Plastic Surgery Resident, Summer 2021

From the publishers of Plastic Surgery News

ISSUE 23 | SUMMER 2021

Sharpening the fighting edge Military plastic surgeons discuss their unique training pathways – and transformative recon cases page 4

» Life after residency

» Here comes your board exam

Experienced plastic surgeons offer tips on choosing a practice model page 26

ABPS executive director counsels on how to approach the Oral Exam like a pro page 32

IN THIS ISSUE » What I know now that I wish I knew then: Military Edition p. 9 » InService Insights: Hand, upper-extremity p. 16 » Program Peek: Vanderbilt University p. 18

A note from the editor

W

elcome to the Summer 2021 issue of Plastic Surgery Resident.

For our cover article this issue, PSR is extremely honored to feature residents and faculty who serve in the U.S. Armed Forces and share their journey through military and medical training in various branches of the Department of Defense. We’re extremely fortunate to share with you their insight – and we’re immeasurably thankful for their service.

Sanjay Naran, MD

This issue’s Program Peek focuses on training at Vanderbilt University’s Department of Plastic Surgery, while our Faculty Focus shines light on Department Chairman Galen Perdikis, MD, and program resident Kianna Jackson, MD, highlights many of the “The Music City” attractions in Nashville.

Chief Medical Editor

Plastic Surgery Resident Chicago

We also bring you Part II of the roundtable featuring Dallas Buchanan, MD; Troy Pittman, MD; and Eric Payne, MD; who tackle “Life after Residency.” Our recurring columns in this issue feature hand and upper-extremity injuries; auricular trauma; and migraine surgery.

From the publishers of Plastic Surgery News

ISSUE 21 | WINTER 2020

» Centennial

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

» Residents Bowl 2020: Two views, one victory

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

Figuring out your finances A primer for residents to set them on a path of financial security page 4 IN THIS ISSUE » Consult Corner: Orbital floor fracture p. 11 » Program Peek: Cleveland Clinic Department of Plastic Surgery p. 17 » What I know now that I wish I knew then: International Edition p. 20

Finally, in time for PRIDE month, we’re excited to share with you the creation of the new ASPS PRIDE (Plastic and Reconstruction Inclusion Driving Equity) Forum. Its mission is to support a community of LGBTQIA+ physicians, medical students and allies who advance the field of plastic surgery through education, advocacy and partnership. I’m truly PROUD to be part of its inaugural Steering Committee, and we look forward to us fostering respect, equality and diversity across our specialty.

Thank you to all of our writers for their contributions. Thank you, our readers, and thanks to our team of editors and the ASPS production staff. We hope you enjoy the read!

Time to get your 2021 Residents Bowl teams together Submit your lineup for the 11th Annual ASPS Residents Bowl by Aug. 13 – one team per program. Each resident participant must be a member of the ASPS Residents and Fellows Forum, as well as registered to attend – either in person or virtually – PSTM21 in Atlanta, slated for Oct. 29-Nov. 1.

Contact Meghan Lyon at mlyon@plasticsurgery.org for additional information.

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Plastic Surgery Resident | Summer 2021

Table of

Contents ASPS and the military: Stepping up for the specialty ................................................ 4

Plastic Surgery Resident | Summer 2021 | Vol.5 No.2

What I Know Now: Military edition......................................................................... 9

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.

Consult Corner: Auricular trauma..................................................................... 12

A SPS PR ESI DEN T Joseph Losee, MD | Joseph.Losee@chp.edu

Six plastic surgeons who are U.S Armed Forces members talk about serving their country through support in peacetime and war.

U.S. Navy Capt. Ian L. Valerio, MD, MS, MBA, highlights the importance of passion, mentors and remaining open to new experiences.

A large, right ear laceration was sustained in a traffic accident; how do you evaluate and subsequently repair this wound?

InService Insights: Soft-tissue reconstruction.................................................... 16

Hand and upper-extremity soft-tissue defects comprise a common trauma consult – which make those a favorite In-Service Exam topic.

Program Peek: Vanderbilt University............................................................ 18 Begun in 1925 as a specialty division, the Department of Plastic Surgery boasts several national leaders and a renowned training program.

Message from the Director: Brian Drolet, MD.................................................................... 21 Vanderbilt’s shift to competency-based training will produce highly trained plastic surgeons fully ready to enter independent practice.

Faculty Focus: Galen Perdikis, MD................................................................ 22 The Department of Plastic Surgery chair reflects upon his entree into the specialty – and the impact of his Fellowship and mentors.

24 Hours In: Nashville.................................................................................. 24 From hot chicken to waterfalls to breakfast at Monell’s, “The Country Music Capital of the World” has something for everyone.

Life after residency, Part II: What’s sustainable – or advisable?.................................... 26

Veteran plastic surgeons discuss the process of setting prices in the market, and whether private aesthetic practices will remain viable.

Invigorating outreach: Striving for worldwide connections.................................... 31

EDITOR Sanjay Naran, MD | sanjaynaran@hotmail.com ASSOCI ATE EDITORS Russell Ettinger, MD | retting@uw.edu Kavitha Ranganathan, MD | kranganathan@bwh.harvard.edu J U NIOR ASSOCI ATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com SEN IOR R ESI DEN T EDI TOR Lisa Gfrerer, MD, PhD | lg frerer@partners.org R ESIDENT EDITORS Janak Parikh, MD | janak.parikh@gmail.com Matt Pontell, MD | matthew.e.pontell@vumc.org Elie Ramly, MD | elie.ramly@gmail.com I N T E R N AT I O N A L R E S I D E N T E D I T O R Konstantinos Gasteratos, MD | kgasteratos1@gmail.com E X EC U T I V E V ICE PR ESI DEN T Michael Costelloe | mcostelloe@plasticsurgery.org STAFF V ICE PR ESIDENT OF COMMU NICATIONS Mike Stokes | mstokes@plasticsurgery.org M A N AG I N G E D I T O R Paul Snyder | psnyder@plasticsurgery.org A S SI S TA N T M A N AGI NG E DI T OR Jim Leonardo | jleonardo@plasticsurgery.org

Resident Representative to the ASPS Board Lisa Gfrerer, MD, PhD, pledges her commitment to increased international collaboration.

A S S O C I AT E E D I T O R Kendra Y. Mims | kmims@plasticsurgery.org

ABPS in focus: Getting ready for the exams................................................ 32

GR A PHIC DESIGN ER Elena Bragg

From recommendations on case collection to advice from the ABPS executive director, we have what you may need to prepare.

New Society initiative: PRIDE Forum.......................................................................... 33 Arya Akhavan, MD, saw the need for an ASPS-backed effort for LGBTQIA+ support, and his efforts culminated in the PRIDE Forum.

Journal Club: Headache Surgery................................................................. 34 Find relevant anatomy, detection methods, surgical techniques and treatment modalities necessary for a deeper understanding and better management of migraine headaches.

Plastic Surgery Perspectives: Microsurgery.......................................................................... 36

This multiple-part series – which addresses microsurgery in a Q&A format – launches with David Song, MD, MBA, and Peter Neligan, MD.

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

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

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

ASPS Home Page: www.plasticsurgery.org

Plastic Surgery Resident | Summer 2021

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PLASTIC SURGERY AND THE MILITARY

Restoring form and function on the front line

By Matthew E. Pontell, MD Editor’s note: The views expressed are those of the author and contributing authors, and do not reflect official policy or position of the U.S. Air Force, Army, Navy, Department of Defense or U.S. government. The author is not a member of the United States military nor does he have any financial disclosures or conflicts of interest.

A

lthough the civilian sector produces the majority of plastic surgeons, another pathway into the field exists: the Medical Corps, a non-combat specialty section within each of the U.S. Army, Navy and Air Force – the three main branches of the U.S. Department of Defense.

began to see critically ill patients survive long enough for the management of more complex injuries. Continued advancements in field care and rapid evacuation during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) boosted the numbers of surviving personnel needing increasingly complex reconstruction in stateside military treatment facilities (MTFs).3

Plastic surgeons have a long history of providing surgical support to service members and their families. In combat operations, aid is rendered through a series of roles in the casualty-evacuation chain. Operational team members occupy Role 1 and deliver lifesaving first aid at the point of injury. Role 2 delivers focused, acute care for up to 72 hours post-injury and can be enhanced by a forward surgical team (FST), which is equipped to perform damage-control procedures and traditionally defer more definitive interventions for the higher echelons of care.

Role 3 is occupied by a combat support hospital with full surgical support, and Role 4 and 5 facilities are tertiary hospitals located outside (i.e., Landstuhl Regional Medical Center, Germany) or inside the United States (i.e., Walter Reed National Military Medical Center).1

Although warfare injury-related mortality is decreasing, combat injury patterns – particularly soft-tissue injuries to the head, neck and extremities3 – remain. Early plastic surgical consultation can help triage patients to limb salvage versus amputation, and a variety of reconstructive techniques, including free-tissue transfer, are now routinely employed.4 Decisions made by multidisciplinary limb-salvage teams closer to the point of injury can help maximize functional limb outcomes and can be conducted simultaneously with lifesaving decisions by other surgical teams. These decisions enlighten damagecontrol surgery during multiple casualty scenarios and emphasize the utility of having key decision-makers present in Role 2 and 3 positions.5

Plastic surgery's role evolved over time to meet the unique challenges of each conflict. In the American Civil War, surgical reconstruction occurred in the delayed setting – usually months after injury and removed from the front lines. Significant surgical advancements during World War I and II allowed for craniofacial and hand reconstruction to be performed closer to the point of injury.2 During the Korean and Vietnam wars, improvements in trauma care and casualty transport resulted in improved combat survival. Plastic surgeons

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Current trends in military medicine demonstrate a need for military plastic surgeons. Recent literature confirms that the proportion of reconstructive procedures in the military is increasing.5 Rapid assessment of limb salvage during damage-control surgery illustrates the need for plastic surgeons closer to the front lines, and decreased combat-related mortality rates also support the need for plastic surgeons on American soil.3,5 To better understand what it means to be a military plastic surgeon, we sought the insight of several plastic surgeons who served in the U.S. military at home and abroad.

Major Erik T. Criman, MD

Major Cody J. Phillips, DO

Cmdr. Yan T. Ortiz-Pomales, MD

U.S. Army Medical Corps

U.S. Army Medical Corps

U.S. Navy Medical Corps

Current Position Fellow, Department of Plastic Surgery Vanderbilt University Medical Center Nashville, Tenn.

Current Position Fellow, Department of Plastic Surgery Vanderbilt University Medical Center Nashville, Tenn.

Current Position Plastic Surgery Department Head CARE Program Director and Head of Education, Training and Research Associate Professor USHS Craniofacial Clinic Chairman Naval Medical Center, San Diego

Cmdr. Anand Kumar, MD

Capt. Ian L. Valerio, MD, MS, MBA

Lt. Col. Paul F. Hwang, MD

U.S. Navy Medical Corps

U.S. Navy Medical Corps

U.S. Army Medical Corps

Current Position Division of Plastic & Reconstructive Surgery Chief UH Cleveland Medical Center Division of Pediatric Plastic Surgery Chief UH Rainbow Babies and Children’s Hospital Cleveland

Current Position Visiting Associate Professor Division of Plastic & Reconstructive Surgery Massachusetts General Hospital, Boston

Current Position Division of Plastic Surgery Service Chief Walter Reed National Military Medical Center Bethesda, MD

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PLASTIC SURGERY AND THE MILITARY / continued from previous page PSR: WHY DID YOU DECIDE TO JOIN THE MILITARY? Dr. Phillips: There’s a strong desire to serve past and present service members (and their families) who protect our nation’s freedoms. Military medicine also offers unique practice opportunities that are often different from those in the civilian sector. Military physicians are trained in fields such as undersea, flight, tactical and wilderness medicine, which allows for participation in combat operations and global humanitarian aid missions. There’s also a desire to care for wounded warriors and treat the variety of complex injuries sustained during conflict. Military medicine provides early leadership opportunities within the Military Health System – such as commanding a forward surgical team or combat support hospitals, both of which are often in austere environments. Additional opportunities include serving in key hospital leadership roles and training the next generation of military physicians. Lastly, with the ever-growing cost of medical education, we’re afforded the peace of mind to train without the compounding medical school debt that looms at the end of civilian-sector training.

Dr. Kumar: As a first-generation, proud citizen of the United States, I joined the military to serve and protect our country, patients, institutions and professions. I joined because my core ethos is one of service – and also to learn about systems leadership and how to engage in leadership roles early in my career. I felt as if I could serve in and out of uniform by being a voice of support to young plastic surgeons considering joining, and to those considering leaving. A life of service doesn’t end when the uniform comes off. I wanted to learn how to walk headfirst into problems and take on the seemingly insurmountable while achieving great outcomes with, at times, only minimal resources. It’s about learning how to take ownership of a situation and becoming confident in the fact that failure does not occur on my watch – no service member or colleague will suffer due to my lack of energy, commitment or will.

PSR: CAN YOU DESCRIBE THE DYNAMIC BETWEEN ENTERING THE MILITARY AND APPLYING TO MEDICAL SCHOOL? Dr. Phillips: For most, the process begins at the start of medical school. Most active-duty physicians attended the Uniformed Services University (USU) School of Medicine or attended medical school in the United States or Puerto Rico through the Armed Forces Health Professions Scholarship Program (HPSP).

