In week 5, we returned to the normal flow of our hospital routine. The Plastics Conference for the week consisted of a background lecture by Dr. Otterburn overviewed the history and current practices of muscle flap procedures, including a discussion of the development of the angiosome concept, of the being composite tissue blocks or 3D vascular territories supplied by arteries and veins. He discussed the time frame for flap/graft integration as well as the ischemic window within which different tissues remain viable for transplantation, from as little as 1 hour for intestinal tissue to as much as 24 hours for bone/skin.
As always, clinical hours with Dr. Spector provided us with exposure to a spectrum of cases, from cosmetic modifications to patients requiring extensive reconstructive procedures. I noted one case in particular where Dr. Spector had consulted with a patient whom had sustained severe burn injuries in her teens 16+ years ago. The accident affected the skin from her lower lip down to her clavicle, which over the years continued to undergo contracture to the point of causing severe muscle and bone deformation. Ideally, multiple procedures would be employed as tissue expanders could be implanted and gradually be used to generate sufficient amount of her non-scarred tissue for coverage of the defect region after freeing the contracted tissue region. However, they discuss and weigh this option versus performing an Integra/split thickness skin graft procedure, as this would be more feasible to coordinate within the limited time window for her travel visa, as well as her having to potentially pay out of pocket for these procedures.
The week was also when Plastics held their monthly Morbidity and Mortality conference, wherein residents and surgeons reviewed major case complications and critique their chosen treatment methodology. One of these cases happened to be a patient of Dr. Spector’s, where they were suspected of having an uncommon condition known as pyoderma gangrenosum. It is a chronic condition where afflicted tissue becomes necrotic, and the etiology remains poorly understood. It is suspected to arise due to dysfunction of the patient’s immune system, particularly in the function of the neutrophils. What had initially led Dr. Spector to suspecting this particular condition had been two previous cases with treating this same patient, where two muscle flaps had initially appeared to successfully integrate, only to become heavily necrotic in a span of 2 weeks. The surgeons discuss the case, but are unable to determine a clear route for treatment beyond debriding/irrigating the site followed by vac placement, as any surgical intervention introduces some degree of tissue trauma and causes the wound site to become further inflamed/necrose further.
Following M&M, we (Aaron and I), were invited to attend their Journal Club, wherein they reviewed several chosen papers from the Journal of Plastic and Reconstructive Surgery. Later into the night reps from Medtronic, whom hosted the evening event, demoed the PEAK PlasmaBlade, which is designed to replace the traditional Bovie cautering device. It is interesting to hear their exchange with the surgeons about the different ways in which they implement the device, such as interchanging the different Bovie tips depending on the task at hand excising through layers of tissue vs pinpoint precision), or how the generator system can support multiple monopolar/bipolar instruments simultaneously. It becomes apparent that the people designing these types of instrumentation would greatly benefit from some clinical exposure, as it aides in understanding how they are actually being implemented and the limitations to their current design so that they may be improved upon.
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