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Plastics in Practice (Resident Review)

Plastics in Practice

A podcast built for plastic surgery trainees. Each episode reviews CME articles and topics from the ASPS Resident Curriculum, breaking them down into core concepts, clinical pearls, and exam-ready takeaways. Listen on your commute, between cases, or while studying—anywhere you want high-yield plastic surgery learning on the go.

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  • 21 episodes
  • Avg 22 min
  • English

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  • Yesterday · 17 min

    Mangled Upper Extremity Salvage

    A mangled upper extremity can look unsalvageable before resuscitation, perfusion, and debridement reveal what function remains. In this episode of Plastics in Practice, we build a practical limb-salvage sequence—from life-threatening priorities and early antibiotics to revascularization, compartment assessment, reconstruction, and rehabilitation. Key takeaways: • Put life before limb. Complete trauma resuscitation, control hemorrhage, and document perfusion, motor function, and sensation before committing to salvage or amputation. • A MESS of seven is a risk signal, not an upper-extremity amputation verdict. A 2024 meta-analysis suggested that at least one in five patients above the included studies’ MESS amputation thresholds underwent limb salvage.[1] • For an open long-bone fracture within BOAST's scope, give intravenous prophylactic antibiotics as soon as possible, ideally within one hour of injury. Hand, wrist, and digit injuries are outside this BOAST’s scope and may be managed locally using similar principles.[2] • If the limb is ischemic, restore flow as soon as possible. When timely definitive vascular repair is not feasible because of patient physiology or skeletal instability, a temporary vascular shunt can rapidly restore perfusion while stabilization proceeds.[6] • In adults with traumatic extremity injury, on repeated or continuous monitoring, delta pressure equals diastolic blood pressure minus intracompartmental pressure. A value above thirty millimeters of mercury may assist in ruling out acute compartment syndrome; thirty or less is concerning but not diagnostic and must be integrated with serial examination.[3] • Functional salvage requires meticulous debridement, stable bone, vascular repair, coordinated tendon and nerve reconstruction, durable soft-tissue coverage, and rehabilitation planned from the beginning.[4,5] This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #MangledUpperExtremity #LimbSalvage #OpenFracture #Revascularization #CompartmentSyndrome #HandTrauma #HandSurgery #PlasticSurgeryEducation #PlasticsInPractice References: 1. Yoneda H, Takeda S, Saeki M, et al. Utility of severity scoring systems for mangled upper limb salvage: a systematic review and meta-analysis. Injury. 2024;55(4):111447. doi:10.1016/j.injury.2024.111447 2. British Orthopaedic Association. BOAST - Open Fractures. Published December 2017. https://www.boa.ac.uk/resource/boast-4-pdf.html 3. American Academy of Orthopaedic Surgeons. Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline. 2025. https://www.aaos.org/acscpg2025 4. Macrì M, Pugliese P, Accardo G, et al. Current principles in the management of a mangled hand. J Hand Surg Glob Online. Published online August 21, 2024. doi:10.1016/j.jhsg.2024.07.009 5. Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. Eur J Orthop Surg Traumatol. 2022;32(3):395-403. doi:10.1007/s00590-021-03008-x 6. Wahlgren CM, Aylwin C, Davenport RA, et al. European Society for Vascular Surgery 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg. 2025;69(2):179-237. doi:10.1016/j.ejvs.2024.12.018

  • August 22 · 24 min

    Ligament Injuries of the Hand and Wrist

    A normal-looking radiograph can hide a ligament injury that becomes stiffness, deformity, or arthritis if it is missed.In this episode of Plastics in Practice, we connect reduction, stability testing, imaging, early motion, and operative decision points across finger, thumb, carpal, and distal radioulnar joint injuries.Key takeaways:• Treat the PIP joint as a motion emergency: permanent stiffness can develop within about two weeks. After reduction, confirm congruity and stability, then begin early protected motion when the joint is stable.[1]• Use the thirty-fifty rule as a guide for dorsal PIP fracture-dislocations: less than thirty percent articular involvement is usually stable, thirty to fifty percent is tenuous, and more than fifty percent is usually unstable. Clinical stability still overrides fragment size.[1]• Avoid axial traction during reduction of a dorsal finger MCP dislocation. Traction can pull the volar plate into the joint and convert a simple injury into an irreducible complex dislocation.• For a thumb UCL injury, no firm endpoint is the strongest red flag for a complete tear; angle thresholds vary. A Stener lesion places the adductor aponeurosis between the ligament and bone, blocking anatomic healing.[2,3]• A scapholunate gap around three millimeters or more, an angle above seventy degrees, or dorsal lunate tilt above fifteen degrees supports instability, but normal static films do not exclude a dynamic injury.[4]• On the lateral wrist radiograph, trace the radius, lunate, and capitate. Loss of collinearity plus median nerve symptoms is the perilunate warning pattern; outcomes are better when treatment begins within seven days than after delay.[5]This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#HandLigamentInjury #WristInstability #PIPJoint #SkierThumb #Scapholunate #Perilunate #HandSurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. Elfar J, Mann T. Fracture-dislocations of the proximal interphalangeal joint. J Am Acad Orthop Surg. 2013;21(2):88-98. doi:10.5435/JAAOS-21-02-882. Dean B, Rodrigues J, Riley N, et al. Guideline on managing thumb ulnar collateral ligament injuries: the British Society for Surgery of the Hand Evidence for Surgical Treatment findings and recommendations. J Hand Surg Eur Vol. 2024;49(10):1195-1201. doi:10.1177/175319342412746123. Qamhawi Z, Shah K, Kiernan G, et al. Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: systematic review and meta-analysis. J Hand Surg Eur Vol. 2021;46(9):946-953. doi:10.1177/17531934219930154. Dietrich TJ, Toms AP, Cerezal L, et al. Interdisciplinary consensus statements on imaging of scapholunate joint instability. Eur Radiol. 2021;31(12):9446-9458. doi:10.1007/s00330-021-08073-85. van der Oest MJW, Duraku LS, Artan M, et al. Perilunate injury timing and treatment options: a systematic review. J Wrist Surg. 2022;11(2):164-176. doi:10.1055/s-0041-1735841

