Plastic Surgery Resident, Fall 2021

From the publishers of Plastic Surgery News

Patient care in a wired world The pandemic has forced medical professionals to be telehealth actors – will it last? page 5

IN THIS ISSUE » The story behind Emory University's rise p. 18 » International Perspectives: Cyprus and India p. 22 » ASPS President: Resident leadership doors are open p. 31

ISSUE 24 | FALL 2021

» The Rx for nailing your online interview

How to control the variables for your finest virtual presence page 10

» Level the

matching playing field Ways to pull even with applicant frontrunners page 25

Join us at PSTM 21!

Be sure to stop by the Allergan Aesthetics sponsored Residents’ Lounge next to our booth.

Experience.

It’s what AlloDerm™ RTM is made of.

With 2.5 million implantations and over 25 years on the market, know that your patients will receive the safety and quality you expect from AlloDerm™ RTM—the industry leader.1-4

INDICATIONS ALLODERM SELECT™ Regenerative Tissue Matrix (ALLODERM SELECT™ RTM refers to both ALLODERM SELECT™ RTM and ALLODERM SELECT RESTORE™ RTM products) is intended to be used for repair or replacement of damaged or inadequate integumental tissue or for other homologous uses of human integument. This product is intended for single patient one-time use only. ALLODERM SELECT™ RTM is not indicated for use as a dural substitute or intended for use in veterinary applications.

IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS ALLODERM SELECT™ RTM should not be used in patients with a known sensitivity to any of the antibiotics listed on the package and/or Polysorbate 20.

WARNINGS Processing of the tissue, laboratory testing, and careful donor screening minimize the risk of the donor tissue transmitting disease to the recipient patient. As with any processed donor tissue, ALLODERM SELECT™ RTM is not guaranteed to be free of all pathogens.

No long-term studies have been conducted to evaluate the carcinogenic or mutagenic potential or reproductive impact of the clinical application of ALLODERM SELECT™ RTM. DO NOT re-sterilize ALLODERM SELECT™ RTM. DO NOT reuse once the tissue graft has been removed from the packaging and/or is in contact with a patient. Discard all open and unused portions of the product in accordance with standard medical practice and institutional protocols for disposal of human tissue. Once a package or container seal has been compromised, the tissue shall be either transplanted, if appropriate, or otherwise discarded. DO NOT use if the foil pouch is opened or damaged. DO NOT use if the seal is broken or compromised. DO NOT use if the temperature monitoring device does not display “OK.” DO NOT use after the expiration date noted on the label. Transfer ALLODERM SELECT™ RTM from the foil pouch aseptically. DO NOT place the foil pouch in the sterile field.

PRECAUTIONS Poor general medical condition or any pathology that would limit the blood supply and compromise healing should be considered when selecting patients for implanting

ALLODERM SELECT™ RTM as such conditions may compromise successful clinical outcome.

Whenever clinical circumstances require implantation in a site that is contaminated or infected, appropriate local and/or systemic anti-infective measures should be taken.

ALLODERM SELECT™ RTM has a distinct basement membrane (upper) and dermal surface (lower). When applied as an implant, it is recommended that the dermal side be placed against the most vascular tissue. Soak the tissue for a minimum of 2 minutes using a sterile basin and room temperature sterile saline or room temperature sterile lactated Ringer’s solution to cover the tissue. If any hair is visible, remove using aseptic technique before implantation.

ALLODERM SELECT™ RTM should be hydrated and moist when the package is opened.

DO NOT use if this product is dry. Use of this product is limited to specific health professionals (e.g., physicians, dentists, and/or podiatrists). Certain considerations should be made to reduce the risk of adverse events when performing surgical procedures using a tissue graft.

Please see the Instructions for Use (IFU) for more information on patient/product selection and surgical procedures involving tissue implantation before using ALLODERM SELECT™ RTM. ADVERSE EVENTS The most commonly reported adverse events associated with the implant of a tissue graft include, but are not limited to the following: wound or systemic infection; seroma; dehiscence; hypersensitive, allergic or other immune response; and sloughing or failure of the graft.

ALLODERM SELECT™ RTM is available by prescription only.

For more information, please see the Instructions for Use (IFU) for ALLODERM SELECT™ RTM available at www.allergan.com/AlloDermIFU or call 1.800.678.1605.

To report an adverse reaction, please call Allergan at 1.800.433.8871.

References: 1. Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995;21(4):243-248. 2. Data on file, Allergan Aesthetics; Search Performed on PubMed in June 2021. 3. Data on file, Allergan, 2018; Number of AlloDerm™ RTM Units Sold. 4. Data on file, Allergan Aesthetics, May 2021; Plastic Surgery Aesthetic Monthly Tracker.

ALLODERM™ and its design are trademarks of LifeCell Corporation, an AbbVie company. © 2021 AbbVie. All rights reserved. ALS149919 08/21

To learn more, visit AlloDerm.com/HCP Follow @AlloDermHCP

A note from the editor

W

elcome to the Plastic Surgery The Meeting 2021 issue of Plastic Surgery Resident.

We welcome you to the host city of Atlanta, and in doing so we highlight the contributions of Atlanta and Emory University to our field. Emory’s residents have also put together a list of “must see” attractions during your downtime here during The Meeting.

Sanjay Naran, MD Chief Medical Editor Plastic Surgery Resident Chicago

From the publishers of Plastic Surgery News

ISSUE 21 | WINTER 2020

» Centennial

of excellence Washington University in St. Louis celebrates 100 years of plastic surgery page 8

» Residents Bowl 2020: Two views, one victory

University of Pittsburgh wins its first title in the annual ASPS contest page 26

Figuring out your finances A primer for residents to set them on a path of financial security page 4 IN THIS ISSUE » Consult Corner: Orbital floor fracture p. 11 » Program Peek: Cleveland Clinic Department of Plastic Surgery p. 17 » What I know now that I wish I knew then: International Edition p. 20

Our cover piece features the evolving role of telehealth in plastic surgery – specifically, its impact on resident training. We share Part II of the PRS Perspectives series on microsurgery, highlighting Phillip Blondeel, MD, PhD, as well as our recurring pieces: InService Insight, Consult Corner and Journal Club. For this print issue, we bring back the Crossword, which hopefully will keep you occupied during time between panels or on the plane home from PSTM. We also feature several special topics for The Meeting issue, including aesthetic training in India; training in Cyprus; the medical student to resident ROADMAP; tips for digital interviews; and a Q&A with ASPS President Joseph Losee, MD. Finally, this marks the last issue for which I will serve as chief medical editor. It has been my honor to act as steward for your publication, and I would like to acknowledge the incredible editorial team that I’ve had the fortune to work with over the past few years.

I say for the last time, but with no less meaning: Thank you to all of our writers for their contributions – and thank you to you, our readers. We hope you enjoy the read!

Plastic Surgery Resident | Fall 2021

3

Table of

Contents The future is here: Telehealth is changing plastic surgery.................................5 Plastic surgeons increasingly are meeting virtually with patients, which can prove a boon for both – if properly deployed.

Virtual job interview?

Here are some tips for success............................................ 10 A good visual first impression, distraction elimination and the right lighting can make the difference.

Consult Corner: Mandible fracture................................................................... 12

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 Joseph Losee, MD | Joseph.Losee@chp.edu

The hidden variables involved in mandible fractures demand a thorough workup of injury timing, mechanism and evaluation.

EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com

InService Insights: Eyelid surgery.......................................................................... 16

ASSOCI ATE EDITORS Russell Ettinger, MD | retting@uw.edu Kavitha Ranganathan, MD | kranganathan@bwh.harvard.edu

Due in part to its growing popularity, the In-Service Exam will challenge applicants by drilling-down on blepharoplasty.

From the beginning: Plastic surgery at Emory University.................................... 18 The launch of Emory’s Division of Plastic and Reconstructive Surgery and its growth into an august program are examined.

24 Hours in: Atlanta......................................................................................20 Emory University’s plastic surgery program director – and three residents – take readers through PSTM21’s host city.

International Perspective: India...........................................................................................22 Samarth Gupta, MBBS, MCh, reveals how the structure of residency in India affects trainees, who can be challenged by overload.

International Perspective: Cyprus.......................................................................................24

J U NIOR ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com SEN IOR R ESI DEN T EDI TOR Lisa Gfrerer, MD, PhD | lg frerer@partners.org R ESIDENT EDITORS Janak Parikh, MD | janak.parikh@gmail.com Matt Pontell, MD | matthew.e.pontell@vumc.org Elie Ramly, MD | elie.ramly@gmail.com I N T E R N AT I O N A L R E S I D E N T E D I T O R Konstantinos Gasteratos, MD | kgasteratos1@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org

Antonia Fotiou, MD, describes the components of Cyprus’s plastic surgery training that make the island-nation unique.

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

Special Topic: ‘ROADMAP’ to matching.......................................................25

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

New ASPS/ACAPS effort is designed to give medical students advice and direction for matching into a preferred program.

Journal Club: Nerves and upper-extremity amputation..........................26 New alternatives are emerging to advance treatment and peripheral-nerve management in upper-extremity amputation.

Plastic Surgery Perspectives: Microsurgery, Part II...............................................................28 This multiple-part series – which engages microsurgery in a Q&A format – resumes with Phillip Blondeel, MD, PhD.

Crossword:...............................................................................30 Atlanta and plastic surgery Spend a few minutes trying to unravel the puzzle constructed with PSTM21’s host city – and plastic surgery – in mind.

Q&A with ASPS President:................................................... 31 Striving for worldwide connections ASPS President Joseph Losee, MD, says the Society has ample opportunities for residents wishing to serve – but they must act.

Voices of advocacy:................................................................34 Outgoing PlastyPAC reps shed light on efforts David Hill, MD, and Benjamin Schultz, MD, look back at their efforts – and the Society’s – to battle for a voice in Washington, D.C.

4

Plastic Surgery Resident | Fall 2021 | Vol.5 No.3

Plastic Surgery Resident | Fall 2021

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

ADAPTING TO A PANDEMIC

THE E VOLUTION OF TELEHE ALTH in Plastic Surgery

By Elie P. Ramly, MD

T

he COVID-19 pandemic accelerated the adoption of telehealth in plastic surgery, with technological and social trends that once held little-to-no clinical relevance to the practicing surgeon now deeply woven into the field. With the mandatory moratorium in place on elective procedures in 2020 and the implementation of distancing guidelines, plastic surgeons had to rapidly and dynamically adapt their practices amid economic challenges and unprecedented changes in regulatory requirements, safety and quality standards, patient preferences and consumer trends.

The trends propelled by the pandemic continue to exert a lasting impact on the specialty. A majority of respondents to a recent survey of ASPS members revealed that telemedicine has been integrated into breast, cosmetic and reconstructive practices for initial preoperative consultations and routine postoperative visits, with plans to continue using virtual platforms.1 Social media also emerged as a unique tool for patient engagement, education and advocacy.2 Taken together, these elements add a new, virtual dimension to the patientphysician relationship that residents

and Fellows should consider as they develop their professional presence and transition to practice. As new stages of the pandemic unfold, plastic surgeons in academic, employed and private-practice settings continue to reimagine their practices and care-delivery models.

Still, while plastic surgeons agree that telehealth options have and should continue to provide benefits for patients and surgeons, there are differing opinions as to the most effective timing of these virtual interventions.

continued on the next page Plastic Surgery Resident | Fall 2021

5

THE EVOLUTION OF TELEHEALTH / continued from previous page AESTHETIC SURGERY

Virtual telehealth visits with patients, combined with proactive social media outreach, provided an avenue for plastic surgery practices to provide uninterrupted access to clients throughout the pandemic – despite office closures and elective procedure cancellations. Through live Q&A sessions, direct messaging and the interactive sharing of audiovisual content and progress updates, the physicianpatient relationship has extended into an ongoing exchange over public platforms.

Social media can facilitate a new range of interactions, but telemedicine encounters performed via non-publicfacing platforms ensure privacy and quality requirements.

For patients seeking an expert opinion remotely, virtual encounters optimize time, travel and cost commitments – and avoid undue exposure to COVID-19. In addition to the convenience of discussing treatment options from the comfort of home, some patients might feel more comfortable with a virtual discussion of the nuances of their appearance than in an in-person visit. Some might enjoy more privacy when seeking consultation or receiving routine, post-op follow-up without being seen at the physician’s office or waiting room. It remains unclear how patients’ perceptions of their providers and surgical options are affected by the nature of an initial, virtual encounter and whether this significantly affects the likelihood that a patient would eventually proceed with aesthetic surgery.3 “One of the main advantages of telehealth is really for the patient,” says Kristen Broderick, MD, director of the Johns Hopkins Resident Cosmetic Clinic. “Many patients who need to travel long distances, obtain childcare or take off work in order to attend a doctor’s visit find that it’s a big burden on them.

Telehealth allows them to really be able to access care in a way that they can avoid that additional cost to their lives.

6

Plastic Surgery Resident | Fall 2021

“It’s more likely to be here to stay for our surgeons, in the initial stages,” she adds. “But surgeons need to figure out: What are the best ways to utilize it for what we do? A lot of what we do as surgeons is to literally place our hands on the patient’s tissues, manipulate, test and maneuver them. It’s a very different interaction as compared to speaking with someone concerning their mental health or blood pressure, as is done in the primary-care setting.”

