Issuu

From the publishers of Plastic Surgery News

ISSUE 19 | SUMMER 2020

Track Switch The COVID-19 pandemic is changing plastic surgery training – likely forever

» Three voices How the pandemic has altered the lives of residents thrust into 'hot zones' page 11

» New: Complex Case Challenge Readers are given case details and asked to select a treatment approach page 28

IN THIS ISSUE » Consult Corner: Lower-extremity trauma p. 12 » Program Peek: Duke University p. 14 » Duke Flap Course: The evolution of a respected educational enterprise p. 26

A note from the editor

elcome to our Summer 2020 issue of Plastic Surgery Resident. Before addressing this installment, we first would like to thank all medical students, residents and Fellows for their commitment to patient care during the past several months. COVID-19 has forced us all into roles that we likely never imagined. We at ASPS are extremely proud of your measure and resilience.

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

In this issue of PSR, Joseph Catapano, MD, University of Toronto; Daniel Cho, MD, University of Washington; and Arya Akhavan, MD, University of North Carolina; document the current and future impact of COVID-19 on plastic surgery training. We also feature the personal experiences of residents from around the country. Our training program highlight takes us to Durham, N.C., where we feature Duke University’s program – as well its renowned Duke Flap Course. If you’d like to have your program featured in a future issue, please send a request to sanjaynaran@gmail.com. We’re also rolling-out a new series: “Complex Case Challenge.” Select your preferred method of treatment for a complicated case, and in the following issue keep an eye out for details on how the case was managed. In keeping with previous Summer issues, we’re seeking applications for new Resident Editors. Resident editors collaborate on all content and provide a critical level of review to ensure content is in line with the magazine’s mission. The term is one year, and it begins at the conclusion of Plastic Surgery The Meeting 2020, and running until next year's meeting. We are accepting applications form individuals in the senior years of their residency (PGY4, 5 or 6). To apply, please complete the online application form (https://www.plasticsurgery.org/documents/ Publications/PSResident/PSResident-Editor-Application.pdf) and submit it to PSN Managing Editor Paul Snyder at psnyder@plasticsurgery.org. The application deadline is Aug. 31. Finally, I’d like to state a correction to our Spring 2020 issue. We incorrectly credited A Neil Salyapongse, MD, for the “24 Hours in Madison” piece. Credit goes to Carol Soteropulos, MD, and Kishan Thadikonda, MD, both PGY4s at the University of Wisconsin, Madison. This correction has been made to our digital print. Carol and Kishan, our apologies. Thank you for your contribution. Thank you to our team of editors and the ASPS production staff for all of their hard work in bringing another great issue of PSR to fruition. Enjoy the read! |

Plastic Surgery Resident | Summer 2020

Table of

Contents Changes in training forced by COVID-19 challenge programs globally................................ 4

Training institutions are modifying their systems and requirements on the fly, but the overall impact the pandemic will bring to bear upon medical instruction is far from clear.

In their words: How the pandemic is affecting training.............................. 10 Three residents describe how COVID-19 has reached into their programs; how their institutions have responded; and how they personally continue to adjust.

Consult Corner: Lower-extremity trauma........................... 12 Neurovascular exams, palpated pulses, brachial indices and tetanus prophylaxis are among the areas of warranted attention when treating this patient.

Program Peek: Duke University............................................ 14

Duke’s Plastic Surgery Residency Program was among the first established in the nation, and its growth as an institution stands as an example of excellence.

Message from the Director: Jeffrey R. Marcus, MD...........17

The Duke Division of Plastic, Maxillofacial and Oral Surgery has trained a host of luminaries in the specialty and boasts the renowned Duke Flap Course.

24 Hours In: Durham, N.C...................................................... 18 Don’t let the bucolic nature of this Eastern Seaboard city fool you – Durham has the sights, sounds, activities and tastes to match larger, metropolitan rivals.

Faculty Focus: Alexander Allori, MD, MPH......................... 21

The director of Pediatric Plastic & Craniofacial Surgery (among other roles) is focused on creating “metrics that matter” – and encouraging residents to enjoy each day.

InService Insights: Branchial arches, clefts and pouches..................................24 Embryology of the neck as it relates to branchial structures is a frequent In-Service Exam focus – and this installment proffers a coherent, in-depth treatment.

Duke Flap Course: Cadaveric dissection at a leading level ..............................26 Direct observation of tissue planes and blood vessels, along with tactile manipulation, have helped build a widely respected – and unrivaled – educational experience.

NEW: Complex Case Challenge What’s your knowledge?.........................................................28

A newborn with multiple congenital anomalies launches this recurring feature that asks residents to consider the variables of a difficult case – and respond as the attending.

Resident Ambassador: Help strengthen PlastyPAC...................................................29 David Hill, MD, details recent efforts to influence members of Congress in their response to the COVID-19 pandemic and ways for residents to become part of the effort.

#TheTrend: ASPS/PSF Video, and QMP Complete...........30 The ASPS Education Network (EdNet) provides a one-stop, fully functional learning portal to manage continuing education; the PRS Digital Media section is filled with free resources Video resources and digital content provided by QMP Complete are impressive and thorough, though the price point may deter some.

Plastic Surgery Resident | Summer 2020 | Vol.4 No.2 The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR ESI DEN T Lynn Jeffers, MD, MBA | LynnJeffersASPS@gmail.com EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com ASSOCI ATE EDITOR Russell Ettinger, MD | retting@uw.edu ASSOCI ATE EDITOR Kavitha Ranganathan, MD | krangana@med.umich.edu INTER NATIONA L EDITOR Mélissa Roy, MD | melissa.roy@mail.utoronto.ca R ESIDENT EDITORS Roger Cason, MD | roger.cason@duke.edu Aaron Kearney, MD | aaron.kearney@northwestern.edu Elizabeth Kiwanuka, MD | elizabeth.kiwanuka@gmail.com Joseph Lopez, MD | jlopez37@jhmi.edu E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org 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

Plastic Surgery Resident | Summer 2020

COVID-19 IMPACT ON RESIDENCY, FELLOWSHIPS

Adaptation, Flexibility Smooth a Bumpy Road of Change and Confusion By Joseph Catapano, MD, PhD; Daniel Y. Cho, MD, PhD; & Arya A. Akhavan, MD

T Joseph Catapano, MD, PhD

Daniel Y. Cho, MD, PhD

Arya A. Akhavan, MD

he first presumptive cases of COVID-19 were diagnosed in the United States and Canada, respectively, on Jan. 21 and Jan. 25. Since the declaration of a national emergency in the United States on March 13 – and with many jurisdictions in Canada declaring equivalent states of emergency – circumstances have evolved rapidly. At Plastic Surgery Resident press time, approximately 9.2 million cases have been documented worldwide, with more than 477,000 deaths; approximately one-quarter of the cases and deaths have occurred in the United States.1 Responding to the burden of COVID-19 on the healthcare system and ICUs, governments instituted social distancing measures that included the closure of schools, daycare centers and non-essential businesses. The Centers for Disease Control and Prevention (CDC)2 and the American College of Surgeons (ACS)3 likewise published guidelines with the aim of preserving healthcare resources for a potential surge in patients requiring hospitalization and critical care. The ACS published the following for managing elective surgical procedures:4 • “Each hospital, health system and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations… until we have passed the predicted inflection point.”

Plastic Surgery Resident | Summer 2020

• “Immediately minimize use of essential items needed to care for patients, including... ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators.” These guidelines, supported by ASPS President Lynn Jeffers, MD, MBA, recommend that all plastic surgeons cease providing any elective or non-essential services.4 Given the elective to non-urgent nature of much of plastic and reconstructive surgery, case volumes decreased significantly in March and April. While the reopening of several states allowed clinical volumes to rise slightly, those reopenings have led to record numbers of new cases; it remains unknown when clinical volumes will return to pre-pandemic levels. While a debate on the impact of these guidelines on patient care is outside the scope of this article, decreased clinical volumes and postponement of elective surgery in some centers is already having an impact on resident surgical education. The University of Washington Plastic Surgery Residency Program recently published its experience, estimating a decline of nearly 100 percent in clinical volumes at the VA Medical Center and of approximately 75 percent at Harborview Medical Center.5

Whether or not one believes the “10,000-Hour Rule” popularized by Malcolm Gladwell in Outliers, we can all agree that exposure and practice are necessary components of resident education. Decreased exposure may limit progression along the learning curve – unless programs and residents adapt and accelerate their learning by maximizing educational opportunities outside and inside the O.R.

DECREASED EXPOSURE, DELAYED SKILL

Resident education is multifaceted; it includes independent learning, interactive lectures, operative experiences and reflection.6 While little can be done about the reduction in elective surgery caseloads, we are fortunate to train in a specialty with creative and dedicated mentors who’ve pivoted to maximize our didactic learning opportunities. International experts within our field have organized interactive educational events through multimedia platforms. ASPS, ASAPS, ASSH, AAHS and several other international societies, hospitals and companies created lecture series that residents can work through interactively or independently. While lectures are not a replacement for clinical and surgical exposure, understanding the literature is a necessary step for application in clinical settings. Plastic Surgery Resident | Summer 2020

COVID-19 IMPACT

The impact of reduced case volumes on residency will declare itself with time. A better understanding of anatomy and the literature learned outside the O.R. can translate into improved understanding and proficiency inside the O.R., thus accelerating the learning curve and allowing residents to maximize their surgical opportunities when elective surgical case loads return to a more typical level. The secondary concern with decreased operative experience is whether residents will meet criteria for graduation upon completion of their program. The American Board of Medical Specialties (ABMS) published a statement regarding the need to provide flexibility, with some subspecialty boards already having made programmatic adaptations.7 The American Board of Surgery (ABS) outlined that for chief residents completing training in 2020, non-voluntary, off-site time used for education can be included as clinical time; 44 weeks of clinical time would be acceptable; and the ABS would accept a 10 percent decrease in total operative case numbers.8 Inability to meet these metrics would result in program directors petitioning the ABS using information gathered from their respective Clinical Competency committees.8 Instructions have been released by the American Board of Plastic Surgery (ABPS) to Written and Oral Board Examination candidates, with the date of the written examination pushed back and the required caseload for the oral examination reduced. Requirements for Continuous Certification (until recently, Maintenance of Certification) have also been adjusted. ACGME guidelines can be referenced for residents.9 As outlined by the group from the University of Washington, graduation from residency is multifactorial and ultimately based on the program’s assessment of the trainee’s competence, with case minimums impacting accreditation and not program completion.5 In Canada, residency program directors and the Royal College of Physicians and Surgeons agreed to be as judicious as possible in determining whether residents have sufficiently achieved competencies in their respective programs, understanding that the pandemic has created unique training circumstances.10 Residents in their graduating year may be concerned with the impact of delays in licensure and board examination. The current pandemic has resulted in delays in both U.S. and Canadian examinations, with the ABPS Written Examination postponed to Oct. 26, 6

