Plastic Surgery Resident, Winter 2021 by PlasticSurgeryNews

ISSUE 25 | WINTER 2021

From the publishers of Plastic Surgery News

Residency in retrospect: How to succeed (and exceed) Demystifying three levels of training page 4 PLASTIC SURGERY PRACTICE

CHIEF RESIDENT

MID-LEVEL RESIDENT

» To the victors go the bragging rights JUNIOR RESIDENT MEDICAL SCHOOL

Mount Sinai grabs 2nd Residents Bowl title in 3 years p. 30

» ‘Insane competition,’ limited openings The numbers – and realities – of plastic surgery training in Italy p. 28

IN THIS ISSUE » InService Insights: Gender-affirming mastectomy p. 8 » PSTM Travel Scholars reveal their annual meeting feelings p. 13 » What I know now that I wish I knew then: Jason Ko, MD, Northwestern University p. 26

A note from the editor

Russell E. Ettinger, MD Chief Medical Editor

Plastic Surgery Resident Seattle

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

elcome to the Winter 2021 issue of Plastic Surgery Resident (PSR).

In our final issue of 2021, I would like to recognize Sanjay Naran, MD, for his leadership and curation of PSR during his tenure as the Chief Medical Editor. As a former Resident Representative to the ASPS/PSF Board of Directors, Dr. Naran conceptualized PSR as a way to formally highlight resident-centric topics and connect residents from training programs across the globe. Through his leadership, PSR evolved into a robust publication that delivers invaluable content that touches upon a multitude of topics relevant to residents at all levels of training. We can’t thank him enough for his original vision and numerous years of service to PSR. We would also like to thank outgoing Resident Editors Janak Parikh, MD (Houston Methodist); Matt Pontell, MD (Vanderbilt); Elie Ramly, MD (OHSU); and Konstantinos Gasteratos, MD (Greece); as well as outgoing Senior Resident Editor Lisa Gfrerer, MD, PhD (Harvard); for their hard work and valuable contributions over the past year. Please join me in welcoming our new Resident Editor team: Michael Hu, MD (University of Pittsburgh); Harry Siotos, MD (Rush Medical Center); Ravi Viradia, MD (University of Tennessee); and Monica Zena, MD (Milan, Italy). We also welcome Megan Fracol, MD (Northwestern), the new Resident Representative to the ASPS/PSF Board of Directors and PSR Senior Resident Editor. Megan will be your voice within ASPS/PSF; be sure to reach out to her with feedback, concerns or ideas.

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

In this issue, our cover feature delves into the qualities and characteristics that help individuals become highly successful at each level of residency training. We highlight Houston Methodist in our Program Peek, and our columns feature discussions on artificial intelligence, gender-affirming mastectomy, and microsurgical emergencies and flap management. Our International Perspective highlights residency training in Italy – and we hear from Dr. Fracol on her plans this year as the Resident Representative to the ASPS/PSF Board of Directors. Finally, we recap the exciting 2021 Residents Bowl with articles from YPS Residents Bowl Subcommittee Chair Edward Davidson, MD – and from 2021 Residents Bowl Champion Mount Sinai, which narrowly defeated the University of Michigan in the finale to take home the hardware and a year’s worth of bragging rights. Thank you to our readers and our team of editors and the ASPS production staff. We hope you enjoy the read!

Plastic Surgery Resident | Winter 2021

Table of

Contents Lighting the residency path: What they did at different levels to succeed....................... 4 Plastic surgeons who’ve served as junior resident, mid-level resident and chief resident reveal how they prospered in each phase.

InService Insights Gender-affirming mastectomy............................................... 8 This procedure’s relation to improved quality of life is one reason why it’s increasingly sought – making it a growing focus of the In-Service Exam.

Consult Corner: Microsurgery emergencies and flap management.......... 10

Plastic Surgery Resident | Winter 2021 | Vol.5 No.4 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 J. Peter Rubin, MD, MBA | rubipj@upmc.edu

“Will I know what to do if something goes wrong?” is answered by plastic surgeons experienced in the nuances of troublesome free flaps.

EDITOR Russell Ettinger, MD | retting@uw.edu

Reflections on a meeting: Travel scholars recap Atlanta............................................... 14

ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com

The eight Resident Travel Scholars who attended the ASPS/PSF annual meeting encapsulate their experiences.

Program Peek: Plastic surgery at Houston Methodist Hospital................ 16 The plastic surgery program launched at St. Joseph’s Hospital but found its long-term home in Houston Methodist.

Message from the Director: Pierre Chevray, MD, PhD....................................................... 19

SENIOR R ESIDENT EDITOR Megan Fracol, MD | mfracol@gmail.com R ESI DEN T EDITOR S Michael Hu, MD | hums2@upmc.edu Harry Siotos, MD | Charalampos_Siotos@rush.edu Ravi Viradia, MD | rviradia1@gmail.com

Residency program director illuminates the auspicious beginnings of plastic surgery training and highlights the leadership that helped build the institution.

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 Monica Zena, MD | monicazena91@gmail.com

Faculty Focus: Michael Klebuc, MD.............................................................. 20

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

Associate professor of Clinical Plastic Surgery at Houston Methodist endeavors to supply residents with “non-technical” advice.

24 Hours in: Houston................................................................................... 22

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

Resident-authors take readers through the culinary delights, outdoor activities and seductive nightlife of the southwestern Texas city.

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

Journal Club: Artificial intelligence and machine learning..................... 24

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

These 10 articles can help light the way through this thickening field of technology that’s already reshaping medicine.

What I Know Now That I Wish I Knew Then: Jason Ko, MD.......................................................................... 26 Northwestern University’s Residency Program director reveals the best and worst parts of his role – and what he’d do differently, given the chance.

International Perspective: Plastic surgery training in Italy........................................... 28 Monica Zena, MD, describes the system in place for training young plastic surgeons – and notes the challenges inherent in that approach.

Residents Bowl: To the peak for Mount Sinai................................................ 30 Mount Sinai residents recount their path to the program's second Resident Bowl title; moderator Edward Davidson, MD, bears witness to the win.

Resident Rep Perspective: Hailing past work and moving forward............................. 33 Megan Fracol, MD, newly installed Resident Representative to the ASPS Board of Directors, thanks her predecessors and maps the year ahead.

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 Michelle Smith (646) 674-6537 | Wolters Kluwer Health

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

Plastic Surgery Resident | Winter 2021

ROADS TRAVELED – AND LESSONS LEARNED

Plastic surgeons reveal their keys for success at the 3 levels of residency

esidency: a simple word that many of us often

consider in its totality. Residency training is the

proverbial largest “box to check” on our pathway

to becoming fully fledged, board-certified plastic

surgeons. However, distilling it down in this manner vastly undervalues the sheer amount of nuanced technical skill,

personal growth and professional development gained during a plastic surgery residency. The person who enters as a newly minted “MD” fresh out of medical school bears almost no

resemblance to the person who exits a training program upon graduation. For this article, we asked three highly successful trainees at different stages of their plastic surgery journey to provide insights on the specific qualities that typify an

outstanding resident at the level of training that they themselves just completed. Through this lens, we hope to demystify some of those “intangibles” and provide guidance to those looking

ahead to excel and “level-up” in the next phase of their training. – Russell Ettinger, MD PSR Editor

Plastic Surgery Resident | Winter 2021

CHIEF RESIDENT:

ROLES AND RESPONSIBILITIES By Sameer Shakir, MD

WHAT ARE THE PRIMARY ROLES OF A CHIEF RESIDENT? A chief resident’s roles involve the ability to manage a clinical service, operate (somewhat) independently and complete various administrative tasks. The successful transition from senior to chief resident requires proficiency in applying a fund of knowledge to make sound clinical decisions and utilize previously acquired technical skills to operate efficiently.

WHAT PERSONAL QUALITIES CAN HELP MAKE SOMEONE SUCCESSFUL AT THIS LEVEL? A chief resident should be a leader. Emotional intelligence, ability and leading by example may be critical attributes to demonstrate throughout residency, but they become even more important at this level. Emotional intelligence means demonstrating empathy, managing conflict, communicating effectively and relieving stress in a constructive manner. Ability means demonstrating proficiency, inspiring confidence and building trust within a team-setting. Leading by example means never asking someone else to do something you wouldn’t do (or haven’t done) yourself.

WHAT ARE THE GREATEST PITFALLS AN INDIVIDUAL COULD ENCOUNTER AT THIS LEVEL?

WHAT ADVICE WOULD YOU GIVE SOMEONE ENTERING THIS PHASE OF THEIR TRAINING?

Although service-related obligations continue to decrease in this role, it would be a mistake to simply coast through the year. There’s always something to learn from every case – big or small. As the team leader, it’s equally important to look after the well-being of others. Are you consistently assigning your co-residents late days? Are you considering the personal and educational desires of your colleagues in addition to your own? As a chief resident, it’s better to be loved than to be feared.

The chief year serves as a unique opportunity to further hone operative skills, identify and remedy knowledge gaps, and function in a pseudoautonomous role. Chief residents typically feel comfortable with the technical execution of most operations and procedures, but opportunities are available to learn case setups, transition to an assistant role to educate junior residents and develop clinical and operative efficiency.

WHAT KEY INTRAOPERATIVE ATTRIBUTES OR SKILLS ARE REQUIRED AT THIS LEVEL? The ability to execute the operation in its entirety; to identify and avoid common pitfalls; and to transition to an assistant role for junior residents in the appropriate circumstance. Every operation has a rhythm and cadence. Certain portions can be quickly executed, while others require slow attention to detail. Mastery of this nuance leads to operative efficiency.

WHAT RESOURCES (TEXTBOOKS, JOURNAL ARTICLES, LECTURES, ETC.) YOU WOULD USE TO PREPARE OR STUDY AT THIS LEVEL? Read daily for 30 minutes. Read anything. There are several excellent resources available – including comprehensive descriptive textbooks, operative atlases and journal articles. During my chief year, I read CME articles from Plastic and Reconstructive Surgery (and watched the accompanying videos), reviewed chapters published in Clinics and Seminars in Plastic Surgery and annotated operative atlases such as Operative Techniques in Plastic Surgery, written by Kevin Chung, MD, MS. Additionally, the references in these resources often include key publications, which are worth a review. Dr. Shakir is PGY-7 and a craniofacial Fellow at the University of Washington, Seattle. Plastic Surgery Resident | Winter 2021

MID-LEVEL RESIDENT: ROLES A N D R E S P O N S I B I L I T I E S By Yusha Katie Liu, MD, PhD

WHAT’S THE PRIMARY ROLE OF A MID-LEVEL RESIDENT? The middle years of residency have the steepest learning curve as residents transition from general surgery and other off-service rotations to full-time plastic surgery training. The primary focus should be on personal learning to understand fundamental surgical principles and to establish a solid fund of knowledge for the breadth of plastic surgery. It’s never too early to think about future goals and explore opportunities for research and career development/committee positions – especially if planning for additional Fellowship training after residency. A mid-level resident should also be proficient at managing both acute care and critically ill patients, as well as the initial evaluation and treatment of new consults. The midlevel resident also can be a valuable mentor for interns and medical students.

WHAT PERSONAL QUALITIES CAN HELP MAKE SOMEONE SUCCESSFUL AT THIS LEVEL? Meticulous attention to detail and inquisitiveness is key. Noticing subtle differences and constantly asking “why” is crucial for learning – everything from positioning and draping to instruments to use and retractors to give the best exposure, to suture, implant and hardware choices, to postoperative rehabilitation protocols. Attendings have personal preferences for good reason, and

Plastic Surgery Resident | Winter 2021

listening to their rationale can help you figure out what makes the most sense. Then develop your own style.