  • August 17 · 20 min

    Principles of Tendon Transfers

    A tendon transfer can be perfectly woven and still fail if the joint is stiff, the tissue bed is scarred, or the donor cannot match the lost motion. In this episode of Plastics in Practice, we build a practical framework for tendon transfers—from donor selection and tensioning to radial, median, and ulnar nerve palsy reconstruction and postoperative retraining. Key takeaways: • Make the hand ready first: joints must be supple, and the transfer must glide through a quiet soft-tissue bed. A contracture release and tendon transfer require incompatible rehabilitation and should not be combined. • Match excursion and power: finger flexors provide about seventy millimeters of excursion, finger extensors fifty, and wrist motors thirty; a donor can lose up to one motor grade after transfer.[1,4] • Favor an expendable donor, a direct line of pull, synergistic motion, one donor for one function, and tension near the donor's working length.[1,4] • For high radial palsy, the classic FCR set restores wrist extension with PT to ECRB, finger MCP extension with FCR to EDC, and thumb extension with PL to a rerouted EPL. A fused wrist favors an FDS donor because tenodesis cannot supplement FCR excursion.[1,2] • Median palsy opponensplasty commonly uses FDS or EIP; the donor and pulley must recreate palmar abduction, flexion, and pronation rather than abduction alone.[3] • In ulnar palsy, a positive Bouvier test identifies simple clawing that may accept a static MCP block; a negative test signals complex clawing that needs dynamic intrinsic replacement. • Protect the transfer for four weeks, add passive stretching around week six, begin strengthening around week eight, and progress toward unrestricted activity at three months.[1] This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #TendonTransfer #RadialNervePalsy #MedianNervePalsy #UlnarNervePalsy #HandSurgery #PlasticSurgeryEducation #PlasticsInPractice References: 1. Gardenier J, Garg R, Mudgal C. Upper extremity tendon transfers: a brief review of history, common applications, and technical tips. Indian J Plast Surg. 2020;53(2):177-190. doi:10.1055/s-0040-1716456 2. Jain NS, Barr ML, Kim D, Jones NF. Tendon transfers, nerve grafts, and nerve transfers for isolated radial nerve palsy: a systematic review and analysis. Hand (N Y). 2024;19(3):343-351. doi:10.1177/15589447221150516 3. Coulshed N, Xu J, Graham D, Sivakumar B. Opponensplasty for nerve palsy: a systematic review. Hand (N Y). 2024;19(7):1037-1043. doi:10.1177/15589447231174481 4. Coulet B. Principles of tendon transfers. Hand Surg Rehabil. 2016;35(2):68-80. doi:10.1016/j.hansur.2015.12.011

  • August 15 · 23 min

    Upper Extremity Tenosynovitis and Tendinopathy

    Radial wrist pain, a locking digit, and lateral elbow pain can all be called overuse—but a few centimeters can change the diagnosis, treatment, and surgical target. In this episode of Plastics in Practice, we map de Quervain tenosynovitis, intersection syndrome, trigger finger, and lateral elbow tendinopathy from focused examination through splinting, injection, rehabilitation, and surgical release. Key takeaways: • Map radial-sided symptoms by location: de Quervain disease localizes at the radial styloid, while intersection syndrome produces dorsoradial pain and often crepitus four to six centimeters proximal to Lister tubercle. • De Quervain disease involves the APL and EPB in the first dorsal compartment; a separate EPB subcompartment can explain incomplete response after injection or release. • Current evidence supports considering corticosteroid injection plus three to four weeks of thumb-spica immobilization as first-line management for de Quervain disease; ultrasonography can help target anatomic subcompartments.[1,2] • Trigger finger localizes to the A1 pulley near the volar metacarpal head—even when the patient feels the click at the PIP joint. • Corticosteroid injection succeeds in roughly two thirds of trigger digits in pooled randomized trials; persistent locking, fixed contracture, or failed conservative care should prompt evaluation for A1 pulley release.[3] • Lateral epicondylitis is better framed as lateral elbow tendinopathy: confirm focal pain with grip or resisted wrist extension, consider radial tunnel symptoms, and avoid promising a rapid cure from any single intervention.[4] This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #Tenosynovitis #TriggerFinger #DeQuervain #HandSurgery #PlasticSurgeryEducation #PlasticsInPractice References: 1. Challoumas D, Ramasubbu R, Rooney E, et al. Management of de Quervain tenosynovitis: a systematic review and network meta-analysis. JAMA Netw Open. 2023;6(10):e2337001. doi:10.1001/jamanetworkopen.2023.37001 2. He KS, He KS, Cheah A, et al. Unblinding de Quervain: a systematic review of ultrasound-guided injection of corticosteroids for treatment of stenosing tenosynovitis of the first extensor compartment. J Med Radiat Sci. 2023;70(3):319-326. doi:10.1002/jmrs.681 3. Pathak SK, Salunke AA, Menon PH, et al. Corticosteroid injection for the treatment of trigger finger: a meta-analysis of randomised control trials. J Hand Surg Asian Pac Vol. 2022;27(1):89-97. doi:10.1142/S242483552250014X 4. Lowdon H, Chong HH, Dhingra M, et al. Comparison of interventions for lateral elbow tendinopathy: a systematic review and network meta-analysis for Patient-Rated Tennis Elbow Evaluation pain outcome. J Hand Surg Am. 2024;49(7):639-648. doi:10.1016/j.jhsa.2024.03.007

