University of Utah
Plastic Surgery Residency
PLASTIC SURGERY
CURRICULUM
Table of Contents
1.
General Plastic Surgical Principles .........................page 4
2.
Plastic Surgery of the Integument ...........................page 27
3.
Plastic Surgery of the Head and Neck ....................page 39
4.
Plastic Surgery of Hand and Upper Extremity .......page 52
5.
Plastic Surgery of the Trunk ...................................page 65
6.
Plastic Surgery of the Lower Extremity..................page 76
7.
Aesthetic Plastic Surgery ........................................page 85
8.
Burn Surgery……………………………………...page 96
2
PLASTIC SURGERY
CURRICULUM
Purpose:
The plastic surgery curriculum (goals and objectives) is provided to
residents and attendings for education and assessment. The curriculum not only is an
educational tool, but a guide for assessment. Residents should utilize the curriculum to
direct independent study and self assessment. Attendings should utilize the curriculum to
direct resident teaching and assessment. The curriculum is the tie between education and
assessment.
Note:
The plastic surgery curriculum is broken down into 7 major sections of
plastic surgery. Each of the 7 sections is in-turn broken down according to
the 6 General Competencies
A.
B.
C.
D.
E.
F.
Medical Knowledge
Patient Care
Practice Bases Learning and Improvement
Interpersonal and Communication Skills
System Based Practice
Professionalism
3
CORE OF KNOWLEDGE
GENERAL PLASTIC SURGICAL
PRINCIPLES AND TECHNIQUES
4
A.
Medical Knowledge
I:
Wound Repair: Principles and Applications
Goal: The resident will demonstrate knowledge of the physiology and biochemistry of
wound healing and manage complex wounds using a variety of techniques to achieve
normal healing and maximum aesthetic benefit.
Objectives:
Recite the physiology and biochemistry of normal healing.
Discuss the physiology and biochemistry of abnormal wound healing including
hypertrophic scars and keloids.
Discuss common agents and processes which result in abnormal healing.
Identify the pharmacologic agents and other nonsurgical methods for treatment of
abnormal healing.
Describe the management of dressings, splints and other techniques utilized in
wound management.
Explain the differences in the healing of cortical and cancellous, membranous and
endochondral bone.
Draw and plan techniques of scar revision (such as Z-plasty and W-plasty).
Describe the various lines of the skin (such as relaxed skin tension) and their
importance in placement of incisions for maximum aesthetic result.
Discuss the role of nutrition in the wound healing process and the standard
methods for diagnosis and treatment of nutritional deficiencies.
Discriminate the pathologic processes involved in keloid formation and the
methods available to treat keloids.
Understand the differences in suture materials and indications for the use of
different materials.
Discuss the basic science of healing, including the anatomy, physiology,
biochemistry, microbiology, immunology, wound healing for:
skin and soft tissue
tendon
bone (different types)
5
nerve
cartilage.
Discuss abnormal wound healing, including:
delayed healing – physiology and treatment
excessive healing (hypertrophic scars and keloids).
6
II:
Flaps and Grafts
Goal: The resident will demonstrate knowledge of the physiology and flaps and grafts,
will be familiar with surgery in all types of flaps and grafts, and will utilize these
effectively in the full spectrum of plastic surgical practice.
Objectives:
1.
Discuss the terminology of flap movement including advancement flap,
rotation flap, transposition of flap, etc.
2.
Recite the terminology of flap vascular supply including random flap,
island flap, free flap, etc.
3.
Identify the variations in flap anatomy including cutaneous flap,
fasciocutaneous flap, musculocutaneous flap, etc.
4.
Explain the physiology of normal flaps, ischemic flaps, and the "delay"
phenomenon.
5.
Discuss the pathophysiology and microbiology of acute, intermediate, and
secondary wounds, and the impact this has for the timing and techniques
of wound closure surgery; be thoroughly familiar with the factors
influencing the choice of flap versus graft for wound closure.
6.
Explain in detail the specific physiology of split and full thickness skin
grafts, dermal grafts, cartilage grafts, bone grafts, tendon grafts, nerve
grafts, fascial grafts, and composite grafts.
7.
Explain the differences in first degree and second degree wound
contraction versus contracture.
8.
Explain the concept of dermatomes and angiosomes and their implications
on wounds and flaps.
9.
Discern the principles and applications of special grafting techniques
including dermabrasion and over-grafting, the crane principle, xenografts,
skin matrix and synthetic or chemically manipulated materials.
10.
Recite the Mathes Classification of muscle flaps.
11.
Discuss the technological, pharmacological, and physiological monitoring
techniques including fluorescence, capillary refill, thermal monitoring,
laser flow probes, oxygen saturation, pH monitoring, etc.
7
III:
Microsurgery
Goal: The resident will demonstrate knowledge of the principles of microsurgery, and
master basic microsurgery techniques including microneural repair and microvascular
anastomosis.
Objectives:
1.
Explain the use of the operating microscope and the technical aspects of
microvascular anastomosis (artery and vein) and microneural repair.
2.
Discern the indications for, the contraindications to, and the techniques for
accomplishing replantation of amputated parts. Recognize the techniques
of monitoring the success of replantation.
3.
Discuss the varying types of blood supply to discrete units of tissue
(including arterialized flap, musculocutaneous flap, fasciocutaneous flap).
4.
List the terms and types of free tissue flaps – skin, skin/muscle,
skin/muscle/bone, skin/tendon, muscle alone.
5.
List in detail the anatomy for harvesting the most common flaps, including
latissimus dorsi, rectus abdominis, radial forearm.
6.
Discern the indications for harvesting various flaps and matching donor
sites to specific recipient site needs.
7.
Discuss radiologic techniques for evaluation of both donor and recipient
sites.
8.
Discuss the mechanisms and consequences of the no-reflow phenomenon;
knows how to treat a failing flap.
9.
Discuss the technologic, pharmacologic and physiologic principles of
postoperative monitoring of free flaps.
10.
Recite the basic physiology of nerve injury (axontomesis, neurotomesis,
neuropraxia, Wallerian degeneration) and of nerve healing.
11.
Draw the intraneural anatomy and anatomic relationships of structures of
the major peripheral nerves.
12.
Explain the principles of repair of nerve injury including need for nerve
grafting, the anatomy of nerve graft donor sites, and the physiology,
timing and techniques of primary, delayed primary and late nerve repair.
8
13.
Discuss the principles and techniques of hematologic manipulation of
abnormal vascular flow characteristics.
14.
Discuss the technical aspects of microsurgery including:
a.
b.
c.
d.
15.
microscopes – principles, usage
sutures – types, indications
microvascular coupling devices
suturing techniques.
Discuss the use of electrophysiologic tools in the evaluation of nerve
injury (EMG, NCS).
9
IV:
Implants/Biomaterials
Goal: The resident will demonstrate knowledge of both biology and physiology of
various implant materials including bone, cartilage, and alloplasts.
Objectives:
1.
Identify the local wound factors which influence bone graft survival.
2.
Discuss the biologic differences between vascularized and nonvascularized bone grafts.
3.
Recite the influence of perichondrial and scoring on the warping of
cartilage grafts.
4.
Discuss the various types of breast implants and the factors involved in
implant choice including surface content characteristics; be aware of the
issues regarding silicone and be able to discuss these with a patient.
5.
Discern the effects of breast implant surface characteristics on formation
of capsular contracture.
6.
Discuss the various injectable materials for subcutaneous filling and the
principles of their use.
7.
Discuss the processes of bone repair: incorporation, osteoconduction and
osteoinduction.
8.
Discuss the difference in incorporation between cortical and cancellous
bone grafts and membranous and endochondral autografts.