WHAT ARE THE GREATEST PITFALLS AN INDIVIDUAL COULD ENCOUNTER AT THIS LEVEL? It’s exciting to progress through the years and realize how far you’ve come, but overconfidence can be a barrier to continued learning. Even if you feel comfortable in your ability to perform certain procedures or steps of an operation independently, always be open to and actively elicit feedback, which will help you become more precise, efficient and dexterous. No matter your stage of training, you can always find ways to be better.

WHAT KEY INTRAOPERATIVE ATTRIBUTES OR SKILLS ARE REQUIRED AT THIS LEVEL? It’s imperative that you develop technical skill with surgical approaches and exposure, as well as master closure techniques for different parts of the body.

WHAT ADVICE WOULD YOU GIVE SOMEONE ENTERING THIS PHASE OF THEIR TRAINING? Take advantage of this phase to soak-up knowledge. You don’t have the day-today duties of an intern, and you don’t have the administrative responsibilities of a chief resident. Read, question, explore, reflect, research.

WHAT RESOURCES (TEXTBOOKS, JOURNAL ARTICLES, LECTURES, ETC.) YOU WOULD USE TO PREPARE OR STUDY AT THIS LEVEL? The best resource may be your chief residents. When learning a new operation, it can be overwhelming to figure out the key elements from the variety of techniques described in textbooks. If senior residents share their notes – especially if it takes you through the exact steps of the operation – it can help you to focus your learning and often may include tips and tricks. This can be supplemented by anatomy atlases and online surgical videos. Dr. Liu is PGY-6 and a chief resident at the University of Washington, Seattle.

JUNIOR RESIDENT:

ROLES AND RESPONSIBILITIES By Philip Tolley, MD

WHAT’S THE PRIMARY ROLE OF A JUNIOR RESIDENT? Simply put, an intern’s primary role is to make the service run smoothly. This simple idea has profound, positive consequences. By constantly asking what needs to be done to further the care of your patients, multiple things occur: Patients benefit from more-effective care and are discharged sooner; other members of your team are then able to think about complex management; and you begin to develop your medical decision-making.

WHAT PERSONAL QUALITIES CAN HELP MAKE SOMEONE SUCCESSFUL AT THIS LEVEL? The most important attributes of a great intern include communicating effectively and taking responsibility for and ownership of patients. Communicating with your team is essential to ensure the medical decisions being made by the team are from an informed perspective. As an intern, you often have the most information about changes in patient status – and often you’re the first to know, as well. Your upper-levels and attendings can’t act on things they don’t know. I always say that as an intern, you never want to be the only person who knows something. If you take a personal sense of responsibility for your patients, you’ll be reliable – since you’ll always ensure that whatever needs to be completed will be completed, no matter how tired or busy you feel.

WHAT ARE THE GREATEST PITFALLS AN INDIVIDUAL COULD ENCOUNTER AT THIS LEVEL? They say there are two types of interns: those who write things down, and those who forget. As an intern, you’re juggling so many different tasks: notes to write, orders to place, patients to check on, consults to see, pages to respond to – and the list goes on. It becomes very easy for things to become forgotten. You’re being relied upon to make sure all the tasks for the day get done – and if you forget, it often gets missed. Come up with a system that works for you and stick to it.

WHAT KEY INTRAOPERATIVE ATTRIBUTES OR SKILLS ARE REQUIRED AT THIS LEVEL? As an intern, you should be absorbing everything that you can whenever you’re in the O.R. Specifically, you should really focus on mastering the fundamentals of surgery, such as proper instrument use and names, needle and tissue handling, suturing, etc. If you start out with bad habits, you’ll only tend to exaggerate them over time.

WHAT ADVICE WOULD YOU GIVE SOMEONE ENTERING THIS PHASE OF THEIR TRAINING? Intern year is very busy, and it often feels like you’re doing more “work” and less “learning.” Trust that everything you do gains you experience. You may not feel

like you become a better doctor day by day, but when you look back over the course of the year, you’ll see the strides you’ve made. So don’t get discouraged – just keep working hard and doing the right thing for your patients. Your knowledge and skill will subtly and steadily accumulate.

WHAT RESOURCES (TEXTBOOKS, JOURNAL ARTICLES, LECTURES, ETC.) YOU WOULD USE TO PREPARE OR STUDY AT THIS LEVEL? The sheer amount of information there is to learn, coupled with the paucity of time you have outside the hospital, can feel overwhelming. Just remember: Doing something is better than doing nothing. If you develop a habit of reading 10-15 minutes a day, you’ll be betterserved in the long run. The knowledge you gain from a single day of 15 minutes of reading may seem inconsequential, but when you add up the knowledge gained week after week, month after month and year after year throughout residency, the result is substantial. Specifically, I think CME articles from Plastic and Reconstructive Surgery (with the accompanying videos); The Plastic Surgery Series by Peter C. Neligan, MD, for specific topics; and Review of Plastic Surgery by Donald W. Buck II, MD, for In-Service Exam review are all great resources. | Dr. Tolley is PGY-4 in the University of Washington Plastic and Reconstructive Surgery Residency Program. Plastic Surgery Resident | Winter 2021

Gender-Affirming Mastectomy By Michael Hu, MD, MPH, MS & Vu T. Nguyen, MD

ender-affirming mastectomy is a highly sought-after procedure to improve quality of life in transmasculine and gender-nonbinary individuals.1 As a result of an increasing demand in gender-affirming surgery, this has become a frequently tested topic in the In-Service Examination.

DR. HU

GENDER DYSPHORIA

Nearly 1.5 million adults – 0.6 percent of the United States population – are affected by gender dysphoria, defined as an incongruence between anatomical sex and gender identity.2 Globally, this number reaches 25 million, or DR. NGUYEN 0.5 percent of the total population worldwide.3 Gender dysphoria treatment is multifactorial; it includes psychotherapy/counseling, hormone treatment and/or surgery.

GUIDELINES

Prior to surgical consideration, plastic and reconstructive surgeons should adhere to the Standards of Care (SOC) published guidelines by the World Professional Association for Transgender Health (WPATH):

Plastic Surgery Resident | Winter 2021

Criteria for mastectomy and creation of a masculine chest (one referral): • Persistent, well documented gender dysphoria • Capacity to make a fully informed decision and to consent for treatment • Age of majority in a given country (if younger, follow the SOC for children and adolescents) • If significant medical or mental health concerns are present, they must be reasonably well controlled Hormone therapy is not a prerequisite. Patients under 18 years of age may be candidates for genderaffirming mastectomy if the patient, their legal guardians and/ or parents, their therapist and their care team believe that delaying surgery until the age of maturity (18) would result in patient harm.

TECHNIQUES

With an increase in insurance coverage, rates of genderaffirming mastectomy have significantly increased – and it’s one of the most-performed procedures for gender incongruence.5 Surgical techniques for gender-affirming mastectomy are derived from surgeries to treat gynecomastia, ptosis and macromastia. As such, two popular methods of genderaffirming mastectomy include the circumareaolar approach and the double-incision mastectomy with free nipple graft (DIFNG), commonly referred to as double incision mastectomy (DIM) in the transgender community.6 Although these two methodologies are most frequently utilized, myriad variations

exist. The optimal surgical approach depends on anatomical considerations, patient desires and aesthetic goals, and surgical expertise. The Fisher grading system is often used to aid in the decision-making process.7 FISHER GRADE

CHARACTERISTICS

SURGICAL TECHNIQUE

Minimal glandular tissue, no skin laxity, NAC above IMF

Circumareolar incision

Moderate glandular tissue, little to no skin laxity, NAC above IMF

Circumareolar incision

Moderate glandular tissue, increased skin laxity, NAC at or below IMF

DIFNG

Significant glandular tissue, irrespective of skin laxity, NAC below IMF

DIFNG

Deflated breast, significant skin laxity, NAC below IMF

DIFNG

to the nipple. Liposuction can be used for contouring. The skin around the NAC can be deepithelialized to re-position the nipple superiorly and laterally to mirror the male chest.

DOUBLE-INCISION FREE NIPPLE GRAFT (DIFNG)

A pinch test should be performed to ensure that the site of nipple excision is encompassed in the transverse closure. A full-thickness incision is made 2 cm below the lateral border of the pectoralis major and carried along the inferior border. The superior incision is made and the flap elevated. A subcutaneous mastectomy is performed through this incision and the NAC is removed. The incision is closed in layers and a 15-French closed suction drain is placed. The new nipple position is marked in the seated position. The skin is deepithelialized and the free nipple graft is thinned and secured in place with suture or staples. Liposuction is performed as needed for contouring. | Figure 2. Double-incision gender-affirming mastectomy with free-nipple graft Plastic and Reconstructive Surgery 139(4):873e-882e, April 2017

*DIFNG – double-incision mastectomy free nipple graft; IMF – inframammary fold; NAC – nipple-areola complex

CIRCUMAREOLAR INCISION

The nipple is marked in an oval shape measuring roughly 2-by-3 cm. An incision is made circumareolar inferiorly from the 3 o’clock to 9 o’clock position, through which the subcutaneous mastectomy is performed. The inframammary fold (IMF) should be disrupted via electrocautery to create the male chest phenotype. At least 2 cm of subcutaneous tissue should be maintained deep to the nipple-areola complex (NAC) to preserve blood supply Figure 1. Gender-affirming mastectomy, circumareolar approach Plastic and Reconstructive Surgery 139(4):873e-882e, April 2017

Dr. Hu is PGY-4, and Dr. Nguyen is an associate professor and residency program director in the Department of Plastic Surgery at the University of Pittsburgh. REFERENCES 1. 2. 3. 4.

Tips and tricks in gender-affirming mastectomy, Plast Reconstr Surg. 147(6):1288-96. American Psychiatric Association. DSM-5 Fact Sheets. Accessed Dec. 1, 2021. Transgender people: Health at the margins of society. Lancet. 388(10042):390400. The World Professional Association for Transgender Health, “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.” https://www.wpath.org/media/cms/Documents/SOC%20v7/ SOC%20V7_English.pdf. Accessed Dec. 1, 2021. American Society of Plastic Surgeons, 2018 Plastic Surgery Statistics. https:// www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgerystatistics-full-report-2018.pdf. Accessed Dec. 1, 2021. Female-to-male gender-affirming chest reconstruction surgery. Aesthet Surg J. 39(2):150-163.

Plastic Surgery Resident | Winter 2021

Microsurgery emergencies and flap management “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 Idanis Perez-Alvarez, MD & David Kurlander, MD 45YOM S/P ALT free flap with venous congestion You’re about to join a breast augmentation procedure with your chief resident. Just before scrubbing-in you receive a page from the floor nurse taking care of a 45-year-old patient who underwent an ALT free flap two days ago, informing you that the flap looks more swollen and purple.

CONSIDERATIONS DR. PEREZ-ALVAREZ

DR. KURLANDER

As microsurgery becomes more commonplace, residents will be increasingly called upon to evaluate patients with free flaps for potential flap compromise. Particularly for the junior resident who’s first to see the patient, the pressure is on to decide if the flap is “healthy” or “dying.” It certainly can be daunting early in training to postoperatively manage these patients. When performing routine flap checks, you might think to yourself: “Will I know what to do if something goes wrong?” Free flaps generally have excellent success rates, ranging between 95-98 percent.1 Although these procedures are reliable, there’s always risk of complications. Luckily, a systematic approach to these patients can help identify common complications. The following is a review of frequently encountered microsurgery emergencies and their management principles.

