Plastic Surgery Resident, Winter 2020 by PlasticSurgeryNews

ISSUE 21 | WINTER 2020

From the publishers of Plastic Surgery News

» Centennial

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

» Residents Bowl 2020: Two views, one victory

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

Figuring out your finances A primer for residents to set them on a path of financial security page 4 IN THIS ISSUE » Consult Corner: Orbital floor fracture p. 11 » Program Peek: Cleveland Clinic Department of Plastic Surgery p. 17 » What I know now that I wish I knew then: International Edition p. 30

A note from the editor

Sanjay Naran, MD Chief Medical Editor

Plastic Surgery Resident Chicago

elcome to the Winter 2020 issue of Plastic Surgery Resident.

I’d first like to thank the outgoing resident editors Roger Cason, MD (Duke); Aaron Kearney, MD (Northwestern); Elizabeth Kiwanuka, MD (Brown); and Mélissa Roy, MD (Canada), for all of your hard work over the past year. We welcome a new crop of resident editors: Janak Parikh, MD (Houston Methodist); Matt Pontell, MD (Vanderbilt); Elie Ramly, MD (OHSU); and Konstantinos Gasteratos, MD (Greece). We also welcome Lisa Gfrerer, MD, PhD (Harvard), who is your new Resident Representative to the ASPS/PSF Board of Directors – and she serves as Senior Resident Editor. In this issue, she shares what she hopes to achieve during her term as Resident Representative. Lisa is your voice within ASPS/PSF; be sure to reach out to her directly with any feedback, concerns or ideas. Along with some of our recurring pieces, we feature international perspectives from Greece and France on how COVID-19 has impacted plastic surgery training in those countries. We highlight the Cleveland Clinic’s stellar training program and faculty. Their residents also share their recommendations on how to spend a day enjoying the best of Cleveland. We also congratulate Washington University in St. Louis on celebrating the centennial of its Plastic and Reconstructive Surgery program. This issue features a timely cover article in the continued midst of a pandemic and difficult economic times. As surgical trainees, we often default to continuing to defer responsibilities other than our surgical education. This piece emphasizes that a strong financial plan is important to implement early to ensure long-term security and wellbeing, and outlines the steps needed to make it happen. Last but not least, we recap the exciting 2020 Residents Bowl with pieces from one of the moderators – and from the ultimate victors from Pitt Plastic Surgery. Hail to Pitt! Thank you to you, our readers, and to our team of editors and the ASPS production staff. We hope you enjoy the read! |

Plastic Surgery Resident | Winter 2020

Table of

Contents Financial growth and stability in residency......................... 4 It may seem out of reach, but a forward-looking approach and discipline can help residents save for the future without sacrificing present comforts.

Washington University in St. Louis at 100........................... 8

A historical perspective of this venerable institution that’s been led by – and has created – legendary leaders in plastic surgery.

Consult Corner: Orbital floor fracture.................................. 11

Patients with these fractures are also trauma patients to a great degree, so the initial examination is important in these complex cases.

InService Insights: Breast anatomy, physiology and breast reduction.......... 14 Key concepts of reduction mammaplasty are addressed, with focus placed upon understanding breast anatomy and physiology.

Program Peek: Cleveland Clinic........................................... 17 After its 1921 founding, Cleveland Clinic went on to develop its influential Department of Plastic Surgery – and a respected residency program.

Message from the Director: Steven Bernard, MD............ 19 Since launching its residency program, Cleveland Clinic has trained more than 75 plastic surgeons using a “balanced” approach.

Faculty Focus: James Zins, MD .......................................... 20 The chairman of the Department of Plastic Surgery brings his influence to resident clinics, workshops and research – through an “open door” policy.

24 Hours In: Cleveland......................................................... 23 While Cleveland is known for its sports teams and the Rock & Roll Hall of Fame, it offers plenty more in the way of food, adventure and entertainment.

University of Pittsburgh takes Residents Bowl 2020..... 26 Seasoned competitors mixed with diverse and solid performers led Pitt to its first title in the 10-year history of the Residents Bowl.

Residents Bowl moderator: Inside perspective from Edward Davidson, MD.............. 27 The intensity of the participants and various team supporters create an unpredictable and hard-fought scholastic contest.

Residency and COVID-19: What’s happening in France.... 28 Elise Lupon, MD, describes the profound effect the pandemic has exerted upon training – and which is only abating by degree.

What I Know Now: International edition........................... 30

Plastic Surgery Resident | WINTER 2020 | Vol.4 No.4 The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities. A SPS PR ESI DEN T Joseph Losee, MD | Joseph.Losee@chp.edu EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com ASSOCI ATE EDITORS Russell Ettinger, MD | retting@uw.edu Kavitha Ranganathan, MD | kranganathan925@gmail.com J U NIOR ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com SEN IOR R ESI DEN T EDI TOR Lisa Gfrerer, MD, PhD | lg frerer@partners.org R ESIDENT EDITORS Janak Parikh, MD | janak.parikh@gmail.com Matt Pontell, MD | matthew.e.pontell@vumc.org Elie Ramly, MD | elie.ramly@gmail.com I N T E R N AT I O N A L R E S I D E N T E D I T O R Konstantinos Gasteratos, MD | kgasteratos1@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org A S S O C I AT E E D I T O R Kendra Y. Mims | kmims@plasticsurgery.org GR A PHIC DESIGN ER Elena Bragg

Jens Berli, MD, describes the long and winding road he’s traveled as an International Medical Graduate.

A DV ERTISING SA LES Joe Anzuena (215) 521-8532 | Wolters Kluwer Health

Residency in Greece: Challenging, but worth the fight ... 33

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.

Konstantinos Gasteratos, MD, faces situations while training in Greece that may be exclusive to that country – especially during a pandemic.

ASPS Resident Representative: Recognizing international opportunities ...........................34 Lisa Gfrerer, MD, PhD, plans to work with the Resident Council to expand the diversity of residents and increase ASPS influence.

Resident Ambassador: Prevailing in a time of challenge... 35 David Hill, MD, knows that change is coming with a new U.S. administration – and that PlastyPAC is poised to not miss an advocacy step.

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

Plastic Surgery Resident | Winter 2020

Achieving financial wellness

A primer for early financial security for plastic surgery residents PGY 1-6

ISTOCK

By Andrew Pelletier

Plastic Surgery Resident | Winter 2020

ecoming a plastic surgeon involves a long journey marked by the increasing financial burden associated with the pursuit of medical education. Upon finishing medical school, most doctors have accrued a high amount of debt.1 The Association of American Medical Colleges reported that 73 percent of medical school graduates in 2019 had $200,000 or more in personal debt, and 18 percent owed more than $300,000.2 Because of the long duration of plastic surgery residency, trainees face unique financial challenges. Residents often must contend with salaries far below the average for others with professional degrees – and lower than other healthcare professionals such as registered nurses and advanced mid-level providers.3,4 Worsening financial conditions contribute to the overall stress of residency, and studies have shown that financial stress contributes to burnout.5,6 Collier, et al., surveyed residents on financial stress and found that higher levels of debt were associated with increased levels of depressive symptoms.7 Although plastic surgeons can earn substantial income following their training, discretionary income is limited during residency, which puts them at risk for financial stress and burnout.8 Financial wellness can help alleviate life and work-related stressors.9,10 Fortunately, plastic surgery residents can achieve financial wellness while also preparing for life as an attending by developing the financial habits listed below.

PGY-1: BUILD A BUDGET AROUND YOUR LIFESTYLE

For many plastic surgery residents, PGY1 is when you get your first paycheck as a physician. According to the 2020 Medscape Resident Salary and Debt Report, the average resident salary in 2020 is $63,400, which after-tax and other withholdings reduce to 75-80 percent, depending on geography.11 During your first year of residency, it’s essential to set a budget to cover all expenses and, ideally, begin to save for the future without falling into further debt. Categorizing your housing costs, utilities, food, transportation, debt repayment and savings will reveal your fixed expenses. The remaining amount is referred to as discretionary income and is used to cover your variable living expenses. There are many online resources and mobile applications that can be used to track your monthly expenses and categorize them, and even provide recommendations for areas to reduce cost and increase savings.12

PGY-2: MANAGING YOUR STUDENT LOANS

As a PGY-2 resident, you need to address your outstanding student loans. The Public Service Loan Forgiveness (PSLF) program was established in 2007, and debtors who work for government organizations, 501(c)(3) organizations or non-profit organizations can enroll in an income-driven repayment plan.13 The PSLF program allows residents to make payments toward the 120 repayments needed to have their federal student loans forgiven. Because plastic surgery residency is six years in addition to one year of possible Fellowship, only three to four years of repayment would be made as an attending. However, it’s crucial to keep a record of all eligible payments made, so that no issues arise at the time of debt forgiveness. It’s recommended that you annually submit the PSLF Employment Certification Form, thereby documenting your qualifying your payments.14

Most student loans are not one large loan, but rather a collection of smaller loans through one or more lenders. Since the PSLF only applies to loans from the federal government, one strategic decision for residents who intend to remain in a non-profit setting is consolidating their loans into a single federal loan. Despite the higher interest rate federal loans tend to carry compared to private loans, federal loans allow you to remain eligible for PSLF.

PGY-3: PLANNING FOR YOUR RETIREMENT

Although you’re only halfway through your residency, PGY-3 is an excellent year to start planning for your retirement. In some plastic surgery programs, residents can participate in their employer’s pretax workplace retirement plan (401K or 403B). These plans, which are sponsored by the employer, usually have mutual fund investment options, and your hospital’s human resources department will have institution-specific information about that. As a result of these plans being pretax, you can invest dollars that haven’t yet been reduced by taxes. For example, if $100 from your bi-weekly salary of $1,600 is withheld from your paycheck and invested in your retirement plan, income tax is only paid on $1,500. So even if your retirement plan grows at the same return rate as a non-qualified account, you will have invested a higher amount – since taxes were not deducted. Over the course of your career, this can result in a much higher investment account balance. Upon leaving your employer, these pretax retirement plans can be rolled-over into your new workplace plan or consolidated into an IRA. Understanding your options and the tax implications that go along with them will optimize your longterm financial growth.

Plastic Surgery Resident | Winter 2020

FINANCIAL SECURITY / continued from previous page PGY-4: TAKING ADVANTAGE OF LIMITED INCOME

By the time you become a PGY-4 resident, you’re likely familiar with delayed gratification – and Roth IRAs embody that principle. A Roth IRA is an individual retirement account that allows you to accumulate tax-deferred investments. But unlike other retirement accounts, a Roth IRA allows for tax-free withdrawals after the age of 59.5. In addition, Roth IRAs are versatile, allowing you to choose between stocks, bonds, mutual funds, exchange-traded funds, real estate, certificates of deposit, promissory notes and more.15 The limitation of this account type is that Congress has limited who can contribute to a Roth IRA based upon income. In 2020, the maximum allowed yearly income is $124,000 if filing single, and $206,000 if filing jointly.16 Therefore, residency is likely the only time a plastic surgeon can take advantage of the Roth IRA. In addition, the maximum contribution allowed per year is $6,000. Assuming a 6 percent internal rate of return, the account’s value at the end of a six-year residency program would be approximately $41,000. After 30 years, even without additional deposits, it would have grown to nearly $136,000, all of which is tax-free. The Roth IRA is a great way to get started with good investing habits and with little to no maintenance.

PGY-5: EXPECTING THE UNEXPECTED

For many plastic surgery residents, PGY-5 is a year marked by planning for your next job – a process that includes Fellowship applications, interviews and the costs associated with all of these. Your savings, which primarily has been your emergency fund until now, will likely now double as your Fellowship fund. An emergency account protects you if something should happen to your main income stream. This account ensures that expenses can be paid on time, thus avoiding any negative credit-report marks and further debt. As a rule of thumb, you should have at least three to six months of expenses saved in your emergency fund. At this point in your training, Fellowship interviews will require travel and accommodations including, but not limited to, flights, ground transportation, hotels and food. All are deemed necessary for your career development; this is an excellent use of your emergency account, as it allows you to invest in your future.

