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PRS Resident Chronicles
Tuesday, July 01, 2014

by Anup Patel, MD, MBA with assistance from Dr. Akshay Deshpande (microsurgery fellow)

India proves home for me for many reasons despite being born in the United States. First, most of my family and many of my friends reside there. Second, Cents of Relief, the nonprofit that I co-founded with Rina, my wife, endeavors to empower victims of human trafficking in India through healthcare and education. Third, with some good fortune, I have had the chance to participate in cleft and burn missions across India in conjunction with Operation Smile. Thus, with my remaining elective time, I decided to head to India after Paris to continue my plastic surgerytraining.

Following a tumultuous departure from France including having all of my credit cards, driver license, and cash stolen off a train, I managed to arrive at Charles de Gaulle Airport and board the ten-hour flight from Paris to Mumbai. Yet, while I hate long journeys, ten hours seemed to be the average time each patient traveled to get to the next hospital I began my stint at. That hospital was none other than Tata Memorial Hospital (TMH) in Mumbai: India’s “Mecca” for oncological resection and reconstruction. Yatin mama (uncle on mother’s side) and Shrutimami (aunt on mother’s side), who work in the medical field, contacted their friend Dr. Shirpad Banavalli, the chair of medical oncology at TMH, to assist me in garnering a rotator position in TMH’s arm of plastic and reconstructive surgery.

Synonymous with the “best in cancer treatment, “TMH treats a wide-range of cancer pathology divided into disease-management groups (DMG). Dr. Banavalli, the chair of medical oncology, advocates this approach as it enables patients with a certain disease to see all the respective consultants in a single area maximizing efficiency. I opted for the head and neck oncologic DMG not only because of a strong interest in the field, but also because Dr. Stephan Ariyan, one of my attendings, recommended it highly.

As a side note, Dr. Ariyan visited TMH in the 1980s at the request of Dr. Jatin Shah, the current chief of head and neck surgery at Memorial Sloan-Kettering, for them to perform joint head and neck tumor extirpation and reconstruction. Dr. Ariyan remembers vividly going to the floor to identify patientswho would require head and neck reconstruction with the pectoralis major myocutaneous flap, which he described its use for head and neck defects in 1979.(1) The task proved immensely difficult as he looked down the hallway seeing numerous patients, with varying types of head and neck tumors, in different anatomical locations, at various disease stages. He told me at TMH one will witness every type of head and neck tumor including many fungating and exophytic lesions due to the abject poverty that delays treatment.

Walking into TMH, everything Dr. Ariyan said proved true. The patients come from all over India, often using every bit of their money just get to TMH, only then to find themselves without any funds left for food or lodging. Thus, one can routinely find patients waiting for surgery sleeping on the footpaths outside the hospital. The ones covering their mouths with masks or handkerchiefsare attempting to hide some sort of fungating lesion in order to avoid the associated social stigmata. The clinics are teeming with patients, many of whom, must wait weeks before being brought to the operative room.

To keep up with this demand, the plastic and reconstructive surgery service at TMH routinely perform three to four free flaps per day operating from head to toe. Specifically, at TMH, of the 500 free flaps performed last year, 400 were for head and neck defects, 50 for breasts, and 50 for lower extremity and chest wall defects.

The unit consists of Dr. Prabha Yadav, its chief, Drs. Vinay Kant Shankhdhar and Dushyant Jaiswal, its two-full time attendings, and a slew of residents and fellows. Drs. Akshay Deshpande and Saumya Mathews proved to be the fellow and resident, respectively, whomI got linked up with and, ultimately, became close friends with. Every member of TMH welcomed me into the operating rooms and took me through the thought-process of the case. Our exchange facilitated provocative discussions continuing to advance the field of reconstructive surgery.

In one operating room, Dr. Jaiswal designed a free fibula flap with a double skin paddle to resurface the mandibular defect (Fig 2).(2) The double skin paddle enabled one free flap to provide both internal mucosal lining and external cutaneous coverage. Rapidly, the flap was elevated identifying the perforators to the skin, dissecting the anterior and lateral compartments off the bone, and garnering adequate pedicle length. The flap was inset and the microanastomosis were performed with the microscope. With the fibula fixed in place with a plate, the soft-tissue was redraped restoring facial harmony.

