Plastic Surgery Resident, Fall 2020

From the publishers of Plastic Surgery News

Inclusion and diversity How can plastic surgery improve its efforts to better represent all groups? page 4

ISSUE 20 | FALL 2020

» Living with the

extraordinary

How pop culture exerts its pull on today's high-profile social movements

page 9

» Mentorship

during COVID-19

Two aspiring plastic surgeons on how leadership can reach out page 30

» Matching during a pandemic

'Boots on the ground' decision-makers set a road map for candidates page 17

IN THIS ISSUE » Consult Corner: Acute care of thermal burns p. 12 » Managing the complication everyone gets p. 32 » 'Black swans:' Matching as international medical students p. 24

A note from the editor

W

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

elcome to our virtual Plastic Surgery The Meeting 2020 (#PSTM20) fall issue of Plastic Surgery Resident.

As the Society is unable to host an in-person annual meeting this year, PSTM20 will be delivered virtually with both live-online and on-demand components.

Specifically for our readers, we remind you of the Senior Residents Conference, which is geared to provide a better understanding of what to expect for life after residency. Important presentations offered through the Senior Residents Conference include the ABPS Message to Future Plastic Surgeons; How to Build a Practice; How to Read a Profit and Loss Statement; Starting a Family While Being a Plastic Surgeon; Contract Negotiations; Telemedicine in Plastic Surgery; and How to Set Your Cosmetic Fees. Also be sure to view the Residents Bowl: With the field of play open to 32 teams, it will be exciting to see who will unseat 2019 Residents Bowl Champion Mount Sinai. (For information on the virtual Senior Residents Conference, please turn to the notice located on the last page of this issue.)

In this issue, Wendy Chen, MD, MS; John Henry Pang, MD; and Paris Butler, MD, MPH; highlight gender, race and sexuality disparities within our own specialty, and provide data and voices for those who may have experienced such disparity in the past. Equally as important, they encourage all of us to be leaders in the charge to be better. Another piece, “Ordinary People in Ordinary Times,” written by Shuting Zhong, MD, documents how recent pop culture has influenced plastic surgery diversity initiatives. These pieces reinforce the need for what are often divisive and difficult conversations – but we cannot be better until after we endure such pain and discomfort. We’re proud to dedicate these pages to continuing the discussion.

We also highlight the efforts put forth by Eduardo Rodriguez, MD; J. Peter Rubin, MD, MBA; Justin Sacks, MD; and Ash Patel, MBChB; in contributing to a roundtable discussion of the effects of COVID-19 upon the current resident match cycle, as compiled by medical student Stav Brown and Francisco Egro, MD. As always, we thank our team of medical editors and the ASPS production staff for all of their hard work in bringing our PSTM20 issue of PSR to fruition.

Enjoy the read! |

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Plastic Surgery Resident | Fall 2020

Table of

Contents Recommendations for plastic surgery as U.S. healthcare struggles with diversity......................... 4 Efforts to right the wrongs of past approaches to staffing are welcome, but failing to reverse underrepresentation of neglected groups can threaten public health.

When events converge and conspire to recast the ordinary into the extraordinary......................9 A plastic surgery resident who collected oral histories of female plastic surgery leaders has seen the lessons learned when regular people work to effect change.

Consult Corner: Acute care of thermal burns.....................................................12 Because burns are seen in conjunction with trauma injuries, evaluating and treating this patient comes with several criteria – including close adherence to “the ABCs.”

Plastic Surgery Perspectives: The match cycle and ‘plastic surgeons to be’....................17

“PRS Resident Chronicles” presents a roundtable discussion featuring four program leaders who describe the match cycle for young surgeons in the COVID-19 era.

InService Insights: Facelift anatomy, pre-op eval, techniques, complications.... 20 The long history of multiple facelift-related factors makes it the perfect topic for InService Exam guidance and refresher information.

Journal Club: 10 articles on head and neck reconstruction....................22 Advances in treating head and neck cancers have been impressive, but their oncologic reconstruction continues to pose demanding challenges.

‘The Black Swans:’ The road to matching for international medical grads..........24 Regardless of the international program’s prestige or the student’s accomplishments, realistic chances for a U.S. match is seen as “almost impossible.”

Hot Topic in Plastic Surgery: Demystifying artificial intelligence......................................26

Plastic Surgery Resident | Fall 2020 | Vol.4 No.3 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 Lynn Jeffers, MD, MBA | LynnJeffersASPS@gmail.com EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.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 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

Artificial intelligence is new and seductive, and it carries infinite yet poorly defined opportunities. But what does it all mean?

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

Complex Case Challenge – Solved: How did he tackle this tough case?.....................................28

GR A PHIC DESIGN ER Elena Bragg

PSR Associate Editor Russell Ettinger, MD, reveals the choices and rationale behind the treatment of a newborn with multiple congenital anomalies.

Mentorship in plastic surgery is key; How can leaders lift their charges during a pandemic?....30 Two medical students highlight the role leadership plays in their growth and suggest ways to continue that during COVID-19 – including using the MENTOR way.

Managing patients with a complication involves more than simple tissue repair.............................32 To truly aid a patient in their recovery, plastic surgeons must include compassion, insist on continuity and bring their “A” game every time.

Resident Ambassador: We need your help more than ever.....................................35 Benjamin D. Schulz, MD, has seen how the COVID-19 pandemic is affecting plastic surgeons across the nation – and sounds the battle cry for support on Capitol Hill.

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.

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

Plastic Surgery Resident | Fall 2020

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If not now, when?

Why diversity is important in plastic surgery – and why it’s time for action

By Wendy Chen, MD, MS; John Henry Pang, MD; & Paris Butler, MD, MPH

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Plastic Surgery Resident | Fall 2020

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his has been a year unlike any other. An unprecedented global pandemic has laid bare unaddressed disparities across minority groups, disproportionately affecting Black and LatinX communities. Asian-Americans – including Asian physicians – experienced racist verbal abuse and violent attacks, exacerbated by political rhetoric. Videotaped hate-killings of Black people renewed Black Lives Matter and Black Trans Lives Matter activism. Most recently, #MedBikini demonstrated the persistence of sexist tropes within professional roles – a pointed statement on the importance of including diverse perspectives to avoid embarrassing, outdated gaffes.

That this pandemic started during Black History month, built steam through Asian Pacific American Heritage month and then barreled on through Pride month seemed to highlight the urgency of an intersectional reckoning with systemic inequality.

The ensuing, global response proves that pervasive structural, institutional and individual racism remain urgent barriers that must be dismantled, particularly by those in medicine and healthcare.

Other professions have already completed organized, wellfinanced strides to understand and fully utilize the benefits of diversity. Diversity has been proven to augment collective intelligence, creativity, innovation and problem-solving.

Even though diversity is expected to positively impact the U.S. healthcare system, multiple papers have concluded that continued under-representation of non-Caucasian/ non-Asian (NC/NA) groups will have a profoundly negative public health effect.i So where do we stand in plastic surgery?

FEMALE PLASTIC SURGEONS

Recent literature demonstrates the preference for female plastic surgeons by female patients, with data supporting better healthcare outcomes by female physicians. However, since its initiation in 1993, the Godina Fellowship microsurgery grant was awarded to a female recipient for the first time only three years ago. The American Association of Plastic Surgery Honorary Citation has never been given to a woman – in fact, since its founding in 1921, the organization has counted just two female presidents, in 2008 and 2018.

Since its founding in 1931, only three women have served as ASPS president, with the first woman of color (Lynn Jeffers, MD, MBA) serving this year.ii Carr, et al.,iii put forth the

notion that “increased number of women in medicine will eventually bring gender equality” – but it’s a sentiment held by men and not shared by women.

Within general surgery, Schroen et al.,iv found female faculty do not succeed at the same rate as men and must overcome a “cumulative career disadvantage,” due to a constellation of variables that include the sense of isolation; harassment; inadequate mentoring; and inadequate career advancement.

Data from 2016 show that women in medicine continue to earn less than men, with an increasing gap even after adjusting for covariates. Women also receive less institutional support than their male counterparts.v In addition, women have a higher rate of attrition in faculty positions. At the assistant professor level, women are almost six times more likely than their male colleagues to leave academia within two years. From 1994-2015, female general surgery faculty saw an annual increase of just 0.3-0.6 percent.

Based on the demonstrated rates of increase, the study postulated that it would take 49, 57 and 121 years for women to comprise 50 percent of, respectively, all assistant, associate and full professors.vi The field of plastic surgery demonstrates a similarly slow growth rate of female faculty, at less than 1 percent per year.vii Female trainees report feeling excluded from networking and career advancement, and their gendered experiences diminish their career goals and ambitions. As this disconcerting perception amplifies with age, the confidence to challenge this culture of inequity dwindles. In addition, when screened for anxiety, depression and post-traumatic stress disorder (PTSD), female trainees are more likely to experience multiple symptoms – including changes in mental health, social behaviors and the desire for or commitment of personal or professional harm.viii Unsurprisingly, women experience more symptoms of burnout.ix Given the physician suicide epidemic, this is a serious concern.

Furthermore, sexual misconduct persists in training.

In a 2018 survey, Chen et al., x found that one-third of current female trainees experience sexual comments about their bodies, 9 percent experience unwanted touching or sexual exposure and 4 percent experience sexual assault or coercion in offer for advancement. More than two-thirds of perpetrators are colleagues, attending physicians or other residents, while one-third are nurses, patients, staff and medical students. Victims are more likely to be minorities, and those minorities are less likely to feel prepared to address the misconduct.

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DIVERSITY / continued from previous page

ETHNIC UNDERREPRESENTATION

In terms of racial minority representation and advancement among plastic surgery faculty, Smith et al., xi noted a total +0.3 percent and +1.7 percent representation of Black and LatinX Americans over the course of 12 years, representing, alarmingly, no change. To put this in perspective, it would take more than 8,013 and 863 years for Black and LatinX Americans, respectively, to attain parity in academic plastic surgery.

Neither the ASPS or The PSF presidential positions have never been held by a Black or LatinX surgeon, nor has there ever been a Black or LatinX recipient of the Godina Fellowship or ASPS Honorary Citation. A review of all board members of national plastic surgery societies revealed only two NC/NA board members from a sample of 136. Of the 375 past presidents of these national societies, 96 percent have been Caucasian, 3.7 percent Asian, 0.3 percent LatinX – and none of other races. In terms of journal editorial boards, NC/NA members average 2.6 percent, and Black/LatinX members are represented in less than half (n=5) of the journals.xii Studies repeatedly show that relative to their majority counterparts, Black and LatinX Americans have poorer baseline health, inadequate health insurance and limited access to care.xiii These disparities are recapitulated in plastic surgery, breast reconstruction, burn care, cleft care, craniosynostosis, pediatric breast reduction and brachial plexus reconstruction.xiv The lack of minority representation in healthcare can compound these inequalities.xv Conversely, an underrepresented in medicine physician is an active member of their care team, minority patients have higher patient-reported outcome measures (PROMs), better compliance and an increased likelihood of participating in clinical studies.xvi This finding is recapitulated in plastic surgery patients.xvii

LGBTQ PLASTIC SURGEONS

Have you ever worried whether you might face physical harm in public based on your physical appearance or with whom you’re holding hands? Have you ever thought twice about talking about the love of your life in the O.R. or bringing him or her to the department holiday party?

In a survey presented at ASPS in 2018, 10.9 percent of plastic surgery trainees and 4.5 percent of plastic surgeons identified as LGB.xviii Ninety-five percent of LGB trainees disclosed their sexual orientation to some/all residents, whereas only 88 percent of LGB trainees did so with some/all attendings.

In the survey, 36 percent of LGB trainees reported purposely concealing their sexual orientation from either residents or attendings for fear of reprisal. At the time of interviewing in plastic surgery, 24 percent had been concerned that disclosure would risk acceptance, as 13 percent of LGB trainees reported being advised by faculty mentors to not disclose their LGB status during interviews.xix Most (93 percent) felt comfortable bringing their significant other (SO) to events with residents, though less feel comfortable bringing their SO to events with attendings (86 percent) or to formal events (79 percent).

Among the respondents, 13 percent of LGB faculty feel uncomfortable bringing their SO to department events regardless of attendees.

Why, in 2020, might this be? Eighteen percent of this cohort reported personally experiencing a direct homophobic remark from a resident, while 27 percent reported experiencing a direct homophobic mark from an attending. Five percent and 11 percent of LGB respondents reported differential treatment by residents and attendings, respectively. LGB respondents also reported hearing general homophobic remarks from nurses, residents and attendings at 62 percent, 38 percent and 34 percent, respectively (compared with rates of 25 percent, 18 percent and 17 percent by heterosexual peers).

Nineteen percent of LGB respondents reported witnessing discriminatory care of LGB patients or their partners, in contrast to just 6 percent of their heterosexual peers.

IT WOULD TAKE MORE THAN 8,013 AND 863 YEARS FOR BLACK AND LATINX AMERICANS, RESPECTIVELY, TO ATTAIN PARITY IN ACADEMIC PLASTIC SURGERY.” 6

Plastic Surgery Resident | Fall 2020

WHAT CAN WE DO?

Plastic surgeons are competitive, creative, innovative and constantly evolving. It leaves us to wonder why these disparities persist – and why clear data has not translated to more diversity, equity and inclusion (DEI). We can do better.

If, as Martin Luther King Jr., so eloquently and timelessly reminds us, “The arc of the moral universe is long, but it bends toward justice,” what are some actionable ways to keep us bending in the right direction?

1. Know that you are a leader Culture is defined by the members of that community. In choosing to become a physician and a surgeon, you have chosen to be a leader in your community. Who are you leading? Maybe it’s the medical student passing through the rotation or on your research team. Maybe it’s the junior residents on your service team or with you in the O.R. As a chief resident or junior faculty, you can speak up at grand rounds, at journal club, in the surgeon’s lounge, in the resident lounge or out with friends.

