Issuu

ISSUE 17 | WINTER 2019

From the publishers of Plastic Surgery News

Resident Retreat Advancing new burnout treatment paradigm

» Gender-

affirmation surgery The Journal Club takes you where you can learn more page 22

» Research abroad

A familiar 'landscape' can turn foreign page 26

IN THIS ISSUE » Life in New York: '24 Hours' in The City That Never Sleeps.............. p. 15 » Program Peek: Mount Sinai Hospital ............................ p. 12 » Naming names: Residents Council list reveals Society's future leaders ...... p. 25

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

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A note from the editor

elcome to our Winter 2019 issue of Plastic Surgery Resident – and congratulations to Mount Sinai, winner of the 2019 Residents Bowl held during Plastic Surgery The Meeting in San Diego. As winner, we highlight their plastic surgery training program in the Big Apple.

Our Cover Story focuses on “Resident Camaraderie,” written by University of South Florida PGY-6 residents Alicia Billington, MD; Connor Barnes, MD; and Ellen Robinson, MD. Their contribution provides an example of how more and more programs are making a concerted effort to encourage resident camaraderie while targeting overall resident wellness and mental health. Should your program currently not engage in such activity, hopefully their article will serve as an inspiration to organize your first annual Resident Camaraderie Day.

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident

In this issue, we also acknowledge the members of The Residents Council, which is led by the Resident Representative to the ASPS/PSF Board of Directors. The Residents Council is charged with improving resident involvement in our Society and advocating for resident interests at the highest levels of plastic surgery. It gives residents the opportunity to contribute to ongoing projects, as well as develop new projects specific to residency training and beyond. The Residents Council serves as the primary modality through which residents can implement change on a national level and impact the future of plastic surgery.

Chicago

From the publishers of Plastic Surgery News

ISSUE 16 | FALL 2019

Is taking a research year – or two – the right career path for you? Most residents look to practice right away, but a research year can have benefits that far surpass the costs

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

Are you coming to San Diego?

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

IN THIS ISSUE » Program Peek: UC San Diego Plastic Surgery ........... p. 14 » 24 Hours In: San Diego ....................................................p. 18 » InService Insight: Transgender Surgery ...................... p. 20

The one-year term begins each July 1 – with a maximum of three consecutive terms – and coincides with the academic year. While applications are currently closed, should you be interested in becoming involved at the next application cycle, please reach out to Joseph Lopez, MD, our current Resident Representative to the ASPS/PSF Board of Directors, at jlopez37@jhmi.edu. Now, a heads up: We will plan to transition to an all-digital publication of PSR, but with an annual print edition to be delivered onsite to Plastic Surgery The Meeting. If you aren’t already, be sure to familiarize yourself with how to access PSR digitally through our online portal. Go to plasticsurgery.org, click on For Medical Professionals, followed by Community, then Residents & Fellows Forum. Then click on Subscriber Benefits, followed by Plastic Surgery Resident. Thank you to our team of editors and the ASPS production staff for all of their hard work in bringing each quarterly of PSR to fruition. And we also thank you, our readership. We hope you enjoy the read! |

Plastic Surgery Resident | Winter 2019

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

Table of

Contents Combatting burnout through a unique retreat endorsed by training program’s leaders.................6 Consult Corner: Laceration through the nail bed.......................................... 10

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.

Program Peek: Mount Sinai Hospital..................................................................12

EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com

University of South Florida plastic surgery residents enjoy a full, 24-hour period away from the hospital – and return for the better.

Begin by gathering accurate data on the timing and mechanism of injury, then prepare to act upon a surfeit of variables.

New York-based institution boasts the first national transgender program, as well as a leadership list of “who’s who” in plastic surgery.

Message from the Director: Peter J. Taub, MD.................................................................... 14 The Mount Sinai Hospital residency program director recounts the past – and confers the present and future – of this distinguished institution.

24 Hours In: New York.................................................................................. 15 The Big Apple, The City That Never Sleeps, home of the Statue of Liberty – and literally thousands of things to do, see and eat.

Faculty Focus: Jess Ting, MD.......................................................................... 18 The Mount Sinai Hospital plastic surgery leader has impacted his charges and institution, but it could’ve been music that received his gifts.

A SPS PR ESI DEN T Lynn Jeffers, MD, MBA | LynnJeffersASPS@gmail.com

ASSOCI ATE EDITOR Russell Ettinger, MD | retting@uw.edu ASSOCI ATE EDITOR Kavitha Ranganathan, MD | krangana@med.umich.edu INTER NATIONA L EDITOR Mélissa Roy, MD | melissa.roy@mail.utoronto.ca R ESIDENT EDITORS Roger Cason, MD | roger.cason@duke.edu Aaron Kearney, MD | aaron.kearney@northwestern.edu Elizabeth Kiwanuka, MD | elizabeth.kiwanuka@gmail.com Joseph Lopez, MD | jlopez37@jhmi.edu E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org

InService Insights: Fingertip amputation ............................................................20

M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org

Journal Club: Gender-affirming surgery.....................................................22

A S S O C I AT E E D I T O R Kendra Y. Mims | kmims@plasticsurgery.org

A well-represented subject in the examination each year, its basic indications and reconstructive modalities are given a close look.

A growing number of patients are seeking change, making it essential that plastic surgeons understand patients’ physical, emotional and social needs.

Resident Ambassador: Welcoming new representative to PlastyPac....................24 David Hill, MD, thanks outgoing Representative to the PlastyPAC Board of Governors JT Stranix, MD, for impactful advocacy, while charting his own course.

Residents Council: Listing up-and-coming members.........................................25 From Arizona to Wisconsin and all points east and west (and north and south), these young surgeons have joined the Society’s leadership ranks.

International research: Boots on the ground, in another country...........................26

Mélissa Roy, MDCM, MSc, and Karen Chung, MD, offer advice on how to approach an international fellowship – including the need to ignore roosters.

Crossword: Basic Science Research.........................................................29 Wound-healing, self-renewing cells, reparative processes in organs or tissues, scar correction and an administrative body: How much do you know?

Plastic Surgery Resident | Winter 2019 | Vol.3 No.4

Plastic Surgery Resident | Winter 2019

A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org

GR A PHIC DESIGN ER Elena Bragg A DV ERTISING SA LES Joe Anzuena (215) 521-8532 | Wolters Kluwer Health

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

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How a 24-Hour Retreat Changed Lives

USF RESIDENTS GET ‘FIRED UP’ TO COMBAT BURNOUT By Alicia Billington, MD, PhD; Ellen Robertson, MD; & Connor Barnes, MD

Plastic Surgery Resident | Winter 2019

hysician wellness has become an increasingly hot topic in recent years, with the World Health Organization now formally recognizing burnout as a syndrome that can evolve from unsuccessfully managed workplace stress. Burnout can be accompanied by several signs, with three associated symptoms being decreased energy; decreased productivity; and increased negative feelings related to occupation.1 But help may be on the way; the classification of burnout as a syndrome is believed by some to help destigmatize and legitimize the diagnosis and the symptoms.2 The average burnout rate among physicians is estimated at 42 percent – and in plastic surgery, studies have shown that roughly 32 percent of plastic surgeons and 37 percent of plastic surgery residents have experienced burnout at some point in their career.3 These are alarming statistics – but we had a plan.

ADVANCE VIA RETREAT

Last year, as we prepared to become chief residents at the University of South Florida Morsani College of Medicine Department of Plastic Surgery, we met with our program director, Michael Harrington, MD, to discuss goals for our upcoming year of leadership. The main areas we desired to focus on during the year were education, communication and resident wellness. We wanted to create a culture of positivity that would welcome intellectual pursuit and encourage hard work. In order to help facilitate this cultural change, we worked with our attending physicians to create an event that highlighted collegiality and caring. We believed that in order to create a paradigm shift in how burnout is perceived and combatted, we had to include buy-in from all members of the team – residents, attendings, the program director and the nursing staff. The event that we crafted was a 24-hour retreat – and the response was incredible. Dr. Harrington immediately supported our efforts and personally volunteered to take call for 24 hours at the busiest Level I trauma center in our region, in order for all residents to take off for 24 hours. Additionally, attendings at all four of our other institutions covered call and rounding responsibilities. We were ready.

