Plastic Surgery Resident, Summer 2022

Resident Events at #PSTM22

Senior Residents Conference

Thursday, Oct. 27 | 8 a.m. to 3:30 p.m. (ET)

Boston Convention and Exhibition Center

Gain a better understanding of what to expect and how to prepare for life after residency. Learn about the financial, legal, and ethical issues of establishing and running a practice.

Requires a separate registration. SRC registration includes access to Residents Networking Reception as well as access to the Allergan Aesthetics KEYS Program Lounge.

Resident Networking/Mentorship Reception

Thursday, Oct. 27 | 6 to 7 p.m. (ET)

Omni Boston Hotel at the Seaport

Enjoy drinks and light appetizers with well-known expert faculty and other residents in the specialty. Seize the opportunity to network with veteran plastic surgeons and get their insights on the next steps in your career.

Residents Bowl

Friday, Oct. 28 - Sunday, Oct 30 | Exhibit Hall

Don’t miss this year’s Residents Bowl occurring every day in the Exhibit Hall, with the final victory match scheduled on Sunday at 11 a.m. View the full game schedule online!

The Senior Residents Conference, Resident Networking/Mentorship Reception, and Residents Bowl are supported by Allergan Aesthetics, Mentor Worldwide, LLC, Advanced Reconstructive Surgery Alliance and MTF Biologics.

2022 Allergan Aesthetics KEYS Program Lounge

Maximize your time at Plastic Surgery The Meeting 2022 and visit the Allergan Aesthetics KEYS Program Lounge – a comfortable space designed specifically for residents. Relax and enjoy this benefit of our in-person annual meeting. Make the Allergan Aesthetics KEYS Program Lounge a key destination during your stay at #PSTM22 to network with peers, connect with leading experts, and celebrate your accomplishments. Allergan Aesthetics KEYS Program Lounge is supported by Allergan Aesthetics.

Resident Scientific Paper Presentations

Friday, Oct. 28 | 8 to 9 a.m. (ET)

The authors of the top-rated 50 resident abstracts will be invited to present live podium presentations in dedicated sessions at #PSTM22. The remaining accepted abstracts will be offered on-demand (resident must be registered for PSTM to submit a recorded video).

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Table

Contents

A foundation in Ukraine:

Mission trips and site visits form a base . . . . . . . . 5

ASPS members who’ve traveled to Ukraine to bring surgical relief and training recall their efforts in a war-torn nation.

On the ground in Ukraine:

How The PSF has prepared one surgeon . . . . . . . 9

Pavlo Badiul, MD, PhD, MSc, took his U.S. training and brought it back to Ukraine, where it made an enormous impact.

Consult Corner:

Treating the youngest of the young . . . . . . . . . 10 How to approach, address and solve the problems that can arise with neonatal and other pediatric populations.

Program Peek:

Penn State Hershey Health Medical Center . . . . 13

Discover the nation’s oldest multidisciplinary cleft-care clinic, as well as a residency program now in its 50th year.

Message From the Director:

John Ingraham, MD . . . . . . . . . . . . . . . . . . . . . . . . . 14

Residency program assistant director highlights Penn State Hershey Health Medical Center strengths – and why residents thrive.

Faculty Focus: Thomas Samson, MD . . . . . . . . . . . . . . . . . . . . . . . 16

Associate professor of Surgery, Pediatrics and Neurosurgery reveals what’s truly important for trainees to know.

24 Hours in: Hershey, Pa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

A bustling downtown center, plenty of boutique shops, a vineyard, live jazz and a resort make this a “bucket list” city.

InService Insights: Body Contouring, Part II . . . . . . . . . . . . . . . . . . . . . 18

The final installment of this body-contouring series concentrates on abdomen and lower-trunk procedures.

Journal Club: International plastic surgeons and surgery . . . . .20

Ten articles highlight the contributions of a very diverse group of plastic surgeons – and how they’ve changed the specialty.

Plastic Surgery Perspectives: Microsurgery, Part IV . . . . . . . . . . . . . . . . . . . . . . . 22

Famed reconstruction microsurgeon Fu-Chan Wei, MD, reviews his past and how he was able to excel in the specialty.

Oral Board Course: Help for resident to prepare for the examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

ASPS has created an educational opportunity for residents to gain valuable insight into this important exam.

Complex Case Challenge – Solved: Closure prior to spinal surgery . . . . . . . . . . . . . . . 25

The answer to a difficult case involving spinal complications has been revealed – did you make the right choice?

Dear Abbe

My attending isn't very supportive . . . . . . . . . . . . 26

Recurring advice column this month addresses a resident’s concerns with a hyper-critical attending.

Plastic Surgery Resident | Summer 2022 | Vol.6 N o.2

The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care, and to maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities.

ASPS PRESIDENT J. Peter Rubin, MD, MBA | rubipj@upmc.edu

EDITOR

Russell Ettinger, MD | retting@uw.edu

ASSOCIATE EDITOR Joseph Lopez, MD | joeyl07@gmail.com

SENIOR RESIDENT EDITOR Megan Fracol, MD | mfracol@gmail.com

RESIDENT EDITORS Michael Hu, MD | hums2@upmc.edu Harry Siotos, MD | Charalampos_Siotos@rush.edu Ravi Viradia, MD | rviradia1@gmail.com

INTERNATIONAL RESIDENT EDITOR Monica Zena, MD | monicazena1@gmail.com

EXECUTIVE VICE PRESIDENT Michael Costelloe | mcostelloe@plasticsurgery.org

STAFF VICE PRESIDENT OF COMMUNICATIONS Mike Stokes | mstokes@plasticsurgery.org

MANAGING EDITOR Paul Snyder | psnyder@plasticsurgery.org

ASSISTANT MANAGING EDITOR Jim Leonardo | jleonardo@plasticsurgery.org

ASSOCIATE EDITOR Kendra Y. Mims | kmims @plasticsurgery.org

GRAPHIC DESIGNER Jun Magat

ADVERTISING SALES

Michelle Smith (646) 674-5374 | Wolters Kluwer Health

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

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

ASPS Home Page: www.plasticsurgery.org

Russell E. Ettinger, MD Chief Medical Editor Plastic Surgery Resident Seattle, WA

A note from the editor

Welcome to the Summer 2022 issue of Plastic Surgery Resident (PSR)

The world has fundamentally changed since we published the Spring issue of PSR. Russian President Vladimir Putin launched a full-scale invasion of Ukraine on Feb. 24, leading to the largest war against a European state since World War II. In its aftermath, the world galvanized behind Ukraine to provide much-needed material support and humanitarian aid. We are fortunate in this issue to highlight three plastic surgeons with longstanding ties to Ukraine through medical mission trips – and who are now finding ways to deliver much-needed medical supplies to physicians treating battlefield casualties and arrange for the transport of Ukrainian pediatric patients to the United States for ongoing surgical care. Michelle Seu, BA, and Charlampos Siotos, MD, in their cover story highlight the work and insights of David L. Brown, MD, University of Michigan; Daniel N. Driscoll, MD, Harvard University; and Brian P. Kelley, MD, University of Texas and Dell Children’s Medical Group. In addition, Pavlo Badiul, MD, MSc, Dnipro, Ukraine, describes his experiences in gaining training in the United States with assistance from The Plastic Surgery Foundation. These stories illustrate the ways that plastic surgeons are making a positive impact for the people of Ukraine.

This issue also will take you – courtesy of Caroline McLaughlin, MD – to Hershey, Pa., for our Program Peek, featuring Penn State University’s Plastic Surgery Residency Program. Penn State’s residency is celebrating its 50th anniversary this year and remains a pillar within the history of plastic surgery residency training. “24 Hours in Hershey ” by Mikayla Borusiewicz, MD, provides a taste of how the program’s residents spend their time outside the hospital and highlights the robust array activities, restaurants and cultural experiences the region has to offer.

We also have an update from the American Board of Plastic Surgery with insights from Executive Director Keith Brandt, MD, on how to prepare for the oral board certification process. For those interested in pursuing microsurgery, this issue’s installment of “Plastic Surgery Perspectives” features insights from renowned microsurgeon Fu-Chan Wei, MD.

Our recurring pieces include Consult Corner, on how to approach neonatal patients; Journal Club, which features the top 10 must-read articles from international plastic surgeons; and the second installment of InService Insights, which highlights abdominal and lower-extremity body contouring. Finally, we revisit the Spring issue’s Complex Case Challenge (C3), where we reveal the reconstructive plan chosen by the treating surgeons – and present the final outcome.

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

RELIEF IN UKRAINE

HOW PLASTIC SURGEONS ARE

SERVING THE INJURED IN A WAR-TORN NATION

By Michelle Seu, BA, and Charalampos Siotos, MD

Russian President Vladimir Putin on Feb. 24 launched a full-scale invasion of the sovereign nation of Ukraine that has killed and injured hundreds while displacing millions of citizens. News of the rapidly escalating crisis spread throughout the world, sparking both a global interest in Ukraine and worldwide outrage toward the Russian government.

Nevertheless, many may not be aware of what Ukraine and its people were like outside of the ongoing conflict with Russia. Furthermore, despite the role of media in strengthening humanitarian efforts during the current war, comparably less light has been shed on the existing partnerships forged between Ukraine and its partners in the West prior to this year.

