship or move closer to home; and other considerations.

I stopped my hormonal birth control, we did some blood work and an ultrasound, and my test results were reassuring.

This pushed me to proceed with planned OC. With good baseline testing, the assumption was that I could expect a higher yield of oocytes, possibly with lower doses of medications needed for ovarian stimulation, which would translate to a lower cost. Knowing my fertility status and a price tag for preserving that status helped me make that choice.

For myself, I put it in these terms: What price would I be willing to pay in, say, 10 years for the option of having my own biologic children? $2,000? $10,000?

On a resident salary, I felt either of those options was acceptable to me.

Other women and couples with whom I’ve spoken have differing opinions – it’s definitely a very personal choice and decision.

TIMELINES AND DICTATES

Planned OC involves ovarian stimulation with injectable gonadotropins; follicle tracking with ultrasound and hormone levels to determine response; and a “trigger” injection for final oocyte maturation; all of which is followed by the oocyte-retrieval procedure performed under IV sedation. All retrieved oocytes are evaluated by trained embryologists to determine oocyte maturity and, ultimately, vitrification of mature oocytes for future use.

The timeline from ovarian stimulation start to retrieval can range from 11-16 days. It’s invasive and can be costly; however, it also provides women with reproductive autonomy.

Patient counseling regarding efficacy, safety, risks, benefits and unknown long-term health effects for offspring is imperative for informed decisionmaking. In 2012, the American Society for Reproductive Medicine Practice Committee noted that oocyte vitrification and warming was no

Additional thoughts on cryopreservation Oocyte cryopreservation has been used for various indications, including fertility preservation for patients receiving gonadotoxic therapies; patients with genetic conditions associated with need for prophylactic salpingo-oophorectomy (BRCA) or primary ovarian insufficiency (Turner syndrome, Fragile X mutation, etc.); patients with a male partner unable to collect a semen sample on day of oocyte retrieval; patients who prefer not to cryopreserve embryos for their desired beliefs; and planned female-to-male gender transition.

longer considered to be experimental.

Current literature reveals that pregnancy rates using cryopreserved oocytes are comparable to pregnancy rates in women undergoing IVF with fresh oocytes.

As I was preparing to start my cycle, I went onto forums to anticipate what the process would be like. Would I be emotional? Unpleasant to be around?

How was it going to affect my call schedule? My In-Service Examination studying? Since the harvest date can be unpredictable, I disclosed to everyone in my call pool that I potentially would need help covering call if my oocyte retrieval (a same-day procedure performed under sedation) landed on a day I was on call. I arranged for my ultrasounds and blood draws to occur as the first appointment of the day, so I could still round on my patients and arrive on time to the pre-op area.

Despite being a doctor, it was still

continued on the next page Plastic Surgery Resident | Summer 2019

7

Lessons learned from my experience Assess your perspective about your fertility with yourself, your partner, your family and friends.

Determine how you feel about your reproductive goals. Don’t let residency be a barrier. There’s never a good time to start a family, and there’s never a good time to go through this process.

But if it’s important enough to you, find the time and money to make it happen.

It’s important to be educated.

Make an appointment, arrange a dinner with a guest REI expert, arrange a grand rounds lecture.

Wellness is important.

It’s doable: It’s affordable, you can find people to support you within your training program and your support group, and people will be willing to – and want to – help you. Ask for help. Rely on people. Look into your health insurance and FSA account to help maximize savings.

You aren’t alone: Talk about REI within your social circles.

Share your experience, thoughts or worries. When I started talking about my process, I was overwhelmed by how many couples were going through the process or had been through the process, as well as how many women (single or in relationships) who were interested in my experience.

It was much more prevalent than I had expected.

8

Plastic Surgery Resident | Summer 2019

CHILD-BEARING FUTURE / continued from previous page rather counter-intuitive to inject myself up to multiple times per day, and to adhere to strict injection time-points.

I worried and obsessed about my lab results and how the follicles looked on my ultrasounds. Toward the second half of the cycle, these tests occurred every two to three days. Some women have described the process as an amplified version of whatever “PMS” symptoms they usually experience.

On the day of oocyte retrieval – about 12 days in – I remember how odd it felt, being in the gurney I’ve seen so many patients in, wearing a gown I’ve undone so many times before to examine patients, experiencing the anxiety of undergoing sedation and wondering how the procedure would go. The procedure itself was unremarkable, and I didn’t experience much discomfort during or afterward.

After the short procedure, my resident friends (and their partners) had arranged plans and back-up plans to take me home, stay with me as I recovered from sedation and celebrate the end of the process with dinner at my apartment.

GREAT SENSE OF RELIEF

In the end, I spent less than $2,000 out of pocket for my cycle, and it was a great sense of relief to know I had gone through with it and preserved my fertility. It costs about $1 a day to keep the oocytes, and the first year

was included in the cost of my cycle.

Currently, I’m considering pursuing a second round of oocyte cryopreservation, to maximize my chances of having live births result from these oocytes.

How many mature oocytes are needed to achieve a livebirth? This number depends upon age, given the issues with age-related decline in oocyte quality as previously noted. A more recent article published in 2017 attempted to formulate a prediction model for this aspect of OC to help guide patient counseling.

For example, in women who undergo planned OC under age 35, approximately 13 mature oocytes would be needed to have an 80 percent chance at livebirth. In women age 37, approximately 23 oocytes would be needed.2 Several investigators have attempted to formulate decision models to assist providers as they counsel patients on the optimal age of OC. For example, a woman who presents at age 37 would have a 57.6 percent chance of livebirth in seven years if utilizing planned OC, compared to 21.9 percent for a woman at age 37 who does not pursue planned OC. UNC Fertility, an organization at the University of North Carolina, Raleigh, has formulated an online “egg banking calculator” that can be utilized as a tool for both patients and physicians (www.

UNCfertility.com/treatment-options/eggcalculator).1 Another option can be found here: https://www.mdcalc.com/bwh-eggfreezing-counseling-tool-efct.2 Once a woman determines her desire to use her previously vitrified oocytes, the oocytes will require thaw, then fertilization with sperm, followed by culture of embryos with subsequent embryo transfer procedure. As noted above, the literature suggests that fertilization and pregnancy rates for vitrified/warmed oocytes are similar to traditional IVF with fresh oocytes3.

Packing a bag with ice packs for the injections of the day.

Short-term studies analyzing outcomes for offspring after planned OC reveal no increase in congenital anomalies

compared with offspring resulting from traditional IVF.4 At this time, there’s a paucity of long-term data on outcomes following use of cryopreserved oocytes in the United States; additionally, long-term data is lacking regarding transgenerational offspring health.

Overall, for women who desire to maintain reproductive autonomy and protect against future, potential infertility as a result of age-related fertility decline, planned OC is a viable option. At present, data supports that pregnancy rates using vitrified/warmed oocytes are similar to those who undergo fresh IVF. Given that planned OC is a relatively new application, uncertainties still exist in regard to its appropriate use and long-term effects. Patient counseling is essential to allow for informed decision-making – and to provide realistic expectations for women who pursue planned OC. |

Dr. Chen is a Chief Resident at the University of Pittsburgh Medical Center’s Department of Plastic Surgery.

Contributing to this article were Rachel Beverley, MD, Fellow, and Sunita Katari, MD, attending physician, both at the Center for Reproductive Endocrinology and Infertility at University of Pittsburgh.

REFERENCES

1. Bourne DA, Chen W, Schilling B, Littleton E, Washington KM, Delacruz C. Family and Fertility in Plastic Surgery Residents and Fellows. Accepted Jan 2019, Plast Reconstr Surg.

2. Mesen TB, Mersereau JE, Kane JB, Steiner Az. Optimal timing for elective egg freezing. Fertil Steril 2015;103:1551-6.

3. Goldman RH, Racowsky C, Farland RV, Munne S, Ribustello L, Fox JH. Predicting the likelihood of live birth for elective oocyte cryopreservation: a counseling tool for physicians and patients. Hum Repro 2017;32:853-9.

4. Cabo A, Meseguer M, Remohi J, Pellicer A. Use of cryo-banked oocytes in an ovum donation programme: a prospective, randomized, controlled, clinical trial. Hum Reprod 2010;25:2239-46.

5. Chian RC, Huang JY, Tan SL, Lucena E, Saa A, Rojas A, et al. Obstetric and perinatal outcome in 200 infants conceived from vitrified oocytes. Reprod Biomed Online 2008;16:608-10

There’s an easy solution

Helping pregnant residents by deploying kindness, common sense and rationality

By Shoshana Ambani, MD

B

eing a surgery resident is not easy. Having a baby is not easy. Being a surgery resident, while also pregnant or a new mom, is downright difficult and, at times, treacherous. Think extreme fatigue, sleep deprivation, nausea, emotional volatility, stress, pain and anxiety, along with the heavy burden of maintaining complete composure and achieving excellence both academically and clinically as a surgeon, without batting an eyelash. That’s what we’re trained to do, after all.

