Plastic Surgery Resident, Fall 2023

From the publishers of Plastic Surgery News

From the publishers of Plastic ISSUE 32 | FALL 2023Surgery News

The magic of mentorship Benefits of the mentor-mentee relationship run deep – and often benefit both sides

» ‘Do what you want to do, go where you want to go’ ASPS president lends career advice built over two decades page 16

» Tennessee experiment looks to open international doors New law lets IMGs in good standing qualify for a temporary license page 22

IN THIS ISSUE » Revisiting the path to leadership with ASPS past President Rod Rohrich, MD p. 24 » Meet the PSTM Travel Scholars during the annual meeting in Austin p. 15 » Consult Corner: Venous thromboembolism prophylaxis p. 18

A note from the editor

W

elcome to our Plastic Surgery the Meeting 2023 (PSTM23) issue of Plastic Surgery Resident (PSR). Welcome, too, to Austin, Texas, known for its live music scene, abundant outdoor activities and renowned food. We hope you have an opportunity to enjoy all that Austin has to offer during your time at the meeting – the preeminent meeting for plastic surgeons. PSTM provides an incredible opportunity to learn about cutting-edge surgical techniques and research innovations, and to partake in discussions about the future directions of our specialty. Beyond these obvious benefits, many of us also travel to the meeting to reconnect with people who’ve had an impact on our careers and journeys as plastic surgeons.

Russell E. Ettinger, MD Chief Medical Editor

Plastic Surgery Resident Seattle

The meeting also provides an annual forum to catch up with those who trained us – and those we’ve had the opportunity to train. This duality in connection between mentors and mentees is one of the most rewarding elements of a career in plastic surgery and one which is on full display during the meeting.

The cover story of this issue of PSR focuses on mentorship and how the relationships we form fundamentally shape who we are as individuals – and how we advance through our careers.

In this issue, our Program Peek features the powerhouse UT Southwestern Plastic Surgery Residency Training Program. A program synonymous with plastic surgery, we learn more about the pillars of the UTSW residency program including their focus on graduated autonomy, strong didactics and close-knit resident culture.

We also provide an interview with ASPS President Gregory Greco, DO, in which he identifies the most important attribute of a successful resident – and who and what inspired him to choose this specialty. We also highlight the inaugural International Residents World Cup, in which 16 teams from renowned international training programs competed in a single-elimination virtual tournament testing core plastic surgery knowledge.

Our columns include Consult Corner on VTE prophylaxis; Journal Club on breast augmentation and mastopexy techniques; In-Service Insights on rheumatoid hand; and an International Perspective evaluating new Tennessee legislation that will alter how international medical graduates obtain U.S. medical licensure in that state. This issue also features Q&A with ASPS past President Rod Rohrich, MD, on how he found lifelong satisfaction with the transformative potential of aesthetic surgery of the face.

In the year ahead, PSR content will move to the pages of Plastic Surgery News as a means to gain wider readership and bring news and topics related to residents to a larger audience of ASPS membership. It has been an honor to serve as chief medical editor for PSR for the past two years and I look forward to seeing the evolution of resident content within Plastic Surgery News.

As always, thanks to our readers, and to our team of editors and the ASPS production staff. We hope you enjoy the read! |

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Table of

Contents Cover Story: The Meaning of Mentorship . . . . . . . . . . . . . . . . . . . . . . . . . . 4 The benefits of the mentor-mentee relationship can be vast – and quite often hidden – for each side of the alliance.

Program Peek: UT Southwestern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Dallas-based institution has produced several celebrated leaders in the specialty while providing high-quality training.

Faculty Focus: Jennifer Kargel, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Associate training director describes the lasting influence of her mentor and advises trainees to be flexible, as career plans usually change.

24 Hours in: Dallas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 “Big D” offers just about everything under the sun – and plenty of cool runnings when the temperatures (inevitably) soar.

Message from the Director: Andrew Zhang, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Strong, faculty-driven programs, hands-on experience, rigorous research, ethics and more propel UT Southwestern plastic surgery.

On the Move: Meeting the 2023 Resident Travel Scholars . . . . . . . . . . . 15 A quick look at the nine 2023 Travel Scholars in Austin have been assembled for this issue.

Raising the Cup: Universidad Peruana Cayetano Heredia . . . . . . . . . . . . . . 15 Peru’s plastic surgery program claims 1st place among 16 competitors in the inaugural International Residents World Cup.

Leadership Q&A: ASPS President Gregory Greco, DO . . . . . . . . . . . . . . . . . . 16 ASPS president responds to the PSR Editorial Board and talks of inspiration, practice locations and giving 100 percent to each patient.

Consult Corner: VTE Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Plastic Surgery Resident | Fall 2023 Vol.7 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 Gregory Greco, DO | plasdoc39@msn.com EDITOR Russell Ettinger, MD | retting@uw.edu ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com Megan Fracol, MD | mfracol@gmail.com SENIOR R ESIDENT EDITOR Olivia Abbate Ford, MD | oford@partners.org R ESI DEN T EDITOR S Aradhana Mehta, MD, MPH | aradhana.mehta@unlv.edu Alexis Ruffalo, MD | aruffolo57@siumed.edu Mark Shafarenko, MD | mark.shafarenko@mail.utoronto.ca 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 Daniel De Luna Gallardo, MD | daniel.delunag@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

How to understand and recognize early red flags of VTE in order to mitigate risks and prevent future events.

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

InService Insights: Rheumatoid Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

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

Advances in treatment notwithstanding, it’s still crucial to understand its pathophysiology and identify specific anatomic injuries.

International Perspective: Talk of Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Daniel De Luna Gallardo, MD, examines the new path to residency programs in Tennessee for international medical graduates.

Plastic Surgery Perspectives: Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 After learning at the side of luminaries, ASPS past President Rod Rohrich, MD, advises residents to learn all aspects of plastic surgery.

Journal Club: Breast Augmentation and Augmentation-Mastopexy . . . 26 Although breast augmentation procedures rank annually among the most popular, questions about approaches still remain.

Message From the Chair: The Latest From the Residents Council . . . . . . . . . . . . . . . 29 Olivia Abbate Ford, MD, provides an update on the latest work done by the Residents Council and an introduction to the incoming chair.

GR A PHIC DESIGN ER Angela Bochucinski & Paul Snyder A DV ERTISING SA LES Michelle Smith (646) 674-5374 | Wolters Kluwer Health

Plastic Surgery Resident (ISSN 2469-9381) is published four times per year and distributed free to members of the ASPS Residents and Fellows Forum and plastic surgery training programs. Letters, questions or comments should be addressed to: Editor, Plastic Surgery Resident, 444 E. Algonquin Road, Arlington Heights, IL 60005.

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

ASPS Home Page: www.plasticsurgery.org

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Mastering mentorship Excelling as a mentor and mentee in residency and beyond

By Alexis Ruffolo, MD, & Jessie Koljonen, MD

M

entorship is an invaluable tool that can reshape the careers of both mentors and mentees within the specialty of plastic surgery. It can guide a medical student toward choosing plastic surgery as their career path or assist a faculty member in establishing a prominent position in academic medicine – in addition to producing personal fulfillment and heightened job satisfaction.

Research has shown that mentorship in academic surgery leads to increased academic productivity, fosters diversity and inclusion, safeguards against burnout and reduces turnover.1 Beyond these quantifiable benefits, mentorship influences career direction, leadership opportunities, research output and personal development, making it an indispensable element of professional growth for plastic surgeons.2,3 THE QUALITIES OF A MENTOR Mentors should embody, among others, three essential qualities: accessibility, relatability and investment.

Accessibility is fundamental, as mentors must be available and approachable for their mentees. Creating an environment where mentees feel comfortable discussing concerns and questions fosters open communication. Informal settings, such as one-on-one teaching in the O.R. or casual meetings over coffee, can be just as meaningful as formal interactions for mentorship.4 Relatability is equally important. Mentees often seek mentors who share similar backgrounds, ethnicities or gender 4

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ALEXIS RUFFALO, MD

JESSIE KOLJONEN, MD

identities, as they can better understand and address specific challenges and concerns. For instance, women in the specialty often seek advice on managing their careers alongside fertility, pregnancy and parenthood – making mentorship by female mentors particularly valuable.5 Similarly, underrepresented minority trainees and young plastic surgeons look for mentors who share their backgrounds to overcome barriers to entry.6 Finally, mentors must demonstrate genuine investment in their mentees’ success. Effective mentorship requires a commitment of time and energy from both parties.3 This can manifest as regular check-ins, advocating for mentees’ professional opportunities or simply being responsive to mentee inquiries. This relationship benefits not only the mentee but also the mentor, leading to enhanced job satisfaction and a sense of “giving back.”

HOW TO BE A GOOD MENTEE Although much has been written about the qualities of a good mentor, less has been said about what makes a good mentee.

A survey of active members of ACAPS and AAPS regarding their experiences mentoring medical students, however, provided some insight. Respondents ranked “honesty, integrity and trustworthiness” as the most important qualities in a mentee, followed by “passion for the specialty,” “teachability,” “commitment and follow-through” and “work ethic.”

Attributes such as “intelligence” and “patient care skills” were considered less important.7 Maintaining the mentor-mentee relationship through regular

Q&A WITH MENTEES TURNED MENTORS We asked two rising plastic surgeons – who now serve as mentors after having undergone the experience as mentees – to provide perspective on topics related to building mentor-mentee relationships; how they approach their roles as mentors; how to become an effective mentor; the paths that brought them to their respective positions in both the specialty and as mentors; and more.

Ashley Amalfi, MD Clinical assistant professor of surgery, University of Rochester School of Medicine

Mentors must demonstrate genuine investment in their mentees’ success

Partner, Quatela Center for Plastic Surgery

meetings and communication is also crucial. In the survey, mentors preferred scheduled one-on-one meetings to discuss career and personal goals. The most common frequency of interaction was monthly, with email being the preferred communication method, followed by in-person meetings, phone calls and text messages.7

ASHLEY AMALFI, MD

Shaun Mendenhall, MD Assistant professor of surgery (plastics) and orthopaedic surgery, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania

CURRENT MENTORSHIP PROGRAMS Professional societies provide opportunities for mentors and mentees to engage in mentorship programs. Many societies have established young members’ groups and structured mentorship initiatives. These programs pair junior mentees with senior surgeons, providing feedback, insights and inspiration.