In this article, we will showcase interviews with three academic plastic

surgeons who have worked with anesthesia colleagues to deliver and develop sustainable medical care with physicians in Ukraine.

Daniel N. Driscoll, MD, serves as assistant professor of surgery at Harvard Medical School. Since 1999, he has specialized in the care and reconstruction of children with burn injuries or congenital conditions at Shriners Children’s, Boston. Dr. Driscoll has participated in several mission trips with a focus in burn care in Ukraine, Colombia and Dominican Republic.

David L. Brown, MD, is the William C. Grabb, MD, Collegiate Professor of Plastic Surgery at the Department of Surgery of the University of Michigan. His practice includes a focus on complex wound reconstruction, reconstructive neurovascular surgery and oncoplastic surgery. Dr. Brown has conducted

extensive research on tissue engineering and medical education, and he has also organized and participated in multiple mission trips in Ukraine over the past several years to treat pediatric and adult burn victims.

Brian P. Kelley, MD, practices in Austin, Texas, in affiliation with University of Texas at Austin and Dell Children’s Medical Group. His interests include wound care and burn reconstruction. He participated in the mission in Ukraine as a resident at University of Michigan and does so now as an attending.

PSR: What sparked your long-term partnership with Ukrainian surgeons and physicians?

Dr. Driscoll: Our first collaboration occurred in 2004, around the time the Orange Revolution happened. The president, who was very westward

INJURED IN A WAR-TORN NATION / continued from previous page

leaning, used the presidential plane to fly a severely burned child – more than 60 percent of her body and complicated by sepsis – to Shriner’s. We were able to save her and watch her grow up. My colleague, Der Fuzaylov, MD, who’s a pediatric anesthesiologist originally from Uzbekistan (fluent in Russian), made friends with burn doctors in Ukraine. Through that collaboration, we had dozens of other children come to Shriner’s for acute and reconstructive care. He then asked me to come with him to Ukraine. We saw various burn units and started identifying areas to improve.

Many plastic surgeons like to do mission work. For some, it is just a one-time thing, but others get more involved, find their spot and return on a regular basis. We used to go every year. Last time we were in Dnipro, not too far from the current front line. I have heard that the airport and a few other facilities in the area were bombed.

Dr. Brown: Each year, one of our senior residents and I travel with a

group of physicians from University of Michigan, Harvard, Shriners’ Hospital and Washington University to various locations in Ukraine to provide pediatric burn reconstruction surgery to children who have no access to such care. We were in Dnipro for 10 days last September – you may have seen it in the news, as the children’s hospital that was attacked. It’s so sad.

PSR: What kind of cases did you perform in Ukraine?

Dr. Driscoll: We really concentrated on pediatric burn reconstruction, scar releases and revisions. In order to prevent any serious complications, we focused our efforts on procedures such as skin grafts, Z-plasty, keloid excisions or tissue expander placement. We avoided complex operations, such as reconstruction with free flaps. If a more complex approach was necessary, we would evaluate the kid in Ukraine and then arrange travel to the United States in order to provide care at Shriner’s.

Dr. Kelley: Residents were involved in all cases. We used to take three residents per year, one typically chosen by each participating surgical attending.

PSR: Are there any particular cases that stuck with you?

Dr. Driscoll: I vividly recall a particular child with severe burn injuries (more than 70 percent of his total body) for whom Dr. Fuzaylov arranged a flight to the United States. He remained hospitalized in the ICU of Shriner’s for about five months, followed by extensive rehab. We saw him for follow-up in Boston and Ukraine quite a bit and then I remember him showing me a video of him dancing “Gangnam Style” – the whole dance, the whole thing, he had every move down. To see this kid who had 70 percent TBSA burn show that he can really dance – that was really uplifting to see.

PSR: How have you funded these efforts to Ukraine?

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

Dr. Driscoll: Rotary International, Women’s Ukrainian Relief Fund, Childrens Burn Foundation and other similar charities would help fund the trips and transport of children to Boston through MedFlight. Some children remain in Boston long-term for sustained care and observation. These endeavors were led by Dr. Fuzaylov of MGH and founder of Doctors Collaborating to Help Children (DCTHC.org). This charity funds many of the mission trips, as well as providing ongoing supply, education and burn prevention.

PSR: What barriers did you face during your mission trips?

Dr. Driscoll: Despite great preparation, the O.R. is not organized the same way as it is in the United States, and occassionally equipment was not functioning perfectly. Language barriers are also present, but we had translators available and we did learn a few Ukrainian words to communicate better with the staff in the O.R., such as ножиці (nozhytsi), which means “scissors.”

PSR: What are the most pressing medical needs you saw in Ukraine?

Dr. Driscoll: In Lviv, in particular, we realized the doctors were quite talented but lacking in resources and educational tools. Through establishing DCTHC.org, Dr Fuzaylov and I are working to fill these gaps. We also set up a telemedicine unit and provide lectures and symposia to help train and work with Ukrainian surgeons and anesthesiologists. Before the war, we were able to transport patients to Boston for special services they could not receive in their hometown, such as radiation therapy for severe keloid scarring or complex microsurgical reconstruction. We were also able to introduce CO2 lasers for scar treatment. Since the war began, several patients have been transferred to the United States. This requires a lot of

University of Michigan surgeons Brian Kelley, MD, (left) and Carrie Kubiak, MD (right), operate on the feet of a child, with the assistance of a local Ukrainian hand surgeon.

coordination – in many cases, patients and doctors reach out on social media.

Unrelated to the mission trip work, we are working on creating a textbook on simple procedures, such as skin graft application, with information on how to perform, indications and post-operative care to distribute to Ukrainian surgeons. Especially in times of war, many Ukraine physicians might need to perform procedures that are out of the scope of their specialty, so they need an easy guide. However, Ukrainian people will be mostly in need of medical care, primary care physicians and supplies such as antibiotics, sterile dressings, local anesthetics, etc.

Dr. Kelley: The greatest needs will come as the conflict dies down. Certainly, acute traumatic reconstruction is ongoing in any battlefield. However, our most critical involvement will be in the stages of secondary reconstruction. In Ukraine, even under normal circumstances, the acute care is dissimilar to the United States. Hospital stays are prolonged, the families care for many of the acute nursing needs of the patients, and surgical options are more limited.

They have the ability to save life and limb, but the resources for such things are definitely stretched thin. Almost certainly, these options are being considered sparingly now, given the economic and social costs of the war. However, in the coming years, secondary reconstruction will be paramount to returning the injured to work and function.

PSR: How has your work in Ukraine been affected by the war with Russia?

Dr. Brown: We’ve been hard at work since the crisis started. We’ve been successful in transporting significant amounts of urgently needed medical supplies directly to the physicians and hospitals that we’ve worked with in the past.

In addition, we’ve been able to transport three children, so far, to the United States for their care. With my close connection to the people there, I have found them to be incredibly kind, generous and caring. As a people, they’re proud of their freedom and are wanting to make the most of their lives following their separation from the USSR.

PSR: How can medical professionals help doctors at the front lines in Ukraine?

Dr. Brown: The recent atrocities have been difficult to watch. I’ve been busy looking for donations of supplies and recently teamed-up with World Medical Relief and Omnis Foundation to ship a cargo plane filled with supplies from here – and from Boston, with the help of our trip leader, Dr. Fuzaylov – straight to the physicians treating the wounded there. We recently spoke to news media, attempting to garner additional support from Michigan hospitals and other donors. I’m also trying to get an area hospital to sponsor treatment of a war-injured patient – our group has brought three to the United States so far to other locations. Other physicians can follow our lead in their own, similar way.

Dr. Kelley: We’ve organized supply transport through the Ukrainian

Ministry of Health. Most big medical centers have redirected their own donations through other entities, so many of those efforts have not been successful. However, any excess supplies would certainly be useful.

PSR: How can non-medical professionals assist?

Dr. Brown: We have a non-profit organization that’s set up to support our work: dctohc.org. People interested in helping can make a tax-deductible donation on the site. Every dollar will be sent directly to helping with care of injured children in Ukraine. We don’t have any overhead to cover.

PSR: What’s the future of the surgical trips to Ukraine?

Dr. Driscoll: At this point, I’m not sure. They may not happen again because of the war. We’ve considered

organizing mission trips to neighboring Poland and have kids travel there for surgery or follow-up.

When great people meet, miracles can happen and the successful mission trips in Ukraine are a great example. U.S. plastic surgeons driven by their passion established a sustained collaboration between Ukraine and the United States, and provided care to multiple children victims of burn injuries. The recent war with Russia might change the needs and the structure of this partnership, but hopefully it will not break the bridge between them. |

Dr. Seu is a fourth-year medical student at Loyola University Chicago Stritch School of Medicine; Dr. Siotos is PGY-4 at Rush University Medical Center Division of Plastic Surgery and a PSR resident editor.

Surgical team members from the United States and Ukraine gather for a debriefing and farewell following a successful week of pediatric burn reconstruction in Dnipro in September 2021.

U.S. training, assistance provides much-needed help in Ukraine

ASPS

International Member

Pavlo Badiul, MD, PhD, MSc, practices at Dnipro Medical University on the banks of the Dnieper River in east-central Ukraine. He teaches burn treatment and plastic surgery basics at his clinical base, the Burn and Plastic Surgery Centre in Dnipro, where he’s treated scores of victims of Russia’s war on his country. Dr. Badiul in 2014 received training in reconstruction, with a focus on microsurgery, under ASPS past President Gregory Evans, MD, at the University of California-Irvine (UCI), while in the United States as a PSF International Scholar. He reflected on that training and its current impact for Plastic Surgery Resident:

PSR: How has your training – and other aid provided by The PSF and ASPS –assisted efforts in Ukraine to treat those wounded in the war, as well as other trauma victims or those in need of reconstruction?