Remember: The burden to point out inequalities, to make change and to make space at the table for others lies with those who yield positions of power and privilege.

If you have a platform, use your privilege and opportunities to further those of others. Point out injustice and inequality. Your omissions are perceived as permissions, and the boundaries you set for professional, respectful behavior do not go unnoticed.

Just because you aren’t a program director or department head doesn’t mean you’re not a leader.

2. Start having difficult conversations Radically accept that your colleagues have had – and continue to have – different experiences than you. Have you ever been mistaken for the nurse? The custodian? Have you ever had your shoulders massaged while insetting a pec flap? Have you watched your attending prance and exaggerate hand gestures to mimic gay people? Have you ever worried that driving in from home call, with your white coat on, you might still get pulled over and have a potentially fatal encounter with law enforcement? Have you ever experienced workplace bullying? Start by simply asking someone different from you what their experience has been.

You’ll be surprised by what you learn. Ask. Listen.

3. Remember that no one’s perfect Everyone has implicit bias. Identify them and understand them (Harvard University Project Implicit), map your privilege and recognize microaggressions when they occur. Hold each other accountable in the moment. Ask, “What did you mean by that?” Role-model respectful discussion. Commit to candor.

We’re all on a journey with different starting points, and it’s OK to ask for help.

4. Educate yourself The last few years have seen greater interest in DEI publications. Not only can you look to medical education literature; there are numerous reading lists to understand the experience of your peers. Social media is a ready source of education and activism (@TimesUpPRS, @WOCPRS).

Your local university has dedicated offices to offer structured training and education (Title IX, Office of Diversity and Inclusion, etc). Remember, the burden to educate yourself and affect change doesn’t lie with your minority colleagues.

Do some homework.

THE TIME IS NOW

According to the U.S. Census, the nation is becoming increasingly diverse; 2030 is the first expected inflection point and the white population is expected to reach minority status by 2045. The observant plastic surgeon understands that a new era is imminent. According to a 2019 Pew Survey, the collective awareness of American businesses perceives this cultural shift, and most American people are similarly aware.

The time for plastic surgery to evolve and lead is now.

The argument for change and the need for evolution is undeniable.

Some individuals may explain away the lack of DEI by questioning the qualifications or interest of underrepresented minorities, but keep in mind this is a long-refuted and archaic argument – and it’s been disproven in plastic surgery.xx If you question the qualifications of minorities, chances are that you’re in a position of privilege. If you don’t understand the need to level the playing field to increase representation, it’s likely you don’t understand the historical context of opportunities (or lack thereof) for women, minorities and queer colleagues.

Instead of blaming maternity as a reason for gender disparity, let’s talk about incorporating and supporting parental leave and family planning.xxi Instead of blaming Black applicants for less publications, let’s talk about increasing sponsorship, inclusion and scholarships.xxii Plastic surgeons are innovators. We need only to look at our history: the first kidney transplant, the first free flap, the first wound VAC. Like any need that incites innovation and evolution, the current times call for our historically unyielding resolve, bravery, investment and persistence. Just as we apply the scientific method to our work, we must be systematic and relentless about our commitment to DEI. There’s no shortcut.

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DIVERSITY / continued from previous page

If not you, then who? If not now, then when? In this short article, we’ve presented data and some starting points you can implement today. As Maya Angelou says: “Do the best you can until you know better. Then when you know better, do better.”

It’s time to do better. | For more information, or to become involved in activism or research, please contact Dr. Chen at wendychenmdms@gmail.com; Dr. Pang at john.henry.pang@gmail.com; or Dr. Butler at paris.butler@ pennmedicine.upenn.edu.

REFERENCES i.

ii. iii. iv. v. vi.

vii. viii. ix. x. xi. xii.

xiii.

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Page SE. The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies-New Edition. Princeton University Press; 2008.

Sullivan LW. Missing persons: minorities in the health professions, a report of the Sullivan Commission on Diversity in the Healthcare Workforce. 2004.

Grumbach K, Coffman J, Muñoz C, Rosenoff E, Gándara P, Sepulveda E. Strategies for Improving the Diversity of the Health Profession. San Francisco, CA: University of California, San Francisco; 2003.

Nivet MA. Minorities in academic medicine: Review of the literature. Journal of Vascular Surgery. 2010;51(4):S53-S58.

Chen W, Baron M, Smith D, Washington KM, Delacruz C. A Report on the Representation of Women in Academic Plastic Surgery Leadership. Accepted July 2019 Plast Reconstr Surg.

Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the national faculty study. J Women’s Health. 2015; 24(3): 190-199.

Schroen AT, Brownstein MR, Sheldon GF. Women in Academic General Surgery. Acad Med. 2004; 79: 310 –318.

Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the national faculty study. J Women’s Health. 2015; 24(3): 190-199.

Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016; 212(4): 566-572. e1.

Chen W, Baron M, Smith D, Washington KM, Delacruz C. A Report on the Representation of Women in Academic Plastic Surgery Leadership. Accepted July 2019 Plast Reconstr Surg.

Chen W and Schilling BK, Bourne DA, Myers SP, Delacruz C. National Survey of Plastic Surgery Trainees: Status of Gender Bias and Sexual Misconduct. Accepted to PRS May 2020.

Stanford Burnout Survey, unpublished data.

Chen W and Schilling BK, Bourne DA, Myers SP, Delacruz C. National Survey of Plastic Surgery Trainees: Status of Gender Bias and Sexual Misconduct. Accepted to PRS May 2020.

Smith BT, Egro FM, Murphy CP, et al. An Evaluation of Race Disparities in Academic Plastic Surgery. Plast reconstr Surg. 145: 268-277. 2020.

Chen W and Lee P, Hall JA, et al. Quantifying the Pipeline of Ethnically Under-Represented In Medicine (UIM) Physicians in Academic Plastic Surgery Leadership. University of Pittsburgh Medical Center Department of Plastic Surgery Resident Research Day. June 2020. Poster presentation.

Williams DR. Miles to go before we sleep: racial inequities in health. J Health Soc Behav. 2012;53(3):279-295.

Sohn H. Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course. Popul Res Policy Rev. 2017;36(2):181-201.

Plastic Surgery Resident | Fall 2020

xiv. Offodile AC, 2nd, Tsai TC, Wenger JB, Guo L. Racial disparities in the type of postmastectomy reconstruction chosen. J Surg Res. 2015;195(1):368-376.

Soni SE, Lee MC, Gwede CK. Disparities in Use and Access to Postmastectomy Breast Reconstruction Among African American Women: A Targeted Review of the Literature. Cancer Control. 2017;24(4):1073274817729053.

Nayyar A, Strassle PD, Reddy KG, et al. Variations in the utilization of immediate post-mastectomy breast reconstruction. Am J Surg. 2019;218(4):712-715.

Sergesketter AR, Thomas SM, Lane WO, et al. Decline in Racial Disparities in Postmastectomy Breast Reconstruction: A Surveillance, Epidemiology, and End Results Analysis from 1998 to 2014. Plast Reconstr Surg. 2019;143(6):1560-1570.

Tan KT, Prowse PM, Falder S. Ethnic differences in burn mechanism and severity in a UK paediatric population. Burns. 2012;38(4):551-555.

Abbott MM, Kokorowski PJ, Meara JG. Timeliness of surgical care in children with special health care needs: delayed palate repair for publicly insured and minority children with cleft palate. J Pediatr Surg. 2011;46(7):1319-1324.

Wu RT, Peck CJ, Shultz BN, Travieso R, Steinbacher DM. Racial Disparities in Cleft Palate Repair. Plast Reconstr Surg. 2019;143(6):1738-1745.

Shweikeh F, Foulad D, Nuno M, Drazin D, Adamo MA. Differences in surgical outcomes for patients with craniosynostosis in the US: impact of socioeconomic variables and race. J Neurosurg Pediatr. 2016;17(1):27-33.

Soleimani T, Evans TA, Sood R, et al. Pediatric reduction mammaplasty: A retrospective analysis of the Kids' Inpatient Database (KID). Surgery.

2015;158(3):793-801.

Bucknor A, Huang A, Wu W, et al. Socioeconomic Disparities in Brachial Plexus Surgery: A National Database Analysis. Plast Reconstr Surg Glob Open.

2019;7(2):e2118. xv. Ashton CM, Haidet P, Paterniti DA, et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18(2):146-152. xvi. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.

Laveist TA, Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 2002;43(3):296-306.

Thornton RL, Powe NR, Roter D, Cooper LA. Patient-physician social concordance, medical visit communication and patients' perceptions of health care quality. Patient Educ Couns. 2011;85(3):e201-208.

Branson RD, Davis K, Jr., Butler KL. African Americans' participation in clinical research: importance, barriers, and solutions. Am J Surg. 2007;193(1):32-39; discussion 40.

Hughes TB, Varma VR, Pettigrew C, Albert MS. African Americans and Clinical Research: Evidence Concerning Barriers and Facilitators to Participation and Recruitment Recommendations. Gerontologist. 2017;57(2):348-358 xvii. Silvestre J, Abbatematteo JM, Serletti JM, Chang B. Racial and Ethnic Diversity Is Limited for Plastic Surgery Clinical Trials in the United States. Plast Reconstr Surg. 2016;137(5):910e-911e. xviii. Reghunathan M, Blum J; Gosman A; Butler P; Chen W. Trends in Diversity and Inclusion Publications: How Does Plastic Surgery Compare to Other Surgical Subspecialties? University of Pittsburgh Medical Center Department of Plastic Surgery Resident Research Day. June 2020. Poster presentation. xix. Pang JH, Fishman JE, Egro F, Zhu X, Losee JE, Nguyen VT. Abstract: Perceptions of LGBT Members in Plastic Surgery. Plast Reconstr Surg Glob Open.

2018 Sep; 6(9 Suppl): 224-225. xx. Butler PD, Aarons CB, Ahn J, et al. Leading from the front: An approach to increasing racial and ethnic diversity in surgical training programs. Ann Surg 2019; 269:1012–1015. xxi. 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.

Chen W, Beverley R, Katari S. Preserving Fertility During Plastic Surgery Residency. Cover article PSN Plastic Surgery Resident Magazine- Summer 2019. xxii. Chen W and Lee P, Hall JA, et al. Quantifying the Pipeline of Ethnically Under-Represented In Medicine (UIM) Physicians in Academic Plastic Surgery Leadership. University of Pittsburgh Medical Center Department of Plastic Surgery Resident Research Day. June 2020. Poster presentation.

Abelson A, Symer M, Yeo HL et al. Surgical time out: Our counts are still short on racial diversity in academic surgery. Am J Surg. 2018 Apr;215(4):542-548.

Ordinary people, extraordinary times

Pop culture’s influence on plastic surgery diversity initiatives

By Shuting Zhong, MD The story of building diversity and inclusion within plastic and reconstructive surgery can be told in two ways: • •

Via an Excel spreadsheet of graphs plotting the number of people of varying sex, race, age and religious affiliation showing trends across time; Or… Via a collection of singular events spurred by ordinary citizens who’ve altered the course of history.

This article follows the second option, because statistics only tell half the truth.

THE POWER OF AN IMAGE

Where were you on March 1, 2018? For Parker Curry, a 2-year-old girl visiting the National Portrait Gallery in Washington, D.C., this day proved pivotal. In a moment’s flash, a photograph taken by North Carolina resident Ben Hines – an amateur photographer – propelled this toddler to international stardom and led her to the opportunity to dance in the White House. The unfolding of this extraordinary day is now retold in Parker’s first book, Parker Looks Up, published when she was age 4, making her the youngest author on The New York Times Bestseller list.1 More than a century ago, Oscar Wilde reflected that “life imitates art,” a statement exemplified by the viral photo of a little girl transfixed and a testament to the power of representation.2 The sensationalist reaction to the image of Parker gazing at the larger-than-life-sized portrait of formally attired former First Lady Michelle Obama is a culmination of several major sociopolitical movements in the last decade.

Lean In, Black Lives Matter, Women’s March on Washington, MeToo and TIME’S UP are just a few examples of how historically marginalized groups have organized in response to pervasive social injustices. Not surprisingly, these campaigns are all spearheaded by women.1-7 Millions of Americans – including four women – in March 2013 watched on TV the acquittal of George Zimmerman, who was on trial for the murder of Trayvon Martin, a 17-yearold Black youth. Alicia Garza, a 39-year-old activist, angered by the acquittal and fearing for the future of her own brother,

The Facebook photo of Parker Curry, posted by Ben Hines; the book Parker had published two years later.

posted on Twitter: “I continue to be surprised by how little Black lives matter… .” Her friend and LGBTQ activist, 37-year-old Patrisse Cullors, honed-in on the last three words of Garza’s post – Black lives matter – and wrote to Garza this ordinary question: “Black lives matter campaign, can we discuss?” An idea between two friends turned into the hashtag #BLM. With the help of 35-year-old Nigerian immigration activist Opal Tometi, #BLM became an international campaign to bring the hidden reality of racial violence to mainstream media.3,4,7 The tragedy of and resulting public outcry surrounding Trayvon Martin’s trial inspired April Reign, a Black attorney, to quit law and embrace social justice as a writer, activist and speaker. In 2014, Reign successfully halted a promotional boxing match between the acquitted George Zimmerman and rapper DMX after she launched the #StopTheFight campaign.

One year later, Reign broadened her advocacy lens to focus on representation of people of color in film, with the hashtag Plastic Surgery Resident | Fall 2020

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EXTRAORDINARY TIMES / continued from previous page “#OscarsSoWhite they asked to touch my hair” in response to the predominantly white Oscar nominee list. Reign’s criticism of the homogenous profile of Academy members – 92 percent male and 86 percent white – prompted the Academy to launch an unprecedented campaign to diversify its membership by 2020, which is now slightly more diverse (68 percent male, 84 percent white)4.

