Plastic Surgery Resident, Spring 2022 by PlasticSurgeryNews

ISSUE 26 | Spring 2022

From the publishers of Plastic Surgery News

Geniuses at work THE PATHWAYS TO REALIZING A DREAM INNOVATION, EXPLAINED page 4

» Growing PRIDE among ASPS members Fledgling group holds 1st gathering in Atlanta

» A new approach to residency in Finland How trainers approach talented 'Gen Y' plastic surgeons

IN THIS ISSUE » Program Peek: Rush University Medical Center p. 14 » InService Insights: Body contouring, Part I p. 22 » Journal Club: Two masters choose upper-extremity VCA articles p. 26

A note from the editor

Russell E. Ettinger, MD Chief Medical Editor

Plastic Surgery Resident Seattle

e would like to welcome our readers to the Spring 2022 issue of Plastic Surgery Resident (PSR).

Innovation has always been integral to our specialty of plastic surgery, so the cover story of this edition of PSR, written by Arman Serebrakian, MD, MS, delves into the ways trainees can approach surgical innovation during residency training. This article demystifies the myriad ways of bringing an invention to market – even as a resident – while Resident Editor Ravi Viradia, MD, details the processes he employs to transform his clinical ideas into novel technologies. We also highlight the recent partnership of ASPS with MedTech Innovation, which has led to an accelerator program for plastic surgeons to take their novel devices and technologies and bring them to fruition. The Spring edition will take you to Chicago for our “Program Peak” on Rush University’s plastic surgery residency, written by Aaron Wiegmann, MD, MS; Mohammed Asif, MD; Gordon Derman, MD; and Keith Hood, MD. Rush is one of the oldest residency programs in Chicago and recently made the transition to an integrated residency program with a rapidly growing faculty group. Our “24 hours in Chicago” by Elizabeth O’Neil, MD, MPH; Brandon Alba MD, MPH; and Christina Tragos, MD; provides a head start on how to spend your time in a city bursting with amazing sights, activities, restaurants and cultural experiences. PSR also supplies an update from the ASPS Pride Forum and LGBTQ+ Interest Group by Arya Akhavan, MD, highlighting the group’s inaugural reception at Plastic Surgery The Meeting 2021 in Atlanta and their plans for future initiatives. For those interested in pursuing microsurgery, “Plastic Surgery Perspectives” by Stav Brown, MD, features insights from renowned microsurgeon Shai Rozen, MD. Our recurring pieces still include “Consult Corner,” “Journal Club” and “InService Insights,” and this month we offer an international perspective to resident education and mentorship models in Helsinki, Finland. Finally, we re-introduce our “Complex Case Challenge,” wherein you can activate your clinical acumen and climb the reconstructive ladder to select your management choice for a complex plastic surgery case. Stay tuned for the next issue of PSR where the final reconstructive plan and outcome will be revealed by the authors. As always, thank you to you, our readers, and our team of editors and the ASPS production staff. We hope you enjoy the read! |

Plastic Surgery Resident | Spring 2022

Table of

Contents The path to innovation: Bringing an invention to the market..................................... 4 Residents may face time constraints and other demands, but a workable path exists for developing their concepts.

Plastic Surgery Resident | Spring 2022 | Vol.6 No.1

Innovation and ASPS: Society offers residents a hand with their inventions.......6 A partnership between ASPS and MedTech Innovator will bring innovations of all types to fruition – even those created by residents.

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.

How I did it: Plastic surgery trainee builds healthcare technology....... 7

A SPS PR ESI DEN T J. Peter Rubin, MD, MBA | rubipj@upmc.edu

Ravi Viradia, MD, saw the need for a better remote orthopedicmeasurement device, so he made it happen during residency.

PRIDE Forum: Gathering in Atlanta.................................................................9 The new special-interest group created along with other, similar ASPS initiatives held its first formal – and successful – reception during the Society’s annual meeting.

Consult Corner: How to approach a potentially septic wrist....................... 10 An acutely painful wrist could have several causes and present in various ways, so the initial assessment of the condition is crucial.

Program Peek: Rush University Medical Center.......................................... 14 Rush boasts a long and illustrious history that’s produced several celebrated plastic surgeons and contributed to major advances in the specialty.

Message From the Director: Deana Shenaq, MD................................................................ 17

The associate program director of plastic surgery residency describes the paths residents can take during training, as well as program benefits.

Faculty Focus: George Kokosis, MD.............................................................. 18 Associate professor of plastic surgery reveals what drew him to the specialty – and advises residents on preparation and life balance.

24 Hours in: Chicago.................................................................................... 20

EDITOR Russell Ettinger, MD | retting@uw.edu ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com 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 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 | monicazena1@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org

Resident-authors bring The Windy City to life through their summary of its numerous activities, events, venues and eateries.

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

InService Insights: Body Contouring, Part I........................................................ 22

A S S O C I AT E E D I T O R Kendra Applewhite | kapplewhite@plasticsurgery.org

Body contouring has become a quite popular choice among patients – and has drawn the attention of InService examiners.

International Perspective: Plastic surgery training in Helsinki..................................... 25 Virve Koljonen, MD, and Kaisu Ojala, MD, PhD, describe a highfunctioning specialty and the roles of residents within this cosmopolitan city.

Journal Club: VCA of the upper extremity..................................................26 Said Azoury, MD, and L. Scott Levin, MD, bring forth their Top 10 articles on vascularized composite allotransplantation of the upper extremity.

Plastic Surgery Perspectives: Microsurgery, Part III..............................................................28 Shai Rozen, MD, head of clinical research in the University of Texas Southwestern Department of Surgery, discusses the specialty’s past – and its promising future.

Complex Case Challenge: Closure prior to spinal surgery.............................................30 This exercise asks readers to delve into a difficult case involving spinal complications and cast their votes on the right solution.

GR A PHIC DESIGN ER Angela Bochucinski 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 | Spring 2022

YOU’VE GOT THAT GREAT IDEA – WHAT NEXT?

HOW TO BUILD YOUR INVENTION DURING RESIDENCY

By Arman T. Serebrakian, MD, MS

potential to improve not only plastic surgery, but also healthcare and society at large. However, becoming aware of these opportunities – not to mention having little to no understanding of how to make an idea reality or gauge the relevancy of an idea – remains an ever-present issue.

As the specialty evolves, it faces numerous challenges – making vital the efforts to keep plastic surgery a specialty that promotes, encourages and inspires innovation. Residents and Fellows can bring innovation to the fore, with the

"Innovation comes from seeing a need and trying to meet it, fixing something or having a vision and just the process of trying to make something better – a device, process or treatment,” says ASPS past President Lynn Jeffers, MD, MBA, who created the Society’s Technology

nnovation has always been an integral part of plastic surgery, from the specialty’s birth beside the battlefields of World War I through today’s facial transplantation procedures. Indeed, translating experiences in the O.R. into cutting-edge techniques or devices is why many choose the field.1

Plastic Surgery Resident | Spring 2022

Innovation and Disruption Presidential Task Force during her term. “There’s room for innovation everywhere.” Nevertheless, for medical professionals accustomed to the healthcare environment – and particularly, residents – facing the vastly foreign world of business and innovation can seem formidable. How can residents – who spend each day training in the O.R. or clinic, with a direct view into the most pressing challenges – successfully navigate the road of innovation? As in surgery, bringing an innovation to

market requires overcoming challenges, and solving intricate problems can be a daunting undertaking. That’s why the Society is working on a roadmap for innovation.

companies for advising or in the companies still forming – all of which are possible through our new partnership – are great ways to get involved.”

ASPS HELP FOR RESIDENTS

IMPACTFUL IDEAS

ASPS recently entered into a partnership with medical-devices accelerator MedTech Innovation (MTI) to accept applications from plastic surgeons – including trainees – to vie for up to $500,000 in cash prizes plus in-kind awards (see article on page 6). However, the deadline for the early-stage cohort closed Feb. 15; future dates will be forthcoming. “You don’t have to wait until you’re an attending to be an entrepreneur or an innovator to pursue your ideas,” Dr. Jeffers says.

The first step toward innovation is deciding whether an idea is impactful. Can it change workflow or add new, necessary technology to a space? If so, a large number of people could be affected by the idea (market size).2 You may ask: What exactly is the “better something” you want to introduce, or the problem being solved? It’s helpful to talk to experts in the field as well as potential users of the new technology to gauge how readily individuals might adopt it.

The PSF President-elect Howard Levinson, MD, who with Dr. Jeffers assisted the Society in forging the MTI partnership, says the initiative is not limited to seasoned doctors. “Residents interested in participating and contributing to the ecosystem, the growth of companies or in taking an idea and moving it forward can have a place in the new accelerator program,” Dr. Levinson says. “Those who have an idea for an invention but are unaware of what to do next or how to bring it forward and get other people involved will be helped. Residents who think, ‘I still want to be a plastic surgeon and I don’t want to work on this project a lot, but I want to invent it,’ can be involved. Whatever their spectrum is, this arrangement will provide an opportunity to learn what to do next.”

“By nature of your training as a resident, you’ll see different aspects of plastic surgery and of practice in general – and you may conceive of many innovations,” Dr. Jeffers maintains. “It might not have anything to do with plastic surgery at all, but if you look for ways to make things better, you’ll always find potential opportunities for innovation.”

“Training is the perfect time to become involved in a startup, because that’s when residents generally are determining the track they want to pursue,” says MTI spokesman Bill Perry. “Applying, screening, judging, connecting with

Once committed to your idea, try to determine whether other startups or companies have tried to solve the same problem. It’s necessary to examine exactly what they’ve done and why they’ve succeeded – or failed. In doing this, innovators often discover their idea is not truly novel and thus needs modification or reconsideration. Another question to ask: Do current technology, manufacturing, resources and infrastructure allow for the creation of this product or idea – or will significant changes be necessary to create it? Higher upfront development costs and harder ideas to adopt may need to be reconsidered prior to further action.

PATENTS AND PROTECTIONS Once committed to moving forward and after the requisite background research, obtaining a patent for the intellectual property (IP) is the next logical step. If you’re wondering whether to share novel ideas with others before filing a patent, the answer varies. An idea can only go so far if it’s not discussed with experts or potential users. Furthermore, forming a competent team is crucial to most innovation endeavors. Speaking to people who can be trusted or can contribute is useful. Frequently, company co-founders are brought together to discuss novel ideas, thereby creating a synergy that can be more powerful than an individual startup founder working on his or her own. Without sharing ideas, innovation often stops. Although rare, the potential downside of disclosing ideas to other individuals or groups is the possibility that the idea will be utilized by someone else. “You might have a great idea but might not think that it’s great,” Dr. Jeffers says. “If it’s a problem you’re trying to

continued on the next page Plastic Surgery Resident | Spring 2022

INNOVATION DURING RESIDENCY / continued from previous page

solve, talk to other people about it – seek resources and find like-minded people who’ll be passionate about your idea. If it’s something you’re passionate about and want to pursue it, do your homework, get good advice, find resources and go for it.” The patent process will likely be the next step, and it can be long, arduous and costly.3 However, investments made in developing a strong IP portfolio could be the most valuable part of the startup process. Investors and future clients alike are attracted to companies with strong IP. To assist with this step, the U.S. Patent and Trademark Office (USPTO) website provides all necessary resources (uspto.gov). Although individually accomplishing this is possible, consulting with a patent attorney is the best way to ensure that proper background research, document filing and communication with the USPTO are performed.