  • August 15 · 27 min

    Extensor Tendon Surgery: Zones, Traps, and Early Motion

    Extensor tendon injuries are easy to underestimate: a small dorsal wound can conceal a complete laceration, a contaminated MCP joint, or a central slip injury that declares itself later. In this episode of Plastics in Practice, we review the examination, zone-based repair strategy, rehabilitation, complications, and reconstruction of extensor tendon injuries. Key takeaways: • Use the eight-zone map to localize injury and choose a repair and rehabilitation plan; odd-numbered zones lie over joints. • Test beyond simple active extension: juncturae can mask a complete zone-six EDC laceration, the Elson test assesses the central slip, and table-top thumb lift helps isolate EPL function. • Repair lacerations involving more than half of the tendon in zone two, the zone-three central slip, and zone four; avoid unnecessary bulk or shortening in the thin distal mechanism. • Treat a zone-five fight bite as a contaminated joint injury—explore the capsule, debride and irrigate, and defer tendon repair until the wound is clean. • Match rehabilitation to repair strength: zones one and two usually need continuous extension protection for six to eight weeks, while stronger repairs in zones four through eight can support protected early motion. Recent randomized trials support relative-motion extension protocols for selected zone-four to zone-six repairs.[1,2] • Anticipate extensor lag, loss of flexion, adhesions, and tendon rupture; consider tenolysis only after a sustained therapy plateau and use grafts or tendon transfers selectively. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #ExtensorTendonSurgery #HandSurgery #TendonRepair #PlasticSurgeryEducation #SurgicalPearls #PlasticsInPractice References: 1. Cela-López M, Méndez-Pérez C, Domínguez-Prado DM, et al. Relative motion extension orthosis versus classic immobilization in extensor tendon repairs (zones IV-VI of the hand): a randomized controlled trial. Hand (N Y). Published online February 27, 2026. doi:10.1177/15589447261422483 2. Hirth MJ, Hunt I, Briody K, et al. Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: a randomized equivalence trial. J Hand Ther. 2023;36(2):347-362. doi:10.1016/j.jht.2021.06.006

  • August 13 · 28 min

    Flexor Tendon Repair: Strength, Glide, and Early Motion

    Flexor tendon repair succeeds only when construct strength, tendon glide, pulley preservation, and rehabilitation are planned as one system. In this episode of Plastics in Practice, we review the evaluation, zone-based strategy, repair principles, rehabilitation, complications, and salvage of flexor tendon injuries. Key takeaways: • Detect loss of the normal cascade or tenodesis effect, test flexor digitorum profundus and superficialis independently, and document neurovascular status. • Let the injury zone drive exposure and repair; zone II demands especially careful sheath and pulley management. • Build a strong, smooth multistrand repair with accurate tendon-end coaptation and no obstructive bulk at the repair interface.[1,2] • Preserve the critical A2 and A4 pulleys when possible, and vent judiciously when needed to restore free tendon glide.[1,2] • Begin therapist-directed protected motion early when the construct, associated injuries, and patient factors permit. The 2026 IFSSH consensus favors true early active flexion, whereas a 2024 randomized trial found better five-year motion after passive mobilization with place-and-hold; protocol choice remains debated and should be individualized.[1-3] • Recognize adhesions, gapping or rupture, bowstringing, quadriga, lumbrical-plus, and the situations that require grafting or staged reconstruction. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #FlexorTendonRepair #HandSurgery #TendonRepair #PlasticSurgeryEducation #SurgicalPearls #PlasticsInPractice References: 1. Miller EA, Teal L. Principles for achieving predictable outcomes in flexor tendon repair. Clin Plast Surg. 2024;51(4):445-457. doi:10.1016/j.cps.2024.02.011 2. Tang JB, Lalonde D, Fernandes CH, Sadek AF, Besmens IS. The IFSSH consensus and current guidelines on flexor tendon repairs and reconstruction. J Hand Surg Eur Vol. 2026;51(2):127-138. doi:10.1177/17531934251404821 3. Chevalley S, Wängberg V, Åhlén M, Strömberg J, Björkman A. Passive mobilization with place-and-hold versus active mobilization therapy after flexor tendon repair: 5-year minimum follow-up of a randomized controlled trial. J Hand Surg Am. 2024;49(12):1165-1172. doi:10.1016/j.jhsa.2024.08.011

  • August 12 · 17 min

    Wrist Fractures: Distal Radius and Scaphoid Decision Points

    Wrist fracture decisions turn on a few measurements, but the right threshold depends on the patient, the image, and the bone. In this episode of Plastics in Practice, we review distal radius and carpal fractures with an emphasis on reduction, fixation, and the diagnostic traps that change management. Key takeaways: • Document median nerve function and distal radioulnar joint stability before and after distal radius reduction. • In study-defined non-geriatric adults, post-reduction radial shortening greater than three millimeters, dorsal tilt greater than ten degrees, or intra-articular displacement or step-off greater than two millimeters supports operative fixation.¹ • Age sixty-five is a study proxy, not a biologic cutoff. Functional demand and patient priorities still matter, and routine fixation has not improved long-term patient-reported outcomes in geriatric cohorts.¹ • Fixation constructs have similar long-term outcomes; volar locking plates mainly offer earlier functional recovery.¹ • A negative scaphoid radiograph does not close the case. Immobilize a clinically suspicious wrist, obtain early MRI for an occult fracture, and use long-axis CT when a fracture is visible.² • Initial below-elbow casting is appropriate for bicortical scaphoid waist fractures displaced two millimeters or less, with prompt fixation if nonunion is confirmed.²˒³ • Fixation is favored beyond two millimeters of scaphoid waist displacement, for any displaced proximal-pole fracture, or with an unstable carpal injury. Confirm union before discharge.² This content is for education only and does not replace clinical judgment, institutional protocols, or individualized patient care. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #HandSurgery #WristFracture #DistalRadiusFracture #ScaphoidFracture #SurgicalEducation #PlasticsInPractice References: 1. American Academy of Orthopaedic Surgeons. Management of Distal Radius Fractures Evidence-Based Clinical Practice Guideline. Published December 5, 2020; adopted by the American Society for Surgery of the Hand May 22, 2021. https://www.aaos.org/globalassets/quality-and-practice-resources/distal-radius/drfcpg.pdf 2. British Society for Surgery of the Hand. Scaphoid Fractures: Standards for Trauma. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/Scaphoid%20standards.pdf 3. Dias JJ, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT). Lancet. 2020;396:390–401. doi:10.1016/S0140-6736(20)30931-4