WHAT WE DID

Our 24 hours of freedom began promptly at 6 a.m., when we turned off our pagers and allowed ourselves to hit the

Above: Residents hold up their matched pairs (peas and carrots, king and queen, etc.) as part of team building activity. Left: Circle of trust followed by surprise water balloon attack between chief residents.

snooze button. Residents met at 7:30 a.m. for breakfast on the beach in St. Petersburg, Fla., a sister city of Tampa, where our residency program is centered. The agenda for the day had several “team-building” activities planned. We kicked those off with an icebreaker where each resident had a word they couldn’t see affixed to their backs – and that word was to be matched with another word placed on another resident’s back. Each “wearer” had to pose questions to other residents regarding the key word, until each found their match. For example: “salt” had to find “pepper.” As hokey as this sounds, it got everyone participating, laughing and inadvertently working on communication. Our next activity began with a large “circle of trust” drawn in the sand. Each resident, one by one, would stand inside the circle, and one resident would then call-out positive things about the resident in the circle – and why they appreciated having him or her as a USF plastic surgery resident. The yelling resident would then get to throw water balloons, and the cycle would repeat for each member.

continued on the next page Plastic Surgery Resident | Winter 2019

24 HOUR RETREAT / continued from previous page What actually developed was a little surprising: We heard praise coming from different people, different levels of residents – it was as though everyone out on the sand felt equal with one another, without the traditional hierarchy of the hospital.

Soon afterward, we began what became an epic karaoke contest. We come from all different walks of life; some of us are introverted; and some of us shine in the spotlight. But for one night, we all grabbed the microphone and sang like everyone should be watching (if not listening).

Perhaps more impressive, we witnessed residents open up about their insecurities in front of the group and explain how someone else had helped them in a time of need. We learned about deeply personal issues that some residents experienced – issues that many of us were unaware someone was struggling with, let alone someone in our program. We learned each other’s fears. Most importantly, we heard how each resident had helped someone else to succeed, and we lifted each other up.

HOW WE DID IT

The rest of the day was spent hanging out on the beach, playing putt-putt, having lunch together, swimming and playing volleyball. In the evening, we met for a group dinner – 20 residents eating outside and watching a beautiful Florida sunset. As the sky darkened, our chiefs surprised us by handing out glow-in-the-dark necklaces and bracelets.

(Above) Putt-putt golf; (top right) volleyball on St. Petersburg beach; (bottom right) USF residents join to sing a Beyonce song during karaoke. 8

Plastic Surgery Resident | Winter 2019

Coordinating 24 hours without resident coverage at a large program such as ours requires immense planning – and buyin from our program director was a must. Dr. Harrington had announced the idea to the attendings and ensured there was appropriate attending coverage at all institutions. Reminder emails were sent out a few times prior to the date. We recommend that programs discuss “what happens” in emergency situations so that contingency plans can go into effect. That eventuality occurred a few hours after all the residents left the hospital, when a free flap went down. We were very fortunate to have had a senior faculty member come in without hesitation to help the on-call attending. We also recommend ensuring the nursing staff is aware of the retreat, as traditionally, the attending is not initially called

for questions and we wanted to ensure a seamless transition of care – and we didn’t want the staff afraid or hesitant to reach out to the attendings for simple orders. We also recommend that the resident team ensure that notes are clear, and orders are placed appropriately, prior to signing-out to the attendings. Finally, it’s important to ensure resident safety. Most residents stayed overnight in St. Petersburg, and all residents were required to use Uber or a designated driver. Again, this would not Our fearless leader and program director, have been possible without Michael Harrington, MD, calls out to the complete support of Dr. a resident-less corridor as he goes to see a consult in the emergency department. Harrington, our program By himself. director. As ridiculous as it may seem to read an article about 20 millennials skipping work for a day, the residents who participated in the first-ever USF Plastic Surgery Resident Retreat gained an immeasurable amount of confidence in themselves and comfort with their peers. We were able to bond in a way that’s simply not possible in the hospital; we were able to all relax; and we saw each other as fellow humans – not just work colleagues. Residents also saw how much the attendings cared about resident wellness by allowing this day of freedom. Doing this early in the year set the stage for the collegiality we expected for the days – and years – to follow.

TACKLING BURNOUT

We believe that tackling burnout starts at the top. Physician wellness isn’t fixed by defining it. It’s changed by living it. Although the retreat lasted just one day, its effects in our program have been profound. Among other lessons, it proved to residents that we do care about and support each other – and that our program deeply values us. The feedback we’ve received has been phenomenal, from social media to residents from multiple specialties and other programs across the country that excitedly shared in our success. Hospital staff from nurses to scrub techs came to ask about our special day. Medical students applying to residency told us how much they would love to be a part of a program with such a strong support system.

Group dinner at O’Maddy’s in St. Petersburg, Fla.

We’re proud to be in a program that promotes a culture of positivity – and we look forward to hearing what the rising chiefs have planned, once they take over the reins. We hope our experience will inspire other programs to consider a yearly resident retreat and, more importantly, consider daily efforts to decrease burnout. We certainly hope this becomes a special USF tradition. On behalf of all the USF residents we offer a sincere “Thank you” to Dr. Harrington for his approval, and to all the attendings who supported this special day for us. Here’s to being less “burned out” and more “fired up” about residency.|

Dr. Billington, Dr. Robertson and Dr. Barnes are each PGY-6 at the University of South Florida Morsani College of Medicine’s Department of Plastic Surgery. REFERENCES

1. Burn-out an “Occupational Phenomenon”: International Classification of Diseases. World Health Organization, 28 May 2019. https://www.who. int/mental_health/evidence/burn-out/en/. 2. Fraga J. Why the WHO’s Decision to Redefine Burnout Is Important. Healthline. Reviewed June 5, 2019. 3. Ribeiro RVEM, Martuscelli OJDM, Vieira ACM, Vieira CFM. Prevalence of Burnout Among Plastic Surgeons and Residents in Plastic Surgery: A Systematic Literature Review and Meta-analysis. Plastic and Reconstructive Surgery Global Open. 2018;6(8):e1854.

Plastic Surgery Resident | Winter 2019

Laceration through the nail bed

“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.

By Jennifer Bai, MD MESSAGE ON YOUR PAGER: LACERATION THROUGH NAIL BED, CALL BACK PLEASE.

It’s midnight, you’re covering hand call in the pediatric E.D. – and your pager goes off. The message reads: “4-year-old girl jammed finger in door and has a laceration through the nail bed”

ANATOMY OF THE NAIL BED

The eponychium refers to the dorsal nail fold and the skin proximal to the nail, while the hyponychium refers to the palmar skin distal to the nail. The paronychium refers to the skin around the lateral nail folds. On the nail itself, the lunula is the white, semilunar part of the proximal portion of the nail. The nail bed lies directly underneath the nail plate. The nail bed is composed of the germinal matrix and the sterile matrix. Proximal to the lunula is the germinal matrix, which is responsible for nail growth and is located from 7-8 mm under the eponychium to the edge of the lunula. Nails grow very slowly, at a rate of 0.1 mm/day, so it will take several months for the nail to regrow. Distal to the germinal matrix is the sterile matrix which is responsible for adherence of the nail to the nail bed.

HISTORY The timing and mechanism of injury is important to document. As with any hand injury, hand dominance and hobbies and/or occupation is important to note, if relevant, since many of these patients tend to be younger kids. Always ask about tetanus vaccination. If that’s not up-to-date, they should receive a tetanus booster. Illustration from Shores J. Anatomy and Physiology of the Fingertip. Fingertip Injuries: Diagnosis, Management and Reconstruction. Springer International Publishing, 2015. 10

Plastic Surgery Resident | Winter 2019

EXAM Oftentimes the nail has already been avulsed, but if not, nailbed lacerations can be associated with subungual hematomas. If the subungual hematoma involves greater than 50 percent of

the nail, the nail should be removed and the nail bed should be examined for the presence of a nail-bed laceration. Other things to note are degree of contamination and exposure of bone. All patients should have a complete hand exam. It’s important to obtain an X-ray to rule out any fractures. Nail-bed injuries are commonly associated with tuft fracture of distal phalanx. Repairing the nail-bed laceration should reduce the tuft fracture.

TO REPAIR A NAIL-BED LACERATION • • • • • • • • •

Lidocaine (digital block) 25-G needle, syringe Digital tourniquet (cut off piece from glove finger) Normal saline Betadine Iris scissors, periosteal elevator 6-0 fast gut or chromic suture Stent for nail fold (part of suture packet if nail is unsuitable) Antibiotic ointment

PROCEDURE You perform a digital block by injecting 1-2ml of lidocaine at the volar aspect of the proximal flexion crease of the finger (in children, always remember to verify the maximum amount of local anesthetic appropriate for the child’s weight, to ensure that you do not administer more than id required). Depending on the age and cooperation of the child, you may need additional forms of sedation. Give the local anesthetic at least 5 minutes to take effect. While you are waiting, you can set-up the rest of your supplies.

It’s important to stent-open the eponychial fold to prevent it from scarring down, which would impair proper regrowth of the nail. To fashion a stent for the eponychial fold, you can use the foil from a suture pack or xeroform; cut into the shape of a nail; and tuck it under the fold. If the parents brought the nail in, that can be used as a stent after being properly washed in Betadine. The stent can be secured with a chromic suture in horizontal mattress fashion, with the knot on the eponychium, so that the nail is pulled under the fold by the suture. One additional, simple suture can be placed through the stent at the hyponychium to prevent the stent from flipping off of the nail bed.