Plastic Surgery Resident | Winter 2020

PGY 6: INSURING YOUR FUTURE

As a plastic surgery resident, your most valuable assets are your education and future income potential. By reaching your final year of residency, you’ve invested in your education and postponed the accruement of wealth. Although your future is bright, any negative impact on your health (e.g., disease, physical or mental disability) can jeopardize your assets. Investing in a disability insurance policy protects your investments. Group and personally owned disability insurance policies are designed to replace your earned income with a monthly benefit in the event of your becoming disabled for longer than 90 days. Group insurance is often offered through your employer, and although it may be less expensive, it’s typically more limited in coverage. Obtaining a personal disability insurance policy as a resident might give you access to better overall policy. Completing a policy as a resident will result in a lower premium, as the rates are directly based on your age, health and specialty. At a minimum, residents should consider a base policy that includes a future purchase-option rider. This allows you to increase your coverage by providing proof of income without any additional testing, and owning this policy earlier in life will protect you against unforeseeable health problems that could increase your rates. Residency is often the last opportunity for you to obtain a disability insurance policy both at a group discount rate and with “starting professional” guidelines, where you may be eligible for enhanced coverage based on your anticipated income. After this “starting professional” period ends, your coverage eligibility is based solely on your income at that moment in time. As for the group rates: Many medical facilities offer their employees discounted premiums on personally owned disability insurance policies. These group rates are usually tiered, and you could benefit from a significant discount by applying for insurance while you’re an employee of a large facility. Where an emergency account protects against a temporary loss of steady income, disability insurance protects your most valuable assets: your surgical education and your anticipated future income.

FINAL THOUGHTS

After successfully completing your plastic surgery residency, you’re finally an attending. By implementing good financial habits as a resident, you’ve maximized your resources and set yourself up for a successful future as a plastic surgeon. |

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Orthopedic Surgery Resident Debt Load and Its Effect on Career Choice. J. P. Johnson, D. B. Cassidy, J. N. Tofte, J. T. Bariteau, A. H. Daniels. Orthopedics 2016;39:e438-443. The Association of American Medical Colleges. The Association of American Medical Colleges Data and Reports. Available at: https://www.aamc.org/datareports. Accessed 11/03/2020 2020. Financial crisis for medical students and residents. A. Heins, C. Keehn. Ann Emerg Med 2003;41:733-735. Over Worked and Under Paid: How Resident Finances Impact Perceived Stress, Career Choices, and Family Life. A. Kovar, H. Carmichael, B. Harms, M. Nehler, S. Tevis. J Surg Res 2020;258:82-87. Effect of educational debt on career and quality of life among academic surgeons. M. R. Kibbe, C. Troppmann, C. C. Barnett, Jr., et al. Ann Surg 2009;249:342-348. Influence of Student Loan Debt on General Surgery Resident Career and Lifestyle Decision-Making. K. Gray, A. H. Kaji, M. Wolfe, et al. J Am Coll Surg 2020;230:173-181. Stress in medical residency: status quo after a decade of reform? V. U. Collier, J. D. McCue, A. Markus, L. Smith. Ann Intern Med 2002;136:384-390. Five Financial Pearls for Medical Students, Residents, and Young Surgeons. L. H. Poppler, K. Sharma, D. W. Buck, T. M. Myckatyn. Plast Reconstr Surg Glob Open 2019;7:e1992. Personal Finance Education for Residents: A Qualitative Study of Resident Perspectives. E. Shappell, J. Ahn, N. Ahmed, I. Harris, Y. S. Park, A. Tekian. AEM Educ Train 2018;2:195-203. Anesthesiology residents' medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey. J. W. Steiner, R. B. Pop, J. You, et al. Anesth Analg 2012;115:170-175.

11. 12. 13. 14. 15. 16.

Medscape Residents Salary & Debt Report 2020. Available at: https://www. medscape.com/slideshow/2020-residents-salary-debt-report-6013072. Accessed 11/3/2020 2020. Toward a Resident Personal Finance Curriculum: Quantifying Resident Financial Circumstances, Needs, and Interests. R. McKillip, M. Ernst, J. Ahn, A. Tekian, E. Shappell. Cureus 2018;10:e2540. Federal Student Aid. Federal Student Aid Available at: https://studentaid. gov/manage-loans/forgiveness-cancellation/public-service. Accessed 11/3/2020 2020. Association of American Medical Colleges. Consolidating your federal student loans. Available at: https://students-residents.aamc.org/financial-aid/ article/consolidating-your-federal-student-loans/. Accessed 11/3/2020 2020. Roth IRAs. Available at: https://www.irs.gov/retirement-plans/roth-iras. Accessed 11/3/2020 2020. Amount of Roth IRA Contributions That You Can Make for 2020. Available at: https://www.irs.gov/retirement-plans/plan-participant-employee/ amount-of-roth-ira-contributions-that-you-can-make-for-2020. Accessed 11/03/2020 2020.

Mr. Pelletier is a wealth management advisor at Barnum Financial Group. Representatives do not provide tax and/or legal advice. Any discussion of taxes is for general informational purposes only, does not purport to be complete or cover every situation, and should not be construed as legal, tax or accounting advice. Clients should confer with their qualified legal, tax and accounting advisors as appropriate. Securities and investment advisory services offered through qualified registered representatives of MML Investors Services, LLC. Member SIPC. (www.SIPC.org) 6 Corporate Drive, Shelton, CT 06484, Tel: 203-513-6000 CRN202211-274201

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C E N T E N N I A L C E L E B R AT I O N

WASHINGTON UNIVERSITY PLASTIC AND RECONSTRUCTIVE SURGERY RESIDENCY:

100 YEARS and COUNTING By Alison Snyder-Warwick, MD, & Keith Brandt, MD

s 2021 begins and we reflect on 2020 and its many challenges, we relish the opportunity to focus on a positive highlight: the 100th birthday of the Plastic and Reconstructive Surgery Residency (PRS) Training Program at Washington University (Wash U) in St. Louis.

This ripe environment, Dr. Blair’s brilliance and dedication to teaching and fostering the development of the specialty, and Evarts Graham, MD, a supportive Wash U chairman of Surgery, all contributed to not only the founding of the plastic surgery residency training program at the university, but also to the development of our specialty as a whole.

Vilray Blair, MD, was selected by the U.S. Surgeon General to head the Section of Oral and Plastic Surgery in the U. S. Army and chief consultant in maxillofacial surgery with the American Expeditionary Forces during World War I. When he returned to St. Louis from the war, Dr. Blair devoted his practice exclusively to the reconstruction of head and neck. His war experience coupled with the publication of his book, Surgery and Diseases of the Mouth and Jaws, made him the authority on facial reconstruction. Starting in 1920, surgeons from the U.S. and abroad traveled to Wash U to train with Dr. Blair.4

The Division of Plastic and Reconstructive Surgery at Washington University has been led by only six

The rich training environment blossomed from the union of Wash U and Barnes Hospital on Oct. 28, 1911 – a collaboration forged from the need for Wash U to rectify a suboptimal review by the 1909 Flexner Report and the desire by Robert H. Barnes, a wealthy St. Louis businessman, to build a state-of-the-art medical center to help heal the losses of his two children due to an unknown illness. The partnership fostered rapid systemic improvements, which led Flexner to rate Barnes Hospital as one of the nation’s best by 1915.3 8

Plastic Surgery Resident | Winter 2020

chiefs: Dr. Blair (1925-55); James Barrett Brown, MD (1955-68); John (Jack) E. Hoopes, MD (1968-70); Paul M. Weeks, MD (1970-96); Susan E. Mackinnon, MD (1996-2020); and Justin M. Sacks, MD, MBA (2020-present). The program at Wash U has produced numerous advances and milestones in plastic surgery through the decades (Table 1). Perhaps more important than any single clinical advancement, however, has been the focus on training exceptional plastic surgeons and academic leaders.

Table 1: Washington University plastic surgery leaders have created, helped develop or materially improved these major, technical landmarks of the specialty CLINICAL CONTRIBUTIONS

SURGEON(S)

Multidisciplinary team care

Dr. Blair

Define “delay” phenomenon

Dr. Blair

Radium treatments for Head and Neck cancers

Dr. Blair

1st reproducible cleft lip repair

Dr. Blair and Dr. Brown

Split-thickness skin graft technique

Dr. Blair and Dr. Brown

Post-traumatic reconstruction

Dr. Brown

Reconstruct radiation injuries

Dr. Brown

Hypospadias repair

Dr. Byars

Craniofacial growth

Dr. Sarnat

Burn care

Dr. Cannon

Transplantation

Dr. Murray

Cleft lip and palate

Dr. Millard; Dr. Randall

Hand surgery

Dr. Peacock; Dr. Weeks

3D Computed Tomography

Dr. Marsh

Nerve transfers, including after spinal cord injury

Dr. Mackinnon and Dr. Fox

Surgical educational videos

Dr. Mackinnon

Drs. Blair and Brown taught by example, were generous with their time and ideas, and wanted other surgeons to be able to reproduce their work. Dr. Blair wrote the first definitive text on the treatment of oral and maxillofacial diseases in 1912, which became the standard operating manual in World War I. Drs. Blair and Brown in 1929 published the first reproducible technique for cleft lip repair and described the technique for harvesting large split-thickness skin grafts, surpassing size capabilities of pinch grafts at the time.1,2,3 Surgeons traveled from all over the world to observe them in the O.R., which Dr. Blair had decorated with murals by Gisella Loeffel to entertain patients (Figure 1). Dr. Brown wanted trainees to look good in front of Dr. Blair, and he frequently whispered suggestions to assistants to answer Dr. Blair’s questions. After proving the need for a distinct specialty during World War I, Dr. Blair recognized the variability in educational quality of the one- or twoyear apprenticeship model for training programs. Dr. Blair championed the idea the American Board of Plastic Surgery (ABPS). The ABPS was founded in 1937, initially as a subsidiary of the American Board of Surgery but became an independent board in 1941. For Dr. Blair’s contributions to the integrity of our specialty, Jerome Webster summarized: “(Dr.) Blair’s place is assured as having done more than anyone in this country to advance the art and practice of Plastic Surgery, to have it recognized as a distinct specialty, and to formulate means of educating on-coming generations of Plastic Surgeons in the principles and technic of reconstructive surgery that mean so much for the function, appearance and happiness of innumerable individuals. Those who have taken or will take the examinations of the Board may be thankful to Blair for his insistence that high standards be

Figure 1: A patient being prepped for surgery in the O.R. of Vilray Blair, MD, circa 1931. Note the observation area above the operating field. (Photo courtesy of the Bernard Becker Medical Library, Washington University School of Medicine.)

maintained in this specialty. You and I and those to come should be grateful for what Blair accomplished and for what he thought, taught and fought for during his lifetime.” 4 The U.S. government first recognized plastic surgery as a specialty when Dr. Brown was appointed as the European Senior Consultant in Plastic and

Maxillofacial Surgery and Burns in 1942 during World War II.3 The need to reconstruct soldiers’ injuries during and after the war spurred rapid training of plastic surgeons across the country, led by Dr. Brown. The tradition of formalizing educational excellence and innovation continued with Dr. Weeks, who championed the Plastic Surgery Resident | Winter 2020

CENTENNIAL CELEBRATION / continued from previous page

concept of a coordinated plastic surgery residency training model. His training model included specific rotations during the three prerequisite years of general surgery that would maximally prepare residents for the following years of focused plastic surgery. With colleagues, Dr. Weeks established the plastic surgery in-training examination. Dedication to education has continued under Dr. Mackinnon. Her surgical educational videos have facilitated surgical training globally, particularly for nerve reconstruction. She’s also recognized for her “white board” summaries of patients and procedures, done by trainees, prior to the start of each case. Additionally, she incorporated full-time faculty focused on aesthetic surgery into the academic model to enhance the resident educational experience. Although less than one year into his tenure at Wash U, Dr. Sacks has gained a national reputation for mentoring students and residents in surgical career development. The program is moving forward under the guiding tenets of clinical excellence, educational rigor, research discovery and biomedical innovation. The legacy of exceptional plastic surgery training at Wash U is steadfast. The Plastic Surgery Residency Program at Wash U has been known for a century for its breadth and depth of cases. It continues to flourish in a progressive, innovative and generous environment, and with a rich collaboration between Washington University School of Medicine and now Barnes-Jewish Hospital within the BJC Health Care System. Trainees benefit from a highvolume, quaternary referral and Level 1 trauma center in a variety of arenas. The division continues to expand, with growing faculty (currently 16 and 19 by the summer of 2021), locations, programs and trainees (currently 19 residents and three Fellows). The division leads in innovation, building on 10

Plastic Surgery Resident | Winter 2020

Washington University School of Medicine

the legacy of landmark contributions. The programs of lymphatic surgery, gender affirmation surgery and limb preservation are actively growing. The division has a long history of excellence in basic, clinical, and translation research, including long-term NIH funding. The research platforms continue to expand in parallel with the clinical program. The educational program continues to evolve with innovations in curriculum. At the turn of the century, AAPS members were surveyed regarding the most influential plastic surgeon of the 20th century.2 While no single winner emerged, we’re extremely proud that five of the Top 10 surgeons have some tie to the Division of Plastic and Reconstructive Surgery at Wash U: Drs. Blair, Brown, Murray, Millard and Jurkiewicz. We continue to forge ahead in the footsteps of those before us – and we’re

well on our way. We cannot wait to see what the remainder of the 21st century brings! |

Dr. Brandt is the executive director of the American Board of Plastic Surgery; Dr. Snyder-Warwick is director of the Facial Nerve Institute and the Plastic and Reconstructive Surgery Residency Associate Program at Washington University, St. Louis.

