Plastic Surgery News, December 2019

December 2019

A new first in face transplants Page 7

A view from Norway Page 11

Highlights of Breast Reconstruction Awareness Day Page 28

“

I WAS SO EXCITED, I did not realize my fat could be transferred to another area of my body!

”

Dessiree

Actual aesthetic surgery patient with fat transfer.

REVOLVE™ System used for fat processing.

Individual results may vary.

Designed for

*

1,

IN FAT PROCESSING

HIGH-QUALITY ADIPOSE TISSUE1,* TIME SAVINGS2,† PREDICTABLE RESULTS1,* Retention data based on animal model. *Correlation between these results and results in humans has not been established.

1

#

COMMERCIAL DEVICE FOR FAT PROCESSING

For more information, please contact your Allergan representative or visit www.REVOLVEFatGrafting.com/hcp.

in the U.S. for aesthetic and reconstructive procedures ‡

FOLLOW @REVOLVESYSTEM Based on time to complete procedure (from lipoaspiration to fat injection) compared to centrifugation.

†

‡

Market share data through October 2018.

Indications and Important Safety Information INDICATIONS The REVOLVE™ Advanced Adipose System (REVOLVE™ System) is used for aspiration, harvesting, filtering, and transferring of autologous adipose tissue for aesthetic body contouring. This system should be used with a legally marketed vacuum or aspirator apparatus as a source of suction. If harvested fat is to be re-implanted, the harvested fat is only to be used without any additional manipulation. REVOLVE™ System is intended for use in the following surgical specialties when the aspiration of soft tissue is desired: plastic and reconstructive surgery, gastrointestinal and affiliated organ surgery, urological surgery, general surgery, orthopedic surgery, gynecological surgery, thoracic surgery, and laparoscopic surgery.

PRECAUTIONS REVOLVE™ System is designed to remove localized deposits of excess fat through small incision and subsequently transfer the tissue back to the patient. Use of this device is limited to those physicians who, by means of formal professional training or sanctioned continuing medical education (including supervised operative experience), have attained proficiency in suction lipoplasty and tissue transfer. Results of this procedure will vary depending upon patient age, surgical site, and experience of the physician. Results of this procedure may or may not be permanent. The amount of fat removed should be limited to that necessary to achieve a desired cosmetic effect. Filling the device with adipose tissue over the maximum fill volume line can lead to occlusion of the mesh resulting in mesh tear.

IMPORTANT SAFETY INFORMATION

ADVERSE EFFECTS Some common adverse effects associated with autologous fat transfer are asymmetry, overand/or under-correction of the treatment site, tissue lumps, bleeding, and scarring. Potential adverse effects associated with REVOLVE™ System include fat necrosis, cyst formation, infection, chronic foreign body response, allergic reaction, and inflammation.

CONTRAINDICATIONS Contraindications to autologous fat transfer include the presence of any disease processes that adversely affect wound healing, and poor overall health status of the individual.

WARNINGS REVOLVE™ System must be used within the same surgical procedure. Reuse of this device in the same patient in a subsequent surgical procedure, or for more than one patient, may result in infection and/or transmission of communicable diseases. Do not use the product if sterile packaging is damaged.

This device will not, in and of itself, produce significant weight reduction. This device should be used with extreme caution in patients with chronic medical conditions such as diabetes, heart, lung, or circulatory system disease or obesity. The volume of blood loss and endogenous body fluid loss may adversely affect intra and/or postoperative hemodynamic stability and patient safety. The capability of providing adequate, timely replacement is essential for patient safety.

2

REVOLVE™ System is available by prescription only.

For more information, please see the Instructions for Use (IFU) and User Manual for REVOLVE™ System available at www.allergan.com/RevolveIFU or call 1.800.678.1605.

To report an adverse reaction, please call Allergan at 1.800.367.5737.

References: 1. Ansorge H, Garza JR, McCormack MC, et al. Autologous fat processing via the Revolve system: quality and quantity of fat retention evaluated in an animal model. Aesthet Surg J. 2014;34(3):438-447. 2. Gabriel A, Maxwell GP, Griffin L, Champaneria MC, Parekh M, Macarios D. A comparison of two fat grafting methods on operating room efficiency and costs.

Aesthet Surg J. 2017;37(2):161-168.

Allergan® and its design are trademarks of Allergan, Inc. REVOLVE™ and its design are trademarks of LifeCell Corporation, an Allergan affiliate. © 2019 Allergan. All rights reserved. RVL121411-v2 04/19

December 2019

A card dedicated to helping make beautiful moments possible.

79% of consumers research payment before deciding to get cosmetic surgery, and 32% have declined surgery due to concerns about cost.1 Promotional financing can help patients move forward with the procedure they want.

With the CareCredit health, wellness and beauty credit card, patients can pay over time for plastic surgery and minimally invasive treatments, as well as deductibles and copays for reconstructive procedures.* Accepting CareCredit works for you, too. ASPS members receive reduced processing rates. Giving patients a convenient way to pay can lead to beautiful results for you both.

The Cosmetic Path to Purchase:

How Consumers Choose Cosmetic Surgery and Treatments Research Update*

Get the latest insights into the cosmetic patient’s path to purchase and learn how to help accelerate their decision. *CareCredit Path to Purchase Research 2018.

Already accept CareCredit?

Login at carecredit.com/providercenterlogin to download the report.

Ready to start accepting CareCredit?

Join the CareCredit network and get your free copy.

Call 855-860-9001 or visit carecredit.com/psn.

December 2019

1 CareCredit Path to Purchase – Cosmetic, 2018. *Subject to credit approval. Minimum monthly payments required.

See carecredit.com for details. ©2019 CareCredit

Endorsed by

PSN2019CA

3

IN THIS ISSUE FEATURES 07 ASPS member performs first full face transplant for African-American patient

Plastic Surgery News

Bohdan Pomahac, MD, performed the historic procedure in July at Brigham and Women’s Hospital in Boston.

08 Seeking clarity in determining RVUs for aesthetic procedures

The ASPS Aesthetics Task Force works toward providing models for accurate RVUs for aesthetic CPT codes.

08 Remembering Ronald Taddeo, MD, 1934-2019

ASPS PRESIDENT

Lynn Jeffers, MD, MBA LynnJeffersASPS@gmail.com

Past president of Ohio Valley Society of Plastic Surgeons was also an avid historian.

THE PSF PRESIDENT

11 Comparing healthcare systems in Norway and the United States

C. Scott Hultman, MD, MBA chultma1@jhmi.edu

Tormod Westvik, MD, vice president of the Norwegian Plastic Surgery Association, answers PSN’s questions.

18 YPS Perspective: Residents Council charts course for the future

ASSOCIATE MEDICAL EDITORS

22 Using pluripotent stem cells to heal wounds

ADVERTISING EDITOR

Scot B. Glasberg, MD scotbg@gmail.com

Henry Hsia, MD, discusses his research toward iPSC-based tissue-engineered graft.

EXECUTIVE VICE PRESIDENT

23 COVER: 30 years of Plastic Surgery News

Michael Costelloe mcostelloe@plasticsurgery.org STAFF VP OF COMMUNICATIONS

Past editors reflect on some of the defining PSN stories and moments from the past three decades.

Mike Stokes mstokes@plasticsurgery.org

28 Breast Reconstruction Awareness Day celebrated across the country

CHIEF MEDICAL EDITOR

Bruce Mast, MD bruce.mast@surgery.ufl.edu Summer E. Hanson, MD, PhD sehanson@mdanderson.org B. Aviva Preminger, MD premingermd@gmail.com

New PROPEL initiative will address the evolving needs of mentors and mentees in the specialty.

December 2019 Vol. 30 No. 8 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 maintain professional and ethical standards through education, research and advocacy of socioeconomic and other professional activities.

MANAGING EDITOR

Paul Snyder psnyder@plasticsurgery.org

More than 300 ASPS member practices and patient advocates took part in Oct. 16 events.

SENIOR NEWS EDITOR

Jim Leonardo jleonardo@plasticsurgery.org ASSOCIATE EDITOR

Kendra Y. Mims kmims@plasticsurgery.org CONTRIBUTING EDITORS

Ashley Amalfi, MD; Joseph Gryskiewicz, MD; Karen Horton, MD; Jeffrey Kozlow, MD; Neal Reisman, MD, JD; Paul Weiss, MD

7

9

CONTRIBUTING WRITERS

Yassie Dunn; Jessica Frasco; Christian Laatsch; Darcy McLaughlin; Erin Mullen COVER DESIGN

Paul Snyder DISPLAY ADVERTISING SALES

Joe Anzuena (215) 521-8532, Wolters Kluwer Health CLASSIFIED ADVERTISING

Jeanne Embrey (847) 228-3364

28

23

COLUMNS 06 President’s Message 06 Editor’s Message 10 CPT Corner 12 On Legal Grounds 12 The Higher Ground

Plastic Surgery News (ISSN 1043-4119) is published eight times per year: March, June, September, December single issues – and combined January/February, April/May, July/August and October/November issues – by ASPS. Phone: (847) 228-9900; Fax: (847) 228-9131

POSTMASTER, send address changes to:

14 Legislative Update 15 Social Media Focus 33 Calendar 35 Classifieds 38 The Last Stitch Correction: The feature “A memorable meeting in San Diego” in the Oct/Nov 2019 edition of PSN listed the wrong state in which Arthur Perry, MD, served on the Board of Medical Examiners. The article should have said he served on New Jersey’s Board of Medical Examiners. PSN regrets the error.

ASPS Membership Department Plastic Surgery News 444 E. Algonquin Road Arlington Heights, IL 60005 Periodicals postage paid at Arlington Heights, IL, and at additional mailing offices. USPS# 508-890.

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

2019 Subscription Rates:

Basic subscription rate: $90; for foreign subscriptions add $90 for first class service. The subscription price for PSN is included in annual membership dues. Letters, questions or comments should be addressed to: Editor, Plastic Surgery News, 444 E. Algonquin Road, Arlington Heights, IL 60005.

plasticsurgery.org Copyright 2019 The American Society of Plastic Surgeons

4

December 2019

REGISTER NOW

Hyatt Regency New Orleans

601 Loyola Avenue, New Orleans, LA 70113 Join us for the ASPS/ASPSP Spring Meeting 2020, March 12-14, in New Orleans at the Hyatt Regency. With fresh, innovative content and interactive educational programming, this is the meeting for your whole team!

Four concurrent tracks: Sep regi arate str requ ation ired

Aesthetica Reconstructive Practice Innovations Complications & Leading-Edge Concepts

2020 M arch 1 3 -1 4, 2020 PlasticSurgery.org/Coding

SPRING MEETING

2020 PLATINUM

Allergan USA SILVER

Galatea Surgical

December 2019

PlasticSurgery.org/SpringMeeting

5

PRESIDENT’S MESSAGE

Connection is important – at a member level and in embracing tech

By Lynn Jeffers, MD, MBA ASPS President

A

s a newly minted plastic surgeon many years ago, I was headed to an airport after a meeting, and it just so happened that a past president of ASPS was also headed that way and offered me a lift. In the ensuing ride, we discussed plastic surgery, leadership and ASPS. A few years later at an ASPS meeting, I was stepping off an elevator and ran into another member who was rising in Society leadership.

We started talking by the elevator bank as his colleagues left for dinner and then sat in a few empty chairs near the elevator, where he proceeded to give me the “lay of the land” in terms of how ASPS functioned. Several hours later, we were still there talking about the Society, when his colleagues came back.

I have been incredibly fortunate throughout my career and my time in ASPS to have so many mentors and people who paved the way for me to become president of this incredible organization. Life is about relationships and connections with other people. When you’re at the end of your life, you’re (probably) not going to look back and say, “Gee, I wish I’d worked one more day.” It’s the connections we make that in turn make life worthwhile, and this Society offers so many options for our members to dedicate their time and foster those kinds of connections.

With that in mind, one of my primary goals for the year ahead is valuing our members and ensuring that not only myself but all of our volunteer leaders are working with

a front-of-mind objective to make sure the plastic surgeons with whom they connect on various committees, task forces and other interactions know that their work for ASPS is appreciated. It’s easy to get bogged down in the day-to-day business of our practices or even hyper-focused on the work that one particular committee is doing – and just as easy to forget that so many of us are giving time and effort to this organization to help advance our specialty as a whole.

Tied to the idea of valuing our members is the goal of improving communication for our members so they can not only receive from the Society information that’s pertinent to them, but to also more easily let us know what they can do to help us.

With any organization, the fine line between too much information and too little is a tightrope that’s always being walked, but if we can better improve transparency in our communication and make it more of a two-

way street, it can lead to your email inboxes receiving more streamlined information more pertinent to you as opposed to an information bombardment that might often seem like white noise.

A technology focus Improving this exchange is dependent upon improving the technology that’s utilized by our members, not only at individual levels, but also by this Society. I’m writing this message on the eve of the first meeting of a new presidential task force I’ve created that will focus on technology, innovation and disruption. It’s a lot to consider, but the first step we can take is to step back and think about how technology impacts plastic surgery. What can we use to make ASPS better – even from a standpoint of engaging with members or via internal processes?

As we start to get a handle on those an-

swers, we can not only look at solutions, but also at bigger-picture items as well. So many of our members are involved in translational research and/or entrepreneurial endeavors. In the same way that The PSF is a great resource for our members who are interested in basic science and clinical research, ASPS/PSF could be a resource for our members for topics ranging from intellectual property; how to obtain funding; business-plan resources; exit strategies; and mentoring. Although we currently have an Innovation Grant, perhaps there’s a role for an evergreen fund or other programs.

Disruption lurks in every corner of the medical field. From A.I. to natural language processing to blockchain, there are countless opportunities for our specialty as well as potential threats to our day-to-day work. The aforementioned task force will explore all of these prospects. We need our members to be aware of this, as well as the policies out there governing this technology and advocacy efforts that we can undertake to protect and strengthen our work.

These adjustments can’t be made without collaboration – not only with other organizations as ASPS has so strongly demonstrated in recent years, but also through improved collaboration with our own members. We want to know what you can bring to the table.

We want to know where your interests lie, and how we can better include you.

Throughout my time in ASPS, I’ve learned there are so many people ready and willing to help steer you wherever you may want to go and help you achieve your goals at several levels. That spirit is still strong in this organization, and I want every member to know your questions and opinions matter – look how far the questions I asked when stepping off an elevator took me. PSN

EDITOR’S MESSAGE

When it comes to team building, think as a coach instead of a boss

By Summer E. Hanson, MD, PhD PSN Associate Editor

I

came across an article in The Atlantic recently about artificial intelligence (A.I.) that really hit home. As an outsider of the field and more of a casual reader, I’m amazed at how A.I. and robotics have evolved – particularly in medicine. Algorithmic programs have been developed in everything from diagnostics to personalized medicine to treatment protocols and patient monitoring.

These programs have the capacity to learn, just as we do, and change accordingly. There’s no question that A.I. will improve the field of healthcare, but the article raised a completely different question about A.I.’s integration into our systems: How can we best work together as a team?

According to author Nicholas Christakis, MD, PhD, MPH, a physician and sociologist at Yale University, a series of experiments were conducted in which human participants interacted with robots in a scenario to lay out railroad tracks in a virtual world. The robots were programmed to make occasional errors, with the intervention being how they responded: In one group, the robots acknowledged the error and would apologize or make light jokes, while the control group did not.

With time, the group with the “confessional robots” were more collaborative, had im-

6

proved communication and performed better overall.

We know that collaboration and communication are fundamental human capacities and key to most team interactions. With the hierarchy in medicine, however, these necessities may be inconsistent. Consider the example of the surgical team. I was in the O.R. recently for several hours on a complex breast reconstruction. Our experienced surgical tech’s lunch break occurred while we were under the scope. Normally, changes like this are smooth, and the Fellow and I might never have even noticed until there was a slight change in the way we were handed the jewelers forceps or a quick heads-up that a new team was entering. The new tech that day wasn’t entirely comfortable with micro cases and it was not exactly a routine anastomosis.

It was the perfect storm for some kind of error to occur, but thankfully, everything turned out fine.

Nevertheless, tensions flared a bit. I’m usually a soft-spoken person, although I admit there were a few times that I raised the volume of my voice and my words were necessarily short. I hate that. I always end my cases thanking the team and highlighting what went well, although, by the time that case wrapped, a couple of hours had passed from the original microscope stress and most people thought nothing of it. I certainly didn’t need to bring it up again. However, with this case, I apologized for raising my voice and adding to the stress of the situation and thanked everyone for being part of the team.

Early in my training, the approach to team building in the operative setting was evolving.

The “speak when spoken to” mentality I experienced early-on when shadowing surgical teams before medical school was giving way to exchanges that were far more engaging and enjoyable. I was taught – and in turn teach those I train; rather than a boss, be a coach: Guide the players through the offense, ask questions to be sure they understand, encourage questions in return and establish a good zone defense. We will always need the hierarchy – I’m still the one who is accountable to my patients

at the end of the day. With that responsibility comes leadership, and it’s incumbent upon us to establish common goals, assign roles and responsibilities, and orchestrate the procedure as best we can to benefit the whole team and streamline the day – particularly when there’s unfamiliarity among the team members.

We’re not setting up virtual railways (indeed, our work is undeniably more consequential), but we can learn from those confessional robots. Setting a collaborative tone in the O.R. can offer a low-cost, high-yield strategy to improve efficiency and performance. PSN

ASPS members attend 7th Congress of WAPSCD in China

More than 20 ASPS members, including ASPS President Lynn Jeffers, MD, MBA, attended the 7th Congress of World Association for Plastic Surgeons of Chinese Descent in Hangzhou, China, from Oct. 18-20. The successful meeting drew more than 1,800 attendees from locations such as China, Taiwan, Hong Kong, Singapore, Australia, France and the United States. PSN

December 2019

First full-face transplant for African-American patient in the books can anymore. So he declined.

“I was glad that he did,” he adds. “We don’t want patients blindly grasping a facial transplantation; we went those who are thoughtful about the implications of the characteristics.

It’s essentially a once-in-a-lifetime choice.”

By Jim Leonardo

R

obert Chelsea, 68, entered the history books in July, as he became both the eldest full-face transplant recipient in the world and the first African-American recipient after a 16-hour procedure led by ASPS member Bohdan Pomahac, MD, at Brigham and Women’s Hospital in Boston. Although a patient of African descent had received a face transplant in 2007 in Paris, that procedure involved only partial facial transplantation.

Chelsea suffered burns to more than 60 percent of his body after a drunk driver struck his stalled vehicle in 2013, according to news reports. A myriad of serious complications and more than 30 surgeries followed; he was finally listed for a face transplant in March 2018.

Although every facial transplantation procedure is infused with risk and unconventionality, the fact that Chelsea is African-American made this a particularly unique situation, Dr. Pomahac tells PSN. “We didn’t really appreciate how hard it would be to find the perfect match,” he says.

“All of our previous patients have been Caucasian – we had completed eight prior to this – and matches have been fairly easy to find. There’s very little skin-tone difference and the blending is remarkably good. We haven’t needed to rely on a Hispanic donor for a Caucasian patient – because in our region, the white donors represent 94 percent of the ‘pool,’ which is an overwhelming segment of the population to recover from.

“What we now realize with African-American patients is that the ethnic shape of some of the features, as well as the skin-shade range, are incredibly specific,” Dr. Pomahac adds.

A transplant nurse found the solution to the skin-tone match question after realizing that the color-match palettes used by prosthestists would work in a similar manner for transplant patients.

“This skin-shade palette contains 18 shades – from white to completely black – which allows us to match as perfectly as possible the donor and recipient,” Dr. Pomahac says.

Dr. Pomahac notes that he and other facial transplantation surgeons had been limited by donor organizations’ confidentiality limits

Further consideration

(Top) ASPS member Bohdan Pomahac, MD, and Robert Chelsea, the eldest full-face transplant recipient in the world and the first African-American recipient of a face transplant. The pictures below show Chelsea during the 16-hour procedure, leaving the O.R. and a post-op meeting with Dr. Pomahac. (Photos courtesy of Brigham and Women’s Hospital in Boston) that preclude photographing donor faces. In addition, photographing small patches of face that keep the donor unrecognized typically are not instructive enough for transplant purposes, he says.

“There’s so much difference in pigmentation that we started to realize that we can’t really communicate accurate shades when we’re at different places, which is normally the case,” he notes. “We needed something for each of us to have. The palette solves many issues. It’s kept on small, silicone squares and numbered, and we kept one and Chelsea kept one. He told us

what colors were acceptable – and we knew we were each looking at the same color.”

The palette may have cleared one hurdle, but another having to do with ethnicity remained. In 2018, the team thought it had a donor match based on color, but Chelsea decided against that donor tissue.

“The patient was of Hispanic origin, and the skin tone was lighter but seemed reasonable,” Dr. Pomahac recalls. “However, the patient thought that having a Hispanic nose and slightly lighter color together would probably not leave him looking like an African-Ameri-

Society reviewing FDA draft guidance on implant labeling

A

SPS is conducting a rigorous review of “Breast Implants – Certain Labeling Recommendations to Improve Patient Communication,” a draft guidance released in October by the FDA that centers on manufacturer information accompanying breast implants. Once ASPS completes its review of the multi-point guidance, the Society will submit comments to the FDA by the Dec. 23 response deadline.

This guidance, which essentially serves as an adjunct to existing related guidance, is designed to ensure patients receive and understand the benefits and risks of breast implants – including the risk of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), as well as symptoms commonly referred to as breast-implant illness (BII).

The FDA is recommending that manufacturers include the following with packaging for breast implants: • “Black box” warning

December 2019

• Patient-decision checklist • Device/materials descriptions, including types and quantities of chemicals and heavy metals that reside in, or are released by, breast implants • Silicone gel-filled breast implant rupture-screening recommendations • Updated patient device card “Since the FDA hearing this past March, ASPS has been working with numerous stakeholders to shape the content and intent of a patient-decision checklist and black box

warning that provides useful information to patients so they can make an informed decision,” says ASPS President Lynn Jeffers, MD, MBA. “Patient safety is always the top priority of the Society and our members.”

ASPS leaders conducted a meeting with patient advocates as well as Binita Ashar, MD, director of the Division of Surgical Devices in the FDA’s Center for Devices and Radiological Health, during Plastic Surgery The Meeting 2019 in San Diego to identify areas in which all parties can work together to improve the flow of information to patients.

“These discussions were tremendously valuable, and further collaboration is underway to improve patient safety,” Dr. Jeffers says.

Public comment on the draft guidance can be delivered electronically at regulations.gov under docket number FDA-2019-D-4467.

Those with questions about the draft guidance are advised to contact the Division of Industry and Consumer Education. PSN

Although face transplants obviously are the most visible example of ethnicity-matching for transplant patients, bilateral hand and arm transplants also carry that component – but according to Dr. Pomahac and L. Scott Levin, MD, chair of Orthopaedic Surgery and professor of plastic surgery at Penn Medicine and director of the Hand Transplantation Program at The Children’s Hospital of Philadelphia and University of Pennsylvania, skin-tone matching is of much less importance.

“The face is obviously different from the hands,” says Dr. Levin, who led the team that completed a successful, bilateral hand transplant for 8-year-old Zion Harvey, an African-American child, in 2015. “You can’t tell the shape and topography of African-American hands from Caucasian hands. There aren’t ethnic features in the hands.

“We approach each patient individually – and each will have their own cultural bias and opinion,” Dr. Levin adds.

“But I don’t approach an African-American hand transplant patient differently than anyone else.”

“There’s a little bit of forgiveness with arms,” Dr. Pomahac says. “The aesthetics of the face are more important than those of the hands and arms. In my opinion, it’s a little less of an issue.”

A longer-term issue impacting facial transplantation is a shallow donor pool for minority patients. According to organ donation statistics furnished by the federal Health Resources and Services Administration, in 2018 Caucasian donors represented 65.4 percent of the donor pool; African-Americans, 16.1 percent; Hispanics, 14.1; Asian, 2.3; and other, 2.0.

In 2017, the AMA adopted a policy during its November Interim Meeting that aimed to increase organ donation rates “particularly among minority populations with historically low donation rates,” according to the association’s website.

Some cite African-American mistrust of the medical community for the low numbers, although research conducted by transplant surgeon Derek Dubay, MD, revealed that potential donors had an inaccurate perception of tissue use – many thought their organs “wouldn’t be usable due to high blood pressure, heart disease” and other health issues common in the African-American population.

