1






How
to
crush
your
plastic
surgery
rotation







Your
plastic
surgery
rotation
will
be
fun,
tough,
educational,
and
hopefully

inspirational.

This
is
how
many
people
decide
they
want
to
become
a
plastic

surgeon.

Expect
to
see
things
you’ve
never
seen
before,
expect
to
work
hard
and
put

in
long
hours.

It’s
worth
it.





This
rotation
changed
my
life.

















































Disclaimer:
this
is
an
introductory
guide
meant
for
medical
education,
not
patient
management.

It
does

not
represent
complete
clinical
advice.

Individual
clinical
circumstances
and
patient
needs
may
change

rapidly
and
a
static
guide,
such
as
this
one,
is
not
appropriate
in
all
situations.

While
we
wish
you

success,
we
cannot
guarantee
any
grade
on
your
rotation
or
success
in
obtaining
a
letter
of

recommendation.


©PlasticsMatch.com



 
 2


Basic
rules:

Be
on
time,
be
eager,
be
pleasant
to
be
around.



This
means
you
should
arrive
first,
leave
last,
never
complain
(ever,
about
anything),

never
lie
about
anything
related
to
patient
care,
and
just
be
friendly
and
outgoing.


The
asset
that
surgeons
value
most
is
hard
work.

And
it
doesn't
have
to
be
all
that

hard.

Medical
students
always
worry
about
"looking
good,"
but
we'd
much
rather

see
that
you've
developed
the
skill
set
and
have
the
personality
to
succeed.





Being
on
time
means
being
early
to
round.

Find
the
intern
and
help
get
numbers,

prepare
lists,
and
start
skeletonizing
notes.

The
same
goes
for
afternoon
rounding.


As
soon
as
you're
out
of
the
OR,
find
the
intern
and
help
them
out.

Offer
to
see

patients,
get
numbers,
whatever
you
can
do
to
help.



In
the
morning,
do
you
notice
how
the
residents
always
write
down
the
plan
as
the

senior
or
Chief
resident
dictates?

For
some
reason
the
medical
students
never
do

that.

Stay
involved.

Write
down
the
plan.

If
you
see
a
patient
on
the
floor
in
the

afternoon,
check
to
see
how
the
plan
turned
out.



We're
not
here
to
spoon‐feed
you.

Once
you
leave
the
lecture
hall,
your
medical

education
is
in
your
hands.

How
much
reading
you
do,
how
much
preparation
for

the
O.R.,
how
much
you
practice
your
technical
skills
on
your
own
time
is
up
to
you.


Plastic
Surgery
services
are
busy.

We
operate
a
lot.

We
get
a
lot
of
consults.

The

residents
work
long
hours.

Most
of
us
love
to
teach.

But
medical
students
can't
be

passive
observers
and
expect
to
glean
much.

Engage
the
residents
and
attendings,

and
they'll
engage
you
back.







This
also
means
that
you
should
always
be
doing
something.

Read,
practice
tying

knots,
help
the
intern.

Doesn't
matter.

Just
don't
get
caught
sitting
there,
checking

your
email,
or
texting.

That's
the
worst.



Key
tip
to
keep
you
out
of
trouble:



It
should
go
without
saying,
but
we've
noticed
a
trend
lately:

PUT
YOUR

CELLPHONE
AWAY.

We
don't
want
to
see
it
on
rounds,
in
conference,
clinic,
or
in

the
O.R.

It's
unprofessional
and
it
makes
you
look
disengaged.

The
faculty,
the

residents,
patients,
and
nurses
all
notice
and
comment
‐
just
not
to
you.

Put
it
away.



How
you
will
be
evaluated:



The
top
qualities
residency
programs
are
looking
for
are
(1)
academic

potential,
(2)
work
ethic,
(3)
initiative,
(4)
technical
ability,
(5)
affability,
(6)

honesty.


This
is
how
you’re
being
graded.

They
are
self‐explanatory.

Keep
them
in

mind.

Don’t
lose
sight
of
the
goal.

You
can
take
vacation
after
you
Match.

Until

then,
get
to
work.





©PlasticsMatch.com



 
 3


Respect:



Treat
everyone
you
meet
with
respect.

Staff
for
sure,
residents,
NPs,
PAs,
nurses,

and
your
fellow
rotators.

This
is
where
students
trying
to
"look
good"
often
shoot

themselves
in
the
foot.

Don't
throw
anyone
under
the
bus.

Answer
questions
only

when
posed
to
you.

Trying
to
show
up
the
other
medical
students
is
always
obvious

and
has
cost
many
students
an
interview.



Expectations:



If
you
are
on
an
"audition"
rotation,
expect
to
work
very
hard.

You
will
likely
work

15+
hours
days,
80‐100
hour
weeks
(or
longer).

This
is
a
4
week
residency

interview.

Make
every
day
count.

If
it's
7pm
and
you're
asked
if
you'd
like
to
see

some
new
hand
trauma
in
the
ED,
the
answer
is,
why
yes,
of
course
you
do.




You
are
not
expected
to
know
everything
about
plastic
surgery.

Even
the
most

senior
attendings
are
still
learning.

That’s
half
the
fun
of
the
specialty.

It
does,

however,
behoove
you
to
learn
the
basics.

Surgeons
value
hard
work
above
just

about
all
other
qualities.

Work
hard
and
you’ll
do
well.





Before
your
rotation:



Find
out
the
name
of
the
Chief
resident
and
administrative
resident
(if
there
is
one).


Find
out
where
and
when
you
will
begin
rounds.

Find
out
what
days
you
have

conferences,
clinic,
grand
rounds,
or
M&M.

You
usually
have
to
wear
a
shirt/tie
for

these
things.