Arya Akhavan, MD, a resident in University of North Carolina’s plastic surgery division, says figuring out when to use telehealth in plastic surgery remains a tricky proposition.

“Careful use can really save time and resources,” he notes. “An initial surgical consultation isn’t the best use, as patients appreciate meeting their physician face-to-face. But for brief preoperative appointments or answering patients’ lastminute questions, a virtual visit can save travel time and clinical resources.”

Dr. Broderick says telehealth provides a good a screening tool for pre-op patients.

“We can help identify appropriate candidates – and perhaps more importantly, identify those who aren’t yet ready without them having to come into the clinic,” she says. “For post-op patients, unless there’s an additional hands-on procedure that needs to be performed – such as pulling a drain or removing sutures – it can be very useful for assessing progress and educating the patients.”

Patrick Assi, MD, a Vanderbilt University Medical Center resident, agrees that the sweet spot for plastic surgeons seems to be in post-op, followup stages.

“Telemedicine theoretically can be applied to every stage of patient care,” he tells PSR. “But it’s not meant to replace

human interaction, physical examination and personal patient-physician rapport, which are the fundamentals of our surgical practice.”

For providers, the recouped time can be repurposed into maximizing the patient experience by more thoroughly discussing goals, setting expectations and reviewing pre-op preparation and post-op considerations. Still, virtual consultations don’t replace subsequent, in-person physical examination. This is particularly true in the setting of complex re-operative scenarios or when addressing urgent post-op concerns, where a virtual visit can only be useful as a preliminary triage tool.

Even in follow-up scenarios, Dr. Akhavan notes critical downsides.

“Getting a good view through Zoom can be difficult and therefore may necessitate an in-person exam, and patients in rural areas may not have adequate internet access,” he says.

RECONSTRUCTIVE SURGERY

Data from academic medical centers reveals diverse applications of telehealth in reconstructive procedures such as breast cancer reconstruction, free-flap monitoring, hand surgery, burn, trauma and craniofacial care.4,5 At the height of the pandemic, experienced centers recorded improvement in the ratio of completed to scheduled visits, compared to in-person clinic visits the year prior.

The expansion of telehealth also allowed providers to see more new patients, with up to a 22-fold increase in the percentage of new patients seen in February to April 2020.4 In Connecticut’s Veterans Health Administration (VA) system, 83 percent of surveyed patients referred for nonurgent plastic surgery consultation expressed high satisfaction and preference for utilization of telehealth

in future visits.6 Data from France confirms the benefits of telemedicine in wound-care procedures, such as pressure ulcers and diabetic foot ulcers, with 75 percent of treated wounds improving or healing; a 72 percent reduction in hospitalizations; and a 56 percent reduction in ambulance transfers to specialized wound centers.7 Although barriers to the implementation of telehealth exist in rural areas, virtual encounters are well-received by patients and are successful when deployed appropriately. Funderburk, et al., developed a telehealth workflow for post-op patient visits using the Lean Six Sigma framework – a qualityimprovement methodology proven to be highly effective in the business sector.8 Seventy-two patients undergoing noncosmetic plastic surgery procedures and living in rural areas of New Hampshire or Vermont with an average travel time of 30-60 minutes to the medical center participated in the study. On initial preoperative survey, 73 percent of patients expressed preference for traditional in-person clinic visits.

After their post-op telehealth encounter, nearly 100 percent expressed satisfaction with the telehealth experience and reported that they would use telehealth again in the future.8 These reports are particularly relevant for institutions serving a broad catchment area. Longdistance travel can be taxing for patients, with time off of work, arranging for the care of dependents and out-of-pocket travel expenses adding to the logistics of attending a clinic visit.9 Plastic surgery patients are reinforcing this preference.

“We have patients who live many hours away, and telemedicine has allowed us to bridge the distances by facilitating outpatient visits without the necessity of travel,” says Francesco Egro, MBChB, chief resident at the University of Pittsburgh Medical Center. “Patients are very grateful for this option.”

HEALTH INSURANCE PORTABILITY AND ACCOUNTABLITY ACT-COMPLIANT TELEMEDICINE PLATFORMS* PLATFORM

DEVELOPER

Skype for Business

Microsoft

Updox

Updox LLC

VSee

VSee

Zoom for Healthcare

Zoom

Doxy.me

Doxy.me LLC

Gooble G Suite Hangouts Meet

Alphabet Inc.

Cisco Webex Meeting/Webex Team

Cisco LLC

Amazon Chime

Amazon

GoToMeeting

LogMeIn Inc.

Spruce Health Care Messenger

Spruce

Telemedicine and Plastic and Reconstructive Surgery: Lessons From the COVID-19 Pandemic and Directions for the Future. Saad NH, AlQattan HT, Ochoa O, Chrysopoulo M. Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future. Plast Reconstr Surg. 2020;146(5):680e-683e. *Obtained from HHS. Available at https://www.hhs.gov/hipaa/for-professionals/special-topics/emergencypreparedness/notification-enforcement-discretion-telehealth/index.html. Accessed April 18, 2020

GLOBAL SURGERY

Reviewing data in Australia on pediatric plastic surgery patients demonstrates that telehealth programs can improve access to care. When appropriate, screening or managing patients within their home environments can reduce the associated financial and psychosocial burdens, and potentially prevent unnecessary transfer to tertiary centers.10 Integrating emerging technologies into surgical education and clinical care can also maximize the scope and impact of outreach interventions. In a 2020 prospective study, Vyas, et al., demonstrated that remote, virtual interactions using an augmented reality platform over 13 months can effectively transfer cleft-surgery knowledge and skills to overseas colleagues.11 The

collaboration between cleft lip-repair surgeons based in the United States and those located in an underserved area of Peru resulted in significant improvement in all facets of this subspecialty.

Remote sessions promoted improved understanding of cleft anatomy as well as operative design and efficiency. At a 30-month follow-up, no children with cleft lip repair required transfer to tertiary care centers.11 With travel bans and limited availability of personnel and resources, communities with limited, local surgical capacity suffer. Suspension of surgical outreach programs in such settings results in significantly delaying patients’ surgeries and crucial aspects

continued on the next page Plastic Surgery Resident | Fall 2021

7

THE EVOLUTION OF TELEHEALTH / continued from previous page

of their comprehensive care. For nongovernmental organizations providing international cleft care, video calls with patients and their caregivers during the pandemic has ensured the continuation of longitudinal care – including perisurgical and speech therapy, education and support.12 Social media can also improve the reach and dissemination of timely educational messages on safety precautions and preventative measures, while providing a forum for answering questions and addressing misconceptions with evidence-based recommendations during uncertain times. Such approaches reinforce partnership, trust and the respect between remote and local professionals and the communities they serve together, while promoting a moresustainable model of care that empowers local providers.

OPTIMIZING THE VIRTUAL ENCOUNTER Table 1. VIRTUAL VISIT PLANNING Scheduling

Obtain demographics, health insurance and billing information, emergency contact information

Technological requirements

Confirm availability of basic requirements: • (wireless (wi-fi) or wired (ethernet) is preferred over mobile/ cellular connection) • Ensure minimum internet service bandwidth is available to the patient for optimal quality • Review device and operating system requirements based on the video platform or application used

Consent

Obtain consent for the visit

Privacy

Use HIPAA-compliant platforms and address any privacy concerns

Billing

Clarify reimbursement and copay responsibilities

Framing

Define the purpose and scope of the visit

Backup

Establish a contingency plan (e.g., phone or future in-person encounter) if technical difficulties or delays occur

Testing

Consider starting the encounter with a virtual “rooming” prelude with clinic staff • Test/troubleshoot connection • Involve interpreter services if indicated • Pre-chart patient-reported vital signs or patient-recorded data (e.g., drain output log, progress photographs, etc.)

Follow-up

Clarify that a subsequent in-person visit may be necessary following the virtual encounter

Pertinent telemedicine CPT codes and related information can be found at cms.gov, by typing “Telehealth Services” into the search field.

RESIDENT TRAINING

The integration of telehealth into plastic surgery is already transforming surgical education. For residents and Fellows joining the workforce in the post-COVID-19 era, the ensuing paradigm shift has important practical implications, as trainees and faculty now experience a sizable proportion of outpatient surgical planning and follow-up in virtual format. This is even more pronounced in complex clinical scenarios that require multidisciplinary collaboration. Meanwhile, the traditional residency-training framework continues to adapt to an evolving emphasis on surgical simulation, virtual conferences and web-based professional interviews.

With these elements at play, trainees have to develop a new skillset that will prove to be valuable throughout their education and eventual clinical practice.

8

Plastic Surgery Resident | Fall 2021

Table 2. WORKSPACE SETUP CHECKLIST Camera positioning

• Use laptop or desktop with a mounted webcam; consider tripod support if using smartphone to ensure image stability • Position camera to maximize eye contact • Consider using a second or a split-screen, if charting during the interview

Background

Use a professional, non-distracting visual background. Avoid virtual backgrounds that may distort your image

Atmosphere

Ensure a calm, private environment (avoid shared workspaces)

Lighting

Use natural lighting (sit while facing a window) or use soft-light support (ring light or panel light)

Audio

• Speak slowly and pause frequently to account for potential delays in transmission and to avoid overlap • Use low profile headphones/microphone if needed, particularly if unable to avoid a shared workspace, to ensure patient privacy and comfort

PRACTICAL ASPECTS, FURTHER CONSIDERATIONS

Regulatory requirements for telemedicine services vary regionally within the United States and abroad.

These are evolving rapidly – and include considerations relating to interstate licensing, liability and malpractice, reimbursement schemes and privacy concerns. Although restrictions on the appropriate use of telemedicine and the use of non-compliant Health Insurance Portability and Accounting Act technology for videoconferencing were lifted during the pandemic, changes are expected as the dust settles.13 The Accreditation Council for Graduate Medical Education and Centers for Medicare and Medicaid Services provide guidance on resident participation in the use of telemedicine under appropriate faculty supervision to mimic in-person care.14,15 The proven benefits of convenience, time and cost savings – as well as patient and physician satisfaction – must be constantly weighed against the limitations inherent in being unable to perform a full physical examination and the attendant risk of potentially missing subtle clinical and interpersonal nuances that would otherwise be accessible in a face-to-face encounter. Additionally, a thoughtful implementation of telemedicine should aim to deliver optimal, quality care with sensitivity to socioeconomic disparity, disability and literacy barriers.

REFERENCES 1. Calderon T, Skibba KEH, Langstein HN. Plastic Surgeons Nationwide Share Experience Regarding Telemedicine in Initial Patient Screening and Routine Postoperative Visits.

Plast Reconstr Surg Glob Open. 2021;9(7):e3690.

2. Hamilton KL, Kim R, Savetsky IL, Avashia YJ, Maricevich R, Rohrich RJ. Social Media Guidelines for Young Plastic Surgeons and Plastic Surgery Training Programs. Plast Reconstr Surg. 2021;148(2):459-465.

3. Salehi PP, Wong BJF, Azizzadeh B. The Potential for Telemedicine to Reduce Bias in Patients Seeking Facial Plastic Surgery. Otolaryngol Head Neck Surg. 2021;164(5):909-910.

4. Wamsley CE, Kramer A, Kenkel JM, Amirlak B. Trends and Challenges of Telehealth in an Academic Institution: The Unforeseen Benefits of the COVID-19 Global Pandemic. Aesthet Surg J. 2021;41(1):109-118.

5. Vyas KS, Hambrick HR, Shakir A, et al. A Systematic Review of the Use of Telemedicine in Plastic and Reconstructive Surgery and Dermatology. Ann Plast Surg. 2017;78(6):736768.

6. Douglas S, Geiger E, McGregor A, et al.

Telehealth in Plastic Surgery: A Veterans Affairs Hospital Perspective. Plast Reconstr Surg Glob Open. 2018;6(10):e1840.

7. Sood A, Granick MS, Trial C, et al. The Role of Telemedicine in Wound Care: A Review and Analysis of a Database of 5,795 Patients from a Mobile Wound-Healing Center in LanguedocRoussillon, France. Plast Reconstr Surg.

2016;138(3 Suppl):248S-256S. 8. Funderburk CD, Batulis NS, Zelones JT, et al.

Innovations in the Plastic Surgery Care Pathway: Using Telemedicine for Clinical Efficiency and Patient Satisfaction. Plast Reconstr Surg.

2019;144(2):507-516.

9. Santosa KB, Cederna PS. Commentary on: Trends and Challenges of Telehealth in an Academic Institution: The Unforeseen Benefits of the COVID-19 Global Pandemic. Aesthet Surg J. 2021;41(1):119-121.

10. Rimal D, Huang Fu JH, Gillett D. Our experience in using telehealth for paediatric plastic surgery in Western Australia. ANZ J Surg. 2017;87(4):277-281.

11. Vyas RM, Sayadi LR, Bendit D, Hamdan US. Using Virtual Augmented Reality to Remotely Proctor Overseas Surgical Outreach: Building Long-Term International Capacity and Sustainability. Plast Reconstr Surg.

2020;146(5):622e-629e.

12. Chahine EM, Annan B, Ramly EP, Hamdan US. Overturning the Impact of COVID-19 on Surgical Outreach Programs Through Innovation: The Role of Telehealth. J Craniofac Surg. 2021.

