Plastic Surgery Resident, Spring 2023

From the publishers of Plastic Surgery News

From the of Plastic ISSUE 30publishers | SPRING 2023Surgery News

Wellness: The burning question Every surgeon suffers burnout – but there’s hope for change

» When you're not given enough to do operatively 'Dear Abbe' provides advice on how to gain more O.R. work page 9

» Striking 'reveal' of the Complex Case Challenge Experts describe repair of abdominal wall wound page 28

IN THIS ISSUE » Consult Corner: Confronted with BIA-ALCL and BIA-SCC p. 32 » L. Scott Levin, MD, talks about the path that led him to hand surgery p. 22 » InService Insights: Lymphedema p. 18

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Table of

Contents Combatting Burnout: How it happens – and how to mitigate it . . . . . . . . . . . . . . . 5 Residents have increasingly become part of the processes designed to alleviate burnout and stress; senior surgeons describe their battles.

Dear Abbe: I'm not given enough in the O.R. . . . . . . . . . . . . . . . . . . . . . . 9

The advice column offers thought processes and recommends approaches explaining why little O.R. work is granted – and how to reverse that situation.

Program Peek: Rutgers New Jersey Medical School . . . . . . . . . . . . . . . . . . 10 The first fully integrated plastic surgery program in the state, Rutgers New Jersey Medical School provides wide-ranging training.

Faculty Focus: Jeremy Sinkin, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

A passion for learning and the ability to absorb and adapt are among the most highly regarded attributes of a resident.

Message from the Director: Edward Lee, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 The heart of plastic surgery residency at Rutgers New Jersey Medical School relies on curiosity – and the skill set to capitalize on that.

24 Hours in: New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 The offerings of New Jersey stretch far beyond the Newark area to provide the best in food, culture and entertainment.

InService Insights Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Definition, classification, staging, physical examination, imaging and treatment are addressed in this installment.

Journal Club: Lower-extremity reconstruction . . . . . . . . . . . . . . . . . . . . . . 20 Numerous advances have enabled lower-extremity defect repair to achieve high success rates – and these 10 articles will tell you why.

Plastic Surgery Perspectives: Hand Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Plastic Surgery Resident | Spring 2023 Vol.7 No.2 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

L. Scott Levin, MD, discusses his journey to becoming one of the nation’s most-respected and experienced hand surgeons.

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

International Perspective: European comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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

Daniel De Luna Gallardo, MD, recounts his career-changing experiences as an aesthetic Fellow at VictoriaKliniken Hospital in Sweden.

For Program Directors and Coordinators: The value of RFF membership . . . . . . . . . . . . . . . . . . . . . . . 26 Winnie Tong, MD, lays out several advantages for signing-up residents to the ASPS Residents and Fellows Forum.

Message From the Chair: The latest from the Residents Council . . . . . . . . . . . . . . . . 27

Volunteers needed for a survey that can affect residency now and in the future; paper on displaced residents is in its final stages before release.

Complex Case Challenge: Complex abdominal-wound solution . . . . . . . . . . . . . . . . . 29 The repair of a crush injury sustained between two garbage trucks is revealed; how well did you fare with your approach?

Consult Corner: BIA-ALCL and BIA-SCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

The evolution of a breast capsule, as well as the presentation, diagnosis and management of BIA-ALCL and BIA-SCC are supplied in depth.

ABPS Certification: Lessons and tips for preparation . . . . . . . . . . . . . . . . . . . . . 35

GR A PHIC DESIGN ER Jun Magat 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

In addition to important facts about the exam, ABPS Executive Director Keith Brandt, MD, sheds light on methods for successful preparation.

Plastic Surgery Resident | Spring 2023

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A note from the editor

W

Russell E. Ettinger, MD Chief Medical Editor

Plastic Surgery Resident Seattle

elcome to the Spring 2023 issue of Plastic Surgery Resident.

The seasonal change from winter to spring is welcome to many of us – especially those living in colder climates. This transition is heralded by longer days, warming temperatures, rain showers, and flowering plants and trees.

In residency, spring is also a time of transition, albeit a more subtle one. It may go unnoticed during the constant demands of clinical work, but there is a transition occurring. The most recognizable sign of this is the occurrence of “Match Day,” where plastic surgery programs across the country reveal their new class of incoming interns for the following year. It’s a major milestone for those who “matched” and will soon begin their training as plastic surgeons, but it’s also a milestone for individuals already in residency training. For current interns, it’s a glimpse into a future where they’re no longer the most junior trainees in their programs. For mid-level residents, it’s the first look at the new crop of interns they will be responsible for mentoring through one of life’s steepest learning curves as they navigate their first year of residency. For the senior residents, it’s a sobering reminder that residency training is a finite period in our lives, and the real world of independent practice is coming whether we feel like we’re ready or not.

This spring transition is real, but it may be overlooked amongst the constant grind of clinical and surgical training. This workload and the requirements of patient care are the ever-present constant that we all experience, irrespective of where we complete our plastic surgery residency training. At times, it can feel never ending, which can result in a loss of perspective and disillusionment with how the work we do is positively impacting people in need of our care. The cover story of this issue delves into this exact process – better-known as “resident burnout” – and offers insights into how we all experience this at some point in our residency training, as well as advice on how to incorporate wellness into our daily lives.

Also featured in this issue is the “Program Peek” featuring the ever-expanding Integrated Rutgers Plastic Surgery Program that now encompasses six training hospitals across New Jersey. In this issue, you’ll also find the final reconstructive outcome to our previous “Complex Case Challenge” of a traumatic abdominal-wall defect following a severe crush injury. Our “Dear Abbe” column offers sound advice on what to do if you feel you aren’t being afforded enough operative autonomy on a rotation. The recurring pieces curated by our Resident Editorial Board feature topics on lymphedema, management of breast capsular contracture and lower-extremity reconstruction, as well as a spotlight on an international aesthetic fellowship. We also have an update on Oral Board preparation from ABPS Executive Director Keith Brandt, MD, and a “PRS Hand Surgery Perspectives” interview with L. Scott Levin, MD, that offers incredible insights from a world-renowned hand surgeon.

Finally, you’ll find an update from the ASPS Residents Council and our Resident Representative to the ASPS/PSF Board of Directors, Olivia Abbate Ford, MD, highlighting the ongoing resident-centric initiatives for this year.

As always, we thank our readers, our team of editors and the ASPS production staff.

We hope you enjoy the read. |

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Plastic Surgery Resident | Spring 2023

Not alone in the struggle Gaining traction on the topic of resident wellness

By Aradhana Mehta, MD, MPH

O

ne life lost to suicide is one too many, but it remains a leading cause of death – second only to malignancy – among all residents, according Michael Hu, MD,inMPH, MS toBy a 2017 study published Academic Medicine. Despite article after published article that highlights the signs of burnout and suggests “wellness modules” to preemptively snuff-out the darkness, the rates of depression, burnout and suicidal ideation remain disproportionately high among residents as compared to the general population. Is this phenomenon a novelty – or one that’s always lurked in the background, only to recently position itself front and center?

The three pillars of burnout involve emotional exhaustion, depersonalization/cynicism and feelings of inefficacy/ inadequate personal achievement. The nature of medicine is grueling and unforgiving, with long hours and maddening isolation. Social media, the lingering effects of the COVID-19 pandemic and another looming recession only seem to magnify the significant difference in the path of residents when compared with the general population – and how vulnerable residents can feel. Fullgrown adults have no say in work hours, vacation time or even pay. We’re at the mercy of those above us.

FOCUSING ON RESIDENTS That doesn’t mean they’re alone. ASPS past President Jeffrey Janis, MD, who’s now chairman of the recently instituted ASPS Wellness Subcommittee, says residents have always been part of the Society’s conversation around improving wellness and increasing awareness of burnout – and resident input will always need to be part of the discussion at both the programming and national levels.

“Wellness is a topic that spans every stage of a plastic surgeon’s career life cycle,” he says. “Residents are, and have always been, critical to the development and ultimate success of the ASPS Wellness initiatives. They’ve been involved from the very beginning – especially as there has been published data that burnout can affect medical students and residents, not just in the United States, but everywhere in the world. If we are to have progress in this discussion, then it’s one that needs to be inclusive of residents every step of the way.”

In fact, Dr. Janis is co-author of a soonto-be-published study that examined the current state of plastic surgery residency wellness programs in the United States, which finds that wellness program leadership can influence the resources offered to residents – so

plastic surgery residents have a vested interest in leading, or at least remaining active, within their respective wellness program(s) as that’s the key difference-maker between effective and ineffective programs. Moreover, the study notes that “greater collaboration within and between plastic surgery residency programs, potentially facilitated by the specialties’ national organizations, can benefit the lives of residents as they navigate challenges in their professional and personal lives.”

The task force headed by Dr. Janis was behind the launch of a program to directly address the physical, mental and emotional stressors that literally no plastic surgeon has avoided. ASPS Project Well modules have been designed to serve as a comprehensive wellness resource that, cumulatively, address the physical, emotional, social, financial and occupational dimensions of wellness.

Fortunately, members of the ASPS Residents and Fellows Forum have free access to the modules, which are easily accessible on the Society’s website. Go to plasticsurgery.org/wellness, click on “Project Well Modules,” log-in with your EdNet credentials, then click on the “Launch” button to get started.

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WELLNESS/ continued from previous page

QUALITY, NOT QUANTITY Balance – whether walking a tightrope or finding that work/life equilibrium in one’s personal journey – is never easily achieved. It’s perfectly valid to argue that without the grueling hours logged by our predecessors, we will never achieve the technical precision required of a plastic surgeon. The response, then, becomes deliberate practice.

With advancements in technology and learning resources, we’ve eliminated much of the “scut” that once occupied a resident’s day. It has been proven time and again that it isn’t the amount of time, but the quality of the time that you spend honing your skills that matters. With the institution of the 80-hour work week, residents gained the opportunity to focus on aspects that made a surgeon excellent rather than assume the role of scribe or secretary.

In an effort to gain a unique perspective, Plastic Surgery Resident interviewed UNLV Residency Program Director Ashley Pistorio, MD, MS, and John Brosious, MD, of Vegas Plastic Surgery Institute and former UNLV residency program director, regarding their individual training experiences and what

"I believe burnout will always be part of medical education.

However, hopefully it manifests itself in small, short doses, rather than prolonged chronic issues."

– John Brosius, MD

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Plastic Surgery Resident | Summer 2022

Ashley Pistorio, MD, MS

John Brosious, MD

they have seen work – and not work – for residents.

productivity and revenue generation changed the mindset of corporate America as to how businesses can be run while maintaining efficiency and employee retention. Medicine – particularly surgery – has been slow to catch up with this shift in priorities, but it’s inevitable given that society has been moving steadily in this direction.

PSR: Did you ever experience burnout during residency/fellowship? If so, how did you deal with it?

Dr. Pistorio: Yes, 100 percent. There was no way to take a “break” to reset, so I relied on value-added activities or relaxation during the times I wasn’t working to help reset and recenter.

Dr. Brosious: Yes. I mainly relied on exercise and maximizing my weekends off to clear my head.

PSR: Why is burnout becoming more openly discussed in today’s society versus in past years?

Dr. Pistorio: We’ve transitioned from the baby-boomer generation, which identified as hard workers who didn’t job jump for greener pastures and didn’t really question working conditions.