Find
out
if
there
is
a
dress
code.

If
possible,
find
out
what
cases
will
be

happening
your
first
day.

Get
parking,
ID,
housing,
white
coat,
and
other
logistics

squared
away
ahead
of
time.

That
way,
when
you
show
up,
you’ll
be
all
set
and
you

won’t
be
scrambling
like
everyone
else.

Preparation
is
rewarded
in
surgery.



What
to
read:



Invest
in
a
copy
of
the
Michigan
Manual
of
Plastic
Surgery
($67
retail,
can
find

used
copies
on
Amazon
for
~$45).

It’s
the
only
portable
handbook
in
the
field.

If

you
prefer
the
question/answer
format,
Plastic
Surgery
Secrets
retails
for
~$60.


Also
very
helpful
is
The
Hand,
Examination
and
Diagnosis
written
by
the
ASSH.


Carry
it
with
you
everywhere.

People
will
notice
that
you’re
reading.

It
helps
fill
the

small
amounts
of
downtime
while
you’re
waiting
for
your
patient
to
extubate,

waiting
for
cases
to
start,
etc.

There
are
links
to
each
of
these
on
our
website

(Plastics
Rotation
page).



First
day:



While
everyone
else
is
scrambling
to
get
an
ID,
you’ll
be
heading
to
the
OR.

Nice.

Go

enjoy.

In
the
afternoon,
page
the
NP
or
intern
and
see
how
you
can
help
them
with

afternoon
rounding
or
take
care
of
some
post‐op
checks.

Don’t
make
a
big
deal
of
it.


©PlasticsMatch.com



 
 4


People
will
notice
that
you’re
helping
the
team
out.

Get
a
sense
of
the
work
flow.

If

you
see
a
resident
heading
out
to
see
a
consult,
go
with
them
(these
are
great

learning
opportunities).

If
the
residents
are
heading
to
PACU
to
do
some
post‐op

checks,
go
with
them
(help
write
the
note
while
they're
examining
the
patient).




Rounds:



Morning
rounds
are
working
rounds.

They
must
go
quickly
and
efficiently.

Do
what

you
can
to
help.

Grab
charts,
go
one
room
ahead
and
get
numbers,
if
a
patient
has
a

complex
dressing
to
come
down
or
a
VAC
to
be
removed,
ask
if
you
can
run
ahead

and
start
taking
it
down.

You
can
also
help
write
progress
notes,
just
make
sure
to

get
them
co‐signed.



You
will
probably
carry
a
bucket
of
dressing
supplies
around
with
you.

Make
sure
it

is
well
stocked.

Even
if
you
don’t
carry
the
bucket,
always
carry
a
few
key
items

with
you
(xeroform,
bacitracin,
kerlex/kling,
scissors
‐
trauma
shears
are
better
‐

tegaderms,
tape).

Again,
preparation
is
rewarded.



Invest
in
a
decent
penlight.

I
use
mine
several
times
a
day
for
flap
checks,

craniofacial
exams,
and
all
manner
of
other
places.

People
ask
to
borrow
it
all
the

time.

I
use
the
Streamlight
66118
Stylus
Pro
Black
LED
Pen
Flashlight.

You
can
buy

it
on
Amazon.



How
you
can
be
helpful:



The
residents
will
typically
always
cover
plastic
surgery
call.

At
many
hospitals,

coverage
for
“hand”
and
“face”
is
often
shared
with
orthopedics
and
either

oral/maxillofacial
surgery
(OMFS)
or
otolaryngology
(ENT),
respectively.


Hand/face
days
tend
to
be
busy.

Let
the
resident
on
call
know
that
you’re
interested

in
helping
see
consults.





Post‐op
patients
admitted
to
the
service
need
post­op
checks.

Think
about
the

procedure
they
had
and
what
the
complications
are.

If
you’re
not
sure,
just
ask
the

residents.

They
will
appreciate
that
you
are
helping.

REMINDER,
for
medicolegal

reasons,
NEVER
examine
a
woman’s
breasts
or
genital
area
without
a
chaperone.


The
nurses
are
accustomed
to
being
asked
to
do
this.


Hematoma
is
one
of
the
most

common
complications
we
have
in
plastic
surgery
and
can
be
VERY
serious.


Hematoma
under
a
flap
or
graft
can
kill
the
tissue.

Retro‐orbital
hematoma
can

blind
a
patient.



1) Make
sure
the
patient
isn’t
receiving
toradol
or
other
NSAIDs,
heparin,
or

aspirin
unless
otherwise
instructed.

If
the
patient
is
to
get
heparin,
it
should

NOT
be
injected
into
the
abdomen
for
TRAM/panniculectomy/

abdominoplasty
patients.

2) Patients
with
bilateral
procedures
who
have
significantly
more
pain
on
one

side
than
the
other,
such
as
breast
reductions,
are
concerning
for
hematoma.

©PlasticsMatch.com




 5


3) For
breast
patients,
always
check
the
axilla
and
drains
as
these
can
tip
you
off

to
a
hematoma

4) Facelift
and
blepharoplasty
(eyelid
surgery)
patients
need
strict
BP
and

nausea
control
as
a
hematoma
can
be
devastating



A
FLAP
CHECK
must
always
include
documentation
of
color,
temperature,
capillary

refill,
soft/firm,
sensation
(if
sensate
flap
or
hand
surgery),
and
if
it
is
a
free
flap,

check
the
Doppler
signal/Vioptix
or
other
monitoring
equipment.

If
you
have
any

concerns,
tell
a
resident
right
away.

DO
NOT
take
dressings
down,
remove
sutures,

or
do
anything
else
crazy
unless
instructed.