13. Saad NH, AlQattan HT, Ochoa O, Chrysopoulo M. Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future. Plast Reconstr Surg. 2020;146(5):680e-683e.

14. Accreditation Council for Graduate Medical Education. ACGME response to COVID-19: Clarification regarding telemedicine and ACGME surveys. https://www.acgme.org/ Newsroom/Blog/Details/ArticleID/10125/ ACGME-Response-to-COVID-19-Clarificationregarding-Telemedici/. Accessed: August 25, 2021.

15. Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge. https:// www.cms.gov/newsroom/fact-sheets/additionalbackgroundsweeping-regulatory-changes-helpus-healthcare-system-address-covid-19-patient.

Accessed: August 25, 2021.

TABLES 1 AND 2 Saad, Noah H. MD; Al Qattan, Husain T. MD; Ochoa, Oscar MD; Chrysopoulo, Minas MD Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future. Plast Reconst Surg.

2020;146(5):680e-683e.

Despite the challenges that still surround the telehealth medium, this evolving paradigm offers plastic surgeons unprecedented opportunities for quality care through innovative pathways. | Dr. Ramly is a chief resident in general surgery at Oregon Health & Science University and plastic surgery Fellow at the Mass General Brigham Plastic and Reconstructive Surgery Program at Harvard Medical School.

Plastic Surgery Resident | Fall 2021

9

THE DIGITAL JOB INTERVIEW:

TIPS FOR SUCCESS

By Paige L. Myers, MD

L

anding your first job as a plastic surgeon is an exciting moment that’s been years in the making, but the first job interview after residency or Fellowship can be uncomfortable and challenging to navigate. With the ongoing pandemic, another stressful piece of the equation is the virtual interview process – but we’re all adapting and there are some strategies to make the situation work in your favor. The Harvard Business Review earlier this year published tips on nailing a digital job interview, and while there’s often little about the interview process that’s guaranteed, some tips can help stack the odds in your favor.

VISUAL IMPRESSIONS

Your virtual environment can make a huge impact on your first impression, and while this can be daunting (especially 10

Plastic Surgery Resident | Fall 2021

in a small living space), it provides in advantage in being able to control your surroundings. Find a neutral, empty wall – possibly with a few tasteful decorations to convey that you are organized and attentive to detail. A cluttered background will appear disorganized and could distract your interviewers to the point where they might be focused more on your background than your words. If you can, avoid sitting directly against the wall; leave some space to give depth to your appearance. The back of your chair should not be higher than your shoulders, as this can also be a distracting visual effect.

Face a window that provides natural light to make yourself more visible. A window behind you can create a silhouette effect that makes you hard to see. A ring light could be a good idea, but make sure it doesn’t cast a glare. Don professional attire (in general, solid colors are less distracting

for interviewers). Even if the interviewer cannot see your legs, it’s still important to wear nice shoes and pants to feel fully prepared – and to avoid any awkward moments if you accidentally stand up.

POINT OF FOCUS

Maintaining eye contact throughout an interview conveys respect and confidence.

This is achieved virtually by looking at the camera lens – not the screen. One tip is to place a small photo of a loved one (pets count!) next to the lens to train your focus and remind you to smile.

Using a laptop or desktop computer is preferrable due to the location of the camera lens. Even though most mobile phone cameras boast high-quality lenses, getting the appropriate angle and position can be challenging; if not executed correctly, bad angles and positions can diminish your virtual presence. Place your laptop on a small box or a stack of books so the camera lens is at eye level to make the interviewers feel engaged.

Try to consistently employ non-verbal cues, such as head nods, for positive affirmation. Exaggerate hand gestures more than usual to really convey emotion in a virtual setting. There will be fewer opportunities to infuse the conversation with your uniqueness and emotions, so these extra physical details can be helpful.

REMOVING DISTRACTIONS

awkward than were the conversation happening face-to-face.

Try to negate any potential breaks in conversation. Many telecommunications platforms provide easy access to prepared notes or questions to ask the interviewers (often optimized as short phrases on index cards and printed with a large font, rather than lengthy paragraphs).

As we’re all now well aware, video calls can be monotonous, so breaking-up a conversation with engaging questions should be welcomed. As would be advised for an in-person interview, research your interviewers and potential future practice in order to ask targeted questions and stimulate good conversation.

It should go without saying, but your interviewers need to know that this conversation is your No. 1 priority. Turn off your pager. Silence your phone. Consider placing these devices out of sight so a pop-up notification or vibration doesn’t steal your attention. Extend this train of thinking to your computer, as well. Disable notifications, close other windows and expand the teleconference window full-screen.

Always confirm a reliable internet connection well beforehand and have a backup device available, in the event an irreparable software issue (or unexpected service interruption) arrives.

Seek-out friends and family to practice and give feedback on your virtual presence. Don’t forget to verify the time zone that your interviewer is in when confirming the interview time.

Be familiar with your mute and stop video buttons if a small break occurs in the conversation. Coordinate with anyone else in your household – well before your interview – so any adjustments that need to be made can happen seamlessly.

Be aware of ambient noise (e.g., open windows that might amplify sounds such as nearby traffic or lawnmowers).

HAVE FUN

PREPARATION IS KEY

Despite the ubiquity of videocommunication over the past 18 months, pauses and inadvertent speaking over the other person will still occur – and in some cases, this can be more

Remember, this moment is something to be celebrated. You made it through training and now you’re ready to join a practice. Enjoy the process as well as the ability to connect with some of the amazing plastic surgeons in our specialty.

Plastic surgery is a small community – even tighter within some subspecialties – so even if one particular job opportunity isn’t for you, you’ll likely interact with your interviewers again at some point. Good luck! | Dr. Myers is a clinical assistant professor of plastic surgery at the University of Michigan.

Plastic Surgery Resident | Fall 2021

11

Mandible fracture

“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 Megan Pencek, MD

E.D.: NEW CONSULT – MANDIBLE FX S/P ASSAULT You’re busy sewing-up a face laceration in the E.D. at 12:30 a.m. (your fifth consult of the night) when your pager goes off: “E.D.: New Consult – mandible fx s/p assault.

INITIAL EVALUATION On arrival, initial evaluation should adhere to the standard assessment of all trauma patients and follow the “A-B-CD-E” (airway, breathing, circulation, disability, exposure) sequence as dictated by Advanced Trauma Life Support (ATLS) guidelines. Injury to the lower face can be associated with injury to the airway – therefore, it’s of paramount importance to first obtain a secure airway.

A thorough patient history should be obtained with focus on the timing and mechanism of injury. Mandible fractures are often the result of assaults or motor vehicle collisions (MVC), both of which may signal injury to other structures, including the brain and cervical spine. The patient should be asked to endorse specific areas of pain and any altered sensation to the face, tongue or oral cavity. They should be questioned on their 12

Plastic Surgery Resident | Fall 2021

premorbid occlusion and if their bite “feels normal.” Any tooth pain, hypersensitivity or subjective loosening should also be elucidated.

After comprehensive trauma evaluation, the skin of the entire face should be examined for lacerations. The oral cavity should be evaluated for lacerations, step-offs and open fractures, and the oral exam should include assessment of the salivary glands, as well as the floor of the mouth. The exam also should focus on the cranial nerves – with special attention to the third branch of cranial nerve V, which innervates the mandibular teeth, buccal mucosa, tongue and lower face.

The teeth should be examined and the patient should be asked to bite down to assess the maxillomandibular occlusal relationship. Any bite discrepancies (i.e., cross-bite, openbite, etc.) should be noted. Examination of the teeth-wear facets also facilitates an estimation of premorbid occlusion.

The temporo-mandibular joints should also be assessed to determine if they are located and/or tender. Maximum interincisal opening (MIO) should be assessed to determine the presence of trismus; normal values are less than 40mm, or at least three of the patient’s fingers. Edentulous patients should be asked if they wear dentures, and if so, if they’re available.

IMAGING At the time of consultation, most patients presenting with concern for mandibular fracture have undergone a CT scan.

Maxillofacial CT is 100 percent sensitive for the diagnosis of mandible fractures (Figure 1) and aides in surgical planning.

Maxillofacial CT with maximum 1-3mm cuts (+/- 3D reconstruction) ideally should be obtained in all patients presenting with mandibular trauma. The maxillofacial CT scan is most often the sole radiographic modality necessary in the diagnosis of mandible fractures, except in cases of suspected, concomitant dental trauma. In these cases, an orthopantomogram (i.e., Panorex) can assist in precise diagnosis (Figure 2).

Figure 1: Three-dimensional reconstruction of a maxillofacial CT demonstration left parasymphysis and subcondylar fractures.

ANATOMY The mandible is composed of buccal and lingual cortices with an intervening, medullary canal that houses the mandible’s neurovascular supply. The mandible can be thought of as two paired hemi-mandibles – each divided into a condyle, coronoid, ramus, angle and body segment – that join midline at the symphysis. The superior aspect of the ramus is capped by the coronoid anteriorly and the condyle posteriorly, which are separated by the sigmoid notch (Figure 3). The condyle articulates within the glenoid fossa of the temporal bone to form the temporomandibular joint (TMJ). The mandibular body begins at the anterior border of the masseter muscle insertion and ends at a vertical line drawn down from the lower canine tooth. The alveolar ridge is the tooth-bearing portion of the mandibular body, and the symphysis/ parasymphysis regions are bordered by the bilateral lower canine teeth. The neurovascular supply (inferior alveolar nerve and artery) enters lingually at the level of the ramus via the mandibular foramen and traverses the mandible below the tooth roots within the medullary canal. The inferior alveolar nerve exits via the mental foramen as the mental nerve just below the second bicuspid (Figure 4).

Figure 2: Panorex demonstrating a left body fracture with comminution.

Note the improved dental anatomy visibility.

Figure 3: Depiction of basic mandibular anatomy as it pertains to fracture referencing.

Two main groups of muscles insert and act upon the mandible: muscles of mastication (masseter, temporalis, and medial and lateral pterygoids) and suprahyoid muscles (digastric, stylohyoid, mylohyoid, geniohyoid). The opposing forces of these two muscle groups often result in displacement of mandible fracture segments as the muscles of mastication pull posterior-fracture segments superiorly, while suprahyoid muscles pull anterior fracture segments inferiorly.

Relative fracture incidences are depicted (Figure 5). Fracture anatomy should be carefully noted and described by anatomic location, as well as whether they are open, comminuted or stable by manual distraction. Deeply rooted teeth present focal areas of weakness, increasing the risk of fracture. The presence of third mandibular molars (“wisdom teeth”), either impacted or erupted, increases the risk of traumatic mandibular-angle fracture and is associated with increased risk of associated infection. Fractures are deemed “favorable” if they are non-displaced and the vectors of muscle-pull result

in fracture reduction. “Unfavorable” fractures are generally comminuted, displaced or are distracted by the vector of pull exerted by the muscles of mastication. continued on the next page Plastic Surgery Resident | Fall 2021

13

CONSULT CORNER / continued from previous page

Figure 4: Clinical photograph demonstrating the inferior alveolar nerve exiting the mental foramen to become the mental nerve.

with the avulsed tooth secured to surrounding teeth via brackets or bonding. Avulsed teeth should be placed in saline or milk media to prevent desiccation prior to reimplantation.

For fractures that involve the alveolar segment and can be reduced, bridle wires can be placed around teeth bordering the fracture to provide support and minimize motion. This may improve patient comfort while they await surgical repair. Antibiotics at the time of injury are recommended for patients with open mandible fractures, including all fractures of tooth-bearing segments of the mandible. Commonly used antibiotics include penicillin, cefazolin, metronidazole and clindamycin. Reliable data pertaining to the dose, duration and route of administration of prophylactic antibiotics is lacking in the current literature.

Figure 5: Photograph depicting the relative incidences of mandibular fractures.

Most mandible fractures require surgical intervention to achieve the two primary goals of treatment: restoration of preinjury maxillomandibular occlusion, and anatomical reduction/immobilization of fracture fragments to facilitate proper healing. Indications for non-surgical management include the following: one fracture site, no comminution or displacement, no mobility or occlusal discrepancies and the patient is reliable/compliant. Special consideration should be given to the atrophic mandible, which is at high risk of non-union due to inherently poor blood supply. These fractures should generally be treated by open reduction and internal fixation (ORIF) +/- immediate bone-grafting when appropriate. While the treatment of mandible fractures is generally not emergent, there is no consensus on the ideal timing of repair (less than 72 hours vs. more than 72 hours post-injury).

SURGICAL APPROACH

MANAGEMENT After initial stabilization, the face and mouth should be copiously irrigated. All lacerations, both intra- and extra-oral, should be exposed completely, which at times necessitates hair removal. They should be cleansed, debrided back to healthy tissue and repaired. Tooth extraction is recommended for teeth with fractured roots; those contained within a comminuted or displaced mandible fracture (to facilitate fracture healing); and those with associated periodontal disease or abscess near the fracture. Reimplantation of avulsed teeth generally isn’t successful; however, if reimplantation is attempted, it must be done expeditiously, 14

Plastic Surgery Resident | Fall 2021

Mandibular fracture treatment algorithms vary widely and depend on numerous factors, including fracture location/ characteristics; patient-specific factors (e.g., comorbidities, dentition, etc.); and surgeon preference/familiarity. Options for reduction and stabilization include maxillomandibular fixation (MMF) alone or ORIF +/- MMF. The ORIF sequence varies between physicians but generally includes the following key steps: exposure of all fractures; establishing premorbid occlusion with MMF; fracture fixation; and releasing MMF to re-examine occlusion and ensure TMJ location replacement of MMF if desired/indicated.