With the arrival of subsequent generations, different priorities surfaced in working conditions, satisfaction and growth, and also in prioritizing workers as people with lives outside of work.

Social media and the internet in general played a large role in raising awareness of these subjects. The IT business boom and its model of working conditions (e.g., having massages and spa time, healthy food that’s accessible during the workday) while still maintaining

Dr. Brosious: The old “macho” mentality of surgery/medicine lent itself to keeping things bottled-up inside. The younger generations have a much greater focus on mental health and work/life balance.

PSR: What are telltale signs of burnout you look for in your residents?

Dr. Pistorio: Exhaustion, distraction, acting out, loss of patience in a usually patient person, missing details, irritability, tardiness and decreased interaction during conference or cases.

Dr. Brosious: Emotional lability, going through the motions at work.

PSR: Is burnout is an inevitable part of residency and something that we all must overcome?

Dr. Pistorio: I do think it’s inevitable in surgical training and as an attending. We must overcome it – and each individual will need to find their own best way to accomplish this. Supportive institutions, partners and attending

ASPS member Daniel Driscoll, MD (left), and Ukrainian surgeon Artem Posunko, MD (right), perform surgery on a pediatric burn patient while anesthesiologist Gennadiy Fuzaylov, MD (center), administers the anesthetic.

faculty are key to helping residents overcome burnout.

Dr. Brosious: I believe burnout will always be part of medical education.

However, hopefully it manifests itself in small, short doses, rather than prolonged chronic issues.

is balanced, they still should be safe, competent doctors – just with slightly less experience.

PSR: With the continual push for wellness and work/life balance, what do you see plastic surgery residency programs looking like in the future?

PSR: What’s your opinion of the 80hour work week and its impact upon the technical skills of residents?

Dr. Pistorio: Hopefully they will have more awareness, a stronger team mentality and no compromise in training.

Dr. Pistorio: Provided there’s sufficient caseload for operative and nonoperative management, 80 hours per week is plenty to get the needed repetitions and see sufficient volume. Residents and Fellows get overwhelmed with low-yield service activities.

Dr. Brosious: It might get to the point where a comprehensive education in plastic surgery is not attainable in six years, and perhaps subspecialties will break out (e.g., microsurgery, hand surgery, craniofacial, etc.) that will only focus on that one, small area of plastic surgery.

Dr. Brosious: The 80-hour work week is reasonable; however, it will lead to less experience in general, and this will probably affect training in all aspects, most notably judgment and technical ability, which are largely fortified by the amount of experience a resident has.

However, that doesn’t mean they won’t be competent. As long as the education

PSR: Although burnout is normally talked about in relation to residency, there’s also a very real prospect for burnout as an attending. Will things improve or simply change?

Dr. Pistorio: Things tend to get worse as an attending for various reasons.

There are different pressures, and hours can be more difficult and demanding.

There’s often less of a support system available – and most attendings will not use employer-based help, due to implications in license and credentialing.

Dr. Brosious: I actually had more burnout as an attending, likely because there’s no built-in time off after you graduate. However, I chose to have an intense career in reconstruction right after I graduated. Residents have no choice in how rigorous their lives are; that’s dictated by the program.

PSR: Every plastic surgery residency program – and individual resident – will handle burnout in their own way. Are there overarching keys that must be part of the approach and/or response?

Dr. Pistorio: The keys are recognition, self-awareness, knowing your limitations and knowing the best ways to decompress that work for you. It’s good to have “quick fixes” to decompress or reset, as well as long-acting ones. For example, are you having a bad day but can’t escape it? Sometimes a quick, three-to-five-minute breathing exercise

Plastic Surgery Resident | Spring 2023

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WELLNESS/ continued from previous page

or a change in location can help you reset to get through the rest of the day. Longer-acting relief is usually found in more time-consuming activities that can be done evenings or on weekends.

Dr. Brosious: The most important thing is to remind trainees that burnout is a common experience, and it doesn’t imply weakness of the trainee. The residents need an environment that allows them to feel comfortable discussing burnout and not fear being dubbed “weak.”

PSR: How did your own experience with burnout affect your residency or your work as an attending?

Dr. Pistorio: I can’t say this is past tense. It’s a never-ending cycle – and awareness of it and countermeasures have to be deployed on a rolling basis. During residency it created exhaustion and enhanced “imposter syndrome,” and generated feelings of apathy and worthlessness – and it all certainly felt impossible to escape at times. Now that I’m an attending, I can say I still feel overwhelmed and burned-out at times, but my overall coping skills allow me to avoid the extremes felt as a trainee. I’m still guilty of saying “yes” too often, of overstretching and overextending, overcommitting my time and not taking enough breaks. I love what I do, and that makes it even more difficult to say “no.”

Dr. Brosious: I often will counsel the trainees on techniques that I used to help combat burnout.

PSR: What are you most excited to see in the evolution of awareness of wellness and burnout as it pertains to resident education?

Dr. Pistorio: A more humane environment starts from the top down, and I think many of us are now able to speak openly about it at all levels. Sharing the management of burnout and promotion of wellness should be a continuing conversation in residency programs. We’re tasked with training future plastic surgeons, and I firmly believe that part of this must include teaching them not just the theory and techniques of plastic surgery, but also practice management – which includes the management of wellness for themselves and their future colleagues/staff.

Dr. Brosious: Every surgical resident will experience burnout at some point. All residents need to know there are options for help when they burn out – not if they burn out. Burnout is inevitable, and it needs to be planned for. | Dr. Mehta is PGY-4 at the University of Las Vegas.

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Plastic Surgery Resident | Spring 2023

D EA R Robert Abbe, MD

Abbe

EDITOR’S NOTE: “Dear Abbe” – named in honor of plastic surgery pioneer Robert Abbe, MD – provides plastic surgery residents an opportunity to anonymously share concerns and seek advice from a highly respected, seniorlevel faculty member. Christian Vercler, MD, a clinical associate professor in the Section of Plastic Surgery at the University of Michigan – where he also serves as co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences – and Kate Kraft, MD, a professor in the Department of Urology at the University of Michigan, step into Dr. Abbe’s shoes for this installment.

The views expressed in this column are those of the author and should not be considered legal advice. Residents and Fellows are encouraged to submit questions to DearAbbe@plasticsurgery.org. Names will be withheld.

Anxious to assume more responsibility Dear Abbe:

What is the best approach to take on a rotation with a surgeon where I’m not getting to do enough operatively?

– Anxiously Waiting

Dear Anxiously, For every resident I know, operative independence is like money – even if you have enough, it would be nice to have a little more. It’s particularly frustrating to feel you’ve achieved a level of surgical competence only to rotate onto a new service where you’re not allowed to demonstrate your operative skills.

A crucial component of solving any problem is arriving at an accurate diagnosis before proceeding with a solution. For every operation, there are at least three variables to consider: you, the attending surgeon and the patient. Although it might seem there’s “something wrong” with this attending if he or she doesn’t let you operate as much as you feel you should, the only element you have direct control over is yourself. Take careful stock of your situation – including some deep self-reflection to make sure you aren’t manifesting the Dunning-Kruger effect. (It’s when those with lower levels of expertise overrate their actual ability to perform.)

The advice we all give to medical students on their sub-internship also applies in residency: Be prepared for every case. Make sure you know the relevant anatomy, indications for the procedure and everything about the patient so that you fully understand why you’re doing this specific operation for this specific patient. Have particular educational goals that are appropriate for your level of training (e.g., don’t expect to do the microsurgery on your first DIEP flap). Take advantage of pre-op conferences to demonstrate your mastery of the subject matter. There have been many instances when a resident so impressed me with their preparation at the weekly indications conference that I let them perform significantly more of an operation than I had first planned. As Louis Pasteur said, “Chance favors the prepared mind.” Assuming that you’re doing all this and still feeling frustrated, there are more direct ways to approach this.

Gaining autonomy in the O.R., while somewhat of a right, is mostly a privilege to be earned through thorough preparation and clearly communicating learning objectives. This is the crux of growth in surgical skill. The BID model offers an excellent blueprint for this, focusing on the individual needs of the learner.1 A good surgical educator should elicit these from you before every case – but don’t wait to be asked. Simply stating something to the effect of, “Last month I did a fair amount of the venous anastomoses under the scope, and my goal for this case is to perform an arterial anastomosis” can be a powerful way to alert your attending to his or her educational role. If I’m preparing for a particularly challenging operation, I might be focused on a specific aspect of the case, and I may lose sight of my educational responsibilities. Making sure that your goals are aligned is a recipe for success.

University of Michigan researchers have identified behaviors among residents and attendings that were reliably “promotion-associated” or “prevention-associated.” 2 A promotion-oriented person is “high energy,” “willing to take risks,” “open to alternative approaches” and “works quickly.” These individuals are considered to be “playing to win.” The prevention-oriented person, meanwhile, “prefers vigilant strategies,” “sticks to known ways of doing things,” is “quiet and calm” and “works slowly and deliberately.” These individuals are considered to be “playing to not lose.”

The researchers found that both residents and attendings reliably perceived traits in themselves and others that could be divided into these categories.

Perhaps unsurprisingly, residents reported the lowest amount of operative autonomy when there was a mismatch in styles (i.e., a resident who “works quickly” and is “willing to take risks” has low entrustment from an attending who “works slowly and deliberately” and “prefers vigilant strategies”). If you can analyze the motivational style of your attending and recognize your own style, you can modify your approach to maximize entrustment.

The best approach is likely the most direct. Say to your attending: “My goal on this rotation is to gain more operative autonomy in these cases. Can you tell me what you need me to do in order to achieve that goal?” Ask for specific, corrective feedback at the end of each case that addresses your learning objectives. Use that feedback to improve your performance; make sure you are improving at an acceptable rate. Benjamin Franklin once said, “Tell me and I forget. Teach me and I remember. Involve me and I learn.” Remember, the faculty-resident dyad, like any other relationship, is a two-way street. | REFERENCES 1.Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009; 208(2): 299-303.

2.Nishee A, Burdine J, Matusko N, Wang T, De Roo A, Lussiez A, Sutzko DC, Minter R, Sandhu G Identificatino of promotion and prevention associated surgeon behaviors in the operating room to facilitate resident self-regulated learning. Am J Surg 2021; 221: 331-335.