While at our institution the veins are generally anastamosed using couplers, at TMH, largely due to the costs constraints, the veins are hand-sewn. The high-volume combined with the surgical skillset at TMH enables the veins to be done as if couplers were being used. In fact, one case I remember standing out was when Dr. Vinay Kant Shankhdhar performed an end-to-side internal jugular vein to the vena comitantes of a free ALT flap for resurfacing the oral commissure and submental area. Using horizontal mattresses stitches to compensate for the size discrepancy, he performed the otherwise challenging suturing effortlessly. After the arterial anastomosis was completed, the flap turned pink without any leaks from the anastomoses.

In fact, these attendings love teaching holding a monthly microsurgical workshop that includes a cadaver dissection course for learning the essentials of flap harvest. The course selects four candidates (on a first-come, first-serve basis) who are required to pay the course fee of $600. The course focuses on head and neck reconstruction providing instruction on how to perform free flaps such as fibula, anterolateral thigh, and radial artery forearm as well as pedicled flaps such as the pectoralis major myocutaneous flap. Comprehensive, didactic lectures are delivered on flap harvest techniques and later in the day the attendees are taken to the operating room to observe the relevant surgeries from Monday to Thursday. The last day consists of an organized cadaver dissection course where the attendees harvest the flaps on the cadaver under the guidance of the faculty. 

The TMH plastic surgery section proved to be one of my best experiences witnessing how in a resource-constrained setting, its staff delivers optimal care to treat some of the most complex oncological cases in the world. The gregarious and welcoming attitude stems from how Dr. Yadav as she treats each and every person with respect and kindness. The surgical education utilizes articles from Plastic and Reconstructive Surgery to stimulate thought and discussion for the weekly didactics and M and M lecture. Furthermore, Drs. Akshay and Dr. Saumaya told me the white journal’s videos and online content enable them to quickly review technical steps for cases the next day.

Those of you wanting to see diverse oncologic pathology, particularly in the head and neck region, should visit TMH to see how the plastic surgery unit here continues to work advance the reconstructive frontier.

Figure 1: Tata Memorial Hospital’s clinic with Saumya and Akshay

Figure 2: Dr. Jaiswal and a fellow are harvesting a free fibula flap for a head and neck oncologic defect at Tata Memorial Hospital.

 

References:

1.         Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979 Jan;63(1):73-81. PubMed PMID: 372988.

2.         Yadav PS, Shankhdhar VK, Dushyant J, Seetharaman SS, Rajendra G. Two in one: Double free flap from a single free fibula osteocutaneous unit. Indian J Plast Surg. 2012 Sep;45(3):459-65. PubMed PMID: 23450653. Pubmed Central PMCID: 3580343.

 


Friday, June 27, 2014
by  Ajul Shah, MD
 
On May 1st, 2014, a group of volunteers embarked upon a plastic surgery mission trip to Mbale, Uganda with the non-profit foundation “Changing Children’s Lives”.  The foundation, founded by Dr. Mark Weinstein, has embarked upon yearly mission trips to areas in need – most often, for children with cleft lips and/or palates.  The foundation has been to multiple countries, including Vietnam, Thailand, Uganda, and others.  I was fortunate enough to be a part of the trip to Uganda this year (the foundation has been to the same site twice in the past), and I can say without hesitation, the experience will change your perspective.
 
The group, consisting of surgeons, students, residents, nurses, physician assistants, and administrators from three separate institutions, met at JFK on May 1st to start upon the long journey to Mbale.  After an eight hour flight to Amsterdam, a ten hour flight to Entebbe, and an eight hour bus ride to Mbale, the group arrived tired and sweaty to the Mt. Elgon Hotel.  The traffic leaving Kampala was….tricky. A view on Google Maps showed a distance from Kampala to Mbale that should have taken 2.5 hours to traverse, but we quickly realized that we would have no chance of leaving Kampala itself in that time period. It took nearly 4 hours to navigate the potholes, single lanes, traffic, and lack of street-lights and stop signs to leave the city of Kampala (25 miles). After arriving in Mbale, the group met at the hotel bar for a few glasses of wine, and turned in for the night in preparation of the next full day of screening.
 