Plastic Surgery Resident | Summer 2020

and the Royal College examination postponed to the Fall 2020 (with the makeup date yet determined). New scheduling permits have to be assigned for residents writing the ABPS exam; however, closures of Prometric sites through May 31 will result in a backlog of exams to be written, and residents may have to be more flexible with location when scheduling the examination. Board examination and licensure differs significantly from the United States and Canada. In the United States, successful completion of residency is sufficient to obtain licensure – and the ABPS examination is necessary to become board-certified. In Canada, completion of residency is necessary to become eligible to write the Royal College examination, which is a two-step process: a two-day written exam followed by a two-day oral exam. Without successful completion of the Royal College exam, Canadian residents are ineligible for an independent practice license. This created confusion regarding the eligibility of graduating residents to practice starting in July. While the guidelines differ between provincial jurisdictions, the College of Physicians and Surgeons of Ontario (CPSO) may issue provisional licenses to residents who are exameligible, although these will be limited licenses that require supervision.10

THE UNCERTAINTY IN FELLOWSHIPS

For residents in their final years looking beyond residency, the impact of COVID-19 on the availability of Fellowship and faculty positions remains unknown, especially for those hoping to train abroad. COVID-19 is unlikely to have a long-term impact on the need for surgical Fellows and surgeons, but the more immediate impact over the next year is difficult to predict. For those currently in a Fellowship or entering one this summer, any shutdown of elective surgeries is likely to have a more significant impact on the quality of education. Over a 12-month fellowship, decreased clinical volumes for a two- to three-month period could represent a significant portion of the educational opportunities. For those applying to Fellowship, interviews in 2020-2021 will likely take a different form than in past years. Some programs held interviews virtually, while the microsurgery match was delayed until the fall. Many residents abroad who are looking to travel to the United States and Canada for residency and Fellowship have yet to receive their credentials, and licensure is delayed.

On April 22, President Trump issued an Executive Order temporarily suspending the issuance of immigrant visas.11 Fortunately, the J-1 non-immigrant visa currently is exempt, allowing residents from foreign countries with Fellowships planned in the United States to proceed. At the other end of the residency, new plastic surgery residents in the 2020-2021 year will have a novel and possibly limited experience. While some jurisdictions across the United States and Canada began the slow return to pre-pandemic operative loads as early as May, some regions opted to delay until July or later. The first year of residency is critical in rapidly developing new skills; if surgical loads and inpatient populations remain limited, this foundational period may not be enough to prepare new residents for the remainder of residency. Additionally, institutions are grappling with potential periods of quarantine following the arrival of incoming residents and Fellows, as well as how to handle orientation training while getting much needed residents efficiently and safely on the wards. The ACAPS/ASPS Boot Camp Joint Committee recently announced the cancellation of the 2020 Boot Camp and is exploring alternative options for providing education content to new trainees.12

Resident safety in the training setting remains a significant concern. Residency exposure may be more limited in certain subspecialty areas, such as facial trauma, which poses a unique risk of exposure to COVID-19, both by nature of being in or near the oronasophyarnx and by the risk of aerosolization. While new guidelines released by the AO CMF may assist in risk reduction, PPE limitations and the nature of these procedures have led some institutions to limit resident exposure to facial trauma cases.

DILEMMA OF MEDICAL STUDENTS

The COVID-19 crisis has also had a significant impact on medical students. Most medical schools suspended operations to help preserve PPE and reduce students’ exposure. Some schools transitioned to online educational courses while others have modified requirements for graduating medical students. Current fourth-year medical students saw their Match Day events as well as graduation cancelled, which precluded them from celebrating these momentous occasions representing years of hard work. Many medical students found ways to contribute to the pandemic response by helping with telemedicine, as well as by providing Plastic Surgery Resident | Summer 2020

COVID-19 IMPACT

childcare and other essential services to healthcare workers. Medical students in some cities – including New York, Boston and Providence, R.I. – have even been allowed to graduate medical school early in order to join frontline efforts against the coronavirus. Rising fourth-year medical students also face significant uncertainty as they prepare to embark on the residency application and interview process. As one of the most competitive specialties, the plastic surgery match is daunting even under normal conditions. Current applicants who have been pulled from clinical rotations must now juggle roles and demands – making up their clinical requirements while navigating an already complex visiting rotation, application and interview process. Studies show that 91 percent of applicants believed an away rotation made them more competitive for matching to a program, and program directors noted that a strong performance on an away rotation was the most important criteria for a successful match.13 In fact, up to 71 percent of medical students match at their home program or a program where they did an away rotation.14 Given the current pandemic, no programs are currently offering positions for visiting students during the summer, while a small number have begun to process applications for the fall. Medical students are told of the importance of letters of recommendation from away rotations, which they may be unable to obtain prior to the ERAS application deadline in September. Additionally, programs will not have one of their strongest recruitment and applicant evaluation tools available to them. The current ACAPS guidelines note that individual medical schools will determine policies regulating visiting sub-internships, but these also recommend waiting until the AAMC makes a recommendation on medical student interactions with patients and ACAPS develops a coordinated approach from all institutions. Even if these governing bodies allow for visiting medical students, many hospital systems may not be able to offer positions due to the lack of PPE and burden of COVID care. As such, medical students and residency programs will need to find new ways to ensure a successful match – and guidance will be needed from ACAPS to ensure an equitable process for all.

A RISE IN RESEARCH?

The plastic surgery community has done an exemplary job anticipating and reacting to the potential impact of COVID-19 on resident education. Strong leadership from societies such as ASPS, ASSH and CSPS, in addition to 8

Plastic Surgery Resident | Summer 2020

leadership from individual institutions, is invaluable in overcoming the limited clinical exposure for residents during COVID-19. With the additional time and resources, residents have a unique opportunity to read, reflect and contribute to research. This may be an opportunity to write grants, submit research ethics board approvals, or start new projects that require time to organize. Plastic and Reconstructive Surgery (PRS) Editor-in-Chief Rod Rohrich, MD, recently reported in the ASPS Virtual Grand Rounds series that PRS has seen a significant increase in article submissions, as a direct result of the research time newly available to plastic surgeons. In addition to virtual lectures, programs can further explore the utility of surgical simulation and models in plastic surgery education. The University of Toronto has explored the use of surgical simulation for procedures that are traditionally more difficult to teach intraoperatively because of confined space, limited visualization and delicate tissue handling.15 High-fidelity surgical simulators that replicate delicate, intraoperative tissue handling required may provide an opportunity for residents

REFERENCES

to maintain their surgical skills during times of decreased clinical load. Using this time to fulfill the other facets of residency will hopefully allow for residents to be better prepared and educated when clinical volumes return to pre-pandemic levels. Unfortunately, only time will reveal how these changes have impacted resident competency for independent practice. The hope is that while adaptations have changed education during this tumultuous period, residents will be no less-prepared at the completion of residency. Furthermore, the online resources created for education during this time may enhance resident education for the future. |

Dr. Catapano is PGY5 in the University of Toronto Division of Plastic Surgery; Dr. Cho is PGY5 in the University of Washington Division of Plastic Surgery; and Dr. Akhavan is PGY4 in the University of North Carolina Division of Plastic Surgery.

1. Corona Resource Center. Johns Hopkins University. https://coronavirus.jhu.edu/map.html. Accessed April 26, 2020. 2. Healthcare Facilities: Preparing for Community Transmission. Center for Disease Control and Prevention. https://www.cdc. gov/coronavirus/2019-ncov/hcp/guidance-hcf. html?CDC_ AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fhealthcarefacilities%2Fguidance-hcf.html. Accessed May 8, 2020. 3. Covid-19: Recommendations for the Management of Elective Surgical Procedures. American College of Surgeons. https://www.facs.org/covid-19/clinicalguidance/elective-surgery. Accessed April 24, 2020. 4. Jeffers L. ASPS Guidance Regarding Elective and Non-Essential Patient Care. American Society of Plastic Surgery. http://email.plasticsurgery. org/q/12EC50dbrptNnCCaBimf8m0W/wv. Accessed April 26, 2020. 5. Cho DY, Yu JL, Um GT, Beck CM, Vedder NB, Friedrich JB. The early effects of COVID-19 on Plastic Surgery Residency Training: The University of Washington Experience. Plast Reconstr Surg. 2020;[EPub ahea. doi:10.1097/ PRS.0000000000000127. 6. Luce EA. The Future of Plastic Surgery Resident Education. Plast Reconstr Surg. 2016;137(3):1063-1070. doi:10.1097/01.prs.0000479982.67922.8a. 7. ABMS Statement Regarding Continuing Certification During COVID-19. American Board of Medical Specialties. doi:10.1001/ jama.1971.03190210145015. 8. Fong ZV, Qadan M, McKinney R, et al. Practical Implications of Novel Coronavirus COVID-19 on Hospital Operations, Board Certification, and Medical Education in Surgery in the USA. J Gastrointest Surg. 2020. doi:10.1007/s11605-020-04596-5. 9. ACGME Response to Pandemic Crisis. Accreditation Council for Graduate Medical Education. https://acgme.org/covid-19. Accessed April 26, 2020. 10. Residents and COVID-19. Professional Association of Residents of Ontario. http://www.myparo.ca/ residents-and-covid-19/. Accessed April 26, 2020. 11. Proclamation suspending entry of immigrants who present risk to the U.S. labor market during the economic recovery following the COVID-19 outbreak. The White House. https://www.whitehouse.gov/ presidential-actions/proclamation-suspending-entryimmigrants-present-risk-u-s-labor-market-economicrecovery-following-covid-19-outbreak/. Accessed April 26, 2020. 12. Important COVID-19 Related Announcements. American Council of Academic Plastic Surgeons. https://acaplasticsurgeons.org. Accessed May 8, 2020. 13. Drolet BC, Brower JP, Lifchez SD, Janis JE, Liu PY. Away rotations and matching in integrated plastic surgery residency: Applicant and program director perspectives. Plast Reconstr Surg. 2016;137(4):13371343. doi:10.1097/PRS.0000000000002029. 14. Nagarkar P, Pulikkottil B, Patel A, Rohrich RJ. So you want to become a plastic surgeon? what you need to do and know to get into a plastic surgery residency. Plast Reconstr Surg. 2013;131(2):419-422. doi:10.1097/ PRS.0b013e31827c71bb. 15. Podolsky DJ, Fisher DM, Wong Riff KW, et al. Assessing technical performance and determining the learning curve in cleft palate surgery using a high-fidelity cleft palate simulator. Plast Reconstr Surg. 2018;141(6):1485-1500. doi:10.1097/ PRS.0000000000004426.