  • August 9 · 18 min

    Hand Fractures: Reduction, Fixation, and Early Motion

    Hand fracture outcomes often hinge on what radiographs miss — rotation, post-reduction stability, and whether fixation permits early motion. In this episode of Plastics in Practice, we review metacarpal and phalangeal fracture management — rotational alignment, stability, fixation strategy, early motion, thumb-base injuries, proximal interphalangeal joint fracture-dislocations, and complications. Key takeaways: • Examine each injured digit in maximal extension and flexion. Scissoring reveals malrotation; persistent rotation after reduction is operative.³ • Stable, nondisplaced closed fractures usually need splinting or buddy taping, early motion, and radiographs at seven to ten days. Clinical union commonly takes three to four weeks.¹ • Open hand fractures except tuft fractures need same-day review and antibiotics. Treat definitively — or wash out and close — within twenty-four hours; stop antibiotics after closure or by seventy-two hours, whichever comes first.² • Selected isolated, closed fifth-metacarpal neck fractures with less than seventy degrees of volar angulation and no rotation can do well with buddy taping and early motion. Open, complex, displaced, rotational, or occupation-limiting patterns need separate judgment.³,⁴ • Choose the least invasive construct that holds reduction and permits motion. Use at least two K-wires in different planes for rotational control; plates add rigidity but also dissection and tendon-adhesion risk.¹,⁷ • For a Bennett fracture, restore a stable, concentric thumb carpometacarpal joint. Less than one millimeter of step-off is a target, not an absolute cutoff; congruity and stability drive treatment.⁶ • For a dorsal proximal interphalangeal joint fracture-dislocation, less than thirty percent involvement is usually stable, thirty to fifty percent is tenuous, and more than fifty percent is usually unstable. Confirm dynamically after reduction.⁵ This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #HandFractures #MetacarpalFracture #PhalanxFracture #BennettFracture #PIPFractureDislocation #PlasticsInPractice #SurgicalEducation References: 1. BSSH. Closed hand fractures. Standards of Care in Hand Trauma. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/1%20Closed%20hand%20fractures%20final.pdf 2. BSSH. Open fractures other than tuft fractures. Standards of Care in Hand Trauma. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/2%20Open%20fractures%20Final.pdf 3. BSSH. Fifth metacarpal neck fractures. Standards of Care in Hand Trauma. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/9%20Metacarpal%20neck%20fractures.pdf 4. Martínez-Catalán N et al. Buddy taping versus reduction/casting for fifth-metacarpal neck fractures. J Hand Surg Am. 2020;45:1134-1140. doi:10.1016/j.jhsa.2020.05.013 5. Tyser AR et al. Stability of acute dorsal PIP fracture-dislocations. J Hand Surg Am. 2014;39:13-18. doi:10.1016/j.jhsa.2013.09.025 6. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett's fracture. J Hand Surg Br. 1990;15(1):58-61. doi:10.1016/0266-7681_90_90049-A 7. Curtis BD et al. Metacarpal shaft fixation: biomechanical comparison. Orthop Surg. 2015;7:256-260. doi:10.1111/os.12195

  • August 8 · 23 min

    Upper Extremity Nerve Injuries and Compression Neuropathies

    Peripheral nerve deficits are a race against irreversibledenervation — misclassify the lesion or miss the level of compression, and observation becomes lost recovery time. In this episode of Plastics in Practice, we review traumaticperipheral nerve injury and the compression neuropathies that matter across the median, ulnar, and radial nerves — how to classify the lesion, time electrodiagnostic testing, recognize localization traps, and choose observation versus decompression or repair. Key takeaways: · Neurapraxia is a conduction block with intactaxons and expected recovery within two to three months; axonotmesis regeneratesat roughly one millimeter per day under ideal conditions; neurotmesis requiressurgical coaptation. · Neurologic deficits after penetrating trauma arepresumed neurotmetic and warrant early exploration. Primary repair is ideallyperformed within seventy-two hours for a sharp, clean laceration, while mostgunshot deficits are concussive and initially observed. · After axonal injury, distal nerve-conductionabnormalities develop over one to two weeks and EMG fibrillations appear at three to four weeks; electrodiagnostic testing is traditionally repeated at four to six weeks. · If a closed deficit shows no clinical orelectrodiagnostic recovery by three to six months, exploration is generally recommended. Denervated muscle loses an estimated one percent per week, and significant motor recovery is unlikely beyond twelve to eighteen months. · Nocturnal radial-digit paresthesias with sparedthenar-eminence sensation support carpal tunnel syndrome; activity-related symptoms involving the thenar eminence suggest pronator syndrome; an isolatedfailed “OK” sign without sensory loss suggests anterior interosseous syndrome. · Dorsoulnar sensory loss localizes ulnarcompression to the elbow rather than Guyon canal. Within Guyon canal, Zone I produces mixed deficits, Zone II motor deficits, and Zone III sensory deficits. · Radial tunnel syndrome is pain-only with normalstrength, posterior interosseous syndrome is painless motor loss, and Wartenberg syndrome is sensory-only. This content is for educational purposes only and is notmedical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon:https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #UpperExtremity#PeripheralNerve #CompressionNeuropathy #CarpalTunnel #CubitalTunnel#PlasticsInPractice #SurgicalEducation References: 1. Seddon HJ. A classification of nerve injuries. Br Med J.1942;2:237-239. 2. Sunderland S. A classification of peripheral nerveinjuries producing loss of function. Brain. 1951;74:491-516. 3. Rydevik B, Lundborg G, Bagge U. Effects of gradedcompression on intraneural blood flow. An in vivo study on rabbit tibial nerve.J Hand Surg Am. 1981;6:3-12. 4. Gelberman RH, Aronson D, Weisman MH. Carpal-tunnelsyndrome. Results of a prospective trial of steroid injection and splinting. JBone Joint Surg Am. 1980;62:1181-1184. 5. Johnson RK, Spinner M, Shrewsbury MM. Median nerveentrapment syndrome in the proximal forearm. J Hand Surg Am. 1979;4:48-51. 6. Apfelberg DB, Larson SJ. Dynamic anatomy of the ulnarnerve at the elbow. Plast Reconstr Surg. 1973;51:79-81. 7.Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anteriortransposition compared with simple decompression for treatment of cubitaltunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone JointSurg Am. 2007;89:2591-2598