COMPANY CREATION AND FUNDRAISING Forming a strong team is fundamental to bringing an idea to reality. Assembling individuals with expertise in various areas will strengthen the group and can avoid potential conflicts. Most residents don’t have a business background, and thus it’s often helpful to collaborate with others. At a certain point, a founder or group of co-founders will need to form a company and begin fundraising. A board of directors will often be created early in the process and usually consists of members from the founding team. The board acts as a governing body that meets at regular intervals and supervises the activities of the company. Recruiting a group of core advisors who are experts in the field is another critical element. These individuals believe in the company mission and are willing to serve as a resource. Payment for these early advisers can be individualized, but this usually consists of stock options or future shares in the company. Typically, 6

Plastic Surgery Resident | Spring 2022

early company executives (CEO, CTO, COO, etc.) consist of founding members and may remain unpaid until a first round of fundraising has been achieved. If additional employees are hired, paying these individuals at market rates will usually be necessary and must be a part of the company’s business plan.

A business plan must be thoughtfully developed as early as possible. Resources abound for creating a proper plan, but market size, revenue models, growth plans, company overhead and expenditures, and financing/fundraising considerations are a must. The business plan will be shared with potential

New ASPS venture into medical 'start-ups' is open to residents, too Plastic surgery residents are invited to join ASPS members in the MedTech Innovator (MTI) accelerator program designed to assist plastic surgeons in the start-up or early commercialization stages of creating a medical device company or technology. Entrepreneurs will compete for up to $500,000 in cash prizes and in-kind awards available through the program, which is still in development. However, this year's application window has closed; dates for the next submission window will be forthcoming. The program stems from a partnership announced in December between the Society and MTI – the largest accelerator of medical devices in the world – to match healthcare industry professionals with innovative medical-technology startups for mentorship and support. This year, the company will select 50 medical technology startups to participate in its annual Accelerator and Showcase cohort. As part of the partnership with ASPS, three companies will participate in a plastic surgery-focused track. The partnership eventually will have roles for residents, according to The PSF President-elect Howard Levinson, MD, associate professor and director of Innovation and Entrepreneurship at Duke University Medical Center. “They could simply be an observer, or they could volunteer to be a screener of companies, similar to an abstract screener for meetings,” he says. “They could be a judge, or they could become involved in networking with experts in this milieu or work with companies that need their help – many need advisors, chief medical officers, executives and others with experience in the space.

“They also could be an investor,” he adds, adding that participation could be a way to connect for assistance in a research project. “This program is a direct gateway to opening untold opportunities for both ASPS and plastic surgery at large moving forward,” says ASPS past President Lynn Jeffers, MD, MBA, who made innovative technology a focus of her presidency. “We’ll have an inside look at technologies that can improve care in plastic surgery – new diagnostics, new technologies and new devices that will advance the specialty as a whole. Residents don’t need to wait until they become an attending to innovate or be an entrepreneur. They’re encouraged to participate in this program.” A major attraction for the program is the wealth of information that will be banked over time and which all participants – including residents – will be able to access. “It’s a great ‘value-added’ feature,” Dr. Jeffers says. “MTI has agreed that our members will have access to those educational materials, offered through videos and web-based sessions, and through many other platforms. I’m excited for the ASPS members who want to learn a little more about what it takes to be in this field; or who want to take a product or service from idea to reality.” Residents with questions about the program can contact ASPS Staff Vice President of Business Development Jennifer Cross at jcross@plasticsurgery.org or (847) 228-3320. |

investors and should contain important milestones, which are defined as necessary achievements that the company needs to reach to make progress toward its overall business goals. Examples include developing a proof-of-concept (POC) product; performing pilot testing; achieving revenue; and scaling to a certain market size. Commercialization and up-scaling the product or service to a greater market size is usually every startup’s eventual major milestone – and the driver behind revenue and profitability. The company should work toward reaching these milestones as early as possible.

Arnold-Peter C. Weiss, MD. “Stock… may be divided into shares that are granted to investors in cases of diluted funding. Nondilutive funding, in comparison, stands alone and does not change ownership in [the] company.”4 Seats on the board may also need to be granted to certain investors. If possible, fundraising with non-diluted sources such as grants or other trusted entities early on is most fruitful. Putting forth a well-positioned business plan, mission statement and team will make the venture more attractive to potential investors.

get started and see their innovation to fruition, or to participate in various aspects of innovation,” she adds. “In addition, we plan to have programming at Plastic Surgery The Meeting, slated for Oct. 27-30 in Boston. We’ll have had at least three companies go through the MTI program by then, and we’ll be interested to learn from their experiences. We will bring like-minded people together to help create this community, and we welcome resident involvement. If residents wish to participate in the MTI accelerator or in this community, we welcome their energy, ideas and commitment.”

Efforts to raise funds to support the company’s goals and bring an idea to fruition need to be considered early. Again, having a well-designed business plan clarifies fundraising needs, and only then should early investors be approached. A “slide deck” graphical presentation is the most common way to share the information about the company and should consist of the company and market background; idea or product description; team information; any potential partnerships; current or future clients or customers; competitors; and financials.

‘HOW DO I EVEN BEGIN?’

EYES ON THE PRIZE

Residents at this point might be thinking: “How in the world can I manage all this while balancing my clinical obligations and continued training?” That’s where the ASPS/MTI Innovator Accelerator Track can provide a useful assist. The goal of the program is not to make one resident do everything on his or her own to secure an investment – the goal is to build a collaborative network to make the next great idea a reality.

During residency, focus and priority should always be on the clinical training and education required to become plastic surgeons – but that doesn’t mean working toward an innovation must necessarily be ignored. Surrounding oneself with individuals who share similar passions for innovation can enable residents to innovate and not only move the specialty, but also move medicine and healthcare as a whole. It can be a rewarding and exciting part of residency training. |

Raising funds can be achieved by diluted or non-diluted means, with diluted investments typically requiring granting a stake in the company once certain milestones are achieved. “Dilutive funding by definition ‘dilutes’ ownership of IP,” according to innovation researchers Maheen Nadeem, BS, and

“The ASPS/MTI initiative is part of a greater plan to create a community and infrastructure within ASPS that will become a resource to which residents and members can go if they need assistance on literally anything from the beginning of their process to the end,” Dr. Jeffers says. “To further help them in navigating the road to their innovation, this partnership also will make acceleratorbased educational materials and sessions available to our members. Companies that go through the process will have access to many resources in the MTI space. Opportunities also will exist for those who are interested in this space but don’t have a company or idea of their own. “The goal is to create resources and opportunities where our members have the help and information needed to

Dr. Serebrakian is PGY-6 at Harvard Mass General Brigham Plastic Surgery. REFERENCES 1.

Rohrich RJ, Rosen J, Longaker MT. So you want to be an innovator? Plast Reconstr Surg. Sep 2010;126(3):1107-1109. doi:10.1097/ PRS.0b013e3181e3b854 Nadeem M, Weiss AC. Medical Product Development Part 1: Idea, Partnerships, and Commercialization. J Hand Surg Am. 08 2021;46(8):703-708. doi:10.1016/j. jhsa.2021.04.020 Nadeem M, Weiss AC. Medical Product Development Part 2: Patent and FDA Issues. J Hand Surg Am. 10 2021;46(10):918-923. doi:10.1016/j.jhsa.2021.07.011 Yost L, Barta K. Funding approaches: who, when, why, and in exchange for what? Orthopaedic Technology Innovation: A Step-byStep Guide from Concept to Commercialization. Wolters Kluwer; 2020:275-291.

Plastic Surgery Resident | Spring 2022

BRINGING A TECHNOLOGY TO MARKET AS A SECOND-YEAR PLASTIC SURGERY FELLOW I’m a boardcertified general surgeon, Fellowshiptrained hand surgeon and a second-year plastic surgery Fellow at the University of Tennessee Ravi Viradia, MD Chattanooga – with a journey to innovation that really took off as I went through general surgery residency at the Charleston Area Medical Center. I quickly understood that innovative health technology and services could substantially improve the quality of healthcare delivered to patients, as well as improve health outcomes.

privacy lawyer with experience in emerging companies and emerging technologies, with hopes of helping people think through considerations such as biotech and medical engineering concepts – as well as healthcare industry-specifics – to develop ideas and services and bring minimally viable products (MVP) to life. COVID-19 arrived shortly after Axxon began to flourish. I soon realized after COVID hit that we needed better remote orthopedicmeasurement devices. I had an idea that would not only give orthopedists, therapists and plastic surgeons adequate and accurate hand measurements while performing remote examinations relating to hand

During this time, I developed a diagrammed blueprint for a trauma stick that would simply but effectively allow for multiple tubes of blood to be drawn at the same time, thus decreasing the associated E.R. times. I quickly discovered that thinking of an idea and turning it into a product – let alone a business – were two totally different things. ‌Image of Digitrack Platform log-in page: I felt an overall lack of support for developing ideas such as this one that could potentially help so many function, but also help post-rehabilitation patients. I had already witnessed some of patients receive home therapy after the hurdles while working on an innovative, sustaining hand surgeries or hand injuries alternative pain-treatment solution. – the hand being among the most common These experiences informed and motivated me to form Axxon LLC, a company that could help provide some of this support to healthcare providers and technologists. Drawing upon experiences through its successful pitching of innovative concepts – such as for SAGES Emerging Technology e-poster presentation – Axxon’s goal is to provide healthcare professionals and others with the support and resources that could allow O.R. ideas to become reality. I began to work with Amy Kabaria, a healthcare data-

Plastic Surgery Resident | Spring 2022

types of workplace injuries.

I had presented to Amy this concept of measuring digit angles through an AI-based remote platform – then to develop the technology, we contacted Manish Hirapara, who is a relative of mine and CEO of Peak Activity LLC, which is an eCommerce and software company; it twice has been named to INC 5000’s fastest-growing companies list.

Thus Digitrack was born. Digitrack is a machine-learning platform based on an algorithm trained on thousands of hand images that can provide – in a matter of milliseconds – accurate angles of arc measurements of the MCPJ, PIPJ and DIPJ of the hand and joints of the wrist. We developed the algorithm and obtained proprietary protection with a provisional patent filed in December 2020. In the Spring of 2021, we applied and won a Top 3 spot in a Harvard pitch competition and subsequently did a “shark tank” presentation with Harvard alumni CEOs and VCs. Then, with the full platform nearing completion, we competed through rounds of applications to present at the ASPS Innovations: The Tank, at Plastic Surgery The Meeting in 2021, where we took first place and innovation of the year. Afterward, we filed the non-provisional patent. With the Digitrack platform complete, we’re now planning to take the platform through rigorous testing with board-certified hand surgeons, plastic surgeons and occupational therapists throughout the country to incorporate their valuable feedback. The next phase will be to get the platform out to companies, therapists, hand surgeons and hospital systems. We may consider raising a Series A round of funding for Digitrack LLC. | To learn more about healthcare innovation, write to rviradia1@gmail.com. Dr. Viradia is a PGY-8 independent plastic surgery Fellow at the University of Tennessee Health Science Center, Chattanooga.