REFERENCES 1. 2. 3.

Cannon B. 1990. The flowering of plastic surgery. JAMA, 263(6):862-864. Hallock GG. 2001. The plastic surgeon of the 20th century. Plast Reconstr Surg, 107(4):1014-1024. Stelnicki E, Young L, Francel T, et al. 1999. Vilray Blair, his surgical descendants, and their roles in plastic surgical development. Plast Reconstr Surg, 103(7): 1990-2009. Webster, J. 1956. In Memoriam: Vilray Papin Blair, 1871-1955. Plast Reconstr Surg, 18(2):83-112.

Orbital floor fracture

“Consult Corner” addresses a consult commonly encountered by an on-call resident. The column begins with the reason for consult and assesses questions that might go through a resident’s mind as he or she heads to the emergency department to see the patient. Key aspects of the history and physical, as well as additional testing that should be obtained, are also presented. Finally, a review of the decision-making process will present possible management strategies, all of which are synthesized into the context of an actual case.

By Erik Criman, MD

23 YOM S/P ASSAULT W/ ORBITAL FLOOR FX. C/F ENTRAPMENT

You’re sewing a face laceration in the E.D. when your pager goes off. Discussion with the E.D. provider concerns an intoxicated, 23-year-old male who was involved in a bar fight. CT of the face confirms the presence of a unilateral orbital floor fracture. The provider is keen to point out that the radiologist is concerned for ocular entrapment and asks you to urgently evaluate.

DESCRIPTION OF THE CONDITION

The orbit is composed of seven different bones, the structure of which generally serves as a shock absorber for the globe. The thin-walled orbital floor is composed of mainly the maxillary bone and is the most fractured segment. The optic foramen is located approximately 40-45mm posterior to the inferior orbital rim and is superior to the horizontal plane of the orbital floor. Orbital floor fractures may occur in isolation (Figure 1) or as part of a pattern, such as zygomaticomaxillary complex and naso-orbital-ethmoid fractures. The incidence of globe injury with orbital fractures ranges from 14-30 percent and may present as a corneal abrasion, retinal detachment, vitreous hemorrhage, traumatic hyphema or globe rupture. Less than 5 percent of fractures may result in the formation of a retrobulbar hematoma, which, in the presence of orbital compartment

Figure 1: Depiction of an orbital floor blowout fracture allowing for downward displacement of periorbital fat, septo-fibrous connections to the periorbita and the extraocular musculature (PRS Vol. 122, No. 3)

syndrome, requires emergent attention. While uncommon, fractures of the orbit may extend posteriorly and involve CN III, IV, V1 and VI, resulting in superior orbital fissure, or Rochen-Duvigneaud syndrome. When the optic nerve is also involved, the diagnosis becomes orbital apex syndrome. Fortunately, the overall incidence of vision loss with orbital fractures is below 2 percent. Plastic Surgery Resident | Winter 2020

CONSULT CORNER / continued from previous page INITIAL EVALUATION

It’s important to remember that patients with orbital floor fractures are also trauma patients. Emphasis should be placed on evaluating for concomitant traumatic brain or cervical spine injuries. In addition to a comprehensive facial exam, it’s paramount to check pupil reactivity and visual acuity. Red desaturation may be an early finding in patients with traumatic optic neuritis. With the eyes open and in neutral position, the examiner may evaluate for enophthalmos, exophthalmos and telecanthus. Extraocular movements are tested with particular emphasis on vertical gaze as the inferior rectus is the most common muscle to become entrapped in the orbital floor. In a patient who is unable to cooperate with examination, a forced duction test with topical anesthetic may be used to evaluate for entrapment (Figure 2). In the setting of a fracture, ocular movements can be limited for multiple reasons, and the clinical diagnosis of ocular entrapment is only made when a patient has extreme difficulty moving the eye in a direction that correlates with fracture anatomy. Ocular movements in this setting are often accompanied by severe pain, nausea and/or vomiting. A rare complication of posterior orbital floor fractures and retrobulbar hematomas is stimulation of the oculocardiac reflex. This may result in bradycardic dysrhythmias causing hemodynamic derangement, nausea, vomiting and/or vertigo. This is a surgical emergency mandating immediate open reduction and internal fixation (ORIF). In the setting of elevated intraocular pressure (normal 10-21mmHg), lateral canthotomy and inferior cantholysis should be performed at the bedside (Figure 3). In general, there should be a low threshold for consulting Ophthalmology in patients with orbital floor fractures – especially patients with traumatic optic neuritis and those felt to be operative. A thorough post-traumatic ocular exam is critical before embarking on procedures that may further traumatize the globe. Radiographically, the fracture may be characterized by measuring its size in the coronal and sagittal views (Figure 4). This also provides the opportunity to delineate associated fractures. Blood is almost always identified within the ipsilateral maxillary sinus, and herniated orbital fat may also be found here. “Rounding” of the inferior rectus and herniation of orbital contents into the adjacent sinuses are common imaging findings and may predict enophthalmos, but they aren’t predictors of orbital entrapment.

Figure 2: The forced duction exam (PRS Vol. 119, No. 1)

Figure 3: Lateral canthotomy (A) and inferior cantholysis (B) (Oper Tech Otolaryngol Head Neck Surg, Vol. 28, Issue 4)

Figure 4: Coronal slice of a CT scan demonstrating a right orbital floor blowout fracture with an ipsilateral fluid-filled maxillary sinus (PRS Vol. 134, No. 6)

MANAGEMENT

Orbital floor fractures may be managed non-operatively if they are small and do not result in functional impairment of the eye. Acute indications (within 24 hours) for repair are ocular entrapment (Figure 5); the presence of the oculocardiac reflex; superior orbital fissure or orbital apex syndromes; 12

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Figure 5: Clinical photograph demonstrating severe limitation of right eye supraduction consistent with entrapment of the inferior rectus muscle (PRS Vol. 109, No. 2)

or ocular hypertension caused by decreased orbital volume refractory to medical management. Additional non-urgent indications include large fracture (>2cm or >50 percent of floor volume) or clinically significant enophthalmos (>2mm). Relative contraindications generally encompass acute injuries to the globe, requiring ophthalmologic intervention, medical instability and contralateral blindness.

SURGICAL APPROACH

The goals of surgery are the restoration of orbital support and normalization of orbital volume. Under general anesthesia and following a thorough eye exam with baseline forced ductions, the fracture is exposed through one of several approaches (Figure 6,7). Herniated contents are gently reduced, and the orbital process of the palatine bone (the posterior “ledge”) is identified. Reconstruction of the orbital floor is mostoften performed with a synthetic implant, but bone graft or alternative alloplastic material may be used in the setting of heavy contamination or in the pediatric population to accommodate future growth. Prior to closure, the eyes are examined for proper globe position and a forced duction test is performed once again. Many surgeons will place a lid suspension suture to prevent the development of lower-lid ectropion. Patients are admitted postoperatively and given perioperative antibiotics at the surgeon’s discretion. Serial visual examinations are conducted to ensure freedom of the extraocular muscles.

Subciliary Subtarsal (Mid-lid) Lid-cheek Junction (not recommended)

Figure 6: Lower eyelid approaches to the orbital rim and floor (Roberts J, and Hedges J. (2010). Clinical Procedures in Emergency Medicine (5th ed.). Philadelphia, PA: W.B. Saunders)

CASE CONCLUSION

The 23-year-old patient was found to have a 2.5cm x 1.4cm pure orbital floor blowout fracture and no other traumatic injuries. His visual acuity was preserved and he did not have clinical evidence of entrapment or a globe injury. Once sober, he was discharged from the E.D. and underwent ORIF later that week. He was observed for a night in the hospital and discharged the next day. | Dr. Criman is PGY-6 in the Vanderbilt University Medical Center Department of Plastic Surgery. SUGGESTED READING

Cole P, Boyd V, Banerji S, Hollier LH. Comprehensive management of orbital fractures. Plast Reconstr Surg. 2007;120(S2):57S-63S Gart MS and Gosain AK. Evidence-based medicine: orbital floor fractures. Plast Reconstr Surg. 2014;134(6):1345-55. Kim HS and Jeong EC. Orbital floor fracture. Arch Craniofac Surg. 2016;17(3):111-118.

Pre-septal Retro-septal Posterior retro-septal

Figure 7: Transconjunctival approaches to the orbital rim and floor (Roberts J, and Hedges J. (2010). Clinical Procedures in Emergency Medicine (5th ed.). Philadelphia, PA: W.B. Saunders) Plastic Surgery Resident | Winter 2020

Breast Anatomy, Physiology and Breast Reduction By Rachel Goldstein, DO

eduction mammoplasty is among the most common procedures performed by plastic surgeons. An understanding of breast anatomy and physiology is critical to ensuring the safety and success of this operation. In this edition of InService Insights, we address key concepts of reduction mammaplasty, with a focus on high yield and previously tested topics.

BREAST ANATOMY

The anatomic footprint of the breast extends from the second to seventh rib, and from the sternocostal junction to the midaxillary line. Breast tissue also extends into the axilla (tail of Spence). The inframammary fold (IMF) consists of a fusion of deep and superficial fascia with the dermis and is not part of the breast. It’s a fixed attachment, and its location on the chest wall is challenging to alter.1,2 Breast tissue is composed of lobules and fat. Lobules, the functional units of the breast, contain acini and are organized in a radial distribution. The acini are connected to the lactiferous ducts, which drain milk through the nipple. The fat component of the breast is responsible for its bulk, contour, softness and shape. Breast content is prone to change over time. Glandular tissue will decrease and fatty tissue will increase after lactation, during menopause and with weight fluctuations. Also within the breast are Cooper’s ligaments, fascial slings from the deep fascial layer, into the breast parenchyma and attaching to dermis. Cooper’s ligaments are responsible for maintaining breast lift; attenuation of these ligaments over time results in ptosis.1,2 14

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The blood supplies to the breast are internal mammary artery perforators medially (T2-T5); lateral thoracic artery laterally; thoracoacromial and thoracodorsal perforators superiorly; and intercostal artery perforators (T3-T8). The medial and lateral perforators travel in a subcutaneous plane toward the nippleareolar complex (NAC), while the intercostal perforators penetrate the pectoral fascia deep to the breast and travel through the parenchyma directly to the NAC. The dominant blood supply to the NAC is from the internal mammary artery from both the subdermal plexus and parenchymal perforators.1,2,3 Sensory innervation to the breast is from the T3-6 intercostal nerves, as well as C3-4 in the upper and lateral aspects. Sensation to the nipple is predominantly provided by the anterolateral cutaneous branch of the fourth intercostal nerve, which travels along the pectoral fascia and innervates the nipple from its deep surface. Secondary nipple innervation is provided from the terminal branches of the fourth and fifth intercostal nerves.1,2

BREAST PHYSIOLOGY & BREAST HYPERTROPHY

During puberty, both estrogen and progesterone contribute to breast development. Estrogen stimulates the growth of breast ductal epithelium while progesterone stimulates glandular proliferation. During normal hormonal cycling, estrogen is responsible for breast engorgement and sensitivity while progesterone triggers ductal dilation. After menopause with the lack of hormonal glandular stimulation, the glandular tissue is replaced by fat.1,2

Table I. AVAILABLE PEDICLES FOR BREAST REDUCTION 1,2 Pedicle

Blood Supply

Advantages

Disadvantages

Inferior

Medial intercostal perforators; pedicle width 3:1, 8-10cm

Ideal pedicle for large volume and secondary reductions for maximum reducible volume and safety; preserves lactation

Prone to bottoming out long-term

Superior

Internal mammary perforator from 2nd intercostal space: travels 1 cm deep and enters just medial to breast meridian