Plastic Surgery Resident | Summer 2020

RESIDENT PERSPECTIVES

WORKING IN

THE TRENCHES OF COVID-19

Plastic Surgery Resident | Summer 2020

Arya A. Akhavan, MD,

Johnathan Shih, MD,

Our institution cancelled all elective and non-urgent cases at the beginning of March, then instituted a moratorium on non-urgent cases until the end of May and put elective cases on indefinite hold. Naturally, our case volumes have dropped drastically. The administrative chiefs are trying to redistribute our remaining cases equitably across all residents, including those off-service, which helps to maintain some semblance of normalcy. For inpatient services, only a single resident rounds per day – and to limit potential exposure to COVID, E.D. consults and rounding on patients is being triaged to only the patients who truly need a physical exam.

As a PGY2 resident at the University of Washington, I served as the “trauma doc” of the E.D. at Harborview Medical Center, Seattle, during the height of our COVID-19 crisis. A role unique to our program, the trauma doc is typically a PGY2 Surgery or EM resident who functions as team leader during the resuscitation of all trauma patients that come through the E.D. As the only Level I trauma center across five states, our patient volume is often near capacity at baseline. With the advent of COVID-19 in the United States – and Seattle becoming the initial national epicenter of the disease – the University of Washington was tasked with pioneering strategies to expeditiously triage at-risk patients while also protecting its healthcare workers.

University of North Carolina

Residents on their aesthetic rotations are using this time as dedicated research time and have strong faculty support. The faculty have weekly meetings and resident check-ins, both from an academic and a mental health/ well-being perspective; didactics, M&M and Grand Rounds are held over Zoom. Residents are also now required to attend at least three webinars per week from the Resident Council calendar. |

Benjamin D. Schultz, MD, Hofstra-Northwell

As a PGY5 in the Northwell Health System, the largest in New York state, my colleagues and I were quickly redeployed to frontlines either in the E.R.s or ICUs as early as mid-March. Our three main hospitals have taken care of more than 6,000 patients with COVID19; personally, I’ve cared for dozens in the ICU. The impact has been severe for us. Since our redeployment, plastic surgery training has been reduced to daily virtual conferences. All of my co-residents have served in COVID ICUs, and they’ve done so with great decorum and care. Personally, I have been separated from my wife and 5-weekold son since the end of March to ensure their safety. As a PlastyPAC Resident Ambassador, I’ve had the opportunity to have Zoom conferences with several congressmen and congresswomen in the past few weeks. I made it a point to discuss the importance of improved access to PPE, hazard pay and student loan forgiveness for all residents even if only minimally impacted by the pandemic, and I’ll continue these efforts as long as I’m able. |

University of Washington

As part of this response, and in an effort to keep pace with the rapid evolution of COVID-19 and the unprecedented disruption of global supply chains, new clinical protocols were being piloted in the E.D. on a weekly basis. Some initiatives, such as the setup of a medical tent outside the E.D. as a pre-triage area for all patients presenting with fever or respiratory symptoms, immediately helped to alleviate patient burden and made it possible to comply with social distancing guidelines when rooming patients. Other protocols, particularly those related to trauma resuscitation, created logistical and communicative challenges that were often difficult to navigate. As an example, all trauma patients who presented to us intubated from the field were presumed to be COVID-positive and treated in an isolated trauma bay under full airborne precautions until a tracheal-aspirate sample could be confirmed negative or positive. To conserve limited PPE, only four providers (trauma doc, trauma surgery resident, RT and RN) would typically be allowed at bedside in the trauma bay for any resuscitation. These personnel restrictions, in conjunction with the challenges of closed-loop communication while wearing an N-95 or PAPR hood, presented obstacles that would have been insurmountable without well-organized pre-arrival team debriefings and role delegation. |

Plastic Surgery Resident | Summer 2020

Lower-extremity trauma “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 Aaron M. Kearney, MD

VEHICLE ROLLOVER, OPEN TIBIAL FRACTURE

You’re about to slip into bed at 11 p.m. when your pager goes off. Your return call reveals that a 35-year-old man was brought to the E.D. following a rollover ATV accident. At the scene, he was noted to have a large, open tibial fracture. The extremity was bandaged and splinted, and the patient was transported to the trauma center where you’re on call. The orthopaedic surgeons have requested you to evaluate the patient for soft-tissue coverage options. How will you approach this patient?

INITIAL EVALUATION

Patients with open lower-extremity fractures often meet criteria for a full ATLS trauma evaluation. Once this has been completed, you can proceed with a detailed evaluation of the extremity. A basic history should be obtained from the patient first. The history should include any medical comorbidities, prior surgeries, allergies, smoking/drug use, occupation and date of last tetanus booster, if known. Following this, a physical examination can be performed. The skin of the extremity should be examined and any abrasions, open wounds, avulsion flaps, etc., noted. Any exposed vessels or nerves in the base of the wound should be noted. The condition of the bone should be noted (i.e., periosteal stripping, large-segment bone loss). 12

Plastic Surgery Resident | Summer 2020

A careful neurovascular exam should be performed at this time. Sensory and motor function should be tested throughout the limb. Dorsalis pedis and posterior tibial pulses should be palpated. If the vascular exam is abnormal or there’s any question of malperfusion, Ankle-brachial index or toe-brachial index should be performed, and computed tomography angiography should be considered. Following the exam, the wound can be redressed, and the fracture reduced and splinted. Any significant wound such as this should lead you to ensure that the patient has adequate tetanus prophylaxis. CDC recommendations for tetanus prophylaxis in wound management are as follows: Table I. TETANUS PROPHYLAXIS RECOMMENDATIONS FOR SIGNIFICANT WOUNDS History of tetanus toxoid-containing vaccines

DTAP, TDAP or TD*

Tetanus immune globulin**

Unknown or < 3

Yes

>= 3

No***

*DTap for children < 7 years old; TDap for patients 11 years or older who haven’t previously received Tdap. ** Patients with HIV or severe immunodeficiency should receive tetanus immune globulin regardless of their tetanus immunization status. *** Yes, if >= 5 years since last tetanus toxoid vaccine dose.

Antibiotics should also be initiated expeditiously for any open fracture. Open long-bone fractures are commonly classified according to the Gustilo classification: Table II. GUSTILO CLASSIFICATION OF OPEN LONG-BONE FRACTURES TYPE

CHARACTERISTICS

Wound <=1 cm, minimal contamination

Wound 1-10 cm, moderate soft-tissue damage and contamination

III-A

Wound >10 cm, extensive soft-tissue damage and contamination, periosteal stripping

III-B

Wound >10 cm, extensive soft-tissue damage and contamination, periosteal stripping, requires flap coverage

III-C

As above, with arterial injury requiring repair

Antibiotic recommendations are based on the Gustilo classification of the injury as follows: Type I and II fractures • 1st generation cephalosporin IV or PO (e.g., cephalexin or cefazolin) until 24 hours after closure • Clindamycin if beta-lactam allergy

saline with surgical soap solution, and a negative pressure dressing is placed. An external fixator is placed to reduce the fracture. The patient is returned to the O.R. in 48 hours for a repeat debridement. Now that the wound has been stabilized, you have a discussion with your attending and the patient regarding his treatment plan. Though the plantar surface of the foot is numb, the tibial nerve is in continuity. The patient is advised that about half of patients in his situation will regain sensation on the sole of the foot. Given the size of the soft-tissue defect, he’s advised of the high likelihood that a free flap will be necessary for coverage. As he’s young, otherwise healthy and motivated, he opts to proceed with an attempt at limb salvage. At three days post-injury, he’s taken to the O.R. by your team and orthopaedic surgery for definitive fixation and softtissue coverage. The orthopaedic surgeons place hardware to provide internal fixation of the fracture (Figure 1). There’s noted to be a bone gap in the tibia of 5 cm. You and your attending discuss treatment options for bone gaps.

Type III fractures • 1st generation cephalosporin IV plus aminoglycoside (e.g., gentamicin) for gram-negative coverage until at least 24 hours after closure • Add penicillin for anaerobic coverage (e.g., with a farm injury) An Infectious Disease consult may be beneficial if any unusual circumstances are present – such as allergies, contamination with fresh or saltwater, or known MRSA colonization. On physical examination, the patient is found to have a 12 cm open wound with periosteal stripping of the exposed, fractured tibia. Dorsalis pedis and posterior tibial pulses are palpable. Sensation is absent on the plantar surface of the foot. The patient receives X-rays in the E.D. to further evaluate the comminuted tibial and fibular fractures. He receives a TDap booster. Cefazolin and gentamicin are started, and you take him to the O.R. in conjunction with orthopaedic surgery for debridement and initial fixation of the fracture.