DRESSING Bacitracin, Xeroform and a gauze wrap are commonly used. Beware that Xeroform can stick to the nail bed which can be very painful to remove in clinic after the dressing has been in place for a few days. Using a nonstick dressing over the Bacitracin and the laceration (such as Telfa) will help with dressing removal. For younger children, it’s prudent to place a soft, bulky gauze dressing with a light Ace bandage wrap on the extremity to prevent additional trauma to the digit. If there is an associated distal tuft fracture, place finger in an extension splint. The distal interphalangeal joint should be splinted in extension. A nail-bed laceration with a tuft fracture is technically an open fracture, so these patients should be discharged on oral antibiotics as well. Follow-up in clinic in one week for a wound check. |

Copiously irrigate the wound with at least 1 liter of irrigation. Apply a finger tourniquet to the base of the digit to aid in hemostasis. Prep the hand with Betadine, and towel appropriately. Assess the nail bed. Repair the nail-bed laceration with dissolvable sutures (fast gut or chromic). Repair any other associated lacerations on the finger which can be done with nonabsorbable sutures for any lacerations outside of the nail bed, if the child will tolerate removal in clinic setting. If not, use absorbable sutures. If the nail’s still in place, use Iris scissors or a periosteal elevator to spread at the hyponychium. Advance proximally until the instrument reaches the nail fold – and then the nail should be able to be easily removed with a hemostat or forceps.

Yam A, Tan SH, and Tan ABH. A Novel Method of Rapid Nail Bed Repair Using 2-Octyl Cyanoacrylate (Dermabond). Plas Reconstr Surg, March 2008, 121(3), 148e-149e. Plastic Surgery Resident | Winter 2019

Mount Sinai Plastic and Reconstructive Surgery (2019 Resident Bowl Champion) By Peter J. Taub, MD History: • Founded in 1952 by Arthur Barsky, MD, a local, national and international leader in the field of plastic and reconstructive surgery. Dr. Barsky is credited with starting the division, as well as the first multidisciplinary clinic for children with clefts of the lip and palate. • Lester Silver, MD, served as the division’s first full-time chief beginning in 1982. • For years, the residency was a three-year, independent program that held five residents at any one time. Today, the Plastic and Reconstructive Surgery Program at the Icahn School of Medicine at Mount Sinai is a fully integrated, six-year residency with three residents selected each year. • The first center for transgender surgery was started at Mount Sinai. • Mount Sinai won the 9th Annual Residents Bowl competition in 2019 during Plastic Surgery The Meeting in San Diego.

Clinical Experience • Rotations through eight hospitals: o Mount Sinai Hospital and Kravis Children’s Hospital: Our flagship hospital located on Fifth Avenue across from Central Park. Founded in 1852, The Mount Sinai Hospital is a 1,134bed, tertiary-care teaching facility acclaimed internationally for excellence in clinical care. In the 2019-20 “Best Hospitals” issue of U.S. News & World Report, the institution was ranked in nine specialties nationally. In the magazine’s 2019-20 “Best Children’s Hospitals” issue, Mount Sinai Kravis Children’s Hospital was listed among the country’s best children’s hospitals in five out of 10 pediatric specialties. The Mount Sinai Hospital consistently earns Magnet status for nursing care, and it’s the only medical center in New York to earn Disease-Specific

Leadership • C. Andrew Salzberg, MD, Professor of Surgery and Chief of Plastic and Reconstructive Surgery • Peter J. Taub, MD, Professor of Surgery, Pediatrics, Dentistry and Neurosurgery, Professor of Medical Education; Program Director • Mark Sultan, MD, Professor of Surgery • Jess Ting, MD, Assistant Professor of Surgery, Fellowship Director in Transgender Surgery National Leadership • Dr. Silver served as chair of the American Council of Academic Plastic Surgeons in 2003, and he’s also a past president of the New York Society for Surgery of the Hand. • Dr. Taub is currently a Director of the American Board of Plastic Surgery and is immediate-past president of the American Society of Maxillofacial Surgeons (ASMS). Previously, he served as chair of the American Academy of Pediatrics Section on Plastic Surgery and the American Association of Pediatric Plastic Surgeons. Dr. Taub is an associate editor of Annals of Plastic Surgery, and since 2006 he’s been an active board member of KomedyPlast Surgical Charity. Regionally, he’s served as chair of the New York Regional Society of Plastic Surgeons and as chair of the Northeastern Society of Plastic Surgeons. 12

Plastic Surgery Resident | Winter 2019

Icahn School of Medicine at Mount Sinai

Care Comprehensive Stroke Center Certification from The Joint Commission. The institution also received a Health Care Innovation Award from CMS to open the first geriatric emergency department in New York City. o Elmhurst Hospital Center: Directed by Ernest Kirchman, MD, Elmhurst serves as the receiving hospital for trauma for New York’s Health and Hospitals Corporation (HHC) in the borough of Queens. The hospital serves the most diverse zip code in the country, treating patients from all over the world. o James J. Peters Veterans Affairs Hospital: Located in the Bronx, this VA is one of the busiest in the federal system. Directed by Jay Meisner, MD, PSY-3 residents get their first chance to serve as a chief resident, performing both reconstructive and aesthetic surgical procedures. o Mount Sinai West Hospital: Founded in 1871 as the Roosevelt Hospital, Mount Sinai West is a full-service, 505-bed medical center with a long history of clinical excellence. Mount Sinai West has been home to the CV Starr Hand Surgery Center and one of the oldest teaching hand surgery fellowships in the country since 1952. It’s renowned for multiple surgical specialties, its robust maternity service and delivering the highest-quality patient-centered care. o Mount Sinai St. Luke’s Hospital: With 495 beds, St. Luke’s serves as the principal healthcare provider for the West Harlem and Morningside Heights communities and operates one of Manhattan’s few Level II trauma services. Founded in 1847, the hospital has an outstanding reputation for services in internal medicine, geriatrics, trauma, bariatric surgery, vascular disease, HIV/AIDS, cardiac care, physical rehabilitation, psychiatric disorders and substance abuse. o Mount Sinai Beth Israel: A teaching hospital founded in 1889 on Manhattan’s Lower East Side, Mount Sinai Beth Israel is notable for its unique approach to combining medical excellence with clinical innovation. Senior residents rotate in the nation’s first transgender service. o Memorial Sloan Kettering Hospital: Located on the upper east side of Manhattan, Memorial Sloan Kettering is one of the most recognized institutions for specialty cancer care in the world. Residents rotate through Memorial in their PSY-4 year, gaining experience in both head and neck reconstruction, as well as torso and extremity reconstruction, notably by free tissue transfer. o Jacobi Hospital Center: Part of New York City’s Health+ Hospitals, Jacobi is located in the Bronx and operates the largest burn unit in the borough. Residents rotate through the burn unit in their PSY-2 year. Education and Research • Curriculum o Weekly didactic conference with alternating indications conference, resident CorQuest lectures, faculty CorQuest lectures and Journal Club (highlighting Plastic and Reconstructive Surgery and the Journal of Hand Surgery, among others) o Monthly Monday evening Morbidity and Mortality o Cleft and craniofacial team conference

Mount Sinai Hospital

o Vascular anomalies team conference • Annual Barsky Memorial Lecture • Visiting professors from ASPS, The PSF and ASMS • Residents are expected to always have at least one ongoing research project and publish one paper per year Fellowship Training • 2020 – Nikki Burish (Mount Sinai transgender surgery); Michael Ingargiola (private practice) • 2019 – Christina Pasick (Penn microsurgery); Vincent Chavanon (Miami hand surgery) • 2018 – Jonatan Hernandez Rosa (Miami craniofacial surgery); Alex Facque (Chicago transgender surgery) • 2017 – Eric Jablonka (Penn microsurgery); Andreas Lamelas (Beth Israel microsurgery) • 2016 – Paolo Piccolo (Penn microsurgery); Jon Lee (Pittsburgh craniofacial surgery) • 2015 – Adam Strohl (Philadelphia Hand Center); Alex Sailon (Operation Smile) • 2014 – Meredith Collins (MD Anderson microsurgery); Alice Yao (MD Anderson microsurgery) • 2013 – Magda Soldanska (Atlanta craniofacial); Paul Pierce (NYU hand surgery) • 2012 – George Xipoleas (private practice); Arvind Pothula (Washington hand surgery) • 2011 – Daniel Maman (Mass General microsurgery); Brian Pinsky (UCLA hand surgery) Resident Benefits • Living in New York. Thanks to an extensive public transportation system, all of Mount Sinai’s institutions are easily accessible at all times of the day • ACAPS Annual Boot Camp for the incoming interns • Annual meeting participation • Holiday Chinatown dinner • In-service recovery ski trip • Spring golf outing | Plastic Surgery Resident | Winter 2019