FREE
FLAP
problems
are
arterial,
venous,
or
both.

The
anastomosis
can
clot,
kink,

twist,
can
be
pinched
off
by
a
hematoma,
among
other
problems.

Venous
problems

are
more
common
than
arterial,
and
tend
to
occur
within
48‐72
hours,
which
is
why

these
patients
are
monitored
so
closely.

A
bluish,
swollen
flap
with
very
rapid

capillary
refill
suggests
a
venous
outflow
problem.

THIS
IS
AN
EMERGENCY.

Tell

your
resident
right
away.

Some
people
confirm
by
pricking
the
flap
with
a
needle
to

see
what
color
blood
drains
out.

DO
NOT
do
this
unless
you
speak
to
the
resident
or

attending
first.

You
don’t
want
to
be
responsible
for
sticking
a
needle
into
the

pedicle.

There
are
many
options
for
treating
including
re‐exploration
in
the
OR,

loosening
the
dressing,
heating
the
room,
adding
leeches,
etc.

The
attending
needs

to
be
notified
if
any
of
this
is
considered.


An
intact
Doppler
signal
in
a
blue,
swollen

flap
is
NOT
reassuring.

This
flap
will
soon
die.

A
pale,
cool
flap
with
delayed

capillary
refill
and
no
Doppler
signal
suggests
an
arterial
inflow
problem.

This
is

also
an
EMERGENCY.



Patients
who
had
craniofacial
surgery,
including
cosmetic
(facelifts,
etc),
need
to

have
relevant
cranial
nerve
function
documented
(facial
nerve
for
facelift
patients,

light
perception
or
visual
acuity
for
orbital
fractures,
V3/mental
nerve
sensation
for

mandibular
fractures,
etc).





What
you
need
to
know:



TRAUMA.

When
sewing
up
a
complex
laceration
in
the
ED
you’ll
need:



This
is
your
chance
to
sew.

Your
odds
of
assisting
or,
better
yet,
actually
doing
it
are

vastly
improved
if
you
take
the
initiative
and
set
everything
up
ahead
of
time.

At
the

very
least,
your
resident
will
greatly
appreciate
the
help
and
it
will
look
good
for

you.

Get
a
suture
kit,
suture,
gloves,
supplies
to
irrigate,
local
anesthetic,
and

dressing
materials.

Get
a
consent
form
(almost
always
this
needs
to
be
done
by
the

resident).

Find
a
good
light
source.

Other
general
guidelines…



1) Decent
tools
–
the
ED
suture
set
is
usually
inadequate
for
a
complex
or
large

laceration.

Get
a
small
kit
from
the
OR.

It
will
make
all
the
difference.




©PlasticsMatch.com




 6


2) Thorough
irrigation
for
ALL
lacerations.

Use
sterile
saline,
wear
eye

protection,
and
irrigate
VERY
thoroughly.

Particles
left
in
a
wound
are
a

nidus
for
infection
and
can
create
a
“traumatic
tattoo.”

Sometimes
gentle

scrubbing
with
a
surgical
scrub
brush
is
needed.



3) Debridement
–
in
general,
DON’T
debride
tissue
when
repairing
lacerations.


You’d
be
surprised
what
will
live/take
in
a
young,
healthy
person.

If
you’re

considering
cutting
something
off,
check
with
a
resident
or
staff
first.

In
the

OR
it’s
a
different
story.

Adequate
debridement
after
trauma
is
the
sine
qua

non
of
healing
a
traumatic
wound.



4) Hand
lacerations
–
most
hand
repairs
use
4‐0
or
5‐0
nylon.

Consider
chromic

if
the
patient
is
unlikely
to
follow‐up
or
removing
the
sutures
would
be

difficult
(e.g.
web
spaces,
children).

Few
people
repair
extensor
tendons
in

the
ED
now,
but
usually
is
Tevdec
or
a
braided
synthetic
(size
depends
on

zone).


Hand/upper
extremity
sutures
typically
come
out
in
10‐14
days.



5) Face
skin
–
make
sure
to
rule
out
parotid
duct
injury,
facial
nerve
injury
as

appropriate
given
the
location
of
the
laceration.

Irrigate
thoroughly.

Place
4‐
0
or
5‐0
monocryl
deep
(fine
undyed
Vicryl
is
also
acceptable),
6‐0
prolene
or

nylon
on
skin.

Always
bring
a
6‐0
fast‐absorbing
gut
suture
for
touch‐ups

and
to
use
in
kids.

Face
sutures
come
out
in
4‐7
days,
shorter
in
people
who

heal
normally,
longer
in
the
elderly,
people
on
steroids,
irradiated
patients,

etc.

It’s
typically
OK
to
shower,
just
have
them
dress
with
bacitracin
to
keep

the
wounds
moist
while
they
heal
(N.B.
bacitracin
can
cause
contact
allergy).



6) Eyelid
lacerations
require
ophthalmology
evaluation
to
rule
out
corneal

injury,
globe
rupture,
lacrimal
involvement,
etc.

BEFORE
sewing,
test
and

document
visual
acuity.

Anesthetic
eyedrops
can
be
administered
after

optho
eval.

Obtain
and
use
a
corneal
shield
BEFORE
you
sew
anything.

The

conjunctiva
does
not
need
to
be
re‐approximated.

After
irrigating,
line
up
the

eyelid
margin
with
a
single
6‐0
prolene.

Try
to
slightly
evert
the
margin
to

prevent
notching.

If
the
tarsus
is
violated,
use
6‐0
vicryl
and
take
a
¾
bite

through
the
tarsus
and
tie
the
knot
AWAY
from
the
cornea.

6‐0
vicryl
to

reapproximate
orbicularis.