TREATMENT Expeditious debridement is critical in any large, open lower-extremity fracture such as this. Devitalized tissue is debrided, the wound is thoroughly irrigated with 9 liters of

Figure 1. Wound after internal fixation and bone grafting.

These include: • Nonvascularized bone graft • Free osseous/ osteocutaneous flap (e.g., fibula) • Distraction osteogenesis (e.g., with Ilizarov frame)

Nonvascularized bone graft is chosen and placed into the defect. The soft-tissue defect is covered with a free anterolateral thigh-flap from the thigh. The patient is started on a dangling protocol postoperatively; he’s discharged from the hospital on postoperative day seven to continue rehabilitation at home. | SUGGESTED READING

Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. NEJM 2002;347:1924-31. CDC guide on tetanus prophylaxis. https://www.cdc.gov/tetanus/clinicians.html#woundmanagement Bosse MJ, McCarthy ML, Jones AL. The insensate foot following severe lower extremity trauma: An indication for amputation? JBJS 2005;87(12):2601-8. Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg 2011;128(5):551e-63e. Medina ND, Kovach III SJ, Levin SL. An evidence-based approach to lower extremity acute trauma. Plast Reconstr Surg 2011;127(2):926-31. Ong SW, Levin SL. Lower limb salvage in trauma. Plast Reconstr Surg 2010;125(2):582-8.

Plastic Surgery Resident | Summer 2020

Duke University Division of Plastic, Maxillofacial and Oral Surgery By Rosie Tillis, MD History • The Duke Division of Plastic, Maxillofacial and Oral Surgery was founded in 1934 by Randolph Jones, MD. • The Duke Plastic Surgery residency training program was started by Kenneth Pickrell, MD, in 1946 and was one of the first in the country. • Oral Surgery, Orthodontics and other Oral Health services are all part of the division going back to its origin. The Duke Cleft Team was one of the first multidisciplinary teams in the United States. • The integrated residency program began in 2013 and the independent program was phased out through 2018. • The integrated residency program takes three residents each year and is a six-year program. • The Duke Plastic Surgery mission is to provide comprehensive education and experiential training in an environment that challenges to foster personal growth, yet nurtures to cultivate integrity, professionalism and leadership. Duke Medical Pavilion

Plastic Surgery Resident | Summer 2020

Leadership • Jeffrey Marcus, MD: Chief, Division of Plastic, Maxillofacial and Oral Surgery; Residency Program Director • Brett Phillips, MD, MBA: Associate Residency Program Director • Suhail Mithani MD: Vice Chief of Clinical Operations • Scott Hollenbeck, MD: Vice Chief of Research • David Brown, MD, PhD: Director, Medical Student Clerkships • David Powers, MD, DMD: Director, Craniomaxillofacial Trauma and Reconstructive Surgery Fellowship and DUHS CMF Trauma program • Linda Cendales, MD: Director, Duke Vascularized Composite Allotransplantation Program; Chair, Diversity and Inclusion Committee • Howard Levinson, MD: Director, Innovation and Entrepreneurship • Alexander Allori, MD, MPH: Assistant Director, Pediatric Plastic & Craniofacial Surgery; Director, DataLab Clinic for Clinical Care and Population Health • Detlev Erdmann, MD, PhD, MHSc: Chief, Plastic Surgery Section, Durham VA Medical Center

Duke University Division of Plastic, Maxillofacial and Oral Surgery medical staff in 2019.

National Leadership • Duke faculty and alumni have historically held multiple leadership roles: o 13 Plastic Surgery Program chairs and directors o Six chairs, American Board of Plastic Surgery o Seven presidents, American Society of Plastic Surgeons o Two presidents, American Association of Plastic Surgeons o Two presidents, American Society of Reconstructive Microsurgeons o Five presidents, Plastic Surgery Foundation o Two presidents, American Society of Aesthetic Plastic Surgeons o Eight presidents, Southeastern Society of Plastic Surgeons o Two presidents, Plastic Surgery Research Council • Dr. Marcus is immediate-past President of the Rhinoplasty Society • Dr. Levinson is the current The Plastic Surgery Foundation Board Vice President and Past President of the Plastic Surgery Research Council • Dr. Cendales recently served as the President of the International Society of Vascularized Composite Allotransplantation and has been elected to serve on the Organ Procurement and Transplantation Network Board of Directors Clinical Experience • Duke has 18 integrated plastic surgery residents (three per year) and 16 full-time faculty. • Duke University Hospital: DUH is a 957-bed hospital

• •

(and expanding with a new inpatient tower to open in 2020) with 51 O.R.s. DUH is a Level I trauma center and has on-site clinics as well as a nearby ambulatory surgery center. Duke Children’s Hospital: Duke Children’s Hospital is located within the main hospital and is the primary site of our Pediatric and Craniofacial services. Durham VA: The Durham VA is a 251-bed, tertiary care center geographically adjacent and associated with Duke University. The plastic surgery program runs a robust VA resident clinic with surgeries staffed by our VA attending physicians. Duke Ambulatory Surgery Center: The ASC is a freestanding surgical center with nine O.R.s and is a short walk from DUH. Duke Aesthetic Surgery Center: The Duke campus also includes the Aesthetic Surgery Center, which houses our aesthetic clinics, resident injectables clinic, as well as two operating rooms. The facility is currently undergoing a $1.3 million renovation to improve and expand clinical spaces. Duke Oral Health Clinic: Adjacent to the Aesthetic Center, this new facility is home to Craniofacial Orthodontic services and Oral Surgery outpatient care. Duke Raleigh Hospital: The newest addition to the Duke Plastic Surgery curriculum is Duke Raleigh Hospital, which has a specific focus on breast reconstruction, lymphedema, and transgender medicine.

Plastic Surgery Resident | Summer 2020

PROGRAM PEEK

Educational Curriculum • Journal Club is hosted monthly at local restaurants and attended by residents and faculty. Residents also participate in Hand Journal Club in conjunction with the Division of Hand Surgery. • Grand Rounds is hosted as a weekly morning conference for residents and faculty along with a monthly M&M session. • Indications Conference is a weekly conference in which residents partake in surgical planning and decision-making for patients in an oral-boards format. • Hand Conference is hosted as a weekly conference with the Hand Surgery program; it includes lectures and dissections with both orthopedics and plastic surgery faculty. • Soft Skills Curriculum is a progressive education over the six-year residency led by faculty members Dr. Allori, Dr. Marcus and Sharon Clancy, MD. The structured multi-modality course covers topics often termed “soft skills,” including teamwork and team building, leadership training, resilience, communication, crucial conversations and introspection • Virtual Education continues during the time of social distancing with weekly educational curriculum including video conferences and national society guest lectures. • Human Fresh Tissue Lab offers the cadaver lab owned by plastic surgery; it’s available 24/7 for case preparation, practice and weekly dissections. It’s the site of our numerous educational courses. • Microsurgery Course involves a rigorous, weeklong course during PGY3 dedicated to practicing microsurgical techniques on live rodent models, with one-on-one instruction. • Microsurgery Lab allows residents to have 24/7 access to our microsurgical laboratory, which is equipped with two microscopes. Research & Conferences • Research is structured so that each resident is expected to be involved in at least one (but generally more than one) active research project. Additional quality improvement projects are undertaken yearly by groups of multiple residents as a program requirement of all surgical residents. • Funding for research projects comes from local and national grants from the DOD, ASPS, NIH and multiple other organizations. • Duke Flap Course, now in its 18th year, is an annual course dedicated to sharing knowledge from national and international attendings while watching and helping in live dissections of flaps in our human fresh tissue lab. • CMF Trauma Course hosted by Duke includes an annual, craniofacial ballistics trauma course with lectures and freshtissue fracture reduction and plating, led by Dr. Powers – an 16

Plastic Surgery Resident | Summer 2020

Duke Hospital

Army-trained craniofacial surgeon who trained at Shock Trauma and Walter Reed. • Oncologic Reconstruction Course allows Duke residents to participate in another yearly course, which started as a partnership between Duke and Hopkins, and focuses on reconstruction of challenging oncologic resection defects. • AO Courses permit PGY2 and PGY3 residents to have the opportunity to choose AO courses in CMF trauma or hand surgery and receive full funding and support to attend these courses. • Support for meetings allows residents to receive full financial and clinical time support from the program to attend any meeting at which they have an oral presentation, along with one additional major and one additional minor meeting for PGY4-6. Resident Benefits • A proud, supportive, team-oriented atmosphere where accomplishments and achievements are encouraged and celebrated • Strong mentorship, career planning and advocacy • Free parking adjacent to the hospital; hospital gym; white coats; and Duke Plastic Surgery Scrubs • Resident fund for loupes purchases in PGY1 and PGY4 • Travel expenses and registration for national and regional meetings • Extensive “swag,” including personalized scrubs, jackets, surgical hats • Education fund for book purchases • Smaller city living with suburbs nearby allow for a social and active outdoor lifestyle • Nearby Blue Ridge Mountains – as well as Outer Banks beaches – for weekend getaways | Dr. Tillis is PGY2 at Duke University School of Medicine.