Preserves projection and superior pole fullness

Not safe for large volume reduction; greatest degree of NAC sensory loss

Central Mound

Multiple intercostal perforators, similar to inferior pedicle except depends on glandular vessels, not subdermal

Preserves NAC sensation; preserves lactation; may enhance upper and medial fullness

Prone to bottoming out longterm

Based on internal mammary perforators from 3rd and 4th intercostal space

May preserve NAC sensation

Not safe for large reductions

Principal vessel is internal mammary perforator from 2nd intercostal space; also includes 1st through 4th internal mammary perforators

Preserves superior and medial fullness; may be safe for larger reductions; minimizes bottoming out

Not ideal for secondary reductions or after trauma with unknown blood supply

Lateral thoracic perforators

Allows creation of shorter pedicles for large-volume reductions

Does not address excess axillary and lateral fullness

Medial

Superomedial

Lateral

Breast hypertrophy is usually due to three main processes: juvenile hypertrophy of the breast in the pubescent female; hypermastia in the adult female; and breast hypertrophy of obesity in any age group. In juvenile breast hypertrophy, there’s a rapid and grossly disproportionate increase in bilateral breast size that occurs beginning at menarche and during puberty. Stromal breast tissue hypertrophies and lobules are poorly formed. This may result in significant psychosocial impact for affected children. Breast reduction is indicated in teenagers if breast enlargement has stabilized for one year, if the patient is mature enough to understand the risks of surgery and if the parents provide consent. In adults, hypermastia develops from an abnormal response of the breast tissue to circulating estrogen. There’s an increase in fibrous tissue within the fatty component of the breast, with a smaller increase in glandular tissue. Obesity at any age may result in enlargement of the fatty component of the breast.1,4

REDUCTION MAMMAPLASTY

Patients with macromastia presenting for breast reduction usually complain of chronic neck and back pain, but in severe cases it can be associated with inframammary intertrigo or pigmented brastrap grooves. Therefore, workup should always include a clinical

breast exam. Mammography is obtained if indicated based on guidelines.10,11 When marking the patient preoperatively, the following are considered: Location of the NAC should be 19-21 cm from the sternal notch; 9-11 cm from the midline; 7-8 cm from the IMF; and 38-45 mm in diameter. The new nipple location should be at Pitanguy’s point, which is the transposition of the IMF onto the breast within the breast meridian.1,2 Breast reduction techniques include suction lipectomy and excision. Suction lipectomy can be used either alone or with excisional techniques. When used alone, advantages include preservation of NAC blood supply, sensation, lactation and minimization of scars. The main disadvantages are that the shape and location of the NAC will not change and ptosis will not be corrected, as excess skin is not treated. Liposuction is not very effective in predominantly glandular breasts.1,2 Excisional reduction can be performed based on several major pedicles, as summarized in Table 1. These can be performed via a circumareolar incision with or without a vertical component, but they’re most commonly and most effectively accomplished via an inverted-T Wise pattern incision. Relief of symptoms is generally based on each individual and doesn’t correlate with the size or volume of tissue resected.1,2 Plastic Surgery Resident | Winter 2020

INSERVICE INSIGHTS / continued from previous page Table I. COMPLICATIONS AFTER BREAST REDUCTION 1,5,6,7 Complication

Incidence

Considerations

NAC compromise and loss

4-7 percent

Delayed wound healing

19-21 percent

Most common complication overall

Decreased nipple sensation

9-25 percent

Risk increases as reduction volume increases.

Decreased lactation

9-31 percent

Preservation partially based on technique

Hypertrophic scarring

4 percent

Risk decreases as reduction volume increases; may be due to decreases tension on chronically stretched skin

Fat necrosis

2-10 percent

Presents as firm soft-tissue mass that resolves spontaneously, may mimic infection or malignancy; primary risk factors: high BMI, greater resection weight, sternal notch-to-nipple distance greater than 37 cm; other risk factors include smoking and surgical technique; likely cause of mass found post-op, but need to work up to rule out cancer starting with ultrasound and mammography

Hematoma

Variable

Pathologic lactation

Extremely rare

See below

Risk increases with intraoperative hypotension May be due to breast, NAC and nerve manipulation and irritation, which stimulates prolactin secretion; treat with bromocriptine

COMPLICATIONS

The risk of overall complications increases with reductions greater than 1,000 grams per breast, obesity and smoking. Complications of reduction mammoplasty are summarized in Table 2.5,6 If the NAC appears congested or ischemic intraoperatively, determine if the closure is too tight or if blood flow to the pedicle is compromised. If the pedicle is of concern, observe the NAC for 10-15 minutes. Check that the pedicle is viable and not kinked. If there’s no improvement, convert to a free nipple graft. If NAC ischemia is noted after closure, release the periareolar sutures and observe. If NAC perfusion improves, attempt closure two to three days after edema decreases. In the immediate postoperative period, NAC congestion can be related to a hematoma, and the patient should be immediately returned to the O.R. for hematoma evacuation and evaluation.1

BREAST CANCER DETECTION CONSIDERATIONS

Incidental breast cancer is found in 0.4 percent of breast reduction specimens and in 5.5 percent, if reduction is performed in the contralateral breast for symmetry after unilateral mastectomy for breast cancer. Breast reduction decreases the overall risk of breast cancer by about 30 percent in average-risk patients.1,8,9| Dr. Goldstein is PGY-6 in the Houston Methodist Hospital Plastic Surgery Residency Program. 16

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REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.

9. 10.

11.

Janis J, ed. Essentials of Plastic Surgery. 2nd Edition. Thieme; 2014. doi:10.1055/b-006-160983 Jones G, ed. Bostwick’s Plastic & Reconstructive Breast Surgery 4th Edition. Thieme; 2020. doi:10.1055/b-006-163726 van Deventer PV, Graewe FR. The blood supply of the breast revisited. Plast Reconstr Surg. 2016 May;137(5):1388-1397. Mestak O, Mestak J, Borsky J. Hyperprolactinaemia: a cause of severe postoperative complication after reduction mammaplasty. J Plast Surg Hand Surg. 2014 Dec;48(6):421-422. Hoppe IC, Patel PP, Singer-Granick CJ, Granick MS. Virginal mammary hypertrophy: a meta-analysis and treatment algorithm. Plast Reconstr Surg. 2011 Jun; 127(6):2224-31. Carlson GW. The Management of Breast Cancer Detected by Reduction Mammaplasty. Clin Plastic Surg. 2016:43:341-347. Lewin R, Göransson M, Elander A, et al. Risk factors for complications after breast reduction surgery. J Plast Surg Hand Surg. 2014 Feb;48(1):10-4. Tarone RE, Lipworth L, Young VL, et al. Breast reduction surgery and breast cancer risk: Does reduction mammaplasty have a role in primary prevention strategies for women at high risk of breast cancer? Plast Reconstr Surg. 2004 Jun;113(7):2104-2110; discussion 2111-2112. Kalliainen LK, ASPS Health Policy Committee. ASPS clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. 2012 Oct;130(4):785-789. Henry SL, Crawford JL, Puckett CL. Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment. Plast Reconstr Surg. 2009 Oct;124(4):1040-1046. NCCN Guidelines Version 1.2020. Breast Cancer Screening and Diagnosis. Sept. 17, 2020. https://www.nccn.org/professionals/ physician_gls/pdf/breast-screening.pdf

Cleveland Clinic - Main Campus

Cleveland Clinic Department of Plastic Surgery By Tripp Leavitt, MD, & Anthony Deleonibus, MD History • Cleveland Clinic was founded in 1921 by three surgeons – George W. Crile, MD, Frank E. Bunts, MD, and William E. Lower, MD – and internist John Philips, MD, with the purpose of creating an institution focused on comprehensive group medical practice. • The Cleveland Clinic Department of Plastic Surgery was first founded in 1979. In 2012, the Residency Program transitioned into a fully integrated six-year residency program. Since that time, the program has continued to expand and currently accepts four residents per year. • In 2009, Cleveland Clinic became the first hospital in the United States to perform a facial allograft transplantation. As of this writing, it also remains the only hospital in the country that has successfully performed three total face transplants. The infrastructure for upper-extremity allotransplantation also has been established. • Its worldwide reputation makes Cleveland Clinic a destination for international visiting dignitaries and physicians, and it has welcomed more than 50 visiting professors from around the globe.

Leadership • Frank Papay, MD – Dermatology and Plastic Surgery Institute Chairman • James Zins, MD – Department of Plastic Surgery Chairman • Steven Bernard, MD – Residency Program Director • Raymond Isakov, MD – Associate Program Director • Bahar Bassiri Gharb, MD, PhD – Plastic Surgery Research Director National Leadership • Dr. Papay is currently an American Board of Plastic Surgery (ABPS) director and treasurer of the American Society of Maxillofacial Surgeons (ASMS). Previously, he has served as Ohio Valley Society of Plastic Surgeons president; ASPS Ethics Committee chair; Plastic Surgery Section of the American Academy of Pediatrics Plastic Surgery Section chair; and ASMS (Education) vice president. • Dr. Zins is also currently an ABPS director, serving as chair of the Bylaws Committee and Plastic Surgery within the Head and Neck Committee. He’s an American Association of Plastic Surgeons (AAPS) past president, and ACGME Residency Review Committee associate chair. He remains on the editorial boards of multiple plastic surgery journals. • Brian Gastman, MD, is Plastic Surgery Research Council chair and Medical and Surgical Director of Melanoma & High-Risk Skin Cancer Program at Cleveland Clinic. Plastic Surgery Resident | Winter 2020

PROGRAM PEEK / continued from previous page He belongs to the Society of Immunotherapy of Cancer’s Melanoma Task Force and numerous National Comprehensive Cancer Network (NCCN) panels, developing treatment guidelines for numerous cancers – including melanoma, squamous cell, basal cell, Merkel cell and DFSP. Clinical Experience The Residency Program faculty include 24 plastic surgeons, of which 15 are based primarily at Main Campus. The facultyto-resident ratio continues to provide a high-volume surgical experience, in addition to their time working with staff in other departments such as Head & Neck Surgery, Orthopaedic Surgery, and Dermatology (Mohs Surgery). Clinical rotations occur across several sites, including: • Cleveland Clinic – Main Campus: “The Mothership,” as it’s known, spans more than 170 acres and houses 1,400 inpatient beds. It’s currently ranked No. 2 on the U.S. News & World Report Best Hospitals Honor Roll, continuing a more than two-decades long tradition of being a top-5 hospital. Residents rotate through the Main Campus throughout their training, performing the full depth and breadth of plastic surgery – including pediatric craniofacial surgery at the adjoined Cleveland Clinic Children’s Hospital. The resident offices in the Crile Building act as a home base for members of the program. • Hillcrest Hospital: One of Cleveland Clinic’s 11 affiliate hospitals across northeast Ohio. Residents will rotate here on several occasions during their training, with a focus predominantly on breast reconstruction. • Beachwood Ambulatory Surgery Center: One of several ASCs in the Cleveland Clinic Health System, this provides experience focused on cosmetic surgery, treatment of skin cancer (high volume of melanoma cases), as well as general plastic surgery. • MetroHealth Medical Center: A Level I Trauma Center located on Cleveland’s West Side, facilitating exposure to the full spectrum of reconstructive surgery, as well as elective procedures. PGY-2 residents also rotate through the Burn Service. • Louis Stokes Cleveland VA Medical Center: Residents have an opportunity for greater responsibility in managing patients both in the office and the O.R., with oversight from the VA faculty. General reconstruction and hand surgery make up the bulk of the operative experience. • Akron Children’s Hospital: PGY-4-5 residents spend several months in the Pediatric Plastic & Reconstructive Surgery Center as part of a focused experience that addresses the full spectrum of pediatric craniofacial surgery – complementing the craniofacial training interspersed across all six years at the Cleveland Clinic Main Campus/Children’s Hospital. • Cleveland Clinic – South Pointe Hospital/Private Practice: Residents spend time in a private practice setting at several intervals throughout their training. The experience covers all facets of cosmetic surgery. 18