9.
Explain the immunology of bone and cartilage transplantation.
10.
List the chemistry and biocompatibility of the commonly implanted
biomaterials including silicone, methyl methacrylate, hydroxyapatite,
tricalcium phosphate and proplast.
11.
Describe the factors involved in the choice of implant materials for
varying reconstructive problems.
12.
Discuss the chemistry and biocompatibility of commonly injected
materials including: collagen (bovine and human), fat, and others.
10
V:
Special Techniques
Goal: The resident will demonstrate knowledge of the principles of a variety of special
techniques in plastic surgery, including: liposuction, tissue expansion, laser treatments
and dermabrasion, and utilize the techniques effectively in appropriate clinical scenarios.
Objectives:
1.
Discuss the basic principles, the common techniques and the
instrumentation of suction lipectomy including tumescence, standard and
ultrasonic liposuction.
2.
Recite the indications for and contraindications to suction lipectomy, and
be familiar with the principles of patient assessment; recognize the
limitations of liposuction.
3.
Explain the preoperative, intraoperative and postoperative management of
the patient undergoing suction lipectomy; be familiar with the
complications of liposuction and their management.
4.
Discuss the physiologic principles of tissue expansion.
5.
Discriminate the various techniques for tissue expansion and be familiar
with the differing expansion devices.
6.
Discuss the principles of management of patients undergoing tissue
expansion; recognize and treat the complications of tissue expansion.
7.
Discuss the physiologic and pathologic principles of dermabrasion,
chemical peel and laser resurfacing; recognize the differences between the
techniques and the indications for choice between the techniques.
8.
Recite the principles of pre- and postoperative management of patients
undergoing facial resurfacing; recognize the complications of the
technique and its management.
9.
Explain the pharmacologic aspects and the techniques of chemical peel.
10.
Discriminate the biophysical properties of commonly used lasers, and
choose different lasers for different types of problems.
11.
Discuss the indications for and contraindications to laser treatments and
techniques of laser use, and the various complications of laser therapy and
their treatment.
11
VI:
Medicolegal and Psychiatric Aspects of Plastic Surgery
Goal: The resident will demonstrate a clear understanding of medicolegal and
psychiatric aspects of plastic surgery practice, regularly obtain informed consent from
patients, and perform a basic psychological evaluation when appropriate.
Objectives:
1.
Discuss the medical and legal perspectives of the contractual agreement
between a physician and his/her patient.
2.
Discern the concepts of informed consent and implied guarantee.
3.
Discuss the role of the medical record as a legal document.
4.
Discern the impact physical deformity can have on patients and their
families.
5.
Discuss techniques to explore the motivations of patients seeking cosmetic
surgery, and how to distinguish acceptable, unacceptable, and pathological
motivations.
6.
Recite the legal and ethical ways to sever the physician/patient
relationship.
7.
Discuss the various types of malpractice insurance.
8.
Discuss the basic principles of risk management.
9.
List the psychiatric and psychological treatment options for patients with
physical deformities and their families.
10.
Discuss the strategies to effectively treat the dissatisfied patient/family.
12
VII:
Anesthesia and Critical Care
Goal: The resident will demonstrate the indications, principles, techniques and
complications of local, regional, and general anesthesia, will be thoroughly familiar with
the principles and techniques of critical care and management of the critically ill burn,
trauma, and postoperative patients.
Objectives:
1.
Discuss common agents for local anesthesia (esters and amides), and
regional anesthesia and general anesthesia (intravenous agents, inhalation
agents, muscle relaxants, antiemetics, etc).
2.
Identify the principles and the techniques for administration of local
anesthesia.
3.
Recite the pharmacology and safe utilization of agents used in "conscious
sedation", including narcotics and benzodiazepines.
4.
Recite the emergency care of burn and trauma patients including
diagnostic techniques and management principles.
5.
Recite the principles and techniques for regional anesthesia, particularly:
a.
b.
c.
d.
e.
digital block
wrist block
brachial block
Bier block
ankle block
6.
Discuss the principles of spinal and epidural anesthesia.
7.
Discuss the principles and techniques for general anesthesia utilizing
different anesthetic techniques.
8.
Discuss the use of common agents for local anesthesia (esters and amides)
including:
a.
b.
c.
d.
e.
mode of action
duration of action
dosage and toxicity
side effects
antidotes.
13
9.
Discuss the general principles and techniques for general anesthesia,
including:
a.
b.
c.
d.
e.
f.
g
patient monitoring
airway management
preoperative mediations
intravenous agents
inhalation agents
muscle relaxants
antiemetics.
14
VIII: Transplantation/Immunology
Goal: The resident will demonstrate knowledge of the basic principles of immunology
and tissue transplantation techniques for treatment of common plastic surgical problems.
Objectives:
1.
Discuss the physiology of skin graft take and the immunology of allograft
rejection.
2.
Recite the basic immune response including antibody recognition of
foreign antigens, first set rejection, and second set rejection.
3.
List the cellular response to foreign tissue or material including the role of
lymphocytes, macrophages, and T-cells.
4.
Discern the actions of and proper usage of pharmacologic agents to alter
the immune response, including cyclosporine, immuran, steroids, and
monoclonal antibodies.
5.
Discuss the role of immunology in host responses to tumor, including
lymphocytic infiltration of melanoma, basal cell carcinoma, and squamous
cell carcinoma.
6.
Describe the role of immunology in response to foreign materials and
regional or systemic reactions, e.g., "silicone synovitis," capsular
contractures.
7.
Describe the difference between skin transplantation and the
transplantation of solid organs.
8.
Discuss current information regarding human immunodeficiency virus and
diseases.
9.
Discuss the immunologic aspects of plastic surgery, including:
a.
b.
c.
autoimmune disease
immunology of skin transplantation
interrelationship of transplantation and microsurgery.
15
IX:
Pharmacology/Therapeutics
Goal: The resident will demonstrate knowledge of the pharmacology of drugs used in
plastic surgical practice including antibiotics, anti-inflammatory agents, analgesics, and
effectively utilize such drugs in a wide variety of settings.
Objectives:
1.
List the common pathogens producing infections of the skin, head and
neck structures, breast and hand.
2.
List the special pathogens related to infections caused by human and
animal bites and infections.
3.
Discuss the indications and proper antibiotics and antimicrobials for
treatment of the problems noted in #1 and #2 above.
4.
List the principles of use (including dosage and complications) of common
analgesics (oral and parenteral).
5.
Discuss the pharmacology and clinical use of steroids in plastic surgery
patients (including scar treatment, hand problems, steroid-dependent
patients).
6.
Discuss the pharmacology of the major types of antibiotics and the
indications for their use.
7.
Discuss the commonly used anti-inflammatory agents including dosage
and mechanism of action.
8.
Discuss the pharmacology, complications and clinical use of common
chemotherapeutic agents for treatment of skin and head and neck
malignancies.
9.
Discuss the principles of management of extravasation injuries involving
chemotherapeutic agents and other drugs.
10.
Discuss the bacteriology of wounds, including:
a
b.
c.
d.
e.
skin infection
breast infections
surgical wound infections
hand infections
special problems
1. animal bites
2. human bites
3. farm injuries.
16
X:
Patient Management/Office Management
Goal: The resident will demonstrate knowledge of patient evaluation, ICD-9 and CPT
terminology, and office operating room management.
Objectives:
1.
Explain how to interview and evaluate the patient, especially a surgery
candidate.
2.
Demonstrate the coding of diagnoses by the ICD-9 system.
3.
Demonstrate coding of procedures by the CPT system.
4.
Discuss ethical principles as they relate to billing and coding.
5.
Demonstrate how to take and catalogue standardized medical photographs.