A Message From the Program Director, Jeffrey R. Marcus, MD

ever stop getting better.” Duke Plastic Surgery was one of the first plastic surgery training programs in the United States. The Division of Plastic, Maxillofacial and Oral Surgery was formally developed in 1934, and the residency program was founded in 1946 by Kenneth Pickrell, MD, who came to Duke from Johns Hopkins in 1944. Jeffrey R. Marcus, MD Dr. Pickrell led the division until 1975 and trained more than 50 residents, with a disproportionate number later moving on to national and international leadership positions. One example was Guido Matton, MD, who trained under Dr. Pickrell in the 1950s and later founded the now-renowned Department of Plastic Surgery at the University of Gent, Belgium. Many noteworthy figures graduated from the Duke program, among them Charles Horton, MD; Frank Masters, MD; C. Lin Puckett, MD; Greg Georgiade, MD; Nicholas Georgiade, MD; Kenna Given, MD; Norman Cole, MD; Ray Broadbent, MD; Jerry Adamson, MD; Rudi Gingrass, MD; Donald Serafin, MD; and L. Scott Levin, MD. I came to Duke via Northwestern University and the University of Toronto in 2002, and in 2017 I became the sixth division chief. As a student of history, I was interested in how each prior leader had contributed aspects of their personae to form the character of the program. I never met Dr. Pickrell or his wife, Katherine, but I’m told by many that their love of the residents and the sense of family they both instilled were critical elements to the success that they had among their graduates. I believe that the stature and success of a training program is directly tied to the success of its graduates above all else. It’s the combination of caring mentorship and high expectations, inspired by the Pickrells, that I hope to emulate today in our program. Dr. Nick Georgiade was the second division chief. He was a dualdegree oral surgeon and plastic surgeon, and along with the fact that Duke has no Dental School, it explains why the division oversees all oral health-related services and is titled “the Division of Plastic, Maxillofacial, and Oral Surgery.” Innovation was one aspect that Dr. Georgiade brought to Duke that endures today. Along with his colleague, Ralph Latham, MD, he was the inventor of the presurgical device to actively move maxillary segments prior to cleft surgery. Later innovations born at Duke include the original “Quill” suture by Gregory Ruff, MD; “Sternal Talon” by Dr. Levin; and my own “Hybrid MMF” device. Many of our faculty are deeply engaged in the process of innovation, including device, process, corporate incubation and the mentorship of interested residents. The multidisciplinary cleft team (one of the first) began under Dr. Nick Georgiade’s tenure and is nationally and internationally recognized. This year, we opened a new craniofacial orthodontic and oral health facility led by Pedro Santiago, MD – one of the original members of the NYU team that introduced naso-alveolar molding to the world. Duke Plastic Surgery and the field of reconstructive microsurgery are inextricably linked. Don Serafin, MD (division chief in

1985-95), and orthopedic surgeon James Urbaniak, MD, were among the pioneer group who introduced and popularized the concepts, principles and procedures for replantation and microsurgical free tissue transfer. The pioneering work of Dr. Serafin was taken to the next level by Dr. Levin (division chief in 1995-2009) who leveraged his dual training in orthopedic surgery to create a concept/specialty of “orthoplastic” surgery – which blended reconstructive microsurgery with orthopedic principles to optimize care and limb salvage. Dr. Levin also founded one of the nation’s first clinical fresh tissue anatomy labs, which continues to be one of the most valuable resources to our residency program. The Duke Flap Course, founded by Dr. Levin and Michael Zenn, MD, is now in its 18th year as a premier educational opportunity for our residents and the many hundreds of reconstructive surgeons who have come to Duke every summer. Newer courses include the Oncologic Reconstruction course led by Scott Hollenbeck, MD, and colleagues; the CMF Trauma Course led by David Powers, MD; and this year, the inaugural NAM/orthodontic Course to be led by Dr. Santiago and Barry Grayson, MD. As a product of an integrated plastic surgery residency program, I believe strongly in its merits. Dr. Greg Georgiade founded and led the transition from an independent to an integrated program at Duke in 2013 based on a best-practice approach to curriculum development. The division has grown more in the past five years than in the many decades that preceded them. We added many new faculty, built a new practice in Raleigh, N.C., at Duke Raleigh Hospital, opened our new Oral Health Facility, and we’re currently renovating our full-service aesthetic surgery center. While remaining true to our history and tradition, the division aims build yet further on the strong foundation built by those who’ve preceded us. It’s our explicit goal to provide the most well-rounded residency training experience and to produce the specialty’s next generation of leaders. I believe that this means not only fostering the development of technical skill and medical knowledge, but also the life skills that aren’t always taught in medical training. Creating leaders and a high-functioning team doesn’t happen by accident – the process is purposeful, beginning with the recruitment of the right people and then mentoring in a structured format designed to inspire and cultivate progression. Our six-year “soft skills” curriculum is based on the fundamentals of interpersonal interaction, classic teaching and philosophical thought in the broad subjects of teamwork, culture, leadership, introspection and communication. We’re currently at a unique time in history. How we respond, and the way we adapt to the changing environment and constraints it imposes will determine how well our graduates will be prepared to take on the challenges before them. Their success is our legacy; it will take creativity and commitment to build the program for 2021 and beyond. Fortunately, our whole specialty is based on creative problem-solving, so I believe we’re all well-suited for the task. | Dr. Marcus is Plastic, Maxillofacial and Oral Surgery Division chief and Integrated Plastic and Reconstructive Surgery Residency Program director at Duke University School of Medicine, Durham, N.C. Plastic Surgery Resident | Summer 2020

Durham, N.C. By Adam Glener, MD & Jared Blau, MD

Duke University Chapel

Plastic Surgery Resident | Summer 2020

Photo: aimintang/istock.com

elcome to Durham, N.C., the dining capital of the South. Located in the middle of North Carolina, this city will delight you and leave you wanting more. Home to Duke University, historic Durham also was the headquarters of “Black Wall Street” as well as James Buchanan Duke, the tobacco titan who funded the university and Duke University Medical Center – ignore the irony of the fact that a major hospital is built on a century of cigarette money. Its weather, low cost of living, social conscience, friendly people and a crucible that forged some of the best (and affordable) restaurants have attracted people from all over the country to call Durham home. Taste it, hike it, explore it – and only regret that you only have 24 hours.

BREAKFAST

Morning is time to discover why Southern Living called us “The South’s Tastiest Town.” Chefs Lindsay Moriarty and Rob Gillespie started the bakery and café Monuts by selling donuts from a tricycle at the Durham Farmers’ Market in 2011; today, they’re in their second brick-andmortar establishment. Everything is locally sourced and made from scratch, they pay a living wage and they kept 100 percent of their employees hired and paid – despite being closed for five weeks during the coronavirus pandemic. The yeast and cake donuts change daily – press your nose against the glass display like a kid to view the eight, unique donut flavors crafted for that day, and you’ll almost taste the sweet goodness. Get a few and share – they pair well with a breakfast sandwich or latte.

HIT THE OUTDOORS

Time to burn off those just-consumed hundreds of calories and escape to the southern sun. The Duke Gardens are right on campus, literally a twominute walk from the medical center. The planners’ original concept was to

Duke Gardens in Creative Commons. (Photo courtesy of Ivy Dawned)

turn the land into a lake. When funds ran short, the much-better option of a massive garden was conceived. The 55-acre treasure has five miles of paths and walkways, an Asiatiac arboretum, a garden of native plants, a cafe´ and an iconic red bridge that crosses a pond. The gardens are a focal piece of the Duke campus. Admission is free.

LUNCH

Chef Ricky Moore founded Saltbox Seafood in 2012 to redefine how a city thinks of fish. He modeled his walkup seafood stand on waterside seafood shacks and drove each morning to the N.C. coast to purchase a fresh catch. You can order whatever’s in season – with today’s offerings (shrimp, flounder, catfish, grouper, scallops) scrawled on a chalkboard on the counter. An official closing time exists, but Saltbox packs up when the last fish is sold, usually in the early afternoon – a testament to its quality. Chef Moore’s efforts landed him a 2020 James Beard nomination for best chef in the southeast. (Chef awardwinners were to be announced May 4, but ceremonies have been postponed, with no new date determined at PSR press time.)

Monuts. (Photo by Jared Blau, MD)

Fresh seafood at Saltbox. (Photo by Jared Blau, MD)

Plastic Surgery Resident | Summer 2020

24 HOURS COFFEE

Even though this may be your first time in Durham, you may have tasted it before. Durham is home to Counter Culture, one of the “Big 3” roasters of Third Wave coffee in the United States. “Third wave” is where we are on our coffee timeline, a chapter that seeks to source coffee from hyper-specific international locations – such as individual farms – to showcase the unique flavor profiles offered by climates and soils across the globe. In the afternoon, head to Cocoa Cinnamon, a Durham staple with three locations and their own roastery. If a single-origin pour-over isn’t your thing, try their incredible real hot chocolate and peruse the innovative “wonder menu” with unique ingredients (think cardamom and crushed rose petals). If you visit their Lakewood location, watch them pour and fry a paquete of churros, dusted in a sugar of your choice.

AFTERNOON

If you’re lucky enough to visit Durham in spring or summer, make sure to catch a Durham Bulls minor league baseball game. As the Triple-A affiliate of the Tampa Bay Rays, the Bulls have a national following attributed to the 1988

EVENING

A chocolate drink and churros at Cocoa Cinnamon. (Photo by Jared Blau, MD)

cult-classic Bull Durham starring Kevin Costner and Susan Sarandon. Even if you’re not an avid baseball fan, the newly renovated Durham Bulls Athletic Park offers a downtown location, local food options and even an in-stadium brewery (Beer Durham), making it an enjoyable evening for all. If the Bulls happen to be out of town, Durhamites can enjoy nearly a dozen breweries within city limits; some favorites include Ponysaurus, Fullsteam and the Durty Bull.

Above: Dr. Blau (left), Dr. Glener (far right) and friends enjoy cups and cones at The Parlour ice cream shop. (Photo by Jared Blau, MD) Right: The Durham Bulls between innings during a game at Athletic Field. (Photo by Adam Glener, MD)

Plastic Surgery Resident | Summer 2020

Dubbed “America's Foodiest Small Town” by Bon Appétit, Durham boasts a long list of must-try restaurants. On that list is Viceroy, an Indian restaurant set in a British colonial-themed pub. Viceroy’s fare beautifully flaunts bold Indian flavors with a British flare – come for the curry, stay for a pint. Once you’ve had your fill, walk around the block for a nightcap at Alley TwentySix and enjoy a craft cocktail. While the bartenders can certainly execute classics to perfection, Alley Twenty-Six brandishes more eclectic options for the bold (Ask for their Tiki-themed menu or the Mexican Herbalist). Finally, end your night with a delicious scoop of ice cream from The Parlour. Originating as a food truck, the brickand-mortar location downtown is a perfect spot to enjoy a scoop of the house-made favorite: salted caramel. Savoring this cool treat is a fitting way to close a busy – and tasty – day. |

Dr. Blau is PGY4, and Dr. Glener is PGY3, in the Duke University School of Medicine Division of Plastic, Maxillofacial and Oral Surgery.