Use
a
6‐0
suture
on
skin.

This
can
be
absorbable

if
the
patient
is
unlikely
to
follow‐up.





For
small,
linear
lacerations
sometimes
a
steristrip
or
dermabond
works

well.

Just
don’t
allow
dermabond
to
get
in
the
eye
itself.



7) Lip
–
mark
out
the
vermilion
and
try
to
use
a
mental
or
infraorbital
nerve

block
to
avoid
directly
injecting
the
lip
and
distorting
your
landmarks.

After

irrigating,
use
5‐0
or
6‐0
chromic
on
the
mucosa
and
5‐0
or
6‐0
nylon,

prolene
or
6‐0
fast
gut
on
skin.

If
there
is
an
intraoral
component,
peridex

(chlorhexidine)
mouthwash
is
often
added.

Tell
them
to
use
it
for
only
3
or
4

days
as
prolonged
use
can
stain
the
teeth.

©PlasticsMatch.com




 7


8) Ear
–
after
irrigating,
reapproximate
the
cartilage
with
fine
vicryl,
as
with
the

eyelid.

The
skin
can
be
closed
with
fine
absorbable
or
permanent
suture,
as

appropriate.

The
key
is
to
prevent
a
hematoma.

Chromic
quilting
sutures

(pass
your
needle
from
anterior
to
posterior,
then
posterior
to
anterior
a
few

millimeters
away,
and
tie
on
the
anterior
side)
or
a
bolster
can
be
used.


These
injuries
typically
require
antibiotics
to
specifically
cover
cartilage

(quinolones
are
good).

Sulfamylon
soaks
can
also
be
used.

These
are
painful,

however,
and
can
provoke
a
metabolic
acidosis.



9) Splints.

Virtually
all
hand
injuries
and
infections
will
need
a
splint.

Learn

how
to
make
an
ulnar
gutter,
thumb
spica,
resting
volar
and
extension

blocking
splints.

Knowing
how
to
make
a
good
splint
will
make
you
a
valued

member
of
the
team.



**Know
the
key
anatomic
landmarks
of
the
face,
nose,
lips,
and
ears
so
you
can

accurately
describe
lesions
**





























 



1.
tip
 
 
 
 
 
 
 1.
helix

2.
dorsum
 
 
 
 
 
 2.
antihelix

3.
sidewalls
 
 
 
 
 
 3.
Triangular
fossa

4.
ala
 
 
 
 
 
 
 4.
concha

5.
soft
triangle
 
 
 
 
 5.
tragus

6.
columella
 
 
 
 
 
 6.
Antitragus


 
 
 
 
 
 
 7.
lobule


 
 
 
 
 
 
 8.
scapha


©PlasticsMatch.com




 8


PRESSURE/DECUBITUS
ULCERS

1) Key
points
are
to
fully
evaluate
the
patient
and
identify
risk
factors
for

wounds
that
can
be
corrected
(1)
malnutrition
(2)
immobilization
(3)
poor

vascular
inflow/outflow.

2) Stage
and
measure
the
wound.

Stage
1
is
a
red
area
with
intact
epidermis,

Stage
2
is
into
the
dermis,
Stage
3
is
full
thickness
skin
loss
without
violation

of
the
fascia,
Stage
4
extends
to
muscle,
bone,
tendon.

3) Eschars,
necrotic
tissue,
and
tough
fibrinous
exudates
make
the
wound

unstageable.

These
should
usually
be
debrided
(the
exception
is
on
the
heel

where
a
dry
eschar
is
usually
left
alone).



4) If
there
is
bone
at
the
base,
typically
imaging
and/or
a
bone
biopsy
is
needed

to
rule
out
osteomyelitis.

ID
often
gets
involved.

5) ALL
patients
need
pressure
reduction
(air
mattress,
clinitron
bed
or
similar,

multipodus
boots
for
the
feet),
frequent
turning
(q2h,
even
in
they’re
in
a
low

air
loss
mattress),
nutritional
optimization
(check
albumin,
prealbumin
for
a

baseline;
get
a
nutrition
consult
if
available,
aggressive
nutrition
repletion

with
calories
and
protein;
most
patients
with
malnutrition
should
take

vitamin
C
and
zinc
supplementation
for
2
weeks.

6) DRESSINGS
–
stage
1
and
2
get
Duoderm/Mepilex/Mepitel
or
a
similar

hydrogel.

Stage
3
and
4
with
exudates
can
be
debrided,
BID
wet
to
dry

dressing
with
¼
strength
Dakins
if
very
heavily
contaminated,
BID
saline
wet

to
dry
dressings
for
light
debridement,
Mesalt
packing
to
manage
exudate

and
help
with
debridement,
silver
sulfadiazine
can
be
applied
to
eschars.


Different
hospitals
have
different
dressings
available,
the
principle
is
to

understand
what
needs
to
be
done
(1)
debridement,
(2)
exudate

management
(3)
removal
of
contamination
(4)
maintain
moisture
(5)

prevent
shearing.

Clean,
granulating
wounds
need
to
be
kept
moist.

Curasol,

duoderm/mepilex/mepitel
are
good
options.

7) Patients
with
ulcers
on
the
feet/legs
should
have
vascular
studies

8) These
patients
are
often
very
ill.

Their
ulcer
is
RARELY
a
source
of
sepsis

unless
there
is
an
undrained
abscess
or
florid
osteomyelitis.

9) Reconstruction
is
typically
reserved
for
those
patients
who
can
surmount
the

risk
factors
that
led
to
their
ulcer
such
as
a
relatively
healthy
person

recovered
from
a
temporary,
severe
illness.



FACIAL
FRACTURES:

1) These
are
trauma
patients
first
and
need
a
trauma
evaluation.