6.
Discuss the principles of risk management.
7.
Recite the basic principles of how to equip and organize an office
operating room to comply with AAAAPSF standards.
8.
Discuss the functioning of an outpatient operating facility, including:
a.
b.
c.
d.
e.
g
equipment
laboratory evaluation
patient records
patient monitoring
AAAAPSF standards
risk management.
17
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective.
Objectives:
1.
Participate in the care and treatment of scars and keloids, including:
a.
b.
c.
2.
Evaluate patients and their nutritional status as related to wound healing,
including:
a.
b.
3.
diagnosis of deficiency
treatment of deficiency
Participate in planning surgical incisions, with respect to:
a.
b.
c.
4.
surgical techniques (Z-plasty, W-plasty, etc)
nonsurgical techniques
camouflage techniques.
selection in relation to skin lines
techniques for closure
suture materials – types and uses.
Participate in wound management, including:
a.
b.
c.
debridement
use of splints, dressings, casts, topics agents
use of biologic substitutes.
5.
Treat complex wound problems such as dehiscence, delayed healing of
complex traumatic wounds.
6.
Evaluate patients with scar problems and revise scars to achieve functional
and aesthetic benefit.
7.
Perform surgical and pharmacologic treatment of hypertrophic scars and
keloids.
8.
Utilize splints, casts, dressings, topical agents, etc., to optimize healing.
9.
Place incisions for elective surgery in such a way as to achieve the greatest
aesthetic benefit.
10.
Utilize biologic and artificial skin substitutes in wound management.
18
11.
Participate in the surgery of grafts and flaps including: skin, dermis,
cartilage, bone, tendon, muscle, fascia, combined tissue; specifically:
a.
b.
c.
d.
e.
f.
g.
grafting techniques
instruments for harvesting grafts
graft preservation techniques
donor site management
recipient site management
special techniques
xenografts
12.
Perform operations incorporating the full spectrum of flaps and grafts
including skin grafts, local flaps, fascial and musculocutaneous flaps, free
tissue transfers, bone grafts, composite grafts, etc.
13.
Treat patients who have complications of flaps and grafts including skin
graft loss, flap necrosis, wound dehiscence, wound infection, etc.
14.
Participate in the use of the operating microscope; perform microvascular
anastomosis and microneural repair in the laboratory and operating room.
15.
Participate, with graduated independent experience, in surgical procedures
for free tissue transfer; harvest flaps and manage donor sites; when
competent, perform vascular anastomosis for free tissue transfer.
16.
Diagnose and treat a variety of nerve injuries, using microsurgery and
nerve grafts where appropriate.
17.
Conduct preoperative evaluation and postoperative management of
patients undergoing free tissue transfer.
18.
Manage long-term aspects, including donor site problems, of patients who
have undergone free tissue transfers.
19.
Participate, with graduated independent experience, in surgical procedures
for replantation of amputated parts, perform vascular anastomosis and
nerve repairs during replantation procedures.
20.
Conduct preoperative evaluation and postoperative management of
patients undergoing replantation of amputated parts and revascularization
procedures.
21.
Manage long-term aspects, including rehabilitation, of patients who have
undergone replantation and revascularization procedures.
19
22.
Prepare methyl methacrylate prostheses.
23.
Perform surgical procedures using solid implant materials including:
a.
b.
c.
d.
e.
cranioplasty
silicone implantation to breasts, orbital floor, malar area, chin or
joints
bone substitution for small defects, such as orthognathic
advancements
non-vascularized bone grafts for a variety of defects:
vascularized bone grafts.
24.
Perform soft tissue augmentation using injectable material.
25.
Achieve certification in laser use.
26.
Evaluate and treat patients with localized lipodystrophy, using suction
lipectomy techniques.
27.
Participate in the evaluation and treatment of patients with a wide variety
of congenital and acquired defects using tissue expansion techniques.
28.
Evaluate and treat patients using dermabrasion and/or chemical peel.
29.
Evaluate and treat patients with problems amenable to laser therapy.
30.
Participate in obtaining informed consent from patients; effectively
documenting that agreement.
31.
Evaluate patients for aesthetic surgery from a physical and psychological
perspective.
32.
Contribute effectively and accurately to the medical record of both
inpatients and outpatients.
33.
Treat patients with physical deformities and explore the psychological
aspects of their care.
34.
Participate in the management of problem patients, including angry
patients, dissatisfied patients, “doctor shoppers”, “drug seekers”, etc.
35.
Participate in the management of critically ill patients in the surgical
intensive care unit.
36.
Participate in the critical care management/emergency management of
burn and trauma patients, including:
20
a.
b.
c.
d.
37.
Participate in the management of ICU patient, including:
a.
b.
c.
d.
e
f.
38.
initial care
diagnosis
preparation for the operating room
postoperative care.
monitoring
respiratory management
cardiovascular management
fluid management
management of infection and sepsis
management of nutrition.
Participate in the care of surgical patients with complications including:
a.
b.
c.
d.
e.
respiratory failure
cardiovascular problems (arrhythmia, DVT, PE)
sepsis
bleeding
hematoma.
39.
Participate in the management of patients with autoimmune and collagen
vascular diseases such as lupus erythematosus.
40.
Identify patients who are at risk for malignancy because of their
immunosuppressed condition and provides screening and education to
these patients.
41.
Identify and treat patients whose condition warrants allografting (e.g.,
large body surface burn).
42.
Perform pre- and postoperative management of immunosuppressed
patients undergoing plastic surgical procedures.
43.
Diagnose and treat patients with surgical wound infections.
44.
Evaluate and treat patients with infections of the head and neck, breast,
skin and hand.
45.
Prescribe analgesics for postoperative care and for pain management.
46.
Prescribe anti-inflammatory agents for appropriate cases.
47.
Utilize steroids for treatment of a variety of plastic surgical problems and
in the postoperative care of steroid-dependent patients.
21
48.
Participate in the management of patients undergoing chemotherapy for
head and neck and/or skin malignancies.
49.
Manage patients with localized extravasation injuries.
50.
Participate in outpatient management including both a clinic experience in
which the resident has independent responsibility and an observation of
faculty managing private patients including initial consultation and
management of complications.
51.
Code diagnoses by the ICD-9 system.
52.
Code procedures by the CPT system.
53.
Photograph his/her own patients with a standardized format.
54.
Attend risk management seminar or studies risk management techniques
and discuss principles with faculty; apply these principles in daily practice
of plastic surgery.
22
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improved patient care practices.
Objectives:
1.
Use information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care for patients and the
scientific evidence for that care.
2.
Routinely analyzes the effectiveness of own practices in caring for
patients.
3.
Improve own practices in the care of patients by integrating appropriately
gathered data and feedback.
4.
Educate medical students and other healthcare professional in the practices
of surgical patients.
5.
Function independently with graduated advancement and appropriate
faculty supervision in the evaluation and treatment of patients.
23
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in pre- and post-operative care of surgical
patients.
2.
Demonstrate compassion for patients and families with traumatic and
acquired anomalies.
3.
Provide adequate counseling and informed consent to patients.
4.
Listen to patients and their families.
5.
Assimilate data and information provided by other members of the health
care team.
6.
Effectively obtain truly informed consent from patients.
7.
Effectively explore the motives of patients seeking cosmetic surgery.
24
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Function within the organization of specialty clinics including the
coordination of all special services in the evaluation of patients.
2.
Participate in tumor-board conference.
3.
Participates in multidisciplinary planning and treatment for patients with
complex diagnoses.
4.
Direct the overall care of patients with complicated wounds by partnering
with the following:
a.
b.
c.
nutritionalists
wound care specialists
occupational therapists
5.