Q&A WITH ALEXANDER ALLORI, MD, MPH 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 Alexander Allori, MD, MPH, assistant director of Pediatric Plastic & Craniofacial Surgery; former director of Quality & Safety for Children’s Surgery; and director of the DataLab for Clinical Care and Population Health at Duke University Hospital and Children’s Health Center, Durham, N.C. Dr. Allori’s research interests range from traditional clinical outcomes, patient-reported outcomes, economic analysis, and management and policy studies. His sweeping goal is to develop what he calls “metrics that matter,” or standardized methods to assess outcomes meaningful to patients, with a particular focus on improving integration of data “into the clinical workflow” of multidisciplinary teams, where communication and coordination of care are critical for success.” His passion, however, is helping children – his primary influence and concern, sparked by growing up with a younger brother with a serious medical condition. Dr. Allori wants residents to keep in mind that their training is a marathon and perseverance is one key to success; yet, there’s a fine line between persistence and becoming a workaholic, and the awareness and execution of one’s obligations outside medicine is critical to maintaining balance. He also adds that no one is ever too old or experienced to embrace a new mentor.

PSR: WHAT DREW YOU TO PLASTIC SURGERY AS A SPECIALTY? Dr. Allori: As do many people, I chose to go into medicine for personal reasons: my younger brother has cerebral palsy; consequently, I grew up with a sincere desire to help children like my brother. Initially, I explored neurosurgery as a field, but for various reasons, this evolved into an interest in craniomaxillofacial surgery and pediatric plastic surgery.

PSR: HOW DID YOU PREPARE YOURSELF DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Allori: I believe critical thinking, creativity and academic productivity are important to success in plastic surgery. I obtained an MPH degree overlapping with my medical studies in Houston. I very much enjoyed graduate school, as the mode of thinking is very different: It’s about total immersion, falling down rabbit holes and exploring where you end up. I really learned a lot about health-services research, health policy, bioethics, epidemiology, statistics, study design, etc., during this time. Next, in the middle of general surgery residency, I devoted two years to basic science research in the traditional wet lab at NYU. Even though I had some early experience in clinical research, this research sabbatical is where I really learned how to think and function like a clinician-investigator. During this time, I read a lot, formulated hypotheses, designed experiments to test those hypotheses, and had to trouble-shoot experiments that didn’t work. There are few things as frustrating as not being able to replicate experiments, few things as humbling as Plastic Surgery Resident | Summer 2020

FACULTY FOCUS

seeing hypotheses that you really believed as being disproven, and few things that will challenge your patience, perseverance and resiliency. It’s all about strategy and the long game. A research sabbatical is an invaluable “growing-up” period – and I highly recommend it. Finally, during the course of my plastic surgery residency at Duke, I took what I learned in my grad-school and lab years and applied those skills toward research related to cleft and craniofacial conditions. This was a great period. I was extremely fortunate to have the strong mentorship of Jeffrey Marcus, MD, and sponsorship of Gregory Georgiade, MD, who believed in the vision that I had for my future. The projects that we did together were fun, reasonably impactful and rewarding. The papers I published during this time created a track record of academic productivity that I believe helped me to earn my spot in a pediatric plastic and craniofacial fellowship at Boston Children’s.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON THE ADVANCEMENT OF YOUR CAREER? Dr. Allori: Well, that’s easy! Even though my exposure to craniofacial surgery while in residency at Duke was quite satisfying, it really isn’t until Fellowship that one really gains sufficient exposure and experience to do it as a career. I loved my time in Boston, and I use the lessons that I learned in my Fellowship every day.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY YEARS OF PRACTICE? Dr. Allori: Mentors are important at many stages in one’s life. I was fortunate to have guidance and support at key moments in my training. But mentorship doesn’t stop at graduation. Arguably, mentorship may be even more important after a resident completes training and starts as junior faculty. Who that mentor should be depends on the circumstances – it could be your new clinical partner at your hospital, or it could continue to be your old mentor from training who continues to follow your progress. For me, it happens to be both! I was hired at Duke, so my partner is Jeff Marcus – who, as I mentioned previously, was a critical mentor during my training years. Presently, he’s my partner in pediatric plastic surgery and division chief at Duke. He’s been so very important in teaching me “the business of medicine,” how to increase productivity, 22

Plastic Surgery Resident | Summer 2020

how to deal with challenging cases, and in helping to regulate my involvement in administrative roles. I’m very grateful for his support throughout the years.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Allori: Admittedly, I’ve been cautious about involvement in societies and committees. I have favored involvement in administrative roles at Duke – such as being Director for Quality and Safety for Children’s Surgery – over committee involvement. That said, I’ve chosen to participate in some task forces and committees that interested me, such as the Data Standards Committee in the American Cleft PalateCraniofacial Association (ACPA) and working with the International Consortium for Health Outcomes Measurement (ICHOM) to develop the Standard Set for the Comprehensive Appraisal of Cleft Care. Committees are important because they help you to meet like-minded and talented individuals, with whom you may enjoy fruitful collaborations. Because of my involvement in ACPA and membership in ASCFS and AAS, I’ve made many academic friendships.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Allori: Perseverance. Residency is hard and long. It’s definitely a marathon, not a sprint. A successful resident must know why he or she started the race; know how fast to run; know when to speed up, slow down, or rest; and must keep his or her spirits up when the going gets tough. Perseverance is not only important for residents – attendings need it just as much.

PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Allori: This is hard for any surgeon. I think to a certain degree, a surgeon has to give up a lot, and his or her family needs to consent to making sacrifices as well. That said, once you establish those ground rules, you also need to resist the (incredibly easy) draw to become a workaholic. Clinical work is hard to control, but one should pay attention to all the academic and administrative roles and choose carefully which time commitments are worthwhile. It’s important to carve-

out the necessary time for family and for your own health and well-being. Again, it’s about the marathon, not the sprint.

PSR: WHAT WAS THE BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY THAT YOU FACED – AND HOW DID YOU OVERCOME IT?

to preserve a “predictable” and “controllable” schedule so that I can fit in time for research. But overall, I can’t complain. We have a great team, and it’s all worked out.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE?

Dr. Allori: I remember when my mother was sick and needed an operation, and how hard it was to take time off work in order to travel to where she lived and to support her during that time. I was able to do that, but of course I had to return back to work after a short while. When my mother had some late complications of surgery, it was pretty rough managing. I was stuck between Scylla and Charybdis.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON?

Dr. Allori: Second to my patients, this is my favorite part of my job. I direct the “Soft Skills Curriculum” for our plastic surgery residents. Soft skills pertain to leadership, teamwork, communication, crisis management, productivity, resiliency and all the other things that are necessary for success in our careers. As director, I get to organize the full curriculum, give lots of lectures and presentations, and design really fun “flipped classroom” workshops. I also serve as a close mentor or coach for the senior residents as they transition from mere management to true leadership, which is really rewarding.

PSR: AS A SEASONED PLASTIC SURGEON, WHAT WOULD BE YOUR WORD OF ADVICE FOR PLASTIC SURGERY RESIDENTS?

Dr. Allori: For me, it’s my patients. I love babies! The cases that I do are very fulfilling.

Dr. Allori: Enjoy what you do! Be grateful for the opportunities to learn even one, small thing each day.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER ON A REGULAR BASIS? Dr. Allori: Duke is accredited by the American College of Surgeons as a Level I Center of Children’s Surgery. As such, we’re required to provide 24/7/365 coverage of pediatric plastic surgery, and therefore my partner and I share call throughout the year. On top of that, add call to cover adult craniomaxillofacial trauma. So most of the challenge is how

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN… ” Dr. Allori: I knew I wanted to become a plastic surgeon as soon as I saw a cleft lip repair. |

Free and Open

JOB BOARDS FOR RESIDENTS AND FELLOWS American Society of Plastic Surgeons

American Council of Academic Plastic Surgeons (ACAPS) Job Board

https://www1.plasticsurgery.org/Job_Opportunity/ (Fellows and Faculty)

https://acaplasticsurgeons.org/jobs/ (Resident, Fellows and Faculty)

Plastic Surgery Resident | Summer 2020

Making Sense of Branchial Arches, Clefts and Pouches By Meredith Kugar, MD

ranchial anomalies account for 20 percent of all congenital head and neck lesions in children. A good knowledge of embryology and surgical anatomy is helpful in diagnosing branchial anomalies, as well as providing appropriate, safe surgical therapy. Embryology of the head and neck, specifically with regard to the branchial structures, is frequently tested on the In-Service exam.

THE PHARYNGEAL (BRANCHIAL) APPARATUS

The pharyngeal – or branchial – apparatus is formed at week 4 of development when the embryo is 5 mm in size. The branchial system is a transient structure that eventually becomes the structures of the head and neck. The pharyngeal apparatus consists of branchial arches, grooves (or clefts) and pouches. Different structures arise from the arches, grooves and pouches. There are five branchial arches, numbered 1, 2, 3, 4 and 6. The fifth arch is thought to disintegrate during development. The branchial arches are masses of mesoderm covered by ectoderm on the external surface and lined by endoderm. The arches are separated by branchial grooves that are visible on the surface of the embryo. On the interior aspect of the arches, the branchial pouches are found between each arch.