Incidence
of
c‐
spine
fractures
is
at
least
10%
in
patients
with
severe
facial
or
mandibular

fractures.

These
patients
should
probably
be
in
a
hard
collar,
unless
already

cleared
by
the
trauma
service
or
ED.

Severe
mandible
fractures
can
lead
to

airway
compromise.

Airway
comes
first.

2) Maxillofacial
CT
scans
with
coronal
and
sagittal
recons
are
mandatory
and

are
particularly
helpful
for
evaluating
the
orbits
and
temporomandibular

joint.

Images
must
include
the
entire
face
and
mandible.

A
regular
head
CT

typically
only
goes
as
low
as
the
skull
base
and
leaves
most
of
the
mid
and

lower
face
out.

Get
used
to
looking
at
the
images
yourself.

The
only
way
you

©PlasticsMatch.com




 9


get
comfortable
reading
a
face
CT
is
to
read
a
lot
of
them.

Have
the
residents

point
out
the
pertinent
findings.

If
there
is
intracranial
injury,
neurosurgery

should
get
involved.

3) Key
exam
findings:
test
all
cranial
nerves,
paying
particular
attention
to

visual
acuity,
EOM,
diplopia,
chemosis,
proptosis,
hyphema,
and
extraocular

muscle
entrapment.

If
there
are
any
concerning
ocular
findings
or
an
orbital

fracture,
get
ophthalmology
involved.

4) Palpate
the
entire
skull
for
tenderness,
stepoffs,
deformity.

To
test
midface

stability,
place
the
fingers
of
the
left
hand
on
the
bridge
of
the
nose
and,
using

the
right
hand,
pull
on
the
maxillary
incisors.

Motion
felt
by
your
left
hand

indicates
some
degree
of
craniofacial
separation.

5) Test
key
sensory
distributions
–
V1,
V2,
V3

6) Ear:
is
cartilage
intact?

Battle’s
sign?

CSF
otorrhea?

7) Nose:
nasal
septal
hematoma?

CSF
rhinorrhea?
(look
for
ring
sign
on
filter

paper,
but
to
confirm
you
must
send
a
beta‐2‐transferrin).

Nasal
septal

hematomas
MUST
be
drained.

A
nasal
speculum
is
a
very
handy
instrument.


Inject
local
and
make
a
small
incision
anteriorly.

Evacuate
the
hematoma

with
a
small
suction.

The
nose
should
then
be
packed
to
prevent

reaccumulation.

If
the
patient
develops
a
fever
or
hypotension
with
nasal

packing
in
place,
consider
toxic
shock.

8) Mouth:
look
carefully
for
lacerations
in
the
mouth,
loose
teeth,
palpate
along

the
mandible
for
stepoffs/tenderness.



HAND:



The
“hand
history”
always
needs
to
include
age,
gender,
handedness
(left
or
right

handed),
occupation,
injured
at
work
?,
and
whether
they’re
a
smoker
or
have

diabetes,
last
tetanus.

If
they
have
a
bad
injury
likely
to
require
the
OR,
find
out

when
their
last
PO
intake
was.



Learning
a
thorough
hand
exam
is
worth
the
effort.

Always
document
a

neurovascular
exam
BEFORE
doing
any
nerve
block.

Color,
capillary
refill,
2‐
point
discrimination
(a
paperclip
is
generally
readily
available
for
this),
joint

range
of
motion/strength
including
the
wrist,
muscle
wasting,
sensation
in

radial/median/ulnar
distributions,
signs
of
carpal
tunnel,
tenderness
at
the

snuffbox.



Don’t
forget
that
these
are
trauma
patients.

You
should
always
ask
about
other

injuries.

Your
priority
is
to
(1)
classify
the
injury
and
(2)
ensure
no
missed

injuries
(such
as
underlying
tendon
or
nerve
injury
in
a
laceration,
carpal

fracture
or
dislocation
accompanying
a
distal
radius
fracture



Common
hand
calls:



Metacarpal
fracture


©PlasticsMatch.com




 10


5th
metacarpal
fx,
the
so‐called
“boxers’s
fracture”
often
results
from
punching

something
(someone)
with
a

closed
fist.

EXAM
–
look
for
“scissoring”
of
the

fingers.

Always
document
ulnar
nerve
function
for
ulnar‐sided
fractures

Order

a
radiograph
with
3
views
–
look
for
comminution,
rotation/angulation.

The

more
ulnar
you
are,
the
more
rotation
you
can
tolerate
(rough
guide
is
10
deg
in

the
index
finger,
20
middle,
30
ring,
and
40
small
digit).

If
there
is
an
ulnar

neuropathy,
you
will
likely
go
to
the
OR.

In
general,
you
will
block
the
wrist
and

add
a
hematoma
block,
closed
reduce,
and
splint
and
operate
in
a
few
days.


Indications
for
OR
include
unstable
fractures,
angulation
beyond
tolerated
limits

above,
combined
or
open
fractures,
intraarticular
fractures.


Non‐border
digits,

such
as
the
middle
and
ring
fingers,
have
some
inherent
stability
provided
by
the

transverse
metacarpal
ligaments
and
are
more
likely
to
be
successfully
reduced

and
splinted.

“Border”
digits
like
the
index
and
small
fingers
are
inherently

unstable
and
are
more
likely
to
go
to
the
OR.









Scaphoid
fracures
–
most
common
carpal
fracture,
generally
resulting
from

axial
loading
on
an
outstretched
hand.

Complains
of
radial‐sided
wrist
pain.


OFTEN
MISSED
ON
INITIAL
FILMS.

You
must
have
a
high
index
of
suspicion.


