Plastic Surgery Resident, Summer 2023

IN THIS ISSUE

» Perspectives and advice from renowned hand surgeon Michael Neumeister, MD p. 25

» InService Insights: Melanoma subtypes, diagnosis, treatment and more p. 23

» Program Peek: University of Rochester School of Medicine and Dentistry p. 10

PSTM23 CORNER NOW’S THE TIME TO PLAN

Plastic Surgery The Meeting 2023 will be held Oct. 26-29 in Austin, Texas. Now’s the time to begin thinking – and planning – on what to do, when and how to do it ahead of traveling to the Austin Convention Center. Here are some things that residents should know ahead of the meeting.

ASPS/PSF Resident Travel Scholarship for PSTM23

• Recipients will be recognized at the Resident Networking Reception, slated to run from 6-7 p.m. Thursday, Oct. 26, with the location yet to be determined.

SENIOR RESIDENTS CONFERENCE COMING OCT. 26 IN AUSTIN

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

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

RESIDENTS BOWL SCHEDULE – WHO WILL YOU CHEER ON?

Stand and cheer for your favorite team at the Austin Convention Center’s Residents Bowl Arena as training programs compete for the coveted title of Residents Bowl Champion. This event is supported by Allergan Aesthetics, an AbbVie Company; and Advanced Reconstructive Surgery Alliance.

Friday, Oct. 27

Opening Round I: 9:30-10:30 a.m.

Opening Round II: 12:30-2 p.m.

Opening Round III: 3:30-5 p.m.

Saturday, Oct. 28

Round IV: 9:30-10:30 a.m. Round V: 12:30-2 p.m. Round VI: 3:30-4 p.m.

Sunday, Oct. 29

Semi-Finals & Finals: 9:30 a.m. – 10:30 a.m.

CALLING ALL RESIDENTS TO MEDICAL STUDENTS MEET AND GREET

ASPS will host the Medical Students Meet and Greet during Plastic Surgery The Meeting in Austin. The Society encourages residents to stop by for drinks and network with medical students who are eager to receive more guidance and learn from residents’ experience. This networking event will take place from 4:15-5 p.m. Saturday, Oct. 28, in the Residents Bowl Arena at the Austin Convention Center.

RESIDENTS ARE CORDIALLY INVITED TO CHILL AT KEYS LOUNGE

Maximize your time at Plastic Surgery The Meeting 2023 by visiting the Allergan Aesthetics Knowledge and Education for Young Specialists (KEYS) Lounge – a comfortable space designed specifically for residents – located near Registration area inside the Austin Convention Center, Exhibit Hall 5. Relax and enjoy this benefit of our in-person annual meeting.

Table of Contents

Cover Story: From Africa to North America – and back

A global health exchange program between Moi Teaching and Referral Hospital in Kenya and Indiana University brings long-term benefits to both.

Program Peek: University of Rochester

10

An early leader in cleft lip and palate repair spurs the formation of one of the nation’s longest-standing plastic surgery programs.

Faculty Focus:

The best mentor is not one, but several – the same concept that residents should embrace when training opportunities arise.

Message from the Director: Clinton Morrison, MD

A comprehensive, diverse, resident-centric and modern training experience at the University of Rochester is the program’s “secret sauce.”

Plastic Surgery Resident | Summer 2023

Vol.7 N o.3

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

Gregory Greco, DO | plasdoc39@msn.com

EDITOR

Russell Ettinger, MD | retting@uw.edu

ASSOCIATE EDITOR

Joseph Lopez, MD | joeyl07@gmail.com

Megan Fracol, MD | mfracol@gmail.com

SENIOR RESIDENT EDITOR

Olivia Abbate Ford, MD | oford@partners.org

RESIDENT EDITORS

Aradhana Mehta, MD, MPH | aradhana.mehta@unlv.edu

Alexis Ruffalo, MD | aruffolo57@siumed.edu

Mark Shafarenko, MD | mark.shafarenko@mail.utoronto.ca

Those who make the trip to this western New York city will find parks, lakes, jazz, breweries, clubs, pumpkin patches and more.

Leadership Q&A Lynn Jeffers, MD, MBA

ASPS past President and AMA Council on Medical Service member shares her history – and the paths that can lead to leadership.

Dear Abbe:

One of my colleagues has a pattern of taking my research and presenting it as their own; what should I do about it?

Consult Corner:

A patient presents with extremely painful and worsening facial edema after yesterday’s rhytidectomy – what do you do?

InService

16

INTERNATIONAL RESIDENT EDITOR

Daniel De Luna Gallardo, MD | daniel.delunag@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

GRAPHIC DESIGNER

Angela Bochucinski

ADVERTISING SALES

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

A review of the clinical findings and subtypes, as well as diagnosis and treatment, for one of the most serious forms of skin cancer.

Plastic

Hand residents who wish to impress senior surgeons must exhibit honesty, enthusiasm and a willingness to take cases at all hours.

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

A note from the editor

Welcome to the Summer 2023 issue of Plastic Surgery Resident.

The month of August signifies that summer is well upon us, bringing warm weather, outdoor activities and long days to enjoy recreation. In the medical field, August also welcomes a new class of matriculating interns into teaching hospitals across the country. Among those individuals are surgeons in training who are now on their path to becoming fully fledged plastic surgeons at the completion of their residency. For those plastic surgery interns, they are getting their first glimpse of newfound responsibilities and challenges as they embark upward onto probably the steepest learning curve they will face in their professional lives. There is a natural anxiety and fear that comes in parallel with the weight of obligation bestowed to physicians and surgeons in training. Over time, this anxiety gives way to confidence through graduated autonomy and guidance that allows for greater perspective into what a unique time residency training is – and how formative these experiences are in forging us into the surgeons we ultimately become. Although the hours might be long, residency training affords numerous opportunities to have a positive impact on the lives of those around us. One of the most indelible experiences of some residency programs is the opportunity to participate in international outreach. Speaking from my own experience, the opportunity to provide surgical care in low-resource settings was one of the most profound experiences I’ve had in my professional career. In this issue of PSR, our cover story will delve into international surgical outreach from both the perspective of a U.S. national resident traveling abroad as well as an international resident traveling to the United States as part of the University of Indiana’s unique resident exchange program.

Also featured in this summer issue is our “Program Peek” featuring the University of Rochester’s historic plastic surgery program, whose notable alumni now populate numerous leadership and academic faculty positions in programs across the country. In this issue you will also find a timely, summer sun-exposure topic through “InService Insights,” which focuses on the management of malignant melanoma. Our “Consult Corner” walks us through the management of rhytidectomy complications and this issue’s “Dear Abbe” column offers advice on how to handle the sticky situation of a coresident attempting to take credit for your research contributions. Finally, our “Plastic Surgery Perspectives” is an interview with The PSF past President Michael Neumeister, MD, which provides incredible insights from a world-renowned hand surgeon.

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

BUILDING A HEALTHCARE RELATIONSHIP IN KENYA

By Julia Cook Beresford, MD

Iconsider myself very fortunate to have participated in a onemonth global health exchange program between the Indiana University Division of Plastic Surgery and Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, as part of the Academic Model Providing Access to Healthcare (AMPATH) program. Established in 2022, the global exchange program was designed to work in conjunction with the general, plastic and orthopedic surgeons at MTRH in Eldoret, to trade experiences and mutually impart knowledge to improve patient outcomes.

By Michael Hu, MD, MPH, MS

The economy in Eldoret is supported by various industries that include large-scale farming and textiles, telecommunications and manufacturing. In addition, runners flock to the 7,218-foot elevation of Eldoret for middle- and long-distance training at the International Association of Athletics Federation High Altitude Training Center.1

Beryl Munda, MD, in July 2022 was the first resident to visit Indiana University as part of this exchange – and I was privileged to visit Eldoret later that fall.

INTRODUCTION TO ELDORET

The fifth-largest city in Kenya, Eldoret is at the center of the Uasin Gishu District of the Rift Valley Province. “Eldoret” is derived from the Massai word “eldore,” meaning “stony river,” which was used to describe the riverbed of the Sosiani River that runs through the city. Swahili and English are the official languages of Kenya, with a preference of Swahili for most people.

Eldoret also is home to MTRH, which was founded in 1917 and serves Kenya, Eastern Uganda, Northern Tanzania, South Sudan and the Democratic Republic of Congo. It serves as the teaching hospital for Moi University College of Health Sciences – as well as for several medical training institutions. MTRH also hosts the College of Surgeons of East, Central and Southern Africa (COSECSA) residency training in general surgery, orthopedics and trauma surgery, and pediatric surgery.2

AMPATH

The Indiana University School of Medicine and Moi University in 1992 established a partnership to care for Kenyan patients, conduct research and

educate Kenyan and American medical students. With the success of this partnership, several North American universities joined the coalition and in 2001 formed the AMPATH program. The program’s mission is to create a sustainable model in which education and research improve healthcare ser-

continued on page 7

Drs. Malungo (left) and Cook Beresford (right) enjoying time post-burn contracture reconstruction.

