Plastic Surgery Resident, Spring 2020

From the publishers of Plastic Surgery News

A lifeline in a sea of paperwork An experienced plastic surgeon offers direction on how to document and organize your professional life

ISSUE 18 | SPRING 2020

» BIA-ALCL 10 articles from Plastic and Reconstructive Surgery that every resident should read page 20

» Diabetic

foot wounds: Will you know how to treat them when you're on call? page 8

IN THIS ISSUE » Program Peek: University of Wisconsin-Madison Plastic Surgery p. 11 » Dennis Orgill, MD, PhD, on the value of innovation, wellness and healthy relationships p. 22 » How international Fellowships helped shape plastic surgery innovater David Fisher, MD, BSc p. 26

A note from the editor

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elcome to our Spring 2020 issue of Plastic Surgery Resident, and the first all-digital edition of this publication. Our cover story is “Organize and Document Your Professional Life,” written by Loree Kalliainen, MD, MA, Brown University.

As you advance from medical student to resident to Fellow to attending, managing your professional career can become increasingly cumbersome. Dr. Kalliainen provides a helpful – and quite detailed – guide to help you organize and streamline this important task.

Sanjay Naran, MD

Our highlighted program is the University of Wisconsin, Madison. Program Director A Neil Salyapongse, MD, and his residents share with us their program’s history, from its founding in the 1970s to now. Those who wish their program to be featured in a future issue are encouraged to submit a request to me at sanjaynaran@gmail.com. Similarly, feel free to send any ideas you have for content that you’d like to see in future issues – or, send in pieces you may like to share.

Chief Medical Editor

Plastic Surgery Resident Chicago

From the publishers of Plastic Surgery News

ISSUE 16 | FALL 2019

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

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

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

Are you coming to San Diego?

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

IN THIS ISSUE » Program Peek: UC San Diego Plastic Surgery ........... p. 14 » 24 Hours In: San Diego ....................................................p. 18 ARLINGTON HEIGHTS, IL 60005 444 E. ALGONQUIN ROAD AMERICAN SOCIETY OF PLASTIC SURGEONS

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» InService Insight: Transgender Surgery ...................... p. 20

Plastic Surgery Resident | Spring 2020

In this issue, we also introduce our readers to the new PROPEL (Professional Resource Opportunities in PRS Education and Leadership) program. ASPS, the American Council of Academic Plastic Surgeons, the Plastic Surgery Research Council and the ASPS Women Plastic Surgeons Forum have joined forces to provide a new mentoring model designed to build relationships and create a continuum of learning opportunities.

Finally, one of my Sunday activities is to listen to Hidden Brain on NPR. I encourage you to download the NPR app and listen to this podcast. At the conclusion, its host, Shankar Vedantam, mentions an “unsung hero,” which made me think of our unsung heroes. From the Editorial Staff in Arlington Heights, Ill., to our talented graphic designer, Elena Bragg, this team works behind the scenes to pull these issues together and comprises an integral part of our ability to provide readers with a publication that all involved can be proud of. Thank you, Team PRS. |

Table of

Contents How to organize to advance your career ............................ 4 Loree Kalliainen, MD, MA, who fought in the trenches and reached the summit of plastic surgery, shares key organizational lessons.

Plastic Surgery Resident | Spring 2020 | Vol.4 No.1

Consult Corner: Diabetic foot wounds .............................................................. 8

Roughly one-quarter of patients with diabetes also develop ulcers, so plastic surgeons should have an approach to their treatment.

The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities.

Program Peek: University of Wisconsin-Madison ........................................ 11

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

The Plastic Surgery Residency Program at UW may not be as old as others, but it’s quickly built a reputation for quality training.

Message from the Director: A Neil Salyapongse, MD ....................................................... 13 The Integrated Plastic Surgery Residency Program director cites the influence of several legends in the specialty for the program’s rise.

24 Hours In: Madison, Wis. ......................................................................... 14 Visitors to this popular, southwestern Wisconsin city can find entertainment, food and outdoor activities in nearly every corner.

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

Faculty Focus: Samuel Poore, MD, PhD ....................................................... 16

Dr. Poore has studied at Brown University and trained in Australia, but his work at the University of Wisconsin has been most impactful.

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

InService Insights: Eyelids – blepharoplasty and ptosis .................................. 18

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

Eyelids are among the smallest units of skin that plastic surgeons may need to address, but the outcome of work done there can be huge.

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

Journal Club: 10 articles on BIA-ALCL ........................................................20

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

Breast implant-associated ALCL may be a relatively new diagnosis, but the PRS journal has already gathered several “must read” articles.

What I Know Now: Dennis P. Orgill, MD, PhD .....................................................22 Professor of Surgery, Wound Healing & Tissue Engineering Laboratory P.I. on the valuable lessons learned while coming up.

Mentorship: Changing the playing field through ‛PROPEL’ .................24 ASPS, its Women Plastic Surgeons Forum, ACAPS and the PSRC created mentor/mentee opportunities through this new organization.

International Fellowships: Their appeal – and value – know no bounds ...................26 An interview with David Fisher, MB, BSc, Toronto, reveals how experience foments confidence – and the birth of a new technique.

Resident Ambassador: Young surgeons, PlastyPAC and advocacy ......................28 Benjamin Schultz, MD, knows the impact residents can exert upon plastic surgery advocacy efforts and encourages more participation.

PSR News: Scholarship and Board Opportunities ...............................29

Learn more about Resident Travel Scholarships and how to nominate a Resident Representative to the ASPS/PSF Board.

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

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

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

ASPS Home Page: www.plasticsurgery.org

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A veteran plastic surgeon’s manifesto

Organizing and Documenting Your Professional Life

By Loree Kalliainen, MD, MA

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s you move through medical training, many pieces of paper will cross your desk. They may be initially placed into folders with broad titles – e.g., undergraduate, medical school, residency. Once in residency, life gets more hectic; and documents may be randomly filed or piled, to be sorted at some later, “better” time.

A note of caution to all trainees: There is no better date, and life will never get less busy. It’s important to know what to save and how to save it, in order to be more efficient when applying for state licenses, hospital privileges and other data-intense events. Creating a professional file will save hours of valuable time with little initial outlay of finances or time.

Not every piece of information will be needed for every license application, but it’s easier to have it than not. All of the information I’ve noted here has been requested on an application.

Plastic Surgery Resident | Spring 2020

MASTER FILE

Label file folders as suggested below and keep all of the folders in a fireproof, waterproof box. Considering how time-consuming it is to get some of the information from the source, it’s a worthwhile investment. In the first folder, keep a running list summarizing all of the information. This is your master resource and allows you to look up facts without having to sift through each folder. Save a copy online in the cloud, or on a frequently backed-up drive. None of the information on the running list should ever be deleted.

ADDRESSES

All addresses, including past and present home addresses, should be saved. This includes the addresses of all institutions you have attended, from high school to medical school through Fellowship. Keep contact phone and fax numbers and web addresses, as well. It’s helpful to call the sites before sending material to them, to ensure that the contact address or person is current.

PERSONAL INFORMATION

Get one or more notarized copies of your birth certificate – and keep the address of the source of the certificate in case you need new copies. Check the data to make sure that it is correct in case you need to make changes. Copy your passport and social security card. Keep the passport up to date. Keep a file of immunizations. Most hospitals require annual TB tests.

Others require documentation of Hepatitis A and B, tetanus, MMR, chickenpox and, depending on your age, smallpox. Keep reasonably current 2-by-3-inch photographs available in color and black-and-white. The widespread availability of digital photography makes this easy to achieve.

EDUCATIONAL ACTIVITIES

Similarly, and in a like fashion, note the precise dates of each of your educational experiences and activities.

You may be asked to provide the month, day and year you began and completed high school, college, medical school, residency and Fellowship. Know the dates of all major exams (e.g., NBME, FLEX, ABPS exams); of hospital appointments; of state licensure; of your DEA license and renewals; and of conferences where CME credits were earned. If applicable, keep track of the expiration dates of memberships.

Keep copies of certificates earned for courses such as BLS, ACLS, ATLS, ABLS, PALS and LASER training. Residency programs generally provide certificates of completion for internship, residency and Fellowships. Save all certificates from the NBME, certifying boards and medical organizations. Make a note of your member number on the running list.

Have at least one notarized copy of each transcript from university to medical school.

Make copies of your diplomas and certificates before framing. Diplomas written in a foreign language will generally need to be translated into English; the granting institution can usually provide a certified translation. Record the address and phone number at your institution where copies can be obtained.

CV

Update your CV frequently to avoid inadvertently omitting items (publications, presentations, committee activities, leadership roles, educational and mentorship activities). Include PMID numbers with publications.

Consider using EndNote to allow for easy updates of your publications. Follow the guidelines of your organization in formatting your CV. For those in academics, review the guidelines in order to see which activities are required for each academic level. When going up for promotion, it will be important for you to be able to demonstrate accomplishments in key areas.

CME

Do not include CME credits on your CV – but keep them in a separate file, separated into Category I and II credits and patient safety, and enter them as soon after the event as possible. Many states now require you to get annual opioid education as well. Many professional organizations keep records of your credits (ASPS and ASSH are two); your hospital and certifying agencies may also require documentation of credits earned.

As an ASPS member, your CME credits earned at the annual meeting and other affiliated large meetings will automatically be entered onto your personal page.

You can manually enter credits earned for smaller

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ORGANIZE AND DOCUMENT / continued from previous page

meetings or meetings not usually attended by plastic surgeons. When needed, the CME file can be transferred to the ABPS. For residents, conferences and work hours ensure that adequate educational hours are being met. Once you finish residency, it’s important to keep track of credits. Twentyfour states use the AMA’s Physician Recognition Award (PRA) to document CME. To receive the award, the physician sends documentation of earned CME credits, and a fee, to the AMA. Taking annual specialty-specific In-Service exams is an inexpensive way to earn credit.