  • May 31 · 23 min

    Hand Infections: Diagnosis and Management

    Hand infections deteriorate fast — the same anatomy that gives the hand its function turns ordinary swelling into ischemia, tendon necrosis, and permanent loss of motion. This episode walks through how to recognize and manage everything from paronychia and felon to pyogenic flexor tenosynovitis, deep space infections, bite injuries, and necrotizing fasciitis — with the surgical pitfalls every resident needs to know cold. In this episode of Plastics in Practice, we cover the anatomy that makes the hand vulnerable, when to splint and when to cut, the Kanavel signs you'll be quizzed on, the herpetic whitlow trap, the high-mortality red flags of nec fasc, and how rising community-acquired MRSA changes empiric antibiotic selection. Key takeaways: • Drainage is non-negotiable for any abscess. Antibiotics are an adjunct, not a substitute. • Never infiltrate local anesthesia into cellulitis — it spreads the infection. Use regional blocks for deep space infections. • Herpetic whitlow is medical, not surgical. Cutting risks systemic viral spread. Confirm with Tzanck smear. • Kanavel's four signs of pyogenic flexor tenosynovitis: semi-flexed digit, fusiform swelling, tenderness along the sheath, pain on passive extension. • Clenched-fist bite injuries seed the MCP joint. Polymicrobial with Eikenella — admit, x-ray, tetanus, and explore in the OR if the extensor mechanism is breached. • Necrotizing fasciitis carries up to 40% mortality. Bright shiny skin, nonpitting edema, violaceous patches — broad-spectrum antibiotics and aggressive debridement now. • Community-acquired MRSA is rising. Culture before empiric antibiotics whenever possible. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #HandInfections #UpperExtremity #SurgicalEducation #PlasticsInPractice #Tenosynovitis

  • May 28 · 17 min

    Upper Extremity Anesthesia Essentials

    Upper extremity surgery is, at its core, a regional anesthesia specialty. Choose the right block in the right place and most hand and arm cases never need general anesthesia. In this episode of Plastics in Practice, we work through the practical anesthesia decision tree for the upper extremity: brachial plexus block locations and their trade-offs, peripheral nerve blocks at the elbow and wrist, the Bier block, digital block techniques, and the modern, evidence-based truth about epinephrine in the finger. Key takeaways: - Severe systemic toxicity is almost always an intravascular accident - aspirate before every injection, and never trust pain as a safety signal in a sedated or proximally blocked patient. - Interscalene for the shoulder, supraclavicular for fast complete arm anesthesia, infraclavicular for elbow and distal, axillary for the hand. - Brachial plexus blocks take 15-25 minutes to mature - perform them in a dedicated block area about 30 minutes before incision. - Bier blocks fit cases under 60 minutes. Keep the tourniquet up for 30 minutes minimum and cycle it down in three releases. - Epinephrine 1:200,000 is safe in fingers and hands - the necrosis fears come from pre-1950s procaine and cocaine reports. - Single subcutaneous volar digital block beats the transthecal block on onset and pain. This content is for educational purposes only and is not medical advice. Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ Free Study Guides: https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #UpperExtremity #RegionalAnesthesia #BrachialPlexus #SurgicalEducation #PlasticsInPractice

  • May 25 · 17 min

    Functional Anatomy and Principles of Upper Extremity Surgery

    Every hand case rests on the same foundation: knowing which joints need mobility, which need stability, and how to run an acute hand with a trauma-first mindset. Get this layer right, and every chapter after it makes sense. In this episode of Plastics in Practice, we cover the foundational anatomy and operative principles of the upper extremity: how the thumb, finger, and wrist joints differ in their tolerance for stiffness and instability; the classic deformities (swan-neck, boutonniere, DISI, VISI) and the ligaments that produce them; the acute hand workup from "life over limb" through ER reduction; how to image and describe fractures in anatomic terms rather than eponyms; intrinsic plus splinting; safe tourniquet use; Bruner incisions; and why elevation is the single most important postoperative instruction you'll ever give. Key takeaways: MCP joints have low tolerance for stiffness; the DIP tolerates it well - stability matters more there than motion. Volar plate disruption at the PIP causes swan-neck; central slip rupture causes boutonniere - opposite mechanisms, opposite deformities. Scapholunate ligament tear leads to DISI; lunotriquetral tear leads to VISI. The lunate follows the ligament that's still intact. Tourniquet time should be 90 to 120 minutes max to avoid ischemic reperfusion injury; pressure about 100 mmHg above systolic. Splint in the intrinsic plus position: wrist in slight extension, MCPs flexed, IPs extended. Routine soft-tissue cases under 2 hours: postop antibiotics show no clear benefit. Open fractures and bony work: 24 hours of perioperative IV coverage. Bruner zigzag incisions across the volar finger and palm prevent contracture; never cross flexion creases perpendicularly. This content is for educational purposes only and is not medical advice. Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ Free Study Guides: https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #UpperExtremity #SurgicalEducation #PlasticsInPractice #HandAnatomy #BoardReview