Important differences in fracture stabilization deserve mention. “Load-bearing” fixation is the situation in which the hardware alone bears the entire load generated by the mandibular function. Load-bearing is required when there’s insufficient quantity and/or quality of bone at the fracture

Figure 6: Depictions of different options for treating different types of mandible fractures.

site (e.g., atrophic mandible, comminuted fracture, etc.).

Load-bearing fixation generally employs the placement of a reconstructive plate. “Load-sharing” occurs when the load generated by mandibular function is shared by the fixation hardware and the host bone at the fracture site. Load-sharing is subdivided into “non-rigid” and “rigid” fixation. Nonrigid, or functionally stable fixation, permits micromotion at the fracture site, thus facilitating bony healing via callus formation. This technique is suitable for isolated, simple fractures with good bone-to-bone contact and generally utilizes lower-profile plates with shorter/smaller diameter screws. Rigid fixation prevents micromotion at the fracture site, facilitating primary bony healing without callus formation. It generally involves higher-profile plates and screws of larger length/diameter. The plate component of a plate-screw construct should span the fracture site, while the screws should be placed on either side of the fracture line in intact bone, with at least two screws on either side of the fracture (Figure 6).

POSTOPERATIVE MANAGEMENT Setting postoperative expectations preoperatively is paramount to successful treatment. Patients should have a thorough understanding of the MMF process before operative consent is obtained. Postoperative instructions should include diligent oral hygiene, MMF precautions, and diet instructions +/- nutrition consultation, depending on availability. The institution of range-of-motion exercises should be initiated when the patient is cleared to do so by the operating surgeon. The utility and duration of postoperative antibiotic therapy remains a topic of considerable debate. | Dr. Pencek is PGY-5 at the University of Rochester School of Medicine & Dentistry.

REFERENCES 1. Pickrell BB, Hollier LH. . Evidence-Based Medicine: Mandible Fractures.

Plast Reconstr Surg. 2017; 140 (1): 192e-200e.

2. Morrow B, Samson T, Schubert W, Mackay D. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014; 134 (6): 1381-90 3. Stacey, D, Doyle, John, Mount, Delora, Snyder, Mary, Gutowski, Karol.

Management of mandible fractures. Plast Reconstr Surg. 2006;117(3):48e-60e.

4. Olson RA, Fonseca RJ, Zeitler DL, Osbon DB. Fractures of the mandible: A review of 580 cases. J Oral Maxillofac Surg. 1982;40:23-28.

5. Lamphier J, Ziccardi V, Ruvo A, Janel M. Complications of mandibular fractures in an urban teaching center. J Oral Maxillofac Surg. 2003;61:745-59; discussion 749-50.

6. Färkkilä EM, Peacock ZS, Tannyhill RJ, et al. Risk factors for cervical spine injury in patients with mandibular fractures. J Oral Maxillofac Surg.

2019;77(1):109-17. doi:10.10 7. Barber HD. Conservative management of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg. 2001;59:789-91.

8. Pickrell BB, Serebrakian AT, Maricevich RS. Mandible Fractures. Semin Plast Surg. 2017;31(2):100-107.

9. Yuen HW, Hohman MH, Mazzoni T. Mandible fracture. [Updated 2021 Feb 17]. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2021 Jan. Available from: www.ncbi.nlm.nih.gov/books/NBK507705 10. Ellis E 3rd, Miles BA. Fractures of the mandible: a technical perspective.

Plast Reconstr Surg. 2007;120(7 Suppl 2):76S-89S. 11. Barker DA, Oo KK, Allak A, Park SS. Timing for repair of mandible fractures. Laryngoscope 2011;121:1160-63.

12. Lucca M, Shastri K, McKenzie W, Kraus J, Finkelman M, Wein R. Comparison of treatment outcomes associated with early versus late treatment of mandible fractures: A retrospective chart review and analysis. J Oral Maxillofac Surg. 2010;68:2484-88.

FIGURES 1-3: Morrow B, Samson T, Schubert W, Mackay D. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014; 134 (6): 1381-90.

4: Yuen HW, Hohman MH, Mazzoni T. Mandible fracture. [Updated 2021 Feb 17]. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2021 Jan. 5: Morrow B, Samson T, Schubert W, Mackay D. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014; 134 (6): 1381-90.

6: Pickrell BB, Hollier LH. Evidence-based medicine: mandible fractures.

Plast Reconstr Surg. 2017; 140 (1): 192e-200e.

Plastic Surgery Resident | Fall 2021

15

EYELID SURGERY

By Jack Hua, MD, DDS

T

he eyes are an important part of facial aesthetics and function. The popularity of blepharoplasty, as well as of possible functional implications, make them a frequently tested topic on the In-Service Exam.

ANATOMY

The anterior lamella of the eyelid consists of the thin skin and orbicularis oculi muscles. The orbicularis is innervated by the zygomatic branch laterally and the buccal branch medially of CN VII. The posterior lamella consists of tarsus, conjunctiva and orbital fat pads. In the upper eyelid, the retro-orbicularis oculi fat (ROOF) sits deep to the orbital septum and is contained in a medial and middle compartment separated by the superior oblique muscle. The lacrimal gland sits within the lateral fat compartment and can be at risk for injury during fat excision. The lower eyelid sub-orbicularis oculi fat (SOOF) sits in a lateral, central and medial compartment. The medial and central fat pads are divided by the inferior oblique muscle.

16

Plastic Surgery Resident | Fall 2021

BLEPHAROPTOSIS

While most patients seeking periorbital rejuvenation will have dermatochalasis (excess eyelid skin), all patients should be evaluated for brow ptosis and blepharoptosis. Brow ptosis can be distinguished from blepharoptosis by manually elevating the brow to its normal position. If the eyelid remains ptotic, then the patient has true blepharoptosis. It’s also important to evaluate for fat herniation versus festoons.

Fat herniation will enlarge with gentle pressure on the globe.

In addition to visual field assessment, several important tests should be performed during your initial evaluation: Margin-reflect distance (MRD): Distance from corneal light reflex to upper-lid margin (MRD-1) or lower-lid margin (MRD-2). MRD-1 less than 3mm indicates blepharoptosis. A difference between MRD-1 and MRD2 of greater than 10mm also indicates blepharoptosis.

Schirmer’s test I: A filter paper strip is placed on lateral sclera. More than 10mm of wetting after five minutes indicates normal tear production. This is important, as transient dry eyes are a common complaint after blepharoplasty. Patients with any cornea procedure should wait six months before blepharoplasty due to decreased blink reflex from cornea insensitivity.

Hering’s test: Since the levator muscle is bilaterally innervated centrally, unilateral ptosis causes bilateral eyelid retraction. This can result in blepharoptosis of the opposite side postoperatively. To assess for this preoperatively, either immobilize the brow in forward gaze and manually lift the affected eyelid, or use phenylephrine drops in the ptotic eye to stimulate the Muller’s muscle. If the contralateral eye has a masked ptosis, it will be demonstrated by this exam.

Snap-back test: This is an assessment of lower-eyelid laxity.

Distract the eyelid from the globe and release. It should return to normal position in less than two seconds without the patient blinking.

Blepharoptosis occurs when the levator aponeurosis is either detached from its insertion or incorrectly attached congenitally, causing a higher-than-normal tarsal crease. The levator aponeurosis originates from the lesser wing of the sphenoid bone and inserts within the orbicularis oculi, dermis and tarsus plate of the upper eyelid. The Muller’s muscle, which is under sympathetic control, sits deep to the posterior lamella of the levator muscle and inserts into the superior border of the tarsus.

Both muscle work in harmony to provide elevation of the upper eyelid.

On the other hand, pseudoptosis is when an extrinsic condition causes the lid to be ptotic, such as a globe deformity in Grave’s disease. True ptosis is most often an acquired deformity that’s caused by either aging (senile ptosis is most common), trauma, neurogenic disease (myasthenia gravis) and/or mechanical defects (brow ptosis or tumors). Less common are congenital conditions which are accompanied by lagophthalmos during downward gaze, due to levator fibrosis overtime.

The goal of ptosis repair is to reattach the levator back onto the tarsal plate. The surgical technique usually depends on the extent of levator dysfunction. If levator function remains at more than 10mm, then aponeurotic repair is sufficient. With 5-10mm of function, levator resection and advancement is required. If levator function is less than 5mm, then a frontalis suspension would be required. In general, 4mm of advancement is needed for every 1mm of ptosis correction.

The surgery is done under sparing use of local anesthesia to prevent distortion of dissection planes and impairment of levator function during surgery. The epinephrine in the local anesthesia may stimulate the Muller’s (superior tarsal) muscle and temporarily accentuate lid elevation (lagopthalmos).

A similar complication can be seen when botulium toxin for corrugators rhytids is injected too close to the superior orbital rims.

BLEPHAROPLASTY

The amount of tissue to be excised during blepharoplasty is determined preoperatively. In the upper blepharoplasty, the lower line is marked 9-11mm above the lash line, while the upper line is determined by the desired amount of redundant tissue to be removed. The area of excision should be canted upward laterally to allow the closure to lie within a rhytid.

The pinch test is utilized so patients can maintain adequate postoperative eye closure.

Conservative resection of SOOF is carefully done to avoid injury to the superior oblique muscle which runs between the middle and medial fat compartments. The objective of the lower blepharoplasty is to restore youthful appearance by skin tightening and elevating the lateral canthus. Either a skin or skin-muscle flap is elevated through a subcillary or subtarsal incision, and dissection is taken inferiorly onto the bony orbit in a pre-septal plane. The lateral skin, fat and portions of tarsal plate can be excised and subsequently suspended to the lower canthal tendon or orbital rim. This will improve lower-lid laxity and tighten the lid skin. Orbital fat excision should be cautiously done between the central and medial fat pad, to avoid injury to the inferior oblique muscle as well as a hollowing appearance of the eyelids. | Dr. Hua is PGY-6 at Houston Methodist Hospital.

REFERENCES 1. Essentials of Plastic Surgery. Janis J, ed. 2nd Edition. New York: Thieme; 2014.

2. Ophthalmic Plastic Surgery of the Upper Face: Eyelid Ptosis, Dermatochalasis, and Eyebrow Ptosis. Burnstine M, Desner S, Samimi D, Merritt H, ed. 1st edition.

Thieme; 2019.

3. Naik, M. N., Honavar, S. G., Das, S., Desai, S., & Dhepe, N. (2009).

Blepharoplasty: an overview. Journal of Cutaneous and Aesthetic Surgery, 2(1), 6–11.

4. Ahmad SM, Della Rocca RC. Blepharoptosis: evaluation, techniques, and complications. Facial Plast Surg. 2007 Aug;23(3):203-15.

5. Drolet BC, Sullivan PK. Evidence-based medicine: Blepharoplasty. Plast Reconstr Surg. 2014 May;133(5):1195-1205.

Plastic Surgery Resident | Fall 2021

17

EMORY UNIVERSITY DIVISION OF PLASTIC AND RECONSTRUCTIVE SURGERY:

Celebrating 50 years of excellence and innovation

By Grant Carlson, MD, & Albert Losken, MD

T

he Division of Plastic and Reconstructive Surgery at Emory University is an example of how the residents trained by Emory and the education it provides have built it into the program it is today. The division was started in 1971 when the new surgery chair, W. Dean Warren, MD, recruited his friend, Maurice J. Jurkiewicz, MD, from the University of Florida Department of Surgery to become plastic surgery chief at Emory. Remarkably, both men would go on to serve as American College of Surgeons president.

“Dr. J,” as he was affectionally known, served as chief for 22 years and produced a premier clinical, educational and investigational program, and in the process helped shape the field of reconstructive surgery. His legacy is measured through the accomplishments of the men and women he trained who later became leaders in the field themselves. When Dr. J retired in 1993, one of his young proteges, John Bostwick, MD, followed him as division chief. Dr. Bostwick was the linchpin for building one of the greatest academic plastic surgery programs in the nation – he was a pioneer in the use of the latissimus flap as well as immediate reconstruction in the treatment of breast cancer. In addition, Dr. Bostwick authored a seminal work, Aesthetic and Reconstructive Breast Surgery.

18

Plastic Surgery Resident | Fall 2021

Emory University Division of Plastic and Reconstructive Surgery faculty in 1979 was represented

by Homer Harpole, MD (left); Maurice Jurkiewicz, MD; John Bostwick; MD; and Rod Hester, MD (missing is Foad Nahai, MD).

Future The PSF President Stephen Mathes, MD, and Foad Nahai, MD, were graduates of the training program and leaders in the development of the musculocutaneous flap, and in 1979 they published the definitive textbook Clinical Atlas of Muscle and Musculocutaneous Flaps. Dr. Nahai, who would become one of the most highly regarded plastic surgeons in the world –

he’s made innumerable contributions in reconstructive as well as aesthetic surgery – will deliver the 2021 Trustees Talk titled “Where Would I Be Without my Mentors,” on Saturday, Oct. 30, during Plastic Surgery The Meeting in Atlanta.