CREDENTIALING

Use of the Federation Credentials Verification Service (FCVS) is required by some state medical boards for certification in that state. It’s operated by the Federation of State Medical Boards of the United States and provides a “centralized, uniform process for medical licensing authorities to obtain a verified, primary source record of a physician’s ‘core’ medical credentials.” The first charge is about $300; subsequent requests cost $65-110. Not all institutions use this, and there may be significant duplication of effort on the applicant’s part in completing both. No universal verifying system yet exists, and most hospitals and surgery centers have their own credentialing forms which must be completed, and fees which must be paid.

Do not underestimate the time it takes to get state licensure and hospital accreditation. In many states, it can take three to five months to get licensed. This shouldn’t need to be said, but if you do call to check on the progress of your application, be polite. For hospital certification, the average time for a file to be completed is 60-90 days.

The most-common reasons for prolongation of the hospital accreditation process are missing information and a file that isn’t “clean.”

For many systems, being named in a lawsuit, having a misdemeanor or other legal problems – however minor – turns the file from one which can be reviewed quickly to one which needs more data and which may need to be approved by the hospital board. This varies by institution and by state. If you think that you’ll be practicing in a certain state (or states), start the accreditation process as early as possible.

Each hospital and surgery center at which you have an appointment outside of your residency needs to be 6

Plastic Surgery Resident | Spring 2020

documented. New institutions may only want information over the latest five years of practice – but to be safe, keep a running tally. Save the letter from the hospital documenting the initial date on which privileges were granted. This will also note the type of privilege (attending, consulting, courtesy, active, etc.)

Keep a list of the addresses of contacts at each hospital, as state licensing agencies or hospitals may need to contact the hospitals directly. A valid state license is generally required to obtain hospital privileges in that state.

LICENSURE

Keep separate files for each state in which you have had a medical license. Note the dates of initiation and expiration, the type of license, the license number and the address of the state medical board. State medical boards generally have well-designed websites. If you need to have license information sent between states, it has become relatively straightforward to pay a nominal fee ($20 or thereabouts) to have states transfer license information to other states or organizations.

Notify the DEA before you move to a new state. Though your number will not change, the DEA license does not automatically follow you. Keep track of expiration dates, save all DEA forms and make note of the drug categories on the permit. If you will practice in more than one state, you will need separate DEA forms for each state.

REFERENCES

Keep a current list of at least three professional references.

The ACS requires five Fellows as references for membership. Other boards and hospitals may require local or regional references within one’s specialty.

PROFESSIONAL ORGANIZATIONS

Keep a record of membership in professional organizations, and save paperwork showing that you are or were a member. Note the dates of membership and the contact information for the organization.

ACADEMIA

For academic positions, it’s important to keep a promotion/tenure file. The format varies with each institution, but the faculty member generally must keep track of lectures given, the audience, whether CME credits were given to attendees, publications, committee activity (local and national), advanced education courses taken and taught, grants applied for and awarded

MASTER FILE ITEMS

Home addresses School addresses Work addresses Dates of enrollment and graduation for high school, university, graduate training, residency/fellowship Dates of employment Dates of certification exams Social Security number Passport number and expiration date Immunizations, dates, titers Courses (CITI, BLS, ACLS, etc.) and dates valid Membership in professional organizations, offices held NBME/FLEX certification, date, certificate number Specialty board certification, certificate number, expiration date, recertification dates

Running list FCVS

Current CV Transcripts

Copies of birth certificate, Social Security card, passport

Current photograph

Immunization records Diplomas

Certificates of postgraduate training completion

Specialty board certificate

State medical license(s)

DEA license

Hospital privileges

Military service

Course certificates (BLS, ACLS, laser, microsurgery, CITI, etc.)

CME certificates (including AMA PRA award)

Professional organizations (separate folders for each organization)

Malpractice records including face sheets documenting coverage Receipts

State medical license(s), license number, granting and expiration dates Hospital and surgery center privileges, privilege type, granting and expiration dates Military service Malpractice history; malpractice certificates with company addresses, amounts of coverage; all information for any lawsuit in which you were named Professional references Website addresses pertinent to the specialty or your location

(including dates, amounts, publications and presentations resulting from the grant) and graduate students mentored.

MALPRACTICE, MISSING TIME, OTHER ISSUES

Necessary malpractice information includes the amount of coverage, the type of insurance (claims made or occurrence), the name and address of the insurer, the dates of coverage and information on lawsuits in which you were named (even if the case was eventually settled out of court or dropped). If you were involved in a lawsuit, you may need to get – from the courthouse or attorney involved – notarized statements regarding the details. You don’t need to keep a record of 180-day letters that did not go further than the exploratory phase.

Explanations of “missing” time must be provided.

Vacation time (summer/holidays) while in school doesn’t count, but deferring time for any reason from undergraduate onward must be explained. You don’t have to list each vacation, but if formal leaves of absence were taken, they must be accounted for. Hospitals and state medical boards need to know if the time was spent

FILE LABELS

in rehabilitation, jail, etc. Documentation must also be provided for felony convictions, jail time, mental or physical disorders that impair ability to practice, or addictions.

If you’ve ever been put on academic probation; if your license to practice has ever been revoked or refused; if you’ve lost your DEA due to practice violations; or if your hospital appointment has been rescinded; it must be documented. Hospitals and state boards want to know why you’ve given up hospital appointments for even benign reasons (e.g., deciding not to moonlight, not using the site for any reason). Recently, a few forms have asked for explanation only if hospital privileges were rescinded.

Most institutions will reimburse new physicians for costs incurred during the application process. Save your receipts for this reason, as well as for documentation that fees have been paid. |

Dr. Kalliainen is an associate professor of plastic surgery in the Brown University (Providence, R.I.) Department of Surgery.

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Diabetic foot wounds “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 M. Kearney, MD HISTORY DIABETIC FOOT WOUND, CALL BACK PLEASE.

You’re at an Italian restaurant and about to cut into a serving of steaming lasagna when your pager shows this message from the Medicine service: “Patient has just been admitted with a diabetic foot wound.” How should you evaluate and treat this patient?

VASCULAR The foot is supplied by the anterior tibial, posterior tibial and peroneal vessels, and normally it has extensive collateral circulation. Each of these vessels gives off smaller perforating arteries on which flaps can be based. The anterior tibial artery continues distally onto the foot as the dorsalis pedis artery lateral to the extensor hallucis longus tendon.

The posterior tibial artery gives rise to cutaneous perforators between the flexor digitorum longus and the soleus as it courses toward the tarsal tunnel. It then gives a medial calcaneal branch before bifurcating into the medial and lateral plantar arteries in the foot. The medial plantar artery then divides into superficial and deep branches – classically, the medial plantar artery flap is based on this superficial branch.

The peroneal artery gives off perforators to supply the posterolateral leg before terminating in an anterior perforating branch and a calcaneal branch.

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About 25 percent of patients with diabetes get an ulcer. In patients with chronic wounds, it’s important to get a sense of the patient’s overall medical history and the underlying factors that led to the development of the wound.

Particular aspects of the wound that should be inquired about include: the amount of time the wound has been present; if any preceding, minor trauma was present; prior instances of osteomyelitis or other infections; and prior treatment of the wound. In patients with foot wounds, it’s also important to determine if they are ambulatory – and if not, when was the last time that they walked.

General medical issues that should be inquired about include neuropathy (the most important risk factor for development of a diabetic foot wound); diabetic control (hemoglobin A1c); smoking status; any history of vascular disease or related symptoms (claudication, rest pain); and any other major medical comorbidities (e.g., congestive heart failure, chronic obstructive pulmonary disease or chronic kidney disease).

EXAM The lower extremity should be observed for its overall condition (e.g., atrophic, swollen, etc.), and the size and extent of the wound should be noted – including signs of infection and any exposed structures (bone, tendon, etc.). A vascular exam should include palpation of dorsalis pedis and posterior

tibial pulses, and if that’s abnormal, a pencil Doppler exam should be conducted. Importantly, a “Dopplerable” pulse in one of these vessels may represent retrograde flow through collateral circulation, so consider occluding collateral flow with your finger to ensure you are hearing an antegrade signal in the vessel. A detailed description of this can be found in the references.

A full sensory and motor exam of the foot should be conducted.

Bony deformities that include hammer toe and Charcot foot are common in patients with diabetes and should be noted, as these predispose to wounds.

The depth and dimensions of the wound itself should be noted, as well as the presence of any exposed bone and surrounding cellulitis.

in this population; perfusion should be assessed and maximized prior to attempting reconstruction. Diagnostic modalities such as lower-extremity arterial flow studies and CT angiography may be used to evaluate perfusion and reconstructive options.

Deformities such as Charcot foot may be managed with casting, or via surgery by foot and ankle surgeons. Optimizing underlying conditions such as these can help maximize the chances of successful soft-tissue reconstruction.

MANAGEMENT A detailed review of foot-wound reconstruction is outside the scope of this article, but a brief summary of reconstructive options follows: Split-thickness skin graft For non-weightbearing portions of the foot

Local flaps Medial plantar artery flap Pedicle: superficial branch of medial plantar artery Notes: This can reach from heel to midfoot. It also has been performed in reverse fashion to reach the forefoot, by raising it on retrograde flow from the dorsalis pedis artery and rotating it 180 degrees.

Intrinsic muscle flaps Small intrinsic muscles of the foot have been used as flaps to cover small defects. These include the abductor digiti minimi, abductor hallucis brevis and extensor digitorum brevis. These can be very useful for small wounds with no other local flap options.

Regional flaps Fig. 1. Patient with diabetic foot ulcer on the plantar surface of the foot.

Plast Reconstr Surg – Global Open7(8):e2371, August 2019

ASSESSMENT Diabetic foot wounds often require multidisciplinary management to obtain an optimal outcome. Osteomyelitis is often present, requiring extended antibiotics with Infectious Disease guidance. Peripheral vascular disease is also common

Reverse sural flap Pedicle: peroneal artery perforator 5 cm proximal to lateral malleolus and lesser saphenous vein Notes: This flap is notorious for venous congestion and partial flap loss. It does provide a decent amount of tissue that can be used for wounds around the ankle.

Lateral supramalleolar flap Pedicle: peroneal artery perforator 5 cm proximal to lateral malleolus Notes: This is a propeller flap based on a distal peroneal artery perforator and is useful for wounds on the lateral ankle and foot.