Plastic Surgery Resident | Spring 2023

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Rutgers New Jersey Medical School

By Laura Reed, MD HISTORY

Renata Weber, MD, Member, American Society for Surgery of the Hand, American Association of Hand Surgeons, American Society for Peripheral Nerve

• Transitioned to a fully integrated plastic surgery program in 2015, expanding to cover seven hospitals in 2023

Robert Herbstman, MD, President, New Jersey Society of Plastic Surgeons

• Established as an independent plastic surgery residency in 1982, with residents covering two hospitals in New Jersey

• The first integrated plastic surgery program in the state of New Jersey

PROGRAM LEADERSHIP

Edward Lee, MD, Division Chief of Plastic and Reconstructive Surgery at the University Hospital in Newark, Program Director Richard Agag, MD, Division Chief of Plastic and Reconstructive Surgery at Robert Wood Johnson University Hospital, Site Director Jeremy Sinkin, MD, Associate Professor at Robert Wood Johnson University Hospital, Assistant Program Director Ashley Ignatiuk, MD, MSc, Associate Professor at the University Hospital in Newark, Assistant Program Director

NATIONAL MEMBERSHIPS

Mokhtar Asaadi, MD, Member, American Society for Aesthetic Plastic Surgery, Northeastern Society of Plastic Surgeons Gregory Rauscher, MD, Vice President, New York Regional Plastic Surgery Society; Member, American Society for Surgery of the Hand, American Society for Aesthetic Plastic Surgery Richard Kim, MD, Member, American Society for Surgery of the Hand 10

Plastic Surgery Resident | Spring 2023

CLINICAL EXPERIENCE

Training sites include the University Hospital Newark, Robert Wood Johnson University Hospital New Brunswick, Bristol-Myers Squibb Children’s Hospital, East Orange Veterans Affairs Hospital, Hackensack University Medical Center, Cooperman Barnabas Medical Center, Saint Peter’s University Hospital • Two Level I trauma and replant centers for resident rotation

• Eight full-time academic faculty between University Hospital Newark and Robert Wood Johnson University Hospital New Brunswick

• More than 30 affiliated faculty members who are private plastic surgeons at community hospitals • 18 residents overall, three residents per year

• 50,000 major operations per year, 100 operations per week between all sites

• Six months of plastic surgery rotations each during first and second year, 12 months of plastic surgery rotations during years three, four, five and six • Operative experience in plastic surgery starting intern year at the Veterans Affair Hospital as well as at University Hospital and Robert Wood Johnson • Residents start taking plastic surgery call starting intern year

• Off-service rotations during the first two years of residency include orthopedic hand surgery, oral and maxillofacial surgery, oculoplastic surgery, orthopedic trauma surgery, dermatology, vascular surgery, surgical oncology and burn surgery at the only burn center in New Jersey

• Comprehensive training in microsurgery, aesthetic surgery, hand surgery, gender-affirmation surgery, traumatic reconstruction and craniofacial surgery • Chief cosmetic clinic for sixth-year residents, where residents run their own clinic, perform injectables on their patients and operate on patients under attending supervision

• Training in both academic and private practice settings, residents have the opportunity to work with private-practice attendings starting in year three and continue throughout training

RESEARCH

• Attending mentorship for research projects focused on craniofacial, traumatic reconstruction, hand and peripheral nerve, aesthetic, microsurgery, basic science and quality improvement • Monthly research meetings as a program to discuss current projects, upcoming conferences and deadlines

• Covered travel and accommodation expenses for conference presentations throughout the year for each resident

• Coverage for ASPS Senior Residents Conference for sixth-year residents

RESIDENT BENEFITS

• Meal money at University Hospital in Newark, Robert Wood Johnson University Hospital, Cooperman Barnabas Medical

Center, Hackensack University Medical Center and Saint Peter’s University Hospital

• 3.5x magnification loupes with attached headlights fitted for every resident at the end of intern year • $600 per year academic allowance to be used on books, tablets, smartphones and equipment that can be carried over year-to-year

• Reimbursement for conference presentations, including travel and accommodations • Covered parking at all hospitals

• Home call at all hospitals, giving all residents at least two golden weekends per month while on plastic surgery rotations

EDUCATIONAL CURRICULUM

• Wednesday morning education weekly, with two hours of didactics given by residents, attendings and guest lecturers

• Weekly indication conferences in which upcoming cases operative plans and reconstructive goals are discussed with patient pictures • Monthly morbidity and mortality conferences at each site, discussing past cases and complications • Yearly microsurgery skills lab

• Biannual cadaver dissections with varying surgical focuses including hand surgery, aesthetic face surgery and peripheral nerve surgery

• Journal Club dinner every three months to discuss new plastic surgery innovations and current research • Weekly hand Journal Club with the orthopedic hand surgery team

• Opportunity to join the Committee of Intern and Residents union

• Four weeks of vacation spread out in one-week intervals, one week off per quarter, per resident

RESIDENT CAMARADERIE

• Resident birthday celebrations – most recently, karaoke night in New York • Annual summer barbeque, hosted by one of the faculty or residents

• Annual Christmas party hosted by one of the residents • Girls’ brunch for female residents

• Happy hours when the clinical day finishes early

• RWJ End-of-Rotation Outing in which the faculty takes the team out for Top Golf, Bowling, Lounge, etc., to celebrate | Dr. Reed is PGY-2 at Rutgers New Jersey Medical School.

• Yearly mock oral boards for all senior residents

• Mentorship with chosen faculty members at the end of intern year to discuss personal and professional goals

• Yearly Cooperman Barnabas Plastic Surgery Symposium with an aesthetic focus and visiting lecturers from around the world • Coverage for University of Pennsylvania Flap Course for fourth-year residents

Plastic Surgery Resident | Spring 2023

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Q&A WITH JEREMY SINKIN, MD

Jeremy Sinkin, MD, is an assistant professor of surgery in the Division of Plastic & Reconstructive Surgery at Rutgers Robert Wood Johnson Medical School. He’s also director of Microsurgery at Robert Wood Johnson University Hospital in New Brunswick, N.J., and co-associate director of the Rutgers New Jersey Medical School Integrated Plastic and Reconstructive Surgery Residency Program. Dr. Sinkin earned his medical degree at the University of Rochester (N.Y.) School of Medicine and Dentistry and completed his plastic surgery residency training at MedStar Georgetown, followed by a fellowship in Complex Microsurgery and Breast Reconstruction at Memorial Sloan Kettering Cancer Center.

PSR: HOW DID YOU PREPARE FOR A COMPETITIVE FELLOWSHIP? Dr. Sinkin: I entered residency without knowing exactly how I wanted to structure my career in plastic surgery, so I remained very open-minded throughout my training toward diverse clinical experiences and research opportunities. My main priority was to become a well-rounded, competent and compassionate surgeon. Organically, my interests began gravitating toward complex reconstruction and “surgical problem-solving” – and the solutions that microsurgery and free-tissue transfer can offer patients.

PSR: WHAT IMPACT DID YOUR FELLOWSHIP HAVE ON YOUR CAREER? Dr. Sinkin: Being a fellow at Memorial Sloan Kettering was a tremendous experience. The volume and complexity of cases accelerated and honed my skill-acquisition and armed me with the confidence to offer my patients the full spectrum of reconstructive options. Additionally, the interdisciplinary collaboration and collegiality I experienced in fellowship set the bar for how I wanted to structure my practice. The year

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also allowed me to connect with new mentors and colleagues, who I carry with me to this day.

PSR: HOW IMPORTANT IS A MENTOR – AND HOW CAN WE FIND ONE? Dr. Sinkin: Mentors are incredibly important throughout training and beyond. Mentors come in all shapes and sizes, and it’s important to recognize that you can have more than one. Many residencies have instituted formal mentorship programs, which can be helpful in ensuring that a resident continues to meet milestones such as clinical competency and timely fellowship applications. But mentor-mentee relationships more often form organically through shared interest and experience. Some mentors might be faculty with whom a resident performs research. Other mentors could be faculty or senior residents who have a career or work ethic that the resident admires. Not every mentor can be everything to the mentee, so having more than one enables a resident to draw from the strengths of many.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE OF A RESIDENT?

PSR: WHAT ARE SOME OF THE CHALLENGES YOU ENCOUNTER ON A REGULAR BASIS?

Dr. Sinkin: Their most important attribute is passion for learning and plasticity. Residency is a period of time when knowledge and skill-acquisition is fast and intense. Residents will be exposed to diverse clinical, social and professional scenarios, therefore it’s essential for them to be open to learning from this heuristic process. Over time and with more experience, a well-rounded resident with a strong foundation will be able to develop their unique style and interests.

Dr. Sinkin: My clinical practice is very diverse. It ranges from aesthetic and reconstructive breast surgery to complex oncologic reconstruction of the head/neck, torso and genitalia, to gender-affirming surgery and traumatic face and extremity reconstruction. Each patient presents their own unique challenges, and I find satisfaction in guiding our residents through the process of identifying viable treatment options and executing successful surgeries.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES?

PSR: WHAT ADVICE DO YOU HAVE FOR PLASTIC SURGERY RESIDENTS?

Dr. Sinkin: The balance between professional and personal life is always in flux. Some days or weeks, the balance will favor more time and energy devoted to professional pursuits.

Other times, it’s the opposite. My wife and family are supportive of my career decisions, and they understand when I need to spend nights or weekends at work. We make the most of the quality time we spend together and encourage each other’s interests. After several years in practice, I found myself desiring a hobby. Initially, I asked friends and colleagues for suggestions and received a variety of fascinating responses, including racecar driving, cocktail mixology, woodworking and watch-making. Ultimately, I decided to start taking saxophone lessons, and it’s been a real boon to my personal life – as well as makes for interesting discussions and music choices in the O.R.

Dr. Sinkin: In the moment, residency may feel interminable, but in retrospect, it’s over in a flash. Trust the process, put in the effort, nurture your relationships and enjoy the ride.

PSR: COMPLETE THIS SENTENCE: “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN…” Dr. Sinkin: I saw how happy my plastic surgery mentors were every day, just doing what they were passionate about. |

PSR: WHAT WAS YOUR GREATEST NON-MEDICAL CHALLENGE OF TRAINING? Dr. Sinkin: Residency is inherently a challenging time in our lives as we focus on our own professional growth and learning.

There were many personal sacrifices, such as missed weddings, birthdays, social gatherings – and neglected friendships.

After several years in practice, I feel like I’ve been able to re-establish healthy routines such as getting regular exercise, socializing with friends and family, and being a thoughtful contributor to my community.

Plastic Surgery Resident | Spring 2023

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A Message From the Program Director, Edward Lee, MD

T

he Rutgers New Jersey Medical School Plastic and Reconstructive Surgery Residency Program has a rich history and has always been a vibrant community. The program has undergone many changes over the years – a testament to its culture of adaptability and innovation. It was initially founded by Lyndon Peer, MD, the renowned craniofacial surgeon, and perhaps the first plastic surgeon in New Jersey. The fellowship program then transitioned to a combined plastic surgery program under Mark Granick, MD, eventually becoming an integrated program in the past decade.

The program grew from a single hospital to six hospitals throughout New Jersey today. There are two academic campuses: University Hospital in Newark and Robert Wood Johnson Hospital in New Brunswick, with eight full-time academic surgeons, including microsurgery, hand, craniofacial and aesthetic fellowship-trained faculty. The two full-time academic groups are now under the Rutgers Biomedical Health Sciences umbrella, which also houses the residency program. Both academic hospitals are Level I trauma centers and have partnerships with the Cancer Institute of New Jersey. The residents benefit greatly from training at both sites as they become familiar with different patient populations of varying socioeconomic status and ethnic diversity. At both sites, residents have ample experience with hand/ facial trauma, lower-extremity reconstruction, oncologic reconstruction and breast reconstruction. In addition to the academic mission-based hospitals, residents also travel to the Veterans Affairs Medical Center, Hackensack University Medical Center, Cooperman Barnabas Medical Center and St. Peter’s University Hospital. At these community-based hospitals, residents work with luminaries of plastic and reconstructive surgery who have private practices in the local area.

The core of our program is a strong emphasis on curiosity that drives academic excellence. We

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Plastic Surgery Resident | Spring 2023

believe that continuous inquiry drives learning, innovation and critical thinking, which are the foundations of a successful career in plastic surgery. Our curriculum is designed to provide a comprehensive and robust educational experience, equipping residents Edward Lee, MD with the knowledge, skills and expertise necessary to excel in an ever-evolving field. We provide flexibility in our teaching methods; with each rotation, the team of residents changes; and while the core curriculum remains the same, we implement different adjunct learning tools to tailor to their style of learning and academic interests. This flexibility provides residents with an extraordinarily well-rounded skill set and unparalleled educational opportunities.