Plastic Surgery Resident | Winter 2021

PATIENT EVALUATION

Early identification of any flap-related issue is critical. Once you receive the page, leave what you’re doing as soon as possible. Flap-related complications are surgical emergencies akin to compartment syndrome or an acute abdomen. Always go see the patient. History and examination are the first steps.

SCENARIOS

History from the patient and nursing should include: When did the flap changes begin? When was the flap last examined? How did the flap appear earlier in the day? Was the patient doing any specific activity during the onset of flap-related change? Your exam should include color, capillary refill, temperature, turgor, pinprick and patient positioning.2

ADVANCED FLAP MONITORING TECHNIQUES

Advanced monitoring techniques can provide additional assistance in flap monitoring. Handheld Doppler can detect an arterial and/or venous signal in the flap. It’s important to know how the signal sounded at the end of the case and throughout the postoperative period. Loss of a venous Doppler signal with preserved arterial Doppler signal could be consistent with early venous compromise. An implantable Doppler can be placed on the artery or vein to continuously monitor blood flow. If the implantable Doppler is on the artery, a normal biphasic or triphasic arterial sound can be appreciated. If it’s placed on the vein, an implantable Doppler will give a constant “hum” or “whoosh” consistent with a normal venous sound. A venous implantable Doppler will augment with manual flap compression or a Valsalva maneuver. Tissue oxygenation (ViOptix, T-STAT) monitoring can also be helpful. The team should be aware of critical absolute values and trends that would be concerning for flap compromise.

A 45-year-old male POD 2 after medial foot reconstruction with an ALT free flap. Venous congestion is the most-common acute complication following microsurgical reconstruction.4 Venous obstruction can occur as a result of intravascular etiology (e.g., thrombosis), or of extravascular etiology (e.g., compression, kinking). This typically occurs within 72 hours of surgery.5 When a flap’s venous outflow becomes compromised, deoxygenated blood pools in the flap – leading to a characteristic presentation of swelling and purple discoloration. Venous congested flaps also typically have brisk capillary refill – less than two seconds – and are cool to the touch. Pinprick with a 20-25-gauge needle or scalpel can also be helpful. Bright, red bleeding from the site is a reliable indicator that perfusion is normal. However, brisk, copious and dark bleeding can indicate venous congestion.6 In this case, the most appropriate treatment would include emergent return to the O.R. to identify and treat the cause of the venous congestion. Figure 2. Image taken from Quintero, et al.7

Figure 1. ViOptix. Images taken from Paydar, et al. 3

Finally, “A picture tells a thousand words.” Make sure to take a photo of the flap – one with and one without flash. This is helpful for communicating with senior residents and attendings, and it also can be helpful for monitoring flap changes over time.

continued on the next page Plastic Surgery Resident | Winter 2021

CONSULT CORNER / continued from previous page

A 62-year-old female with history of Factor V Leiden deficiency, four hours after arrival in the PACU after bilateral DIEP flap. Arterial occlusion is another potential complication of free tissue transfer. Arterial-related complications usually present early and are related to technical errors at the anastomosis. Flaps with arterial compromise present as pale or mottled and have slow cap refill of more than three seconds. Flaps with arterial compromise may have diminished turgor. A minimal amount of dermal bleeding is seen with pinprick, and the flap may be cool to the touch. Loss of arterial Doppler signal can be another sign of arterial obstruction. In this case, the most appropriate treatment would include emergent return to the O.R. to identify and treat the cause of the arterial occlusion.

A 50-year-old female with history of breast cancer POD 3 from bilateral delayed DIEP free flap. Postoperative hematoma is another commonly encountered emergency following free-flap surgery. Bleeding in any scenario may be life-threatening and may be a surgical emergency. However, in a patient who had free tissue transfer, even a small hematoma may be associated with flap-related complications. As previously discussed, venous congestion may develop secondary to extravascular compression, one cause of which can be a hematoma. Alternatively, venous compromise can cause hematoma: A clot or kink in the vein directly causes pressure buildup within the flap vasculature, leading to bleeding at the anastomosis or previously coagulated or clipped branches.8 As with arterial or venous compromise, when a hematoma develops technical monitoring such as Doppler and tissue oxygenation may detect deviations in perfusion. continued on page 32

Figure 3. Image taken from Largo, et al.1

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Figure 4. Image taken from Largo, et al.1

Resident scholars reflect on PSTM21 experiences Compiled by Paige Myers, MD

Attending Plastic Surgery The Meeting 2021 was a crucially important experience for me. Not only was I able to meet key leaders in the specialty, I was also able to observe the governing mechanism by which significant decisions that affect the entire field are carried out. I plan to participate further in the Society because there are inflection points that are affecting the scope and practice of plastic surgeons, and these will require a united front to bring about positive change. Specifically, I’m interested in The PSF as it advances scientific research for plastic surgeons. Obviously, discussion topics for the Residents Council were closely relevant for me; in particular, we hope to organize protections for residents who unfortunately find themselves in programs under investigation. We elaborated on potential contingency plans to be enacted, so residents are not individually adrift and left to fend for themselves without support or funding if their programs lose accreditation. Other takeaways were the necessity for our specialty to be outspoken on Capitol Hill to ensure that patients are informed and protected from surgeries being performed by untrained personnel. Although plastic surgeons can be very individualistic, there are many important issues that require our collective effort. It was often difficult in deciding which event to attend while leaving space to meet friends, colleagues and leaders in the field. It was particularly inspiring to meet the outgoing and incoming ASPS and The PSF presidents, and presenting my research at the largest meeting of plastic surgeons was incredibly fulfilling, as was responding to their questions and queries. Directly interacting with these leaders and role models motivates me to follow in their footsteps. Plastic surgery truly is the most collaborative and innovative field, and receiving this generous scholarship will spur me to be active in ASPS and The PSF. – David Chi, MD, PhD Washington University in St. Louis

There was a palpable sense of community interwoven throughout Plastic Surgery The Meeting. It could be due to the fact that this was the first major in-person meeting since the onset of the COVID-19 pandemic, but it may also have to do with the genuine excitement that ASPS members have in coming together to share their knowledge and experience with colleagues and friends. Surveying the committee meetings served as a reminder that ASPS is a living entity made up of vibrant and engaged surgeons who are passionate about our specialty and generous with their time. It was a nice reminder that all of the benefits that I avail myself of as a resident member of ASPS are the direct result of someone else’s hard work and dedication – something I want to pay back through continued committee involvement and service. The greatest joy was reconnecting with mentors and colleagues from other institutions to exchange knowledge and experiences. It was incredibly rewarding to see colleagues who I’d met on the interview trail coming into their own as residents and figuring out where their career will take them. In that vein, the educational sessions also helped me to solidify my dedication to a career as a reconstructive microsurgeon. The meeting reinvigorated my drive to pursue my professional goals and underscored the importance of mentorship on goal development and attainment. I’m very grateful to the ASPS/PSF for investing in my education and development, and I’m committed to paying it forward in the near future. – Elizabeth Moroni, MD, MHA University of Pittsburgh

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RESIDENT SCHOLARS REFLECT / continued from previous page As a lucky recipient of the travel scholarship, I was fortunate to attend Plastic Surgery The Meeting 2021 in its entirety. One of the most essential experiences for me was attending the numerous events sponsored by the Women Plastic Surgeons (WPS) Forum, as it facilitated the opportunity to build new relationships and explore the facets that make a successful female plastic surgeon, and to reflect on my ultimate career goals. At the WPS Steering Committee meeting, I was introduced to female leaders in the Society who work together not only to chart a course for female membership going forward, but also to synergistically tackle challenges. At the WPS luncheon, we witnessed a powerful and inspiring keynote address about being female surgeons and leaders. It was inspiring for me to be able to meet so many women in all phases of their career, and I shared lunch with two inspiring third-year medical students who reminded me of the excitement of our field and the pride we have in our specialty. I reconnected with a mentor practicing outside of my residency program whom I had met at a previous networking event and received real-time career advice and encouragement. The Resident Travel Scholarship for PSTM allowed me the chance to catch a glimpse of all of the exciting things that lie ahead for me as a female plastic surgeon. – Sarah Hart, MD Univeristy of Michigan

My selection as an international scholar to Plastic Surgery The Meeting and being among residents and future colleagues from throughout the world opened for me the possibilities of participation and improving my knowledge and the educational skills that can help me back in Argentina. I’m thankful to have finally met colleagues and dedicated residents from the United States and abroad, and I will forever be appreciative of how helpful and kind they were with me when I inquired about a topic or simply introduced myself. Residents are the keystone of plastic surgery’s future, so it was impressive to see their level of involvement in ASPS and The PSF to improve the organization and provide their points of view on the structure and function of the Society. From what I saw, active members are actively engaging residents, listening to them and doing their best to steer the educational changes that need to be made. This was my first experience engaging with ASPS and I hope it’s the beginning of a long relationship. The cooperation between countries fosters a great opportunity to share information and experience – and it will surely improve the standards of the organization from all over the world. – Robertino Basso, MD Hospital Italiano of Bueno Aires

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I was impressed by the diversity of the educational programming at Plastic Surgery The Meeting 2021 – and my favorite sessions included learning about the management of mangled upper-extremities, tips on microsurgery efficiency and the challenges facing plastic surgeons in underserved communities. As a resident at Duke University, I never had exposure to practice models in underserved communities. The speakers who discussed this subject broadened my knowledge of the hurdles involved in starting a solo practice, the impact that a single plastic surgeon can have in a rural community and the steps being taken to recruit and retain surgeons in rural America. The ability to participate in the WPS Steering Committee meeting was special, because it gave me a sense of community and belonging among this highly accomplished and motivated group of female plastic surgeons. It was interesting to learn about the history of the committee and how much it has grown since its inception. Similarly, the YPS Steering Committee brought together the future leaders of the Society and addressed ways to educate and promote medical student and resident engagement. Being able to sit-in at the Legislative Advocacy Committee meeting was exciting, as I witnessed how the priority agenda for the coming year is set – as well as brainstorming that addressed scope-of-practice issues. Overall, the Resident Travel Scholarship provided an inside look at the Society’s committees and structure, and it served as motivation to stay involved and, hopefully, one day be a leader within ASPS. – Hannah Langdell, MD Duke University

I want to thank the ASPS, The PSF, ASMS and The Rhinoplasty Society for putting on a wonderful national meeting and providing both optimism for the future of our specialty and a return to normalcy with in-person meetings. I would also like to thank KLS Martin for sponsoring the Resident Travel Scholar Award that allowed me and other residents to attend the meeting, present our research and interact with the governing body. The Residents Council meeting, led by Lisa Gfrerer, MD, PhD, was inspiring. The group discussed several issues and generated real solutions to the problems experienced by the residents of programs that closed over the past year. The efforts to streamline and elucidate the process of finding a new residency position highlight the support that residents and ASPS members have for our colleagues, particularly during difficult times. That sense of community continued through the YPS Steering Committee meeting, as the specialty’s future leaders collaborated on ways to stay up-to-date in a changing world and economy. I was able to present my research with Raymond Tse, MD, Seattle, on unilateral cleft-lip nasal deformity and the changes expected following primary repair and foundation-based rhinoplasty. This steered me toward several amazing sessions on the ASMS Track, learning from national experts on congenital, post-traumatic and postoncologic craniofacial reconstruction. The meeting reinvigorated my love for plastic surgery, craniofacial surgery and global surgery, and I look forward to collaborating with everyone next year at Plastic Surgery The Meeting in Boston. – Benjamin Massenburg, MD University of Washington