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CONSULT CORNER / continued from previous page

Free tissue transfer Many free flaps have been performed on the foot – and this is often the gold standard for distal lower-extremity reconstruction. Individual choices depend on the size, location and other characteristics of the wound in question, as well as the potential donor sites. Especially in patients with vascular disease, it can be prudent to perform the microsurgical anastomosis in end-to-side fashion to preserve as much distal perfusion to the foot as possible.

CONCLUSION Foot wounds are very common in patients with diabetes, and as plastic surgeons we are sometimes called to assist in their management. Any assessment of a diabetic foot wound should include an understanding of the “big picture” of the patient’s care to ensure that their underlying condition is optimized.

The other, arguably more important, aspects of the woundcare regimen – such as proper pressure offloading, treatment of infection and maximization of perfusion – should be optimized in concert with planning for soft-tissue coverage.

Despite efforts to resolve diabetic foot wounds, up to 10 percent of patients will ultimately require amputations rather than salvage. |

Fig. 2. The Rotation Flap: This type of flap is supplied by antegrade flow from the perforating branch of the peroneal artery. Incision over the lateral malleolus isn’t necessary if the pivot point of the flap is the perforating artery (<cutaneous branch for the flap; >superficial peroneal nerve). Ref: Masquelet, et al., 1988

Propeller flap Notes: As previously noted, each of the three major vessels to the leg gives off numerous cutaneous perforators as they travel to the foot. Any of these can be used to design a propeller flap. Careful dissection of the perforator is paramount, and it should be ensured that the pedicle does not occlude when the flap is rotated. These can be useful to prevent the need for free tissue transfer.

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Dr. Aronson is PGY2, and Dr. Kearney is PGY4, in the Northwestern University Feinberg School of Medicine’s Division of Plastic Surgery.

SUGGESTED READING

Attinger CE, Janis JE, Steinberg J, et al. Clinical approach to wounds: Debridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconst Surg 2006;117(7S);72S-109S. Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and clinical implications for limb salvarge: Reconstruction, incisions, and revascularization. Plast Reconst Surg 2006:117(7S);261S-293S. Glat P, Orgill D, Galiano R, et al. Placental membrane provides improved healing efficacy and lower cost versus a tissue-engineered human skin in the treatment of diabetic foot ulcerations. PRS Global Open 2019: 7(8);e2371 Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and lower extremity reconstruction. Plast Reconst Surg 2011:128(5);551e-563e.

Masquelet AC, Beveridge J, Romana C, et al. The lateral supramalleolar flap.

Plast Reconst Surg 1988: 81(1);74-84 Reddy V, Stevenson TR. MOC-PS(SM) CME Article: Lower extremity reconstruction. Plast Reconst Surg 2008:121(4);1-7.

University of Wisconsin-Madison Plastic Surgery

By Sarah Lyon & Rosaline Zhang History • The University of Wisconsin Plastic Surgery Residency Program was founded in the 1970s by Bernard Frank, MD. • The program was expanded by Col. Dave Dibbell, MD, after serving in the U.S. Air Force. He established international outreach initiatives as a cornerstone of the division and residency program with his efforts in Central and South America.

• The resident class size was expanded from two to three residents in 2008.

Leadership • Michael Bentz, MD: Layton F. Rikkers Chair of Surgical Leadership; Chair, Division of Plastic Surgery; Professor of Surgery, Pediatrics and Neurosurgery • A Neil Salyapongse, MD: Professor of Plastic Surgery; Program Director, University of Wisconsin Integrated Plastic Surgery Residency Program National Leadership • Dr. Bentz served as chair of the American Board of Plastic Surgery; president of the American Association of Plastic Surgeons; president of the American Council of Academic Plastic Surgeons; president of the American Association of Pediatric Plastic Surgeons; and chair of the Plastic Surgery Section of the American Academy of Pediatrics.

• Dr. Salyapongse is the current chair of the Global Health Committee at the American Council of Academic Plastic Surgeons.

• Delora Mount, MD, in 2019 was selected as the first female president of the American Society for Maxillofacial Surgeons (ASMS).

Clinical Experience • There are 18 integrated plastic surgery residents (in addition to one research resident); there are no plastic surgery Fellows.

• Clinical rotations occur at the following sites: o UW Health University Hospital is a Level I adult and pediatric trauma center and NCI Comprehensive Cancer Center located in the heart of Madison. This is the site of general surgery rotations in the PGY1 and PGY2 years.

In the PGY3-6 years, this is the primary location of major reconstructive procedures, including breast reconstruction, lower-extremity reconstruction, gender surgery and facial reconstruction.

University of Wisconsin Medical Complex

o American Family Children’s Hospital: A nationally ranked Children’s Hospital, residents here learn the fundamentals of pediatric plastic surgery – including cleft lip and palate, craniosynostosis and congenital hand surgery – under the tutelage of Drs. Bentz, Mount and Garland. Additionally, facial free-flaps for treatment of Parry Romberg disease are performed here by John Siebert, MD. o William S. Middleton Memorial Veterans Hospital: The VA rotation is an opportunity for PGY4-5 residents to take ownership of cases with oversight from faculty members.

Residents perform a wide variety of cases, including hand surgery and general reconstructive procedures. o Transformations Surgery Center: This off-campus, outpatient cosmetic surgery center is where PGY3s and PGY5s learn cosmetic surgery and common reconstructive procedures.

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PROGRAM PEEK / continued from previous page o Madison Surgery Center is an outpatient surgery center where PGY2s and PGY4s complete a hand surgery rotation with plastic and orthopedic surgery faculty. o UnityPoint Meriter and St. Mary’s Hospitals are community hospitals where PGY3-5 residents experience general plastic surgery practice. Unique opportunities at these sites include in-office facial reconstruction after Mohs surgery and oculoplastic procedures.

• International Collaborations: UW Plastic Surgery emphasizes the development of long-term, sustainable global-health programs focused on local capacity-building and education of local plastic surgeons. Our flagship program is in Nicaragua. We’ve also established partnerships in Thailand, Egypt, Ecuador, Ethiopia and Vietnam.

• Resident Injection and Laser Clinic was started due to a resident desire for more exposure to lasers and injectables such as fillers and Botox. This initiative is overseen by faculty volunteers and held biannually.

Educational Curriculum Conference time is protected for all residents, including junior residents who may be off-service. Typically, conferences occur three times a week and include: • Plastic Surgery Grand Rounds, which features lectures by a faculty member, resident or visiting professor. A morbidity and mortality conference is held monthly.

• Weekly Indications Conference is led by a faculty member and focuses on core plastic surgery topics for preparation for the InService exam and for oral boards. The conference is conducted in oral boards style.

• Weekly Hand Conference is held in conjunction with orthopedic surgery. Conferences are led by a resident and faculty member and cover core topics in hand surgery.

Additional educational opportunities include: • Journal Club, which is held monthly and features articles and discussion relating to a specific theme (e.g., gender surgery). It’s typically hosted at a faculty member’s home and includes time for the department to enjoy a meal together.

• Holistic Journal Club, which is held quarterly and is led by Dr. Venkat Rao. This is an opportunity to discuss articles and notable current events published outside of the plastic

surgery literature which pertain to plastic surgery or the medical field as a whole.

• Subspecialty Courses, which include, but are not limited to, an annual Maxillofacial Trauma course and an annual Microsurgery course. These multidisciplinary courses provide opportunities for cadaver dissection, anatomy review and collaboration among specialties and programs.

Research • All residents are engaged in research projects that range from craniofacial, gender, hand and microvascular to surgical education and global surgery research.

• Basic and clinical science research is overseen by Samuel Poore, MD, and Ahmed Afifi, MD, respectively.

• One resident per class completes a fully funded research year between PGY3 and PGY4 years.

• Residents complete a variety of basic, translational and clinical research projects, and they are encouraged to apply for national research funding grants. Established sources of research funding include DARPA and VA Merit Grants with Dr. Poore, and Dr. Siebert’s endowed chair for research of hemifacial atrophy.

• A dedicated research coordinator helps facilitate resident-led research projects.

Fellowship Training • 2020: Microsurgery (St. Vincent’s, Melbourne, Australia); Hand (Mayo Clinic); Cosmetic Surgery (Atlanta, Ga.); General Practice • 2019: Craniofacial (Pittsburgh); Microsurgery (UPenn); Hand (Stanford) • 2018: Craniofacial (USC); General Practice • 2017: Hand (UCLA); Craniofacial (Emory); Cosmetic Surgery (Grant Stevens, MD, Los Angeles) Resident Benefits • Year-round one-on-one training in microsurgical skills lab with experienced microsurgeon • One funded international trip alongside faculty member • One funded course during PGY5 year (ASMS Craniofacial or AO Hand) • Junior/senior mentoring program • Educational/book stipend • Funding for conference travel when presenting • Funded trip to ASPS for chief residents Follow us on Instagram at @uwiscplasticsurgery or on Twitter at @WiscPlasticSurg! |

Sarah Lyon (PGY3) and Rosaline Zhang (PGY1) are current residents at the University of Wisconsin-Madison.

12

A Message From the Program Director, A Neil Salyapongse, MD

W

had’ya Know? Not much, you?” For over three decades, Michael Feldman welcomed listeners from around the globe to this entertaining, educational, irreverent and Madison-based quiz show. Working from an incredible depth and breadth of knowledge, his team would poke, prod and push to reveal new, sometimes surprising, ways of seeing the world. This same countercultural spirit fueled the historic Madison protests, birthed the progressive political festival – Fighting Bob Fest – and now inspires our approach to plastic surgery training. To quote Michael Bentz, MD, our chairman, “If you want a program that’s done things the same way for years, this is not your program.”