T. Roderick Hester, MD, joined the faculty in 1979. A talented and versatile surgeon, he started an aesthetic surgery

center that would become the Emory Aesthetic Center. After Dr. Bostwick’s untimely death, Dr. Hester became the division chief in 2002 and strengthened Emory’s aesthetic surgery training by merging his private practice into the resident training program. The division continued to attract top applicants from across the country and, today, the division has an alumni base of 160 plastic surgeons who’ve become specialty leaders in their own right.

Future Emory leaders PG Arnold, MD; Stephen Mathes, MD; John McGraw, MD; and Foad Nahai, MD.

Grant W. Carlson, MD, assumed the chief position upon Dr. Hester’s retirement in 2010, with Albert Losken, MD, continuing as program director.

Under their watch, the program has continued to grow and strengthen – aided by the addition of an integrated residency program to compliment the independent program, as well as more faculty members and clinical rotations to provide services and educate the now-18-resident complement. Emory continues its contributions to breast surgery advancement with such highlights as the refinements to skinsparing and nipple-sparing mastectomy introduced in the 1990s, and the expansion of the oncoplastic approach to partial breast-reconstruction introduced in the 2000s.

Emory educators today include the core faculty as well as clinical faculty from greater Atlanta, many of whom are Emory alumni. The craniofacial experience at the Children’s Healthcare of Atlanta is headed by Joseph Williams, MD, who runs a craniofacial Fellowship and a multidisciplinary team. Children’s Healthcare also is one of the nation’s busiest craniofacial centers.

Emory University Division of Plastic and Reconstructive Surgery is well-positioned to build on its tradition. The residents and alumni are who make Emory plastic surgery what it is today. They continue to raise the bar and make a difference in

Emory University Division of Plastic Surgery Chief Grant Carlson, MD (left), with residents Drew Metcalfe, MD; Jinnie Page, MD; Paul Ghareeb, MD; and Karan Desai, MD; and Residency Program Director Albert Losken, MD.

their communities. The key to Emory plastic surgery’s success is an example of Dr. J’s original vision on education: When you bring the right group of people together to learn, they’ll learn from one other and their knowledge will grow exponentially.

We’re looking forward with excitement to seeing our colleagues in Atlanta.

We’re looking forward to sharing our city with you – and we’d like to extend some Southern hospitality, so when you see us, feel free to let us know if there’s anything we can do to help you plan or enjoy your stay. | Dr. Carlson is Emory's plastic surgery division chief; Dr. Losken is Emory's residency program director.

Plastic Surgery Resident | Fall 2021

19

Atlanta

By Ciara Brown, MD; Morgan Martin, MD; Samuel Payne, MD; & Albert Losken, MD

G

reater Atlanta is home to nearly 6 million people and has all the attractions of a big city, with “good old” Southern charm not too far away. Whether you’re visiting alone or you’re with family, Atlanta and the surrounding areas will keep you busy and entertained – when you’re not attending Plastic Surgery The Meeting events, that is.

Atlanta’s metropolitan area sprawls across a huge swath of land roughly the size of Massachusetts, with the city proper bounded on all sides by Interstate 285 – a boundary known locally as The Perimeter. Atlanta is large and diverse, with something for everyone. The restaurant scene is impressive – there are numerous great foodie locations in different neighborhoods throughout the city, with such offerings as fine dining, “Southern” BBQ , high-end casual spots and comfort food, to authentic cuisine

20

Plastic Surgery Resident | Fall 2021

that reflects the melting pot of Atlanta’s diverse population.

The subtropical climate encourages outdoor activities, rooftop bars are open year-round and sports fans can attend matches or games in every season.

We’re proud to host elite professional sports teams such as baseball’s Braves, basketball’s Hawks, football’s Falcons and soccer’s Atlanta United. Many residents enjoy attending Falcons and United games at the new Mercedes-Benz stadium, and the new Braves stadium and surrounding Battery area have become very popular in the last few years.

A unique feature of Atlanta is the Beltline: a paved pathway lined with restaurants, bars and shops that follows the course of an old railroad through the heart of the city. The Beltline is a popular place to run, bike or simply stroll with friends. Atlanta also boasts excellent art and theater options, including the

nationally renowned Atlanta High Museum of Art; the Fox Theatre; the Atlanta Symphony Orchestra; and several other smaller venues.

Finally, while there’s plenty to do in the city, if you have a few days before or after PSTM, the beauty and isolation of the Appalachian mountains are nearby and offer plentiful hiking, fishing, mountain-biking and even rock-climbing opportunities to those adventurous (and athletic) enough to seek them.

Atlanta is home to many popular tourist destinations, including the Georgia Aquarium; the Atlanta Botanical Garden; the World of Coco-Cola museum and “brewery;” the College Football Hall of Fame; Atlanta Zoo; the CNN Center (our keystone hotel for PSTM); and Centennial Olympic Park.

However, since your time is limited, we’ve a created a list of a few “must see” places that Emory residents like to visit:

Ponce City Market

• The Atlanta Beltline: Whether you want to exercise, walk leisurely or chance your fate to a scooter, the 22-mile “redevelopment” loop/trail is a great way to appreciate Atlanta daily life. Plus, there are a variety of restaurants to satisfy any food or beverage craving – and which can be enjoyed with a view of the Atlanta skyline.

• Piedmont Park: This is another beautiful, outdoor location in the heart of midtown. With access to the Beltline, the park is a great meeting spot. The dog lovers out there will be pleased to know that multiple dog parks and hiking trails are also nearby.

• Inman Park: Here’s a quaint neighborhood filled with trendy restaurants of all cuisines. Some of the residents’ favorites include Barcelona (Spanish Tapas); Del Bar (Persian); Hampton and Hudson (American); and BarTaco (Mexican).

• Dark Horse: For those who enjoy the spotlight and late-night adventures, Dark Horse Tavern offers Live Band Karaoke.

• Rooftop/Patio Bar: Atlanta’s skyline is breathtaking, so be sure to enjoy this sunset view at least one night during your weekend. Popular locations include New Realm, Whiskey Blue and the Roof at Ponce City Market.

• Ponce City Market: A popular food hall located in the heart of the city, the market offers cuisine from multiple continents, along with a rooftop bar.

• The Georgia Aquarium: You won’t regret a visit to this aquarium, as it’s the largest in the United States (3rd-largest in the world). The marine life will impress people of all ages, and walking the aquarium is a great activity if traveling with your loved

ones. A new shark exhibit has opened, and visitors can view the incredible Ocean Voyager gallery – complete with a 100-foot-long tunnel and a 4,574-square-foot viewing window where endangered whale sharks can be observed up-close.

• More parks: There are plenty of other smaller parks within the city, such as Mason Mill Park and the incredible Chastain Park. These provide easy access to some of the hospital locations, for those of us who feel energetic and want a quick run after work.

• North Georgia mountains: For those with a free weekend, an escape to the lower reaches of the Appalachians can be the perfect getaway. There are endless opportunities for hiking, camping, kayaking, mountain-biking, fishing and rock-climbing.

As residents at Emory, we feel incredibly fortunate to train in plastic surgery in a beautiful city that has something to offer everyone – and we’re excited to share our city with you. | Dr. Brown is PGY-4; Dr. Martin is PGY-3; Dr. Payne is PGY-5; and Dr. Losken is residency program director; at Emory University.

Emory University School of Medicine plastic surgery residents (and Dr. Losken, fourth from left) enjoy a relaxing Tex-Mex meal at Monterrey Restaurante Mexicano in Tucker, Ga., near Atlanta.

Plastic Surgery Resident | Fall 2021

21

INTERNATIONAL RESIDENCY PERSPECTIVES: PLASTIC SURGERY TRAINING IN INDIA

Aesthetic training sorely needed for India’s plastic surgery residents

By Samarth Gupta, MBBS, MS, MCh

A

esthetic surgery training for plastic and reconstructive surgery residents in developing countries has yet to gain the momentum often seen in the West. In India, residency programs run by state-funded institutions are usually overloaded with trauma and oncological reconstructive procedures, which doesn’t allow ample opportunity for trainees to gain adequate exposure to aesthetic surgery.

Like many other developing countries, India has seen a rise in the number of aesthetic procedures. According to statistics garnered from the International Society of Aesthetic Plastic Surgery (ISAPS) database, plastic surgeons in India – mostly in private practice – in 2018 performed 895,896 surgical and non-surgical cosmetic procedures, ranking fifth globally in the aesthetic surgery industry. Additionally, there were 54,234 rhinoplasties performed in the country. These are staggering figures given that only one institute in India offers a dedicated, board-accredited aesthetic surgery Fellowship.1 As a result, many residents who complete their residency programs not only lack experience and confidence, they also have little direction as to where to obtain aesthetic training.

CHANGES IN TRAINING STRUCTURE

With the advent of integrated programs, several private hospitals are being incorporated in the plastic surgery training system. The concept of resident clinics, however, remains a foreign concept in India. A study published in Plastic Surgery International revealed that 58.1 percent of respondents in the United States had access to resident clinics and that the majority had formal training in aesthetic surgery.2 These clinics form a major component of current aesthetic training, enabling residents to develop patient-interaction skills and perform office procedures.

22

Plastic Surgery Resident | Fall 2021

The outpatient clinics in Indian public health institutions are typically flooded with patients from weaker economic sections.

Nevertheless, some patients do seek procedures such as rhinoplasty, scar revisions, hair transplant and others. Setting up dedicated days in these clinics for aesthetic procedures could ensure that patients come to the right place.

The Indian public is often not adequately educated on what cosmetic procedures are available. Public awareness in the form of pamphlets, posters and resident camps in remote areas can promote procedural information and facilitate better access to aesthetic care overall. It’s also important to make the public aware that such aesthetic procedures may be performed in public hospitals at a lower cost.

INNOVATIVE LEARNING TOOLS

Cadaveric dissections, which are frequently performed for flap-harvest demonstrations, could be used for demonstrating nose, face and breast anatomy. A study in PRS Global Open stated that 87 percent of respondents feel they would want further training in rhinoplasty if given additional time during residency.3 Cadaveric nasal dissection can aid junior residents to understand nasal anatomy. Most state-funded institutions have sophisticated anatomy cadaver-dissection labs for firstyear medical students; these can be accessed for training junior residents, as well.

Simulation-based training is another avenue that residents in Western countries employ in their training, as it has the advantage of a controlled environment, thus omitting the common hurdles observed in intraoperative teaching.

Several prosthetic models have been developed – including a reusable, synthetic breast-augmentation model with anatomic landmarks and a submuscular plane by Kazan, et al. Although simulation seems to be a promising tool for learning, there are limitations (high costs along with the time and energy required to incorporate these models).4 The simulators are being made available by many companies that provide service in India and other developing countries. In addition, the use of 3-D printing, along with sculpture workshops, can easily be organized and have proven to be good teaching tools.

CHANGING TRENDS AND THE FUTURE

Aesthetic surgery is the most sought-after speciality by Indian residents, as shown by a study published in the Indian Journal of Plastic Surgery.5 Although this is in concordance with the West, residents in the developing countries are not as confident as their counterparts, as conveyed by Kraft, et al; in their study, there’s a substantial increase in the percentage of American

residents feeling prepared to incorporate aesthetic surgery into their practice after graduation, ranging from 36 percent to 59 percent in 2017.6 Due to the increasing performance of aesthetic procedures by many allied specialities such as otolaryngology, dermatology and ophthalmology, it’s essential that plastic surgery residents be properly trained in aesthetic procedures. According to specialty data in 2015, a total of 1.1 million aesthetic procedures were performed in India; although 75 percent were performed by plastic surgeons, current trends show that this ratio is reversing as doctors from other specialities have easy access to training in these procedures.7 In addition to increased training opportunities, regional workshops and international society partnerships are extremely beneficial to residents who may not have time to travel. Memberships of both international and local societies should be encouraged among residents and sponsored by residency programs.

A definitive demand exists to integrate aesthetic surgery training into the Indian resident curriculum – and through the efforts of plastic surgery organizations and program directors, a diverse and well-rounded education with adequate exposure to aesthetic surgery can be ensured. | Dr. Gupta is PGY-6 equivalent at SMS Hospital, Jaipur, India.

He can be reached at Samarth.4@gmail.com.

REFERENCES 1. Thakurani S, Gupta S. Evolution of aesthetic surgery in India, current practice scenario, and anticipated post-COVID-19 changes: a survey-based analysis. Eur J Plast Surg. 2020; December 2019.

2. Momeni A, Kim RY, Wan DC, Izadpanah A, Lee GK. Aesthetic surgery training during residency in the United States: A comparison of the integrated, combined, and independent training models. Plast Surg Int. 2014;2014:1-7.

3. O’Neill R, Raj S, Davis MJ, et al. Aesthetic training in plastic surgery residency. Plast Reconstr Surg Glob Open. Published online 2020.

4. Agrawal N, Turner A, Grome L, et al. Use of simulation in plastic surgery training. Plast Reconstr Surg Glob Open. 2020;8(7):e2896.