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The HPSP is offered by each of the three branches of the military to a variety of professional students across multiple disciplines such as medicine, dentistry, veterinary medicine, optometry, clinical psychology and nursing. After acceptance into an accredited medical school, candidates can apply through a local healthcare recruiting office. Those accepted to the HPSP are direct-commissioned as military officers into one of the respective military branches. HPSP scholarship recipients receive full tuition, fees and reimbursement for required books and equipment, in addition to a monthly living stipend throughout medical school. A signing bonus of $20,000 is also offered. In exchange for funding, a service duty “payback” obligation is incurred for the number of years of scholarship benefit or a threeyear minimum, whichever is greater.

Certain residency or Fellowship training programs can also acquire additional active-duty service obligations. All commissioned officers are required to graduate Officers Basic Leadership Course, which, for HPSP students, is usually offered during the summer months between medical school Year 1-2.

Throughout medical school, HPSP students are placed on inactive ready reserve (IRR) and cannot be called into service obligations until the completion of schooling.

PSR: HOW DOES STATUS AS A MILITARY PHYSICIAN AFFECT TRANSITION INTO RESIDENCY? Dr. Phillips: After medical school, HPSP students are trained in ACGME-certified military residency programs at various MFTs or deferred to civilian residency programs. In the military, candidates enroll in a match process similar to civilian training programs. During residency, one remains on active duty; however, the “payback” doesn’t begin until graduation from residency and involves working as an attending physician in an MTF; on deployment; or serving in one of the many unique job opportunities available to military physicians. Those unsure of whether they would like to commission may do so during residency via the Financial Assistance Program (FAP).

Board-certified physicians who complete their training can apply to be a Direct Commissioned Officer and begin service upon commissioning.

PSR: HOW DOES STATUS AS A MILITARY PHYSICIAN AFFECT THE COMPETITIVE EDGE AS A SUBSPECIALTY APPLICANT? Dr. Ortiz-Pomales: As a military physician, you feel welcomed most places you interview. In general, people understand that your background enabled you to handle seemingly insurmountable challenges in difficult settings; that you’re no stranger to a shortage of resource availability; and that you’ve had experience operating in stressful circumstances with

minimal support. Most PDs understand that you’re durable, adaptable and mature – and that most of your learning curves will be shortened compared with your peers.

In the independent pathway, general surgery residency training is extremely helpful for the military plastic surgeon and amplifies the breadth of procedures you’ll be able to perform after training.

To apply for a subspecialty surgical Fellowship, one must first enroll in the military match. Successful completion lets you enroll in the civilian subspecialty surgical matches. This equates to one round of military “vetting” prior to enrolling in the civilian subspecialty match and is the manner by which the military ensures that the best-of-the-best are ready for subspecialty surgical training and have the full support of the military. During subspecialty training, you’re protected from deployment to focus on education and only need to complete a physical readiness test.

PSR: WHAT EXPERIENCES HELPED PREPARE YOU FOR A PLASTIC SURGERY CAREER? Dr. Criman: After general surgery residency, I deployed to Afghanistan as a part of a forward surgical team to provide medical support for U.S. and partner forces in the region. We worked out of a tent, had no dedicated O.R. lights and no lab capabilities. Our radiology department consisted of the X-ray that was owned and operated by our bomb-disposal specialist, and the O.R. table was a stretcher. This necessitated a certain creativity with respect to surgical problems, which is one of the fundamentals of plastic surgery.

On one occasion, an adolescent child was brought to our outpost for treatment. He had a proximal third lower-leg soft tissue defect with exposed tibia from a remote blast injury. Knowing the child would have to walk four kilometers along mountain paths for follow-up care, we opted for the least-invasive option.

Using multiple, small relaxing incisions, we were able to close the wound primarily after debridement. The child healed well and without complication. The situation helped me begin to understand reconstructive concepts and left me with a deep appreciation for what I had yet to learn.

PSR: WHAT INFLUENCED YOUR DECISION TO PURSUE PLASTIC SURGERY? Dr. Hwang: Before I joined the Medical Corps, I attended the United States Military Academy at West Point. After initially deciding on a career in general surgery, I spent a significant amount of time after 9/11 taking care of people with whom I graduated from West Point as they returned from combat.

After a harrowing experience as a trauma and general surgeon, I decided to not only help people survive, but help them regain

as much form and function as possible. A career as a military plastic surgeon allowed me to offer my services in this regard.

PSR: HOW HAS MILITARY PLASTIC SURGERY COMPLEMENTED YOUR CAREER AS A CLEFT AND CRANIOFACIAL SURGEON? Dr. Kumar: Both jobs are similar in many ways – first and foremost, they center on a core ethos of service. In both jobs, I spend every day caring for the sick, disenfranchised and poor.

Developmental craniofacial abnormalities have been shown to disproportionately affect the indigent and least-resourced in society. Continuing to deliver state-of-the-art medical and surgical care to those who most need it is the epitome of military plastic surgery.

PSR: WHAT ARE SOME ADVANTAGES OF A CAREER AS A MILITARY PLASTIC SURGEON? Dr. Valerio: Serving as an active-duty member at Walter Reed during the height of war was a fortuitous experience.

It was a busy time that required a significant amount of reconstructive surgery. I had the opportunity to participate in reconstructive endeavors from head-to-toe and dealt with a variety of unusual combat injuries. Aside from the advantages of a remarkable reconstructive experience, the military allows you to remain in active duty or transition into academia. I elected to pursue academia but still had the opportunity to serve in the reserves, through which I remained engaged in post-warfare reconstruction, military missions and deployment in Afghanistan.

As a captain, I gained invaluable leadership and mentorship opportunities that were occasionally operational and occasionally plastic surgery-related. I served as team leader for COVIDrelated missions and oversaw military ICU groups. I continue to serve on missions inside and outside the continental United States, and often MTFs will call-out to reserves for additional plastic surgical assistance in the event of an increased number of deployed surgeons. This career also affords opportunities for special outreach missions across the globe, including serving on the USNS Comfort. Global outreach missions allow plastic surgeons to serve in medical leadership positions to combat global medical crises, such as the Ebola epidemic.

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PLASTIC SURGERY AND THE MILITARY / continued from previous page ASPS creates Military Plastic Surgeons Forum PSR: ARE FIELD SALVAGE IMPROVEMENTS CREATING ADVANCED RECONSTRUCTION OPPORTUNITIES? Dr. Kumar: The short answer is “yes.” As point-of-conflict care and rapid evacuation systems improve, we see more patients survive with complex wounds in dire need of restorative plastic surgery. This fosters timely advances in limb salvage surgery, targeted muscle innervation, regenerative peripheral nerve interfaces and advanced prosthetics.

PSR: HOW DO MILITARY PLASTIC SURGEONS MAINTAIN THEIR SKILLS DURING NON-CONFLICT TIMES? Dr. Kumar: Military plastic surgeons can collaborate with civilian plastic surgeons through partnerships that enable them to remain active. Plastic surgeons often rotate at regional academic centers to stay up-to-date on advancements in plastic surgery.

PSR: WHAT’S YOUR ADVICE TO SOMEONE CONSIDERING A CAREER AS A MILITARY PLASTIC SURGEON? Dr. Ortiz-Pomales: Be willing to be a “jack of all trades” and build a practice composed of many different niches.

I’m chairman of our craniofacial program and also run the only DOD transgender team. On deployment during the Venezuelan crisis in 2019, I performed more than 250 procedures – half of which were cleft lip and palate-related.

This career is an excellent choice for someone looking to be prepared for whatever comes their way.

Dr. Valerio: This a great career for exceptional professional and academic growth. Some of the greatest innovations in reconstructive surgery occurred during times in conflict. It’s also a great opportunity to give back through service – not only through the military. There are opportunities to serve families of the military, veterans and wounded warriors, and there are civilian-military collaboratives. It’s an especially rewarding opportunity for those also boarded in general surgery, as being dual-boarded maximizes one’s ability to help those in need.

Don’t join the military based on someone else’s experience, though. You need to assess the lay of the land, air and sea.

Different times have different tempos, goals and missions, and non-conflict time is very different than wartime.

Dr. Hwang: This career affords a great opportunity to perform the full spectrum of plastic surgery while developing specific interests. Plenty of opportunities exist to explore cuttingedge advancements in warfare-related reconstruction, and the military is grateful to have its members cared for.

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ASPS recently launched the Military Plastic Surgeons Forum (MPSF) to serve as a central hub in supporting plastic surgeons and other providers who, through education, advocacy and military-civilian partnerships, advance reconstructive surgery for military populations.

The MPSF structure allows members to network and engage on issues unique to military plastic surgeons and their patient populations. Login to plasticsurgery.org, click on "Medical Professionals" followed by "Community," then on the "Military Plastic Surgeons Forum" link.

PSR: WHAT DOES THE FUTURE HOLD FOR MILITARY PLASTIC SURGEONS? Dr. Kumar: It’s an exciting time for limb salvage and prosthetics. Free-tissue transfer, targeted muscle reinnervation and regenerative peripheral nerve interfaces changed the way we manage the traumatized limb. More than anything, we need to make sure we continue the service line. We need to encourage military plastic surgery careers as members transition back into civilian service. There’s a continuous need for service and reservists as the need for plastic surgeons continues to grow. During OIF in Iraq, casualty evacuation times from point of conflict to the continental United States were as fast as 72 hours. Decreased combat mortality means an increased need for reconstruction – and after all, there’s always surgical theatre.

IN CLOSING…

Military plastic surgeons are critical members of the plastic surgical community. Unique opportunities range from frontline limb salvage to domestic, complex reconstruction at specialized U.S. military facilities, among many others. Significant advances have been and will continue to be made during conflict times – and military plastic surgeons serve as physician leaders in times of crisis, in surgical and non-surgical roles.

Plastic Surgery Resident thanks these men and women for their service to the country and the field of plastic surgery. | Dr. Pontell is PGY-7 in the Department of Plastic & Reconstructive Surgery at Vanderbilt University Medical Center.

REFERENCES

1. Fox JP, Markov NP, Markov AM, O’Reilly E, Latham KP. Plastic surgery at war: a scoping review of current conflicts. Mil Med. 2021;186:e327-e335.

2. Chambers JA, Davis MR, Rasmussen TE. A band of surgeons, a long healing line: Development of craniofacial surgery in response to armed conflict. JCraniofac Surg.

2010;21(4):991-997.

3. Valerio IL, Sabino J, Mundinger GS, Kumar A. From battleside to stateside: The reconstructive journey of our wounded warriors. Ann. Plast. Surg. 2014;72:S38-S45.

4. Chattar-Cora D, Perez-Nieves R, McKinlay A, Kunasz M, Delaney R, Lyons R. Operation Iraqi Freedom: A report on a series of soldiers treated with free tissue transfer by a plastic surgery service. Ann. Plast. Surg. 2007; 58(2):200-206.

5. Maitland L, Lawton G, Baden J, Cubison T, Rickard R, Kay A, Hettiaratchy S. The role of military plastic surgeons in the management of modern combat trauma: An analysis of 645 cases. Plast Reconstr Surg. 2016;137(4):e717-e724.

WHAT I KNOW NOW

That I WISH I KNEW then

By Ian L. Valerio, MD, MS, MBA | Interviewed by Lisa Gfrerer, MD, PhD

U.S. Navy Capt. Ian Valerio, MD, MS, MBA, is a leader in reconstructive, regenerative and restorative surgery, microsurgery and peripheral nerve surgery.

He’s an internationally recognized surgeon-scientist with extensive clinical plastic and reconstructive surgery experience spanning both military and civilian practices.

Given his background and experiences, Dr. Valerio offers trainees unique insights and valuable perspectives within our specialty. He completed his plastic and reconstructive surgery residency at the University of Pittsburgh Medical Center and an AO Fellowship in craniofacial microsurgery in Taiwan prior to entering active duty status at the Walter Reed National Military Medical Center, Bethesda, MD. He transferred in 2015 to the U.S. Navy Active Reserves, transitioning to a civilian academic career at The Ohio State Wexner Medical Center. Dr. Valerio was recruited in 2019 to Massachusetts General Hospital/Harvard Medical School to build a comprehensive microsurgical peripheral nerve program and expand his well-funded research globally.

M

entorship is the most valuable thing that will help guide you through professional development and growth as a medical student to resident and eventually senior surgeon. I strive to nurture all types of students and residents in their plastic surgery careers as I mentor and train the next generation of plastic surgeons and surgeon-scientists.

Ultimately, my goal is to expand on today’s capabilities for a better tomorrow through those I train and mentor to impact our specialty. My thinking around mentorship has evolved over time, and there are some important things that I wish I had known at the beginning of my career.

AS A MEDICAL STUDENT

Be aware that plastic surgery is becoming more competitive every year. During medical school, seek to become a wellrounded, strong candidate with a diverse background and set of experiences to aid in matching into your preferred program. Consider early involvement in basic and/or clinical research; gain a grounded foundation in principles while also pursing projects involving innovation; and embrace advocacy efforts to strengthen your application and the understanding of the breadth this specialty.

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WHAT I KNOW NOW / continued from previous page

In your first and second years, keep in mind that plastic surgery is a field that operates from “head to toe.” Each patient should be considered as “a whole” that includes all organ systems – not just their skin and soft tissues where the injury or deformity may be focused. Seek to acquire a basic understanding of surgical skills, but don’t overlook the principles and experiences of anatomy and physiology, medicine and critical care medicine, psychiatry, rehabilitation and other specialties – which will aid one to fully comprehend the complexities of plastic surgical care.

Ensure that you are well-educated in all core subjects of medicine, as our field requires us to incorporate such understanding due to this specialty tending to be the “goto consult for surgical problem-solving.” Plastic surgery has been recognized as a specialty of conceptualization and applied innovation. Focus on understanding the broad concepts, but gain insights from the creativity employed when it comes to finding solutions for difficult clinical problems by the surgeons to whom you are exposed.