Plastic Surgery Resident | Winter 2020

Educational Curriculum Due to COVID-19, all conferences/didactics are held virtually to maintain safe social distancing. Regular teaching conferences include: • Weekly didactic conference led by faculty covering topics based on the full PSEN curriculum • Weekly oral boards-style conference directed by residents and faculty • Monthly “Deep Dive” lectures focusing on advanced topics in the fields of aesthetic, hand, craniofacial and microsurgery • Monthly Journal Club • Monthly Morbidity & Mortality conference • Visiting professors (two to four per year) • Fresh cadaver labs two to three times per year, including highly-regarded flap dissection labs Fellowship Training 2021: Hand (Mayo Clinic); microsurgery (Cleveland Clinic); private practice/military service 2020: Aesthetic surgery (Dallas Plastic Surgery Institute); hand (Alabama); private practice (New York) 2019: Aesthetic surgery (UTSW); aesthetic surgery (BI Deaconess) 2018: Aesthetic surgery (Dallas Plastic Surgery Institute); hand (Ohio State) Resident Benefits • City living in Cleveland without the associated big-city challenges (easy to enjoy life on a resident’s salary) • Full financial support toward the costs of meeting attendance for residents presenting at regional or national meetings. Funding also provided for PGY-5 and PGY-6 residents to attend the AAPS and ASPS meetings, respectively • ACAPS Annual Boot Camp for incoming interns • Educational stipend (annually) and surgical loupe stipend (interns) • Resident Cosmetic Clinic for trainees in the PGY-5-6 years • Microsurgery lab: A week-long microsurgery course during intern year with one-on-one teaching that facilitates early, hands-on experience, performing microvascular anastomoses in a rat model. The lab is available at any time for all residents wishing to hone their skills or perform research. • Access to the Cleveland Clinic Innovations Center, which guides providers through the process of idea development, patent acquisition and realization. • Year-round access to a state-of-the-art, fresh cadaver lab on campus and the opportunity to collaborate with Richard Drake, PhD, editor of Gray’s Atlas of Anatomy. Residents can earn the title of Clinical Instructor of Anatomy through teaching in the anatomy lab. Follow Cleveland Clinic Plastic & Reconstructive Surgery on Instagram @ccfplasticsurgery. | Dr. Leavitt is PGY-4 and Dr. Deleonibus is PGY-2 in the Cleveland Clinic Department of Plastic Surgery.

A Message From the Program Director, Steven Bernard, MD

ou succeed as a teacher when those you teach become better than you. The Cleveland Clinic Plastic Surgery residency program started in 1983. Since then, we’ve trained more than 75 plastic surgeons and our alumni group is growing exponentially in both size and influence. As one of the toptwo ranked hospital systems both Steven Bernard, MD nationally and internationally, the spirit of the Cleveland Clinic is one of innovation with both national and international excellence. The Cleveland Clinic was founded in 1921, so we’ll be celebrating our 100th anniversary in just a few months. With “Patients First” as our motto, the four pillars of our mission statement are patient outcomes; education; research; and service. We’re also Ohio’s largest employer with more than 65,000 employees – and we experience 5.4 million patient visits per year. We have hospitals in Florida, Las Vegas, Toronto, Abu Dhabi and London. What do all these accolades mean for our Department of Plastic Surgery? We have the honor to care for patients from all walks of life and our international reputation leads to care for all medical conditions. We have a mix of staff that allows us to perform pioneering procedures such as the first face transplant in the United States, the world’s first laryngeal transplant and groundbreaking lymphedema treatments. We’re always working on our next big breakthrough. I came to the Cleveland Clinic after training at the University of Pittsburgh and working at MetroHealth Medical Center for 10 years. During my time at the Cleveland Clinic, we’ve grown at an astronomical pace. The chief of our department is James Zins, MD, who’s held that position for more than 25 years – and in that time, he’s fostered the growth of our staff from five when I started 14 years ago to 19 as of 2020. We continue to recruit and anticipate more than 20 staff on our main campus and 10 in our affiliated hospitals.

surgery as interns and in keeping with our philosophy, our residents spend the large majority of their time on plastic surgery rotations for their remaining years 2-6. While at MetroHealth Medical Center, our residents run their own trauma clinic; as sixth years, run their own Chief Resident Clinic, both with close mentoring by the plastic surgery staff. Looking at our caseload in detail, in any given week we average more than 100 cases at our main campus alone. As our residents cannot cover all these cases, we assign residents to the cases based on their educational value. We have carefully developed our Fellowships to augment our residency by preventing the overemphasis of highly specialized procedures, while enhancing resident teaching in a balanced fashion. Our growth in staff and residents has also fueled our innovation and research. Our department produced 73 peer-review articles last year. We’re on the leading edge of all plastic surgery subspecialties. We have Graham Schwarz, MD, and Wei Chen, MD, performing lymphatic bypass and super microsurgery to help patients with lymphedema. Antonio Rampazzo, MD, PhD, and Bahar Bassiri Gharb, MD, PhD, lead our alloplastic transplant program as we continue to perform face transplants and research for hand transplants. The research undertaken by Brian Gastman, MD, is NIH supported in melanoma – and his ENT training benefits our residency with extensive head and neck reconstructive procedures. Another plastic surgeon in our group with ENT training is our institute Chair, Frank Papay, MD. As a judge for the National Inventors Hall of Fame, Dr. Papay is a leader in innovation. He has pioneered procedures to alleviate airway obstruction and migraine headaches through surgery and his patented implants. For aesthetic surgery, as a testament to his research, every significant panel on facelift includes Dr. Zins. Through his leadership, our residents are exposed to the subspeciality of aesthetics to a greater depth than can be achieved with either outside rotations or faculty doing aesthetic surgery as a sideline. We have injection clinics for our residents, and Dr. Zins helms the chief resident cosmetic clinic.

We are a department, rather than a division, which gives us total control of our destiny. Our status has allowed us to grow as a residency from four residents (two per year in an independent model) in 2012 to four residents per year in an integrated model, with our current number at 19. This growth has been possible by both the expansion in our staff and the variety of cases we perform. We’ve increased our footprint to address vulnerabilities in our residency by adding the premier trauma hospital in northeast Ohio (MetroHealth Medical Center), as well as the Cleveland Veteran’s Hospital and our sister hospitals of Hillcrest and South Pointe. We now have the flexibility to pick and choose the cases that best match our resident’s educational needs and cover every aspect of plastic surgery.

Our department leaders are involved nationally as past presidents of the American Association of Plastic Surgeons; the American Society of Maxillofacial Surgeons; past presidents (four) of the Ohio Valley Society of Plastic Surgeons; and the current chair of the Plastic Surgery Research Council, Dr. Gastman. They also sit or have sat on the ABPS, as well as the boards of ASPS, the Residency Review Council and the American Council of Academic Plastic Surgeons. |

As a department, we’re also in control our rotation schedule for all six years. We integrate our residents into plastic

Dr. Bernard is the Residency Director for the Department of Plastic Surgery at the Cleveland Clinic.

It is with this groundwork that we become even more excited for the future of Cleveland Clinic’s Integrated Plastic Surgery program. We continue to grow and build on the strength of our nearly four decades in plastic surgery education.

Plastic Surgery Resident | Winter 2020

Q& A WITH JAMES ZINS, MD

By Demetrius M. Coombs, MD

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.

serves as an Oral Board senior examiner for ABPS. He also serves on the editorial boards of plastic surgery journals that include Annals of Plastic Surgery, Aesthetic Plastic Surgery, and the Aesthetic Surgery Journal.

In this installment of Faculty Focus, we present ASPS member James E. Zins, MD, chairman of the Department of Plastic Surgery at Cleveland Clinic. After receiving his medical degree from the University of Pennsylvania, Dr. Zins completed his internship, residency in general and plastic surgery, and a Fellowship in craniofacial surgery, at the Hospital of the University of Pennsylvania. He then completed a maxillofacial Fellowship at Great Ormond Street Hospital, London, and an honorary research Fellowship at University College Hospital, London.

Dr. Zins is closely involved in resident education; our resident clinics and injection workshops; didactics; and champions clinical and basic science research at our bi-monthly research meetings. He maintains a busy operative schedule, and his cases and clinics are popular among residents and visiting students. Perhaps most importantly, his office door is always open, and he’s always willing to lend an ear or meticulously review a manuscript – even if it’s over the weekend.

Dr. Zins specializes in comprehensive facial aesthetic surgery – particularly facelift – and frequently lectures nationally and internationally. He has served as president of the American Association of Plastic Surgeons and currently is an American Board of Plastic Surgery director and Oral Board senior examiner. Dr. Zins also has served as associate chair of the Residency Review Committee of the ACGME, and as past president of the Northeast Ohio Society of Plastic and Reconstructive Surgeons and the Ohio Valley Society of Plastic Surgeons. He’s a founding member of the American Society of Craniofacial Surgeons, an American College of Surgeons Fellow and an American Association of Plastic Surgeons board member. Dr. Zins is a Professor of Surgery at the Cleveland Clinic Lerner College of Medicine and

PSR: WHAT DREW YOU TO PLASTIC SURGERY?

Plastic Surgery Resident | Winter 2020

Dr. Zins: When I was a senior in medical school, I was fortunate to work with Project HOPE – on the good ship SS HOPE – in Maceio, Brazil. At that time, I worked with a wonderful plastic surgeon from Chico, Calif., and that initially stimulated my interest in plastic surgery because we did a number of pediatric plastic surgery cases, including cleft lip and cleft palate repairs. Then I became an intern in general surgery at the University of Pennsylvania, and my first rotation was, surprisingly, plastic surgery. There I met my mentor for life, Linton Whitaker, MD, and I became enthralled with craniofacial surgery. From that point, I knew I was going to be a plastic surgeon.

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Zins: I was a resident some time ago – and in those days, Fellowships were not necessarily as sought after as they are now. I did my first Fellowship, which was embedded in my surgical training, with Dr. Whitaker as a PGY-4 general surgery resident. This Fellowship was a combination of basic science research and clinical pediatric craniofacial surgery – and it was definitely a unique experience. After I finished plastic surgery training, I did a second Fellowship in oral and maxillofacial surgery at the Great Ormond Street & University College Hospitals in London.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON THE ADVANCEMENT OF YOUR CAREER? Dr. Zins: You can’t be too well-trained. I think Fellowships are extremely important and they’re becoming more important as time goes on. Because plastic surgery is such a diverse field, it’s important to develop your own niche. My niche, in the early days, was craniofacial surgery. My blood pressure went down and my heart rate was a little lower when I did those cases early in my career, and I felt extremely comfortable because of my advanced Fellowship training. It may depend a bit on personality, but I like to “know a lot about a little.” Fellowship certainly puts you in a good position from a competitive standpoint when you bring something special to the table. So from a career-standpoint, whether it’s personal or for your institution, you’re going to be a more valuable asset if you are subspecialty trained. Not only to an academic career, but also to a private practice career, because you will be much more sought after with Fellowship training that has given you something that many people will not have. Also, it’s a long road in plastic surgery – six years, minimum – and that final year in Fellowship, while many may be anxious to get out into the world and “feed their family,” will hold you in great stead over a hopefully 30-year career.

PSR: HOW IMPORTANT IS A MENTOR IN ONE’S EARLY PRACTICE? Dr. Zins: Everybody needs a coach. Serena Williams didn’t become the tennis player she is by “seeing one, doing one and teaching one;” she had a coach from when she was very young. If you look at any of the outstanding athletes or performers today, they’ve all had coaches from an early age. Mentorship is critical in the early formative years, and also once you leave formal plastic surgery training. You’re not going to stop learning, and you need to be able to bounce things off some more mature heads when you start practicing. In other words, you should have a coach forever.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Zins: First of all, it’s very fulfilling. You meet extraordinary people, you rub shoulders with very bright people, you get exposed to new ideas and you help advance your career, because you get to know people outside of wherever you practice. It’s also important because we’re very lucky to be able to do something that we love. There are very few people who actually can go to work everyday and do something they really enjoy. We’re blessed, and because of that, we should be willing to give back. Certainly all of the work you do for the professional societies is gratis, but again, you’re giving back as far as your patients, residents, Fellows and colleagues are concerned. This is critical.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE FOR A SUCCESSFUL RESIDENT? Dr. Zins: Being a team player, being able to work hard and giving 150 percent. If you’re able to do that, you’ll be eminently successful. Then, you can always look at yourself in the mirror, win or lose, and say you gave it your best.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Zins: It’s very healthy to achieve balance as best as you’re able. Fortunately, in my case, plastic surgery is my sport and my hobby, as well as my profession. I would encourage everyone to make time for themselves, make time to enjoy life and not overwork. That being said, people these days have a better handle on this than my generation.