Iembarked upon my first journey to the United States in July 2022, courtesy of a one-month global health exchange program between the plastic surgery division of Indiana University and Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, as part of the Academic Model Providing Access to Healthcare (AMPATH) program.

I had the good fortune to rotate in four departments during my month in Indiana. I started with trauma service at Sidney and Lois Eskenazi Hospital in Indianapolis under Clark Simons, MD. At Eskenazi, I shadowed residents in the trauma service as they conducted ward rounds and responded to emergency cases. It was interesting to me that the leader of the trauma response team was the chief resident, who mobilized the team and assigned roles to each person attending to the patient. The organization and coordination of the team was inspiring, and I was excited to encourage this kind of practice in Kenya. In addition to shadowing the trauma team, I was also able to assist in some minimally invasive surgical procedures – both laparoscopic and robotic surgeries. Although we have laparoscopic surgery in Kenya, it’s not as widely practiced as in the United States – primarily because the equipment is expensive and most surgeons lack the expertise. My rotation at Eskenazi was my first experience with robotic surgery, and I was taken with its precision.

My second week was in the burns center at Eskenazi Hospital under Leigh Spera, MD, who led a truly diverse team that included residents from Pakistan, Iran, India and Canada. I found it incredibly interesting to compare medical practice in the different places and gain the residents’

FROM

AFRICA TO AMERICA TAKEAWAYS FROM A MONTH IN INDIANA

By Beryl Munda, MD

perspective of working and studying in the United States. The facilities available in the burns unit at Eskenazi are world-class and, for the first time in my career, I had the chance to witness a patient who had more than a 60 percent burn-surface area survive the wounds thanks to the availability of a 24hour critical care unit. It was also the first time I saw cadaveric allografts used in burn management. I was awed by the advanced instruments available for procedures, such as the waterjet hydro surgery system for wound debridement, the use of a Zimmer Dermatome and derma carriers that make surgery both fast and efficient.

My third week in Indiana was at the hepatobiliary/endocrine service at the Indiana University (IU) Hospital where I had the chance to participate in Whipple procedures, parathyroidectomy and thyroidectomy, in addition to attending hepatobiliary clinics. The clinics are run in stark difference to the surgical clinics in MTRH. The patients are assigned rooms and the doctor can peruse their charts prior to going to the rooms to discuss the patients’ progress after surgery; any impending procedure; or the next step of care in their treatment. In Kenya, patients often queue outside the doctor’s room as they await their turn to be seen.

My final week was spent rotating in breast surgery at Methodist Hospital, where I was able to assist in breast augmentation procedures, oncoplastic surgery and other procedures. In addition to the rotations, I attended resident education sessions – both at Eskenazi and at the IU hospi-

tal – as well as morbidity and mortality meetings. It was interesting to observe residents’ interactions with the attendings and how relaxed the sessions were. I was impressed by the way the attendings and professors took accountability for their procedures and how they were open to criticism.

It wasn’t all work and no play, though. I had the opportunity to visit the Indiana State Fair, and we also had the chance to see an Indianapolis Colts game – my first time experiencing American football, which was exhilarating. The global health-exchange program doctors who had been to Kenya also organized get-togethers with their families, which allowed us to talk about about their time in Kenya and the differences in practicing medicine at home and abroad.

All in all, I’m grateful for the opportunity to travel and experience different cultures. The program afforded me the opportunity to work with brilliant surgeons and residents who were more than willing to teach, discuss and learn. Global health provides us an opportunity to optimize patient care, not only through exposure to different medical care facilities, but also through the bilateral case conferences that shine a light on best practices. It’s my sincere hope that more residents have similar opportunities to participate in global health opportunities. |

Dr. Munda, who’s training at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, is the first Kenyan surgery resident to complete a surgery rotation at Indiana University through the AMPATH partnership.

Drs. Munda (left) and Cook Beresford with Brian Christie, MD, at Indiana University.

vices, decrease healthcare disparities and mitigate social determinants of health. In addition, this program has been instrumental in working with the Kenyan government in establishing a universal healthcare program to improve access to care. Given the success of this model in Eldoret, the program has been able to expand to more than 300 care sites in Kenya, as well as Ghana and Mexico.3

TIME IN KENYA

I arrived in Eldoret on Sept. 26 for my month-long rotation under the guidance of Brian Christie, MD, and Gregory Borschel, MD. Although I had no previous global health experience, I prepared for a month of working alongside our colleagues to expand surgical access to patients and improve patient outcomes.

On our first day of clinical work, we were invited to round on patients and discuss clinical needs. The rounds were led by the orthopedic surgery chief resident, who commanded the team with the expectation that every team member was well-versed on the patient’s history, pertinent anatomy, disease process and expected clinical course. Unlike the consultant-heavy nature common in the United States, the orthopedic and plastic surgery physicians managed all aspects of patient care – including wound

care, general medicine conditions and laboratory abnormalities, as well as post-discharge social needs.

The wards were very different from the United States, with up to 20 patients maintained in a single room – often with multiple patients to one bed. Family members were often responsible for dressing changes, as well as providing food and clothing to the patients. Acknowledging these limitations, wound care was designed so that it could easily be completed by patients or their families. Following rounds, surgical patients were discussed, and the residents arranged for O.R. time in the upcoming week.

MTRH surgeons identified two main areas in which they desired improvement: microsurgery and nerve surgery/ brachial plexus. Although an operating microscope had been donated to

MTRH, and microsurgical instruments had been obtained through the help of a grant, the surgeons had no formal training in microsurgery, and micro-suture quantity was very limited. In addition, availability for postoperative flap care was limited by a lack of ICU beds for hourly flap monitoring, no nursing education on flap monitoring, limited availability for O.R. access overnight and inconsistent access to a pencil doppler.

Although supply concerns could be mitigated with grants and donations, surgeon and nursing education – along with the logistics of flap monitoring and care – necessitated a longer-term approach. The plan was made to start with microsurgery training, providing the surgeons with microsurgical training kits and meeting regularly to discuss improvements in technique. In the future when microsurgical reconstructions are planned, education can be provided to residents and nursing on flap monitoring – and an O.R. team can be identified to assist with takebacks overnight.

Drs. Munda (left) and Cook Beresford (right), the first residents to participate in the Moi Teaching and Referral Hospital and Indiana University global health exchange program.

Drs. Cook Beresford, Estru and Lwegado (left to right) discussing pedicled flap options for dorsal hand coverage.

Brachial plexus and nerve injuries are common in Kenya due to obstetrical injury, high-morbidity motorbike accidents, work-related accidents and trauma. The injuries are devastating to patients, given that the affected adults are often the primary breadwinners of their families, and there’s no access to disability payments or worker’s compensation. Adult patients also often present late after injury due to delayed referral. MTRH surgeons made clear that they wanted experience with surgical management of brachial plexus injuries, given that they’d had no previous formal training.

Fortunately, essential occupational therapy (OT) access was available at

MTRH, with a very knowledgeable staff, led by occupational therapist Roy Kirwa. In fact, all obstetric brachial plexus injuries at MTRH are immediately referred to OT, and the pediatric brachial plexus patients who were assessed at the time of our visit had notably supple joints with good adaptive functioning.

We met with many brachial plexus adult and pediatric patients, and we found several patients appropriate for surgery. We performed a latissimus dorsi/teres major transfer for shoulder external rotation and abduction in a pediatric patient – and the OTs and casting technicians were involved in the immediate post-op period by assisting in the

construction of a shoulder spica cast for the patient. We also performed a spinal accessory to suprascapular nerve transfer, a Leechavengvong procedure and an Oberlin transfer for a patient with a C5/6 injury from eight months prior.

There was no formal nerve stimulator available for intraoperative assessment, so a train-of-four stimulation box was adapted with sterile wiring and 18G needles to create a low-cost nerve stimulator. Given the successful completion of these procedures, the ready access to OT and the significant patient need, MTRH has a very promising brachial plexus program ahead once community education on early referral is adopted.

Sural nerve harvest for median nerve reconstruction with Drs. Vadgama (left) and Cook Beresford (right).

Our time in Kenya was a collaborative experience that placed emphasis on building sustainable systems to improve patient care. We attempted to integrate ourselves into the wards, clinic and O.R., but also to make sure to listen to the needs of the local surgeons and staff, and provide education as requested. I hope that through these efforts, we’ve built a strong bond that will improve healthcare access and patient outcomes in the future. I feel privileged to be a part of the first visit to MTRH, and I look forward to seeing how this relationship grows and develops in the future.