A key objective is to foster the development of independent decision-making among our residents.

We recognize the importance of autonomy in the practice of plastic surgery, and we aim to cultivate this essential skill throughout our training program. Our residents are encouraged to actively participate in patient care, contribute to clinical decision-making and take ownership of learning.

We provide a supportive and supervised environment that allows our residents to build confidence and competence in making independent and informed decisions. We’re confident in the training we provide and place great trust in our chief residents’ surgical and decision-making abilities.

In addition to clinical experience, we also emphasize the significance of research and scholarly activities. Engaging in scholarly pursuits is essential for advancing the specialty and staying at the forefront of scientific knowledge. Our residents can participate in ongoing research projects,

A Message From the Program Director, Edward Lee, MD

collaborate with esteemed faculty to generate new projects and present their work at national and international conferences. We are committed to providing the necessary resources and mentorship to support our residents in their scholarly endeavors, and we encourage them to develop a lifelong habit of academic inquiry and evidence-based practice.

Furthermore, our program is committed to promoting diversity, equity and inclusion in plastic surgery. This has become a mission for plastic surgery programs across the country, but we recognized this need early due to New Jersey’s patient population. Our diverse group of residents broadened the patients’ experience and our understanding of how disease and patient outcomes are affected by social determinants of health. Several residents have taken great interest in starting quality-improvement projects and applying for

grants that can make access to care equal for patients of underprivileged and underrepresented backgrounds. We’re proud of our program’s advancements and remain dedicated to fostering an inclusive environment that values and respects individual differences, promotes equitable opportunities and embraces diversity in all forms. We hope to continue to recruit and retain a diverse group of residents, faculty and staff to promote a culture of inclusivity, mutual respect and understanding.

At the heart of our program is curiosity. Our faculty take pride in providing the residents with the skill set necessary to capitalize upon this curiosity.

This is paramount in any training environment, but we hope they continue to utilize this mindset in their careers, continuously evolving and innovating.

As Socrates said: “I cannot teach anybody anything, I can only make them think.”|

THURSDAY | OCT. 26, 2023 SRC registration includes the Residents Networking and Mentorship Reception!

PlasticSurgeryTheMeeting.com/SRC

Plastic Surgery Resident | Spring 2023

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New Jersey

By Derek Woloszyn, MD

T

he day of a resident begins early, but it takes just one look at the Hudson River from Jersey City, N.J. – and watching the sunrise above the New York skyline – to remember how lucky you are to be here. Living in Jersey City leaves the world readily accessible at your doorstep. As a state, New Jersey is one of the most diverse in the county, with access to cuisine that’s as diverse as the population. The food choices and quality are unmatched – both within the state and just 15 minutes away in New York. There are numerous coffee shops, bars and food joints rounding every corner in downtown Jersey City. This diversity makes living here vibrant and accessible while retaining the quiet evenings and peaceful Sunday afternoons.

New Jersey is a commuter-heavy state, but the entire state can be traversed within two hours, which means everything it has to offer is within reach. Commuting during residency might be less than ideal, but there are idyllic, rural communities throughout the state where roads lined with old trees wind between horse farms and other beautiful scenery. For bikers, these same roads provide a beautiful backdrop for a bit of exercise.

For runners, you can choose from racetracks, gorgeous state parks or even the pier overlooking the NYC skyline. Shoppers can get their steps in at the American Dream, the second-largest mall in the country that, in addition to world-class shopping, offers both indoor skiing and a water park.

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If arts and theater are more your speed, the state is peppered with performing arts centers that host a variety of shows from the community level to offBroadway. Broadway itself is just a subway ride away to some of the world’s most iconic shows. Most concert tours also stop in the area, so music buffs never have to miss a concert, whether in small or large, indoor and outdoor venues.

Summertime is where New Jersey really shines. The long days and late sunsets let you really explore. Start your day early with a coffee and head down to the shore. The state is lined with 130 miles of beach that range from quiet places to enjoy reading to full party towns with an energy that’s irresistible. Surfing is allowed on most beaches and the state’s gentle slope means long rides for both beginners and experts alike.

Deep-sea fishing charters run daily and there’s nothing like having a drink next to the ocean to round out your day. Runners, both novice and professional, enjoy using the state’s 18 boardwalks to soak-up the atmosphere.

Those of you who might be saltwater averse will be happy to know that the northern part of the state is speckled with lakes and rivers for fishing, canoeing, hiking and camping – and it’s always worth hopping in the Delaware River with a tube, a cooler and some friends to spend hours lounging down the river.

New Jersey has an immense number of activities and amenities to offer, but the best thing about living here is the people you meet.

The New Jersey community is truly a melting pot of people, and the friends you make will be for a lifetime. I was thrilled to come home for residency – and I invite you all to come experience what it’s like here in the Garden State. | Dr. Woloszyn is PGY-3 at Rutgers New Jersey Medical School Jersey City Mural Festival I wouldn’t recommend swimming in the Hudson River, but there are sailing clubs that litter the river and offer a fun way to experience the island of Manhattan.

The different seasons also demonstrate exactly why New Jersey is known as the Garden State. It may not seem like it when you fly into Newark International Airport, but much of New Jersey is preserved farmland, providing fresh and delicious fruits and vegetables.

Sweet Jersey corn and good, old Jersey tomatoes are summer musts.

Come fall, pumpkins, apples, pears and squash are at your doorstep and make for the perfect fall Instagram post.

Complement this with the festivals and events run by all the towns. In spring, Newark is home to the largest collection of Japanese cherry blossom trees in Branch Brook Park, which is also the spot of an annual festival.

During the winter, skiers and snowboarders have access to smaller mountains for a quick day trip, but the entirety of East Coast skiing is readily accessible for a weekend away. The collection of state parks provides hiking options for all different abilities.

The proximity to New York and Philadelphia means an endless supply of museums to visit while taking shelter from the winter temperatures. Lastly, if you’re looking to travel a little further, the international airport is a 10-15-minute drive from Rutgers New Jersey Medical School.

Some of the ethnically oriented dishes found in Jersey City, N.J.

Jersey Shore Boardwalk

Plastic Surgery Resident | Spring 2023

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LYMPHEDEMA

By Danielle Olla, MD, & Alexis Ruffolo, MD

L

ymphedema is caused by an accumulation of lymphatic fluid within the interstitial space of the tissue due to an imbalance between the lymphatic system’s ability to produce and eliminate fluid.

This leads to a progressive state of lymphatic dysfunction, resulting in accumulation and stasis of the lymphatic fluid. A chronic inflammatory response occurs, ultimately resulting in remodeling of the extracellular matrix, with fibrosis and deposition of fibroadipose tissue. The lymphatic vessel lumen becomes obliterated if this process persists over time.

CLASSIFICATION Primary lymphedema is the result of lymphatic channels that are structurally and functionally abnormal. This may be due to obstruction, malformation or hypoplasia.1,2 Primary lymphedema is further categorized based on the patient’s age at the time of symptom onset: • Congenital lymphedema presents as isolated sporadic bilateral lower-extremity edema occurring in the first two years of life.

This is the second-most common type of primary lymphedema and affects females twice as often as males.

• Milroy’s primary congenital lymphedema is a specific etiology of congenital lymphedema due to a mutation in the FLT4 gene, which encodes the vascular endothelial growth factor receptor 3 (VEGFR-3) and is involved in lymphatic development. This condition is relatively rare and follows an autosomal dominant inheritance pattern with incomplete penetrance.

• Familial lymphedema praecox (Meige’s disease) typically presents as unilateral lymphedema which affects the foot and calf, around the age of puberty. This is the most-common form of primary lymphedema, with females affected four times as often as males. Inheritance is autosomal dominant and associated with a mutation in the family transcription factor (FOXC2) gene, which is involved in lymphatic valve formation.

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DANIELLE OLLA, MD

ALEXIS RUFFOLO, MD

• Lymphedema tarda occurs after the age of 35 and is the rarest form of primary lymphedema.

Secondary lymphedema is the result of destruction or obstruction of normal lymphatic channels. Filariasis is the most-common cause of secondary lymphedema worldwide and is caused by the Wuschereria bancrofti nematode which obstructs the lymphatic system. Cancer and the effects of cancer treatment are the most common cause of secondary lymphedema in the United States.

STAGING The International Society of Lymphology staging system is the most-commonly used and classifies lymphedema into four stages:3 • Stage 0 (latent) lymphedema occurs when lymphatic channels are damaged, but there’s no evidence of edema on physical exam.

Patients may report heaviness or discomfort of the affected extremity with activity.

• Stage I (spontaneously reversible) lymphedema is characterized by pitting the edema of the affected extremity that resolves with complete decongestive therapy (CDT).

• Stage II (spontaneously irreversible) lymphedema is characterized by the pitting edema of the affected extremity that does not resolve with CDT. At this stage, adipose deposition and fibrosis of the tissue has taken place.

• Stage III (lymphostatic elephantiasis) lymphedema is characterized by significant non-pitting edema, fibroadipose deposition, hyperkeratosis and acanthosis of the affected extremity. This does not resolve with conservative treatment, and skin infections frequently occur.

PHYSICAL EXAMINATION Intermittent pitting edema is an early physical finding of lymphedema. A pitted, peau d’organge texture of the skin might develop as the disease progresses, eventually taking on an indurated, leathery skin texture.

Irreversible lymphedema is characterized by non-pitting edema. The Kaposi-Stemmer sign is pathognomonic for chronic lymphedema, in which the examiner is unable to pinch the fold of skin at the base of the second toe. At the final stage of lymphedema, elephantiasis nostras verrucosa develops.

Patients with chronic lymphedema are prone to ulceration, infection and wound formation of the involved skin.1

(Schaverien MV, Coroneos CJ. Surgical Treatment of Lymphedema. Plast Reconst Surg.

2019 Sep;144(3):738-758)

IMAGING Radionuclide lymphoscintigraphy is the gold standard for evaluation of the function of the lymphatic system. This testing is noninvasive, easy to perform and available at most centers. Most commonly, technetium-99 is injected into the distal portion of the limb being studied and the migration of the radionuclide is visualized through discrete lymph vessels and nodes. Abnormal findings include interruption of lymphatic flow; collateral lymph vessels; dermal backflow; delayed flow; delayed visualization or non-visualization of lymph nodes; reduced number of lymph nodes; dilated lymphatics; or no visualization of the lymphatic system.4 The presence of dermal backflow on contrast-enhanced imaging of the lymphatic system is diagnostic for lymphedema. The severity and distribution of the backflow correlates with the pathologic condition of the lymphatic vessels.

Magnetic resonance lymphography, with or without gadolinium-based contrast, enables detailed visualization of individual lymphatic vessels, lymph nodes and soft-tissue changes. This can be used for the diagnosis of lymphedema and surgical planning.

Indocyanine green fluorescent lymphography is a technique which provides real-time, dynamic functional evaluation of the superficial lymphatic system. This can be used for intraoperative lymphatic mapping when performing a vascularized lymph node transplantation. Staging systems using indocyanine green lymphography are very commonly used. These systems consider the status of lymphatic transport, presence of functional lymphatic vessels, and pattern and distribution of dermal backflow.