Plastic Surgery The Meeting 2021 was a great event with many interesting presentations, forums and discussions that stimulated my motivation to conduct further research and pursue innovation in plastic surgery. The organizing committee did an amazing job of bringing people together both from the different corners of the nation and internationally – as speakers and attendees – despite the pandemic. I specifically enjoyed participating in the discussion for the plane change in breast reconstruction. Subpec to prepec change is in high demand at the moment, and learning tips from faculty at various centers of excellence was very valuable. It was a great honor for me to be chosen as a Resident Travel Scholar; receiving the award from ASPS/PSF Board Vice President of Membership Steven Williams, MD, will be a lasting, lifetime memory. – Harry Siotos, MD Rush University Medical Center

I’m incredibly thankful for the opportunity to attend Plastic Surgery The Meeting 2021 as a travel scholar, particularly for the chance to be involved in committee meetings. I attended meetings of the Residents Council, the YPS Steering Committee, WPS Steering Committee and Legislative Advocacy Committee. These experiences provided firsthand insight into how residents, private practice and academic plastic surgeons around the country collaborate to enact change to support our specialty, patients and education at local, regional and national levels. The committee meetings taught me that it’s never too early to enact change through collaboration and empowering others. Perhaps most significantly, I learned that being involved in the plastic surgery community begins at the residency level. The experience inspired me to apply next year to the Residents Council and educate my fellow residents on ways to get involved. Attending the various pediatric and craniofacial seminars and meeting (and learning from) various leaders in the field solidified my goal to became a pediatric plastic surgeon. My experiences supported what I learned from my mentors – that ASPS has a strong focus on humanism in plastic surgery and provides a multidisciplinary avenue for plastic surgeons to be involved in ethics, research, health policy, advocacy and wellness. As physicians, we have strong moral responsibilities to improve our patients’ quality of life through research, health policy, advocacy and access, while also having moral obligations to be advocates for our colleagues. I would like to thank KLS Martin and my chief, Ash Patel, MBChB, for making this scholarship possible. – Christina Rudolph, MD Albany Medical Center

Plastic Surgery Resident | Winter 2021

Houston Methodist Hospital By Janak A. Parikh, MD HISTORY • 1954: Thomas Cronin, MD, and Raymond Brauer, MD, launch a program to train young surgeons interested in plastic surgery, employing a preceptorship model. • 1962: Dr. Cronin and Frank Gerow, MD, invent the first silicone gel-filled breast implant and place it in a patient. • 1970: A formal plastic surgery training program begins at St. Joseph Medical Center. • 1986: Dr. Cronin and Benjamin Cohen, MD, perform the first TRAM flap for breast reconstruction in Houston. • 1987: Dr. Cronin establishes the first cleft-care team in Houston. • 2006: The plastic surgery training program moves to Houston Methodist Hospital. • 2015: Michael Klebuc, MD, performs the world’s first scalp-skull transplant. LEADERSHIP • Jeffrey D. Friedman, MD: Cathy and Ed Frank Centennial Chair in Plastic and Reconstructive Surgery, Department of Surgery; Associate Professor of Plastic Surgery, Academic Institute; Division Chief, Reconstructive Surgery, Department of Surgery

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• Pierre M. Chevray, MD, PhD: Associate Professor, Department of Surgery; Director, Plastic Surgery Residency Program; Chair, Graduate Medical Education Committee • Donald R. Collins Jr., MD: Assistant Professor of Clinical Plastic Surgery; Clinical Assistant Professor of Surgery; Associate Director, Plastic Surgery Residency Program • Tue A. Dinh, MD: Assistant Professor of Surgery (Plastic & Reconstructive Surgery); Director, Center for Genitourinary and Pelvic Reconstruction • Anthony Echo, MD: Assistant Professor in Plastic Surgery; Director, Clinical Research in Plastic Surgery • Warren A. Ellsworth IV, MD: Associate Professor of Clinical Plastic Surgery; Associate Professor of Surgery (Plastic & Reconstructive Surgery); Director, The Center for Breast Restoration; Chief, Division of Plastic & Reconstructive Surgery, Houston Methodist West Hospital • Michael J.A. Klebuc, MD: Associate Professor of Clinical Plastic Surgery; Associate Professor of Clinical Plastic Surgery (Plastic & Reconstructive Surgery); Associate Professor of Clinical Neurosurgery; Director, Center for Facial Paralysis Surgery and Functional Restoration • Aldona J. Spiegel, MD: Professor of Clinical Plastic Surgery; Director, Center for Breast Restoration; Chief, Division of Surgical Innovation

NATIONAL LEADERSHIP • Dr. Friedman: Board of Directors, American Board of Plastic Surgery • Dr. Collins: Board Member, CHRISTUS Foundation for Healthcare • Dr. Dinh: Vice President, Texas Society of Plastic Surgeons; Board Member, Vietnamese American Medical Association • Dr. Ellsworth: Board of Directors, ASPS; Secretary, Houston Society Plastic Surgeons • Dr. Klebuc: Vice President, American Society for Reconstructive Microsurgery; President, Tagliacozzi Surgical Society • Dr. Spiegel: President, Houston Society Plastic Surgery; Program Chair, American Society of Reconstructive Microsurgery; Co-Founder, Chair and International Meeting Organizer, Group for Advancement of Breast Reconstruction; Program Chair, Breast Reconstruction Subcommittee Chair, Annual Meeting Educational Program Committee, ASPS CLINICAL EXPERIENCE Houston Methodist has six independent residents (two per year) and provides broad training in all aspects of plastic surgery with a concentrated experience in reconstructive microsurgery, aesthetic surgery and craniofacial surgery. The training encompasses a variety of clinical settings and institutions, including private-practice settings; a county hospital; a Level I trauma center; community hospitals; Texas Children’s Hospital; and an academic medical center. Houston Methodist Hospital (Texas Medical Center) Ranked the best hospital in Texas and the 16th best in the United States by U.S. News, Houston Methodist Hospital provides high-quality complex care and is nationally ranked in 10 specialties. The 984-bed hospital has 85 O.R.s and is home to 45 ACGME- (and 14 non-ACGME) accredited training programs. Houston Methodist West Hospital (Katy, Texas) A 219-bed hospital located 20 miles west of the medical center, Houston Methodist West Hospital plastic surgery does a high volume of autologous and implant-based breast reconstruction, Mohs reconstruction and aesthetic surgery. Houston Methodist Willowbrook Hospital (Willowbrook, Texas) A large community hospital with 358 beds, Houston Methodist Willowbrook has a robust breast reconstruction and peripheral-nerve surgery experience for trainees. Memorial Hermann Hospital (Texas Medical Center) The largest Level I adult and pediatric trauma center in Texas, Memorial Hermann Hospital and Children’s Memorial Hermann Hospital – which is housed inside

Hermann Memorial Hospital – provide a high-volume experience in lower-extremity and facial reconstruction, as well as pediatric and craniofacial procedure experience. Texas Children’s Hospital (Texas Medical Center) A nationally ranked, freestanding 973-bed children’s hospital, Texas Children’s Hospital is the primary site for pediatric and craniofacial services. Lyndon B. Johnson (LBJ) Hospital A county hospital, LBJ provides experience in a wide range of plastic surgery procedures and gives residents an opportunity for independence in the clinic and the O.R. St. Joseph Medical Center Located in downtown Houston, St. Joseph Medical Center is the birthplace of our residency program. It continues to provide an excellent aesthetic surgery and general plastic surgery experience. EDUCATIONAL CURRICULUM • Journal Club: A monthly review of key current and past articles is run by residents, with faculty input. • Core Curriculum: Weekly resident presentations are held on key topics in plastic surgery and attended by faculty as well as residents. • Indications Conference: An oral board-style conference is led by a different faculty member each Wednesday morning and attended by both Methodist and Baylor Plastic Surgery residents. • Hand conference: A review of topics in hand surgery is held every Thursday morning, together with Baylor plastic surgery residents. • Facelift/Rhinoplasty course • Annual cadaver course: Usually held in March after the In-Service Exam, the course is led by faculty members and focuses on cosmetic rhinoplasty and facelift procedures. It includes patient assessment and developing a surgical plan, as well as hands-on experience. • MD Anderson conference: A weekly conference is held each Friday morning to discuss reconstructive plans after oncologic resections. • Microsurgery Lab: This is a one-week microsurgery training course for first-year residents, and it contains open times for residents to further hone their microsurgical skills throughout the year. • Resident Aesthetic Clinic: A weekly resident aesthetic/ injection clinic is offered, with hands-on experience using the different Botox and filler products available on the market. Participants also see and evaluate patients for different cosmetic and plastic surgery procedures, under the supervision of attending physicians.

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PROGRAM PEEK / continued from previous page

Faculty and residents of Houston Methodist Hospital's Plastic Surgery Program

RESEARCH, CONFERENCES AND COURSES Research: Faculty offer numerous research opportunities in which residents can participate, and the program has ample support for resident research ideas with two full-time research Fellows. Additionally, funding for research is available through the department and Houston Methodist Hospital. Synthes Maxillofacial Trauma: An annual course is offered by Memorial Hermann plastic surgery faculty for plastic surgery and oral surgery residents from all programs in the Houston area. Support for meetings: Full financial support is available for residents presenting their work at local or national meetings. Financial support is also provided for senior residents to attend the ASPS annual meeting and the ASPS Senior Residents Conference. Mock Oral Exams: Citywide mock oral exams are held each Spring for second- and third-year residents from the UT Houston, Baylor and Methodist programs. Dallas Rhinoplasty: Attendance at the Dallas Rhinoplasty and Facial Aesthetics course is funded in the second year. Courses: Funding and/or time is provided for subspecialty educational opportunities such as the AO Hand and Synthes Maxillofacial trauma courses. 18

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Mission Trips: Residents in their third year can participate in the international craniofacial surgery mission trip with Operation San Jose. RESIDENT BENEFITS • Cameras: The program provides a digital SLR camera to each incoming resident, each of whom has access to Mirror to store and categorize their clinical photographs. • Textbooks: The program provides a copy of Grabb and Smith’s Plastic Surgery to each incoming resident. • Personalized program fleece jacket: The program provides a personalized fleece to each resident as soon as they match into the program. • Subscription to Thieme’s MedOne Plastic Surgery: This provides residents online access to all Thieme-published textbooks and surgical videos. • Methodist benefits: As Methodist employees, residents have free access to employee wellness programs (including free counseling, gym and group classes, and access to reduced-cost massages and acupuncture). Residents receive 10 parental PTO days for the birth of a child; have access to discounted childcare; and have 401k benefits with an employer match. • Methodist employee bonuses: Residents automatically receive monetary bonuses for hand washing, holidays and other programs throughout the year. | Dr. Parikh is PGY-7 at Houston Methodist Hospital.