Dr. Badiul: My training with Dr. Evans in 2014 was of great importance in my professional life. I realized there were absolutely different levels of medicine and plastic surgery in particular. I tried to observe all the procedures performed in his department and learn everything I could to the fullest. Reconstructive procedures – especially microsurgical cases – were central to me.

At that time, the first Russian invasion into Ukraine had started and I knew that upon my return to Ukraine, there would be patients who needed microsurgical reconstruction. (Editor’s note: Kyiv’s Independence Square was the site of protests in February 2014 that led to more than 100 fatalities and hundreds more wounded when special riot police and protesters clashed.) After that, I completed training in other countries (Germany, South Korea, Romania), but the first important step was made thanks to The PSF International Scholar Program.

PSR: Can you discuss the importance of international help in an area of conflict such as Ukraine – where visiting surgeons provide help for local plastic surgeons?

Dr. Badiul: International help is crucial for us now. Many colleagues and friends help us in the form of delivering essential medicine, instruments and even some equipment. As to visiting plastic surgeons, we’d be happy to receive our colleagues and their help in hospitals – first of all, it means sharing experience that proves beneficial to both parties. Before the war, our friends from different countries came to our institution to perform complex reconstructive procedures with us and help with training. The situation today, however, is that the Russian army constantly shells peaceful cities and has no mercy for the civilian population, residential areas, schools or hospitals. More than 30 foreign journalists have already been killed in Ukraine; so any visit from our colleagues can be exceptionally dangerous.

PSR: How important is training young plastic surgeons to provide exposure to the kinds of wounds that you’re currently treating?

Dr. Badiul: It’s very important, of course, because we can never know when exactly we’ll need that knowledge. With the kind of conflict there is now in Ukraine, all surgeons have to face treatment of wartime wounds – and it’s impossible to remain uninvolved at such times. Taking into account the fact that the Russian invasion essentially has been happening since 2014, our doctors already have this experience and now, with the number of wounded being much greater because of an active war, our surgeons already know what to do to treat such wounds. However, in the beginning, a lot of mistakes were made, which resulted in negative consequences for the wounded.

Pavlo Badiul, MD, PhD, MSc

PSR: How do you train young surgeons during an ongoing war?

Dr. Badiul: We continued theoretical classes for our young surgeons according to the curriculum, but those were online courses. In training, all our residents were assigned to hospitals that treated wounded patients and that needed extra help. Personal preferences (of surgeons’ treatment abilities and interests) were also taken into account. Now the group of residents interested in plastic surgery and burn treatment are working with me, and they provide invaluable help to the hospital. It’s a very good and extensive practice for them. They quickly learn upto-date methods of reconstructive surgery, and they’re already treating patients on par with more experienced doctors. |

Approaching Neonates and Other Non-Adults

“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 Andrew Bonett, MD, & Christina Tragos, MD

Andrew Bonett, MD

Christina Tragos, MD

It’s Sunday afternoon and you’re on call by yourself when you receive a message about an iatrogenic newborn scalp laceration following an emergency C-section. There’s concern that it involves the face; the pediatric team has dressed it with dry gauze.

APPROACHING THE CONSULT AND CONSENT

The pediatric population ranges from neonates to age 17. Obviously, different approaches are required for patients at each end of the spectrum and for those in between. Although the teenage patient can be accompanied by parents and can’t legally sign their own consent, they typically understand the informedconsent process.

However, when seeing a consult for younger patients, you’ll interact

with one or both parents (or guardians) before and after the procedures. Make sure when introducing yourself that you verify the relationships between the pediatric patient and the adults in the room. It’s easy to assume a parent/child relationship, but don’t put it past an uncle or grandmother to willingly sign a consent for the patient. This could be through simple ignorance of the process –or intentionally deceitful. Consent should be signed by a parent or the legal guardian for any patient younger than 18 years old. If there’s uncertainty, involve your senior/ attending – and potentially your social work team – before proceeding with any procedure.

Bedside manner with pediatric patients is critical from the start. You’re likely seeing the consult because the child has a congenital problem; was injured at home or even iatrogenically; developed an infection; and so on. This is a stressful time for the parents, and it’s important to be sensitive while at the same time trying to be positive. Be cognizant of the entire situation and acknowledge the circumstances. If you see a newborn in the NICU or maternity ward, start by congratulating the parents on the birth of their child. If you see a toddler for an injury, provide early reassurance that you will take care of them and will get them through this event. The caretaker might feel guilty, so it could be helpful to try to relieve them of that weight by normalizing the situation and not placing blame. Let them know that accidents happen. Empathy is paramount.

It’s also important to consider your bedside manner when working with nurses, RTs or APPs in the NICU or motherbaby unit. Always try to find the patient’s nurse before entering the room – especially before manipulating anything. Understand that their job is also to ensure the safety and health of the patient above all else. Chances are, you don’t have a preexisting professional relationship with that team member. Thoughtfulness will not go unnoticed – and it likely will result in more assistance than you might expect.

Important note: If you suspect abuse or neglect when seeing a consult, immediately raise your concerns to your senior, supervisor or current primary provider. If the patient is in the E.D., recommend admission for observation. As a plastic surgery resident, it’s probably not your place to confront the caretaker. Still, you can still play a crucial role by ensuring the appropriate measures are taken by the appropriate parties.

NEONATE EXAM

The pediatric exam can be tricky, as these patients rarely have the capacity or attention span to participate. However, we’ve assembled a few useful tips:

• Explain to the parents what you’ll do. If the child is old enough to understand, explain the exam to them as well. Reassure them that you just want to look first and it won’t hurt. You may even want to demonstrate the exam on yourself or the parent first, so they can see that the exam is harmless. For a school-age child, asking about their shoes is a great icebreaker.

• Examine the contralateral/unaffected side first so the patient can get acclimated.

•

In addition to the focused exam, perform a comprehensive physical exam on a neonate, as certain conditions/ syndromes have associated anomalies. You also might note an unrelated finding such as overriding sutures of the calvarium that will need to be followed over time. It’s easiest to think of a quick head-to-toe exam that includes the following:

ƒ

Head shape and size (microcephaly, overriding sutures, etc.)

ƒ Fontanelles

ƒ

Ear shape, size and position (microtia, low-set, etc.)

ƒ Eyes and nose (coloboma, hypotelorism, Tessier clefts 3-6 and 8-11)

ƒ Mouth and oropharynx (cleft lip and palate, ankyloglossia)

ƒ

Mandible and lower face/neck (micrognathia, branchial cleft cysts)

ƒ

Upper/lower extremities (constriction band syndrome, polydactyly, syndactyly)

ƒ

Trunk (abdominal wall defects, spina bifida/ meningocele)

ƒ GU/anorectal (micropenis, hypospadias, imperforate anus, etc.)

•

Insert a gloved finger in the neonate’s mouth to palpate the palate and induce mouth opening/crying for better visualization

•

Be mindful that sensitive exams can be traumatic and should not be performed unless absolutely necessary starting around the late toddler years.

BEDSIDE ANESTHESIA , COORDINATION AND NICU

In most cases, almost any bedside procedure on an adult can be performed with 1 percent lidocaine with epinephrine. Pediatric patients require more consideration. Will the procedure be painful? Is bleeding expected? How much time will you need? How much local will you have to use and what’s the toxic dose? You likely ask yourself the same questions with the adult patient, but there are more limiting factors with the pediatric patient. Similar to the physical exam, babies and children are less likely to participate or hold still, so you will also need to gauge the parents’ ability and/or willingness to participate.

Sedation and general anesthesia should be avoided if possible, as they add unnecessary risks such as respiratory depression, arrhythmias, aspiration, loss of airway, etc. However, procedures that are expected to be complex, timeconsuming, or near vital or sensitive structures require complete control, so general anesthesia or deep sedation may be warranted. If in doubt, have a multidisciplinary discussion with the family, pediatrics, ED, anesthesia or NICU teams. Remember the adage: “Expect the best but prepare for the worst.” The last thing you want is to have concern for a child’s airway and not have anesthesia on hand.

BEDSIDE LACERATION REPAIR

Once you determine that a laceration can be repaired at the bedside, you will need to obtain consent from the parents and gather your supplies. Run through the entire procedure in your head – from prep to dressings – so that you don’t forget anything. Your list will include:

• Alcohol, betadine, chloraprep for skin prep

• Local anesthetic, appropriate syringes and needles

• Sterile gloves for you and your assistant

• Saline irrigation

• Laceration repair kit (preferably, a minor procedure tray)

• Plenty of suture

• Dressings (skin glue, steri-strips, gauze, tape, etc.)

Discuss suture choice with your attending or senior. If possible, an absorbable suture is usually preferable to avoid a suture removal visit that could be painful for the patient (as well as you and the parents, albeit on a different level). It’s vital that you understand how to calculate concentrations and avoid toxic levels of common anesthetics. Depending on what you read, the maximum dose for lidocaine is 4-5 mg/kg without epinephrine and 7mg/kg with epinephrine. For bupivacaine, it’s about 2mg/kg plain and 3mg/kg with epinephrine.