Participation in such programs allows members to contribute to the field of plastic surgery and enhance their professional networks.

The ASPS mentorship program, Professional Resource Opportunities in Plastic and Reconstructive Surgery Education and Leadership (PROPEL) aligns junior and senior residents with early-career and established surgeons based on individual preferences and interests. (To access the PROPEL guidebook, enter the ASPS website at plasticsurgery.org, click on the Community tab, then on “Mentorship Program” located under Directories & Networking.)

In addition, the Plastic Surgery Research Council offers multiple tiers of mentorship that cater to medical students, residents, chief residents, Fellows, junior faculty and senior faculty. These programs exemplify the variety of mentorship opportunities available at national, regional, state and institutional levels within the plastic surgery community.

SHAUN MENDENHALL, MD

PSR: WHAT QUALITIES IN YOUR MENTORS MADE THEIR GUIDANCE PARTICULARLY EFFECTIVE? Dr. Amalfi: I always felt it was helpful when a mentor approached me as an individual. As a woman and a mother, more specific guidance as to how I would create that balance and prioritize my family as well as my career resonated with me. The small details of how my mentors made that balance work and carved-out the time they needed for their career and family, but also for themselves and self-care, is something I remember and often think about.

Dr. Mendenhall: I simply wouldn’t be where I am without my mentors. A quality in my early mentors that stands out was their ability to recognize my potential and to help put me on a path to reach that potential. This took time on their behalf – to get to know me and to help guide me on my journey. They also got me involved in the specialty of plastic surgery through research – bringing me to meetings and introducing me/ promoting me to leaders in plastic surgery.

PSR: HOW DO YOU MAKE THE MOST OF A MENTORSHIP AS A MENTEE? Dr. Amalfi: Open communication is very important in keeping that relationship going. Of course, that communication initially may be more in-depth and more of a time commitment, but as the relationship continues, the mentee can help to keep that going. Small opportunities to reach out and connect will keep that relationship going for

ASPS member Daniel Driscoll, MD (left), and Ukrainian surgeon Artem Posunko, MD (right), perform surgery on a pediatric burn patient while Plastic Surgery Resident |the Fallanesthetic.

2023 anesthesiologist Gennadiy Fuzaylov, MD (center), administers

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PSR: HOW HAVE YOUR MENTORS INFLUENCED YOUR CAREER CHOICES? Dr. Amalfi: My mentors have always been honest and given me very specific feedback that encouraged me along the way.

With career choices, job changes and some of the major decisions I’ve made in my career, I always consulted with the mentors I trust most and who know me best. I never made any major decisions in isolation without consulting others I trust.

Dr. Mendenhall: I’m totally a product of my mentorship – every major career decision I’ve made was influenced by my mentors. The reason I chose plastic surgery was primarily because I had mentors in this specialty who took me under their wing. Same with hand surgery. I would have never been on this path if it weren’t for them taking the time to focus on me and my interests, and then inspiring me to be a little like each one of them.

Effective mentorship requires a commitment of time and energy from both parties.

years to come, whether that be a text or email, a phone call for advice or getting together at national meetings.

Dr. Mendenhall: Taking advantage of the opportunities that mentors provide – such as working on and completing research projects, going to meetings, etc. – is an important part of the reciprocal mentor-mentee relationship. Following through on commitments and always striving to make mentors proud is important.

PSR: HAVE YOUR MENTORSHIPS BEEN PRIMARILY INFORMAL OR A STRUCTURED MENTORSHIP PROGRAM (SUCH AS PROVIDED BY ASPS, ACAPS, PSRC, ETC.)?

Dr. Amalfi: All of my mentorships developed organically and informally. ASPS and other societies have been instrumental, however, in providing smaller break-out events, social outings and more-intimate meetings that lend themselves to relationship building. These events are always been a great way for me to mingle and introduce myself to various people in the specialty – some of whom became my mentors. I’ve also met mentees in this way and am always open to building these relationships. The opportunities offered by professional organizations absolutely provided important relationshipbuilding and reinforcement throughout the years of my training and career.

Dr. Mendenhall: Informal mentorship has always been the primary means of my mentorship. I did try some formal programs, but they never seemed to go very far (probably because I didn’t follow through with them).

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PSR: WHAT APPROACH DO YOU TAKE TO SERVING AS A MENTOR? Dr. Amalfi: I always build very fluid and organic relationships with my mentees. So much interaction occurs naturally when I’m teaching and working oneon-one with the residents. I get to know who they are, what’s important to them and what Maintaining the mentor-mentee relationship through type of support regular meetings and communication is also crucial. they need as they grow and build.

For those who value that mentorship, their interest allows us to interact more and guide them in various other ways. It’s a reciprocal relationship for sure, and when the relationship is right for both, it organically builds upon itself and can be as involved as fits the mentee.

Dr. Mendenhall: Our most scarce resource is time, and that’s what it takes to offer mentorship to others. Taking time to get to know mentees, seeing what makes them tick and get excited – and then trying to tailor advice and project toward these things is an important part of my mentorship strategy.

Then it’s a matter of being there for them when they need it, getting them involved and introducing them to key players.

I’m always their advocate, especially when they need it the most (such as around match time).

PSR: WHAT QUALITIES OF YOUR MENTEES MAKE THE MENTORSHIP MORE PRODUCTIVE? Dr. Amalfi: Shared interests and values allow me to connect more easily with my mentees. However, I’ve had meaningful relationships with so many different mentees who pursued different paths. However, I do find that the ones who have a similar career path to my own are the relationships that are most enduring throughout all stages of their careers. When our career trajectories are similar, there are just so many more opportunities to connect and to sponsor that mentee along a similar path.

Dr. Mendenhall: Hard working, honest, self-motivated, a can-do attitude and persistence are all good qualities.

PSR: WHAT’S ONE PIECE OF ADVICE YOU HAVE FOR SOMEONE AIMING TO A BECOME BETTER MENTOR?

I’m still figuring this out myself – is to always be an advocate for your mentees. There will always be times when they will need your help, and being there for them during those times is critical. Taking the time to hear their dreams and fears, and then guiding them on their path, will certainly lead to a good mentor-mentee experience. | Dr. Ruffolo is PGY-5 and Dr. Koljonen is PGY-4 at Southern Illinois University, Springfield.

REFERENCES

1. Myers P, Amalfi A, Ramanadham S. Mentorship in plastic surgery: A critical appraisal of where we stand and what we can do better. Plast Reconstr Surg. Sept.

2021;148(3)

2. DeLong M, Hughes D, Tandon V, Choi B, Zenn M. Factors influencing fellowship selection, career trajectory, and academic productivity among plastic surgeons.

Plast Reconstr Surg. 2014 Mar 2014;133(3).

Dr. Amalfi: Don’t overthink it. If someone asks for advice and is willing to have a conversation about their career, that’s a great opportunity to engage. As with any relationship, sometimes things will progress easily, and others just are less organic. If a mentee shows interest, do your best to guide them to the best of your ability, and if a colleague may better serve their needs, be open to making those introductions to better serve them.

3. Janes L, Kearney A, Taub P, Gosain A. The importance of mentorship in shaping the careers of academic leaders in plastic surgery. Plast Reconstr Surg. 07/01/2022 2022;150(1).

Dr. Mendenhall: This is a little tough; everyone has their own styles and ways of doing things. My one piece of advice – and

7. Janis J, Barker J. Medical student mentorship in plastic surgery: The mentor’s perspective. Plast Reconstr Surg. 2016 Nov 2016;138(5).

4. Barker J, Rendon J, Janis J. Medical student mentorship in plastic surgery: The mentee’s perspective. Plast Reconstr Surg. 2016 Jun 2016;137(6).

5. Plana N, Khouri K, Motosko C, et al. The evolving presence of women in academic plastic surgery: A study of the past 40 years. Plast Reconstr Surg. 2018 May 2018;141(5).

6. Butler P, Britt L, Longaker M. Ethnic diversity remains scarce in academic plastic and reconstructive surgery. Plast Reconstr Surg. 2009 May 2009;123(5).

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University of Texas Southwestern

By Keith Sweitzer, MD HISTORY

• Established in 1969 by Ted Mills, MD, who appointed Kenneth E. Salyer, MD, to the role Division of Plastic Surgery chief. The first resident to graduate the program was Miguel Vargus, MD, in 1973.

• 1983 – Fritz Barton, Jr., MD, was named division chief.

He modeled the construction of the division after his NYU mentor, John Converse, MD, and recruited subspecialized faculty to build the program. He began Selected Readings in Plastic Surgery in 1978.

• 1992 – Rod J. Rohrich, MD, became chair of the Department of Plastic Surgery, one of the first plastic surgery departments in the United States.

• 2015 – Jeffrey Kenkel, MD, named department chair

LEADERSHIP

Jeffrey Kenkel, MD, Professor and Chair, Department of Plastic Surgery Andrew Zhang, MD, Professor and Vice-Chair of Education, Program Director of Integrated and Independent Plastic Surgery Residencies Alex Kane, MD, Professor and Vice-Chair of Academic Affairs Shai Rozen, MD, Professor and Vice-Chair of Clinical Research

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Nicholas Haddock, MD, Associate Professor and Vice-Chair of Business Affairs

NATIONAL LEADERSHIP

• Dr. Kenkel, Editor-in-Chief, Aesthetic Surgery Journal (as of January 2024), past president, American Society for Aesthetic Plastic Surgery • William P. Adams Jr., MD, past president, American Society for Aesthetic Plastic Surgery • Al Aly, MD, Editor-in-Chief, Aesthetic Surgery Journal Open Forum (as of January 2024) • Bardia Amirlak, MD, Editorial Board, Aesthetic Surgery Journal • Douglas Sammer, MD, Associate Editor, Journal of Hand Surgery • Nicholas Haddock, MD, Associate Editor, Plastic and Reconstructive Surgery • Dr. Rosen, Associate Editor, Plastic and Reconstructive Surgery

CLINICAL EXPERIENCE • Core training sites include William P. Clements Jr., University Hospital; Parkland Memorial Hospital; Children’s Medical Center – Dallas; Dallas Veterans Affairs Medical Center; Baylor University Medical Center

• Additional rotations at private practices and community hospitals • 27 full-time faculty and 30 adjunctive faculty from the Dallas-Fort Worth community • 30 integrated residents, three independent residents

• Craniofacial fellowship (one Fellow/year); hand surgery fellowship (two Fellows/year), aesthetic surgery fellowship (one Fellow/year), microsurgery fellowship (one Fellow/year) • Two-and-a-half months of plastic surgery rotations during first year; 10 months during second year; all year from third year to chief year • Night float rotation during second and third year

• Cosmetic focused rotation during fourth year; up to six weeks of elective time available fifth year; community rotations during sixth year

• Resident-run, year-round aesthetic clinic during PGY 5-6

EDUCATIONAL CURRICULUM • Tuesday: Hand Indications Conference

• Wednesday: Pediatric indications conference; microsurgery indications (2nd and 4th Wednesdays); 1-2-3 conference (lectures for junior residents, 1st and 3rd Wednesdays) • Thursday: hand conference (morning conference); grand rounds (faculty lectures); photo/teaching conference (afternoon)

RESEARCH

• Department pays to cover resident salary and benefit for offsite rotations.