A Message From the Program Director, Pierre Chevray, MD, PhD

he Plastic Surgery Residency Program at Houston Methodist Hospital had its beginnings 75 years ago when Thomas Cronin, MD, and Raymond Brauer, MD, in 1954 began a training preceptorship based in their Houston private practice office. In these early days, they mostly worked with one young physician at a time who was interested in plastic surgery. This continued until 1970, when it was deemed that plastic surgery training must be lodged in a formal residency program affiliated with a hospital. St. Joseph Hospital in Houston was chosen as the home of the residency program that has continued for 51 years, albeit now headquartered at Houston Methodist Hospital. We like to think of our residency as a preceptorship, and we continue to maintain this spirit. We’re a close-knit program with relatively few core faculty who are experienced and long tenured; with little turnover; and with only two residents per year in a threeyear Independent program. We’re most proud that we are a stable program that gives residents a balanced experience in cosmetic and reconstructive plastic surgery in a collegial environment. In the three quarters of a century that our plastic surgery training program has been in continuous existence, there have been only four program directors. Dr. Cronin, one of the inventors of the breast implant in the early 1960s and the first director, presided from 1954-1970, when we became an accredited residency program – and he continued for another decade. Dr. Brauer took over from 1980-1985. Along the way, the then-twoyear program had grown to having two residents in each year. In 1985, Benjamin Cohen, MD, took over as program director for an astounding 30 years. He developed a microsurgical research and training laboratory with an attached Fellowship and oversaw the transition of the residency from St. Joseph Medical Center to Houston Methodist Hospital in 2006. In 2015, Pierre Chevray, MD, PhD, became program director and Donald

Collins, MD, became associate program director – positions they still hold. Houston Methodist Hospital – the top-ranked hospital in Texas – is where our residents obtain exposure to a broad range Pierre Chevray, MD, PhD of reconstructive and cosmetic cases, with internationally known faculty expertise in facial reanimation, gender affirmation and microsurgical breast reconstruction surgery. Experience in trauma reconstruction is obtained at the Memorial Hermann Hospital, a Level I trauma center, which is literally across the street from Houston Methodist Hospital in the Texas Medical Center. Concentrated experience in pediatric plastic surgery is obtained at the renowned Texas Children’s Hospital, also within the Texas Medical Center. A few miles to the north is Saint Joseph Medical Center, Houston, where our residents are immersed in cosmetic surgery but also care for general reconstructive surgery patients. Residents take charge, test their abilities and hone their skills at the Lyndon B. Johnson Hospital. Our residents are also exposed to private-practice cosmetic surgery throughout Houston from one of many affiliated faculty. Located on the Gulf Coast of Texas, Houston is the nation’s fourth-most populous city. It’s diverse, it has a wonderfully plentiful and varied restaurant scene, it’s situated within a subtropical climate which permits year-round outdoor activities and it’s known for housing NASA’s Mission Control at Johnson Space Center – and it boasts the world’s largest rodeo! | Dr. Chevray is Weill Cornell Medical College associate professor of plastic surgery; Baylor College of Medicine adjunct associate professor; and Methodist Plastic Surgery Residency Program director.

Plastic Surgery Resident | Winter 2021

Q&A WITH MICHAEL KLEBUC, MD By Jim Leonardo In this installment of Faculty Focus, we present ASPS member Michael Klebuc, MD, associate professor of Clinical Plastic Surgery at Houston Methodist Institute for Reconstructive Surgery, Weill Cornell Medical College. After finishing medical school at the University of Saskatchewan School of Medicine, Dr. Klebuc completed his general and plastic surgery residencies at Baylor College of Medicine, Houston, and a clinical Fellowship in pediatric microsurgery at The Hospital for Sick Children, Toronto, as well as a research Fellowship at Baylor. His focus is devoted to facial plastic surgery, reconstructive and aesthetic surgery, and microvascular surgery. Dr. Klebuc’s path easily could’ve been different – he interned with groundbreaking heart specialist Michael E. DeBakey, but many of plastic surgery’s inherent elements proved too strong to resist. Dr. Klebuc, the current American Society for Reconstructive Microsurgery vice president, found time away from his busy schedule to answer the following questions for PSR – and provide a useful perspective for plastic surgery residents wishing to expand their grasp of a few non-technical aspects of the specialty.

PSR: WHAT DREW YOU TO PLASTIC SURGERY? Dr. Klebuc: Initially, I wanted to be a cardiovascular surgeon. However, during a summer research project I came to see how the field was restricted to a rather limited number of procedures. As an undergrad, I pursued a degree in anatomy but also had an interest in art and sculpture – and, at one point, I even seriously considered a career in art history. In medical school, I had an opportunity to scrub with plastic surgeons – and I was totally hooked. The creative problemsolving, applied anatomy and aesthetic element were right up my alley. Although I wouldn’t recommend this, I skipped a lot of lectures to be in the O.R., and I definitely wouldn’t have had competitive grades without a classmate sharing her incredible notes – thanks, Leanne. Ultimately, I matched into one of the 20

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first combined plastic surgery programs at Baylor College of Medicine, and the rest is history. As fortune would have it, my early interest in CV surgery came in handy, as I was an intern with Michael E. DeBakey, MD, and associates, and the volume of open-heart surgery during the first three years of training was immense.

PSR: HOW CAN RESIDENTS PREPARE FOR A COMPETITIVE FELLOWSHIP? Dr. Klebuc: The best way is to demonstrate sustained interest. Find a faculty member who works in the subspecialty and scrub their cases as much as possible, and definitely pursue a research project in the field. Attend instructional courses and breakout sessions at national meetings, introduce yourself to the presenters and ask questions. Fellowships are a two-way street. Your mentor can provide clinical opportunity and share years of experience; however, you bring youthful energy, new perspectives and a comfort with evolving technologies.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER? Dr. Klebuc: You will obtain a special set of skills, learn subtleties that are hard to convey in publications and build relationships with like-minded individuals who can provide opportunities to showcase your work. I was incredibly fortunate to secure a facial paralysis Fellowship with Ron Zuker, MD, at the Hospital for Sick Children in Toronto. He’s been an incredible mentor and friend, and we’ve had the opportunity to travel to many countries, giving combined lectures on the treatment of the paralyzed face. I would encourage anyone who’s identified a special interest in an area of plastic surgery to pursue a Fellowship.

PSR: WHAT’S THE IMPACT OF A MENTOR ON THE EARLY YEARS OF PRACTICE? Dr. Klebuc: There’s really no substitute for experience, and during the first five years of practice, having senior associates or

a mentor is invaluable. The confidence you feel as chief resident tends to fizzle as you get into the driver’s seat and have the only set of hands on the wheel. Bouncing cases off someone who’s been there before is beneficial for you and your patients, and it makes the first years of practice more enjoyable. During the early years, you’ll cover multiple E.R.s and get consulted on some of the sickest patients in the hospital. These are some of the toughest cases you’ll tackle in your career, and a little seasoned advice goes a long way. Even as a senior surgeon, having trusted colleagues willing to share their experience is incredibly valuable. Also, I’d encourage young surgeons to form travel clubs. These types of organizations were once very popular, and I think they should make a resurgence. Essentially, 10-15 plastic surgeons with varied practices and interests have a yearly meeting at a site that has special significance to the organizing member. It’s a fantastic way to become exposed to emerging techniques and to share your victories and failures.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Klebuc: Joining the American Society for Reconstructive Microsurgery (ASRM) was one of the best things I’ve done in my career. It’s an incredible organization filled with talented, creative, hardworking people who are always willing to share their experience. ASRM has become my surgical home, and I’ve made many long-lasting friendships with surgeons from all over the world. I’m currently serving as the society’s vice president. I would encourage all residents with an interest in reconstructive surgery to apply for candidate membership. It’s a great organization, the meetings are top-notch and you’ll feel welcome. Participation in the ASRM young microsurgeons group is a great way to get involved, meet new colleagues and jumpstart your career.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Klebuc: When it comes to being a successful resident, you just can’t beat enthusiasm. If you’ve matched into a plastic surgery program, then by definition you’re bright, dexterous and hardworking. Residents who are truly excited about plastic surgery and come into the O.R. with energy and a sense of adventure really shine.

PSR: HOW DO YOU BALANCE YOUR TIME BETWEEN YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Klebuc: That’s a tough one. I tell my residents that factories close for routine maintenance to keep their machinery running smoothly. In the case of surgeons, we’re a human asset and shouldn’t feel guilty about taking time to maintain our health and wellbeing. Try to have a regular date night with your spouse or significant other. Find a family activity. My family loves skiing and we just took up golf. We

play horribly, but it’s fun to be together. Try to take special trips with each one of your children. When they’re alone with you, the dam will eventually break and you’ll be flooded with amazing insight. My two sons and I also try to make dinner every Sunday. It’s another wonderful opportunity to bond – and they’ve really become accomplished in the kitchen.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Klebuc: The ability to make transformational changes. It’s awe-inspiring.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU REGULARLY ENCOUNTER IN YOUR PRACTICE? Dr. Klebuc: Cumbersome electronic medical records, increased certification and licensure requirements, declining autonomy and decreasing reimbursement are real-world problems all plastic surgeons face. We need to meet the challenges with a combination of adaptability and political engagement.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Klebuc: I’m with the residents and medical students every day. It’s one of the best parts of my job. Their energy, excitement and challenging questions really help keep things fresh.

PSR: WHAT ADVICE DO YOU HAVE FOR PLASTIC SURGERY RESIDENTS? Dr. Klebuc: It’s great to have a diverse practice; however, I’d encourage everyone to find a special niche and explore it over the course of your careers. You’ll be surprised by the contributions you make. I have three other unrelated pieces of advice: Find a good attorney and to incorporate as a way of protecting your hard-earned money from frivolous lawsuits. For parents, as soon as your children are born, set up a low-fee college savings fund and be disciplined about your contributions, no matter how small. You’ll be astounded how it will grow with time and how quickly that little bundle of joy will be asking for the car keys. Finally, keep a “good-book.” Set aside all the cards, letters and well-wishes you receive during your career. During challenging times they can be a powerful inspiration.

PSR:HOW WOULD YOU COMPLETE THIS SENTENCE? “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN …” Dr. Klebuc: I saw a cleft lip repair. It was the closest thing to magic I had ever witnessed. | Plastic Surgery Resident | Winter 2021

Houston

By Rachel L. Goldstein, DO, & Jack Hua, MD, DDS

e’re excited to bring you on a tour of our proud city of Houston, a city that often surprises people by its status as the most ethnically and racially diverse city in the country. Houston boasts the fourth-largest population in the United States – and it’s a welcoming place for all. Located just off the Gulf Coast in a state notoriously rich with oil, the city was originally built on exportation and energy economies. Since then, the economy has widely diversified and Houston has become one of the fastest expanding cities in the country – with booming real estate, medical and tech opportunities. Notably, Houston is home to the Texas Medical Center, the world’s largest concentration of healthcare and research institutions, and it contains the second-most Fortune 500 headquarters of any U.S. municipality within its city limits (after New York). Houston is recognized worldwide for its oil and natural gas industry, as well as being the home of NASA. 22

Plastic Surgery Resident | Winter 2021

Houston is regarded as a cosmopolitan destination, filled with world-class dining, arts, hotels, shopping and nightlife. Considering its endless job opportunities and low cost of living, it’s no surprise that Houston draws an increasing number of transplants. With so much to see and experience in a visit, you may be enticed to stay longer than you planned.

MORNING: LOCAL ADVENTURE AWAITS

Chances are that it will be a beautiful, sunny, warm day in Houston, so start your morning enjoying Houston’s natural beauty with outdoor activities. Houston is surprisingly green, with the most total area of parks of the 10 most-populous cities in the nation. Jog through Memorial Park around its three-mile loop or through the arboretum. From there, bike along the water through the two-plus-mile stretch of Buffalo Bayou Park and check out the bat colony. Then find yourself in Hermann Park, where beneath the skyline of the Texas Medical

Center you can paddle boat with ducks, play a round of golf or explore the renowned and expansive Houston Zoo – the second-most visited zoo in the country. You’re now in the Museum District, where you can visit any of the 19 museums, galleries and community spaces – including The Museum of Fine Arts and the Houston Museum of Natural Science, which boasts the largest paleontology hall in the United States. If you prefer to relax and catch some rays, head to the pool at the Marriott Marquis downtown and take selfies while floating along their giant, Texasshaped lazy river. Or make an hour’s drive and hit the beach in Galveston, with its 32 miles of sand along the Gulf shore.