In your third and fourth years, find a topic of interest that goes above and beyond your foundation. Be sure to find an area of interest in which you are passionate. Whether it’s wound healing, cancer care, congenital hand surgery, microsurgery, peripheral nerve research or regenerative medicine, it’s all relevant to our field. As you advance, finetune your interests and engage in more defined research projects that you may even find yourself initiating.

Actively look to present your work at local, regional, national and even international venues; your mentors will be excited to support such efforts. Attend conferences where you can network with your peers (who will likely become future colleagues in the field) and spend time with your mentors as well as their global network in these fertile academic fields, all the while gaining greater insight and exposure to this specialty and its leaders. Publish your work to showcase your abilities and interest to “get things done.” Recognize that mentorship is not exclusive to one individual, but that mentorship encompasses a network of people/surgeons who can give advice on different levels depending on your specific needs. In your fourth year, speak to your mentors and seek their help in preparation for your interviews. Do your due diligence and investigate which programs align with your interests and how they can support your professional growth and development.

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Lastly, enjoy the experience, as this is truly a special time and so much is learned, despite the known stress associated with the process.

AS A RESIDENT

Residency training is the time to learn and perfect the tools of your trade. There’s a lot to learn during this period of rapid growth and learning. Residency is often compared to “drinking from a fire hydrant,” as one is engrossed into all areas of this expansive specialty and its various subspecialties, and even techniques and innovations that expand into other fields. Engage and enjoy the broad exposures as well as training that will be thrust upon you, and maximize your learning every day. Research or read a new topic or article each day; residency is a lot about time management, including maximizing one’s time for each task and prioritizing them accordingly. This spans not only one’s educational pursuits, but also don’t ignore or underestimate your support network, family and friends, and outside pursuits – which are all important in achieving some sort of balance during this time warp. You will see that these years seem long as you go through them, but actually upon reflection, they pass way more rapidly than one at first recognizes.

Couple your training years with research projects that you find of interest rather than “going through the motions.”

It’s important to follow your passion and feel that you’re making a difference in global patient care as well as the research interests you pursue to hopefully have a greater impact within the specialty and beyond.

THE MOST IMPORTANT THINGS I’VE LEARNED

Rely on solid foundational relationships and mentors on a professional level. Plastic surgery is not only crossfunctional, but also multidisciplinary, so mentors often extend beyond the plastic surgeons with whom you’re working or assigned. Closely work with colleagues, residents and Fellows from different specialties, as it’s important not only for clinical practice experience expansion, but also to contribute to innovation in research and clinical care.

Be a visionary and have an open mind to new experiences. I never thought I would be doing what I’m doing now. Quite frankly, many of the things I’ve adopted in my practice didn’t exist during my training – they evolved with my greater understanding and application of principles I put toward new areas of clinical medicine.

With a diverse background, solid foundation and pursuit of passions and interests, you can easily transition to different or new areas that you may come across in the future that are truly impactful in the global world and to you personally. Those who are visionaries, are adaptable, flexible, thoughtful and mindful do very well in residency and beyond.

Find your passion and succeed in whatever you wish to do. Push yourself outside of your comfort zone. When you suffer failure, embrace the teaching and learning; adapt to it; and make it a healthy experience to move past. Don’t be afraid to talk about it with your mentors and confidants, as we can relate to what you’re going through. The reflections and insights gleamed from this process will make you a better surgeon and respected leader within the field.

Be self-aware and self-critical, willing to reflect and selfimprove. Always seek improvement in all aspects of your professional growth and development. Apply this same intensity to your outside interests and family/friends in achieving the necessary balance.

Find and nourish the maturation you’ll experience with your various mentors over the years. You’ll find these to form a basis for long-lasting relationships which you will cherish for a lifetime.

MEDICAL STUDENT OR RESIDENT WITH MILITARY BACKGROUND/INTERESTS

The mission and needs of the U.S. Air Force, Army and Navy focus on tenants of quality clinical care and innovative research, but they are inherently different than the demands of civilian medical institutions and may change based upon engagements in military conflict.

The mission is primarily focused on supporting those involved in combat and their families or beneficiaries.

As a student and/or resident with a military background or service commitment, it’s important to understand the

complex career path to becoming a plastic surgeon that’s determined by the positions “billeted,” or allotted, to our specialty. These open positions will depend on the ebb and flow of active engagements, as more positions are available during such times given the need for our specialty’s expertise. For those who are selected to pursue plastic surgery training, it’s even more important to gain a broad background to include medicine, general and orthopedic surgery, hand and craniofacial surgery, and administrative competence – as there will be a demand for these broader skillsets in war and operational settings.

Be ready to serve in different roles throughout your military career, which evolves as one advances in rank and positions. For example, after my residency training, I entered the military during a time of need in which we saw a significant amount of battle injuries. I was able to adapt civilian best practices to the military setting and a heavy combat casualty-care tempo while also still treating breast cancer patients, providing care for congenital issues and completing elective procedures common to civilian practices. Given my academic and surgeon-scientist background, I was able to apply my critical thinking around microsurgery, perforator flaps and peripheral nerve to help restore critically injured patients while also advancing applied translational research – i.e., “from the bench to the bedside.”

Now that I’m in a civilian academic setting at Massachusetts General Hospital/Harvard Medical School, I’m able to expand these concepts and programs between the civilian and military settings – for even greater advancement and adoption of surgical/medical innovations into the global arena. |

Dr. Gfrerer is an international medical graduate and chief resident in the Mass General Brigham Plastic and Reconstructive Surgery program at Harvard Medical School.

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Auricular trauma “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 Michael Hu, MD, MPH, MS & Miles Pfaff, MD, MHS

14YOM W/EAR LACERATION You’re nearing the end of Friday night call at the children’s hospital and looking forward to the warm weather anticipated for your post-call day when you’re paged by the pediatric trauma team. A 14-year-old male presents as a Level I trauma after a motor-vehicle collision. He has a large, right ear laceration that you’re asked to evaluate.

INITIAL EVALUATION

Initial care of all trauma patients should follow the Advanced Trauma Life Support algorithmic rapid assessment: ABCDE (airway, breathing, circulation, disability, exposure). Only after these critical elements have been addressed and the patient has been stabilized should consultant evaluation proceed. A thorough history and focused head-and-neck physical examination should then be performed.

As with other parts of the head and neck, the physical examination of the ear includes the skin, soft tissue, neurovascular structures, cartilage and bone. Gross examination will reveal skin and soft-tissue defects and any exposed cartilage and/or bone. Ecchymosis of the 12

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postauricular region, or “Battle’s Sign,” should raise concern for underlying skull-base fractures. The contralateral ear can be used to assess symmetry. Any evidence of external ear trauma warrants an otoscopic examination.

Although facial injuries themselves are rarely lifethreatening, the extent of damage suggests the energy of the mechanism. As such, the astute plastic surgery resident should be cognizant of potential underlying or associated injuries. For example, hemotympanum is often a sign of temporal bone fracture, and high-energy mechanisms are frequently associated with cervical spine injuries and blunt cerebrovascular injuries.

Next, the external ear and surrounding bony structures should be palpated in a systematic fashion to identify tenderness, deformities and step-offs. Neurologic deficits can be assessed in this manner and must be documented, or postoperatively they could be attributed to surgical intervention. A gross hearing and otoscopic exam should be performed, and an otolaryngology consultation should be obtained for any concerning findings. Proper recordkeeping with rough sketch drawings or photographs (with proper consent) will be beneficial in the treatment of secondary deformities. Dedicated craniomaxillofacial computed tomography (CT) scans with cuts of 3mm or less should be obtained if there’s suspicion of an underlying skeletal injury.

ANATOMY

Figure 1. The topographical landmarks of the ear define its anatomy: A, helix; B, scaffoid fossa; C, antihelix; D, superior crus of antihelix; E, inferior crus of antihelix; F, triangular fossa; G, cymba concha; H, root of helix; I, concha cavum; J, antitragus; K, tragus; and L, lobule.

The auricle’s exposed position at the sides of the head predisposes it to injury during head and neck trauma. The external surface anatomy of the ear is shown in Figure 1. The auricle receives its dominant blood supply from the posterior auricular artery, as well as additional arterial supply from branches of the superficial temporal artery and occipital artery.

MANAGEMENT

Traumatic injuries can be closed – as in the case of an isolated auricular hematoma – or open; they span from simple lacerations to complete auricular amputations/avulsions.

Auricular sensory innervation is complex and requires a thorough understanding to achieve complete local anesthesia for bedside procedures.

The auricle is innervated by a complex network of sensory fibers from the greater auricular nerve, the lesser auricular nerve, the lesser occipital nerve and the auricular branch of the vagus nerve. A thorough understanding of auricular sensation is paramount to achieve complete local anesthesia for bedside procedures."

AURICULAR HEMATOMA

Auricular hematomas often occur during sports such as rugby, water polo, boxing and wrestling. Shearing forces can tear perichondrial blood vessels and result in hematoma formation between the auricular cartilage and overlying perichondrium.

Because cartilage lacks intrinsic blood supply, it’s at high risk of infection or necrosis, scarring and “cauliflower” deformity.

Treatment involves prompt drainage via aspiration with a large-bore needle or incision with a scalpel. A bolster with a dental roll or rolled-up petrolatum gauze sutured with throughand-through mattress sutures will decrease the chance of hematoma recurrence.

Figure 2. A clinical photograph demonstrating an undrained, closed auricular hematoma (left). A depiction of one type of bolster placement after drainage of an auricular hematoma (right).

LACERATIONS

Management of all open wounds of the ear includes debridement, tetanus prophylaxis and antibiotic therapy with a fluoroquinolone. Wound debridement ranges from gentle cleansing to jet irrigation to sharp excision of non-viable tissue. Human bite wounds have a higher risk of infection – particularly with exposed cartilage – and require special attention. Lacerations of the ear can be subdivided into fullthickness and partial thickness injuries by basing them on cartilage involvement.

Cartilage-sparing injuries often occur at the lobule and often can be repaired by layered primary repair. Z-plasty can be performed at the time of repair to prevent notching of the inferior edge of the lobule. Corticosteroid injection at the

Cotton roll on medial surface Perichondrium Cartilage

Skin

Medial

Lateral Incision site Lateral

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CONSULT CORNER / continued from previous page

time of repair can be performed for patients with a history of keloid scarring.

Full-thickness injuries involve the underlying cartilage and occur throughout the auricle. A careful assessment of the injury should be made to determine if primary repair is possible, or if there’s insufficient skin and/or cartilage. If primary repair is possible, the transected cartilage should be repaired with absorbable monofilament if absolutely necessary, as this is considered a contaminated field. Skin should then be closed over the cartilage repair and a bolster should be considered to prevent hematoma formation.

Insufficient skin can be managed by initial placement of an antibiotic impregnated dressing – such as petrolatum gauze – as a bridge to flap reconstruction. Small amounts of missing cartilage can be repaired with chondrocutaneous advancement flaps, such as the Antia-Buch flap (Figure 3).

With large segments of missing cartilage, skin should be preserved and repaired primarily in anticipation of second-stage reconstruction using a cartilage graft.

Figure 3: Antia-Buch chondrocutaneous advancement flaps

PARTIAL AVULSIONS

Critical assessment of partial auricular avulsions involves an assessment of pedicle viability and perfusion to the avulsed segment. As such, it’s important to check the distal capillary refill of the part. Small incisions can be made in the distal segment to check for bleeding. If appropriate, repair is performed with a layered closure, suturing perichondrium and skin for lateral defects and soft tissue and skin for medial wounds. Occasionally, anchoring sutures through cartilage must be placed to bring wound edges together but should be used sparingly to preserve blood supply. If the laceration extends into the external auditory canal, the skin must be meticulously approximated to prevent stenosis. A wick can be placed for several days to keep the repair intact and immobile.

If the avulsed segment is non-salvageable, all non-viable tissue should be debrided in preparation for delayed closure by local flaps (Figure 4). Exposed cartilage with viable perichondrium is also amenable to skin grafting.

COMPLETE AVULSIONS/AMPUTATIONS

Small, avulsed full-thickness segments (<1.5cm) can often be reattached as a composite graft within six hours of injury if the amputated segment is amenable.

If larger amputated parts are otherwise viable, microvascular replantation can be attempted. The superficial temporal artery or post-auricular artery are often used for anastomosis. A venous anastomosis is not required and leeches are often needed even 14

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in the presence of an adequate venous anastomosis. If the amputated part is unavailable, the wound is debrided and closed with available skin. Available cartilage can also be banked in a postauricular skin pocket for delayed reconstruction. Principles of delayed total auricular reconstruction follow the same tenets as microtia reconstruction. Techniques employed include costal cartilage or alloplastic framework covered by a variety of flaps (Figure 5) or placement of an auricular prosthetic.

CONCLUSION

The 14-year-old patient is found to have a 5-cm curvilinear right ear avulsion from the preauricular region through the tragus, helical root, concha and antihelix through the cartilage.

The distal end of the avulsed segment has appropriate capillary refill. Pan-CT scans are negative. An auricular nerve block is performed, the wound is thoroughly irrigated with 10 percent povidone-iodine solution, and the laceration is repaired with 5-0 fast-absorbing gut suture. A bolster dressing using dental rolls wrapped with petrolatum gauze and through-and-through mattress sutures using 3-0 nylon is placed. The ear is bandaged in a light head-wrap and gentle compression is provided. The patient is observed for a night in the hospital and discharged the following day. | Dr. Hu is PGY-3, and Dr. Pfaff is a craniofacial Fellow, at the University of Pittsburgh Medical Center.