A Message From the Program Director, Peter J. Taub, MD

ount Sinai is internationally acclaimed for its excellence in research, patient care and education across a range of specialties. The Mount Sinai Health System is an integrated healthcare system that provides exceptional medical care to local and global communities. It was created from the combination of the Mount Sinai Medical Center and Continuum Health Partners, which agreed to merge the two entities in July 2013. The system encompasses the Icahn School of Medicine at Mount Sinai (ISMMS) and eight hospital campuses in the New York metropolitan area, as well as a large, regional ambulatory footprint. Across the eight campuses, there are 3,815 beds and 147 O.R.s. Currently, the health system has more than 42,000 employees, including more than 7,200 physicians; more than 410 ambulatory practice locations; more than 39 multidisciplinary research, educational and clinical institutes; 152,520 inpatient admissions; more than 3,499,000 annual, outpatient visits to offices/clinics; and 536,443 E.D. visits each year. With more than 2,000 residents and clinical Fellows, Mount Sinai has the largest graduate medical education program in the country. The Plastic and Reconstructive Surgery Residency at Mount Sinai began in 1952 by Arthur Barsky, MD. Since then, the program has trained numerous plastic surgeons in academic and private practice. Many have completed competitive fellowships in craniofacial surgery, microsurgery, hand surgery, aesthetic surgery and mission surgery; others have directly entered private practice settings. The program for many years was a three-year, independent program that accepted residents mostly from the Northeast after completion of three years of general surgery. At any one time, there were five residents in the program that covered four hospitals across diverse clinical settings. In 2013, the program transitioned to a six-year, integrated program that accepts three residents per year from

Plastic Surgery Resident | Winter 2019

throughout the nation (and the world). The current residents cover eight clinical centers of excellent throughout Manhattan, Queens, the Bronx and Westchester County. The School of Medicine was started in the 1970s. ISMMS started the first program in the world to have a Peter J. Taub, MD fellowship in transgender surgery. Residents are exposed to the full breadth of plastic surgery. New York is the most dynamic and energetic city in the world, and its diversity is unparalleled. The city offers access to the other plastic surgery residency programs in the area, with all coming together yearly for the Annual Residents Night sponsored by the New York Regional Society of Plastic Surgeons. Often described as the greatest city in the world, New York has everything to offer. According to Open Table, one can eat at a different spot in New York once a day for 22.7 years and never go to the same place twice. The theater industry is literally defined by the shows that appear on-Broadway and off-Broadway. Lincoln Center is home to the ballet and the opera. The tri-state area fields two MLB teams (including the 27-time World Champion Yankees!), two NFL teams, three NHL teams, two NBA teams and two MLS teams. The U.S. Open Tennis Championships are held in Flushing Meadows at the end of each summer; the third leg of the Triple Crown is held at Belmont Park in the spring; and numerous U.S. Open Golf Championships have been held in the area. Just to the east are some of the best beaches in the world, just to the north is skiing and hiking. The residency program has been fortunate to attract the best and brightest medical students from across the country (as well as Brazil). During their time in New York, they become excellent surgeons and even better physicians. In the absence of fellowship programs (other than transgender surgery), the residents play the lead role in the care of their patients. Upon completion, residents are fully qualified to enter practice; however, most choose to pursue further training at the most competitive fellowships. |

New York City By Francis Graziano, MD

n a city like New York, 24 hours never feels like enough for exploring the city’s incredible sights, neighborhoods, restaurants and cultural centers. As the most populous city in the United States and one of the most ethnically diverse, it’s easy to feel overwhelmed by options.

Want a slice of pizza at midnight in the West Village? You’ll have to choose between 10. Set on exploring the outdoors for cityscape views? You’ll have to get more specific. Craving some live comedy with friends? You can take your pick. While the options can feel overwhelming, you’ll never go wrong sticking to some of New York’s classics – the triedand-true favorites of both tourists and natives alike.

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Plastic Surgery Resident | Winter 2019

24 HOURS / continued from previous page

IN THE MORNING

You may want to get up early – it’s the city that never sleeps, after all. Morning is the best time to explore Central Park. Grab a coffee at Zabar’s and make your way to The Mall. You’ll see New Yorkers walking their beloved dogs, and athletes of almost every variety exhibiting their skills. This park is truly the centerpiece of NYC, spanning neighborhoods and creating a green haven within the bustling city. It’s a place for exercise, art, socializing and simply being outdoors. Take a jog on the Bridle Path or get lost wandering in the Bramble. The Conservatory Garden is not to be missed.

best food in the city. Some of the best are the ultra-casual classics that many can agree on – including a burger at J.G. Melon or a pastrami sandwich at Katz’s Deli. If you crave Chinese, head over to Joe’s Shanghai for some of the best soup dumplings in the city. While the best ramen spot is certainly up for debate, Ivan Ramen on the Lower East Side is a beloved favorite and recently featured on the Netflix series “Chef ’s Table.”

While you’re in the neighborhood, you can get your art fix at the Metropolitan Museum of Art. Choose one wing or one exhibit – as the largest art museum in the United States, you’d need days to cover the entire museum. Many rave about the Egyptian Temple of Dendur, the ancient Greek and Roman statuary and the medieval armor from around the world. If it’s warm, grab a drink on the rooftop and take in the beautiful sights of Central Park from above.

MIDDAY PROVISIONS

Lunch in New York is a great way to try some of the casual favorites. Ask around for suggestions, but be prepared for endless debates among natives as to the 16

Plastic Surgery Resident | Winter 2019

Central Park

Famous pastrami on rye from Katz’s Deli

After lunch, consider making the trip to Brooklyn for an afternoon of craft breweries and trendy shops. Hop on the subway – it’s the best and fastest way to get around the city. Once in Brooklyn, head to Other Half Brewery or Grimm Artisanal Ales, two of the best craft breweries in the area.

selling ice cream, coffee and other street food. At the south end of the High Line is the Whitney Museum of American Art. If you have enough time, take a look through the Whitney – they have a mixture of 20th- and 21st-century American art. The museum just recently opened and the architecture is beautiful.

LATE AFTERNOON SORTIES

EVENING OPTIONS

For dinner, if you are looking for Italian food, we highly recommend heading to Via Carota in the West Village or Misi in Brooklyn. Both make amazing homemade pasta that will make you want to return for more the next night. This wouldn’t be a proper NYC guide if we didn’t talk about pizza. One of our favorite places to grab a slice would be from Rubirosa in SOHO. Their vodka sauce and tie-dye pizzas are must-haves. Looking for something more high end? Try Manhatta on the 60th floor in the Financial District; it holds arguably some of the best dinner views in the city – Hudson River, midtown Manhattan and the Statue of Liberty. After dinner, check out the High Line on the lower west side of Manhattan. The High Line is a 1.45-mile-long elevated park created on a former New York railroad bridge. The views of the city are fantastic and there are street vendors

After dinner, there are a host of options depending on what you are in the mood for. You could head to the world-famous Madison Square Garden to see the New York Knicks or the Rangers play or perhaps catch a concert. If something smaller and casual is more your style, check out the Comedy Cellar in Greenwich Village, where some of the most famous stand-up comedians go to

Times Square

practice their new material. Make sure to check online to reserve a ticket about a week before or you can stand by to grab an open spot. Another local highlight are the Broadway musicals. The Theater District, near Times Square, is home to 41 of the best theaters in America. Lastly, if it’s a nice summer night, there’s no better way to spend it than at a Yankees or Mets baseball game in true American fashion – with a hotdog and beer.

IT AIN’T OVER ’TIL IT’S OVER

The day isn’t over quite yet, so make your way over to The Aviary NYC in the Upper West Side. Located on the 35th floor of the Mandarin Oriental, The Aviary specializes in making innovative cocktails, and you will feel more like you are in a chemistry class than a bar. The prices are steep, but the experience is worth it. Feeling something more lowkey? Head to the Broken Shaker located in Kips Bay. The Broken Shaker has a great roof deck and a long list of craft beers on draught. You’ll probably find it best to get some rest after a long day, but believe or not, we’ve only just scraped the surface of what New York has to offer. Anyway, thanks for coming – and be sure to come back soon! | Plastic Surgery Resident | Winter 2019

Q&A WITH JESS TING, MD

By Kendra Y. Mims Plastic Surgery Resident strives to provide readers with career advice designed to aid them in their professional advance after residency – by sharing insights that may help them create their own, desired path. In this installment of Faculty Focus, we present ASPS member Jess Ting, MD, assistant professor of surgery at the Icahn School of Medicine at Mount Sinai Hospital. Dr. Ting completed his general surgery training at the Columbia-Presbyterian Medical Center and his plastic surgery training at the University of Pittsburgh Medical Center. Dr. Ting also completed a fellowship in Hand Surgery and Microsurgery at the Hospital for Special Surgery in New York. But the area of expertise for which he’s now in most demand is transgender surgery – he’s the director of surgery at Mount Sinai’s Center for Transgender Medicine and Surgery. Dr. Ting grew up in New York and is musically gifted, as well as being a leader in plastic surgery. The combination bore great fruit when he earned undergraduate and graduate degrees from the Juilliard School of Music as a classical double bass player. Dr. Ting says he’s proud to be at the forefront of transgender surgical training, and he’s encouraged by the interest in this important and burgeoning field being demonstrated by residents and young plastic surgeons. He recommends that above all, residents keep an open mind for whatever life’s possibilities may present – and he says he’s arrived at a place of work/life balance that includes his three loves: family, music and medicine.