 ‐
If
index
of
suspicion
is
high
but
no
fracture
on
films,
bring
them
back
for

repeat
films
in
a
week
or
get
a
CT.

Make
sure
to
splint
with
thumb
immobilized

and
in
abduction.


 ‐
Treatment
remains
controversial,
but
for
non‐displaced
fractures
casting

for
12
weeks
is
common.

For
displaced
fractures,
ORIF
is
done.





Triquetral
fractures
–
2nd
most
commonly
fractured
carpal
bone.

Complains
of

ulnar
sided
wrist
pain.

Chip
fractures
are
common
and
are
treated
with

immozilization
for
2‐3
weeks,
based
on
symptoms.

Larger,
non‐displaced

fractures
are
treated
with
longer
splinting,
and
displaced
fractures
usually
need

ORIF.



Lacerations



(1)
examine
as
fully
as
possible
before
doing
anything,
document
neurovascular

exam;
obtain
films.

LOOK
FOR
fractures
as
well
as
debris/foreign
body

(2)
block

(3)
re‐examine
now
that
pain
is
controlled

(4)
Irrigate
thoroughly
with
normal
saline.

Some
irrigate
with
dilute
betadyne,

but
this
is
probably
unnecessary.

DO
NOT
irrigate
with
pressurized
hydrogen

peroxide.

You
can
cause
air
emboli.

(5)
If
heavily
contaminated,
don’t
close.

Just
dress
it
for
2‐4
days,
give

antibiotics,
and
plan
for
possible
delayed
primary
closure.

(5)
in
general,
don’t
repair
tendon
lacerations
in
the
ED

(6)
If
suitable
to
close,
close
with
4‐0
nylon
or
chromic.

Make
sure
to
evert
the

edges.

(7)
dress
with
xeroform/kling,
and
splint
the
patient
appropriately

©PlasticsMatch.com




 11




Bleeding?

DO
NOT
CLAMP
anything
blindly.

EVER.

Arteries
almost
always
run

with
nerves
in
the
extremity.

You
will
almost
certainly
clamp
a
nerve
and
will

cause
irreversible
injury.

Hold
pressure
or
place
a
tourniquet
and
get
the
patient

to
the
OR.



Bites



Largely
the
same
treatment
as
in
lacerations.

BUT
strongly
consider
an
I&D,

overnight
observation
for
IV
antibiotics.

These
patients
NEED
close
monitoring.





I&D
of
bites
frequently
fails.

Cat
bits
are
probably
the
worst,
followed
by

humans,
followed
by
dogs.

If
the
animal
was
a
stray
or
something
other
than
the

above,
consider
an
ID
consult
or
a
rabies
vaccine
series.




Splint,
elevate,
QID
soaks
in
dilute
betadyne.



“Fight
bites”
over
the
MCP
joints
can
be
deceptive.

The
joint
capsule
is
often

violated,
necessitating
operative
washout.



Infiltrations



Generally
benign
but
don’t
underestimate
the
potential
for
disaster.

Check
for

compartment
syndrome.

Document
a
complete
neurovascular
exam.

Splint
and

elevate.

Lots
of
arguments
over
whether
to
use
warm
compress,
cool
compress,

or
no
compress,
which
means
that
none
of
them
are
superior
to
the
others.



Paint
gun
injuries
or
other
high
pressure
injections
are
BAD.



The
particles
are

often
forced
into
deep
soft
tissues,
including
the
flexor
sheaths,
and
can
find

their
way
deep
into
the
forearm
from
a
simple
finger
injection.

These
go
to
the

OR,
period.



Replants



The
decision
to
replant
or
not
is
difficult.

A
few
key
facts
to
keep
in
mind.

Average
return
to
work
after
a
replant
is
7‐9
months.

Half
of
patients
will

achieve
only
protective
sensation.

Average
mobility
is
about
half
of
normal.


Most
patients
will
require
multiple
operations.

All
patients
will
require

extensive
physical
therapy.



Mechanism
is
important.

Crush
and
avulsion
create
large
zones
of
injury
with

resultant
gaps
in
arteries,
venae
commitantes,
and
nerves.



Mallet
finger








Closed
–
closed
splinting
for
6‐8
weeks







Open
–
soft
tissue
repair

©PlasticsMatch.com




 12




Physical
exam
PEARLS

‐when
you
have
a
metacarpal
fracture,
look
at
the
fingers
for
scissoring.

Your

resident
will
ask.

‐
if
worried
about
septic
wrist,
pain
on
axial
loading
is
the
test
to
do

‐
Kanavel’s
Cardinal
signs
(for
flexor
tenosynovitis):


(1)
fusiform
swelling,
(2)
finger
held
in
flexion,
(3)
pain
on
passive

extension,
(4)
pain
on
palpation
of
the
flexor
tendon

‐
Distal
radius
fractures
–
always
document
median
nerve
exam.

The

swelling
associated
with
a
distal
radius
fracture
can
cause
acute
carpal

tunnel,
requiring
urgent
operative
release.



Nail:

‐
Distal
phalanx
fractures
require
nail
plate
removal
to
look
for
nailbed

laceration.

Repair
a
nailbed
laceration
with
6‐0
chromic
under
loupe

magnification
(if
you
don’t,
there
will
be
a
permanent
nail
deformity).

You

must
stent
the
eponychial
fold
with
something
–
the
nail
itself
(after
you

clean
it),
or
sterile
foil
from
a
suture
wrapper
is
good.

‐
Subungual
hematoma
–
if
>
50%
of
nail
surface,
should
be
drained.

Drain

by
pushing
an
18G
needle
through
the
nail,
or
remove
the
nail
plate.