“We need to enhance education to let them know that a lot of times, these organs are acceptable for transplant,” Dr. Dubay told BBC News.

Considering the dearth of organs available for minorities, Dr. Pomahac’s advice for transplant surgeons who are treating these patients is, therefore, to have patience.

“Be ready for a long period to pass before finding a donor,” he says, adding that surgeons must also be aware of skin-tone blending. “If the patient is a candidate for a partial face transplant, know that it’s very hard to blend.

You may need to consider a full-face transplant, which isn’t our first choice; if that fails in 10 years, treatment options are extremely limited.” PSN

7

Society task force looks to provide RVU guidance for aesthetic work

By Paul Snyder & Catherine French

R

elative value units (RVUs) are a measure of value used to accurately reimburse healthcare expenditures. Most payers multiply the RVU for any given CPT code by a conversion factor to determine payment.

With more than 10,000 codes, CPT is the most widely accepted medical nomenclature used to report medical services. CMS uses the RVUs associated with a CPT code as their basis of reimbursing most CPT codes. Those codes without RVUs might include codes that are considered “aesthetic” (or, not medically necessary), catch-all codes for both procedural and nonprocedural services or codes that do not have a valid survey of the RVUs, which can then be determined to be “carrier priced.”

Most aesthetic services were purposefully never ranked on the RVU scale and instead designated as “carrier priced,” which allows a payer to independently judge the medical necessity of the procedure and set their own levels for compensation. The accounting for and compensation of these “zero” RVU services are typically forgotten, in plastic surgery and other specialties, such as cardiology and thoracic surgery.

As of today, there are at least 13 surgical services considered aesthetic CPT codes that are typically performed by plastic surgeons but do not have RVUs assigned to them. Due to the breadth of work that plastic surgeons perform, the universe of “zero-value” codes may

include maxillofacial work (e.g., dental-related services) that can be done by a plastic surgeon and considered to be aesthetic); oral surgery (e.g., custom facial prosthesis and excision of pericoronal tissues are considered aesthetic); dermatology (e.g., “testing” services such as photo patch tests, and reflectance confocal microscopy); general surgery services (such as free omental flap with microvascular anastomosis); and urology procedures (such as plastic operations of the penis). By comparison, cardiac surgery has just one code without an RVU, neurosurgery has one, ophthalmology has two, orthopedic surgery has five, thoracic surgery has seven and vascular surgery has nine codes.

To ensure plastic surgeons working in an RVU-based productivity formula are compensated fairly for both reconstructive and aesthetic services, the ASPS Aesthetics Task Force was created to develop a model that ensures accurate assignment of RVUs for aesthetic CPT codes. The PSF President C. Scott Hultman, MD, MBA, says the Society had heard from several members who wanted guidance before signing any productivity-based compensation plan, as well as guidance in filling out case reports. What the task force quickly learned, however, is that a one-size-fits-all approach could ultimately cause more harm than good.

“There are many different ways of tracking

Plastic surgeon held a deep affinity for history

By Paul Snyder

A

memorial service was held on Nov. 9 for Ronald Taddeo, MD, of Willougby Hills, Ohio, who passed away Oct. 27 at age 85.

Dr. Taddeo, a past president of the Ohio Valley Society of Plastic Surgeons, earned his medical degree from the University of Pittsburgh School of Medicine in 1962 and served an internship and general surgery residencies at St. Luke’s Hospital in Cleveland.

It was there he met a young nurse, Sandra Raffeth, with whom he would spend the rest of his life. He continued training plastic surgeons at Norfolk General Hospital and joined the staff at Lake Hospital Systems.

ASPS member Michael Wojtanowski, MD, also a past president of the Ohio Valley Society of Plastic Surgeons, notes that Dr. Taddeo was one of the first plastic surgeons in private practice to have his own outpatient surgery center and also helped Dr. Wojtanowski establish his own center.

“He was always helpful,” Dr. Wojtanowski recalls. “He was never threatened by other plastic surgeons in the area or younger plastic surgeons coming into practice, and it was a good lesson for me. His view was that we’re all in the same business and if we work together, it benefits the whole specialty. I’ve always remembered that. He encouraged the golden rule with being kind to patients and others and told me that it always pays off in this business.”

Dr. Taddeo was an avid historian and served for many years as the regional society’s historian – “Nobody else wanted to do it, or could do it as well as he could,” Dr. Wojtanowski laughs.

ASPS member Steven Bernard, MD, Cleveland, says Dr. Taddeo enjoyed sharing his love of history with others.

“He was a leader of the Allan Memorial Library of Case Western Reserve University in Cleveland,” Dr. Bernard notes. “He was responsible for the acquisition of an original

8

Ronald Taddeo, MD, shows off his copies of Gaspare Tagliacozzi’s De Curtorum Chirurgia Per Insitionem at the 2018 Annual Meeting of the Ohio Valley Society of Plastic Surgeons.

The text, which Dr. Taddeo had in both original and 16th-century pirated form, contains one of the most famous illustrations in the specialty (inset). copy of Gaspare Tagliacozzi’s 1597 book, De Curtorum Chirurgia Per Insitionem (“On the Surgery of Mutilation by Grafting”). Contained within this book is perhaps the most famous illustration in plastic surgery. He was also able to acquire a pirated copy of the book from the 16th century – it was interesting to me that they pirated books back then, but also that the book sold well enough that it was illegally copied in the first place.”

Dr. Bernard notes that Dr. Taddeo spoke at the 2018 Annual Meeting of the Ohio Valley Society of Plastic Surgeons, detailing the history and provenance of the book and allowing members to handle and view the artifact.

Over the course of his career, Dr. Taddeo received numerous honors – including Lake Hospital’s Physician of the Year. In addition to being published in several medical journals, he was a regular contributor to La Gazzetta Italiana, an Italian-American newspaper. Dr.

Wojtanowski says he was struck by the diversity of attendees at the Nov. 9 service.

“It wasn’t just older plastic surgeons – there were a lot of younger people there and that speaks to the respect that so many people had for him,” he says. “Dr. Taddeo was very humble man and had an impact on so many of us. He will he missed by all whose lives he touched both personally and professionally.”

Dr. Taddeo is survived by his wife of 55 years, Sandra J. (Raffeth) Taddeo; his children, Ronald M. (Stephanie) Taddeo, MD, Gina (Mark) Aliberti and Christy Taddeo; grandchildren Joseph and Angelina Alberti; siblings Pam Caputo and Albert Bodanza, and several nieces and nephews. Memorial contributions may be made to the Lake County Blue Coats, P.O. Box 1211, Willoughby, OH 44096-1211, or the Trinity Lutheran Church Foundation, 37728 Euclid Ave., Willoughby, OH 44094. PSN

productivity when it comes to aesthetic cases and one formula will not work for everybody,” Dr. Hultman says. “There are so many different reimbursement systems and there are already several different practice models – private, academic, military, HMO, employed – you can’t have one formula that fits all.”

What’s more, he says that among the doctors who came together to work on the task force, there were already several good examples of determining RVUs at various institutions.

For example, when Bruce Mast, MD, left private practice to join the staff at the University of Florida, he says there was no way of quantifying productivity when it came to aesthetic procedures, so he worked to set up RVUs for aesthetic procedures.

“For things like blepharoplasty and body contouring, there were some codes already in existence that we could use,” he says. “But when it came to procedures such as facelifts, mastopexy or liposuction, there were no values, so what we did was look for similar procedures that had an assigned RVU. The breast reduction RVU, for example, could be used for breast lifts. For facelifts, we started with the RVU value for parotidectomy, and then extrapolated upward, based on bilaterality and postoperative care. By doing so, the physician practice group was comfortable we weren’t pulling these values out of thin air.”

Dr. Mast says these efforts ultimately led to the creation of master spreadsheet with values for “every procedure you can think of.”

However, other universities developed their own plans and as Victoria Vastine, MD, points out – trying to push everyone into one way of thinking could pose problems. Especially for members who are in private practice.

“I would hate to have an RVU assigned to my cosmetic patients because then I’m limited to that value,” she says. “Whereas now, I have a stratified fee schedule for a tummy tuck. There isn’t just one RVU for my tummy tuck – there are four different fee schedules based on what I’m doing and how much time I think I’m going to take. That can flow easier than an RVU system, because I decide, ‘You know what? This tummy tuck is worth more because it will take longer.”

Moreover, she says RVUs don’t always reflect the amount of work surgeons do, and doctors might be putting in more time and work than one assigned value suggests.

“In the perfect world, people can help define how they can be the most productive,” she says. “If they’re the most productive, that brings value back to the institution.”

Information gathered via conference calls and correspondence between task force members highlighted the fact that, across the United States, multiple, and often unique, compensations models – not all of which are dependent on RVUs – have already been developed and implemented to accurately account for aesthetic services. With that in mind, the task force is continuing to solicit input from members throughout the country who might have their own approach to defining RVUs on aesthetic procedures. Instead of bringing the specialty under one defined formula for RVUs, the task force members with whom PSN spoke say it’d be better to offer multiple solutions and let individual members find the best fit for their practice.

“It would be nice for ASPS to come up with maybe five – or at least two or three – models that can be applied to individual practices,” Dr. Hultman says. “Aesthetics is a major part of plastic surgery and we have to help solve the problem and provide that help to our members.”

If you have RVU information to share with the task force, contact ASPS Director of Health Policy Catherine French at 847-981-5401 or cfrench@plasticsurgery.org. PSN December 2019

ASPS Honorary Citation

A curious mind leads the search for (and discovery of) answers

By Keith Loria

G

rowing up as the son of a urologist, Mark Constantian, MD, saw firsthand the importance of medicine and was drawn to the idea of helping people from an early age.

“I didn’t like being ignorant about the body and injuries to it,” he recalls. “If someone from school got a cut, I didn’t know what to do and I didn’t like that feeling – that ignorance bothered me.”

His interest in plastic surgery took root during his third year of medical school. After two years at Dartmouth, Dr. Constantian was finishing his degree at the University of Virginia, where he met Milton Edgerton, MD, who came from Johns Hopkins to start the university’s first Department of Plastic Surgery.

“Everyone was intimidated by him, but I was just fascinated by what he did,” Dr. Constantian says. “I had always thought of plastic surgery as being cosmetic surgery, but he did all kinds of stuff – craniofacial, hand surgery, etc. – and he was a wonderful teacher. He was on the edge of plastic surgery. He was one of the first to do immediate reconstruction after head and neck cancer, which was considered crazy in those days.”

Dr. Edgerton laid footprints that Dr. Constantian sought to follow, and since 1978, he’s been in private practice in New Hampshire, as well as serving as an adjunct professor of surgery at the University of Wisconsin and visiting professor of surgery at the University of Virginia. The decision to open shop in New Hampshire, he says, was driven by patient need.

“When I came to New Hampshire, there were only four plastic surgeons in the state, and three of them were at Dartmouth, two hours away,” he remembers. “There were over 1 million people in the state at the time. I was determined to go to an unserved area, and I liked the idea of it being in New England.”

Early in his career, Dr. Constantian had no designs on teaching, much less becoming wellknown in the field. In fact, he turned down three academic offers because he wanted to go into private practice – and he immediately took on his share of unique cases.

“I was busy right away, doing tons of hand surgery, because no one had done any sophisticated hand surgery in this area, and I was seeing fascinating cases,” he says. “I did lower extremity trauma, facial trauma and the first breast reconstruction in this region.”

Before he went into practice, Dr. Constantian spent two months studying for his boards. During that time, he decided to learn about rhinoplasty from up-and-coming surgeon Jack Sheen, MD, who shared Dr. Constantian’s Armenian ethnic background.

“I had very little exposure to rhinoplasty in my residency, so I went to Los Angeles and watching him was an amazing experience,” Dr. Constantian says. “It was like Eric Clapton hearing Robert Johnson for the first time – something clicked. I thought, ‘This guy is so good and what he’s doing is so interesting. I love the way he thinks, he’s technically wonderful and doing a lot of things that were novel and effective.’ We’re still friends – he’s 94 years old and I visit him a couple of times a year.”

Although he didn’t think he would do many rhinoplasty procedures, Dr. Constantian felt he could use Dr. Sheen’s way of thinking and efficient organization of the O.R. and apply it to other procedures. After about six years in practice, he renewed his interest in studying rhinoplasty.

“I had some interesting thoughts, wrote up a manuscript and sent it in to PRS, and the results were good enough that they published it,” Dr. Constantian says. “I wrote another December 2019

Mark Constantian, MD paper, and then another, and in the 1980s, someone asked me to teach an instructional course at ASPS. So even though I continued a broad practice until five years ago, my reputation became increasingly that of a rhinoplasty surgeon.”

Over his long and distinguished career, Dr. Constantian has authored more than 100 text chapters and peer-reviewed papers; completed a 600-patient airflow study; invented a simulator (before the concept became more well-known); appeared on numerous panels; and he has three books to his credit, including the recently-released Childhood Abuse, Body Shame, and Addictive Plastic Surgery, written for surgeons and patients.

“I continued to generate ideas. What I loved during my five years in immunology research was seeing something brand new and telling people about it,” he says. “That became my public persona, but in real life, I was still a local guy in a medium-sized town in New Hampshire.”

‘An original’ Dr. Constantian’s continued work to advance the specialty led to him receiving the ASPS Honorary Citation Award at Plastic Surgery The Meeting 2019 in San Diego. He says he was surprised by the award, as it’s something he had not considered in his years of service.

“It’s an honor to serve and to teach, but I’ve always seen myself as a working stiff in private practice,” he says. “To me, the leaders are those who train young surgeons day-in and day-out.

Being recognized for something that I’m happy to do and would be doing anyway is somewhat amazing. I feel it should be me giving, and not them giving.”

ASPS immediate-past President Alan Matarasso, MD, has known Dr. Constantian for a quarter-century and says he was an easy choice for the honor, as Dr. Constantian represents the level to which all plastic surgeons should aspire and admire.

“He’s erudite, prolific and an original contributor to plastic surgery,” Dr. Matarasso says. “His seminal work on rhinoplasty surgery is internationally noted for its importance.

He represents the link from Dr. Sheen’s original rhinoplasty work to today’s standards. Dr. Constantian’s name, in many ways, has become a metonym for the operation.”

He adds that Dr. Constantian’s work in other areas – including body dysmorphic disorder (BDD), his research and textbook writings, as well as teaching colleagues on critical issues faced on an everyday basis – only fortified the list of reasons to honor him.

“When the Affordable Care Act was introduced, Dr. Constantian was one of the only people who read every word of the legislation and published an acclaimed op-ed piece in The Wall Street Journal about it,” Dr. Matarasso says.

This year’s annual meeting saw ASPS partner with The Rhinoplasty Society for the first time – a society Dr. Constantian helped conceive and bring to fruition.

“Everything Dr. Constantian does is done with complete dedication, keen insight and the highest standards,” Dr. Matarasso says.

“He’s been recognized as an award recipient at numerous medical societies, and he’s even received the key to the city where he lives.”

Away from the office Dr. Constantian has been married to his wife, Charlotte, for 26 years – a second marriage for both – and between them they have four boys and seven grandchildren. When not at

work or with family, he can usually be found swimming or target shooting, or indulging in his passion for the guitar.

“I was in a band when I was in school and sang in the college’s octet – which became Sha Na Na after I graduated,” Dr. Constantian notes. “Once I got into medical school, I would only play for maybe someone’s wedding. I still play and have a little studio in my house. One of my retirement projects is to finish writing enough songs to fill a CD and send them to a friend of mine in Austin, who has a recording studio. I want to go down there, lay some tracks down and produce a CD for myself.”

Looking back Dr. Constantian doesn’t think of himself as a technically innovative surgeon, but more of a “concept” person.

“I think that a lot of Dr. Sheen’s ideas are still extremely good, and he was a very intuitive operator who wrote two excellent textbooks,” he says. “What I try to do when I write is expound on what his ideas were and explain them in a different way that may reach new surgeons.”

His recent research into BDD, he says, brings him right back to the days on the playground when one of his classmates would be injured and he didn’t know what to do.

“I followed the trail until I was able to link the body shame that people have to childhood abuse and neglect – it starts way before BDD starts,” Dr. Constantian says. “The paper I’m writing now shows that the body shame is what separates patients who are addicted to plastic surgery and unhappy with the surgery from others.”

Nevertheless, of everything he’s achieved in his career, Dr. Constantian says he’s most proud of simply serving New Hampshire for all these years.

“The state has been very good to me,” he says. “I was lucky to practice largely before the internet and managed care – when patients came to you because of your reputation and results. It’s not that way so much anymore, and I’m glad that I experienced it – because that’s the only kind of medicine that I understand.” PSN

9

CPT CORNER

Coding analysis and critique as the year comes to a close “CPT Corner” provides general information, available at the time of publication, regarding various coding, billing and claims issues of interest to plastic surgeons. ASPS is not responsible for any action taken in reliance on the information contained in this column.

height, or complex) would be appropriate, since the documentation includes the relevant details for this code.

Case 3: Division of omental flap

By Paul Weiss, MD, & Jeffrey Kozlow, MD

T

he Coding and Payment Policy Subcommittee frequently receives operative notes from ASPS members requesting review and guidance for coding surgical procedures.

Committee members evaluate the operative note with proposed CPT codes and, based on what has been documented, provide recommendations on proper coding. Committee members also provide suggestions for improved documentation on future operative notes.

Poor documentation of anatomic site, defect size, the absence or inadequate description of the procedure, and unnecessary or enhanced information are unfortunately very common. Surgeons may wish to refer to the CPT Corner article from the December 2017 edition of PSN (“Operative Reports Can Ensure Safety and Accuracy”), which describes what’s important to include in an operative note. Remember that you can only code for what has been documented. If it isn’t documented, then it didn’t happen. Proper documentation can help avoid insurance denials, audits and delayed payment.

It should come as no surprise that deficiencies in operative reports may also have an impact on the overall assumptions of a surgeon’s record-keeping. To help our members, we’ll provide some case examples, which have been edited, eliminating dialogue unimportant to the analysis. For each case, we’ve provided the coding expected from the surgeon along with the coding that’s recommended based on the documentation of the procedure provided – since only steps documented can be assumed to have been performed in the operation.

Case 1: Ischial pressure sore Description of procedure: Preoperatively, the patient was prepped and draped. We did prep around the outside of the wound to allow us to get a culture without the prep solution in the wound. The aerobic and anaerobic culture was then taken. The left ischial wound did not have evidence of gross infection, but it was quite inflamed. It didn’t look quite as well as when I had seen it preoperatively, but it did appear that we could excise the ulcer and close it.

The wound was extensively undermined and had a lot of edema in the deep tissues.

Used 50 ml of 0.5 percent lidocaine with epinephrine for hemostasis, since this is an area that bleeds quite profusely – especially when the tissues are inflamed. Excised the entire ulcer. It was widely undermined and extended into the gluteus maximus muscle. The tissue was quite edematous.

Care was taken to avoid injury to the rectum and urologic structures, balancing taking out as much as we could from the tissue standpoint that appeared marginal as well as leaving the necessary structures. The wound did go down to the ischium and I debrided the ischial tuberosity which was soft, but I didn’t need to use an osteotome. I scraped off the surface to firm bone; the patient has been treated for osteomyelitis. The patient did have edematous tissue, especially around the usual area. It’s a chronic wound that has been treated for a long time through numerous modalities. The gluteus maximus muscle was freed up as far as the inferior border to cover the ischium. Part of it was previously debrided, so the mobilization was somewhat

10

limited but still helped cover the ischium. I felt it was best to close it rather than keep it open. I didn’t think we would have any better chance of it healing more than we did today. I reviewed the pulse lavage to clean out the entire wound. The area of debridement was approximately 100 square cm, since it was a very large wound that was undermined extensively.

It bled quite a bit, although I did get good hemostasis at the end of the procedure. He’s at increased risk for bleeding due to the vascularity but hopefully will do just fine. I did put in a 19-French drain that exited laterally and was sewn in place with a silk suture. I used several No. 2 Prolene deep through-and-through pullout stitches to avoid putting in any deep absorbable stitches that would increase risk for infection. These were kept in for quite a while. I also used multiple 0-Prolene vertical mattress stitches. I then used a 3-0 Prolene horizontal mattress skin closure to help seal up the superficial portion of the wound.

Bacitracin ointment was applied. Patient was placed directly into the Rite Hite Clinitron bed. SCOs were placed at the beginning of the procedure. We didn’t provide vancomycin until after the culture was taken.

What was billed: CPT Codes 15734 (Muscle, myocutaneous or fasciocutaneous flap; trunk) and 15944 (Excision, ischial pressure ulcer, with skin flap closure) Documentation issues: This operation note demonstrates a common example of significant superfluous language without actually documenting the critical steps of the operation. Pressure sore reconstruction includes both a debridement along with a closure technique. Depending on the closure technique, the reconstructive portion of the procedure may be bundled with the appropriate pressure sore code. It may be separately coded if a muscle/myocutaneous flap is used or a skin graft is used per CPT guideline. In this operative report, there are issues with both the documentation of the debridement and with the reconstruction. For the debridement, there’s no documentation of what layers of tissue were debrided, and the area was estimated at “approximately 100cm2.”

There’s also no documentation of an ostectomy and no documentation of debridement of bone, as the note indicates they didn’t have to use the osteotome but rather just “scraped” the bone. In terms of the reconstruction, while the author has intended to code for a myocutaneous flap, the operative note only mentions undermining. There’s no indication of flap elevation, vascular pedicle or rotation/ advancement of the flap, which are required to document 15734.

Correct coding based on operative report: CPT Code 15940 (Excision, ischial pressure ulcer, with primary suture) given lack of detail for a gluteus maximus myocutaneous flap.

Case 2: Malignant lesion of lip with repair Description of procedure: The patient was taken into the O.R. and placed supine on the operating table, underwent anesthesia and was prepped and draped. Each area of basal cell carcinoma that had been marked was excised with at least 2-mm gross margins. I excised full-thickness skin into the subcutaneous tissue and sent them to pathology for frozen section. On the left side of the upper lip, I was able to fashion this into an ellipse extending across the vermilion cutaneous border. This resulted in a 4-cm-long incision.

This was undermined medially and laterally preserving the labial artery. The area was closed with interrupted sutures. On the right side of the upper lip, the excision was too large to be closed by undermining. In light of that, I extended it around the base of the philtrum and down across the vermilion and performed a wedge resection, full thickness, full height of the lip with two-layer closure.

What was billed: CPT Codes for the left upper lip – 11644 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm) and 13152 (Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm). CPT codes for the right upper lip – 40510 (Excision of lip; transverse wedge excision with primary closure) and 40654 (Repair lip, full thickness; over one-half vertical height, or complex).

Documentation issues: For both of the lesions excised, the operative note doesn’t include the size of the lesions or the final size of the lesions with margins. A reviewer could piece together from the note that the two lesions were basal-cell carcinoma and both on the upper lip, but it’s not immediately clear based on the documentation. For the closure on the left upper lip, there’s no documentation of why the closure was complex (instead of intermediate or simple), as “undermining” does not qualify for complex repair unless it’s “extensive undermining” (admittedly, a vague term itself with further definitions of “extensive” expected in the upcoming CPT book).

No measurements are given for the second defect, which leads to problematic coding.

Correct coding based on operative report: CPT Code 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less) should be used twice (once for each lesion excised) since no measurements are provided. CPT code 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6cm to 5cm) should be used to report the repair on the right-upper lip, since only a single layer repair was documented and the extent of the undermining isn’t specific.

For the left-upper lip, CPT code 40654 (Repair lip, full thickness; over one-half vertical

Description of procedure: The patient has a history of a previous omental flap for management of his complex sternal wound infection from more than a year ago. He subsequently has developed an epigastric hernia that includes a portion of his colon. He was brought to the O.R. today by Dr. General Surgeon for a laparoscopic hernia repair. I was consulted intraoperatively for evaluation and suggested management of the omental flap, which was an inherent part of the hernia.

Upon entering the operative field, Dr. General Surgeon showed me the laparoscopic view of the omental flap extending into the thoracic cavity. After Dr. General Surgeon dissected the transverse colon off of the omentum and reduced the colon into the abdomen, we decided that given the omental flap was placed over a year ago, it would be fine to simply divide the pedicle instead of reducing the entire omentum, which was filling the sternal defect and would be well-vascularized at this point. Dr. General Surgeon then divided our omentum using the vessel sealer. Dr. General Surgeon then took control of the case again and completed the hernia repair.