MENTORSHIP, LAW AND MORE – UPDATES FROM THE ASPS PRIDE FORUM

‌SPS PRIDE Forum organizers ‌were excited to prepare for the ‌forum’s first official reception ‌at Plastic Surgery The Meeting last October in Atlanta. As the annual meeting approached, though, we ran into an issue: Too many people were planning to attend – and the venue needed to be upsized. Arya Andre Akhavan, MD

For context, the ASPS PRIDE Forum is a new membership group created in the wake of ASPS initiatives designed to create interest groups to recognize and foster diversity in plastic surgery. The PRIDE Forum had formed just before PSTM21 and hadn’t yet held an in-person event, so we were certainly excited to have too many people for our reception. The night was graciously supported by Allergan, with the Atlanta Gay Men’s Choir opening for us with amazing renditions of queer anthems. A volume of surgeons, residents and medical students were in attendance – LGBTQ+-identified and allies alike. Thanks in part to the content of the many conversations born from that night, the PRIDE Forum has begun working on its first offerings to our membership. At the PRIDE Forum reception, the most commonly asked question by residents and medical students was: “When will the PRIDE Forum have a mentorship program?” Some LGBTQ+-identified mentees were interested in mentorship from LGBTQ+-identified surgeons, and some residents with plans to enter a gender-affirmation surgery fellowship were looking for mentors in the same field. Therefore, this was discussed at our January Steering Committee meeting – and we’ll offer a targeted mentorship setup through the ASPS PROPEL program next cycle (details are pending). Resident members of the PRIDE Forum should keep an eye out for that announcement; medical student members may have to wait a bit longer.

Surgeons, residents and medical students also brought up concerns about the antiLGBTQ+ legislation being proposed in multiple states that could impact both plastic surgery surgeons/trainees and our LGBTQ+-identified patients. We’re happy to confirm that the Society’s Legislative Action Committee (LAC) is well aware of these proposed laws, and the PRIDE Forum will be working with the LAC on that front. As details emerge, the PRIDE Forum will reach out to our membership with opportunities to get involved. The PRIDE Forum has a few other offerings that are either currently available or in the works. Members should already have access to a private discussion board – accessible through the ASPS Members Only page – or through the ASPS app. We’ll be using the private forum for monthly discussion topics and to allow private discussion for LGBTQ+-related issues in plastic surgery. Some of the PRIDE Forum members have formed @pridePRS (not affiliated with ASPS), and we’re also working with medical students and residents on research efforts. It’s shaping up to be an exciting year. The ASPS PRIDE Forum supports LGBTQ+ plastic surgeons and trainees. Its mission is to support a community of LGBTQ+ physicians, trainees and allies who advance the field of plastic surgery through education, advocacy and partnerships. You can join the ASPS PRIDE Forum by going to www.plasticsurgery.org, then clicking on “For Medical Professionals, followed by “Community” then “PRIDE Forum.” | Dr. Akhavan is PGY-6, a clinical research Fellow and pending burn surgery Fellow at Johns Hopkins. Plastic Surgery Resident | Spring 2022

Rule-out septic wrist

“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 Olivia Means, MD E.D.: WORSENING WRIST PAIN W/DECREASE ROM It’s 11 p.m. on a quiet Sunday and you’re nearing the end of your four-day Thanksgiving weekend call – until you receive a page from the E.D. that reads: “67yoM, right wrist pain, rule-out septic wrist.”

INITIAL CONSIDERATIONS

Several conditions can cause an acutely painful wrist, such as infection, trauma, recent surgery, arthritis and crystalline arthropathy. Patients present in a variety of ways, and it’s the hand surgeon’s responsibility to assess and determine the next steps. The importance of a wrist tap is its provision of objective data to further guide the need for operative intervention. If the patient indeed has a septic wrist, urgent washout is warranted.1,2 The presence of gout or pseudogout crystals in the synovial fluid doesn’t exclude the possibility of a concomitant bacterial infection, although such an occurrence is unusual1.

HISTORY AND PHYSICAL

The patient is a 67-year-old male with a past medical history of gout, hypertension, chronic kidney disease, hyperlipidemia and peripheral artery disease. He presented with three days of worsening right-wrist pain with associated swelling, erythema, warmth, decreased range of motion and subjective fevers. He denies any prior wrist surgery, infection or injury. He’s an active smoker, right-hand dominant and on apixaban for recent stents placed in the lower extremities. He’s also on allopurinol for gout and reports gouty flares in the past, but always in his lower extremities.

Plastic Surgery Resident | Spring 2022

On physical exam of the upper-right extremity, the patient has +2 radial and ulnar pulses. Sensation is intact in the radial, medial and ulnar nerve distributions. There’s erythema and edema present to the right wrist and dorsal hand with associated pain with flexion, extension and axial loading. He has full, active range of motion of forearm. Passive range of motion of wrist and fingers are intact but limited due to pain and edema. He has normal abduction/adduction of the finger and normal thumb oppositions. There’s no streaking extending proximally to the forearm. Compartments are soft. Additional workup showed degenerative changes, but on X-ray no acute skeletal injury or foreign body was shown. CBC showed normal WBCs at 7.8; CRP elevated at 13; and sedimentation rate elevated at 26. The patient was afebrile.

MATERIALS NEEDED FOR WRIST TAP

• Alcohol wipes (used to clean the area prior to administering local anesthetic) • Sterile technique: chlorhexidine solution, sterile gloves, sterile gauze • 2-5cc syringe, 18-gauge sharp needle (for joint aspiration), sterile cap • 18-gauge blunt-tip needle (to draw up local); 27-gauge needle (to administer local) • Local anesthetic: 1% lidocaine with epinephrine 1:100,000 • Towel (used for wrist bump) • Sterile bandage

WRIST TAP PROCEDURE

Prior to any procedure, informed consent must be obtained. The risks, benefits, complications and alternatives of the procedure are discussed with the patient. Once obtained, the performing resident should review the relevant anatomy. Access to the dorsal radiocarpal joint is obtained by placing the wrist in flexion and ulnar deviation. Palpate the Lister’s tubercle at the distal end of the radius, or visualize the path of the extensor pollicis longus as it crosses on the ulnar side of Lister’s tubercle. Slightly ulnar and distal (approximately 1 cm) to this landmark is the depression for needle insertion. 3

The procedure begins with achieving appropriate anesthesia. An alcohol wipe is used to cleanse the area to be injected, again slightly distal and ulnar to Lister’s tubercle. Local anesthetic – 1% lidocaine with epinephrine 1:100,000 – is used to anesthetize the small area of needle insertion. The hand is placed on the towel bump to provide some wrist flexion. The dorsal wrist is then prepped with a chlorhexidine prep stick and a sterile field is created with sterile towels. An assistant places the wrist on traction, while maintaining the hand on the bump and in flexion and ulnar deviation. An 18-gauge sharp-tip needle is inserted slightly distal and ulnar to the Lister’s tubercle. The needle is inserted, angled 10 degrees proximally, to respect the volar tilt of the radius, with gentle aspiration as you advance. Once fluid is obtained, the needle is removed and a sterile cap is placed. The hand is cleaned and sterile dressing is placed. 3 Aspirated fluid is sent for the following analysis: culture body fluid with gram stain; crystal; cell count; synovial lactate; synovial glucose; culture anaerobic; and culture fungus with smear.1 The amount of fluid is usually limited, so it’s our practice to identify the level of priority in the instructions to the lab, with No. 1 culture body fluid with gram stain, No. 2 crystal and No. 3 cell count. Depending on past medical history, associated co-morbid conditions, clinical presentation and level of suspicion for septic wrist, patients are admitted to E.D. observation, internal medicine or the hand surgery service while labs are pending.

CASE EXAMPLES

Case One (follow-up from the patient above): Following wrist tap, patient was admitted to medicine, started on IV antibiotics and made NPO at midnight for a possible procedure pending culture results. The initial gram stain showed no organisms, and the following morning, crystal analysis confirmed needle-shaped, weakly birefringent crystals which polarize as calcium pyrophosphate dihydrate. He was diagnosed with pseudogout. Patient was discharged with prednisone, pain medication and to follow-up with PCP for continued management of gout. Final culture body with gram stain, culture anaerobic and culture fugus were no growth. He was seen in follow-up by the attending hand surgeon with noted improvement in pain, swelling and the return of range of motion equivalent to the contralateral side.

continued on the next page

Plastic Surgery Resident | Spring 2022

CONSULT CORNER / continued from previous page Figure 1: Photos courtesy of the Hand and Plastic Surgery Centre, Grand Rapids, Mich.

CASE

CASE ONE

CASE TWO

CASE THREE

Plastic Surgery Resident | Spring 2022

CLINICAL IMAGE

WRIST TAP ASPIRATE

Case Two: A 68-year-old male was admitted with altered mental status and bacteremia of unknown origin with possible septic wrist. His exam was significant for gross left-hand swelling without visible signs of trauma, tender to palpation and with wrist flexion, extension and axial loading. Radiographs demonstrated underlying osteoarthritis. A wrist tap was performed with immediate return of purulent fluid. Fluid aspirate was sent for culture, but given the frank purulence noted, the patient was taken urgently to the O.R. for I&D. Operative findings confirmed purulence in the radiocarpal and midcarpal joints. Case Three: A 93-year-old female was admitted with acute respiratory failure from CHF exacerbation. Hand surgery was consulted for three days of right-wrist pain with associated edema, erythema and pain without recent trauma or overlying skin injury. Exams were significant for limited wrist flexion/ extension due to pain, and no tenderness with axial loading. Radiographs showed underlying arthritic changes. A wrist tap was performed. Crystal analysis confirmed intracellular monosodium urate crystals and intracellular calcium pyrophosphate crystals. She was diagnosed with gout vs.

pseudogout, likely secondary to high-dose furosemide. The patient was started on prednisone by the primary physician, with a noted improvement in symptoms. A final culture body with gram stain and culture anaerobic demonstrated no growth. Special thanks to Matthew Fahrenkopf, MD, Hand and Plastic Surgery Centre, Grand Rapids, Mich. | Dr. Means is PGY-4 at Spectrum Health/Michigan State University, Grand Rapids, Mich. REFERENCES 1. Claiborne JR, Branch LG, Reynolds M, Defranzo AJ. An algorithmic approach to the suspected septic wrist. Ann Plast Surg. 2017 Jun;78(6):659-662. PMID: 28187026. 2. Jennings JD, Zielinski E, Tosti R, Ilyas AM. Septic arthritis of the wrist: Incidence, risk factors, and predictors of infection. Orthopedics. 2017 May 1;40(3):e526-e531. Epub 2017 Apr 11. 3. Patel A, Punnapuzha S. Wrist arthrocentesis. [Updated 2021 Jul 25]. In StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2021 Jan. Available at www.ncbi.nlm.nih.gov/books/NBK559228/

Residents: Submit an abstract for PSTM22 – and an opportunity to deliver it live Plastic surgery residents from all programs are invited to attend Plastic Surgery The Meeting, slated for Oct. 27-30 in Boston, and to submit their abstracts. The deadline for submission is Friday, April 29. The authors of the 50 top-rated resident abstracts will be invited to deliver live podium presentations in dedicated sessions during the annual meeting – the premier educational and networking event of the year and featuring domestic as well as international plastic surgeons.