TREATMENT Conservative treatment CDT is the standard of care for lymphedema. CDT is administered by a certified lymphedema therapist and involves manual lymphatic drainage, compression, therapeutic exercise, skin care and education.5 Diuretics are a proposed adjunct to conservative lymphedema therapy but have not been found effective. In fact, diuretics may augment the development of fibrosis.

Surgical treatment The surgical treatment of lymphedema can be categorized into two categories: physiologic and ablative.4,6 Surgical treatments improve symptoms and patients’ quality of life but are rarely curative.

Physiologic procedures address lymphatic flow by augmenting the number of patent lymphatic pathways and are an option in the early phases of lymphedema. Lymphaticovenular bypass is a procedure that involves connecting lymphatic vessels to nearby veins to create new pathways for lymphatic fluid to drain. Vascularized lymph node transfer is a procedure that involves transplanting healthy lymph nodes from one part of the body to the area affected by lymphedema to improve lymphatic function.

Ablative procedures debulk areas of lymphedema and can be performed at any time, but these are typically reserved for the later stages of lymphedema. | Dr. Olla is PGY-6 and Dr. Ruffolo is PGY-4 at Southern Illinois University, Springfield.

REFERENCES

1. Grada A, Phillips T. Lymphedema: Pathophysiology and clinical manifestations.

JAAD. 2017 Dec 2017;77(6)doi:10.1016/j.jaad.2017.03.022 2. Hespe G, Nitti M, Mehrara B. Pathophysiology of Lymphedema. In: Greene AK, Slavin SA, Brorson H, eds. Lymphedema: Presentation, Diagnosis, and Treatment. Springer International Publishing; 2015:9-18.

3. Executive Committee of the International Society of Lymphedema. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020 2020;53(1) 4. Schaverien M, Coroneos C. Surgical Treatment of Lymphedema. Plast Reconst Surg. 2019 Sep 2019;144(3)doi:10.1097/PRS.0000000000005993

5. McLaughlin S, Staley A, Vicini F, et al. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel : Part 1: Definitions, Assessments, Education, and Future Directions. Ann Surg Oncol. 2017 Oct 2017;24(10)doi:10.1245/s10434-017-5982-4 6. Kung T, Champaneria M, Maki J, Neligan P. Current Concepts in the Surgical Management of Lymphedema. Plast Reconst Surg. 2017 Apr 2017;139(4) doi:10.1097/PRS.0000000000003218

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Journal Club; 2023 Spring

1. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm Lee ZH, Stranix JT, Rifkin WJ, et al. Plast Reconstr Surg.

2019;144(3):759-767.

Groups were stratified into timing of coverage: three days or less (early); four to 90 days (delayed), which was further stratified into four-nine days and 10-90 days; and greater than 90 days (late).

There was no difference in total or partial-flap failures, take-backs or overall complications for flaps performed within three days versus four-nine days. Flaps performed 10-90 after injury had significantly higher total flap-failure and major complication rates compared to flaps performed four-nine days after injury. Therefore, Godina’s original paradigm can be updated, and the ideal period of early reconstruction can be extended to 10 days following injury.

JOURNAL ARTICLES ON

LOWER-EXTREMITY RECONSTRUCTION

EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Mark Shafarenko, MD, & Blake Murphy, MD, PhD

2. Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity Ricci JA, Abdou SA, Stranix JT, et al. Plast Reconstr Surg.

2019;144(4):982-987.

Gustilo type IIIC injuries were compared with Gustilo type IIIB injuries with only a single patent vessel. No significant differences were found with respect to partial or total flap loss, take-backs, salvage rate and rate of major perioperative complications. When sub-stratifying the Gustilo type IIIB group according to the number of patent vessels, the rate of complete flap loss and major perioperative complications increased as the number of patent vessels decreased. However, the rates of partial flap loss, take-backs, and salvage rates were not different between groups.

3. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis Cho EH, Shammas RL, Carney MJ, et al. Plast Reconstr Surg.

2018;141(1):191-199.

Mark Shafarenko, MD

Blake Murphy MD, PhD

L

ower-extremity defects frequently result from trauma or ablation following tumour resection. The ultimate goals remain maximizing function while achieving stable skeletal fixation and soft-tissue coverage. Numerous advances have enabled these reconstructions to achieve high success rates, such as locoregional flaps – including keystone and propeller flaps – as well as increasing use of fasciocutaneous flaps. These advances are reviewed in detail, together with the orthoplastic approach to limb reconstruction, to better inform residents of the surgical armamentarium available to treat these challenging defects.

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Plastic Surgery Resident | Spring 2023

Free flaps were performed for acute traumatic injuries or chronic traumatic sequelae, with flaps subdivided into fasciocutaneous or muscle subgroups. No significant differences were observed in the rates of flap thrombosis, flap salvage, flap loss or rates of tibial non-union. Both groups achieved similar rates of limb salvage for both the acute and chronic trauma subgroups. Flap choice was not associated with functional recovery in either group. Secondary skin-grafting procedures were more commonly required for muscle flaps, while fasciocutaneous flaps were more commonly re-elevated for secondary orthopedic procedures.

4. Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications and Extended Clinical Applications Mohan AT, Rammos CK, Akhavan AA, et al. Plast Reconstr Surg.

2016;137(6):1909-1920.

The authors advocate for flaps with a greater size ratio than 1:1 depending on surrounding laxity, as well as centering flaps over areas of high perforator density (hot spots). Fascial incision is performed in a stepwise fashion to facilitate advancement, and undermining away from perforator hot spots allows for further

mobility and versatility of these flaps. Flaps should be oriented parallel to the dominant axiality of flow. Keystone flaps can be designed as the primary reconstructive option or in conjunction with regional perforator flaps. Forty-two flaps were performed with an average size of 344 cm², and no partial or total flap losses were encountered.

5. Lower Extremity Reconstruction After Soft-Tissue Sarcoma Resection Parikh RP, Sacks JM. Clin Plast Surg. 2021;48(2):307-319.

The authors advocate for preoperative radiotherapy when indicated, as well as immediate reconstruction when possible.

The reconstructive approach is site-specific and dictated by defect location and size; expected functional loss; involvement of underlying structures; and radiotherapy. Considerations for flap selection also include the required pedicle length for anastomosis and donor-site morbidity. For femoral shaft reconstruction, the Capanna technique is preferred. Free-functioning muscle transfers are advocated when sarcoma resection will result in significant functional deficit. When amputations are necessary, TMR should be performed to minimize pain.

6. Propeller Flaps in Lower Extremity Reconstruction Blough JT, Saint-Cyr MH. Clin Plast Surg. 2021;48(2):173-181.

Skin-paddle orientation should be based according to the orientation of the linking vessels in the extremity. Perforators are located in four longitudinal rows (one for each source artery).

For harvest, perforators are first localized with a Doppler, a skin paddle is designed longitudinally and an exploratory incision is made to accommodate backup flap options. Dissection proceeds subfascially and the perforator closest to the edge of the defect is generally selected. The flap is designed to be slightly larger than the defect. After rotation, Doppler is used to confirm adequate flow. Complication rates in the literature are generally comparable to that of free-tissue transfer.

7. The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction

Sugg KB, Schaub TA, Concannon MJ, Cederna PS, Brown DL. Plast Reconstr Surg Glob Open. 2015;3(9):1-9.

A significant number of flap failures owing to venous congestion were encountered when using the reverse superficial sural artery flap (RSSAF). Modifications to the flap design and design were employed: the pedicle width was increased to a minimum of 4 cm, and the island-type design was replaced by either a full fasciocutaneous or adipofascial design. The incidence of venous congestion requiring leech therapy was decreased from 42 percent in the early group to 0 percent in the late group. The limb salvage rate also increased from 50 percent to 93 percent following modification. The combined rate of partial and complete necrosis was 30 percent for all flaps with an overall complication rate of 70 percent, which is in keeping with that reported in other studies.

8. Current Concepts in Lower Extremity Reconstruction

Soltanian H, Garcia RM, Hollenbeck ST. Plast Reconstr Surg.

2015;136(6):815e-829e.

The authors provide a comprehensive review of principles of lowerextremity reconstructions. Attempts should be made to perform anastomoses outside of the zone of injury. In the oncologic setting, reconstructions should provide robust vascularized tissue to withstand radiation and avoid wound breakdown. Limb salvage is indicated in all children with lower-extremity injuries and all adults with sensate limbs after trauma. Common flap options are reviewed according to anatomic region: gastrocnemius flaps for the upper third; soleus muscle flaps, keystone flaps or free-tissue transfer for the middle third; and propeller flaps, reverse sural flaps or free-tissue transfer for the lower third.

9. Bone Repair Using the Masquelet Technique

Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis P V. J Bone Jt Surg - Am Vol. 2019;101(11):1024-1036.

The first stage includes debridement of any necrotic bone/ infection, insertion of a polymethylmethacrylate spacer and bony fixation. The second stage is typically carried out four to eight weeks later, and involves removal of the cement spacer, preservation of the membrane and autologous bone grafting.

If bone autograft volume is insufficient, volume expansion can be achieved by mixing the autograft with allograft, xenograft or synthetics. Revision of bony fixation can also be performed during the second stage if necessary. Good outcomes can be achieved with this technique,although some unanswered questions remain, such as the optimal type of cement or method of fixation.

10. Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

Azoury SC, Stranix JT, Kovach SJ, Levin LS. J Reconstr Microsurg.

2021;37(1):42-50.

The orthoplastic approach is defined by a collaborative approach to limb salvage by orthopaedic and plastic surgeons working in concert. In this surgical approach, both teams work together closely during preoperative planning, intraoperative decisionmaking and in the postoperative setting. The guiding principles of management include restoring adequate blood flow, skeletal fixation and soft-tissue reconstruction. Expediting care of these patients with standardized protocols has been shown to improve outcomes. A set of guidelines has been developed to assist with decision-making for transfers to specialized centers. In patients at risk of amputation, this multidisciplinary approach has the potential to increase the rate of successful salvage. | Dr. Shafarenko is PGY-4, and Dr. Murphy is an assistant professor, in the Division of Plastic and Reconstructive Surgery at the University of Toronto.

Plastic Surgery Resident | Spring 2023

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PLASTIC SURGERY PERSPECTIVES

HAND 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 of the series featuring leaders in hand surgery, Dr. Brown interviews L. Scott Levin, MD. – Rod J. Rohrich, MD, Editor Emeritus, Plastic and Reconstructive Surgery

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

L. Scott Levin, MD Chair, Department of Orthopaedic Surgery, Co-Director, Penn Nerve Center, Paul B. Magnuson Professor of Bone and Joint Surgery, Professor of Plastic Surgery at UPenn

PSR: WHY DID YOU CHOOSE PLASTIC SURGERY AND HAND SURGERY IN PARTICULAR? Dr. Levin: My exposure to hand microsurgery started when I was an undergraduate at Duke, pushing patients around and mopping floors. That’s where I saw some of the first cases of replantation. I first started my career training in general and thoracic surgery – and two years of general thoracic were required as a prerequisite in the early 1980s before you could even enter into orthopedic training. During that time, I became very enamored with vascular surgery. It was clear that if I was going to master surgery of the upper extremity, microsurgical skills would be essential. I figured that if I really wanted to know about soft tissue, I had to become a plastic surgeon. I had an opportunity to work with Harry Buncke, MD, and decided I would extend my training for three years, which included a hand fellowship in Louisville with Harold Kleinert, MD, and Joe Kutz, MD, along with other luminaries such as Rob Acland, MBBS. I came back to Duke to finish my plastic surgery training, heavily influenced by late William Barwick, MD, and Chris Peterson, MD. All these factors were instrumental in my evolution as a clinician and educator.