What was billed: CPT 15600 (Delay of flap or section of flap [division and inset]; at trunk) Documentation issues: It’s unclear from the operative note who exactly performed the division of the omental pedicle. Even if the plastic surgeon did the actual division, this would normally be considered part of the work of the hernia repair. In addition, a simple pedicle ligation does not include the work of inset of a flap that’s intended for CPT 15600. The other question is if the plastic surgeon could be a considered a co-surgeon or assistant surgeon to Dr. General Surgeon.

A co-surgeon modifier (-62) is used when two surgeons perform distinct parts of a procedure and each is required to dictate an operative note for their portion of the procedure.

Reimbursement is typically 50 percent to 62.5 percent of the entire procedure for each surgeon. An assistant surgeon modifier (-80 -81 or -82) is used when a second surgeon assists the primary surgeon with the procedure.

The specific modifier -80, -81 or -82 depends on the involvement of the surgeon, the availability of a qualified resident in teaching hospitals and the payer’s policies. The assistant surgeon submits a separate bill but doesn’t need to dictate a separate operative note. The primary surgeon needs to dictate the use of an assistant surgeon, including the indications for an assistant surgeon. The assistant surgeon will typically be reimbursed a separate 16-25 percent of the entire procedure.

It’s important to check with each insurer if a primary CPT code is eligible for co-surgeon or assistant surgeon modifiers. In this case, the other option is for the consulting plastic surgeon to bill the appropriate evaluation and management code based on time given that the surgeon was consulted intraoperatively – and based on the operative note, that the plastic surgeon did not specifically perform or assist with any specific part of the procedure, other than provide guidance to Dr. General Surgeon that it was appropriate to divide the omental flap.

Correct coding based on operative report: Based on the operative note, the recommendContinued on page 34

December 2019

International spotlight

Norwegian association vice president provides insights from abroad

T

he past year has proved quite prolific for ASPS in terms of developing relationships with numerous plastic surgery societies throughout the world. At Plastic Surgery The Meeting 2019 in San Diego, ASPS signed eight new Memorandums of Understanding, one of which is with Norway.

Although Norway has a relatively small community of about 200 plastic surgeons, it has one of the world’s highest ratio of plastic surgeons per capita.

In October, ASPS President Lynn Jeffers, MD, MBA, at the invitation of Norwegian Plastic Surgery Association (NPKF) leadership, presented at the NPKF annual meeting, where she informed local plastic surgeons and new members of breast surgery in the United States. Her presentation generated a lively discussion about the different approaches to breast cancer treatments. Norway has socialized medicine and a different mindset when it comes to cancer treatment and subsequent reconstructive surgery.

Tormod Westvik, MD, ASPS member and vice president of NPKF, is board certified in the United States. He studied and worked for almost a decade in the United States before moving back to his native country. PSN interviewed him to gain his unique insight into both countries’ healthcare systems.

PSN: Can you first describe the healthcare system in Nordic countries and how it differs from the U.S. system?

Dr. Westvik: In Scandinavia, we have a socialized healthcare system, with a single government-run payer. Because of this, all resources are allocated based on how most people would get help for the same amount of money. The best comparison from a U.S. standpoint is to think of our countries as having nationwide V.A. healthcare systems.

In Norway, only hospital-employed physicians can admit and treat patients in the hospital system. The hospitals can only treat government-covered procedures. Any private patient has to pay out-of-pocket and be treated at a separate private clinic.

From a patient standpoint, it isn’t possible to demand studies, procedures, etc., without the doctor confirming the medical need for these.

We have no personal litigation of doctors, and our judicial system is such that the losing party in any trial could be ruled to pay all expenses for both parties – hence, very few dubious lawsuits.

PSN: What does the path to becoming a plastic surgeon in the Nordic region entail?

Dr. Westvik: All medical students have to complete 18 months of internship, combining at least internal medicine, surgery and family practice to obtain an unrestricted authorization as a medical doctor.

Plastic surgery training is a minimum of six years – two of these being general surgery.

We don’t have a structured residency program, and there’s no July 1 start date every year. Each teaching hospital (there are seven in Norway) has a set number of resident positions. These will be filled by application once a slot opens.

Norway has case-log requirements, which were recently increased to 850 procedures. Because of the relatively low volume of cases performed, four years of plastic surgery often are not be enough to fulfill these case requirements.

No hospital can by itself fulfill all requirements of plastic surgery training, hence the trainee will have to apply for vacant spots at other hospitals to complete their training. As a result, very few residents manage to complete their training in just six years.

December 2019

PSN: Does the government or any other entity regulate the supply of plastic surgeons?

Dr. Westvik: The number of residents per teaching hospital is mainly regulated by the hospitals themselves, based on salary lines.

From a hospital standpoint, the residents must generate reimbursements to justify the cost of their position. The Norwegian plastic surgery specialist committee (similar to RRC) will comment on the need for (or lack of) plastic surgeons. Currently there are 42 resident positions in Norway, with 14 of these finishing within two years, while hardly any attending positions are open.

ASPS President Lynn Jeffers, MD, MBA, (left) with Tormod Westvik, MD, and Sverre Harbo, MD, in Norway in October.

PSN: What would you say are the main issues facing the specialty in Norway?

Dr. Westvik: We’re training many more residents than the government-based system

needs. The geographic distribution of plastic surgeons is very skewed, with the Oslo area having almost 50 percent of all plastic surgeons, while the Oslo population only

represents 25 percent of the country.

Hospitals are more interested in volume and budget obligations than research and innovation. Hence, very little progress is seen in developing new treatment options compared to our neighbors Sweden and Finland. Hospital leaders have become a group of professional bureaucrats without medical backgrounds and few leaders see plastic surgery as a specialty, allowing other surgical disciplines to excel.

It’s not uncommon to have a non-physician as the head of a department.

Since all cosmetic procedures are performed in private plastic surgery clinics without residents, no teaching of these procedures occurs. Cosmetic treatments performed by non-medical personnel is problematic, as the public often thinks of these as providers Continued on page 32

Face Lift Retractor ASSI•ABR 53926R 80x16mm, reverse handle and blade with teeth, with fiber optic, suction and adapter ASSI•ABR 531026R 120x16mm, reverse handle and blade with teeth, with fiber optic, suction and adapter ASSI•ABR 529026R 120x16mm, reverse handle and blade with teeth, with fiber optic, suction and adapter, insulated ASSI•ABR 43926R 80x16mm, reverse handle and blade with teeth, with fiber optic and adapter

Detail of blade with teeth

Avoids difficulty of accessing the neck through a submental incision due to the reverse handle.

Retractor shown larger than actual size ® ACCURATE SURGICAL & SCIENTIFIC INSTRUMENTS ®

For diamond perfect performance®

accurate surgical & scientific instruments corporation 800.645.3569 516.333.2570 fax: 516.997.4948 west coast: 800.255.9378 Info: assi@accuratesurgical.com • Orders: orders@accuratesurgical.com • www.accuratesurgical.com Not all ASSI products shown in our literature or on our website are available for sale in Canada

©2019 ASSI®

By Yassie Dunn

11

ON LEGAL GROUNDS

Take caution when performing liposuction and avoid perforation “On Legal Grounds” provides a general informative overview of the topics addressed. It is provided with the understanding that the author is not engaged in rendering legal advice and the column is not a substitute for obtaining the services of a lawyer or other appropriate professional to independently research and address specific legal or practice problems, issues or situations.

in his physician’s office, and was resuscitated in an E.R., only to die the following day of sepsis.

occurs, the better the outcome. Patients have presented with a perception of increased pain or dehydration as well as unstable vital signs.

A review of many of these cases reveals that many patients are seen after the surgery by non-physician staff and either given I.V. fluids or have their pain medications increased.

Case One: Monica H. is a 34-year-old mother of two seeking abdominal contouring. Her consult concluded with an abdominoplasty and liposuction of her upper abdomen and waist. She is 5’2”, weighs 159 pounds and does not smoke. Her five-hour surgery is uneventful, yielding 2,900-cc lipo-aspirate. She was kept overnight in the O.R. facility, and her vital signs remained stable – other than a slight tachycardia that was attributed to pain. Monica complained of pain and received IV medication during the night, with her urine output also remaining stable. The following morning, her surgeon called to check on her via the nurses and was told she was stable, had voided and had her pain medication.

Monica had trouble getting out of bed, however, and was somewhat unsteady. Due to facility rules, she was discharged with instructions, pain medications and told she was to be seen in two days. The following day, her pain increased, which she reported and was told to continue with her pain medication. Ultimately, her husband took her to the E.R., where she was unstable and arrested. A surgical consult brought her to the O.R. where she had necrotic stomach and bowel, and within hours died.

By Neal R. Reisman, MD, JD

L

iposuction remains a popular surgical procedure, and although most patients experience positive results, there continue to be complications resulting from perforations below the musculature – both abdominally and posteriorly. With significant numbers of deaths and morbidity as a result of such perforations, some states now suggest restrictions on liposuction both in practice and facility.

With regard to the risk of perforation, you need to be aware of various factors, such as the angle of the cannula, which could make the patient more susceptible. You should also be aware of abdominal breathing associated with the level of anesthesia, as well as any prior history of abdominal surgery with adhesions or abnormal anatomy that could result in the bowel being adherent to the anterior abdominal wall. Other observations suggest the smaller tumescent cannulae may be the culprit, as fluid is being injected and their size can easily penetrate muscles.

The other important aspect is early recognition of this complication. Pain is common in and around the areas of liposuction. The level of pain and associated findings, such as abdominal guarding or a significant inflammatory patient response, however, should trigger concern. The earlier that intervention

Case Two: Carla W. is a 31-year-old woman seeking liposuction of her abdomen, trunk and extremities. After appropriate consultation and consents, she had an uneventful surgery in an outpatient facility with 5,200-cc aspirate. She was kept overnight, remaining somewhat stable with abdominal pain. She was discharged the following morning and called the office complaining of pain in her abdomen. She was seen in the office two days after surgery and given IV fluid, although deemed

to be stable with all areas healing well. Pain medications increased. Two days later (now four days after surgery), the pain intensified and she collapsed at home. Carla was taken to the E.R. and ultimately explored with no obvious perforation – but a necrotic bowel and a large fluid accumulation were found; she arrested and ultimately died.

Case Three: Laurie B. is a 48-year-old woman seeking abdominal body contouring and waist liposuction. She’s a good candidate for the procedure and the surgery is uneventful. General anesthesia with an LMA was utilized; 2,400 cc of aspirate was removed using 3mm and 4mm cannulae. She does satisfactorily on the first post-op visit two days later, although she does complain of some abdominal tenderness. Her pain medication is increased. She ultimately collapses at home two days later and is taken to a hospital, where a small bowel perforation is diagnosed. Laurie survives and files a lawsuit alleging negligence in performing surgery and follow-up care.

Case Four: Jared D. is a 39-year-old male seeking contour improvement of the chest, flanks and abdomen.

Liposuction is performed during an uneventful surgery and he’s examined five days later after calling about abdominal pain. All the incisions were healing and pain medications renewed. Nine days later, Jared passed out

Case Five: Mia N. is a 52-year-old female seeking facial rejuvenation and body contouring. She underwent a browlift, upper blepharoplasty and liposuction of the abdomen, thighs and waist, all uneventfully. She was seen postoperatively and appeared to be doing well. Mia did call the office twice about abdominal pain; she was told to rest and take pain meds. Ten days later, she went to an E.R. for abdominal pain where a small bowel perforation was diagnosed. She had emergency surgery to repair the bowel and seeks reimbursement for her additional expenses, pain and suffering, as well as the trauma inflicted and additional scarring.

Summary State medical boards are looking at the complications like those outlined in these five cases, and they may legislate additional restrictions on certain procedures. There have been several deaths in Florida, for example, resulting from perforations. Taking caution when evaluating the prospective patient for a higher risk of perforation due to past medical history and abdominal examination combined with anesthesia planning, especially during the tumescent stage of liposuction, should be beneficial.

Assessing the patient with any issues in the early post-op period is also important.

The complication may not be obvious to diagnose, but patients should be evaluated specifically to these symptoms and presentations. Increasing hydration and pain medication without a complete evaluation that looks for signs and symptoms of a perforation likely will not be helpful. Early recognition of the complication and the appropriate immediate treatment may save a life. PSN

THE HIGHER GROUND

Is it unethical to claim that removing implants will make patients feel better?

By Joe Gryskiewicz, MD

Editor’s Note: “The Higher Ground” columnist Joe Gryskiewicz, MD, is a former chair of the ASPS Ethics Committee, a past member of the ASPS Judicial Council, and he has been in practice for more than 30 years. Readers are encouraged to submit queries to him at drjoe@tcplasticsurgery.com. Names will be withheld, and the views expressed in this column are those of the author and should not be considered legal advice.

Q: I am concerned about our patients who believe their implants are causing symptoms of “breast-implant illness” (BII). I’m equally concerned for our patients over the Biocell withdrawal by Allergan with respect to anaplastic large-cell lymphoma (ALCL).

Many of my patients are calling with questions, and they seem distraught.

This isn’t the time to exploit them, but a plastic surgeon in town is doing just that: She shows surgery videos on her website claiming a patient is experiencing symptoms such as fatigue, joint pain and muscle aches from her implants – something that has not been established by science as of yet. The doctor goes on to claim that after the surgery to remove the implants, the patient will feel much better. Now, there might be an emotional component to this, but how can anyone guarantee relief of physical symptoms such as these? This isn’t exactly the scientific method.

Isn’t this unethical?

12

A: The recent concerns surrounding the Biocell withdrawal and widespread media reporting over BIA-ALCL and BII have put these kinds of questions into a grey area. As plastic surgeons, we should always listen, be empathetic and compassionate for our patients, and we should by no means lead them down a path simply to line our pockets. If you’re simply trying to grab the brass ring in this situation, you absolutely will run afoul of the ASPS Code of Ethics.

Under Section 1: General Principles III. “Members should practice a method of healing founded on a scientific basis and should not voluntarily associate professionally with anyone who violates this principle.

IV. They should expose, without hesitation, illegal or unethical conduct of fellow Members of the profession.

X. To assist the public in obtaining medical services, Members are permitted to make known their services through advertising.

Advertising, however, entails the risk that the Member may employ practices that are false, fraudulent, deceptive, or misleading. Regulation is, therefore, necessary and in the public interest. Subsection II of the Specific Principles permits public dissemination of truthful information about medical services, while prohibiting false, fraudulent, deceptive or misleading communications, and restricting direct solicitation.”

If we don’t run our practices on the scientific method, we might as well be living in the Dark Ages and selling snake oil instead of healing and curing. As stated in the code

above, you have an obligation to report fellow members for unethical conduct, and this practice may be a violation of our Code. If we don’t hold plastic surgeons accountable for trying to capitalize on fear or heightened emotions, this behavior will only expand like a wildfire. Let the Ethics Committee sort this out. Our Code of Ethics further speaks to this behavior: Section 2: F. “The Member uses, participates in or promotes the use of any form of public communication (as defined in Glossary to the Code) or private communication (as defined in the Glossary to the Code) containing a false, fraudulent, deceptive, or misleading statement or claim, including a statement or claim which: 1. Contains a misrepresentation of fact or fails to state any fact that is necessary to make the statement not deceptive or misleading, when considered as a whole.

2. Omits facts or information of which the public ought to reasonably be informed before selecting a qualified plastic surgeon.

8. Is intended or is likely to create false or unjustified expectations of favorable results.”

VII. Glossary E. “Public communications media” includes, but is not limited to, electronic media, television, radio, recorded video or motion picture, telephone, written correspondence, electronic mail/e-mail (other than those which are which are private communications), print (i.e., newspaper, magazine, book), marketing materials and branding (i.e., directory, business card, professional announcement card,

office sign, letterhead, telephone directory listing or professional notice).

Promising relief for symptoms that haven’t been scientifically tied to breast implants seems questionable at best to me. If you feel comfortable calling your colleague, I believe the best thing would be to discuss the matter with this doctor directly. Explain how her marketing material could appear misleading, and if that doesn’t work, you could report her to the Ethics Committee.

The downside of this approach is that if you do ultimately report her, she likely will know it was you – even though the complainant is not revealed to the reported member. Still, I feel like this situation merits some discussion.

It reminds me of the days of bloodletting to cure disease, only today it seems that the twist is bleeding patients for money.

Of course, there are two sides to every story, and I suppose it could be argued that in the case of these patients who were interviewed, they did feel better after their implants were removed. We would do well to remember that if we’re willing to implant devices with no medical necessity, it’s not out of the question that we would be willing to explant those same devices with no medical necessity. These are the questions the Ethics Committee would consider in the course of an investigation Prior to 1977, physicians didn’t advertise. It was considered “demeaning to the profession;” now we advertise like mad. While advertising around a sensitive topic can seem offensive, as long as it’s truthful it perhaps will seem tame in a decade. We’ll have to see. PSN

December 2019

United States Patent #8,784,347 B1

Fat Grafting and Body Sculpting Line - US Patent 8,784,347 B1-

800.442.5800 • 510.970.7990 www.DesignVeronique.com ©2018 DESIGN VERONIQUE December 2019

13

LEGISLATIVE UPDATE

Looking at the Society’s work at the state level in 2019

By Darcy McLaughlin, Christian Laatsch & Jessica Frasco

A

SPS is the only society advocating specifically for plastic surgery’s interests at the federal and state levels.

These advocacy efforts constitute an essential member benefit and protect the profession from proposals that can hamstring plastic surgery practices while promoting policies that ensure greater access to our members’ services. Although other societies may advocate on behalf of all physicians or surgeons, ASPS and the local plastic surgery societies in each state have been actively working on your behalf, on a handful of key issues specific to the specialty.

With the calendar year coming to a close, let’s take a look at some of the efforts made on behalf of plastic surgery that the Society made at the state level in 2019.

Oregon Coverage of ADMs in breast reconstruction The Oregon Health Evidence Review Commission (HERC) reviewed whether the state’s Medicaid program, the Oregon Health Plan, should continue noncoverage of acellular dermal matrix (ADM) in breast reconstruction.

ASPS contacted members throughout the state in an effort to secure plastic surgery representation during the Aug. 8 HERC Value-based Benefits Subcommittee (VbBS) meeting.

ASPS member Allen Gabriel, MD, Portland, agreed to provide expert testimony

on the efficacy and common use of the device in the procedure. Dr. Gabriel, who regularly uses ADMs in post-mastectomy breast-reconstruction procedures, cited the various benefits of the device, such as allowing for single-stage procedures for tissue expander or implant-based primary breast reconstruction; limiting inflammatory changes that can cause capsular contracture; and decreasing risk of all complications related to radiation. During the hearing, HERC VbBS members received a review of the evidence from HERC Medical Director Ariel Smits, MD, prior to Dr. Gabriel’s testimony. Dr. Gabriel also highlighted that younger plastic surgeons are primarily trained to utilize ADMs in breast reconstruction.

In comments submitted by ASPS to the HERC, the Society stressed that the use of ADMs has become a standard of care and is by far the most prevalent method used in breast

Advocacy in the states A quick look at some of the work ASPS did in October to advocate on behalf of the specialty at the state level.

reconstruction. ASPS voiced concern that private carriers may follow Oregon Health Plan’s lead, further limiting access to care for patients. The Society does not believe the state should place additional burdens on breast cancer survivors by continuing noncoverage.

Unfortunately, the VbBS voted to continue noncoverage. The subcommittee cited the fact that many coordinated-care organizations have the option to cover ADM regardless of HERC guidance, and that they would like to see more evidence from randomized controlled critical trials before reevaluating the issue. ASPS will continue to engage the state in an effort to overturn the decision.

Texas State ban on balance billing Addressing out-of-network billing has been on the Texas Legislature’s radar since 2009, when legislators passed a first-in-the-nation system that allowed patients to appeal certain types of unanticipated medical bills through mediation. Although the system was improved last session, there was another push during the 2019 session to further protect patients from surprise bills. The Texas Society of Plastic Surgeons (TSPS) monitored off-session committee activity and took part in several stakeholder meetings that occurred during the latter months of last year. Throughout that process, TSPS worked with ASPS to ensure that the state’s plastic surgeons had a seat at the policymaking table.

Lawmakers introduced several bills at

the start of the 2019 legislative session, but unfortunately, none of the proposals were acceptable solutions for the house of medicine, as they took flawed approaches that would disrupt the state’s healthcare delivery system.

TSPS worked with other physician stakeholder groups to lean on lawmakers to amend the legislation – and ASPS partnered with TSPS through the State Partnership Advocacy Grant Program, which awarded the state plastic surgery society a $10,000 grant to fund advocacy activities.

TSPS and other medical specialties on the ground focused their efforts on a measure sponsored by State Sen. Kelly Hancock (SB 1264). TSPS played an integral role in crafting and amending this bill throughout the legislative process, which helped secure major concessions to protect plastic surgeons and the patients they serve. Ultimately, negotiations culminated in a compromise proposal that bans balance-billing in certain scenarios; protects patients so they are only responsible for their in-network cost-sharing; and establishes a dispute-resolution system through baseball-style arbitration. Baseball arbitration was first implemented by New York to settle out-of-network payment disputes and has a successful track record of impartiality.

During the session, ASPS reached out to the sponsors, Sen. Hancock and State Rep. Tom Oliverson (a board-certified anesthesiologist), with suggested amendments to reimburse physicians fairly at market value for their services and strengthen the arbitration requirements.

ASPS expressed concern that the bill’s inclusion of allowed amounts within the definition of the “usual and customary rate.”

The bill also lacked transparency and accountability, which could allow insurers to manipulate rates to their benefit. ASPS also voiced concerns regarding the inclusion of the 50th percentile of rates paid as a criterion that must be considered during the baseball-style arbitration process. The Society opposes that benchmark as it isn’t representative of a fair-market reimbursement – which ASPS believes is the 80th percentile of all billed amounts.

The bill passed the Legislature without further amendments and Gov. Greg Abbott signed it into law June 14. ASPS sent a letter to the governor urging him to work with Continued on page 34

Thank you, PlastyPAC contributors

P

lastyPAC, the bipartisan political action committee of ASPS, works to educate and influence Congress on issues that directly affect plastic surgery. As the largest voice for reconstructive and cosmetic surgery, PlastyPAC is grateful for the support of the following people whose contributions during October 2019 help play a key part in the specialty’s success on Capitol Hill.

• ASPS briefed the Medical Society of Virginia on ASPS and the Virginia Society of Plastic Surgeons’ concerns with the state’s in-office compounding rules.

• The Society submitted two scope-of-practice requests cosigned by the Connecticut Society of Plastic Surgeons opposing dental and esthetician scope expansion efforts in the state.

• ASPS recruited members to serve on the Vermont Pharmacy Board’s compounding task force, which will have jurisdiction over the reconstitution of Botox and lidocaine within physician offices.

• The Society urged members in Idaho to contact the state nursing board in opposition to a proposal that would allow nurse anesthetists to call themselves nurse anesthesiologists.

14

California Debra Johnson, MDI Bradley Mudge, MD Danielle Rochlin, MDn Florida Melanie Aya-ay, MD Peter Marzek, MDu Iowa W. Thomas Lawrence, MD Kentucky Jack Burns II, MDn John Derr Jr., MD Louisiana Louis Mes, MDI

Maryland Justin Sacks, MD, MBAu Massachusetts Theodore Calianos, MDu Michigan Calvin Young, MD, MHSn New Jersey Paul LoVerme, MDu Gary Smotrich, MDu New York Scot Glasberg, MDI

Pennsylvania Joanna Ng-Glazier, MDn Chen Yan, MDn

Evan Matros, MDI Colleen McCarthy, MDu Ash Patel, MBChBI Aviva Preminger, MDI Malcolm Roth, MDI

Texas Stacy Wong, MDn

North Carolina Lynn Damitz, MDI Rosiane Roeder, MD

Washington Cristiane Ueno, MDn

Ohio Kihyun Cho, MDn R. Michael Johnson, MDI Rebecca Knackstedt MD, PhDn Nicholas Sinclair, MDn

West Virginia Peter Ray, MDu

Presidential Circle: $5,000 (max) L Congressional Circle: $3,500+ H Premier Circle: $2,000+ Chairman’s Club: $1,000+ u Patron: $500+ s Young Plastic Surgeons: $200+ n Residents: $25+ J

I

December 2019

SOCIAL MEDIA FOCUS

The tricky prospect of sharing before-and-after images on Instagram

By Karen Horton, MD

A

ccording to a July 2019 survey, Instagram is now used by an estimated 500 million people on a daily basis – and 52 percent of those users are female. These users are our patients. Instagram is a visual platform, and an ideal one for plastic surgeons to showcase their results.