If
you

remove
the
nail
plate,
see
above
for
stenting
instructions.



DIGITAL
BLOCKS/WRIST
BLOCKS:

(see
photos
below)



Learn
how
to
perform
a
digital
block,
and
median/ulnar/radial
nerve
wrist

blocks
early
in
your
rotation.

They
take
about
10
minutes
to
work,
so
plan

ahead.

Use
1%
plain
lidocaine
(NO
epinephrine).





The
dorsal
approach
to
a
digital
(middle
finger)
block
on
the
left.

The
volar

approach
is
shown
on
the
right,
along
with
a
thumb
block
(shows
injection

points
for
both
digital
nerves
as
well
as
the
subcutaneous
wheal
that
extends

dorsally
to
get
the
dorsal
sensory
branch).

There
are
nerves
on
both
sides
of
the

digits.

You
have
to
block
both.



There
is
a
flexor
tendon
sheath
injection
technique
as
well
for
digital
blocks,

though
few
people
use
it.





A
median
nerve
block
at
the
wrist
is
typically
done
1cm
proximal
to
the
wrist

crease
and
1cm
ulnar
to
the
FCR
tendon
(blue
dot).

15%
of
people
don’t
have
a

palmaris
longus
tendon.

If
the
patient
describes
paresthesias
in
a
median
nerve

distribution,
pull
back
slightly
before
injecting.

You
want
to
inject
near
the

nerve,
not
in
it.

Also
inject
1‐2
cc
subq
to
block
the
palmar
sensory
branch
on

your
way
out.




©PlasticsMatch.com




 13


The
ulnar
nerve
runs
with
the
ulnar
artery
just
under
the
FCU
tendon
at
the

wrist.

Note,
the
artery
is
volar
and
radial
to
the
nerve.

Place
your
needle

horizontally
just
under
the
FCU
tendon
and
insert
about
1cm
(green
dot).

Pull

back
to
ensure
you’re
not
in
the
artery.

To
get
the
dorsal
sensory
branch,
the

needle
is
placed
subcutaneously
and
directed
dorsally
toward
the
base
of

the
fifth
metacarpal.



The
radial
nerve
block
is
performed
by
injecting
3
finger‐breadths
proximal
to

the
radial
styloid
(red
dot)
and
then
directing
the
needle
subcutaneously
and

raising
a
wheal
dorsally
to
block
the
dorsal
sensory
branches.

You
can
also
go
about
a
full
hand
width
proximal
to
the
radial
styloid
and
inject
a

wheal
where
the
nerve
exits
the
brachioradialis.


















 




If
you
place
a
digital
tourniquet,
leave
yourself
a
reminder
to
remove
it.


You

can
cut
the
finger
off
a
sterile
glove
and
hold
it
in
place
with
a
Kelly
clamp.



A
GREAT
resource
for
hand
is
orthobullets.com

http://www.orthobullets.com/topic/dashboard?id=6&specialty=Hand



Check
it
out.








©PlasticsMatch.com




 14


What
should
I
do
in
the
OR?



OK,
now
you’re
on.


 

This
is
where
the
attendings
will
be
watching
you.


Every
day
for
the
first
week,

until
you
get
to
know
people,
when
you
walk
in
to
a
new
OR
write
your
name
on

the
board,
introduce
yourself
to
the
circulator
and
scrub
and
offer
to
help
with

whatever
they
need.

If
they
like
you,
they
will
watch
out
for
you
and
keep
you

out
of
trouble.



You
should
ALWAYS
know
who
you’re
operating
on.

You
should
know
the
one‐
liner.

For
instance,
40F
BRCA1
positive
undergoing
bilateral
risk‐reducing

prophylactic
mastectomies
with
sentinel
lymph
node
mapping
and
bilateral

immediate
TRAM
reconstruction.

Just
knowing
that
will
put
you
in
the
top
5%
of

medical
students.



You
should
ALWAYS
know
the
relevant
anatomy
of
the
area
you’re
working
on

or
the
flap
you’re
designing.

If
you’re
doing
a
flap
case,
check
out

microsurgeon.org.

FANTASTIC
resource.



Before
the
case,
help
move
the
patient
onto
the
OR
table,
place
the
pneumoboots,

and
position
the
arm
boards
(ask
the
resident
how
they’d
like
the
patient

positioned).

Have
the
resident
show
you
the
first
few
times,
because
improper

positioning
can
lead
to
pressure
ulcers,
brachial/peroneal
plexus
palsies,
and

other
avoidable
problems.



During
the
case,
for
the
most
part
keep
quiet
and
observe
closely
what’s
going

on.

If
it’s
a
case
you’re
going
to
be
seeing
again,
jot
down
some
notes
afterward

on
the
flow
of
the
operation.

That
way
you’ll
be
able
to
anticipate
next
steps
and

be
more
helpful.

The
more
plugged‐in
you
are,
the
more
you’ll
get
to
do.



Plan
to
spend
each
day
with
ONE
attending.

Residents
are
also
typically

assigned
this
way.

They’ll
be
more
comfortable
with
you
after
a
few
cases.

Don’t

expect
to
be
sewing
a
lot
on
your
first
case,
or
even
the
first
day
or
first
week.


Let
people
get
to
know
you.



When
the
case
is
done,
help
place
the
dressing
so
the
resident
can
enter
post‐op

orders.

Ask
anesthesia
if
it’s
OK
for
you
to
bring
the
bed
into
the
room.

Help
get

the
patient
moved
onto
the
stretcher.

Whatever
you
do,
DON’T
be
the
person

sitting
in
the
corner
checking
your
phone
(surprisingly
common
mistake).

Do
it

at
home.

If
there’s
nothing
to
do,
you
should
have
your
Michigan
manual
with

you.