The program traces its origins to the 1920, but the first accredited residency in plastic surgery at the University of Wisconsin (UW) started in 1952. Led initially by Frank Bernard, MD, the scope of training expanded tremendously under David Dibbell, MD, one of the key contributors to the development of muscle flaps as reconstructive options and the architect of Nicaplast, the plastic surgery collaborative training program in Leon, Nicaragua, that would serve as a model for building capacity in low/middle income countries. In 1999, Dr. Dibbell recruited Dr. Bentz as his successor; building on the existing training paradigm and global surgery experience, Dr. Bentz transitioned the residency to an integrated model and expanded the international collaborations to plastic surgery programs in Ecuador, Thailand and Egypt. Widely recognized for his expertise in mentorship, it comes as no surprise that faculty he mentors have extended these partnerships even farther – including sites in Vietnam, Myanmar, Ghana and Nepal.

Residents are enriched by these experiences, developing lasting connections that continue even after graduation.

Located within the UW campus and on the shores of Lake Mendota, the UW Hospital, American Family Children’s Hospital and the Veterans Administration Hospital comprise the core training sites of the program.

Recognized annually for nearly a decade as the top hospital in Wisconsin and one of the top hospitals in the country, the UW system offers experience in the full spectrum of plastic surgery, with dedicated multidisciplinary clinics for gender surgery, breast surgery, brachial plexus care, craniofacial anomalies, and vascular malformations.

For graduates of the program, this routinely yields more than 2,000 operative cases spanning the entirety of plastic surgery. Proximity to the undergraduate campus enables collaboration with partners in basic science, ranging from experts in stem cell biology to robotics. Research cross-pollination over the past decade includes projects in adipose stem cell development, transplantation and immune tolerance, peripheral nerve

regeneration and integrated neural prostheses. An active Simulation Center located within the main hospital houses models for migraine injection and carpal tunnel releases, while a microsurgical training lab provides simulation for super-microsurgery and internal mammary arteryharvest training.

A Neil Salyapongse, MD

As much as the faculty and residents enjoy working together, everyone should tip their hat to the 80-hour workweek and leave the climate-controlled safety of the hospital to feed their spirits. Luckily, the same proximity to the university makes it easy to relax with colleagues at the Memorial Union or cheer on the Badgers as the football, basketball or hockey teams prepare to trounce our rivals. Sailing on the adjacent lakes, cycling the miles of bike trails (including a NORBA-sanctioned racecourse), and rock-climbing are all within easy reach of the downtown. If mental sparring better suits you, Wisconsin’s capitol offers plenty of opportunities for political engagement (entertainment) as well as mentorship from faculty and alumni who’ve actively led state medical societies. A cornucopia of restaurants has garnered Madison a top-five ranking in Foodie Cities (Livability.com), and while every small town now boasts microbreweries, Madison continues to push the boundaries with meaderies and small-batch distilleries.

While the experiences and processes involved in plastic surgery training continuously evolve, our commitment to the Plastic Surgery Residency Program as the centerpiece of our group has remained constant. The absence of local Fellowships engages residents in both operative and management roles early and facilitates rapid development of autonomy. This competency enables graduates to maximize learning as they proceed to Fellowship (about 2/3 of our graduates) or as they enter practice. We’re proud of our alumni, who’ve uniformly developed successful practices in both academic and private settings.

Ultimately, we strive to develop young plastic surgeons who will use what they’ve learned to question that knowledge, take their operative skills and practice them in innovative ways, and encourage those around them to do likewise. “If you want to be a Badger, just come along with me…” | Dr. Salyapongse is director of the Integrated Plastic Surgery Residency Program at the University of Wisconsin-Madison School of Medicine and Public Health.

Madison, Wisconsin

By A Neil Salyapongse, MD

W

elcome to Madison! Located in the southcentral portion of the state, Madison is the crown jewel of Wisconsin, as well as its capital and a vibrant college town that blends big-city culture with small-town charm. Surrounded by four lakes and miles of bike trails that wind through the city, Madison offers something for everyone. Visitors could spend weeks discovering the city’s bounty, but we’ve spared our readers that task by assembling this guide to help them navigate “Madtown” like a pro.

learn about Wisconsin’s history. The observation deck atop the capitol dome offers views of the city and surrounding lakes in the summer.

From April through November, the Saturday Farmer’s Market surrounding the capitol is a sight to see (and taste). Grab a loaf of Stella’s cheesy bread, make your way through America’s largest “producer-only” farmer’s market and enjoy all that it has to offer!

LAKES AND PARKS

Geography lesson: Madison is located on an isthmus – a narrow strip of land surrounded by water on each side. Mendota, the larger lake, is located to the north; Monona, the smaller lake, is located to the south. Both provide year-round fun and activity.

In the summer, Lake Wingra is a popular place to enjoy water activities – you can rent a canoe, kayak, rowboat, paddleboat or stand-up paddle board from Brittingham and Wingra Boats. If you’d rather be in the lake than on it, more than a dozen parks and beaches will help you beat the heat. In the winter, join the local ice fishermen and rent a pair of snowshoes from Outdoor UW and follow the glow stick-lit path out to a campfire at a nearby park along Lake Mendota – Picnic Point – where hot chocolate and s’mores await.

CAPITOL OR ‘THE SQUARE’

Sitting above the city, in the heart of downtown Madison, is the gorgeous State Capitol building – the largest after Washington, D.C. Daily tours are offered where visitors can 14

Plastic Surgery Resident | Spring 2020

Madison Farmers Market surrounds the Capital Building.

BRUNCH SPOTS

Madisonions love their brunch. Even in the dead of winter, locals queue outside during the Sunday brunch hour at hotspots that include Madison Sourdough, Short Stack and Marigold Kitchen, and which feature local, rotating seasonal options and year-round staples. At Madison Sourdough, you can sate your appetite with the Eggs Diablo, freshly baked breads, pastries and cakes. Marigold Kitchen boasts a national top avocado toast contender – thinly sliced pickled onions and housemade chili oil with the perfect avocado-to-toast ratio - best ordered in twos.

CURDS

Most people know that Wisconsin equals cheese; however, the upscale, fancy cousin of cheese – the batterfried cheese curd – really sets us apart. Bite-sized balls of curd goodness are dipped in batter and fried to yield a warm, melted center covered in a golden crisp. Capitol Square supports what the locals call a “curd crawl:” Begin at the Tipsy Cow, Cheese curds move north to Graze, then hit The Old Fashioned (and pair with the classic Wisconsin Bourbon Old Fashioned!), then end at Heritage Tavern with exotic bacon-wrapped, tempura-battered curds with an array of dipping sauces.

DINING OPTIONS

DRINKS

Wisconsinites love their beer, and Madison has no shortage.

Sample the many spots around town, making sure to grab the popular IPA known as Fantasy Factory at local favorite Karben4, where you can also bring your four-pawed friends.

Just a short trip outside the city, make sure to visit New Glarus Brewery and grab a Spotted Cow while enjoying the scenic countryside. If you’ve outgrown the craft beer scene, stop by Funk Factory Geuzeria and sip on a variety of rotating sours. Of course, you can always enjoy some of the best craft cocktails in the city at cozy neighborhood lounges Robin Room and Gibs, while making time to grab a glass (or bottle) of wine at rooftop bar Eno Vino, which also boasts panoramic views of the city.

SPORTS

Being a college town, Madison is proud to be home to the Badgers. Watch the city come alive on game day and follow the rest of the city to Camp Randall, where you can catch the UW football team and “Jump Around” with thousands of your closest friends. Make sure to also check-out our perennially great UW hockey teams at the Kohl Center or our local minorleague baseball team, the Mallards.

MUSIC

Madison boasts an amazing list of venues for live music. The newly opened Sylvee hosts the hottest emerging acts and cultural A-listers for you and 2,500 of your closest friends. For a more intimate setting, check-out the historic Barrymore Theater on the East Side. If you prefer the outdoors for enjoying the local talent, stop by Memorial Union Terrace for views of Lake Mendota or double-back to the Capitol and catch a “Concert on the Square.”

Madison’s East Side is home to unique “hipster casual” dining options. Begin at Mintmark with its shared, rotating, small plates ranging from roasted and deep-fried cauliflower to Southern biscuits and honey butter. Pair with creative cocktails from a drink menu that’s at least four times larger than the entrée menu. Head across the street to indulge in homemade Italian food at Bar Corallini. Start with the local charcuterie board, follow that with handmade bolognaise and end with tiramisu and/or affogato. For a late-night snack, head back westward to Natspil, an unassuming venue just off the square.

Dim-sum, a distinctive pizza selection and hand-crafted cocktails will be sure to delight.

An underground haunt known to regulars as home of “steak sammies” – the Tornado Room – is a high-class steak and seafood establishment with an old-timey speakeasy feel that turns into an absolute steal of a late-night menu at around 10 pm. If you can make it ‘til then, get downstairs and feast on a $10 steak sandwich or scallops, curds (obviously) and a dirty martini.

Lake Terrace

Still not sure what to do? The best part of Madison is that the Midwest spirit is alive and well. Everyone is incredibly friendly and would love to show you everything our amazing city has to offer. Make sure to come visit soon! | Plastic Surgery Resident | Spring 2020

15

Q&A WITH SAMUEL POORE, MD, PHD

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

In this installment of Faculty Focus, we present ASPS member Samuel Poore, MD, PhD, associate professor of plastic surgery in the University of Wisconsin-Madison (UW) Division of Plastic Surgery. Dr. Poore earned his MD and PhD at Brown University, Providence, R.I., and he completed his plastic surgery residency at UW, as well as a microsurgery and research Fellowship at Bernard O’Brien Institute of Microsurgery, Melbourne, Australia.

Dr. Poore believes that plastic surgeons should absorb all the information, education and life experience that becomes available to them – and to seek-out that which isn’t readily offered. This way of thinking enabled him early in his medical career to see the comparisons between the anatomy and function of flight birds, and plastic surgery – an unexpected development that resulted from his studies under a renowned Brown University evolutionary biologist.

Dr. Poore fully realizes the benefits of balance and separating work from outside interests and that family should always come first, as well as the value of trusted mentors to whom one can turn with any question, at any time. A personal tragedy also led to a concerted effort to face head-on the trials that life imposes upon all – and he’s quick to inform residents that the path to real success in the specialty lies in being honest, in practicing integrity and in making the effort to work well with others, no matter their station in life or medicine.