  • May 24 · 23 min

    Lymphedema: Diagnosis and Treatment

    Lymphedema is the chronic disease plastic surgeons are best positioned to treat — and the most commonly mismanaged. After axillary node dissection, up to 50% of breast cancer patients develop it, and most never get the early, disciplined care that prevents progression to fibrofatty disease. In this episode of Plastics in Practice, we review the essentials of lymphedema management — from how the lymphatic system fails to the diagnostic threshold (2 cm or 200 ml difference), staging by the International Society of Lymphology, the role of Complex Decongestive Therapy as the gold-standard nonsurgical approach, and how to think about surgery: physiologic methods like lymphaticovenous bypass and vascularized lymph node transfer, versus reductive options like liposuction and direct excision. We also cover the late complications residents should not miss — recurrent cellulitis, and the rare but devastating Stewart-Treves lymphangiosarcoma. Key Takeaways: Diagnostic threshold: limb circumference difference > 2 cm or volume increase > 200 ml is clinically significant. Up to 50% of patients with axillary lymph node dissection develop lymphedema; only 4–7% after sentinel node biopsy. Complex Decongestive Therapy (CDT) is the gold-standard nonsurgical management — Phase 1 intensive (4–6 weeks), Phase 2 maintenance for life. ISL staging: Stage 0 latent → Stage I pitting → Stage II non-pitting fibrofatty → Stage III lymphostatic elephantiasis. Physiologic surgery (lymphaticovenous bypass, vascularized lymph node transfer) can reduce limb volume ~35% at 12 months in selected patients. Liposuction is the workhorse for non-pitting, fibrofatty lymphedema — requires ≥ 600 ml volume difference, failed 3 months of CDT, and lifelong compression after surgery. Stewart-Treves lymphangiosarcoma: rare but aggressive — 5-year survival < 10%, average survival 19 months after diagnosis. Always biopsy suspicious nodules in a long-standing lymphedematous limb. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #Lymphedema #BreastReconstruction #SurgicalEducation #PlasticsInPractice #Microsurgery #Liposuction

  • May 19 · 24 min

    Pressure Sore Fundamentals

    Pressure sores are the wound the plastic surgeon gets consulted on after everything else has gone wrong — and the recurrence rate is brutal if you skip the basics. The lesson nobody teaches you in residency is that the surgery is the easy part. In this episode of Plastics in Practice, we review the basics of pressure sore management: the pathophysiology of pressure-time injury, the six-stage NPUAP system, what you absolutely have to optimize preoperatively (albumin, A1c, spasm, contractures, osteomyelitis), how to choose between fasciocutaneous and musculocutaneous flaps for ischial, sacral, and trochanteric defects, and why the recurrence numbers stay high no matter what flap you pick. Key takeaways: - Tissue injury starts deep — muscle over bone fails first, the skin lesion is just the tip of the iceberg. - Capillary perfusion fails above ~32 mm Hg; five minutes of off-loading every two hours is enough to prevent breakdown even at high pressures. - Pressure x time is parabolic: 500 mm Hg for 2 hours or 100 mm Hg for 10 hours both kill muscle. Skin ulcerates last. - Optimize before you operate: albumin >2.0 g/dL, A1c <6%, control spasm (baclofen, dantrolene, botulinum toxin), treat osteomyelitis surgically — not medically. - Avoid primary closure and skin grafts — these wounds have a true tissue deficit. Use flaps. - Fasciocutaneous vs. myocutaneous: in a 94-patient series there was no difference in recurrence, complications, or morbidity — pick the flap that preserves future options. - Avoid radical ostectomy — total ischiectomy redistributes pressure and creates the next ulcer. - Recurrence after flap closure runs ~39%; the most vulnerable window is the first 15–22 months. - Watch for Marjolin ulcer in long-standing wounds — aggressive SCC with metastatic rates over 60%; wide excision is the answer. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #PressureSores #WoundCare #SurgicalEducation #PlasticsInPractice #Reconstruction #PressureUlcer

  • May 17 · 20 min

    Perineal Reconstruction: Principles and Flap Selection

    Few regions punish poor planning like the perineum — the pelvic outlet sits at the crossroads of the urinary, gynecologic, and GI tracts, and the wrong flap choice in an irradiated or contaminated field gets you back in the OR fast. In this episode of Plastics in Practice, we walk through the core principles of perineal reconstruction: anatomy and vascular supply, the reconstructive ladder, pelvic dead-space management, and the workhorse flaps you actually need to know — VRAM, gracilis, posterior thigh, Singapore, and the greater omentum. We finish with functional restoration in both female and male patients, including the Cordeiro classification for acquired vaginal defects, scrotal reconstruction after Fournier's, and the basics of microsurgical penile replantation. Key takeaways: The perineum is a diamond between the pubic symphysis, ischial tuberosities, and coccyx — anterior urogenital triangle and posterior anal triangle.¹ Pelvic dead space after APR or exenteration is dangerous — fill it with a well-vascularized flap to cut abscess, dehiscence, and bowel-obstruction risk.² VRAM is the workhorse for combined pelvic and perineal defects; it beats thigh flaps on major complications in this setting.³ Gracilis is the workhorse when you don't want a laparotomy — versatile, low donor morbidity, but watch the short pedicle and unreliable skin paddle for large defects.⁴ Singapore flap is the go-to for vaginal reconstruction — sensate, axial, and preserved by the superficial perineal artery. Use the Cordeiro classification for acquired vaginal defects: IA → Singapore, IB → VRAM, IIA → rolled rectus, IIB → bilateral gracilis.⁵ Scrotal reconstruction after Fournier's: up to 50% primary closure; otherwise meshed STSG with tunica vaginalis intact and spermatic cords sewn together first.⁶ Penile replantation: microsurgical repair within 6 h warm or 16 h cold ischemia — urethra, tunica albuginea, dorsal artery and vein, dorsal nerve, plus suprapubic cystostomy.⁶ This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #PerinealReconstruction #VRAM #PlasticsInPractice #FournierGangrene #VaginalReconstruction #SurgicalEducation References (AMA): Tran PH, Lemaine V. Reconstruction of the perineum. In: Thorne CH, ed. Grabb & Smith's Plastic Surgery. 8th ed. Butler CE, Rodriguez-Bigas MA. Pelvic reconstruction after abdominoperineal resection: is it worthwhile? Ann Surg Oncol. 2005;12:91-94. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175-183. Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for complex pelvic and perineal reconstruction. Plast Reconstr Surg. 2010;126:146-155. Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002;110:1058-1065. Campbell MF, Wein AJ, Kavoussi LR. Campbell-Walsh Urology. 9th ed. Saunders; 2007.