5. Khare N, Puri V. Education in plastic surgery: Are we headed in the right direction? Indian J Plast Surg. 2014;47(1):109-115.

6. Kraft CT, Harake MS, Janis JE. Longitudinal assessment of aesthetic plastic surgery training in the United States: The effect of increased ACGME case log minimum requirements. Aesthetic Surg J. Published online 2018:1-7.

7. Botox touches new horizons – Indiaretailing.com. Accessed March 19, 2021. https://www.indiaretailing.com/2015/01/07/beauty-and-wellness/growthaesthetic-centres-2/

Plastic Surgery Resident | Fall 2021

23

INTERNATIONAL RESIDENCY PERSPECTIVES: PLASTIC SURGERY TRAINING IN CYPRUS

A solid program, but more international links would greatly help

By Antonia Fotiou, MD

T

he Plastic Surgery Department of Nicosia General Hospital is the sole accredited plastic surgery training center in Cyprus. Part of the largest public-tertiary hospital on the island, it offers full training Antonia Fotiou, MD in the specialty. The program is designed to accept one new resident every year for a total of five trainees, after the applicants pass the Pancyprian Residency Examination.

Residents are trained under supervision for four years.

The department is composed of the Plastic Surgery Clinic, where patients are admitted for scheduled and emergency surgeries, as well as postoperative monitoring; the Outpatient Clinic; and the Burns Intensive Care Unit – the only ICU on the island for patients who’ve sustained major burns. Residents are trained in all three posts, as well as in the O.R. Also, due to close distances in the island, they’re often called to examine patients in other cities and even take part in operations there under supervision.

TRAINING OPPORTUNITIES

Due to the hot temperatures and sunny weather, Cyprus records a relatively high number of skin cancer and melanoma diagnoses each year. (Nicosia averages nearly 2,995 hours annually; for comparison, Chicago averages 2,565.) The department has established a Pancyprian nevus and skin cancer clinic, where patients from throughout the island are referred for definitive treatment. Furthermore, the plastic surgeons often consult patients at the Hospital’s Breast Center and conduct more than 100 breast reconstruction procedures annually. Residents get the chance to observe the weekly MDTs organized by the department in collaboration with the Bank of Cyprus Oncology Center.

As mentioned above, a critical aspect of trainee education is the time spent at the burns ICU. At the unit, patients who’ve sustained moderate to severe burns are admitted, and every resident is in charge of their daily care on rotation. It’s one of the most constructive periods for the trainees, since they learn to take initiatives and gain experience in the care of critically ill patients.

24

Plastic Surgery Resident | Fall 2021

In addition, as part of the hospital’s trauma team, a significant number of reconstructive microsurgical operations are performed annually at the department. Under the supervision of the Ministry of Health, a pilot program run by the department over the past three years is allowing residents under supervision to perform weekly aesthetic operations.

Nicosia General Hospital is also affiliated with the three medical schools in the country (University of Cyprus, European University of Cyprus and University of Nicosia).

Many medical students are taught at its clinics every year, and plastic surgery trainees participate in the educational program during their plastic surgery rotations.

Last, but not least, the European Society of Plastic Reconstructive and Aesthetic Surgeons held its 2018 annual meeting in Limassol – which was met with great success.

OVERCOMING UNIQUE CHALLENGES

Although the Plastic Surgery Residency Program in Cyprus is high-quality with good standards of practice, there are unique challenges that residents in Cypriot must face.

After the emergence of COVID-19, specialty training has suffered in various ways. Hospital beds in the past year have been quickly occupied by patients needing treatment for the disease, and consequently the maximum capacity for surgical specialties has decreased dramatically. As a result, many scheduled operations have been canceled in the past six months – and even emergency surgeries (trauma, cancer, etc.) are being put on hold wherever possible. This period clearly has led to lost opportunities for residents in all surgical specialties, due to the inability to further improve their knowledge and skills.

In addition, due to the increased demand for doctors, plastic surgery residents are summoned to assume care responsibilities in the COVID-19 clinics and ICUs several times every month, further depleting them of their surgical training schedules.

Another distinct challenge residents have been trying to tackle is the small number of specialized seminars or training

continued on page 33

SPECI AL TOPIC

‘ROADMAPS’ TO SUCCESS – FROM MED STUDENT TO RESIDENT

By Shamit Prabhu, MS, & Joseph Lopez, MD, MBA

P

lastic surgery over the last decade has become one of the most competitive fields in all of medicine, with a 73.8 percent match rate recorded in the 2020 Match statistics.1 The “arms race” to match has produced the highest average Step 1 score (249), highest average Step 2 score (256) and second-highest mean abstracts, presentations and publications (n=19.1) among all specialties.1 Examination of applicant demographics in the Match statistics also reveals a recognized problem of poor representation of Black and Hispanic residents, with minimal change year-over-year.2 Applicants without a home program face an additional disadvantage by having to spend thousands of dollars to attend away-rotations in an effort to improve their chances of matching.3 Among matched applicants in the 2020 Match, only 66 percent of applicants came from a non-top-40 medical school based on NIH funding.1 But help has arrived for medical students who find it difficult to match into a plastic surgery residency program: the recently launched Recruitment of Accomplished & Diverse Medical-student Applicants into Plastic Surgery (ROADMAPS) program, an effort by ASPS in conjunction with the American Council of Academic Plastic Surgeons.

The program strives to level the playing field for less-equipped applicants by providing resources and opportunities that many others enjoy.

SMALL NUMBERS, LARGE COSTS

Although most surgical subspecialties are highly competitive, plastic surgery is among the smallest subspecialties in terms of available resident spots. Therefore, because there are small class cohorts that can range from one to five residents – and because residencies last six to seven years – applicant “fit” becomes crucial. Typically, “fit” is determined by assessing applicants beyond their academic achievements; however, an understanding of an applicant’s personality and character can be difficult to assess in one interview. In addition, applicants without home programs are often required to complete several away-rotations as an “audition” for other programs. These away rotations can be costly – exceeding thousands of dollars.4 Naturally, applicants with stronger financial backing can apply to, and potentially attend, more away-rotation “auditions.”

Medical students who enjoy home programs also have the advantage of getting to know faculty beyond the professional

continued on page 33 Plastic Surgery Resident | Fall 2021

25

Journal Club; 2021 Fall; (24)

JOURNAL ARTICLES ON

PER I PH ER AL N ERV E M A NAG E M ENT I N U PPER- E X T R E M IT Y A M PU TAT I O N

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Lindsay Janes, MD, & Gregory Dumanian, MD

A

n estimated 70-80 percent of patients with major limb amputation suffer from post-amputation pain in the form of either local residual limb pain or phantom limb pain. This can decrease quality of life, inhibit prosthesis use, interfere with patients’ ability to work and lead to chronic opioid dependence. Traditional management of peripheral nerves during amputation involves traction neurectomy or attempts to bury the nerves in muscle. Postoperatively, chronic pain is typically managed with desensitization therapy and long-standing narcotic use, with limited efficacy. More recently, targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI) and agonist-antagonist myoneural interface (AMI) techniques have emerged. Initially developed for moreintuitive myoelectric prosthesis control, their respective impacts on the treatment of post-amputation pain, phantom limb sensation and function has become clearer in the past decade – and the application of these techniques has exploded.

26

Plastic Surgery Resident | Fall 2021

TMR is a nerve transfer procedure designed to reroute amputated nerve ends to nearby motor-nerve branches, therein providing a physiologic healing mechanism for the amputated nerve end. Animal and human data have demonstrated physiologic reinnervation of target muscles. RPNI utilizes small, denervated and devascularized free muscle grafts to cap amputated nerve endings and has shown efficacy in its ability to generate strong EMG signals. AMI, which consists of two muscles linked in agonist-antagonist orientation, attempts to improve musculotendinous proprioceptive feedback and enable bidirectional control of external prostheses. However, no evidence has surfaced of AMI’s effect on pain outcomes.

Additionally, while it’s important to be aware of AMI when discussing amputee management, it also should be noted that AMI thus far has only been described for lower-extremity amputation in humans.

1. Risk factors for neuropathic pain following major upper-extremity amputation

Lans J, Hoftiezer Y, L Lozano-Calderón SA, Heng M, Valerio IL, Eberlin KR. J Reconstr Microsurg. 2021; 37(5):413-420.

This is a retrospective review of patients who underwent upper-extremity amputation from 2000-19. In total, 142 patients with 148 amputations were identified. Neuropathic pain occurred in 42 percent of patients, of whom 48 (32 percent) had phantom limb pain and eight (5.4 percent) had a symptomatic neuroma, while six (4.1 percent) had a combination of both. Traumatic amputations (odds ratio [OR]: 4.1, p = 0.015), transhumeral amputations (OR: 3.9, p = 0.024), and forequarter amputations (OR: 8.4, p = 0.003) were independently associated with the development of neuropathic pain.

2. The use of targeted muscle reinnervation for improved myoelectric prosthesis control in a bilateral shoulder disarticulation amputee

Kuiken TA, Dumanian GA, Lipschutz RD, Miller LA, Stubblefield KA. Prosth and Orth Inter. 2004; 28(3):245-253.

This article was the initial description of TMR in a shoulder disarticulation patient for control of a myoelectric upperlimb prosthesis. The article details the surgical approach and intuitive prosthetic control. The patient was able to simultaneously control two degrees-of-freedom with the experimental prosthesis, the elbow and either the terminal device or wrist. Objective testing showed a doubling of blocks moved with a box and blocks test, and a 26 percent increase in speed with a clothespin-moving test.

3. Targeted muscle reinnervation in the initial management of traumatic upper-extremity amputation injury

Cheesborough JE, Souza JM, Dumanian GA, Bueno RA Jr. Hand (NY). 2014;9(2):253-257.

This was the first report of TMR performed at the time of major limb amputation for prevention of neuroma pain and future myoelectric prosthesis control – in this case, in a traumatic shoulder disarticulation. Eight months postoperatively, the patient demonstrated multiple, successful nerve transfers and no evidence of neuroma pain on clinical exam. Using the Patient Reported Outcomes Measurement Information System (PROMIS), the patient demonstrated minimal pain interference or pain behavior.

4. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees Dumanian GA, Potter BK, Mioton LM, Ko JH, et al.

Annals of Surgery. 2019; 270(2):238-246.

This article contains the first surgical randomizedcontrol trial for the treatment of post-amputation pain in patients with major limb amputation. Twenty-eight major limb amputees age 18 and older with chronic pain were prospectively enrolled in the surgical trial at Northwestern University and Walter Reed National Military Medical Center. They were randomized to undergo either TMR or neuroma excision and muscle burying. At one year post-op, TMR improved phantom limb pain and trended toward improved residual limb-pain compared with conventional neurectomy.

5. Targeted muscle reinnervation in the upperextremity amputee: a technical roadmap

Gart MS, Souza JM, Dumanian GA. J Hand Surg Am. 2015; 40(9): 1877–1888.

The surgical technique for TMR nerve transfers in transhumeral and shoulder disarticulation patients is described in this article. The article presents the surgical rationale and technique as well as postoperative care in patients with amputation at these levels.

6. A novel muscle transfer for independent digital control of a myoelectric prosthesis: the starfish procedure

Gaston RG, Bracey JW, Tait MA, Loeffler BJ. J Hand Surg Am. 2019 Feb;44(2):163.e1-163.e5.

This article introduces the “Starfish Procedure” in a cadaveric study and case report of transferring the interossei muscles for each digit to power a more-intuitive myoelectric partial hand prosthesis. The flexor sheath and volar plate are interposed to minimize cross-talk.

7. Regenerative peripheral nerve interfaces for the management of symptomatic hand and digital neuromas

Hooper RC, Cederna PS, Brown DL, et al. Plast Reconstr Surg Glob Open. 2020;8(6):e2792.

A retrospective review was undertaken of 30 therapeutic RPNIs performed on 14 symptomatic hand and digital neuromas. Eighty-five percent of the patient charts reviewed indicated that pain had improved after RPNI surgery, although no quantitative measure was provided. Seventy-one percent of patients had a documented, negative postoperative Tinel’s sign.

8. A regenerative peripheral nerve interface allows real-time control of an artificial hand in upper-limb amputees Vu PP, Vaskov AK, Irwin ZT, et al. Science Translational Med. 2020; 12(533):e2857.

This article builds upon the large volume of basic science work on RPNI and translates it to human use in two patients.

Ultrasound assessments of upper-extremity RPNIs revealed prominent contractions during phantom finger flexion.

Implanted indwelling, bipolar EMG electrodes produced electromyography signals with large signal-to-noise ratios.

Using these RPNI signals, subjects successfully controlled a hand prosthesis in real-time for up to 300 days without control algorithm recalibration.

9. The Ewing amputation: the first human implementation of the agonist-antagonist myoneural interface

Clites TR, Herr HM, Srinivasan SS, Zorzos AN, Carty MJ. Plast Reconstr Surg Glob Open. 2018;6(11):e1997.

This article describes the first human application of agonistantagonist myoneural interfaces. It describes surgical technique, rehabilitation and outcomes measures for the first three patients treated with this amputation technique for below-knee amputation. The authors report that EMG signals from AMI muscles were more focused, with less background contraction of muscles not involved in the desired movement. Additionally, they report that none of the three patients reported phantom limb pain.