Demonstrate knowledge of cost-effective surgical care.
6.
Advocate for patients within the health care and insurance system.
25
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives:
1.
Develop a sensitivity of the unique stress placed on families under care for
surgery.
2.
Exhibit an unselfish regard for the welfare of patients.
3.
Demonstrate firm adherence to a code of moral and ethical values.
4.
Be respectful to patients and their families especially in times of trauma
and stress to the family unit.
5.
Respect and appropriately integrate other members of the healthcare team.
6.
Provide appropriately prompt consultations when requested.
7.
Demonstrate sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to their surgical diagnosis.
8.
Be reliable, punctual, and accountable for own actions in the OR and
clinic.
9.
Accurately and honestly counsel patients regarding risks and
complications of breast implant surgery.
10.
Effectively deal with dissatisfied patients.
11.
Understand the physician/patient relationship.
12.
Professionally and ethically perform CPT coding.
13.
Understand the benefits and functionality of multidisciplinary health care
teams.
14.
Refer patients to the appropriate practitioners and agencies.
15.
Facilitate the timely discharge of patients.
26
PLASTIC SURGERY OF THE
INTEGUMENT
27
A.
Medical Knowledge
I:
Anatomy/Physiology/Embryology
Goal: The resident will demonstrate knowledge of the histology, function, and
development of the skin.
Objectives:
1.
Discuss the structure and functions of the epidermis.
2.
Discuss the structure and functions of the dermis.
3.
Discuss the structure and functions of the skin appendages.
4.
Discuss the structure and function of subcutaneous tissue and fascial
layers.
5.
Recite the embryologic origin of the skin and at which gestational age
components of the skin appear.
6.
Describe the differentiation of the stratum germinativum into surface
appendages, and the differentiation of the dermis.
7.
Describe the structure and function of the nails.
8.
Discuss the components of dermis including: fibroblasts, collegen, elastin,
ground substance.
9. Discuss the structure and function of the skin appendages including:
hairs
eccrine glands (sweat glands)
apocrine glands (axilla, anal-genital region, external ear, eyelid, breast)
sebaceous glands
neural end organs.
10. Discuss the reaction of skin to the following:
a.
b.
c.
d.
e.
f.
g.
heat
cold
mechanical trauma
microbial trauma
UV light trauma
pharmacologic agents.
Smoking
28
II:
Benign and Malignant Skin Lesions
Goal: The resident will demonstrate knowledge of benign and malignant lesions,
recognize the morphologic and histologic features of the more common lesions, and
effectively manage small and large skin tumors using a variety of treatment methods.
Objectives:
1.
List the clinical presentation of benign and malignant skin lesions and
generalized skin disorders.
2.
Discuss the natural history of both treated and untreated benign and
malignant cutaneous lesions and generalized skin disorders.
3.
Recite the histologic grading and clinical staging systems used for
malignant and premalignant skin tumors.
4.
Discuss other treatment modalities including, but not limited to: excisional
therapy, Moh’s micrographic surgery, cryotherapy, laser therapy, and
chemotherapy.
5.
Discuss the histologic characteristics of benign and malignant cutaneous
lesions.
6.
Discuss the pathology, biologic behavior, and treatment of the following:
a.
b.
c.
d.
benign epithelial and adnexal tumors (nevi, papillomas, keratinous
cysts)
benign mesodermal tumors (hemangioma, vascular malformations)
malignant cutaneous tumors, epithelial and mesodermal (basal cell
carcinomas, squamous cell carcinoma, malignant melanoma,
sarcomas)
premalignant skin tumors.
29
III:
Burns and Trauma
Goal: The resident will demonstrate knowledge of the pathophysiology of burns,
principles of burn resuscitations, and the techniques of burn wound repair and
reconstruction.
Objectives:
1.
Recite the normal skin anatomy and circulation and how it is impaired by
thermal injury.
2.
Understand the pathophysiologic changes which occur with thermal injury
and specific changes which occur in the zones of coagulation, stasis, and
hyperemia.
3. Utilize the Rule of Nines and more detailed body surface area charts, to
compare the relative difference in body surface area in children and adults.
4. Recite the parameters which define major, moderate, and minor burns.
5. Discuss the various factors, in addition to body surface area, which impact the
prognosis of a patient with a thermal injury.
6. Explain the pathophysiology and treatment of inhalation injury and carbon
monoxide poisoning.
7. Explain the principles and techniques of fluid resuscitation, using isotonic and
hypertonic solutions, and the principles of monitoring fluid status in acute
burn patients.
8. Describe the pathophysiologic changes unique to chemical burns, specifically
acid burns, alkali burns, chemotherapy extravasations and hydrofluoric
acid burns.
9. Describe the injuries and sequelae associated with electrical injuries, such as
cardiac dysrhythmias, central nervous system damage, intra-abdominal
and vascular injury, cataracts, etc.
10. Discuss the anatomy and physiology pertinent to the excisional treatment of
burns and treatment by split thickness skin grafting.
11. Describe the principles pertinent to burn reconstruction, including the
aesthetic units of the face, tissue expansion, hair transplantation, splinting,
etc.
30
12. Discuss the pharmacology and utilization of topical antibacterials and
analgesics in the treatment of burns.
13.
Discuss the pathophysiology of acute and chronic radiation injury.
14.
Recite the pathophysiology of frostbite and its natural history.
15.
Discuss the principles of nutritional management of the burn patient.
31
IV:
Congenital, Aesthetic and Functional Problems
Goal: The resident will demonstrate knowledge of the common congenital disorders and
disease processes of the skin, as well as the pathophysiology of aging.
Objectives:
1.
Explain the basic physiology of the aging process of the skin.
2.
Describe the basic physiologic processes of sun exposure and its effect on
the skin.
3.
Discern the role of lasers in the management of various skin conditions.
4.
Describe common inflammatory disorders of the skin such as cellulitis,
lymphangitis, hidradenitis suppurativa, necrotizing fasciitis, and its
medical and surgical treatment.
5.
Discuss common generalized dermatologic diseases such as: scleroderma,
dermatomyositis, lupus erythematosis.
6.
Discuss the common congenital disorders of the skin, such as: xeroderma
pigmentosa, Ehlers Danlos syndrome, basal cell nevus syndrome, etc.
7.
Recite the basic principles of medical management and surgical treatment
of common congenital disorders of the skin.
8.
Explain the surgical aspects of treatment of patients with skin disorders
such as scleroderma and lupus erythematosis.
32
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of disorders of the Integument.
Objectives:
1.
Evaluate both simple and complex cutaneous lesions, and proceed with
diagnostic steps necessary to secure a definitive diagnosis.
2.
Formulate definitive treatment plan for particular skin lesions by choosing
a surgical or nonsurgical treatment modality (based on size, anatomical
location, and physical condition of the patient).
3.
Participate in diagnostic studies of the skin, including incisional and
excisional biopsy, needle biopsy, and punch biopsy.
4.
Participate in extirpative surgery for a variety of benign and malignant
skin lesions and associated locoregional disease, choosing the optimal
treatment for the particular region to be treated.
5.
Participate in complex procedures (including skin grafts, local or distant
flaps, or free tissue transfer) for the reconstruction of surgical wounds
resulting from skin tumor extirpation.
6.
Evaluate patients with minor, moderate, and major burns of chemical and
thermal origin.
7.
Manage outpatient burns operatively and non-operatively.
8.
Participate, with graduated surgical independence, in the treatment of
acute burns including escharotomies, fasciotomies, excision, grafting, etc.
9.
Manage patients with burns of the hand including the operative and
postoperative therapy and late reconstructive surgery.
10.