PSR: WHAT WAS YOUR BIGGEST NON-MEDICAL CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE THAT? Dr. Zins: When I started training, we worked every other night during our general surgery training and it was incredibly time-consuming. Another difficulty relates to these early years in training. We had a very stiff pyramid and went from 20-something interns at Penn to six chief residents. It was tough for me to see some of my friends fall by the wayside.

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FACULTY FOCUS / continued from previous page

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Zins: Hanging out with the residents and the Fellows, and being able to discuss things with them, teach them and have them teach me. It’s what keeps you vital and young, and also allows you to give back. It’s very much a two-way street. It’s a lot of give-and-take in many aspects, inside and outside the O.R. In the O.R., it allows you to be more efficient – and to be more efficient in patient care. You can also be much more extensive. It’s particularly rewarding to me to work with the residents on clinical research and manuscripts, and to bring out the best in them with regard to their writing and speaking skills.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER IN YOUR PRACTICE ON A REGULAR BASIS? Dr. Zins: Things are becoming increasingly difficult from a time-constraint standpoint. We’re being asked to do more and more with less and less; there’s less time to think, and when there’s less time to think, you lose some of your innovation. My big fear is that we’re becoming so busy that we run the risk of losing our innovative talents. This is a general problem, and certainly COVID-19 has made this more of an acute problem. To be your best, you need to have rest and be able to think clearly without feeling overwhelmed. You need to take a break, take a deep breath and have some time off to recharge your engines when needed.

PSR: WHAT ROLE DOES TEACHING PLAY IN YOUR SCHEDULE? Dr. Zins: It takes time. However, as I mentioned earlier, it’s immensely rewarding. It’s also important to highlight the payback from the residents in how they help you. They relieve you from a lot of work in patient care. They save you time during the day as far as operating and seeing patients, and they save you time at night. When they’re working hard taking care of the patients, you’re home and not in the hospital. This should not be overlooked. We very often think that we’re working hard, but if you look at the residents, they’re putting in a lot more hours than we are.

Plastic Surgery Resident | Winter 2020

Project HOPE's hospital ship, the S.S. Hope.

PSR: AS A SEASONED PLASTIC SURGEON, WHAT’S YOUR ADVICE FOR PLASTIC SURGERY RESIDENTS? Dr. Zins: Specialize as early as you can. Find that niche or area of particular interest early, and work hard to develop it. That sounds difficult, particularly when you go out in practice and you think, “I have to do everything.” You can do everything; however, at least make it known what area you have a special interest in. Learn more about that small area than anybody else, and if you do that, you’ll be more successful, your department will be more successful and your institution will be more successful.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN…” Dr. Zins: When I went to Maceió, Brazil as a fourth-year medical student and was introduced to pediatric plastic surgery by caring for cleft patients. | Dr. Coombs is PGY-4 in the Cleveland Clinic Department of Plastic Surgery.

Cleveland, Ohio By Anthony Deleonibus, MD; Demetrius Coombs, MD; William “Tripp” Leavitt, MD; & Nicholas Sinclair, MD

ISTOCK

ou’re invited on a 24-hour trip to Cleveland, nicknamed the “Forest City” and widely regarded as one of the greatest All-American cities of the 20th and 21st centuries. Cleveland sits in the northwest corner of Ohio, tucked away on the southern shore of Lake Erie. It boasts a metropolitan population of around 2.8 million and is the former home to the industrial giants who shaped Cleveland’s landscape – including John D. Rockefeller, Henry Sherwin and Edward Porter Williams of Sherwin-Williams, and railroad moguls such as the Van Sweringen brothers. Cleveland’s cultural community, world-class professional sports teams, affordability, ease of living, renowned restaurants and sense of belonging make it an attractive destination for many to call home. Sit back, relax and enjoy this brief trip through one of America’s greatest cities.

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24 HOURS / continued from previous page

West Side Market

SUNRISE ADVENTURES

Due to its location on the Lake Erie shore, Cleveland is home to incredible sunrises and sunsets. Before your day starts, head over to the Edgewater beach located near downtown for a beachside morning sunrise. It’s not uncommon to see paragliders sailing over Edgewater Park, catching the morning warmth. Or visit any of the Cleveland Metroparks that make up the Emerald Necklace for golf, a beautiful bike ride, run or kayak under the Cleveland sun. Then venture down to the West Side Market, one of the largest and last remaining, daily indoor farmers markets in the country. Located in the heart of the trendy Ohio City, West Side Market is home to fresh produce, culturally crafted meats, baked goods and international delicacies.

BREAKFAST

Once you’ve had your fill of the West Side Market, there’s no better way to continue the day than with a Cleveland24

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style breakfast. Start with one of Cleveland Scene’s highly acclaimed breakfast hot spots, including Grumpy’s Café, Lucky’s Café in Tremont, the Inn on Coventry, Cleveland Bagel or a lavish, Sunday brunch at Pier W – Yelp’s Top 100 restaurant. You may prefer to stay near West Side Market and have brunch at one of the many popular, neighboring breweries.

CULTURALLY RICH AFTERNOON

A trip to Cleveland isn’t complete without a stop at the Cleveland Art Museum, considered one of the nation’s most complete museums and one of the busiest in the world, reportedly with the 4th-wealthiest art museum endowment – meaning there’s always a constant influx of new art. After spending time at the museum, enjoy a trip next door to Severance Hall, which houses one of the “Big Five” national orchestras: the Cleveland Orchestra that The New York Times in October 2020 called “America’s finest.” If you’re a fan of

music and enjoy the Cleveland Orchestra, your musical desires are not complete without visiting the one and only Rock & Roll Hall of Fame. This venue is home to music icons both young and old and will surely take all music lovers on a trip back in time.

LUNCH

While enjoying your time around Wade Circle – bordered by the Art Museum, Botanical Gardens and Museum of Natural History – stop by Little Italy for boutique shopping and a game of bocce at the Little Italy Alta House. Afterward, enjoy a decadent lunch at Mia Bella or Trattoria on the Hill, and if you’d like to sample some of the finest pastries in the Midwest, stop by the historic Presti or Corbo bakeries.

EVENING OF EXCITEMENT

As day turns into night, indulge your musical interests by visiting the Coventry neighborhood, home to the famous Grog Shop – a music venue open 365 days of the year and which hosts live music from jazz to reggae to hip hop to comedy acts (though the pandemic led to a second, temporary closure in late November). Cleveland’s revival isn’t complete without spending a night in downtown Cleveland, attending one of Cleveland’s three major professional sports teams, the NFL’s Browns, the MLB’s Indians or the NBA’s Cavaliers – at least, when COVID-19 restrictions aren’t in place. If you’re lucky enough to be in Cleveland during Christmastime, a short walk from all three sporting venues will bring you to Public Square – home to the Cleveland Winterfest, which is filled with live music, food, outdoor ice skating, fireworks and holiday fun. Playhouse Square, which recently hosted the Tony Awardwinning play “Hamilton: An American Musical,” is a stone’s throw away and a highly sought-after destination for many theater aficionados. Numerous options for dinner and drinks are available as the night winds down. Keep the fun going by grabbing food and drinks at Corner Alley on the famous East Fourth Street, or at Iron Chef Michael Symon’s restaurants Mabel’s BBQ or Lola. For a more relaxed night, venture over to the trendy, tucked-away Tremont for a perfect finish to a beautiful day at the world-famous Dante Boccuzzi’s restaurant Dante, or the high-end Asian-fusion restaurant Parallax. Cleveland is a phenomenal place to call home and clearly filled with too much to complete in one day – so, unfortunately, your time is up. Before your 24 hours in Cleveland are complete, make sure to end your visit with our city’s most underrated contribution: the ice cream scene. Take your pick from the homemade selections of Ohio City’s Mitchell’s Ice Cream, Gordon Square’s Sweet Moses or Tremont’s Mason’s Creamery

Rock & Roll Hall of Fame

Mabel’s BBQ on East Fourth Street

for the sweetest finish to a perfect day. Thank you for coming with us on our journey through Cleveland – and we hope you come back soon. | Dr. DeLeonibus is PGY-2; Drs. Coombs and Leavitt are PGY-4; and Dr. Sinclair is PGY-5; in the Cleveland Clinic Department of Plastic Surgery. Plastic Surgery Resident | Winter 2020

‘HAIL TO PITT’

University of Pittsburgh takes 2020 Residents Bowl crown By Angela Prescott, MD; Walter Joseph, MD; Xiao Zhu, MD; & Francesco M. Egro, MBChB, MSc, MRCS

his year’s virtual Plastic Surgery The Meeting achieved phenomenal results in providing a new platform for education and interaction for our specialty – and the 2020 Residents Bowl perfectly encapsulates that achievement. The moderators, Edward Davidson, MD, and Raj Sawh-Martinez, MD, added flair to the event as they donned black-tie formal wear to celebrate the final championship round. The University of Pittsburgh added its name to the list of champions – the first time in the Residents Bowl 10year history that Pitt ascended to the winner’s circle. In prior years, Team Pitt competed honorably but was unable to claim the No. 1 position. This year, Team Pitt welcomed back two seasoned competitors, well-versed with the rules and pressure of the game: Francesco Egro, MBChB, MSc, MRCS, and Walter Joseph, MD, both of whom are integrated chief residents. The Pitt team was rounded-out by PGY-3 Xiao Zhu, MD, and Chief Resident Angela Prescott, MD. The goal was to diversify the team and maintain residents with historically solid In-Service Exam performances. Rules changed this year: Each team was still consisted of four members; however, the team score would be an average of each member’s individual score. Submitting the correct answer with the fastest speed would produce the highest score. Every player’s score counted. 26

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Team Pitt members (clockwise from top-left) Dr. Egro, Dr. Zhu, Dr. Joseph and Dr. Prescott.

To prepare, Team Pitt members studied recent In-Service questions, as well as considered the potential for onlineconnectivity interruptions and the technical difficulties that could arise in a totally virtual format. Therefore, the venue with the fastest connectivity and largest bandwidth was chosen. Pitt’s final strategy was to know the answer before the multiple-choice options were presented, which allowed team members to “buzz-in” as quickly as possible.

In the Quarter Final round against Mt. Sinai, technical difficulties arose. Five additional questions were added to the round, in which Pitt went on to triumph. In the Semi-Final round, Pitt went headto-head against the Johns Hopkins team. This team was not only accurate, but incredibly fast. Hopkins held a clear lead until the final question – when a Hopkins team member answered incorrectly, bringing down the team average. With each advancing round, the tachycardia

became more palpable. The support of the faculty and alumni was unparalleled; Pitt had a virtual cheering section during each round. The excitement and pressure built with each game. In the championship round, the University of Michigan took an early lead. Pitt regained control by answering a challenging question regarding indications for traumatic orbital floor repair. For the remainder of the championship game, Pitt answered with accuracy and intent – and captured the win. Winning the 2020 Residents Bowl was half unbelievable and half incredible, as Team Pitt knew the competition would be unrelenting and fierce. What made the victory sweeter was being able to share the win with the fabulous residents, faculty and alumni who logged-in to watch. All we can say is, “Hail to Pitt.” |

Team Pitt supporters watch as their colleagues gain Pitt’s first championship in the 10-year history of the Residents Bowl. Moderators Raj Sawh-Martinez, MD, and Edward Davidson, MD.