SUGGESTED READING

Figure 4: Standard posteriorly based flap (left); bipedicled flap (center); pedicled postauricular flap (right)

Henry M, Hern HG. Traumatic injuries of the ear, nose and throat. Emerg Med Clin North Am. 2019 Feb;37(1):131-136. doi: 10.1016/j.emc.2018.09.011. PMID: 30454776.

Pearl RA, Sabbagh W. Reconstruction following traumatic partial amputation of the ear. Plast Reconstr Surg. 2011 Feb;127(2):621-629. doi: 10.1097/ PRS.0b013e318200a948. PMID: 21285767.

Kind GM, Buncke GM, Placik OJ, Jansen DA, D’Amore T, Buncke HJ Jr. Total ear replantation. Plast Reconstr Surg. 1997 Jun;99(7):1858-1867. doi: 10.1097/00006534-199706000-00008.

PMID: 9213842.

Mladick RA, Horton CE, Adamson JE, Cohen BI. The pocket principle: A new technique for the reattachment of a severed ear part. Plast Reconstr Surg. 1971 Sep;48(3):219-223. PMID: 5566470.

Lavasani L, Leventhal D, Constantinides M, Krein H. Management of acute soft tissue injury to the auricle. Facial Plast Surg. 2010 Dec;26(6):445-450. doi: 10.1055/s-0030-1267718. Epub 2010 Nov 17. PMID: 21086230.

Miller AL, Cohen MS. Auricular hematoma. N Engl J Med. 2020 Nov 5;383(19):1877. doi: 10.1056/ NEJMicm2004765. PMID: 33211931.

Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg.

1967;39(5):472-477.

IMAGES

Figure 5: Two examples of full-thickness auricular reconstruction with carved cartilage framework

Figure 1: Lavasani L, Leventhal D, Constantinides M, Krein H. Management of acute soft tissue injury to the auricle. Facial Plast Surg. 2010 Dec;26(6):445-450. doi: 10.1055/s-00301267718. Epub 2010 Nov 17. PMID: 21086230.

Figure 2: (left) Miller AL, Cohen MS. Auricular hematoma. N Engl J Med. 2020 Nov 5;383(19):1877. doi: 10.1056/ NEJMicm2004765. PMID: 33211931. (middle/right) https://www.wolverem. com/a-red-and-swollen-ear/ Figure 3: Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg. 1967;39(5):472-477.

Figures 4-5: Pearl RA, Sabbagh W. Reconstruction following traumatic partial amputation of the ear. Plast Reconstr Surg. 2011 Feb;127(2):621-629. doi: 10.1097/PRS.0b013e318200a948.

PMID: 21285767.

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Upper-Extremity and Hand – Soft-Tissue Reconstruction

By Mark Yazid, MD

A

s one of the most common trauma consults, hand and upper-extremity soft-tissue defects must be understood by all plastic surgeons – and their varied degrees of severity and large scope of reconstructive options make them a favorite topic for the In-Service Exam.

ASSESSMENT HIGHLIGHTS

Approaching this sequentially, we will move distal to proximal in describing the reconstructive options for various upperextremity anatomic defects. With each defect, it’s critical to recognize which structures are injured or exposed, and to determine the best option for coverage in each patient depending on their clinical picture. Factors such as patient age, smoking history and neurovascular viability are critical to achieving optimal outcomes.

In the E.R., this evaluation begins with copious irrigation to adequately visualize the wound; performing a thorough musculoskeletal and neurovascular exam; and ensuring

16

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appropriate antibiotic and tetanus prophylaxis administration depending on the mechanism of injury faced by the patient. If bleeding is problematic, remember that hand/arm elevation and temporary tourniquets can be used for better evaluation. With the latter, care must be taken to document placement time and removal of all devices, in order to ensure no ischemic insult occurs with the tissue. Finally, adjuvant plain-film imaging as indicated can be added for further decision-making assistance.

PRINCIPLES OF RECONSTRUCTION AND INTERVENTIONS

Generally, most In-Service Exam questions on this topic follow the principles of the reconstructive ladder – with specific caveats such as when bone and other vital structures are exposed, or when a patient has a contraindication for a local option. Minimal intervention sometimes is correct however, especially on smaller fingertip injuries, and the concept of sacrificing the health of a donor site for reconstruction potential should always be viewed with caution.

FINGERTIP WOUNDS

HAND/WRIST/FOREARM FLAPS

LOCAL HAND FLAPS

For elbow defects, reverse ulnar artery flaps can be used, with the pedicle running between the FCU and FDS tendons and superficial to the respective nerve. One can also use a variety of other options, including brachioradialis as well as FCU flaps (either muscle only or myocutaneous) for smaller defects.

Reverse lateral arm flap, whose blood supply is the radial recurrent artery when doing a distally based flap, is often tested as another option. Other pedicled flaps that have been used include a more second-line groin flap option which is based on the superficial circumflex iliac artery, as well as using a latissimus for a larger upper-arm soft-tissue defect.

Wounds less than 1cm 2 on the pulp with no bone exposed can simply be allowed to heal secondarily with good cosmetic outcome and minimal neuropathic pain. For wounds greater than 1cm 2 or with exposed bone/tendon, begin thinking about local flaps. Finally, with traumatic amputations in patients who work with their hands, revision amputations in the E.R. can be a good option when a prolonged recovery course is not desired.

In-Service questions regarding a lumbrical-plus deformity have been noted in the past if a revision amputation does not address the residual FDP tendon, allowing paradoxical extension of the PIP/DIP when attempting to flex the digit due to continuing lumbrical function.

For the fingertip, V to Y local flaps such as the volar-based Atasoy-Kleinert or the more lateral-based Kutler flaps allow for neurovascular bundles to be kept, while advancing tissue to cover defects from 1-1.5cm 2 at the tip of the digit. For larger tip defects, we move into more substantial local flap options such as antegrade homodigital – and reverse classic versus dorsal homodigital island flaps, if the aim is to keep donor morbidity limited to a single, impacted digit that has not lost either digital arterial supply. When unable to support homodigital flaps due to vascular concerns, and with a patient young enough to tolerate immobility-induced stiffness, a thenar/hypothenar/or cross-finger flap can also be used for volar defects. Generally, cross-finger flaps have been noted to cause less stiffness than thenar variants, with reverse crossfinger flaps used to cover a dorsal finger defect.

For thumb defects up to 1.5cm in size in patients who can tolerate some resulting IP flexion, and with an intact princeps pollicis arterial supply to the dorsal aspect of the digit, a Moberg advancement flap can be used. This type of volar advancement flap can be used uniquely in the thumb due to the noted secondary, concurrent dorsal blood flow. Another often-tested coverage option is the first dorsal metacarpal artery flap, with its reliable pedicle position, and optional radial sensory nerve component, which can be used for larger defects of the thumb in more geometric variants compared to the Moberg flap. Littler flaps have been referenced in some In-Service questions more so as a historic flap rather than a common workhorse in modern practice, given the steep price exacted when sacrificing an intact ulnar side of the long finger to cover thumbtip defects.

For larger defects, the radial forearm flap is viewed as one of the most reliable and customizable flaps. After confirming a complete palmar arch, the radial forearm flap can be raised as a free or pedicled flap with any combination of skin/fascia/ bone and tendon, with the ability to cover even elbow defects.

Common questions in the past have included how to perform an Allen’s test; pedicle location (between the FCR and brachioradialis); and whether to use a cephalic or basilic vein as an adjunct venous-outflow source. In a reversed pedicled fashion based on retrograde radial flow, this flap can also be used to cover even more distal hand defects. As a backup, posterior interosseus flaps have been described for dorsal hand defects, given its low donor-site morbidity from an arterial standpoint.

Finally, free tissue transfers involving a variety of flap options (fasciocutaneous such as ALT, being easier to raise in future tendon revision surgeries when compared to muscle only flaps) have been described for the upper extremity. As adjuncts to these as well as to local flaps, skin grafting is used for donor site and muscular flap coverage, with full thickness traditionally used on the hand – and split thickness if needed more proximal.

Dr. Yazid is PGY-7 in the Houston Methodist Hospital Division of Plastic and Reconstructive Surgery. |

REFERENCES Chung, K et al. Grabb and Smith’s Plastic Surgery: 8th Ed. 2019. Lippincott Williams and Wilkins (LWW) Janis, J et al. Essentials of Plastic Surgery: Second Edition. 2017. Thieme Medical Publishers Rehim SA, Chung KC. Local flaps of the hand. Hand Clin. 2014;30(2):137-v. doi:10.1016/j.hcl.2013.12.004

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Vanderbilt University Medical Center Department of Plastic Surgery

By Patrick E. Assi, MD

History • The Vanderbilt Department of Plastic Surgery began in 1925 as a surgical specialty division under the Department of Surgery at Vanderbilt University Medical Center.

• The education mission started in 1973 with John B. Lynch, MD, chairman of the Department of Plastic Surgery, who founded the independent residency with three residents per year and 114 graduates thus far.

• Since 2017, the Department of Plastic Surgery has been under the leadership of Department Chair Galen Perdikis, MD. • In 2019, the integrated residency was launched under the leadership of Program Director Brian Drolet, MD. 18

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Leadership • Galen Perdikis, MD: Chair and Professor of the Plastic Surgery Department. His clinical interest areas include breast, aesthetic and reconstructive microsurgery.

• Kent “Kye” Higdon, MD: Associate Professor, Vice Chair of Clinical Practice and Development, Program Director of the Independent Plastic Surgery Fellowship. His clinical interest areas include breast, aesthetic and reconstructive microsurgery.

• Brian Drolet, MD: Associate Professor, Vice Chair of Education, Program Director of Independent Plastic Surgery Residency and the hand surgery Fellowship. His clinical interest areas include hand and upper extremity surgery and biomedical ethics.

• Salam Kassis, MD: Assistant Professor, Research Director. His clinical interest areas include migraine, peripheral nerve, transgender and aesthetic surgery, and reconstructive microsurgery.

• Stephane Braun, MD: Assistant Professor. His clinical interest areas include pediatric plastic and fetal surgery, breast reconstruction and reconstructive microsurgery.

• Michael Golinko, MD: Professor of Plastic Surgery and Otolaryngology, Chief of Pediatric Plastic Surgery, Director of the Cleft and Craniofacial Program.

• Kevin Kelly, MD, DDS: Associate Professor. His clinical interest areas include pediatric and adult craniofacial surgery.

• John Bradford Hill, MD: Assistant professor. His clinical interest areas include hand and upper-extremity surgery.

• Blair Summitt, MD: Assistant Professor. His clinical interest areas include burns, aesthetic and reconstructive surgery.

• Wesley Thayer, MD, PhD: Associate Professor, Research Vice Chair. His clinical interest areas include hand, reconstructive and aesthetic surgery.

• Megan Vucovich, MD: Assistant Professor. Her clinical interest areas include breast and aesthetic surgery.

• Brinkley Sandvall, MD: Assistant Professor. Her clinical interest areas include pediatric hand surgery and microsurgery.

• Julian Winocour, MD: Assistant Professor. His clinical interest areas include microsurgery and transgender surgery.

National Leadership • Dr. Perdikis is board-certified by the American Board of Plastic Surgery and is a member of ASPS, the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS) and the American Association of Plastic Surgeons (AAPS). He’s served as president of the Florida Society of Plastic Surgeons, and he’s a SESPRS Board Trustee and co-chair of the ASPS Practice Management Committee.

• Dr. Higdon is board-certified by the American Board of Plastic Surgery and is a member of ASPS, SESPRS and AAPS. He serves on the American Council of Academic Plastic Surgeons (ACAPS) Professionalism and Ethics Committee; ASPS Patient Safety Committee; ASPS Young Plastic Surgeons Steering Committee; and the Aesthetic Society Patient Safety Committee.

• Dr. Drolet is a board-certified by the American Board of Plastic Surgery and is a member of ASPS; American Society for Surgery of the Hand (ASSH); American Association for Hand Surgery (AAHS); SESPRS; and AAPS. He serves on the ACAPS Education Committee (Co-Chair); ACAPS Resident Selection Committee

(Chair); ASSH Ethics and Professionalism Committee; and ASSH E.R. Hand Care Committee.

Clinical Experience Vanderbilt University Medical Center provides 1,105 total beds – 834 adult and 271 pediatric. The cosmetic surgery practice has three dedicated private O.R. suites, while VUMC’s main campus has 56 adult and 16 pediatric O.R.s, which enables VUMC to annually perform more 51,000 surgeries. There are 14 plastic surgeons on faculty, and the residency program consists of two independent recruits per year and one integrated recruit per year, for a total resident complement of 12 – which offers the best of both worlds.

We take pride in our early graduated independence and our high operative volume. On average, chiefs graduate with 2,202 reconstructive cases (required minimum 1,000) and 305 aesthetic cases (required minimum 150). Additionally, the graduating chiefs have the opportunity to direct their own aesthetic clinic and to schedule their own surgical cases, with oversight from faculty as needed. Furthermore, residents have the opportunity to be part of a grant-funded research team with major focus on peripheral nerve studies, transgender outcome studies, quality improvement studies and migraine surgery. The research lab is currently under the leadership of Dr. Kassis and Dr. Thayer.

The clinical experience of the residents occurs across four sites: The Vanderbilt University Medical Center – Main Campus: Where the majority of residents rotate through different pods such as reconstructive/transgender; breast/ aesthetic; microsurgery (roughly 100 DIEP flaps and more than 150 free flaps per year); hand/nerve surgery; and craniomaxillofacial surgery.