• Built-in time for elective rotations (international possible)

• Up to $2,000 annual travel stipend (PGY 4-6) for domestic meetings of their choice • Additional up to $2,000 travel stipend (PGY 1-6) for podium presentations at domestic meetings • Department support of ASPS membership

• MedOne access for vast number of eBooks and journals • Mileage reimbursement for off-site rotations • 25 days of PTO

• Night float service during the week eliminates overnight call and allows residents to rest and prepare for cases • $125 meal money for Parkland Hospital rotations

• Prize for best plastic surgery In-Service performance

• Bridge Harrison Humanitarian Award to support international missionary trips

RESIDENT CAMARADERIE

• Annual pool party at the program director’s house celebrating the end of the year and welcome incoming residents to the program

• Annual themed holiday party hosted by the department chair

• M&M once per month

• Team-building events throughout the year with residents and faculty; beach volleyball, bowling, cooking – just to name a few

• Formal case-based knowledge assessment exam twice a year

• Women in Plastic Surgery (WPS) dinners

• Friday: VA and Parkland indications conference

• Journal Club meetings at local restaurants covering major subspecialties of plastic surgery

• Annual Thanksgiving work-out day hosted by a program faculty

• Anatomy labs five to six time per year from head to toe

• Annual Alumni Day event featuring early-, mid- and late-career alumni sharing their life and practice experiences; during Alumni Day, graduating residents put their own best case during residency up for the coveted “Mr. Chips” award

• LASER course twice per year • Injection clinic quarterly • Visiting professors

• Professional development lectures series twice per year (focusing on how to build a successful practice, contracts and coding, etc.)

• Resident-led informal gatherings happen organically on a weekly basis |

• Professional leadership training with multiple helpful assessments and six lecture/small group training sessions (every three years) • Formal mentorship group paring with regularly scheduled meetings and outings

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Q&A WITH JENNIFER KARGEL, MD Jennifer Kargel, MD, is associate professor of surgery and associate program director for the Integrated and Independent Plastic Surgery programs at UT Southwestern Medical Center, Dallas. Dr. Kargel earned her medical degree and completed her plastic surgery residency at the University of Texas Medical Branch, Galveston, and followed that training by completing a fellowship in hand surgery and microsurgery at UT Southwestern.

Her clinical interests include a sharp focus on hand surgery, striving to provide the highest care possible for pediatric patients – including repair of congenital hand and wrist deformity and brachial plexus injuries – and adult patients with hand and wrist conditions that include Dupuytren contracture and Reynaud’s disease.

PSR: HOW DID YOU PREPARE FOR A COMPETITIVE FELLOWSHIP? Dr. Kargel: I looked for opportunities in my field of interest – in this case hand surgery – and worked with colleagues in plastic surgery and orthopedic surgery to get the most exposure and experience possible prior to fellowship. I asked attendings questions, made sure I knew the relevant anatomy and read papers and chapters reviewing techniques for surgeries I was scheduled to observe and scrub-in on. I found attending national meetings in the subspecialty also to be very helpful, as this allowed me to learn more about interesting topics led by leaders in that field, and to network with a large group of academic leaders from all parts of the United States and internationally under one roof.

PSR: WHAT IMPACT DID YOUR FELLOWSHIP HAVE ON YOUR CAREER? Dr. Kargel: I always wanted to be involved in academic medicine. I love to teach and to be challenged. When training medical students, residents and Fellows, you must stay on top of innovations and updates in the field. Participating in a hand and micro fellowship not only allowed me to sharpen my skills, it exposed me to a variety of conditions and procedures concentrated into a single year to establish a solid foundation in hand surgery fundamentals. It also provided me with a network of colleagues to help look for opportunities in 10

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academic centers. Additionally, a huge benefit of a fellowship is the long-term relationships you build with mentors to whom you can reach out throughout the years, if and when you need someone to bounce-off ideas for a particularly tricky patient presentation or surgical technique.

PSR: HOW IMPORTANT IS A MENTOR – AND HOW CAN WE FIND ONE? Dr. Kargel: Having a mentor is extremely important, and I think we can sometimes take it for granted in large academic centers. Mentorship can take many shapes, depending on where you are in training and career, and what resources you have available. This can be as simple as meeting with the head of plastics at your institution, seeking residents who you feel comfortable speaking to and asking advice of, or meeting people at regional and national meetings that you can subsequently develop a relationship with over time.

When I was a first-year medical student, Linda Phillips, MD, our plastic surgery division chief, gave a talk to the plastic surgery interest group. I remember listening to her speak while she showed us slide after slide of reconstructive surgery.

By the end, I knew I wanted to train under her. Additionally, during early elective rotations, research paper projects, and subsequent scheduled surgical rotations, I had the opportunity to work with strong female residents who were facile in the O.R., led the resident and student teams efficiently and effectively throughout the workday, and portrayed excellent

bedside manner. I modeled work practices and patient interactions after them, tweaking here and there as my own confidence and knowledge levels grew.

Even as an attending, it’s important to have mentors who can provide insight and guidance, both surgical- and businessrelated. Finding the right mentor isn’t always an automatic fit; sometimes it ends up looking like a mentorship team, rather than a mentor-mentee relationship.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE OF A RESIDENT? Dr. Kargel: The residents who are most impressive to me are the ones who treat the patients on service as their own. They listen to them in the clinic and on rounds, they advocate for them to ensure they are receiving the best care and they prepare for cases.

These are the residents who are thorough and thoughtful, take initiative and make me excited to see they’re coming on service.

When they go out into the world, I make note of where they’re practicing so I can refer patients, if needed.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Kargel: Work-life balance or “integration” is a constant struggle and something we all deal with in our field. Since we don’t work shifts, unless we’re out of town and have handedoff our service to a colleague to babysit, we’re never truly away from our work and our patients. However, since having my daughter, it’s actually been a little easier to shut-off the computer, delay answering email and decline things, since I know it directly impacts her.

At work, I’ve looked for ways to be efficient – answering emails when I have a few minutes between cases, prepping notes and reviewing clinic lists prior to arriving in clinic, and trying to set concrete deadlines for work assignments, so that I’m not working at the last minute to finish presentations and talks.

PSR: WHAT WAS YOUR GREATEST NON-MEDICAL CHALLENGE OF TRAINING? Dr. Kargel: One of my greatest challenges was learning how to better communicate with my partner. Particularly early in residency, I’d call to let my husband know I was finishing up with work and would be on my way home soon, but then I’d get sidetracked taking care of a patient issue, putting in orders, speaking to a consulting service or helping with procedures.

By the time I’d get home, it was much later than I’d initially said and my husband had been waiting for ages. We’d both end up frustrated – me because I’d been busy working, and him because he had no communication from me aside from the initial plan.

Over the years, we both improved. My husband learned to accept that certain days or procedures would likely mean I wouldn’t be home for a while, and I learned to better

anticipate my time estimates and to communicate updates if there were delays or changes.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER ON A REGULAR BASIS? Dr. Kargel: As with most people who utilize electronic medical records, it’s always a race to ensure documentation is done appropriately and efficiently while still seeing patients in clinic in a timely fashion. I try to make sure I have everything completed before I leave at the end of the day, so that I’m not spending time at home finishing up charting.

Along with that, sitting down and spending enough time with each patient to explain their condition and surgical (and non-surgical) treatment options while not falling behind is something I try to be mindful of. When possible, I try to scan my schedule before clinic to have an idea of what I’m walking into in the room, and the staff I work with help by printing-out relevant imaging studies so that I can read, highlight relevant points and have a copy to go over and then give to the patient. The people you work with – including nurses, schedulers, MAs and APPs – have a huge impact on the success of your practice, and I’ve been very blessed to have strong partners in both my pediatric and adult practices who are vital to making sure everything runs smoothly.

PSR: WHAT ADVICE DO YOU HAVE FOR PLASTIC SURGERY RESIDENTS? Dr. Kargel: It’s important to realize that your surgical practice will evolve over time. Your 10-year plan as a resident may be completely different than the plan you form once you’re out on your own. As they arise in residency and fellowship, make sure you take advantage of learning opportunities even on the rotations-focused aspects of plastic surgery that you think you may not need later in your career. In plastic surgery, we teach principles, not just techniques – and your patients will benefit from things you learn how to do well, whether it’s communication style, bedside manner, clinical flow or surgical steps, and things you learn may have less than desired outcomes.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN…” Dr. Kargel: I realized that it allowed me to care for patients of all age ranges and almost all aspects of the body. The idea of being able to fixate bony trauma and in the next breath focus on delicate anastomoses under the microscope, followed by figuring out how to provide effective soft-tissue coverage with the end goal of achieving a functioning extremity, was thrilling to me. In the world of plastic surgery, innovations are constantly challenging us to do more for our patients, and I’m honored to be a part of the field and someone who gets to train the new generation of plastic surgeons. |

Plastic Surgery Resident | Fall 2023

11

Dallas

VIRGINIA BAILEY, MD

CLAIRE DAVIS, MD

By Virginia Bailey, MD; Claire Davis, MD; & Denzil Matthews, MD

T

he Dallas-Fort Worth (DFW) metroplex is one of the largest and fastest-growing in the United States. Dallas has plenty to offer visitors – a booming restaurant scene, professional sports teams, music venues and hiking trails – all of which can be enjoyed in our three seasons of patio weather.