Remember that a 1 percent lidocaine solution has 1g per 100ml, or 10mg/ml. For example, if you are planning to use 1 percent lidocaine with epi for a 6kg patient, the maximum allowable dose is 6kg x 7mg/kg = 42mg. Since the bottle contains 10mg/ml, simply divide by 10 and draw up no more than 4.2ml. To keep it safe and simple, the maximum dose used for this solution is 1cc/kg. |

Dr. Bonett is chief Fellow in the Plastic and Reconstructive Surgery Residency Program, and Dr. Tragos is an assistant professor in the Division of Plastic and Reconstructive Surgery, at Rush University Medical Center, Chicago.

Newborn with a unilateral, complete cleft lip and palate. All images have been approved for use by children’s families.

HISTORY

• The residency program celebrates its 50th anniversary this year.

• The Lancaster Cleft Palate Clinic is the oldest multidisciplinary cleft care clinic in the nation and continues to serve our Penn State cleft patients.

• Our faculty has included multiple ABPS chairs and presidents of several of the major societies.

LEADERSHIP

• Donald Mackay, MD, DDS: Interim Chair, Department of Surgery; clinical expertise includes cleft, craniofacial and orthognathic surgery

• T. Shane Johnson, MD: Chief, Division of Plastic Surgery; clinical expertise includes hand surgery, head and neck reconstruction and breast reconstruction

• Thomas Samson, MD: Surgeon-inChief, Penn State Health Children’s Hospital; clinical expertise includes cleft, craniofacial and pediatric plastic surgery

• John Ingraham, MD: Residency Program Director; clinical expertise includes skin oncology, hand surgery and limb salvage

• John Roberts, MD: Residency Program Assistant Director; clinical expertise includes hand surgery and limb salvage

• Randy Hauck, MD: Chief, Division of Hand Surgery; clinical expertise includes hand surgery

• Dino Ravnic, DO: Chair, Regenerative Medicine and Surgical Sciences; clinical expertise includes reconstructive microsurgery

• John Potochny, MD: clinical expertise includes breast reconstruction and aesthetic surgery

• Cathy Henry, MD: clinical expertise includes cleft and craniofacial surgery and breast reconstruction

• Kavita Vakharia, MD: clinical expertise includes skin oncology and hand surgery

NATIONAL LEADERSHIP

• Dr. Mackay: Past President of the American Association of Plastic Surgery; Past Chair of the ABPS; Past President of the American Society of Maxillofacial Surgeons; Past President of the American Council of Academic Plastic Surgeons; Chief Medical Officer of Operation Smile

• Dr. Hauck: ASPS InService Examination Committee; Advisory Council of the ABPS

PENN STATE HERSHEY MEDICAL CENTER

• Prior to the hospital’s opening in 1970, the chairman of the Hershey Chocolate Corporation called the Penn State president to discuss building a teaching hospital and medical school in Hershey to care for Hershey employees – this is termed the “$50 million phone call” due to the gift Hershey gave to create the institution.

• The medical center has steadily grown in the past 50 years, recently acquiring multiple community hospitals in the region.

• Penn State Health serves 19 counties in Pennsylvania and is the only Children’s Hospital in the region.

CLINICAL EXPERIENCE

• Two residents per year.

• Work with 10 core faculty and three private-practice community plastic surgeons.

• Alternate hand-trauma call every other day with orthopaedic surgery and face trauma call every other month with ENT.

• All call is at our single, primary institution.

• Exposure to the oldest multidisciplinary cleft clinic in the nation.

• Robust multidisciplinary rotations in PGY 1-3, including head and neck oncology, oculoplastic surgery, abdominal wall reconstruction, limb salvage and orthopaedic hand surgery.

• One-month burn rotation at Hopkins Bayview Medical Center in Baltimore.

• Private-practice experience for six months throughout PGY 5-6.

• Early exposure to cosmetic practice through Esteem Cosmetic Clinic in Harrisburg, Pa., where we host resident-run injection clinics under the guidance of attendings.

• During the final year, chief residents run an autonomous clinic spanning all aspects of reconstructive and aesthetic surgery to simulate transition into practice.

A Message From the Program Director, John Ingraham, MD

We’re all familiar with the wonderful breadth and depth of plastic surgery, a fact enjoyed by faculty, residents, and students alike. Despite not being in a large city, our fully integrated plastic surgery residency program at Penn State Health Hershey Medical Center sees no lack of this incredible variety through our expansive catchment area in the central state; our Level 1 adult trauma center; and the only Level 1 pediatric trauma center in south-central Pennsylvania.

We treasure what we have here – a relatively young but thriving legacy culminated through the strong leadership and lasting examples of our prior division chiefs, William Graham III, MD (1971-85, 1996-99); Ernie Manders, MD (198595); and Donald Mackay, MD, DDS (19992018). Dr. Mackay moved on to his current position as interim chair of the Department of Surgery, but among many other challenges, his leadership, intuition and initiative were paramount in guiding us through the early and most uncertain months of the COVID-19 pandemic. Similarly, our current chief, Shane Johnson, MD, proved to be an incredible role model during this time and continues to build and support our thriving, 10-member division.

Our division has also been fortunate to share close ties with the Lancaster Cleft Palate Clinic (LCPC), which began in 1938 at Dr. H.K. Cooper’s orthodontics practice in Lancaster, Pa. He recognized that the complexity of care for cleft patients would be best addressed through multidisciplinary care. He teamed up with Robert Ivy, MD, a plastic surgeon from Philadelphia, with whom he performed joint clinics. This first-of-its-kind template

has served to guide the present-day cleft team accreditation requirements overseen by the American Cleft Palate Association. LCPC remains a freestanding, fully accredited cleft team that provides comprehensive cleft care. Our residents frequent this clinic where Drs. Mackay and Samson, and Cathy Henry, MD, see patients weekly. The patients undergo any needed surgery here in Hershey. It’s a dynamic and highly successful relationship.

Our residency, which became fully integrated in 2008, accepts two residents per year and has trained more than 75 residents since its inception in 1971. In addition to the unique and robust above-mentioned craniofacial exposure, our residents gain broad experience and autonomy in hand and wrist surgery, skin oncology, limb salvage, microsurgery, breast reconstruction and general plastic surgery. We’re extremely proud of our residents and take pride in watching them grow to the point at which they can perform even the most complex operations while we serve as their assistants. We know how hard they work on behalf of their education and our patients –it’s a privilege to watch them succeed in their professional and personal goals. We’re a family here at Penn State.

Our program has many accomplishments, but there are a couple in particular that I want to highlight, because they underscore two virtues we strive to instill in our trainees: the themes of

John Ingraham, MD

doing what’s best for the patient no matter what and striving for excellence.

Over the past five years – with support from Dr. Mackay and assistance from John Roberts, MD (a recent resident and now faculty) – John Potochny, MD, took the lead to globally confront the ethical imperative to inform patients of their potential risks to a novel lymphoma: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). After diagnosing our first institutional case in early 2013 and recognizing that the real risk of disease was likely much higher than initially believed, we lobbied and convinced our hospital’s legal and risk departments to act, even though ASPS had not yet adopted that position.

Over an 18-month period in 2016-18, we identified patients, informed and collaborated with other stakeholders in pathology, breast surgery and radiology, and sent certified letters to inform and treat all patients who had ever received breast implants at our institution. This landmark project was published in Plastic and Reconstructive Surgery in 2019*, the same month that breast implant manufacturer Allergan voluntarily removed all Biocell macro-textured breast implants from the world inventory.

The letters and methods that our plastic surgery division developed were subsequently customized by many other major university, academic and cancer centers in the United States and abroad to inform more patients.

The second highlight is our Plastic Surgery Research Laboratory, directed by Dino Ravnic, DO, and managed by Srinivas Koduru, PhD. The lab was previously run by the late and missed Paul Ehrlich, MD, who shed much light on the benefit of high-dose vitamin A on wound-healing in the setting of systemic steroids, among other accomplishments. Now, the laboratory’s primary research effort is geared toward the creation of autologous vascularized engineered tissue that’s suitable

for microsurgical implantation and immediate reperfusion. To achieve its goals, the lab collaborates with experts in materials science for scaffold fabrication; biomedical engineers for 3D bioprinting assembly of cells/scaffolds/ proteins; and vascular biologists for optimization of microvascular development, integration and function.

Their research is funded by several NIH and foundational awards. Since its inception five years ago, the lab has had the privilege of training more than 10 undergraduates, medical students and surgical residents. Recently, Dr. Ravnic was named the first Dorothy Foehr Huck and J. Lloyd Huck Chair in Regenerative Medicine and Surgical Sciences by the university’s Huck Institutes of the Life Sciences. This endowed chair will allow for the continued development and investigation of new plastic surgery research.

We absolutely treasure what we have here in Hershey. Although it will be virtual, we look forward to our next cycle of interviews – the yearly opportunity to add to our growing family. Many of us who’ve been fortunate to train with Dr. Mackay can recall him saying in the middle of a busy day or a great case: “Can you believe we get paid to do this?” It’s amazing that we’re paid for the privilege of caring for others through reconstructive surgery. |

*Roberts JM, Carr LW, Jones A, Schilling A, Mackay DR, Potochny JD. A prospective approach to inform and treat 1340 patients at risk for BIAALCL. Plast Reconstr Surg. 2019 Jul;144(1):4654. PMID: 31246798.