Monroe Carell Jr. Children’s Hospital at Vanderbilt: Residents rotate here for additional craniomaxillofacial and pediatric plastic surgery experience. They also have the opportunity to be part of the cleft care multidisciplinary team.

Veterans Affairs (VA) Medical Center at Vanderbilt University Medical Center: Residents’ main exposure at the VA is general reconstructive plastic surgery and elective hand surgery.

Nashville Community: The senior residents and Fellows have the opportunity to rotate with aesthetic plastic surgeons in the community to increase cosmetic surgical exposure and learn the intricacies of private practice.

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PROGRAM PEEK / continued from previous page

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Educational Curriculum • Weekly didactic conference led by faculty covering the breadth of plastic surgery • Monthly mortality and morbidity conference • Monthly oral boards-style conference led by faculty • Monthly Journal Club • Quarterly visiting professors • Fresh cadaver labs three times per year • Quarterly city-wide Journal Club with community plastic surgeons • Annual microsurgery lab training • The annual Thuss Lecture is a great opportunity for the residents to learn about advances in plastic surgery from the specialty’s leaders. This lecture is made possible through the generosity of Charles J. Thuss Jr., MD, and Mrs. Charles J. Thuss. Dr. Thuss was a 1961 Vanderbilt Medical School graduate.

Resident Benefits • Living in Nashville, the “Music City” we all love.

Nashville is a booming city with an artistic tint; it offers an ever-growing real estate market, all four seasons and a sophisticated culinary experience.

• Allocated academic funding • Sponsored meeting attendance • High-volume operative exposure early in residency, with graduated autonomy • Assigned clinical mentor to help guide you through residency • Loupe/equipment expense fund per year • Junior resident – Senior resident procedure clinic starting at PSY-II level • Integrated residents work with independent Fellows in a supportive educational culture. |

Fellowship Training Programs 2020: Adult & Pediatric Craniomaxillofacial Surgery Fellowship launched under the leadership of Dr. Golinko 2021: Hand and Upper-Extremity Surgery Fellowship launched under the leadership of Dr. Drolet

Dr. Assi is PGY-7 at Vanderbilt University Medical Center.

Plastic Surgery Resident | Summer 2021

A Message From the Program Director, Brian Drolet, MD

I

nnovation is a hallmark of plastic surgery.

From Nobel Laureate Joseph Murray, MD, who performed the first successful kidney transplant in 1954, to modern tissue engineering – innovation is at the heart of patient care and research for plastic surgeons. Yet the creativity of our specialty has only recently translated into how we train plastic surgeons. Like elementary school, high school or medical school, training was time-based, with little or no opportunity for advancement or extension. The most-advanced as well as the most-delayed residents in a program graduated based on when they started training and the duration required by our specialty.

Although this regimented approach makes training pretty straightforward – do your time and get out – time-based training neither ensures that all graduates are competent plastic surgeons nor allows for early advancement and subspecialization. For this reason, our program has shifted to a competency-based training model, with broad reaching implications on how we train plastic surgeons.

We will graduate our first competency-based trainees in June 2023. These residents will have had the opportunity to participate in embedded Fellowships during their senior year of training, after they have demonstrated competency in all the primary domains required by the American Board of Plastic Surgery. This paradigm shift not only ensures that our trainees are fully competent plastic surgeons, but when they complete PSY-6 (chief resident year) our residents are fully ready to enter independent practice without a Fellowship or to pursue further Fellowship training – where they will be highly prepared based on advanced, intentional prerequisite training experiences. High-volume clinical and operative experiences with early graduated independence define the training experience and help residents become competent in the breadth of plastic surgery. Meanwhile, focused-educational plans developed by each trainee help to tailor each resident’s education in the specialty areas that will define their practice as surgeons.

In order to assess for competency, residents in our program receive feedback on their case performance using the SIMPL Collaborative. Operative performance is tracked to determine when individual patient-care

competencies are met. Meanwhile, standardized oral and written exam are administered at the end of PS-4 and PS-5 rotations to assess medical knowledge and patient care understanding.

When competency has been demonstrated, residents move into focused clinical practice Brian Drolet, MD tracks that may align with a transition to practice experience or an embedded Fellowship – depending upon the specific goals of the trainee. Trainees who need more time to meet baseline competency will have their senior-most rotations focus on a combination of core discipline weaknesses and transition to practice training.

Our goal is to deliver a training experience tailored to the resident’s goals and needs – and importantly, you shouldn’t need a Fellowship when you graduate from a strong residency program. There are many reasons that Fellowships add value, but residency should be sufficient training for any type of practice, with any complexity – and we’re confident that we deliver that training here.

Shifting gears a little bit, this is a very exciting time to be here at Vanderbilt beyond just our educational innovations. We’ve seen incredible growth in the plastic surgery department over the last five years, and this growth has been built on a long history of outstanding education and patient care. Our independent residency program, which launched in 1971, has been training plastic surgery Fellows assiduously for more than 50 years. In 2019, we started our integrated training pathway with one resident per year – and we look to expand that soon. Our craniofacial Fellowship started in 2020 and our first hand Fellow joins us this July. This increase in trainees has been matched with a doubling of our clinical faculty and a concomitant doubling in case volume.

This is the basis for superlative training – and it’s allowed us to move quickly and definitively to competency-based training. We’re lucky to have ample training experiences so that we can innovate in education, and we look forward to the benefits this innovation will have for our residents. |

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Q&A WITH GALEN PERDIKIS, MD

By Jim Leonardo Plastic Surgery Resident strives to provide readers with career advice designed to aid them in their professional advance after residency – by sharing insights that may help them create their own, desired path.

In this installment of Faculty Focus, we present ASPS member Galen Perdikis, MD, Department of Plastic Surgery chair and professor of surgery at Vanderbilt University Medical Center. A native of South Africa, Dr. Perdikis earned his medical degree at the University of Witwatersrand, Johannesburg, and he completed his general surgery residency – as well as a research Fellowship – at Creighton University Medical Center, Omaha. Neb., and a plastic surgery Fellowship at Vanderbilt.

A member of the ASPS Quality and Performance Measurement Committee and Performance Measure Workgroup – Reduction Mammaplasty, among several other current and past Society panels, Dr. Perdikis’ areas of interest include post-mastectomy breast reconstruction, as well as communication and safety in plastic surgery generally. The son of a general surgeon and O.R. nurse, Dr. Perdikis also married into a surgery family – his father-in-law, too, is a surgeon.

Dr. Perdikis says he’s developed a deep understanding of the challenges faced by breast reconstruction patients in particular, and as a result strives to provide each with not only understanding, patience and surgical skill, but also with a return to the quality of life they, and all plastic surgical patients, deserve.

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PSR: WHAT DREW YOU TO PLASTIC SURGERY? Dr. Perdikis: It’s a very technically oriented specialty more than a diagnostic specialty, and also it deals in improving quality of life rather than quantity of life – which I appreciate.

PSR: HOW DID YOU PREPARE DURING RESIDENCY TO GET INTO A COMPETITIVE FELLOWSHIP? Dr. Perdikis: You never know the path your life will take. I’ve always had the philosophy that I would put opportunities in my back pocket because I might need them someday – so I’d say “yes” to whatever opportunity came along, and research became a very important part of that. Even though a lot of my research is in general surgery, it still helped me get a top-notch plastic surgery Fellowship. Also, it’s all about managing things you can control. For instance, the In-Service Exam scores and board scores are in your control. So the better you do with those, and the more you publish and develop your CV, the more competitive you’ll be as an applicant. As a foreigner, that was important to me as I competed for a plastic surgery training spot.

I’m from South Africa, where I completed medical school and a one-year internship before relocating to England for six months in ENT surgery as a senior house officer.

Then I did military service in South Africa (a compulsory enlistment) for one year, followed by ENT training in South Africa. I soon moved to the United States, where I did research for two years in Creighton’s Department of General Surgery. I followed that with a six-year surgical residency a plastic surgery residency at Vanderbilt University – then to the Mayo Clinic in Jacksonville, Fla., for 15 years before returning to Vanderbilt four years ago.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER? Dr. Perdikis: It was critical in placing me on an academic pathway. If you go into a top-notch training program that academic feel, it can create the pathway that I wanted to follow. I already created my benchmarks around academia with my research and all of that. The Fellowship galvanized that thought process for me.

PSR: HOW IMPORTANT IS A MENTOR IN THE EARLY YEARS OF PRACTICE? Dr. Perdikis: Very important. To be honest, I lacked a bit of mentorship early-on in my plastic surgical career. I had very powerful and important mentors when I was starting out in general surgery, but I sort of lost my way a little bit. That speaks to the importance of mentorship; it meant I took a longer path and needed extra time to re-energize my academic career in plastic surgery, because I don’t feel I had the mentorship I had in general surgery.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER? Dr. Perdikis: Volunteerism and serving societies are important, but you’ve got to be careful about volunteering for every shiny object that comes along. It’s important to be focused and only volunteer for that which you’re passionate about and that you feel you can make a difference in.

Otherwise, you’ll lose your way by chasing different things that seem important. The last thing you should be doing society and committee work for is because you think people will think better of you. It’s all about service and helping your specialty.

PSR: WHAT’S THE MOST IMPORTANT ATTRIBUTE A RESIDENT NEEDS? Dr. Perdikis: We can generally teach most residents to be technical proficient and to take care of people, so it boils down to two things: You can’t get your integrity back if it’s compromised, so integrity is No. 1, and the top-notch residents have that in abundance. Also, kindness: If you can’t demonstrate kindness toward your staff, patients, family and friends, you aren’t going to get to where you want to be in your career.

PSR: HOW DO YOU BALANCE YOUR PROFESSIONAL AND PERSONAL LIVES? Dr. Perdikis: I’d love to find the right answer to that; I always struggled to balance my professional and personal lives. I’m fortunate that my family is very strong; I work inordinately hard, so it’s great to have a family that understands why I do

what I do. My wife’s father was a general surgeon, and that was huge in allowing me the freedom to chase my professional career. But I don’t have a perfect balance.

PSR: WHAT DO YOU ENJOY THE MOST ABOUT BEING A PLASTIC SURGEON? Dr. Perdikis: I truly think it places quality over quantity with regard to life. That’s special. We truly believe in improving the patient’s quality of life. For me, that’s enough sometimes.

We totally appreciate lengthening people lives, treating cancer and other wonderful work, but quality also is important. That’s where we fly.

PSR: WHAT ARE SOME OF THE CHALLENGES YOU REGULARLY ENCOUNTER? Dr. Perdikis: Time management and the burden of documentation that doesn’t benefit patient care. If you ask most plastic surgeons, they feel we’re being burdened more and more with documentation to check boxes – and that doesn’t help us be present and patient-centric.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE? Dr. Perdikis: We belong to an academic institution and department, and hence one of our primary core values is education and teaching. It’s woven into the fabric of everything we do each day. It’s something we cherish as surgeons; we love being teachers and mentors to our residents.

PSR: DO YOU HAVE ANY WORDS OF ADVICE FOR RESIDENTS? Dr. Perdikis: It’s easy to get distracted in plastic surgery by all the super-cool stuff and pathways. I feel residents need to enjoy the process that is their residency; don’t just look at the end goals, be patient and focus on what you want to be and who you are. Understanding who you are as a surgeon is critical to long-term success.

PSR: WOULD YOU PLEASE COMPLETE THIS SENTENCE? “I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN …”

Dr. Perdikis: I was a third-year general surgery resident assisting on a free latissimus flap to a complex leg fracture. It was the ability to improve the quality of that patient’s life that was critical to me being happy – and hence my decision to go down the path of plastic surgery. | Plastic Surgery Resident | Summer 2021

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Nashville

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elcome to Nashville, which is the “Country Music Capital of the World,” as you may know. But we’ll show you that Nashville has something for everyone beyond music aficionados – and even if you’re not into country music, we think you’ll have the urge to pull-on a pair of cowboy boots after a visit to one of our honky-tonks.

find a restaurant here that doesn’t have a delicious original recipe. We start our day at one of Nashville’s most unique restaurants – and we hope you came hungry. At Monell’s, you’ll get a full sampling of Southern cooking with a breakfast menu that includes skillet fried chicken, biscuits and gravy, fried apples, corn pudding and cheese grits. Can’t decide what you want? Monell’s serves

As you enter the city, you may notice that we’re under protection from Gotham’s finest – with the “Batman Building” (officially titled the AT&T Tower) looming over our downtown skyline.

You’ll also notice that a few architects seemingly got lost on their way to erect great structures, as they’ve built a replica of the Greek Parthenon in Centennial Park. Just as in Greece, the Parthenon is home to our very own 42-foot Athena statue, leading to Nashville’s moniker as “The Athens of the South.” This statue is also the tallest enclosed sculpture in the Western Hemisphere.

BREAKFAST AT MONELL’S

It wouldn’t be a proper visit to the South without biscuits, and it’s honestly hard to 24

Plastic Surgery Resident | Summer 2021

Burgess Falls

By Kianna Jackson, MD

large family-style platters to share with your neighbors. Don’t be shy – you’ll need energy for the morning hike that we have planned after breakfast.