PSR: HOW HAS HAND SURGERY CHANGES SINCE YOU STARTED? Dr. Levin: One of the main things – which is an area of concern – is that we are going backward in our enthusiasm and passion for hand surgery and microsurgery, which could be related to reimbursement. There are only a few people in the United States doing consummate, trauma hand surgery who truly have the concepts needed to keep up with other places in the world. I’m concerned that we aren’t training people like a Neil Jones, MD, or Joe Upton, MD, at the rate necessary to service the needs of our population. We certainly have turned our back on a number of areas that our colleagues around the world do effectively and with great results.

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Another thing is that the concept of super microsurgery needs to find its place, particularly in the extremities. Despite outstanding work by people such as Joseph Dayan, MD, and David Chang, MD, the adaptation of lymphovenous anastomosis is something that I think needs to continue to evolve – specifically for the upper extremity and the hand surgeon. That is an area only plastic surgeons who perform a lot of microsurgery will become interested in, and it should find its place in our educational programs.

PSR: IS THERE A PARTICULAR CLINICAL CASE THAT INFLUENCED YOU? Dr. Levin: The first vascularized composite allotransplantation (VCA) we did absolutely convinced me that this is the future – and we’ve done subsequent work in vascularized joint and vascularized bone transfer in the lab. I’m absolutely convinced that once we crack the barriers – not only insurance and funding, but also those related to immunosuppression – this will become, as Joe Murray said, the “Nobel Prize winner.” The new field of restorative surgery for hands, faces, penis and abdominal wall is exciting. We’ve even started a uterus transplant program here at Penn. Steve Kovach, MD, one of my partners here, is an exquisitely talented microsurgeon, and I’ve helped those who work on infertility here get a program up and running that has now seen three or four babies born to women who’ve had uterus transplantation. It comes down to VCA, a vascular anastomosis, immunosuppression and teamwork. Plastic surgeons have always been the innovators within medicine. We go beyond what’s thought of as conventional.

If we really look down the road, the idea of seeing xenotransplantation, robotic surgery, regenerative peripheral nerve interfaces, osseointegration – all of those new areas will continue to find their place in plastic surgeons’ armamentarium.

The world is our oyster and we’re only limited by our imagination and our grit. As Angela Duckworth, a psychology professor at Penn, who wrote the book Grit, says: It takes grit to go from identifying a problem to solving it. If we have grit, imagination, determination, a strong work ethic and teamwork, we will continue to make great advances.

PSR: WHAT DO YOU LOOK FOR IN A HAND SURGERY FELLOW? Dr. Levin: I’ve trained general surgeons, orthopedic surgeons and plastic surgeons as hand Fellows for almost 33 years. A Fellow has to come with good, fundamental knowledge and passion for the field. I don’t think you can perform the full range of hand surgery if you’re not doing microsurgery. Hand surgery has no specialty boundary, so the ideal hand surgery Fellow is passionate and wants to contribute new knowledge through academic work. The ability to get along with others is important, since surgery is a team sport. The most important thing is the strong work ethic. William Osler, MD, who was the chair of medicine at Penn, wrote that the key to success is surgery comes down to two words: “Hard work.” |

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF HAND SURGERY? Dr. Levin: The idea of robotic microsurgery is exciting. By way of disclosure, I consult for a company called MMI, which has key opinion leaders from around the world who agree that this area has tremendous promise for the future. Plastic surgeons are also leaders in this area, as we continue to reinvent ourselves and think outside the box. All of us should continue to have imagination and, rather than say, “It can't be done,” we need to ask: “How do we do it?” I started my internship 41 years ago. What’s plastic surgery or hand surgery going to look like 41 years from now? The problems that were thought to be intractable 41 years ago we solve routinely now with a variety of techniques – bone substitutes, microsurgery, tissue engineering, microneural surgery, brachial plexus, you name it. A lot of what we have now didn’t exist 41 years ago, so just imagine 41 years from now. Hopefully somebody will read this interview someday and say, “What that guy was talking about is so archaic. Taking tissue from one part of the body and moving it?”

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Hidden gem of the North

Aesthetic fellowships in Sweden – comparisons and contrasts

By Daniel De Luna Gallardo, MD “Just follow the KISS principle – Keep it simple and safe.”

Charles Randquist, MD VictoriaKliniken, Sweden, Plastic Surgeon Daniel De Luna Gallardo, MD Plastic surgery is one of the world’s most competitive medical specialties. From its application in different specialty programs, outstanding results are required throughout the different evaluations of practicing plastic surgery – and the journey continues throughout one’s career. The requirement of each program highlights the importance of comprehensive training for residents in all scenarios.

The vast majority of training centers tend to concentrate resources on the needs of each medical institution, where reconstructive procedures tend to dominate. As a result, this can limit practice in aesthetic procedures, which yields a challenge for programs in providing quality exposure during residency – similar to other subspecialties such as oncologic reconstruction, pediatric plastic surgery, microsurgery, and craniofacial and hand surgery.

The solution to this educational gap lies in fellowships. These programs promote education to increase levels of proficiency in the aesthetic field, allowing residents to immerse themselves in a more-focused approach and preparing them for the challenges and demands ahead.

Leaving the comfort zone Plastic surgery residents typically pursue aesthetic fellowships within their own country – or at least on the same continent (e.g., Americans within North America, Europeans within Europe, etc.), which creates homogeneity and training centered on similar ideology and vision. After venturing out of my comfort zone and progressing through several interviews and demanding processes, I was accepted into an aesthetic fellowship at VictoriaKliniken in Stockholm, Sweden, led by Charles Randquist, MD, PhD, Jessica Gahm, MD, PhD, and Marie Jaeger, MD, PhD, which sparked a 360-degree turn in my own training as a resident.

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During this three-month experience (with an option of six months’ duration), I was exposed to countless procedures that encompass a variety of fields, including facial surgery (rhinoplasty, blepharoplasty, face and neck lift), primary and secondary breast surgery, body contouring and hair transplantation. I also received training in minimally invasive aesthetic procedures such as botulinum toxin and fillers.

In the aesthetic surgery environment, all patients expect optimal results in their outcomes; to get there as a plastic surgery resident, the following are the pearls I learned along the way.

A place for the plastic surgeon The patient experience with a plastic surgeon begins with the first step inside the clinic. “Patient satisfaction does not only depend on the post-surgical result; it is all about the journey.” Every detail of this step is a direct reflection of the surgeon’s personality, care, mission and vision. The staff should make the patient feel comfortable, inspiring peace and confidence from all senses – smell via natural flowers and relaxing aromas, sight via neutral colors and clean corners, taste through freshly prepared coffee or tea and chocolate, sound via calm music, and so forth. The patient should intrinsically feel that they’re in an environment that prioritizes their safety and comfort.

First consultation and patient education The first consultation is the first step for a successful procedure.

Punctuality and strong patient-doctor communication should always be the objective. Comprehensive communication forges a bond of trust and loyalty between the patient and surgeon. An exhaustive medical history must be sought, as well as taking the time to understand the patient’s motivations, desires and expectations.

The doctor-patient dialogue must establish clear goals, limitations for each patient and individualized risk assessment while prioritizing patient safety.

Easy access to online information and the prevalence of social media often create unrealistic expectations and deliver misinformation for prospective patients. All doubts, concerns and post-surgical complications must be clarified and explained beforehand and in detail, through numbers and specific percentages.

Physical examination and anthropometric assessment The simple act of removing clothing puts the patient in a vulnerable position. The conditions and the physical space in which the physical examination is carried out must afford the patient privacy in a respectful environment that limits discomfort.

For plastic surgery residents, the experience can play a counterproductive role, so all physical examination and anthropometric measurement processes must be deployed through standardized and validated tools. This will diminish bias in patient selection, establish the characteristics of each patient and allow the evaluation of therapeutic options and limitations on an individual basis.

Preoperative planning A detailed and comprehensive surgical plan, including a checklist of equipment and material required during surgery, are crucial steps in any aesthetic procedure. A correct anamnesis, judicious measurement of physical anthropometry and pursual of results that maintain harmony in the patient’s proportions should always be a priority.

The day of surgery: the five P’s Up to 99 percent of the success of surgery is determined by the five “P’s” of best practice principles: patient selection, preoperative planning, proportional thinking, performance, and postoperative care with long-term follow-up.

One of the most marked differences in the European vision is the long-term, post-surgical follow-up period. After initial, early and regular follow-ups, the common long-range period for American plastic surgery is a one-year – or two-year, at the most – follow-up after the procedure. One of the great teachings I picked up in Europe is to follow our patients even up to 10 years, as it allows us to know the durability and validity of our techniques and results in a more complete way.

Measure and judge your results constantly This long-term follow-up provides the necessary tools to make a complete judgment and evaluation of our own surgical techniques. Once again, the plastic surgery resident must promote their practice through standardized processes. If we don’t know our preoperative assessment in detail – or our surgical steps and postoperative care – we will not find the breakpoint to improve our results and patient satisfaction.

Opportunities and options Aesthetic surgery training is an integral part of becoming a plastic surgeon, and fellowships are key to achieving this. Among the innumerable options for fellowships, the opportunities available in Europe add great value to our training, which focus on a scrub-in and hands-on experience that incorporates the resident throughout the entire journey.

I don’t have the space to adequately express my thanks to Drs. Randquist, Gahm and Jagaer for their warm welcome, exhaustive desire to teach and, above all, for making me feel like a member of their team and family. I am forever in their debt. | Dr. De Luna Gallardo is chief resident and PGY-4 at Hospital Central Sur de Alta Especialidad de Petróleos Mexicanos, México City.

The entire process and duration of the surgery must be constantly evaluated, and the resident must understand that there’s no room for improvisation during the transoperative period, as it can lead not only to post-surgical complications but also surgical failure as a result of poor planning and prolonged surgical times.

Plastic surgery residents are often bombarded with new papers that highlight innovative procedures and extraordinary results.

Just follow the “KISS” principle: “Keep it simple and safe.” Master the basic techniques, understand your surgical skills and limitations, and then progress to more complex procedures – all without ever compromising patient safety.

Postoperative care with long-term follow-up Residents also must understand postsurgical complications. No procedure should be underestimated in the aesthetic field, no matter how small or short it might be. Post-surgical assessment should focus on ruling-out complications associated with the procedure.

Prescriptions and indications at the point of hospital discharge must be clear and precise. The patient must understand what he or she can and cannot do. At this point, doctor-patient communication is again crucial.

Dr. De Luna Gallardo (left); Jessica Gahm, MD, PhD, attending physician at the VictoriaKliniken Plastic Surgery Training Academy; VictoriaKliniken attending physicians Charles Randquist, MD, PhD, and Marie Jaeger, MD, PhD; and Slovenian plastic surgery Fellow Nevio Medved, MD; rest between cases at the Stockholm-based academy.

