Plastics

Course Coordinator: In flux
Course Director: In flux
UCH Intern Pager: 303-266-4354

Welcome to Plastic Surgery! MS3s split their time between the University Hospital and Children's. The University Service is separate from the Hand Service, but you are more than welcome to attend those cases as well. The rotation is quite busy and you are expected to round and help prepare the list in the morning with the University Service except when your lecture day starts at 6am. Please round with the team before attending clinic at Children's. Make sure you contact the intern on service before you start so you can coordinate for rounds and preparing the list. The intern can let you know where the dressing bag is currently being kept so you can pick it up before rounds.

You are expected to read and prepare for each case you attend. You are expected to have read and prepared for the case you will attend the night before. The best medical students will pick their assignments for the week before the start of the week.

Reading tips for success – I highly suggest obtaining the following books. You can search by ISBN number in Library Genesis. Or you can buy them on Amazon.
Operative Steps (Best way to get all the “pimp” question right!): Operative Techniques in Plastic Surgery (Chung). ISBN: 9781496339508
General Reading: Grabb and Smith's (ISBN: 978-1451109559)
Pocket Manual: Michigan Manual (ISBN: 978-1451183672)
The American Society of Plastic Surgery (ASPS) also provides a pocket manual that is “essential”: Essentials for Students (ASPS).

Finding the OR Control desk
- University - 2 nd floor on the North side of the OR’s, across the hall from the Cardio-Thoracic ICU

Directions AIP/Central (CEN) OR:
Find elevator D and take it to the 2nd floor. Follow signs for the Cardio-Thoracic ICU and go around a 2 corners. You will end up in a hallway that runs East to West. The locker rooms will be on your left and the scrub machines in a room just after the “Staff Lounge”. If you are already in scrubs, you can get directly to the ORs and Control Desk by going through the badge access double doors. (please note that this is the AIP OR, not the AOP OR).

Directions AOP/East OR:
Find elevator D and take it to the 2nd floor. Instead of following signs for the Cardio-Thoracic ICU, go the other way out of the elevator hallway and make a left. You will now be in a long hallway walking East. Continue down this hallway past the call room (2022). Keep walking through the bridge that connects AIP and AOP and you will eventually see signs for “Outpatient Surgery”. Follow these signs to the AOP/East OR and PACU.

- Children’s - 2 nd floor on the North-West side of the hospital

Daily MS3 Assignments:
Monday - Lecture vs Any Attending at University AIP/AOP
Tuesday - Any Attending at University AIP/AOP
Wednesday - Craniofacial Clinic at Children's with Dr. Khechoyan and French. (Please wear your clean white coat and business attire, but be prepared to scrub in for a surgery. Children's has its own scrubs.)
Thursday - Any Attending at University AIP/AOP (This is a good day to see Hand Service with Dr. Iorio)
Friday - Any Attending at University AIP/AOP

Show up each day having a plan for what cases you will attend and read up on relevant anatomy, complications, attending's technique (found on the wiki).

Surgical resident work room - 6th floor across from patient room 661. Take elevator E to the 6th floor.
Plastics call room - near elevator D on the 2nd floor. Turn left coming out of elevator D and find room 2022. Code is master code (84845).

The Plastic Surgery (University) Dressing Bag for morning rounds is the red courier bag on the right wall. Make sure you keep the supply bag well stocked (you can access new supplies in the supply room near the surgical resident's lounge or the ED). Supplies include:

• Tegaderm of all sizes
• 4×4 gauze
• Xeroform of various sizes
• Bacitracin
• Suture removal kit
• Staple removal kit
• ABD pads (abdominal pads)
• Bias (a wrap)
• Various tape
• Other supplies will depend on specific patient population

It is a good idea to familiarize yourself with what everything looks like and what the residents/healthcare professionals call them. Google images can be your friend. Every morning before rounds, ask your intern if there are any special dressing supplies you will need for rounds. Do your best to gather these and carry them either in the courier bag or in a plastic bin (these and other supplies can be found in the cubby tower in the Plastics call room). It is also often helpful to have trauma shears with you for rounds.

Childrens Multidisciplinary Clinic - 2nd floor from the main entrance. Follow signs to “multidisciplinary clinic”. EPIC - use “MDC Craniofacial”, go to schedule, drop down MDC Craniofacial. Topics to cover for Craniofacial Clinic: deformational plagiocephaly, craniosynostesis, cleft palate and lip, and sutures of the skull.