WOMEN MARCH INTO HISTORY

By 2017, the legacy of Trayvon Martin’s death and the rising momentum of the Black Lives Matter movement emboldened women’s voices and outreach nationwide across a diverse array of topics. A retired lawyer, Theresa Shook, created a Facebook page asking friends to protest the election of Donald Trump. Shook didn’t know the women of the Los Angeles knitting group that created the famed “pink p---yhats,” but together they inspired the largest, single-day protest in U.S. history: the Women’s March on Washington.

TIME’S UP, PRS STYLE

Two years after the photo of Parker Curry went viral, TIME’S UP came to plastic surgery in the form of an 10

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Protestors march in the Woman’s March on Washington D.C. on Jan. 21, 2017.

Instagram platform: TIME’S UP PRS, which was created by ASPS Active Member Wendy Chen, MD, and launched March 2. TIME’S UP PRS shares intimate profiles of underrepresented plastic surgeons of diverse backgrounds, and the hardships encountered and overcome by marginalized individuals, with the goal of creating an equitable work environment for plastic surgeons of all backgrounds, free from discrimination and harassment.8 In the midst of a global COVID-19 lockdown, TIME’S UP PRS is forging a virtual community of surgeon activists, role models, allies, trainees, students and mentees – one unique story at a time.

One of the early posts on TIME’S UP PRS are excerpts from an interview series I co-produced with Allergan, “LIMITLESS: Inspiring Stories for Future Leaders in Plastic Surgery.” Curious about the history

PHOTOS: WIKIMEDIA/ TECH. SGT. DANIEL GAGNON, FACEBOOK

While 7 million women marched for women’s rights the day after President Trump’s inauguration, females everywhere were chiming-in against sexual harassment in the simultaneously growing #MeToo movement.5-6 Inspired by the outpouring of women’s experiences with discrimination, two attorneys – Tina Tchen, former chief of staff for Michelle Obama, and Roberta Kaplan, a LGBT Columbia law professor – co-founded the legal defense fund of TIME’S UP, a movement against sexual harassment that has effected lasting change. TIME’S UP is now challenging the status quo in politics, tech, healthcare and media, with more than 800 volunteer attorneys backed by the legal defense fund that’s now worth more than $22 million.6

REFERENCES 1.

2.

3.

Alicia Garza

Opal Tometi

April Reign

4.

5.

Teresa Shook

Wendy Chen, MD

of women plastic surgeons, I created LIMITLESS to collect of oral histories of female plastic surgeons who’ve served as presidents within national plastic surgery organizations.9 (To view “LIMITLESS,” go to plasticsurgery.org/WPS.) I’m emboldened by the examples set by the women founders and grassroots activists. Despite struggling with the time and monetary restraints of a surgical resident, I’ve chosen to participate in the national dialogue.

The idea to create LIMITLESS was solidified when I watched Alicia Garza lecture in Chicago, where she retold her journey of growing Black Lives Matter into a campaign. LIMITLESS took shape as I watched millions of women mobilize on the streets of Washington, D.C., fueling a momentum to act – until finally, LIMITLESS became a reality, perfectly coinciding with the debut of TIME’S UP PRS in conjunction with Women’s History Month in March.

Tina Tchen

Although Dr. Chen and I have not yet met in person, our shared goals to promote diversity within plastic surgery have brought us together. When I’m distressed by the slow pace of progress or intimidated by the sheer effort required to make a noticeable change, I’m reminded of a few names: Alicia Garza, Opal Tometi, Patrisse Cullors, Teresa Shook, April Reign, Tina Tchen, Roberta Kaplan and Dr. Chen. (Tina Tchen’s photo is courtesy of Time's Up.) These women have taken on an extraordinary mission.

Embrace their example – discuss, ask “what if?,” share a photo, an idea or a phrase. Sometimes a seemingly ordinary act can lead to extraordinary results. | Dr. Zhong is PGY-5 in the Division of Plastic and Reconstructive Surgery at the University of North Carolina School of Medicine, Chapel Hill.

6.

7.

8.

9.

How Michelle Obama Inspired 4-Year-Old Parker Curry to Become NYT Bestselling Author. Posted Nov. 13, 2019. https://www.youtube.com/ watch?v=0abXurCSJH8 The Westologist Cultral Insight.

Oscar Wilde-Life Imitates Art. Retrieved Aug. 19, 2020. http:// www.thewestologist.com/ideas/ when-life-imitates-art King, J. #blacklivesmatter: How Three Friends Turned a Spontaneous Facebook Post into a Global Phenomenon.

Retrieved Aug. 19, 2020. https://stories.californiasunday. com/2015-03-01/black-livesmatter/ Noveck, J. (Dec. 24, 2019). Pop Culture in 2010s Mark Gains in Diversity, Inclusion. Retrieved Aug. 20, 2020. https://abcnews. go.com/Entertainment/ wireStory/pop-culture-2010smarked-gains-diversityinclusion-67918391 Reimel, E; Arneson, K. ( Jan. 22, 2017). Here’s the Powerful Story Behind the Pussyhats at the Women’s March. Retrieved Aug. 20, 2020. https://www. glamour.com/story/the-storybehind-the-pussyhats-at-thewomens-march Langone, A. (March 22, 2018). #MeToo and Time’s Up Founders Explain the Difference Between the 2 Movements – And How They’re Alike. Retrieved Aug. 20, 2020. https://time.com/5189945/whatsthe-difference-between-themetoo-and-times-up-movements/ Jackson, S; Bailey, M; Welles, B. ( June 5, 2020). Trayvon Martin and the Hashtag Campaign That Set the Stage for Black Lives Matter.

Retrieved Aug. 19, 2020. https://thereader.mitpress.mit. edu/trayvon-martin-hashtagblack-lives-matter-movement/ TIME’S-UP/PRS Instagram.

Retreived Aug. 19, 2020. https://www.instagram.com/ timesupprs/?hl=en LIMITLESS: Inspiring stories for future leaders in plastic surgery. ASPS Women Plastic Surgeons Forum. Retrieved Aug. 19, 2020. https://www. plasticsurgery.org/for-medicalprofessionals/community/womenplastic-surgeons-forum

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Acute Care of Thermal Burns “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 Sofia Aronson, MD, & Aaron Kearney, MD

You’ve settled into your favorite chair and have opened the book you’ve been waiting to read when you receive a page from the E.D.: A patient has just presented with a burn injury. How should you evaluate and treat this patient?

INITIAL EVALUATION THE ABC’s Burns are often seen along with traumatic injuries. Trauma ABC’s and adjuncts should be evaluated and intervened upon if appropriate.

Airway, Breathing Burn patients may suffer acute respiratory failure due to inhalation injury and/or the impending high-volume fluid resuscitation required for extensive burns. Inhalation injury and fluid resuscitation both can result in airway edema that progresses during the first few hours after injury and may result in catastrophic loss of airway patency – and difficult, if not impossible, oral intubation. Early intubation should be considered in patients with suspected inhalation injury (criteria detailed below) or with extensive burns of less than 40 percent total body-surface area (TBSA) in anticipation of a large volume of resuscitative fluid.

Inhalation Injury Inhalation injuries are caused by three distinct mechanisms: inhalation of superheated air, causing thermal damage and edema of the upper airway; toxic byproducts of fires/chemicals inhaled 12

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into the deeper airways, resulting in chemical pneumonitis; and carbon monoxide (CO) toxicity. Inhalation injuries should be suspected for burns that occur in enclosed spaces, and when the exam reveals intraoral or extensive facial burns; singed facial or nasal hairs; soot in airways or sputum; upper-airway edema; hoarseness/stridor; accessory muscle use/sternal retractions; respiratory fatigue; or altered mental status. Confirmation or evaluation of the extent of inhalation injury is performed via nasopharyngoscopy or fiberoptic bronchoscopy.

Early intubation should also be considered in patients with dysphagia – or those undergoing transfer to a burn center by transporters without the qualified training or resource availability to allow for intubation in route.

Chemical Pneumonitis Patients intubated for acute respiratory failure due to chemical pneumonitis should be managed with lung-protective ventilation (higher PEEP, FiO2 ≤ 60 percent) and airway-clearance therapy.

Carbon Monoxide Toxicity CO has a greater affinity for hemoglobin than oxygen (O2) and displaces O2 from hemoglobin, which results in tissue hypoxia.

CO poisoning should be suspected in patients with altered mental status and cherry-red mucous membranes. Oxygen desaturation is often not observed on pulseoximetry because the apparatus cannot differentiate between hemoglobin molecules carrying O2 vs. CO. Carboxyhemoglobin levels should be checked, with goal levels <7 percent. Treatment of CO toxicity is with 100 percent FiO2 to decrease the half-life of CO from four hours to one hour.

Circumferential Chest or Abdominal Burns Circumferential or near-circumferential burns of the chest and abdomen must be assessed for restricted chest expansion leading to acute respiratory failure. Elevated peak pressures >30 cmH 2O may be observed in ventilated patients. In circumferential burns of the abdomen, abdominal compartment syndrome may be suspected if urine output declines due to hypoperfusion of renal vasculature; bladder pressure which can be transduced via a Foley catheter will become elevated > 30 mmHg; and ventilation may be compromised due to pressure on the diaphragm. These patients are managed with releasing incisions called escharotomies, described below (Figure 1).

Circulation Intravenous Access IV access is necessary for timely initiation of fluid resuscitation, administration of analgesics and other medications, and lab draws. Large bore (16-18 gauge) IVs should be used. Medium sized veins (i.e., antecubital or more proximal) are preferred given they are less susceptible to turbulent flow with high infusion rates. Burned tissue should be avoided if possible, due to progressive edema and the high risk of IVs becoming dislodged. Circumferential IV dressings should be avoided to prevent a tourniquet effect as tissue edema progresses. If central access is indicated, early placement is beneficial before edema obscures landmarks in the neck, chest or groins.

Circumferential Extremity Burns Circumferential or near-circumferential burns of the extremities may result in neurovascular compromise due to a restrictive pathology. Likewise, the penis may also be involved in circumferential burns and could be neurovascularly compromised. If compromise is suspected due to pain, parasthesias, weakness or weak/absent pulses, escharotomies must be performed immediately (Figure 1), as this may progress to compartment syndrome with greater morbidity and may require fasciotomies.

Escharotomies for Circumferential Burns An escharotomy is a full-thickness incision that bridges healthy tissue to healthy tissue, and spanning the full length of a circumferential or near-circumferential burn; it extends to underlying subcutaneous adipose tissue with the aim of releasing restriction on the chest, abdomen, extremity or penis.

Incisions should be made with monopolar electrocautery and do not require anesthesia, as full-thickness burns will be insensate.

• • •

Chest and abdomen: mid-axillary and transverse incisions across the chest or abdomen Limbs: medial and lateral axes of the affected extremity Penis: oriented longitudinally along the mid-dorsal line; foreskin should be placed over the glans to avoid pseudophimosis; additionally, early placement of a Foley catheter prevents post-obstructive uropathy due to progressive penile edema.

Figure 1. Burn escharotomies: An example of how to orient incisions.

Resuscitation Burn patients experience significant insensible fluid losses due to a violation of the normal, protective skin barrier and thus require fluid resuscitation that corresponds to the extent of injury. The volume of fluid required for burn resuscitation in the first 24 hours after injury can be estimated by the formulas below (adapted from the well-known Parkland formula). Half of total fluid is given in the first eight hours after the burn, and half in the next 16 hours.

TBSA < 20 percent • Maintenance IVF until able to take adequate oral hydration TBSA ≥ 20 percent and weight ≥ 30kg • 24-hour fluid requirement = 2-4 cc x % TBSA x weight in kilograms TBSA ≥ 20 percent and weight < 30kg • 24-hour fluid requirement = 3-4 cc x % TBSA x weight in kilograms • In addition to resuscitative fluid, add maintenance IVF • Maintenance IVF 24-hour total: › 100 cc / first 10 kg of body weight › 50 cc / next 10 kg of body weight › 20 cc / remaining 10 kg of body weight • In patients ≤1 year, D5LR is used as the maintenance IVF. Over- and under-resuscitation are both associated with morbidity.

Fluid status should be assessed hourly in critically ill patients.

Volume overload increases risk of respiratory complications (ARDS, prolonged ventilator dependence) and increases tissue edema with greater tissue loss or need for escharotomies/ fasciotomies. Under-resuscitation contributes to acute kidney injury and hypoperfusion of peri-viable tissue, with greater tissue loss.

Assessing Volume Status • A Foley catheter is often placed for patients with extensive burns to allow titration of resuscitative fluids to goal urine output. › 0.5 mL/kg/h in adults › 1 mL/kg/h in children › Urine output may lag initially, so if other parameters are improving, it’s prudent to wait a few hours before increasing the rate of resuscitative fluids if all other parameters are improving.

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CONSULT CORNER / continued from previous page

•

•

• If urine output is < goal, rate of LR infusion should be increased by 1/3 of the calculated hourly requirement.

• If urine output is >> goal, urine should be checked for glucosuria and rate of LR infusion should be decreased by 1/3 of the calculated hourly fluid requirement.

• In patients with comorbid kidney disease, urine output may not be a reliable metric.

An arterial line may be useful in patients who require massive resuscitation, to allow frequent lab monitoring – specifically evaluating for closure of base deficit, clearance of lactic acidosis and improvement in pH during fluid resuscitation. Additionally, ventilated patients benefit from blood-gas analysis to modulate ventilator settings and monitor progress or when working up clinical deterioration.

Swan Ganz catheter placement may be considered in patients who are intubated with TBSA ≥ 30 percent, age >50 years, or inhalation injury.

• If a patient has UOP < goal and normal central pressures, this indicates adequate volume resuscitation but with residual vasoplegia ›› start low dose Dobutamine at 5 mcg/kg/min and titrate to goal UOP, reassessing volume status regularly.

• If a patient has UOP < goal and low central pressures, this indicates need for continued volume resuscitation and resuscitative fluid rate should be adjusted accordingly.

After 24 hours, continue titrating to previously described urine-output goals, now aiming to maintain euvolemia.