We all “understand” these difficulties, but no one truly feels the compassion owed to those going through the physical process of surgical training while trying to build a family – until they go through it themselves. Thankfully, the culture is changing, slowly but surely, as female surgeons have grown more vocal about these issues, and as male colleagues have become more aware and now advocate as well for more

appropriate parental rights and protections. If this means hiring support staff to offload the extra call nights and clinical work that would otherwise fall on the shoulders of co-residents, just do it. Figure it out!

We must break the cycle of negativity and resentment associated with a resident becoming pregnant or taking maternity leave, by not forcing those who remain to “pick up the slack.” Hire a moonlighter, for example. The culture change will be worth it.

With that, a piece of advice to support the cause: Have compassion for those going through the process of surgical training and building a family – and ask what you can do to help.

We will all be better for it. | Dr. Ambani is the medical director of plastic surgery at Henry Ford Allegiance Health, Jackson, Mich.

Plastic Surgery Resident | Summer 2019

9

A facial injection gone sideways

“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.

Intra-arterial injection of soft-tissue filler with impending necrosis

By Jared W. Garlick, MD MESSAGE ON YOUR PAGER: PATIENT HERE WITH FILLER COMPLICATION. PLEASE COME EVALUATE! You’re at home at 11:30 p.m., preparing for your next day’s cases, when you receive a page from the E.D. The page reads: “Patient here with concern of a filler complication. Please come evaluate!”

You call back the page. The E.D. attending describes a 33-yearold female who had her nasolabial folds injected with filler hours earlier at a medical spa, with worsening pain on the one side of her face since her injection. She tried to call the spa, but there was no answer and no way to get in contact with anybody there – so she’s presented to the E.R.

BRIEF DESCRIPTION OF THE ISSUE Dermal fillers are gaining popularity throughout the world for facial aesthetic treatments. Given the number of blood vessels in the face, there’s always a risk for vascular complications from accidental intra-arterial injection. Intravascular injections causing occlusion are now becoming not-so-rare events, with an incidence of up to three in 1,000.1 With the increased 10

Plastic Surgery Resident | Summer 2019

popularity of soft-tissue filler injections as well as the number of inexperienced injectors entering the cosmetic marketplace, the number of vascular occlusions is projected to continue to rise.

That said, complications can happen even in the hands of the most experienced injector.2 It’s estimated that an injection of 0.1 mL or more is needed to cause substantial injury.3 A number of potential complications can arise from injected softtissue fillers – some may appear early, others may appear later.4 We will focus on diagnosing and managing an acute intraarterial injection with impending necrosis, given its seriousness.

Patients may present immediately after or a few hours following their injection, with the majority of consults seen in the E.D. likely to be of the latter.

SEND INSTRUCTIONS AHEAD It’s important to recognize that time is of the essence with these patients, as studies have shown the use of hyaluronidase to be a successful salvaging procedure for injected hyaluronic acid (HA) fillers when injected within four hours of the vascular occlusive event.5 While preparing to go to the E.D., think of what can be started

prior to your arrival. You call the E.D. back and ask them to order multiple vials of hyaluronidase from the pharmacy; to begin applying warm heat-compresses with massaging of the area; and to have the “filler crash kit” ready. Instruct no ice on the patient (ice can cause vasoconstriction, further limiting blood-tissue perfusion to the area of impending necrosis). This is important to note, because if the intra-arterial injection was missed by the injector, the patient was likely recommended to “ice” the injected locations post-injection to help minimize swelling. Additionally, the providers in the E.D. may not understand the underlying presentation and will provide ice to the patient, thinking that it’s extensive bruising.

Figure 1

ANATOMY The human face has a rich, vascular network with many collaterals and anastomoses, making it a target-rich environment. The most common arterial-injection sites which lead to necrosis are the angular artery and its branches, which supply the nasolabial folds and nose; and the supratrochlear artery, supplying the glabellar region (Figure 1). The glabella is also the most-common injection site associated with blindness.2 As an injector, thorough knowledge of facial anatomy and their “danger zones,” as they pertain to injection locations, is paramount.6

HISTORY AND PHYSICAL EXAM It’s important to ask the patient what time the substance was injected; this gives you an idea of how long the artery has been occluded. Also, ask what type of filler was injected. Some patients might not know what was injected, but it’s important to try to determine this information. There are a number of different filler materials being injected, so it’s important to know what injected material you’re dealing with. Hyaluronic acid fillers are the most commonly used; therefore, for the purpose of this case, we will act as though an HA filler was injected.

Also, ask for a timeline of symptoms they have experienced – from the time of injection until the time you are with them.

Ask about any change in their vision or mental status, or new onset headaches. Ask them to describe the changes they’ve noticed of their skin overlying the affected area since injection.

Make sure to: • Undertake an eye exam (rule out visual involvement) • Evaluate pain (will be severe) • Evaluate temperature (will feel cool) • Evaluate sensory and motor nerve of the face (may have decreased sensation) • Check capillary refill (delayed, or no cap-refill present) • Evaluate skin discoloration and demarcation zone (you may outline the area, to trend changes over time) Having a sound understanding of the clinical progression of vascular occlusion is important in helping diagnose and manage the complication. The first clinical sign of arterial occlusion is

Schematic drawing showing vascular distribution and connections between the ophthalmic and facial arterial systems. (From Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A. Blindness Caused

By Cosmetic Filler Injection: A Review of Cause and Therapy. Plast Reconstr Surg. 2014;134:1197-1201.)

Figure 2 CLINICAL FINDINGS

TIMING

Blanching: invariably immediate, usually seen during the actual injection

Lasting seconds to tens of seconds

Livedo pattern or, alternatively, immediate reactive hyperemia if insufficient material injected to occlude the artery (typically <0.1 mL for the angular artery)

Minutes, sometimes up to tens of minutes

Blue-black discoloration

Tens of minutes to hours

Blister/bullae formation

Hours to days

Skin breakdown, ulceration, demarcation, slough

Days to weeks

Typical complication progression following accidental intra-arterial injection of filler. (From DeLorenzi C. Complications of Injectable Fillers, Part 2: Vascular Complications. Aesthetic Surgery Journal 2014;34:584-600.)

skin blanching, which usually occurs immediately following the injection. A good injector should recognize this change and begin managing right away; however, not all injectors know or understand how to recognize and treat a complication like this. If you’re seeing the patient in the E.D., this was likely missed. After the initial blanching, the site will then change in appearance to a blotchy livedo pattern within minutes, due to the venous drainage.

continued on the next page Plastic Surgery Resident | Summer 2019

11

CONSULT CORNER / continued from previous page Note there can be an immediate, reactive hyperemia present if the amount of filler injected was insufficient to completely occlude the artery. Otherwise, the livedo pattern will gradually be replaced with a deep-bluish discoloration which then can turn to blistering and bullae formation. Ultimately, without any intervention, the demarcating area will turn into softtissue necrosis.1,3 (Figure 2) Intense pain at the injection site is the most-common symptom reported, but it’s important to note this may be delayed in presentation for a few hours post-injection. This is due to many fillers having a local anesthetic compounded with the product.

Additionally, patients may have been pretreated with nerve blocks. Some patients who have an accidental intra-arterial injection may notice more discomfort than normal at the time the injection occurs, compared to their previous injections at those sites. It’s very typical for their pain to worsen over the hours following injection, to the point they likely will not want you to touch the affected area.

MANAGEMENT Upon diagnosing the vascular compromise, it’s critical to immediately begin treatment. If they report vision changes

Figure 3

and/or blindness, emergent ophthalmology consultation should also be requested. If you are injecting, first and foremost, stop any further filler injection. All clinical locations should have a “filler crash kit,” consisting of the materials needed to treat these clinical emergencies.1,2,4,7 Start by massaging with the application of hot/warm compresses to the area to increase vasodilatation. If an HA filler was used, inject hyaluronidase into wherever the vasculature appears compromised – using a “flood the field” mindset, not just at the site of the filler injection.

Hyaluronidase is an enzyme that catalyzes HA hydrolysis.7 It’s worth mentioning that hyaluronidase has been reported showing benefit on other filler materials, such as calcium hydroxylapatite (CaHA).8 Hyaluronidase is known to cause potential, rare allergic reactions in some patients – including angioedema, urticaria or anaphylaxis – so asking patients about known allergies is important. Additionally, prior to injecting the compromised area of concern with large quantities of hyaluronidase, you may inject a small amount – roughly three units – on the dorsum of the forearm and wait five minutes for any reaction to occur before proceeding.