The 2022 resident abstract program will be a hybrid event that offers live and on-demand presentations. Submissions will be accepted in the areas of aesthetic; breast reconstruction; hand; maxillofacial; reconstruction/burn/microsurgery; and research. To be eligible, submitters must be a resident at the time the abstract is submitted and presented. Medical students, Fellows and non-residents aren’t eligible to submit or present a paper to the Resident Abstract Sessions. To submit an abstract, go to PlasticSurgeryTheMeeting.com/residents, and click on "Resident Abstract Sessions."

For information or assistance with creating an account on plasticsurgery.org, contact memserv@plasticsurgery.org; call (800) 766-4955 within the United States; or call (847) 228-9900, ext. 471, outside the United States.

Rush University Medical Center

By Aaron Wiegmann, MD, MS; Mohammed Asif, MD; Gordon Derman, MD; & Keith Hood, MD

AARON WIEGMANN, MD, MS

MOHAMMED ASIF, MD

GORDON DERMAN, MD

KEITH HOOD, MD

HISTORY • Paul Greeley, MD, established the first plastic surgery program in the Chicago region shortly after World War II at Rush and affiliated hospitals. • John Curtin, MD, a former resident of Dr. Greeley’s, succeeded him as Department of Plastic and Reconstructive Surgery chairman at Rush University Medical Center for 25 years. Dr. Curtin, who retired in 1989, was an internationally recognized plastic surgeon who introduced craniofacial surgery to the Chicago region. • Paul Tessier, MD, the father of craniofacial surgery, performed surgery at Rush; the inspiration from these experiences led to the development of the Rush Craniofacial Center. • Amir Dorafshar, MD, was appointed chairman in 2018. • The program transitioned to an integrated pathway in 2019. 14

Plastic Surgery Resident | Spring 2022

LEADERSHIP • Amir Dorafshar, MBChB, The John W. Curtin, MD, Chair of Plastic and Reconstructive Surgery, Division Chief, Plastic & Reconstructive Surgery. His clinical interests include craniofacial and gender affirmation surgery, and reconstructive microsurgery. • Deana Shenaq, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Program Director, Integrated Plastic and Reconstructive Surgery Residency. Her clinical interests are breast reconstruction, microsurgery and lymphedema. • Keith Hood, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Associate Program Director, Integrated Plastic and Reconstructive Surgery Residency. His clinical interests include cancer reconstruction, body contouring and cosmetic surgery. • Loren Schechter, MD, Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery. His clinical interests include gender-affirmation surgery. • Gordon Derman, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery. His clinical interests include hand surgery and lowerextremity reconstruction.

• Christina Tragos, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Director, Rush Craniofacial Center. Her clinical interests include craniofacial surgery. • John Cook, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery. His clinical interests include cosmetic surgery. • George Kokosis, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery. His clinical interests include breast reconstruction, microsurgery and lymphedema. • David Kurlander, MD, Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery. His clinical interests include sarcoma reconstruction, peripheral nerve and microsurgery. • Mark Grevious, MD, MBA, Chairman, Division of Plastic and Reconstructive Surgery, Cook County Health and Hospitals System. His clinical interests include general reconstruction and hand surgery. • Jafar Hasan, MD, Attending Plastic Surgeon, Division of Plastic and Reconstructive Surgery, Cook County Health and Hospitals System. His clinical interests include breast reconstruction and craniofacial trauma. • Matthew Doscher, MD, Attending Plastic Surgeon, Division of Plastic and Reconstructive Surgery, Cook County Health and Hospitals System. His clinical interests include hand surgery. NATIONAL LEADERSHIP • Dr. Dorafshar is an internationally renowned facial surgery expert; former Facial Transplant program codirector at Johns Hopkins; and Board of Directors member for Illinois Society of Plastic Surgeons (ISPS). • Dr. Schechter serves on the Board of Directors for the World Professional Association for Transgender Health. • Dr. Shenaq is the vice chair of the ASPS Young Plastic Surgeons Steering Committee and serves on the ISPS Board of Directors. CLINICAL EXPERIENCE • Rush University Medical Center is a top-20 U.S. hospital (U.S. News & World Report's Best Hospitals Honor Roll) and provides 671 beds serving adults and children. The Division of Plastic and Reconstructive Surgery had 10,434 outpatient visits and performed 1,071 surgeries in 2021. There are nine faculty plastic surgeons in a rapidly growing division. There are currently eight residents in the six-year ACGME-accredited, integrated plastic surgery residency program, and in 2021 the program received approval to increase the resident complement to two categorical residents per year.

The clinical experience of residents occurs across the following sites: • Rush University Medical Center is one of the top-rated hospitals in the country (No. 1 in the 2019 Quality and Accountability Study by Vizient Inc.) and is where the majority of residents rotate across various services such as craniomaxillofacial, gender affirmation, microsurgery, etc. • Rush Copley Medical Center is widely considered one of the most impressive healthcare facilities in the Midwest. Residents have the opportunity to rotate and gain an indepth experience in breast reconstruction, body contouring and cosmetic surgery. • Rush Oak Park Hospital holds a Magnet designation, the most prestigious honor a healthcare organization can achieve for nursing excellence and quality patient care. Residents frequently spend time there and gain insight into community-based practice. • John H. Stroger Jr., Hospital of Cook County, a storied institution where generations of prestigious surgeons have trained, is a Level I trauma center where residents get an immersive experience in upper extremity, lower extremity and craniofacial trauma, as well as burn surgery. The autonomy the residents experience here is second to none. EDUCATIONAL CURRICULUM • Weekly conference: The resident formal didactic curriculum consists of three hours of dedicated conference time each Wednesday. Residents are excused from clinical duties to attend. Conferences include lectures from invited and distinguished guest speakers, case presentations, “unknowns” conference, didactic sessions by program faculty, anatomy labs, small group workshops, quality improvement, quality assurance and outcomes sessions. • National and local meetings: Residents are given support to attend state and national meetings. • The residents participate in the Chicago-wide Mock Oral Board Examination, to prepare for future board exams.

continued on the next page Plastic Surgery Resident | Spring 2022

PROGRAM PEEK / continued from previous page

Members of the Rush University Medical Center Residency Program and the program’s leadership.

• Journal Club: The program hosts informal gatherings to discuss relevant medical journal pieces. Residents present assigned readings at the meeting and facilitate excellent discussions. • Visiting professor lectureships: We welcome multiple visiting professors each year, recognized experts in the field of plastic surgery and its subspecialties. Residents review cases with the visiting professor to discuss innovative techniques and gain additional feedback. • Labs: The program sponsors several cadaver labs throughout the year to review anatomical dissections, in addition to an annual flap course, an annual microsurgical course, plating workshops and cosmetic injection workshops.

Plastic Surgery Resident | Spring 2022

RESIDENT BENEFITS • Plastic and reconstructive surgery residents receive benefits from both the Department of Graduate Medical Education as well as from the Division of Plastic and Reconstructive Surgery. • The Division of Plastic and Reconstructive Surgery also provides several resources for residents to enhance their educational experiences, including membership to ASPS and PSEN, and customized elective rotations. | Dr. Wiegmann is PGY-3 and Dr. Asif is PGY-7; Dr. Derman is an assistant professor; and Dr. Hood is an assistant professor and assistant residency program director; at Rush University Medical Center, Chicago.

A Message From the Program Director, Deana Shenaq, MD

he Plastic Surgery Residency

for aesthetic surgery. The

Medical Center is one of the

and is obtained at Cook

Program at Rush University oldest residency programs

in Chicago, with its origins beginning in the

traditional independent pathway. The residency

converted to an integrated program in July 2020

after matching the first PGY-1 integrated resident. The integrated residency program is a combined experience through Rush and Cook County Hospital.

Beginning in their first year of residency, residents spend a significant amount of time on plastic

surgery-specific rotations at all Rush-affiliated

locations and Cook County Hospital. We believe

in an apprenticeship model during plastic surgery

training, such that residents have the opportunity to work directly with specific attendings each

month. Thus, residents will participate not only in

the actual surgeries, but understand the full gamut of patient care from preoperative planning to

postoperative aftercare. The apprenticeship model also provides residents in their more junior years

trauma experience is vast County Hospital, which

is one of the busiest Level I trauma centers in the

country. As an institution, Rush is one of the leading

Deana Shenaq, MD

regional hospitals in both

breast oncology and orthopedic surgery through Midwest Orthopedics. Thus, our residents are

exposed to a high volume of breast and orthopedic sarcoma and trauma reconstruction. Rush also has one of the oldest craniofacial centers, a very busy pediatric plastic surgery practice and in-house

orthodontic care. Rush University is also home to the first comprehensive Center for Transgender Health in Chicago. In addition, the residents

are involved with impactful research projects,

including large cohort and quality-improvement

studies throughout residency and especially during the dedicated research year between clinical PGY3 and PGY-4.

with exposure to complex cases earlier in their

Our residents and faculty are a close-knit

a PGY-2 or PGY-3 resident working under the

high-volume and varied training experience in

training. For example, it’s not uncommon to find microscope with an attending – an opportunity

that may not otherwise present itself without an apprenticeship model.

family, and we’re pleased to provide a

a collegial environment within the great city of Chicago. |

We’re very proud of the variety of cases and

training environments that our program provides. Situated in the heart of Chicago, residents have

ample exposure to diverse patient populations and practice types, and through-rotations not only

at the main hospital, but within various suburbs

at Rush-affiliated locations and in private offices

Plastic Surgery Resident | Spring 2022

Q&A WITH GEORGE KOKOSIS, MD By Jim Leonardo Plastic Surgery Resident strives to provide readers with career advice designed to aid them in their professional advance after residency – by sharing insights that may help them create their own, desired path. In this installment of Faculty Focus, we present ASPS Candidate for Active Membership George Kokosis, MD, Division of Plastic and Reconstructive Surgery assistant professor at Rush Medical College, Chicago. Dr. Kokosis earned his medical degree at Athens (Greece) Medical School, and he completed his general surgery residency at Duke University School of Medicine and his plastic surgery residency and Fellowship at Johns Hopkins Hospital. He’s also completed a microsurgical oncological reconstruction Fellowship at Memorial Sloan Kettering Cancer Center, as well as a research Fellowship for wound healing and fibrosis at Duke University Medical Center. PSR: WHAT DREW YOU TO PLASTIC SURGERY? Dr. Kokosis: I decided to become a plastic surgeon when I was a fourth-year medical student in an orthopedic surgery rotation. A lower-extremity trauma patient required a multidisciplinary approach, including plastic surgery involvement and a free latissimus dorsi flap for reconstruction. I was fascinated by the level of complexity and detail in planning and executing the procedure. After a formal rotation in plastic surgery, I realized that the breadth of knowledge and skills that a plastic surgeon needs to possess, as well as the opportunity to operate from head to toe, make this specialty the most unique. I decided then that I would focus my efforts in becoming a plastic and reconstructive surgeon. I’ve been grateful to be given the opportunities to make my dream come true.