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MESSAGE TO PLASTIC SURGERY TRAINING PROGRAM DIRECTORS AND COORDINATORS

By Winnie Tong, MD ASPS Membership Committee Chair

ASPS leadership is encouraging plastic surgery training program directors and coordinators to take advantage of ASPS resources and enroll their residents in the ASPS Residents and Fellows Forum (RFF) as they plan for the upcoming academic year.

The RFF offers numerous benefits, including subscriptions to the journal Plastic and Reconstructive Surgery and Plastic Surgery News; discounted admission to Plastic Surgery The Meeting; and access to the online ASPS Education Network.

The cost to enroll a resident in the ASPS Residents and Fellows Forum is only $100 per year, and you can easily complete your enrollments online: • Log-in to your account on plasticsurgery.org • From “QUICK LINKS” on your dashboard, select “Resident/Fellows Program” The Society encourages directors and coordinators while enrolling new residents to please make any relevant updates to your institution’s training program director, coordinator and existing resident records. Please be sure to populate the date of birth for all residents, as this information is used as part of their login credentials for the ASPS In-Service Exam.

Should you have any questions, please contact the ASPS Member Services Center at 847-228-9900 or 1-800-766-4955 from 8:30 a.m.-5 p.m. (CT), Monday through Friday. You may also email the Center at membership@plasticsurgery.org.

We look forward to your enrollment and a successful academic year. Thank you for your ongoing commitment to educating the specialty’s future leaders. |

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MESSAGE FROM THE RESIDENTS COUNCIL CHAIR

By Olivia Abbate Ford, MD As spring passes and summer approaches, I wanted to share the latest updates with you from the ASPS Residents Council.

• Our Residents Council Report project has launched and we’re actively looking for residents from all PGY years and programs to volunteer to participate in our anonymous survey. If you’re interested in a chance to impact residency now and for future generations, please reach out via email to participate. The goal of this project is to provide a foundational compilation of achievements and deficiencies in current plastic and reconstructive surgery training programs, which can serve as a reference for identifying areas for improvement.

Olivia Abbate Ford, MD

• The program closure group is working on publishing a paper that was also presented at the ACAPS winter meeting regarding the experience of displaced residents from two programs last year. The manuscript should be in its final stages of revision and submitted soon. Additionally, we’ll attempt to write another manuscript to give more of a roadmap to residents should such closures happen again. We’re hoping to work both with the RRC and ACAPS to provide the best information.

• The Society’s Professional Resource Opportunities in Plastic and Reconstructive Surgery Education and Leadership (PROPEL) mentorship program is actively recruiting for another year of membership. We’ve had several successful virtual meetups between all mentors and mentees this year.

• Save the date! Medical Students Day will take place virtually on Saturday, Sept. 23.

Please reach out if you’re interested in participating. | Thank you – and I look forward to hearing from and working with all of you!

Dr. Abbate Ford is PGY-5 in the Harvard Mass General Brigham Integrated Plastic Surgery Program.

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COMPLEX CASE CHALLENGE

The Fall issue of Plastic Surgery Resident contained Part I of the Complex Case Challenge, where readers were asked to study the summary of an injury and then decide upon the correct course of action. The summary is provided below, followed by the surgical approach to the problem and how it led to the case’s successful completion. For this case, we thank Ava Chappell, MD; Jennifer Bai, MD; and Gregory Dumanian, MD, of Northwestern University. How did you fare?

CASE INTRODUCTION: COMPLEX ABDOMINAL WOUND 19 y/o M with a history crush injury between two garbage trucks with resultant splenic and colon injury, multiple rib fractures, left lung injury, open and unstable pelvic fracture and extensive full-thickness soft-tissue loss of the left flank region from the semilunar line to the posterior axillary line, with only the peritoneal lining intact containing the abdominal wall viscera and left femoral nerve avulsion injury (see clinical photos and radiology studies below).

PREOPERATIVE IMAGING

F

D

PREOPERATIVE CLINICAL PHOTOS

E G

A

B

A) Anterior Trunk B) Oblique Trunk C) Lateral Trunk D) X-ray AP, Supine in Traction E) CT Abdomen, Pelvis Axial

F) Sagital G) Coronal

The patient underwent primary trauma management with splenectomy, colonic repair, rib plating and chest tube placement by the trauma surgery team, followed by stabilization of his pelvic injuries by orthopedics. His soft-tissue injury was managed with irrigating wound VAC therapy and serial debridements until his wound was deemed stable for definitive wound closure. In the Fall 2022 issue, we presented this case to two abdominalwall reconstruction experts in Jeffrey Janis, MD, and Donald Baumann, MD, who provided their own perspectives to this case:

C

If you have a complex case that you would like to feature, please email PSR Medical Editor Russell Ettinger at retting@uw.edu.

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COMPLEX CASE SOLUTIONS The perspective of Donald Baumann, MD

The perspective of Jeffrey Janis, MD I would make sure we had culturenegative debridement before proceeding; once accomplished, I would get a pre-op CT angiogram to confirm patency to the descending branch of lateral femoral circumflex artery, given the extent of the crush injury.

Then, I would do a reverse Gillies maneuver to see if a pedicled ALT – or, better yet, a subtotal thigh flap – would work. (It may be hard to reach the superior aspect without a subsartorial transposition or, even so, you may need a possible free flap.)

The flap would definitely require back-grafting to the donor site, given the size. I’d use incisional NPWT around the incision while still being able to visualize and monitor the flap.

The surgeon could use biologic mesh in-between the viscera and the flap, though that will certainly bulge over time – and I don’t think it would add much to the result besides cost. I wouldn’t put synthetic mesh into a wound like that at the index operation, however, for fear of risk of mesh infection.

I would separate the abdominal problem from the rest of the problem. First, I would address the abdomen by closing-off the belly with a biologic mesh. It’s unlikely he will herniate because the degree of inflammation to the viscera is similar to a radiated patient, so everything should be sucked in. However, if he does end up herniating, I would come back in delayed fashion to perform an innervated free latissimus.

With this in mind, I would tag any intercostal nerves at the initial stage, in case we need to come back for that.

Next, I would consider the status of the femoral nerve. If it’s not reconstructable, then I would do a pedicled left thighbased flap for skin closure of the abdomen. If the femoral nerve is reconstructable, then I would stay away from the left thigh as a donor site and use the right thigh donor site as a free flap. The options for recipient vessels – depending, of course, on CT studies – would be something from the femoral system with or without an AV loop.

In summary, I would compartmentalize things: Close off the belly, then vac until ready for next operation. Next, consider whether he may have femoral nerve recovery. Next, come back for skin closure with regional versus free thigh-based flap – or possibly innervated latissimus flap.

FINAL RECONSTRUCTION

INSET-SPECIFIC DETAILS

Final surgical plan one week after wound vac therapy, two washouts in the O.R. and placement of antibiotic beads was for either a pedicled or free subtotal thigh flap to cover the defect and stabilize the abdominal wall.

The vastus lateralis was used to cover pelvic bone, with fascia lata sewn to external oblique muscle and fascia. Distal femoral nerve was identified and planned to coapt end to side to obturator nerve at later time, as due to positioning we could not find the obturator nerve or motor nerve to adductor magnus. The donor site was temporarily managed with roman sandal technique and wet dressing for eventual stsg.

A flap 30cm long by 18cm wide that included vastus lateralis muscle (left muscle over femur) and TFL was designed. After full dissection of flap and lateral femoral circumflex artery with perforator to TFL, we were still short by 8 cm and had to convert to free flap. We dissected-out left common femoral artery and the left saphenous vein. Left saphenous vein was used as vein grafts to both artery and vein for anastomoses via an AV loop.

Microsurgical specific details: A turn-up saphenous vein graft sewn end-to-side to the common femoral artery with 7-0 prolene, then the AV loop was divided to sew end-to-end to lateral femoral circumflex artery (pedicle) with 8-0 prolene and sew end-to-end to flap vein.

Four days later, he underwent stsg to the donor site and transfer of the left femoral nerve to motor nerves of the adductor magnus and the gracilis.

FOLLOWUP The patient was last seen in plastic surgery clinic and orthopedic clinic roughly six months after surgery. He does still lack active knee extension and has grade 2/5 strength in his hip abductors.

However, he’s just needing one crutch to ambulate, and all wounds are healed. |

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COMPLEX CASE CHALLENGE/ continued from previous page

Medial incision along axis of ASIS to superior-lateral patella, perforators to skin “Dopplered” to ensure its capture with elevation of flap.

Five days postoperative, initial free flap with stsg to donor site

Six months postoperative

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Immediately postoperative

PSTM23 CORNER

NOW’S THE TIME TO PLAN

P

lastic Surgery The Meeting is approaching – perhaps more quickly than we realize. With that in mind, now’s the time to begin thinking – and planning – on what to do, when and how to do it while PSTM23 is being held Oct. 26-29 in Austin, Texas. One opportunity and one chance to become champions before an adoring throng at the Austin Convention Center are highlighted here.

Residents Bowl • Applications for teams to sign up will open in June (all team members must be resident subscribers of ASPS and registered for PSTM) • The Residents Bowl will be held Friday, Oct. 27, through Sunday, Oct. 29

ASPS/PSF Resident Travel Scholarship for PSTM23 • Application period opens in May • Training Program Directors may nominate one resident per institution (Only residents in the first four clinical years of an integrated program or the first year of an independent program may be nominated; they also must be a resident subscriber of ASPS) • The recipients will be recognized at the Resident Networking Reception, slated to run from 6-7 p.m. Thursday, Oct. 26 at the Hilton Austin. |

SENIOR RESIDENTS CONFERENCE COMING OCT. 26 IN AUSTIN As trainees head toward the completion of their residency, they likely will have questions about topics not routinely covered in training. The annual Senior Residents Conference (SRC) is the unofficial kick-off to PSTM on Thursday, Oct. 26. SRC co-chairs have put together seven-and-a-half hours of pertinent information and opportunities for dialogue broken into small, palatable segments most relevant to the seasoned resident.

Our experienced faculty will provide their insight about the realities and rewards of these career choices. Attendees will hear straightforward advice on how to network, interview and land a job. Panelists also will talk candidly about mistakes they’ve made, things they wish they had known when they were a senior resident and barriers that exist in this market for surgeons who are building their first practice. More information can be found at plasticsurgerythemeeting.com/residents/senior-residents-conference. |

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BIA-ALCL and BIA-SCC “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

50 y/o female with history of breast augmentation 15 years ago with unknown type of implants presents with possible seroma of the left breast with no known trauma.

BREAST CAPSULE EVOLUTION

A breast-implant capsule is not inherently a cause of concern, as it’s the body’s natural reaction to any foreign body. Capsule formation begins immediately following placement of the implants, and when fully formed, contains three distinct layers. The inner layer consists of fibroblasts and macrophages; the intermediate layer is highly vascular due to loose connective tissue fibrils; and the outer layer is dense and also richly vascular.

The transformation of a breast-implant capsule from an expected reaction to a foreign body to something far more insidious isn’t completely understood. Evidence has shown that certain factors – including implant texture, radiation and infection – seem to predispose individuals to this unwanted capsular evolution. Although the vast majority of capsules are benign, there’s a subset that can eventually develop a seroma or mass. There has been increased awareness surrounding pathologies linked with breast-implant capsules – particularly BIA-ALCL, and more recently, BIA-SCC. Although it’s important to remain vigilant with regard to malignant etiologies, benign pathologies remain statistically more likely.