Suspected Intravascular Injection Local Pain Discoloration Blanching Bruising

1st Line Therapy Stop Injection Massage Warm Compresses Nitroglycerine Paste Hyaluronidase*

Orbital Pain Visual Disturbance

Unproven/Supportive Therapy Systemic/Topical Steroids Aspirin Prostaglandin (IV) LMWH (IV/IL) Puncture Removal or Filler

Frequent Follow Up Necrosis/Slough Complete Recovery Topical Wound care Antibiotics (PO/IV) Surgical Debridement

Immediate Ophthalmology Consultation

Ocular Massage Timolol Drops Diuretics (IV) Corticosteroids (IV/PO) Hemodilution Vasodilators 02/CO2 Therapy Anticoagulation/Thrombolysis Needle Decompression of Anterior Chamber

Algorithm for treatment of severe complications following filler injections. (From Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications Following Injection of Soft-Tissue Fillers. Aesthetic Surgery Journal 2013;33:862-877.)

12

Plastic Surgery Resident | Summer 2019

There are many published reports offering different doses of hyaluronidase to inject. However, the Global Aesthetics Consensus Group recommends a minimum of 200-300 U of hyaluronidase injected over the entire area of impending necrosis, repeated at least daily for a minimum of two days.

Others report injecting hourly with doses up to 1,000 U until blood circulation has been reestablished.1,3,4,9 Many patients will describe their intense pain as starting to improve following the first injection of hyaluronidase. Apply topical nitroglycerin (1-2 percent) paste with complete covering over the compromised area to allow more vasodilatation. This can be applied every 1-2 hours and then continued at home three times per day, as long as the patient’s vitals remain normal and no dizziness is reported.

Both aspirin and oral prednisolone can be considered but are without proven efficacy.4 Aspirin is administered with 325mg initially, then moving to 81mg daily thereafter. The thought is that aspirin will block platelet aggregation within a partially occluded vessel, and it also has anti-inflammatory properties.

Oral prednisolone, 20-40mg daily, for three to five days can also be initiated. This may prevent further vascular compromise by decreasing the inflammatory component of the injury10.

In severe cases, low-molecular-weight heparin and systemic anticoagulation may be helpful, but this is without clear evidence.3 The patient should be seen at least once every 24 hours to follow improvements in the soft-tissue perfusion.

PROTOCOLS There a number of suggested protocols in both the plastic surgery and dermatology literature, but the protocol (Figure 3) referenced by the Global Aesthetic Consensus Group and Ozturk, et al., appears to be the most complete.2,4

CONCLUSIONS & KEY POINTS • Vascular occlusion and necrosis can occur as the result of injection of all types of fillers.

• As an injector, thorough knowledge of facial anatomy and the “danger zones,” as they pertain to injection locations, are crucial.

• Familiarity with the prevention, presentation and immediate treatment of filler-induced vascular occlusion should be standard for any injector.

• Intense pain at the injection site is the most-common symptom reported.

• Every office and E.D. should have a “Filler Crash Kit” on hand.

• If vascular occlusion occurs, stop injecting; apply a warm compress and massage; apply nitroglycerine paste; inject hyaluronidase; and maintain consistent follow-up.

• Hyaluronidase is best indicated for hyaluronic acid fillers.

• All injectors should take steps to minimize any risk of intravascular injection (Figure 4). |

Figure 4 • Use reversible fillers (i.e., hyaluronic acid fillers) • Use small needles (i.e., 27-guage or smaller) • Use cannulas when appropriate • Use an anterograde/retrograde injection technique, keeping the needle in constant motion • Use small syringes (0.5-1 cc) an inject in small increments • Use low pressure; injections requiring high pressure signify danger and/or inappropriate location • Use extreme caution when injecting in areas of previous trauma/scar or avoid altogether • Be aware of the pertinent anatomy outline in the danger zones • Have a filler rescue kit available at all times

General principles for safe filler injections. (From Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF, Rohrich RJ. Facial Danger Zones: Techniques to Maximize Safety During Soft-Tissue Filler Injections. Plast Reconstr Surg, 2017;139:1103-1108.)

Dr. Garlick is a PGY-6 Chief Plastic Surgery Resident at the University of Utah, Salt Lake City. He can be reached at jared. garlick@hsc.utah.edu.

REFERENCES

1.Rzany B, DeLorenzi C. Understanding, Avoiding and Managing Severe Filler Complications. Plast Reconstr Surg 2015;136:196s-203s.

2.Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications Following Injection of Soft-Tissue Fillers. Aesthetic Surgery Journal 2013;33:862877.

3.DeLorenzi, C. Complications of Injectable Fillers, Part 2: Vascular Complications. Aesthetic Surgery Journal 2014;34:584-600.

4.Signorini M, Liew S, Sundaram H, et al. Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers – Evidence- and Opinion-Based Review and Consensus Recommendations. Plast Reconstr Surg 2016;137:961e-971e.

5.Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES. Vascular Complications of Hyaluronic Acid Fillers and the Role of Hyaluronidase in Management. Journal of Plastic, Reconstructive & Aesthetic Surgery 2011;64:1590-1595.

6.Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF, Rohrich RJ. Facial Danger Zones: Techniques to Maximize Safety During Soft-Tissue Filler Injections. Plast Reconstr Surg 2017;139:1103-1108.

7.DeLorenzi, C. Complications of Injectable Fillers, Part I. Aesthetic Surgery Journal 2013;33:561-575.

8.Dayan SH, Arkins JP, Mathison CC. Management of Impending Necrosis Associated With Soft Tissue Filler Injections. Journal of Drugs in Dermatology 2011;10:1007-1012.

9. Loh KTD, Phoon YS, Phua V, Kapoor KM. Successfully Managing Impending Skin Necrosis Following Hyaluronic Acid Filler Injection, Using High-Dose Pulsed Hyaluronidase. Plast Reconstr Surg Global Open 2018;6:e1639.

10. Beleznay K, Humphrey S, Carruthers JD, Carruthers A. Vascular Compromise From Soft Tissue Augmentation: Experience With 12 Cases and Recommendations for Optimal Outcomes. Journal of Clinical and Aesthetic Dermatology 2014;7:37-43.

Plastic Surgery Resident | Summer 2019

13

Hand Nerve and Tendon Transfers Maximize your In-Service Examination score by revisiting lessons learned early in your career as a physician.

To lend an assist for achieving this goal, “Hand – Nerve and Tendon Transfers” will cover the most-commonly tested tendon and nerve transfers employed in upper-extremity reconstruction

Table 1. NERVE TRANSFERS DEFICIT

TARGET FUNCTION

RECIPIENT NERVE

DONOR PREFERENCE

Radial Nerve

Wrist Extension Digit Extension

ECRB PIN

FDS FCR/PL

Median Nerve

Pronation Finger/Thumb Pinch Opposition 1st Webspace Sensation

Pronator Branch AIN Recurrent Motor Branch 1st Webspace Branch

ECRB Supinator Terminal AIN Dorsal Ulnar Nerve

Ulnar Nerve

Intrinsic Function Ulnar Sensation

Ulnar Motor Branch Ulnar Sensory Branch

Terminal AIN Third Webspace Branch

By Steven D. Kozusko, MD, MEd & Jeremy Chang

N

erve transfers are used in the acute setting to preserve and restore essential hand and upperextremity function after nerve injury. With prolonged denervation, the focus of restoring function shifts to tendon transfers.

PRINCIPLES

Nerve transfers are performed 12-18 months from the time of injury. Beyond this timeframe, loss of neuromuscular junctionendplates precludes successful reinnervation after nerve transfers.

Thus, when presented with a patient who’s 18 months out from the initial injury, tendon transfers are the indicated treatment modality.

Tendon transfers are performed using an expendable donor tendon that, once taken, does not leave a major functional deficit.

The chosen tendon should have synergistic action, facilitate tenodesis and provide adequate strength.

14

Plastic Surgery Resident | Summer 2019

Moore AM, Franco M, Tung TH. Motor and Sensory Nerve Transfers in the Forearm and Hand. Plast Reconstr Surg 2014 Oct;134(4):721-30.

Nerve transfers are most efficacious when performed within six months of injury. With early transfer, a high percentage of patients will achieve M3 function for elbow flexion and shoulder abduction.

PRESERVING DISTAL MOTOR FUNCTION IN HIGH NERVE INJURIES

The most critical nerve transfer used to babysit hand-muscle function while nerve regeneration occurs is the anterior interosseous nerve transfer (AIN) to the motor branch of the ulnar nerve in the distal forearm. High ulnar-nerve injuries lead to loss of grip strength and the development of claw-hand

deformity. This injury is proximal to the innervation of the flexor carpi ulnaris (FCU) and flexor digitorum profundus (FDP) muscles near the elbow.

High ulnar nerve injuries take longer than the 18-month window for regeneration. The anastomosis of the AIN to the ulnar nerve occurs 8-10cm proximal to the wrist crease to preserve intrinsic muscle function.