A Moderator’s Viewpoint

A fun, frantic and completely unpredictable Residents Bowl By Edward Davidson, MD

n its 10th year, the Residents Bowl may have gone virtual, but the tension, drama and entertainment were real. Twenty-six teams from coast to coast – along with teams from India, Italy and Argentina – battled for the title of Residents Bowl Champion over two weeks of Zoombased plastic surgery trivia. The format for this virtual PSTMrelated event sported new software that tested the speed and accuracy of the teams and individual players. Many of the memorable moments had little to do with the scores and everything to do with the intensity of the fans and participants. Faculty supporters cheered on their teams from the O.R., from the dinner table and, for USC, from cars stuck in L.A. traffic – where they might still remain. A professional roster of moderators was also not free from incident, with one having to stop mid-game to wrangle her cat out of the blinds. The final saw Michigan face-off against the University of Pittsburgh. Pitt came through the tougher side of the draw, defeating Hopkins in a close Semi-Final after a controversial, overtime defeat of Mount Sinai in the Quarter Finals. Michigan

cruised to the Final, seeing off University Chicago in the SemiFinals just in time to scrub back into surgery. The razzmatazz of the Final was transcended only by the performance of both teams in a finely poised affair that pivoted on a single question that split the sides and sent the Pitt team of Angela Prescott, MD; Francesco Egro, MBChB, MSc, MRCS; Walter Joseph, MD; and Xiao Zhu, MD; into a frenzy as they took the trophy. The overall highest score in the competition for an individual was from Paul Shay, MD, of reigning champions Mount Sinai. We would like to thank the YPS Committee, ASPS staff members Jerime Wargo and Yassie Dunn, and Allergan Aesthetics, an Abbvie Company, for its generous support. Next year will be epic! |

Dr. Davidson is the director of Craniomaxillofacial Surgery and Plastic Surgery Residency Program director at Case Western Reserve University/University Hospitals, Cleveland. He’s also chair of the YPS Resident Bowl Subcommittee and served as a moderator at the event. Plastic Surgery Resident | Winter 2020

COVID-19 and plastic surgery residency: A French experience By Elise Lupon, MD

he COVID-19 pandemic has profoundly altered the ways in which plastic surgeons around the world practice.1 While the number of surgeries has been reduced significantly, residents often over-staff those that do occur. In the first months following the pandemic’s emergence, surgical residents were asked to assist in the ICU with such tasks as turning COVID-19 infected patients to the prone position and helping with intensive care stretching. At nine months from the pandemic’s first events, surgical activity is still significantly reduced and anxiety about losing essential training time still exists. Many

residents are present in the O.R. during surgery, making for a very uncomfortable situation. This situation makes learning difficult, due to our reduced visibility in the O.R. and rare opportunities for practice.2 The management of anxiety and nervousness in patients whose surgeries have been canceled is a daily challenge for the residents managing their surgical department’s administration.3 We’ve observed women with delays in breast cancer management due to suspension of non-urgent surgeries.4 We’ve seen women who underwent mastectomy for breast cancer who’ve been canceled for reconstruction and rescheduled several times – who then no longer wish to be reconstructed, due to a feeling of abandonment.5,6 From the theoretical point of view, although it has become more modern, virtual learning can lead to difficulties in concentration through a tendency for distraction (typically, it’s the realization of other activities in parallel to a virtual meeting). Online courses often have less impact than face-toface classes, where mentors could more easily motivate and energize residents with their physical presence.7,8

Hopital Europeen Georges Pompidou, Paris 28

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Moreover, we’ve seen the emergence of pathologies indicating management in reconstructive surgery indirectly related to COVID-19, such as nasal reconstructions by frontal flap due to nasal ulcers caused by prolonged ventral decubitus in reanimation.

A FEW POSITIVE EFFECTS

On the other hand, residents have more time for research, which before COVID-19 was often a real shortcoming. For example, plastic surgery journals have seen a record number of manuscript submissions. We’ve put into practice original surgical training techniques, such as microsurgical anastomoses on chicken thighs or using the pasta model.9 A relatively improved climate surrounding residents is also noticeable, with the observation of training of young residents by more-experienced residents and the absence of quarrels between residents related to overwork in the context of colleagues’ absences (for personal or academic reasons). Some time-consuming activity of cutting-edge research in plastic surgery was observed – as was the case in my department specializing in vascularized composite allotransplants. For example, the complex preparation of patient files for face and hand transplant candidates was finalized.10 The creativity and transversality of plastic surgeons have sometimes been highlighted, as was the case in our department with the proposal of a study improving the management of COVID-19 patients,11 thanks to the use of a particular molecule already tested in the optimization of the preservation of a graft intended for a face re-transplantation.12

REFERENCES 1.

A STRICT LOCKDOWN

Finally, it’s interesting to note that one of the particularities of COVID-19 crisis management in France was mainly the very strict, controlled lockdown with a ban on circulating more than 1 km from one’s home and not more than one hour per day, except for the journey to work only for jobs considered essential. This lockdown was in effect during the first wave (from March to May) and again during the second wave (since October). Severe police controls have been put in place to ensure respect of the rules.13 Residents were sometimes among those who suffered the least from isolation, as they had the ability to move around and go to work, compared to most of the general population, who were distressed by being forced into lockdown by the French government.14 Thus, even if the activity is no longer the same, being in the O.R. remains an invaluable opportunity in this context. |

Dr. Lupon is PGY-4 in the Department of Plastic, Reconstructive and Aesthetic Surgery at Hôpital Européen Georges Pompidou, Paris, and a Research Fellow at the Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Harvard Medical School, Boston.

9. 10.

11.

12.

13.

14.

Hollier LH Jr, Tanna N, Kasabian AK, Abu-Ghname A, Davis MJ, Gibstein A, Reece EM. The COVID-19 Pandemic: Crisis Management for Plastic Surgeons. Plast Reconstr Surg. 2020 Nov;146(5):1197-1206. doi: 10.1097/PRS.0000000000007230. Sarac BA, Schoenbrunner AR, Wilson SC, Chiu ES, Janis JE. The Impact of COVID-19-based Suspension of Surgeries on Plastic Surgery Practices: A Survey of ACAPS Members. Plast Reconstr Surg Glob Open. 2020 Aug 3;8(8):e3119. doi: 10.1097/ GOX.0000000000003119. Sigorski D, Sobczuk P, Osmola M, Kuć K, Walerzak A, Wilk M, Ciszewski T, Kopeć S, Hryń K, Rutkowski P, Stec R, Szczylik C, Bodnar L. Impact of COVID-19 on anxiety levels among patients with cancer actively treated with systemic therapy. ESMO Open. 2020 Oct;5(5):e000970. doi: 10.1136/ esmoopen-2020-000970. Rocco N, Montagna G, Di Micco R, Benson J, Criscitiello C, Chen L, Di Pace B, Esgueva Colmenarejo AJ, Harder Y, Karakatsanis A, Maglia A, Mele M, Nafissi N, Ferreira PS, Taher W, Tejerina A, Vinci A, Nava M, Catanuto G. The Impact of the COVID-19 Pandemic on Surgical Management of Breast Cancer: Global Trends and Future Perspectives. Oncologist. 2020 Oct 12:10.1002/onco.13560. doi: 10.1002/onco.13560. Chang J, Wignadasan W, Kontoghiorghe C, Kayani B, Singh S, Plastow R, Magan A, Haddad F. Restarting elective orthopaedic services during the COVID-19 pandemic: Do patients want to have surgery? Bone Jt Open. 2020 Nov 1;1(6):267-271. doi: 10.1302/2046-3758.16. Van de Poll-Franse LV, de Rooij BH, Horevoorts NJE, May AM, Vink GR, Koopman M, van Laarhoven HWM, Besselink MG, Oerlemans S, Husson O, Beijer S, Ezendam NPM, Raijmakers NJH, Wollersheim BM, Hoedjes M, Siesling S, van Eenbergen MC, Mols F. Perceived Care and Well-being of Patients With Cancer and Matched Norm Participants in the COVID-19 Crisis: Results of a Survey of Participants in the Dutch PROFILES Registry. JAMA Oncol. 2020 Nov 25. doi: 10.1001/jamaoncol.2020.6093. Arezzo A, Vignali A, Ammirati CA, Brodie R, Mintz Y. Is it possible to continue academic teaching in surgery during the COVID pandemic era? Minim Invasive Ther Allied Technol. 2020 Nov 26:1-9. doi: 10.1080/13645706.2020.1845210. Dharini 1, Kumar S, More A, Harikar M. The Impact of COVID-19 and Lockdown on Plastic Surgery Training and Practice in India. Indian J Plast Surg. 2020 Aug;53(2):273-279. doi: 10.1055/s-0040-1716458. Loh CY, Tiong VT, Loh AY, Athanassopoulos T. Microsurgery training--a home do-it-yourself model. Microsurgery. 2014 Jul;34(5):417-8. doi: 10.1002/micr.22242. Lupon E, Cetrulo CL, Lantieri L, Lellouch AG. Comment on: Composite Allotransplantation in a Post-COVID-19 Pandemic Vascularized World. Plast Reconstr Surg. Accepted July 2020. PRS-D-20-02190. Lupon E, Lellouch AG, Zal F, Cetrulo CL, Lantieri L, Combating hypoxemia in COVID-19 patients with a natural oxygen carrier, HEMO2Life® (M101). Medical Hypotheses (2020). doi: https://doi.org/10.1016/j.mehy.2020.110421 Lantieri L, Cholley B, Lemogne C, Guillemain R, Ortonne N, Grimbert P, Thervet E, Lellouch AG. First human facial retransplantation: 30-month follow-up. The Lancet. Volume 396, Issue 10264, 2020, Pages 1758-1765, ISSN 0140-6736. https:// doi.org/10.1016/S0140-6736(20)32438-7. Zongo P, Zorom M, Mophou G, Dorville R, Beaumont C. A model of COVID-19 transmission to understand the effectiveness of the containment measures: application to data from France. Epidemiol Infect. 2020 Sep 22;148:e221. doi: 10.1017/S0950268820002162. Lal A, Sanaullah A, M Saleem MK, Ahmed N, Maqsood A, Ahmed N. Psychological Distress among Adults in Home Confinement in the Midst of COVID-19 Outbreak. Eur J Dent. 2020 Nov 26. doi: 10.1055/s-0040-1718644.

Plastic Surgery Resident | Winter 2020

WHAT I KNOW NOW

That I WISH I KNEW then INTERNATIONAL EDITION By Jens Berli, MD As interviewed by Lisa Gfrerer, MD, PhD

Jens Urs Berli, MD, is an International Medical Graduate from Switzerland who trained at the Johns Hopkins School of Medicine in Baltimore. He’s an associate professor as well as Residency Program director at Oregon Health & Science University. His clinical focus is Gender Surgery.

s an International Medical Graduate (IMG) and program director in a U.S. plastic surgery training program, I’ve had personal experience finding my path into a U.S. residency and I’ve witnessed the journey of many of my IMG colleagues. It’s fair to say the road to becoming a successful plastic surgeon in the United States is not straightforward – and can be long, winding and lined with obstacles. Here are the things I learned along the way that may prove helpful to other IMGs.

MENTORSHIP

Find an IMG mentor who’s gone through the same process and is well-connected. Even though every international student has a unique story, an IMG mentor can help highlight the aspects of the application process that are the most important and pertinent to foreign graduates. Sometimes the answer you may get is not what you want, but it’s important to be realistic about your chances and have 30

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a backup plan. While perseverance and hard work has led many IMG to their dream career, it also has led some to a long and disappointing detour. As program director, I review many national and international graduate medical student applications. Some of the most important things for IMGs to focus on are: • A U.S. mentor who’s genuinely advocating on your behalf is probably the single-most important factor in a successful application.Trying to apply remotely for a U.S. residency will most likely not be successful. The U.S experience can mean observerships, clinical elective rotations, as well as research and conferences. Be aware that you may be allowed to do elective rotations as a medical student, but not after you graduate. Further, some programs require completion of at least USMLE Step 1 prior to your rotations. When deciding upon the laboratory at which to undertake your research, do your due diligence and evaluate the faculty’s track record, funding, prior students’ experiences and the fate of prior IMGs. • When applying for residency, evaluate which programs have previously interviewed and matched IMGs and are therefore “IMG friendly.” • A letter of recommendation alone won’t be sufficient. Ideally, the letters you submit will offer comments on both your academic and clinical abilities.

KEEP AN OPEN MIND

As an IMG, your most important feature should be an open mind – and be flexible when it comes to planning. If you’ve determined that you want to take a certain path, you have to understand that achieving your goal may take some luck and may require you to take a couple of unexpected turns prior to arriving at your final destination. Many roads lead to becoming a plastic surgeon in the United States; plastic surgery is one of the most competitive specialties to match, and very few IMGs match directly into a categorical integrated plastic surgery residency. However, there are other tracks to consider. You could complete general surgery and match into an independent plastic surgery program. This route often involves a

preliminary general surgery position for one to two years, with the hope of finding a categorical general surgery position. During that time there’s also a chance that a categorical plastic surgery position may open up as programs expand (this happened to me). If you do match into a categorical general surgery residency and apply for the independent track, you do need to be aware that programs are currently downsizing the number of independent residents they match every year. Therefore, it’s unclear how many positions will be available by the time you’re eligible to apply. It’s also a very long road. Here's the advice I would give anyone going that route: They should be willing and motivated to pursue other surgical specialties should they not match into an independent position. You don’t want to spend a long, difficult residency in general surgery if you don’t find joy in that specialty. General surgery should not be a means to an end – otherwise, you most certainly will not perform to the best of your abilities, and you will face a very difficult time. As noted, preliminary general surgery positions will help you start your training in the United States and allow you to later pivot to plastic surgery. It also gives you a good foundation in surgical patient management and a skillset that you can use wherever your journey takes you. For preliminary general surgery positions, find a program that’s invested in preliminary residents and work hard. Ideally, the institution you choose has a plastic surgery program, and you can always work to find a mentor in that program during your time on general surgery. You’re also most likely to stay at the institution where you complete your preliminary year, so choose wisely. Lastly, make sure you have a backup plan, in case you cannot train in the United States. You may consider doing an internship in your home country prior to leaving for America, in order to stay plugged-in and connected.