©PlasticsMatch.com



 
 15


What
to
ask?

Bear
in
mind
that
some
surgeons
like
a
quiet
OR
and
will
NOT
enjoy
having
the

medical
student
asking
non‐stop
questions
the
whole
time.

One
or
two
questions

posed
during
non‐stressful
parts
of
the
case
will
show
that
you’re
engaged,
curious,

and
thinking.





Every
medical
student
struggles
with
this.

Just
relax.

There
is
a
lot
going
on
and
you

should
be
genuinely
curious
about
this
stuff.

First,
a
few
caveats:



(1)
any
question
you
ask
can
be
turned
around
on
you.

For
instance,
I
once
heard
a

medical
student
ask
a
simple
question
about
blood
supply
to
the
flap
being

dissected.

This
led
to
his
having
to
him
having
to
do
a
detailed
drawing
of
every

structure
in
the
thigh.



(2)
even
the
best
question
posed
at
the
wrong
time
earns
you
no
points.

Pay

attention
to
what’s
going
on.

(3)
don’t
stress
about
this.

Even
if
you
stay
perfectly
quiet
for
10
hours,
sometimes

that’s
the
best
option.

Your
time
to
shine
is
when
the
attending
asks
something
of

you.



If
you
just
can’t
help
yourself
and
NEED
to
ask
a
question,
you
can
always
ask
about

the
“plan
B.”

All
plastic
surgeons
operate
with
a
plan
B
in
mind
should
something
go

awry.

You
can
always
ask
for
career
advice
or
get
them
talking
about
the
field
in

general.

What
first
got
you
interested
in
plastic
surgery?

What
do
you
think
are
the

major
challenges
facing
plastic
surgeons?

WARNING:
posing
these
questions
out
of

mid‐air
6
hours
into
a
free
flap
will
seem
forced/awkward.

Use
your
judgment.



What
cases
should
I
see?



See
whatever
interests
you,
but
also
realize
that
if
you’re
doing
an
away
or

“audition”
rotation,
you’ll
want
to
put
in
some
time
with
key
faculty
including
the

program
director,
chairperson,
and
other
influential
attendings.

If
you
don’t
already

know
who
they
are,
ask
the
residents.

A
few
guidelines:

(1)
stick
with
one
attending
for
the
day.

Don’t
bounce
around.

Otherwise
they’ll

never
get
to
know
you.

(2)
if
there
are
other
rotators
on
service,
respect
that
they
will
also
want
time
with

the
program
director.

Divide
up
cases
fairly.

(3)
some
of
the
best
cases
to
showcase
your
technical
skills
are
panniculectomies

and
body
contouring
cases,
where
there
is
a
ton
of
sewing
to
do.

(4)
aesthetic
cases
are
great
to
see,
but
realize
that
even
the
chief
residents
are
often

holding
hook

(5)
when
there
is
more
than
one
of
the
same
kind
of
case
in
a
row,
it
will
earn
you

HUGE
points
if
you
remember
the
general
flow
of
the
operation
and
can
function
as

a
capable
assistant.

For
instance,
if
there
are
several
breast
reductions
going
on,

learn
exactly
how
to
retract
to
facilitate
the
operation
(the
retraction
is
KEY).

(6)
when
in
doubt,
ask
the
residents
for
advice





©PlasticsMatch.com



 
 16




Going
the
extra
mile:



Pick
an
attending
you’ve
established
a
relationship
with
and
are
looking
for
a
letter

from.

Offer
to
spend
a
morning
or
afternoon
in
clinic
with
them
(it’ll
be
one
on
one,

no
residents,
so
you
can
stand
out
and
he
or
she
will
have
a
chance
to
get
to
know

you).

Don’t
plan
on
any
longer
than
½
day.

You
should
still
try
to
get
to
the
OR.

If
it

goes
well,
you
may
get
invited
back
for
the
following
week.

These
are
their
private

patients,
so
be
very
polite.

I
often
was
asked
to
see
new
patients
and
do
a
quick

H&P.

When
I
walked
in,
I
introduced
myself
like
this:


 

“Good
morning,
my
name
is
Gavin
and
I’m
a
medical
student
working
with

Dr.
Whatever.

She
is
just
finishing
up
with
another
patient
and
asked
if
I

could
get
started
with
you.”

No
one
ever
minded.



Ask
the
attendings
or
residents
if
there
are
any
case
reports
you
can
help
write
up.


It’s
a
great
way
to
get
involved
and
get
published.





Letter
of
Recommendation
meeting:



So
you’ve
mastered
everything
above,
spent
time
in
the
OR
and
clinic
with
a

particular
attending,
now
you’re
ready
to
ask
for
a
letter.


Be
professional.

You

should
schedule
a
formal
meeting
with
your
attending.

Bring
a
copy
of
your
CV.

Let

them
know
when
the
letter
is
due.

Feel
free
to
discuss
your
goals
in
plastic
surgery.



If
you’re
meeting
with
a
senior
attending
or
chairperson,
strongly
consider
not

wearing
scrubs.



As
for
who
to
get
letters
from….you
will
need
three
good
letters,
period.

One
of

them
should
be
from
an
academic
chair
(several
programs
require
a
“Chair”
letter).


This
can’t
just
be
any
letter.

Your
letter
writer
should
(ideally)
be
(1)
well
known

nationally,
(2)
know
you
well,
(3)
have
a
very
positive
outlook
on
your
future
in

plastic
surgery.

Getting
a
good
letter
requires
going
the
extra
mile.

A
fantastic
letter

may
be
enough
to
get
you
an
interview,
so
don’t
skimp
on
this
step.




©PlasticsMatch.com