At times, the AIN innervated muscles – especially the flexor pollicis longus (FPL) and FDP to the index and long fingers – need babysitting of the endplates. The two most common methods of nerve transfer are the extensor carpi radialis brevis branch of the posterior interosseous nerve and the brachialis branch of the musculocutaneous nerve. Either can be used while the AIN regenerates.

RESTORING ELBOW FLEXION WITH NERVE TRANSFERS

Oberlin was the first to describe transfer of the FCU fascicle to restore elbow flexion. MacKinnon then advocated for transfer of the FCU fascicle of the ulnar nerve to the biceps, and the FCR fascicle of the median nerve to the brachialis. These transfers maximize elbow-flexion recovery. This is important to provide the opportunity for the patient to bring his or her hand to a functional position for feeding. The priority with restoring function in the elbow is to address flexion deficits.

RESTORING SHOULDER FUNCTION WITH NERVE TRANSFERS

Restoration of shoulder abduction is achieved with nerve transfer to innervation of the deltoid muscle. The nerve transfer most commonly employed is transfer of a triceps branch of the radial nerve to the deltoid. This transfer may also enhance teres major function, as the target of the transfer – the axillary nerve – innervates both the deltoid and teres major muscles.

Another consideration for shoulder stability is external rotation.

This is provided with partial transfer of the spinal accessory nerve to the suprascapular nerve. Normal external rotation is provided by the supraspinatus and infraspinatus muscles; therefore, the target is the supraspinatus muscle.

RESTORING EXTENSOR FUNCTION WITH TENDON TRANSFERS

The most common mechanism of injury to the radial nerve is a fracture of the humerus, with damage to the radial nerve as it crosses the spiral groove. The patient presents with an inability to extent the fingers, thumb and wrist. The pronator teres (PT) is the tendon of choice to provide power and excursion for wrist extension. Transfer this tendon to the extensor carpi radialis brevis (ECRB), as this inserts on the third metacarpal and is centrally oriented for wrist extension.

Table 2. TENDON TRANSFERS DEFICIT

FUNCTIONAL CONCERN

RECIPIENT TENDON

DONOR PREFERENCE

Radial Nerve

Wrist Extension Thumb Extension MCP Extension

ERCB EPL EDC

PT EIP, PL or Ring FDS FCR, FCU or FDS

Median Nerve

Opposition Thumb IP Flexion Index IP Flexion

Abductor Pollicis Brevis FPL Index FDP

Ring Finger FDS BR ERCL

Ulnar Nerve

Key Pinch Clawing

Adductor Pollicis Lateral Band

ERCR or BR ECRB or ECRL

Sammer DM, Chung KC. Tendon Transfers: Part I. Principles of Transfer and Transfers for Radial Nerve Palsy. Plast Reconstr Surg. 2009 May;123(5):169e-177e. Sammer DM, Chung KC. Tendon Transfers: Part II. Transfers for Ulnar Nerve Palsy and Median Nerve Palsy. Plast Reconstr Surg 2009 Sep;124(3):212e-21e.

Transfer of the FCU to the extensor digitorum communis (EDC) is an option to provide extensor function to the fingers.

Alternative options for finger extension include the flexor carpi radialis (FCR) and flexor digitorum superficialis (FDS).

The extensor pollicis longus (EPL) muscle usually ruptures from a chronic pathology such as rheumatoid arthritis and distal radius fracture. Treatment is focused on tendon transfer.

The extensor indicis proprius (EIP) is the tendon of choice and has excellent excursion. An alternative option is the PL as an interposition tendon graft. This requires healthy proximal and distal segments of the EPL and timely repair.

RESTORING FINGER FUNCTION WITH TENDON TRANSFERS

In a patient who presents with clawing of the ulnar fingers or all fingers (as seen in both a median and ulnar nerve injury), the Brand transfer makes use of the extensor carpi radialis longus (ECRL) or brevis, as well as the extensor digitorum longus (EDL) from the lower extremity. The EDL tendon and its multiple slips is grafted from the leg. This bridges the gap between the ECRL or ECRB and the desired insertion on the lateral band of the proximal phalanx.

Another option to restore finger flexion is the functional gracilis muscle. This is transferred with the anterior branch of the obturator nerve. For optimal function, the muscle needs to be inset at the same tension it was under in the leg. The gracilis can be used to provide simultaneous restoration of both elbow flexion and finger flexion.

continued on page 30

Plastic Surgery Resident | Summer 2019

15

The University of Kansas Department of Plastic Surgery

By Jacob Grow, MD, and James Vargo, MD History: • Established: 1905 • Residency Start: 1943 • Established By: Frank Masters, MD, and David Robinson, MD • Notable Faculty o Earl Padgett, MD: Invented the dermatome in 1938 o David Robinson, MD: Former ASPRS President o Kathryn Stephenson, MD: Former Editor PRS o David Zamierowski, MD: Co-Creator of negative pressure wound therapy Leadership • Richard Korentager, MD; David Zamierowski Endowed Professor of Plastic Surgery; Chair, Department of Plastic, Burn and Wound Surgery • James Butterworth, MD; Associate Professor; Program Director of Integrated Plastic Surgery Residency Program • Ryan Endress, MD; Assistant Professor; Assistant Program Director of Integrated Plastic Surgery Residency Program • Wojciech Przylecki, MD: Assistant Professor; Fellowship Director of Microsurgery Fellowship • Jeffrey Goldstein, MD: Clinical Assistant Professor; Section Chief, Plastic and Reconstructive Surgery, Children’s Mercy Hospital Clinical Experience • 12 Integrated residents, one microsurgery Fellow • Residents work with a large number of staff physicians (11 full-time faculty at the University of Kansas Hospital, five faculty at Children’s Mercy Hospital, multiple adjunct community plastic surgeons) • Clinical sites include the University of Kansas Hospital, Indian Creek Ambulatory Surgery Center, Children’s Mercy Hospital, Kansas City VA Hospital • High volume of breast and head/neck microsurgery, pediatric plastic surgery, elective and traumatic hand surgery, aesthetic surgery, bread-and-butter plastic surgery • Private practice and elective rotation • Chief resident clinic • Significant plastic surgery exposure beginning intern year Educational Curriculum • Didactics are held weekly. Topics are covered with a resident or faculty lecture, followed by board style cases and clinical scenarios 16

Plastic Surgery Resident | Summer 2019

• Residents participate annually in mock oral-boards, including known and unknown cases • Frequent visiting professors and outside lecturers. Monthly visiting professors through the Kansas City Plastic Surgery Society. Frequent lectures from physicians outside of the plastic surgery department, including facial plastic surgery, radiology, medical ethics, financial planning, malpractice and legal, and practice management • Annual facelift and facial aesthetics cadaver lab with visiting professor (2017: Bryan Mendleson, Mike Lee; 2018: James Zins; 2019: Jamil Ahmad) • ACAPS annual Plastic Surgery Intern Boot Camp site • Quarterly microsurgery training in dedicated microsurgery lab • Bi-monthly Journal Club at off-campus location

Research • All residents participate in clinical research projects • Residents funded to attend conferences when presenting research (In 2018, seven of 12 residents were represented at Plastic Surgery The Meeting, with residents also attending the ASAPS meeting, International Society of Craniofacial Surgery meeting, International Society for Burn Injuries meeting, Midwest Association of Plastic Surgery meeting) • Residents have recently been published in Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, Annals of Plastic Surgery, Journal of Reconstructive Microsurgery, Journal of Craniofacial Surgery and Journal of Burn Care and Resuscitation • Residents have protected research time in the first and third years • Access to perform basic science with department-employed PhD A.J. Mellott Fellowship Training • 2015: Hand, Baylor College of Medicine • 2016: Craniofacial, University of Michigan • 2017: Pediatric, The Hospital for Sick Children (Toronto) • 2018: Aesthetics, Cleveland Clinic. Hand, University of Massachusetts • 2019: Hand, Pennsylvania State (Hershey) Resident Benefits • Meal money • Loupes fund • Embroidered department jackets and white coats with dry cleaning • Golden weekends if not on call • AO Facial and Hand Trauma courses as (PGY-3 and PGY-4) • Chief conference of your choice • Resident social events (Brew Day, resident welcome party, graduation team building, holiday party) | More on our program can be found at http://www.kumc.edu/school-of-medicine/ plastic-surgery/residency-program.html. Follow us on Instagram @ku_plasticsurgery_residency.

A Message From the Program Director, James Butterworth, MD

K

ansas City? Who knows anything about Kansas City?

I certainly didn’t before coming to the University of Kansas Medical Center – and I’m a Midwesterner. What I found in the heart of our country is a city that is a hidden gem of sorts, exciting and full of opportunity; and a department that was thriving and providing incredible James Butterworth, MD education to its trainees. Midwestern through and through in the kindness and generosity that one receives from its people, Kansas City is also a bustling metropolitan area with a population more than 2 million in the greater metro. It offers entertainment opportunities from professional and collegiate sporting events to fine arts, to an amazing restaurant scene with some of the best BBQ in the country.