Q&A WITH WITH THOMAS SAMSON, MD

In this installment of Faculty Focus, we present ASPS member Thomas Samson, MD, associate professor of Surgery, Pediatrics and Neurosurgery, and Surgeon-in-Chief at Penn State Health Children’s Hospital, Hershey, Pa.

Dr. Samson completed medical school at Creighton University School of Medicine, Omaha, Neb., and his general surgery residency at General Mayo Clinic, Phoenix. He completed his plastic surgery residency at Milton S. Hershey Medical Center, Hershey, Pa., and a craniofacial fellowship at The Hospital for Sick Children, University of Toronto. Dr. Samson believes residents can control their own destinies by stepping forward – and must put their families before anything else. A heartfelt and meaningful response by his colleagues to a family crisis during residency drew Dr. Samson closer than ever to Penn State, where he continues his career as a respected and sought-out faculty member.

PSR: WHAT DREW YOU TO PLASTIC SURGERY?

Dr. Samson: I rotated on a craniofacial service and Day 1 consisted of a bilateral cleft lip repair followed by a sagittal synostosis repair. The combination of precise, detailed surgery with absolutely no templates to follow was exactly what I was looking for – I was hooked.

PSR: HOW DID YOU PREPARE FOR A COMPETITIVE FELLOWSHIP?

Dr. Samson: I did a general surgery residency first and set about my long-term plan on Day 1. I spent much of my free time with the plastic surgery team scrubbing cases, participating in didactics and performing research. That strategy resulted in published research in plastic surgery, as well as exposure to several plastic surgeons who subsequently played critical roles in shaping my future.

PSR: WHAT IMPACT DID THE FELLOWSHIP HAVE ON YOUR CAREER?

Dr. Samson: My fellowship was the most critical aspect of the shaping and advancement of my career as a craniofacial surgeon. You “learn” your craft during fellowship and gain exposure to mentors who will support and guide you throughout your career.

PSR: HOW IMPORTANT IS A MENTOR ON THE EARLY YEARS OF PRACTICE?

Dr. Samson: Having a mentor is absolutely vital to your early years. They act as sounding boards, long-term strategists and counselors. It’s a good thing they don’t charge for their services.

PSR: HOW HAS YOUR INVOLVEMENT IN SOCIETIES AND COMMITTEES HELPED YOUR CAREER?

Dr. Samson: Involvement in societies and committees, especially early in your career, sets the stage for your career. Academic practice lends itself to this involvement – but you have to take the first step.

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

Dr. Samson: Attention to detail. If you demand this of yourself in all you do, you will perform at the highest level and be a leader amongst others. I feel if you are going to do it, do it right.

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

Dr. Samson: Prioritize and stick to it. Family is Priority No.1 for me and always will be. When I’m at work, I focus and commit. When I leave work, my focus shifts to my family. You only get one chance to be there for your family – don’t compromise them.

Hershey, Pa.

By Mikayla Borusiewicz, MD

Y

ou’re advised to start your morning in Hershey, Pa. – an unincorporated community of about 15,000 residents in south-central Pennsylvania – with a cup of locally sourced coffee at the Cocoa Beanery. This purveyor of caffeine inhabits a storied farmhouse that first appeared on county maps in 1858 and boasts a front lawn that doubles as grounds for the local farmers market in the summer and a venue for a summertime concert series. If you’re feeling particularly caffeinated, several scenic paths radiate in all directions through local parks and across picturesque Hershey farmland. The Beanery sits at the base of a hill that boasts a well-traveled running trail – and where locals assemble during summer evenings for the most spectacular sunset displays in town.

From there, head about six miles west to downtown Harrisburg for a midmorning refill at Little Amps Coffee Roasters – a hip, downtown corner coffeeshop at the midpoint between the capitol building and the running trails along the Susquehanna riverfront. It’s brimming with retro décor, robust house brews and a bevy of dairy alternatives fit for the modern age. Just a few minutes down the road is historic Broad Street Market,

which delivers a parade of vendors peddling a satiating blend of local and international delicacies and hand-crafted wares for five city blocks. A fabulous place to people-watch, and just a few cattycorner steps away, proudly sits Midtown Scholar Bookstore. A local epicenter of art and literature, this historic bookshop is a hometown favorite and a trove of new and used prints. Its bright and bustling upper floors present a cheery front for the winding labyrinth of rare and antique books that lies in the basement below.

Spend the afternoon exploring Hershey’s namesake chocolate-related attractions, catch a ride on a few rollercoasters or watch the Hershey Bears face-off with the mid-state’s ice hockey fans at the Giant Center. Try Spring Gate Vineyard and its food trucks for delicious food and beverages in a great outdoor space; Troegs Independent Brewing for craft beers and an upscale snackbar; or Mellow Mink if you’re looking for a variety of craft brews, sours and ales in an all-inclusive taproom. Finish the evening at the grand Hotel Hershey, an iconic and sprawling resort outfitted with a luxurious spa and a handful of deluxe and popular bars and restaurants. If you’re lucky, you’ll catch some live jazz on the hotel veranda – a surefire hit every Friday night, all summer long.

For dinner and desserts, sample appetizers during trivia challenges at Rotunda Brew Pub and chase them with the unbeatable confections next door at Desserts, Etc. Or take a short drive to Lancaster for some incredible international food: Awash for Ethiopian; Callalloo for Trinidadian; Luca for Italian; and Bistro Barberet for French. Finally, don’t skip a nightcap at Conway Social Club, a moody speakeasy with a rich and creative cocktail menu. |

Dr. Borusiewicz is PGY-4 in the integrated residency Program at Penn State Health Hershey Medical Center.

Mikayla Borusiewicz, MD

BODY CONTOURING (PART 2)

ByAnjali Raghuram, MD; Michael Hu, MD, MPH, MS; and Jeffrey Gusenoff, MD

ABDOMINAL CONTOURING

The demand among patients for bodycontouring procedures is on the rise, due in large part to an increasing number of massive weight-loss patients. In the previous installment of InService Insights, we focused on preoperative patient evaluation, and upper-extremity and upper-trunk contouring; in Part II, we address bodycontouring procedures involving the abdomen and lower trunk – which are among the most commonly performed in the United States.1 Ranging from panniculectomy and abdominoplasty to lower-body and thigh lifts with adjunctive use of liposuction and fat grafting, the spectrum of surgical and non-surgical enhancements is an important focus for plastic surgery trainees preparing for the InService Examination.

Abdominal contouring procedures are performed to remove redundant, loose skin and excess adipose tissue; repair muscular diastasis and musculoaponeurotic laxity; and address scars and striae. 2 In contrast, a panniculectomy is a functional procedure with limited skin and subcutaneous tissue resection below the level of the umbilicus to treat patients with intertrigo. This latter procedure does not address rectus diastasis or ensure preservation of the umbilicus. 2 Abdominoplasty techniques have evolved since the late 1800s, with approaches including the traditional, high lateral tension, mini, umbilical float, vertical, reverse and lipoabdominoplasty.

The traditional abdominoplasty involves creating a transverse incision and performing wide undermining of the abdominal flap. 3 For improved resection of excess epigastric skin in the horizontal and vertical directions, Lockwood’s high lateral tension abdominoplasty involves lateral skin resection and additionally permits less distortion of the mons and a tightened anterior thigh.4 The mini-abdominoplasty is a technique applicable to fewer patients overall and corrects limited infraumbilical skin laxity. 2 As a hybrid technique, the umbilical float abdominoplasty is suited for patients with a high or tethered umbilicus. In this procedure, the epigastrium is tightened without an umbilical scar – and, if necessary, rectus plication can be performed.5

ANJALI RAGHURAM, MD MICHAEL HU, MD, MPH, MS JEFFREY GUSENOFF, MD

Figure 1. (Top left) Traditional abdominoplasty incision (dotted line) and area of skin undermining (yellow). (Top right) High-lateral-tension abdominoplasty as described by Lockwood, with limited area of undermining (yellow). (Below left) Mini-abdominoplasty resection. (Below right) Vertical scar abdominoplasty with limited undermining beyond the excision site. Reprinted from Almutairi, et al.2

To address epigastric skin laxity and abdominal folds, the “Fleur-de-lis” or vertical abdominoplasty is a favored approach. However, this technique limits undermining to the area of intended resection, with little undermining outside the central skin excision to protect the underlying blood supply.6 Another unique resection approach is conferred by the reverse abdominoplasty technique, which targets existing scars in the inframammary region and those from prior abdominal contouring surgery. With the reverse abdominoplasty, patients can undergo tightening of the epigastric region without a vertical scar, as seen with a vertical abdominoplasty.2 Lastly, to preserve the lateral blood supply to the abdominoplasty flap, lipoabdominoplasty entails replacement of wide, lateral undermining with liposuction to enable satisfactory draping of the central abdominal flap.7

BUTTOCK AND LOWER EXTREMITY CONTOURING

Patients who seek procedures for lower body-contour deformities are frequently offered either a belt lipectomy or a circumferential lower-body lift. The former involves higher incision placement than the latter, with greater emphasis on waist shape and

decreased pull on the lateral thighs.8 With a lower-body lift, the buttocks can be directly shaped, sometimes with the incorporation of deepithelialized dermal pedicles, and there’s a strong, vertical pull on the lateral thighs.2