Welcome to the University of Colorado Sub-I! We are really excited to have you. 4th year medical students rotate through Denver Health, UCH and Children's. The sites are a nice strength of the program and you will see a variety of patient populations and cases. Please make sure to coordinate with the different residents on each service. The on site resident can be found on the front page of this wiki. There is also an important section with contact information that can be found on the sidebar. It is recommended that Sub-Is take four “24 hour” call during your month. These calls should be when we are on Hand and/or Face call. You can see this on the front page calendar noted as Name-H/F.

Dr. Mathes is the Chief of Plastic Surgery and Dr. Chong is the Program Director. You should try and scrub as many cases as possible with them at UCH. See the schedule above to see how EPIC works for looking for cases. You should “plan” your week and know what cases you are going to each day. If there is a third year medical student, you are also in charge of splitting up and assigning the cases and clinic for the week.

Core topics to cover during your rotation

• General: wound healing, infections, flaps and grafts
• Peds: cleft lip/palate, craniosynostosis, vascular malformations/skin lesions
• Hand: fractures, nerve compressions, tendons, infections
• Breast: augmentation, reduction, recon (implant and autologous)
• Trunk/Lower Extremity: trunk recon, pressure sores, lower extremity recon
• Head/Neck: facial trauma
• Aesthetic: body contouring, facial aesthetic procedures, injectables and lasers

Your first and most important job is to learn. The best way to accomplish this is to see as many patients as possible and learn why everything is being done for each patient. To stay active, present patients on rounds and then to help update the list. This allows you to have a detailed understanding of a few patients and then keep up to date on all the patients on the service. You are expected to help gather numbers and print the list in the morning. Please make sure you are printing the cover sheet with the following custom columns included: Antibiotics, anticoagulation, To Do. Include drain outputs on first cover page. Write the numbers as follows:

Temp range / HR range / BP range / RR single value / Desaturation events and times + Oxygen/Vent settings

Ins and Outs
PO | UOP
IV | Other

N: # A: #

PO - Includes oral intake and any enteric feeds
IV - Anything intravenous
UOP - Urine output. Please also include dialysis
Other - Everything else. Emesis, stools, etc…
Make sure you are opening up all the tabs in Ins&Outs (BTW you can save it open with that little green plus)

N = Net 24 hour volume status
A = Net admission volume status

AM Rounds: Medical students should LEAD rounds. You plan the route. Don’t wait for us to finish with a patient. You should be ready and start leaving the room as the we finish with the patient. Get whatever tasks are needed for the next patient done and start figuring out where the next patient’s room is. On a heavy dressing change service (like plastic surgery) please carry the dressing supply bag (in call room). Make sure to leave it outside the room though. Please present 1 patient every day. This presentation should be given to the attending as well. Here is my outline of a presentation:
1-liner
O/N events
Vitals
Labs
Plan by systems

OR Cases: Scrub every case you can. Divide up the cases fairly. If the attendings ask you pimp questions, please share at the end of the day so we all learn!!

In the OR here are all the tasks you should help with.
write your name and residents name on the board. Write your gloves size too. Get your gloves and hand them to the circulator.
help transfer patient from the stretcher to the OR bed
Get the belt on the patient
Put the SCDs on the patients legs
Be an extra pair of hands to anesthesia to help intubate or put in new IVs
At the end of the case, remove the drapes and put in garbage, help extubate, take off bovie pads, get the stretcher and transfer patient back to stretcher.
Please walk the patient to PACU by opening doors

Clinic: You will likely be assigned to clinic. Please ask how to help prep for clinic. This may be printing out the last note for each patient or helping prepare a list. Wear clinic clothes. Having a spare set of clinic clothes ready in your car can be a lifesaver.

Weekend Rounding: Medical students round 1 weekend day per week and leave once all weekend work is completed if appropriate.

The List:
Pt info:

Path:

PMH:
PSH:
Home Meds:
——–
N:
P:
CV:
GI:
GU:
Heme:
Endo:
ID:
FEN:
————–
Operation:

Foley: - nice to write when d/c’d and if patient voiding

Drains:
———–
XC – Primary team if a consult, No labs

Team – include the plan for the upcoming days here

Discharge – things for discharge like PT recs or ppx for discharge

Recommended Apps:
Touch Surgery - Great overall resource for walking you through the steps of an operation and pertinent anatomy.
Complete Anatomy - A nice Anatomy Atlas for on the go on your phone.
Epocrates - Pharmacy app that is good for looking up medications and dosing.