Figure 1 – Entrance to Mbale Regional Hospital
 
We arrived at the hospital the next morning to set up the operating rooms and screening tables. The hospital environment was striking – although a sizable complex, most wards were no more than open-air buildings with four walls, packed with beds side-by-side. Chickens ran freely throughout the various wings, with patients crammed in to each ward of the complex. The operating theater consisted of three operating rooms stocked with the basic necessities – a table that cannot be moved up or down and operating room lights that often failed to work. We brought the remainder of the supplies with us, including gloves, instruments, anesthesia equipment, and dressings. The operating rooms and the screening areas were set up simultaneously, and then…we waited. And waited.  As I was informed by Dr. Weinstein, the patient screening process was markedly different in Uganda than it was in the Southeast Asian countries – during the first day in Vietnam the year before, the staff screened 150 patients.  He told me that although the foundation had a contact in the local community that spread the word of the upcoming mission trip, the local population demonstrated a general sense of hesitation to visit the international surgeons.  He let me know that rather than screening all patients on the first day, there would be a constant daily stream of patients after word of successful surgeries spread through the community. And he was correct.  Slowly, patients arrived. A patient with a bilateral cleft lip. A unilateral cleft lip. A burn contracture. A Veau II cleft. A Veau III cleft.  By the end of the day, the operating schedule for Monday was full.
 
Figure 2 – One of the hospital wards
Figure 3- Senior Administrator Shefali Shah in foreground beginning the screening process with Dr. Mark Weinstein and Dr. Devinder Singh (attending surgeons) in background evaluating patients
 
The week was filled with operating and screening. The patients arrived on a daily basis as successful surgeries were completed.  The majority of patients operated upon had cleft pathology – cleft lips, cleft palates, or both.  There were also patients with AV malformations, burn scar contractures, soft tissue tumors, and others.  Some stories were truly emotional. A 28 year-old male patient presented with an incomplete unilateral cleft lip.  He said that during his school years, he was so ridiculed by his peers that he could not stand the thought of returning. He left school at the equivalent of the 7th grade, and later went to look for work in the city. He found that older people were just as malicious – he felt so ostracized in his surroundings that he left the city and moved, in his words, “to the edge of the forest to be away from people”.  We completed a Fisher repair of his cleft lip, and let him look in a mirror – his face relayed his underlying emotions.  My feelings were bittersweet – I felt very grateful for the opportunity to help this man, but also felt saddened at the thought that a simple 45-minute operation as a child could have saved him a lifetime of heartache.
 
Figure 4 – Ajul Shah with a patient after the completion of the patient’s operation
 
These types of feelings pervaded the trip.  The backdrop of the Ugandan countryside, lush and green, contrasting to the poverty and underdevelopment at its forefront, was striking. I felt happy to provide assistance to a community that needed it, but felt distraught by the lack of resources available to the general public. Discussions with local staff and surgeons revealed a community torn by strife and corruption whose natural resources, in their opinion, were being misused and mismanaged. The interactions we had with the people of the community were the most affecting.  Each patient, each parent, and each relative brought with them an individual story of achievement and overcoming the odds in an environment where the odds were set against them.  I stood in admiration of a community in solidarity, whose children were stronger than most adults I know (including myself). It puts life in to perspective, and makes you question what is truly important in your own.
 
If you have any stories from mission trips of your own, please do not hesitate to comment.
 
Here's a link to the documentary of the trip:
 

Monday, June 16, 2014
by Justin Perez
 
As I walked into Carnegie Hall wearing my cap and gown on graduation day, my head was swimming with mixed emotions.  I wondered how the last four years have gone by so fast. I felt thankful for having made it to this point in my career with the support of my loving family. And while I couldn't wait to be joining the ranks of fresh interns with their newly minted MDs, truth is, I also felt pretty nervous about taking this next big step in my life -- and I'm willing to bet that almost every so-to-be intern out there had similar sentiments.
 