Ideally, the infusion rate should be decreased by 50 percent from the first 24 hours to avoid complications associated with volume overload, but if the fluid requirement remains high, consider transition to 5 percent albumin. Serum Na+ and K+ should be checked the second day after injury and fluids adjusted accordingly to maintain normal Na+ level.

DISABILITY A neuro exam, usually involving exam of the pupils and completion of the Glasgow Coma Scale, should be performed to identify deficits and assess changes in mental status – which may be present in patients with trauma, shock, substance use and carbon monoxide poisoning among other etiologies.

Patients with GCS ≤ 13 require cross-sectional brain imaging, and patients with GCS ≤ 8 warrant intubation for airway protection.

Facial burns should prompt early ophthalmologic evaluation. A fluorescein exam may be done to assess for corneal injury, and intraocular pressure should be determined.

Exposure It’s imperative that any thermal/chemical stimuli are removed during initial assessment to prevent progression of the burn and to fully assess the extent of injury.

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Figure 2. Lund Browder Diagram of adult patient for calculating TBSA by anatomic region involved; table above with modifications for pediatric patients.

Depth of Burn Burns of different depths result from different mechanisms of injury; variable durations of exposure to thermal insult; appear differently on physical exam; and necessitate different management from conservative to operative. Some burns don’t immediately “declare” the full severity of injury; for example, splash burns can initially appear to be superficial but may progress to superficial partial-thickness burns with blistering over the first 24-48 hours.

TBSA Calculation TBSA is calculated from skin involved in partial- and fullthickness burns and is used to guide initial fluid and nutritional requirements. Pediatric patients have a greater ratio of TBSA to mass and have higher resuscitative requirements, while patient of larger body habitus have been shown to require less initial resuscitative fluid but experience higher mortality rates. The Lund Browder diagram (Figure 2) may be used for more precise TBSA calculations. Rougher estimates may be made by applying the “Rule of 9’s” which allots multiples of 9 percent TBSA to anatomic regions (Figure 3), or the “Rule of Palms” which estimates that the palm of the hand is 0.5 percent TBSA or the palmar surface of the hand including digits approximates 1 percent TBSA (Figure 4).

More precisely, in men, the whole palmar-surface of the hand is 0.8 percent; in women, 0.7 percent.

continued on page 16

Table I. Depth of Burns

CRITERIA FOR TRANSFER TO A BURN CENTER

FIRST DEGREE

SECOND DEGREE

Superficial

Superficial Partial-Thickness

• Involve epidermis only • Akin to sunburns • Exam: skin is hyperemic, blanching, painful/ tender to palpation, no blisters • Heal without surgical intervention • Moisturize injured skin

• Involve papillary dermis • Exam: skin blistering is present (intact or ruptured); raw surfaces are red, blanching, painful/tender to palpation because sensory nerves intact • Expected to heal without surgical intervention in 10-28 days • Managed with local wound care (i.e., silver sulfadiazine)

Most burns can be managed outpatient or by a non-specialized hospital.

However, initial evaluation and stabilization of a burn patient may indicate that immediate or subacute transfer to a burn center is warranted.

The following guidelines have been established by the American Burn Association: •

Partial-thickness burns >10 percent TBSA in patients <10 years or patients >50 years

•

Partial-thickness burns > 20 percent TBSA in any patient

•

Full-thickness burns of any size in any patient

•

Burns involving the face, hands, feet, genitalia/ perineum or joints

•

Electrical or chemical burns, including lightning

•

Inhalation injuries

•

Burns in patients with comorbidities that could impact morbidity and mortality, including hospital length of stay

•

Any patients with concomitant traumas in whom the burn injury poses the greater risk to morbidity and mortality

•

Pediatric burn patients at hospitals without pediatric-care capabilities

•

Patients requiring assistance from social, emotional or long-term rehabilitative services

Blister intact

2

Blister unroofed

1

3

THIRD DEGREE Deep Partial-Thickness • Involve reticular dermis and skin appendages • Exam: wound is white and non-blanching (dermal capillaries lost, no cap refill), decreased sensation, moderately painful/ tender due to loss of skin appendages (including sensory structures) • Heal in 3-8 weeks with severe hypertrophic scarring • Require surgical management to heal within acceptable time frame and to minimize morbidity

Full-Thickness • Involve subcutaneous tissues (if muscle, bone, etc., involved, it may be referred to as fourth-degree burns) • Exam: white, dry, leathery or may show immediate eschar formation, not painful (due to destruction of sensory nerves) • Do not heal on their own and require surgical debridement and closure or coverage

White, dry, leathery skin

5

6

Dark leathery eschar

4

A necessary transfer should follow immediately after all life- and limb-threatening injuries are addressed. Time should not be wasted on burn dressings, given that the burn center will have to reassess injuries. Patients should be covered with a clean plastic sheet to avoid insensible fluid losses if possible, or with clean warm linens.

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CONSULT CORNER / continued from previous page WOUND CARE Non-viable tissue should be debrided at bedside. Topical antimicrobials should be used to dress wounds to help prevent insensible losses and decrease risk of wound infections and burn sepsis. Options are described here: •

•

•

•

•

Bacitracin ointment › Gram-positive coverage › Penetrates eschar › Safe around eyes

Silvadene ointment › Gram-positive and negative coverage › Poor penetration of eschar › Unsafe near eyes, in patients with sulfa allergies › May cause neutropenia

Sulfamylon ointment › Gram-positive and negative coverage › Penetrates eschar › Excellent cartilage penetration › May cause hyperchloremic acidosis when used for extensive burns; limit to use on <20 percent TBSA Silver Nitrate solution › Gram-positive and negative coverage › Poor penetration of eschar › May cause hyponatremia

Acticoat sheets › Silver impregnated dressing › Sterile water should be applied if the dressings dry out › Change sheets every three days › Glove configuration for hand burns

Debridement and Grafting Definitive debridement and grafting/closure of burn wounds in the O.R. usually follows resuscitation within 2-4 days of injury, although some have advocated for debridement and grafting in the acute phase to halt progression of systemic inflammation by removal of the inciting stimulus (i.e., the injured tissue).

Burns are debrided with tangential or fascial excisions, depending on the depth of injury. As with any debridement, the wound bed should be debrided to clean, healthy, bleeding tissue, layerby-layer in the case of tangential excision. Large burns require a staged approach given paucity of available donor sites for skin grafting. Areas unable to be autografted initially may be temporarily covered with cadaveric skin-grafts or burn dressings with later staged autografting.

Most burns may be covered with split-thickness skin grafts.

Meshing is reserved for non-joint surfaces where scar contracture would not cause significant morbidity. Sheet grafts are used for functionally and aesthetically sensitive areas such as joints, hands, feet, face, breasts and genitals. Early full-thickness autografts, if donor skin is available, are useful for eyelid burns to prevent ectropion. Burns with small areas of cartilage exposure (i.e., ears) 16

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Figure 3. Rough estimate of TBSA using the rule of 9’s.

may be appropriate for cartilage debridement to allow healing by secondary intention, whereas large areas of exposed cartilage require vascularized coverage prior to grafting. Burns of hands should be splinted in intrinsic plus, with the thumb abducted to prevent contracture. K-wire intrinsic plus fixation may be used in patients with tendon exposure. Passive range-of-motion exercises should be performed at least twice daily for any non-fixated joints to prevent stiffness. Feet are managed similarly.

NUTRITION Patients with burns ≥20 percent TBSA should have enteric feeding tubes placed as soon as possible to allow for supplementation, due to an increase in metabolic rate until wound healing is complete.

Dobhoff tubes are preferred, given that post-pyloric feeds do not require discontinuation in the perioperative period compared to nasogastric tubes.

The Curreri formula estimates daily caloric requirements: 24 hour caloric needs =

25 kcal x kg body weight 40 kcal x % TBSA

Intake should include 2.5-3 g/kg/day of protein for adults and 3-4 g/kg/day for children. | Dr. Aronson is PGY-3 at McGaw Medical Center of Northwestern University, Evanston, Ill.; Dr. Kearney is PGY-5 at McGaw Medical Center.

FIGURE AND IMAGE REFERENCES

Figure 1: Geary Philip M, Pape Sarah A. Combined Limb Escharotomy and Fasciotomy Following Delay in Surgery. Plast Reconst Surg, Dec 2005: 116, 7, 2057-2058.

Images 1, 4 and 5: Faulkner Heather R, Colwell Amy S, Liao Eric C, Winograd Jonathan M, William Jr G. Thermal Injury to Reconstructed Breasts from Commonly Used Warming Devices: A Risk for Reconstructive Failure. Plast Reconstr Surg, Oct 2016: 4, 10, e1033.

Images 2, 3 and 6: Marchalik Rachel, Rada Erin M, Albino Frank P, Sauerhammer Tina M, Boyajian Michael J, Rogers Gary F, Oh Albert K. Upper Extremity Friction Burns in the Pediatric Patient: A 10-Year Review. Plast Reconstr Surg, Dec 2018: 6, 12, e2048.

PL A S TI C SU RG E RY PE RS PEC TI V E S

PLASTIC SURGEON TO BE “Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by medical student Stav Brown at the Sackler School of Medicine at Tel Aviv University, Israel. Since our blog is still on temporary hiatus, I didn’t want this timely entry from Brown and Francesco Egro, MD, from the University of Pittsburgh (and a former PRS Resident Ambassador) to go unread. Please enjoy this roundtable interview in which Brown and Dr. Egro interview Eduardo Rodriguez, MD, DDS; J. Peter Rubin, MD, MBA; Justin Sacks, MD, MBA; and Ash Patel, MD, MBChB; on the effects of COVID-19 in the current match cycle.

Rod J. Rohrich, MD Editor-in-Chief Plastic and Reconstructive Surgery

Eduardo Rodriguez, MD, DDS Dr. Rodriguez is chairman of the Hansjorg Wyss Department of Plastic Surgery at New York University (NYU) Langone Medical Center.

J. Peter Rubin, MD, MBA Dr. Rubin is chair of the Department of Plastic Surgery at the University of Pittsburgh Medical Center (UPMC).

Justin Sacks, MD, MBA Dr. Sacks is division chief of Plastic and Reconstructive Surgery at Washington University in St. Louis.

Ash Patel, MD, MBChB Dr. Patel is division chief of Plastic Surgery at Albany Medical Center, New York.

WHO’S THE IDEAL CANDIDATE FOR A PLASTIC SURGERY RESIDENCY? Dr. Rodriguez: The ideal candidate is ethically sound and academically superior, has a solid research background and understands the culture, strengths and challenges of our program – and is ready to embrace them.

Dr. Rubin: We’re looking for self-starters and team players who have a natural sense of curiosity. Everyone who has made it this far in their medical careers has proven themselves to be intelligent. What really makes a difference in a successful plastic surgery career is having the initiative to continually explore every aspect of the complex problems that we encounter in plastic surgery and the rationale and execution of the solutions. That’s the only way you can understand the relevant issues of each case and design individualized solutions.

Moreover, we’re dedicated to training leaders in plastic surgery at the University of Pittsburgh, and we’re looking for people who are good communicators, enjoy working in a culture of collegiality and respect, and have a strong desire to contribute to our specialty.

Dr. Sacks: Many factors go into choosing a great plastic surgery resident. Some programs are academically inclined and some programs are clinically inclined. At Washington University (WashU) and Johns Hopkins, the programs are both clinically inclined and academically inclined, so we’re looking for people who look to be future leaders in plastic surgery – the best at clinical, educational and research components. Successful applicants have to do really well in medical school, 3rd year clerkship grades are important – they show that you can handle the stress of being in a clinical rotation – and academically it’s important to perform well on tests. Alpha Omega Alpha Honor Society (AOA) membership is looked at, as are USMLE scores, letters of recommendation and research papers (first/second author). Research can be clinical, translational or basic science, and it shows commitment and interest in the field. If you aim for these three things – clinical, educational and research excellence – your chorus starts to sing in a positive way.

Dr. Patel: There are many attributes that can contribute to someone being a successful plastic surgery resident and, in turn, a practicing plastic surgeon. I think it’s very important for a resident to demonstrate high emotional intelligence and humanism. This combined with honesty, persistence and a Plastic Surgery Resident | Fall 2020

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PLASTIC SURGEON TO BE / continued from previous page strong work ethic, in my opinion, make for an outstanding plastic surgery resident.

HOW HAS THE PANDEMIC INFLUENCED THE EDUCATION CURRICULUM IN YOUR DIVISION/DEPARTMENT? Dr. Rodriguez: With respect to didactics, they have been maintained either in person or virtually, and usually with a combination. Due to institutional mandates, we’ve had to curtail outside visitors, visiting professorships, etc.

Dr. Rubin: I believe we, like other plastic surgery programs, have been fortunate to have videoconferencing platforms that we can leverage for our regular conferences. The pandemic has really highlighted the evolving role of remote digital learning. Additionally, we’ve been very privileged to develop a “virtual” sub-internship that allows medical students from other universities to spend time with our residents and faculty in a structured program. This has been very well-received. Of course, we would rather have these bright students rotating with us on site and standing shoulder-to-shoulder in the O.R., but this still gives all of us a chance to interact and let students get a flavor for our residency program.

Dr. Sacks: I left Johns Hopkins after a decade and started at WashU in February. COVID-19 hit St. Louis in the middle of March. I was starting to integrate myself into the new division and I had to break down the way the division was working because we had to be in emergency mode. We had to make sure everyone had PPE and that the residents and faculty were safe. Just getting started in a new program and a new city where I didn’t know people would have been hard enough, but confronting COVID-19 challenged me to move into this new administrative mode really quickly. Everyday, we had multiple Zoom meetings and also a lot of visiting lectures from different parts of the country and the world. We usually have journal clubs on Monday nights and an academic day on Wednesday, so that branched out to other days. We’ve been doing visiting lectureships and online educational seminars with other programs – which I think is great; that will stay in the future, as well.