PSR: WHAT FIRST DREW YOU TO PLASTIC SURGERY? Dr. Poore: During the combined MD/PhD program at Brown University, I had the unique privilege to work with Professor G.E. Goslow Jr., studying the anatomy and biomechanics of bird flight. We were studying the organization of the wing musculature, bony anatomy and nervous system.

While fascinating in its own right, it was far from human pathophysiology and medicine. As I approached the clinical component of the program, I became interested in the peripheral nervous system and its remarkable ability to heal after injury. When I rotated through the plastic surgery service, one of the first cases I encountered was an individual with an upper-extremity injury involving muscle, peripheral nerves and fractures. A light bulb went off: Here was a profession where I could apply to a human condition all the techniques I’d been using to study bird flight! At the time, I had no idea that the work of plastic surgeons had laid the pioneering groundwork on peripheral nerve regeneration, and the thought of contributing to that study was enthralling.

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Poore: I was lucky to have trained at The University of Wisconsin-Madison, where I was surrounded by excellent mentors, including our chairman, Michael Bentz, MD. I was encouraged to subscribe to the philosophy of exploring every subspecialty, read outside the primary literature, write papers and find mentors and friends at other institutions. I worked hard to present a well-rounded package that extended way beyond InService exam scores.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER? Dr. Poore: I trained at the Bernard O’Brien Institute of Microsurgery in Melbourne, Australia, under the mentorship

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Plastic Surgery Resident | Spring 2020

of Professor Wayne Morrison. The Fellowship was unique in that it combined clinical training with training in basic science research. This was important for me, because I began to see the complexity in balancing a career in research and clinical surgery. Having Dr. Morrison (a true “triple threat”) as a mentor gave me the confidence that one could, in fact, have a productive career in both research and microsurgery.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Poore: It’s critical. There’s so much to navigate that the importance of having a mentor as a “tour guide” through this journey cannot be overstated. At the University of Wisconsin, I was fortunate to have a mentor in surgery (Dr. Bentz) as well as basic science research (Susan Thibeault, PhD). They helped me identify strategies for maintaining a busy microsurgical practice and a federally funded laboratory. I’m 10 years into this game and rely on their mentorship as much today as I did when I was a first-year attending.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Poore: I feel strongly that contributing to the field-at-large within and beyond our own institution through committee and society participation is not only a duty but a privilege.

Being involved in ASPS and the Midwest Association of Plastic Surgeons has given me countless opportunities to network outside our own institution, to develop friendships and collaborations with other plastic surgeons and to work on my leadership skills. It’s exciting to know that in working on committees and holding society leadership positions, I’m making contributions that will move the field forward. This excitement helps me get out of bed in the morning (and I’m not known for being a morning person).

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Poore: Integrity, honesty and the ability to work with others. It’s also important to keep an active mind outside the boundaries of plastic surgery.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Poore: By setting boundaries and remembering that family comes first. I try to leave the “work at work,” so when I’m home I can be as present and in the moment as possible.

It all starts with organization, having trusted colleagues as partners and learning to say “no.”

PSR: WHAT WAS YOUR GREATEST, NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU OVERCOME THAT? Dr. Poore: When my father passed away. He was my best friend – and his death was surprising and equally brutal. I relied on my partners for help and sought solace in activities other than medicine, such as playing the guitar, reading and spending time with my family.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Poore: The diversity of cases and the long-term relationships I form with my patients and their families. I tell the students with whom I work that plastic surgery is the “family practice” of the surgical specialties. Also, the global health work we do at the University of Wisconsin is immensely enjoyable and highlights the impact that our specialty can have on a global scale.

PSR: WHAT ARE SOME OF THE RECURRING CHALLENGES OF YOUR PRACTICE? Dr. Poore: The balance of research and clinical practice. It’s always a struggle – but being organized and having good people to work with (associate scientists, research Fellows) makes it so much easier (and so much fun).

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Poore: I constantly remind myself that education is one of the most important academic responsibilities. It’s our direct connection to the next generation of clinicians, researchers and thinkers. The teaching component of my job is meshed within the daily routines of being a surgeon and researcher. My classroom is often the O.R., my lecture hall is the laboratory, and my “office hours” are held in clinic.

PSR: AS A SEASONED PLASTIC SURGEON, WHAT’S YOUR ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Poore: Develop life-skills beyond surgery. Read beyond the surgery texts, and remember that every day as a plastic surgeon is a privilege that should never be taken for granted.

And keep smiling.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN…” Dr. Poore: I saw a mangled hand in the O.R. and someone said: “Let’s roll up our sleeves and fix this!” | Plastic Surgery Resident | Spring 2020

17

Eyelids - Ptosis and Blepharoplasty

By Arya Andre Akhavan, MD

A

lthough relatively small anatomically, the eyelid is critically important both for facial aesthetics and for functional vision. Perhaps due to this, eyelid conditions and procedures are a commonly tested topic on the In-Service exam.

ANATOMY HIGHLIGHTS

The anterior lamella contains the skin and orbicularis oculi; the posterior lamella consists of the eyelid retractors, retroseptal fat and conjunctiva.

The levator palpebrae inserts into the skin and superior tarsus via the levator aponeurosis and is innervated by the oculomotor nerve (CN3). Muller’s muscle inserts onto the posterior superior tarsus, is sympathetically innervated, and contributes 2-3 mm of lid retraction. Compared to the Caucasian eyelid, the Asian eyelid has a shorter tarsus, a lower insertion of the levator aponeurosis with minimal attachments to the upper lid skin, and more descended pre-aponeurotic fat.

The lacrimal gland lies superolaterally in the upper lid and is divided into orbital and palpebral lobes by the lateral horn of the levator aponeurosis. The upper-lid medial fat pad is pale compared to the central fat pad.

The inferior rectus-capsulopalpebral fascia envelops the inferior oblique muscle. The inferior tarsal muscle is analogous to Muller’s muscle. The inferior oblique muscle runs between the medial and middle fat pads of the lower lid.

PRINCIPLES OF PTOSIS

The positions of a normal lid are at the upper and lower limbi of the iris. MRD-1 is the distance from the upper-lid margin to the pupillary light reflex, and it’s normally 4-5 mm.

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True blepharoptosis is defined by the inferior descent of the upper-lid margin, and it’s measured by MRD-1. Etiologies of blepharoptosis can be structural, such as with dehiscence of the levator aponeurosis (most common); myogenic, such as in muscular dystrophy; neurogenic, as seen with the accidental diffusion of botulinum toxin; mechanical, like with a heavy upper eyelid mass; or secondary to traumatic injury.

Pseudoblepharoptosis is apparent ptosis, but with normal upper-lid positioning. Etiologies include brow descent or lacrimal gland descent, dermatochalasis (excess eyelid skin) and steatoblepharon (fat protrusion through septal attenuation).

PREOPERATIVE ASSESSMENT

Patients should be asked about any bleeding disorders, use of anticoagulants or hypertension – these conditions can increase the risk of retrobulbar hematoma. Additionally, they should be asked about thyroid conditions (Graves’ disease), or any current symptoms of dry eyes or excessive tearing, which can be exacerbated by eyelid surgery.

Schirmer’s test for dry eyes inserts filter paper under the eyelid and tracks how tear fluid wicks across the paper. Tear breakup time is a more accurate test, which measures fluoresceindye drying time. Additionally, a visual field exam should be performed to assess the degree of functional deficit caused by the patient’s ptosis. Assessment of the integrity of a patient’s protective upward gaze during eyelid closure, known as Bell’s phenomenon, should also be assessed by having the patient close their eyes, then forcefully retracting the upper lid.

The lower-lid snapback test pulls the lower lid inferiorly.

If the lid returns to its normal position after more than

one second, this may indicate that the patient has poor tone of the orbicularis oculi muscle. Similarly, the lowerlid pinch test pulls the lower lid anteriorly away from the globe, with more than 6 mm of pull indicating tarsal laxity.

Abnormalities in either of these tests means that the lid laxity may need to be addressed during the procedure to prevent postoperative ectropion. Additionally, a negative midface vector should be documented, as this also increases the risk of postoperative ectropion.

Hering’s law states that the levator palpebrae receive equal innervation bilaterally. In asymmetric ptosis, the more-ptotic lid will have reflex levator activation, which leads to the lessptotic lid being hyperstimulated. Phenylephrine will activate Muller’s muscle in the more-ptotic eye and will unmask contralateral ptosis.

PTOSIS REPAIR

The Fasanella-Servat procedure is useful for senile and congenital ptosis with normal levator function. It is a posterior approach that uses a clamp to assist in resecting conjunctiva, Muller’s muscle, and part of tarsus. An isolated Muller’s muscle-conjunctival resection (MMCR) has a lower risk of eyelid floppiness and eyelid contour change.

Levator aponeurosis advancement can be used in senile ptosis with normal levator function. The dehisced or attenuated levator aponeurosis is plicated from a transcutaneous approach.

As levator function worsens, a resection with advancement becomes necessary.

Congenital ptosis with visual field compromise requires early surgical treatment to prevent vision loss, while cases without visual field compromise should be treated at age 3. A frontalis sling is reserved for poor levator function and can be performed in children. A ptotic lacrimal gland should have the inferior pole pexied to the inside of the supraorbital rim.

BLEPHAROPLASTY

Blepharoplasty is contraindicated in patients without Bell’s phenomenon; patients with severe dry eye; or patients with lagophthalmos. Portions of the orbicularis oculi can be resected along with the skin to decrease upper-lid bulk and create a supratarsal fold, but this may increase the risk of injury to the levator mechanism.

In certain instances, such as with severe lower-eyelid laxity, a concomitant canthopexy (3-6 mm laxity) or canthoplasty (more than 6 mm laxity) may be required to prevent ectropion.

A transconjunctival approach minimizes scarring of the middle lamella and can help prevent ectropion, but that will make fat-pad access more difficult and increase the risk of injuring the inferior oblique muscle.