SOUTHERN WATERFALLS

Just about 90 minutes away, you’ll find one of Tennessee’s most breathtaking outdoor hikes. Burgess Falls is a popular spot that affords locals and tourists the

opportunity to get away from the city life, with the end of the trail marked by a stunning waterfall. With fishing, birdwatching, hiking and swimming, you could spend all day at Burgess Falls. If you’re looking for more outdoor adventures, Nashville has many beautiful hikes within the city – including Percy Warner Park and Harpeth Woods – and seven additional beautiful waterfalls are located within a short drive. Unfortunately, we only have 24 hours together, so after a quick dip and Instagram photo, we have to head back to the city to continue our tour.

MELTING POT IN THE FARMERS MARKET

Nashville is certainly known for its hot chicken (which of course, we’re having for dinner), but it also boasts an incredible variety of cuisines from across the world. Nashville is one of the fastestgrowing cities in the country, and the majority of that growth has resulted from immigration – leading the city to become an amazing melting pot of culture. One of our favorite spots for lunch is Jamaica Way, a family-owned restaurant serving traditional Jamaican dishes within the Nashville Farmers Market. On your way out, grab some Jeni’s ice cream and fresh produce for the week.

MICHAEL HICKS (BURGESS FALLS), KAREN BLUMBERG (HATTIE B'S)

PRETEND TO DO WORK AND SEE THE CITY

One of the best ways to see the city without having to worry about parking is to book a ride on a Pedal Tavern. In case you haven’t heard of it, a pedal tavern is a small “party bike” where 15 of your closest friends can enjoy beverages as you pedal together to propel the ride (and have your pride stripped when you find out that the bike actually has a motor).

The Nashville Pedal Taverns will give you a tour of Music Row and Broadway – two of Nashville’s most famous areas.

Riding down Broadway during the day, you’ll hear many amazing artists playing live music at nearly every restaurant and bar. You can find music of every genre, though we’re certainly known for our country music scene. It wouldn’t be a trip to Music City without being blown away by the next undiscovered star, so

Broadway, both the street and the historic downtown Nashville district.

make sure to enjoy a show or two. If you’re feeling up for it later, come back to Broadway at night for the best nightlife the city has to offer.

MORE CHICKEN, MORE MUSIC

You can’t come to Nashville without trying hot chicken, which we’ve left for last in order for the line to shorten a little bit. (An hour’s wait to place your order isn’t unusual.) Hattie B’s is the go-to restaurant in Nashville, and there’s never a day that goes by that the line isn’t wrapped around the corner. Try the pimento mac & cheese with the hot chicken; you won’t be disappointed.

If we’re in Nashville on Aug. 2-6, we’re grabbing our meal to-go, because awaiting us is Live on the Green – Nashville’s free, annual summer music festival held downtown at Public Square Park. You’ll see local, regional and national artists, and inevitably you’ll find some new favorites.

Of course, we must have dessert, and you can’t visit Nashville without trying a Goo Goo Cluster. This is a chocolate candy that mixes caramel, peanuts and marshmallow, and it’s made exclusively in Nashville by Goo Goo Shop & Dessert Bar. (According to the company, the Cluster represents the first time that multiple elements were mass-produced in a “retail confection.”) We couldn’t think of a better way to end the night!

‘TIL NEXT TIME

We hope y’all enjoyed your 24 hours in Nashville, and we can’t believe it went by so quickly. We know that the small taste of the city we’ve guided you to will leave you wanting more, and we can’t wait to see you again! We’re so happy to have you visit our ever-growing city. | Hattie B’s Hot Chicken

Dr. Jackson is PGY-2 at Vanderbilt University Medical Center.

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Life After Residency – Part II

Where your future lies: Prizes, pitfalls, paths and projections

By Janak Parikh, MD

Editor’s note: Most young plastic surgeons by the end of training haven’t acquired the practical, non-medical skills that can help them run a plastic surgery practice – expertise that includes negotiating and reviewing contracts, writing a business plan, billing processes and managing an office. Therefore, while the joy of reaching the end of the training tunnel can be palpable, so can the anxiety that accompanies the first steps toward a plastic surgery career.

ASPS offers symposia, webinars and other training to help young surgeons fill gaps. Adding to these efforts, Plastic Surgery Resident is providing advice on the pros and cons of certain startup options by speaking with three plastic surgeons in private practice and in different geographic locations. We hope that our readers can glean important information from these conversations, which in Part II includes the timing to practice maturity; the future of private aesthetic practice; aesthetic vs. reconstruction; and financial realities.

PSR: WHICH PERSONAL CHARACTERISTICS ARE MOST CLOSELY ASSOCIATED WITH A SUCCESSFUL PRACTICE? Dr. Buchanan: The constant motivation to make everything better, more efficient, etc. Without the drive to constantly question what you do and why, and to seek a better way, you won’t be successful in the long run. You also must be affable. This may sound overly simple, but any part of a business is selling your product – and in private practice, you are the product. If you don’t enjoy cultivating those types of relationships and investing in a positive personality and image, then building a practice will be difficult. Humility helps, too. If you ask 100 plastic surgeons if they’re the best in their market, likely 95 will say “yes.” In reality, plastic surgeons are a Bell curve distribution: 10 will be terrible, 10 exceptional and 80 average. You don’t need to be one of the 10 exceptional people – if you do good work, treat people well and care about your patients and their outcomes, you’ll be fine. Just resist the urge to think you’re the best; in reality, you’re probably among many who are as good – or maybe even better than you.

Dr. Pittman: The key is the Three As: affability (to patients and referring physicians), availability (never say no) and ability, in that order. You also need humility: Understand that people are going to complain, but instead of blowing off their comments, use them to improve your practice. Also, look at your work critically; review before-and-after photos so you’re always improving.

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PSR: WHAT’S THE AVERAGE COST OF STARTING A PRACTICE? Dr. Buchanan: A rough estimate is at least $300,000 split into three $100,000 pools. One pool is for office buildout.

You’ll likely not find an ideal office space, so you may renovate or remodel the space you do find. The second pool targets equipment purchases: furniture and decorations, office and medical equipment, office supplies (i.e., printers and computers) and IT investments such as an EHR system.

If big equipment purchases are needed (lasers, injectables, instruments, etc.), that $100,000 can go pretty fast. The final pool is startup capital: As soon as you open your doors, several months likely will pass where you’ll make no money but still must pay overhead such as rent, bills and employees.

You’ll need enough startup cash to sustain yourself until you can cover that. You can move money among these pools, however – for example, if you only need $50,000 to renovate and build out, move the leftover $50,000 into your equipment budget.

Dr. Pittman: The answer varies greatly based on practice location and income needs. In my market, I’d estimate $500,000.

Dr. Payne: You can typically expect a start-up to run approximately $300,000-$500,000.

PSR: HOW LONG CAN IT TAKE FOR A PRIVATE PRACTICE TO MATURE? Dr. Buchanan: This can depend heavily upon the market and the practice you desire. A practice launched in a relatively underserved area and which provides a unique yet desirable service can reach maturity fairly rapidly. But if you start a Botox® practice in Beverly Hills, expect to never reach maturity. Most plastic surgeons would say it takes an average of three to five years.

Dr. Pittman: About three years on average – that’s usually when you’ll have a steady flow of patients from referring doctors and/or patient referrals.

PSR: WHAT’S COMPENSATION LIKE OVER THE FIRST FIVE YEARS? Dr. Buchanan: I can speak from personal experience: Not good. Assume the average U.S. plastic surgeon’s salary is $400,000. Employed surgeons may start at around $300,000-350,000 and have room for growth over time – so by year 5, they’re making the average and may max-out later at $450,000-$500,000. That curve will be very different in private practice: I’d fully expect you’d make nothing that first year. In years 2-3, you wouldn’t make much, with lot of profit re-invested in growth of the business; you may take home enough to cover your bills, living expenses and maybe a little extra, say $100,000-$150,000 annually. After this, the business should grow rapidly and your compensation curve will increase compared to the employed surgeon – so by year 5-6, each is making around $400,000. Hopefully, after that, your growth curve expands while theirs stays the same.

Dr. Pittman: There are many variables. In solo private practice, you’re the last person to get paid. Additionally, during the first few years you’re often reinvesting additional revenue into growing your business. Our practice projected 60 percent growth in revenue over five years. Since expenses are mostly fixed, that can help determine what you can pay yourself. But going into private practice should never be solely a monetary decision.

Dr. Payne: The first two years in solo private practice will bring the lowest compensation. After years 3-5, you’ll make significantly more than years 1-2. But be prepared for future economic downturn (such as a pandemic) or a recession – especially if you’re 100 percent cosmetic.

PSR: WHAT’S YOUR ADVICE FOR RESIDENTS INTERESTED IN PRIVATE PRACTICE? Dr. Buchanan: Use the resources at your disposal. Make the effort to not only be learning the practice of plastic surgery but also the business of plastic surgery from those in private practice or with experience in it. Start planning early. Figure out what kind of practice you want, where you want it to be and why, and start making plans to make that happen right after training.

Dr. Payne: Spend time with mentors willing to share how they got started in private practice. Spend time with their staff; they’ll give you insights into how to run the business and can teach you coding and billing for insurance.

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LIFE AFTER RESIDENCY / continued from previous page

Dallas R. Buchanan, MD

Troy Pittman, MD

Eric Payne, MD

Years in practice: Seven Practice location: Tampa Bay, Fla. Practice model: Solo private; cosmetic and reconstructive (primarily breast) Fellowship: None

Years in practice: Nine Practice location: Washington, D.C. Practice model: Two-surgeon private; all aesthetic Fellowship: Aesthetic and breast reconstruction

Years in practice: Nine Practice location: Houston Practice model: Solo private; craniofacial and aesthetic Fellowship: Craniofacial surgery

Path to current practice 2014: Completed training 2014-18: Joined another plastic surgeon in Spokane, Wash.

2018: Started solo private practice in Tampa Bay

Path to current practice 2012: Completed training 2012-13: Faculty at John’s Hopkins 2013-18: Faculty at Georgetown, director of breast reconstruction 2018: Private practice

Path to current practice 2012: Completed training 2012-14: Joined another plastic surgeon 2014: Solo private (shared office)

PSR: WHO NEEDS TO PURSUE AN AESTHETIC FELLOWSHIP IF THEY’RE CONSIDERING A PRIVATE PRACTICE FOCUSED ON AESTHETICS? Dr. Buchanan: It depends on your training, practice plan and market. If you want to do only aesthetic surgery and your training program was very limited in that, then maybe consider it. If your aesthetic training was relatively good, you’ll be just fine. If your practice plan will be more balanced, you’ll do what you know while learning what you don’t know. This depends on the market, though. If you’re in area with less competition, you don’t need as much specialization or training to distinguish yourself from the competition. However, if you’re in a highly competitive area and want to establish yourself as a unique expert in a certain procedure or practice type, some additional training could be beneficial.

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Dr. Pittman: All the tools you need to be a good cosmetic surgeon you’ll have at the end of training. Nothing is harder than reconstructive surgery. What you’ll learn in an aesthetic Fellowship are technical things you don’t know – such as how to do an aesthetic consult and how to run an aesthetic practice. If you want a solo private aesthetic practice, do a Fellowship to learn all of the intangibles.

Dr. Payne: If you don’t feel comfortable doing aesthetic surgery, then seek further training with an aesthetic Fellowship. If you don’t feel comfortable with the idea of running your own practice, a Fellowship can be very helpful in gaining that experience. After spending years in academic residency training, a craniofacial private practice Fellowship gave me insight into the fact that craniofacial surgeons aren’t all academic-based practices. I also gained experience in how one of the largest private group partnerships in the country ran their practice. That gave me the confidence to go out and build a practice from the ground up.

PSR: WHAT ABOUT BOARD-COLLECTION CASES IN PRIVATE PRACTICE, IF YOU'RE AIMING FOR AN AESTHETIC PRACTICE? Dr. Buchanan: Don’t reveal right away that you’re aiming for an aesthetic-focused practice. You can do the hard work and know how to help people. Practice the full breadth of what you’ve spent so much time learning. There’s a reason we set ourselves apart from “cosmetic surgeons:” Can they do a breast augmentation on a healthy, 25 y/o female? Probably.

A gastroc flap on an overweight, 60 y/o diabetic with an exposed knee prosthesis? No chance in hell.

The Board exam shows the ABPS that you’re well-trained in all of plastic surgery – and that you can provide care in a comprehensive and safe manner. They don’t want to hear that following all your training, you only want to perform tummy tucks and breast augmentations, because you haven’t paid your dues like they did. Put your nose down, do the work and earn the respect. How long is board collection – 10 months?

You can make it, trust me. In time, you can create what you want with appropriate planning and execution.

Dr. Pittman: This can be an issue if you’re starting off in a 100 percent aesthetic practice. However, by taking E.R. call at multiple hospitals, you should be able to get enough cases to sit for your oral boards.

Dr. Payne: It can be challenging to have enough variety for board collection if you’re solely aesthetic. One way to overcome this: Take E.R. call to get variety in your case collection.

PSR: HOW DO YOU SET YOUR CHARGES FOR AESTHETIC CASES? Dr. Buchanan: Charge what you think you’re worth and the market will tell you if you’re right. For example, in 2019 (most recent data), the average breast augmentation surgeon fee was $4,000; facility and anesthesia fees, and implants, each around $1,500, so charge $7,000. But your quote/book ratio is 10:1. The market is saying you’re too expensive. If you can’t negotiate better prices with the facility or implant seller, you’ll need to cut your fees by $1,000 just to get business.