Plastic Surgery Resident | Winter 2019

PSR: WHAT WAS IT THAT DREW YOU TO PLASTIC SURGERY? Dr. Ting: I had intended to do internal medicine and did a sub-i in plastics on a whim. It ended up being the closest thing in medicine to the creative outlet that music had been for me – I trained at Juilliard to be a classical musician – and that made the decision easy. Three years ago, I was unexpectedly given the opportunity to re-train in gender surgery as part of our institution’s drive to start a transgender surgery program. I learned how dire the need for more gender surgeons was and how underserved the population is. That’s when I decided to switch full-time to gender surgery.

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Ting: The best preparation I did for my Fellowship was to network in the hand surgery world. Fellowships are often about who you know, not necessarily who you are.

PSR: WHAT EFFECT DID THE FELLOWSHIP HAVE UPON YOUR CAREER ADVANCEMENT? Dr. Ting: Being hand-fellowship trained got me my first (and present) job, but I gradually shifted into other clinical areas. I think that happens a lot, so my advice to young surgeons is to keep an open mind and never stop learning.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Ting: As an Asian-American, I found it particularly helpful to have other Asian-Americans as role models and mentors. It’s very helpful to have mentors whose past experiences mirror your own and after whom you can model your own trajectory.

PSR NEWS PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Ting: Honesty and integrity. Everything else can be taught or compensated for.

PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Ting: Family comes first. Then music – I’m still an avid amateur musician. Medicine is a great career, but it’s only once facet of my life.

PSR: HOW DID YOU HANDLE YOUR BIGGEST NONMEDICAL CHALLENGE OF RESIDENCY? Dr. Ting: Developing a healthy work/life balance and learning to prioritize things outside of work made me a happier and more effective doctor.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Ting: Being able to do something new every day.

PSR: WHAT ARE SOME OF THE RECURRING CHALLENGES OF YOUR PRACTICE? Dr. Ting: Juggling a crushing backlog of patients with the development of a new clinical program. In three years, we’ve grown from one to three-and-a-half surgeons – and we’ve had a waitlist for appointments of more than a year.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Ting: I started the nation’s first gender-surgery fellowship, just one year after starting to do gender surgery myself. It became one of the most challenging and most rewarding parts of my practice. We also have many visiting students and residents who want to learn about this emerging specialty.

RESIDENT EDUCATION CENTER: UPDATED AND IMPROVED The Resident Education Center is now available on the new and enhanced learning management system ASPS Education Network (ASPS EdNet). Residents can view their institution, curriculum, resident progress and reporting on ednet.plasticsurgery.org. However, the institution dashboard on plasticsurgery.org will not change. Please note that the REC on the previous platform at www.PSENetwork.org was discontinued July 1. This new platform includes added functionality such as a communications center; assignment center; grade book; a modern look and feel; enhanced analytics; and more. Residents’ login information to access REC will not change, so please log-in to ednet. plasticsurgery.org using your existing PSEN username and password. Those with questions can contact onlineeducation@ plasticsurgery.org. |

PSR: AS A SEASONED PLASTIC SURGEON, WHAT’S YOUR ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Ting: Anything is possible if you believe in it.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN… ” Dr. Ting: I saw my first toe-to-thumb transfer. | Plastic Surgery Resident | Winter 2019

Fingertip Amputations By Roger W. Cason, MD

Figure 1

ingertip amputations are common injuries that, perhaps unsurprisingly, are well represented on the In-Service Exam each year. In order to help residents better-prepare for this section of the exam, this article will focus on the indications of each reconstructive modality, highlighting some the basic indications and limitations of the various reconstructive modalities for fingertip amputations. Those who would like to pursue a more in-depth discussion of technical details of these are encouraged to visit the “Suggested Reading” section at the end of this article.

ANATOMY

The fingertip is defined by the distal phalanx and soft tissue distal to the insertion of the flexor and extensor tendons. The nail bed is tightly adherent to the distal phalanx and is composed of the germinal and sterile matrices. It’s bordered by the eponychium proximally, paronychium laterally and hyponychium distally. Vascular supply is from the proper digital vessels, which arborize past the level of the DIP joint.

EVALUATION

Fingertip injuries are best approached in an algorithmic fashion dictated by the injury geometry (Fig. 1), defect size and presence of exposed bone or tendon. The functional priorities of each digit should also be taken into account. For example, reconstructive options that allow for preservation of sensation are preferred for the thumb and index, which serve a primary precision function. Maintenance of length is the priority for the middle finger; thus, sacrificing considerable length for sensation may not be the optimal choice. As the ulnar digits play a primary role in power grip, reconstructions that preserve joint mobility and provide a flexor surface devoid of potentially painful scars are favored. 20

Plastic Surgery Resident | Winter 2019

Injury geometry. (Reprinted from Operative Techniques: Hand and Wrist Surgery, 3rd Edition. Yang G, Kamnerdnakta S, Brown M, Chung KC, Flap Coverage of Fingertip Injuries, Pages 655-664, Copyright (2018), with permission from Elsevier).

SALVAGE VS. REVISION AMPUTATION

Generally, injuries proximal to the lunula are best treated with a revision amputation. Additionally, some patients may prefer an amputation, the classic example of which is a laborer who favors an expedited return to work at the expense of a shortened digit. In pediatric patients, the amputated part can be replaced as a composite graft, though the published success rates are highly variable.

SECONDARY INTENTION, SKIN GRAFTS

Injuries ≤1.5cm2 without exposed bone or tendon can be left to heal secondarily with excellent sensation and functional outcomes. Exposed distal phalanx can be conservatively shortened to allow for secondary intention, but shortening should not exceed the distal-most aspect of the nail bed to prevent a hook-nail deformity. For defects >1.5cm2, splitand full-thickness skin grafts can be used, and patients may recover protective sensation, but can result in cold intolerance.

FLAP OPTIONS (INDEX, MIDDLE, RING, SMALL)

Exposed bone or denuded tendon are indications for flap coverage if salvage is desired. The flap options can be broadly categorized as local, homodigital or heterodigital flaps. Local flaps allow for excellent preservation of sensation but are typically limited to smaller defects (≤1cm). Homodigital flaps also provide good sensory outcomes and can be applied to larger defects (≤2cm), but often require shortening of the digit to achieve adequate coverage. For even larger defects, heterodigital flaps can be used, but these have the poorest sensory outcomes amongst the flap options.

based flap nourished by the contralateral digital artery. The digital nerve can be left in situ or, for a sensate flap, incorporated in the flap and coapted to the contralateral digital nerve (Fig. 3).

Figure 3

LOCAL FLAPS

The volar V-Y flap (Atasoy) can be used for dorsal-oblique and distal-transverse amputations on any digit. The apex of the flap typically extends to the distal flexion crease resulting in advancement up to 1cm (Fig. 2). Bilateral V-Y advancement flaps, described by Kutler, can be used for transverse and lateral-oblique amputations, but result in a scar at the volar fingertip. For lateral-oblique injuries with exposed bone, a lateral pulp flap can provide bony coverage by mobilizing the adjacent volar pulp to allow for healing by secondary intention.

Figure 2

Reverse homodigital island flap with inclusion of digital nerve, coapted to contralateral digital nerve. (Reprinted from Operative Techniques: Hand and Wrist Surgery, 3rd Edition. Yang G, Kamnerdnakta S, Brown M, Chung KC, Flap Coverage of Fingertip Injuries, Pages 655-664, Copyright (2018), with permission from Elsevier).

HETERODIGITAL FLAPS Atasoy volar V-Y advancement flap. (Reprinted from Principles of Hand Surgery and Therapy, 3rd Edition. Trumble TE, et al. Nail Bed and Fingertip Injuries, Pages 193-205, Copyright (2017), with permission from Elsevier).

HOMODIGITAL FLAPS

The oblique triangular neurovascular island flap is an axial flap, based on one of the proper digital neurovascular bundles, and can provide coverage of volar-oblique, lateraloblique, and transverse defects up to 2cm. Extending the apex of the flap proximal to the PIP joint affords greater mobility for advancement. The Hueston flap is a laterally based, volar rotation-advancement flap with a proximal back cut that can be used for transverse amputations. Reverse-flow homodigital island flaps take advantage of the anastomoses between the radial and ulnar digital arteries at the interphalangeal joint spaces, allowing for a distally

The thenar flap is an option for larger defects of the index finger – but it’s particularly attractive for the middle finger, as it reliably allows for preservation of length. It’s contraindicated in patients with a high risk for developing joint contractures. The cross-finger flap can be used for volar defects of the ring and small fingers, where the primary goal is preservation of power grip, so preservation of IP joint mobility and absence of volar scars are ideal. Contrarily, for dorsal defects of the digits, a reverse crossfinger flap may be utilized.