Manage inpatients with major burns including resuscitation, nutrition,
inhalation injury, and rehabilitation.
11.
Evaluate and treat patients with acute and chronic radiation injuries.
12.
Manage patients with chemical burns including intravenous infusion
injuries.
33
13.
Perform reconstructive surgery on burn patients including functional and
aesthetic procedures.
14.
Manage patients with frostbite injuries.
15.
Perform, with graduated surgical experience, laser treatments for
conditions of the skin including:
a.
b.
c.
d.
vascular lesions
pigmented lesions
unwanted hair
skin resurfacing.
16.
Participate in surgery on patients with congenital skin disorders.
17.
Utilize pharmacologic agents for treatment of aging skin
18.
Recommend pharmacologic agents for prevention of sun exposure,
instruct patients in their use and in general principles of skin protection
from the sun.
19.
Evaluate and treat patients with bacterial, viral and fungal infections such
a cellulitis, lymphangitis, necrotizing fascitis, and gas gangrene.
20.
Perform surgical extirpation and reconstruction for hidradenitis
suppurativa.
21.
Participate in the surgical care of patients with generalized dermatological
conditions such as scleroderma and lupus erythematosis.
22.
Formulate a definitive treatment plan for regional or distant sites of
malignant cutaneous metastasis.
34
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives:
1.
Use information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care and the scientific evidence
for that care.
2.
Routinely analyze the effectiveness of own practices in caring for patients
with diagnoses involving the skin.
3.
Improve own practices in the care of patients by integrating appropriately
gathered data and feedback.
4.
Educate medical students and other healthcare professionals in the practice
of skin care and prevention of skin cancer.
5.
Function independently with graduated advancement and appropriate
faculty supervision.
35
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in the strategies to prevent skin cancer.
2.
Demonstrate compassion for patients and families with burns.
3.
Provide adequate counseling and informed consent to patients.
4.
Listen to patients and their families.
5.
Assimilate data and information provided by all members of the burn
team.
6.
Chart and record accurate information.
7.
Be able to explain in a comprehensible but simplified manner to patients
the nature of skin cancer, its extent, treatment options and long term
results.
36
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Coordinate all aspects of burn rehabilitation, including splinting, pressure
garment use, physical therapy, occupational therapy, and social work.
2.
Direct the rehabilitation of the burn patient by partnering with the
following:
a.
b.
c.
Physical Therapy
Occupational Therapy
prosthetic and orthotics specialists.
3.
Demonstrate knowledge of cost-effective burn care.
4.
Advocate for burn patients within the health care system.
5.
Refer burn patients to the appropriate practitioners and agencies.
6.
Facilitate the timely discharge of skin cancer patients.
7.
Coordinate care of skin cancer patients with primary care providers,
general dermatologists, and Moh’s surgeons.
37
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives:
1.
Develop a sensitivity of the unique stress placed on families under care for
burn injuries.
2.
Exhibit and unselfish regard for the welfare of burn patients.
3.
Demonstrate firm adherence to a code of moral and ethical values.
4.
Be respectful to burn patients and their families, especially in times of
trauma and stress to the family unit.
5.
Respect and appropriately integrate other members of the burn care team.
6.
Provide appropriately prompt skin care consultations when requested.
7.
Demonstrate sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to burn reconstruction.
8.
Be reliable, punctual, and accountable for own actions in the OR and
clinic.
38
PLASTIC SURGERY OF THE HEAD
AND NECK
39
A.
Medical Knowledge
I:
Anatomy/Physiology/Embryology
Goal: The resident will achieve detailed knowledge of the anatomy, physiology,
embryology of the head and neck, and will apply this knowledge to the medical
management of disorders and processes in this anatomic area.
Objectives:
1.
Describe the anatomy of the skull including sutures, foramina, and cranial
nerves.
2.
Identify the anatomy of the facial bones.
3.
Identify the anatomy of the eye including normal dimensions, bony
structures, eyelids, extraocular muscles, innervation, vascular supply, and
lacrimal apparatus.
4.
Identify the anatomy of the ear including common measurements,
relationships to other structures, and the vascular and sensory supply.
5.
Draw the anatomy of the nose and septum including bones, nerves and
vascular supply.
6.
Recite the anatomy of the oropharynx including muscular structures and
contiguous neurovascular structures.
7.
Recite the physiology of the oropharynx including palatal function,
speech, and swallowing.
8.
Explain the general principles of embryology of the head and neck, with
special reference to the development of the facial structures and the
occurrence of congenital anomalies such as cleft lip and palate.
9.
Recite the basic anatomy of the dental structures and the TMJ.
40
II:
Congenital Disorders
Goal: The resident will achieve familiarity with the anatomy, embryology and principles
of treatment of congenital disorders of the head and neck.
Objectives:
1.
Demonstrate intimate knowledge of the common congenital disorders of
the head and neck including cleft lip and palate, craniofacial syndromes,
vascular malformations, and auricular abnormalities
2.
Discuss the etiology, genetics, embryology and anatomy of congenital
disorders of the head and neck.
3.
Be familiar with growth and development of the craniofacial skeleton and
its affect on anomalies and their treatment
4.
Be able to recite the diagnostic criteria and discus the evaluation and
treatment for congenital anomalies such as:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
5.
craniosynostosis
hemifacial microsomia
rare craniofacial clefting
orbital hypertelorism
Pierre-Robin sequence
craniofacial tumors
choanal atresia
nasal anomalies
ear anomalies (prominent ear, microtia)
vascular anomalies
branchial cleft cysts
thyroglossal duct cysts
lymphatic anomalies
Discuss the cephalometric landmarks and analysis in the presurgical
planning of patients with congenital head and neck anomalies.
41
III:
Benign and Malignant Tumors
Goal: The resident will obtain knowledge of benign and malignant tumors of the head
and neck, understand the biologic basis of treatment options for these lesions, and
perform complete management of such lesions including diagnosis, surgery and
nonsurgical therapy.
Objectives:
1.
Recognize the clinical presentation of squamous cell carcinoma of the
head and neck.
2.
Recite the lymphatic drainage pattern of the head and neck structures and
the relationship to the management of malignant tumors.
3.
Recite the methods for diagnosis and the options for treatment of
squamous cell carcinomas of the head and neck.
4.
Recite the TNM staging system for tumors of the head and neck; know the
features and biologic behavior of these lesions.
5.
Describe the general principles and techniques of adjuvant therapy such as
radiation therapy and chemotherapy for head and neck malignancies.
6.
Discuss the indications for an d the role of neck dissection in the treatment
of head and neck malignancies.
7.
Recite the process of long-term follow-up for patients with head and neck
malignancies.
8.
Recite the diagnosis of and principles of care for:
a.
b.
c.
d.
rhinophyma
eyelid and lacrimal neoplasms
infections of the head and neck
disease of nasal cavity and paranasal sinuses
9.
Discuss the differential diagnosis of hemangiomas and vascular
malformations.
10.
Discuss the treatment options, including steroid therapy, laser therapy, and
surgery for hemangiomas and vascular malformations of the head and
neck.
42
IV:
Trauma
Goal: The resident will be familiar with the mechanisms of traumatic head and neck
injuries, understand the diagnostic techniques and therapeutic options for such problems,
and perform complete management of traumatic injuries of the head and neck.
Objectives:
1.
Describe the priorities involved in treating patients with head and neck
injuries.
2.
Describe the mechanical and structural properties of the facial skeleton as
they relate to fracture patterns in facial trauma.
3.
Describe the concepts of primary bone healing, malunion, nonunion and
osteomyelitis.
4.
Discuss the advantages and disadvantages of various techniques of
treatment of facial fractures including:
a.
b.
c.
d.
e.
f.
g.