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO LAND A COMPETITIVE FELLOWSHIP? Dr. Kokosis: My pathway to plastic surgery is a bit unique. I went to medical school in Athens, Greece. When I decided to come to the United States for surgical training, I planned my steps in a way that would allow me to become competitive for a fellowship. I first completed a two-year research fellowship in plastic surgery and wound healing at Duke University, under the mentorship of The PSF President-elect Howard Levinson, MD, where I completed the categorical five-year training program in general surgery. During training, I committed extra time into conducting more research and developed strong relationships with the faculty in Duke’s plastic surgery division who were willing to mentor and support me. By the time I applied for an independent plastic surgery residency position, my CV was competitive. I was fortunate enough to match into the combined plastic surgery program at Johns Hopkins/ University of Maryland, where I worked and trained under leaders in plastic surgery who supported my endeavors. My interest in microsurgery grew more intense as I was rotating in our reconstructive rotations during residency. I wanted to match into a competitive, clinically heavy microsurgery program. I maintained a very active research portfolio and presented at a minimum of one or two meetings every year. I ultimately matched into Memorial Sloan Kettering Cancer Center for a microsurgical reconstruction fellowship. I believe my successful matches were a combination of strategic planning, commitment to research with active participation in meetings and hard work that allowed me to have very supportive letters of recommendation.

PSR: WHAT IMPACT DID A FELLOWSHIP HAVE ON YOUR CAREER? Dr. Kokosis: My microsurgical fellowship has had a major impact in my career. As mentioned, I was fortunate to match into one of the most competitive fellowships in microsurgery. The advantage of spending this extra year is significant. First, I honed the skills a microsurgeon needs but are otherwise

Plastic Surgery Resident | Winter 2021

harder to acquire during plastic surgery residency. This skillset made me more competitive when looking for academic jobs, which was my ultimate career goal. I believe I was able to land in my current job at Rush and be given the opportunity to develop my ideal practice (breast reconstruction and lymphedema) due to the trust in my training. Additionally, during this year I participated in many research projects involving a very big database that leads to impactful research. I’m further collaborating with my mentors in ongoing projects and therefore building my academic portfolio. Furthermore, this extra year leads to building relationships with great mentors and developing the networking that creates opportunities for professional advancement.

PSR: HOW IMPORTANT IS A MENTOR IN THE EARLY YEARS OF PRACTICE? Dr. Kokosis: It’s extremely important. Mentorship is an ongoing relationship that never stops. I’ve been extremely fortunate to have had great mentors who coached me and shaped my surgical identity. The impact is everlasting; I feel I’ll always carry with me a piece of their experience, pearls of wisdom and advice. I often find myself in the O.R. teaching my residents through my mentor’s methods. Finally, many of my mentors’ numbers are on speed dial – and I can call them anytime I need advice with any of my cases.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Kokosis: Being involved in societies and committees gives me the opportunity to network and learn from other people. An early career is much more than just being able to execute in the O.R., and the years of training prepare you well for this. However, there are so many other aspects of professional development, including resource utilization to maximize your efficiency, administrative tasks and developing a research team. We’re not trained to do this, and meeting peers outside of your institution allows for bouncing-off ideas, discussing the business of plastic surgery and learning from others.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE A RESIDENT NEEDS? Dr. Kokosis: It requires perseverance and passion for what you do, or as Angela Duckworth suggests in her book Grit, it’s not as much talent as it is resilience. Throughout the years of my training, I’ve seen very talented residents who didn’t perform well due to their inability to accept that residency is a long-term process, a marathon that requires awareness of why you’re into this. I always tell my residents they need to focus on the big picture. It’s only once

that you know your why and embrace the process, that you’ll be prepared to enjoy this beautiful journey.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Kokosis: I’m trying to set boundaries. The hardest thing to do as a new attending is to say “no,” as there’s always the fear of not developing a robust presence. Equally hard is identifying the aspects of a practice that you really enjoy and pursue only those, rather than being spread thin between multiple, mundane tasks. I also try to enjoy my time off on weekends to rest and recharge. This way, I’m more focused and productive when I need to be.

PSR: WHAT WAS YOUR GREATEST, NON-MEDICAL CHALLENGE OF RESIDENCY? Dr. Kokosis: As a Greek national who immigrated to the United States, having my family living thousands of miles away has always been a big challenge. Time off during residency is limited and an international trip is hard to plan on a regular basis. I’m thankful for the opportunities I had to travel back to Greece, but also for the video and audio platforms that allowed me to “see” my family as often as I could.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Kokosis: I enjoy the creativity that comes along with complex reconstructive cases; so much planning goes into preparing for those cases. I also feel grateful to be able to collaborate with other specialties to tackle challenging problems and provide the best patient care possible. Additionally, I really enjoy scrubbing-in with my colleagues as co-surgeons and learning from each other.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU REGULARLY ENCOUNTER? Dr. Kokosis: I find challenging to keep up with EMR. I believe that physicians are already burdened with busy clinical practices, fully booked clinics and block time (for surgical specialties). The administrative burden that comes along with EMR can lead to burnout.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Kokosis: This is my time to “give back.” As a new attending, I appreciate even more the time that my mentors spent teaching

continued on page 31 Plastic Surgery Resident | Winter 2021

Chicago

By Elizabeth O’Neill, MD, MPH; Brandon Alba, MD, MPH; & Christina Tragos, MD

elcome to Chicago – one of the most vibrant and culturally diverse cities in the United States. As the third-largest city by population in the country and seated on the southwestern coast of beautiful Lake Michigan, Chicago has something to offer everyone. Chicago is probably most notably (and rightfully) regarded as one of the best “foodie ELIZABETH O’NEIL, MD cities” in the country, and Chicagoans feel very strongly about the caliber of restaurants in our city. “The City of Broad Shoulders” comes alive in the spring and summer with countless, BRANDON ALBA, MD fabulous outdoor activities throughout the city – and even in the fall and Chicago’s brutal winters, there are plenty of fantastic ways to spend time in CHRISTINA TRAGOS, MD the city, particularly in the many outstanding museums and arts venues. Here are just a few of our favorite things about Chicago 20

Plastic Surgery Resident | Spring 2022

– and a few of the ways we’d spend our time if we only had 24 hours in the Windy City.

OUR FAVORITE NEIGHBORHOODS

There are more than 77 unique and distinct communities within the Chicago city limits. Here are a few of our favorites.

West Loop and Pilsen A few blocks northeast of Rush’s main campus is the West Loop, one of the newest and fastest-growing neighborhoods in the city. The West Loop is best known as the food hub of the city, with a wide array of amazing cuisine. It’s also a great stop for shopping and nightlife. Walking just a few blocks south of the West Loop brings you to Pilsen, a historic neighborhood with rich cultural roots. Predominantly Latinoinfluenced, Pilsen is the best stop in town for all types of Latinx cuisine. While you’re there, check out the National Museum of Mexican Art. Greektown Another popular attraction quite near Rush is the famous Greektown, a quaint neighborhood on the West Side with streets lined with Hellenic ceramic work, Greek-inspired statues and a plethora of

eateries to indulge in authentic Greek cuisine. Diners here can enjoy their ouzo while being overpowered by the constant call of “Opa!” as another saganaki cheese dish is set afire. Walk-off the meal by visiting the National Hellenic Museum as well as the Taste of Greece festival, which will be held this year on Aug. 26-28.

Lincoln Park The Lincoln Park neighborhood is situated adjacent to the famous Lincoln Park itself. Presenting a more suburban feel within downtown Chicago, Lincoln Park is home to townhomes, condos and single-family homes, as well as urban restaurants, bars and shops. The Lincoln Park Zoo is a free treasure available to Chicagoans and visitors alike – and it’s a highlight of this family-friendly neighborhood. Andersonville This North Side neighborhood located just west of Lake Shore Drive’s northern terminus is well worth the short drive from downtown. Andersonville is woven with Scandinavian influences and home to New Age clubs, Swedish pastry shops and a vibrant LGBTQ+ social scene. It’s in close proximity to northern beaches and its quaint, hipster

vibe makes Andersonville a hidden gem of the city. No wonder Andersonville was voted No. 2 in Time Out’s “49 Coolest Neighborhoods in the World” in October 2021.

OUTDOOR ACTIVITIES Lakefront Trail Whether you enjoy a casual stroll, a leisurely bike or training for the Bank of America Chicago Marathon, the Lakefront Trail has something to offer everyone. The 18-mile, combineduse trail is diligently maintained and monitored, and it offers dedicated lanes for pedestrians as well as bikers. The trail provides access to many of the city’s most frequented Lake Michigan public beaches, as well as boat tours, viewpoints and restaurants. Millennium Park and Grant Park In the heart of downtown and right on the Lake Michigan shoreline, Millennium Park is an aesthetic and functional highlight of the city. Home of the iconic Cloud Gate (“Bean”) sculpture, it hosts countless free events throughout the summer, including concerts, movie viewings and concerts – including serving as the home base of Lollapalooza. This massive expanse – part of the 319-acre Grant Park – even boasts a massive, outdoor ice rink for fun in the winter. Festivals Chicago is famous for innumerable festivals held year-round, but

Cloud Gate, aka "The Bean," in Millenium Park

particularly in the summer when each neighborhood hosts its own unique event. When the snow melts and the weather’s warm, the city is packed with people hopping from neighborhood to neighborhood to explore. Some of the best (in our opinion) are Taste of Chicago in Grant Park; Chinatown Summer Fair in Chinatown; Chicago The Art Institute of Chicago Latin Jazz Festival in Humboldt Park; Fiesta del Sol in Pilsen; and, of course, the world-famous Lollapalooza. Lou Malnati’s Every Chicagoan has their own (very FOOD & DRINK stern) opinion on Chicago pizza. Here’s Any experienced Chicagoan will tell you the entire spectrum of pizza – from thin that any amount of time spent in our city crust Neapolitan-style to “fancy” fast is de facto centered around eating and food-style and traditional Chicago deep drinking. Here are some of our dish. Lou Malnati’s is an acknowledged favorite eateries: Chicago staple, with locations throughout the city. Lou Malnati’s even Monteverde makes frozen pizza that can be shipped Arguably serving the best Italian food worldwide (and often is). in Chicago, Monteverde is a true West Loop staple. Some people may say Gathers Tea Bar Monteverde is among the top restaurants There seems to be a national trend of any kind in the city. Famous for its toward increasing availability of boba handmade pasta and a bar where guests tea (aka, bubble tea) – and Chicago is can dine while watching the magic of the at the forefront of the boba explosion. pasta-making happen, Monteverde can Gathers Tea Bar is among the best boba suit any taste. Among the most famous spots in the city, hidden within a sushi dishes are the tried-and-true Burrata bar on Taylor Street in the city’s Little e Ham starter and the Gnocchetti con Italy neighborhood and within walking Pesto, but Monteverde boasts daily distance of Rush. Gathers is an on-call specials featuring local and seasonal staple for the in-house call teams at ingredients. Stroger Hospital of Cook County, and the pride these tea specialists take in Au Cheval their authentic boba tea is well-deserved. The best burger in town is quite possibly served at Au Cheval and is a must-try McDonald’s headquarters for anyone looking for a quintessential We know it sounds crazy to have taste of Chicago. McDonald’s on this list, but when the They don’t take global behemoth of a fast-food chain’s reservations, but world headquarters is in your city, you put your name just have to visit. The flagship brickdown and grab and-mortar location offers rotating a drink at any of international menus: Indian, Asian, the incredible bars Mexican, Eastern-European and many, along Randolph many more inspired dishes that are a Street while you must-try! wait.

continued on page 31 Plastic Surgery Resident | Spring 2022

Body Contouring (Part 1) By Anjali Raghuram, MD; Michael Hu, MD, MPH, MS; and Jeffrey Gusenoff, MD

he growth in popularity of body contouring procedures is partly attributable to an increasing number of massive weightloss (MWL) patients, who can achieve a reduction in up to 50 percent of their body weight through exercise, diet, bariatric surgery or a combined approach. In addition to MWL patients, others seek body contouring to treat anatomical deformities resultant from pregnancy or aging.1 Patients desire effective and safe removal of excess skin and fat. Given the woundhealing risks inherent to the MWL population2 – particularly for patients with greater than 100 pounds of weight loss – it’s important to appropriately select and preoperatively evaluate patients for their body-contouring procedure candidacy. As a result, this topic has become frequently tested on the In-Service Exam to ensure plastic surgery trainees are cognizant of the framework for treating these patients.