The question remains, however: How you can share your cosmetic and reconstructive results responsibly, ethically and respectfully?

I’ve been active on Instagram since December 2015 through my @drkarenhorton account and I’ve grown my follower-count to more than 18,000.

Although I previously tried sprinkling-in some before-and-after images to my page, they seemed out of place with my regular “day in the life of a board-certified plastic surgeon” posts.

Earlier this year, I launched a second “vertical” @drkarenhortonbeforeandafters account to share a before-and-after case each day, with a detailed description of my patient’s surgical journeys.

My goal was to display my surgical results and to encourage followers to visit my website to see more.

What did I learn? Several things. First, you have to appreciate that female nipples, pubic hair and buttock creases need to be obscured.

You can land in “Facebook jail” for inadvertently posting “inappropriate content” via a reconstructed nipple (local flap and medical tattoo), an uncovered buttock crease or intraoperative images with areola tissue showing.

You’re alerted to this violation by a message detailing cumulative penalties per offence (24 hours, three days, one week or permanent

removal of your page). It’s important to understand that what we find acceptable and see every day as plastic surgeons isn’t always considered appropriate by social media platforms.

Instagram is owned by Facebook, so it has parallel policies when it comes to displaying body parts. Showing a female nipple is a misdemeanor, while showing enlarged male nipples in gynecomastia before-and-after cases, transgender nipples or an actively breastfeeding nipple, even in a suggestive pose, is acceptable. Although the #freethenipple campaign promotes equality of showing women’s nipples or reconstructed nipples with gender equality on social media, it hasn’t made sharing these photos widely acceptable.

Therefore, how do plastic surgeons display their results without violating these policies or offending viewers? Placing various emojis over these body parts via a smartphone app or third-party desktop program is common – but even this necessitates caution. A July 2019 Facebook/Instagram policy update targeted particular emojis that could be interpreted as

sexually suggestive, including the peach emoji (over female buttocks) and the eggplant (over male genitalia). Accounts can be flagged or shut down for violating this policy. The ASPS Social Media Subcommittee is closely following this development and closely scrutinizing its own social media posts for potential violations.

For social media sharing of my results, I created circles, triangles and rectangles featuring my initials and brand colors to cover up body parts as needed (see images). I add a clear title, my name and practice information to each post that acknowledges the work is mine and discourages reposting by others as their own (theft). I post my before-and-after photos mainly on my page, rather than in Instagram stories, which are featured as the small circles at the top of your home feed. The stories function copied Snapchat and encourages daily posts to which you can add text, emojis, stickers, location and time information, and tag others in.

Instagram stories have a less formal and curated feel than most home pages. Some users primarily view stories rather than scroll

their home feed. Posting your cases in a story requires additional steps – and likely several posts per case for a detailed description and to allow viewers to take in all pertinent details. These posts disappear after 24 hours and are not visible on your page afterward. Therefore, they won’t be viewed by all your followers, instead just capturing the attention of some Instagram users.

You need more than 10,000 followers on your account to activate the “swipe up” function – which will take viewers to a particular web link (such as the full case on your website without covering up nipples and pubic hair). It takes time to grow your page organically to this level, and you should never buy fake followers.

Finally, Instagram is gradually rolling-out the hiding of “likes” to everyone other than the account owner. How will this affect plastic surgeons? It may indeed level the playing field, as most of us don’t have thousands of likes per post. It also will free-up posting times to when it’s convenient, rather than trying to game when most users are online and to gain as many likes as possible.

Many businesses are focusing more on engagement per post rather than likes. If followers comment on your post, respond and continue the conversation. Be sure to remove all identifying features on before-and-after images, such as tattoos, jewelry or other body markings. It’s also paramount that you have full consent to share patient images online. A sample consent form for social media sharing can be found at plasticsurgery.org. PSN Dr. Horton is a member of the Social Media Subcommittee and practices in San Francisco.

You can find her online at drkarenhorton.com.

Top ASPS social media posts for October 2019

December 2019

15

ASPS 2020

Informed Consent Bundle Help Patients Make Informed Decisions More than 90 forms are now simplified to verify readability and to ensure patients understand the risk and benefits of plastic surgery procedures.

The 2020 IC bundle includes: • Shorter, user-friendly forms • Updated content for BIA-ALCL • Revised BBL form • Off-label form • General risk of surgery • Procedure-specific risks of surgery forms

FOR LIMITED TIME ONLY

Special Introductory Price of $425!

ORDER YOUR COPY NOW! plasticsurgery.org/ICR

16

December 2019

NBIR builds on successful first year Plastic surgeons write new chapters

T

he National Breast Implant Registry (NBIR) in early October concluded its first year of data collection. To date, the NBIR has captured data on more than 5,500 breast-implant procedures from patients across 46 states. The PSF continues to work with surgeons, patients, the FDA, implant manufacturers and other stakeholders to effectively utilize this data in strengthening national quality surveillance efforts. Participation in this registry is a crucial tool for quality improvement and safety surveillance, while improving patient care.

A complete summary of the first-year registry operations is underway – it will highlight the major accomplishments of this inaugural year and showcase summary data resulting from its first in-depth data analysis.

Increasing usage As of July 1, the NBIR became capable of transmitting breast-implant device manufacturers’ device-tracking data in accordance with federal requirements. The NBIR case-report form was designed to capture data that’s required for the purposes of device tracking, so physicians participating in the NBIR can simultaneously submit data to the registry and register their patients’ implants for Allergan, Sientra and, soon, Mentor.

Looking ahead, one of the primary goals of the NBIR Steering Committee is to strategize methods and optimize marketing initiatives to increase participation and case capture –

A

SPS members (and already published authors) issued new books that went on sale in stores and online retailers, including Amazon, in the past few months.

not only among active ASPS members, but also among non-members. It’s crucial that the NBIR captures 100 percent of implant procedures in order to better understand why reoperations occur. The steering committee is also focusing on ease-of-use and is working to improve the data-entry experience for doctors. In early 2020, The PSF will begin piloting a patient-reported outcome (PRO) component of the NBIR. Following the pilot, which is anticipated to take between 12-18 months, PROs will be launched broadly to all participants.

ASPS and The PSF believe well-designed clinical data registries such as the NBIR are a powerful means to understand real-world patient outcomes through the surveillance of comparative effectiveness and safety signals – and that these registries will continue to demonstrate their value for providing a vitally important view of clinical practice.

To learn more about the NBIR, please visit thepsf.org/NBIR or contact NBIR Project Manager Erin Mullen via email at emullen@plasticsurgery.org. PSN Support for the NBIR is provided by Allergan, Mentor and Sientra.

1ST ANNUAL

Playing God Anthony Youn, MD, with Alan Eisenstock Published by Post Hill Press Dr. Youn’s latest book follows his 2012 memoir, In Stitches, and focuses on his journey to becoming a plastic surgeon, from medical school through residency training and early practice. Dr. Youn shares stories of some of the trials and tribulations he faced early in his journey that helped turn him into the surgeon he is today.

“Several plastic surgeons told me that reading this book made them reminisce about their own years in training and early practice,” he says. “We all go through similar trials, and I’m proud that my book has touched so many.”

The Business of Plastic Surgery (2nd Edition): Navigating a Successful Career Edited by Joshua Korman, MD, & Heather Furnas, MD Published by Thieme It’s been nearly 10 years since Dr. Korman

and Dr. Furnas published the first edition of The Business of Plastic Surgery, and the latest edition launched at Plastic Surgery The Meeting 2019 in San Diego. Dr. Furnas says the book provides even more useful information to plastic surgeons who might feel overwhelmed by the non-surgical side of operating a practice.

“Even though Dr. Korman and I both had great clinical training, we knew nothing about contracts, negotiation or managing others,” she says. “We gathered experts to write on topics such as why some plastic surgery groups succeed and others fail. We asked colleagues from three different groups from around the country to contribute, and we compiled their words into one great chapter. The authors contributed several examples of partner and fellow contracts.”

Dr. Korman notes this volume also has insights from specialty veterans on topics such as retirement and even transitioing in the middle of one’s career.

“We want to make it easy for plastic surgeons to find skilled and experienced consultants, attorneys and financial experts who have a sophisticated knowledge of the challenges facing plastic surgeons,” he says.

“Although this is the second edition, most of this version is new, as we have worked to respond to the changing landscape in our specialty and medicine in general.” PSN

36TH ANNUAL

SESPRS/ISAPS PERIORBITAL & FACIAL SYMPOSIUM

ATLANTA BREAST SURGERY SYMPOSIUM

JANUARY 23, 2020

JANUARY 24-26, 2020

INTERCONTINENTAL HOTEL ATLANTA, GEORGIA

INTERCONTINENTAL HOTEL ATLANTA, GEORGIA

“BEST

PRACTICES

ON

VIDEO”

for information and registration visit: www.sesprs.org December 2019

17

YOUNG P L A S T I C

S U R G E O N S

PERSPECTIVE WRITTEN BY AND FOR YOUNG PLASTIC SURGEONS

Creating a more dynamic future with the Residents Council

By Kathryn Skibba, MD

YPS P e r s p e c t i v e

A

s a third-year plastic surgery resident and new member of the ASPS Residents Council, I was fortunate to be supported by my residency program to attend Plastic Surgery The Meeting 2019 in San Diego. It not only offered me a direct network to my peers, it also provided insight into the work that can be put into improving resident experience during training.

The Residents Council was created for plastic surgery residents training across the United States and Canada, and designed to foster collaboration and advocacy for the interests of plastic surgery residents and residency programs. It’s a pathway to national change and the future of plastic surgery residency, as well as a great opportunity for residents to gain leadership experience during training.

At my first council meeting in San Diego, I entered the meeting room with a few minutes to spare. Several residents were already there, although I didn’t recognize a familiar face among them. We gathered chairs to form

a circle to start the meeting; Kavitha Ranganathan, MD, began by discussing progress made over the past year.

After that, nearly 50 residents introduced themselves and we began to compile a list of goals for the coming year. I truly appreciated the individual attention given to each person who spoke, and it was a great way to meet residents from across the nation. I found it humbling to be among so many influential residents and I was grateful to be a part of something bigger than myself and my home institution.

As I looked around the room, I was overcome with a surreal sensation that I was looking at the future leaders of plastic surgery.

It became apparent that we shared many common goals, all with intention to improve resident education, experience and outreach.

I left the meeting feeling inspired and as a valued part of a national community of plastic surgery residents. Residents Council is a great way not only to meet new people and network, but also to collaborate on improving residencies from coast to coast. Whether

it be in ASPS, YPS or positions in academic practice, I’m fortunate to have access to experiences that can pave a path to leadership in the future.

The following initiatives were set forth by the Residents Council: 1. Encourage programs and ACGME to allow residents to participate in global surgery and have the time away not be considered vacation.

2. Provide residents with professional development days to use for attendance at conferences and interviews.

3. Establish fair parental-leave policies that mimic, at minimum, the standard for other professions.

4. Continue the development of guidelines for social media use by residents and residency programs.

5. Support programs that establish resident wellness experiences.

6. Improve resident didactics, as well as request programs to provide residents

adequate time and resources for board review.

How to get involved

The application period for Residents Council is closed – but check the ASPS Residents Council webpage in the spring to apply for the 2020-21 year. There are 21 unique committees that residents can apply to serve within. Visit the ASPS Residents and Fellows webpage for more information.

To keep up to date, subscribe to the ASPS Residents and Fellows Forum at plasticsurgery. org/for-medical-professionals/community/residents-and-fellows-forum.

A new cross-organizational mentorship program is forming called PROPEL (Professional Resource Opportunities in PRS Education and Leadership), wherein practicing plastic surgeons and residents are paired-up based on interests within the field of plastic surgery.

Visit plasticsurgery.org/menteeapplication to apply as a mentee. YPS

PROPEL looks to create a continuum of mentorship, learning opportunities

By Kavitha Ranganathan, MD

T

he term “mentorship” took root in the mid-18th century and originated from Homer’s “Odyssey” as a means of expressing the actions that a teacher takes to lead a less-experienced trainee. Over time, areas such as humanities, science and mathematics adopted the concept, given the dedication and steadfast commitment to the arts required by these scholars.

The transmission of knowledge and success became commensurate with proper mentorship, and the resultant connection and loyalty were worn as badges of honor by both the mentor and the mentee. The power of a successful mentor-mentee bond notwithstanding, one cannot help but question whether the same structure and format of mentorship that developed 300 years ago still resembles the concept in place today. Is it possible for one person alone to satisfy the career needs of a multifaceted trainee, and likewise, does a mentor ever graduate from needing mentorship in a field that demands lifelong learning?

The increase in articles on “mentorship malpractice,” in journals ranging from the New England Journal of Medicine, to JAMA Surgery and PRS, begs this question – and passively hints at the need to revolutionize the current approach to mentorship. In plastic surgery, we begin residency by learning that when “Plan A” fails, you must have a “Plan B,” and that the two plans cannot be the same – even backup plans must have backup plans.

The downfall of traditional mentorship models lies in its non-adherence to this exact principle. By assuming that one mentor is

18

enough, we fundamentally have no “Plan B.” In our current model, we presume that one person should be able to give individualized clinical, research and life advice to a trainee

in need. The multifaceted nature of today’s life as a surgeon makes this feat impossible; as such, the idea of an assigned mentor-mentee pairing is doomed to failure.

Introducing...

The NEW ASPS Mentorship Program PROPEL: Professional Resource Opportunities in PRS Education and Leadership Experience a new approach to mentorship and collaboration in plastic surgery as you engage in the next phase of your career. The new ASPS Mentorship Program is your opportunity to build relationships and create novel learning opportunities that reflect the vast, yet overlapping, experiences between faculty members and trainees.

Collaborate with your peers, learn from the experts and prepare to excel.

Visit plasticsurgery.org/MentorApplication to apply as a mentor Visit plasticsurgery.org/MenteeApplication to apply as a mentee

To address the evolving needs of mentors and mentees, ASPS, the American Council of Academic Plastic Surgeons, the Plastic Surgery Research Council and the Women Plastic Surgeons Forum have joined forces to restructure mentorship through an initiative called PROPEL (Professional Resource Opportunities in PRS Education and Leadership).

Created by the Residents Council and Young Plastic Surgeons groups of ASPS, mentorship in plastic surgery will move to a teambased format through PROPEL. “Launch teams” will be composed of a senior faculty member, junior faculty member, senior resident and junior resident. This team structure will foster a form of bidirectional learning in which the mentor-mentee label is less restrictive compared to traditional formats.

The goal of each group is to build relationships and create a continuum of learning opportunities that reflects the vast (albeit overlapping) experiences between faculty members and trainees in a longitudinal fashion.

Given the needs of trainees today, teams will be created based on a variety of interests including research, clinical training, practice type and approaches to work-life integration. Another distinguishing feature of this program is the integration of private practice and academic faculty mentors into one mentorship system to support the diversity of practice patterns unique to plastic surgery. In this manner, PROPEL can begin to change the paradigm of mentorship to a team-based approach focused on developing the clinical, research and interpersonal facets of a young trainee’s career, ultimately using an innovative approach to a solution rooted in the tradition of success. YPS

December 2019

Reflections on what I know now that I wish I knew then Editor’s Note: Plastic Surgery Resident will become available as an online-only publication in 2020 – found in the “Education & Resources” section of plasticsurgery.org. As a way to bring more eyes to some of the great content featured in the magazine, PSN will periodically reprint some of the features from Resident.

This piece was originally published in the Fall 2019 edition.

surgeons – and there’s no part of the body that, as plastic surgeons, we wouldn’t touch.

Understanding the anatomy is always a great default.

Spend time in clinic. It’s easy to get lost in the O.R., but if you don’t see your patients before and after surgery, you’ll never know what to operate on – and what’s happened as a result.

See as many complications as you can and track them – the only way not to get complications is not to operate. Looking after them is the hardest thing we do.

By Christopher R. Forrest, MD, MSc

D

Watch, learn – and ask Know when to ask for help – then do it.

It took me a while to realize that it wasn’t always on my shoulders. Surgery is a cooperative, team sport – and it was important that I understood I wasn’t expected to know everything. It speaks to the importance of membership and collegiality: Having a guide to take you through the nuances of all aspects of surgical training is incredibly beneficial.

because I believe it’s an important component of balancing my week. If people ask when they see me leave the hospital, I’m happy to tell them where I’m going. When I was a resident, I really had little idea what the extracurricular lives of my staff were like.

Be kind to yourself. This is huge – and as Type A personalities, most surgical residents probably don’t do enough to promote health, both mental and physical. It’s OK to have a life beyond residency; make sure that you carve out a little bit in an appropriate way. Exercise, spend time with family, do something every week that you look forward to and learn how to “turn off.”

Random thoughts Support your attending. Know their patients better than they do, check their schedule, anticipate what they need – and that will translate into a better educational experience.

It’s easy to have strong opinions as a trainee, and while there are many ways things can be

December 2019

As staff, we want you to succeed; it’s our greatest source of educational satisfaction.

Challenge and engage your staff person. Suck the information from them until they are dry.

There are no “small” operations; you can learn from them all. Even if you’re lost in the crowd during a major operation and feel the chances of doing a fronto-facial mono-bloc advancement are slim-to-none after graduation, you can always engage in the anatomics.

That’s the common language we have as

OK, that’s enough to fill your brains for now. Being a surgical resident is a privileged time. You have the best of all worlds available to you, but it’s easy to lose perspective when you’ve been up all night and have rounds to organize the next morning. There’s an old Hollywood movie with James Stewart that could sum-up a career in plastic and reconstructive surgery: “It’s a Wonderful Life.” It will be – just make sure you don’t lose sight of that in the deep, dark recesses of residency training. YPS Dr. Forrest is chair of the Division of Plastic and Reconstructive Surgery at the University of Toronto, and medical director of the Centre for Craniofacial Care and Research.

ANNUAL MEETING

Never underestimate your influence as a surgical leader. It doesn’t matter if you’re in your first week of residency – as a surgeon, the team will look to you for direction and leadership. Well, as a PGY-1, the hardened and battle-worn O.R. nurses may not take you quite so seriously until you’ve proven yourself, but the impact you will have on medical student can be profound. Always act professionally.

You never know who’s watching.

C O R P O R AT E SUPPORTER

Keep a record of all the people you work with and all the cases you do. As grapes grow and soak up the terroir of the land to make a great wine, so will you become the sum of the parts of all your teachers – and it’s nice to know where you got certain things from, before you evolve into your own being.

Be confident. There are many types of cases in our world of plastic and reconstructive surgery, and it’s impossible to see them all during your training. Be confident in the skills that you acquire, that you’ll be able to adapt them to whatever type of case falls in your lap.

Mountain West Society of Plastic Surgeons

Watching experienced surgeons negotiate the traps and challenges of dealing with ED referrals, case preparation, staff idiosyncrasies and even hospital parking are some examples where a mentor can be a huge advantage. A program and surgical residency should foster cooperation and community, not competition.

The business of surgical practice is much neglected during most residency programs, and mine was no different. I wish I had spent more time learning from my staff (i.e., attendings) MOUNTAIN WEST SOCIETY OF PLASTIC SURGEONS about the challenges and hurdles they encountered once they had started their own practices.

2020 I also wish I had takenPthe time to ask my staff L AT I N U M what their lives were really like.

Allergan USAI have a scheduled tennis lesson at 1:30 p.m. each Thursday,

done, keep an open mind. Even if you disagree with the way a staff person does something and think to yourself: “This must be crazy,” you can always learn from an experience – even if it’s how not to do something.

Talk to the “elders” at conferences. When I was attending national meetings as a resident and even as junior staff, I would always be nervous about approaching a plastic surgery icon to ask a question. Now that I’ve reached senior status, one of the biggest joys of attending meetings or doing a visiting professorship is talking to you guys – the next generation of surgeons. It keeps me in touch with what’s going on. So, to me it’s a win-win.

FEBRUARY 27-MARCH 1, 2020 Westin Snowmass Resort

Featuring Keynote Speaker Rod Rohrich, MD Interested in formally joining the Mountain West Society of Plastic Surgeons?

Membership is open to eligible plastic surgeons and residents in all 50 states.

Download an application at: MountainWestSPS.com

MOUNTAIN WEST SOCIETY OF PLASTIC SURGEONS C O R P O R AT E SUPPORTER

2020

P L AT I N U M

Allergan USA

Visit us on facebook

An affiliated organization of ASPS

19

YPS P e r s p e c t i v e

rake’s song “From Time” features the lyric “It’s been a minute.” It’s a good reminder of how quickly it all goes by and that you should enjoy the journey and not focus on the destination. I was really fortunate as a resident to have the benefit of great teachers, a wealth of clinical material, excellent co-residents (well, except for maybe one) and a program that seemed to care about my well-being and success.

That being said, there are several things that would have been nice to know before I started my surgical training. It has been a while, but the feeling never goes away – and I still occasionally have nightmares where I awaken and wonder if I really did pass my final exam.

The journey to surgical excellence never really ends. There are moments when you feel you’ve hit a home run and done something amazing, but just around the corner is an unexplained and unexpected complication.

That’s when the surgical gods decide to deflate your ego a little. Still, I would emphasize that during residency, it’s crucial to learn the skills for survival and health that will last your career – and also facilitate your evolution and maturation as a surgeon.

PROUD OF SUPPORTING

SURGEONS AND PATIENTS FOR

YEARS AND COUNTING

INDICATIONS ALLODERM SELECT™ Regenerative Tissue Matrix (ALLODERM SELECT™ RTM refers to both ALLODERM SELECT™ RTM and ALLODERM SELECT RESTORE™ RTM products) is intended to be used for repair or replacement of damaged or inadequate integumental tissue or for other homologous uses of human integument. This product is intended for single patient one-time use only.

ALLODERM SELECT™ RTM is not indicated for use as a dural substitute or intended for use in veterinary applications.

IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS ALLODERM SELECT™ RTM should not be used in patients with a known sensitivity to any of the antibiotics listed on the package and/or Polysorbate 20.

WARNINGS Processing of the tissue, laboratory testing, and careful donor screening minimize the risk of the donor tissue transmitting disease to the recipient

patient. As with any processed donor tissue, ALLODERM SELECT™ RTM is not guaranteed to be free of all pathogens. No long-term studies have been conducted to evaluate the carcinogenic or mutagenic potential or reproductive impact of the clinical application of ALLODERM SELECT™ RTM. DO NOT re-sterilize ALLODERM SELECT™ RTM. DO NOT reuse once the tissue graft has been removed from the packaging and/or is in contact with a patient.

Discard all open and unused portions of the product in accordance with standard medical practice and institutional protocols for disposal of human tissue. Once a package or container seal has been compromised, the tissue shall be either transplanted, if appropriate, or otherwise discarded. DO NOT use if the foil pouch is opened or damaged. DO NOT use if the seal is broken or compromised.

DO NOT use if the temperature monitoring device does not display “OK.” DO NOT use after the expiration date noted on the label. Transfer ALLODERM SELECT™ RTM from the foil pouch aseptically. DO NOT place the foil pouch in the sterile field.

Allergan® and its design are trademarks of Allergan, Inc. ALLODERM™ and its design are trademarks of LifeCell Corporation, an Allergan affiliate. © 2019 Allergan. All rights reserved. ALS128506 09/19

20

December 2019

Millions of lives impacted, and an unwavering commitment to innovation and research.1 For more information, call Customer Service at 1.800.367.5737 or visit WWW.ALLODERM.COM/HCP.

PRECAUTIONS Poor general medical condition or any pathology that would limit the blood supply and compromise healing should be considered when selecting patients for implanting ALLODERM SELECT™ RTM as such conditions may compromise successful clinical outcome. Whenever clinical circumstances require implantation in a site that is contaminated or infected, appropriate local and/or systemic anti-infective measures should be taken.

ALLODERM SELECT™ RTM has a distinct basement membrane (upper) and dermal surface (lower). When applied as an implant, it is recommended that the dermal side be placed against the most vascular tissue. Soak the tissue for a minimum of 2 minutes using a sterile basin and room temperature sterile saline or room temperature sterile lactated Ringer’s solution to cover the tissue. If any hair is visible, remove using aseptic technique before implantation.

ALLODERM SELECT™ RTM should be hydrated and moist when the package is opened. DO NOT use if this product is dry. Use of this product is limited to specific health professionals (e.g., physicians, dentists, and/or podiatrists).