A day in Dallas is a vibrant blend of culture, history and modernity. Start your morning with a visit to the Village Bakery Co., for a delightful pastry or a cup of artisanal coffee, followed by a stroll down the picturesque Katy Trail. This is a 3.5-mile running trail (that actually extends much further) in the heart of downtown Dallas, where you’ll always find people walking, biking and rollerblading. If you need a bit longer trail, White Rock Lake is a man-made lake just five miles northeast of downtown Dallas with a 9.33-mile trail. It’s home to the Dallas Arboretum, which offers seasonal installments that include a summer concert series, an autumn pumpkin patch, a winter holiday stroll and spring botanical gardens – a great place for everything from first dates to family outings.

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DENZIL MATTHEWS, MD

FOOD, ARTISANS AND MUSIC Once you’ve worked-up an appetite and if the weather (that is, the heat) permits, grab a bite at a historic staple like Oddfellow’s for brunch/lunch and spend the afternoon walking around the Bishop Arts District. Here you’ll find a neighborhood littered with side streets filled with local small-business-owned shops that offer everything from artisanal home goods, clothing boutiques, record shops and plant shops. Once you’ve worked-up your second appetite, check out Reveler’s Hall – known for its live music and great cocktails.

Non-native Texans who find the weather too hot can grab a bite at Pecan Lodge – a renowned barbecue joint that serves mouthwatering brisket and ribs – located within the Deep Ellum neighborhood of Dallas. Then hop over to explore downtown Dallas and the Museum District (all air-conditioned, of course), where you’ll find the iconic Reunion Tower. Ride the elevator to the GeO-Deck for panoramic views of the city, including the sprawling Trinity River and the impressive skyline that

symbolizes Dallas’s growth. Just across the street you can spend the afternoon at the Dallas Museum of Art and the Nasher Sculpture Center, which you can follow with a stroll through Klyde Warren Park – an urban oasis where you can catch a food truck meal, enjoy live music or simply relax under the Texas sun.

EVENING ATTRACTIONS As evening falls, satisfy your shopping desires at the upscale NorthPark Center and then head to the Carrollton/Plano area for your choice of Korean barbecue and dumplings. If shopping isn’t your thing, explore the vibrant nightlife of Deep Ellum, known for its live music venues and eclectic bars – maybe try Café Salsera to show off your dance moves, or tickle your funny bone at the Dallas Comedy Club.

For our more low-key friends, Dallas is a city of craft breweries. You can spend your entire evening checking-out local options such as White Rock Brewing, Peticolas Brewing, Community Brewing or Manhattan Project Beer Co., near downtown.

A LITTLE OF EVERYTHING There’s something for everyone in Dallas in the evening. The city has a diverse and ever-expanding restaurant scene, and residents love to meet after work for cocktails and appetizers at Beverley’s or happy hour and oysters at Hudson House. Checkout Invasion on the east side for one of the city’s award-winning fried chicken sandwiches that’s artery-clogging but worth every bite. While over on the East side, stop by Crywolf for an intimate cocktail setting or Jimmy’s Italian market – you’ll find some of the best Italian subs and frozen meatballs you’ll find in Dallas. Or stick with a Dallas staple at Mi Cocina for some Texas queso and famous mambo taxi.

No matter what you decide to explore in Dallas – take your time.

We have a little of everything for every visitor. Explore on your own terms and find your home with us in Dallas. | Dr. Bailey is PGY-6; Dr. Davis is PGY-5; and Dr. Mathews is PGY2; at UT Southwestern Medical Center. .

The Bishop Arts District Plastic Surgery Resident | Fall 2023

13

A Message From the Program Director Andrew Zhang, MD

T

he UT Southwestern Plastic Surgery Residency Training Program is dedicated to cultivating compassionate, technically skilled surgeons who lead with innovation in aesthetic and reconstructive surgery and hold a strong desire to give back to their communities. We foster a collaborative learning environment that integrates faculty-driven, strong didactic programs; hands-on clinical experience with graduated autonomy; rigorous academic research; and a commitment to ethical practice; ultimately preparing our residents to deliver patient-centered care of the highest quality.

Our residency program has a proven history of graduating plastic surgeons of the highest competency who are ready for anything in any practice environment.

Several factors contribute to the growth of our residents during residency, but three stand out: supervised graduated autonomy, strong didactics and culture. Our residents experience unparalleled autonomy at multiple training sites throughout their training. Our chief residents act as junior faculty at Parkland Memorial Hospital, our Level I trauma county hospital. Our resident team runs the reconstructive plastic surgery service. They evaluate, plan and execute operations on cases from the routine (e.g., breast reductions) to the most complex (e.g., toe-to-thumb transfers and free vascularized bone transfers for complex facial reconstruction). All the while, highly knowledgeable and experienced faculty are on standby to assist if needed. This approach builds surgical competence and confidence by accelerating a resident’s transition from passively absorbing knowledge to actively making decisions and independently doing cases, backed up by on-demand guidance from expert clinician educators.

At UT Southwestern, we value strong didactics, incorporating numerous conferences covering all major areas of plastic surgery. The majority of lectures are given by our world-class faculty. Like the resident experience at Parkland, our didactic commitment is a cornerstone of our program, dating back more than 40 years. Thursday afternoon is our main protected-education time. The hour-long grand round lecture by faculty is followed by teaching conference, during which PGY 4-6 residents are questioned by our expert faculty about cases they performed in the previous week. Our residents are expected to be prepared and understand the anatomy, pathology, preoperative evaluation, complications, postoperative care and relevant literature pertinent to their cases. This weekly case-based knowledge assessment session promotes sustained self-directed and expert guided learning. I find myself learning something new at each conference.

Building on a solid foundation of core plastic surgery teaching, we recently expanded our curriculum to incor-

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porate leadership training courses, which provides residents effective means to communicate with team members and make critical decisions under pressure. Furthermore, as residents progress with increased autonomy, they will be tasked with mentoring and guiding junior residents and medical students. Possessing leadership Andrew Zhang, MD skills ensures that knowledge and best practices are passed down efficiently – promoting both individual growth and the collective advancement of the surgical team. With help from the UT Southwestern Office of Organizational Development and Training, we’ve integrated several pertinent topics into our leadership curriculum, such as personal behavior profile assessment, leveraging your strength, effective communications, giving and receiving feedback, and negotiations.

We deeply value our residents and their insights, and we maintain a radically open-minded approach to new ideas. Two years ago, a group of junior residents approached leadership about implementing a nightfloat system. The suggestion sparked considerable debate among the residents and faculty – many of whom were concerned about potential drawbacks. Nevertheless, we set aside our biases, consulted other programs with established night-float systems, meticulously reviewed the logistics of incorporating it at UTSW and then weighed the pros and cons. After piloting our version of the system, even its initial critics now commend its benefits.

Our residents maintain strong personal relationships outside of the work environment. They hang out with one another, studying, dining, going to concerts, dog-sitting, working out and even traveling. Every class organizes regular dinner outings to reconnect. Recently, a large group of residents and rotating students got together with one of our faculty and started a Saturday morning cross-fit workout group. It’s not uncommon to see 15-20 trainees working out together on a Saturday morning with faculty. The UTSW plastic surgery family is also expanding in other ways. Several residents married during residency and we welcomed 12 newborns in the past three years.

At UT Southwestern, we strive to foster an environment where individuals feel valued, included and empowered to contribute their best. We champion a culture of open-mindedness, communication, mutual respect and continuous learning. Collaboration thrives, innovation is encouraged and individuals collectively work toward shared goals, while celebrating each other’s success and supporting one another during challenges.|

Meet the Resident Travel Scholars at PSTM23

Andi Cummins, MD PGY-3 University of Texas Medical Branch

Alessandra Ceccaroni, MD PGY-2 University of Salerno Italy

Nicholas Oleck, MD PGY-3 Duke University

Emily Finkelstein, MD PGY-1 University of Miami

Kelly Spiller, MD PGY-2 University of Cincinnati

Ankur Khajuria, MD PGY-3 Royal Free NHS Foundation Trust UK

Tiourin Ekaterina, MD PGY-3 University of CaliforniaIrvine

Garrison Leach, MD PGY-3 University of CaliforniaSan Diego

Alita Indania, MD PGY-3 Universitas IndonesiaCipto Mangunkusumo

Peru plastic surgery program captures first International Residents World Cup title

T

he plastic surgery training program at Universidad Peruana Cayetano Heredia (UPCH) in Peru emerged as the winner of the inaugural ASPS International Residents World Cup in July with a victory over the training program from Shaare Zedek Medical Center in Israel.

The one-of-a-kind, online competition engaged 16 plastic surgery training programs (in teams of up to four residents) from around the world to answer questions on case studies and the core curriculum of plastic surgery. Each matchup consisted of 10 multiple-choice questions, leading to a final championship match that consisted of 15 questions. Each member of the team answered every question individually, with scoring based on both accuracy and speed. Team members were allowed to consult with one another before answering – bearing in mind that slower answers could negatively affect the overall score.

The UPCH resident team included Luis Gerardo Sandoval-Ortiz, MD, MSc; Oscar Pérez-Aguilar, MD; Deivis Torres-Bonilla, MD; and Ricardo Gómez-Galindo, resident coordinator of plastic surgery. The team will have an opportunity to defend its title in the second annual ASPS International Residents World Cup next summer. | Plastic Surgery Resident | Fall 2023

15

‘The best part of residency training is learning what not to do.’

Q&A WITH ASPS PRESIDENT GREGORY GRECO, DO Ahead of Plastic Surgery The Meeting 2023 in Austin, Texas, the Plastic Surgery Resident Editorial Board collaborated on a set of question to be addressed by ASPS President Gregory Greco, DO, Red Bank, N.J. The questions were not only designed to gain insight on his year in leadership, but to also draw invaluable advice and guidance to residents as they pursue a career in plastic surgery.

PSR: WHAT INSPIRED YOU TO PURSUE PLASTIC SURGERY AS A CAREER – AND WHAT DO YOU LOVE MOST ABOUT IT? Dr. Greco: Like most pet-owning kids, I thought I wanted to be a veterinarian.

Working for veterinarians while in high school and college convinced me to pursue a career in surgery. These jobs convinced be that I loved being in the O.R., as well as the art of surgery. While in medical school, I had the opportunity to work with Joseph Reichman, MD, a plastic surgeon who served as a mentor and role model – and that experience solidified my love for plastic surgery.