PREOPERATIVE PATIENT EVALUATION

ANJALI RAGHURAM, MD

MICHAEL HU, MD, MPH, MS

JEFFREY GUSENOFF, MD

This review will focus on preoperative patient evaluation, as well as upper-extremity and upper-trunk contouring. A second review in the next issue will include body-contouring procedures as they relate to abdominal, thigh, buttock and lower-extremity surgery.

Plastic Surgery Resident | Spring 2022

MWL results in redundant skin across the body, with patients frequently complaining of an inability to fit clothing properly, intertriginous rashes and infections from accumulated moisture, and the social stigma that accompanies their new appearances.3 Patient evaluation involves a detailed medical and surgical history, social history, relevant blood tests and imaging, and often collaboration with other surgical and medical providers. Contraindications such as tobacco use must be obtained. The history also includes inquiring about personal or hereditary cancers and screening, endocrinopathies and coagulopathies, which can subsequently direct patients to specialists for preoperative risk assessment. During the evaluation, patients should be assessed for their surgicaloutcomes expectations and their motivations in seeking these procedures. Evidence suggestive of body dysmorphic disorder from the patient interview warrants a psychiatric evaluation. In addition, it’s necessary to document stability of weight loss or gain, as patients should maintain a stable weight for at least three months preoperatively.1 Post-bariatric surgery patients should also be at least one year out from surgery. For these patients, particularly those who have had a Roux-en-Y gastric bypass, nutritional deficiencies should be addressed to optimize protein intake and ensure adequate levels of iron, zinc and the fat-soluble vitamins (A, D, E, K) for wound healing.1,3 During the physical exam, and as corroborated by relevant imaging, the presence of hernias and skin changes in the form of laxity, striae or intertriginous rashes can also be documented.4

UPPER-EXTREMITY CONTOURING

A recent study has revealed that the body-contouring procedures such as brachioplasty and breast lift have shown the most marked increase over the past two decades.5 When evaluating a patient for upper-extremity contouring, it’s useful to note skin quality and tone, and to perform a motor and sensory exam of bilateral upper-extremities.5 Arm bands should be noted preoperatively, as they often worsen after surgery.6 Importantly, patients should be counseled about the likelihood of postoperative scarring after brachioplasty and must be willing to accept this risk.

Figure 1. The anatomic relationship between the medial antebrachial cutaneous nerve and the basilic vein. Adapted from Almutairi K., Gusenoff JA., & Rubin JP. Body Contouring. Plast Reconstr Surg. 2016;137(3):586e-602e.

The brachioplasty approach is informed by skin quality, skin amount and adipose tissue quantity, enabling patients to be stratified into one of four groups as determined by the Teimourian classification system (Table 1).7 For patients who have a moderate excess of skin and adiposity with good skin quality, primarily and notably in the proximal one-third of the upper arm, a limited medial-incision brachioplasty or “minibrachioplasty” may be performed.5 In the case of most MWL patients, an extended brachioplasty is performed to correct significant skin laxity and achieve improved arm contour. Moreover, MWL patients will frequently require longitudinal scar brachioplasty, while short-scar procedures better serve the non-MWL patient population.1 TABLE 1: THE TEIMOURIAN CL ASSIFIC ATION* GROUP

DESCRIPTION

Minimal to moderate subcutaneous fat with minimal skin laxity

Generalized accumulation of subcutaneous fat with moderate skin laxity

Generalized obesity and extensive skin laxity

Minimal subcutaneous fat and extensive skin laxity

*Adapted from Teimourian B., Malekzadeh, S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545-551.

Technical pearls with any brachioplasty approach include avoiding injury to the medial antebrachial cutaneous (MABC) nerve, which travels in close proximity to the basilic vein (Figure 1), and avoiding excess skin resection that would lead to undue tension with wound closure. The former can be avoided by preserving a 1-cm cuff of fat over the deep fascia to prevent dissection-related nerve injury.

For patients with minimal skin laxity and mild to moderate adiposity, liposuction may be performed as a standalone or adjunct to traditional brachioplasty – often performed posteriorly to avoid the area of concomitant resection.8 As with brachioplasty techniques, liposuction should be performed above the deep fascial layer to avoid injury to the MABC, lymphatics and creation of contour irregularities.5

UPPER-TRUNK CONTOURING

Composed of multiple, interconnected subunits of mammary glandular and adipose tissue, the breast experiences increased adiposity with post-lactation or menopause-related glandular decrease. Further, breastfeeding, aging and skin changes from weight gain/loss can lead to decreased support of the soft tissues of the breast by attenuating fascial layers and the suspensory Cooper ligaments.5 MWL patients can present with deflated, ptotic breasts characterized by lack of lateral breast definition and superior pole deficiency. The nipple may also be displaced more medially and the inframammary fold (IMF) more inferiorly. Each of these anatomic changes poses a unique challenge for optimal breast contouring.

Plastic Surgery Resident | Spring 2022

For patients with mild deformities after weight loss, traditional mastopexy techniques with short scars can be offered. However, more-significant breast volume and ptotic changes – along with the often encountered axillary skin roll – are better corrected via dermal suspension and total parenchymal reshaping.9 Though this approach provides favorable results with respect to breast-tissue shape and the skin envelope, patients must be counseled preoperatively about scarring and longer operative times involved with extensive deepithelialization and intraoperative tailoring. Patients with insufficient volume may require an augmentation/mastopexy with implant but are at high risk of recurrent ptosis or implant malposition.10 TABLE 2: THE PIT TSBURGH WEIGHT LOSS SC ALE** GROUP

DESCRIPTION

Normal back contour

Excess adiposity or a single fat roll

Multiple skin and fat rolls

Ptosis of the fat rolls

**Adapted from Song AY., Jean RD., Hurwitz DJ., Fernstrom MH., Scott JA., & Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116:1535-1544.

Lastly, excess adipose tissue with skin laxity in the upper and middle back can be resultant from MWL or aging. The Pittsburgh Rating Scale for weight loss has been adopted to describe tissues of the posterior trunk (Table 2).4 These axillary and back rolls can be excised via a posterior midback or bra-line lift procedure. Patients may be counseled that scars after excision are created in either a transverse manner on the upper back, or as bilateral, longitudinal or oblique scars along the lateral chest.1 | Dr. Raghuram is PGY-1 and Dr. Hu is PGY-4 in the Integrated Plastic Surgery Residency Program, and Dr. Gusenoff is a professor of plastic surgery, at the University of Pittsburgh Department of Plastic Surgery. Part II of Body Contouring will appear in the Summer 2022 installment of PSR.

Plastic Surgery Resident | Spring 2022

REFERENCES 1.

Almutairi K, Gusenoff JA, Rubin JP. Body contouring. Plast Reconstr Surg. 2016;137(3):586e-602e. 2. Constantine RS, Davis KE, Kenkel JM. The effect of massive weight loss status, amount of weight loss, and method of weight loss on body contouring outcomes. Aesthet Surg J. 2014;34(4):578-583. 3. Beidas O, Gusenoff J, Manders E. Principles of plastic surgery after massive weight loss. In Thorne C, ed. Grabb and Smith’s Plastic Surgery. 8 ed. Philadelphia: Wolters Kluwer/Lipincott; 2019:2203-2225. 4. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116(5):1535-1544; discussion 15451536. 5. Colwell A, Phillips N. Brachioplasty and upper trunk contouring. In Thorne C, ed. Grabb and Smith’s Plastic Surgery. 8 ed. Philadelphia: Wolters Kluwer/ Lipincott; 2019:2299-2327. 6. Chen W, James IB, Gusenoff JA, Rubin JP. The constriction arm band deformity in brachioplasty patients: Characterization and incidence using a prospective registry. Plast Reconstr Surg. 2018;142(6):856e-861e. 7. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545-551; discussion 552-543. 8. Bossert RP, Dreifuss S, Coon D, et al. Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: is it safe? Plast Reconstr Surg. 2013;131(2):357-365. 9. Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J. 2006;26(2):214-222. 10. Coombs DM, Srivastava U, Amar D, Rubin JP, Gusenoff JA. The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient: Technical Considerations. Plast Reconstr Surg. 2017;139(5):1090-1099.

MENTORING A NEW GENERATION OF RESIDENTS IN HELSINKI, FINLAND By Virve Koljonen, MD, PhD, & Kaisu Ojala, MD, PhD

i‌nland’s Ministry of Social Affairs and Health in 2020 issued a new decree in medicine, in which specialist training was updated to be nationally uniform and knowledge-based. The residency still consists of periods in primary care, general surgery and plastic VIRVE KOLJONEN, surgery, but residents are now responsible MD, PHD for their surgical, clinical and theoretical skills. To benefit its residents, a system such as this requires specified learning objectives, functioning observation tools and facilitated feedback. Through continuous observation and competencebased assessment, this system is enabling professional growth and personalized KAISU OJALA, MD, PHD teaching. It also represents a challenge to Finnish healthcare to make already existing high-quality teaching visible and transparent.

A NEW GENERATION

In Helsinki, the rise of a new generation plastic surgery residents – “Generation Y” or millennials – has been recognized.1 We regard our millennial residents as significantly different from previous generations; they are tech-savvy and visual learners, sometimes with a shorter attention span and a stronger desire for feedback. We’ve changed our training and education accordingly, with great feedback from the residents. Our department score in the Clinical Learning Environment Supervision (CLES) query rose to 7.90 in 2021 from 7.71 in 2020 – and was markedly better than overall 7.03 score for Helsinki University Hospital.

HOW DID WE DO IT?

We established a mentoring program in 2021 to support professional growth and increase social cohesion in our department. Implementing this mentoring system was planned carefully, with the basics and benefits of mentoring thoroughly discussed with residents and consultants. We found strong opinions and even prejudices, but we eventually reached a pleasant and cooperative atmosphere. We decided that residents should choose their mentor, not the other way around. We base mentoring on volunteering and voluntary consultants wrote an introduction that gave insights into their ideas for mentoring. Our consultants really put themselves into this and introductions were outstanding! Of note, this is not customary in the Finnish culture. Residents were given the responsibility of organizing the appointments, bringing in the subject of each meeting and taking notes. We prepared a short guidebook to get the process started; however, there are no strict guidelines. We’ve scheduled two meetings per year, but we hope for more. After six months, we received very positive feedback – all 10 residents who started mentoring found the process useful and had booked several appointments. In addition, the mentors found the program necessary and rewarding on personal level. Furthermore, inspired by the mentoring program, some junior consultants have started mentoring processes on their own. We’ve received several inquiries from other specialties on how we succeeded, and we’ve shared our experiences. We can proudly say plastic surgery has become the pioneer of mentoring in Finland.