BRANCHIAL ARCHES

The development of the branchial arches occurs between the fourth and seventh week of gestation. The branchial arches

Plastic Surgery Resident | Summer 2020

are the embryological precursors of the ear as well as the muscles, blood vessels, bones and cartilage of the face, neck and pharynx. The In-Service exam tests knowledge of the specific muscles and skeletal structures that develop from each arch, as well as the cranial nerves and arteries associated with each arch. The mnemonic “Make Some Important Schtuff” is helpful for committing the development of the branchial arches to memory (Table I). “M” represents structures that develop from the first arch, with “S” and “I” representing structures from the second and third arches. “Schtuff ” represents structures that develop from both the fourth and sixth arches. It’s helpful to first commit to memory which cranial nerves are associated with the arches. The first, second and third branchial arches give rise to, respectively, the fifth, seventh and ninth cranial nerves. Arches four and six give rise to cranial nerve 10. Structures beginning with “M” that develop from the first arch are as follows: maxillary artery; muscles of mastication (commit to memory the ones that do not begin with the letter m); maxilla; mandible; malleus; and incus. “S” refers to the structures that develop from the 2nd arch, which include the stapedial artery; smile muscles (muscles of facial expression); stylohyoid muscle; stapes; and styloid. “I” refers to the internal carotid artery which is derived from branchial arch three. The stylopharyngeus muscle develops from the third arch, which can be remembered because it’s innervated by the glossopharyngeal nerve. The fourth arch contributes

to important structures that include the aortic arch; right subclavian artery; soft muscles of the palate, including the pharyngeal muscles, levator veli palatini, cricothyroid muscle; and thyroid and laryngeal cartilages. Lastly, the sixth arch develops into the pulmonary artery and ductus arteriosus, as well as the intrinsic muscles of the larynx – with the exception of the cricothyroid. Embryologic origins of the external ear are also tested on the exam. The external ear forms from tissues of the first and second branchial arches, specifically tissue elevations that are termed auricular hillocks. Hillocks 1-3 arise from the first branchial arch and give rise to the tragus, helical root and helical crus. Hillocks 4-6 arise from the second branchial arch and give rise to the antihelix, antitragus and lobule.

Type I branchial cleft cysts are located near the external auditory canal, often inferior and posterior to the tragus. Type II cysts are found at the angle of the mandible and may involve the submandibular gland. Failure of the second branchial cleft to involute is more common. Second branchial cysts are found most commonly along the anterior border of the upper-third of the sternocleidomastoid muscle adjacent to the muscle. |

Meredith Kugar, MD, is PGY3 at the University of North Carolina, Chapel Hill. REFERENCES

BRANCHIAL GROOVES AND POUCHES

The first branchial cleft is the only one to persist and develops into the external auditory canal. The second, third and fourth branchial clefts merge to form the cervical sinus of His, which will normally become involuted. When a branchial cleft is not properly involuted, a branchial cleft cyst forms. Failure of involution in both the branchial cleft and branchial pouch results in complete fistula formation between the pharynx and the skin.

Acierno SP, Waldhausen JH. Congenital cervical cysts, sinuses and fistulae. Otolaryngol Clin North Am. 2007 Feb;40(1):161-176. Adams A, Mankad K, Offiah C, Childs L. Branchial cleft anomalies: a pictorial review of embryological development and spectrum of imaging findings. Insights Imaging. 2016 Feb;7(1):69-76. LaRiviere CA, Waldhausen JH. Congenital cervical cysts, sinuses, and fistulae in pediatric surgery. Surg Clin North Am. 2012 Jun;92(3):583-597. Li W, Xu H, Zhao L, Li X. Branchial anomalies in children: a report of 105 surgical cases. Int J Pediatr Otorhinolaryngol. 2018 Jan;104:14-18. “Pharyngeal Arches Parts 1 through 3.” Online video clip. YouTube. YouTube, 5 May 2012. Web 14 May 2020. Todd, N. Wendell. “Common Congenital Anomalies of the Neck: Embryology and Surgical Anatomy.” Surgical Clinics of North America, vol. 73, no. 4, 1993, pp. 599-610., doi:10.1016/s0039-6109(16)46076-7. “8 – Cosmetic Otoplasty and Related Ear Surgery.” Cosmetic Facial Surgery, by Joe Niamtu, Elsevier, 2018. 473-532.

Table I. BRANCHIAL ARCHES PHARYNGEAL ARCH

ARTERY

MUSCULAR STRUCTURES

CN V – Trigeminal nerve (V2 and V3)

Maxillary artery

Muscles of mastication (masseter, medial pterygoid, mylohyoid, anterior belly digastric, tensor tympani, tensor veli palatine, anterior 2/3 of tongue)

CN VII – Facial nerve

Stapedial artery

Smile muscles (muscles of facial expression) Stylohyoid muscle

Stapes Styloid Portions of hyoid (upper body, lower horn)

III

CN Ix – Glossopharyngeal nerve

Internal carotid artery, common carotid artery

Stylopharyngeus

Portions of hyoid (lower body, greater horn)

CN X – Vagus nerve (superior laryngeal branch)

Aortic arch Right subclavian artery

Muscles of soft palate, levator veli palatini, cricothyroid muscle

Thyroid cartilages, laryngeal cartilages

CN x – Vagus nerve (recurrent laryngeal branch)

Pulmonary artery Ductus arteriosus

Intrinsic muscles of larynx (except cricothyroid)

NERVE

SKELETAL AND OTHER STRUCTURES

Mandible Maxilla Malleus Incus

Plastic Surgery Resident | Summer 2020

Honoring History While Adapting to Change By Andrew Atia, MD & Scott Hollenbeck, MD

adaveric dissection courses have emerged in numerous venues as an irreplaceable educational tool in plastic and reconstructive surgery. Firsthand visualization of tissue planes and blood vessels, along with tactile manipulation, allows for an unprecedented learning experience. The Duke Flap Course has been a leader in this approach for nearly two decades. Originally the vision of L. Scott Levin, MD, Duke University’s Plastic, Maxillofacial and Oral Surgery division chief from 1995-2009, the Duke Flap Course was born in the basement of Duke’s Bell Building in 2003. In subsequent years, Dr. Levin would secure a large portion of space within the medical school to form a state-of-the-art facility known as the Human Fresh Tissue Lab. Critical to the success of the flap course was the pioneering work of Clinton Leiweke in cadaver tissue preparation and latex injection. Clint’s techniques, along with years of refinements, have allowed thousands of learners to clearly see tiny blood vessels entering into the outer layers of the skin in ways not previously possible. In addition to the Duke Flap Course, the lab has held a variety of courses that include the Craniomaxillofacial Trauma Course, Breast Perforator Course and the Oncological Reconstructive Course.

THE STRENGTH OF EVOLUTION

Now entering its 18th year, the Duke Flap Course has evolved. The original format of the course mostly focused on the dissection of muscle flaps; in subsequent years, reconstructive surgery rapidly evolved to shift toward perforator flaps with muscle preservation. With enhanced latex-injection techniques developed in the Duke lab, it became possible to demonstrate these small blood vessels as they traversed the muscle and entered the skin. 26

Plastic Surgery Resident | Summer 2020

Fu-Chan Wei, MD, Duke’s honorary guest for 2019, performs a dissection for the flap video series.

Over the next decade, Dr. Levin and Michael Zenn, MD, continued to build the course into an event with an international draw. In 2009, Dr. Levin took a position at the University of Pennsylvania, where he’s continued his work with Dr. Zenn and others in anatomic dissection. In the past five years, the Human Fresh Tissue Lab and the Duke Flap Course have undergone a substantial overhaul. Under the leadership of Greg Georgiade, MD (Duke University Plastic Surgery chief, 2011-17) and Jeff Marcus, MD (Duke University Plastic, Maxillofacial and Oral Surgery chief, 2017-present), a significant financial investment has been made to bring the facility back to the cutting edge in tissue processing, lighting, visual display and recording capabilities.

Duke residents get together at the 2019 Flap Course Gala.

The Duke Flap Course is currently directed by Detlev Erdmann, MD (an original member of the 2003 flap course), and Scott Hollenbeck, MD. Under their leadership, the course has evolved to incorporate the newest techniques in reconstructive surgery, recently adding lymphatic dissection and nerve repair to the growing list of flap course topics. Participants now have the opportunity to “tailor” their course work. Some find upper- and lower-extremity flaps and techniques more useful to their practice and dedicate more time to these stations, while others prefer to focus on breast and lymphatics. This flexibility in course structure has set the Duke Flap Course apart from other more scripted approaches. Additionally, as the plastic surgery workforce continues to diversify, Duke Flap Course organizers have felt it important to have faculty that represent our trainees and surgeons. The principles of the course remain simple: Bring people together to learn, while honoring our past and adapting to change, so we’re equipped to lead in the future.

OUR NEW CHALLENGES

We have a new and unforeseen challenge for the Duke Flap Course. The COVID-19 pandemic has limited travel and social interaction. This has threatened the existence of many things once considered automatic. Yet, with every challenge comes opportunity. The Duke Flap Course team is working

to continue fulfilling the mission of education, networking, team-building and leadership. To achieve these goals, the course directors have prepared a unique, virtual program which will include a combination of didactic lectures from around the world, live cadaver dissections from the Duke Lab and highdefinition videos of flap dissection from previous course faculty. This year’s course is being offered free of charge to all members of the plastic surgery community and, at this time, more than 1000 participants have registered. The ability to reach across the globe to provide educational content has never been more important. Like years past, the Duke Flap Course will continue to innovate and evolve in this new paradigm – and bring people together to learn the art of flap dissection and reconstructive surgery. Learn more about the Duke Flap Course at http://plastic. surgery.duke.edu/flapcourse, and follow the course on Facebook and Instagram at @dukeflapcourse. | Dr. Atia is PGY3 at Duke University. Dr. Hollenbeck is an associate professor of Surgery and the director of Breast Reconstruction at Duke University, and he also serves as director of the Human Fresh Tissue Lab; co-director of the Duke Flap Course; and co-founder of the Oncological Reconstruction Course. Plastic Surgery Resident | Summer 2020

COMPLEX CASE CHALLENGE

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

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

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

YOUR RECOMMENDATION

Neurosurgery has been consulted – in addition to plastic surgery – for reconstruction of the wound. What is your treatment recommendation?

A) B) C) D) E)

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

Put some thought into your preferred reconstruction method, stay tuned for the next edition of PSR magazine – and learn how this case was managed by the treating surgeon. | If you have a complex case that you would like to feature in PSR, please email Russell Ettinger, MD, at retting@uw.edu.