THUMB

The Moberg flap is an axial advancement flap that provides excellent sensation and can resurface volar defects up to 1-1.5cm (Fig. 4). Because both neurovascular bundles are included in the flap, its use is reserved for the thumb due to a reliable dorsal blood supply via the princeps pollicis

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Plastic Surgery Resident | Winter 2019

Journal Club; 2019 Winter; (17)

1. Standards of Care for the Health of Transgender, Transsexual, and Gender-Nonconforming People, Version 7

Coleman E, Bockting W, Botzer M, et al. Int J Transgenderism 2012(13):165-232 These guidelines from the World Professional Association for Transgender Health (WPATH) were created in 2012 and address the unique healthcare needs of gender-diverse patients, based on current literature and expert recommendations. This summarizes, and includes references for, the current influential literature at the time of its publication. It provides recommendations in regard to social needs, mental health, hormone therapies, preoperative decision-making, postoperative care and long-term health maintenance. This document also discusses the recommendations for treatment prior to genderaffirming surgery. The updated Version 8 is scheduled to be released in 2020.

2. Facial Gender Confirmation Surgery – Review of the Literature and Recommendations for Version 8 of the WPATH Standards of Care

JOURNAL ARTICLES ON

GENDER-AFFIRMING SURGERY

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Vanessa D. Leonhard, DO; & Shane D. Morrison, MD

s more gender-diverse individuals seek gender-affirming treatment, it’s become essential that providers understand the specific needs of their transgender and gender non-conforming patients. The following articles recognize such needs, make informed recommendations and describe techniques to address the physical, emotional and social needs of this growing patient population.

Plastic Surgery Resident | Winter 2019

Berli JU, Capitan L, Simon D, Bluebond-Langner R, Plemons E, Morrison SD. Int J Transgenderism 2017;18(3):264-270 This comparative literature review summarizes recent publications on facial gender confirmation surgery (FGCS). Articles published since WPATH Standards of Care, Version 7, demonstrate minimal complications and significantly higher satisfaction rates in people who have facial gender dysphoria and underwent FGCS relative to those who did not. It provides statistical results, outlines systematic approaches to full FGCS and describes the changes in standardized outcome measures. The authors advocate for these as medical necessities for gender affirmation in the upcoming WPATH Standards of Care, Version 8.

3. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts

Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. JAMA Pediatrics 2018;172(5):431-436 This cohort study of minors and young adults evaluates chest satisfaction pre- and postoperatively in transmasculine youth ages 13-25. The study’s original Chest Dysphoria Scale considers physical wellbeing, avoidance of certain activities, emotional distress and future planning due to chest appearance. In the sample of 136 patients, the mean age of both the pre- and post-op groups was 17, with 25 percent of the post-op group under age 15. There were very low rates of regret in postsurgical patients. Nonsurgical participants had a stronger desire for reconstruction proportional to the length of time of hormone therapy. Limits include cross-sectional design and the unvalidated Chest Dysphoria Scale. This study concludes that individuals should be considered for surgery regardless of their age and potentially in conjunction with puberty blockers.

4. Nonsurgical Management of Facial Masculinization and Feminization

Ascha M, Swanson MA, Massie JP, et al. Aesthetic Surgery Journal 2019;39(5):NP123-NP137 This literature review summarizes articles on nonoperative facial gender confirmation, as well as techniques currently used in cisgender patients. Fillers and neurotoxins provide temporary and less-invasive, yet powerful, options for facial feminization or masculinization. The authors identify and address the classic characteristics of each gender and provide nonsurgical techniques for facial modification. They additionally discuss the differences in treatment for transwomen, primarily that genetically male skin tends to require additional volume of fillers and neurotoxin. They conclude that cisgender techniques can be employed and modified for facial gender confirmation.

5. Chest-Wall Contouring Surgery in Female-toMale Transsexuals: A New Algorithm

Monstrey, S., Selvaggi, G., Ceulemans, P., et al. Plast Reconstr Surg 2008;121(3):849-859 This retrospective review of a total of 184 mastectomies (92 patients) compares the outcomes of five subcutaneous mastectomy techniques used at one hospital. The indications, procedural steps, strengths and limitations for the semicircular, transareolar, concentric circular, extended concentric circular and free nipple-graft techniques are described. Hematoma was most common in the transareolar and semicircular techniques, while complications requiring reoperation were most commonly seen in the extended concentric circular technique. The authors recommend increased consideration of skin laxity, along with breast size, ptosis and nipple-areolar complex size, when determining the approach for subcutaneous mastectomy, and they present an algorithm for preoperative decision-making.

6. Breast and Body Contouring for Transgender and Gender Non-Conforming Individuals Morrison SD, Wilson, SC, Mosser SW. Clinics in Plastic Surgery 2018;45(3):333-342

This article reviews breast and body contouring procedures for transfemale patients in order to guide surgical planning, patient expectations and understanding of surgical limitations. It covers the basic anatomical differences between genders, highlighting the bony differences and soft tissues. Hormone therapies, antiandrogens and estrogen for transwomen, and testosterone for transmen, may alter soft-tissue distributions; however, some patients may desire further surgical gender affirmation. For breast augmentation, the authors briefly discuss ideal dimensions, then identify techniques addressing the obstacles of augmentation. These primarily include insufficient skin envelope and nipple-areolar complex positioning due to gender anatomy. While limited, feminization using body contouring with liposuction and fat grafting is summarized as a means of addressing the fat distribution between the sexes.

7. Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women

Buncamper ME, van der Sluis WB, van der Pas RS, et al. Plast Reconstr Surg 2016;138(5):999-1007 This article outlines the operative technique of penile inversion vaginoplasty and describes a retrospective review of the intraoperative and postoperative complications at one major center. The intraoperative and immediate post-op complications, including rectal or urethral injury and bleeding, are low, with the exception of small wound-healing issues or dehiscence reported at 24.6 percent. Compared to current literature, this study reports lower rates of introital and vaginal stenosis, attributing this to their dilation protocol and perineoscrotal flap. Less than 3 percent of patients required revision vaginoplasty. The authors conclude that, despite moderately high post-op complications, the majority of post-op issues are minor and few require reoperation.

8. Long-Term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery

Morrison SD, Satterwhite T, Grant DW, Kirby J, Laub DR Sr., VanMaasdam J. Plast Reconstr Surg 2015;136(2):386-394 This retrospective review of 83 patients over a 22-year period is one of the largest studies of pedicled rectosigmoid neocolporrhaphy. It includes a brief summary of the primary surgeon’s technique, then focuses on the short- and long-term outcomes. While complications rates were 58 percent, they were primarily minor and improved with medical therapy or minor surgery. The most common complication was stricture, followed by protrusion of the corpus spongiosum and shortterm muccorhea. In this sample, only 40 percent of responders required vaginal dilation beyond six months. The discussion directly compares the advantages and complications of rectosigmoid neocolporrhaphy and penile inversion vaginoplasty, and it concludes by advocating for rectosigmoid neocolporrhaphy as an effective and safe method for vaginal reconstruction.

9. Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique? Monstrey S, Hoebeke P, Selvaggi G, et al. Plast Reconstr Surg 2009;124(2):510-518

This article briefly describes the history of penile reconstruction and the four major goals of transmasculine patients: sensation, intercourse, upright voiding and an aesthetically appropriate penis and scrotum. Currently, the radial forearm flap is considered the standard technique, and this article reviews the ability of the current technique to accomplish the above goals. The technique reviewed describes a combined approach with elevation of the radial forearm flap and simultaneous vaginectomy and urethral reconstruction. A second stage was used to address erections for intercourse. The major

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Welcoming the challenges we face as incoming ambassadors By David Hill, MD Resident Ambassador, PlastyPAC Board of Governors

must begin by thanking my predecessor, JT Stranix, MD, for his hard work and dedication during his term as resident ambassador to the PlastyPAC Board of Governors. His efforts were very successful in educating and motivating others to get involved in the activities of the PAC. He’s left some very big shoes to fill; however, I know both Benjamin Schultz, MD, and I are extremely excited to be the incumbent resident ambassadors. In just over a year, another highly contested presidential election will take place. The Democrat debates continue to become more intense and the presidential tweets continue to become more frequent. Despite all the ongoing political gamesmanship, PlastyPAC continues its bipartisan mission to represent and support critical issues in regard to the practice of plastic surgery. Its support of candidates from both political parties in order to ensure that the needs of all plastic surgeons are addressed is perhaps one of the most important aspects of the PAC. As residents/Fellows, you may feel daunted by the many tasks encountered on a daily basis and therefore as though