I’m humbled and honored to have worked alongside the talented surgeons, residents and staff at MTRH. I also want to emphasize that global health should be an extension of what we do at our core: We help patients. Global

health shouldn’t be seen as a chance to “save” a population or establish a non-sustainable healthcare program. Global health provides us with a unique opportunity to critically assess patient needs and collaborate with our international colleagues to optimize patient outcomes given the resources provided. As such, we should all strive to make participation in global health equitable and accessible. |

Dr. Cook Beresford last year completed a one-month surgical rotation at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya.

ACKNOWLEDGEMENTS

Thank you to Dr. Munda, Dr. Mutwiri, Dr. Momanyi, Dr. Vadgama, Dr. Mwangi, Dr. Lelei, Dr. Lwegado and Dr. Malungo for their hospitality, mentorship and guidance throughout my time in Kenya.

REFERENCES

1. MeetMinneapolis. Eldoret, Kenya. https://www. minneapolis.org/about-us/sister-cities/eldoret-kenya/. Published 2023. Accessed 07/04/23.

2. Hospital MTaR. Moi Teaching and Referral Hospital: About Us. https://www.mtrh.go.ke/about-us/ Published 2023. Accessed 07/04/23.

3. AMPATH. AMPATH Kenya. https://www.ampathkenya.org/. Updated 2023. Accessed 07/08/23.

Drs. Vadgama, Borschel, Mwangi, Momanyi and Cook Beresford (left to right) enjoying dinner after a full day of cases.

University of Rochester Plastic Surgery

By Keith Sweitzer, MD

HISTORY

One of the oldest plastic surgery programs in the country, the University of Rochester Division of Plastic Surgery was established in 1947 under the leadership of Forrest Young, MD. An early leader in cleft lip and palate surgery, he also gained acclaim for early publications on the management of third-degree burns. In September 1950, Robert McCormack, MD, who had completed his residency in plastic surgery under Dr. Young, was recruited from his practice in Milwaukee to succeed his mentor. Lester Cramer, MD, in 1959 established the first cleft and craniofacial program in upstate New York. Additional leadership recruits for the group in this period included Harold Bales, MD, and George Reading, MD. The division in 1962 hosted the first national Plastic Surgical Residents Conference in Rochester. Joseph Serletti, MD, joined the faculty in 1990 and assumed the position of division chief in 1998, continuing the tradition of microsurgical excellence at the university. When he left in 2005 to become division chief at the University of Pennsylvania, he was replaced by world-class microsurgeon Howard Langstein, MD, from MD Anderson Cancer Center in Houston, a position that Dr. Langstein continues to hold.

LEADERSHIP

Howard Langstein, MD, Professor of Surgery and Chief, Associate Program Director, Division of Plastic and Reconstructive Surgery

Clinton Morrison, MD, Plastic Surgery Integrated Residency Program Director, Cleft and Craniofacial Anomalies Center, Assistant Professor, Plastic Surgery

Patrick Reavey, MD, Assistant Professor, Department of Surgery, Plastic Surgery, Assistant Professor, Department of Orthopedics, Joint Associate Program Director, Plastic Surgery

ALUMNI – AND CURRENT POSITIONS

Megan Pencek, MD, Craniofacial Fellowship, University of Pittsburgh; Microsurgery Fellowship, Washington University, St. Louis

Katy Skibba, MD, Community Practice, Iowa

Trevor Hansen, MD, Hand Fellowship, Southern Illinois University

Jaqueline Lyons, MD, Private Practice, Philadelphia

Cassie Nghiem, MD, Bitar Cosmetic Surgery Institute for an Aesthetic Fellowship; Private Practice, Washington, D.C.

Nicholas Wingate, MD, Private Practice, Philadelphia

Ronald Brown, MD, Hand and Upper-Extremity Fellowship, University of Washington, Seattle; Ohio State University Faculty

Dahlia Rice, MD, Private Practice, Kenosha, Wis.

Sara Neimanis, MD, Cleft and Craniofacial Fellowship, Children’s Hospital of Atlanta; URMC faculty

Paige Myers, MD, Reconstructive Microsurgery Fellowship, Memorial Sloan Kettering Cancer Center, New York; University of Michigan Faculty

Elaina Chen, MD, Private Practice, Chicago

Joseph Khouri, MD, Orthopaedic Hand and Microsurgery Fellowship, Mayo School of Graduate Education, Rochester; Faculty, Case Western University, Cleveland

Oren Mushin, MD, Private Practice, Houston

Peter Koltz, MD, Microsurgery Fellowship, University of Pennsylvania

Chester Mays, MD, Private Practice, Louisville, Ky.

Rene Myers, MD, Craniofacial and Pediatric Plastic Surgery Fellowship, University of Texas Southwestern; Program Director, University of Alabama-Birmingham

Joshua Waltzman, MD, Aesthetic Fellowship, Cleveland Clinic

Additional notable alumni include UPMC Plastic Surgery

Department Chair and ASPS past President Joseph Losee, MD; and Steven Moran, MD, Hand Surgery Chair, Mayo Clinic

CLINICAL EXPERIENCE

Training sites include Strong Memorial Hospital, an academic Level I Trauma Center and one of only 56 ABA verified burn centers in the nation; Wilmont Cancer Center; Golisano Children’s Hospital; Sawgrass Surgical Center (an outpatient surgery center); Highland Hospital (an academic community hospital, home to our breast reconstruction programs and robust life-afterweight-loss center); Erie County Medical Center, Buffalo, N.Y. (home to a focused head and neck oncology and reconstructive microsurgery experience); and The Lindsay House (a community aesthetic surgical practice, where residents get firsthand, private practice exposure).

• Eight full-time plastic surgery academic faculty, as well as 10 community faculty members

• No plastic surgery Fellows, leading to maximum operative experience for residents

• 2,932 major cases at the academic center in 2022, with approximately 60 operations per week

• Five months of dedicated plastic surgery during intern year, seven months of dedicated plastic surgery/hand surgery during second year and nine months of dedicated plastic surgery/hand surgery training during third year. Twelve months of plastic surgery training during the fourth year, 10 months during the fifth year and 12 months during the sixth year

• Off-service rotations include ACGME minimums in general surgery experience; otolaryngology (one month); occuloplastics (one month); community Mohs reconstruction (two months); OMFS (one month); and an outpatient aesthetic surgical experience (six months)

• Six months over PGY 2-4 of dedicated hand surgical experience under the orthopedic department, with six dedicated full-time academic faculty

EDUCATIONAL CURRICULUM

• Monday morning didactic conference

• Thursday morning divisional grand rounds, including indications conference and M&M

• Monthly faculty-hosted journal clubs

• Tuesday didactic conference for residents on the hand service

• Dedicated one-on-one microsurgery skills course and advanced microsurgery skills course weekly during the craniofacial rotation with Jonathan Leckenby, MD

RESEARCH

The research mission of the Integrated Plastic Surgery Residency Program is accomplished within the context of the University of Rochester’s peer review-funded basic science and clinical research programs. The University of Rochester ranks in the top third of medical schools with NIH peer-review grant funding. The federal grant-funded basic science lab is run by Dr. Leckenby, focusing on peripheral nerve and VCA. The university also offers a fully funded Burn Research program. The annual Resident Research Day involves PGY-2s and above, who are expected to present for a visiting professor. The Joseph Serletti Research Award, with a cash bonus for the most productive research, is presented annually to one resident. One to two medical student research Fellows are selected per year.

RESIDENT BENEFITS

• Two fully funded plastic surgery meetings per year for residents with accepted work

• Fully funded burn research with two meetings per year per resident

• Eleven dollars per diem for meals per overnight shift

• Four weeks of vacation

• One copy of the plastic surgery reference book Grabbe and Smith is given to each resident at the start of their intern year

• Each resident receives one pair of surgical loupes paid for by the program

• The hospital provides each resident with a smartphone

RESIDENT CAMARADERIE

Camaraderie is inspired by the annual chief roast, annual retreat and monthly, faculty-hosted Journal Clubs – and just check out our Instagram @roc_prs_residency. |

Dr. Sweitzer is PGY-4 at the University of Rochester.

Q&A WITH SARA NEIMANIS, MD

In this installment of Faculty Focus, we present ASPS member Sara Neimanis, MD, assistant professor of surgery and pediatric and craniofacial plastic surgeon at the University of Rochester (N.Y.) Medical Center.