"Cheers, to the Class of 2014! I wish you all the best of luck over the coming weeks as we make our transitions into our new homes, new neighborhoods, and new roles as the next generation of plastic surgeons."
 
"Will I measure up?" and "to the bottom of the totem pole I go!" are just some of the preoccupations I've heard others in my class endorse before starting their residencies. And though all of us may have certain insecurities about being the "new kids on the block," I feel fortunate to be starting my career in a familiar environment where I feel well supported (hence the importance of doing away rotations **cough cough**). The flurry of emails, texts, and phone calls welcoming me to the UTSW family since Match Day has been humbling. Whether it's an offer to help me find an apartment or move a couch, the hospitality of my future colleagues has been endless. So I quickly realized that being a ‘newb’ in your residency program isn't something to scoff at or fear; it should be embraced.  And in the right community, you will be embraced.  
 
So consider this blog one of the many thank you’s I owe not only to those who've made me feel so welcome, but also those who've nurtured my path to this point. Too, I encourage you, other members of my class: don't forget those who've helped you get here. Whether it's a handwritten postcard from your 4th year travels, a handshake, or a hug (my preferred Puerto Rican means of gratitude), be sure to give a shoutout to those who've helped you find your way.
 
Cheers, to the Class of 2014! I wish you all the best of luck over the coming weeks as we make our transitions into our new homes, new neighborhoods, and new roles as the next generation of plastic surgeons. One day day when we're attendings we'll look back on these good ol' days of intern-hood, so buckle up and enjoy the ride.

Friday, June 13, 2014
by Andre Alcon
 
The first week of my first sub-I rotation is over and it’s been an abrupt transition from my research year in the lab. Gone are the days when I could set my own hours and work at my own pace. At the same time, however, I was looking forward to getting back to the OR and working in the hospital. Nonetheless, I had some anxiety as my rotation approached. There’s a lot riding on these four-week auditions; around 75% of students who match in plastic surgery do so at a place where they did a rotation.

Unfortunately, things started out a little slow for me after being in the lab for so long. Everything moves so quickly on surgical services; it was as if I had moved from New Hampshire to NYC. Not surprisingly, anticipation is key in this type of environment. During the first week, I spent a lot of my time figuring out how the team operates. Easier said than done no doubt, and finding the right balance between taking the initiative and biting off more than you can chew can be delicate. However, after a couple of days, I had a pretty good understanding of what needed to be done and when, which will hopefully put me in a good position moving forward.
Also on the team are two other sub-I’s, two third year medical students and a PA student. That’s a lot of people to share valuable OR time with. Luckily, all of them are friendly and understanding, but establishing ground rules early with fellow students has helped to avoid any confusion or poaching. Of course, sometimes residents will tell a student to scrub in on a case that isn’t theirs, but talking about it with your colleagues can minimize any unnecessary drama. Ultimately, two or three sub-I’s who function well as a team is much more impressive than each one competing with the others. Moreover, it shows that you’re a team player and that you’re not afraid to lay down a bunt to advance a teammate.
If there isn’t much going on, I’ve also found it helpful to take the third year medical students aside to talk to them about any cases or lectures they might have in the coming days. I can give them tips on what to expect and how to prepare, which can be extremely helpful for them and keeps them occupied so that the residents can focus on other, more important things. The med students usually return the favor later on, which has been enormously helpful at times. It also shows the residents that you can be a leader and that you take an interest in teaching, which is a great skill to have during residency.
A lot of what sub-I’s do is a reiteration of third year, but with higher expectations and more responsibilities. The last week has been a whirlwind and I’ve already learned a ton. Rotating at my home institution has undoubtedly made the transition easier.  The next three or four months will definitely be a rollercoaster when I leave for my away-sub-I’s, but for now I’m just focused on the next three weeks.
 