THE FOODIE SCENE

The most important thing to do on a trip to Houston is eat, so pack a larger-sized pair of pants. Houston’s rapidly growing culinary prowess is widely recognized, with several major publications naming

the city “one of America’s best food cities” and “the most exciting food city,” just to cite a few. Houston’s highly diverse population is represented by cuisines from over 70 countries and American regions in more than 10,000 restaurants. Local James Beard Award recipient and finalist celebrity chefs Justin Yu, Chris Shepherd and Hugo Ortega continue to flex their ingenuity with new and longstanding venues across all price points. Texas is most famous for Tex Mex, BBQ and steak. Try fajitas and tacos at The Original Ninfa’s and Pico’s Restaurant. Chow down on BBQ brisket and splurge on the wagyu beef rib at The Pit Room. For an upscale steakhouse experience, savor the dry-aged beef at Doris Metropolitan or B&B Butchers. Not a carnivore? Explore a wide variety of cuisines at top joints like MF Sushi, MAD, or Bludorn, authentic Vietnamese and pan Asian food in Chinatown, or Snoop Dogg’s favorite, Turkey Leg Hut (which is self-explanatory). If your group just can’t agree on dinner, head to a food hall such as The Post Office. These halls spice-up the city with their own unique flair and high-quality, diverse, delicious cuisine in a modern street-food atmosphere. Some also

serve as event space for art markets and live performances. When you’re ready to wash it all down, look no further than Houston’s growing brewery scene. In fact, so many breweries have been perfecting New England Style IPAs that the city has earned the nickname “Juiceton.” About 65 breweries serve greater Houston with a wide array of beer styles and taproom experiences. Some notables include Buffalo Bayou, Heights beer garden, Kirby Ice House, 8th Wonder, St. Arnold and Spindletap.

AFTERNOON: UNIQUE ATTRACTIONS

Livestock Show and Rodeo, held over 20 days from early to late March, and the largest annual livestock show and rodeo in the world. The rodeo usually opens with a large BBQ cookout hosted by local and Fortune 500 companies, while the show features championship rodeo action, livestock competitions, carnival, pig racing, Rodeo Uncorked!, an international wine competition, shopping, sales and livestock auctions. The rodeo has drawn some of the world’s biggest recording artists such as Cardi B, Ariana Grande, Usher, Lizzo, Bruno Mars, Maroon 5, Blake Shelton, Garth Brooks and Luke Bryan.

Let your inner rocket scientist take flight as you spend the afternoon exploring the Space Center Houston, the official science museum of NASA Johnson Space Center. The Johnson Space Center is the home of Mission Control and NASA’s official astronaut training program. Learn more than you can imagine at these larger-than-life exhibits and check out the museum’s 400 space artifacts, climb into the world’s only interactive Space Shuttle replica, examine three flown spacecrafts and gaze at actual moon rocks.

Sports fans can enjoy competition by every major professional league except hockey. The Houston Texans play their home NFL games at the NRG stadium (tailgating is a whole production of its own and the games are a riot). The Houston Astros carried the city to a World Series title in 2017 and postseason appearances in 2005, 2019 and 2021, while the Houston Rockets have been home for NBA all-stars such as James Harden, Yao Ming, Hakeem Olajuwon and Tracy McGrady.

If you’re here in March, check out the Houston Rodeo – the annual Houston

There’s something for everyone after sunset in this culturally rich and funloving city with its active visual and performing arts scene in the Theater District. It’s one of the few U.S. cities with permanent, professional, resident companies in all major performing arts disciplines: opera, ballet, symphony and theater. Those with less spending cash can picnic on the lawn in Hermann Park, or enjoy various cinema art festivals, concerts and shows for free at the Miller Outdoor Theater, an enormous amphitheater.

NIGHTLIFE

Larry Goodwin

Houston has a great bar scene as well with a variety of unique flavors. Challenge your friends to classic and contemporary arcades games at Cidercade Houston, a large modern warehouse with 275-plus free arcade games. If you’re more of a cowboy at Houston Rodeo

continued on page 32 Plastic Surgery Resident | Winter 2021

Journal Club; 2021 Winter; (25)

1. Big Data and Machine Learning in Plastic Surgery: A New Frontier in Surgical Innovation

Kanevsky J, Corban J, Gaster R, Kanevsky A, Lin S, Gilardino M. Plast Reconstr Surg. 2016 May; 137(5):890e-897e. A thorough review of machine learning and how it’s applied to subspecialties including burns, craniofacial, aesthetics microsurgery and hand. A deep dive into what’s been impacted in the field and what the future holds for ML, and one that all plastic surgery residents should read to understand ML and AI, and how they impact our field.

2. Artificial Intelligence in Plastic Surgery: What is it? Where Are We Now? What is on the Horizon?

Murphy DC, Saleh DC. Ann R Coll Surg England. 2020 October; 102(8):577-580.

JOURNAL ARTICLES ON

A RT I F I CIAL I NT EL L I G EN CE A N D M ACH I N E LEARNING

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Ravi Viradia, MD; Robert Kimmel, MD & Jason Rehm, MD

rtificial intelligence and machine learning continue to impact medicine and influence plastic surgery. It’s reshaping the specialty, as multiple areas have already begun to incorporate this novel technology. This surge in surgical innovation has illuminated many examples of machine learning in platforms that help patients and clinicians. The following articles will help broaden plastic surgery residents’ understanding of machine learning and artificial intelligence (AI); how they impact the field of plastic surgery; how residents can foster ideas and develop their own innovations in AI and machine learning (ML); and how we can use to this technology to improve patient care and our processes as plastic surgeons. 24

Plastic Surgery Resident | Winter 2021

Plastic surgery is an innovative surgical specialty that’s fully expected to integrate AI to further the specialty. This article discusses potential limitations as well as ethical considerations involving AI in practice, and the concept of bias in AI that will keep plastic surgeons alongside AI rather than replace them.

3. A Practical Approach to Artificial Intelligence in Plastic Surgery

Chandawarkar A, Chartier C, Kanevsky J, Cress PE. Aesthet Surg J Open Forum. 2020 January; 8:2(1). An interesting discussion on the limitations and applications of AI in plastic surgery. Worthy of a review from the standpoint of how AI will shape our field; some of the subsets of AI in healthcare; the problems of AI; and high-quality data collection in AI plastic surgery.

4. Photographic and Video Deepfakes Have Arrived: How Machine Learning May Influence Plastic Surgery

Crystal DT, Cuccolo NG, Ibrahim A, Furnas H, Lin S. Plast Reconstr Surg. 2020 April; 145(4):1079-1086. To quantify success and improve outcomes, plastic surgery requires the accurate documentation of results using photography and video. The expert use of editing software can sometimes call into question the accuracy of surgical results. More recently, technology has allowed the creation of novel computer-generated images and videos, also known as “deep fakes.” While technology may be useful in some teaching settings, care must be taken that it’s not used inappropriately. AI can detect deepfakes and manipulated images so that their nefarious use might be prevented.

5. Facelift Surgery Turns Back the Clock: Artificial Intelligence and Patient Satisfaction Quantitate Value of Procedure Type and Specific Techniques

Gibstein AR, Chen K, Nakfoor B, Lu SM, Cheng R, Thorne CH, Bradley JP. Aesthet Surg J. 2021 September; 41(9):987-999. An interesting take on neural-network AI algorithms to predict and estimate the reduction in age following a facelift. Different facelift techniques and additives like fat grafting were also evaluated using a neural network. This study was a good example of how implementing AI in aesthetic surgery can predict outcomes for procedures such as facelifts.

6. The Auto-eFACE: Machine LearningEnhanced Program Yields Automated Facial Palsy Assessment Tool

Miller M, Hadlock T, Fortier E, Guarin D. Plast Reconstr Surg. 2021 February; 147(2):467-474. Compared to clinical grading, the automated Auto-eFACE system predicts more facial landmark asymmetry in normal patients and less in patients with severe synkinesis and complete flaccid paralysis. This article addresses the use of ML and AI, and how both can augment clinician observation bias and be another assessment tool for standardization of facial palsy outcome measures.

7. Applied Deep Learning in Plastic Surgery: Classifying Rhinoplasty with a Mobile App Borsting E, DeSimone R, Ascha Mu, Ascha, Mo. J Craniofac Surg. 2020 February; 31(1):102-106.

Deep learning has been instrumental in natural language processing, computer system data and moving forward in healthcare. This article describes the use of a mobile app based on a deep learning algorithm that predicts rhinoplasty status and detects accuracy from surgeon performance. RhinoNet was established to detect before-and-after rhinoplasty status and detects superficial changes with the same accuracy as compared to surgeons.

8. Role of Simulation and Artificial Intelligence in Plastic Surgery Training Turner, AE., Abu-Ghname, A., Davis, MJ., Kausar, A., Winocour, S. Plast Reconstr Surg. 2020 September; 146(3):390e-391e.

A great literature review on how ML and AI can impact plastic surgery training. One example addresses digital simulation with the use of ML, which allowed Plana et al., to demonstrate improvement in performance of cleft repair surgery versus textbook learning in trainees. By using ML in plastic surgery, we can analyze large amounts of data and learn to recognize patterns and predict outcomes better to help plastic surgery trainees increase surgical accuracy and reduce errors.

9. Artificial Intelligence in Plastic Surgery: Current Applications, Future Directions, and Ethical Implications

Jarvis T, Thornburg D, Rebecca AM, Teven CM. Plast Reconstr Surg Glob Open. 2020 October; 8(10):3200e. A systematic review of electronic publications in PubMed, Scopus and Web of Science databases reviewing AI in plastic surgery, highlighting important applications of AI in a variety of plastic surgery settings and describing their various applicability to plastics. ML, deep learning, natural language processing, facial recognition and data processing are described in the article and help influence careers in plastic surgery.

10. The Use of Emotional Artificial Intelligence in Plastic Surgery Levites HA, Thomas AB, Levites JB, Zenn MR. Plast Reconstr Surg. 2019 August; 144(2):499-504.

The authors use AI to evaluate the emotional reaction to certain hashtagged words like nose job, tummy tuck and plastic surgery, allowing researchers the ability to quantify the emotion engagement and awareness of the terms. They propose that the application of AI in this fashion will allow for the collection and use of this data to assess a person’s interest in certain products or procedures, as well as the demographics of those who access a certain practice’s social media platforms.

ADDITIONAL READING Art, Artificial Intelligence, and Aesthetics in Plastic Surgery

Wheeler DR. Plast Reconstr Surg. 2021 September; 148(3):529e-530e. Plastic surgery and artistry are consistently blended. AI may be helpful in consistently judging facial beauty, use patient-specific markers to help design operations or generate realistic photos to help predict the goals of an operative intervention.

Artificial Intelligence Is Still Far from Truly Revolutionizing Plastic Surgery

Liu J. Plast Reconstr Surg. 2020 September; 146(3):390e. The authors note that AI has and will be useful in many sectors of industry. However, its use in medicine – particularly plastic surgery – will only be useful when how and why AI decisions are made are defined and understood clearly, and its use has the ability to improve patient care.

What is Your Reality? Virtual, Augmented, and Mixed Reality in Plastic Surgery Training, Education, and Practice

Lee GK, Moshrefi S, Fuertes V, Veeravagu L, Nazerali R, Lin S. Plast Reconstr Surg. 2021 February; 147(2):505-511. A compelling article on the differences in virtual, augmented and mixed realit with an explanation of how to the use of various companies’ headsets (Microsoft, Google and others) can assist in plastic surgery education for residents and Fellows.