Postoperative lagophthalmos in not uncommon and can often be treated with early massage and taping. Depending on the etiology, ectropion can be treated with canthoplasty if it’s secondary to poor lid tone or laxity. Cicatricial ectropion may require release of the scarred lamella with placement of an interposition graft. A retrobulbar hematoma is a surgical emergency marked by pain, proptosis, vision changes or bradycardia, and it can result in blindness if not promptly treated with a lateral canthotomy and cantholysis. |

Dr. Akhavan is PGY4 in the University of North Carolina (Chapel Hill) School of Medicine’s Division of Plastic and Reconstructive Surgery.

REFERENCES

Janis, J et al. Essentials of Plastic Surgery: Second Edition. 2017. Thieme Medical Publishers.

Thorne CH et al. Grabb and Smith’s Plastic Surgery, Seventh Edition.

Lee CK, Ahn ST, Kim N. Asian upper lid blepharoplasty surgery. Clin Plast Surg.

2003. 40:167-178 Carraway JH. The impact of Hering’s Law on blepharoplasty and ptosis surgery.

Aesthetic Surg J. 2004. 24:275-6

Ptosis

Levator excursion Excellent 10-15mm

Good 8-10mm

Fair 5-7mm

Poor <4mm

Mild <2mm

Fasanella-Servat

Levator resection and advancement

Levator resection and advancement

Frontalis sling

Moderate 3mm

Levator aponeurosis advancement

Levator resection and advancement

Levator resection and advancement

Frontalis sling

Severe 4mm

Levator aponeurosis advancement

Levator resection and advancement

Levator resection and advancement

Frontalis sling

Plastic Surgery Resident | Spring 2020

19

Journal Club; 2020 Spring; (18)

HISTORY 1. Pioneers of Breast Implant-Associated Anaplastic Large Cell Lymphoma: History from Case Report to Global Recognition

Miranda RN, Medeiros LJ, Ferrufino-Schmidt MC, et al. Plast Reconstr Surg 2019;143:7s-14s This paper reviews the early history of breast implant-associated ALCL and introduces the pioneers behind the landmark studies that led to its recognition. Through a series of interviews, these researchers describe the research that leads to the acceptance of BIA-ALCL as it is own clinicopathologic entity.

PATHOPHYSIOLOGY 2. Theories of Etiopathogenesis of Breast ImplantAssociated Anaplastic Large Cell Lymphoma

Rastogi P, Riordan E, Moon D, Deva AK. Plast Reconstr Surg 2019;143:23s-9s This review offers insight into the evidence behind the theories of chronic infections, including gram-negative organisms, biofilm formation, implants textures and tumorigenesis.

JOURNAL ARTICLES ON

BIA-ALCL EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Elizabeth Kiwanuka MD, PhD & Joseph J. Disa, MD

A

lthough relatively few plastic surgeons have ever encountered breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), it has impacted the perception of the safety of breast implants. While BIA-ALCL was recognized more than 20 years ago, it wasn’t until the FDA issued a safety warning in 2011 that most of the medical community became aware of the disease. This installment of Journal Club addresses the history, pathophysiology, epidemiology, diagnosis and treatment of BIA-ALCL.

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Plastic Surgery Resident | Spring 2020

3. Insights into the Microbiome of Breast Implants and Periprosthetic Tissue in Breast ImplantAssociated Anaplastic Large Cell Lymphoma

Walker JN, Hanson BM, Pinkner CL, et al. Scientific Reports 2019;9:10393 BIA-ALCL is a CD30 positive, anaplastic lymphoma kinase (ALK) negative T-cell lymphoma, and the progression of the disease is characterized by T-cell activation. This paper investigates the hypothesis that BIA-ALCL is triggered by an inflammatory stimulus, possibly infectious, and analyzes the microbiota of breast, skin, implant and capsule in seven BIA-ALCL patients. However, using 16S rRNA microbiome sequencing and immunohistochemistry, the authors did not find a significant difference in the diversity of bacterial microbiota in any of the analyzed material.

4. Molecular Drivers of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Blombery P, Thompson ER, Prince HM. Plast Reconstr Surg 2019;143:59s-64s The genomic characteristics of BIA-ALCL are qualitatively similar molecular abnormalities to those seen in its more common counterpart, such as ALK-negative systemic anaplastic large-cell lymphoma. Despite the similarities on a molecular level, the clinical outcomes are quite different. This review described the finding of the genetic sequencing of BIA-ALCL and the insights these studies have given into the molecular drivers of this rare lymphoma subtype.

EPIDEMIOLOGY 5. Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology (PROFILE): Initial Report of Findings, 2012-2018 McCarthy CM, Loyo-Berrios N, Qureshi AA, et al. Plast Reconstr Surg 2019;143:65s-73s

ASPS, The Plastic Surgery Foundation and the FDA in 2012 developed a register called Patient Registry and Outcomes for Breast Implant and Anaplastic Cell Lymphoma Etiology and Epidemiology (PROFILE). The purpose of the registry was to capture patients with BIA-ALCL. From August 2012 to March 2018, 186 cases of BIA-ALCL were reported to the registry, of which 48 percent are analyzed for this study. All patients in the registry had a history of textured implants. The most common symptom at the time of presentation was a fluid collection, and at the time of the submission of this paper, three deaths were reported.

DIAGNOSIS AND TREATMENT 6. Breast Reconstruction Following Breast ImplantAssociated Anaplastic Large Cell Lymphoma Lamaris GA, Butler CE, Deva AK, et al. Plast Reconstr Surg 2019;143:51s-8s

The initial treatment of BIA-ALCL includes implant removal and capsulectomy, as well as the removal of involved lymph nodes. This retrospective review of 66 consecutive patients with BIA-ALCL offers insight into the reconstructive options, including the timing and the technique of reconstruction. At the time of presentation, 56 percent of patients were stage IA; 17 percent were stage IB; 6 percent were stage IC; 11 percent were stage IIA; and 11 percent were stage III. In this case series, only 27 percent of patients underwent reconstruction, of which the majority received delayed reconstruction.

7. Optimizing Breast Pocket Irrigation: The Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Era Culbertson EJ, Felder-Scott C, Deva AK, Greenberg DE, Adams WP. Aesthet Surg J 2019

Due to the association between BIA-ALCL and chronic inflammation caused by bacterial infections, this paper sets up to study the antimicrobial effectiveness of Betadine and non-Betadine solutions against multiple organisms, including common gram-negative bacteria associated with chronic breastimplant infections and inflammation. Betadine-containing irrigations were found to be superior, and the authors conclude that Betadine Triple should be used to minimize the adverse wound-healing effects of povidone-iodine. They also point out that local antimicrobial wound therapies have been proven to have better antimicrobial effects and enhanced wound angiogenesis, as well as less-resistance development.

8. How to Diagnose and Treat Breast ImplantAssociated Anaplastic Large Cell Lymphoma

Clemens MW, Brody GS, Mahabir RC, Miranda RN. Plast Reconstr Surg 2018;141:586e-99e This CME paper describes the diagnostic criteria for BIA-ALCL

and presents an algorithm for how to evaluate patients. The goal is to provide guidelines for appropriate imaging, laboratory test and pathologic evaluation, and help to understand the operative treatment of BIA-ALCL.

9. Characteristics and Treatment of Advanced Breast Implant-Associated Anaplastic Large Cell Lymphoma

Collins MS, Miranda RN, Medeiros LJ, et al. Plast Reconstr Surg 2019;143:41s-50.

Advanced BIA-ALCL is marked by persistent and recurrent growth refractory to treatment and affects a subset of patients.

This retrospective review of 39 patients with advanced BIAALCL identified seven patients with bilateral disease, 24 patients with lymph node and organ metastasis, and eight patients with disease-related death. Treatment options for advanced-disease patients were complete surgery for 16 patients; limited surgery for 19 patients; chemotherapy for 26 patients; salvage chemotherapy for 11patients; radiation for 15 patients; and autologous stem cell transplant for six patients.

10. Breast Implant Informed Consent Should Include the Risk of Anaplastic Large Cell Lymphoma Clemens MW, Miranda RN, Butler CE. Plast Reconstr Surg 2016;137:1117-22

Informed consent and risk disclosure by healthcare providers are essential; however, the difficulties with determining an accurate assessment of risk, diagnosis or treatment regiment makes the preoperative discussion of BIA-ALCL difficult. This article reviews the need for BIA-ALCL risk disclosure and outlines the pertinent aspects of informed consent. |

ASPS offers full-scale repository filled with facts, direction and experts on BIA-ALCL ASPS has developed a repository that holds several up-to-date resources relating to breast implant-associated anaplastic largecell lymphoma (ALCL). Located at plasticsurgery.org/alcl, the repository contains numerous categories and links, starting with a lengthy Safety Advisory and enhanced by biannual updates for members on recent disease developments, government regulatory communications and consensus recommendations related to BIA-ALCL – all compiled through a joint effort by ASPS and the American Society for Aesthetic Plastic Surgery (ASAPS).

Links provided through this Resources page include Summary and Quick Facts; FAQ for Physicians; Recommended Insurance Coverage Criteria for Third-Party Payers; Informed Consent Language; Recommendations for Talking With Your Patients About BIAALCL; and a direct link to the Patient Registry and Outcomes for Breast Implants and Anaplastic Large-Cell Lymphoma Etiology and Epidemiology (PROFILE) registry.

In an effort to bring plastic surgeons in direct contact with colleagues who have a broad base of experience with BIA-ALCL, the site offers the Breast Implant Expert Network, where they can submit questions relating to clinical management and research – and receive a personal response from one of the available experts.

To access this valuable repository, go to plasticsurgery.org/alcl.

Plastic Surgery Resident | Spring 2020

21

WHAT I KNOW NOW

That I WISH I KNEW then

By Dennis P. Orgill, MD, PhD

“Most people overestimate what they can do in one year and underestimate what they can do in 10 years.”

– Bill Gates

T

he time it takes to arrive as an independent plastic surgeon following medical school graduation is anywhere from six to 11 years. During this time, I’ve seen individuals be highly productive – and those who’ve been less productive. The following is what I’ve learned from both.

MASTER OPERATIVE TECHNIQUE

When you start as a plastic surgery staff member, it’s very important that you can efficiently and effectively perform the surgical procedures assigned to you. This can be incredibly stressful for the first few cases – this is the first time you independently make decisions, and you hold complete responsibility. Obviously, if you fail in the first few cases, this can have an adverse effect on your career and self-confidence.