Certain considerations should be made to reduce the risk of adverse events when

December 2019

performing surgical procedures using a tissue graft. Please see the Instructions for Use (IFU) for more information on patient/product selection and surgical procedures involving tissue implantation before using ALLODERM SELECT™ RTM. ADVERSE EVENTS The most commonly reported adverse events associated with the implant of a tissue graft include, but are not limited to the following: wound or systemic infection; seroma; dehiscence; hypersensitive, allergic or other immune response; and sloughing or failure of the graft.

ALLODERM SELECT™ RTM is available by prescription only.

For more information, please see the Instructions for Use (IFU) for ALLODERM SELECT™ RTM available at www.allergan.com/AlloDermIFU or call 1.800.678.1605.

To report an adverse reaction, please call Allergan at 1.800.433.8871.

Reference: 1. Data on file, Allergan. 2018. Sales Data.

21

National Endowment for Plastic Surgery Grant

Working to heal wounds via induced pluripotent stem cells PSN: What has been your favorite scientific or research project to date?

Dr. Hsia: I’ll stay on the theme of when I was young and mention a class project where we had to figure out a way to drop an uncooked egg from the third floor of our school and have it land on the ground intact. While classmates focused on designing parachutes and gliders, I estimated the amount of force the egg would sustain on impact and built a box for the egg using various lightweight household items that could absorb that force and shield the egg. It didn’t look very high-tech or as cool as some of my classmates’ ideas, but it worked and got the job done.

By Jim Leonardo

Editor’s note: The following is part of an ongoing series highlighting The PSF Research Grant Award winners, and research they’re conducting to improve patient safety and develop new technologies for plastic surgeons. These features examine research funding awarded prior to the current year, as projects to which grants were awarded this year may not yet have results ready to discuss.

FOCUS ON PLASTIC SURGERY RESEARCH

THE RESEARCHER Henry Hsia, MD Title: Associate Professor of Surgery, Founding Director of the Yale Regenerative Wound Healing Center, Yale University School of Medicine, New Haven, Conn.

Award: National Endowment for Plastic Surgery Grant Project: iPSC-based Tissue-Engineered Graft for Wound Healing PSN: Can you tell us about the wound-healing breakthrough you hope to achieve?

Dr. Hsia: My lab is focused on how the wound-healing process can be improved for patients who suffer from problematic wounds, by using approaches associated with regenerative medicine. One of those approaches includes induced pluripotent stem cells (iPSCs), which have the ability to become any tissue in the body like embryonic stem cells but are derived instead from adult cells. This project takes advantage of advances over the past decade in iPSC technology, which allows my lab to easily produce iPSC-derived vascular cells that can be embedded in a collagen scaffold. This then allows investigations into how properties such as scaffold composition and other microenvironmental cues impact the embedded cells in ways that would facilitate regenerative healing of difficult wounds.

PSN: What have you learned thus far?

Dr. Hsia: We have preliminary data suggesting that the composition of scaffolds can consistently modulate embedded cells’ ability to secrete proteins that are associated with anti-inflammatory and pro-angiogenic effects, properties which are associated with facilitating regenerative healing. We’re in the process of confirming and following-up on these findings and hope to publish a manuscript in the coming months.

PSN: What do you see as this project’s practical applicability?

Dr. Hsia: Developing an artificial skin-graft based on a patient’s own cells has been a longtime goal of tissue engineering. This project would not only contribute to that goal, it also would help develop wound therapies customized to target a patient’s healing deficiencies as well as provide a way to model and study those problems.

PSN: Who are your mentors and key collaborators on this work?

Dr. Hsia: This project relies on a multidisciplinary approach, and I’m extremely fortunate to have in my lab Biraja Dash, PhD, a scientist who brings to the project his deep expertise in iPSC technology. I’m also very lucky to have as my collaborators Alan Dardik, MD, a vascular surgeon and colleague

22

Henry Hsia, MD, (right) talks with past PSF President and Yale University Plastic Surgery Section Chief John Persing, MD, after a recent conference; Dr. Hsia, his two daughters, Viola and Talia, and his wife, Yin Ho, relax on an Icelandic glacier in April. at Yale, and Francois Berthiaume, PhD, a biomedical engineer at Rutgers University. Both are international experts in their respective fields with their own established funding from agencies such as the National Institutes of Health and Department of Defense. In terms of my own development as a surgeon-scientist, there’s a very long list of people who have provided inspiration and advice over the years, but I’m particularly grateful for the research mentorship of Jean Schwarzbauer, PhD, at Princeton University and Stephen Lowry, MD, former chair of Surgery at Rutgers-Robert Wood Johnson Medical School, who passed away several years ago.

At Yale, I happily acknowledge the strong support of our Chief of Plastic Surgery, John Persing, MD, and our Department of Surgery Chair Nita Ahuja, MD, who’ve endeavored to create an academic and clinical environment at Yale conducive to surgeon-scientists like myself. Finally, I’d like to express my deep gratitude to Deepak Narayan, MD, a colleague and friend at Yale, who I’ve known

since I was a medical student and generously provided me with important advice at key points in my life and career, and whose untimely passing this past year was a tremendous loss to me as well as plastic surgery research and practice in general.

PSN: What did you want to be when you grew up?

Dr. Hsia: When I was in grade school, I wanted to be a map maker. I liked the idea of always knowing where I’ve been, where I am and where I can go, and I spent many hours drawing maps of various places, both real and imaginary. At some point, I stumbled on an atlas of human anatomy, and I suppose that was my entrée into medicine and eventually surgery. Even now, when I have free time, I’ll often spend it browsing various maps and atlases, especially old or unusual ones. And while it’s no longer all that useful in this age of phone-based navigation apps and GPS, if I had to claim a superpower, I would say it’s my ability to use any good map to quickly locate myself and find my way anywhere.

PSN: How do you spend your time away from the lab?

Dr. Hsia: When I’m not at work, I’m with my family: my wife, two teenage daughters and aging parents, as well as a very large extended family. Although work-life balance remains a perennial challenge, we do our best to keep up certain habits and traditions in the hopes of keeping us grounded as a family. One habit we’ve continued since my daughters were babies is reading to them. We’ve gone from “Goodnight Moon” to “Olivia” to “The Cricket in Times Square.” Believe it or not, even now with my daughters in high school, I still read to them regularly, though usually just once a week if we’re lucky and almost always on a weekend night. If I forget, my daughters will often remind me. At the moment, we’re going through the Sherlock Holmes stories.

PSN: What kind of music do you like to listen to in your lab?

Dr. Hsia: I like a wide range of music and will let my residents, nurses or patients (if they’re awake) choose. But if left on my own, I’ll choose music I grew up and came of age with: Billy Joel, Elton John, Queen, Sting, REM, the B-52s, etc.

For more information about the many research studies funded by The PSF or to support our current and future research initiatives, please go to ThePSF.org. PSN

The PSF offers a new funding opportunity

By Brian Gastman, MD

D

eveloping a career as a plastic surgeon-scientist requires departmental support, strong mentorship and funding through both direct support for research and indirect support for administration and laboratory infrastructure.

For several years, The PSF has supported the career development of early investigators through research fellowships and pilot research grants. The Foundation strives to fund as many worthy projects as possible, with the goals of supporting career development of these investigators and assisting them in securing additional funding from other sources, such as the NIH. Thanks to a new grant from The PSF, the Innovation in Wound Care Research & Academic Development Fellowship, an early-career plastic surgeon-scientist can

receive both direct and indirect funds that will provide the support necessary to flourish as an independent investigator. Through this new grant opportunity, The PSF looks to provide funding that will successfully establish a career model as a physician-scientist in their institution. Through his/her research, the recipient can develop data that will enable them to

apply for and succeed in obtaining federal funding for a sustainable future in academic medicine. Although this new grant supports wound based research, The PSF expects this program will provide a successful model for additional industry partnerships that can be expanded to include a variety of plastic surgery sciences.

This is a significant two-year award with funding up to $300,000 over the project period. As this is a new program, we have extended the grant deadline (for this funding opportunity only) to Jan. 13, 2020, to give applicants a bit more time to learn about this offering and prepare their applications. More information can be found on the Grants Program page under the “Research” tab at thepsf.org.

Further questions about this and other grant opportunities can be emailed to Mary Ruth Arway at rarway@plasticsurgery.org. PSN

December 2019

A

lthough it’s slightly disingenuous to say 2019 marks the 30th anniversary of Plastic Surgery News (that would be a disservice to the four-page newsletters of the same name that members received from the 1960s through the 1980s), 2019 does indeed mark the 30th anniversary of the current format of the publication that now arrives in your mailbox eight times each year.

“My immediate editorial predecessor at the helm of PSN, James Wells, MD, held that our current tabloid size made it difficult to fold up in a briefcase and even more difficult to read on an airplane,” former PSN Editor Phil Haeck, MD, wrote in a January 2004 column. “While it might have been more convenient to take along on the go, the smaller format seemed to lose the subtle eminence that is inherent in the larger tabloid size and risked PSN getting lost in the shuffle of mail that floods your desk daily.”

Of course, 15 years removed from that column, you can now read PSN on your cellphone in addition to this oversized print upon your desk. Although delivery means have evolved, PSN still holds true to its core responsibility of providing members with the most comprehensive plastic surgery-related news and information possible. Over the past three decades, that mission has been fortified with countless awards for the reporting and design work that fill the magazine’s pages and has become the specialty’s most-read news publication.

“Whether it’s bringing a topic to light, such as physician burnout, or something controversial, the discussion generated by the stories in PSN is profound,” says Bruce Mast, MD, the publication’s newest chief medical editor. “It remains the best source for organized plastic surgery to not only receive professional information, but to learn what’s going on and share that information in a quick and contemporaneous way.”

To celebrate 30 years in its current format, the past editors of PSN discuss over the next few pages some of their favorite stories and those that made a significant impact on the specialty.

December 2019

23

19 95

19 92

19 89 February 1989: The first edition of PSN in magazine format arrives in members’ mailboxes. Leon Block, MD, is the magazine’s medical editor.

June 1991: Ronald Iverson, MD, becomes PSN Medical Editor.

October 1995: Walter Erhardt, MD, becomes PSN Medical Editor.

March 1992: ‘Panel calls for implant restrictions’ Just ahead of an FDA moratorium on silicone gel-filled breast implants that would last 14 years, the agency’s General and Plastic Surgery Devices Panel wrapped two 12-hour days of hearings and unanimously recommended that the implants only be available through clinical-research protocols. Society members who served as consultants to the panel protested the process leading up to the decision and the larger ramifications that would follow, but with scrutiny on implants riding high since a 1990 Face to Face with Connie Chung special on CBS, anti-implant sentiments were high.

“We have heard presentations by everyone who has anything to say about this – regardless of their scientific background, regardless of whether they have any publication history, even regardless of the fact that some of those individuals have had medical licenses withdrawn for one reason or another. And there is nothing that gives us a solid link with rheumatic disease (or other serious health problems).”

– Mary McGrath, MD, 1995 PSF President Dr. Iverson: I remember spending a lot of time in the Board of Directors meetings and then I would report what was discussed in PSN in terms of how to approach the problem. It’s hard to convey the tremendous amount of anxiety among members at the time because there were just unbelievable numbers of lawsuits. It was overwhelming. It was a very personal thing and there really was no scientific evidence at the time to back all these concerns up. Lawyers were having a field day. Looking back, I don’t think the Board had the same level of transparency that they have now, and manufacturers were not really clear about the work they were doing. We didn’t even have the same relationship with the FDA that we do today. We’re much more proactive now, which I think benefits everyone.

October/November 1999: ‘Annual meeting sets stage for change’ After roughly five years of debate over a possible name change – and 68 years after the American Society of Plastic & Reconstructive Surgeons was founded, an 88 percent margin of membership voted at the 1999 Annual Meeting to officially change the organization’s name to the American Society of Plastic Surgeons. Although debate typically centered around tradition and identity, the majority of membership agreed that the name change would help clarify the wide breadth of work that plastic surgeons do.

“Consultants have consistently told us that our name is too wordy and confusing to the public.

It’s also ungrammatical, since plastic means reconstructive.”

– Paul Schnur, MD, 1999 ASPS President Dr. Erhardt: It’s difficult to understate how big of an issue that was at the time, but dropping those two words really engendered some interesting debate.

June 1995: ‘Plastic Surgery Online’ Plastic Surgery Online, the Society’s first foray into cyberspace, was a joint effort with ASAPS. The service put information on forums, conferences and communication with both Society leadership and colleagues – as well as a wealth of plastic surgery information – on the web.

“Effective utilization of computer technology for electronic communication and information management is essential for maintaining a competitive edge in the practice of medicine… Plastic Sugery Online will be designed to accommodate all levels of computer literacy – from novice to expert – as plastic surgeons begin to drive on the information superhighway.”

– William Riley Jr., MD, 1995 ASPRS President Dr. Iverson: I don’t think anybody then could anticipate how the whole ecosystem would change in terms of connectivity and social networking and just how people communicate on a daily basis now. I remember one of the main issues that sprang up almost immediately with members was their websites and how they were being advertised. It was very difficult to keep some kind of control on that from a Board level, because there were a lot of truth-in-advertising issues that popped up immediately. There’s still a lot of misinformation out there, but from a Society perspective, I think we were able to get a better hold on our messaging and even with issues today like gluteal fat-grafting, you see ASPS working with other societies to look into these matters and better warn people about the risks and misinformation that’s out there. Moving all these resources online was a significant event in our history, but it took us a little time to really get our arms around it.

March 2003: ‘Leadership issues OK for ‘Extreme Makeover’ TV’ With the debut of ‘Extreme Makeover’ on ABC in 2002, plastic surgery found its way into millions of TVs around the country and a slew of plastic surgery-related “reality” and dramatic programming followed. The show featured the work of then-ASPS member Garth Fisher, MD, and despite ongoing debate about participating in such programming and whether it adhered to the Society’s Code of Ethics, the ASPS Executive Committee made the decision to endorse the show as a way to review and comment on the qualifications of the participating surgeons.

“I actually tore out the Code of Ethics section from the bylaws and gave it to [‘Extreme Makeover’ producer] Howard Schultz. When I gave it to him, I said: ‘No matter what, I have to adhere to these policies.

That’s very important to me.’”

– Garth Fisher, MD

Dr. Wells: There’s no arguing that different points of view exist, but the Executive Committee decided there was merit to participation in the program. ASPS didn’t seek participation in it and we know there are many other non-board certified “plastic surgeons” who are willing to participate. It provided us an opportunity to reinforce the importance of board certification.

January 2000: James Wells, MD, becomes PSN Medical Editor.

24

December 2019

20 09

20 06

19 99

20 03

December 2006: ‘FDA approves return of silicone breast implants to U.S. market’

December 2001: Phil Haeck, MD, becomes PSN Medical Editor.

On Nov. 17, 2006, the FDA lifted its restrictions on silicone breast implants, after years of efforts by plastic surgeons who called for scientific review and clinical trials for the devices prior to and during the decade-and-a-half moratorium on sales. Although an application to go to market by Inamed in 2005 was rejected, the FDA General and Plastic Surgery Devices Panel the next day approved “with conditions” an application by Mentor, which ultimately led to a reversal on the Inamed decision. The success was credited to the collaborative efforts between ASPS and ASAPS to present a unified front and share information with the agency.

May 2006: ‘Extreme body modification culture pushes surgical, ethical boundaries’

“Silicone breast implants have been scrutinized more than any medical device, and we applaud the FDA for making its well thought-out decision and allowing American women to make informed choices about their healthcare.”

– Roxanne Guy, MD, 2006 ASPS President

In the midst of a “body modification” trend, patients were seeking professionals to help them do everything from put horns on their head to split their tongues and make their faces appear more like an animal (whiskers, modified noses and mouths included).

Some patients derided plastic surgeons who’d turned them down and claimed the decision was economical rather than ethical, but the trend sparked healthy debate within the Society on just how far members could (and would) take aesthetic surgery.

“The ASPS Code of Ethics is based largely on common sense… There’s nothing in our code that specifically says you can’t split someone’s tongue, but bottom line is that it’s mutilation, and beyond our Society’s ethical rules – our most primal oath as physicians is ‘Do no harm.’”

– Matthew Concannon, MD Dr. Hultman: That article was a great lesson in ethics and morality. Even though we’ve been given these gifts of being able to restore form and function, we shouldn’t use them to transform patients for nonmedical reasons. We could have seen our specialty change a little bit and I’m glad we stayed focused on taking care of patients as opposed to becoming technicians who can put horns on people or create Vulcan ears. It helped with our identity – we aren’t just people who do Botox, we help people in so many other ways. We didn’t commoditize ourselves. We didn’t sell out. We kept it ethical, moral and focused on the patient.

Dr. Haeck: The re-introduction of silicone gelfilled breast implants was one of the most important decisions ever made for plastic surgery – and we treated it as such. While we also covered the subsequent hearings four years later that were messy and politicized, you had to be there to know how hard my colleagues fought to keep them on the market. We worked hard to get the flavor of this issue right, as we wrote about the FDA and what the devices meant to the business we were all in.

January 2008: Anne Taylor, MD, MPH, becomes PSN Chief Medical Editor.

Thoughts at Thirty Former PSN editors reflect on the magazine’s evolution over the years.

Dr. Iverson: I believe that PSN has evolved in a very positive fashion – the key sections have been improved and I think we’ve seen improved coverage of a variety of issues that are so important to members.

Advocacy issues, for example, have always been key, but they are so much better covered today than they were back when I was editor. I mean, I remember I personally had a meeting with Hillary Clinton advocating for breast reconstruction to be a covered procedure, but now there’s just much more action taken as a whole Society in terms of advocacy and I think that’s promoted very nicely through PSN. Dr. Taylor: As times change and many news magazines become irrelevant, PSN defies the trend and remains relevant to members. Although I have had many committee positions within ASPS, my favorite was PSN editor, because of the great staff, and because it covered the breadth of the specialty and the major topics.

December 2019

January 2009: ‘Obama’s healthcare reform plan: What can plastic surgery expect?’

Although it was neither the Society’s nor PSN’s first foray into government policy and advocacy on behalf of the specialty, the changes to the healthcare landscape that came during the Obama administration and the need to better understand how the details and specifics – sometimes down to a granular level – not only steered PSN toward more legislative and policy-related content, but also steered its chief medical editor at the time to fortify her own educational pursuits on “how the sausage is made” in Washington, D.C. “Throughout the campaign, we heard very few specifics from either candidate on how they would enact significant healthcare reform. Bipartisan support will be required, so it’s still difficult to predict exactly in what ways healthcare reform under the next administration will affect plastic surgery.”

– Malcolm Roth, MD, 2012 ASPS President Dr. Taylor: I think our advocacy efforts really came to the fore in a “perfect storm” of ASPS members and leaders who understood the paramount nature of advocacy to plastic surgeons and all doctors. Folks like Jack Bruner, MD, William Huffaker, MD, Dr. Haeck and Dr. Wells could see into the future and understand what was needed. The crisis of physician-payment reform was what first awakened many docs to the importance of advocacy – as long as the government is paying, medicine and politics will be playing together – and we needed to level the playing field. Healthcare reform then became the bigger issue and we’ve been addressing it as ASPS and in PSN ever since. We delved into the specifics of the ACA, the effects on MACRA and so on. As the country began to discuss the ACA, I realized my lack of expertise in this field, which prompted me to pursue my MPH. With my job as the magazine’s chief medical editor and covering the politics of that time, I wanted to understand as much as I could about politics and policymaking. All of these experiences helped me understand the importance of relationships and keeping an eye on advocacy goals. It’s a slow process, but it’s worth it.

25

20 13

20 10

December 2011: ‘Don’t be a sitting target when your reputation comes under fire online’

January 2010: Michele Shermak, MD, becomes PSN Chief Medical Editor.

July 2011: PSN Connection launches The PSN Editorial Board had often discussed the need for members to know what was being written about plastic surgery in the lay press – in other words, what patients might be reading in the waiting room or before they come in for a visit. The PSN Connection email (now known as PSN Media Update) was launched as a means of providing some of the hottest stories of the week – good, bad or ugly.

Dr. Hultman: When we started doing PSN Connection, we had a lot of pushback. People didn’t understand the purpose of it. We aren’t necessarily endorsing the stories – we’re just sharing what members or patients might be talking about. We’d have members calling in and saying, “Why are you running this story on silicone buttock injections in a New York hotel when we don’t endorse that?” We had to communicate again and again that we’re just letting you know what the public is hearing about from, say, CBS, CNN or The New York Times. It took awhile, but I think people eventually began to better understand that.

March 2011: ‘Face transplant’s voyage from science fiction to next reconstructive frontier’ PSN has covered every step of the evolution of face transplantation since the first partial transplant was performed in France in 2005 to the first full face transplant performed on an African-American earlier this year (see feature on page 7). Dallas Wiens was the first patient in the United States to receive a full face transplant, and this article (written shortly before he received the call that he had a donor) detailed the background of his journey and the work done in preparation for his historic procedure. Not only do plastic surgeons continue to break new ground in facial transplantation, but the patients are showing remarkable progress as well. ASPS past President Jeffrey Janis, MD, who worked with Wiens immediately after the patient suffered the severe electrical burns that would ultimately necessitate a transplant, reports that Wiens has regained his sense of smell – and recovery of sensation in his face.

“The time for semantics is over – you can’t transplant more than has already been transplanted in terms of first, second, full, partial – we are done with that. It will now be much more important to realistically look at the function, quality of life and complications of patients who have received the procedure.”

– Maria Siemionow, MD Dr. Shermak: Face transplantation really became the most elite of all transplant procedures – a descendant of the original kidney transplant performed by plastic surgeon Joseph Murray, MD, in Boston. Our specialty has seen a huge evolution and advancement in the field of transplantation since Dr. Murray’s achievement in 1954, which is really not that long of a history in the grand scheme of things. Although facial transplantation is still nowhere near as common as liver or kidney transplants, there is a significant need for the procedure considering the large numbers of burn and trauma victims who have suffered severe mutilation. In the years since this article was published, I think we’ve seen more of an evolution in the procedure itself – including more facial tissue and structures – than in prevalence. In an age of increasing control over medical costs and hospital spending, it will be interesting to see whether this will slow the growth of innovative procedures like this.

January 2012: C. Scott Hultman, MD, MBA, becomes PSN Chief Medical Editor.

26

As an increasing number of social media networks took hold, plastic surgeons experienced a boon in terms of promoting their practices through the likes of Facebook, Twitter and Google+.

Unfortunately, the anonymity and reach of these vehicles reared its ugly head as nameless and faceless critics were able to fire online shots at doctors, airing their grievances with plastic surgeons’ results, manners and even reputations for anyone to see.

The discussion on how best to combat these “reviews” continues to this day.

“Opinions are opinions. There is defamation per se, assumed defamation without requiring proof of damages (convictions, sexual misconduct, etc.). For instance, a post that claims: ‘Dr. Reisman has been convicted for beating up his patients’ might be actionable. But you can’t sue against an opinion, no matter how baseless it may be.”

– Neal Reisman, MD, JD Dr. Shermak: This conversation has become exponentially amplified since 2011.

In the past, plastic surgeons became successful through word-of-mouth referrals resulting from their good work on appreciative patients, and the most eminent plastic surgeons had years of experience and a large portfolio of satisfied patients. That metric dramatically changed. An individual plastic surgeon’s web identity – whether good, bad, true or false – has become so much more important for practice recognition and financial success than great work and years of dedicated patient care. Reviews are now balanced between word-of-mouth among patients and the word-of-mouth spread online. Where once these reviews were passively appreciated, now they’re actively pursued. Still, doctors today feel like sitting ducks when it comes to online reviews. They feel victimized by sites such as Yelp and by patients empowered by the microphone provided by social networks. What was meant to meaningfully educate patients can serve to mislead them. I believe this is more of a problem for plastic surgeons than for surgeons in other specialties, as it relates to intra-specialty competition.

Thoughts at Thirty Former PSN editors reflect on the magazine’s evolution over the years.

Dr. Shermak: The magazine does a great job covering all aspects of plastic surgery, including scientific innovations, advocacy, medico-legal help, and coding and ethics guidance. Although many of these topics don’t “sizzle,” readers turn to PSN to understand what is going on outside each member’s own silo. Our mutual understanding connects us – and this is why PSN is one of the greatest services ASPS provides, allowing this connection to occur across the globe.