5.
nonoperative treatment
closed reduction
mandibulomxillary fixation
open reduction with and without fixations
intraoral splints
external fixation
bone grafting.
Describe the treatment of facial fracture complications including:
a.
b.
c.
d.
e.
secondary deformities
infections and osteomyelitis
malocclusion
nonunions
malunions.
6.
Describe the neuroanatomy, cranial nerve anatomy and soft tissue
anatomy pertinent to facial fractures.
7.
Recite the treatment of soft tissue injuries of the had and face including:
a.
b.
c.
parotid gland and duct
facial nerve
lacrimal apparatus.
43
8.
Describe the evaluation and treatment of secondary deformities of facial
fracture including:
a.
b.
c.
d.
e.
9.
malocclusion
enophthalmos
frontal sinus mucoceles
facial nerve paralysis
soft tissue contractures.
Discuss the principles of care and the surgical steps in the treatment of the
following facial fractures:
a.
b.
c.
d.
e.
f.
g.
h.
frontal sinus
naso-orbital ethmoid
orbital
zygomatic
nasal
maxillary
mandibular
pan-facial.
44
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of hand and neck problems.
Objectives:
1.
Obtain cephalometric measurements and analyze cephalometric data in the
presurgical planning.
2.
Perform a comprehensive head and neck exam followed by facial form
analysis.
3.
Utilize radiographic and special diagnostic studies to evaluate head and
neck anomalies.
4.
Formulate a definitive short- and long-term treatment plan for common
congenital disorders, choosing the most appropriate surgical or
nonsurgical modality.
5.
Draw the reconstruction of a cleft lip and palate.
6.
Diagnose and develop a treatment plan for velopharyngeal incompetence.
7.
Coordinate nonsurgical treatment of congenital head and neck disorders.
8.
Participate in the Cleft-Craniofacial Team’s multidisciplinary evaluation
and treatment planning for congenital disorders of the head and neck.
9.
Provide perioperative care and participate in surgical treatment of patients
with craniofacial anomalies.
10.
Utilize diagnostic techniques for head and neck tumors including
radiographic methods (e.g., sialogram, MRI scan, etc) and fine needle
aspiration.
11.
Perform fine needed aspirate biopsies.
12.
Recite the steps in the surgical treatment of:
a.
b.
c.
oropharyngeal tumors
salivary gland tumors
neck dissections
45
d.
tumors of bony and dental origin.
13.
Participate in the extirpative surgery for oropharyngeal tumors, including
performing neck dissection.
14.
Evaluate and treats patients with head and neck tumors of a vascular
origin.
15.
Perform an orderly and systematic physical examination of the patient
with facial trauma.
16.
Interpret radiographic diagnostic studies including panorex films,
cephalograms, CT/3D CT scans, MR imaging, and angiography with
respect to the head and neck trauma patient.
17.
Perform the staged management of devastating open facial injuries
including wound care, debridement and reconstruction.
18.
Perform surgical procedures of facial fracture management including:
a.
b.
c.
d.
e.
f.
g.
h.
maxillary
mandibular
orbital
frontal sinus
zygomatic
zygomatic arch
nasal
panfacial.
19.
Perform all surgical techniques of access to the craniofacial skeleton.
20.
Perform a comprehensive examination of the facial nerve.
21.
Perform acute repair of soft tissue facial trauma.
22.
Perform secondary scar revision from facial trauma.
23.
Perform primary facial nerve repair, and associated procedures (i.e. global
weight, static, and dynamic reconstruction) for the patient with facial
paralysis.
24.
Perform systemic therapy and local injection of steroids for treatment of
facial hemangiomas.
25.
Perform laser treatment for vascular malformations.
46
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improved patient care practices.
Objectives:
1.
Use information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care for patients with head and
neck diagnoses and the scientific evidence for that care.
2.
Routinely analyzes the effectiveness of own practices in caring for head
and neck patients.
3.
Improve own practices in the care of head and neck patients by integrating
appropriately gathered data and feedback.
4.
Educate medical students and other healthcare professional in the practices
of head and neck surgery.
5.
Function independently with graduated advancement and appropriate
faculty supervision in the evaluation and treatment of patients with head
and neck diagnoses.
6.
Participate in, and appreciate the value of outcome studies as they apply to
diagnoses of the head and neck.
47
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in pre- and post-operative care of head and
neck patients.
2.
Demonstrate compassion for patients and families with congenital and
acquired anomalies of the head and neck.
3.
Provide adequate counseling and informed consent to patients.
4.
Listen to patients and their families.
5.
Assimilate data and information provided by the craniofacial team and
other members of the health care team, in the care of patients with
congenital head and neck anomalies.
6.
Assimilate date and information provided by the head and neck team and
tumor board in the care of patients with congenital head and neck cancer.
48
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Function within the organization of specialty clinics (Cleft Palate Center,
Craniofacial Clinic) including the coordination of all special services in
the evaluation of children with these anomalies.
2.
Be able to coordinate the nonsurgical treatment of patients with congenital
anomalies among contributing specialties (prosthetics, orthodontics,
speech therapy).
3.
Understand the value of and function within a team approach to treat
patients with head and neck malignancies
4.
Participate in tumor-board conference.
5.
Participates in multidisciplinary planning and treatment for patients with
head and neck malignancies.
6.
Coordinate all aspects of head and neck rehabilitation, including physical
therapy, sensory reeducation, and maxillofacial prosthetics.
7.
Direct the rehabilitation of head and neck patients by partnering with the
following:
a.
b.
c.
d.
e.
physical therapy
occupational therapy
prosthetic and orthotics specialists
ENT cancer services
Speech and swallow specialists.
8.
Demonstrate knowledge of cost-effective head and neck reconstruction.
9.
Advocate for congenital craniofacial patients within the health care and
insurance system.
10.
Understand the benefits and functionality of multidisciplinary craniofacial
teams.
49
11.
Refer craniofacial patients to the appropriate practitioners and agencies.
12.
Appreciate the functioning of the multispecialty fetal diagnosis and
treatment committees and the potential role prenatal diagnosis plays in the
family unit.
13.
Facilitate the timely discharge of head and neck patients.
14.
Partner with pediatricians in the combined care of infants undergoing
systemic steroid therapy for head and neck hemangiomas.
50
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives:
1.
Develop a sensitivity of the unique stress placed on families under care for
congenital craniofacial anomalies.
2.
Exhibit an unselfish regard for the welfare of head and neck patients.
3.
Demonstrate firm adherence to a code of moral and ethical values.
4.
Be respectful to head and neck patients and their families especially in
times of trauma and stress to the family unit.
5.
Respect and appropriately integrate other members of the craniofacial
team.
6.
Provide appropriately prompt consultations when requested.
7.
Demonstrate sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to head and neck diagnoses of
trauma, malignancy, and congenital anomalies.
8.
Be reliable, punctual, and accountable for own actions in the OR and
clinic.
51
PLASTIC SURGERY OF THE
HAND AND UPPER EXTREMITY
52
A.
Medical Knowledge
I:
Anatomy/Physiology/Embryology
Goal: The resident will achieve a detailed knowledge of the anatomy, physiology, and
embryology of the upper extremity and will utilize this knowledge in the complete
management of the hand, arm, and brachial plexus.
Objectives:
1.
Describe in detail the anatomy and physiology of the muscles, tendons,
ligaments, and bones of the hand and upper extremity.
2.
Identify in detail the anatomy of the vascular tree of the upper extremity
including relationships to the surrounding structures.
3.
Identify in detail the anatomy of the major nerves and their branchings in
the upper extremity including relationships to surrounding structures.
4.