The medial thigh is addressed separately with either a vertical or horizontal excision. The vertical excision can be performed with liposuction and is often more effective at addressing laxity than a horizontal excision that purportedly offers diminished scar burden. Furthermore, aggressive horizontal excision for a medial thigh lift can result in cosmetic and functional problems such as pleating or labial distortion, which are otherwise preventable with a vertical thighplasty.2

ADJUNCTIVE TECHNIQUES

A discussion on lower-extremity body contouring would be remiss without consideration of liposuction and its role in treating resistant areas of adiposity in non-obese patients. Liposuction may be performed via a powered cannula, ultrasound vibration or even laser, with the goals of breaking down connective tissue, emulsifying fat and tightening skin.2 With the development of wetting solutions to permit decreased concentrations of local anesthetics and epinephrine, aggressive liposuction can be performed without requiring general anesthesia. However, liposuction is an adjunctive procedure that isn’t without its own complications, which primarily include secondary deformities. “SAFELipo,” as described by Simeon Wall, MD – or “Separation, Aspiration and Fat Equalization” liposuction – is a technique to reduce the incidence of these deformities by meticulously performing circumferential liposuction of the trunk with abdominoplasty.9

With a converse aim in the realm of body contouring, fat grafting has become perhaps the most popularized for buttock augmentation. Using the principle of aesthetic units of the buttock, fat can be selectively applied to augment volume and projection that has become lost in massive weight-loss patients.1

COMPLICATIONS

The most common complications encountered in bodycontouring procedures, irrespective of upper vs. lower trunk, are wound dehiscence and delayed wound healing. Less frequently encountered but other notable complications include seroma, hematoma and wound infection. Wound infections are generally superficial and respond to oral antibiotic therapy.10 While neuropathies in the early and general postoperative period are rare, these can be further minimized by appropriate consideration of intraoperative patient positioning and padding.2 Meralgia paresthetica, which is a syndrome characterized by numbness, tingling and burning pain on the lateral thigh by damage to the lateral femoral cutaneous nerve, can be avoided by leaving

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READ

1. The Supraclavicular Artery Flap: A Versatile Flap for Neck and Orofacial Reconstruction

Nthumba PM. J Oral Maxillofac Surg. 2012 Aug;70(8):1997-2004. Epub 2011 Dec 16. PMID: 22177819.

Dr. Nthumba presents a literature review of studies on the supraclavicular artery flap with a minimum of 10 patients. He includes clinical and surgical pearls based on his personal experience using this flap in his practice in sub-Saharan Africa. The pedicled supraclavicular fasciocutaneous flap is a reliable option for coverage of neck and orofacial defects. The skin color and pliability resemble the skin of the head and neck region; the blood supply is consistent; and this flap is versatile in its application.

2. Nipple Reconstruction: A Novel Triple Flap Design

Krogsgaard SHH, Carstensen LF, Thomsen JB, Rose M. Plast Reconstr Surg Glob Open. 2019 May 21;7(5):e2262. dPMID: 31333978; PMCID: PMC6571305.

Although there are many designs for nipple reconstruction, no gold standard yet exists. This study took place over the course of three years and included 26 nipple reconstructions in 22 patients (four of which were in irradiated tissue). A template design was used and nipple projection was measured at several follow-up appointments over the course of a year. There were no instances of necrosis; however, the nipple projection did decrease over time.

3. Mirror Facelift: Concept, Description, and Evaluation 1 Year Postoperatively

Divaris M, Sabri E, Ohana S. Plast Reconstr Surg Glob Open. 2020 Mar 27;8(3):e2697. PMID: 32537353; PMCID: PMC7253247.

By Jordan Bilezikian, MD; Delquis Mendoza, MD; & Ravi Viradia, MD

P lastic surgery has benefitted from enormous contributions from its practitioners around the globe, so we decided to turn this Journal Club ’s spotlight on international plastic surgeons. We hope to open the discussion for residents to understand the contributions from such a diverse group and how these plastic surgeons have affected – and continue to advance – our current plastic surgery training. The following highlights journal articles from plastic surgeons across Europe, Africa, the Middle East, Central and South America, the Caribbean, India and parts of Asia.

The principle of this mid-face rejuvenation technique is based upon the preoperative pictures taken in different positions that both exaggerate and minimize facial fat compartment distribution. During the operation, each side of the face is treated differently based upon anatomic studies that demonstrated that there is a weak side (baby hemi-face) and strong side (adult hemi-face). The Divaris, et al., locked cheeklift technique is employed as well as correcting fat compartments specifically based on migration. Postoperative follow-up includes analysis of the patient sitting and lying down to demonstrate the stability of the repair regardless of positional changes.

4. Plastic Surgery and Fighting: Our Experience During Nagorno-Karabakh War in 2020

Knipper P, Bégué T, Pasquesoone L, Guerre E, Khonsari R, Girard P, Berger A, Khachatryan L, Tchaparian M. Chirurgie plastique et conflit armé : notre expérience lors du conflit au Haut-Karabakh en 2020. Ann Chir Plast Esthet. 2021 Jun;66(3):201-209. French. Epub 2021 May 7. PMID: 33966906.

As part of surgical training and often in routine practice, plastic surgeons have experience with traumatic injuries –but often not with war-related trauma. This article details the experience of three French surgical mission trips in the fall of 2020 to care of those wounded in the Artsakh

war. They describe their work in the Yerevan Burn Center with the treatment of likely white phosphorus burns; their collaboration with orthopedic surgeons for limb salvage; and their introduction of the induced membrane technique of Masquelet AC to Armenia. This article, perhaps, gains even more relevance when considering current war victims in Eastern Europe and the surgical reconstructive efforts that are presently underway.

5. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture

Hoyos, Alfredo E.; Perez, Mauricio E.; Domínguez-Millán, Rodrigo. Plast Reconst Surg. 147(5):1072-1083, May 2021.

Gynecomastectomy is a common procedure for plastic surgeons. However, most surgeries are focused on resection and little effort is given to the ideal male chest contour. In this paper, Dr. Hoyos, internationally known for his highdefinition liposculpture techniques, retrospectively reviews 436 patients who underwent breast-mound excision and liposculpture. He provides thorough video and images, and relevant anatomic zones in developing the chest ideal through liposuction and fat grafting. His results show high patient satisfaction with minimal complications. As the number of men seeking body contouring procedures increases, mastering techniques such as the ones described in this article become a must.

6. Labiaplasty with Stable Labia Minora Retraction— Butterfly-like Approach (Best Latin American Paper)

Filho, Osvaldo Pereira; Ely, Jorge Bins; Lee, Kuang Hee; Paulo, Eliz abeth Machado Less. Plast Reconstr Surg Glob Open. 8(4):e2664, April 2020.

This paper describes a labiaplasty technique that stabilizes the labia minora to the inner thighs in order to better design and execute the procedure. It reviews 12 patients in which the procedure was performed and provides pre- and postoperative pictures with good symmetric results. A video with application of the technique is also included.

7. Consensus Recommendations for the Use of HyperDiluted Calcium Hydroxyapatite (Radiesse®) as a Face and Body Biostimulatory Agent

de Almeida, Ada Trindade; Figueredo, Vinicius; da Cunha, Ana Lúcia Gonzaga; Casabona, Gabriela; Costa de Faria, Joana Ribeiro; Alves, Emerson Vicente; Sato, Mauricio; Branco, Adeíza; Guarnieri, Christine; Palermo, Eliandre. Plast Reconstr Surg Glob Open. 7(3):e2160, March 2019.

This paper shows different areas of the body that could be improved with diluted calcium hydroxyapatite (Radiesse®), which through an inflammatory process acts as a biostimulant for production of type I collagen in the areas injected. It gives consensus guidelines on best practices and includes before-and-after photographs with good results. It provides a roadmap to safely expand the use of CaHa to non-facial

areas, which translates into providing services to more patients interested in non-surgical rejuvenation.

8. Non-Scarring Minimal Incision NeoOmphaloplasty in Abdominoplasty: The Alvarez Technique – A New Proposal

Alvarez, Edwar; Alvarez, David; Caldeira, Alberto. Plast Reconstr Surg Glob Open. 9(11):e3956, November 2021.

Umbilical aesthetics during abdominoplasty is always a debated topic among plastic surgeons – and it’s definitely a hot topic among patients in social media groups. In this article, Dr. Alvarez shows his technique on neoumbilicoplasty after amputation of the native umbilicus during abdominoplasty. He describes a step-by-step technique and provides videos along the way. Although most surgeons would be hesitant to amputate the native umbilicus in primary abdominoplasties, Dr. Alvarez’s technique may become very useful in secondary procedures to reconstruct the umbilicus when it has been lost.

9. Best Local Flaps for Lower Extremity Reconstruction

AlMugaren, Faris M.; Pak, Changsik John; Suh, Hyunsuk Peter; Hong, Joon Pio. Plast Reconstr Surg Glob Open. 8(4):e2774, April 2020.

A great reference for residents to review before cases involving perforator-based local flaps – such as a propeller or keystone flap – to aid in lower-extremity reconstruction with minimal donor-site morbidity. This article also highlights the best available local flaps for lower-limb defects.