Wednesday, May 28, 2014
by Anup Patel, MD, MBA

In our fifth year of plastic surgery training, we are given 12 weeks of elective time to use at our discretion, with emphasis to go to centers to hone our surgical skills. Dr. John Persing, our chairman, espouses this model as it enables you to develop your surgical acumen as well as establish collaborations for research. To this end, I applied to go to Paris, the city where craniofacial surgery burgeoned from under the leadership of “Docteur” Paul Tessier.

Its geographical location, as well as its reputation, enables the center at Hopital Necker to be a catchment-area for rarest of craniofacial disorders. The craniofacial pathology that many of us just memorize for passing board exams actually proves paramount in this clinic as it routinely comprises the differential. In Necker’s multi-disciplinary clinic composed of plastic surgery, neurosurgery, and oral maxillofacial surgery, the diversity of craniofacial syndromes proves stunning. In one, four-hour session, we witnessed patients with the following: Apert’s, Pffeifer’s, Crouzon’s, Saethre-Chotzen (mom and patient), turribrachycephaly secondary to multi-suture fusion, and Solomon’s syndrome. Admittedly, the latter I had never heard about until seeing the patient in clinic. This translates into a huge volume for craniofacial surgery that demand utilization of the procedures developed initially by Drs. Tessier and Fernando Ortiz-Monasterio in the late 1960s through the early 1970s.
As a historical note, Dr. Tessier never operated at Hopital Necker, but rather at the Hopital Foch, where he tended to focus on adult patients. It was not until Dr. Daniel Marchac, a plastic surgeon, teamed up with Dr. Dominique Renier, a neurosurgeon, to develop the pediatric craniofacial unit that stands at Hopital Necker since 1976. Today, Dr. Eric Arnaud and Dr. Federico DiRocco, the plastic surgeon and neurosurgeon, respectively, oversee the unit treating patients from all over the globe. There has always been in the unit a true sense of collaboration between craniofacial surgeons and neurosurgeons.
 
After meeting Dr. Arnaud at the International Society of Craniofacial Surgery (ISCFS) Congress this past October, he fortunately agreed to allow me to observe him in Paris. Mentored and trained by Drs. Marchac and Ortiz-Monasterio, Dr. Arnaud performs some of craniofacial’s most challenging surgeries with ease and efficiency. In one morning, he performed “H” procedure cranioplasty to reshape a child with severe sagittal craniosynostosis, followed by a frontal-orbital advancement for a child with metopic craniosynostosis. Dr. Arnaud’s dexterity and numerous years of experience facilitate his ability to perform both operations in less than 60 minutes. It became obvious that morning why craniofacial centers around the world routinely refer him patients or fly him directly to their center for patients needing complex craniofacial surgeries such as the Monobloc or LeFort III. This has translated into him having one of the world’s highest series of Monoblocs and LeFort IIIs.

To no surprise, on my final day, he performed a combined LeFort III with a facial bipartition for a teenage girl referred from Qatar with Apert’s syndrome. Dr. Arnaud took fellows, residents, and observers through the steps of arguably two of plastic surgery’s most difficult operations providing historical anecdotes and pearls related to them. His amicable and jocund nature create a stress-free environment that welcomes questions and discussion.
 
 
 
Using a bicoronal incision, he elevated the scalp flap to gain access to the orbits, zygomatic sutures, and nose. Next, he prepared the craniofacial disjunction using a combination of power tools with an osteotomy/mallet. Then, the midface was advanced using the Rowe disimpactors and plated in place with a series of screws eradicating the midface hypoplasia and exorbitism. Following this, to simultaneously medialize the orbits and transversely expand the palate, the bipartition was conducted followed by bilateral medial canthopexies. Finally, external and internal distractors were applied endeavoring to circumvent relapse of the midface advancement. In less than four hours, he restored facial harmony to a child who otherwise would be socially ostracized.
 