Draw the anatomy of the brachial plexus.
5.
Demonstrate the detailed radiographic anatomy of the bony structures of
the upper extremity.
6.
Utilizes the radiologic techniques, including plain films, CT scan,
angiography and MRI of the upper extremities.
7.
Discriminate the principles of electrical evaluation and recite knowledge
of the techniques of electrical examination of the upper extremities
including conduction studies and EMG evaluation.
8.
Recite the principles of upper extremity biomechanics.
53
II:
Congenital Disorders
Goal:
The resident will achieve familiarity with the spectrum of congenital
abnormalities of the upper extremity and perform comprehensive diagnostic evaluation
and surgical management of such problems.
Objectives:
1.
Recite the classification system for congenital hand anomalies including:
a.
b.
c.
d.
e.
f.
g.
failure of part formation
failure of differentiation
duplication
overgrowth
undergrowth
congenital bands
generalized musculoskeletal anomalies
2.
Describe the embryologic development and the physiologic theories which
explain the etiology of hand anomalies.
3.
Recite the operations including timing and techniques used in the surgical
management of hand anomalies.
54
III.
Benign and Malignant Tumors
Goal: The resident will understand the principles of diagnosis and treatment of extremity
tumors and undertake comprehensive management of a wide variety of such lesions.
Objectives:
1.
Describes the principles and techniques of management of upper extremity
tumors.
2.
Describe the etiologic factors, epidemiology, and modalities of treatment
for tumors of the upper extremities.
3.
Describe the clinical manifestations of both soft and hard tissue tumors of
the upper extremities.
4.
Describe the reconstructive principles and techniques for restoration of
form and function after surgical resections.
5.
Recite the indications and use of adjunctive therapy (i.e. radiation therapy
and chemotherapy) in the management of and the prognosis for upper
extremity tumors.
6.
Describe the principles and techniques of management for upper extremity
tumors, including reconstruction after surgical extirpation, for:
a.
b.
c.
d.
e.
7.
vascular tumors
nerve tumors
benign deep soft tissue tumors
malignant deep soft tissue tumors
primary bone tumors
Rationalize the utilization of radiotherapy, medical oncology, hand
therapy, occupational therapy, and prosthetics where appropriate for
patients with upper extremity tumors.
55
IV:
Trauma
Goal: The resident will understand the principles of diagnosis and treatment of extremity
trauma, and perform comprehensive management of acute injuries and other traumarelated problems of the hand and arm.
Objectives:
1.
Recite the principles and applications of diagnostic techniques for the
evaluation of hand and upper extremity trauma.
2.
Describe the techniques for operative management of traumatic injuries of
the upper extremity, their indications and contraindications, and their
possible complications and the treatment thereof.
3.
Explain the indications for, contraindications to, and techniques in
nonoperative management of traumatic injuries of the hand and upper
extremity.
4.
Describe the options for soft tissue coverage of upper extremities
including:
a.
b.
c.
skin grafts
local flaps
free tissue transfer
56
V. Functional Problems of the Upper Extremities
Goal: The resident will achieve familiarity with aesthetic and functional problems of
the hand and arm, understand the principles of rehabilitation of the upper extremity
and the management including comprehensive rehabilitation of the upper extremity.
Objectives:
1.
List the surgical and nonsurgical treatment of nerve compression and
entrapment syndromes of the upper extremity.
2.
Draw the pathologic anatomy and physiology of upper extremity
contractures and Dupuytren’s disease.
3.
Recite the basic pathophysiology of rheumatoid and nonspecific arthritis
of the upper extremity.
4.
Describe with the pharmacological therapy of rheumatoid arthritis.
5.
Demonstrate the surgical treatment of rheumatoid arthritis, timing of
therapeutic treatment and interactions with medical therapy.
6.
Describe the common circulatory disorders of the upper extremity
including, but not limited to: arterial thromboses, aneurysms, embolic
disorders, arteriovenous fistulae, vasospastic disease and scleroderma.
7.
Describe the diagnosis and treatment of common pain syndromes
including sympathetic dystrophy.
8.
Recite the management of upper extremity lymphedema.
57
VI.
Reconstruction
Goal: The resident will understand the principles and techniques of upper extremity
reconstruction and apply these to a variety of developmental, traumatic and acquired
problems.
Objectives:
1.
Recite the diagnostic techniques for evaluation of function including EMG
and conduction studies, arteriography, CT scan, and MRI evaluation.
2.
Recite the use of tendon transfers.
58
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of hand problems.
Objectives
1.
Perform the clinical techniques for physical examination of the hand and
upper extremity.
2.
Perform the surgical techniques
developmental hand anomalies.
3.
Perform postoperative care of patients with congenital and developmental
anomalies of the upper extremity.
4.
Apply casts and splints for the preoperative and postoperative care of hand
patients.
5.
Utilizes the diagnostic techniques for upper extremity tumors.
6.
Demonstrate the techniques of management of extremity tumors.
7.
Performs the procedures for the acute management and participates in the
post-operative rehabilitation of traumatic injuries of the upper extremity
including:
a.
b.
c.
d.
e.
f.
g.
h.
i.
used
to
treat
congenital
and
fractures and dislocations
nerve injury including brachial plexus
major amputation and avulsions
joint injury
tendon extensor and flexor injury of the hand
muscle and tendon injury of the arm
nail bed injuries
infections
fingertip and other minor injuries
8.
Perform the surgical treatment options for contractures.
9.
Perform treatment for tenosynovitis and tendon rupture.
10.
Describe the indications for and perform the techniques of tendon
reconstruction including tendon grafting – sources, methods, indications
59
11.
Perform the management of nerve injuries including primary, delayed
primary and secondary repair.
12.
Perform the techniques for reconstruction of the amputated thumb
including lengthening, pollicization, free toe to thumb, and free wraparound techniques.
13.
Perform the technical methods of soft tissue coverage including skin
grafts, local flaps, distant flaps, and transfers.
60
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives
1.
Uses information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care and the scientific evidence
for that care.
2.
Routinely analyzes the effectiveness of own practices in caring for hand
patients.
3.
Improves own practices in the care of hand patients by integrating
appropriately gathered data and feedback.
4.
Educates medical students and other healthcare professionals in the
practices of hand surgery.
5.
Functions independently with graduated advancement and appropriate
faculty supervision.
61
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives
1.
Educates patients and families in post operative strategies for hand
therapy.
2.
Demonstrates compassion for patients and families with traumatic and
congenital hand deformities.
3.
Provides adequate counseling and informed consent to patients.
4.
Listens to patients and their families.
5.
Assimilates data and information provided by hand therapists and other
members of the health care team.
6.
Charts and records accurate information.
62
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives
1.
Coordinates all aspects of hand and upper extremity rehabilitation,
including splinting, prosthesis use, physical therapy, and sensory reeducation.
2.
Direct the rehabilitation of upper extremities following trauma by
partnering with the following:
a.
b.
c.
Physical Therapy
Occupational Therapy
prosthetic and orthotic specialists
3.
Demonstrates knowledge of cost-effective hand care.
4.
Advocates for hand patients within the health care system.
5.
Understands the basics of the Worker’s Compensation.
6.
Refers hand patients to the appropriate practitioners and agencies.
7.
Facilitates the timely discharge of hand patients.
63
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives
1.
Develops a sensitivity of the unique stresses placed on families under care
for congenital anomalies of the hand.
2.
Exhibits an unselfish regard for the welfare of hand patients.
3.
Demonstrates firm adherence to a code of moral and ethical values.
4.
Is respectful to hand patients and their families especially in times of
trauma and stress to the family unit.
5.
Respects and appropriately integrates other members of the hand care
team.