It takes an entire career to master surgery – and even those at the end of their careers continue to learn and refine technique.

In my years training residents, the transition to becoming a staff member is very stressful; many struggle with the change.

There does not seem to be a solid correlation between how good you are as a resident and how easy this transition will be.

I’ve seen many in this transition act out, berate others when things go wrong and make bad decisions in the O.R. I have found that those who struggle with this transition often lack confidence in their operative skills and decisionmaking.

Former residents often call me for advice on a particular or challenging case. Most of the time this involves a decision

22

Plastic Surgery Resident | Spring 2020

about what operation to do or how to manage a postoperative complication. These types of requests are easy for me to manage, and I hopefully give some helpful advice. In contrast, if someone calls and doesn’t actually know how to do the surgery required, this is something that can’t be conveyed over the phone. During their training, I encourage our residents to take advantage of every case they do – and to think of each case as if all the decisions were theirs alone to make.

Because of increasing hospital regulation, learning independence as a resident or Fellow can be challenging.

My advice is to try to do even simple cases independently with the attending looking over your shoulder. See patients before and after the operation in order to learn the nuances of patient care. And don’t be afraid to ask for help.

MAKE INNOVATION A PART OF LIFE

This specialty is constantly evolving, and operations and procedures that we design today will naturally and eventually be performed by individuals in other disciplines.

It’s incumbent that we continue to innovate to preserve our profession. Innovation can come in a variety of forms – including basic or clinical research, device development and collaboration with people of other disciplines. It certainly isn’t restricted to academic medical centers, as many of our most important innovations have come from private practice.

To be successful with innovation requires outstanding time management. We now have the ability to do our work anywhere in the world with an internet connection. Try to use down time – such as when you’re waiting for a case to start – to write, answer emails and phone calls that foster innovation. As Bill Gates suggested, using this time wisely can be quite rewarding over the long term. Make time in your lives each day to read and learn new things that foster innovation.

BUILD STRONG RELATIONSHIPS

Plastic surgery has become a team effort, and building the best team possible will make your career fulfilling. Hire the smartest people to work with you – and people who will be kind to your patients. I’ve been fortunate in my career to be in an institution that attracts the best residents and

researchers from around the globe. Working with them has allowed me to make innovation a priority. Similarly, having outstanding nurses, administrative support, physician assistants and others can allow us to focus on surgery and leave nonsurgical tasks to others, who generally will do them better than if we attempted to do them ourselves.

Building strong relationships with your patients will allow them to be some of your best supporters. Of course, taking time to support your family and the loved ones in your life is why we all go to work each day. Those who have children will find that the years when they are home are busy but can be quite rewarding, and that these children can be of great support later in life. Those who neglect family relationships can end up feeling lonely and unfulfilled in the later parts of their careers.

Wellness has become increasingly recognized as an important area – it’s incumbent upon us to avoid burnout and maximize the time that we can be productive. I’ve seen far too many physicians not take care of themselves, a few of whom have had issues with drugs or alcohol – which can be tragic. Early in careers, surgeons are under intense pressure to perform, and it becomes easy to neglect nutrition and exercise. We don’t know the optimal way to do this, but certainly taking time each day to be active, watching our diets and avoiding alcohol are methods that will improve wellness.

Plastic surgery is a special field that has great opportunities as we move into the next few decades. I can’t imagine a field with more opportunities and the ability for the vast majority of plastic surgeons to do substantial good in the world. As we move forward, we will see larger numbers of challenging patients to treat – but through our combined efforts and collaboration, we should be able to greatly improve the quality of their lives. |

Dr. Orgill is a professor of Surgery and the Wound Healing & Tissue Engineering Laboratory principal investigator at Brigham & Women’s Health at Harvard Medical School, and medical director of the Wound Care Center at Brigham & Women’s Hospital.

Plastic Surgery Resident | Spring 2020

23

PROPEL:

Changing the Dynamic of Mentorship

By Kavitha Ranganathan, MD

T

he term “mentorship” took root in the mid-18th century and originated from Homer’s “Odyssey” as a means of expressing the actions that a teacher takes to lead a less-experienced trainee. Over time, areas such as humanities, science and mathematics adopted the concept, given the dedication and steadfast commitment to the arts required by these scholars.

The transmission of knowledge and success became commensurate with proper mentorship, and the resultant connection and loyalty were worn as badges of honor by both the mentor and the mentee. The power of a successful mentormentee bond notwithstanding, one cannot help but question whether the same structure and format of mentorship that developed 300 years ago still resembles the concept in place today. Is it possible for one person alone to satisfy the career needs of a multifaceted trainee – and likewise, does a mentor ever graduate from needing mentorship in a field that demands lifelong learning?

NEED ‘PLAN A’ – AND ‘PLAN B’

The increase in articles on “mentorship malpractice,” in journals ranging from the New England Journal of Medicine, to JAMA Surgery and PRS, begs this question – and passively hints at the need to revolutionize the current approach to mentorship.

In plastic surgery, we begin residency by learning that when “Plan A” fails, you must have a “Plan B,” and that the two plans cannot be the same – even backup plans must have backup plans.

The drawback of traditional mentorship models lies in its nonadherence to this exact principle. By assuming that one mentor is enough, we fundamentally have no “Plan B.” In our current model, we presume that one person should be able to give individualized clinical, research and life advice to a trainee in need. The multifaceted nature of today’s life as a surgeon makes this feat impossible; as such, the idea of an assigned mentormentee pairing is doomed to failure.

To address the evolving needs of mentors and mentees, ASPS, the American Council of Academic Plastic Surgeons, the Plastic Surgery Research Council and the ASPS Women 24

Plastic Surgery Resident | Spring 2020

Plastic Surgeons Forum have joined forces to restructure mentorship through an initiative called PROPEL (Professional Resource Opportunities in PRS Education and Leadership).

Created by the ASPS Residents Council and Young Plastic Surgeons Steering Committee, mentorship in plastic surgery will move to a team-based format through PROPEL. “Launch teams” will be composed of a senior faculty member, junior faculty member, senior resident and junior resident. This team structure will foster a form of bidirectional learning in which the mentor-mentee label is less-restrictive compared to traditional formats.

The goal of each group is to build relationships and create a continuum of learning opportunities that reflects the vast (albeit overlapping) experiences between faculty members and trainees in a longitudinal fashion.

CHANGING MENTORSHIP’S PARADIGM

Given the needs of trainees today, teams will be created based on a variety of interests – including research, clinical training, practice type and approaches to work-life integration. Another distinguishing feature of this program is the integration of private practice and academic faculty mentors into one mentorship system, in order to support the diversity of practice patterns unique to plastic surgery.

In this manner, PROPEL can begin to move the paradigm of mentorship into a team-based approach focused on developing the clinical, research and interpersonal facets of a young trainee’s career – ultimately using an innovative approach to a solution rooted in the tradition of success. |

Dr. Ranganathan is a Fellow in the Johns Hopkins School of Medicine Department of Plastic and Reconstructive Surgery.

Residents interested in joining a mentorship team can apply at https://www.surveymonkey.com/r/9QGV6Z2.

Plastic surgery leaders interested in becoming a mentor can apply at https://www.surveymonkey.com/r/CVKMK6G.

#PRSJournalClub

A New Globally Interactive Journal Club, Podcast, and Live Discussion Series THREE WAYS TO JOIN: 1 l

Read Journal Club picks of the month. Each month, three articles are selected, and paired with 2 classic articles and 1 classic CME. This is a ready-made Journal Club Discussion for academic and clinical groups around the world.

2 l

Listen and learn as Resident Ambassadors and a special Plastic Surgeon guest discuss the 3 Journal Club picks on the monthly Podcast. Episodes are available on PRSJournal.com, YouTube.com/ PRSJournal, and via iTunes (search “PRS Journal Club”).

3 l

Discuss. Join our live Twitter talk. Each month, the Resident Ambassadors moderate a discussion with the authors. We invite YOU to join in with Q&A, sharing, and re-tweeting. Find this monthly chat—and tag your own posts — via #PRSJournalClub on Twitter.

Follow @PRSJournal on Twitter and join the PRS Journal Club

6-Q244

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5/10/16 1:12 PM

GLOBAL EXPOSURE

The Value and Appeal of International Fellowships

By Mélissa Roy, MDCM, MSc

F

ellowships allow surgeons to seek expertise training while bonding with new mentors, being exposed to new techniques, expanding job opportunities and better-molding their budding careers. All want to maximize learning and skills acquisition in this carefully selected apprenticeship that can take place anywhere in the world.

Expert surgeons are defined as “experienced surgeons with consistently better outcomes.”1 David Fisher, MB, BSc, embodies such a definition – equipped as he is with passion, talent and extensive international training and experience. His anatomically based cleftlip repair technique has revolutionized David Fisher, MB, BSc, the surgical approach to cleft lips.2 The technique, published in 2005, has been widely adopted internationally.

Dr. Fisher is the medical director of the multidisciplinary Cleft Lip and Palate Program at the Hospital for Sick Children, Toronto, Ontario. He graciously agreed to discuss his career journey – and how his international fellowships shaped his practice.

TRAINING JOURNEY Dr. Fisher graduated medical school in Ireland. He completed residencies in General Surgery and Plastic Surgery in Grand Rapids, Mich., and his first fellowship took place in Paris alongside Daniel Marchac, MD. He pursued further training in Taipei, Taiwan, under the mentorship of Samuel Noordhoff, MD, and Yu-Ray Chen, MD. Dr. Fisher became a pediatric Fellow at the Hospital for Sick Children, Toronto, where he has established his practice.

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Plastic Surgery Resident | Spring 2020

PSR: WHEN DID YOUR INTEREST IN CRANIOFACIAL SURGERY AND CLEFT LIP AND PALATE BEGIN? Dr. Fisher: You may not believe this, but it started when I was 12 years old. I saw a child opposite to me on the bus with a cleft. I remember specifically thinking to myself: “There has to be a better way.” Later, my interest in clefts really started with embryology and grew from there.