The case reminded me of the operation that I witnessed as a medical student that ultimately motivated me to apply for a plastic surgery residency. A child with Pfeiffer’s syndrome from Syria who other children teased at the playground due to her looks was flown for Dr. Persing to perform a LeFort III. Just like Dr. Arnaud did, Dr. Persing gave this child a new sense of confidence by applying the powerful procedures developed in craniofacial surgery. Now, six years later, the same excitement of knowing the impact one can make on a person’s life through plastic and reconstructive surgery remains confirming that I chose the right surgical specialty.
 
Those of you interested in learning craniofacial surgeries outside of the United States should consider visiting Dr. Arnaud at Hopital Necker. Not only will he teach you about the fine French cuisine and wines, but also he will heighten your craniofacial surgical skillset. This is the one of remaining bastions to learn craniofacial surgery from undoubtedly one of the world’s best.
 
About the Blog

Plastic and Reconstructive Surgery

PRS Resident Chronicles” is the official Resident blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit this blog to follow the unique journeys of several young doctors as they go through residency in their respective Plastic Surgery Programs across the country.

We want to hear from Plastic Surgery Residents across the globe as well: how do you use PRS in your residency? What are some of the challenges you’ve faced and successes you’ve had? Join the on-going conversation by commenting, and if you think you have a potentially interesting-enough entry to be a unique blog post, email us at prs@plasticsurgery.org.

Bookmark the “PRS Resident Chronicles,” subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your journal; have fun, be respectful, get engaged and interact with the PRS community.

Keep in mind that the views and recommendations presented in this blog do not necessarily indicate official endorsements or opinions of the Publisher, PRS, or the ASPS. All views are those of the authors and the authors alone.

Rod J Rohrich, MD
Editor-in-Chief

Contributors

Andre Alcon is a fourth-year medical student at Yale University where he is starting a one year research fellowship in tissue engineering with the department of plastic and reconstructive surgery.

Ashley Amalfi is currently a fifth year Plastic Surgery Resident at Southern Illinois University School of Medicine. She attended the George Washington University and received dual degrees in Fine Arts and Art History. She returned home to attend The University of Rochester School of Medicine and Dentistry in Rochester, NY. Ashley met her husband, a urologist, during her training at SIU. She enjoys yoga, reading, travel and cooking in her free time.

Jordan Ireton is in her first of six years at the University of Texas Southwestern Plastic Surgery residency program.

 

 Anup Patel, MD, MBA, is a resident in the Yale Plastic and Reconstructive Surgery Program. He co-founded Cents of Relief, a 501(c)3 nonprofit, that empowers victims of human trafficking through health and educational initiatives including those related to reconstructive surgery. Along those lines, he has interest in surgical burden of disease and healthcare policy. He has been selected to serve on the American Society of Plastic Surgeons Board of Directors as resident representative.

 

Justin Perez is a fourth-year medical student at Weill Cornell Medical College. Born and raised in Reading, Pennsylvania, Justin moved to New York City to attend Fordham University, where he graduated summa cum laude with degrees in Biology and Spanish Literature. His academic interests include tissue engineering and wound healing, the topics of his current research. His hobbies include theater and biking.

 

Raj Sawh-Martinez, MD is a current resident at the Yale Plastic and Reconstructive Surgery program.  He grew up in Yonkers, NY and completed his undergraduate work in Neural Science at New York University.  He graduated from the Yale School of Medicine in 2011.

Ajul Shah, MD is a graduate of University of Texas Southwestern Medical School and is now a resident in his second of six years at the Yale Plastic Surgery residency program.

Jacob Unger, MD was raised in New Jersey on the shore. He attended Tulane University for his undergraduate work where he rowed on the Tulane Crew Team and majored in Philosophy. He graduated Phi Beta Kappa, Summa cum Laude with honors and then attended New York University School of Medicine. When not working, he enjoys traveling with his wife, surfing, and skiing.

Former Resident Chronicle contributors

Eamon O’Reilly, MD LCDR USN is an active duty US Navy full-time outservice resident in his second of three years at the University of Texas Southwestern Plastic Surgery residency program in Dallas, TX.