The Things I Carried:
4 Color Pen: BIC 4-Color Grip Ball Pen
Flashlight: Streamlight 66118 Stylus Pro LED Pen Light with Holster, Black
Trauma Shears: Prestige Medical Fluoride Scissor, Black, 7 1/2 Inch (Amazon)
Stethoscope: Some attendings want this: Schulick, Vogel
Headlight: Useful on ENT
Reflex Hammer: Useful on NSGY

Great Resources:
In my opinion you need 3 things to be successful studying. Don’t go chasing too many other things to read:
1. Question bank: U-world is terrific. I recommend doing at least two NBME exams during your surgery block.
2. All inclusive go to resource: medbullets.com. This also has an accompanying premium version with good questions and it’s not too expensive. This website has everything you need for “pimp questions” and the tests. I don’t recommend chasing things further than this.
3. Passive learning through onlinemeded.org - these videos are gold. Watch them all for each rotation you are on.

To look up the cases for the week, go to EPIC → Schedule and enter then following attendings. Make sure you choose All Departments. You are expected to have read about the patients and each case the night before. In the morning, you will get asked what cases you are doing for the day.

Frequently Asked Questions:

The List
- What should I be printing out? Both the “current list” and “handoff”.
- Where do you prefer us to write the vitals and updates? On the “Handoff.”
- Do you prefer the list stapled? yes
- Is it okay to help update the list? Yes, it is your job to add patient's to the list that you are operating on and help update the list with the intern after rounds.

Rounding
- Should I pre-round? Yes, we expect you to see your patient that you will present on rounds. You should be ready to present a 1-liner on your patient, overnight events, vital signs and labs, pain status, diet issues, urine and foley status, anticoagulation plan and antibiotic plan. This should be followed by your plan for the day.
- I feel like I am in the way on rounds. How can I be helpful? I too felt in the way as a medical student. Personally, I stuffed a bunch of gloves in my pocket and had a bottle of hand sanitizer clipped to my jacket. The best way to be helpful is to pay attention to what is in the dressing coming off and then to be ready with the same items to hand to us. Patient's with flaps will always need the doppler ready.
- Where can I get dressing supplies? You will be carrying around the dressing supply bag which is kept in the resident room. It is your job to stock this daily. It is a good idea to go “shopping” on the 6th floor med rooms to stock the bag.
- What are the basic dressing supplies? Kerlix, 4×4 gauze, Medpore tape, ABD pads, ACE wrap, bacitracin, cotton applicators (q-tips), 1/4 inch packing, tegaderm, biopatch, marking pens.
- What does ABD and ACE stand for? ABD is an old acronym for Army Battle Dressing. ACE stands for All Cotton Elastic. These are common pimp questions that you will be asked.
- Should I really lead rounds? Having the medical student help lead rounds is unbelievably helpful. Our patients are all over the hospital and it's easy to miss people. Knowing where we are going next as we are leaving the room will make you very useful. You can help grab the elevator or help get isolation gowns out.

OR
- How do I help get the patient ready for the OR? Make sure you read about the patient and know the PMH/PSH and reason for their operation. Ask the nurse if they would like help transporting the patient to the OR. Almost all cases will have arms out. For breast cases, the arms need to be wrapped. Most people use kerlix, Dr. Mathes uses cast padding, Dr. Livermore uses blankets. First pad the arms with purple foam. Make sure the SCDs are ready on the bed. Help get the bed in and out of the room. Help anesthesia get set up. You can help them set up the extra IVs or a-lines. Makes sure you give the circulator your gloves and gown and write your name on the board under medical student.

I would watch youtube videos the night before of each procedure and review the anatomy. For understanding post op care, I thought Pestana’s surgery notes were useful. Touch surgery app was excellent but they didn’t cover many of the cases I saw. I would also note to prepare for multiple of your teams attending’s cases as your day can vary. Overall I think spending a time at night made the OR educational even if I wasn’t actively involved and amazing when I was.
–
My only feedback is that the basics of dressing changes were new to me since I haven’t gone through gen surgery yet so I don’t know if you know of a good resource with the basics of dressing changes and materials but that was something that might be helpful. In terms of resources I think it would be great to include Michigan and Janis because they got me through many of the basics of all of the procedures I saw. I think that having high expectations of us is really valuable in preparing us and helping build our knowledge and confidence during third year and moving forward.
–
How to do well as a M3 on your surgery clerkship

Rule #1: Know your place on rounds.

Your objective as a third-year on rounds is to help out the efficiency and flow of the team. You should do everything you can to (1) not get in the way of the flow of rounding and (2) speed up the flow. One particular example of the former is standing near the door so you can leave before your team and direct the team to the next patient’s room; this contributes positively to rounding because you are helping out the team without getting in their way. You should also carry 4×4 (gauze), a variety of medical tape, saline flushes, and clean gloves (for future rooms) to supply to your team if they choose to change the dressings. Be on time and be prepared to present patients at table rounds.

Rule #2: Know your place in the OR.