10. Reinventing extremity amputation in the era of functional limb restoration

Herr HM, Clites TR, Srinivasan S, Talbot SG, Dumanian GA, Cederna PS, Carty MJ. Ann Surg. 2021 Feb 1;273(2):269-279.

A CME article outlining approach and technique to amputation and targeted muscle reinnervation as well as current advances in prosthetics, including pattern-recognition myoelectric prostheses and osseointegration. | Dr. Janes is PGY-6 and Dr. Dumanian is chief of plastic surgery at Northwestern Medicine, Evanston, Ill. Plastic Surgery Resident | Fall 2021

27

PLASTIC SURGERY PERSPECTIVES – PART II

MICROSURGERY “Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, at the Sackler School of Medicine in Tel Aviv University, and Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In the second part of this series featuring leaders in microsurgery, Dr. Brown interviews Phillip Blondeel, MD, PhD. – Rod J. Rohrich, MD, Editor-in-Chief, Plastic and Reconstructive Surgery

Interview by Stav Brown, MD Research Fellow Memorial Sloan Kettering Cancer Center Phillip Blondeel, MD, PhD Dr. Blondeel is Department of Plastic and Reconstructive Surgery vice-chair at the University Hospital Gent, Belgium, and president-elect of the European Association of Plastic Surgeons (EURAPS).

PSR: WHY DID YOU CHOOSE THE FIELD OF PLASTIC SURGERY – AND MICROSURGERY IN PARTICULAR? Dr. Blondeel: I didn’t choose the field; the field chose me.

I’ve always been good with my hands, so I went into general surgery – and during PGY-1, I did a rotation in plastic surgery and felt motivated to pursue this field. My professor gave me many opportunities; I was allowed to perform 25 free flaps in my first year of residency. It might have been a little risky back then, but I did pretty well and it gave me a great head start. I went to Plastic Surgery The Meeting as a PGY-5 resident, and there I saw Rob Allen, MD, and Claudio Angrigiani, MD, talk about perforator flaps. We figured that we needed to get good proof through evidence-based medicine to demonstrate the role of perforator flaps in reconstructive surgery. I earned 28

Plastic Surgery Resident | Fall 2021

my PhD, and we wrote a book and started the International Course of Perforator Flaps. It was genuinely a natural flow. I like a good challenge, and microsurgery has definitely been one, dealing with very small dimensions and instruments.

PSR: HOW HAS MICROSURGERY CHANGED SINCE YOU STARTED? Dr. Blondeel: The greatest change has been moving from myocutaneous flaps to perforator flaps. Besides the flap itself, we used to perform very rudimentary reconstructions with very poor aesthetic results at the recipient and donor sites.

Using perforator flaps, we’ve refined the donor site – not only the functional part, but also the aesthetic part. For example, a DIEP flap isn’t only about taking the flap but also taking care of the “dog ears,” making the umbilicus look nice and achieving perfect proportions. For the recipient site, we’ve established a way, with my publications on the three-step principle, to analyze the aesthetic problems of a breast and offer a treatment plan from a more engineering point of view and a more refined way of looking at aesthetics. With supermicrosurgery, we can now operate in smaller dimensions – and this has definitely expanded the array of pathologies we’re able to treat. For instance, lymphatic surgery has been added to our scope of treatment and understanding of lymphatic problems, and its patient-selection criteria is an evolving field.

PSR: WHAT ARE YOUR MAIN INTERESTS WITHIN THIS SUBSPECIALTY? Dr. Blondeel: Clinically, I’m striving for personalized medicine with significant patient participation. It’s important to master all the tools in a certain surgical plan. For example, a breast reconstruction surgeon must be able to offer implants, lipofilling, lymphatic surgery and free flaps. You’re not a good

surgeon if you only know two of the four options for your patient. Doing autologous reconstruction when possible is always better than implant surgery; however, to provide the most-effective patient care, you need to offer the patient the full array of options and perform all the available techniques.

From a research perspective, we’re heavily pursuing 3D bioprinting – we’re recruiting funding and working with other faculties in chemistry, engineering, bioengineering and so on, to build a multidisciplinary approach. If you stay within the walls of your own specialty, you end up being very limited and unable to evolve. You must be able to look at the other side of the wall to see other parts of the whole picture. This leads to innovation and discovery.

PSR: WAS THERE A PARTICULAR CLINICAL CASE THAT INFLUENCED YOU? Dr. Blondeel: One of the milestones in my career has been the face transplant we performed. (Editor’s note: This facial transplantation was Belgium’s first and the 19th worldwide, and transpired over 20 hours in late 2011.) It has changed a lot in our view of craniofacial surgery and aesthetic facial surgery. I remember how difficult it was explaining preoperatively to the patient and his family that we were going to do a major surgery that we’d never before attempted. We successfully completed the surgery and the patient is doing extremely well. It also brought us back to the anatomy lab, which made me look at a facelift in a totally different way. You suddenly can go from imitating somebody else’s technique to being creative, due to a deep understanding of facial anatomy.

Another experience that has influenced my perspective as a surgeon was being a patient myself. I underwent a neck operation since I had a C6-C7 fusion as a result of years of performing microsurgery. Aside from teaching me the importance of spending time on ergonomics, being a patient is a real eye-opener. I’m in the field – and it’s taken me a long time to find the right surgeon. Surgeons have the tools to look for a surgeon: We review literature and evaluate outcomes, but it’s still been an extremely difficult process. The experience taught me how patients feel and how difficult it is to make decisions – and this has made me a better doctor.

PSR: WHAT ROLE DOES TECHNOLOGY PLAY IN MICROSURGERY? Dr. Blondeel: One of the major things we’ve done over the past 25 years is improve the safety of perforator flaps through technology: CTA, MRI, dermo scans, ICG and so on. It’s all about looking for that golden vessel – the major dominant perforator – and imaging has a significant role in that process.

PSR: WHAT MOST EXCITES YOU WHEN YOU ANTICIPATE THE FUTURE OF MICROSURGERY? Dr. Blondeel: Tissue engineering is definitely the future, and I’m excited to go back to the basics of cells and biology.

It’s very complex, which is discouraging and exciting at the same time, because there’s so much room for innovation and discovery. Looking at the history of flap surgery, we’ve gone from bigger, deeper vessels to more-superficial, smaller vessels. However, there’s a certain limit to what we can put together in terms of the sizes of vessels, and I think we’ve reached that limit in flap surgery. That’s one of the main reasons why I’m currently not investing much of my time and effort in clinical research of flaps. I’m instead spending more time exploring tissue engineering. We’d be able to get rid of scarring and foreign bodies such as implants or perform these repetitive surgeries as we do with lipofilling. Surgeries will be done in one “go,” using a super-elegant technique. I see a very bright future for tissue engineering. We’ll have to walk away from being full-time surgeons and become part-time surgeons and part-time tissue engineers.

PSR: FOR A RESIDENT INTERESTED IN A MICROSURGERY FELLOWSHIP, WHAT ADVICE DO YOU HAVE? Dr. Blondeel: Come to us! I love teaching Fellows because not only do the Fellows benefit from that, but so do their future patients – so I’m helping a much wider scope of people.

If you’re able to develop a technique – for example, perforator flaps or maybe in the future, tissue engineering – even people you haven’t taught directly will adopt that technique, make it a part of their armamentarium and use it to help their patients. Suddenly, you’ll have a pyramid where you progress from the one-on-one patient-surgeon relationship to massive amounts of people – and now you’re making a difference and improving medicine on a global scale.

As for my ideal candidate for a Fellowship, we’re looking for someone who is curious and involved. A great example is one of the best Fellows I’ve ever had: John Hijjawi, MD, who wrote the papers on the three-step principle with me. He was constantly asking questions, trying to figure out my surgical moves and techniques, and to deeply understand the rationale behind them. He kept pushing, insisting to have everything explained clearly. I realized that although I constantly got things right and had great results, I didn’t know how to translate my techniques into a written text. It took us weeks to structure and solidify it to three simple steps – and finally the paper came out as a series of four parts. This is an example of a great Fellow: one who initiates interaction with you, doesn’t take “no” for an answer, thinks with you, brings new ideas and pushes you to your limits. | Plastic Surgery Resident | Fall 2021

29

Put your plastic surgical vocabulary skills to the test!

Plastic Surgery The Meeting – Atlanta 1 2

3

4

5

6

7 8

9

10 11

Answer key on page 32

ACROSS

DOWN

2. Superficial abdominal fascia

1. Deep hand space superficial to Pronator Quadratus

6. Famous ATLANTA's beverage 7. Eponym for the cervicofascial flap for cheek reconstruction 8. Brand name of toxin used for facial rejuvenation

3. First name of the gentleman of the ABPS logo 4. Chiasma were several facial muscles converge including: risorious, depressor anguli oris, levator anguli oris, orbicularis

9. Nasal structure often missing in secondary rhinoplasties

5. Superficial neck structure on which we create a 'window' for neck contouring

11. Eponym to the 4 cardinal signs of Flexor tenosynovitis

10. Tell-tale sign of high tension

Clues for the Plastic Surgery Resident crossword. Disclaimer: please do not use as medical advice.

Created using the Crossword Maker on TheTeachersCorner.net

30

Plastic Surgery Resident | Fall 2021

Q&A WITH ASPS PRESIDENT JOSEPH LOSEE, MD

Growth, leadership opportunities for residents are there – grab them Ahead of Plastic Surgery The Meeting 2021, the ASPS Residents Council collaborated on a set of questions for ASPS President Joseph Losee, MD, to gain his insight on forging an early path to leadership, taking advantage of Society resources as residents transition from residency to practice and, of course, why the annual meeting is a particularly useful event for residents and young plastic surgeons.

PSR: DID YOU ALWAYS KNOW YOU WANTED TO BE PART OF ASPS LEADERSHIP? WHAT SPARKED YOUR INTEREST? Dr. Losee: Although I’ve always been a goal-oriented person, being ASPS president wasn’t on my list of ambitions, like becoming a division chief, or serving on the American Board of Plastic Surgery or becoming professor of surgery had always been. I’ve always been involved in ASPS, so I don’t know why being in the ASPS leadership was never on my written list of three-, five-, 10- or 15-year goals when I finished training. I still have the UPenn notepad from my Fellowship when I wrote out these goals. As I became more involved in subspecialtysociety leadership, I recognized what kind of contribution and difference one can make in those roles. That’s what ultimately sparked my interest in ASPS leadership.

PSR: WHAT’S BEEN THE MOST EXCITING CHALLENGE YOU’VE TACKLED AS ASPS PRESIDENT? Dr. Losee: Leading the task force that’s redesigning our Society’s leadership structure. Many of us believe that our Board of Directors and Executive Committee structure has evolved in a way that results in a “top-down” leadership style, resulting in less-than-optimal Board of Directors (BOD) engagement and an overactive Executive Committee (EC).

The ASPS Board Composition Presidential Task Force has been working hard – engaging the Society’s BOD, EC, Trustees and Governance Task Force – and proposed a new leadership structure similar to that of the ACS and AMA. This new, proposed structure consists of a Council of Representatives and a new BOD (expanded former Executive Committee). I believe this new structure will result in greater engagement and a grassroots, “down-up” leadership style.

ASPS President Joseph Losee, MD

PSR: WHAT ASPECTS OF PLASTIC SURGERY RESIDENCY TRAINING WOULD YOU IDEALLY LIKE TO SEE EVOLVE IN THE COMING DECADE? Dr. Losee: Coming from Pitt, I’ve been engaged in our program’s experimental, competency-based, time-variable model of post-graduate medical education (GME). I would like to see this model of GME training to take hold and expand to other programs throughout the country.

continued on the next page Plastic Surgery Resident | Fall 2021

31

Q&A WITH ASPS PRESIDENT JOSEPH LOSEE, MD / continued from previous page

PSR: WHAT’S YOUR MOST IMPORTANT CAREER ADVICE FOR RESIDENTS? Dr. Losee: Get involved – with organized medicine, with hospital leadership committees (credentialing, O.R. leadership, etc.), state and regional medical politics (state medical boards, state medical societies, etc.) and ASPS/ PSF committees. Stay involved in your residency program as an alum, or as faculty. Maintain relationships with your mentors, mentees, colleagues and patients. This involvement will not only provide professional fulfillment, it also will help immunize you against burnout and provide meaning in medicine.

PSR: WHAT’S YOUR ADVICE TO PLASTIC SURGERY RESIDENTS AND FELLOWS WHO FIRST JOIN THE WORKFORCE IN THE COVID/POST-COVID-19 ERA? Dr. Losee: I have no special or unique advice from what I’ve mentioned before. We’re all currently figuring out what the “new world” will look like – and, pragmatically, how much of our virtual world (medical care, professional societies, meetings, conferences) will remain.

PSR: WHAT ADVICE WOULD YOU GIVE RESIDENTS INTERESTED IN CONTRIBUTING MORE ACTIVELY TO ASPS? Dr. Losee: Again, get involved. Get involved in WPS, YPS, the In-Service Exam Committee, the Scientific Program Committee and the activities of the PlastyPAC with state/ regional fly-ins to Washington. Educate yourself so that you can become involved in the politics of medicine.

Answer key from page 30

1.

K AV N E L 01 .