Dr. Hultman: To this day, I love getting PSN in hard copy and reading it cover to cover. There are only two magazines I do that with – PSN and Rolling Stone. PSN just feels like home. You know there’s going to be the CPT Corner, you know there’s going to be The Higher Ground column on ethics, a piece on new research that’s underway, Legislative Update and so on. It gives me a lot of pleasure when it arrives.

Dr. Bajaj: PSN has done a good job through the years of keeping its pulse on the specialty – topics that are introduced through these pages quite often become hot topics for the specialty at large.

Dr. Smotrich: PSN and the weekly PSN Media Update email really have become the preeminent sources of news for board-certified plastic surgeons, and their importance will only grow in parallel with the challenges and threats to the specialty.

December 2019

20 19

20 17

20 15

October/November 2017: ‘ASPS members discuss their own breast cancer diagnoses, journeys’

January 2015: Anu Bajaj, MD, becomes PSN Chief Medical Editor.

September 2015: The first edition of Plastic Surgery Resident, a quarterly publication from the PSN team designed specifically for residents, is published. Alex Spiess, MD, serves as the first chief medical editor for the publication, which features articles and columns predominantly written by residents and young plastic surgeons.

September 2016: ‘Growing presence of social media in the O.R. raises ethics, safety concerns’ Just as the advent of the internet forever changed the way patients and professionals alike gained information about plastic surgery, the rise of social media arguably made accessing that information (and misinformation) even more immediate. The truth-in-advertising discussions that occurred as plastic surgeons first logged online returned with a hearty dose of ethical questions and safety concerns centered around doctors’ use of mobile phones in the E.R. and posting pictures and videos of patients “on the table” through apps such as Snapchat and Instagram.

“I and many of my colleagues take issue with videos that show onthe-table results – and being celebratory and lauding how great they are – which can be very misleading to the public; results in the O.R. aren’t what they will be one month out. These portrayals don’t necessarily represent the long-term result, particularly in fat grafting.

Doesn’t this set-up a set of false expectations for the viewer/patient?”

– David Song, MD, MBA, 2016 ASPS President Dr. Bajaj: PSN has really covered social media from the very beginning and it’s been interesting to trace our view of it as a Society. It’s really evolved from something that was considered unprofessional to something that is necessary for our specialty. It initially had a negative connotation because we would think of Dr. Miami and his over-the-top posts on Snapchat, but now most of us view it as a necessary marketing tool – whether we like it or not. The main issues have been ethical in terms of what is appropriate to post and what are our boundaries. What’s interesting is that the social media platforms are also grappling with these same issues – the guidelines for some platforms keep changing with regard to nudity and what constitutes body shaming, etc. For me, social media has always been a challenge. I find a lot of what I see on different social media posts to feel inauthentic – people are trying to post simply to elicit a response. I find it frustrating when what I see on social media does not really reflect the reality of who that person is.

October 2016: PSN publishes its first Breast Reconstruction supplement. The patient-facing publication includes articles from breast cancer survivors, plastic surgeons and advocates highlighting the options available to women after a mastectomy. The magazine becomes a mainstay in several plastic surgeons’ offices and the response is such that it becomes an annual publication – and an award-winner in its own right.

Breast Reconstruction Awareness Day began as a concept in 2011 by Canadian plastic surgeon Mitchell Brown, MD, as a way to advocate a multi-specialist team approach to make breast cancer patients aware of their options following mastectomy. A year later, ASPS joined the effort and spread this awareness across the United States, with now more than 300 members across the country participating every year in these advocacy efforts (see feature on page 28 for highlights of this year’s events). In addition to providing an annual, patient-facing supplement on breast reconstruction, PSN in 2017 turned the lens toward its own members. Although plastic surgeons are commonly the ones helping patients through their breast cancer and reconstruction journeys, four members provided their own stories of breast cancer – and what it was like to be on the other side of the consultation.

“I was the worst patient on the planet. My first surgery was on a Wednesday morning. I was out of the office for 11 days before my drain came out because I didn’t exactly follow instructions.

Although you know what you are supposed to do and what you would expect of your patients, reality has a way of altering your judgment and behavior… It’s a pain in the ass to have a plastic surgeon as your patient.”

– Emily McLaughlin, MD Dr. Bajaj: I think showing that many of us have experienced struggles similar to those of our patients humanizes us. There is a fine line, though, because showing our human side too much can also cloud our medical authority. By sharing with our patients some of the personal struggles with breast cancer or other procedures, we can empathize and I think these women’s stories were enlightening to many of us in the specialty as well.

September 2018: ‘Not going under’ Although scope-of-practice battles have festered for years, the combined effects of patchwork state regulations and social media-spawned confusion have only multiplied the consequences of non-plastic surgeons doing plastic surgery procedures in recent years. ASPS continues to push for various pieces of legislation at the state and federal levels geared toward protecting patients and ensuring procedures are performed by board-certified plastic surgeons, but the battle remains far from decided.

“When I first looked into this, I was appalled that there was no differentiation between ‘medicine’ and ‘surgery’ in licensing requirements, but unfortunately this appears somewhat common… If you’re not a surgeon, you shouldn’t be able to practice surgery.”

– Joshua Zuckerman, MD Dr. Smotrich: Before U.S. News devolved into a mashup of hospital and college rankings, it ran a column called “News You Can Use,” and that phrase was always front-and-center during my time at PSN. Scope of practice is generally ranked first among members’ concerns, and it’s the main reason we descend upon statehouses to plead our case to legislators. We tried to focus on the intersection of industry, technology and complacent politicians in enabling non-surgeons to become surgeons, as well as the entire panoply of non-physicians playing doctor. That issue was very well-received by our readership, and we could run a scope-of-practice story every month and not wear out the topic, because the abuses continue unabated.

December 2017: Gary Smotrich, MD, becomes PSN Chief Medical Editor.

October 2019: Bruce Mast, MD, becomes PSN Chief Medical Editor.

December 2019

27

ASPS members share highlights of Breast Reconstruction

By Kendra Y. Mims

M

ore than 300 ASPS member practices and breast cancer patient advocates around the world, including in Israel and New Zealand, organized and hosted events on Oct. 16 to celebrate Breast Reconstruction Awareness Day. ASPS and The PSF in 2012 launched the Breast Reconstruction Awareness USA Campaign, with a mission to educate, engage and empower women to make an informed decision about reconstruction following a breast cancer diagnosis. The movement continues to grow as individuals, breast cancer support groups, nurse navigators, plastic surgeons, patients and organizations join the effort to honor and advocate for cancer patients.

The campaign reached new heights this year with a record number of Breast Reconstruction Awareness Day affiliates. Events included fundraisers, seminars, fashion shows, advertising campaigns, patient appreciation lunches, sports competitions and other activities to promote in their local community patient education and research relating to women’s health and breast reconstruction. More than 25 percent of the groups that hosted an event this year committed to contributing to The PSF 30 percent of the donations received during their fundraising efforts, with many affiliates contributing 100 percent of their donations.

Here are just some of the highlights from around the country from Breast Reconstruction Awareness Day 2019.

Team TBG – Santa Monica, Calif.

Tiffany Grunwald, MD, and her cancer support group, Team TBG, hosted The Champion Paddle to honor and support women who have battled breast cancer and treatment. Attendees also created “healing in progress” baskets for women recently facing a cancer diagnosis.

Plastic Surgery & Skin Specialists by BayCare Clinic – Green Bay, Wis. The fifth annual event featured breast cancer survivors, breast reconstruction surgeons, a local celebrity as the emcee and a raffle. Area businesses and individuals decorated bras for the Bay Decorating Bra contest in advance, which were then voted on and auctioned at the event. Through B.R.A.s of the Bay, an awareness and fundraising campaign coordinated by Plastic Surgery & Skin Specialists by BayCare Clinic, BayCare Clinic Foundation provides funds to Ribbon of Hope. In addition, 500 Breast Reconstruction Awareness T-shirts were purchased and worn by Aurora BayCare corporate and clinical staff to show their support and bring awareness to their community.

SIU School of Medicine – Springfield, Ill. SIU Medicine teamed up with Danenberger Family Vineyards to host the “Angels Among Us” fashion show in Springfield. The show featured 15 local breast cancer survivors walking the runway and wearing AnaOno Intimates – a lingerie, loungewear and swimwear line for women who have or are undergoing breast cancer treatment. Nicole Sommer, MD, and Michael Neumeister, MD, educated the audience about the Breast Reconstruction Awareness Day campaign and different breast reconstruction options for patients.

“SIU Institute of Plastic Surgery’s BRA Day event was an emotional and empowering fashion show filled with our breast reconstruction patients strutting their confidence and courage,” Dr. Sommer tells PSN. “By the finale, there wasn’t a dry eye in the house. Our patient models represented the multiple, different options chosen after mastectomy, including implant, autologous and no reconstruction – emphasizing that women need to be presented with all of their options to make the best choice for them.”

Albright Plastic Surgery – Woodlands, Texas The first annual event for the Woodlands Community of North Houston included a silent auction to help women receive the financial supported needed for breast reconstruction.

Nearly 130 people showed their support, raising more than $3,000 for The PSF Breast Reconstruction Awareness Fund.

Donate a Photo campaign One photo helps a breast cancer survivor afford reconstructive surgery

A

SPS members can still get involved and make a difference in the lives of breast cancer patients through the Johnson & Johnson Donate a Photo campaign. For every photo donated, Johnson & Johnson gives $1 to the Breast Reconstruction Awareness Campaign. That $1 assists a low-income woman undergoing breast reconstruction surgery with costs of travel to and from the hospital.

It takes 50 photos to help one woman undergoing breast reconstruction.

Choose, shoot and share. The campaign’s goal is to educate, engage and empower women to make the reconstruction decision that’s best for them following a breast cancer diagnosis.

Simply download the free Donate a Photo app to share one photo each day and help women battling breast cancer. The #DonateAPhoto campaign ends Dec. 31. Visit donateaphoto.com to learn more. PSN

28

PRMA Plastic Surgery – San Antonio PRMA Plastic Surgery hosted the San Antonio Breast Reconstruction Awareness Day event, which featured door prizes, live entertainment and an educational presentation on the latest breast reconstruction techniques – including the ability to help restore breast sensation following a mastectomy and a live demonstration on 3D nipple tattooing. Attendees also had the opportunity to visit the Show-and-Tell room to see real results from breast cancer patients and gain insight from their breast reconstruction journeys.

December 2019

n Awareness Day 2019 events from around the country Constance Chen, MD – New York Constance Chen, MD, her staff and her patients, the Bosom Buddies, hosted an event to educate the public about the latest breast reconstruction options, including fixing problems after unsatisfactory reconstruction and restoring sensation to breasts after mastectomies. A private Showand-Tell room connected women who are contemplating mastectomy or breast reconstruction to women who have already undergone surgery. The event also featured a “decorate a bra” contest and mini-makeovers. Guests mingled, learned and celebrated a woman’s right to choose her own breast reconstruction journey.

Ellsworth Plastic Surgery – Houston Nearly 300 people attended the Ellsworth Plastic Surgery’s annual celebration (more than doubling last year’s participation), which brings past, present and future breast cancer patients together in an intimate setting and provides them with an opportunity to network, discuss their journey and learn about their options, as well as advancements in breast reconstruction. Ellsworth Plastic Surgery, founded and operated by Warren Ellsworth IV, MD, also held a silent auction and raised more than $2,000 for The PSF.

December 2019

Y Plastic Surgery – Roswell, Ga. The “Botox for Boobies” event provided food, refreshments and discounted services in an effort to encourage patients to join the fight against breast cancer. All Botox profits for the day were donated to The PSF Breast Reconstruction Awareness Fund and The Pink Agenda.

Breast Body Beauty – Atlanta To celebrate breast cancer survivors, previvors and thrivers in the Atlanta area, Breast Body Beauty hosted an intimate gathering for Breast Reconstruction Awareness Day in partnership with Susan G. Komen. Attendees learned about breast cancer’s impact on the local community and options for breast cancer reconstruction with Aisha Baron, MD. They also received pampering treatments from beauty partners Sientra and BeautyCounter.

29

2020 ASPS SELF-ASSESSMENTS 2020 ASPS In-Service Exam Plan Now to Take the Ultimate Test of Your Plastic Surgery Knowledge

2020

2020

• Identify the most up-to-date information on the core curriculum of plastic surgery

Surgeons OnlineASSESS ExamANALYZE NEW Testing Window: Apr. 29 – Jun. 10, 2020

REVIEW

• Assess your base knowledge in IMPROVE OUTCOMES the five clinical component areas • Establish a benchmark for areas of focus needing further concentrated educational efforts

Immediate scoring available upon submission

REGISTER NOW!

Early bird registration ends Feb. 26.

• Attend appropriate educational activities based upon self-assessment evaluation • Earn up to 37.5 AMA PRA Category 1 Credits™

PlasticSurgery.org/ISE Life-Long Learning Exercise (L3E): 2020 Aesthetic In-Service, is our aesthetic-only self-assessment. This activity will provide additional focus for the cosmetic subspecialty and includes: • 200 aesthetic surgery questions • Eligible for up to 30 AMA PRA Category 1 Credits™ • Exam window is open June 17 through July 29, 2020

PlasticSurgery.org/L3E

E special pricing bundle deadline April 28 | ISE/L L E early registration deadline

The American Society of Plastic Surgeons® (ASPS) is accredited by the Accreditation Council for Continuing Education to provide continuing medical education for physicians.

In-Service Exam 37.5 AMA PRA Category 1 Credits™

The ASPS designates each enduring material for the number of AMA PRA Category 1 Credits™ listed below. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3

3

30

L3E: Aesthetic In-Service 30 AMA PRA Category 1 Credits™

December 2019

Working through language barriers and informed consent (These recipients don’t include providers who only receive Medicare Part B payments.

However, providers that receive funding from any government program such as Medicaid or Medicare Advantage are subject to the requirements.)

To determine the extent of the obligation to provide language assistance, it’s recommended that plastic surgeons analyze the following four factors:

By Richard Cahill, JD, & Susan Shepard, MSN, RN

C

lear and unambiguous communication constitutes the key component of the physician-patient relationship.

Misunderstandings often create frustration and distrust, especially when an adverse event occurs, and can result in professional liability litigation or reports to state medical boards and third-party payers by disgruntled patients and family members. Proactively implementing office procedures for both physicians and staff to promote optimum communication reduces the risk of surprise and the potential for expensive, protracted and unpleasant disputes.

• Number: The greater the number or proportion of LEP persons served or encountered by a clinic, the more likely language services will be needed.

• Frequency: Even if unpredictable or infrequent, there must be a plan for providing language assistance for LEP persons.

Example Marie D., a naturalized U.S. citizen from Southeast Asia, presented to E. Landingham, MD, for a consultation regarding extensive acne scarring on her face and neck. The patient reported that she felt self-conscious about her appearance and sought advice on possible treatment options. According to the chart, Marie spoke limited English. Her reading proficiency was not noted.

Following an examination of the affected area, Dr. Landingham offered CO2 laser resurfacing. The benefits and potential disadvantages of the procedure were discussed – including the possibility that her complexion type posed an increased risk of scarring and changes in pigmentation. Marie subsequently agreed to undergo laser resurfacing and signed a written consent that specifically identified scarring and changes in skin color as possible postoperative outcomes.

The patient returned the following week.

The treatment record reflects that Dr. Landingham performed the procedure under local anesthesia and conscious sedation. The surgery was uneventful, and no intraoperative complications occurred.

Marie presented on numerous occasions over the next several months. Hyperpigmentation was noted, and Solaquin Forte 4 percent and Pramosone lotion were prescribed. At one point, the patient complained of experiencing a burning sensation on her face. Approximately one year after the procedure, Marie returned for further evaluation. The scarring was barely visible; the discoloration on her neck was noticeably improved. However, the patient expressed dissatisfaction with the result.

Marie thereafter retained counsel and initiated suit alleging causes of action for medical malpractice and negligent infliction of emotional distress. In substance, the patient

claimed that because of her limited proficiency with English and the failure of the physician to utilize any translation services, including for any preoperative documentation, there was no informed consent.

Providing services With our increasingly diverse national population – including many who speak a language other than English at home – language barriers raise the risk for an adverse event. The Department of Health and Human Services (HHS) Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient (LEP) Persons outlines the requirements for recipients of federal financial assistance from HHS to take reasonable steps to ensure LEP persons have access to language services.

• Nature: Determine whether a delay in accessing a physician’s services could have serious or life-threatening implications. The more important the nature of the services offered by the physician, or the greater the consequences of not accessing treatment, the more likely language services will be needed.

• Resources: Consider the resources available and the cost to provide them. Solo practitioners aren’t expected to provide the same level of service as a large, multispecialty group. Therefore, solo practitioners should investigate technological services or sharing resources with other providers.

It isn’t recommended to use a family member as an interpreter. Lay personnel are rarely familiar with medical terminology. Additionally, the patient may not want a family member Continued on page 32

Safe products entering and remaining on the U.S. market?

"It matters to me.”

Amy K. Alderman, MD, MPH, FACS North Atlanta Plastic Surgery

Sharing your data is essential to ensuring patient safety

Register today at ThePSF.org/NBIR December 2019

31

Language barriers

might affect their health and well-being.

Continued from page 31

to access their confidential health information.

An adult member of the prospective patient’s family should serve as interpreter if a family member must be used – unless no adult is available, and care must be provided immediately to prevent harm. It’s preferable to have a trained clinical-staff member provide interpretation; alternately, the practice can use certified interpreter services. Plastic surgeons can consult their local hospital or the patient’s health plan for a list of qualified interpreters.

Other resources include a local nationality society, the Registry of Interpreters for the Deaf or the local center for the deaf. Also, keep consent forms – especially for invasive procedures – translated into the applicable non-English languages by a certified translator.

Certain areas of a plastic surgery practice may be at higher risk of receiving claims from LEP patients. The Agency for Healthcare Research and Quality (AHRQ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following: • Medication use: Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies and side effects.

• Informed consent: Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving truly informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that

• Follow-up instructions: Understanding discharge instructions is especially challenging for LEP patients. Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge – not just during the acute phase of treatment.

Relatively simple communication tools can provide some helpful solutions. To protect patients from harm resulting from their LEP, plastic surgeons are encouraged to develop and implement a plan for language access in their practice.

For more information, see the Centers for Medicare and Medicaid Services’ Guide to Developing a Language Access Plan. For more information on the types of medical malpractice claims faced by plastic surgeons, go to The Doctors Company’s Plastic Surgery Closed Claims Study. PSN Rich Cahill is vice president and associate general counsel for The Doctors Company; Susan Shepard is senior director of patient safety education for The Doctors Company.

Editor’s note: The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

International spotlight

breast reduction), rhinoplasty and cosmetic treatments such as fillers.

of cosmetic procedures. It’s difficult for the public to understand the difference between a plastic surgeon and someone providing “cosmetic medicine.”

PSN: What’s the philosophy behind reconstructive procedures (in terms of tumor removal vs. double mastectomy), and what are the reasons for this preferred approach?

Dr. Westvik: Because of socialized medicine, all procedures will follow a cost-benefit principle. For instance, without clear survival benefits from contralateral prophylactic mastectomy, only BRCA carriers will be offered bilateral mastectomies and reconstruction. There’s a huge push for BCT from the breast surgeons, and autologous reconstruction has so far been reserved for secondary breast reconstruction after completed XRT.

Continued from page 11

PSN: Can private-practice plastic surgeons help with hospital cases?

Dr. Westvik: There are only two ways to practice in Norway – hospital employed and private practice. Hospital-employed plastic surgeons will treat all covered procedures, i.e., only reconstructive patients.

Private-practice will only deliver private-pay cosmetic procedures. No private surgeons gain hospital privileges.

Some private clinics have received contracts with the government to treat a set group of patients when the hospital is unable to treat them within the guaranteed timeframe from referral. These clinics still treat them in their own private clinics.

PSN: What are the most popular procedures in Norway?

Dr. Westvik: In terms of reconstructive (hospital-based procedures), breast reconstruction is by far the largest group. Body contouring after massive weight loss is also treated in certain hospitals with specialized teams. After that, melanoma care, for which some centers cooperate with other specialties for sentinel node biopsies and lymph node dissections; cancer and trauma reconstruction; and congential malformations.

In terms of cosmetic work done in private practice, the most popular procedures are breast augmentation, liposuction, facial procedures, body contouring (including

PSN: How does partnering with ASPS benefit the Norwegian Association of Plastic Surgeons?

Dr. Westvik: There are roughly 200 members of the Norwegian Association of Plastic Surgeons, with a 50-50 mix in terms of hospital-based and private-practice plastic surgeons. The number of female plastic surgeons is rapidly increasing, with a 50-50 distribution at the resident level. Partnering with ASPS opens the door to the most trusted resource in plastic surgery, which is of vital importance for a small country like Norway to expand on the level of treatment offered. Online resources will be highly valued – especially the ASPS EdNet and being able to access PRS online. Access to discounted meetings will lower the threshold for Norwegian surgeons to attend U.S. meetings. PSN

Encourage Your Staff to Join ASPSP today!

Take your practice to the next level! Encourage your office staff to join the American Society of Plastic Surgery Professionals (ASPSP)! Membership will provide them with educational and networking opportunities that can directly benefit your practice.

Networking

Professional Growth Not only do ASPSP members receive discounts on workshops and meetings but they will also receive access to the members-only area of our website in development. This includes our professional development tool kit and Plastic Surgery News online publications.

With their colleagues, your staff will be able to explore such topics as credentialing, onboarding new employees and tax considerations. ASPSP members also receive access to our member directory – making networking with those in the industry that much easier.

Meetings and Discounts

Education

ASPSP collaborates with the American Society of Plastic Surgeons (ASPS) to co-host an annual Spring Meeting and is an official partner of Plastic Surgery The Meeting. ASPSP presents dedicated tracks at each event that provide attendees with new ways to take their practices to the next level.

Programs feature speakers who focus on topics relevant to today’s demanding business practices. Plus, members receive access to the ASPS Education Network.

As ASPSP members, not only will your staff receive discounted pricing on their annual PSTM registration, but you won’t need to provide them with any additional documentation when they register!

ASPSP is an affiliated organization of ASPS

www.plasticsurgeryprofessionals.org 32

December 2019

CALENDAR For additional ASPS/PSF meeting information, visit the Meetings & Education page at www.plasticsurgery.org/meetings; e-mail registration@plasticsurgery.org; or call (800) 766-4955 / (847) 228-9900.

Dates, locations and program information are subject to change without notice.

DECEMB ER 12-15

5

Palm Beach, Fla. Contact: (435) 602-1326 Web: fsps.org Endorsed by ASPS

Online Contact: (800) 766-4955 Web: plasticsurgery.org/ise Directly provided by ASPS

Florida Plastic Surgery Forum

5th Annual Residents Symposium Dallas Contact: (800)364-2147 Web: surgery.org

J AN UARY 2020

Dallas Cosmetic Surgery and Medicine Meeting/Dallas Rhinoplasty Meeting

Dallas Contact: (214) 821-9114 Web: dallasrhinoplastyandcosmeticmeeting.com

8-11

12-14

2020 AAHS Annual Meeting

ASPS/ASPSP Spring Meeting 2020

Fort Lauderdale, Fla. Contact: (978) 927-8330 Web: meeting.handsurgery.org Jointly provided by ASPS

New Orleans Contact: (800) 766-4955 Web: plasticsurgery.org/springmeeting Directly provided by ASPS & ASPSP

10-12

13-14

Fort Lauderdale, Fla. Contact: (978) 927-8330 Web: periperalnerve.com Jointly provided by ASPS

New Orleans Contact: (800) 766-4955 Web: plasticsurgery.org/coding Directly provided by ASPS

2020 ASPN Annual Meeting

Plastic Surgery Coding Workshop

10-14

ASRM Annual Meeting

Electronic subscriptions: Plastic and Reconstructive Surgery Journal (PRS) Plastic Surgery News (PSN) ®

ASPS Education Network (EdNet)

Fort Lauderdale, Fla. Contact: (312) 456-9579 Web: microsurg.org Jointly provided by ASPS

23

First Annual SESPRS/ISAPS Periorbital and Facial Symposium Atlanta Contact: (435) 901-2544 Web: sesprs.org

24-25

36th Annual Atlanta Breast Surgery Symposium

Members-only Access: Products and services to help grow your practice Inclusion on Find-A-Surgeon feature on www.PlasticSurgery.org Member discounts on educational meetings and symposia Advocacy that focuses on public and private sector issues, so you can focus on your practice

Atlanta Contact: (435) 901-2544 Web: sesprs.org

27-30

33rd British Virgin Islands Plastic Surgery Workshop Tortola, British Virgin Islands Contact: (603) 880-4385 Web: bviworkshop.com

FEB R UAR Y 2020

AP RI L 2020 23-28

The Aesthetic Meeting Las Vegas Contact: (800) 364-2147 Web: surgery.org

23

The Rhinoplasty Society Annual Meeting 2020

Las Vegas Contact: (904) 786-1377 Web: rhinoplastysociety.org/meetings2020

29-June 10

ASPS In-Service Exam For Surgeons Online Contact: (800) 766-4955 Web: plasticsurgery.org/ise Directly provided by ASPS

29-May 1

15th Congress of the European Federation of Societies for Microsurgery Cluj-Napoca, Romania Contact: (004) 722-575-963 Web: efsm.eu

6-9

WPS Enrichment Retreat Nashville Contact: (800) 766-4955 Web: plasticsurgery.org Directly provided by ASPS

27-March 1

Mountain West Society of Plastic Surgeons Annual Meeting

CALENDAR

ASPS Membership Benefit Highlights:

ASPS In-Service Exam For Residents

11-14

13-15

PlasticSurgery.org/Dues

MARCH 2020

MAY 2020 22-25

70th California Society of Plastic Surgeons Annual Meeting San Diego Contact: (510) 243-1662 Web: californiaplasticsurgeons.org

Snowmass, Colo.