MENTORING

In addition to changes in clinical training, the new residency program underlines continuous professional development. The new skills-based training program obliges the mentoring system to support professional growth. Mentorship is a great tool for professional development and career success, as well as for personal development.2 Supportive mentorship affords higher job satisfaction, and it protects against burnout and increasing academic-surgery attrition rates.3 Since mentoring has not been common in the Finnish medical community, we faced a challenge.

continued on page 31 Plastic Surgery Resident | Spring 2022

Journal Club; 2022 Spring; (26)

1. A provider perspective of psychosocial predictors of upper-extremity vascularized composite allotransplantation success

Kinsley SE, Williams EE, Lenhard NK, Shah SB, Edwards RR, Katz JN, Talbot SG. J Hand Surg Am. 2021 Jul 12:S03635023(21)00280-X. Epub ahead of print. PMID: 34266683.

JOURNAL ARTICLES ON

VA S C U L A R IZ ED CO M P O S IT E A L LOT R A N S PL A NTAT I O N

OF THE

UPPER EXTREMITY By Saïd C. Azoury, MD; & L. Scott Levin, MD

he world’s first kidney transplant was performed in 1954 at Peter Bent Brigham Hospital, Boston, by Joseph Murray, MD, an American plastic surgeon. Ten years later, the first hand transplant was reportedly performed in Ecuador, but it failed due to irreversible rejection. In 1998, a second hand transplant occurred in Lyon, France – and it failed due to immunosuppression noncompliance. In 1999, the first successful hand transplantation occurred in the United States – and that transplant is still viable and functioning. Upper-extremity vascularized composite allotransplantation (VCA) has been criticized for its non-lifesaving nature. However, its potential for improved quality of life through the restoration of function, sensation and physical image cannot be ignored. It was initially and formally accepted that appropriate candidates for upper-limb transplantation should be ages 18-65; however, in 2015, the first bilateral pediatric hand-forearm transplant was performed on an 8-year-old African-American child who also was a prior kidney-transplant recipient. The team was led by this article’s senior author (L. Scott Levin, MD) and his colleagues at the Children’s Hospital of Philadelphia. Several years later, that same team coordinated successful bilateral upper-extremity transplantation in two patients across continental borders. The following articles provide a comprehensive summary of the current literature on advances made in upper-extremity VCA. 26

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Success in upper-extremity VCA relies on more than excellent surgical technique. The authors performed face-to-face interviews with VCA recipients and caregivers, and identified the following key factors as contributing to a successful patient experience: social support, realistic expectations about function and lifelong immunosuppression, and a positive perspective.

2. 18-month outcomes of heterologous bilateral hand transplantation in a child: A case report

Amaral S, Kessler SK, Levy TJ, et al.: Lancet Child Adolesc Health 2017;1:35-44. The world of VCA changed in 2015, when the first pediatric upper-extremity transplantion was performed in an 8-year-old boy and prior kidney transplant recipient. This article reviews in detail the first 18-month follow-up outcomes, post-transplantation immunosuppression and rejection episodes, as well as recovery of sensation and function.

3. Four-year follow-up of the world’s first pediatric bilateral hand-forearm transplants: Do they grow as expected?

Azoury SC, Milbar N, Kimia R, Nguyen JC, Othman S, McAndrew C, Kovach SJ, Carrigan RB, Steinberg DR, Bozentka DJ, Lin IC, Levin LS, Chang B. Plast Reconstr Surg. 2020 Dec;146(6):1325-29. PMID: 33234963. At the time of the first pediatric upper-extremity transplantation, little was known about the transplant’s potential for future growth. This study analyzes postoperative radiographs at one-, two-, threeand four-year follow-up under the supervision of a dedicated pediatric musculoskeletal radiologist, to determine total growth per year as well as contribution of growth from the distal versus proximal extremity. The authors not only demonstrated that the transplanted extremities grow, but they also found that they grow at rates similar to normal upper-extremities and that the majority of the growth is contributed by the proximal physis as one would expect.

4. 20-year follow-up of two cases of bilateral hand transplantation

Schneeberger S, Petruzzo P, Morelon E, Hautz T, Kanitakis J, Weissenbacher A, Messner F, Bernardon L, Seulin C, Berchtold V, Ninkovic M, Öfner D, Badet L, Gazarian A, Lanzetta M, Margreiter R, Dubernard JM. N Engl J Med. 2020 Oct 29;383(18):1791-92. PMID: 33113303 This article reports on the 20-year follow-up of two patients who underwent bilateral upper-extremity VCA by teams led by Raimun Margreiter, MD, of Innsbruck, Austria, and Jean-Michel Dubernard,MD, of Lyon, France. Induction and maintenance immunosuppression regimens are reviewed, and although patients experienced several rejection episodes, all were treated successfully. The authors summarize the risks and complications related to prolonged immunosuppression but also celebrate the patients’ sensorimotor recovery, their ability to perform activities of daily living and integrate into society, and mental-health benefits.

5. Estimation of health utility and quality-adjusted life years in bilateral hand transplantation: A time trade-off study Harijee A, Thankappan K, Sharma M, NageswaraRao NN, Patel T, Bhaskaran R, Raj M, Sundaram KR, Iyer S. Ann Plast Surg. 2021 Mar 1;86(3):345-350. PMID: 32881744.

Although much has been reported on the quality of life gained following upper-extremity VCA, few studies have evaluated the health utility and quality-adjusted life years gained by upper-extremity transplantation or prosthesis over amputation. The authors demonstrate that bilateral hand transplantation stands above amputation and prosthetics with regard to health utility.

6. The current outcomes and future challenges in pediatric vascularized composite allotransplantation

Azoury SC, Lin I, Amaral S, Chang B, Levin LS. Curr Opin Organ Transplant. 2020 Dec;25(6):576-583. PMID: 33044345. This article provides an overview of the progress made in pediatric VCA, with a focus on the first bilateral upperextremity transplant in an 8-year-old boy. The authors review current challenges unique to pediatric patients including informed consent, psychosocial implications, limited donor pool, compliance issues following the transplant, and prolonged immunosuppression and related risks given the younger age at transplantation.

7. Prosthetic rehabilitation and vascularized composite allotransplantation following upper limb loss Kubiak CA, Etra JW, Brandacher G, Kemp SWP, Kung TA, Lee WPA, Cederna PS. Plast Reconstr Surg. 2019 Jun;143(6):1688-1701. PMID: 31136485.

The decision to pursue prosthetic rehabilitation versus VCA following bilateral upper-limb amputation is very complex, particularly since both options have distinct limitations and benefits. This review provides a direct comparison of both VCA and prosthetic rehabilitation and concludes that both modalities should not be perceived as competing – but rather that either can be optimal for an individual patient depending on patient-specific risk-to-benefit considerations.

8. Clinical significance of alloantibodies in hand transplantation: a multicenter study

Berglund E, Andersen Ljungdahl M, Bogdanović D, Berglund D, Wadström J, Kowalski J, Brandacher G, Kamińska D, Kaufman CL, Talbot SG, Azari K, Landin L, Höhnke C, Dwyer KM, Cavadas PC, Thione A, Clarke B, Kay S, Wilks D, Iyer S, Iglesias M, Özkan Ö, Özkan Ö, Krapf J, Weissenbacher A, Petruzzo P, Schneeberger S. Transplantation. 2019 Oct;103(10):2173-82. PMID: 30817406. The relevance of donor-specific antibodies (DSAs) and related consequences specific to vascularized composite upperextremity transplantation continues to unfold. It’s known that DSAs negatively impact long-term success in solid organ transplantation. The authors present an impressive, tour du

force international, multi-institutional study assessing the occurrence and significance of antibodies in upper-extremity VCA, while discussing possible implications for clinical outcomes.

9. Upper-extremity transplantation using a cellbased protocol to minimize immunosuppression

Schneeberger S, Gorantla VS, Brandacher G, Zeevi A, Demetris AJ, Lunz JG, Metes DM, Donnenberg AD, Shores JT, Dimartini AF, Kiss JE, Imbriglia JE, Azari K, Goitz RJ, Manders EK, Nguyen VT, Cooney DS, Wachtman GS, Keith JD, Fletcher DR, Macedo C, Planinsic R, Losee JE, Shapiro R, Starzl TE, Lee WP. Ann Surg. 2013 Feb;257(2):345-51. A systematic review of electronic publications in PubMed, Scopus and Web of Science databases reviewing artificial intelligence (AI) in plastic surgery, highlighting important applications of AI in a variety of plastic surgery settings and describing their various applicability to plastics. Machine learning, deep learning, natural language processing, facial recognition and data processing are described in the article and help influence careers in plastic surgery.

10. An economic analysis of hand transplantation in the United States Chung KC, Oda T, Saddawi-Konefka D, Shauver MJ. Plast Reconstr Surg. 2010 Feb;125(2):589-598. PMID: 19910847; PMCID: PMC4387885.

Despite several decades of experience with upper-extremity transplantation, its economic impact remains largely unknown. This study evaluates the utility and cost of upper-extremity VCA, as well as the use of hand prostheses for forearm amputation. The authors demonstrate that while prosthetic use is favored for unilateral hand amputation over upper-extremity VCA, bilateral upper-extremity VCA is favored over prosthetics for bilateral amputees.

ADDITIONAL READING Successful transatlantic bilateral hand transplant in a young female highly sensitized to HLA class II antigens

Azoury SC, Johnson FB, Levine M, Veasey S, McAndrew C, Shaked A, Lantieri L, Kamoun M, Levin LS. Transpl Immunol. 2021 Apr;65:101377. Vascularized composite allografts are more susceptible to rejection than other type of organ transplants. This is even more of a concern in upper-extremity transplantation, given the highly antigenic nature of skin and the multiple tissue types of various embryonic origin (i.e., muscle, bone). This concept becomes particularly relevant in sensitized recipients. This article describes a successful hand transplant in a woman highly sensitized to class II HLA antigens. The authors describe the process of donor selection, ethical considerations, rejection surveillance, and recovery of sensibility and function.

continued on page 31 Plastic Surgery Resident | Spring 2022

PLASTIC SURGERY PERSPECTIVES – PART III

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

Interview by Stav Brown, MD Research Fellow Memorial Sloan Kettering Cancer Center Shai Rozen, MD Dr. Rozen is professor, vice chair, microsurgery Fellowship director and head of clinical research, Department of Plastic Surgery at the University of Texas Southwestern (UTSW) Medical Center, Dallas, and director of the UTSW Facial Paralysis Clinic.