Application of Artificial Intelligence for Real-Time Facial Asymmetry Analysis Ogawa K, Tomioka Y, Okazaki M. Plast Reconstr Surg. 2020 August; 146(2):243e-245e.

The application of real-time video to assess facial asymmetry with AI has a promising future on postoperative facial rehabilitation and the tracking of progress after facial reanimation surgery. This article addresses this experience and the future that real-time facial analysis tracking will have over time on facial-animation surgical outcomes. | Dr. Viradia is PGY-8, Dr. Kimmel is PGY-6, and Dr. Rehm is vice-chair of plastic surgery at University of Tennessee Health Science Center, Chattanooga, Tenn. Plastic Surgery Resident | Winter 2021

WHAT I KNOW NOW

That I WISH I KNEW then Jason Ko, MD Residency Program Director Northwestern University Interviewed by Megan Fracol, MD Jason Ko, MD, earned his medical degree at Duke University School of Medicine, Durham, N.C.; completed his plastic surgery residency at McGaw Medical Center of Northwestern University, Chicago; and followed that with a Fellowship in hand and microvascular surgery at the University of Washington, Seattle. An associate professor of Surgery and Orthopaedic Surgery at Feinberg School of Medicine at Northwestern, Dr. Ko also serves as director of Northwestern’s Residency Program and specializes in peripheral nerve and extremity reconstruction. In this interview, Dr. Ko lends advice on what it takes to “make it” in academic medicine – and what he learned in training along the way.

PSR: WHAT’S THE BEST THING ABOUT BEING A PROGRAM DIRECTOR? Dr. Ko: Early into my plastic surgery career, I thought about the most influential ways to potentially impact our specialty. Although I like to think I do really cool, complex surgeries and I enjoy research – some of which has been very innovative – I’ve always thought that I could best contribute to our specialty by helping train future generations of plastic surgeons. Because if I do a good job teaching residents to be safe and good surgeons – and they push boundaries and advance our field – those residents can then train the next generation of surgeons. One thing I’m passionate about is education, and as program director I’m given the privilege of shaping the teaching and training of Northwestern’s plastic surgery residents – which I find more fulfilling than research or surgery alone. But I also really enjoy super-cool, complex reconstructive cases.

PSR: WHAT’S THE TOUGHEST PART ABOUT BEING A PROGRAM DIRECTOR? Dr. Ko: As the liaison between residents and faculty, a program director is pulled in many directions and therefore must navigate sometimes-competing interests while also advocating for the residents, their well-being and their education. Program director is definitely a demanding job – you serve as advocate, teacher, parental figure, colleague and therapist all at once. It’s difficult to always maintain a good balance between those varied roles while making sure the program itself still moves in the right direction.

PSR: WHAT’S THE HARDEST YEAR OF TRAINING? Dr. Ko: At Northwestern, the hardest year of training traditionally is the fifth (the year after our dedicated research 26

Plastic Surgery Resident | Winter 2021

year). The residents have been away from clinical medicine for a year – then they’re thrust into the position of being senior residents. At Northwestern, fifth-year residents on the main plastic surgery rotation tend to “run the service,” where they’re placed in a leadership role that’s overseen by more senior residents. The amount of responsibility as a fifth-year resident coming out of the research year is exponential, in terms of expectations for knowledge and performance, compared to prior years.

PSR: WHAT QUALITIES MAKE A GOOD INTERN; JUNIOR RESIDENT; AND SENIOR RESIDENT? Dr. Ko: Successful interns are hard-working team players who often put the needs and priorities of the team ahead of their own. It’s important as an intern to follow through with tasks while also being good at navigating interpersonal interactions throughout the hospital system with non-plastic surgery services. Like interns, junior residents have the benefit of not being expected to know everything – so successful junior residents read incessantly, prepare for cases and try to understand why we do what we do, while also getting their reps in the O.R. The best senior residents are those who take ownership of the team, the patients and the service, and approach their workday as if they’re the attending surgeon. Talking to patients and colleagues on a higher level requires a higher level of knowledge, preparation, surgical skill and ability.

PSR: IF YOU HAD TO REPEAT RESIDENCY KNOWING WHAT YOU KNOW NOW, WOULD YOU DO IT DIFFERENTLY? Dr. Ko: I was a late bloomer in residency, in that during my junior years I wasn’t as dedicated toward reading about and preparing for cases, and trying to get involved with research, as I should have been. I would’ve pursued research earlier and approached plastic surgery cases with better preparation and seriousness.

PSR: WHAT’S YOUR ADVICE FOR RESIDENTS INTERESTED IN GOING INTO ACADEMIC MEDICINE? Dr. Ko: Academic medicine is very rewarding, but also very demanding. There’s much more involved with academic plastic surgery than just doing surgery and seeing patients. It’s important for residents considering future career paths

to take a step back and be honest with themselves about what’s important to them. There are pros and cons to all the practice types within plastic surgery. I find academic medicine most rewarding for reasons I mentioned previously about my passion for education. Also, in most academic centers, you’re able to handle the most complex types of patients, which I find exciting. However, I think you need the “love” for academic plastic surgery. My father was a private-practice urologist in a small town in Ohio, and he always told me that private-practice surgery is the hardest model within surgery. Knowing what I know now, I would strongly disagree. Academic medicine is much more demanding in different ways, although I appreciate that private practice is very stressful and demanding in its own ways.

PSR: WHAT’S YOUR ADVICE FOR RESIDENTS ABOUT TO GRADUATE? Dr. Ko: Everyone talks about the “3 A’s” – be available, affable and able. As cliché as that is, it’s very good advice for anyone trying to build a practice. Especially during board collection period, it’s important to try to be safe, at least initially. Once you build good relationships with referring physicians, then you can try to be a little more creative with some of the techniques that you’re performing. Most importantly, remember to take care of yourself and your family – and remember that there’s much more to life than work.

PSR: HOW DID YOU MAKE THE MOST OF YOUR FELLOWSHIP YEAR – AND WHAT’S YOUR ADVICE FOR THOSE CURRENTLY IN THEIR FELLOWSHIP? Dr. Ko: I did a combined orthopedic/hand and microvascular surgery Fellowship at the University of Washington, Seattle. I made the most of my Fellowship by completely diving headfirst into learning as much as I could about hand and wrist surgery, and really focusing on making the most out of that one capstone year of training before going out into practice. Seattle was also a great place to live for one year; my wife and I were newlyweds and we definitely had an enjoyable time in the Pacific Northwest. My advice would be: View your Fellowship as a one-year adventure. Geographic location may not be the most important thing as long as you learn the type of stuff you really want to learn, because it’s your last year to not be 100 percent responsible for the surgeries you perform.

continued on page 32 Plastic Surgery Resident | Winter 2021

PLASTIC SURGERY RESIDENCY IN ITALY

THE NUMBERS – AND THE PEOPLE BEHIND THE SYSTEM

By Monica Zena, MD

he path to becoming a plastic surgeon in Italy is long and challenging – as is the case in most, if not all, countries. After graduating from medical school – which is a numerous clausus (closed number) course that lasts six years – students acquire the title of medical doctor. To be subsequently accepted at a residency program, they must pass the entrance examination held annually on the same day throughout the country. The exam comprises a score for the candidate’s qualifications (graduation mark and publications: maximum 7 out of 147 points), and a score obtained in a national multiple-choice test (140 questions, maximum 140 out of 147 points). A ranking is drawn upon the basis of the final score and, according to the position in their ranking, the candidates choose their desired program among the available slots. The number of slots available for every program is fixed annually by a Ministry of University and Research decree, taking into account the predicted national requirement. The competition for plastic surgery is insane; every year, plastic surgery resides in the top three of the most-desired specializations, but the slots are limited. For example, in 2021 there were 88 slots out of 13,400 overall.1 Plastic surgery residency lasts five years and there are currently 20 accredited schools in the country. The number of residents per year per school ranges from one to 12, depending on the size of the university and of the

Plastic Surgery Resident | Winter 2021

hospitals attached. The core-curriculum is not standardized and the regulations of the various schools differ between universities, but they’re substantially in line with European Union standards.2 At the school of plastic surgery, the trainee surgeons cover a program of formal lessons, ward-based activities, outpatient clinics and progressively difficult operations. Practical training is carried out on a rotation basis in the various general surgical units attached to the school. Moreover, the residents have the opportunity to spend up to 18 months in departments outside the training network, either in Italy or abroad, which is a huge chance to deepen the knowledge in specific fields that might be neglected during the program and that can be hard to explore, due to the lack of Fellowship opportunities in Italy and in Europe.3 Finally, the Italian Society of Reconstructive and Plastic Surgery (SICPRE) has a specific section dedicated to trainees and provides scholarships, books, webinars, articles and some free registration to courses and meetings. Residents are evaluated every year through a theoretical and practical exam. At the end of five years, they acquire the title of specialist with a dissertation. This diploma can be complemented by a certificate of special interest in a plastic surgery subspecialty (breast, head and neck, etc.) that describes the resident’s expertise and skills in the field.

This is briefly how the system works. Still, there remains room for improvement. Every year, all residents are required to complete a mandatory and anonymous survey about the education they’re receiving. This tool is useful to monitor the quality of the programs and to verify that every school meets the required standards. The results are published on the Ministry of University and Research website.4 The following is a brief overview regarding plastic surgery outcomes:

•

them. Tele-education during the pandemic emergency was activated for 63 percent of them, and 52 percent argued that this modality should be continued in subsequent ordinary situations

REFERENCES

Rotations in the training network were arranged in 52 percent of the cases and were considered appropriate by 29 percent of the residents

•

The overall satisfaction for practical activities (number and assortment of surgical cases, autonomy achieved) was assessed 6.7 out of 10 69.4 percent of the respondents participated in research activities, and the overall satisfaction of their involvement was 7 out of 10

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Overall satisfaction about the program was judged 6 out of 10

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The level of education that residents thought they had achieved according to their goals was assessed 6 out of 10

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93 percent of the respondents claimed that plastic surgery was the career they wanted to pursue; 44 percent would enroll in the same program, whereas 42 percent would again choose plastic surgery but at a different school

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90 percent of residents declared that annual leaves and holidays are planned and respected, but 48 percent are asked to work beyond the scheduled hours

Pursuing a residency in plastic surgery is challenging in Italy, as in most of countries, but it’s worth it. Unfortunately, in the current selection process very little importance is given to the background of the candidate. Residency programs are in general valid, and the trainees can make up for possible deficiencies by spending months during residency in other hospitals in Italy – or even abroad. |

•

Formal educational activities were provided to 71 percent of the respondents but were judged satisfactory only by 21 percent of

MUR, Decreto Direttoriale n. 1205 del 21-05-2021, accessed Nov. 30, 2021. Cola B, Surgical Training in Italy – Bulletin of The Royal College of Surgeons of England Ann R Coll Surg Engl (Suppl) 2007;89:348–350. Papas A, Montemurro P, Hedén P. Aesthetic Training for Plastic Surgeons: Are Residents Getting Enough? Aesthet Plast Surg. 2018;42:327–330. MUR, Scuole di Specializzazione di Area Sanitaria: Ecco i Risultati Della Valutazione dei Medici. https://www. mur.gov.it/it/news/martedi-20072021/ scuole-di-specializzazione-di-areasanitaria-ecco-i-risultati-della, accessed Nov. 30, 2021.

Dr. Zena is PGY-4 equivalent at the University of Genoa’s San Martino Hospital, Italy.