Plastic Surgery Resident | Winter 2019

political activism is too far-fetched – and requires too much energy. However, when you realize your future practices and rights as plastic surgeons are at stake, this matter should have significant priority. One such highly popularized legislative bill – the No Surprises Act (H.R.3630) – should invoke particular interest. The goal of the bill is to limit patients from being stuck with surprise bills for emergency care. ASPS has voiced its concerns with this legislation in its advocacy efforts on Capitol Hill. However, in particular, this bill contains a section that would potentially allow insurance companies to reimburse physicians at less-thancommercial value. This would result in a major disincentive for fair reimbursement and would negatively influence contract negotiations. An additional proposed provision would require physicians to accept in-network reimbursement when surgery is performed at an in-network facility. This once again would detrimentally influence contract negotiations between providers, hospitals and insurance companies. These fixed outof-network reimbursements at the median in-network rate would be a giant victory for the for-profit insurance industry. PlastyPAC has supported the Society by educating members of Congress about the issue of balance billing and the importance of removing patients from payment disputes. Although these reimbursement issues might seem too far in the future, the passage of this legislation now would severely affect us when it comes time to

open the doors to our practices. Because of important issues like this and the many others designed to protect not just us but our patients – such as ensuring coverage for children with congenital anomalies – I’m a passionate advocate and member of the PlastyPAC. ASPS has been a leading advocate during the 116th Congress for the Ensuring Lasting Smiles Act (H.R. 1379), which ensures individuals have necessary insurance coverage to treat congenital anomalies. We have many great ways for other residents to get involved, including opportunities to meet with and present checks to your local members of Congress. I encourage all to contact me at hilld793@gmail.com, or Dr. Schultz at benschulzmd@gmail.com, with any questions, comments or concerns in regard to PlastyPAC and any issues we are currently fighting for. As the future of plastic surgery throughout the United States and the world, your issues and priorities are mine as well – and I want to make sure we address these issues with as many perspectives as possible. For additional information about PlastyPAC or to contribute, visit our website PlastyPAC.net. Your generosity, even at a resident amount, provides us with the resources needed to address policy issues in our favor. We have many more important updates coming in future publications – so be sure to keep an eye out! |

Dr. Hill is a PGY-7 at Houston Methodist Hospital.

MEET YOUR RESIDENTS COUNCIL MEMBERS ASPS is proud to introduce members of the Society's Residents Council. The purpose of this group is to improve resident involvement in ASPS and advocate for resident interests at the highest levels of this specialty. This group will afford residents the opportunity to contribute to ongoing projects within the ASPS and YPS Forum as well as develop new projects specific to residency training and beyond. Welcome, all!

NEW MEXICO

ARIZONA

KENTUCKY

Howarth, Ashley, Mayo Clinic Plastic Surgery Program - Arizona Residency Program Pflibsen, Lacey, Mayo Clinic Plastic Surgery Program - Arizona Residency Program

Burns, Jack, University of Kentucky College of Medicine Residency Program

Kunkel, Ryan, University of New Mexico Residency Program

MASSACHUSETTS

Brown, Ronnie, University of Rochester Residency Program Ruter, Daniel, Albany Medical College Salibian, Ara, New York UniversityPlastic Surgery Residency Program Schultz, Benjamin, Hofstra-Northwell Smith, Benjamin, Zucker School of Medicine at Hofstra/Northwell Plastic Surgery Residency Program

CALIFORNIA

Chaudhry, Obaid, N/A Fligor, Jennifer, University of California-Irvine Hauch, Adam, University of CaliforniaSan Diego Kanack, Melissa, University of California-Irvine Lambi, Alex, University of CaliforniaLos Angeles Lentz, Rachel, University of CaliforniaSan Francisco Maan, Zeshaan, Stanford University Motakef, Saba, Loma Linda University Pien, Irene, University of CaliforniaLos Angeles Zeiderman, Matthew, University of California-Davis COLORADO

Colakoglu, Salih, University of Colorado FLORIDA

Girardot, Alexandra, University of South Florida Zimmerman, Amanda, University of South Florida ILLINOIS

Aronson, Sofia, Northwestern University/McGaw Medical Center Atencio Bohorquez, Daniela, University of Illinois-Chicago Bruce, Timothy, University of Chicago Hagan, Matthew, University of Illinois-Chicago Hutchinson, Lauren, Southern Illinois University Residency Program Janes, Lindsay, Northwestern University/McGaw Medical Center INDIANA

Bamba, Ravi, Indiana University, Indiana Cook, Julia, Indiana University, Indiana

Celestin, Arthur, Harvard Independent Plastic Surgery Residency Godfrey, Natalie, University of Massachusetts Residency Program Serebrakian, Arman, Harvard Independent Plastic Surgery Residency Taylor, Erin, Brigham and Women's Hospital/Harvard Medical School Residency Program MICHIGAN

Fahrenkopf, Matthew, Spectrum Health/Michigan State University Lisiecki, Jeffrey, University of Michigan Sherif, Rami, University of Michigan MINNESOTA

Deshpande, Sagar, University of Minnesota Johng, Heidi, University of Minnesota Integrated Residency Program MISSISSIPPI

Googe, Benjamin, University of Mississippi Medical Center Residency Program MISSOURI

Chi, David, Washington University, St. Louis Grow, Jacob, University of Kansas School of Medicine Residency Program Ha, Austin, Washington University, St. Louis Martin, Andrea, University of Missouria Columbia Residency Program NEBRASKA

Hon, How Yee Heide, University of Nebraska Medical Center NEVADA

Kleban, Shawna, University of Nevada School of Medicine Residency Program NEW JERSEY

Rodby, Katherine, Rowan UniversityCooper Medical School Residency Program

NEW YORK

NORTH CAROLINA

Akhavan, Arya, University of North Carolina Hospital Residency Program Fredman, Rafi, University of North Carolina Hospital Residency Program Hein, Rachel, Duke University Residency Program NOVA SCOTIA, CANADA

Boehm, Kaitlin, Dalhousie University Residency Program OHIO

Anderson, Spencer, Wright State University Residency Program Knackstedt, Rebecca, Cleveland Clinic Kraft, Casey, Ohio State University Sinclair, Nicholas, Cleveland Clinic Foundation Starr, Brian, University of Cincinnati Tanaka, Shoichiro, Summa Health Plastic Surgery Residency Program Yalamanchili, Suma, University of Cincinnati OREGON

Joslyn, Nichole, Oregon Health & Science University Residency Program PENNSYLVANIA

Azoury, Said, University of Pennsylvania Hu, Michael, University of Pittsburgh Jacobs, Aaron, Lehigh Valley Health Network Joseph, Walter, University of Pittsburgh Medical Center Medical Education Residency Program Raj, Mamtha, University of Southern Florida - Lehigh Valley Health Network Steele, Andrew, Lehigh Vally Health Network

QUEBEC, CANADA

Azzi, Alain, McGill University Residency Program Boghossian, Elie, N/A RHODE ISLAND

Jehle, C. Christopher, Brown University Residency Program TENNESSEE

Kozusko, Steven, University of Tennessee Residency Program TEXAS

Hamilton, Kristy, Baylor College of Medicine Hill, David, Houston Methodist Hospital Kalaria, Shana, University of Texas Medical Branch Hospitals Residency Program Maiorino, Eric, University of Texas at Houston Plastic Surgery Residency Program Ourian, Ariel, Houston Methodist Hospital - Plastic Surgery Residency Program Padilla, Pablo, The University of Texas Medical Branch (UTMB) Rodriguez, Abigail, Texas A&M College of Medicine-Scott & White Residency Program Weeks, Dexter, University of Texas Medical Branch UTAH

Garlick, Jared, University of Utah Residency Program VIRGINIA

Joy, Matthew, Carilion Clinic Plastic Surgery Residency Program Millendez, Maridelle, Georgetown University Residency Program WASHINGTON

Morrison, Shane, University of Washington Residency Program WEST VIRGINIA

Carruthers, Katherine, West Virginia Integrated Plastic Surgery Residency Program WISCONSIN

Farmer, Rebecca, University of Wisconsin Residency Program

Plastic Surgery Resident | Winter 2019

EXPLORING THE UNKNOWN

INTERNATIONAL RESEARCH EXPERIENCES: REFLECTIONS AND INSIGHTS By Karen Chung, MD, & Mélissa Roy, MDCM, MSc

Plastic Surgery Resident | Winter 2019

“The real voyage of discovery consists not in seeking new landscapes, but in having new eyes” – Marcel Proust

t’s 5 a.m., and roosters have begun to crow. You scramble awake, but then you quickly realize this strange noise isn’t the incessant beeping of a pager – it’s the sound of an inoffensive, colorful bird somewhere outside, announcing the day. You’ve traded time in a minuscule, city-center apartment within a large concreteand-corporate environment for a shared house with only essential furniture, no running water and a small, comfortable bed covered by a much-needed mosquitero. At home, you feel eloquent and accustomed to engaging in discussions of a somewhat sophisticated nature. Here, you attempt to expand your basic vocabulary and ensure you’re intelligible by using body language and simple drawings. But you’re not home; you’re conducting research abroad. Plastic surgeons who perform research in such drastically contrasting surroundings are often inspired to work harder and be more open to novelty. This international experience can allow researchers to approach their work with a new vision… International research initiatives have become increasingly available to surgical residents. These opportunities take place in a context of a growing need for surgical care worldwide as demonstrated by the Lancet Commission on Global Surgery. Approximately 30 percent of the global burden of disease was found to be attributed to surgically treatable conditions. It was also estimated that 5 billion individuals worldwide cannot access safe and affordable surgical care.1 Undertaking research projects in international settings presents intrinsic challenges and rewards. Below are a few reflections that could help facilitate and enrich research experiences for plastic surgery residents abroad.