Dr. Patel: The pandemic made us transition to a largely teleconference-based format. We were forced to postpone any visiting professors, as well as cadaver labs and simulated patient sessions. The change to a teleconference format has allowed us to invite grand rounds speakers from around the country to share their expertise with our residents.

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AWAY ROTATIONS (OR SUB-INTERNSHIPS), ARE A GREAT OPPORTUNITY FOR APPLICANTS TO EXPAND THEIR PLASTIC SURGERY EDUCATION AND SKILLS, GET A SENSE OF PROGRAMS’ CULTURE, SHOWCASE THEIR ABILITY AT THEIR DESIRED RESIDENCY PROGRAMS AND ULTIMATELY SOLICIT LETTERS OF RECOMMENDATION. WHAT ADVICE DO YOU HAVE FOR CURRENT APPLICANTS INTERESTED IN MATCHING INTO A PLASTIC SURGERY RESIDENCY PROGRAM DURING THE COVID-19 ERA? Dr. Rodriguez: Sub-internships are a two-way street. The applicants get to know what we have to offer and they get a sense of the culture, the caseload, the teaching environments, the workload, etc. We get a sense of the applicant and, with crucial resident input, a sense of their potential “fit” with the program. Lack of in-person sub-internships will be a challenge. We’ve reached out to the non-NYU sub-internships previously selected and offered them mentorship at the resident and faculty level with identified members of our department.

With respect to advice, the usual USMLE scores, grades, research and letters will be looked at closely. The difference this year is that the applicants will do best to reach out to programs of interest directly and through their home faculty advisors.

Faculty who have graduated relatively recently and work at outside programs are also a great resource. The applicants need to inform themselves maximally about other programs – and when they narrow their choices, they likely should impart their interest to a limited number of select programs.

Dr. Rubin: The inability for students to do live, onsite awayrotations definitely hampers their ability to get to know the programs and impedes the ability of the program to see how the students function in their system. As I mentioned above, this is an opportunity to make use of video-communication platforms so that students can interact with faculty and residents at other institutions.

Dr. Sacks: It’s unfortunate that this year will be affected in a significant way. Some programs are doing virtual subinternships, and that’s program specific. WashU will be hosting a two-day symposium with faculty and residents to highlight the program. As for virtual interviews, I believe it levels the playing field for everybody. You can present your CV, LORs and board scores, and then we can have an interview with you to get a sense of who you are as a candidate. You can also apply to many programs, because it’s very easy to do an online interview.

On a personal level, take a deep breath, be calm and present your true self – who you want to be, where you want to go and how you’re going to get there. Have your story set in your mind – who you are, how you got to that seat and why you want to be a plastic surgeon. It might be too soon right after

medical school to know who you want to be, but if you know that you want to be a plastic surgeon who operates from head to toe, someone who does both reconstructive and aesthetic work, that’s a great start. Make that connection with the interviewers, be ready to tell your story and tell people where you want to go and why the program you’re interviewing at will help you get there. To learn more about a program, reach out to that program, and contact residents and graduates of the program. Also take advantage of your network – faculty members who know you from previous interactions and previous work together.

Dr. Patel: Aside from reviewing program websites and social media, try to find out more about programs by talking to recent alumni from your medical school who may have rotated at different programs. It’s also worthwhile trying to contact residents at different programs to find out what attracted them to their program. I think that trying to find programs that resonate with you is very important, as every educational environment is different, and finding a program that has the best environment for you will allow you to be as successful as possible.

WHAT’S YOUR ADVICE FOR PROGRAMS REGARDING APPLICANTS’ SELECTION DURING COVID-19, WHILE AIMING FOR AN EQUITABLE, PLAUSIBLE RESIDENCYSELECTION PROCESS? Dr. Rodriguez: Programs need to be maximally active in terms of mentorship and guidance for their students. All things being equal, home students already have advantages at their programs. We aren’t convinced this will change much. Also, it’s the home students who will have much less exposure to other programs – and as a result they may be the driving force with respect to remaining at their institutions. We’ll likely do more personalized due-diligence with faculty at the outside applicant’s institutions.

Dr. Sacks: While many things will be different this year, clinical excellence, educational excellence and research excellence remain the most important components of a successful application. LORs from people who know applicants well are also critical.

Dr. Patel: This year is unprecedented and will force a huge departure from what we’re accustomed to. I think it’s important that every program be as prepared as possible and present as much helpful information as possible to applicants. Those of us who review applications will need to be as open-minded about each applicant as possible, as this year’s applicants have not had the same opportunities as those from prior years.

WHAT ARE THE ADVANTAGES OF A VIRTUAL PLASTIC SURGERY MATCH CYCLE? Dr. Rodriguez: That’s unclear, but it’s certainly a challenge – so in that respect, it will be a learning experience. Moreover, even when the pandemic is over, the switch to having virtual activities will have long-lasting impact; hybrid systems for didactics, interviews, meetings, etc. will likely persist. Having been there for the creation of these alternative methods of communication will be useful in an altered educational landscape.

Dr. Rubin: I’ll answer questions four and five together. Most certainly, there are advantages of a virtual match cycle, in that candidates can apply to other necessary expenses the multiple thousands of dollars they would’ve spent on travel. If anything, a virtual match cycle levels the playing field even more, because candidates don’t have the advantage of having done an away rotation add a program to which they have applied, and a limited travel budget won’t prevent anyone from interviewing at a specific program.

Prior to COVID-19, most of us would be reluctant to make residency selections entirely by video interviews. However, this is the situation at hand, and I have no reason to believe that it will be less-equitable than the pre-pandemic process. In our program, we will still do the initial screening of applications and the selection of the cohort to be invited for interviews as we’ve done in the past. The interviews themselves will, of course, be by video conference. If anything, I would expect that residency programs will have a higher acceptance rate for their interview invitations, because the candidates don’t have to travel.

Dr. Sacks: A virtual match cycle allows more qualified people to apply to many more programs – and for many programs to see many qualified people. It levels the playing field for many people.

The interview process will be easier and more comfortable for applicants when they’re at home, favoring people who are a little bit more nervous in an interview setting. Applicants won’t have to make a decision necessarily on finances and time, and they’ll have a great opportunity to have many programs look at them. Programs will have the opportunity to find candidates who might not have been seen because of other reasons and circumstances. Online interviews allow many people to be in many places quicker and easier, and information flows much faster. It makes it a more efficient marketplace for everyone – for both the “buyer” and the “seller.” Information becomes much more transparent and free-flowing in an online system.

Dr. Patel: The cost and time constraints related to travel for interviews has been eliminated. | Stav Brown is a medical student at Sackler School of Medicine, Tel Aviv, Israel; Dr. Egro is the administrative chief resident in the Department of Plastic Surgery at the University of Pittsburgh Medical Center, Pittsburgh.

Plastic Surgery Resident | Fall 2020

19

Facelift anatomy, pre-op eval, techniques and complications

By Nicholas R. Sinclair, MD

N

early 124,000 facelifts were performed in 2019

by ASPS members, according to the Society’s procedural statistics, which ranks it as the sixth most-performed aesthetic procedure. Its long duration in the Top 10 of the most-popular procedures mirrors its frequency in the In-Service/Self-Assessment Exam. As previous exam questions have focused on facial anatomy, preoperative evaluation, facelift techniques and management of common complications, this installment of InService Insights will revisit those areas in order to provide additional guidance.

PERTINENT ANATOMY

The face and neck are composed of continuous soft-tissue layers through which the branches of the facial nerve reliably cross. Immediately deep to the subcutaneous plane, the superficial fascia is known as the galea aponeurotica (scalp); temporoparietal fascia (lateral upper face); superficial musculoaponeurotic system/SMAS (midface and lower face); and platysma (neck). The deep fascia is known as the perisoteum (scalp); deep temporal fascia (lateral upper face); parotidmasseteric fascia (midface); and deep cervical fascia (neck).

All branches of the facial nerve run deep to the superficial fascia layer, making dissection in the subcutaneous plane safe. Outside of the parotid region, the branches of the nerve cross between the deep and superficial fascia, increasing the risk of injury. The frontal and marginal mandibular branches are the most feared during facelift surgery, due to their

20

Plastic Surgery Resident | Fall 2020

minimal cross-over with other branches. Injury to the buccal or zygmoatic branches is often clinically insignificant due to rich arborization.

The path of the frontal branch can be estimated by Pitanguy’s line, which courses from a point 0.5-cm inferior to the tragus to a point 1.5-cm superior to the lateral eyebrow. After crossing the middle-third of the zygomatic arch just above the periosteum, the rami cross from deep to the deep temporal fascia to a level immediately deep to the temporoparietal fascia.

The marginal mandibular branch exits the caudal aspect of the parotid gland and travels anteriorly. In 20 percent of patients, it will initially travel below the mandible. After passing superficial to the facial vessels, it’s always superior to the inferior mandibular border. It then continues anteriorly to innervate the depressor anguli oris (DAO) on its undersurface.

The cervical branch travels into the neck posterior to the gonial angle in a sub-platysmal plane. Cervical branch injuries can mimic marginal mandibular injuries, as both the platysma and the DAO depress the corner of the mouth. With cervical branch injury, however, lower-lip eversion will remain present through persistent mentalis muscle function.

The great auricular nerve (GAN) arises from the cervical plexus to provide sensory innervation to the earlobe. The GAN follows a parallel course posterior to the external jugular vein and crosses the mid-belly of the sternocleidomastoid muscle 6-7 cm below the external auditory canal (McKinney’s point).

PREOPERATIVE EVALUATION

COMPLICATIONS

The most important preoperative risk factor to identify is a history of hypertension, particularly poorly controlled hypertension, as this is a risk factor for hematoma. Cigarette smoking should be stopped at least four weeks prior to facelift surgery, as active smokers have a 12-fold increased risk for wound-healing complications.

To minimize wound-healing issues, thick skin flaps should be raised and minimal tension should be placed on the skin closure. Excessive tension around the lobule will lead to a pixie ear deformity, which is defined as an anterior-tethered appearance of the healed lobule.

The typical signs of facial aging include rhytids, deepening of facial folds (nasojugal groove, nasolabial folds, marionette lines), soft-tissue ptosis, development of jowls, midface volume loss, obtuse cervicomental angle, excess neck skin, platysma laxity and platysma banding. Overall, the youthful face is considered to be an inverted triangle, whereas the aged face takes on a more square shape.

Genetic skin conditions such as cutis laxa, EhlersDanlos, progeria and elastoderma should be screened.

While patients with cutis laxa can safely undergo facelift surgery, the other listed conditions increase the risk for wound-healing complications.

SURGICAL TECHNIQUE

Facelift surgery can be performed under general anesthesia or intravenous sedation. The use of intravenous sedation has been associated with a lower risk of deep venous thrombosis and pulmonary embolism.

Facelift techniques differ in how they treat the underlying SMAS and platysma. A subcutaneous facelift does not directly treat the underlying soft tissues. Rather, it removes excess skin and relies on skin tension to reposition the deep structures.

Excessive tension on the skin increases the risk of woundhealing issues, abnormal scarring, abnormal flattening of the face and early recurrence of aging changes.

Various SMAS tightening techniques have been described to reshape the deeper structures and decrease tension on the skin closure. These techniques include SMAS plication, cranial suspension with looped sutures, SMAS excision (SMASectomy) and elevation of a SMAS flap. Large systematic reviews have not demonstrated the superiority of one technique over another.

The most common complication in facelift surgery is hematoma. Risk factors for hematoma formation include male gender, history of hypertension, NSAID use, elevated BMI and smoking. Strict perioperative blood-pressure control with clonidine has been shown to significantly decrease hematoma incidence, particularly in male patients. Hematomas should be treated with prompt return to the O.R. for evacuation.

Facial nerve transection is rare. Transient nerve dysfunction immediately following a facelift is relatively common and likely due to the residual effects of the local anesthetic.

Persistent dysfunction after the local anesthetic has worn off may be caused by suture placement, traction or thermal damage from the use of cautery. These issues should spontaneously resolve within days or weeks. Nerve dysfunction that persists beyond the initial postoperative period should resolve within three to four months.

Chemodenervation of the contralateral muscle groups during this period can be performed with botulinum toxin to achieve better symmetry.

Similarly, GAN disturbances usually resolve spontaneously.

Lower-ear numbness should initially be treated with observation. Persistent numbness and allodynia six to 12 months postoperatively can be treated with surgical exploration to release an entrapped nerve or excise a neuroma.

Parotid fistula and sialocele development following facelift surgery have been described. Initial treatment consists of serial aspiration, diet modification and scopolamine patches.

Refractory cases are best treated with intra-gland injection of botulinum toxin. | Dr. Sinclair is PGY-5 in Integrated Plastic Surgery at Cleveland Clinic.

REFERENCES 1.

2.

Warren RJ. Facelift: Principles of and surgical approaches to facelift. In: Rubin JP, Neligan P, eds. Plastic Surgery Volume 2: Aesthetic Surgery. 4th ed. Elsevier; 2017.

Hashem AM, Couto RA, Duraes EFR, Çakmakoğlu Ç, Swanson M, Surek C, and Zins JE. Facelift Part I: History, Anatomy, and Clinical Assessment. Aesthet Surg J. 2020;40(1):1-18.

Plastic Surgery Resident | Fall 2020

21

Journal Club; 2020 Fall; (20) 1. Important aspects of head and neck reconstruction

M. Hanasono, E. Matros, J. Disa. Plast Reconstr Surg 2014;134:968e-980e This CME article reviews surgical techniques for reconstructing the oral cavity, maxilla, hypopharynx and mandible after head and neck cancer. The learning objectives include conceptualizing the reconstructive algorithm for oral cavity, tongue, maxillary, hypopharynx and mandibular defects and understanding the advantages and disadvantages of local, pedicled and free flap reconstruction options.