PSR: WHAT MOMENT BEST-DEFINED YOUR CAREER AS A PLASTIC SURGEON? Gregory Greco, DO Dr. Greco: Over the course of nearly 22 years of practice, there are so many “moments” that can’t be captured in words. However, I can PSR: WHEN YOU THINK BACK UPON YOUR TRAINING, recount one situation that changed my approach to patient WHO INSPIRED YOU? care. As a surgery resident, I remember being on call, making my evening rounds and coming across a 35-year-old patient Dr. Greco: So many people inspired me. As a traditional who had undergone a colectomy. It was obvious that she pathway resident, I completed nine years of residency, general wanted to talk to someone, beyond the officious daily rounds surgery and plastics. Surgical training is one of the most chat. I silenced my pager, sat in a chair and just listened. rigorous things a physician can undertake. I was always Several months later, a gift appeared for me at the hospital. inspired by surgeons who were not only technically gifted but It was just a sweatshirt, but it came with a note thanking me also kind, compassionate and empathetic to their patients. for listening and letting her know that someone cared about These surgeons treated residents similarly in a caring and her – beyond her diagnosis and vitals. To this day, every time respectful manner. I realized that I felt an obligation to these I enter my exam rooms, I take a seat – no phone, no computer, attending surgeons to work harder and not disappoint them just me – to listen to my patients. on rounds, in the O.R. or at the patient’s bedside. I also got

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involved in my state societies and ASPS early in my career, which helped me meet so many inspirational leaders.

PSR: IF YOU GO BACK IN TIME, WHAT MISTAKES WOULD YOU TRY TO AVOID DURING YOUR RESIDENCY PROGRAM? Dr. Greco: I’m not sure “mistakes” is an appropriate word – however, if I look back, I could have done better about knowing when to ask for help. I would also try to get a research mentor. Residency is difficult enough from a clinical standpoint, and continued scholarly activity output can be difficult if you don’t actively pursue it. I think this can set the stage for your academic career. If you realize in residency that research, outcomes studies, etc., are integral to practice, then you easily incorporate it into your clinical practice. The best part of residency training is learning what not to do.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE OF A RESIDENT? Dr. Greco: GRIT. As I said, surgical residency is difficult – and becoming a doctor and a surgeon is a privilege that most will never get to achieve. It’s incredible to realize that what you do every day – no matter how trivial it seems to you – will affect someone. Being a patient or having a loved one as a patient is stressful. I watch my surgical residents sometimes get agitated about having to place orders, discharge patients or see consults in the E.D. I frequently remind them that every patient deserves 100 percent of you, all the time. Get away from the computer and go see the patient.

PSR: WHAT’S YOUR MOST IMPORTANT CAREER ADVICE FOR RESIDENTS? Dr. Greco: Practice where you want to be and do what you want to do. Don’t worry about how many plastic surgeons are in the area; who tells you not to come; or why the community doesn’t need another plastic surgeon. Go, do great work, take call and service your community in a kind and caring manner.

Have an actual human answer your office phone and, most importantly, don’t be greedy. It seems like simple advice, but that simple advice works nearly 100 percent of the time. I have given it to many graduating seniors residents in many different surgical specialties.

PSR: WHAT STRENGTHS AND AREAS OF OPPORTUNITY DO YOU SEE WITH INTERNATIONAL PLASTIC SURGERY RESIDENTS? Dr. Greco: International residents offer a wonderful practice perspective for our U.S.-based residents. Depending on the economic climate and cultural norms of their home country, these residents are often training in very different ways than their U.S. counterparts. There’s an opportunity for aesthetic, procedural and technical nuance that can go unnoticed in U.S.based programs.

PSR: WHAT WOULD YOU SAY IS YOUR GREATEST ACHIEVEMENT AND WHAT ARE YOU MOST PROUD OF DURING YOUR ASPS PRESIDENTIAL TERM? Dr. Greco: First, I’m incredibly humbled and proud of being able to represent ASPS and plastic surgery on the national and world stages. I think my greatest achievement is the creation and workshopping of the Private Academic Initiative for Research and Education (PAIRe) Program, which will create virtual and in-person collaborations among residents, faculty and private practitioners throughout the country. The initiative is in its early stages of development and will be betatested later next year. The ultimate goal is to increase scholarly opportunities for residents in training.

I’m also very proud of ASPS participation in repealing the sunsetting of the S-codes for microsurgical breast reconstruction. We launched a massive grassroots campaign, developed a four-pillared national approach and I personally testified to CMS, which ultimately cited the ASPS position papers for its reasoning to repeal the sunset of the S-codes. |

Plastic Surgery Resident | Fall 2023

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Venous Thromboembolism Prophylaxis “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 Aradhana Mehta, MD, MPH

This is the pharmacy, there’s a critical platelet value on a patient currently on heparin. Platelets appear to be downtrending and there is some concern for HIT. Please advise.

CASE HISTORY

A 63-year-old female presents to the E.D. with abdominal cellulitis.

She has a history of breast cancer s/p bilateral DIEP reconstruction roughly six months ago. The patient was admitted for IV antibiotics and started on pharmaceutical venous thromboembolism (VTE) prophylaxis with heparin 5,000 U q8h. After 24 hours, platelets were noted to have slightly decreased with a precipitous decrease of 50 percent by 48 hours. The patient has no history of any reaction with heparin.

Hematology was consulted and subsequently recommended that heparin be held and an anti-PF4/heparin antibodies assay be performed. Antibody was found to be positive and she was then started on argatroban for anticoagulation. Platelet counts were monitored and noted to be steadily increasing over the course of the next 48 hours. The patient was ultimately discharged without any significant events.

For plastic surgeons – or any surgeon for that matter – thrombotic events can be disastrous for surgical outcomes and for the patients.

It’s important to understand and recognize some of the early red flags to mitigate the risks and prevent future events. This article will summarize VTE risk stratification and the potential downsides of pharmaceutical prophylaxis.

VENOUS THROMBOEMBOLISM

VTE includes the diagnosis of pulmonary embolism (PE) and deepvein thrombosis (DVT), and it often occurs in the postoperative 18

Plastic Surgery Resident | Fall 2023

period – making it a leading cause of post-op mortality. The exact incidence in plastic surgery is unknown, but VTE-associated mortality rates range between 8-50 percent, according to various studies. Although the risk of death is present with VTE events, there are also long-term consequences that can include right-heart strain; pulmonary hypertension; post-thrombotic syndrome; and recurrent VTE. These risks must be weighed against the risk of bleeding due to pharmacologic prophylaxis.

Pathophysiology: Virchow’s triad of venous stasis, endothelial damage and hypercoagulability form the main pillars of VTE. When an inciting event causes endothelial damage, an activation and deposition of circulating platelets occurs. Concurrently, the coagulation cascade is triggered by exposure to tissue factor, which results in thrombin generation and fibrin deposition. General endotracheal anesthesia incapacitates the lower-extremity muscle pump system which effectively creates venous stasis – a key component to Virchow’s triad. DVT is attributed to hypoxia and stasis. Typically, this is an asymptomatic state; however, issues can arise with proximal DVT as it can progress to pulmonary embolism in approximately one-third to one-half of patients.

Risk stratification: Medicine and surgery is a balance of pros and cons, and risk-stratification scores assist in determining the appropriate prophylaxis regimen. The 2005 modification of the Caprini Risk Score has been specifically validated in plastic surgery (Table 1). The particular components of the Caprini score that are most relevant to plastic surgery patients is highlighted below (Table

TABLE 1 2005 MODIFICATION OF THE CAPRINI SCORE

TABLE 2 CAPRINI SCORE FACTORS MOST RELEVANT TO PLASTIC SURGERY PATIENTS

TABLE 3 FIVE EVIDENCE-BASED PRECAUTIONS FOR HIGH-RISK PATIENTS

TABLE 4 BENEFITS, RISKS AND DOSING FOR VTE CHEMICAL PROPHYLAXIS Tables source: Agrawal, Nikhil A. M.D.; Hillier, Kirsty MD; Kumar, Riten MD, MSc.; Izaddoost, Shayan A. MD, PhD.; Rohrich, Rod J. MD. A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery. Plast and Reconstr Surg. 149(1):p 121e-129e, Jan. 2022.

2). This risk-stratification technique further supports the idea that elective patients are typically lower risk and do not require pharmacologic prophylaxis. Patients with scores of 8 or greater should be candidates for pharmacologic prophylaxis. It’s important to consider risk-factor modification and possible avoidance of surgery in these patients, as well.

haul travel; hormone replacement therapy; and selective estrogen receptor modulation. Additionally, tranexamic acid (TXA) is becoming increasingly popular in various procedures including craniosynostosis, facelift, rhinoplasty and massive weight-loss surgery. TXA works by preventing the conversion of plasminogen to plasmin, which prevents clot breakdown and can have a hemostatic

Other risk factors: When evaluating patients, it’s crucial to note several other factors that can contribute to VTE, including long-

continued on page 28 Plastic Surgery Resident | Fall 2023

19

RHEUMATOID HAND

By Justin Davis, MD, & Alexis Ruffolo, MD JUSTIN DAVIS, MD

S

urgical intervention for rheumatoid hand is becoming less common as a result of advancements in medical treatments that prevent disease progression. Nevertheless, it’s crucial to understand the disease pathophysiology and identify specific anatomical injuries based on physical examination findings, as this area is consistently tested on the InService Exam. In this installment of InService Insights, we review the pathophysiology and treatment of rheumatoid arthritis in the hand and wrist.

Rheumatoid arthritis (RA) is systemic, immunologic disease of the synovium that can lead to multiple, subsequent pathologies of the hand and wrist. Rheumatoid arthritis affects about 1 percent of all adults. The diagnosis of RA involves a clinical history of symmetric hand pain lasting more than six weeks.2 There are criteria established by the American College of Rheumatology to diagnose RA, including lab values such as rheumatoid factor, anti-CCP, ESR/CRP and the level of joint involvement.3

MANAGEMENT

The mainstay of RA treatment is medical management, and significant advances have been made over the past 30 years. The number of patients seeking surgical treatment for rheumatoid hand has declined with the increased use of disease-modifying antirheumatic drugs (DMARDs).4 When uncontrolled by medication, RA progresses in a well-established pattern. Synovitis is the sentinel event that leads to bony erosions, joint instability and tendon destruc20

Plastic Surgery Resident | Fall 2023

ALEXIS RUFFOLO, MD

tion. A pannus of inflamed synovium expands, causing both compression and subsequent destruction of adjacent structures. RA frequently affects the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and wrist joints first with sparing of the distal interphalangeal (DIP) joint.