The University of Kansas Plastic Surgery residency program is one of the oldest training programs in the country, dating back to Frank Masters, MD, and David Robinson, MD, in 1948. Over the years, it has had many chapters and numerous phases of leadership, continually evolving to provide an outstanding training experience. The current department chairman, Richard Korentager, MD, has created a flourishing environment of clinical and academic productivity. With full departmental status, we’ve made progressive changes to the residency program’s rotation schedule and didactics. This includes increased, early plastic surgery exposure in the first and second years. Residents are in the O.R. from the first day of residency, and due to high operative-volume there’s minimal double-scrubbing. As a result, maturity and comfort in the O.R. occurs early in our program as we truly span the full breadth of plastic surgery. In addition to our home base, residents also rotate at Childrens’ Mercy Hospital, where five full-time plastic surgeons provide a prolific congenital/pediatric experience. Academically, the program continues to grow and has represented the institution with many presentations at national meetings over the past few years.

Without a doubt, our proudest accomplishment is the culture that we’ve built. We champion collaboration and camaraderie among the residents and faculty. In doing so, we ‘ve established an environment of genuine interest and concern for the program and for one another. This has been done by empowering the residents with guiding the direction and details of all aspects of the program. As a result, we not only have residents who will graduate and represent the institution favorably – we have residents who will always be active members of our family. |

Plastic Surgery Resident | Summer 2019

17

Q&A WITH RICHARD KORENTAGER, MD

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

In this installment of Faculty Focus, we present ASPS member Richard Korentager, MD, Integrated Residency Program director, David Zamierowski Endowed Professor of Plastic Surgery; and chair of the University of Kansas Department of Plastic Surgery, Burn and Wound Surgery.

Dr. Korentager completed his plastic surgery residency at the University of Toronto, as well as fellowships in breast reconstruction and micronerve surgery at Etobicoke General Hospital and St. Joseph Health Center, both Toronto, and he enjoys double-certification in plastic surgery through ABPS and the Royal College of Surgeons of Canada. He’s particularly interested in treating patients after weight loss, as well as being deeply involved with breast reconstruction, cosmetic surgery and burn surgery.

Dr. Korentager urges plastic surgery residents to never relinquish the passion for helping people that first drew them to medicine, while also advising residents to keep their close personal connections with family and friends – and to realize that success in the specialty may depend in large part upon their support, but also residents’ willingness and ability to prioritize keeping those relationships fresh and balanced, even if that means working into the night, if that’s the free time available.

18

Plastic Surgery Resident | Summer 2019

PSR: WAS THERE AN INCIDENT IN YOUR LIFE THAT DREW YOU TO THE SPECIALTY? Dr. Korentager: During my first year of medical school, a close friend of my family suffered a severe burn injury and was treated at the Hospital for Sick Children in Toronto.

I had the opportunity to do an elective at the hospital and become involved in his treatment as a student. I had the good fortune of meeting Wally Peters, MD, who ran the adult burn unit in Toronto at that time. I spent a summer doing research with him and shadowing him. I was able to see the broad range of patients and conditions that Dr. Peters treated, as well as spend time in the O.R. with many of the great surgeons practicing in Toronto at that time. From that point, I was quite sure that I wanted to pursue plastic surgery as a career.

PSR: HOW DID YOU PREPARE YOURSELF DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Korentager: When I was training – and this may be hard for many people to believe – the Internet didn’t exist. I was quite naïve about how far ahead I should have been working on obtaining a fellowship. My dream had been to train in Australia with Ian Taylor, MD, but I didn’t take into account the (literally) months it could take for letters to get back and forth. One of my few regrets is that I wasn’t able spend a year expanding my horizons and training abroad. I try very hard to encourage all of our residents to do everything they can to obtain their dream fellowships – and I do what I can to assist them.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER? Dr. Korentager: I was fortunate. I ended up spending six months with Ron Levine, MD, and six months with Michael Drever, MD, during which I learned a tremendous amount about complex peripheral-nerve reconstruction as well as breast reconstruction. Under their tutelage, I advanced my skills and was able to start practice in a very confident fashion.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Korentager: I think it’s terribly important to have a mentor during those early years. In fact, if you’re fortunate you’ll have many mentors. These can include the faculty under which you trained, as well as the residents who graduated ahead of you in your program. Depending on the kind of practice you join, hopefully you’ll be able to look to your senior partners to mentor you in the practice of plastic surgery. If you end up in an academic setting, you’ll need mentors for your research and educational activities.

PSR: HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Korentager: As my career has progressed, I’ve become more involved in our plastic surgery societies and have served on numerous committees. My changing practice interests helped focus the societies I’ve been most involved with and the committees I’ve served on. When I moved from private practice to an academic practice, I gravitated toward ACAPS and have had the privilege of becoming progressively more involved on ACAPS committees and its board.

PSR: WHAT IS A SUCCESSFUL RESIDENT'S MOST IMPORTANT ATTRIBUTE? Dr. Korentager: Successful residents come in many shapes and sizes, and success can be defined in different ways.

Residents need to be adaptable to different situations and know how to work with different faculty, nurses, administrators and patients. Being honest and always having the patient’s best interest in mind is critical to being a successful resident as well.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Korentager: Without a doubt, it’s a challenge to find the right balance between our professional and personal lives. Unfortunately, the high rate of physician burnout seen in our specialty is a testament to how challenging finding that balance can be. My wife and family are sensitive to the importance of the work that I do, and they understand I can’t always be around as much as we all would like. I try to plan carefully and make sure that I’m around for the important events in my wife and kids lives. This does mean a lot of late nights answering emails and catching up on paperwork.

PSR: WHAT WAS THE GREATEST NONMEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE IT? Dr. Korentager: I think the biggest nonmedical challenge of residency for me was the number of hours and the challenges of trying to keep a balanced life physically, mentally and emotionally. I’m not sure I always handled it that well. The times that I did a better job at it usually involved staying connected with friends and family.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Korentager: Without a doubt, it’s the look of the patient and family whom I’ve been able to help. In some cases it’s a surgery, and in some cases it’s simply being there for them during challenging times.

Plastic surgery has given me the opportunity to meet people in all walks of life and all around the globe. I couldn’t ask for anything more.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Korentager: Overall, my biggest challenge is balancing the time required for my administrative duties with our department, my clinical practice, my research interests and teaching of both undergraduates and postgraduates. I’m fortunate to have a tremendous group of partners who are always around for me to bounce ideas off of, and who can help bail me out when needed!

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Korentager: The beauty of an academic practice is that I always have the opportunity to teach Fellows, residents, medical students and other health professional students, so that teaching is an integral part of everything that I do.

Teaching at the graduate level has taken on a much bigger role in my schedule over the past couple of years, as I’m involved with problem-based learning and coaching for our first- and second-year medical students in our new ACE curriculum. I’d also say that during my years in private practice, I sought-out opportunities to teach and always found people willing to listen.

PSR: WHAT’S YOUR FINAL WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Korentager: You’re being given a tremendous opportunity and privilege to enter into a specialty that, through innovation and teamwork, has had a huge impact on the quality of life of countless individuals and families.

Never take that for granted – and never lose the passion to help those in need that brought you into medicine and plastic surgery.

PSR: PLEASE COMPLETE THIS SENTENCE: I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN… Dr. Korentager: I realized the profound impact that plastic surgeons make on patients, families and society. |

Plastic Surgery Resident | Summer 2019

19

Kansas City “Oh, yeah, Kansas City.”

“Wait. Kansas City, Missouri? Or Kansas?”

(Yes, Kansas.)

20

Plastic Surgery Resident | Summer 2019

By James Vargo, MD & Jacob Grow, MD

F

or many, Kansas City is just a halfway point 30,000 feet below on a flight from New York to Los Angeles. However, if you were to take an Anthony Bourdain-style, 24-hour layover, you would quickly see that K.C. isn’t a farm town in the middle of the heartland. This sprawling metropolis of more than 2.1 million people is filled with urban excitement complemented by Midwestern hospitality and charm.

merchants from across Missouri and Kansas. Here we leave you the choice of catching an affordable tee time (<$50) at one of the many public golf courses across the metro – or if you’re feeling more ‘namaste,’ free yoga on the picturesque lawn of the Nelson-Atkins Museum of Art.