UNDERSTANDING VISAS

The importance of understanding visas prior to accepting a position in research or residency as an international medical student cannot be stressed enough. Many students – and even residents – have been forced to end their U.S journey early due to visa-related issues that might have been avoided with careful planning. Contact your local embassy and an immigration lawyer to understand the exact rules your home Plastic Surgery Resident | Winter 2020

WHAT I KNOW NOW / continued from previous page Table 1. MOST COMMON VISA CATEGORIES – AND WHAT THEY MEAN FOR RESIDENCY Consult an immigration lawyer for exceptions and for current information

VISA CATEGORY

SPONSOR

DURATION

HOMECOMING RULE

WAIVER/TIME TO GREEN CARD

GREEN CARD

N/A

No expiration

N/A

J-1 (PHYSICIAN)

ECFMG1

Maximum seven years

Two years

• Persecution in home country • Hardship for spouse and/or children in home country • Sponsored visa by governmental agency2 If waiver granted: Three years until eligible for Green Card

J-1 (RESEARCH)

Employer

Up to three-anda-half years

Not always

N/A

H-1B

Employer3

Up to six years

N/A

O-14

Employer

Renewable indefinitely

N/A

1) Educational Commission on Foreign Medical Graduates 2) Each state can sponsor up to 30 J-1 physicians per year to provide underserved communities (known as Konrad waiver). An example of another state agency that can grant visas waiver: Department of veterans affairs 3) Hospitals have significant cost and administrative burden to do this and are unlikely to offer H1B visas. Also applicants must complete USMLE step 3 and apply for state medical license (each state requirements differ). 4) Employer and applicant need to prove exceptional abilities of the applicant.

For more information on visas and IMGs, go to: https://www.ama-assn.org/education/international-medical-education/immigration-information-international-medical-graduates https://resident360.nejm.org/expert-consult/applying-for-residency-as-an-international-medical-graduate

country requires you to follow. For an overview of different visa categories that are relevant for residents, see Table 1. Be aware that a J-1 has a homecoming requirement of two years. (Before a J-1 person with a two-year home residency requirement can change to nonimmigrant status or adjust to U.S. permanent esident status, he or she must either return to the country of last residence for two years or obtain a waiver of the two-year home residency requirement.) Waivers for this exist, but you may be required to work with an underserved population after you complete your residency – which can have geographical implications for you and your family. Be sure to ask about these points prior to accepting a visa. 32

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FINAL THOUGHTS

The decision to immigrate to the United States for surgical training has been the best professional decision I’ve made. Yes, it came with a lot of uncertainty and there was always a door that opened – but in my case, and in many other IMG’s cases, it wasn’t the door I expected. Keep an open mind, have a backup plan, work hard and, most of all, have fun while doing it. Make friendships. | Dr. Berli and Dr. Gfrerer are both international medical graduates.

PLASTIC SURGERY RESIDENCY IN GREECE

Challenges abound, but we can gain strength from within By Konstantinos Gasteratos, MD

he post-graduate pathway for plastic surgery training in Greece includes two years of general surgery, three years of plastic and reconstructive surgery, and two semesters spent in other related subspecialties (pediatric surgery, OB/GYN, ENT, neurosurgery, etc). There’s no official “match” for plastic surgery residency in Greece – applicants are put on a “waiting list” that can last anywhere from four to seven years. To avoid this long period of unemployment, many Greeks seek training outside their country, with the UK, Germany and Switzerland being common destinations. The option of training abroad allows for not only continuing education in a preferred specialty, but also for a more structured, evidence- and competency-based clinical practice. The absence of a robust, comprehensive curriculum from the majority of the Greek residency programs leads to a discrepancy amongst residents’ competencies – which may range from poor to excellent, depending on the individual trainee.

GREECE’S UNIQUE CHALLENGES

Plastic surgery training in Greece poses unique challenges for residents. Financial support for post-graduate training is nonexistent and salaries are low. Residents must independently pursue expensive training courses (cadaveric, microsurgery, etc.) and conferences, as well as pay for the associated fees on their own. The cost is in the thousands of dollars for each. Given COVID-19, however, the majority of these meetings have now become virtual, which allows residents from overseas to attend and participate in webinars and lectures based in different parts of the world from the comfort of their homes. There are many problems in both training and patient care in Greece. The traditional academic residency programs in Greece have an off-the-record, unaudited and high rate of inter-resident bullying. Access to healthcare is very much dependent on the location and socioeconomic status of the patient. Primary care services are not equipped with competent general practitioners (GPs). As a result, minor trauma, such as a simple hand laceration, may be referred to tertiary hospitals for evaluation and treatment. This decreases the quality of the training for the residents called to deal with these cases. Sadly, it’s also common that in order to get better care in public hospitals, patients often bribe their doctors.

In the COVID-19 era, plastic surgery training has been hobbled in several ways. All aspects of patient care have been affected. Currently, the majority of the largest hospitals in major cities in Greece are reaching their maximum capacity due to the increasing number of confirmed COVID-positive patients requiring admission. To respond to this crisis, O.R.s have shut down and are being converted to COVID beds; outpatient clinics receive no patients; and all elective and emergency operations are canceled with the exception of life- and limbthreatening cases. The private sector is being employed in an attempt to shift patient load from public to private hospitals. As per hospital policy, almost every doctor, including residents, irrespective of their main specialty, are ordered to work in COVID units to help with the extreme pressures. In the light of these changes, the training opportunities for plastic surgery residents within their specialty have become extinct.

OVERCOMING COVID-19 ADVERSITY

During these adversities, I have devised a list of actions that help me stay focused and keep me going strong. These may help international residents whose training has been affected in similar ways. • Take care of your body: Sleep well, eat healthy, exercise, practice grounding/earthing, yoga, spend time in nature, take a break to practice mindful breathing or take a relaxing shower. • Take care of your mind and spirit: Meditate, listen to your favorite music, play music, draw, connect with loved ones and reach out to significant others. • Stay up-to-date with webinars: The International Confederation of Plastic Surgery Societies (ICOPLAST) has a large number of monthly webinars on various topics; watch surgical videos. • Use ASPS resident resources: Subscribe to the ASPS Residents and Fellows Forum (International option; go to plasticsurgery.org) for a relatively small fee and gain access to the ASPS Education Network (EdNet); electronic access to the journal PRS; free admission to Plastic Surgery The Meeting (if meeting “earlybird” requirements); access to the Job Opportunity Board; and many more items of interest. |

Dr. Gasteratos is a final-year resident in Plastic and Reconstructive Surgery at Papageorgiou General Hospital, Thessaloniki, Greece. He serves as the International Editor for Plastic Surgery Resident. Plastic Surgery Resident | Winter 2020

EXPANDING INTERNATIONAL EXCHANGE AND DIVERSITY IN PLASTIC SURGERY

I By Lisa Gfrerer, MD, PhD ASPS Resident Representative

nternational collaboration and communication between plastic surgeons, residents and medical students fosters advances in plastic surgery patient care, as well as research and innovation. Diversity among trainees and graduates promotes inclusion of different backgrounds, viewpoints and ideas allowing for expansion of the plastic surgery horizon. As part of the global plastic surgery community, ASPS and the Resident Council (RC) have great interest in promoting international exchange and diversity to create lasting partnerships and work toward uniting plastic surgeons and trainees around the world.

CULTIVATING RELATIONSHIPS

As an international medical graduate (IMG) training in the United States, I’ve continued to cultivate my relationships with international peers and participated in many efforts to promote multicultural inclusion. This year, as part of my role as resident representative to the ASPS/ PSF Board of Directors, I plan to expand existing RC projects to include international trainees and surgeons, as well as create new projects to encourage diversity and international teamwork. The RC set up a subcommittee to identify areas of improvement surrounding international inclusion and diversity in order to tackle relevant and timely problems that the plastic surgery community is facing – and to act upon these concerns. In addition, we are planning to expand the ASPS mentorship program Professional Resource Opportunities in PRS Education and Leadership (PROPEL) 34

Plastic Surgery Resident | Winter 2020

to include international members, residents and medical students. This expansion will improve diversity among ASPS members and resident members, as well as improve the reach of ASPS globally.

COLLABORATION, WITH A ‘ROADMAP’

A specific sub-focus of this project will be the recruitment of groups of plastic surgeons and residents who aren’t yet represented or are underrepresented in the ASPS community. We further plan to include a section for IMGs and researchers in an upcoming ASPS medical student web-based platform “Medical Student to Plastic Surgery Resident: A ROADMAP (Recruitment of Accomplished & Diverse Medical-student Applicants into Plastic Surgery) to Success” to guide international researchers and medical students early in their plastic surgery career paths. Lastly, we hope to collaborate with international ASPS sister societies to include their members and trainees in RC activities. On a personal note, I hope to get the chance to speak to more of my colleagues in national and international residencies and in medical schools, and to provide mentorship and support in their professional development. The RC and I hope that we can contribute to uniting the international community – even in times of unprecedented challenges. |

Dr. Gfrerer is a chief resident in the Harvard Integrated Plastic Surgery Residency Program.

We’re transitioning to a new era – join us in our advocacy efforts By David Hill, MD Resident Ambassador PlastyPAC Board of Governors

he year 2020 has been filled with surprises that resulted in many changes – including the evolution into a more virtual world. This new era has many advantages, including being able to partake in virtual Plastic Surgery The Meeting from the comforts of your home. Hopefully, most were able to participate in the many educational opportunities during the conference.

HIGHLIGHTS AND CHANGES

Thank you to all who explored the various PlastyPAC events. One of the highlights was the virtual reception with Rep. Raul Ruiz, MD (D-Calif.), who discussed his efforts to address the balance-billing issue in Congress and his opposition to solutions that tie physician reimbursement to the median in-network rate. This was truly a remarkable opportunity to

gain insight and discuss a big change, which will significantly impact the practices of medicine in the near future. Also, a special congratulations to Sagar Deshpande, MD, from the University of Minnesota, for winning the first annual PlastyPAC Political Pub Quiz. This was no easy feat, but Dr. Deshpande pulled off an impressive victory over many of the Society’s advocacy veterans. With the conclusion of the recent highly contested elections, many changes are in store for Washington. Our PAC was very successful in supporting a significant number of political candidates who won their respective races across the country. Through this support, we’re able to continue developing our relationships with these members and maintain open lines of communication. As the new congressional personnel begin their terms and get acquainted with their new roles, it’s ever important to continue educating these members as to our practices and concerns as plastic surgeons. From balanced-billing reimbursements to Medicare payment cuts and scope of practice protection, these proposals continue to be forefront issues that will exert a vast impact on our lives.

LET’S PLAN TOGETHER

As this long and tumultuous year comes to a close, we continue to look ahead and plan for future advocacy retreats and meetings which will take place in 2021. These events are designed for persons of all backgrounds, from experienced PlastyPAC members to first time participants. They are a perfect introduction to all things advocacy. Be sure to be on the lookout for more information regarding these experiences coming – and be sure to check out our website (www.PlastyPAC. net) for the most updated materials. Meanwhile, I encourage all to contact me (hilld793@gmail.com) or Benjamin Schultz, MD (benschultzmd@gmail. com), with any questions, comments or concerns on PlastyPAC or for information on the issues we’re fighting for. Your continued input and support of our advocacy efforts help protect the future of plastic surgery throughout the United States. For additional information about PlastyPAC, please visit our website at www.PlastyPAC.net. |

Dr. Hill is PGY-8 at Houston Methodist Hospital.

Plastic Surgery Resident | Winter 2020

March 20-21, 2021 LIVE ONLINE and ON DEMAND Featuring 2 concurrent clinical tracks covering aesthetic and reconstructive breast, facial rejuvenation and body contouring

These activities have been approved for AMA PRA Category 1 CreditTM

March 5, 2021 LIVE ONLINE and ON DEMAND Learn from expert faculty and industry-leading practice management consultants to help your team succeed! Jointly provided by ASPS and ASPSP.