Contact: (847) 228-9900 Web: mountainwestsps.com Directly provided by ASPS

December 2019

33

Legislative Update Continued from page 14

the Legislature to enact future laws that will ensure that physicians are reimbursed fairly without relying on proprietary insurer data and remove the 50th percentile of rates paid as a criterion that must be considered during arbitration.

Following enactment, the Texas Department of Insurance (TDI) began the rulemaking process with a call for stakeholder input and a subsequent hearing in July. ASPS and TSPS submitted comments responding to TDI’s request for more information to help shape the rules, and we expect to be involved during each step of the rulemaking process as it continues into 2020.

New York Adverse event reporting The New York State Department of Health (DOH) released a proposal that would require physicians who perform procedures in office-based surgery (OBS) settings to adhere to additional reporting requirements. The proposal aimed to minimize adverse events, yet the measure goes beyond that in requiring physicians to report on all procedures performed in OBS settings. ASPS and the New York State Society of Plastic Surgeons (NYSSPS) believe that more work should be done with appropriate data-sharing between the recognized accrediting agencies and state departments of health, especially as many plastic surgery practices are not readily equipped to handle reporting requirements through advanced electronic health record systems.

NYSSPS conducted numerous discussions with the DOH in advance of the proposal’s release in hopes of enlightening the department on the proposal’s impact. In a collaborative effort, NYSSPS aided ASPS and the New York Regional Society of Plastic Surgeons (NYRSPS) in crafting additional responses to the proposal. The societies also sent a grassroots alert to members in the state asking them to sign a letter requesting changes to the proposal in order to protect OBS practices.

Ultimately, a strong showing of 72 New York-based plastic surgeons signed on to the grassroots letter sent to the DOH, along with separate letters from ASPS, NYSSPS and NYRSPS. Following the public comment period, NYSDOH announced that OBS practices will not be mandated to report under the OBS monitoring program for 2019.

Furthermore, the NYSDOH indicated that less-burdensome, alternative data sources for procedural monitoring will be sought.

Washington Gender confirmation coverage ASPS and the Washington Society of Plastic Surgeons in 2018 submitted two rounds of comments in opposition to the Washington Health Care Authority’s proposed rules on gender dysphoria treatment services. The proposed rule failed to recognize basic principles of transgender health, and if adopted would severely harm transgender individuals in the state.

To protect these patients, the societies urged the Authority to continue to recognize breast reconstruction as a medically necessary procedure, as the proposal only included augmentation mammoplasty. The comments also requested that the proposal include an example of gender confirmation surgery (GCS) in the early and periodic screening, diagnostic and treatment (EPSDT) program.

The EPSDT program is not all-inclusive, and the Society believes an example of GCS would strengthen the program in order to help individuals who are under the age of 21.

Additionally, the societies urged the Authority to include several noncovered services to the list of covered services with prior au-

34

thorization, including brow lift, cheek/malar implants, chin/nose implants, forehead lift, jaw shortening and trachea shaving. These procedures help individuals diagnosed with gender dysphoria achieve the physical appearance and functional abilities of their preferred gender identity. Reclassifying these procedures to noncovered services would create significant barriers to access of care.

We are pleased to report that the rules were formally withdrawn on April 16. This was a huge victory for the societies and the patients they serve because, if adopted, these rules would have created new barriers to transition care in Washington.

Maryland Optometric scope of practice ASPS and the Maryland Society of Plastic Surgeons (MSPS) voiced opposition to House Bill 471/Senate Bill 447 in comments submitted to the Maryland House of Delegates Health and Government Operations Committee and the Maryland Senate Education, Health and Environmental Affairs Committee. The bills would repeal the current law and allow optometrists to perform laser surgery on the eye, scalpel surgery on the eyelid (removal of lesions, cysts and tumors), and administer injections into the eye and eyelid. Following hearings in early March, S.B. 447 was amended and passed committee, and then went on to pass the Senate on March 18. ASPS and MSPS resubmitted comments throughout this process expressing opposition to the measure.

Throughout the legislative session, ASPS and MSPS worked closely with the state’s medical society, MedChi, and with the American Academy of Ophthalmology to coordinate efforts that demonstrated the lack of clinical and educational expertise of optometrists.

In March, a compromise was reached with the Maryland Optometric Association that improved the bill significantly and prohibited optometrists from performing surgery.

That compromise, which was a big win for medicine, advanced through the remainder of the legislative process and was signed into law April 30 by Gov. Larry Hogan.

The continued efforts of ASPS to help state and regional societies are only strengthened by the commitment and support of these societies and plastic surgery advocates who are on the ground reinforcing the Society’s position. These collaborative efforts are done on behalf of all plastic surgeons in the state and help protect the future of the specialty. ASPS is proud to have such committed partners in the local, state and regional plastic surgery societies who ensure the specialty’s voice is heard within all 50 state legislatures. PSN

CPT Corner

drains (one midline and one laterally for each donor site). Dressings were placed.

ed coding would be CPT 49572-81 (Repair epigastric hernia (e.g., preperitoneal fat); incarcerated or strangulated) if allowed by the payer. The -81 modifier would be used, as the plastic surgeon is providing minimal assistance during the operation since they are present for only the small portion dictated and not the entire procedure. It would then not be appropriate to also bill a consult E&M code if the only patient contact was undertaken in the O.R. and if the intraoperative services are being already billed. Alternatively, the appropriate consult evaluation and management code based on time could be used if the time involved was included in the operative note and may be more appropriate. Dr. General Surgeon should also not bill for 15600, as the division of the omentum would be consider part of the hernia repair code in this situation.

What was billed: CPT 15734 (Muscle, myocutaneous or fasciocutaneous flap; trunk) x 2, CPT 13101 (Repair, complex, trunk, 2.6 to 7.5cm) and CPT 13102 (Repair, complex, trunk, each additional 5cm or less).

Continued from page 10

Case 4: Closure of perineal defect Description of procedure: I was called to the O.R. following the planned abdominal-perineal resection (APR) for advanced anorectal cancer. There was a large defect where the anus and rectum used to be, as well as the pelvic floor and perineum. The skin could not be closed primarily due to the resection. After irrigation of the wound, I was able to perform a multiple layer closure in complex fashion. Using a combination of 2-0 vicryl and No. 1 PDS in standard fashion and in multiple layers, I closed the pelvic floor x 10 cm. Attention was then turned to the superficial defect. V-Y advancement flaps were drawn with a marking pen over the gluteus maximus and minimus. The right side was started first with an incision carried through the skin and subcutaneous tissue. The fascia overlying the muscle was incised and the skin/subcutaneous tissues could be advanced medially. Attention was then given to the left side, where incision duplicated through skin and soft tissue followed by bovie cautery through fascia and muscle to advance medially. On both sides, I included a small amount of the gluteus maximus and minimus muscles which were closed along the midline with 2-0 vicryl under minimum tension for perineum reconstruction. The midline closure was accomplished in multiple layers. The midline skin defect and donor site incisions were all closed with 3-0 vicryl deep dermal sutures and 3-0 nylons after the placement of three

Documentation issues: Although the operative note mentions V-Y flaps with potentially some muscle included, it doesn’t describe the elevation of muscle or development of a musculocutaneous unit, but only minor advancement of muscle. It would be inappropriate to use CPT 15734 for this procedure which, based on documentation, is better described as an adjacent tissue transfer. The second issue is the closure of the perineum. The deep closure of the pelvis is an inherent part of an APR and isn’t separately billable by the plastic surgeon when repaired primarily. In addition, if the V-Y advancement flaps were used to close the deep pelvis, then that closure would be considered part of the adjacent tissue transfer. It’s also important to note that terms such as “standard fashion” do not actually provide detail on what was performed by the surgeon.

Correct coding based on operative report: CPT Code 14000 (Adjacent tissue transfer or rearrangement, trunk; defect 10 sq. cm. or less), although with correct documentation of defect and flap dimensions, it would be appropriate to bill other codes from the adjacent tissue transfer family instead of the base CPT code 14000 as suggested here.

Summary These examples should emphasize the importance of documenting the procedure to ensure it can be matched correctly to a CPT code. However, it’s not just coders who need clear and concise operative reports. These are legal documents and are important information for other clinicians treating the patient. Always read your notes before signing to correct errors and omissions such as those noted in these examples.

Our committee welcomes your coding questions. If you would like committee input on coding for a specific case, please submit the full operative report and your planned coding via the coding question submission form, which can be found at plasticsurgery.org/documents/Health-Policy/ Coding-Payment/Coding-Question-Submission-Form.pdf. PSN

Statement of ownership, management and circulation 1. Publication Title: PLASTIC SURGERY NEWS 2. Publication No.: 1043-4119 3. Filing Date: 9-13-19

11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 percent or more of Total Amount of Bonds, Mortgages or other Securities: None.

4. Issue Frequency: 8 times annually

12. The Purpose, Function, and Nonprofit Status for Federal Income Tax Purposes: Has not changed during preceding 12 months.

5. No. of issues published annually: 8

13. Publication Title: PLASTIC SURGERY NEWS

6. Annual Subscription Price: $90.

14. Issue Date for Circulation Data: Sept. 2019

7. Complete Mailing Address of Known Office of Publication: 444 E Algonquin Rd., Arlington Heights, IL 60005

15. Extent and Nature of Circulation: Membership benefit. a. Total No. Copies (not press run) 7,917 b. (1) Mailed outside-County Paid Subscriptions stated on form 3541: 7,156 (2) Mailed in-County Paid Subscriptions Stated on form 3541: 0 (3) Paid Distribution Outside the Mails including Sales through Dealers and Carriers, Street Vendors, County Sales, and other Paid Distribution Outside USPS: 293 (4) Paid Distribution by Other Classes of Mail Through the USPS (1st class): 27 c. Total Paid and/or Requested Circulation: 7,476. d. (1) Free or Nominal Rate Distribution, Outside-County as Stated on Form 3541: 0 (2) Free or Nominal Rate In County as Stated on Form 3541: 0 (3) Other Classes Mailed Through the USPS: 0

8. Complete Mailing Address of Headquarters of General Business office of Publisher: Same 9. Full Names and Complete Addresses of Publisher, Editor and Managing Editor: Publisher: American Society of Plastic Surgeons (ASPS)/Mike Stokes 444 E Algonquin Rd., Arlington Heights, IL 60005; Editor: Bruce Mast, MD (ASPS), 444 E Algonquin Rd., Arlington Heights, IL 60005; Managing Editor: Paul Snyder (ASPS), 444 E. Algonquin Rd., Arlington Heights, IL 60005 10. Owner: ASPS, 444 E Algonquin Rd., Arlington Heights, IL 60005

(4) Copies distributed outside the mail: 441 e. Total Free or Nominal Rate Distribution: 441 f. Total Distribution (sum of 15c and 15e) 7,917 g. Copies Not Distributed: 0 h. Total: 7,917 i. Percent Paid and/or Requested Circulation: 94% 16. Electronic Copy Circulation: a. Paid electronic copies: 0; b. Total Paid Print Copies: 7,476; c. Total Print Distribution: 7,917; d. Percent Paid (both print & electronic copies): 94% This Statement of Ownership will be printed in the Dec. 2019 Issue of this Publication Title of Editor, Publisher, Business Manager or Owner: Paul Snyder, Managing Editor; Date: 9/13/2019 I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions including fines and imprisonment) and/or civil sanctions (including civil penalties).

December 2019

CLASSIFIEDS

OPPORTUNITIES

Northern New Jersey & NYC Expanding 2 MD group practice inviting ASPS members, fellows and residents to join our team in Northern N.J. with satellite office in Manhattan. Offering a wide diversity of aesthetic, reconstructive, hand and microvascular. Associates complementing our practice will receive financial support leading to early partnership. Ideal location in Paramus, N.J. with easy access to an abundance of higher educational and cultural opportunities.

Confidential inquiries email drboss@drbossps.com or call me at (201) 967-1100. For additional insight visit drbossmd.com or plasticsurgerypartnerships.com.

Plastic Surgery Opportunity Midwest Location Well-established, well-rounded, private practice with Midwest location (Iowa/ Illinois). Competitive salary with both cosmetic and reconstructive variety with excellent quality of life. Accredited in-office OR suite. On-campus multi-specialty surgicenter with buy-in potential; associateship with early partnership potential.

Please fax your resume to (563) 359-4781 or e-mail to psc@plasticsurgeryqc.com.

Beautiful Scottsdale, AZ Seeking BC/BE plastic surgeon to join growing plastic surgery practice in beautiful Scottsdale, AZ. 75/25 reconstruction/cosmetic surgery, competitive compensation, and the opportunity to join a fast-growing, young practice with immediate kickstart to your practice. Hospital call and trauma is part of the position.

Contact prs.az85260@gmail.com for inquiries.

Boston and Brookline Cosmetic Practice Well Established cosmetic surgical practice with two office locations in Boston and Brookline is seeking a BE/BC Plastic Surgeon. Premises include a large Med Spa and a fully accredited AAAASF surgical suite. The two plastic surgeon practice offers its new associate an immediate patient base and a large volume of non-surgical procedures.

Please email CV to Betty Maxwell, Office Manager at bmaxwell@leonardmillermd.com.

Louisville, Kentucky Established diversified cosmetic, reconstructive and hand surgery group in Louisville, Kentucky seeking BC/BE plastic surgeon. Compensation package includes base salary, productivity bonus, medical malpractice and health insurance. Excellent quality of life. Contact: Fox8706@aol.com.

Long Island, Suffolk, Queens and NYC We are a multi surgeon practice seeking an additional plastic surgeon. Our practice covers Long Island and New York City and includes a broad base of cosmetic and reconstructive surgery.

Position available immediately, and is open to recent graduates or established practitioners alike.

We offer competitive compensation and benefits.

Compensation: Highly competitive compensation package includes base salary, potential productivity bonus, medical malpractice, health insurance and possible future partnership opportunity.

Applicant: Successful candidate will be board certified/board eligible in plastic surgery. We seek an enthusiastic surgeon interested in being part of a team and helping build the premier multispecialty plastic surgery practice in the country.

About the Practice: North Texas Plastic Surgery has three office and medspa located in Southlake, Plano and Dallas. The practice has a fully accredited AAAASF two operating room surgery center and a large established surgical and non-surgical patient base. The founding surgeon, Dr. Sacha Obaid is a member of the RealSelf 100, has been named a Top Doc by Fort Worth magazine numerous times and has been called a “Rising Star” by Texas Monthly. For more information about our practice, please visit our website at: northtexasplasticsurgery.com.

Please contact: elainet@psofny.com

Contact: All inquiries are confidential and can be submitted online via email to Linsey at linsey@northtexasps.com or by phone at 817-416-8080.

Exceptional Long Island, NY Practice Opportunity Busy Long Island plastic surgery group of five plastic surgeons seeks to add another due to growth. Surgeries include both cosmetic and reconstructive. Excellent salary plus partnership track and excellent school system. Interested candidates should contact Roy Olesky at (781) 772-1020 and send CV to roy@olesky.com

Park Ave, NYC Practice Transition Established and prestigious 100% aesthetic surgery practice. Can accommodate multiple doctors.

Beautiful office, accredited on site OR, equipment and experienced staff. Buy in with apprentice transition. Contact: kblarson1@yahoo.com.

Include resume. All confidential.

Faculty with Hand Surgery Fellowship Training Division of Plastic & Reconstructive Surgery The University of Iowa Department of Surgery, Division of Plastic & Reconstructive Surgery, invites applications for a faculty position within the Division of Plastic Surgery. We are specifically seeking an individual with specialized interest and training in Hand Surgery. This position is open rank and may be either tenure or clinical (non-tenure) track dependent upon the qualifications and goals of the individual.

The candidate must be a graduate of an accredited Plastic Surgery training program as well as an accredited Hand Fellowship. Candidates must be board certified/eligible in Plastic Surgery as well as eligible for a CAQ in Hand Surgery. Applicants with established research are preferred. Experience in research at a level which enables procurement of outside funding is required for tenure track appointments.

Applicants will need to demonstrate effective interpersonal and communication skills and be committed to ongoing performance improvement. Dedication to enhancing a diverse workforce and academic environment is vital.

Applicant credentials are subject to verification; background checks will be conducted on final candidates for all positions in the University of Iowa Hospitals and Clinics. To apply, visit The University of Iowa website at jobs.uiowa.edu, requisition #73838.

For additional information contact: W. Thomas Lawrence, MD Director, Plastic and Reconstructive Surgery Department of Surgery University of Iowa Health Care thomas-lawrence@uiowa.edu (319) 384-9961 The University of Iowa is an equal opportunity/affirmative action employer. All qualified applicants are encouraged to apply and will receive consideration for employment free from discrimination on the basis of race, creed, color, national origin, age, sex, pregnancy, sexual orientation, gender identity, genetic information, religion, associational preference, status as a qualified individual with a disability, or status as a protected veteran.

December 2019

100% Aesthetic Practice in Dallas Well-established plastic surgery practice focused on body contouring seeks plastic surgeon associate to join already busy, growing team.

Orlando, Fla. Very rare opportunity for the right doctor.

Extremely busy plastic surgery practice seeks experienced BE/BC plastic surgeon. 100% cosmetic surgery. Guaranteed minimum $300,000.

Brand new state of the art office/accredited surgery center. www.bassinplasticsurgery.com Send resume to Valerie@drbassin.com or call us at 321-255-0025.

San Diego Solo Practice For Sale Retiring, doubly boarded solo plastic surgeon looking to transition-sell very active practice specializing in Lipo, Fat Transfer, LipoAbdominoplasty, Gynecomastia, and Renuvion (J-Plasma) facial rejuvenation and internal skin tightening procedures. Located in North County San Diego in Carlsbad, Cliniquesculpture (.com) has grown each year for 12 years, grossing over seven figures collected.

The 2,200-sq. ft. leased facility has its own certifiable OR with pre-op, recovery, HBOT chamber room. Staff of three full-time MAs all trained in all front, back and OR duties, keeping overhead low. All procedures under Awake Anesthesia ensures safety and convenience.

Email cliniquesculpture@gmail.com North Suburban Chicago Established diversified solo practice available for transition. Competent staff with turn key fully accredited AAAASF surgical suite. No buy in and willing to help with transition. A potential for share in adjacent ASC available. Excellent opportunity to assume an established practice.

Email at maryjmanager@gmail.com

Faculty, Division of Plastic & Reconstructive Surgery The University of Iowa Department of Surgery, Division of Plastic & Reconstructive Surgery, invites applications for a faculty position within the Division of Plastic Surgery. We are specifically interested in an individual with training and an interest in microsurgery. This position is open rank and may be either tenure or clinical (non-tenure) track dependent upon the qualifications and goals of the individual.

The candidate must be a graduate of an approved medical college with postgraduate training in an accredited Plastic Surgery training program. Candidates must be board certified/eligible in Plastic Surgery. Subspecialty training in microsurgery is highly desirable. Established experience in research at a level which enables procurement of outside funding is also desirable.

Applicants will need to demonstrate effective interpersonal and communication skills and be committed to ongoing performance improvement. Dedication to enhancing a diverse workforce and academic environment is vital.

Applicant credentials are subject to verification; background checks will be conducted on final candidates for all positions in the University of Iowa Hospitals and Clinics. To apply for this position visit The University of Iowa website at jobs.uiowa.edu, requisition number 73834.

For additional information contact: W. Thomas Lawrence, MD Director, Plastic and Reconstructive Surgery Department of Surgery University of Iowa Health Care thomas-lawrence@uiowa.edu (319) 384-9961 The University of Iowa is an equal opportunity/affirmative action employer. All qualified applicants are encouraged to apply and will receive consideration for employment free from discrimination on the basis of race, creed, color, national origin, age, sex, pregnancy, sexual orientation, gender identity, genetic information, religion, associational preference, status as a qualified individual with a disability, or status as a protected veteran.

35

CLASSIFIEDS San Diego, Calif.

Looking for a Plastic Surgery career in beautiful San Diego? Changes Plastic Surgery and Spa has an opportunity for a board certified/ board eligible, Plastic Surgeon to join our well-established, cutting edge private practice.

We also offer exciting 6 or 12 month aesthetic Plastic Surgery fellowships! This rare opportunity offers an experienced mentor to assure success and potential job opportunity. Interested?

Please send cover letter, C.V., and letters of rec to kaydee@changesplasticsurgery.com.

West Hollywood/Beverly Hills Office ASPS member interested in sharing space with individual private office, three exam rooms, and AAAHC accredited surgical center. Access to EMR and shared office staff also negotiable.

Transitioning to retirement within 5-7 years, with opportunity to assume lease, domain names, etc.

Contact: info@plasticsurgery90210.com Plastic Surgeon Busy plastic surgery practice on Long Island seeking a BE/BC plastic surgeon to join our practice. We are looking for a talented, energetic and personable individual to join our group. The practice treats a variety of cosmetic, reconstructive and hand surgical patients. Competitive salary and benefits package with partnership opportunity. Contact KHPSOffice@gmail.com for more information.

Plastic Surgery Practice For Sale A highly successful plastic surgeon is seeking to sell his solo practice in suburban Philadelphia.

Well established, experienced staff, turn key, great opportunity for young plastic surgeon at exceptional price. Hospital with tremendous need for both aesthetic and reconstructive coverage. Email with CV to horvathplaticsurgery@comcast.net.

Oakland, Pittsburgh Solo Practitioner Seeks Associate International renowned innovator, University of Pittsburgh Clinical Professor of Plastic Surgery and director of busy academically oriented private practice seeks to employ hard working associate interested in facial, breast and body contouring surgery. Opportunity to participate in cutting edge techniques and technology, leading to scientific presentations and publications.

Active participation in the Pitt Residency program is encouraged. AAAASF operating room in beautifully remodeled penthouse clinic and four aesthetician medispa in the University portion of Oakland, Pittsburgh. Opportunity to rapidly advance to partnership leading to ownership. Apply if you’re looking to make a difference in plastic surgery. 412-802-6100 or drhurwitz@hurwitzcenter.com.

Los Angeles Excellent opportunity to join a prestigious, well-established, high-volume, 100% aesthetic, private-academic, solo plastic surgery practice.

Due to patient demand, the practice seeks an experienced, motivated, Board Certified plastic surgeon to work with an internationally respected and recognized plastic surgeon as an Associate/ Partner. For over 35 years, this successful practice has been built on the foundation of personalized patient-care, innovative research, and centers of excellence. We have grown into an elegant and updated 6,500-square-foot facility that integrates a certified AAAASF OR, advanced SkinCare Center, distinguished Injectable-Device Center, and renowned Surgical Center. The practice is located in metropolitan Los Angeles that offers unparalleled quality of life with ample cultural, sports and recreational activities. Confidential and serious inquiries only. Cover letter, CV and contact information to socalsosuite@gmail.com.

North Shore Plastic Surgery Romanelli Cosmetic Surgery Board Eligible or Board Certified Plastic Surgeon Highly respected practice is offering unique opportunity to develop your busy surgical practice. Excellent platform for both cosmetic and reconstructive surgeries, with the support needed to facilitate success.