AFTERNOON:

Kansas City loves its sports. We recommend you experience the National World War I Museum and Memorial. atmosphere at a Chiefs game, home of the Guinness World Record “loudest If you don’t want to take our word for it, National Geographic stadium” and reigning NFL MVP Patrick Mahomes. If a picnic recently ranked Kansas City as the only American destination is more your vibe, crushing hotdogs and enjoying some local beer on its “Best Trips” list for 2019. Give it just one day – K.C. while watching the MLB Kansas City Royals never disappoints. will keep you coming back for more than just the world’s If you opted for morning yoga, one of the many local hiking best barbecue. or biking trails may be more appealing. History buffs are sure to enjoy the National World War I Memorial and impressive MORNING: museum overlooking the downtown skyline, a must for firstSleeping in. Hey, it’s the Midwest, and we certainly don’t pass time visitors. For those into consumer retail (aka shopping), the judgment on catching a few extra hours of sleep. If you’re feeling Country Club Plaza is one of the top destinations in the Midwest, like a go-getter, grab a Bird or Lime scooter and kick-start your with millions of visitors each year flocking to this outdoor, day with a latte at K.C.’s own Roasterie Coffee Company. Fear Spanish-style commercial district with high-end retail and not, hipsters – you could also choose from an impressive selection excellent dining options overlooking the canal. of obscure coffee shops with a “chill vibe, delectable avocado toast and a quality grind of ultra-rare beans.” Once refreshed, roll up to continued on the next page the River Market area just north of downtown and check out the expansive farmer’s market, complete with street performers and

Plastic Surgery Resident | Summer 2019

21

24 HOURS IN KANSAS CITY / continued from previous page HAPPY HOUR:

Nothing caps off a great afternoon quite like a solid Happy Hour. Options abound throughout K.C., although we absolutely recommend a stop at the famous Boulevard Brewery. With its 10,000-square-foot beer hall overlooking downtown K.C., it’s the perfect setting to plan the evening while trying a flight of some of the best brews we’ve ever had (Start with Tank 7, scored at a 98 overall by RateBeer.com). There are also a number of other small microbreweries, distilleries and wineries from which to choose, based on your palate.

DINNER:

If you’ve never had Kansas City BBQ , or if you think your town has the best ‘cue, we do feel sorry for you. Ranked by Anthony Bourdain as one of the 13 places to eat before you die, as well as a perennial favorite of rankings by The New York Post, Food Network, USA Today and Forbes, Kansas City Joe’s (formerly Oklahoma Joe’s) is a religious experience of sorts. Modestly housed within an old gas station near the KU Medical Center, you will know you’ve found it when you see a line of patrons typically extending out the door and around the corner.

Kansas City Joe’s Brisket Plate.

For those looking for additional recommendations, Q39 is a formal “American Royale BBQ Champion” and has quickly become a local favorite, while Fiorella’s Jack Stack offers a slightly more-refined dining experience with unmatched beans, slaw and cheesy corn. Please don’t mistake Kansas City cuisine for being one-dimensional though. Foodies will find the gastronomy here exceptional and surprisingly broad for being in the “middle of the nowhere.” We’re currently home to eight of the 2019 James Beard Award semi-finalist chefs (known as the Oscars of the restaurant industry). We have even recently been transported to “Flavortown,” with Guy Fieri joining the list of famous chefs to have a restaurant in K.C.

22

Plastic Surgery Resident | Summer 2019

The Power and Light District Kansas City Live! stage.

A NIGHT ON THE TOWN:

This is what you got dressed-up for, right? And if you are lucky enough to be downtown for First Fridays, the streets will be packed with artists, musicians and food trucks as thousands come out to enjoy the summer nights and each other’s company.

Pop into UpDown, an old school arcade bar with more than 100 freestanding games and an impressive craft beer list. The Power and Light District is at the heart of downtown, organized as a full street block with two stories of bars opening centrally into an open-air patio that hosts a fantastic concert series, with recent performances by Steve Aoki, Dillon Francis and Brett Young, just to name a few. Since we’re in the middle of the country, almost all major touring musicians also visit the Sprint Center each year, but we just couldn’t mention Taylor Swift or Justin Bieber in good faith. The best part of going downtown at night? Easy accessibility, free public parking and cheaper drinks (<$7) than most major cities.

LATE NIGHT:

Still not quite ready to call it a night? Impressive. If you are looking to end the evening on a soft note, cocktails and free Jazz at the Green Lady Lounge will be just what the doctor ordered (see what we did there?). There are also a number of awardwinning speakeasies tucked away throughout the city, with Manifesto being consistently ranked as a top 10 best cocktail bar in America – and a former hangout of famous gangster Al Capone. Everyone loves a good cover band, and if dancing at a dive bar is your thing, check out The Levee. Finally, if you want to “turn it up all the way to 11,” there’s always craps at Harrah’s.

Although the range of interests is quite vast among our residency group, one thing we certainly do hold in common is our love for K..C, as none of us are ever left wanting for something to do in our free time. We all feel very lucky to spend six years of our life here, and many ultimately call Kansas City home. Come check it out. You won’t leave disappointed. |

DIRECTLY PROVIDED BY:

AUGUST 15-17, 2019 | Rosemont, IL Preparation is the key to success.

Attend the most interactive and comprehensive meeting with the best overview of plastic surgery principles and case-based instruction.

EXPANDED FOR 2019!

Cleft Lip Drawing Instruction Sessions

PROGRAM CHAIR:

Joseph K. Williams, MD

BACK BY POPULAR DEMAND: Realistic oral examination simulation sessions

PROGRAM CO-CHAIR:

John B. Hijjawi, MD

Hotel discount ends Wednesday, August 1

Learn more today at PlasticSurgery.org/OWB

Efforts to engage residents and Fellows gain heightened understanding of PlastyPAC

By JT Stranix, MD Resident Ambassador, PlastyPAC Board of Governors

A RESIDENT AND FELLOW FOCUS GROUP WAS RECENTLY CONDUCTED in order to better understand how PlastyPAC is viewed among this cohort, and also to gain insight into how we can improve resident involvement in ASPS legislative activities – and in PlastyPAC specifically.

To all the residents who participated in the conference call, I would like to give my sincere thanks; taking time from your busy schedules to share thoughtful views and opinions on what PlastyPAC means to residents, and how we can improve outreach within our community, was immensely helpful.

We began our discussion with general comments and taking questions designed to determine what PlastyPAC is and how political disbursements are performed. The PlastyPAC Board of Governors meets six times a year to discuss political disbursements to various members of Congress. The PlastyPAC Board of Directors (BOD) identifies and supports lawmakers and candidates who understand and care about our issues. The goal is to see that those elected remain in office, and that those vying for a seat get elected and remain in office.

There are two ways that members of Congress are brought before the BOD for consideration: The member sits on a committee of jurisdiction or in a leadership position, or a current PlastyPAC member recommends that the Board consider the member of Congress. From there, the BOD goes through a checklist compiled

by ASPS legislative staff members to see whether that member of Congress has a track record of demonstrated support for the

24

Plastic Surgery Resident | Summer 2019

specialty. If they are aligned with the ASPS political agenda and positioned to influence or sponsor bills of interest to our field, then they are lawmakers who we support in order to establish a productive, working relationship with common goals in mind.

The conference call next covered resident involvement, engagement and outreach, as well as future directions and areas for improvement. Residents want to become more engaged in PlastyPAC and contribute to ASPS advocacy – but who also have a difficult time finding potential areas for involvement and lack good resources to stay up-to-date on our current legislative priorities. We’re working on ways to improve areas for getting more residents involved by defining specific resident-initiatives and potentially setting up meetings with local representatives.

A salient point was raised: If residents are unaware of our legislative priorities, then they are much less likely to want to get involved in our efforts. Along those lines, the current legislative priorities for ASPS are listed below for reference and discussion:

ENSURING LASTING SMILES ACT (H.R. 1379/S. 560)

This bill corrects inequities in insurance coverage for the treatment of congenital anomalies. State laws vary on what’s covered, and oftentimes procedures to correct congenital anomalies are denied by insurance companies. Furthermore, even when comprehensive state laws are in place, these do not apply to ERISA plans and may only apply to patients up to a certain age or with specified conditions. Minor-age patients with cleft lip and palate are singled-out most for coverage.

Patients with other congenital anomalies conditions – such as ectodermal dysplasia – are not currently covered under the law.

This bill would address these loopholes within the coverage.