2. Updates in head and neck reconstruction

R. Largo, P. Garvey. Plast Reconstr Surg 2018;141:271e-285e

JOURNAL ARTICLES ON

HEAD AND NECK RECONSTRUCTION

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Elizabeth Kiwanuka MD, PhD; Luke P. Poveromo, MD; & Farooq Shahzad, MD, MBDD

H

ead and neck cancers account for approximately 4 percent of all cancers in the United States, with an estimated 65,000 new cases diagnosed annually. Head and neck cancers are typically squamous cell in origin and can be further categorized by the anatomic origin of the tumor: the oral cavity, the pharynx, the larynx, the paranasal sinuses, the nasal cavity and salivary tumors. Advances in surgical and non-surgical therapy has significantly improved the overall survival and quality of life for patients. However, oncologic resection of these cancers continues to pose demanding reconstructive challenges. The following 10 articles provide a comprehensive survey of the algorithms and techniques developed to address the reconstructive problem posed by resection: the restoration of form and function.

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Plastic Surgery Resident | Fall 2020

Virtual planning and rapid prototype modeling are increasingly used in head and neck reconstruction. This paper reviews the advantages and disadvantages of virtual planning, rapid prototype modeling, three-dimensional printing, and computer-assisted design and manufacture.

3. The latest evolution in virtual surgical planning: customized reconstruction plates in free fibula flap mandibular reconstruction.

Z. Lee, A. Alfonso, E. Ramly, et al. Plast Reconstr Surg Post Acceptance: June 23, 2020

Virtual surgical planning has contributed to technical advancements in free fibula flap mandible reconstruction. This retrospective chart review presents a decade-long experience with free fibula flap-based mandibular reconstruction using virtual surgical planning with patient-specific, preoperatively customized reconstruction plates.

4. A new intraoral flap: facial artery musculomucosal (FAMM) flap

J. Pribaz, W. Stephens, L. Crespo, G. Gifford.

Plast Reconstr Surg 1992;90:421-429 Julian Pribaz, MD, in 1992 combined the principles of nasolabial and buccal mucosal flaps to design a new axial musculomucosal flap based on the facial artery. The facial artery musculomucosal flap, which can be based either superiorly or inferiorly, can be used to repair modest defects of the palate, aveolus, nasal septum, upper and lower lips, and floor of mouth. Authors preferred the FAMM flap given its “likeness” to the surrounding oral mucosa and its wide range of coverage as a transposition or island flap.

5. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction P. Yu. Head Neck 2004;26:759-769

This paper by Peirong Yu, MD, et al., describes the detailed anatomy and flap thickness of the anterolateral thigh (ALT) flap in 69 patients who underwent head and neck reconstruction at the University of Texas MD Anderson Cancer Center in Houston. The authors present the characteristics of the ALT flap; identify and classify the vascular anatomy patterns; and describe their surgical techniques.

6. Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects C. Driessen, N. van Hout, P. van Kuppenveld, et al.

Microsurgery August 2020

To facilitate the insetting of flaps in head and neck reconstruction, the authors use a handmade template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volumes and components of the resulting defects. One-hundred reconstructions for head and neck defects were performed in 97 patients, and the authors found that the template facilitated the insetting of the free flap.

7. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

P. G. Cordeiro, E. Santamaria. Plast Reconstr Surg 2000;105:2331-2346.

Maxillectomy defects can involve critical structures such as the orbit, globe and cranial base, making the reconstruction challenging. This paper by Peter Cordiero, MD, et al., presents a classification system and treatment algorithm for maxillary reconstruction. This algorithm is based on restoring the various walls of the maxilla by conceptualizing the bone as a hexahedron bounded by the orbit above; the cheek anteriorly and laterally; the nasal cavity medially; the skull base posteriorly; and the oral cavity inferiorly.

8. Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases J. Disa, A. Pusic, D. Hidalgo, P. Cordeiro. Plast Reconstr Surg 2003;111:652-660

The primary goal of laryngopharynx reconstruction is to improve health-related quality of life by restoring alimentary-tract continuity so patients can eat and manage oral secretions. This retrospective review of 165 consecutive microvascular reconstructions of the hypopharynx presents a classification system and a reconstructive algorithm for approaching hypopharyngeal reconstruction.

9. Classification of mandibular defects

J. B. Boyd, P. J. Gullane, L. E. Rotstein, D. H. Brown, J. C. Irish. Plast Reconstr Surg 1993;92:1266-1275 The majority of mandible defects result from the removal of squamous cell cancer. A minority of defects are caused by osteogenic sarcoma or benign tumors. J. Brian Boyd, MD, et al., developed a reconstruction algorithm based on the location of the bone defect and the extent of softtissue involvement.

10. Fibula free flap: a new method of mandible reconstruction

D. A. Hidalgo. Plast Reconstr Surg 1989;84:71-79 In 1989, the first mandibular reconstruction with a free fibular flap was described. A number of free-flap donor sites existed at the time for bony reconstruction, but with several shortcomings: difficulty with two team approach surgery, limited bone length and poor bone shape. The versatility of the fibula free flap included ample bone length, optimal shape and cross section, minimal osteotomy restriction and excellent periosteal blood supply. Because of its many advantages, the fibula is the most commonly used flap for mandible reconstruction. |

Dr. Kiwanuka is a reconstructive microsurgery Fellow at Memorial Sloan Kettering Cancer Center, New York; Dr. Poveromo is PGY4 in the Division of Plastic Surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center; and Dr. Shazad is a reconstructive surgeon at Memorial Sloan Kettering Cancer Center.

Plastic Surgery Resident | Fall 2020

23

THE BLACK SWANS

Matching in plastic surgery as international medical graduates

By Angelo A. Leto Barone, MD, & George Kokosis, MD

T

raditionally, the profile of the typical plastic surgery resident in the United States has been very homogenous: They’ve attended a top-tier medical school in the continental U.S.; they’ve been inducted to the Alpha Omega Alpha Society; they’ve received multiple awards; and up to a few years ago, they were predominantly male.

When a medical student or graduate of a non-U.S.-based medical school (IMGs) – regardless of the institution’s prestige and reputation, or the student’s academic accomplishments – inquires with North American colleagues about realistic chances for matching in the United States, the typical response used to be (and often still is): “It’s impossible… or almost impossible.”

Medical schools outside of the United States work via a fundamentally different structure than their North American counterparts, therefore making it harder for international students to adapt quickly enough during their rotations in America to shine, compared to students who’ve been bred within our domestic system. Similarly, often times IMGs are at a competitive disadvantage for the United States Medical Licensing Examinations (or USMLEs). This intrinsic disadvantage, paired with the competition that the incredibly talented U.S. medical students represent, render matching to a U.S. plastic surgery program extremely challenging even for the most qualified IMG applicants. Things, however, are changing.

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Plastic Surgery Resident | Fall 2020

IMGs AS ‘WILD CARDS’

America is the great, innovative and forward-thinking leader in most fields mainly due to its establishment by a diverse group of the most resilient and adventurous of international populations.

Therefore, the inverse paradigm of limiting the recruitment of our field to talent from one geographical location seems destined to limit the growth potential that could be achieved if talent from anywhere around the world was recruited.

However, while this is often accepted by most, IMGs remain “wild cards”– the black swans of plastic surgery.

The term “black swan” comes from a popular Latin expression.

It appears that it was first referenced by Latin poet Juvenal who quoted: “Rara avis in terris nigroque simillima cygno,” which can be translated as “A good person is as rare as a black swan.”1 The expression seemed to be common in 16th-century London, as a statement that describes an impossible occurrence – derived from the traditional presumption that ‘’all swans must be white” simply because all historical records of swans reported that they had white feathers.2 Thus, the black swan is often cited in discussions of the improbable, which was thought to be true until the discovery of black swans in Australia.

In the interesting 2007 book The Black Swan: The Impact of the Highly Improbable by author and prior trader Nassim Nicholas Taleb, the extreme impact of rare and unpredictable outlier events is described and expanded. The book has been described

by The Sunday Times as one of the 12 most influential books since World War II and was featured for 36 weeks in The New York Times Bestseller list.

Figure 3. Research output among IMG’s before applying to the NRMP or SF match. From Kokosis & Leto Barone, et al. 3 7

Integrated Independent

6

The integrated and independent paths attract different type of applicants, who therefore must address different hurdles to be successful. While applicants to the integrated track compete with medical students who’ve dedicated several years and focus to plastic surgery – therefore needing higher USMLE scores, numbers of publications, grants and awards – independent candidates have already proven themselves. Typically, they access the U.S. medical system via a one- to two-year preliminary general surgery position, and then complete their general surgery training; therefore, they have surgical training and board eligibility before applying to the plastic surgery match.

Number of IMGs

5

4

3

2

THE BEST OF THE WORLD

1

0

0

1-3

3-5

5-10

10-15

More than 15

Number of Publications

Figure 2. Representation of IMG USMLE step 1 and 2CK test results. (a) USMLE step 1 score ranges for integrated and independent IMGs who matched into plastic surgery; (b) USMLE step 2CK score ranges for integrated and independent IMGs who matched into plastic surgery between 2008-2018. From Kokosis & Leto Barone, et al. 3 7

A

6

Integrated Independent

5

Number of IMGs

Having managed to be successful in this daunting process, plastic surgery black swans are contacted continuously by medical students from across the globe in efforts to learn what the key elements to success in the match were. We have discussed this in one of our recent papers3 published in an open-access journal to allow widespread reach.

4 3 2

Since many IMGs have proven themselves to being exemplary physicians, some programs such as the Johns Hopkins General Surgery Program reserves all the preliminary positions to outstanding internationals in order to attract “not the best of America, but the best of the world,” according to General Surgery Program Director Pamela Lipsett, MD. Some studies have even confirmed that a physician’s overall performance is not linked to their medical school, but rather to the quality of the residency training obtained.

Although no longer considered impossible, matching into plastic surgery as an IMG is still difficult, yet possible with hard work, dedication and good mentorship. Of the successful applicants, many have made significant contributions to the field. They are department chairs, program directors in prominent academic programs, founders of startups and nonprofits, developers of innovative surgical techniques, medical device inventors and patents holders, and leaders in editorial boards of plastic surgery journals and societies.

As the world becomes more and more international, plastic surgery should continue to select and embrace innovators and passionate physicians – regardless of their country of education. |

26 127 0

0 25 126

24 125 0

0 23 124

22 123 0

21 122 0

-2 10 20 0

19 0

0

-1 99

1

Score Ranges 7

Number of IMGs

6 5

B Integrated Independent

4

Dr. Barone is a chief resident at The Johns Hopkins Medicine Department of Plastic and Reconstructive Surgery, Baltimore; Dr. Kokosis is an assistant professor in the Rush Medical College Division of Plastic and Reconstructive Surgery, Chicago.

3

REFERENCES

2

1.

1

N o

Score Ranges

26 127 0

0 25 126

24 125 0

0 23 124

22 123 0

21 122 0

-2 10 20 0

-1 99

2.

19 0

re sp on se

0

3.

Puhvel, J. (1984). The Origin of Etruscan Tusna (“Swan”). The American Journal of Philology. 105 (2): 209. doi:10.2307/294875. JSTOR 294875.

Taleb, Nassim Nicholas. Opacity: What We Do Not See. Fooledbyrandomness.com.

Kokosis & Leto Barone et al., International Medical Graduates in the U.S. Plastic Surgery Residency: Characteristics of Successful Applicants.

Eplasty. 2018 Nov 27;18:e33. eCollection 2018. PMID: 30542504.

Plastic Surgery Resident | Fall 2020

25

HOT TOPIC IN PLASTIC SURGERY

Demystifying Artificial Intelligence: A Brief Overview

By Mélissa Roy, MDCM, MSc

T

he integration of the best research into practice or evidence-based medicine is guiding daily clinical decision-making and greatly shaping surgical training. This evidence is built on data gathering, analysis and interpretation that can be substantially enhanced by the use of machines. A new and seductive research keyword has become artificial intelligence – and for many of us, this term resides in an unchartered territory of research and carries infinite yet poorly defined opportunities. What follows is the clarification of the meaning of AI and the illustration of its applications – as well as its limitations.

Artificial intelligence (AI) represents the study of algorithms from which machines can execute cognitive functions (e.g., problem solving, word recognition and more).1 AI encompasses machine learning, natural language processing, artificial neural networks and computer vision.

Machine learning (ML) provides predictions based on pattern recognition by combining mathematics and computer science. 2 It can further be broken down into supervised and unsupervised learning. Supervised learning can be used to train an algorithm to predict a known result or outcome via partially labelled data. On the other hand, unsupervised learning can be useful to find patterns within the data.

ML can aid in the identification, within large datasets, of small changes that may be undetectable for humans and not captured by conventional statistical-modeling strategies.1 ML algorithms can also be combined to reach previously inconceivable levels of accuracy.

Natural language processing (NLP), or the processing of the human language, allows machines “to infer meaning and sentiment from unstructured data.”1 NLP has great potential for electronic medical records and physicians’ clinical documentation, as it consolidates semantics and syntax by understanding and processing human-level language.

Artificial neural networks (ANN) simulate the nervous system by processing simple computational units (representing neurons). Deep learning networks are ANN with several layers. ANN have demonstrated that they can surpass the performance of traditional risk-prediction clinical calculators.

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Plastic Surgery Resident | Fall 2020

Computer vision is the machine understanding of images and videos, which can be applied to object recognition, image acquisition, image interpretation, image-guided surgery and more.

Although succinct of the various subfields of AI, this overview highlights its tremendous potential for clinical applications. Examples of AI applied to perioperative care and to plastic surgery are multiplying. Such reports of AI within the literature include the prediction of genetic risk for disease (e.g., non-syndromic orofacial cleft);3,4 preoperative surgical morbidity;5 healing time (e.g., using reflectance in burns);6 postoperative complications using electronic medical records;7 and surgical site infections8. It has also been employed to assess, for example, the severity in cleft lip nasal deformities,9 craniosynostosis head shapes10 and tissue perfusion in microsurgery.11

PROMISING – THOUGH CAUTIONS REMAIN

Although very promising, it remains crucial to recognize the limitations of AI and avoid unrealistic expectations.