Now you’re at $6,000 for a breast aug. After a few months of this, you see your next available breast aug surgical date is three months away. It’s time to raise prices; the demand now exceeds the value. Raise your surgeon fee some – $500, $1,000, whatever you think is appropriate. You’ll either stay busy – or maybe your available booking date goes to one or two months out (perfect; your price increase was appropriate for the market and demand), or if you raise prices, you go back to 1:10 quote/book and know to back-off the price increase. Repeat for other procedures and your practice in general. Some surgeons get paid $10,000-$20,000 for a breast aug. I assure you they didn’t start out there. They established a unique and desirable product and limited access while building value.

Dr. Pittman: First, go to the ASPS website for published average surgeon fees by procedure by region. You don’t want to be the most-expensive or least-expensive surgeon in town.

Patients view higher prices as validation that you know what you’re doing. Second, use the practice management services offered by any of the three major implant manufactures. They have data on what your area’s surgeons charge for a specific procedure, a good source of information.

Dr. Payne: One way is to see what the market allows for each procedure. Another is to estimate what you would make per hour during surgery: Calculate how long a procedure will take, then multiply that time by your determined hourly rate.

More-complicated surgeries will have a higher charge.

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LIFE AFTER RESIDENCY / continued from previous page PSR: WILL A SOLO PRIVATE PRACTICE REMAIN A SUSTAINABLE MODEL? Dr. Buchanan: As of 2019, more than 50 percent of ASPS members were in solo private practice. Another 25 percent were in a single-specialty group practice. If that model isn’t sustainable, then why are the majority of us doing it?

Some pessimists are aging-out solo private practitioners who’ve seen changes they don’t like: decreased reimbursement, more paperwork, more costs, increased marketing requirements, etc. They’ve seen their margins decrease and believe the model won’t sustain. But they’re not wrong. Others work in a different model outside private practice and it’s too much business work, or too much responsibility, too much time, whatever. They can’t imagine themselves doing it in the current climate, so they certainly can’t imagine doing it in the future.

We’ll eventually come to understand better and hopefully accept that there’s power in numbers. A group allows the sharing of overhead, staff, marketing and other costs and provides increased leverage for negotiations, etc. We’ll see more people try to make that approach work – but we’re not great at working together, so the majority of us stay in solo private practice.

What won’t be sustainable is a solo private practice model that still offers a wide variety of procedures. With dwindling insurance reimbursement overall, increased burdens of bookkeeping and documentation, increased denials of payment, etc., the insurance game is getting harder, making less money for more work. And a solo provider has no way to leverage power with the insurances to get better reimbursement – so the model is getting so squeezed that it’s almost impossible to “tread water” long enough on insurance work to wait for the “lifeboat” of elective cosmetic surgery.

Not many surgeons will have both an active cosmetic surgery practice with a broad base while maintaining a broad recon practice. The recon work increasingly will be pushed toward either large groups or institutions that can force high reimbursement from insurances and pay salaried physicians to do the work; cosmetic work will be pushed toward people who practice exclusively in the cash-pay space.

And unfortunately, the cash-pay space is getting increasingly crowded. People will pursue a recon career (employed) or a cosmetic career (private practice) after training – and the chasm between those will grow.

Dr. Pittman: For an aesthetic practice, there will always be demand. However, it may become difficult to do cosmetic cases in a hospital – cosmetic cases aren’t as profitable as insurance cases.

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Dr. Payne: As long as there’s cosmetic surgery, solo private practice can be sustainable. The question is: Will the next generation of plastic surgeons want to run their own business? As noted earlier, there are a lot of advantages to being in a group.

PSR: DO YOU HAVE ANY FINAL WORDS? Dr. Pittman: The ASPS Senior Residents Conference is good for topics such as malpractice insurance, how to avoid lawsuits, contract negotiation, etc. The most important thing is talking to surgeons in private practice to gain a better idea of what you’ll be getting yourself into and how to succeed.

Dr. Payne: Your three important advisors are: accountant, lawyer, banker. Also, your marketer; don’t rely only on a website designer to market your practice. In addition, never underestimate the power of creating a business plan and a budget. Finally, stay lean in your personal expenditures.

Learn your budget’s assets and liabilities. Most physicians are financially illiterate and mistake a liability for an asset – then learn the hard way that they’re losing big money.

Don’t buy a large house unless until you can truly afford it.

Large-ticket items like a new luxury car and a large house will cost two to five times more than you estimate or the salesperson will admit. | Dr. Parikh is PGY-6 at Houston Methodist Hospital.

Let PS2 focus on the business of your practice – including getting your start PS2 comprises a team of highly trained professionals who know the most effective ways to open, manage and bill for plastic surgeons. From staff training and retention to project management, increased conversion rates and best practices, PS2 will bring the expertise you need, forged through extensive, hands-on experience. PS2 can help every facet of your plastic surgery practice, including starting your practice – find out just what it can do for you. To learn more, log-in to the ASPS website at plasticsurgery.org/ps2-practice-management; send e-mail to Jennifer Cross at jcross@plasticsurgery.org; or call (847) 228-3320.

Working to reinvigorate outreach

Inclusion, expansion, diversity – with an international perspective

I

By Lisa Gfrerer, MD, PhD Resident Representative ASPS/PSF Board of Directors

nternational collaboration and communication among plastic surgeons, residents and medical students fosters advances in plastic surgery patient care, as well as research and innovation. Diversity among trainees and graduates promotes inclusion of different backgrounds, viewpoints and ideas, which allows for expansion of the plastic surgery horizon. As part of the global plastic surgery community, ASPS and its Residents Council (RC) share a great interest in promoting international exchange and diversity to create lasting partnerships – and to unite plastic surgeons and trainees around the world.

As an international medical graduate training in the United States, I’ve continued to cultivate my relationships with international peers and have participated in many efforts to promote multicultural inclusion. This year, as part of my role as resident representative to the ASPS/PSF Board of Directors, I plan to expand existing RC projects to include international trainees and surgeons, as well as create new projects to encourage diversity and international teamwork.

The RC has created a subcommittee designed to identify areas of improvement that focus on international inclusion and diversity, in order to tackle relevant and timely problems that the plastic surgery community is facing – and then act upon these concerns. In addition, we’re planning to expand the Society’s recently launched Professional Resource Opportunities in Plastic and Reconstructive Surgery Education and Leadership (PROPEL) mentorship program to include international members, residents and medical students. This expansion

will improve diversity among ASPS members and residents, and the global reach of ASPS. A specific sub-focus of this project will be the recruitment of unrepresented or underrepresented plastic surgeons and residents throughout the ASPS community.

We further plan to include a section for international medical graduates and researchers in an upcoming ASPS medical student web-based platform titled “Medical Student to Plastic Surgery Resident: A ROADMAP (Recruitment of Accomplished & Diverse Medicalstudent Applicants into Plastic Surgery) to Success.” (Click on “Community,” followed by “Resident & Fellows;” then “Residents & Fellows Forum,” followed by “Subscriber Benefits;” then on “Medical Students Forum.”) The objective of this is to guide international researchers and medical students early in their plastic surgery career.

Finally, we’re hoping to collaborate with international ASPS sister societies to include their members and trainees in RC activities.

I hope to get the chance to speak to more of my national and international resident and medical student colleagues, and to provide mentorship and support in their professional development. The RC and I hope that we can contribute to the unification of the international community – even in times of unprecedented challenges. | Dr. Gfrerer is an international medical graduate and chief resident in the Mass General Brigham Plastic and Reconstructive Surgery program at Harvard Medical School.

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HELP AND ADVICE ON YOUR BOARD EXAMS

By Plastic Surgery Resident Staff

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

• Be selective. The board has set a limit to the number of

The ABPS mission is “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” – and the administration of the annual ABPS Written Examination and Oral Examination are primary ways through which to meet this charge. This year, the written exam took place May 11; the virtual oral exam will be held Nov. 12-14.

• Everyone makes mistakes. Don’t try to cover them up –

CASE IN POINT

• The ABPS will review your billing practices. Understand

Candidates for the ABPS Oral Exam are required to submit all cases performed during a nine-month practice period. To be eligible for this exam, candidates must reach a minimum of 50 major operative cases. The case list must also have sufficient diversity and complexity to allow adequate evaluation of the candidate’s knowledge and skills. The candidate will be examined on seven cases, selected by the Oral Exam Committee, during the Case Report session of the November exam. In addition to the Case Book session, candidates will also be examined on theory and practice cases designed 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.

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.

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Plastic Surgery Resident | Summer 2021

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. instead, demonstrate to the examiners what you’ve learned from this experience.

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

• Though not required, the inclusion of intraoperative pictures can help to explain your cases.

the reason behind the submission of every CPT code and be prepared to explain the rationale.

Preparing for the oral board exam can be stressful, overwhelming and isolating, but support is available. Plastic surgery residents are encouraged to register for the 2021 ASPS Oral Board Preparation Course, hosted virtually on two consecutive weekends, Aug. 7-8 and Aug. 14-15.

Registrants may also sign up for an oral exam simulation session slated for Sept. 18; these have been rated highly 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 highyield responses to clinical questions.

Register for the course by visiting PlasticSurgery.org/BoardPrep; by calling (800) 766-4955 or (847) 228-9900; or by sending email to registration@plasticsurgery.org. |

ASPS PRIDE FORUM

SOCIETY CREATES A NEW RESOURCE FOR LGBTQIA+ ATTENDINGS AND RESIDENTS

W

By Arya Akhavan, MD

ith the increasing acceptance of LGBTQIA+ issues and the recent expansion of gender-affirming medical and surgical care, one would expect that LGBTQIA+ representation in medicine would be increasing. Certainly, some specialties have expanded or formalized LGBTQIA+ subgroups or advocacy committees. However, for a specialty that does so much for transgender patients, plastic surgery historically has provided a somewhat low level of visibility for LGBTQIA+ surgeons and trainees – and no unified or coherent resource for surgeons or residents who plan to make gender-affirming surgery a large part of their practice.

Some medical students applying to plastic surgery are still being advised to hide their sexual orientation or gender identity during residency applications – just like I was – and a recent study in PRS Global Open reported that LGBTQIA+ residents and attendings are still subject to prejudice and discrimination.

Research from #timesupprs even suggests that one in five LGBTQIA+ residents would not feel comfortable discussing their same-sex partner with attendings.

‘I HAD TO TRY’

Given that context, when some of my female colleagues were discussing the high value they placed on the existence of the ASPS Women Plastic Surgeons Forum (WPS), I had an idea. Why not form our own equivalent of WPS, but for LGBTQIA+ identified plastic surgeons? I was the only openly gay resident at my residency program, and had nearly no openly LGBTQIA+ contacts within plastic surgery. To be honest, I thought the idea would gain no traction and likely go nowhere – but given the Society’s continued push for diversity and inclusion, I had to try.

I brought up the idea to a good friend, Wendy Chen, MD, the founder of #timesupprs and a strong advocate for inclusion and diversity in plastic surgery. She pointed me to a number of LGBTQIA+ plastic surgery residents, who all commented on how valuable they would find such a group. After a few discussions with John Pang, MD, director of the transgender center and gender surgery Fellowship at Mt. Sinai, he and I brought the proposal to ASPS leadership.

IMMEDIATE SUPPORT

The response I had was mind-blowingly positive. ASPS President Joseph Losee, MD, and ASPS/PSF Vice President of Health Policy & Advocacy Gregory Greco, DO, were immediately on board and highly encouraging. Not only is the Society actively working on expanding diversity initiatives, but under the guidance of ASPS/PSF Vice President of Membership Steven Williams, MD, ASPS is also developing various subgroups similar to WPS but with different target audiences. The timing couldn’t have been better.

We are proud to announce the creation of the new ASPS PRIDE Forum. We plan to develop programming and resources to support LGBTQIA+ plastic surgeons and residents, create a network LGBTQIA+ plastic surgeons and facilitate career advancement, as well as advocate for our LGBTQIA+ patients. Although the forum is brand new, we have every intention to grow the group into something sustainable, with long-term positive impacts on LGBTQIA+ surgeons and our LGBTQIA+ patients.

Dr. Akhavan is PGY-4 in the University of North Carolina Division of Plastic and Reconstructive Surgery.

Plastic Surgery Resident | Summer 2021

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Journal Club; 2021 Summer; (23)

1. A placebo-controlled surgical trial of the treatment of migraine headaches

Guyuron, B., Reed, D., Kriegler, J. S., Davis, J., Pashmini, N., & Amini, S. (2009). Plast Reconstr Surg, 124(2), 461-468 This study presents the highest-rated evidence for the efficacy of headache surgery. Patients reporting frontal, temporal or occipital pain sites were randomized to either surgical treatment of that site or sham surgery, with significant improvement in pain and elimination of migraines in a majority of those receiving true surgery – although a notable placebo effect was noted.

2. Five-year outcome of surgical treatment of migraine headaches

JOURNAL ARTICLES ON

MIGR AINE SURGERY EVERY

PLASTIC SURGERY RESIDENT

SHOULD READ

By Casey T. Kraft, MD & Jeffrey E. Janis, MD

C

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Guyuron, B., Kriegler, J. S., Davis, J., & Amini, S. B. (2011).

Plast Reconstr Surg, 127(2), 603-608 After demonstrating the efficacy of headache surgery in a placebo-controlled trial, Dr. Guyuron, et al., demonstrated that this effect is durable over a five-year time frame, addressing any concerns regarding a placebo effect in the initial trial. All measured variables improved significantly, with a large percentage of patients reporting complete elimination of migraine headaches.