• • • • •

AAAASF surgical facility Two Long Island locations Competitive salary and benefits Partnership opportunity available jrcs.com Inquire at jr@jrcs.com with interest and CV

36

University of Missouri Plastic Surgery Seeking Division Chief The Department of Surgery at the University of Missouri-Columbia is seeking qualified candidates for the position of Chief of the Division of Plastic Surgery. Ideal candidates should be board certified by the American Board of Plastic Surgery, hold a rank of Associate Professor or Professor, have a demonstrated record of clinical and academic excellence, and demonstrate previous leadership and administrative excellence.

The Division of Plastic Surgery at MU has a long and proud tradition of clinical and academic excellence and was one of the original five programs to institute the integrated training model in plastic surgery. We are seeking candidates who can lead the Division through a period of continued growth, maintain the highest levels of excellence in clinical care, foster resident and medical student education, and enhance research productivity. Candidates must have the ability to work collaboratively as a team leader and demonstrate a vision for continued expansion and development.

The University of Missouri is fully committed to achieving the goal of a diverse and inclusive academic community of faculty, staff and students. We seek individuals who are committed to this goal and our core campus values of respect, responsibility, discovery and excellence.

Applicants should send inquiries and curriculum vitae to: Ami Patel, Department Administrator Department of Surgery University of Missouri-Columbia One Hospital Drive | Columbia, MO 65212 Email: patelami@health.missouri.edu The University of Missouri is an Affirmative

Action/Equal Opportunity Employer and complies with ADA Act of 1990. Women and Minorities are encouraged to apply.

Dallas, Texas Plastic and Reconstructive Surgeon Texas Center for Breast Reconstruction is actively seeking an associate to join our reconstructive surgery practice in North Dallas, Texas. Our practice consists of two plastic surgeons that focus primarily on breast reconstruction, microsurgery, as well as lower limb salvage and other complex reconstruction.

This is an excellent opportunity for a BC/BE plastic surgeon who is fellowship trained in microsurgery to join a well-established, successful and growing practice. We prefer an experienced candidate, with interest and/or experience in microsurgical breast reconstruction, however those recently completing a fellowship in microsurgery are also encouraged to apply. Ideal candidates will share our core values of providing excellent care to our patients and maintain a strong work ethic. Qualified out of state candidates encouraged to apply. A Texas Medical License will be required prior to hire.

Email CV or inquiries to jesseca@texaspsa.com or fax 855-683-4582.

Plastic Surgery Opportunity Well established private practice in the Washington D.C. area looking for energetic plastic surgeon desiring a position in an expanding practice. Mix of both cosmetic and reconstructive surgery. Partnership track available for the right candidate.

Send inquiries to dmvplasticsurgery@gmail.com or fax your resume to 301-762-3424.

Westchester, NY Well established plastic surgery practice located in Southern Westchester County, NY is looking for an additional plastic surgeon to join our team, board eligible or Board Certified. Great location, beautiful office space and experienced staff. Fellowship in hand and second language preferred.

• Full time position • Competitive salary • Benefits • Bonus • CAQ nice but not required • Opportunity to purchase equity in on-site Medicare licensed ASC Please send CV and letter of interest to: lauren@nycosmeticmd.com December 2019

CLASSIFIEDS Craniofacial and Pediatric Plastic Surgeon South Florida MEDNAX and the Atlantic Center of Aesthetic & Reconstructive Surgery are expanding our practice in South Florida. We are seeking to add a talented, fellowship trained pediatric plastic and craniofacial surgeon to our prestigious team.

We are the largest pediatric reconstructive practice in South Florida’s Broward and Palm Beach Counties. Founded the Cleft and Craniofacial Center at Joe DiMaggio Children’s Hospital, one of the largest craniofacial centers in Florida.

Utilize telehealth technology, participate in active research, and teach at three local universities. Procedures performed at all the major Children’s Hospitals across South Florida.

Contact Ann Taggart 954-384-0175 x6366 or ann_taggart@mednax.com.

TRAINING MGH/Harvard Adult Reconstructive and Aesthetic Craniomaxillofacial Surgery Fellowship Adult Reconstructive/Aesthetic Craniomaxillofacial Fellowship at Massachusetts General Hospital (Boston, Mass.), a Harvard teaching hospital, beginning July 2020 (12 months). Highvolume experience in all areas of reconstructive and aesthetic craniomaxillofacial surgery.

Emphasis on primary and secondary post-traumatic reconstruction as well as aesthetic facial skeletal contouring. Opportunities to participate in other areas of clinical interest, research, and teaching. Must have completed plastic surgery residency.

ASAPS Endorsed Plastic Surgery Clinical and Research Fellow The Bitar Cosmetic Surgery Institute (BCSI) is offering a 1 year comprehensive ASAPS endorsed fellowship in Advanced Aesthetic Plastic Surgery.

BCSI is one of the most prominent aesthetic practices in the metropolitan Washington DC area. The fellowship position is an exciting opportunity to combine clinical experience in aesthetic surgery with academic research. A formal clinical and research curriculum will be offered. The Fellow will gain hands-on surgical experience with two highly skilled BC plastic surgeons in advanced rhinoplasty, facial rejuvenation, breast and body contouring techniques including MWL, hair restoration, as well as injectables, laser treatments, skin care, and the latest in non-surgical body contouring modalities. Didactic conferences will be held at Johns Hopkins University and University of Virginia Departments of Plastic Surgery. Candidates who have successfully completed training in Plastic Surgery and are BE/BC are encouraged to apply.

Applicants should send CV, 2 letters of recommendation, in-service and USMLE scores, and a letter of intent to: George Bitar, MD, FACS, Fellowship Director and Medical Director of Bitar Cosmetic Surgery Institute and Rana Shalhoub, Fellowship Coordinator.

E-mail: ranashalhoub@bitarinstitute.com O-703-206-0506,125 F-703-206-9157 Website: www.bitarinsitute.com

Forward CV to: Dr. Michael Yaremchuk, 55 Fruit Street, WACC435 Boston, MA 02114.

Fax: 617-726-8089 Email ABENIGNI@PARTNERS.ORG

Integrated Reconstructive Microsurgery and Craniofacial Fellowship (CMFMicro) The Division of Plastic and Reconstructive Surgery at William Beaumont Hospital and Oakland University William Beaumont School of Medicine offers a 1-year fellowship combining microsurgery and craniofacial surgery.

Plastic/Reconstructive Opportunity with Partnership Track Long Island & NYC Excellent opportunity with partnership track.

Well-established cosmetic plastic surgery practice with locations in Long Island and Manhattan seeks a plastic/reconstructive board certified/board-eligible surgeon to join our thriving practice.

Modern offices, professional team environment, state-of-the-art and accredited facilities, knowledgeable and professional staff, competitive compensation and benefits.

Greenbergcosmeticsurgery.com To apply, forward CV to docstg@aol.com or call 516-364-4200 December 2019

The Fellow engages in a comprehensive experience in patient management spanning from pre-operative planning through post-operative care. The fellow participates in microsurgical cases including DIEP/GAP/TUG/PAP flap breast reconstruction (100+ cases annually), head and neck free flap reconstruction (30+ cases annually), and lower extremity reconstruction with free flap (20+ cases annually).

The fellow is expected to take part in facial reconstruction following Mohs resections (100+ cases annually), implant based breast reconstruction (50+ cases annually), and other complex reconstructive cases. The fellow plays a pivotal role in the monthly multidisciplinary Cleft Palate and Craniofacial Clinic. Each year, the craniofacial team performs at least 30 primary cleft lip and palate repairs, 60 secondary cleft lip and palate repairs including septorhinoplasty, 20 intracranial procedures including cranial distraction, 5 midface and mandible distractions, and 40 orthognathic surgeries.

William Beaumont Hospital is a level I trauma center with ample opportunity to manage facial trauma and post-traumatic deformities. The American Society for Reconstructive Microsurgery has awarded Dr. Chaiyasate with the “2014 Best Microsurgical Case of the Year” and “2017 Best Microsurgical Save of the Year” awards. Candidate selection is completed through San Francisco Match Program. For further information, please contact Dr. Kongkrit Chaiyasate via email at Kongkrit.chaiyasate@beaumont.edu.

Craniofacial Fellowship Post Graduate Fellowship 1 yr. – Craniofacial Surgery. ACGME accredited since 2003. BC/ BE plastic surgery residency/fellowship required, Beginning July 1, 2020. Focus on congenital and traumatic reconstruction, tertiary cleft lip/ palate, orthognathic and mandible midface, and cranial vault distraction. Diverse facial trauma, peds & adult. Research activity encouraged.

Administered by Dept. of Plastic & Reconstructive Surgery, Medical College of Wisconsin.

Contact: Robert Havlik, MD, Director, Center for Craniofacial Disorders, Children’s Hospital of Wisconsin. (414) 266-2825 or e-mail: dpalick@chw.org MD Anderson Microsurgery Fellowship Clinical Fellowship positions are available beginning 7/1/2021 at the University of Texas, MD Anderson Cancer Center in oncology-related reconstruction and microsurgery. A wide variety of complex reconstructive procedures are performed each year with a high volume of microvascular cases, especially autologous breast, complex head and neck, lymphatic, and perforator flap reconstructions. Opportunities are available to participate in microsurgery laboratory training and established basic science and clinical research projects. Fellowship duration: 12 months. Please send letter of intent and CV to: Matthew M. Hanasono, MD Director, Microsurgery Fellowship Program Department of Plastic Surgery, Unit 1488 MD Anderson Cancer Center 1400 Pressler Houston, Texas 77030 (713) 794-1247 mhanasono@mdanderson.org MGH/Harvard Reconstructive/Aesthetic Breast Surgery Fellowship Reconstructive/Aesthetic Breast Fellowship at Massachusetts General Hospital (Boston, Mass.), a Harvard teaching hospital, beginning July 2020 (12 months). High-volume experience in all areas of aesthetic and reconstructive breast surgery.

Emphasis on microsurgery and cutting-edge prosthetic techniques. Opportunities to participate in other areas of clinical interest, research, and teaching. Must have completed plastic surgery residency.

Forward CV to: Dr. William G. Austen Jr. 55 Fruit Street, WACC435 Boston, MA 02114.

University of Pittsburgh Microsurgery Fellowship The University of Pittsburgh Department of Plastic Surgery offers a one year (2021-2022) Microsurgery fellowship position, starting August 2021. The position provides a comprehensive microsurgical experience, including head & neck, lower extremity, trunk, and breast, including perforator flaps and lymphatic surgery, at a center that performed more than 150 free flaps last year.

Complex conventional reconstructive surgery is also represented. The fellow participates in heavy clinical volume, conferences, resident teaching, and research.

Applicants should send CV and three letters of recommendation to Michelle Gigliotti: Michelle Gigliotti Department of Plastic Surgery University of Pittsburgh School of Medicine 3550 Terrace Street 675 Scaife Hall Pittsburgh, PA 15261 O-412-383-8082 F-412-383-8986 E-mail: gigliottim@upmc.edu

MISCELLANEOUS Plastic Surgery Biller Specializing exclusively in Plastic Surgery billing with over 25 years experience. We check for correct coding for maximum reimbursement, and review each before submission. Once the claims are submitted, we follow closely and appeal when necessary. We work remotely, off-site with excellent references.

Call Ana at 239-541-9993.

Canfield Vectra H1 3D Camera + Mirror + Vectra Software For Sale Purchased recently, closing practice, comes with automated facial analysis software, perfect for rhinoplasty. License transferable. $6000 (purchased for $10,000) 480-239-4799

Classified Ad Policy Rates for printed classified ads are based on word count and must be paid prior to publication. Logos, boxes and color enhancements can be designed for additional fee. The editors do not investigate positions of employment and assume no responsibility for them. ASPS reserves the right to accept, reject or cancel any advertisements in its sole discretion.

Fax: 617-726-8089 Email ABENIGNI@PARTNERS.ORG North Texas Plastic Surgery Aesthetic Fellowship North Texas Plastic Surgery is proud to offer an aesthetic fellowship under the direction of senior partner, Dr. Sacha Obaid. Very competitive salary and benefits provided. The fellow will have the ability to assist in over 1,000 cosmetic cases per year with a heavy emphasis on breast, butt, and body contouring. In addition, graduated independent operating responsibility will be given to the fellow, and a “fellow clinic” will be established with the expectation that the fellow will independently book a large volume of cases. In addition to the operative experience, the fellow will be involved in a thriving med spa featuring topical skin care, injectables, non-ablative skin treatments and non-invasive body contouring.

Ad Rates ■ ■ ■ ■ ■ ■

1 to 50 words: $165 51 to 100 words: $305 101 to 150 words: $440 151 to 200 words: $555 201 to 250 words: $763 More than 250 words: Contact jembrey@plasticsurgery.org for “designed” ad options

Designed Ad Rates ■ ■ ■ ■

1/8 page: $930 1/4 page: $1,440 1/2 page: $2,175 Full page: $3,195

To place a classified ad, email:

Applicants must have, or obtain prior to commencement, a Texas medical license, hospital privileges, and be BC/BE in plastic surgery.

Jeanne Embrey Advertising Coordinator jembrey@plasticsurgery.org 847-228-3364

Fellowship opportunities are available to begin July 2021. For more information, please contact Linsey at linsey@northtexasps.com or check out our website www.northtexasplasticsurgery.com.

Visit the Job Opportunity Board plasticsurgery.org/job.

37

SURGEON SPOTLIGHT Editor’s note: The bulk of PSN’s pages are devoted to specific elements of our mission statement – to keep members informed of the social, political and economic trends and educational opportunities that affect the specialty of plastic surgery.

PLASTIC SU RG EO N , SO N PLACE 3 RD I N EN DU RANCE RACE

I

magine driving for 36 straight days, 12 hours at a stretch inside a vintage car, over hundreds of miles of unpaved roads, through eight time zones in 12 countries, in city traffic and on race tracks – and fighting with machine, nature and one’s own emotions and focus. What more, really, could a plastic surgeon want?

PSN is pleased to take liberties with the “social” aspect of its mission statement by presenting a good-natured look at the lives of notable members who we believe are making significant contributions to the specialty.

The challenge caught the eye of ASPS member Tjerk “T.J.” Bury, MD, Thousand Oaks, Calif., while reading a magazine article on the Peking to Paris (P2P) Motor Challenge. An avowed car aficianado, the article piqued Dr. Bury’s interest – particularly when one of the cars the magazine deemed suitable for the race, a 1972 Datsun 240-Z, belonged to his son, Chris, and was parked in his garage.

The pair competed in two P2P races – their first in 2016 followed by the recently completed 2019 edition – and followed their first race’s respectable 26thplace finish with a 3rdplace overall out of 110 cars, less than 5 minutes behind the leaders.

“We were absolutely thrilled,” Dr. Bury says.

“Chris and I thought top 15-20 would have been fabulous. We never thought we’d be on the Bury and his son, Chris, (inset) took 3rd place in the 2019 podium (for the top-three Dr. P2P endurance race in their Datsun 240-Z. finishers), receiving a big cup.” The winner was a Layland P76-driving Australian who had two previous victories under his belt, followed by a U.S.-based Porsche 911 husband-and-wife team. The Burys actually held 2nd place until the race moved to tarmac tracks, which put their Datsun 240-Z and its 150 horsepower at a disadvantage.

“The cars with more power just went flying by; we couldn’t keep up with them,” he says.

The race originated in 1907, after the French newspaper Le Matin issued a challenge to the fledgling automotive industry to prove “that as long as a man has a car, he can do anything and go anywhere,” and suggested the Peking (then-capital of China, today Beijing) to Paris route. It took an Italian prince, Scipione Borghese, exactly two months to finish, though “he made a detour to St. Petersburg, Russia, to have dinner with the tsar – because he knew he was going to win,” Dr. Bury says. (Fun fact: Every Ferarri and Maserati racer is painted red, the color of Borghese’s rally-winning Itala.)

Due to war, politics and a variety of other factors, there wasn’t another P2P race until 1997, when the Endurance Rally Association (ERA) revived it. The third P2P was held in 2007 – and it proved so popular that it’s been held every three years since.

In both 2016 and 2019, Chris did most of the driving while Dr. Bury handled navigation – which is more difficult that it sounds: Routes chosen by ERA months earlier regularly changed, so each team was provided with a new set of routes early each day. It was up to Dr. Bury to make the adjustments while ensuring they met their preassigned times for checkpoint arrivals and such, with penalties levied for certain infractions.

(Scoring is complex; for that information and more, go to endurorally.com.)

“Trust is key,” he says. “The driver must trust the navigator – and since we’re driving in sometimes hazardous conditions, the navigator must trust the driver. But I would never do this with anyone other than my son. It was a rare experience and I got to spend six weeks with my son doing something we both like and being a team. It was special.”

Although Chris, who’s 28 and an aerospace engineer for Richard Branson’s Virgin Orbit, may one day take up the challenge with another teammate, Dr. Bury says the 2019 version is likely his last. “It’s such a long haul and huge commitment,” he says. “I’m afraid that if I do it again and don’t do better than 3rd place, I’ll be disappointed. Sometimes you have to quit while you’re ahead.” PSN

PSN AT 30: TIME CAPSULE In celebration of PSN’s 30th anniversary, we’re taking a look at some of the news coverage from the magazine’s very first year. The December 1989 issue included the second of a two-part look at advertising plastic surgery and the Society’s efforts to help regional societies struggling to see a return on their investment in plastic surgery public education campaigns: “What we are doing as a Marketing Committee is looking at the whole concept of regional society marketing and seeing that we have not been successful in our efforts to help them. We need to determine how we can best assist them... The other thing is getting regional society members to work together. We have to figure out what types of marketing assistance will meet the needs of a whole regional society.”

– Paul Schnur, MD 1989 ASPRS Marketing Department Chairman PSN

38

Dr. Hultman during his tenure as PSN editor.

Throughout 2019, in celebration of PSN’s 30th anniversary, we’re pleased to feature the distinguished alumni who have served as the magazine’s chief medical editor, and we’ve asked them to reflect on their time in charge. In this issue, we present C. Scott Hultman, MD, MBA, Baltimore, who served as PSN chief medical editor from 2012-2015. Dr. Hultman is currently The PSF president and says his path to leadership was forged during his time with PSN. In the years since, he’s served on a number of committees, including the Academic Affairs Council, the Young Plastic Surgeons Steering Committee, the Membership Recruitment, Compliance & Development Committee and as ASPS/PSF Vice President of Academic Affairs & Reconstructive Surgery, among many other positions for the Society and The Foundation.

Why did you want to become a PSN editor? I had been involved in YPS, and I knew I wanted to contribute to ASPS any way I could. Becoming an editor for PSN was a great way to get into the organization at a high level – I had access to a lot of the dialogue on different issues and I was able to get a seat with leadership. I also liked the idea of being a journalist and documenting what was happening within the organization without actually having the responsibility of impacting policy or strategy. I’d been an editor before – I was editor of our school paper in high school and a music publication in college.

I was passionate about those things at those points in my life and now I’m passionate about plastic surgery, so it seemed like the right way to help move the organization along. Being able to go to the Board of Directors meetings was exciting for me as a rising editor. I took that very seriously. I felt like I was the lens through which leadership and membership could communicate with each other.

What coverage, in particular, were you most proud of during your tenure as PSN editor? We did a series of stories regarding consolidation of the ASPS/PSF Board of Directors. During the early 2000s, we had two separate boards for each organization with different vice presidents. What was neat about the plan – which was communicated well to membership through PSN – is that we consolidated and besides there being a huge savings in terms of man hours it would take to run the Society from the physician side, we also increased the number of vice presidents, creating specific tasks for advocacy, research, academic affairs, etc. We’ve since seen some additional modifications to that, but that was a real breakthrough for the organization.

What was the best part of being the PSN editor? The dinners at the annual meeting. I also really enjoyed working with staff and Charles Verheyden, MD, PhD, as the advertising editor. PSN seemed like the best of what ASPS had to offer. I always felt like if there was any group I wanted to belong to, it was the PSN group.

I could always count on those folks. They were always great writers and I thought we always delivered a great product. I was always proud of that publication.

What was the worst part of being the PSN editor? Honestly, there was never anything that was bad.

If there was one thing you could go back and change about your time in charge, what would it be? Part of me always wished that I had been able to see PSN through to the final product – as in maybe I could’ve been more involved in some of the copy editing and layout work. Obviously, as surgeons, we don’t have the time for that and the folks in the office are the professionals, but it always seemed like you’d work on the issue, go over the topics and then all of the sudden it would just show up in your mailbox. This is going to date me, but when I was editor of the high school newspaper, we would have a weekend where we would have the copy printed out and we used wax boards. We would cut out columns and literally do the layout. I never got to have that experience with PSN, but there was always a yearning to be part of that. I think it’s the best surgical news publication that’s out there and I wanted to be as involved as possible.

What reader feedback do you most remember during your time as a PSN editor? The most feedback we got was always regarding the ads. Dr. Verheyden did a great job with all of that. We might, say, have an advertisement for an ENT meeting and someone Dr. Hultman (right) relaxes with his wife, Suzanne, would call in and be upset that we were giving space and their three children on Daufuskie Island in South Carolina this summer. to that. You’d always have a couple members who had some problem with some ad. We had to take it seriously, but on the other hand, we also had to chuckle about some of the complaints. Every now and then we did come across something that needed our attention, but I don’t remember having to retract or apologize for anything. We always stood by our journalism.

What advice would you give to future PSN editors? Your editorials are really an amazing opportunity to let you think about the specialty, reflect on it and try to provide direction for the readers. I took those very seriously. I did a lot of research and would do multiple drafts. I’m always grateful that I had the opportunity to journal that way and to get my message out – and that people were reading. It meant a lot to get feedback – both positive and negative – because I was making a connection. So my advice would be to spend a lot of time to make sure your message is well crafted. PSN December 2019

Tirelessly defending the practice of

GOOD MEDICINE. We’re taking the mal out of malpractice insurance.

By constantly looking ahead, we help our members anticipate issues before they can become problems. And should frivolous claims ever threaten their good name, we fight to win—both in and out of the courtroom. It’s a strategy made for your success that delivers malpractice insurance without the mal.

See how at thedoctors.com The nation’s largest physician-owned insurer is now expanding in New York.

December 2019

39

Have You Felt the

MENTOR® MemoryGel® Xtra Breast Implant?

In a blinded comparison 9 out of 10 consumers chose MemoryGel® Xtra Breast Implants as feeling more like a natural breast than the other leading brand.*1

@BreastImplantsbyMentor #MemoryGelXtra #MentorBreastImplants #OwnTheDay *Head-to-head blinded in-person tabletop product comparison (MemoryGel Xtra vs. Inspira Responsive vs. Inspira Cohesive) with 452 respondents. 1. Mentor Consumer Preference Market Research Report - July 2017.

IMPORTANT SAFETY INFORMATION MENTOR® MemoryGel® Breast Implants are indicated for breast augmentation in women who are at least 22 years old. Breast implant surgery should not be performed in women: With active infection anywhere in their body; With existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions; Who are currently pregnant or nursing. Safety and effectiveness have not been established in patients with autoimmune diseases (for example lupus and scleroderma), a weakened immune system, conditions that interfere with wound healing and blood clotting, or reduced blood supply to breast tissue. Patients with a diagnosis of depression, or other mental health disorders, should wait until resolution or stabilization of these conditions prior to undergoing breast implantation surgery.

There are risks associated with breast implant surgery. You should be aware that breast implants are not lifetime devices and breast implantation may not be a one-time surgery. You may need additional unplanned surgeries on your breasts because of complications or unacceptable cosmetic outcomes. Many of the changes to your breast following implantation are irreversible (cannot be undone) and breast implants may affect your ability to breastfeed, either by reducing or eliminating milk production.

Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. The most common complications for breast augmentation with MemoryGel® Breast Implants include any reoperation, capsular contracture, nipple sensation changes, and implant removal with or without replacement. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture.

Detailed information regarding the risks and benefits associated with MENTOR® Breast Implants is provided in the educational brochure for MemoryGel® Implants: Important Information for Augmentation Patients about MENTOR® MemoryGel® Breast Implants. The brochure is available from your surgeon or visit www.mentorwwllc.com. It is important that you read and understand the brochure when considering MENTOR® MemoryGel® Breast Implants. © Mentor Worldwide LLC 2019 109944-190320