(This is also our 2019 White Hat issue.)

continued on page 30

2018 Resident Club Members Alabama

Minnesota

Pennsylvania

Ashley Thorburn, MD

Christopher Stewart, MD

Debra Bourne, MD

Krishna Vyas, MD, PhD, MHS

Logan Carr, MD

California Michael Hu, MD

John Roberts, MD

Missouri Austin Ha, MD

Connecticut Marc Walker, MD

Alexander Kaminsky, MD, MPH

New Hampshire

Steven Kozusko, MD

Christopher Funderburk, MD

Amie Miller, MD

Florida Wilton Triggs, MD

Illinois

Tennessee

Muntazim Mukit, MD

New Jersey Vinod Chopra, MD

Texas

Katherine Rodby, MD

Jasson Abraham, MD

Daniela Atencio Bohorquez, MD

Kristen Aliano, MD

Uma Maduekwe, MD

New York

Paul Deramo, MD

Brian Shafa, MD

Kevin Chen, MD

Ryan Dickey, MD

Chad Teven, MD

Jordan Frey, MD

Julie Ferrauiola, MD

Ira Savetsky, MD

Matthew Kaufman, MD

Kansas

Benjamin Schultz, MD

Eric Maiorino, MD

Zachary Clary, MD

John Stranix, MD

Hossein Masoomi, MD

Nicholas Wingate, MD

Alyson Melin, MD

Maryland

Anson Nguyen, MD

Justin Broyles, MD

North Carolina

Pablo Padilla, MD

Karan Chopra, MD

Kate Krucoff, MD

Meenakshi Rajan, MD

Kavita Vakharia, MD

Analise Thomas, MD

Michigan

Ohio

Nicholas Berlin, MD

Spencer Anderson, MD

Ashley Chandler, MD

Demetrius Coombs, MD

Geoffrey Hespe, MD

Eileen Curry, MD

Catherine McGee, MD

Sean Figy, MD Grzegorz Kwiecien, MD

Journal Club; 2019 Summer; (15) FACELIFT TECHNIQUES 1. Lateral SMASectomy.

Baker DC. Plast Reconstruct Surg. 1997; 100: 509-513.

The author begins this historical article with an insightful discussion of the evolution of his facelifting technique, discussing the earliest facelifts in which he was involved and highlighting the changes in management and manipulation of the SMAS. In particular, he discusses the transition in his practice from a formal SMAS dissection to a technique in which a small segment of SMAS is resected, a technique named SMASectomy. The relative advantages of this SMAS management technique are discussed.

When comparing lateral SMASectomy to formal SMAS elevation, the author highlights that the decreased risk to tearing and weakening the fascia and, therefore, the SMAS flaps tend to be more substantial for holding suture fixation. The problems of postoperative dehiscence and relapse are therefore reduced.

JOURNAL ARTICLES ON

FACELIFTS

EVERY

Additionally, there’s a decreased risk of facial nerve injury, as the SMASectomy is carried out over the parotid and the nerve branches are protected below. Advantages over SMAS plication are also highlighted. The author discusses that the SMASectomy is performed at the interface of the fascia fixed by retaining ligaments, and the more-mobile anterior facial fascia. The author believes that upon closure, this allows for a more durable elevation of superficial fascia and facial fat, and allows a more-favorable vector of pull when compared to plication alone.

PLASTIC SURGERY RESIDENT

SHOULD READ

Part II

By Michael V. Chiodo, MD & Jordan D. Frey

F

acial aesthetic surgery can often be an exciting but daunting area 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-, intraand postoperative management strategies – are all necessary to achieve a successful facelift result.

However, a keenly executed facelift procedure can be one of the most fulfilling and altering procedures that plastic surgeons perform. The first installment of this review, which appeared in the Spring 2019 issue of Plastic Surgery Resident, contained the first five articles of our 10 and addressed anatomy, preoperative assessment and technique. The following five articles in this final installment will address technique, complications and outcomes.

26

Plastic Surgery Resident | Summer 2019

2. Lift-and-Fill Facelift: Integrating the Fat Compartments.

Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Plast Reconstr Surg. 2014; 133: 756e-767e.

This article is intricately related to “The Individualized Component Facelift: Developing a Systematic Approach to Facial Rejuvenation,” which appeared in Part I. This work is the technical application of the described systematic, facial rejuvenation approach and an objective analysis of patient results gained by measuring malar projection. The authors highlight that facial aging is a combination of volume deflation and tissue laxity, and that successful rejuvenation requires volume restoration through fat compartment augmentation as well as SMAS manipulation. The authors discuss specific technical aspects of using SMASectomy vs, SMAS stacking, and how systemic facial analysis helps the surgeon chose one technique over the other.

Technical aspects related to fat injection of specific compartments are highlighted – including deep malar, deep nasolabial, high and middle superficial malar.

3. High SMAS Facelift: Combined Single Flap Lifting of the Jawline, Cheek and Midface.

Marten, TJ. Clin Plastic Surg. 2008; 35: 569-603

This Clinics of Plastic Surgery article is reminiscent of a book chapter ,in that it’s full of background, meticulous detail and excellent illustrations. We include it here due to the beautiful description of the high SMAS technique – though the article contains much more. The author’s opinion is that the traditional low-cheek SMAS flap elevated inferior to the level of the zygomatic arch inherently has less of an impact on tissues of the midface and infraorbital region. Rather, the low-SMAS design targets the lower cheek and jowl areas only. The article details how planning a high-SMAS design, along the superior border of the zygomatic arch and carrying the dissection medially to mobilize midface tissue, overcomes the limitations of the low design and allows simultaneous lift of the jawline, cheek and the midface. Further, midface and infraorbital tissue planes are not dissected, leaving this area particularly amenable to fat grafting and negating the need for potentially problematic procedures – such as orbital fat transposition or orbital septum reset. The article proceeds to provide a step-by-step approach to the high-SMAS facelift, including incision planning, skin-flap elevation, temple dissection, SMAS dissection and suspension, and specifics about closure, including insetting of the ear lobule. Recommendations regarding anesthesia type, drain placement, and dressings are also provided.

COMPLICATIONS 4. Evolution of Hypertension Management in Face Lifting in 1089 Patients: Optimizing Safety and Outcomes.

Ramanadham SR, Mapula S, Costa C, Narasimhan K, Coleman J, Rohrich RJ. Plast Reconstr Surg 2015; 135: 1037-1043.

Hematoma is the most-common complication after facelift.

As young facelift surgeons, a primary goal for residents is to avoid morbidity. Small hematomas in the postoperative period following rhytidectomy can be appropriately managed by bedside aspiration and observation. However, most large hematomas require operative intervention, as they can threaten skin-flap

viability, contribute to edema, compromise nerve function and cause hyperpigmentation – and they can threaten the airway.

Perioperative hypertension is a known risk factor for hematoma, and meticulous blood pressure control has been shown to reduce incidence of postoperative hematoma. In this retrospective review of 1,089 facelifts performed by the senior author, a specific algorithm using a combination of transdermal clonidine, labetalol and hydralazine is defined for preoperative, intraoperative and postoperative blood pressure control.

OUTCOMES 5. A 20-Year Experience with Secondary Rhytidectomy: A Review of Technique, Longevity and Outcomes.

Beal EW, Rasko YM, Rohrich RJ. Plast Reconstr Surg 2013; 131: 625-634.

Secondary facelifting procedures present an additional level of complexity when compared to primary procedures. Patients may pursue secondary facelift as a result of complications related to the primary procedure; of the continued natural aging process; or through a combination of the two. In this discussion of the senior author’s 20-year experience with revision facelifting, the differences in patient characteristics, techniques and specific challenges related to secondary facelift are delineated. A review of 70 revision facelifts over a 20-year period revealed a similar risk profile and longevity when compared to the primary operation.

The authors provide a technical framework for revision facelift which focuses on the “five Rs:” resect skin/scar; release of abnormal SMAS vectors; refill by means of fat grafting; reshape with SMASectomy or SMAS-stacking plication; and redrape skin. Common stigmata secondary to facelift such as pixie ear, cross-cheek depression and J-deformities are discussed, and strategies for management of these deformities are described. |

Plastic Surgery Resident | Summer 2019

27

#TheTrend #THETREND: PROBLEMS IN PERIORBITAL SURGERY

Who thought Metallica could provide a periorbital surgery-related lesson?

By James Vargo, MD & Jacob Grow, MD 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 early 1990s, Metallica sat firmly on the throne as the reigning lords of heavy metal, amassing five platinum records and multiple Grammy awards. These achievements were unheard-of at that time for such an aggressive rock band. But then in 1996, at the peak of their dynasty, they did something that shocked the music world: They all cut their hair. The rock ‘n’ roll community was in outrage, with many diehard fans wondering if their beloved band would ever be the same again.

What happened next, you may ask? Well, Metallica released six more albums that went platinum – defying their critics and showing that change isn’t always a bad thing. I give this brief rock history lesson not to dissuade you from reading the article, but rather to alert our readers that although we have switched things up with this edition and venture away from the realm of pure tech reviews, we’re still the same guys delivering the most relevant reviews available in plastic surgery educational resources. That being said, we’ve recently been provided the opportunity to take a peek at a new textbook, Problems in Periorbital Surgery. We would be remiss if we didn’t say this book caught our eye – and we think it will catch yours, too.

Foad Nahai, MD

Ted Wojno, MD In their newly published book, Foad Nahai, MD, and Ted Wojno, MD, fold decades of experience into a text aimed at describing the feared complications of periorbital aesthetic and reconstructive surgery. Ocular rejuvenation and reconstruction are areas that many plastic surgeons address, but our comfort most likely falls short of our ophthalmology peers.