Plastic Surgery Resident | Summer 2020

Join our team – and strengthen our influence in Washington, D.C. By David Hill, MD Resident Ambassador PlastyPAC Board of Governors

et me begin by saying thank you all for the hard work and dedication you’ve contributed in treating this global pandemic. Thank you to those who were reassigned to new roles and took on these new responsibilities eagerly and enthusiastically – and to your families, who were forced to make great sacrifices as well during this difficult time. With the transition back to performing surgical cases “as usual” in this new era of medicine, advocacy efforts continue, and actually never stopped. Hidden in the confines of our homes and apartments, PlastyPAC members were hard at work protecting the futures of our practices. During the global crisis, PlastyPAC members from all across the country participated in virtual meetings with congressional leaders such as Reps. Andy Harris, MD (R-Md.); Dan Kildee (R-Mich.); Brad Wenstrup (R-Ohio); and Yvette Clarke (D-N.Y.) as part of its new PlastyPAC Speakers

Series. These meetings served as an opportunity to educate the congressional speakers about issues impacting the specialty and to urge them to prioritize financial assistance to the healthcare industry when offsetting the negative economic effects of COVID-19 on the nation’s economy. PlastyPAC also requested that members of Congress prioritize financial assistance to plastic surgery societies, support the nation’s medical supply chain and adopt physician policy provisions to help address the increasing demands on the physicians during the national emergency. In attempts to protect those in private practice, PlastyPAC stressed the importance of including direct financial relief for independent physicians’ offices in the federal government’s response. Lastly, we also spoke directly to congressional members to advocate on behalf of resident, alerting them of the difficulties we face as well as the reassignments which occurred – resulting in many physicians in training being “voluntold” to serve on front line. These are just a few of the at-home efforts which have taken place. A significant portion of advocacy deals with educating personnel in a field where they have no experience. Out of 535 total United States congressional personnel, only 16 are physicians. Thus,

97 percent of policymakers have limited knowledge as to the pertinent issues that affect us daily. It’s incredibly important to continue to encourage these direct lines of contact with political members so that we may educate them on pressing matters. Even more importantly, these personnel are happy to hear from and listen to us, which enables them to make educated decisions on pressing healthcare policies. That’s why I encourage you to join us for our Northeast & Midwest Virtual Regional Fly-in taking place on Sept. 15-16. This is a wonderful event to attend and the perfect introduction to all things advocacy related. In the meantime, I encourage you all to contact me (hilld793@gmail.com) or Benjamin Schultz, MD (benschultzmd@ gmail.com), with any questions, comments or concerns you may have with regard to PlastyPAC and any issues we’re currently fighting for. Your continued input and contributions will help to strengthen and protect the future of plastic surgery throughout the United States and the world. For additional information about PlastyPAC or to contribute, please visit our website at www.PlastyPAC.net. Your generosity provides us with the resources needed to effect legislation in our favor. |

Dr. Hill is PGY8 at Houston Methodist Hospital.

Plastic Surgery Resident | Summer 2020

#TheTrend #THETREND endeavors to spotlight resources with the highest value and greatest potential to plastic surgery residents.

Video Learning Resources from the Society and more Jacob Grow, MD, and James Vargo, MD, are “tekkies” who are immersed in trending resources and tech (apps, websites, etc.) available to the plastic surgery community. Through #TheTrend, they will endeavor to spotlight resources with the highest value and greatest potential to plastic surgery residents, that they can help protect a resident’s most valuable commodity: time. These reviews will be specific to plastic surgery – and unbiased, as the authors are free from financial disclosures... “unfortunately,” they say. |

By James Vargo, MD; Jacob Grow, MD & PSR Staff

he 1979 hit “Video Killed the Radio Star” by the British pop band Buggles was a whimsical take on the development of video in the 1960s and the massive impact it would have on the music industry. Prophetically, this song and video was the first aired during the 1981 debut of MTV, transforming the way the youth of America would consume music. Today, a revamped version of the song could be written, as video is again taking on a traditional goliath. This time, however, it’s printed textbooks – not radio – that are the target. There’s no doubt that surgical trainees are more than ever gravitating toward operative videos and lectures. Video is capable of efficiently communicating information more clearly than textbooks through a visual medium that surgeons naturally prefer. While this march has been underway for some time, COVID-19 has certainly provide some acceleration towards online and remotely accessible educational resources. Here, we review three resources available to residents: ASPS EdNet, QMP Complete and video resources available through PRS.

ASPS EdNet, PRS Video Plus: Complete, Convenient and Easy ASPS is committed to providing education to its members and residents, with a focus on video offerings – an irreplaceable and crucial resource in this period of COVID-19 quarantine. Two of the vehicles through which the Society meets this commitment for residents are the ASPS Education Network (www.ednet.plasticsurgery.org), and the Plastic and Reconstructive Surgery (PRS) Video Gallery in the Digital Media section (prsjournal.com). Both include free content as benefits for all ASPS members, including International and Affiliate members. ASPS EdNet (formerly Plastic Surgery Education Network) is a centralized, interactive educational website, created by surgeons for surgeons and offering a lifetime of learning from residency to retirement. It’s a one-stop, fully functional shop for all plastic

Plastic Surgery Resident | Summer 2020

surgery specialties. This learning portal, which has undergone a recent upgrade, offers plastic surgeons methods by which to manage their continuing education – by keeping track of videos and courses to review; by viewing course and test details; by checking grades; and more. ASPS University leads this effort via virtual courses on clinical topics and practice management, led by professionals in the respective fields. Course formats are offered through e-learning, webinars, surgical videos and the ASPS Enhance Your Practice podcasts. Other learning modes involve the review of select PRS articles; the ASPS EdNet PRS Quarterly Review (QR) Program for creating one’s own “journal club;” monthly case studies; and an exclusive, high-definition video program produced by ASPS EdNet called Surgery Spotlight – a “how-to” program featuring surgical videos that demonstrate plastic surgery procedures

from markings through final stiches, addressing the gamut of aesthetic and reconstructive cases. Residents would be particularly interested in the ASPS EdNet’s Resident Education Curriculum (REC), a joint ACAPS-ASPS program that offers self-assessment modules for residents and practicing surgeons. Each contains journal article readings, videos, presentations, clinical case scenarios and tests that cover the specialty’s spectrum. In addition, through ASPS EdNet, residents can earn AMA PRA Category 1 and Patient Safety credits for reviewing select PRS articles. The PRS Digital Media section includes video discussions; PRS Journal Club podcasts; PRS Grand Rounds; Baker Gordon Video Collection; Plastic Surgery Hot Topics Videos; Masters Series Video Vignettes; Blogs; and the Video Gallery, which supports a complete index of literally thousands of videos. Finally, the upheaval created by the COVID-19 pandemic has been as disruptive and widespread as it’s been unprecedented; plans and dreams have been demolished or delayed, creating stress and uncertainty among all ranks of medical professionals – and residents are certainly part of this cohort. PRS and PRS Global Open offer COVID-19 articles and other resources for residents to access, therefore allowing them to read the latest viewpoints, editorials and scientific studies on the pandemic submitted by members of the plastic surgery community. Go to PRSJournal.com or PRSGlobalOpen. com and explore the resources under the COVID-19 banner. Additionally, the Operative Technique Videos section offered through PRS Global Open provides residents with a series of educational video offerings

aimed at global education and supplied by plastic surgeons from across the globe. Go to PRSGlobalOpen.com and scroll down to the “Additional Resources” area to explore the Operative Technique Videos.

QMP Complete: Volume, structure and duration create ‘Complete’ video database QMP Complete was developed as an amalgamation of QMP’s various video resources and digital content. QMP Publishing has recognized the value of these resources and through its library created a comprehensive streaming platform. In total, it boasts more than 750 hours of HD video. Many document full surgical operations through professional filming that’s actively described by the surgeon in real time. This includes evaluation of preoperative imaging to discuss surgical planning; narration of the operation with discussions of key steps that may have overlaid illustrations; and evaluation of postoperative results. The content is relevant and up-to-date, which QMP ensures by annually adding 100-plus hours to the resource. In addition to the surgical videos available through QMP Stream, the subscription also includes access to QMP eLearning courses. These are 30-90-minute modules presented in more of a lecture format or roundtable discussions covering the entire gamut of topics from cosmetics to practice management and everything in between. These courses are engaging,

– and they’re supplemented with diagrams, drawings and intraoperative clips. There are currently 173 of these eLearning courses, with QMP’s intent of adding 20 more each year. In addition, the membership also includes access to QMP Pulse – an online news journal – and 20 percent off any registration to QMP meetings, cadaver courses and live webcast events. From a user interface and access standpoint, the website functions smoothly and is intuitive. Although an app isn’t available for accessing the content, the mobile version of the website is adequate, and the videos stream well without any formatting issues. This makes streaming videos while on the go, in the hospital or waiting for an O.R. case to start very feasible. One criticism is that off-line viewing isn’t available, so accessing content on a cellphone in an area with bad mobile service, or watching a video during a flight, isn’t possible. Ultimately, we feel QMP Complete is user friendly and thorough, and topics are extremely relevant. The final decision really comes down to price: QMP Complete is subscription based, with annual fees of more than $1,000. This price point presents one of the highest annual fees of any digital resource, but it provides the subscriber with access to a comprehensive library of mixed media content in plastic surgery. Both ASPS EdNet/PRS Video Learning and QMP Complete offer an expansive library of multimedia resources, each of which provide invaluable access to learning. Current circumstances certainly force us all to seriously explore these offerings as part of our continuing education. |

Plastic Surgery Resident | Summer 2020

DIRECTLY PROVIDED BY:

New Dates! New Format! August 8, 2020 & August 14-16, 2020 P R O GR AM C H A I R :

P R O G R AM CO-CHAI R:

John B. Hijjawi, MD

Matthew Trovato, MD

Virtually prepare with minimal time away from your practice! Attend the most interactive and comprehensive virtual meeting with thebest overview of plastic surgery principles and case-based instruction. EXPANDED FOR 2020! Cleft Lip Drawing Instruction Sessions NEW THIS YEAR! Mobile-friendly, Electronic Flash Cards

Learn more today at PlasticSurgery.org/BoardPrep