PSR: WHY DID YOU CHOOSE PLASTIC SURGERY – AND MICROSURGERY IN PARTICULAR? Dr. Rozen: It wasn’t straightforward. I was convinced during medical school that my path was cardiac surgery. I worked in the cardiac ICU, cardiac step-down unit and cardiac rehab, and my thesis was on the subject. Luckily, during those years I had the opportunity to rotate in plastic surgery and thoroughly enjoyed it. Still, I was certain in my plan to be a heart surgeon. Only during my early years in general surgery training at Johns Hopkins – after speaking to several cardiac surgeons and understanding the paradigm shifts occurring in that field – did plastic surgery resurface strongly. It had all the components I wanted: creativity, problem-solving at its 28

Plastic Surgery Resident | Spring 2022

core, the ability to work on both adults and children, and the options of connecting small vessels (even smaller than those in heart surgery). No less important, plastic surgery provided me the autonomy I really wanted. I’m an academic surgeon and truly enjoy it, but I’ve learned that in life, so many things are out of our control. If I wasn’t happy in a large system and my place in it, I could always opt-out and create my practice, without the need for a cardiac bypass machine and team. Plastic surgery allowed me options and flexibility. My path to microsurgery wasn’t so direct, either. I was always interested in all aspects of facial reconstruction – the soft tissue and bony aspects. I was lucky to have great mentors who were passionate about what they did and not only experts in facial surgery, but also in microsurgery, peripheral nerve and aesthetic surgery. Naively, when I took my first job, I thought most of what I’d be doing would be facial reconstruction. It doesn’t work that way (at least for me it didn’t). You initially do everything that comes your way and slowly create something you’re passionate about if it doesn’t exist. The great thing about microsurgery is that it’s an instrument that provides the surgeon an enormous degree of reconstructive flexibility when more traditional techniques are limited. Because I needed to hone this tool for things I wanted to do, I became more immersed in it. That said, I believe microsurgery is a means to an end – but not the end, and it shouldn’t replace basic tenets of reconstructive and aesthetic surgery.

PSR: HOW HAS MICROSURGERY CHANGED SINCE YOU STARTED? Dr. Rozen: Dramatically. Several areas have truly evolved: The entire field of vascularized composite allotransplantation (VCA) has emerged, lymphatic surgery has evolved, replantation surgery has taken new directions with more aggressive approaches to salvage extremities, and the

evolution in thinking from angiosome to perfasome opens new opportunities. Although not microsurgery per se – but resulting from the understanding the VCA’s current limitations – we’re seeing incredible work being done in the areas of neural prosthetic interfaces. That’s the great thing about science: You might know where you start, but not where you end. Additionally, surgeons are becoming more technically efficient, using pre- and intraoperative imaging to assist in decision-making, microscopes have improved and even the instrumentation has become finer. Also, judicious use of cautery during dissection has increased to shorten operative times.

PSR: WHAT ARE YOUR MAIN INTERESTS WITHIN MICROSURGERY? Dr. Rozen: I don’t know if I can point to a certain field; I look at microsurgery more as a surgical tool and reconstructive philosophy. That said, over the years I’ve gained experience and interest in the facial paralysis patient population, who pose both reconstructive and aesthetic challenges that necessitate the use of microsurgery, peripheral nerve surgery and aesthetic procedures to obtain optimal results. That’s challenging and satisfying, and we have quite a few unresolved problems that beg solutions in this group. I continue to very much enjoy taking care of patients with breast cancer, facial deformities, specific challenging peripheral nerve problems and certain aesthetic procedures that coincide and complement my reconstructive practice. As for my clinical research, the majority of it concentrates on facial paralysis.

PSR: TELL US ABOUT A CASE THAT’S INFLUENCED YOU. Dr. Rozen: In general, the cases that have influenced me most were failures. That’s when you step back and objectively evaluate what you did, what you would’ve changed and what you’ll do in the future. Those are definitely periods of growth. Other equally memorable and significant cases are those in which standard approaches won’t work and you need to think outside of the box to provide solutions. The best scenario is if I come up with a solution. The second-best is when I have to “steal” a solution from a colleague who beat me to it, after hearing it in a conference or while visiting them in their center. That’s the great thing in our field – you constantly learn from your colleagues. For me, this usually involves going to the anatomy lab, doing a few dry runs with small adjustments and then implementing it in the O.R. These rare moments are even more exciting when you know that if they succeed, they might open a new avenue of treatment for other, similar patients.

PSR: WHAT ROLE DOES TECHNOLOGY PLAY IN MICROSURGERY? Dr. Rozen: Technology plays an important adjunct role in microsurgery but certainly doesn’t replace good

clinical judgment and decision-making. The main areas in which technology contributed most are preoperative and intraoperative imaging that mainly contributed to vascularpattern assessments and often expedited dissections; computeraided design and models especially in head and neck cases; and high-resolution microscopes especially in areas as lymphatic surgery. It’s important to emphasize that many of these cases were performed expertly by surgeons prior to the advent of these technologies, which reminds us that technology helps in decision-making but doesn’t make decisions.

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF MICROSURGERY? Dr. Rozen: One of the most exciting areas is VCA. Although I’m not directly involved in the area, I believe that once the immunologic challenges are overcome, the area will experience enormous expansion secondary to an increased donor-tissue pool and elimination of patient-donor site morbidity. This will also further push researchers to overcome the second-most difficult challenge: successful and effective motor and sensory renervation. Indirectly, two other non-microsurgery-related fields will further develop in parallel: neural prosthetic interfaces, especially in extremity surgery, and tissue engineering combined with 3D printing. I’ll gamble to say that the former will develop several decades prior to the latter, but subsequently that both will be used more routinely.

PSR: WHAT’S YOUR ADVICE FOR A RESIDENT INTERESTED IN A MICROSURGERY FELLOWSHIP? Dr. Rozen: Scrub-in as many possible cases and evaluate whether you enjoy it. If you enjoy it – do it! The rest is less important. Also, prepare for each case as though it was your own, create your own detailed plan and compare it to what you ended up doing. This will both improve your skills and encourage you to think – you’ll learn that different valid solutions exist to the same problem. Also, attend an American Society for Reconstructive Microsurgery or World Society for Reconstructive Microsurgery meeting to see if you feel good and excited about what you hear from colleagues and experts. Anyone who’s hungry to innovate, to improve patient care, is continuously curious and likes problem-solving will be a good candidate for a microsurgery Fellowship. Obviously, they should be technically good, be able to endure and persevere when needed, and have good common sense and clinical judgment. Subsequently, I think the motivation should be how to optimize patient outcomes at all levels: function, aesthetics, efficiency and safety. |

Plastic Surgery Resident | Spring 2022

COMPLEX CASE CHALLENGE

Editor’s note: Welcome to another edition of our Complex Case Challenge, also known as “C3,” wherein we present a challenging case to get your reconstructive mind working! Read on, and you’ll find a challenging clinical vignette along with several options for reconstructive solutions. Make note of your choice – and make sure you read the next issue of Plastic Surgery Resident to see the author’s ultimate management of this case.

PATIENT PRESENTATION

YOUR OPTIONS FOR CLOSURE

A patient who was referred to you by neurosurgery colleagues arrives in clinic for plastic surgery closure prior to spinal surgery. The patient is a 35-year-old male with a history of a thoracic spinal sarcoma that was initially resected in 2012, followed by cervicothoracic fusion and chemotherapy/ radiation. The patient underwent multiple additional spinal surgeries – including a resection for recurrence in 2018 complicated by a wound infection – as well as multiple hardware revisions. Prior plastic surgery closures included bilateral paraspinous flaps and a right trapezius flap.

Primary closure

Pedicled right latissimus flap

Free omental flap to intercostal vessels

Free right latissimus flap to transverse cervical vessels

Left trapezius muscle flap

The patient is stable with a good prognosis from a cancer standpoint, but he now presents with fractures in two of the four rods, and they require replacement. On exam, very thin skin is present, and radiation changes overlay the protruding rods (see image). There’s a paucity of muscle in the region, and an old surgical scar overlays the left scapula with no contraction of the left latissimus. The right latissimus contracts on exam. The patient enjoys running and would like to avoid any donor sites outside the back. How would you close the wound after neurosurgery performs a rod exchange?

Choose your preferred reconstruction method and stay tuned for the next edition of PSR for the results of the survey – and to see how this case was managed by the treating surgeon. | This patient was treated by Robert Galiano, MD, associate professor in plastic and reconstructive surgery at Northwestern Memorial Hospital, Chicago. Photos courtesy of Northwestern Memorial.

Anyone with a complex case they would like to feature in PSR should contact Medical Editor Russell Ettinger, MD, at retting@uw.edu.

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FACULTY FOCUS / continued from page 19 me, and I feel obliged and inspired to dedicate my time to teaching my residents now. It’s very gratifying to see your residents evolve over time and grow professionally.

PSR: DO YOU HAVE ANY WORDS OF ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Kokosis: Look at the big picture and enjoy the journey. With every challenge comes experience and skills that you will possess for the rest of your career.

PSR: PLEASE COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN …” Dr. Kokosis: I witnessed a plastic surgeon being the surgeon`s surgeon in a complex orthopedic surgery procedure that required wound coverage with a free flap. |

24 HOURS / continued from page 21 ARTS & CULTURE

The Art Institute of Chicago The Art Institute is one of the most iconic cultural points of Chicago. Offering exhibits from 3,000 B.C. to contemporary works, the Art Institute hosts countless, priceless works of art to suit any artistic palette. The institute is also known for rotating exhibitions and events, and it recently hosted the Monet exhibition and the Obama portraits – and the Cezanne exhibition is slated to run May 15-Sept. 5. Green Mill Green Mill is a famous jazz bar on the city’s North Side that offers an unforgettable night. Pull up to the bar, order a cocktail and sit just feet away from some of Chicago’s finest jazz artists as they perform jaw-dropping live shows. The Second City Chicago is home to The Second City, the world’s premiere comedy training center. The Second City has played host to many of the world’s famous comedians and offers an abundance of cabaret, improv and comedy shows all year long. Some of the “greatest of the great” received their comedy training and have performed here: Tina Fey, Bob Odenkirk, Chris Farley, John Belushi, Steve Carell, Stephen Colbert and more. |

Journal Club / continued from page 29 Logistics in coordinating the first adult transatlantic bilateral hand transplant: lessons learned

Ben-Amotz O, Kruger EA, McAndrew C, Lantieri L, Bozentka D, Steinberg D, Chang B, Levin LS. Plast Reconstr Surg. 2018 Sep;142(3):730-35. Success in VCA requires a multidisciplinary, intraoperative approach but also vigilant postoperative care to ensure compliance with rehabilitation and immunosuppression, and close rejection surveillance and treatment. This process becomes exceedingly complex when coordinating care overseas – an important concept given the limited access to VCA care for potential candidates worldwide. The authors describe the first transatlantic transplantation and related logistics. | Dr. Azoury is a clinical Fellow in microsurgery in the Division of Plastic Surgery, Department of Surgery at Memorial Sloan Kettering Cancer Center, New York; Dr. Levin is professor and chair of the Department of Orthopedic Surgery and co-director of the Penn Nerve Center at the University of Pennsylvania.

A NEW GENERATION / continued from page 25 We believe the keys of our success to this point are voluntary consultants who are eager to show the other side of their personality apart from work; the freedom of the residents to choose their mentors; strong guidelines; and a flexible, tailor-made program. | Dr. Koljonen is a professor and director of the plastic surgery residency program, and Dr. Ojala is academic adviser for plastic surgery residents, at the University of Helsinki. REFERENCES 1. 2.

Koljonen V, Lassus P. Training the generation Y plastic surgeon. J Plast Reconstr Aesthet Surg. 73(10):1897-1916, 2020 Myers P, Amalfi A, Ramanadham SR. Mentorship in plastic surgery: A critical appraisal of where we stand and what we can do better. Plast Reconstr Surg. 148: 667, 2021 Lin J, Reddy R.M. Teaching, mentorship, and coaching in surgical education. Thorac Surg Clin 29.3: 311-320, 2019

Dr. O’Neill is PGY-2 and Dr. Alba is PGY-3; and Dr. Tragos is an assistant professor in the Division of Plastic Surgery; at Rush University Medical Center. Plastic Surgery Resident | Spring 2022

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