Dr. Neimanis earned her medical degree at the University of Buffalo and completed her plastic surgery residency at the University of Rochester. Following that, she completed a fellowship in pediatric craniofacial plastic surgery at Children’s Healthcare of Atlanta. A Buffalo native, Dr. Neimanis returned to New York prepared to bring to Rochester surgical offerings that include ear reconstruction as well as different techniques in cleft jaw surgery and midface distraction. She has expressed her embrace of plastic surgery as the perfect combination of art and science, which provides her with the opportunity to help her patients while being creative and approaching each problem with a unique perspective.

PSR: HOW DID YOU PREPARE FOR A COMPETITIVE FELLOWSHIP?

Dr. Neimanis: I tried to get exposure to everything early in residency in order to figure out what I liked best. I loved craniofacial surgery and confirmed that I wanted to do a craniofacial fellowship during my third year. Once I knew that, I focused my research efforts on craniofacial projects and regularly attended the American Cleft Palate Craniofacial Association annual meeting to learn and network.

PSR: WHAT IMPACT DID THAT FELLOWSHIP HAVE ON THE ADVANCEMENT

OF YOUR CAREER?

Dr. Neimanis: I owe so much to my fellowship (shout-out to the amazing people at Children’s Healthcare of Atlanta). Specializing in pediatric plastic and craniofacial surgery really requires fellowship training to gain adequate exposure and experience. My program was extremely busy, and I operated nonstop that year. It prepared me to take on almost anything in the world of pediatric plastic surgery – and it provided me with incredible resources and mentors who I can reach out to when I have a complicated case I’d like advice on. I had a great experience on our craniofacial service in residency with our Plastic Surgery Integrated Residency Program Director Clinton Morrison, MD, which helped me have an even more successful fellowship year building upon what I already knew.

PSR: IS A MENTOR IMPORTANT – AND HOW CAN WE FIND ONE?

Dr. Neimanis: A mentor is absolutely important, but I don’t think you need to have one, single mentor. You can have different mentors for different aspects of your career and life. The easiest way to find a mentor is to reach out to people who you aspire to be. If you’re a medical student, it may be a resident who has matched into your desired field. If you’re a resident, it may be an attending who has a practice you’d like to have some day. A good mentor is someone like this – who you feel comfortable with and who takes the time and makes the effort to support you.

PSR: WHAT’S THE MOST IMPORTANT QUALITY IN A RESIDENT?

Dr. Neimanis: Collegiality. Intelligence, research productivity and excellent technical skills are great, but a person who’s dependable, gets along well with their co-residents and hospital staff, and has a good attitude makes an ideal resident.

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

Dr. Neimanis: Traveling is my favorite thing to do, so I block-off a few weeks every year and take epic vacations. I also

continued on page 27

The motto of the University of Rochester is “Meliora” or “even better” – and that philosophy has permeated our plastic surgery residency program since its inception in 1947 as one of the country’s first training programs. In the following eight decades, Rochester has developed a reputation for leadership in the specialty, with many chairs, chiefs and program directors of America’s premier plastic surgery departments and divisions having passed through Strong Memorial Hospital, our primary training facility.

What is it about this program that fosters success in our trainees? A focus on YOU. A diverse, comprehensive and modern training experience here will open doors to whatever career our residents choose is right for THEM. That might mean academic practice, a surgeon-scientist path, or community or private-practice plastic surgery. Our faculty is here to support our residents in becoming the plastic surgeon THEY want to become, and hence there’s not a single, isolated model of success when they leave Rochester. Our goal is for trainees to develop a long, satisfying and healthy career.

A listening ear and openness to change are fundamentally important pillars of our program’s leadership. This has created a dynamic resident curriculum and training structure that capitalizes on the best plastic surgery training opportunities that exist throughout upstate New York. While our programmatic home is based out of the tertiary referral hub and Level I trauma center that is our University of Rochester hospitals, our residents also spend time in the community with talented surgeon-educators, gaining additional exposure to microsurgery, aesthetic surgery and gender-affirming surgery.

CLINTON MORRISON, MD

Rochester is a program focused on resident education. There are no plastic surgery Fellows to dilute resident exposure to complex burn reconstruction, microsurgery, hand surgery or cleft and craniofacial cases. Our faculty are here to train residents, and the expansive clinical volume of our hospitals and practices presents thousands of complex and routine cases each year.

We’re incredibly proud of our residents and of the program that supports their development. Watching this talented group of young surgeons become exactly who they want to be brings us great joy – and we look forward to welcoming two more members to our “family” each and every year. |

Rochester, N.Y.

By Rebecca Patrick, MD

Welcome to Rochester, N.Y. –or “Raaachester,” as it’s pronounced by the locals. Rochester was historically recognized as “Flour City” by those who developed it, due to the many flour mills that had been built along waterfalls near the downtown area. It was later rebranded “The Flower City” due to its establishment as the then-world epicenter of seed companies within its boundaries. Our city is equal parts old and young – etched in history as an original American Boomtown with its strategic positioning on the Erie Canal, and it remains in the national spotlight by hosting events such as the International Jazz Festival and the 2023 PGA Championship at Oak Hill Country Club.

Rochester has consistently attracted some of the best and brightest minds in technology, music, business and art while boasting the heritage of momentous figures such as Susan B. Anthony and Frederick Douglass, who altered the course of history through their contributions to, respectively, women’s rights and abolitionism. George Eastman was a revolutionary in photographic innovation and philanthropy – his generosity fueled the development of the city’s educational institutions, healthcare systems and fine arts community.

Rochester’s advantageous geography blends a bustling metropolis with Mother Nature, as the city is nestled amongst the beloved Finger Lakes region, the grand Lake Ontario and the famous Adirondack Mountains. The sound of music echoes throughout our city, as the Eastman School of Music consistently draws the most talented musicians in the country, and our beloved “RPO,” the Rochester Philharmonic Orchestra, has serenaded

our community for over a century. Be sure to snack on a “garbage plate” and scope-out the diverse food scene our city has to offer. The Flower City provides a variety of activities to visitors and locals alike, depending on the time of year.

SPRING

Springtime in Rochester highlights our city’s international reputation for horticultural excellence. Be sure to catch our celebrated floral gardens at Highland Park during the annual Lilac Festival. Here, you can peruse more than 500 varietals while attending musical performances and art walks. The Rochester Public Market is one of the best in the country, each Saturday offering products from hundreds of local food vendors and artisans. Hike one of the many trails in the greater Rochester area – Mendon Ponds Park offers more than 2,500 acres of woodlands, Corbett’s Glen harbors a charming stone bridge waterfall and Durand Eastman Park hosts several lakeside trails to ensure you never stop wandering.

SUMMER

A summertime visit to Rochester must include a trip to one or more of the Finger Lakes. A water lover’s paradise, you can go sailing, hop on a boat cruise or participate in countless water sports available in this area. Outdoor summer concerts at the CMAC performing arts center in Canandaigua are a local favorite. Regularly named a top wine region in the United States, our wine country offers several tours scattered amongst the Finger lakes. In addition, Rochester is widely recognized as a top golf destination in the country – so be sure to take advantage of our city’s rich golf heritage and play a round at one of the 50-plus courses in the region. Check out the jazz festival, one of the top music events in the country, hosting more than 300 concerts and 1,500 artists each June. An excellent summer nightcap involves a stop at Pittsford Farms Dairy for a scoop (or two).

REBECCA PATRICK, MD

FALL

If you’re lucky enough to visit Rochester in the fall, the foliage will not disappoint.

Letchworth State Park offers spectacular views of the Genesee River as it snakes through a large gorge and cascades down several waterfalls. The “Grand Canyon of the East” offers hiking trails and is a local favorite to “leaf-peep” the breathtaking fall colors. If you have more time on your hands, take a weekend trip north to the Adirondacks or south to the Catskills to soak in some mountain time. Rochester offers a plethora of breweries, apple orchards and pumpkin-picking venues. Attend a silent disco (where guests listen to music through wireless headphones instead of through a speaker system) or one of the countless theater and musical performances at the local Fringe Festival.

WINTER

Winter is a magical time of year, full of the lively traditions of the Flower City. Our downtown “Roc Holiday Village” offers a festive ice-skating rink, igloos, local artisan shops, cozy drinks and live music to celebrate all December long. Head to the Eastman Theatre to catch an evening showing of the Nutcracker featuring the Rochester City Ballet, or a groovy holiday pops performance by the Rochester Philharmonic Orchestra. You can channel your Clark Griswold

and venture to one of our local farms to chop-down your own holiday tree and check out Bristol Mountain for a nearby ski slope. If you want to warm up indoors, check out the Memorial Art Gallery and the Strong Museum of Play, or catch a Broadway show at the Auditorium Theatre. |

Dr. Patrick is PGY-2 at the University of Rochester.