  • May 15 · 21 min

    Foot and Ankle Reconstruction: Core Principles

    Saving a foot is rarely about the flap. It's about the angiosome you re-perfuse, the millimeters of debridement you take, and whether you lengthen a tight Achilles before you ever think about closure. In this episode of Plastics in Practice, we cover the principles of foot and ankle reconstruction: the six angiosomes and how they should drive every revascularization, incision, and flap design; the role of the multidisciplinary team in salvaging a limb that traditionally would have been amputated; and the practical algorithm for moving a chronic wound to closure — debridement, NPWT, dermal templates, and the simple techniques that resolve roughly 90% of these wounds without ever needing a microsurgical free flap. We finish with a location-by-location reconstructive playbook from forefoot to hindfoot, including why Achilles tendon lengthening is the single highest-yield biomechanical move in the diabetic forefoot. Key takeaways: - The 5-year mortality after major lower-limb amputation in diabetics exceeds 50% — higher than colon or breast cancer. - The angiosome concept divides the foot into six vascular territories; direct revascularization of the affected angiosome increases healing 50% and decreases major amputation fourfold. - Biofilm exists in >90% of chronic wounds and penetrates up to 4 mm — debridement, not coverage, is the rate-limiting step. - Achilles tendon lengthening cuts diabetic forefoot ulcer recurrence in half at 2 years and is the single highest-yield biomechanical intervention. - Roughly 90% of foot and ankle wounds heal with simple techniques; only ~10% require flap reconstruction. - For plantar coverage, the medial plantar fasciocutaneous flap remains the workhorse — sensate, durable, glabrous skin with a wide arc of rotation. - Free flaps to the foot have the highest failure rate of any anatomic location; anastomose outside the zone of injury and use end-to-side to spare a major vessel. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #FootAndAnkleReconstruction #LimbSalvage #SurgicalEducation #PlasticsInPractice #DiabeticFoot #Microsurgery

  • May 14 · 25 min

    Lower Extremity Reconstruction: Core Principles

    Lower extremity reconstruction is the most unforgiving testing ground in plastic surgery — every decision is graded by whether the patient can bear weight, walk, and protect a sensate foot for the rest of their life. In this episode of Plastics in Practice, we walk through the core principles of lower extremity salvage: the zone-of-injury concept, when to fix vs. amputate, fracture management, soft-tissue coverage by leg third, and the trade-offs between limb salvage and a well-fit below-knee amputation. Key takeaways Salvage is judged against amputation, not “normal.” The goal is a limb more functional than a prosthesis — loss of the tibial nerve and plantar sensibility is a relative contraindication. Stabilize the skeleton first. Vascular and nerve repairs done before fixation are routinely disrupted during fracture reduction; external fixation is the workhorse for grade IIIB / IIIC injuries. Early soft-tissue coverage wins. Closure within 72 hours of injury carries the lowest complication rate; delayed closure (1–6 weeks) climbs to ~50%. Match the flap to the leg third: gastrocnemius proximal, soleus middle, free tissue distal. Bone gaps have a tiered answer: cancellous graft for short defects, Ilizarov distraction for 4–8 cm gaps, vascularized fibula up to ~24 cm. VAC therapy buys time, not closure. It improves the bed and reduces flap size, but use beyond 7 days is associated with higher infection and amputation rates in IIIB tibias. BKA is a reconstructive choice, not a failure. It adds ~25% to the energy cost of ambulation vs. ~65% for AKA; preserve the knee whenever possible, including with a foot-fillet free flap from the amputated part. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #LowerExtremityReconstruction #LimbSalvage #PlasticsInPractice #Microsurgery #FreeFlap

  • May 13 · 22 min

    Abdominal Wall Reconstruction: Core Principles

    Abdominal wall reconstruction is where plastic surgery principles get tested in real time — and it's where most failures start with one wrong assumption about force distribution. In this episode of Plastics in Practice, we review the basics of abdominal wall reconstruction: how to think about the abdomen as a pressurized cylinder, why supported repairs beat bridged repairs almost every time, how to read the components separation technique like a physiology problem instead of a memorization problem, and how to choose between synthetic and bioprosthetic mesh in a contaminated field. We close with soft tissue strategy — when to skin graft early, when to reach for a perforator flap, and how to decide between rebuilding the wall first or rebuilding the cover first. Key takeaways: Hernias expand because sutures cut through tissue like a wire through ice — load-sharing supported repairs are the answer, not bigger primary sutures. Large hernias convert isometric abdominal contraction into isotonic shortening, derailing diaphragm function and torso mechanics — repair restores physiology, not just anatomy. Components separation can move each rectus 8–10 cm to the midline through external oblique release alone; preserving periumbilical perforators is what keeps the skin alive. Synthetic mesh is for clean fields. Bioprosthetic mesh is for contamination, radiation, bowel suture lines, or any field where the soft tissue cover might fail. In the open abdomen, early skin grafting over granulated bowel is your friend — it heals in two dimensions and tolerates poor nutrition far better than flaps. If the hernia is expanding, it's ready to repair — that means the adhesions have softened enough to dissect cleanly. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #AbdominalWallReconstruction #HerniaRepair #SurgicalEducation #PlasticsInPractice #GeneralSurgery #ComponentsSeparation