Surgical management is not curative; rather, it aims to alleviate pain, correct deformity and improve function. The paradigm of surgical management is to address disease from proximal to distal. RA pathophysiology and management can be divided into wrist vs. hand and fingers.

WRIST

In the wrist, erosions appear initially at the scaphoid waist, ulnar styloid and distal radioulnar joint (DRUJ). RA typically affects the radiocarpal joint (between the proximal row and forearm) more commonly than the midcarpal joint (between the proximal and distal row).

Attenuation of the TFCC, palmar and dorsal ulnocarpal ligaments, and DRUJ ligaments leads to dorsal dislocation of the ulna, supination of the proximal row and volar

Rehim S, Chung K. Applying evidence in the care of patients with rheumatoid hand and wrist deformities. Plast Reconstr Surg. 2013 Oct 2013;132(4)

subluxation of the ECU, commonly referred to as caput ulnae syndrome.

As the radiocarpal arthritis progresses, characteristic changes include radiocarpal collapse, volar translation, carpal supination and angulation of the lunate with compensatory midcarpal extension. This collapse causes the metacarpals to radially deviate, and synovitis and radial sagittal band laxity or rupture at the MCP joint will then cause the fingers to ulnarly deviate.

Wrist synovitis can grow around the extensor tendons, causing them to rupture. The caput ulnae (or “ulnar cap”) dorsally dislocates and the tendons rupture in an ulnar to a radial pattern, termed Vaughan-Jackson syndrome. Osteophytes on the radius or carpus can also cause tendon rupture. Scaphoid osteophytes or synovitis can lead to FPL rupture, termed a Mannerfelt lesion.5 Prophylactic tenosynovectomy may be performed to reduce pain and swelling, and decrease the chance for tendon rupture. Tendon reconstruction is typically achieved through tendon transfers.

The final stages of wrist pathology include ankylosis, arthritic stable and arthritic unstable. An ankylotic wrist is often in functional alignment and doesn’t require further intervention. For wrists that are in the arthritic stable and unstable categories, fusion or salvage may be necessary to improve stability and function.

Reconstructive wrist procedures and their indications are listed in the table below.

Radioulnar

Radiocarpal

Total wrist

PROCEDURE

INDICATION

DETAILS

Darrach

DRUJ arthritis and distal ulnar instability (caput ulnae)

Distal ulna resection

Sauve kapandji

DRUJ arthritis and distal ulnar instability (caput ulnae)

Ulnar head preservation

Ulnar head arthroplasty

Chronic DRUJ instability or failure of above procedures

Ulnar head replacement

Partial wrist arthrodesis

Volar subluxation with preserved midcarpal joint

Radiolunate or radioscapholunate

Total arthrodesis

Pancarpal disease

Wrist arthroplasty

Wrist arthroplasty

Pancarpal disease

If a tendon can extend passively and maintain extension, it’s likely due to ulnar subluxation of the extensor. If it’s unable to maintain extension, this may be due to tendon rupture, or less commonly MCP subluxation or PIN palsy.

Rehim S, Chung K. Applying evidence in the care of patients with rheumatoid hand and wrist deformities. Plast Reconstr Surg. 2013 Oct 2013;132(4)

Passively correctable ulnar translation of the MCP or tendons can be corrected with extensor-tendon centralization or cross-intrinsic tendon transfer.

If the digit is shortened, irreducible or possesses severe articular erosions, joint replacement with silicone MCP arthroplasty is the first line, with arthrodesis the secondary option.

Two common digital abnormalities are swan neck and boutonniere deformity. Swan neck deformity is more common and can be due to several pathologies occurring at the MCP, PIP or DIP joints. Typically, it develops because of attenuation of the PIP joint volar plate, collateral ligaments, rupture of the FDS insertion or chronic mallet finger.

Boutonniere deformity is always caused by disruption of the central slip. Over time, the collateral bands translate volar to the PIP joint, resulting in DIP joint hyperextension.

Common reconstructive procedures for swan neck and boutonniere deformity are listed in the table below.6 Splinting is also an option for management of swan neck deformity, but does not help with boutonniere deformity.

PROCEDURE FDS tenodesis

Proximal slip of FDS divided proximally leaving distal end attached, proximal end attached to A1 with PIP in 30 degrees flexion

Retinacular ligament reconstruction

Ulnar lateral band divided proximally, proximal end mobilized under Cleland’s ligament volar to PIP axis and sutured proximally to flexor tendon sheath; tensioned for PIP flexion and DIP extension

HAND AND DIGIT

RA at the MCP joint often presents with the inability to extend the fingers. This finding has three supported mechanisms: ulnar subluxation of the extensor tendon due to attenuation of the radial sagittal band; volar subluxation of the proximal phalanx from the MCP; and/or an ulnarly-directed vector of force that occurs during pinch. Rarely, patients will lose extension due to posterior interosseous nerve (PIN) palsy from synovitis around the nerve.

DESCRIPTION Swan Neck

Boutonniere Central slip reconstruction

Central slip shortening and dorsal mobilization of lateral bands, divide extensor tendon while maintaining ORL to restore flexion and maintain extension respectively

continued on page 28 Plastic Surgery Resident | Fall 2023

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International Medical Graduates

New Tennessee law paves easier road to U.S. residency – but will it work?

By Michael Hu, MD,ByMPH, MSDe Luna Gallardo, MD Daniel

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istorically, an International Medical Graduate’s (IMG) pursuit of a medical license in the United States has been a highly regulated and certified process involving multiple organizations – among which are the AMA and the Educational Commission for Foreign Medical Graduates (ECFMG). In addition, specific regulations licensure requirements exist in each state within the American territory.

IMGs currently comprise more than 25 percent of all physicians in the United States – all of whom, as required, were trained through residency or fellowship programs within states accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Such training implies long, rigorous processes and lengthy periods, and is required regardless of previous training or years of experience in the young physician’s country of origin.

But a serious and intractable problem exists for IMGs: The shortage of health personnel in some states (i.e., Tennessee, Alabama), coupled with the artificially capped

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number of residency slots imposed in the 1990s by Congress, has in large part led to a shortage of IMGs. Some contend adding residency slots will solve the issue, but adding slots will still take years before any noticeable improvements are made.

A novel and historic solution was enacted April 6 by Tennessee Gov. Bill Lee, who signed a law that allows IMGs who hold full licenses in good standing in other countries to bypass U.S. residency training and enter into practice as a temporary license physician within the state if they meet certain qualifications.

Under the new law (Tenn. HB 1312), IMGs should demonstrate competence to the state’s medical board, in addition to completing either three years of training during a post-graduate program in the country they are licensed in, or otherwise having practiced as a medical professional in which they performed the duties of a physician for at least three of the past five years outside the United States. If they are considered to obtain a temporary licensure, IMGs must also provide proof of an active employment offer from a health system. After

REQUIREMENTS OF THE INTERNATIONAL MEDICAL GRADUATES FOR APPLICATION Present law provides that a person desiring to practice medicine or surgery in Tennessee must submit an application in writing to the board of medical examiners or via an online application, which must include the following if the applicant is an international medical school graduate:* • A certificate from a medical school whose curriculum is judged to be acceptable by the board • A copy of a permanent Educational Commission for Foreign Medical Graduates (ECFMG) certificate • A non-refundable application fee as set by the board and an examination fee • Sufficient evidence of good moral character • Evidence of being a citizen of the United States or Canada, or legally entitled to live or work in the United States • Evidence of satisfactory completion of a three-year, post-graduate training program approved by the AMA or its extant accreditation program for medical education, or its successor. Such a person may apply to the board for licensure or testing in accordance with the present law within 12 months of completion of the post-graduate training program if satisfactory performance in such program is demonstrated to the satisfaction of the board • Evidence of basic fluency in the English language • Sufficient evidence that the applicant is an IMG and has an offer for employment as a physician at a healthcare provider that operates in Tennessee and has a residency program accredited by the ACGME in place * For the purpose of promulgating rules, this bill takes effect upon becoming a law, and for all other purposes, this bill has taken effect July 1, 2024.

successfully completing the two-year probationary period, the applicant can also apply for a full, unrestricted license within the state of Tennessee.

It’s expected that this new precept not only will ameliorate the predicted shortages of health personnel in the future years, but also provide a hopeful opportunity for physician refugees, immigrants and even U.S. citizens trained abroad, thus sparking an unprecedented exchange of perspectives and new approaches of the highest level, and eliminating redundant residency training.

In addition, the bill not only improves healthcare accessibility but also promotes cultural diversity and economic growth. By embracing the contributions of IMGs, we build a more inclusive, resilient and equitable healthcare system for all.

Despite these benefits, this new paradigm has generated new criticism in relation to a potential reduction in the quality of doctors treating American patients. Therefore, its constant evaluation and strict regulatory processes will play a fundamental role for its extrapolation to other states within America; in fact, Alabama recently

followed in Tennessee’s footsteps and in June passed similar legislation.

HB 1312 represents a significant shift in the landscape of U.S. medical practice. The future remains unclear, and some are expressing hesitancy while others are looking forward to the change. What remains are questions about what this policy will mean for IMGs, the hospitals that hire them, the patients they’ll serve and medical training at large. Who wins – and who loses – when the Tennessee law goes into place?

The real effects on residences and medical practices across the United States will become more clear as we observe the law’s implementation and impact in the coming years. | Dr. De Luna Gallardo is chief resident and PGY-4 at Hospital Central Sur de Especialiodad de Petreleos Mexicanos, Mexico City.

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PLASTIC SURGERY PERSPECTIVES

AESTHETIC SURGERY “Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In this installment, Dr. Brown interviews ASPS past President and PRS Editor Emeritus Rod Rohrich, MD.