10. Aging and the Indian Face: An Analytical Study of Aging in the Asian Indian Face

Shome, Debraj, Vadera, Sapna, Khare, Stuti, Ram, M. Shiva, Ayyar, Anuradha, Kapoor, Rinky Desai, Niharika. Plast Reconstr Surg Glob Open. 8(3):e2580, March 2020.

A recent PRS Global Open award-winning paper on Indian aging patterns of the face that highlights differences in regional aesthetic facial anatomy. The articles presents comparisons between North, South, East and West Asian Indians’ facial aging process by studying more than 300 participants from throughout India. This journal article and analysis assists in ascertaining and redefining the various treatment algorithms for facial rejuvenation in this population. |

Dr. Bilezikian is PGY-6; Dr. Mendoza is PGY-7; and Dr. Viradia is PGY-8; at the University of Tennessee Health Science Center, Chattanooga.

MICROSURGERY

“Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In the fourth part of this series featuring leaders in microsurgery, Dr. Brown interviews Fu-Chan Wei, MD. – Rod J. Rohrich, MD, immediate-past Editor-in-Chief, Plastic and Reconstructive Surgery

Interview by Stav Brown, MD

Research Fellow Memorial Sloan Kettering Cancer Center

Fu-Chan Wei, MD

Dr. Wei is chairman of the Department of Plastic and Reconstructive Surgery at Chang Gung Memorial Hospital, and chancellor of the College of Medicine at Chang Gung University, Taiwan.

PSR: HOW HAS MICROSURGERY CHANGED SINCE YOU STARTED?

Dr. Wei: Microsurgery has indeed changed significantly. Microsurgery has become a staple element of the specialty; it’s no longer a fancy technique done occasionally. It has further evolved into an independent discipline/practice in which a surgeon can just perform microsurgery as their main service. I also noticed that microsurgery is no longer exclusive to plastic surgeons, and interest in microsurgery soared among other specialties over the past few decades. In my opinion, we have witnessed a paradigm shift in microsurgery, which is not only utilized for coverage and reconstruction for improved survival rates, but also for restoring optimal form and function with minimal donor site morbidity, especially with widespread application of perforator flaps. Finally, we’ve witnessed great development in the microneural field, such as brachial plexus reconstruction and the treatment of facial palsy – and in the micro-lymphatic field, such as the treatment of lymphedema.

PSR: WHAT ARE YOUR MAIN INTERESTS WITHIN MICROSURGERY?

PSR: WHY DID YOU CHOOSE PLASTIC SURGERY –AND MICROSURGERY IN PARTICULAR?

Dr. Wei: Well, I didn’t. Microsurgery wasn’t a thing when I finished my residency.I wanted to follow the recommendation of my mentor, Samuel Noordhoff, MD. He encouraged me to bring something new to serve our patients in Taiwan and it was during my fellowship training in Toronto General and The Hospital for Sick Children that I decided to immerse myself in microsurgery – then an emerging and exciting new field. I was drawn to it by its potential and technical demands, and it was a good opportunity for me to show my perseverance, dedication and skills.

Dr. Wei: It has been a long ride and I’ve had a thorough and comprehensive practice spanning trauma-related reconstruction of upper and lower extremities, brachial plexus, breast reconstruction, gender-reconfirming surgery and head and neck. But my recent years have mainly focused on perforator flaps, fibula flaps, head and neck microsurgical reconstruction, toe-to-hand microsurgical transplantation and vascularized composite allotransplantation (VCA).

PSR: WHICH CLINICAL CASE OR ASPECT HAS MOST INFLUENCED YOU?

Dr. Wei: I’ve had many, but I remember vividly the case of a 6-year-old boy who suffered from flame-burn injuries that were treated with amputation of all 10 fingers at a proximal level and a skin graft. He came into my clinic with his parents in despair – but since the thenar movement was present, I did microsurgical toe transplantation to his amputated hands. The right hand received three toes, the whole great toe and the combined second and third toe for the thumb, and middle and ring fingers. The left hand received two toes; two lesser toes to the thumb and middle-finger reconstruction after groin flap transfer. Since then, I’ve accumulated experience treating similar cases and developed the concepts of toe-to-hand transfer, including metacarpal hand.

PSR: WHAT ROLE DOES TECHNOLOGY PLAY IN MICROSURGERY?

Dr. Wei: I’m convinced that without technology, we wouldn’t have reached the state-of-the-art in reconstructive microsurgery nowadays. Improved magnification and enhanced operating microscopes now allow reliable supermicrosurgical techniques to be carried out successfully. Innovations in imaging systems such as “spy” devices and ultrasonography have improved our ability to plan and map different reconstructive procedures such as flap harvest, LVA, case monitoring, etc. Revolutions in smartphones has made it easier to diagnose a failing flap and to speed-up management.

Virtual surgical planning and computer-aided design and manufacturing in mandibular reconstruction with vascularized bone is another technological innovation that has increased the speed and accuracy of reconstruction in a cost-effective manner. Furthermore, in robotic-assisted microsurgical procedures, a possibly promising, new application for the manned robot is now a real thing and does allow – in carefully selected patients – minimal donor-site morbidity while allowing access to reconstruction that would otherwise be avoided or result in massive morbidity.

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF MICROSURGERY?

Dr. Wei: The future is bright. Microsurgery is an indispensable part of trauma and oncologic reconstruction. In our institution, its multidisciplinary application has expanded to biliary and hepatic artery and vein anastomoses following liver transplantation; intracranial-extracranial bypass in collaboration with neurosurgeons; and gender-affirming surgery. I’m certain we will continue to expand, not shrink. I also feel the enthusiasm for microsurgery among the younger generation. We’ve accommodated 2,300 visiting scholars and Fellows from 86 counties in the past 35 years, with more than 100 visitors every year. In my opinion, microsurgeons will remain irreplaceable by other innovations such as AI, unlike certain medical specialties.

PSR: WHAT’S YOUR ADVICE FOR A RESIDENT INTERESTED IN A MICROSURGERY FELLOWSHIP?

Dr. Wei: I basically look on residents and Fellows the same: The journey to become a microsurgeon is long and demanding – do not take the journey if commitment, dedication and a strong desire to give back to the specialty and microsurgical society are not part of your key traits and passions. When it comes to recruitment, I prefer commitment, perseverance, passion, a good work ethic, a pleasant personality and Fellows who are coachable. I also seek those who are willing to give back by becoming mentors themselves, thus honoring the “training the trainer” philosophy. |

BE PREPARED FOR CERTIFICATION

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

The board’s mission is to ensure plastic surgeons “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 successful completion of the annual written and oral examinations is a primary way to meet the charge. This year, the written examination took place May 10, and the oral exam will be held Nov. 10-12 in Phoenix.

Candidates for the oral examination are required to submit all cases performed during a nine-month practice period. To be eligible for the ABPS Oral Exam, candidates must reach a minimum of 50 major operative cases. The case list must also have sufficient diversity and complexity to allow adequate evaluation of the candidate’s knowledge and skills. The candidate will be examined on five cases selected by the Oral Exam Committee during the Case Report session of the November exam. In addition to the case book session, candidates will be examined on theory and practice cases created by the Oral Exam Committee. Young plastic surgeons are encouraged to approach the case report materials and submission process with urgency and due diligence.

ABPS Executive Director Keith Brandt, MD, St. Louis, offers the following recommendations:

• Case book preparation affects a candidate’s success on the exam, so prepare them carefully. Examiners use the case books to evaluate your ability to practice safely.

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

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

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

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

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

Preparing for the oral board exam can be stressful, overwhelming and isolating, but support is available. To help, the ASPS has created the Oral Board Preparation Course. Residents are encouraged to register for the 2022 ASPS Oral Board Preparation Course, hosted virtually Aug. 25-27. Registrants may also sign-up for an oral exam simulation session slated for Aug. 26-28, which has been highly rated by previous participants.

This interactive and comprehensive prep course utilizes more than 100 plastic surgery cases to provide a thorough overview of plastic surgery principles and management problems. With a focus on oral exam preparation, the course faculty will guide participants through critical criteria applicable for examination and demonstrate an efficient format for the delivery of high-yield responses to clinical questions. |

COMPLEX CASE CHALLENGE

PART 1: PATIENT PRESENTATION

You see a patient in clinic who was referred to you by your neurosurgery colleagues for plastic surgery closure for an upcoming spinal surgery. The patient is a 35-year-old male with a history of a thoracic spinal sarcoma that was initially resected in 2012, followed by cervicothoracic fusion and chemotherapy/radiation. The patient underwent multiple additional spinal surgeries, including a resection for recurrence in 2018 complicated by a wound infection, as well as multiple hardware revisions. Prior plastic surgery closures included bilateral paraspinous flaps and a right trapezius flap. The patient is stable from a cancer standpoint with a good prognosis, but now presents with fracture of two of the four rods, requiring replacement. On exam, there is very thin skin with radiation changes overlying the protruding rods (see below). There is a paucity of muscle in the region. There is an old surgical scar overlying the left scapula and no contraction of the left latissimus. The right latissimus contracts on exam. The patient enjoys running and would like to avoid any donor sites outside the back. What is your plan for closing the wound after neurosurgery performs a rod exchange?

A) Primary closure

B) Pedicled right latissimus flap

C) Free omental flap to intercostal vessels

D) Free right latissimus flap to transverse cervical vessels

E) Left trapezius muscle flap

Case credit: This patient was treated by Robert Galiano, MD, associate professor of Plastic and Reconstructive Surgery at Northwestern Memorial Hospital, Chicago.