One reason may be the dreaded complications associated with periorbital surgery, which has a tendency to push many surgeons out of their comfort zone with respect to the globe and orbital contents.

Problems in Periorbital Surgery tackles these issues head-on, assisting surgeons with clear instruction on how to avoid complications at the time of the initial surgery – and then manage many of the difficult situations that can arise. Topics covered include over-resection of upper and lower lid-skin or fat; entropion; ectropion chemosis, dry eye, retrobulbar hemorrhage, vascular complications from filler, and epiphora. The book is well-written, yet concise. It takes a partial case-based approach, supplemented by many high-quality images and illustrations.

The associated video library is also high quality and thorough, allowing replicable results intraoperatively. Given the format, it also functions well as a reference tool, should one find themselves needing succinct direction on how to manage a specific problem involving the orbit.

Problems in Periorbital Surgery is a valuable addition to any residency library; however, it’s not a book intended to be on every resident’s nightstand. Overall, Problems in Periorbital Surgery is an excellent reference when preparing for a periorbital case – and a must-own for anyone planning to devote a significant percentage of their future practice to ocular plastic surgery or reconstruction. Rock on! |

28

Plastic Surgery Resident | Summer 2019

Put your plastic surgical vocabulary skills to the test!

DOWN

By Sanjay Naran, MD ACROSS 2. Facial immobility, strabismus, and syndactyly of the ring and little fingers are suggestive of this syndrome.

5. The association between craniofacial defects and cardiac malformations in patients with velocardiofacial syndrome results from a disruption in the cellular development of these cells.

8. This abbreviated nasal structure is absent in patients with Binder Syndrome.

16. Patients with CHARGE syndrome have this ocular deformity.

17. Postoperatively, patients with 22q11.2 deletion may be at higher risk than non-deletion patients to develop this electrolyte imbalance.

18. This muscle is used to construct the sphincter during a sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency.

19. In the United States, occurrence of encephaloceles is most common in this anatomic region.

20. This nasal structure arises from the lateral nasal processes during embryologic development.

21. This muscle courses around the pterygoid hamulus.

22. This orbital deformity is observed in a patient with Apert syndrome.

23. This syndrome is most commonly associated with Pierre Robin sequence.

1. In the Tessier cleft classification system, this numbered cleft represents the most common facial cleft.

2. Weakness of this branch of the facial nerve is often demonstrated in patients with hemifacial microsomia.

3. Syndrome characterized by craniosynostosis, exorbitism, and midface retrusion; the extremities are unaffected.

4. Lower eyelid colobomas and malar deficiency points to this syndrome.

6. Patients with hemifacial microsomia have an increased incidence of this insufficiency.

7. In reconstructing the palate, repair of this muscle is most likely to improve eustachian tube function.

9. The harlequin deformity occurs most commonly in patients with craniosynostosis of this suture.

10. Premature fusion of this suture is most often associated with abnormalities in the corpus callosum.

11. Epibulbar dermoids, maxillary hypoplasia, orbital dystopia, and complete absence of the mandibular condyle are suggestive of this syndrome.

12. This is the suspected syndrome in a patient with a unilateral cleft lip and palate deformity and small sinuses in the lower lip.

13. Albright syndrome affects metabolism of calcium and this other electrolyte.

14. The C flap in the Millard rotation advancement repair of unilateral cleft lip is used to lengthen this structure.

15. Autosomal recessive syndrome that manifests as hypoplasia of the orbits, zygoma, maxilla, mandible, and soft palate, as well as hypoplasia or agenesis of the radius, thumbs, and metacarpals.

Answer key on page 30 Plastic Surgery Resident | Summer 2019

29

INSERVICE INSIGHT / continued from page 15

PLASTYPAC / continued from page 24

TAKE HOME

ACCESSIBLE CARE BY CURBING EXCESSIVE LAWSUITS (ACCESS) ACT

With prolonged denervation after nerve injury, decreased regenerative ability is noted. Reinnervation of the muscle must occur within 12-18 months, otherwise motor endplates are permanently affected. If this occurs, tendon transfer is the treatment of choice to restore hand function.

With nerve transfer, an expendable, donor motor-nerve is used for reinnervation, and this nerve is situated close to the target muscle to decrease time needed for reinnervation.

With tendon transfer, a synergistic tendon is chosen to restore a specific function – such as wrist extension or elbow flexion – in a patient with longstanding denervation. This article lists the most-commonly tested nerve and tendon transfer on the In-Service Examination since 2010. |

Dr. Kozusko is a PGY-4 integrated resident interested in hand fellowships; Mr. Chang is a fourth-year medical student pursuing a plastic surgery residency, both at the University of Tennessee Health Science Center, Memphis.

REFERENCES

1. Sammer DM, Chung KC. Tendon Transfers: Part I. Principles of Transfer and Transfers for Radial Nerve Palsy. Plast Reconstr Surg. 2009 May;123(5):169e-177e.

2. Ozkan T, Ozer K, Gülgönen A. Three Tendon Transfer Methods in Reconstruction of Ulnar Nerve Palsy. J Hand Surg Am. 2003 Jan;28(1):35-43.

3. Novak CB, Mackinnon SE. Distal Anterior Interosseous Nerve Transfer to the Deep Motor Branch of the Ulnar Nerve for Reconstruction of High Ulnar Nerve Injuries. J Reconstr Microsurg. 2002 Aug;18(6):459-64.

4. Colbert SH, Mackinnon SE. Nerve Transfers for Brachial Plexus Reconstruction. Hand Clin. 2008 Nov;24(4):341-61.

5. Tung TH, Mackinnon SE. Nerve Transfers: Indications, Techniques, and Outcomes. J Hand Surg Am. 2010 Feb;35(2):332-41.

Answer key from page 29 15. NAGER 14. COLUMELLA 13. PHOSPHATE

23. STICKLER

12. VANDERWOUDE

22. EXORBITISIM

11. GOLDENHAR

21. TENSOR

10. METOPIC

20. ALA

9. CORONAL

19. OCCIPITAL

7. LEAVATOR

18. PALATOPHARYNGEUS

6. VELOPHARYNGEAL

17. HYPOCALCEMIA

4. TREACHERCOLLINS

16. COLOBOMA

3. CROUZON

8. ANS

2. MANDIBULAR

5. NEURAL

1. SEVEN

2. MOBIUS

DOWN

ACROSS

30

Plastic Surgery Resident | Summer 2019

The ACCESS Act is currently awaiting introduction in the 116th Congress. This bill creates medical liability reform while preserving states’ rights to maintain more stringent statutes that are already in place. It allows patients to recover the full amount of economic damages incurred –limiting noneconomic damages to $250,000 – and ensures the patient is granted the intended award by limiting attorney contingency fees. The bill provides increased protections for providers through a threeyear statute of limitations from the date of injury or one year following the date of discovery, and it exempts providers from liability suits involving FDA-approved products. According to a 2017 assessment by the Congressional Budget Office, Protecting Access to Care Act reforms can potentially reduce federal budget deficits by almost $50 billion over 10 years.

RESIDENT PHYSICIAN SHORTAGE REDUCTION ACT (H.R. 1763/S. 348)

This bill would direct the HHS secretary to increase the resident limit for Medicare-supported training slots at qualifying hospitals, thus addressing an outdated 1997 policy that put a cap on residency slots. The bill would increase the total number of slots by 15,000 from fiscal year 2019 to 2023 (3,000 per year), bringing the total to 105,000. Half of these slots will be used for training in a specialty that has a physician workforce shortage.

Word of mouth was the primary mechanism for distributing knowledge about PlastyPAC among the resident community, so I encourage you to speak with our colleagues about becoming more involved – and please send me any ideas or questions you have regarding PlastyPAC resident involvement (jtstranixmd@gmail.com).

For additional information about PlastyPAC or to make a contribution, please visit the PlastyPAC website https://plastypac.aristotle.com/. Your generosity, even at the resident amount, provides us with the resources needed to effect legislation in our favor. |

Dr. Stranix is the Microsurgery Fellow, Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia.

FO LLOWING TH E BRE A ST SU R G ERY & B O DY CO NTO UR I NG SY M P O S I U M

NEW! Gender-Affirming Master Class DIRECTLY PROVIDED BY:

Learn about new horizons in patient care.

JULY 20, 2019 Program Chair: Loren Schechter, MD Faculty Includes: Cori Agarwal, MD | Rachael Bluebond-Langer, MD Josef Hadeed, MD | David Teplica, MD | Paul Weiss, MD

This activity has been approved for AMA PRA Category 1 CreditTM.

Learn more and register today at PlasticSurgery.org/GAMC or call 1-800-766-4955.

REGISTER NOW 2019

TH 88 ANNUAL

MEETING

CALIFORNIA SEPTEMBER 20-23, 2019 SAN DIEGO CONVENTION CENTER

PlasticSurgeryTheMeeting.com