Your objective as a third-year in the OR is to help out the efficiency and flow of your OR team (Surprise! The goal is not different – how you implement it is though). You may have learned that anesthesia transfers the patient from their preop bed onto the OR bed and back onto the preop bed for transfer to PACU. In truth, you should be assisting, if not doing this. You can help a lot by anticipating the flow of the OR, that is, anticipating what you need to do next to get the patient perfectly ready to be operated on. A brief general outline of this is included below:

• Transfer patient onto OR bed
• Attach on arm boards onto OR bed and secure patient’s arms w/ purple foam padding
• Remove lower segments of OR bed to shorten OR bed (if called for)
• Attach stirrups if operation requires lithotomy position
• Shave around incision site and tape up hair
• Secure the patient with belt or tape (depending on attending preference)
• Know when to scrub in aka when there is a lull in the set up (your resident may already be walking to the door).
• When the operation is complete, stay to clean up and be quick about it. You may have already broken scrub and discarded your scrub material, but grab gloves immediately and help out.
• Prior to transfer secure the patient’s arms. Anesthesia will thank you for this because then they won’t have to worry about the patient trying to claw out the IVs/tubes they took time to insert.
• Follow your patient to pacu and write down your team’s pager number on the patient’s file in the PACU.

how_to_rock_plastic_surgery_-_intern_guide.docx

If you are a medical student who has rotated with PRS, please add something here. It can be something you learned, coffee/food recommendations around the hospital, things to do to impress nurses/residents/attendings, or quotes from residents or attendings that stuck with you.

Nicholas R W Cleland, Class of 2023
Plastics is a surgical field that has an incredible amount of variety. Try and see as many different kinds of surgeries as you can. Since you also need to get evaluations from attendings, it is also a good idea to spend a lot of time working with one or two attendings. This is also a great time to learn general wound care. Sure, being in the OR and learning the steps to a DIEP are cool, but learning how to change a wound vac is more likely to benefit you in the future.

If you haven't already, get compression socks. You will spend a lot of time standing and your feet will be swollen by the end of the day. I also recommend getting 3-5 scrub caps depending on how often you do laundry. I would also recommend getting a qbank on your phone so you can do practice questions in between cases. The Michigan Manual of Plastic Surgery is also nice to have on your phone so you can do some reading on a procedure before a case. A pdf version can be found in the Media Manager of this wiki (upper right corner).

When you are holding a flap for a resident or an attending, the goal is to maximize THEIR view, not yours. Hold it so they can see what they are doing.
“It is not for you to see.”
Dr. Kaoutzanis

If you see something that you think is wrong or off, say something. The most important person in the room isn't the attending, it isn't the resident, it isn't you, it's the patient.
“Don't be scared to speak up. The most important person in the room isn't Dr. K, it's the patient.”
Christian the scrub nurse

Pimp Questions:
What are the stages of skin graft healing?
Diffusion: skin graft acquires nutrients from nearby areas, but not from extant blood vessels. This keeps the graft alive during days 1-2.
Imbibation: skin graft begins to acquire nutrients from extant capillaries, but the capillaries are not yet lined up. Days 2-3.
Inosculation: capillaries in the graft and the recipient site line up. Days 3-4.
Revascularization: skin graft becomes vascularized. Day 5.
(The answer changes depending on who you ask, but if you get asked this, this is a good answer.)

What are the layers of the abdominal wall?
Above the arcuate line: Skin, subcutaneous tissue (Camper's fascia then Scarpa's fascia), external oblique aponeurosis, internal oblique aponeurosis, rectus muscle, internal oblique aponeurosis, transversus abdominus aponeurosis, transversalis fascia, extraperitoneal fascia, peritoneum.
Below the arcuate line: aponeuroses of external oblique, internal oblique, transversus abdominus are all shallow to rectus muscle.

What are the anatomical borders of the breast?
Superior: clavicle or 2nd rib
Inferior: IMF (inframammary fold)
Medial: sternum
Lateral: latissimus dorsi
Deep: pectoralis major

What is the blood supply of the breast?
Internal thoracic artery, intercostal arteries, lateral thoracic artery, thoracoacromial artery.

Why do we de-epithelialize a flap for a DIEP or the skin under a nipple for a nipple reconstruction?
The natural life cycle of the epidermis is to slough off. If you leave the epidermis there and then put it underneath more skin, you can end up with a cyst.

What plane do we put a TAb block in?
TAb = transversus abdominus. The block is put in the transversus abdominus fascial plane with ultrasound guidance.

Why do you remove erectile tissue from the penis when making a neo-vagina during a vaginoplasty?
If the patient were to get an erection after the procedure has been completed, you could tear sutures or damage the neo-vagina.