Interview by Stav Brown, MD Research Fellow Memorial Sloan Kettering Cancer Center

Rod Rohrich, MD ASPS past president; Plastic and Reconstructive Surgery editor emeritus; clinical professor of plastic surgery, Baylor University; past chair, Department of Plastic Surgery, University of Texas Southwestern; Baylor College of Medicine; founding member, The Rhinoplasty Society; past president, Association of Academic Chairs of Plastic Surgery

PSR: WHY DID YOU CHOOSE PLASTIC SURGERY – AND AESTHETIC SURGERY IN PARTICULAR? Dr. Rohrich: I always wanted to be a surgeon – in fact, I wanted to be a cardiac surgeon. The turning point occurred when I saw Melvin Spira, MD, DDS, perform a cleft lip repair at Baylor.

He asked me to scrub in, and that was it. I saw him transform a child’s lip into something that was going to be normal-looking and make such a significant impact on that kid’s life – and that’s what I wanted to do. Craniofacial surgery and pediatric plastic surgery transformed me. I wanted to help people to be as great as they can be, and that passion has led me to plastic surgery.

Plastic surgery is both art and a science. I love using my hands and artistic skills; both are epitomized in plastic surgery – particularly in aesthetic surgery. I’ve had three careers, including hand surgery, microsurgery and craniofacial surgery. I’ve been fortunate to enjoy all these three different careers in my life as a plastic surgeon and it has been an evolution.

I don’t really separate reconstructive from cosmetic surgery because they both have the same goal: Get the best artistic result, whether it’s a breast reconstruction or breast augmentation, whether it’s a facelift/rhinoplasty or a forehead flap for Mohs cancer reconstruction. For me, it’s been a natural evolution.

Aesthetic surgery is an extremely challenging area if you want to be an expert, as it requires a lot of art, skill and hard work.

PSR: HOW HAS AESTHETIC SURGERY CHANGED SINCE YOU STARTED? Dr. Rohrich: The ability to deliver consistent and excellent results has been the main change in recent years. Now we can truly fast-track people into learning how to be good plastic surgeons and aesthetic surgeons in much shorter periods of time because of how we teach it, as well as the ability to use videos and media. You still need the skills, but they can be taught more rapidly. The techniques have evolved rapidly as well.

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Social media has transformed plastic and aesthetic surgery in particular. The patients are much more informed – although it has also given people a false sense of what’s possible. I call it the “Kardashian effect.” We see things that may or may not be a reality, and our job as plastic surgeons is to tell people that.

PSR: WHAT ARE YOUR MAIN INTERESTS WITHIN AESTHETIC SURGERY? Dr. Rohrich: I primarily perform facial surgery – mainly rhinoplasty and facelift surgery. If you love it, are skilled, can perform these procedures and teach them – and write about the advances – you become better every day. My favorite procedure is rhinoplasty. It’s challenging because it’s a surgery of millimeters and there’s such intricate anatomy between the bone, cartilage and skin. It’s also the most-protruding part of our face and really a part of our identity.

PSR: WHICH PLASTIC SURGEON MOST INFLUENCED YOU? Dr. Rohrich: That would be Jack Gunter, MD, because he popularized the use of open rhinoplasty in both primary and secondary rhinoplasty, which proved transformational. I think the role of role models and true masters is very important to anyone who wants to go to the next level. I just saw one of my patients, a 17-year-old, who had a very significant nasal deformity. I performed her rhinoplasty six months ago. She has transformed not only in the way she looks, but also in the way she acts. She said she’s experienced a significant change in her self-confidence – and I hear that every day from my patients.

These are the things that make your day and that make it all worth it.

PSR: WHAT ROLE DOES TECHNOLOGY PLAY IN AESTHETIC SURGERY? Dr. Rohrich: Technology has played a major role in aesthetic surgery – not only in how we computer-image to let people know what’s possible, but also in our ability to get better and safer results. This includes anesthesia, medications such as tranexamic acid (TXA) and our instruments, which are all technology-driven. These tools have been refined so we can do procedures better and more efficiently – and get better results.

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF AESTHETIC SURGERY? Dr. Rohrich: Noninvasive or minimally invasive procedures, including rhinoplasty and facial rejuvenation. We’re on the cusp of having much better and improved technology to get results that will soon emulate a true rhinoplasty or facelift, and that’s very exciting. It will not happen overnight; it’s a gradual process, but I think we’re going to see some epic changes in the coming years that will truly work.

PSR: WHAT’S YOUR ADVICE FOR RESIDENTS INTERESTED IN AESTHETIC SURGERY? Dr. Rohrich: Go to a great plastic surgery training program to learn all the aspects and fundamentals of plastic surgery – not just cosmetic surgery. To be a good aesthetic surgeon, you must be a good doctor and a skilled plastic surgeon, and you learn from doing the difficult reconstructive cases. Work hard, be focused, write about it, publish and do not be afraid to make mistakes that will make you better. Find excellent role models you can emulate to help guide your career, go visit them and spend time with them. It’s essential to love what you do. If you have that in your life, you have nirvana. |

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Journal Club; 2023 Summer

1. Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast AugmentationMastopexy?

Lista F, Austin RE, Al-Zamani M, Ahmad J. Aesthetic Surg J. 2020;40(5):499-512.

JOURNAL ARTICLES ON

BREAST AUGMENTATION & AUGMENTATION MASTOPEXY

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Mark Shafarenko, MD, & Ryan E. Austin, MD

This study assessed whether implant surface texture affects the risk of capsular contracture for implants placed in a subglandular plane for breast augmentation and augmentation mastopexy. During the study period, 526 patients were evaluated. Five cases of capsular contracture occurred in the textured group and seven cases in the smooth group; this difference was not statistically significant.

Adherence to a strict surgical technique to minimize bacterial contamination is of greater importance than implant surface texture with respect to the development of capsular contracture.

2. Correlation between Capsular Contracture Rates and Access Incision Location in Vertical Augmentation Mastopexy Bresnick SD. Plast Reconstr Surg. 2022;150(5):1029-1033.

The inframammary access incision was associated with the lowest capsular contracture rate at 1.64 percent; this was significantly different than the periareolar group with a capsular contracture rate of 5.36 percent. Vertical access incision had an intermediate capsular contracture rate of 3.48 percent. These findings lend support for an inframammary incision when placing silicone implants for single-stage augmentation mastopexy.

3. Concepts in Aesthetic Breast Dimensions: Analysis of the Ideal Breast Mallucci P, Branford OA. J Plast Reconstr Aesthetic Surg. 2012;65(1):816.

Mark Shafarenko, MD

A

Ryan E. Austin, MD

ccording to ASPS National Clearinghouse of Plastic Surgery Procedural Statistics, breast augmentation annually ranks among the most popular aesthetic procedures. However, despite its frequency, there remain several areas of ongoing debate in augmentation mammaplasty – including optimal pocket location, methods of pocket irrigation, BIA-ALCL and breast implant-related illness. Similarly, augmentation-mastopexy has increased in popularity but continues to be an area of ongoing discussion. These articles provide a thoughtprovoking review of some of the available evidence, while also providing guidance for future generations of plastic surgeons.

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Photographs of natural breasts from 100 models were first analyzed to determine characteristics common to all of them. The second part of the study compared both unoperated and operated breasts with the previously established norms to determine how divergence from the ideals may impact attractiveness. Four common parameters were identified: the proportion of upper pole to lower pole is a 45:55 ratio; the upper pole is either straight or concave; the nipple is angled upward at a mean of 20 degrees from the horizontal; and the lower pole is a smooth convex curve.

Deviations from this pattern yields a less-attractive breast and may serve as a guide for aesthetic breast surgery.

4. Simultaneous Augmentation/Mastopexy: A Retrospective 5-Year Review of 332 Consecutive Cases Calobrace MB, Herdt DR, Cothron KJ. Plast Reconstr Surg.

2013;131(1):145-156.

Preoperative assessment is critical to patient counseling and surgical planning in simultaneous augmentation/mastopexy. The

overall complication rate was 22.9 percent, and the majority of these complications (15.1 percent) were tissue-related. The three most-common complications were capsular contracture, poor scarring and recurrent ptosis. The overall reoperation rate was 23.2 percent. Tissue-related indications accounted for 13.3 percent of reoperations, which was comparable to the mastopexy-only reoperation rate of 10.2 percent. Overall, the revision rate of combining these two procedures is not more than additive.

5. Superiorly Based Short-Scar Mastopexy Augmentation: A 10-Year Review of 1217 Consecutive Cases Wall SH, Claiborne JR, Wall HC. Plast Reconstr Surg.

2023;151(6):918E-930E.

The authors describe key concepts to allow safe and predictable results in mastopexy augmentation. The most important patient-driven aspects of the plan include the desired breast size and amount of upper-pole fullness. The authors advocate for subpectoral implant placement without dual planing, to keep the implant completely isolated from the mastopexy dissection.

Breast tissue equalization and SAFElipo are performed where appropriate. The overall revision rate was 4.8 percent, with 86 percent of revisions being implant- or implant-pocket related. This lends further support to the safety, reliability and low complication rates of single-stage mastopexy augmentation.

6. Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes: The High Five Decision Support Process

Tebbetts JB, Adams WP. Plast Reconstr Surg. 2005;116(7):2005-2016.

This decision-support system addresses the five most critical decisions in breast augmentation and builds upon the previous TEPID system: optimal soft-tissue coverage/pocket location for the implant; implant volume (weight); implant type/size/ dimensions; optimal location for the inframammary fold; and incision location. The system does not replace patient or surgeon preferences, but rather prioritizes certain decisions and provides guidelines based on tissue characteristics. Overall, this adds a much more scientific approach to planning in breast augmentation and has helped to minimize overall reoperation rates.

7. Surgical Treatment for Capsular Contracture: A New Paradigm and Algorithm

Hidalgo DA, Weinstein AL. Plast Reconstr Surg. 2020;146(3):516-525.

One-hundred-eighty patients surgically treated for Baker grade III/IV capsular contracture were retrospectively reviewed. Acellular dermal matrix (ADM) was used in bilateral cases and in previous failed surgical treatment for capsular contracture. ADM was used in 32 patients and was successful in 96.9 percent of patients.

Bilateral capsular contracture and previous treatment failure were significantly associated with conventional treatment failure. Using the authors’ algorithm of applying ADM for bilateral cases and

cases of previous treatment failure, the overall treatment success rate improved to 85.6 percent from 64.2 percent when this algorithm was not followed.

8. Evidence-Based Medicine: Augmentation Mammaplasty

Lista F, Ahmad J. Plast Surg Complet Clin Masters PRS-Breast Augment.