Furthermore, some skepticism already exists regarding entrusting machines to perform cognitive functions that would apply to healthcare delivery – and that physicians could achieve with possibly more accuracy. Integration into clinical practice may initially be limited by liability as well as financial requirements (reimbursement of a machine model and implications for physicians).

AI may also bring some disruption to the healthcare workforce in its current form, and physician adaptation to learning new skills will likely be required. Physician-machine interactions would appear essential in many circumstances to maintain accuracy, diminish costs and maximize output. For example, although ML can develop robust risk models, liability remains a barrier to implementation. By enabling machine and physician interactions, the machine can have greater sensitivity (to avoid missing true positives) and physicians can contribute to higher specificity (identifying true negatives), for an efficient and optimal model of care.2 The premise of having access to AI algorithms implies having access to large amounts of unbiased data in order to achieve acceptable performance levels. Collection of such

volume of data in a quality fashion is imperative to promote generalizability of findings – which may represent a challenge and introduce additional burdens to the system.12 Similarly, particular attention to the appropriateness of the clinical inquiry as it relates to the available data will be necessary.

The emergence of AI in daily healthcare delivery is taking place and will likely be omnipresent in the future. Translation of large amounts of data into knowledge has the potential to transform diagnostic accuracy, prognostication, imaging analysis and more.12 Opportunities to explore AI within plastic surgery for the provision of cutting-edge care are promising – and this should continue to be encouraged. | Dr. Roy is a plastic and reconstructive surgery resident at the University of Toronto with a research interest in AI and its future clinical applications.

REFERENCES 1.

Hashimoto DA, Rosman G, Rus D, Meireles OR. Artificial Intelligence in Surgery: Promises and Perils. Ann Surg. 2018;268(1):70-76.

2.

Deo RC. Machine Learning in Medicine. Circulation.

2015;132(20):1920-1930.

3.

Zhang S-J, Meng P, Zhang J, et al. Machine Learning Models for Genetic Risk Assessment of Infants with Non-syndromic Orofacial Cleft. Genomics Proteomics Bioinformatics. 2018;16(5):354-364.

4.

Asif M, Martiniano HFMCM, Vicente AM, Couto FM. Identifying disease genes using machine learning and gene functional similarities, assessed through Gene Ontology. PloS One. 2018;13(12):e0208626.

5.

Cooper JN, Wei L, Fernandez SA, Minneci PC, Deans KJ. Pre-operative prediction of surgical morbidity in children: comparison of five statistical models. Comput Biol Med. 2015;57:54-65.

6.

Yeong E-K, Hsiao T-C, Chiang HK, Lin C-W. Prediction of burn healing time using artificial neural networks and reflectance spectrometer. Burns. 2005;31(4):415-420.

7.

Weller GB, Lovely J, Larson DW, Earnshaw BA, Huebner M. Leveraging electronic health records for predictive modeling of postsurgical complications. Stat Methods Med Res. 2018;27(11):3271-3285.

8.

Soguero-Ruiz C, Fei WME, Jenssen R, et al. Data-driven Temporal Prediction of Surgical Site Infection. AMIA Annu Symp Proc AMIA Symp.

2015;2015:1164-1173.

9.

Xi W, Vista F, Kim DW, Chong KT. Assessing the deformity of cleft lip nose based on neural network. Int J Precis Eng Manuf. 2010;11(3):473482.

10. Mendoza CS, Safdar N, Okada K, Myers E, Rogers GF, Linguraru MG. Personalized assessment of craniosynostosis via statistical shape modeling. Med Image Anal. 2014;18(4):635-646.

11. Kiranantawat K, Sitpahul N, Taeprasartsit P, et al. The first Smartphone application for microsurgery monitoring: SilpaRamanitor. Plast Reconstr Surg. 2014;134(1):130-139.

12. Obermeyer Z, Emanuel EJ. Predicting the Future — Big Data, Machine Learning, and Clinical Medicine. N Engl J Med. 2016;375(13):1216-1219.

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COMPLEX CASE

CHALLENGE SOLVED Editor’s note: In this issue, we roll out the new series we’re calling “Complex Case Challenge,” wherein we test residents by providing them with a case overview, and follow that up by asking them to select a treatment approach. Keep an eye out in the fall issue of PSR for the explanation of how the case was ultimately managed by the treating physician – PSR Associate Editor Russell Ettinger, MD.

38 WEEKS, C-SECTION AND MULTIPLE CONGENITAL ANOMALIES: OUR APPROACH THE CASE

You’re consulted by the NICU service regarding a neonate born at 38 weeks via C-section with multiple congenital abnormalities including gingival hyperplasia, single palmar creases, bilateral small-finger clinodactyly and extensive cutis aplasia of the scalp. The scalp defect is full thickness with complete lack of skin, subcutaneous tissue, galea, pericranium and calvarial bone over an area measuring 5-by-6 cm. Attenuated dura is intact in the base of the wound, with the sagittal sinus and underlying brain parenchyma visible. Neurosurgery has been consulted in addition to plastic surgery for reconstruction of the wound. What’s your treatment recommendation?

A)

B) C)

D) E)

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Local wound-care with dressing changes Immediate skin-grafting Bilaminar skin-substitute application and staged skin grafting Scalp advancement flaps Autologous switch cranioplasty

THE SOLUTION

BILAMINAR SKIN-SUBSTITUTE APPLICATION AND STAGED SKIN GRAFTING This was a challenging case with several viable reconstructive options. The reconstructive modality ultimately selected by the treating surgeon was application of bilaminar skin substitute with plans for staged skin-grafting from the lower abdomen (abdominoplasty type graft) allowing for temporization and protection of the wound, while giving time for additional growth and development given the early post-natal status. Unfortunately, the bilaminar skin substitute failed to incorporate due to an undiagnosed protein deficiency. Wound care was continued during a period of nutritional optimization, and the wound was ultimately closed with bilateral, opposing rotational scalp-advancement flaps with plans for definitive bony reconstruction with split calvarial bone grafting at an older age.

Application of bilaminar skin substitute.

1a

1b

3

4

5

6a

2

6b Final result.

If you have a complex case that you would like to feature in PSR, please email Russell Ettinger, MD, at retting@uw.edu.

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MEDICAL STUDENTS TO LEADERSHIP:

Here's how to support us during COVID-19

By Helen Xun & Pooja Yesantharao

W

e are the average of the five people we spend the most time with.” What happens when a global pandemic restricts your ability to spend time with your role models?1 Mentorship in plastic and reconstructive surgery is integral to a successful career.2 Every year, medical students look forward to the opportunity to brush shoulders with leaders in plastic surgery. However, in light of the COVID-19 pandemic, students are now facing limited clinical experiences, canceled away rotations and virtual interviews.

While national organizations and programs across the country have created robust virtual programming, providing some comfort in this uncertainty, mentors and mentees alike are perplexed by the au curant landscape. As the plastic surgery community turns virtual, applicants everywhere are seeking to find meaning through a 22 MHz bandwidth WIFI connection.

During these times of uncertainty, the power of mentorship becomes exceedingly foundational. Applicants across the board face isolation, uncertainty and a lost connection with the field of plastic and reconstructive surgery – all of which resident mentors have the power to address. It’s well-documented in the surgical literature that mentors can facilitate students’ success by mediating integration and engendering a feeling of “belonging.”3 Residents, in particular, can provide valuable advice given their relative proximity to students with regard to training and experience.

Historically, studies have demonstrated that while mentees preferred one-on-one meetings, mentors often preferred group activities.4 In the context of COVID-19, where applicants may feel increasingly detached, such traditional notions of mentorship may need to be adjusted. As such, personalized mentor and mentee meetings may become exponentially more valuable.

Our initial interest in plastic surgery was sparked by resident mentors and role models, who took the time to share the specialty with us and help us understand our own value and potential.

When stay-at-home restrictions were first enacted, we joked that even a pandemic could not shake our desire to become plastic surgeons – being naively uninformed of how the world around us would quickly evolve. As temporary cancelations evolved into a completely virtual platform for the 2020-21 application cycle, however, our trepidations regarding the upcoming match increased exponentially.

Although it’s difficult to prepare for the unknown, we felt at peace knowing that we had a strong network of mentors 30

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supporting us. Even before we realized what was to come, our mentors had anticipated it and were building a safe and supportive environment for us to continue to grow and learn. We were touched when residents forwarded virtual meet-and-greet sessions and offered us opportunities to network and start new research projects. Even in the midst of the busy clinical environment during our sub-internships, our mentors never failed to ask: “How can we support you?” One resident mentor even offered to review our personal statements despite being on a busy night float, and we watched with admiration and humility as his comments started populating in the document, 1:21 a.m., 2:45 a.m. and 6:30 a.m., envisioning the immense effort it must have taken him to thoughtfully read our statements between consults.

We found security through our current mentors and renewed inspiration from new mentors who recognized the challenges of applying during COVID-19 – and reached out. Although we certainly have our apprehensions about the upcoming cycle, the adversity and uncertainty brought about by COVID-19 has cultivated a unique opportunity to build new relationships and truly understand the power of community in plastic surgery.

After reflecting on the valuable mentorship we’ve received from our residents, we propose five key, actionable ways by which residents can support students during COVID-19. These are summarized as “MENTOR:” Motivate, Educate, Network, Tell (i.e., share personal experiences), Offer (i.e., offer opportunities for students) and Research (Table 1). We recognize that every mentormentee relationship is unique, but we hope this framework will provide a helpful starting point. We are proud that our future careers will be a testimony to the extraordinary resident mentorship we received over the past four years, built upon the shoulders of giants. We hope other students can also benefit from such incredible relationships. | Xun and Yesantharao are fourth-year medical students at Johns Hopkins School of Medicine.

REFERENCES 1.

2.

3.

4.

5.

Rohrich, R. J. (LWW, 2018).

Ramanadham, S. R. & Rohrich, R. J. (LWW, 2019).

Ulloa, J. G. et al. Perceptual and Structural Facilitators and Barriers to Becoming a Surgeon: A Qualitative Study of African-American and Latino Surgeons. Academic medicine: journal of the Association of American Medical Colleges 93, 1326 (2018).

Janis, J. E. & Barker, J. C. Medical Student Mentorship in Plastic Surgery: The Mentor's Perspective. Plast Reconstr Surg 138, 925e-935e, doi:10.1097/ prs.0000000000002670 (2016).

Kokosis, G. et al. International Medical Graduates in the U.S. Plastic Surgery Residency: Characteristics of Successful Applicants. Eplasty 18, e33 (2018).

Table I. Mentor model for medical student mentorship in plastic surgery during COVID-19 PRECLINICAL

CLINICAL

SUB-INTERNS

APPLICANTS WITH NO HOME PROGRAM/IMG APPLICANTS

Develop the Interest

Refine the Interest

Provide Ancillary Support

Provide early exposure to the specialty. This is crucial especially during COVID-19.

Preclinical students cannot shadow this year and topics are typically not heavily covered in the preclinical curriculum.

Provide students with the exposure and skills they need to succeed on the wards. Clinical experiences are limited this year, with shorter/canceled clerkships.

Provide students with support for residency applications and information on other programs that you have knowledge about. Away rotations are canceled this year for students with home programs.

Provide students with connections/resources specific to their backgrounds. These students are especially vulnerable in this application cycle, and may need ancillary support.

Virtual teaching is key this year. Provide short online “chalk talks” or interesting case presentations on Zoom through your institution’s Plastic Surgery Interest Group to grab students’ interest.

Students at this stage are currently back on clinical rotations. However, learning opportunities are limited. Virtual suture workshops and other clinical skills sessions (i.e., how to use a doppler, wound care 101) would be very helpful.

Sub-interns don’t have away rotations this year, and home caseloads are often reduced due to COVID precautions. Provide clear expectations of knowledge and skills, and help students supplement what they don’t experience in the O.R. with additional resources for self-directed learning.

These students may have limited, if any, clinical opportunities in the specialty this year.

Directing students to written resources and virtual teaching sessions will be key in helping these students stay current with topics in plastic surgery.

Facilitate connections with additional mentors (attendings and residents) who are willing to set up Zoom calls with students and get them involved with research, since shadowing opportunities are limited.

Facilitate connections with attendings who are amenable to having students in their O.R.s and clinics, and who are historically committed to teaching students in clinical settings. Given the shortened clerkships, this can help maximize limited experiences.

Facilitate connections with your colleagues at students’ target programs. Connect students to attendings or residents within your own program to talk about their experiences at other institutions.

Facilitate connections with additional mentors who have similar backgrounds or who are at programs that traditionally have a good track record with international applicants or applicants with limited home opportunities.

Tell Loss of in-person conferences, lectures, subinternship, and interviews result in disconnect. Sharing your personal experiences are not meant to completely replace the lost experiences, but they provide comfort, security and knowledge.

Share how you got interested in the specialty through virtual sessions. Interfacing with your institution’s Plastic Surgery Interest Group can help with this. At this stage, group meetings are ideal, since students usually don’t typically need one-on-one support.

Share tips and tricks for how to prepare for surgeries and how to be helpful in the O.R. setting. Students have abridged clinical experiences, so helping them get acclimated will make their limited time more meaningful.

Share personal experiences of sub-internships in the specialty to bridge cancelled away sub-internships. Oneon-one meetings at this stage can be helpful to address students’ specific concerns and questions. Also, share personal experiences of the application cycle.

Share personal experiences or experiences of colleagues who have similar backgrounds.

Offer Oftentimes, mentees are not aware of opportunities or may feel hesitant to ask.

Offer these opportunities.

Share virtual learning opportunities. Many programs are having lecture series (i.e., Hopkins/UMD).

These lectures provide scoping introductions to various topics in the specialty and can be great ways for younger students to not only interface with attendings, but also to learn more about the field in lieu of clinical experiences.

Share virtual learning opportunities. Have students take part in virtual conferences and webinars to get a head start on residency planning. In-person away rotations may take place next summer, so helping students keep track of what opportunities are available as the year progresses will be critical.