The Rochester Lilac Festival

Waterfall in the Finger Lakes Region

live in a global society. We share the same issues.’

ASPS past President Lynn Jeffers, MD, MBA, on fostering global communication

Interview by by Daniel De Luna Gallardo, MD

ASPS past President Lynn Jeffers, MD, MBA, now serves as chair of the ASPS International Subcommittee, which helps develop strategies for the Society’s international efforts. These strategies address education, membership, communications, products and services, and relationships with international plastic surgery societies.

Dr. Jeffers spoke to Plastic Surgery Resident about her path into the specialty, her time as a resident, her advice to current residents in the United States and abroad – and how global collaboration is vital to pushing the specialty forward.

PSR: WHAT INSPIRED YOU TO PURSUE PLASTIC SURGERY AS A CAREER – AND WHAT DO YOU LOVE MOST ABOUT IT?

Dr. Jeffers: I was doing a research project as an undergraduate student on cleft palates and Steve Cohen, MD, invited me to watch him in the O.R. as he created a child’s ear from the child’s rib. I was hooked. I loved the idea of creating, building and transforming lives. I loved the idea of neither being tied to one part of the body nor one age group, as well as having the versatility to perform many types of operations. I loved that plastic surgery functions at the intersection of many different specialties and works collaboratively with most physicians and most areas of the hospital and health system. Most of all, I love the innovation inherent in our specialty.

PSR: WHEN YOU THINK BACK UPON YOUR TRAINING, WHO INSPIRED YOU?

Dr. Jeffers: Just about everyone in my training program at the University of Michigan – attendings and residents – made me who I am today. I was fortunate to train with people who are great contributors and giants in our field. What impressed me the most was how dedicated everyone was to excellence –whether that was patient care, education, research, leadership, innovation or all of the above. There was a sense that we all were expected to make a lasting contribution to our patients, our profession and society. (Go Blue!)

residency, I found that once I got into practice, I wished that I had paid more attention to the smaller details – why they chose

‘We

Lynn Jeffers, MD, MBA

Daniel De Luna Gallardo, MD

that marking, those sutures, those dressings, that patient position, etc. All that plays into bigger decision points, and I would wonder what tricks I missed that could’ve made the cases go more smoothly. I wished I would’ve tapped more into the resources I had available to me in an academic setting – or learning even more from all the brilliant people around me.

PSR: WHAT STRENGTHS AND AREAS OF OPPORTUNITY DO YOU SEE WITH INTERNATIONAL PLASTIC SURGERY RESIDENTS?

Dr. Jeffers: International residents can provide different perspectives and different approaches to various plastic surgery problems. International plastic surgeons may have more experience with certain procedures or disease processes than we do in the United States. In some countries, the volume of certain pathology or procedures exceeds those in the United States. Various innovations originate internationally as well. As we come together and discuss these issues, we can learn from best practices and innovative insights from each of us.

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

Dr. Jeffers: The willingness to learn. Skill and knowledge can be taught, but character and motivation – the inherent curiosity and interest in learning – must come from within. The best thing we can do is stimulate that spark and not squash this enthusiasm for questioning and innovating.

PSR: WHAT’S THE IMPORTANCE OF FELLOWSHIPS? WOULD YOU RECOMMEND THAT ALL RESIDENTS PREPARE FOR ADVANCED TRAINING?

Dr. Jeffers: It depends on your career plans. A fellowship may be crucial if there are certain procedures in which you think you need to gain more proficiency before being comfortable performing them in your intended practice setting. You might also find a fellowship desirable if you think it will help to differentiate yourself either in a private-practice setting or in pursuing an academic or employed job. But I don’t necessarily think that a fellowship is warranted in all circumstances.

PSR: WHAT ARE THE MOST VALUABLE RESOURCES ASPS OFFERS RESIDENTS?

Dr. Jeffers: Access to other residents and practicing surgeons that now reach around the world. I was so fortunate for these

connections not only for my clinical questions, but for career connections – and for personal and professional support and mentorship. On a more concrete level, the educational online hub and the resident curriculum and meetings, symposia, webinars and other opportunities for education both in-person and virtually. I would also highlight the opportunity for leadership, advocacy, research, entrepreneurship/innovation and teaching, if those are areas of interest to you.

PSR: WHAT SHOULD RESIDENTS OR NEW PLASTIC SURGEONS IN PRACTICE BE DOING TO HELP FACILITATE SURGICAL OUTREACH TO UNDERSERVED AREAS OUTSIDE THE UNITED STATES?

Dr. Jeffers: There are options such as The PSF’s Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program, as well as several international programs and opportunities to volunteer – including a PSF/ Operation Smile International Scholarship. ASPS members can also offer observerships and sites for our International Scholars or other exchanges. Creating connections and understanding of the true needs of underserved areas and then helping to find sustainable, meaningful ways to make a difference.

PSR: IS THERE MORE OPENNESS TO INTERNATIONAL OUTREACH AND COLLABORATION FROM AMERICAN PLASTIC SURGEONS THAN THERE HAS BEEN IN THE PAST?

Dr. Jeffers: There’s an increasing acknowledgement that we live in a global society – we share the same issues, and that was made especially apparent during the COVID-19 pandemic. Definitely during my presidency, we benefited from the experience of our international colleagues and it helped all of us to better address the issues that we faced. ASPS has more than 50 countries with whom we collaborate in our Global Leadership Forum and it’s made clear time and again that we face the same issues faced by our partner countries – whether regulation, supply shortages, public understanding of what we do, etc.

PSR: WHAT ADVICE WOULD YOU GIVE RESIDENTS INTERESTED IN CONTRIBUTING MORE ACTIVELY TO ASPS?

Dr. Jeffers: Determine what kind of activities you’re interested in and see how these align with the opportunities for residents in ASPS. There are so many more opportunities for residents now to get involved in ASPS than when I started – and residents are now eligible to serve on most ASPS committees.

continued on the next page

There’s a Resident Council with a representative from every residency program. There are several opportunities to get involved and a number of positions for residents, including with PRS or PRS Global Open, or the resident representative to the AMA. Sometimes you need to create the opportunity as well – that’s how the resident position on the ASPS/PSF Board of Directors, residents on committees, the Residents Council and the Residents Bowl all were created.

PSR: WHAT SPARKED YOUR INTEREST IN ASPS LEADERSHIP?

Dr. Jeffers: My early start at ASPS was somewhat serendipitous. At that time, most people settled into their practices a few years before getting involved. I was a first-year attending and I saw a blurb in Plastic Surgery News about a new leadership program – and the blurb had an email address you could write to for more information. I had been involved in leadership of some sort (Student Council, etc.) since fourth grade – and health policy and advocacy since middle school. I replied to the email saying I wanted to know more. Up to that point, previous leadership retreat invitations involved being “tapped on the shoulder” by an existing leader. However, the ASPS president at the time, Jim Wells, MD, and presidentelect, Rod Rohrich, MD, decided to expand the opportunity and perhaps find leaders they might not otherwise have known. I discovered later that I was the only person who actually replied to the email – I’m glad they didn’t tell me that until years later, otherwise I would have been pretty intimidated.

After the retreat, I was placed on two committees. As is often the case, if you actually show up and do some work, you get put on more committees the next year, and then you’re asked to chair a few. I was lucky early-on that I had a number of people who took me under their wing and opened doors.

PSR: WHAT’S YOUR MOST IMPORTANT CAREER ADVICE FOR RESIDENTS?

Dr. Jeffers: Remember that once you graduate, your career should meet your expectations. You aren’t trying to build something to fulfill someone else’s expectations or those of your program or program directors. This is now your life, your career. So really think about what excites you – what type of procedures do you like doing? In which setting would you like to practice: What geographic location? Lifestyle? Research? Teaching? Leadership? Advocacy? Administration? Entrepreneurship? Put that together. Talk to as many people

as possible and start working and building the career that you envision. Be ready to pivot and to adapt, but know that plastic surgery of all specialties gives you some of the best opportunities to build the career that you want.

PSR: AND WHAT ADVICE WOULD YOU GIVE TO RESIDENTS OUTSIDE OF THE UNITED STATES?

Dr. Jeffers: We share a great profession and learn so much from our colleagues globally. I would recommend connecting as much as possible with our plastic surgery residents and surgeons around the world. ASPS has multiple opportunities for international residents and practicing plastic surgeons that I highly encourage participating in. We have the International Resident Membership category, which provides access to a comprehensive online curriculum, as well as a virtual International Visiting Professors program, opportunities for observership and exchanges, the new international Residents Bowl, opportunities to participate in committees and programs, the Global Leadership Forum and its corresponding Young Plastic Surgeons group, international webinars with our MOU countries and so much more. As I say to U.S. residents, work to be the best plastic surgeon you can be and find the way to make a difference – whether that’s to your patients, your community, our profession or all of the above. |

Dr. De Luna Gallardo is chief resident and PGY-4 at Hospital Central Sur de Alta Especialidad de Petroleos Mexicanos, Mexico City.