Published online 2015:1684-1696.

The authors provide a summary of the best available evidence for augmentation mammaplasty. Use of antimicrobial pocket irrigation, implant insertion funnels and nipple shields are all measures to prevent contamination of the implant. The data regarding the impact of incision location, pocket selection, implant fill (saline vs silicone), surface texture and implant shape on outcomes is more mixed. When combined with clinical expertise, this article serves as a useful resource to assist the plastic surgeon with individualized decision-making.

9. Impact of Capsulectomy Type on Post-Explantation Systemic Symptom Improvement: Findings from the ASERF Systemic Symptoms in WomenBiospecimen Analysis Study: Part 1 Glicksman C, McGuire P, Kadin M, et al. Aesthetic Surg J. 2022;42(7):809-819.

The authors provide a summary of the best available evidence for augmentation mammaplasty. Use of antimicrobial pocket irrigation, implant insertion funnels and nipple shields are all measures to prevent contamination of the implant. The data regarding the impact of incision location, pocket selection, implant fill (saline vs. silicone), surface texture and implant shape on outcomes is more mixed. When combined with clinical expertise, this article serves as a useful resource to assist the plastic surgeon with individualized decision-making.

10. Heavy Metals in Breast Implant Capsules and Breast Tissue: Findings from the Systemic Symptoms in Women – Biospecimen AnalysisStudy: Part 2 Wixtrom R, Glicksman C, Kadin M, et al. Aesthetic Surg J. 2022;42(9):1067-1076

In Part 2, heavy-metals testing found these materials in the breast tissue of the control group, with some at higher levels than patients with implants. Multiple confounders may explain the higher levels of arsenic and zinc in patients with BII, and therefore metal toxicity should not be used an indication for total capsulectomy. |

Dr. Shafarenko is PGY-4 in the Division of Plastic and Reconstructive Surgery at the University of Toronto. Dr. Austin is a staff plastic surgeon at The Plastic Surgery Clinic in Mississauga, Ontario, and serves as a Next-Generation editor for the Aesthetic Surgery Journal.

Plastic Surgery Resident | Fall 2023

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CONSULT CORNER / continued from page 19

INSERVICE INSIGHTS / continued from page 21

effect for up to 17 hours. A holistic approach to the patient that includes consideration of all the above factors is vital in decreased risk of VTE. Table 3 highlights five evidence-based precautions to consider with high-risk patients.

THUMB

Mechanical prophylaxis: A cost-effective, low-risk method for VTE prophylaxis is intermittent pneumatic compression, which has direct and indirect effects on VTE prevention. It serves to emulate the normal caudal-to-cranial blood flow and augments fibrinolytic activity.

Pharmacological VTE prophylaxis: The “gold standard” pharmaceutical prophylaxis is under investigation. Unfractionated heparin and low molecular-weight heparin – with respective halflives of 90 and 270 minutes – are the most widely used agents. Each carries its own risks and benefits as highlighted in Table 4. The risks include possibility of hematoma formation and the risk of heparininduced thrombocytopenia.

HEPARIN-INDUCED THROMBOCYTOPENIA

Pathophysiology: Immune-mediated adverse drug effects resulting from the use of unfractionated or low molecular-weight heparin can have dire consequences that include thrombocytopenia and thrombotic events. This is the direct result of the development of platelet-activating antibodies against platelet 4 and heparin complexes. Clinical manifestations and outcomes of HIT include thrombosis, bleeding events, amputation, mortality and an increased length of stay. The most concerning manifestations are disseminated intravascular coagulation (DIC), injection-site necrotizing skin lesions and anaphylactoid reactions to IV heparin bolus.

Diagnosis: Enzyme immunoassay (EIA) can be used to determine if anti-PF4/heparin antibodies are present, as well as their abundance.

Rapid immunoassays are similar to EIA but provide results in less than 30 minutes. C-serotonin release assay (SRA) is the “gold standard” functional assay and determines if the anti-PF4/heparin antibodies are pathogenic.

Management: Mainstay of management includes heparin avoidance and the use of non-heparin anticoagulation. It has been shown that the incidence of HIT is decreased when heparin exposure is limited to a duration of less than five days. Platelet transfusion is not recommended, as it can paradoxically increase the thrombotic risk.

IVIg can be considered in severe/refractory thrombocytopenia or thrombosis.

VTE pharmaceutical prophylaxis does not come without inherent risk. Our role as plastic surgeons is to effectively evaluate a patient’s risk of VTE and do everything possible to mitigate the risk, whether this means pharmaceuticals, risk-factor modification or holding the surgery. Understanding the pathophysiology of not only VTE, but also pharmaceutical prophylaxis, prepares us to appropriately manage any possible complications. |

Dr. Mehta is PGY-5 at University of Nevada Las Vegas.

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Plastic Surgery Resident | Fall 2023

Thumb deformities have general categories known as the Nalebuff classification6: Type I: Boutonniere deformity (most common) Type II: Boutonniere deformity with carpometacarpal (CMC) joint dislocation or subluxation Type III: Swan-neck deformity with metacarpal adduction Type IV: Gamekeeper’s deformity (attenuation of MCP ulna collateral ligament) Type V: Swan-neck deformity without metacarpal adduction deformity Type VI: Arthritis mutilans Boutonniere deformity in the thumb occurs at the MP joint due to attenuation of the EPB tendon.

Thumb pathology treatment is dependent on MP stabilization and tendon recon, often with arthrodesis of MP best to create a stable MP. | Dr. Davis is PGY-3, and Dr. Ruffolo is PGY-5, at Southern Illinois University, Springfield.

REFERENCES

1. Gabriel SE. The epidemiology of rheumatoid arthritis. Rheumatic Disease Clinics of North America. May 2001;27(2):269-281.

2. Farng E, Friedrich JB. Laboratory diagnosis of rheumatoid arthritis. J Hand Surg Am. May 2011;36(5):926-7; quiz 928.

3. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. Sep 2010;62(9):2569-81.

4. Chung K. Grabb and Smith's Plastic Surgery. Lippincott Williams & Wilkins; 2019.

5. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel: A clinical and radiological study. J Bone Joint Surg Br. May 1969;51(2):270-7.

6. Rehim S, Chung K. Applying evidence in the care of patients with rheumatoid hand and wrist deformities. Plast Reconstr Surg. 2013 Oct 2013;132(4).

MESSAGE FROM THE RESIDENTS COUNCIL CHAIR

By Olivia Abbate Ford, MD It has been a great honor to serve as the Residents Council chair this year. We’ve seen tremendous growth and are excited to continue working to represent each program as best as possible both within the United States and abroad.

We expanded our participation into the newly established Residents and Fellows Forum, which allows for post-graduate involvement as Fellows, as well as international involvement from programs abroad. We’re thrilled to report that the Residents Council Report is well underway – we’ve completed our survey administration and heard from 52 programs. Did you know that almost three-quarters of programs surveyed take 24-hour call, and more than half take at-home call? More details will be released as we analyze and report on this remarkable data. Our thanks to all who participated.

Olivia Abbate Ford, MD

Medical Students Day was a great success, with a record turnout of students. Medical students’ interest in pursuing a career in plastic surgery continues to exponentially grow, and we’re extremely thankful for the time our faculty surgeons and members dedicate to making this day possible.

Our Recruitment of Accomplished & Diverse Medical Student Applicants Into Plastic Surgery (ROADMAPS) working group has made this possible by continuing to show support for students early in their educational journey.

The Professional Resource Opportunities in Plastic and Reconstructive Surgery Education and Leadership (PROPEL) mentorship program continues to thrive. Due to the record-breaking number of applications this year, we had to adapt a more-selective model for pairing our mentees and mentors. We also have a new Journal Club-styled curriculum to guide group discussions about the importance of mentorship in shaping one’s career.

We’re also excited to share our international collaboration with PLASTAUK, which is a U.K.based association of residents that boasts more than 2,500 members around the world.

Finally, we welcome the new Residents Council Vice Chair, Liz Moroni, MD, chief resident at the University of Pittsburgh. Liz has served on the Residents Council for two years, and we’re excited to have her in this new role. Liz obtained her Bachelor of Science degree from Cornell University, and her MD and Master of Healthcare Administration degree from Georgetown University, where she was elected into the Gold Humanism Honor Society and Upsilon Phi Delta Healthcare Administration Honor Society. At Pitt, Liz has pioneered the CompetencyBased Time-Variable Resident Education model – and she’s the first U.S. plastic surgery graduate to complete their training in five clinical years. During her residency, she also dedicated a year to research, contributing to microsurgical and peripheral nerve research. Next year, she will continue her training in hand and microsurgery at the world-renown Buncke Clinic for fellowship. I’m excited to welcome Liz into this new role. As a lifetime colleague and friend, I would like to share my personal gratitude to Dr. Moroni for all that she’s doing to push our field forward in search of new horizons.

We’re looking forward to another productive and inspiring year with you. | Dr. Abbate Ford is PGY-5 in the Harvard Mass General Brigham Integrated Plastic Surgery Program.

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WE NEED YOU ON CAPITOL HILL! FIGHT FOR PLASTIC SURGERY AND YOUR FUTURE PATIENTS. DEC. 4-6, 2023 | Washington D.C. Join us and take action at the 2023 Advocacy Summit as we advocate for plastic surgery issues on Capitol Hill! After a three-year hiatus, ASPS members will return to the U.S. Capitol to meet with their United States senators and representatives to actively influence healthcare policies in Congress.

Your patients and practice are counting on you to advocate for their best interests in the hallowed halls of Congress. Now is not the time to remain on the sidelines. Take a stand with us, and together, let us enact change!

During the Advocacy Summit you will have the exclusive opportunity to: • Meet with your United States Senators and Representative to actively influence health care policy decisions and secure funding • Engage directly with political thought leaders to gain invaluable insights into health care policymaking and the legislative process • Participate in workshops and panels designed to deepen your understanding of state, federal and regulatory issues • Play a pivotal role in shaping the ASPS advocacy agenda by selecting the ASPS federal and state policy priorities that our specialty will advocate for • Forge meaningful connections with ASPS and local, state and regional plastic surgery societies, allowing you to learn from best practices and gain valuable insights

The future of plastic surgery is in your hands. Can we count on you?

Register now to secure your spot in Washington this December!

REGISTER NOW: PlasticSurgery.org/AdvocacySummit