.9 SE P T U M

.5 PL TA Y SM A

8 . BO TX

PI X I E

4. MODILUS

. 7 M USAT R DE

3. GA SPA R E

6 . C O A C OL A

1. PA RONA

2 . SCA R PA

DOWN

ACROSS

32

Plastic Surgery Resident | Fall 2021

PSR: WHAT DO YOU THINK ARE SOME OF THE MOST VALUABLE RESOURCES THAT ASPS OFFERS RESIDENTS? Dr. Losee: For anyone going into academic practice, we have educational resources that are envied around the world. For those who plan to go into private practice, we also have a wonderful collection of Practice Management offerings that should be utilized.

PSR: WHAT SHOULD RESIDENTS OR NEW PLASTIC SURGEONS IN PRACTICE BE DOING TO HELP FACILITATE SURGICAL OUTREACH TO UNDERSERVED AREAS OUTSIDE THE UNITED STATES? Dr. Losee: I would encourage you to get involved with The PSF’s new Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program.

The goal of the program is to improve surgical care in regions of the world with limited access to – but high incidence of conditions requiring – plastic surgery. The program consists of three groups: global learners and researchers (surgeons in areas of need); global educators (ASPS member surgeons); and global peers (residents and medical students). Identify an area in the world with surgical needs and develop an ongoing relationship by making your own contributions and ongoing trips.

PSR: WHAT WOULD YOU SAY ARE THE MOST VALUABLE ASPS RESOURCES AVAILABLE TO RESIDENTS OR NEW PLASTIC SURGEONS IN TERMS OF STATISTICAL ANALYSIS AND GRANT WRITING? Dr. Losee: The PSF has courses and resources for each of these areas and can make vital connections to help identify partnerships and resources.

PSR: IN YOUR OPINION, WHAT’S THE HIGHLIGHT FOR RESIDENTS AT PSTM? Dr. Losee: There are three things that are absolutely invaluable for residents: educational offerings that you simply can’t get anywhere else, social events to begin new friendships – or fortify the ones you already have – and engage in networking. This is the one time of the year when so many of the “who’s who” of our specialty gather in one place and are available to talk to you. Email them. Ask to connect. Set up meetings. This is an absolutely golden opportunity to meet, engage and make life-long connections. |

PLASTIC SURGERY TRAINING IN CYPRUS / continued from page 24 opportunities outside the hospital. Plastic surgery is a specialty with a wide array of specific procedures, and trainees often strive to focus their skills on specific areas such as microsurgery or pediatric surgery. Despite the morethan-satisfactory training at our department, it’s expected that residents will have to travel at least twice a year to other countries in order to attend hands-on cadaveric courses, often at their own expense. One of the starkest examples is the Advanced Burns Life Support course – undoubtedly one of the most important programs in our specialty – which is not offered in Cyprus.

FINAL THOUGHTS

The Cypriot program overall is unique and strong, despite its various challenges. Improvements – even though difficult during this hard time – are possible. New affiliations with international plastic surgery organizations would be greatly beneficial, as more doors to education, practical training and trainee exchange would be opened. I’m very hopeful that the future will be even more innovative and brilliant. | Dr. Fotiou is a plastic surgery resident at Nicosia General Hospital, Cyprus. She can be reached at antonia-fotiou@hotmail.com.

‘ROADMAPS’ / continued from page 25 level. Additionally, many of these home programs are active in research, with many offering formal and informal mentorship opportunities for the students. In the 2020 Program Director survey (n=16), 75 percent of program directors cited involvement in research (4th-most cited factor) – with a mean importance rating of 4.3/50 as factors in interview selection.5 In ranking applicants, research was cited 55 percent of the time, with a mean importance of 4.3/5.0.5 Many applicants without adequate research opportunities take research years – but these research years can be unpaid positions, further widening the financial gap.

The end result is a system that works against those with less financial backing; minorities; and those without home programs.

ROADMAPS MADE FOR MED STUDENTS

The COVID-19 pandemic opened the door for technology to benefit applicants with financial limitations and those without home programs. Virtual away-rotations now allow applicants to gain familiarity with distant programs without the associated expenses. Additionally, many programs offer virtual meetand-greets and other social media activities to better advertise themselves to students. Previously, students would have to be selected for an interview to further explore the program.

Through the program, students can access pre-recorded videos and transcriptions to describe steps to take in each year of medical school to generate a competitive application.

Additionally, students will have access to a diverse array of resident mentors who can provide valuable guidance in navigating the complex specialty of plastic surgery. Since many medical school curricula do not include plastic surgery topics, ROADMAPS offers students the opportunity to learn the wide array of procedures in plastic surgery.

All resources provided by the ROADMAPS program undergo review to ensure that it remains a centralized, trustworthy resource to foster the growth of future generations of plastic surgeons. We encourage all residents and trainees to let students know about this new program.

An online ROADMAPS forum was slated to go live Oct. 9 during ASPS Medical Student Day (past the deadline for this Plastic Surgery Resident issue, therefore no link is available), so please be on the lookout for this opportunity for students.

We hope that it can serve as a means to “close the gap” and improve the recruitment of students of all backgrounds to this wonderful specialty. | Dr. Prabhu is a medical student at Wake Forest School of Medicine, Winston-Salem, N.C.; Dr. Lopez is a head and neck oncologic surgery Fellow at Memorial Sloan Kettering Cancer Center, New York.

REFERENCES 1. National Resident Matching Program. Charting outcomes in the match: U.S. allopathic seniors. National Resident Matching Program, Washington, D.C. 2020.

2. Parmeshwar N, Stuart ER, Reid CM, Oviedo P, Gosman AA. Diversity in plastic surgery: Trends in minority representation among applicants and residents. Plast Reconstr Surg. 2019;143(3):940-949.

3. Baghchechi M, Oviedo P, McLean P, Dean R, Dobke M. Disparity in opportunities: Is it harder to match into plastic surgery residency without a home plastic surgery division? Ann Plast Surg. Published online June 16, 2021.

4. 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):1337-1343.

5. National Resident Matching Program, Data Release and Research Committee: Results of the 2020 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2020

Plastic Surgery Resident | Fall 2021

33

PlastyPAC’s impact becomes more apparent after residency

By David Hill, MD Resident Ambassador PlastyPAC Board of Governors

I

t’s been a pleasure serving alongside Benjamin Schultz, MD, as resident ambassador to the PlastyPAC Board of Governors. Over the two-year term, it has become incredibly more apparent that legislation will always play a significant role in how we practice medicine, in practice environments from private to academic and pediatrics to geriatrics. The only way for us to have a chance to protect our practices and patient safety is to continue advocating.

Although it seems the policies we fight for are obviously beneficial for the general public and should pass unanimously, resistance is common. Politicians have many priorities and, unfortunately, our plastic surgery goals don’t always align with their obligations. It’s a continuous uphill battle to educate them on the principles for which we stand.

Within a week of entering private practice and treating patients, I’ve

34

Plastic Surgery Resident | Fall 2021

experienced issues that could have been prevented by policy solutions advocated by the Society. For example, a patient walked into the office with large, fullthickness wounds after undergoing liposuction by a “board-certified cosmetic surgeon.” This patient was traumatized not only from the complication, but also from psychological aspects – how she let herself undergo a surgical procedure by a physician who didn’t have the credentials she believed he had. From the physician’s website to testimonials and social media pages, the patient was convinced this practice was the best of the best. However, after her complication developed, she discovered that many other patients suffered similar injuries.

She also learned that the practitioner was a pediatrician by training. This patient’s story exemplifies the importance of the Society’s advocacy on truth-inadvertising protections. PlastyPAC is working to educate Congress about the need to require all practitioners to publish more accurate and transparent information in their marketing. This will allow patients to better understand who their providers are so they can make more informed decisions. This is one of many critical issues for which we need to continue fighting to protect our patients – and plastic surgeons’ reputations.

It’s critical that we take the necessary steps to prevent personnel who haven’t undergone the rigorous training we have from claiming comparable training.

It’s been an honor representing you as resident ambassador, and I encourage all to get involved. The PAC is always welcoming and happy to have everyone’s involvement. There are annual events such as the Advocacy Summit, as well as local state congressional meetings throughout the year – and the Society is always looking for more residents to participate. You’re welcome to contact me (hilld793@gmail.com) or Dr. Schultz (benschultzmd@gmail.com) with any questions you may have regarding PlastyPAC, or go to PlastyPAC.net for information. | Dr. Hill recently began a private practice at The Graivier Center in Alpharetta, Ga.

PlastyPAC contributions of $25 made in January-August by Residents Club members:

Why advocacy as a resident is critical

By Benjamin Schultz, MD Resident Ambassador PlastyPAC Board of Governors

T

wo years ago, I had the opportunity to join David Hill, MD, as one of two new resident ambassadors to PlastyPAC and serve on the Board of Governors. While filling the shoes of J.T. Stranix, MD, our resident ambassador predecessor, seemed like a tall order, we were motivated and encouraged to grow resident awareness and participation in PlastyPAC during our term. The last 18 months have proven to be some of the most critical times in advocacy – especially for our specialty – as more than half our colleagues practice in a smallbusiness fashion.

Members of PlastyPAC wasted no time or opportunity to meet and speak (albeit mostly virtually) regularly with members on Capitol Hill to be the voice of our specialty, and to fight for improvements and safeguards that would ensure our ability to offer the much-needed care to not only our patients, but also to our staff and community members. Virtual meetings became all too common throughout the world, and PlastyPAC representatives took hold of this opportunity and scheduled

more-frequent – and seemingly moreintimate – meetings with members of Congress than in years past. We were able to secure dedicated one-on-one time with the members, instead of just their aides, to voice our experiences and trials during the COVID pandemic. Our stories delivered a personal note that helped underscore the importance of our advocacy goals.

One goal of significant importance that we were able to achieve was the expansion of Paycheck Protection Program loans that provided direct financial support to many private plastic surgery practices during the pandemic. This unique opportunity to “meet” with members of Congress was a truly unforgettable experience.

I’ve just begun my career as the only employed plastic and reconstructive surgeon at a community health system in Baltimore. The insight I’ve gained through my time serving as a resident ambassador has already become integral in my ability to navigate the unique health insurance system in my home state and the complexities of a corporate health system.

I’m excited to contribute to our specialty in the years to come through continued advocacy engagements via PlastyPAC and the Legislative Advocacy Committee. Our work has just begun, and we have much left to achieve. Join the movement! | Dr. Schultz recently began practice at LifeBridge Health, Baltimore.

CALIFORNIA

Zeshaan Maan, MD Chen Yan, MD CONNECTICUT

Catherine Ly, MD GEORGIA

David Hill, MD IOWA

Ali Abtahi, DO MARYLAND

Benjamin Schultz, MD MASSACHUSETTS

Alannah Phelan, MD MICHIGAN

Geoffrey Hespe, MD NORTH CAROLINA

Hannah Langdell, MD NEW JERSEY

Nikita Shulzhenko, MD OHIO

Spencer R. Anderson, MD Demetrius Coombs, MD PENNSYLVANIA

Vipul Gargya, MD Michael Hu, MD SOUTH CAROLINA

Carlos Martinez, MD TENNESSEE

Ravi Viradia, MD TEXAS

Rachel Goldstein, MD Janak Parikh, MD UTAH

Paul Tenzel, MD WEST VIRGINIA

Mihail Climov, MD

Plastic Surgery Resident | Fall 2021

35

RESIDENTS: Do Not Miss This!

Join us for a variety of programming made just for you!

PSTM21 RESIDENT HIGHLIGHTS: 1. Senior Residents Conference – Georgia World Congress Center - Building C, C111 (Oct. 28 from 9 a.m. – 4 p.m. ET) 2. Residents Networking Reception – Omni Atlanta Hotel at CNN Center, International Ballroom D (Oct. 28 from 6 p.m. – 7 p.m. ET) 3. Resident Abstract Presentations – Georgia World Congress Center – Building C, C103, C104, C105, C106 (Oct. 29 from 8 a.m. – 9 a.m. ET) 4. Allergan Aesthetics Next Gen Lounge – Georgia World Congress Center - Building C, near C111 (Oct. 29 – Nov. 1) 5. “Meet and Greet” Networking Event with Medical Students – Georgia World Congress Center – Building C, Exhibit Hall – Residents Bowl Arena (Oct. 30 from 3:30 p.m. to 4:30 p.m. ET) Sponsored by:

Allergan Aesthetics, an Abbvie company | The Plastic Surgery Center | Mentor Worldwide, LLC

Come support residency programs from across the globe as your peers compete in the ASPS Residents Bowl Championship! Teams will be competing in this global competition to crown the best of the best.

SCHEDULE

Georgia World Congress Center - Building C, Exhibit Hall – Residents Bowl Arena Friday, October 29, 2021

Saturday, October 30, 2021

Sunday, October 31, 2021

Opening Round I: 9 a.m. – 10 a.m. ET

Round IV: 9 a.m. – 10 a.m. ET

Semi-Finals & Finals: 9 a.m. – 10 a.m. ET

Opening Round II: 12 p.m.– 1:30 p.m. ET

Round V: 12 p.m. – 1:30 p.m. ET

Opening Round III: 3 p.m. – 4 p.m. ET

For more information visit PlasticSurgeryTheMeeting.com/Residents Times are subject to change