Robert Abbe, MD

Abbe DEAR

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, senior-level 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.

Stealing the merit for another’s deeds

Dear Abbe:

How should I deal with a co-resident who’s taking credit for my work?

––Resident Purloinee

O, what a tangled web we weave, when first we practise [sic] to deceive!

- Sir Walter Scott, Marmion 1808

Dear Purloinee,

Your dishonest and fraudulent co-resident is on a ruinous path. I assume this is regarding a research project, as deception in the clinical context is challenging to maintain (e.g., the nurse and patient know that you changed the dressing and pulled the drain after rounds, not your co-resident. How can that subterfuge last?). Academic productivity is the “coin of the realm” in our hypercompetitive specialty, so the pressure to publish is significant. Hence, there exists a perverse incentive to steal someone’s idea and present it as your own at a lab meeting, or claim to have done the data analysis that a student did, etc. Unfortunately, the propensity for humans to pass off someone else’s work as their own is as old as recorded history. As irritating and outrageous as it is, there’s no advantage to giving into your righteous indignation. Approach this professionally and systematically.

First, gather evidence of your work: emails, lab notebooks, documents – anything time-stamped can demonstrate you having done the work prior to your co-resident’s involvement. (If you are not in the habit of documenting your work, now is the perfect time to start.) Then communicate directly with your co-resident. Arrange a meeting and present your evidence and express your concerns about them taking credit for your labor. Allow them to explain their actions and listen to their perspective. There’s a chance that this could all just be a miscommunication or misunderstanding that can be straightforwardly resolved.

If a collegial discussion does not clear things up, then you need to involve your research mentor. Make sure to present your evidence as well as relate your unsuccessful prior attempts at resolving the issue. A good approach is to ask your mentor for advice on how you can resolve the situation rather than asking her to “fix it.” A good mentor should recognize her role in adjudicating this and step in appropriately. The next step is to familiarize yourself with your institution’s policies and procedures regarding authorship, intellectual property and research integrity.

In extreme cases, you might need to escalate the matter to a section chief, department chair, ombudsman or research integrity office.

Remember to keep a professional demeanor while going through this process, focusing on correcting the situation, rather than engaging in an acrimonious interpersonal conflict. |

RHYTIDECTOMY

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

By Aradhana Mehta, MD, MPH

E.D: WORSENING WRIST PAIN W/DECREASE ROM

A 60 y/o M has presented to the E.D. with sudden onset of unilateral leftsided facial edema that’s worsening and extremely painful. Of note, he had a rhytidectomy performed yesterday by a local surgeon. History is notable for hypertension only.

MOST-COMMON COMPLICATIONS AND MANAGEMENT

The most-common postoperative complication in the rhytidectomy patient remains hematoma, with rates reported as high as 15.6 percent. The presence of a hematoma can threaten tissue viability and compromise the final aesthetic outcome. Depending on its severity, the patient may require a return to the O.R. Prophylaxis is the best tool a plastic surgeon has in their armamentarium. Several methods have been introduced in an effort to prevent the development of a hematoma, including appropriate management of postoperative nausea; meticulous blood pressure control; use of tumescent, intraoperative TXA; plasma utilization and hemostasis.

Intraoperative blood pressure control can be achieved with the use of various medications including beta blockers, alpha agonists and anxiolytics. However, a strong preference exists among seasoned plastic surgeons for the use of clonidine.

The use of pre-infiltration solutions in rhytidectomy relies on the same principles as those relating to liposuction. The composition of the tumescent consists of a local anesthetic and vasoconstrictive agent which act together to facilitate hydrodissection while simultaneously reducing intraoperative bleeding.

The use of intraoperative TXA and platelet-rich plasma have recently been gaining traction as methods to reduce hematoma rates. TXA is continuously being evaluated, and evidence is growing in support of its use as an adjunctive intervention to decrease intraoperative bleeding, ecchymosis and seroma formation.

A major point of contention remains the use of drains in rhytidectomy procedures. The current evidence highlights that there are potential benefits for the reduction of ecchymosis and seroma formation; however, it does not suggest that the use of drains reduces hematoma rates. Similarly, the use of quilting sutures is not currently in favor. While its use in abdominoplasty has been popularized, the use in rhytidectomy procedures carries an undue risk to the patient, as it increases the risk of facial nerve palsy and deformities to the overlying skin.

There are studies which have proposed the use of fibrin tissue sealants as a tool to eliminate dead space and decrease hematoma and seroma rates. Evidence has shown that its use likely decreases ecchymosis, edema and postoperative drainage. Its role in decreasing hematoma rates remains controversial, and it’s important to note that there are possible consequences of utilizing fibrin tissue sealants. They carry a risk of allergic reactions and, of course, an added expense to the patient.

While many methods carry some risk, there are additional low-risk methods that can be utilized. Many surgeons utilize a “second look technique” in which one side is temporarily closed while the contralateral dissection is completed. The initial side is then examined and hemostasis is achieved, and this is repeated on the contralateral side. Additionally, the patient can be placed in the Trendelenburg position in an effort to identify any quiescent sources of bleeding.

A less-common, but still feared, complication is iatrogenic injury to any of the branches of the facial nerve. Many facial nerve injuries will resolve with time, as they usually are a neuropraxia rather than nerve laceration. Additionally, a risk exists for numbness, scarring, alopecia and infection associated with rhytidectomy procedures.

RISK FACTORS

There are well-defined risk factors that increase the risk of a hematoma, including the male sex, hypertension, anticoagulants, antiplatelet agents, NSAIDs and smoking. In addition to these, it’s important to evaluate the patient holistically and assess for any history of coagulopathies, use of supplements or any other factors that may increase the risk of postoperative hematoma development.

APPROACHES TO RHYTIDECTOMY

Attempts to combat the signs of facial aging can drastically alter various components of facial anatomy. As with medicine in general, surgical approaches for facial rejuvenation have evolved – and continue to evolve in regard to complexity, plane of dissection and redraping of skin. In general, rhytidectomy techniques can be divided into three main categories: superficial, SMAS manipulation and SMAS elevation (Table 1)

The subcutaneous facelift may vary from a skin pinch to more significant undermining that allows for repositioning in a single vector. This technique has a higher safety profile; however, results are limited due to normal skin physiology, with decreased longevity noted in comparison to the other techniques.

SMAS manipulation techniques avoid a deeper plane of dissection in the sub-SMAS. These techniques include SMASectomy, SMAS plication and stacking, and they share the fundamental principle of skin flap elevation toward the midcheek. This increased dissection between the skin and SMAS is advantageous in skin redraping, reducing skin tension and minimizing the temporal hairline incision. Furthermore, SMAS plication and SMASectomy allow for improvement in lateral cheek deflation and reduce the risk for iatrogenic facial-nerve injury.

Superficial SMAS Manipulation SMAS Elevation

Categories of Rhytidectomy Techniques. An Evidence-Based and Case-Based Comparison of Modern Face Lift Techniques. Plast Reconst Surg. 152(1):p 51e-65e, July 2023.

DEEP DIVE

• SMAS plication does have limitations due to the fact that there’s not a full ligament release. The repositioning of the malar pad can also be problematic (Figure 1: See full explanation under “References” ).

• A lateral SMASectomy arguably provides better superficialfat repositioning, which can improve the longevity of the final result.

• SMAS elevation techniques have differing degrees of subSMAS dissection – high SMAS, SMAS flap/extended SMAS, deep plane and composite – which allow the surgeon to reposition superficial fat in a vertical vector. Movement in the vertical vector is advantageous to the surgeon, as it allows restoration of volume to the midcheek and malar area, and sharpens mandible definition. The level of separation between the SMAS and skin flap varies with each technique. All SMAS elevation techniques focus on the superficial fat and do not affect deep compartment deflation.

• High SMAS and deep-plane approaches have limited separation between the SMAS and skin flap, so the vertical shift of the SMAS is paralleled by the skin flap (Figure 2: See full explanation under “References” ). Some aesthetic limitations to note include the temporal hairline incision to prevent the elevation of the sideburn, being mindful of a “lateral sweep” by accentuating the lateral cheek flatness and the creation of “Joker lines” by accentuating the submalar deflation. Theoretically, an advantage of this technique is improved fixation, especially laterally.