BUILDING ON PRE-EXISTING COLLABORATIONS, HAND-IN-HAND WITH THE COMMUNITY

Conducting research in a community far different than your own begs the questions: Why? And, how can one contribute in an integrative and participatory manner?2 The literature highlights the importance and value of participatory research and establishment of long-term partnerships. This participatory approach (whether with local experts or community members) should be initiated prior to the deployment of active research efforts. It also should help direct research topic and study design-selection to answer the

(Opposite page) The view from Sidist Kilo, near Yekatit Hospital, Addis Ababa, Ethiopia; the view from Enqu Ledeta Lemariam Church, where Dr. Chung rests after a brief hike.

needs of the community. Local mentors, research assistants and community leaders are allies in this process. Preexisting institutional partnerships increase the feasibility of studies and creates space for even more meaningful research projects in the future.

INTRODUCTIONS AND FIELD VISITS

Once a protocol has been designed, reviewed and approved by all parties and team members, an on-site visit may provide better understanding of the research environment and setting. Unexpected challenges can arise from environmental amenities (e.g., internet connection) to cultural and linguistic differences. Meeting research collaborators ahead of time may help identify possible, unanticipated barriers – as well as facilitators – for your research.

ETHICS APPROVAL ACROSS THE BOARD

Ethical review and approval from your own institution and the host institution is usually required. Such a process benefits from being started early. The research you’re conducting may be a new and unfamiliar initiative that requires more preparation. Evidence previously published in similar settings (e.g., low-resource) can be essential to demonstrate need and feasibility.

continued on the next page Plastic Surgery Resident | Winter 2019

INTERNATIONAL RESEARCH / continued from previous page

PSYCHOLOGICAL, SOCIAL AND PHYSICAL PREPARATION

Psychological: Finding a grounding activity outside of research can be helpful in helping to engage with the community, make friends, learn the local language and explore the cultural diversity. Staying engaged with friends and family back home also facilitates adjusting in both the host and home environments. Physical: A consultation to a travel clinic to discuss vaccinations and medications is recommended. Oral rehydration salts, hand sanitizer and eating thoroughly washed and cooked foods can help protect from new and unfamiliar pathogens. Social: Informing the appropriate institution, embassy and licensing bodies of your travel plans is important. It’s suggested that you become familiar with linguistic, cultural and social norms of the community prior to traveling to the research location. You may also want to invest in a local SIM card that may provide you with mobile and internet data.

THE IMPORTANCE OF PILOT STUDIES

View of the Mercado de Otavalo (Otavalo market), Imbabura, Ecuador, where surrounding communities gather to sell handmade art and other products.

A pilot study allows for preliminary testing of a research protocol and provides ideas and approaches that may not have been thought of before. It also leads to the recognition of potential barriers and facilitators especially in an international and less-familiar setting. Finally, it provides space to make amendments prior to the start of the study.

flourishes with collaborations. The wealth of international research experiences lies in the sharing of new perspectives and approaches, the exchange of ideas and the establishment of a partnership dialogue.

TEAMWORK MAKES DREAM WORK

DATA QUALITY CHECKS

Overall, whether in home territory or in an international foreign environment, research remains teamwork and

Data may be collected in a different language and may require electronical entry, transcription or translation. It’s necessary to check the data regularly for quality assurance to ensure uniformity and collection as per the established protocol. |

Dr. Karen Chung is a plastic surgery resident who has been conducting a multi-center research study for the past five months in Addis Ababa, Ethiopia while completing her MSc. The later focuses on health-related quality of life methods, patient preferences, and their applications in economic analyses. Dr. Mélissa Roy is a plastic surgery resident who has taken part in an international cooperation project in Langue, Honduras and a participatory research partnership in the community of Chilcapamba, Ecuador. REFERENCES

A child plays with a soccer ball in the small village of Langue, El Salvador, with the Honduran mountains nearby and the El Salvadoran mountains visible in the background. 28

Plastic Surgery Resident | Winter 2019

1. The Lancet Commission on Global Surgery. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. 2. Macaulay AC. Participatory research: What is the history? Has the purpose changed? Fam Pract. 2017;34(3):256-258.

Put your plastic surgical vocabulary skills to the test! By Michael Hu, MD 1

ACROSS 1.

5. 7.

Commonly performed cosmetic surgery in the United States that can produce an abundance of adult multipotent cells.

Most commonly used mammalian research model species due to high homology with humans, ease of maintenance and handling, and high reproduction rate (two words).

3 4

5 6

7 8 9

Type of wound healing that resembles regeneration.

13. The “I” in the acronym for a piece of grafted autologous muscle that regenerates and becomes reinnervated by an implanted residual peripheral nerve.

14 15 16

14. Type of cell with the ability to selfrenew and diﬀerentiate into other cell types.

16. Holder of an independent grant and lead researcher for a given grant project (two words). 17. Strategy to re-establish tissue polarity, structure, and form by promoting this pathway over ﬁbrotic repair.

18 Method widely used in molecular biology to make copies of speciﬁc DNA segments (acronym).

19 Dr. Shinya Yamanaka was awarded the 2012 Nobel Prize in Physiology or Medicine for the discovery of this (acronym). 20 Structural framework used to facilitate repair/regeneration of stromal tissues. 21 Novel technology that allows researchers to easily alter DNA sequences and modify gene function (acronym).

22 Three scientists have shared this year’s Nobel Prize in Physiology or Medicine for research in this area.

Popular ﬁeld of research among plastic surgeons aimed at using artiﬁcial tissues, organs, or organ components to replace damaged or absent parts of the body.

12. Popular area of plastic surgery research involving the transplantation of multiple tissues such as muscle, bone, nerve, and skin, as a functional unit (acronym).

Answer key on page 30

DOWN 2.

6. 8. 9.

First performed by Gustav Neuber in 1893 to correct scars formed from osteomyelitis and popularized by Dr. Sydney Coleman in the 1990s (two words).

10. Site of privileged wound healing with little to no scarring in the adult.

Breed of species found to be a promising model of hypertrophic scarring (three words).

15. Result of reparative/reactive process in an organ or tissue.

Popular laboratory technique that analyzes the transcriptome of gene expression patterns (acronym).

11. Popular technique that provides a method for sorting a heterogeneous mixture of cells based upon speciﬁc light scattering and ﬂuorescent characteristics of each cell (acronym).

One of three key features of stem cells.

23. Administrative body established to protect the rights and welfare of human research subjects (acronym).

Plastic Surgery Resident | Winter 2019

INSERVICE INSIGHTS / continued from page 21 Figure 4

JOURNAL CLUB / continued from page 23 disadvantages were high rates of fistulae, urologic complications and donor-site scarring. In conclusion, the radial forearm flap is deemed an appropriate, but not ideal, method of penile reconstruction – and the authors highly recommend the multidisciplinary approach with urologic assistance intraoperatively.

10.Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty Selvaggi G, Hoebeke P, Ceulemans P, et al. Plast Reconstr Surg 2009;123(6):1710-1718

Dr. Leonhard is PGY-2, and Dr. Morrison is PGY-6, at the Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle.

Answer key from page 29

M U S

U S F E 6 R R I N G A 11 12 F S V A C E C Q S 5

T I O N

Plastic Surgery Resident | Winter 2019

N V E S T

A T I O N

Mailey B, Neumeister MW. The fingertip, nail plate and nail bed: Anatomy, repair, and reconstruction. In: Chang J, Neligan P, eds. Plastic Surgery: Volume 6: Hand and Upper Extremity. Elsevier, Inc.; 2017:122-145.

F T A L T G 8 R R C A E F D T D I U N R I G A T O R C 18 P C R I G

Martin C, Gonzalez del Pino J. Controversies in the treatment of fingertip amputations. Conservative versus surgical reconstruction. Clin Orthop Relat Res. 1998 Aug;(353):63-73.

C A F F O L D

Lee DH, Mignemi ME, Crosby SN. Fingertip injuries: an update on management. J Am Acad Orthop Surg. 2013 Dec;21(12):756-66.

P R

Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008 Sep;122(3):105e-117e.

B I O E