3. The anatomy of the greater occipital nerve: Part II. Compression point topography

Janis, J. E., Hatef, D. A., Ducic, I., Reece, E. M., Hamawy, A. H., Becker, S., & Guyuron, B. (2010). Plast Reconstr Surg, 126(5), 1563-1572 In order to properly address migraine trigger points, all areas of compression must be released. This anatomic study identified and analyzed the six primary compression points of the greater occipital nerve that must be released in these patients. This elucidation of compression anatomy resulted in changing the surgical approach to this trigger site. Mastery of this anatomy is essential for any surgeon looking to perform these procedures.

hronic migraine can be a debilitating condition, affecting more than 35 million people in the United States alone. It’s also associated with more than $1 billion in annual medical costs as well as a significant societal burden, with more than $16 billion in lost productivity in the United States. More than a third of patients with migraine headaches don’t find benefit in traditional treatments, and those who gain some relief often don’t achieve complete or lasting results.

4. Migraine Surgery

Bahman Guyuron, MD, in 2000 pioneered a surgical approach that has proven helpful to countless patients, in particular those who’ve failed first-line medical therapies. Many diagnostic modalities exist to help identify trigger sites in these patients, including nerve blocks; onabotulinumtoxin type A; Doppler evaluation; and CT scans. Over the last 20 years, substantial evidence has been published on the efficacy of this type of surgery, which has been reproducible by many surgeons across the world.

The following 11 articles provide a comprehensive summary of the relevant anatomy, detection methods, surgical techniques and treatment modalities necessary for a deeper understanding and better management of migraine headaches.

5. Targeted peripheral nerve-directed onabotulinumtoxin A injection for effective long-term therapy for migraine headache

Plastic Surgery Resident | Summer 2021

Gfrerer, L., Austen Jr, W. G., & Janis, J. E. (2019) Plast Reconstr Surg GO, 7(7) This article is an excellent primer for those looking to break into migraine surgery, as it highlights critical aspects of all elements of care for these patients. Proper diagnostic workup, anatomy, surgical techniques and postoperative care are all covered – with detailed videos to help those interested in treating this patient population.

Janis, J. E., Barker, J. C., & Palettas, M. (2017).

Plast Reconstr Surg GO, 5(3)

While not as efficacious or cost-effective as surgical treatment, targeted Botox® injections can be used for long-term

management of migraine headaches and can be associated with reduced costs compared to other, more diffuse, injection methods. For patients unwilling or unable to undergo surgical intervention, this remains an important treatment modality.

6. Supraorbital rim syndrome: definition, surgical treatment, and outcomes for frontal headache Hagan, R. R., Fallucco, M. A., & Janis, J. E. (2016).

Plast Reconstr Surg GO, 4(7)

For patients suffering from frontal migraine headaches, complete decompression of the supraorbital and supratrochlear nerves is essential. Supraorbital rim syndrome is an all-encompassing term for compression of the supraorbital nerves within the corrugator muscle as well as possible constriction via bony foramina or notches with fascial bands. This study helped better elucidate the relevant anatomy and – similar to the third article mentioned above – helped redefine the surgical approach to this trigger site based on improved anatomical understanding.

7. A review of current evidence in the surgical treatment of migraine headaches

Janis, J. E., Barker, J. C., Javadi, C., Ducic, I., Hagan, R., & Guyuron, B. (2014). Plast Reconstr Surg, 134(4S-2), 131S-141S This review article serves as an excellent reference point for those interested in the surgical treatment of migraine headaches. It provides a comprehensive overview of the evidence for surgical interventions for different trigger sites, as well as the anatomic and clinical studies demonstrating their efficacy.

8. The current means for detection of migraine headache trigger sites

Guyuron, B., Nahabet, E., Khansa, I., Reed, D., & Janis, J. E. (2015). Plast Reconstr Surg, 136(4), 860-867 Detection of all migraine headache trigger-sites affecting a patient is essential for proper management and treatment.

This study highlights the authors’ algorithm for identifying all trigger sites requiring treatment for each patient based on history and physical exam, allowing surgeons to maximize the chances of success.

9. Migraine surgery: An all or nothing phenomenon?

Prospective evaluation of surgical outcomes Gfrerer, L., Hulsen, J. H., McLeod, M. D., Wright, E. J., & Austen Jr, W. G. (2019). Annals of surgery, 269(5), 994-999

The authors in this study prospectively studied 83 patients receiving surgical treatment for migraine headaches. While the study continues to highlight the efficacy of surgical treatment, the authors most notably recognized that the majority of patients either had substantial improvement in symptoms or almost no improvement – with very few patients falling in between. This importantly highlights that while surgical treatment can be efficacious, proper patient selection is essential.

Cost-effectiveness of long-term, targeted 10. onabotulinumtoxin A versus peripheral trigger site deactivation surgery for the treatment of refractory migraine headaches Schoenbrunner, A. R., Khansa, I., & Janis, J. E. (2020).

Plast Reconstr Surg, 145(2), 401e-406e

Botox® has been used for a number of years to treat migraine headaches and is most effective when injected into specific trigger sites. This study evaluated the cost-effectiveness of surgical decompression versus targeted Botox® injection and found that surgery resulted in cost-savings at an average of 6.75 years after the initiation of treatment. This consideration is particularly important knowing that targeted Botox® injections must be continued indefinitely for effective management of migraine headaches.

ADDITIONAL READING 10a.

Patient pain sketches can predict surgical outcomes in trigger-site deactivation surgery for headaches

Gfrerer, L., Hansdorfer, M. A., Ortiz, R., Nealon, K. P., Chartier, C., Runyan, G. G., Zarfos, S.D., & Austen Jr, W. G. (2020). Plast Reconstr Surg, 146(4), 863 Determining appropriate candidates for headache surgery can be challenging, particularly for surgeons just starting to perform these procedures. Questionnaires can have difficultly conveying the entire picture of a patient’s pain, particularly for more complex patterns. The authors describe their experience having patients sketch the origin and path of their headache. Patients with atypical pain sketches were found to be less likely to have significant improvement in symptoms after surgery. This tool can help surgeons identify appropriate surgical candidates for headache surgery and simplify complex pain patterns. |

Additionally, ASPS in 2018 released a policy statement that reviewed the evidence for migraine surgery and determined that trigger-site surgery is safe and effective for patients suffering from trigger point-related migraine headaches.

The official statement can be found at plasticsurgery.org/ Documents/Health-Policy/Positions/ASPS-Statement_ Migraine-Headache-Surgery.pdf.

Dr. Kraft is PGY-5 in the Ohio State University Wexner Medical Center Department of Plastic Surgery; Dr. Janis is a professor of plastic surgery, neurosurgery, neurology and surgery at Ohio State Wexner Medical Center, chief of plastic surgery at University Hospital and ASPS past president.

Plastic Surgery Resident | Summer 2021

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PLASTIC SURGERY PERSPECTIVES – PART I

MICROSURGERY “Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, at the Sackler School of Medicine at Tel Aviv University, and Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. Although our blog is still on temporary hiatus, I didn’t want this timely entry to go unread. Please enjoy this roundtable interview in which Dr. Brown interviews Peter Neligan, MD, and David Song, MD, MBA, in Part I of a multi-part series featuring leaders in microsurgery.

Interview by Stav Brown, MD Research Fellow Memorial Sloan Kettering Cancer Center Peter Neligan, MD Dr. Neligan, 2009 The PSF president, is University of Washington professor and director of the Center for Reconstructive Surgery, editor-in-chief of Plastic Surgery and editor emeritus of the Journal of Reconstructive Microsurgery.

David Song, MD, MBA Dr. Song, 2016 ASPS president, is executive director for MedStar Plastic & Reconstructive Surgery and professor and academic chair for the Department of Plastic Surgery at Georgetown University Medical Center.

PSR: WHY DID YOU CHOOSE PLASTIC SURGERY – AND MICROSURGERY IN PARTICULAR? Dr. Neligan: I chose plastic surgery by accident. I didn’t know what plastic surgery was as a medical student. However, I interned on the plastic surgery service and got hooked. I loved microsurgery when I was first introduced to it and immediately wanted to do it.

Dr. Song: Microsurgery made an impression on me when I was a third-year medical student on orthopedics, walking home at 2 a.m. at Harbour-UCLA. I walked in one of the O.R.s and the surgeon was reattaching a finger. I was immediately drawn to it; I stayed for the whole operation and realized that this is what I was going to do. The finger turned pink again and I was blown away. There were very few integrated programs when I trained, so I did general surgery first, plastic surgery and then an additional year as a microsurgery Fellow.

PSR: HOW HAS MICROSURGERY CHANGED SINCE YOU BEGAN? Dr. Neligan: Microsurgery has become more sophisticated; at first, we were able to do replants, then we graduated to filling holes. Instruments, sutures and microscopes improved – as did our knowledge of anatomy – and we were able to develop more sophisticated flaps and also consider donor-site morbidity.

Dr. Song: It’s no longer magical – it’s routine, a tool that everyone can use. Also, the different types of flaps from myocutaneous free flaps to perforator flaps, to freestyle flaps and what I do – supermicrosurgery and lymphatic and perforator to perforator. We’ve seen a gradual shrinking of the specialty from big vessels to 0.3mm and 0.2mm vessels, along with the fact that everyone can do this and we’re training young people very well.

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Plastic Surgery Resident | Summer 2021

PSR: WHAT ARE YOUR MAIN INTERESTS WITHIN MICROSURGERY? Dr. Neligan: Lymphatic surgery and perforator flaps.

Dr. Song: Supermicrosurgery, lymphatic surgery. Also, bringing sensation back to deep flaps is something I now do routinely.

From a research perspective, we’re looking at “Big Data” and how we can better model healthcare delivery. A lot of disparities exist in the United States; if you’re a certain zip code, race or income, access to complex reconstruction is significantly less than being in a better neighborhood with higher income, the white race and so forth. We’re looking at that on a different level and how to model it better. We also launched our ERAS protocol a couple of years ago and that’s now become routine.

PSR: TELL US ABOUT A CLINICAL CASE OR ASPECT THAT’S INFLUENCED YOU. Dr. Neligan: No single case stands out; I just thought the concept and execution of microsurgery was elegant when I was first exposed to it.

Dr. Song: I’ve performed a few twin-to-twin transplants; I like that aspect of treating using the same protocol as VCA, but it’s not an allograft – it’s an isograft. My hope, and what I love to see, is that young people figure out how we could make transplantation more routine, the same way we have for microsurgery. To accelerate that, we must develop a better way to determine immune tolerance. There are tremendous benefits to doing transplantation – not just for lifesaving purposes, but also for delivering quality-of-life-enhancing treatment to patients placed under a substantial burden of disease.

We’ve seen face, penile and uterus transplantation, which demonstrates the different ways of utilizing that technology. It won’t be far-fetched in the future to transplant body parts such as the ear, finger and nose. Imagination is the only limitation.

PSR: WHAT ROLE DOES TECHNOLOGY PLAY IN MICROSURGERY? Dr. Neligan: It’s very important. When I started my career, our options were limited by sutures, instruments and microscopes.

These have all improved significantly. Robots are now being developed for microsurgery, and I think we’re about to see some exciting new developments. Also, “heads up” systems are starting to appear.

Dr. Song: Technology is key. By using “Big Data,” and using EHRs to feed into a modeling routine, there are a lot of ways we can tailor reconstructive outcomes and options.

A lot of things now utilize technology to modelize sick patients or complications – and that’s gotten really good at predicting

things from happening, through machine learning and artificial intelligence to mine the data and tailor the best-suited flap for each patient according to different parameters such as cancer stage, body habits, BMI, etc., in order to improve outcomes.

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF MICROSURGERY? Dr. Neligan: New techniques and solutions, and the new horizons that technology will open up.

Dr. Song: The young generation. Information travels so fast now; with this phone, you have in hand every single article ever written in PRS and textbooks... The cloud has a tremendous amount of information at your fingertips.

When I was a resident, we would go to the library and locate a book, Xerox it and read the article. It excites me because information that’s so fast and ready will allow really smart people to innovate faster and consider things we’ve never considered before.

PSR: WHAT’S YOUR ADVICE FOR A RESIDENT INTERESTED IN A MICROSURGERY FELLOWSHIP? Dr. Neligan: Choose a Fellowship that gives you what you want. Some are heavy in a particular area – e.g., breast – and if this is what you want, great. For a more general Fellowship, go for that. My feeling is that the more general, the better. Be open to new ideas and explore areas you’re not familiar with.

I want a hard-working Fellow, someone who doesn’t mind working a 15-hour case, who’s inquisitive and ready to try new things. And I want honesty.

Dr. Song: Just dive in. Microsurgery isn’t just a technique, it’s a lifestyle, and that’s the key that people have to understand.

Read, interact, go to meetings, write papers, get to the leaders in our field and become an outstanding microsurgeon.

Plastic surgery is very open and friendly, but microsurgeons are more accessible and friendly. We also have social media such as Instagram and Twitter, and there’s an entire Facebook group on microsurgery. Become a part of it all and just dive in.

There are two types of people who go into a microsurgery Fellowship: One, those who already know how to do microsurgery but want to refine their skills and be academic.

Then there’s the other type: Those who come to us to learn how to do microsurgery, since not all places have good microsurgery training as part of residency. These two types are very different, but the commonality is work ethic, honesty and stubbornness to achieve perfection. These are what I look for in a microsurgery Fellow: people who are super-honest with themselves and with me; who are hardworking; and who are absolutely critical in looking to be perfect. | Plastic Surgery Resident | Summer 2021

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Aug. 7-8 & Aug. 14-15 (Course)

Our efficient two-weekend format means less time away from your weekday practice!

Sept. 18 (Oral exam simulations*) Attend a trusted and comprehensive virtual Oral Board Examination Prep Course with expert and experienced faculty.

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