• The extended SMAS or bilamellar approach has the aforementioned advantages but also allows the surgeon to vary the skin flap vector, as there’s an increased degree of dissection between the skin flap and SMAS (Figure 3: See full explanation under “References” ). The skin flap is able to be positioned more obliquely while placing more tension on the SMAS to alleviate skin tension and improve scar positioning. However, it should be noted that there’s significant variation in the viscoelastic properties of the SMAS and can affect the longevity of the volume restoration.

• Finally, an important adjunct to the modern rhytidectomy is facial fat-grafting. As we age, there are various topographic changes in facial aging that include superficial and deep fat compartment atrophy as well as attenuated ligaments that contribute to fat descent. The repositioning of superficial facial fat into the areas of deflation is a universal principle shared among all rhytidectomy techniques whether it be SMAS manipulation or elevation. The addition of facial grafting serves to augment the goal of a rhytidectomy by correcting central and deep facial deflation and creating a more comprehensive facial rejuvenation |

Dr. Mehta is PGY-5 in the University of Nevada-Las Vegas Department of Plastic Surgery.

REFERENCES

Figure 1. Ninety-Degree SMAS Plication. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 139(1):p 151e-1673, Jan 2017. Markings for 90-degree SMAS plication. The junction between the zygoma and zygomatic arch is palpated and methylene blue is used to mark a horizontal limb from this junction to the external auditory meatus along the lower border of the arch. The vertical limb is carried inferiorly and then along the posterior border of the platysma. The mobile SMAS is grasped and pulled posteriorly to the extent that it will oppose the horizontal and vertical limbs before suture anchoring.

Figure 2. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 139(1):p 151e-167e, Jan 2017. The high SMAS marking is carried posteriorly from the apex of the horizontal limb triangle, passing above the arch and toward the vertical methylene blue limb.

Figure 3. Evidence-Based Medicine: Face Lift. Plast Reconstr Surg. 139(1):p 151e-167e, Jan 2017. The SMAS flap is elevated just deep to the sparse sub-SMAS fatty layer.

Fig. 3

Fig. 1

Fig. 2

Melanoma

By Jessie Koljonen, MD

Melanoma comprises a small percentage of skin cancers, but it’s considered the most serious and is responsible for the majority of deaths from skin cancer. In this installment of Inservice Insights, we review the clinical findings and subtypes, as well as diagnosis and treatment, for the commonly tested topic of melanoma.

Melanomas develop in the melanocyte, the pigment-producing dendritic cell in the basal layer of the skin and can grow in both a radial and vertical direction. Vertical growth of malignant cells, from the epidermis to the dermis, indicates a more-invasive tumor and a worse prognosis. Risk factors for melanoma include personal and family history of melanoma, fair complexion and cumulative sun exposure.

SUBTYPES

Melanoma can be classified into various subtypes, based on growth characteristics and appearance. The most common subtype of melanoma is superficial spreading melanoma, representing approximately 50-70 percent of melanoma types. 1 These often arise from pre-existing nevi and initially appear as flat lesions, but they may progress and appear raised or irregular as the lesion develops. As the name suggests, superficial spreading melanoma typically has a prolonged radial-growth phase, ranging from six months to six years, before invading deeper tissues.1 This lends to an overall better prognosis seen in this subtype.

Nodular melanoma is the second most-common subtype of melanoma and accounts for 10-20 percent of melanomas.1 These are commonly seen on the head, neck and trunk, and they have a higher incidence in men. 2 They are described as having a darker color and are dome-shaped, and they may appear as a blood blister. Frequently thick at the time of diagnosis, nodular melanoma is known to have a rapid vertical growth phase, and thus has increased metastatic potential.

Lentigo maligna melanoma is a slow-growing type of melanoma with a relatively low malignant potential. It typically arises from the in-situ lesion of lentigo maligna and presents as large, tan lesions with varied patterns and multiple amelanotic patches. This subtype of melanoma is strongly correlated with sun exposure; are often found on the head, neck and face; and is more prevalent in women and the older population.1,2

Superficial spreading melanoma (Figure 12, “Cutaneous Malignancies: Melanoma and Nonmelanoma Subtypes.” DOI: 10.1097/PRS.0b013e318206352b)

Nodular melanoma (Figure 2, “Managing Malignant Melanoma.” DOI: 10.1097/ PRS.0b013e31829ad411)

JESSIE KOLJONEN, MD

Acral lentiginous melanoma is seen most frequently in dark-skinned individuals, accounting for 3060 percent of melanoma in this population, yet it’s the rarest form of melanoma in the Caucasian population. 2 This subtype tends to develop in relatively sun-protected areas such as the palms of the hands, soles of the feet and the nail bed, leading to a later diagnosis. This subtype is known to be more aggressive and frequently metastasizes.1,2 Subungual and periungual melanoma is a variant of acral lentiginous melanoma that commonly involves the nail bed of the thumb or great toe. It’s typically seen as a darkly pigmented, black-brown band which is greater than 3 mm in width, with irregular borders. 3

A less-common subtype of melanoma is amelanotic melanoma, which accounts for approximately 2-8 percent of invasive melanoma.2 Due to its lack of pigmentation, these lesions present a diagnostic challenge. They are commonly mistaken for other nonmelanoma lesions such as intradermal nevi or nodular basal cell carcinoma. The diagnosis of melanoma is not initially suspected, and these are often diagnosed late.

Desmoplastic melanoma is another rare subtype of melanoma that’s also often difficult to diagnose. Representing approximately 4 percent of melanoma, it’s a spindle cell tumor that’s commonly confused with Spitz nevi, blue nevi, common nevi, hemangiomas and pyogenic granulomas. 2 It has a primarily dermal component; can appear nodular or scar-like; often lacks pigment; and otherwise lacks distinct characteristics to aid in diagnosis.4 These lesions are often characterized as having aggressive local growth, but they rarely metastasize. 2 Desmoplastic melanoma is typically seen in the head and neck in older Caucasians with a history of sun exposure.

DIAGNOSIS AND STAGING

Common characteristics of skin lesions concerning for melanoma can be summarized by the “ABCDE of Melanoma.”

A symmetry of lesion

Border irregularity

Color variegation

Diameter > 6 mm

Evolution/Enlarging (changing lesion)

Lesions that are suspicious for melanoma should be biopsied. This allows pathologic evaluation of the lesion and determination of the Breslow thickness, which is the measurement of melanoma tumor cells down to the deepest point of the lesion within the dermis – and is the most important histologic prognostic factor. Other important pathologic factors of note include mitotic rate and ulceration. 2 Full-thickness excisional biopsy is recommended. Incisional biopsy can be considered for large lesions in sensitive locations, such as the face. Other types of biopsies, including shave and punch biopsies, are typically not recommended as these don’t allow for full pathologic evaluation.5

Staging for melanoma is executed through the American Joint Committee on Cancer Tumor, Node, Metastasis (TNM) Staging System.

TREATMENT AND RECONSTRUCTION

Surgical excision is the mainstay of treatment for melanoma. This includes wide, local excision with clinical margins based on Breslow depth, including all the subcutaneous tissue down to the fascia. The National Comprehensive Cancer Network recommends 0.5 cm margins for in situ lesions; 1 cm margins for Breslow thickness less than 1 mm; 1-2 cm margins for Breslow thickness of 1.01-2 mm; and 2 cm margins for Breslow thickness greater than 2 mm.6

Lentigo maligna melanoma (Figure 3, “Managing Malignant Melanoma.” DOI: 10.1097/ PRS.0b013e31829ad411)

Acral lentingenous melanoma (Figure 4, “Managing Malignant Melanoma.” DOI: 10.1097/ PRS.0b013e31829ad411)

Advanced subungual melanoma (Figure 3, left and center images, “Subungual Melanoma A Review of Current Treatment.” DOI: 10.1097/ PRS.0000000000000529)

‘ABCDE’ OF MELANOMA

PLASTIC SURGERY PERSPECTIVES

HAND SURGERY

“Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, at the Sackler School of Medicine in Tel Aviv University, and Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In this installment of the series featuring leaders in hand surgery, Dr. Brown interviews The PSF past President Michael Neumeister, MD. – Rod J. Rohrich, MD, Editor Emeritus, Plastic and Reconstructive Surgery

PSR: HOW HAS HAND SURGERY CHANGED SINCE YOU STARTED?

Dr. Neumeister: Two things that have become popular in recent years are wide-awake surgery and the use of epinephrine. Wide-awake surgery enables the patient to actively participate in rate of motion assessment in real time, which isn’t possible under general anesthetic. This enables us to achieve much better results compared to performing the same procedure under general anesthetic.

PSR: IS THERE A PARTICULAR CLINICAL CASE THAT INFLUENCED YOU?