Once a patient passes the one-year mark after implant placement, the development of a seroma is considered “late.” Most late seromas are associated with textured implants. It’s important to note that while any patient who presents with a late seroma and textured

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implants should be a double-red-flag for BIA-ALCL, the likelihood of malignancy is exceedingly low. In fact, it’s been reported that only 9 percent of late seromas in breast-implant patients were shown to be BIA-ALCL. Any late seroma or mass noted in a patient with breast implants should be thoroughly evaluated and the proper workup should be performed. This article reviews several high-yield points regarding BIA-ALCL, BIA-SCC, capsular epithelialization, late hematoma and double capsule.

BIA-ALCL (fig. 1)

Presentation: Sudden-onset unilateral breast swelling, typically seen approximately 10 years after placement of implants. BIA-ALCL is primarily associated with textured implants; the FDA states that all confirmed cases worldwide either have a history of a textured device or an incomplete clinical history available for review.

Diagnosis: Patients should undergo US/MRI with needle aspiration of any effusion or FNA for a capsular mass. Considered positive if flow cytometry and immunohistochemistry are positive for CD30 and ALK negative.

Management: For extracapsular disease, the patient should undergo complete capsulectomy and excision of the mass, if possible. Additionally, they should be referred to hematology for potential adjuvant chemotherapy or radiotherapy. However, if the disease is solely found in the capsule, the patient can undergo a complete capsulectomy and implant removal.

BIA- SCC

BIA- ALCL

What is it?

Epithelial based tumor

T cell lymphoma

Pathology

Sheets of squamous cells lining the capsule in nests and bundles

Lymphoma with mass confined to single area

Potentially

Potentially

Time since implantation?

Avg 22.74 years

Avg 10.32 years

Implant type

Smooth or textured

Textured

Invasive?

Flow cytometry

Markers

Positive for squamous cells and keratin

C5/6+, p63+

CD30+, ALK negative

Mortality

Unknown*

2.8% at 1 year

Chemo/XRT

No response

Brentuximab plus CT

80% at presentation

28% at presentation

Extracapsular spread

* 43.8% at 6 months based on limited cases in literature

FIG. 1

Patient after breast reconstruction with breast implant (top left). Breast implant capsule shown on MRI (top right). BIA ALCL cells shown under magnification (left). The neoplastic cells show strong and diffuse immunoreactivity CD30. En bloc capsulectomy is shown (middle right). Plast Reconstr Surg150(5):970e987e. Nov 2022.

BIA-SCC (fig. 2)

Presentation: Unilateral breast pain and enlargement that can be associated with axillary lymphadenopathy. A rare diagnosis seen in patients with implants for more than 15 years. Current thinking is that the evolution of disease parallels that of a Marjolin ulcer.

Diagnosis: Breast ultrasound with FNA of fluid which should be sent for tissue markers CK5/6 and p63 with flow cytometry for squamous cells and keratin. MRI should also be ordered to evaluate for capsular involvement or mass. In cases where a mass is found, biopsy should be performed. High risk for locoregional metastasis if the tumor becomes extracapsular. If disease is confirmed, a PET-CT should be considered prior to surgical intervention.

Management: In cases with risk of metastasis, management should be deferred to surgical oncology and include explantation and en bloc capsulectomy. Patients should also receive adjuvant chemotherapy and radiation therapy.

Positive for T cells

FIG. 2

Preoperative CT scan of the chest (top).

A 48F patient with history of bilateral breast augmentation with the development of SCC of the right breast implant capsule (center); patient subsequently underwent chemotherapy, radical mastectomy and full thickness chest-wall reconstruction with mesh (bottom).

Plast Reconstr Surg151(1):20e-30e, Jan 2023.

SYNOVIAL METAPLASIA

Presentation: Seroma or unilateral breast swelling. It’s a benign condition that doesn’t appear to be associated with a particular implant texture or fill. There’s an increasing prevalence leading up to the first five years postoperatively, after which there’s a decreasing prevalence noted.

Diagnosis: Typically, an incidental finding on pathology. Occurs secondary to microtrauma from the implant moving within the capsule, which leads to an attempt at repair by developing a synovial lining which resembles that of an articular joint. When the capsule is entered, viscous, cellular fluid is encountered due to the inner layer of cells that display secretory properties. There is a void in definitive diagnostic imaging; however, it can show capsular thickening in conjunction with peri-implant fluid.

Management: Capsulectomy with or without implant exchange.

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CONSULT CORNER / continued from previous page FIG. 3 LATE HEMATOMA

Presentation: Unilateral swelling of the breast that’s typically chronic and progressive but can present acutely. Various etiologies have been reported, including inciting trauma, erosion of capsular artery and inflammation.

Diagnosis: CT or MRI can be used to localize fluid of the breast.

The fluid should be aspirated and sent for cytology and pathologic examination.

Management: Evacuation of hematoma and capsulectomy.

DOUBLE CAPSULE (fig. 3)

Presentation: Unilateral breast swelling that’s usually associated with a more chronic onset and is seen in patients with textured implants.

Exact etiology has not been elucidated but is thought to be multifactorial – mechanical and infectious.

Diagnosis: Intraoperatively, the surgeon will note an adherent capsule to the implant, as well as residual capsule in the breast pocket.

Management: Capsulectomy and implant exchange.

REPORTING The FDA notes that healthcare providers can submit case reports of BIA-ALCL, SCC, various lymphomas and any other cancers in the capsule around breast implants to the PROFILE Registry (thepsf.org/profile), a collaborative effort between ASPS, The PSF and FDA. The FDA reviews data from the PROFILE registry on an ongoing basis. The FDA also continues to recommend that physicians also report all cases of SCC, various lymphomas, BIA-ALCL and any other cancers in the capsule around the breast implant to the FDA directly.

TAKEAWAYS The disease pathologies listed above are not comprehensive, but they are of utmost importance to the plastic surgeon. With increased recognition and screening, we may be able to elucidate the etiology of these late seromas.

Whenever a patient presents with an implant in conjunction with breast pain or edema, remember to adhere to the basic principles of your physical exam and include a thorough lymph-node exam, as well. Adhering to the NCCN screening guidelines will also provide a pathway to diagnosis for many capsular abnormalities. The table on page 33 is a summary that highlights the key differences between BIA-SCC versus BIA-ALCL. | Dr. Mehta is PGY-4 at the University of Las Vegas.

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Inner capsule of a patient with a double capsule.

REFERENCES Plast Reconstr Surg. 151(1):p 20e-30e, Jan 2023.

Buchanan PJ, Chopra VK, Walker KL, Rudolph R, Greco RJ. Primary squamous cell carcinoma arising from a breast implant capsule: A case report and review of the literature. Aesthet Surg J. 2018 Jun 13;38(7).

Cordeiro PG, Ghione P, Ni A, et al. Risk of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) in a cohort of 3546 women prospectively followed long-term after reconstruction with textured breast implants. J Plast Reconstr Aesthet Surg. 2020;73:841–846.

Goldberg MT, Llaneras J, Willson TD, Boyd JB, Venegas RJ, Dauphine C, Kalantari BN. Squamous cell carcinoma arising in breast implant capsules. Ann Plast Surg. 2021 Mar 1;86(3):268-272.

Olsen DL, Keeney GL, Chen B, Visscher DW, Carter JM. Breast implant capsule-associated squamous cell carcinoma: A report of two cases. Hum Pathol. 2017 Sep;67:94-100.

Kitchen SB, Paletta CE, Shehadi SI, Bauer WC. Epithelialization of the lining of a breast implant capsule. Possible origins of squamous cell carcinoma associated with a breast implant capsule. Cancer. 1994 Mar 1;73(5):1449-52.

Liu Z, Liu, C, Chengglong, Z, Yu, Q, Zhang G, Wang X, Yu Z. Breast prosthetic implant-associated squamous cell carcinoma: A case report and literature review.

Research Square. 2021 Jan. Paletta C, Paletta FX Jr, Paletta FX Sr. Squamous cell carcinoma following breast augmentation. Ann Plast Surg. 1992 Nov;29(5):425-9; discussion 429-32.

Satgunaseelan L, Cheung D, Reddy, J. Breast implant-associated squamous cell carcinoma – a rare long-term complication. Pathology. Volume 47, Supp 1, S72-S73, 1 Jan 2015.

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How to prepare for board certification

D

iscipline, dedication and determination are all attributes required to successfully complete any examination. However, these characteristics play an especially critical role for candidates preparing to take the American Board of Plastic Surgery (ABPS) certification exams.

With the board’s mission “to promote safe, ethical, efficacious plastic surgery to the public by maintaining high standards for the education, examination, certification and continuous certification of plastic surgeons as specialists and subspecialists” as its guide, the administration of the annual written and oral examinations is a primary way by which to heed this charge. This year, the written examination took place May 9, and the oral exam will be held in Phoenix Nov. 9-11.

Candidates for the oral examination are required to submit all cases performed during a nine-month practice period.

To be eligible for the ABPS Oral Exam, candidates must reach a minimum of 50 major operative cases. The case list must also have sufficient diversity and complexity to allow for adequate evaluation of the candidate’s knowledge and skills. The candidate will be examined on five cases, selected by the Oral Exam Committee, during the Case Book session of the November exam. In addition to the Case Book session, candidates will also be examined on theory and practice cases created by the ABPS Oral Exam Committee.

Young plastic surgeons are encouraged to approach the case report materials and submission process with urgency and due diligence.

The executive director’s recommendations

ABPS Executive Director Keith Brandt, MD, St. Louis, offers the following recommendations: • Case Book preparation affects a candidate’s success on the exam, so prepare them carefully.

Examiners use the case books to evaluate your ability to practice safely.

• Be selective. The board set a limit to the number of hospital and medical records that can be uploaded, so include only the most-relevant documentation. If additional materials are needed by the exam team, the board will request specific documents to be submitted by the candidate.

• Everyone makes mistakes. Don’t try to cover them up – instead, demonstrate to the examiners what you learned from the experience.

• Take professional medical photos. Selfies are not appropriate or acceptable.

• Starting in 2023, intraoperative photos will be required.

• The ABPS will review your billing practices. Understand the reason every CPT code was submitted and be prepared to explain the rationale.

Prep courses are available

Preparing for the oral board exam can be stressful, overwhelming and isolating, but support is available. To help, the ASPS has created the Oral Board Preparation Course. Residents are encouraged to register for the 2023 ASPS Oral Board Preparation Course, hosted virtually Sept. 7-9. Registrants may also sign up for an oral exam simulation session slated for Sept. 8-9, which have been highly rated by previous participants.

This interactive and comprehensive prep course employs more than 100 plastic surgery cases to provide a thorough overview of plastic surgery principles and management problems. With a focus on oral exam preparation, the course faculty will guide participants through critical criteria applicable for examination and demonstrate an efficient format for the delivery of high-yield responses to clinical questions. | Editor's Note: The ABPS does not endorse any specific review course.

Register by visiting plasticsurgery.org/BoardPrep, by calling (800) 766-4955 or (847) 228-9900, or by sending email to registration@plasticsurgery.org.

Plastic Surgery Resident | Spring 2023

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Connect. Collaborate.

Transform.

Oct. 26 - 29, 2023 Austin Convention Center • Four Days of Programming designed for your entire practice • Hands-On Sessions with expert faculty • Access to On-Demand content ahead of the in-person meeting • Access to Recorded Sessions following the meeting • Social Events and Networking, and so much more!

REGISTER NOW!

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