Plastic Surgery Resident | Winter 2021

MOUNT SINAI RECLAIMS RESIDENTS BOWL TITLE WITH WIN OVER UNIVERSITY OF MICHIGAN

Mount Sinai Residency Program Director Peter Taub, MD (left), with Residents Bowl victors Jared Gopman, MD; Paymon Sanati-Mehrizy, MD; Yasmina Zoghbi, MD; and Stefani Fontana, MD.

s Plastic Surgery The Meeting returned to an inperson format, Mount Sinai returned to its former glory as ASPS Residents Bowl champions. Moderated for the second consective year by Edward Davidson, MD, and Raj Sawh-Martinez, MD, the Residents Bowl provided a familiar and fun energy of competition among ASPS’s youngest members. Having won the 2019 Residents Bowl in San Diego, Mount Sinai entered the 2020 Residents Bowl as favorites – only 30

Plastic Surgery Resident | Winter 2021

to lose to the University of Pittsburgh in the quarterfinals. This year, Mount Sinai returned with heightened energy, passion and determination to bring the trophy back to New York. The team was composed of previous participants Paymon Sanati-Mehrizy, MD; Jared Gopman, MD; Yasmina Zoghbi, MD; and new team member Stefani Fontana, MD, PhD. Team selection was guided by In-Service Exam scores and plastic surgery areas of individual interest. Traditionally, physical buzzer systems were used to determine the fastest

respondent, a system that often was criticized by residents as inexact. Last year, as the Residents Bowl transitioned to a virtual platform, the Kahoot! App was used. Similarly, this year’s in-person contest was also conducted on Kahoot! Rather than each team providing one answer, each team member’s answer – based on accuracy and speed – was averaged to calculate the team’s final score. Over the first four rounds, Mount Sinai confidently defeated Northwestern University, Cooper University, Stony

Brook and local favorite Emory University. Competition came to a head in the final round against the University of Michigan in a final test of 15 multiple choice questions. Team members from Mount Sinai and the University of Michigan were supported by, respectively, coaches Peter Taub, MD, and Steven Buchman, MD – who both sat anxiously in the front row and cheered-on their residents. While the University of Michigan jumped to an early lead, Mount Sinai pulled ahead by Question 5. The lead was cemented after Question 6 – a query on upperextremity trauma – when all four Mount Sinai participants selected the right answer and, conversely, all four Michigan residents missed. However, Michigan, unwilling to be defeated that easily, nearly tied the match on Question 7. The competition remained neck-andneck, but the Mount Sinai team remained calm and continued to answer the questions with accuracy and speed, clenching the victory. The final score was Mount Sinai 12,080, Michigan 10,675. Mount Sinai’s Residents Bowl championships place them in an elite group with UT Southwestern and Ohio State. Two of Mount Sinai’s members will graduate this year, so the team has begun preparing its participants in the 2022 Residents Bowl in Boston – where they’ll make an attempt at an unprecedented third-overall victory. This recap was written by Icahn School of Medicine at Mount Sinai residents Paymon Sanati-Mehrizy, MD (PGY-6); Jared Gopman, MD (PGY-6); Yasmina Zoghbi, MD (PGY-5); and Stefani Fontana MD, PhD (PGY-5). |

A Moderator’s Viewpoint

RESIDENTS BOWL 2021 – A HYBRID OF VICTORY AND DEFEAT By Edward Davidson, MD

mong the many exciting aspects of a return to an in-person meeting was the return to a live-action Residents Bowl – even if some of the teams weren't in Atlanta. Contestants from coast to coast – as well as from Italy, India, Argentina and Kenya – competed for the chance to lift the trophy that glistened in the candescent Exhibit Hall light. A hybrid format, itself a feat of AV engineering, allowed for teams (and the audience) to play in every possible permutation of inperson and virtual participation. Reigning champion University of Pittsburgh was dethroned by debutants Stony Brook in a virtual first-round encounter, with the newcomers-turned-giant-killers then proceeding to eliminate Harvard before succumbing to the eventual winners, Mount Sinai. The highest individual score was achieved by Ciara Brown, MD, of Emory in the semi-final round – but this wasn’t enough to stop the climb of Mount Sinai to the summit of victory. In the other semifinal, the match between rivals Ohio State and Michigan was as ferocious on stage as it was animated from faculty in the audience, with Michigan ultimately reaching the final. Congratulations to the Mount Sinai team of Jared Gopman, MD; Paymon Sanati-Mehrizy, MD; Yasmina Zoghbi, MD; and Stefani Fontana. Champions again – and for the second time in three years. Thanks go to members of the YPS Steering Committee for reviewing questions and moderating; to supporters Allergan Aesthetics, Mentor, 3M, The Plastic Surgery Center and MTF; and to the ASPS team of Yassie Dunn, Angie Oswald and Molly Dziedzic. Let the tailgating for Boston 2022 begin! Next year will be epic! | Dr. Davidson, director of Craniomaxillofacial Surgery in Case Western Reserve University’s Department of Plastic Surgery, served as a Residents Bowl moderator. Plastic Surgery Resident | Winter 2021

CONSULT CORNER / continued from page 11

24 HOURS / continued from page 23

In this case, the most appropriate treatment would include emergent return to the O.R. to identify and treat the cause of the hematoma. This will include control of bleeding around the flap and interrogating the anastomosis for a flap-related circulation issue.

heart, check out Neon Boots Dancehall and Saloon, an award-winning C&W bar-themed dance hall with more than 11,000 square feet of dance floor. If bar hopping is your kind of night, West Washington Avenue is the place to go – located in the Greater Heights, it hosts arguably some of the best bars in town.

WHAT TO DO, IN A NUTSHELL

If Las Vegas-style pool parties are your jam, Cle is the place to be. The venue is spacious and fashionable, with daytime pool parties and an evening nightclub space that often hosts famous international DJs and music artists. For a classy way to end the night, check out Bisou in the River Oaks District. It’s an upscale, contemporary bar lounge that always promises a great time and fabulous cocktails. They also serve an excellent brunch for the morning after, curated by master chef of France Frederic Perrier.

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Evaluate the patient. Flap changes can be surgical emergencies.

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Make a diagnosis. Identify the flap as appearing normal or having venous congestion, arterial compromise, hematoma, or something else.

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If you have uncertainty, ask someone with more experience. Talk to a senior resident, fellow, or the attending surgeon.

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Make a treatment plan. Quick return to the operating room is almost always the treatment for flap-related changes. The room should be ready for microsurgery and flap salvage, including in the event of a hematoma. |

Dr. Perez-Alvarez is PGY-1, and Dr. Kurlander is an assistant professor of surgery in the Division of Plastic Surgery, Rush University Medical Center, Chicago. REFERENCES 1.

2. 3.

6. 7.

Largo RD, Selber JC, Garvey PB, et al. Outcome analysis of free flap salvage in outpatients presenting with microvascular compromise. Plast Reconstr Surg. 2018;141(1):20e-27e. Chao AH, Lamp S. Current approaches to free flap monitoring. Plast Surg Nurs Off J Am Soc Plast Reconstr Surg Nurses. 2014;34(2):52-56; quiz 57-58. Paydar KZ, Hansen SL, Chang DS, Hoffman WY, Leon P. Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate. Plast Reconstr Surg. 2010;125(4):1129-34. Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996;98(7):1230-33. Chen KT, Mardini S, Chuang DCC, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120(1):187-95. Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg. 2009;124(6 Suppl):e295-e302. Quintero JI, Cárdenas LL, Achury AC, Vega-Hoyos D, Bermúdez J, FSFB Hand and Microsurgery Research Group. Negative Pressure Wound Therapy as a Salvage Procedure in Venous Congestion of Microsurgical Procedures. Plast Reconstr Surg Glob Open. 2021;9(8):e3725. Chu CK, Fang L, Kaplan J, Liu J, Hanasono MM, Yu P. The chicken or the egg? Relationship between venous congestion and hematoma in free flaps. J Plast Reconstr Aesthetic Surg JPRAS. 2020;73(8):1442-47.

We hope you’ve enjoyed your 24 hours in Houston. Surely, you realize that it’s just not enough time to experience all the wonderful things our great, big city has to offer. So we hope you’ll come back soon! | Dr. Goldstein is PGY-7 and Dr. Hua is PGY-6 at Houston Methodist Hospital.

WHAT I KNOW NOW / continued from page 27 PSR: HOW DO YOU BECOME A GOOD TEACHER IN THE O.R.? Dr. Ko: I believe in “graduated autonomy.” I had the benefit of excellent teaching mentors throughout my training and even in practice. Like most things in life, the best way to learn is doing – so I always let the residents operate as much as possible, with the appropriate level of oversight.

PSR: WHAT’S YOUR FAVORITE CASE TO DO – AND WHY? Dr. Ko: I love microsurgery. My passion has always been extremity reconstruction, which is why I went into plastic surgery instead of orthopedic surgery. I don’t have a specific favorite case, but I love super-complex extremity reconstruction. If you can throw in vascularized bone and maybe some nerve reconstruction, I’ll be a happy surgeon. | Dr. Fracol is a chief resident at Northwestern University and ASPS Residents Council chair.

Plastic Surgery Resident | Winter 2021

ANSWERING THE CALL TO HELP ALL RESIDENTS

hope this message finds you all healthy and well this holiday season – and as the incoming Residents Council (RC) chair, I want to take this opportunity to acknowledge the contributions of the outgoing RC and provide an update on our focus for the coming year.

By Megan Fracol, MD Resident Representative ASPS Board of Directors

Last year, the RC accomplished many things – from expanding its outreach to include an international presence, to following through with ongoing projects such as the Professional Resource Opportunities in Plastic and Reconstructive Surgery Education and Leadership (PROPEL) mentorship program that creates mentorship groups of four (junior/senior residents paired with junior/senior faculty), and expanding the Roadmap to Success website. All was accomplished in the face of COVID-19 via a virtual presence and drive to push forward. The RC also worked hard to address the challenges posed to a large number of residents when two programs closed last year. As a result of these unforeseen closures, 22 active residents and three prospective trainees who had matched found themselves suddenly displaced. The RC stepped up, listened to their concerns, helped identify problems and solutions, and most importantly, assisted many with finding new positions. We heard from many residents how the disruption caused by these closures affected them and highlighted the vulnerable position in which residents can find themselves. Perhaps stimulated by the challenges posed

by these program closures, we had one of the largest turnouts ever for our annual ASPS RC meeting this October in Atlanta. There, the RC led a thought-provoking, brainstorming session that yielded a number of constructive ideas to improve the process should any programs close in the future. Moreover, it underscored that residents as a group have a strong desire to support one another – and collectively the creativity, drive and influence to have a positive impact. In light of the importance of this issue to residents, our immediate focus as a council is on following through on the ideas recently proposed to improve the ACGME program review process. We’ll also continue working on ongoing projects: encouraging greater participation in PROPEL, updating the Roadmap website with a section geared toward general surgery residents interested in plastic surgery and planning for our annual Medical Students Day. We’re also hoping to develop projects looking into factors that affect resident wellness and ways the RC can contribute to that wellness. I want to emphasize that we’re open to new ideas and happy to onboard residents or Fellows interested in getting involved in any ongoing project – please don’t hesitate to reach out. Above all, remember we’re a community and here to support each other. I look forward to working with all over the coming year. | Dr. Fracol is a chief resident at Northwestern University and ASPS Residents Council chair. Plastic Surgery Resident | Winter 2021

PLASTIC SURGERY EVOLVES WITH EVERY SEASON...

JOIN US IN 2022!

A MEETING FOR THE SPRING...

AND A MEETING FOR THE FALL

OCTOBER 27-30, 2022