PSR: WHAT WAS THE FIRST FELLOWSHIP YOU DECIDED TO PURSUE? Dr. Fisher: The first Fellowship I applied for was the craniofacial Fellowship with Dr. Marchac, while still being a general surgery resident (before even being accepted into a plastic surgery program). I knew the waiting list was four to five years, but I wanted to work with Dr. Marchac as he was an internationally recognized craniofacial expert and a pioneer in craniosynostosis surgery. The Fellowship was also based in Paris, and I knew I wanted to travel. In parallel, I needed to leave the United States for a period of two years, due to the limitations imposed by my visa (J1).

My ultimate goal when planning the Fellowships was to have training and experience that would allow me to secure a job, be well-trained and, ideally, develop confidence to do the job I was seeking.

PSR: WHAT WAS THE NEXT STEP IN YOUR FELLOWSHIP JOURNEY? Dr. Fisher: I applied for the Sick Kids Hospital craniofacial Fellowship. There was now a six-month gap between Paris and Toronto. I had met Dr. Chen at The International Society of Craniofacial Surgery meeting in New York in 1986, and he offered me a Fellowship.

PSR: DID YOU FACE ANY LINGUISTIC OR CULTURAL CHALLENGES WHILE ABROAD? Dr. Fisher: Language was a problem, but the Fellowships were well-designed and expected a lack of fluency from the Fellows. I could not interact with the patients to the extent that I preferred, during both the France and Taiwan Fellowships. The advantage was that I was able write a research paper in English with the local teams – which they very much appreciated.

PSR: DID THESE FELLOWSHIPS GIVE YOU THE CONFIDENCE YOU WERE SEEKING? Dr. Fisher: Absolutely. At the end of my residency, I really thought I knew a lot about clefts, since I had concentrated my efforts on that particular topic throughout the years. I’d even taken part in a mission and performed/assisted cleft surgeries as a resident. But when I was in Taiwan, Dr. Chen was about to leave me alone to do a cleft – and I knew I wasn’t ready to be unsupervised. Clearly, I still had a lot to learn and confidence to build. Two years later, I started my practice and I performed my own repair on my first patient, so I obviously had gained more confidence by then.

DEVELOPMENT OF A NEW TECHNIQUE PSR: WHAT INSPIRED YOU IN THE DEVELOPMENT OF YOUR CLEFT LIP REPAIR? Dr. Fisher: When I left Taiwan, I was very confident with the Chang Gung repair, which is a modification of the Millard version. I believed that I would use this repair technique if I were to get a pediatric craniofacial cleft position. But I then trained with Hugh Thomson, MD, and saw a modified inferior-triangle technique. I thought of it as a wonderful repair. It became less clear which repair I was going to adopt for my own practice. Once I got the Sick Kids position, it was time to make a decision. I decided to use the best parts of each repair and combine them. I knew there was a way to put the scar where I wanted it to be.

PSR: HOW LONG WAS THE DEVELOPMENT PHASE OF YOUR CLEFT-LIP REPAIR TECHNIQUE? Dr. Fisher: It was pretty quick, probably over a few months. It was during my last Fellowship at Sick Kids. My first son was born then. I remember spending a lot of time thinking about what kind of a repair I would have liked him to have, had he been born with a cleft.

PSR: WHEN DID YOU FIRST SHARE YOUR TECHNIQUE IDEA? Dr. Fisher: Before attempting my own repair on my first patient, I presented the technique to the pediatric plastic surgeons at weekly rounds when I was still a Fellow at Sick Kids. I didn’t get any really concerning feedback. I knew it would work. However, I was extremely careful. Once on staff, I first attempted the repair on an incomplete cleft. Considering you always throw away the majority of the C flap, I knew I could convert the repair to a Chang Gung one if needed.

But it worked.

I didn’t publish the technique for the first five years.

I performed 157 repairs first and wanted to obtain adequate outcomes data.

WORDS OF WISDOM PSR: DO YOU HAVE ANY RECOMMENDATIONS FOR RESIDENTS PLANNING ON COMPLETING INTERNATIONAL FELLOWSHIPS? Dr. Fisher: Plan ahead. Think about the Fellowships that interest you and make according arrangements. I had no expectations prior to completing my Fellowships, but I was confident that they were in great institutions and with exceptional surgeons to learn cleft surgery. I was ready to accept whatever challenge was to come my way. I definitely recommend highly international Fellowships. It’s a time in your life when you can be the most selfish and get more education in an area of your choice, with really wonderful surgeons and teams.

While abroad, my favorite moments were definitely social ones.

I was able to spend time and get to know surgeons who I’d only read about in books and admired. They generously allowed me to learn from their experiences and how they overcame challenges. You also make connections with individuals and teams that you stay in touch with over the years.

PSR: ANY LAST WORDS FOR FUTURE CLEFT SURGEONS? Dr. Fisher: Most of us in medicine are used to delayed gratification. I see that some residents are anxious to complete training, make money and move on. But I think that delaying entry into a position by one or two years for further training will make you much richer on many levels in the long run… |

Dr. Roy is PGY4 at the University of Toronto Division of Plastic and Reconstructive Surgery.

REFERENCES

1. Schaverien MV. Development of expertise in surgical training. J Surg Educ.

2010;67(1):37-43.

2. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg. 2005;116(1):61-71.

Plastic Surgery Resident | Spring 2020

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Why and How Residents Can Be Strong Specialty Advocates

By Benjamin Schultz MD, Resident Ambassador PlastyPAC Board of Governors

Y

ou’ve seen the headline above and have decided to read this far.

Congratulations!

You most likely have an interest in PlastyPAC, the political action committee (PAC) and advocacy wing of ASPS. The political system is an ever-changing and turbulent landscape, as the daily news cycles continuously remind us. In order for us, as plastic and reconstructive surgeons, to continue providing optimal care for our patients and protect the needs of our colleagues, we must turn to PlastyPAC, which serves a critical role in helping us reach our desired outcomes.

Recently, ASPS member Teri Hill, MD (D-Md.), decided to run for congressional office in Maryland’s 9th District to fill the seat of the late Elijah Cummings. We held a “meet and greet” for Dr. Hill with more than 11 physician organizations in Washington, D.C., where she discussed her positions on balance billing and prior authorization – both of which align with ASPS principles. We congratulate her on this outstanding milestone for our specialty.

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Plastic Surgery Resident | Spring 2020

GIVE ADVOCACY TWO DAYS IN D.C.

WHAT’S THE WORD?

However, efforts to support Society members at the national level and help guide the establishment of meaningful legislation cannot be done without your help. ASPS will be hosting a second regional Fly-in for the Northeast and Midwest members on June 10-11 in Washington, D.C. For those interested in advocacy, this is one of the best ways to begin participating.

We would love to see more plastic surgeons join in our efforts. In an effort to provide easier access to information and details of PlastyPAC, we’ll send your program a brief video and slide show further detailing the PAC’s work.

You can continue the efforts to make great strides for our specialty in the coming years by participating today.

In early February, ASPS held the Southeast & West Regional Fly-in to Washington, D.C. This was another successful meeting with representatives from both the Senate and House to underscore issues of significant importance to the Society. One such piece of legislation is the Resident Physician Shortage Reduction Act, specifically designed to create more ACGME-accredited residency training positions with an emphasis on increasing subspecialty positions – including plastic surgery.

Included in the event is an introductory information session targeting all ASPS-supported policies and an explanation of how the congressional site visits work, thus making for an easy first experience. To register, visit www.plasticsurgery.org/flyin.

Co-Resident Ambassador David Hill, MD, and I have recently turned our attention toward understanding why more residents aren’t involved in PlastyPAC. In order to gain insight, we created and distributed surveys at our own programs. We found that roughly 23 percent of residents have never heard of PlastyPAC – and what’s more, nearly 20 percent of residents have limited understanding of PlastyPAC’s role. The most promising numbers show that upward of 70 percent of residents are interested in participating should more information be made available to them.

For more information, check out the PlastyPAC website (plastypac.org), or feel free to email me (benschultzmd@ gmail.com) or Co-Ambassador David Hill (hilld793@gmail.com). |

Dr. Schultz is PGY5 at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York.

PSR NEWS

ASPS/PSF to award resident travel scholarships to Plastic Surgery The Meeting 2020 in San Francisco

A

Resident Travel Scholarship is available to cultivate future leaders among junior residents and international trainees in plastic surgery. Nine resident scholarships of $1,200 each will be awarded for travel and lodging to Plastic Surgery The Meeting 2020 (PSTM) slated for Oct 1619 in San Francisco.

Calls for applicants will be sent to program directors and program chairs to identify residents in the first four clinical years of an integrated program or the first year of an independent program, and who they feel have potential as future leaders within ASPS/PSF. Each institution may only nominate one resident for consideration.

Applications will be accepted through May 15 (no late applications will be accepted).

Selected residents will be expected to participate in at least three committee meetings during PSTM. Upon completion of the program, residents will be sent a survey to evaluate: •

• •

• •

Committees in which they participated, and an assessment of their experience within those committees Sections/committees of ASPS/PSF to which they would like to contribute in the future How attendance at Plastic Surgery The Meeting 2020 in San Francisco affected their choice of ASPS/PSF committees for future participation Ideas they may have for these sections or committees Merits of the program for their career goals

Program directors: Nominate a Resident Representative to ASPS/PSF Board

E

very year, the Young Plastic Surgeons Steering Committee nominates one resident representative to serve on the ASPS/PSF Board of Directors. This position is intended as a means to promote closer interaction between plastic surgery residents and ASPS. The representative serves as the voice of the residents to the ASPS leadership; in turn, the representative communicates with residents periodically about ASPS initiatives. The current resident representative is Joseph Lopez, MD; the upcoming Resident Representative term will run from October 2020 through October 2021.

A call for applicants will be sent to program directors asking that they submit nominations for the resident representative position. In order to be eligible for consideration, applicants must be in the final two years of their residency. The deadline for applications is April 30.

For more information, email Stuart Tucker at stucker@plasticsurgery.org. |

For more information, email Stuart Tucker at stucker@plasticsurgery.org. |

Plastic Surgery Resident | Spring 2020

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