Share virtual conferences, webinars, resources and mailing lists. Offer to review personal statements, CVs and applications to identify strengths and weaknesses.

Share webinars and resources for applications specific to these vulnerable student groups.5 Offer to review personal statements, CVs and applications to identify strengths and weaknesses.

Topics in the specialty are not typically covered in the preclinical curriculum.

Research can help younger students learn more about plastic surgery. When having a student help you in a project, teach them how to conduct literature searches and guide them toward pivotal papers.

Continue to engage clinical students in research projects. Having students help with and take the lead on clinically focused projects can help them to learn more about various operative procedures and gain experience as a researcher.

Help sub-interns finalize their ongoing research projects and add final touches to the research portion of their applications.

This can include providing them with case report opportunities or other shortterm, manageable projects that can be easily completed before applications are due in October.

Research can help students gain a foothold and boost their applications. This is especially crucial for students without home programs/home research opportunities. For these students, research is an important way to network, and thus the focus is to build relationships through research.

Spark the Interest

Motivate Positive support provides validation for students entering the specialty, and assertion of identity.

Educate Loss of in-person teaching opportunities and clinical learning results in reduced opportunity to explore the field and in uncertainty in knowledge.

Network Networking is critical for students to learn more about the field and build relationships.

Research Research opportunities provide students with additional learning opportunities and networking that may be lost due to cancelled away rotations and conferences.

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Managing patients with complications

OFFER COMPASSION, CREATE CONTINUITY – AND BRING A SOLID PLAN

By Lars Johan M. Sandberg, MD

W

riting a piece on complications warrants the standard hedging sentence to start, so here it comes: “My career is not garnered with more complications than others; however, I do operate – and thus complications do arise at an expected frequency.”

No one wants to be known as “the complication guy,” especially not early in their career. Complications can be a topic more comfortably discussed late in one’s career, however, once ample recognition has been achieved. There’s still shame associated with having complications, even if we know that all of us experience our allotted share.

Things that have gone wrong remind us that we aren’t perfect. In our specialty, we aim to be perfect.

Some surgeons back away from talking about their complications, but I choose to share my experiences as a young attending – as I believe that handling complications is something that’s a difficult part of our job and does require an active management strategy. The surgical management of complications is a topic that can be read about in books; however, the interaction with the patient who has a complication is less written about.

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A TEXAS PEARL

My experience of complications comes from my five years in practice. I don’t back away from complex cases, but I also choose my patients wisely. I also have experience from being a resident/Fellow and watching senior surgeons handle unfavorable results.

However, it struck me during my training that attending surgeons rarely interacted with patients who had a complication. Doctor-patient complication interactions are a sensitive subject and for obvious reasons are not suitable for a large – or even a small – audience. The surgical management of the complications are explained and understood. Nevertheless, the actual interaction is not focused upon.

I was lucky enough to get a true Texas pearl served to me during residency training. I found it hard to believe at first, but I now can confirm these words of wisdom and share them. My enlightening moment occurred at a cadaver dissection course of the hand.

During lunch, a very famous Southern surgeon informally commented about a case that had been up for discussion at a recent conference. He casually said: “The most grateful patients you will ever get are the patients who have a complication that you successfully manage.” This was not at all one of

those catchy one-line phrase that we as surgeons say to easily avoid a complex topic. It sounded like wellreflected and wise words from a master of surgery. But still I couldn’t fully believe it. That somehow just had to be an exaggeration and at least a little bit of fluff, I thought.

How should one handle complications?

First of all: NO communicational strategies can compensate for poor decisions, bad surgery or poor surgical technique. If you aren’t a good surgeon, you won’t be able to salvage the procedure and appropriately help your patient with complications appropriately. You’ll just continue down a slippery slope.

However, a good surgeon with a good plan and excellent execution in the salvage will still feel the sense of failure that hangs in the air. We all know the feeling of a complication from a re-explored flap, for instance – at first, it’s a deep-seated abdominal ache, black butterflies, that turns into a slightly nauseating feeling that turns into an annoying headache – or maybe if you’re lucky, just an annoying itch.

Much depends upon the scale of the complication’s consequences and how good you are at fixing the problem.

Your body somehow screams at you to

avoid exposure to these unpleasant facts – and avoid exposure of your perceived failure. Still, that deep-seated ache will not resolve by ignoring patients who need to be managed and seen.

and a “great unknown.” Where do things go from here? No preoperative consent can ever cover these questions.

The patient most likely has never seen anything like what’s happening and will be overwhelmed.

ADOPT THE PATIENT’S PERSPECTIVE

In a fearful situation without support we, as humans, tend to react by fight or flight – surgeons, as well as patients. If you, as an inexperienced surgeon, let your fear or anger take command and abandon or distance yourself from the patient at this time of extreme trial, you’ll likely be the target of all the fears and anger of the patient.

Looking at the situation from the patient’s perspective offers the allimportant view. The patients in this situation are afraid, first and foremost.

They’ve had the stressful experience of having surgery in the first place and are now faced with an untoward event

Remember that the patients have seen you in clinic before, and they know and trust that you are a good surgeon. The fact is that the deep-seated abdominal ache of yours does not come from the patient; it comes from within. I always tell my residents that the patients they feel the most uncomfortable dealing with are the ones they should spend the most time with during rounds or in clinic.

One should avoid focusing on the perceived failure in this situation and instead focus on the patient and the situation at hand. Problem-solving is Plastic Surgery Resident | Fall 2020

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PATIENTS WITH COMPLICATIONS / continued from previous page what we do as surgeons. That’s our job.

This allows a structure for us as young surgeons to manage unexpected events.

BE AVAILABLE – NO MATTER WHAT

As a surgeon, you can’t lose your composure during unexpected findings in the O.R. You can’t walk away from the O.R. without resolving the situation. The same applies for postoperative care: You can’t lose your composure with unexpected postoperative findings. It takes strong surgeons, confident in their skills, without any chips on their shoulders, to manage complications correctly.

It’s our job to be a steady and strong captain who takes the complication on our shoulders and steers the patient to calmer waters.

We have to be available, and we never abandon a patient. We have to see them as often as needed, even if deep-down we really feel that we don’t want to.

It actually isn’t that unpleasant – it only gets unpleasant when we ignore and abandon.

After a couple of years, I realized that the ache in my stomach will probably never completely disappear, even if it gets a lot less prominent. I believe it has to do with our unattainable wish to be a perfect surgeon without complications.

It’s part of the pain in our important strive to improve ourselves as surgeons – a motivating factor that plays part in our learning process.

THE IMPORTANCE OF CONTINUITY

My experiences in a socialized healthcare system, where ownership of patient and ownership of complications is a much less prominent factor in practice, further illustrated the importance of continuity and support for patients experiencing complications.

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unfortunately often can be seen in clinic by one surgeon; be operated on by a second surgeon; and cared for postoperatively by a third surgeon or by multiple different residents on a daily basis. This is detrimental to continuity and ownership of care.

I’ve learned that fear and anger at times is directed at the official person who at that specific point in time is representing “the system,” even if he or she isn’t the actual surgeon having performed the procedure leading up to the complication. I’ve also surprisingly learned that any captain will do, as long as the complication is successfully managed and continuity is provided. However, not surprisingly, the reputation of the primary operator will suffer if he abandons ship and allows the vessel to be managed by another surgeon.

As I mentioned earlier, I don’t recall overhearing any conversations between attendings and patients that involved a complication. My own approach has been to be informative, balanced and honest. I don’t exaggerate or diminish.

I will first confirm that I understand their frustration and that this is a complication, a result which is not intended. I inform them about where we’re at, what options are available, where we are going and how this will affect the patients care with regard to results (cosmetic, function and so on) and to time. Specifically, time in the hospital, delay of any other relevant treatments, time in rehab and so on. I address all questions and inform them that I’ll see them every day, and that I’ll follow them until the complication and all issues are resolved.

For hostile patients (this has only happened once with a patient who was unknown to me from before), I’ll let the patient blow off any steam as necessary, for whatever time necessary. I’ll listen carefully to what’s said – and while listening, plan how to address the issues

mentioned. It’s important to remember that the hostile patient is really a scared patient.

THE LESSON OF THE TEACUPS

“Complications mean wound care” is another thing I remember being told during residency. This was one of those one-liners that you hear, a phrase that’s clearly to the point but that perhaps doesn’t qualify as a wisdom. The field of post-bariatric surgery is full of complications. I intermittently managed post-bariatric patients in my previous job and once found myself in a situation where an abdominoplasty incision had ruptured due to a very large seroma.

The treatment was conscientious wound-care for several weeks.

During this period of wound care, before the complication was adequately treated and corrected, I received a kind letter and a gift “for being there.” I was given two teacups. This caught me very much off-guard and offered me a flashback to that day in Texas where those wise words were uttered. Of course, I also remembered the comment about complications and wound care…

Though I was a believer all the time, I did have my doubts – but after receiving the teacups, I stopped doubting. I was honestly surprised that a patient would bring me gifts for not abandoning her care. But of course, it makes sense.

The patient was later taken to the O.R. for a revision. A good result was achieved, and the patient was satisfied.

I do favor those teacups for reflective tea time. | Dr. Sandberg is head of Head and Neck Reconstruction and an assistant professor at Karolinska Hospital, Stockholm.

We need you more than ever – here's why

By Benjamin D. Schultz, MD Resident Ambassador PlastyPAC Board of Governors

T

he onset of the COVID-19 pandemic and ongoing social tensions in cities across the nation continue to challenge physicians everywhere and in all specialties. Aside from the emotional and physical strains of the everyday work environment, many of us have made significant personal, professional and life sacrifices during these unprecedented times. As we have in the past, we acknowledge and thank all of you who remain entrenched in the fight against COVID-19.

As the battle to treat these patients and fight this global scourge continues, so too does our battle on Capitol Hill endure for our plastic surgery colleagues. A recent survey targeting ASPS members found that a significant portion of privatepractice surgeons have been forced to temporarily lay-off employees – or use personal savings to keep their workers employed and businesses afloat during the pandemic.

Through the new PlastyPAC Speakers Series, the PAC conducted 17 meetings with members of Congress and educated them on the financial challenges that plastic surgery practices are facing during the pandemic. Our initial meetings stressed the importance of ensuring that plastic surgery practices have direct access to capital and small-

business loans such as the Paycheck Protection Program (PPP) to help weather the financial consequences of the COVID-19 pandemic.

HOW WE’VE HELPED SMALL PRACTICES While beneficial to many, the PPP fell short in areas that left some plastic surgery practices still financially troubled. Specifically, the law contained a provisionary “75/25 rule” mandating that 75 percent of the small-business loan to be used for payroll and 25 percent to be used for non-payroll costs such as rent and utilities. Over the past few months, PlastyPAC worked to educate members of Congress about why we would support the repeal of the 75/25 rule to give plastic surgery practices the additional flexibility they need to spend their loan proceeds on limited allowed uses in the way that most helps their business. That’s why we were pleased to see the passage of the Paycheck Protection Flexibility Act, which reformed the PPP loan requirements to be loosened to a 60/40 deal – wherein 40 percent of the loans could be used for operating costs.

Given the new circumstances forced upon patient interactions, necessary modifications to practices are being put into place. Such upgrades include touchless thermometers, new air purifiers, COVID testing kits and upgrades to current office equipment to enhance patient safety. PlastyPAC advocated for expenses such as these to be eligible for loan forgiveness.

These are just a few examples of how PlastyPAC has been working hard to ensure that plastic surgeons looking to maintain a private practice, or a small-

business model, are able to do so even during these unprecedented times.

The future of medicine and our specialty is currently at stake, as more legislation that could significantly impact how we practice is being considered – and passed into law.

LEND YOUR ASSISTANCE – JOIN US IN VIRTUAL D.C. That’s why we need your help now.

Young plastic surgeons should consider registering for one of the upcoming “virtual Regional Fly-in” events.

Attendees will experience an outstanding gathering – and the perfect introduction to advocacy-related information, events, meetings and camaraderie unlike any they’ve yet to encounter. Register today, learn how you can interact with members of Congress and begin supporting your own future.

As always, my Resident Co-Ambassador, David Hill, MD, and I remain available and at your disposal to discuss any questions, comments, ideas or concerns you may have regarding PlastyPAC and how we can better-serve you and our community. For additional information on PlastyPAC and how to contribute, please visit our website at PlastyPAC.net.

With your continued generosity and insight from you, our colleagues, we will continue to be equipped to move our specialty and our Society forward – while protecting the rights of us all. | Dr. Schultz is PGY-6 at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health. He can be reached at benschultzmd@gmail. com. Dr. Hill is PGY-8 at Houston Methodist Hospital. He can be reached at hill793@gmail.com

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Learn. Lead. Succeed.

VIRTUA L

Oct 15, 2020 Residents at Virtual Plastic Surgery The Meeting 2020 Senior Residents Conference

Thursday, October 15 | 9:00 a.m. — 3:30 p.m. Central time • Effective techniques, advice and resources to help you select the right employment model for you • Strategies to achieve work/life balance during board collection and throughout your career • Skills for negotiating contracts with future employers * Registration fee required

Residents Networking/Mentorship Reception Thursday, October 15 | 3:30 - 4:00 p.m. Central time

Network, connect and win prizes! This virtual party is the prime opportunity to meet prospective employers and get a sneak peek of the exciting resources that are planned for the first virtual Plastic Surgery The Meeting. Join us for great conversation in our virtual break-out rooms and chances to win $50 ASPS EdNet certificates!

Free to all residents/fellows, advance registration required

Residents Abstract Presentations

Saturday, October 17 | 6:00 - 7:00 p.m. Central time Top 50 Resident Abstract Presentations - Live streamed!

V IRT U A L

202 0 RESIDENT PROGRAM SUPPORTERS:

Register today at PlasticSurgeryTheMeeting.com/Residents or call ASPS Member Services Center at 800-766-4955 for more information.