PART 2: TREATMENT

Answer: D. After neurosurgery completed a rod exchange, plastic surgery performed a free right-sided latissimus flap to the right transverse cervical vessels. The flap vessels were tunneled under a skin bridge from the posterior cervical spine to the right lateral neck. The patient healed uneventfully and a donor site outside the back was avoided. |

Editor Russell Ettinger at

The Spring issue of Plastic Surgery Resident contained Part 1 of the Complex Case Challenge, where you were asked to read the provided summary below and then decide upon the correct course of action. The summary is provided below, followed by the surgical approach to the problem that resulted in the successful completion of the case. How did you fare?

Abbe DEAR

Robert Abbe, MD

Sensing friction with my attending

Dear Abbe:

EDITOR’S NOTE : “Dear Abbe” – named in honor of plastic surgery pioneer Robert Abbe, MD – provides plastic surgery residents an opportunity to anonymously share concerns and seek advice from a highly respected, seniorlevel faculty member. Christian Vercler, MD, a clinical associate professor in the Section of Plastic Surgery at the University of Michigan – where he also serves as co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences – steps into Dr. Abbe’s shoes for this installment. The views expressed in this column are those of the author and should not be considered legal advice. Residents and Fellows are encouraged to submit questions to DearAbbe@plasticsurgery.org. Names will be withheld.

I don’t seem to be getting along with the attending with whom I work. This individual has made negative comments about me, related to both the work I do and my personal life. However, this person seems to be the only one that has a problem with my performance, as the other attendings at my program have all been complimentary of my work and have not made any complaints. I really enjoy my job, but Iworry about what the continued friction between this individual and myself could cause. Is there anything I can do?

– Troubled in training

Dear Troubled:

This question warrants advice on two levels. The first is how you conceptualize the interaction – the framework with which you interpret life –and the second focuses on the actions you should take.

First, refrain from feeling “victimized” by this attending. It is statistically unlikely that you will get along with everyone, so resetting your ex pectations may be in order. Try to figure out what you can learn from this attending. Negative comments about your performance are inevitable within a training program, so search yourself to see if this person is shining a light on some aspect that you could improve. If the answer you find is, “There is nothing I could do to improve,” my advice would be to keep searching. We are often blind to our own weaknesses and surrounding ourselves with people who only give us affirmation does little to identify our shortcomings. Does the plethora of compliments you receive from other attendings help you achieve your goals as a trainee? What are your goals as a trainee? Is it to get through life as frictionless as possible? Or is it to train to be the best possible surgeon you can be, to achieve more than you ever thought you could and to provide the best possible care to your patients? We now know that negative comments are not the most effective way to improve the performance of a trainee, but this nevertheless is a form of feedback that you can use to achieve your goals of personal betterment.

Secondly, you should address the situation head on. Ask to speak to the attending and communicate the dissonance you perceive between your per formance and the feedback that you are receiving. Maybe this person does not realize that the comments are coming across as overly negative, and perhaps they’re borne of an “old school” demeanor that never pays compliments to trainees. I had an attending who was uncharacteristically nice to a junior resident who had decided to drop out and become a psychiatrist – all the while berating me for my incompetence day after day. When I asked him point-blank about this unfairness, he responded, “He will never be one of us. Why would I waste my time trying to make him better? I need to make sure you know what you are doing.” Knowing that his goal was aligned with my own goal of becoming a safe and competent surgeon significantly buoyed my spirits.

If this attending is unfairly targeting you in a truly malicious or mean-spirited way, then you should not only speak up to him or her, but also report it to your program director. If the negative comments are related to immutable attributes (race, sex, gender, religious affiliation, etc.), that needs to be reported to your residency program director immediately, as there are laws against discrimination. Alerting your program director about your concerns is important if indeed this attending does indeed “have it out for you.” Your PD carefully documents these things and that can help you in the long run if things take a turn for the worse.

You used the term “job” when referring to residency. The late Paul Kalinithi wrote in his book When Breath Becomes Air that surgery is a calling, not a job. “You can’t see it as a job, because if it is a job, it’s one of the worst jobs there is.” Plastic surgery is one of the most rewarding professions there is, and we are all lucky to be able to do it. There will always be people with whom we have conflict, but hopefully you can find the satisfaction from the practice of our specialty energizing enough to equip you to soldier on in the face of adversity. |

RESEARCH EXPERIENCE

• All travel for research presentation is funded by the Department of Surgery.

• Residents routinely present at local, regional and national meetings including AAPS, ASPS, ASRM, ACAPS, ASSH.

• Access to the Division of Outcomes Research and Quality for professional assistance with IRB approvals, grant submissions and statistical analysis.

• Opportunity to perform basic science research in Dr. Ravnic’s bioengineering lab.

• A monthly research and quality improvement meeting where we discuss new and existing research ideas in an open forum.

EDUCATIONAL EXPERIENCE

• Quarterly one-on-one microsurgery training in our state-of-the-art simulation lab with microsurgeon. Mingjie Sun, MD, provides hands-on time under the microscope beginning the first month of residency.

• Quarterly Cadaver Dissection led by attendings and senior residents to practice flap dissections and bony work

• Monthly journal club held at attendings’ homes.

• $1,000 each year toward books or educational expenses is disbursed to trainees.

• Robust protected, weekly didactic schedule are offered and consist of:

ƒ Hand conference in conjunction with orthopedic hand surgery

ƒ Picture rounds to openly discuss current complex patients as a group

ƒ Resident-led didactic

ƒ Indications conference in the format of the oral board exam

ƒ Resident small-group gatherings where we undertake hands-on activities and attend lectures from attendings from other related specialties. |

Dr. McLaughlin is PGY-5 and Dr. Massand is PGY-6 at Penn State Health Hershey Medical Center.

PSR: WHAT WAS YOUR GREATEST NON-TRAINING CHALLENGE OF RESIDENCY – AND HOW DID YOU HANDLE THAT?

Dr. Samson: My wife and I had a miscarriage during my chief year and our families were 3,000 miles away. The attendings and their spouses and my co-residents rallied and became our “family” during a very challenging time. This experience played a large part in choosing to come back on faculty at Penn State after fellowship. That was 12 years ago.

PSR: WHAT DO YOU ENJOY MOST ABOUT BEING A PLASTIC SURGEON?

Dr. Samson: The complexity and variety of cases, and working with residents and my pediatric patients bring me great satisfaction. My job is never “work.”

PSR: WHAT ARE SOME OF THE CHALLENGES YOU REGULARLY ENCOUNTER IN YOUR PRACTICE?

Dr. Samson: Not having enough time. I do charting, dictations and answer emails once the house is asleep.

PSR: HOW DOES TEACHING PLAY A ROLE IN YOUR SCHEDULE?

Dr. Samson: It’s enmeshed into my daily schedule. I don’t think you can carve-out time for teaching in our profession.

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

Dr. Samson: Follow your passion and don’t compromise. There are always people who will tell you can’t do it. Pay absolutely no attention to them. If you want it, you can make it happen.

PSR: HOW WOULD YOU COMPLETE THIS SENTENCE?

“I KNEW I WANTED TO BECOME A PLASTIC SURGEON WHEN …”

Dr. Samson: I saw my first cleft lip repair. |

the fascia intact in an approximately 4 cm radius medial to the anterior superior iliac spine.

Late complications of body contouring include scarring, lymphedema and recurrent skin laxity. Scarring can be addressed in revision procedures with surgical release. Lymphedema is more commonly encountered after lower-body-contouring procedures and can be mitigated by early detection and initiation of conservative therapies, including limb elevation, compression garments and lymphatic massage. Recurrent skin laxity after full healing is best approached with consideration for re-excision in a way to minimize this outcome moving forward.

Dr. Raghuram is PGY-1 and Dr. Hu is PGY-4 in the Integrated Plastic Surgery Residency Program, and Dr. Gusenoff is a professor of plastic surgery, at the University of Pittsburgh Department of Plastic Surgery.

REFERENCES

1. Ferry AM, Chamata E, Dibbs RP, Rappaport NH. Avoidance and correction of deformities in body contouring. Semin Plast Surg. 2021;35(2):110-118.

2. Almutairi K, Gusenoff JA, Rubin JP. Body Contouring. Plast Reconstr Surg. 2016;137(3):586e-602e.

3. Vernon S. Umbilical transplantation upward and abdominal contouring in lipectomy. Am J Surg. 1957;94(3):490-492.

4. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(3):603-615.

5. Matarasso A. Classification and patient selection in abdominoplasty. Operative Techniques in Plastic and Reconstructive Surgery. 1996;3(1):7-14.

6. Friedman T, O'Brien Coon D, Michaels VJ, et al. Fleur-de-Lis abdominoplasty: a safe alternative to traditional abdominoplasty for the massive weight loss patient. Plast Reconstr Surg. 2010;125(5):1525-1535.

7. Saldanha OR, De Souza Pinto EB, Mattos WN, Jr., et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg. 2003;27(4):322-327.

8. Lockwood TE. Lower-body lift. Aesthet Surg J. 2001;21(4):355-370.

9. Wall S, Jr. SAFE circumferential liposuction with abdominoplasty. Clin Plast Surg. 2010;37(3):485-501.

10. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg 2006;117(2):414-430.