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

Dr. Neumeister: I’ve always liked the musculoskeletal system including knees, hips, hands and shoulders. As I watched patients after total hand transfers and saw how functional they were with their new digits after that very intricate surgery, I knew that was what I wanted to be doing for the rest of my life. During residency, I always enjoyed complex reconstruction all over the body, which follows the same principles as the total hand transfers – restoring form and function. I pursued a fellowship in microsurgery and then one in hand surgery.

Dr. Neumeister: Hand fractures have changed the way I practice significantly since I started. Obtaining an anatomic reduction of the metacarpal and phalangeal fractures has always been wonderful. However, in many cases, patients end up having stiffness and complications because of surgery. These cases have made me question my goals operating on them – and in cases where they already have normal range of motion, which is what I believe to be the goal of the open reduction, I will not operate on them. I examine their range of motion carefully and make a decision despite the actual fracture pattern, which can look very bad in the X-ray. I wouldn’t want to operate on a patient who I think could only go backward, developing stiffness as the result of the dissection and the open reduction. Therefore, I very rarely operate on fractures in the hand unless they are intra-articular, or if gross scissoring or malrotation are apparent. I get patients moving right away, I do not splint them (except for nighttime) with these fractures and they continue to move. Since we know that micromotion aids in the healing, it helps them get back faster rather than operating on them. This philosophy really modified the way I treat these, and this is how I now teach our residents, as well. The most important thing is defining your goals and seeing what needs to be done to achieve them – not everything needs to be operated upon.

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

Michael Neumeister, MD Chair and Professor, Department of Surgery Chief, Division of Plastic Surgery Hand Fellowship Program Director SIU Medicine Institute for Plastic Surgery, Springfield, Ill.

PLASTIC SURGERY PERSPECTIVES/

continued from previous page

PSR: WHAT ARE YOUR CLINICAL AND RESEARCH INTERESTS?

Dr. Neumeister: I like the concept of pre-fabrication, which was taught to me by Julian Pribaz, MD. You bring in new blood supply to a tissue bed and this new blood supply sprouts vessels into that new bed, so you can transfer that tissue as a flap. As a result of this innovation, we have gone on to creating new flaps – such as in an area that does not have a pedicle, cartilaginous constructs such a trachea on a thigh that we move up as a tissue transfer, ear reconstruction – and even mandible reconstruction – by taking cadaveric mandibles, prefabricating them and moving them as a free-tissue transfer. I believe that all tissues can be pre-fabricated and although not a common procedure, it’s one of those procedures that I find very intriguing – which creates a lot of enthusiasm in the operating theater.

PSR: WHAT MOST EXCITES YOU ABOUT THE FUTURE OF HAND SURGERY?

Dr. Neumeister: More residents now are interested in hand surgery, and we see a lot more applications to the fellowships in hand surgery. It’s rather exciting to know that the discipline is going to grow, especially since there are many novel innovations and new concepts that have to be looked at. The idea of nerve prosthetic interface, for example, is very intriguing and more work needs to be done to optimize that. Right now, we’re looking at things like targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), but down the road there may be new ideas that will come out that change that nerve wire interface. Rather than doing something like transferring nerves into muscles which supply these muscles, we’re covering them with a muscle graft such as in RPNI. We have a faster, easier way with high fidelity to create prosthetics that are like the Luke Skywalker arm.

PSR: WHAT DO YOU LOOK FOR IN A HAND SURGERY FELLOW?

Dr. Neumeister: First, we want to see an honest and deep desire to do hand surgery. Enthusiasm is key, since enthusiasm generates creativity and creativity generates innovation. Sheer enthusiasm works well for the patient. It changes how we do things for the better, and that creates more enthusiasm – which creates more creativity and more innovation. I’d like to see that they would like to improve the care that we’re giving today, as well as present at national meetings so the world can see

what changes they are trying to make. Second, hand surgeons have to be willing to wake up in the middle of the night to put fingers and toes back on – therefore, there needs to be a willingness to practice your craft when called upon, in order to restore the function of these amputated parts. |

FACULTY FOCUS/ continued from page 12

take advantage of free weekends to travel more locally, hike and unplug from responsibilities and the EMR. I’m fortunate to be part of an academic practice where I share call with several other surgeons and have amazing residents, which helps immensely with work-life balance. We cover each other when people are unavailable, so I know my patients are always in good hands if I’m not around. That can be a lot harder for people in solo or smaller practices.

I was interested in plastic surgery during my first year, and hence finding a summer research position in the field, but once I saw the incredible reconstructive surgery happening there, nothing else on my clinical rotations could compare. |

Aabra Ahmed, MD, PGY-5 at the University of Rochester, assisted in the completion of Faculty Focus.

PSR: WHAT WAS YOUR GREATEST

NON-MEDICAL CHALLENGE OF YOUR TRAINING?

Dr. Neimanis: My dad died during my fourth year of med school, so starting residency as my family navigated that loss and the financial and logistical sequelae was tough. I felt bad that I couldn’t be as supportive as I would’ve liked because I had my own priorities trying to figure out intern year and not having much free time. Fortunately, I matched at a residency program close to home, which made being around for holidays and events much easier. I’m very grateful for that.

INSERVICE INSIGHTS / continued from page 24

PSR: WHAT

ARE

SOME OF THE CHALLENGES YOU ENCOUNTER ON A REGULAR BASIS?

Dr. Neimanis: I’m still early in my career, so at least a couple of times a month I see something I’ve never seen before. It’s always stressful when you don’t know exactly what to do to help someone. Having mentors and colleagues to talk to is so important in these cases. We also have a great “Indications” conference monthly, and I love hearing my partners’ opinions and the residents’ ideas. The other biggest challenge is getting insurance approval for cases I feel are medically necessary for my pediatric patients – but there’s not enough time to talk about that!

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

Dr. Neimanis: Find which clinic you hate the least. I’m partially joking, but it’s true. I think every plastic surgery resident enjoys being in the O.R., even if it’s not necessarily a case they love. It’s clinic to me that defines where your real passions are. I genuinely enjoyed craniofacial clinic in residency. Some people love guiding breast cancer patients through their reconstructive journeys, watching hand trauma patients regain function, etc. If you like the less fun parts of a practice, it’s probably a sign that that’s where you belong.

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

Dr. Neimanis: I spent a summer at MD Anderson Cancer Center between my first and second years of medical school.

Sentinel lymph node biopsy should be performed in patients with melanomas of Breslow depth greater than 1 mm, and should be strongly considered for high-risk lesions with melanomas between 0.8-1.0 mm.4,7 Positive nodal metastasis on sentinel lymph node biopsy should be followed by a complete lymph node dissection.

While surgery remains the primary treatment for melanoma, adjuvant and neoadjuvant systemic therapy have shown improved survival benefits particularly in patients with latestage disease. Targeted therapy and immunomodulation agents, including BRAF inhibitors Vemurafenib and Dabrafenib; IL-2 agents; and CTLA-4 monoclonal antibody Ipilimumab; have been approved for the treatment of malignant melanoma and should be considered in certain patients.4

Most melanoma defects can be reconstructed by primary closure with undermining, local flaps or skin grafts. |

Dr. Koljonen is PGY-3 at Southern Illinois University, Springfield.

REFERENCES

1. Netscher DT, Leong M, Orengo I, Yang D, Berg C, Krishnan B. Cutaneous Malignancies: Melanoma and Nonmelanoma Types. Plast Reconstr Surg. 2011;127(3):37e-56e.

2. Dzwierzynski WW. Managing Malignant Melanoma. Plast Reconstr Surg 2013;132(3):446e-460e.

3. Cochran AM, Buchanan PJ, Bueno RA Jr., Neumeister MW. Subungual Melanoma: A Review of Current Treatment. Plast Reconstr Surg. 2014;134(2)

4. Pavri SN, Clune J, Ariyan S, Narayan D. Malignant Melanoma: Beyond the Basics. Plast Reconstr Surg. 2016;138(2):330e-340e.

5. Tadiparthi S, Panchani S, Iqbal A. Biopsy for Malignant Melanoma – Are We Following the Guidelines? Ann R Coll Surg Engl. May 2008;90(4):322-5.

6. Knackstedt T, Knackstedt RW, Couto R, Gastman B. Malignant Melanoma: Diagnostic and Management Update. Plast Reconstr Surg. 2018;142(2):202e-216e.

7. Brănişteanu DE, Cozmin M, Porumb-Andrese E, et al. Sentinel Lymph Node Biopsy in Cutaneous Melanoma, a Clinical Point of View. Medicina (Kaunas). Nov. 3, 2022;58(11).

Sept. 7-9, 2023

Course and Simulation Sessions*

PROGRAM CHAIR: Matthew J. Trovato, MD

PROGRAM CO-CHAIR: Sami Khan, MD

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