  • May 12 · 28 min

    Chest Wall Reconstruction Essentials

    Chest wall reconstruction is where rigid skeletal support and versatile soft tissue coverage meet — and where a wrong flap choice or a missed debridement step turns a small defect into a respiratory disaster. In this episode of Plastics in Practice, we review the basics of chest wall reconstruction: the anatomy that drives every decision, when you actually need to rebuild the skeleton, how to classify and treat sternal wound infections, and how to pick the right flap based on the location and depth of the defect. Key takeaways: Skeletal reconstruction is classically indicated for defects involving four or more ribs or greater than 5 cm in diameter — but posterior and superior defects often tolerate soft tissue coverage alone.¹ Methylmethacrylate–mesh "sandwich" gives you rigid protection for large anterior defects, but its rigidity can cost you respiratory comfort.¹ Pectoralis major is the workhorse for the upper and middle sternum; for the lower sternum, think IMA-perforator turnover flap or rectus abdominis (VRAM/TRAM).² Omentum is your bailout when local flaps fail — large surface area, thin, perfect for wrapping vascular grafts — but you're paying for it with a laparotomy.³ Bilateral IMA harvest strips the sternum of its segmental blood supply and dramatically raises mediastinitis risk; sternal plating is reserved for high-risk re-operative patients.⁴ Sternal wound infections are classified by timing: Class 1 (early, sterile), Class 2 (1–3 weeks, purulent mediastinitis), Class 3 (chronic draining sinus). Class 2 and 3 demand thorough debridement plus flap coverage.⁵ Single-stage radical debridement with concurrent flap coverage has comparable success to staged debridement — pick based on the patient and the wound, not dogma.⁵ This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #ChestWallReconstruction #ReconstructiveSurgery #SurgicalEducation #PlasticsInPractice #Mediastinitis #FlapSurgery References: Carey JN, Otake LR, Echo A, Lee GK. Chest Wall Reconstruction. In: Thorne CH, ed. Grabb and Smith's Plastic Surgery. 7th ed. Wolters Kluwer; 2014. Coleman JJ 3rd, Bostwick J. Rectus abdominis muscle-musculocutaneous flap in chest-wall reconstruction. Surg Clin North Am. 1989 Oct;69(5):1007-1027. Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction. Thorac Surg Clin. 2010 Nov;20(4):543-550. Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg. 1996 Oct;98(5):804-810. Lee CH, Hsien JH, Tang YB, Chen HC. Reconstruction for sternal osteomyelitis at the lower third of sternum. J Plast Reconstr Aesthet Surg. 2010 Apr;63(4):633-641.

  • May 10 · 22 min

    Hair Transplantation Essentials

    Hair restoration is one of the most planning-dependent procedures in plastic surgery — a single wrong call on the hairline or the donor strip can show up for the rest of the patient's life. In this episode of Plastics in Practice we walk through what residents actually need to know about modern hair transplantation: how to evaluate the donor area, how to think about lifetime donor yield, the trade-offs between strip excision and FUE, graft preparation and the out-of-body clock, recipient site design (hairline placement, angle and direction, ethnic and gender variations), postoperative management, and where finasteride, minoxidil, and PRP fit in. Key takeaways: The Safe Donor Area (SDA) defines what is truly permanent — and a 30-year-old destined for Norwood V/VI averages roughly 5,393–6,404 lifetime FUs from average-density donor scalp.¹ Strip excision still dominates (~88.5% of cases) vs. FUE (~11.5%); transection rates can be pushed below 10–15% with tumescent solutions and skin-hook technique.² Graft survival drops about 1% per hour out of body — chilled saline gives ~88% survival at 8 hours; pear-shaped grafts under 6× magnification protect the bulb, sebaceous glands, and dermal papilla.³ Hairline placement: never too low. The mid-frontal point lives where the vertical forehead transitions to the horizontal scalp, ~7–10 cm above the glabella. Build in micro- and macro-irregularities so it never reads as a wall.⁴ Density target for natural long-term coverage in younger patients is 25–30 FU/cm²; high-density "dense packing" >30 FU/cm² is reserved for ideal donor/recipient profiles.⁴ Adjuncts matter: finasteride 1 mg is ~87% effective at slowing AGA progression; topical minoxidil reduces postoperative effluvium and is encouraged 5–12 weeks post-op.⁵,⁶ Cicatricial alopecia (post-facelift, burn, traction): keep recipient density conservative at 15–20 FU/cm² to avoid overwhelming a compromised blood supply.⁷ This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HairTransplantation #FUT #FUE #SurgicalEducation #PlasticsInPractice #HairRestoration #Aesthetic #SurgicalPearls References: 1. Unger W, Unger R, Wesley C. Estimating the number of lifetime follicular units: a survey and comments of experienced hair transplant surgeons. Dermatol Surg. 2012;1-6. 2. Pathomvanich D. Donor harvesting; a new approach to minimize transection of hair follicles. Dermatol Surg. 2000;26:345-348. 3. Limmer R. Micrograft survival. In: Stough D, Haber R, eds. Hair Replacement. St. Louis, MO: Mosby Press; 1996:147-149. 4. Shapiro R. Principles of creating a natural hairline. In: Unger W, Unger R, Unger M, Shapiro R, eds. Hair Transplantation. 5th ed. New York, NY: Marcel Dekker; 2011:374-382. 5. Rossi A. Finasteride, 1 mg daily administration on male androgenetic alopecia and different age groups: 10-year follow up. Dermatol Ther. 2011;24(4):455-461. 6. Bohannon P. Topical minoxidil used before and after hair transplantation. J Dermatol Surg Oncol. 1989;15:50-53. 7. Unger W, Unger R, Wesley C. The surgical treatment of cicatricial alopecia. Dermatol Ther. 2008;21(4):295-311.

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