6.
Provides appropriately prompt hand consultations when requested.
7.
Demonstrates sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to hand surgery.
8.
Is reliable, punctual, and accountable for own actions in the OR and hand
clinic.
64
PLASTIC SURGERY OF THE
TRUNK
65
A.
Medical Knowledge
I:
Anatomy/Physiology/Embryology
Goal: The resident will demonstrate knowledge of the anatomy, physiology, and
embryology of the trunk and breast, and apply this knowledge to the comprehensive
management of a variety of problems in these anatomic areas.
Objectives:
1.
Draw the musculature, blood supply, lymphatic drainage and innervation
of the trunk, abdominal wall, and breast.
2.
Discuss the embryonic development of the trunk, abdominal wall, and
breast.
3.
Recite the knowledge of the glandular structure and function, as well as
understand hormonal influence on breast development and function.
4.
Discuss the differences in breast structures and function in adolescence,
reproductive years, pregnancy, lactation and menopause.
5.
Discuss the structure and function of the male, as well as female genitalia.
6.
Draw the anatomy of the breasts, including:
a.
b.
c.
d.
e.
f.
7.
location on the chest wall
underlying structures
glandular structure: lobes, lobules, alveoli/histology
the nipple and its ducts
variations in anatomy: polymastia, polycythemia
vasculature, innervation and lymphatic drainage.
Discuss the anatomy of the trunk, anterior and posterior abdominal wall,
including:
a.
b.
c.
d.
e.
f.
g.
muscles forming the abdominal wall
deep and superficial fascia of the abdominal wall
anatomy of trunk muscles as related to flaps for reconstructive
purposes
fat distribution
innervation, blood supply, and lymphatic drainage.
skin and its elastic quality
the male and female escutcheon
66
II:
Congenital Disorders
Goal: The resident will demonstrate knowledge of congenital disorders of the trunk,
breast, and abdomen, and perform complete plastic surgical management of these
problems.
Objectives:
1.
Discuss the normal male and female breast growth and development and
understand the general physiologic principles of disease in which breast
abnormalities may be but one manifestation.
2.
Discuss the physiologic consequences of developmental chest wall
deformities.
3.
Recite the surgical aspects of treatment of patients with developmental
chest wall deformities such as pectus carinatum and pectus carivatum.
4.
Discusses the basic principles and techniques of the surgical treatment of
common developmental breast anomalies including amastia, Poland’s
syndrome, asymmetry, ectopic mammary tissue, virginal hypertrophy and
gynecomastia.
5.
Discuss the knowledge of the common deformities of the posterior trunk.
6.
Discuss the reconstructive surgery of posterior trunk lesions, including
meningomyelocele, sacrococcygeal teratomas, etc., and recognize the
benefit of a team approach to these problems.
7.
Recite the embryology and developmental anatomy of congenital
abdominal deformities such as gastrocscesis, prune belly and omphalocele.
8.
Discuss the reconstructive surgical management of congenital abdominal
deformities such as gastroscesis, prune belly, and omphalocele.
67
III:
Benign and Malignant Tumors
Goal: The resident will demonstrate knowledge of the biologic behavior, histology,
physiology and management principles of benign and malignant processes of the breast,
and carry out comprehensive medical and surgical management of such problems.
Objectives:
1.
Describe the biologic behavior, histologic characteristics, and clinical
manifestation of malignancies of the breast.
2.
Discuss the plastic surgical options for management of breast
reconstruction after mastectomy for carcinoma and the principles of longterm follow-up patients with breast carcinoma.
3.
Discuss the diagnostic techniques and treatment methods (surgical and
nonsurgical) for management of premalignant disease and other processes
of the breast.
4.
Discuss the implications of genetic predisposition to breast cancer and the
options of prophylactic mastectomy.
5.
Describe the etiology of gynecomastia and be familiar with the surgical
options for treatment.
6.
Discuss the various treatment protocols (including surgery, radiation, and
chemotherapy plus combinations) for management of carcinoma of the
breast including sentinel node survey.
7.
Discuss the complete treatment of malignancy of the breast including:
a.
b.
c.
d.
e.
f.
pathology and biologic behavior
diagnostic techniques
principles of primary treatment
techniques of primary treatment
secondary treatment
management of the opposite breast after mastectomy.
68
IV:
Trauma and Reconstruction
Goal: The resident will demonstrate knowledge of management of problems of the
breast and trunk, and carry out surgical management including reconstruction for such
disorders.
Objectives:
1.
Recite the basic principles of medical and surgical management of
common acute traumatic trunk and breast injuries including sternal
infections.
2.
Recite the etiology and nonsurgical management of pressure sore ulcers
(including preventative measures).
3.
Recite a detailed knowledge of surgical aspects of pressure sore
reconstruction.
4.
Discuss the surgical aspect of breast reconstruction and the rationale for
choices between different methods.
5.
Discuss the use of prosthetic devices for breast reconstruction, including
implants, tissue expanders, and external prosthesis.
69
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of reconstructive surgery.
Objectives:
1.
Perform reconstructive surgery on the trunk, breast, and abdomen with
increasing independence and surgical responsibility.
2.
Participate in treatment of patients with malignancy of the trunk, thorax
and abdominal wall.
3.
Participate in the surgical management of thoracic and abdominal wall
reconstruction with graduated independence, including:
a.
b.
c.
d.
e.
4.
reconstruction following sternal dehiscence and/or infection
reconstruction after tumor resection utilizing flaps and grafts
reconstruction of radiation injury of the thorax and trunk
abdominal wall fascial reconstruction
abdominal wound dehiscences and hernias utilizing prosthetic
material, grafts, separation of parts.
Participate in surgical and nonsurgical management of pressure sores
including:
a.
b.
c.
d.
e.
f.
etiology and staging
prevention
nonsurgical considerations and management including patient
compliance
pressure sore surgery utilizing local flaps, muscle and
myocutaneous flaps, and distant flaps
complications of surgery
rehabilitation.
5.
Participate in the surgical care of common developmental breast
anomalies, with graduated surgical independence, including amastia,
Poland’s syndrome, asymmetry, ectopic mammary tissue, virginal
hypertrophy, and gynecomastia.
6.
Participate in the full spectrum of reconstructive surgery after breast
carcinoma, including procedures on the opposite breast; participate in
long-term treatment and follow-up of these patients.
70
7.
Evaluate and treat patients with premalignant diseases of the breast,
including prophylactic mastectomy in selected patients.
8.
Evaluate and surgically treat patients with gynecomastia.
9.
Participate in breast reconstruction following mastectomy, including:
a.
b.
c.
d.
e.
f.
tissue expanders
implants
flaps
nipple reconstruction
other procedures including tattooing
management of contralateral breast.
10.
Participate in the evaluation and treatment of patients with post surgical
breast deformities.
11.
Participate in the evaluation of patients with developmental breast
abnormalities and perform diagnostic studies; interact with appropriate
consultants in allied areas.
12.
Perform perioperative care and surgery on patients with developmental
and acquired breast abnormalities, including breast hypertrophy,
asymmetry, tubular deformity, and Poland’s syndrome.
13.
Critically analyze patients with developmental chest wall deformities for
aesthetic and functional reconstruction.
14.
Participate in reconstructive surgery on patients with developmental chest
deformities.
15.
Participate in the surgical care of posterior trunk lesions, including
meningomyelocele, sacrococcygeal teratomas, etc.
16.
Evaluate and participate in the multispecialty surgical evaluation of
patients with congenital deformities of the posterior trunk.
17.
Participate in the reconstruction of posterior trunk congenital defects.
18.
Participate in the surgical care of congenital abdominal wall deformities
such as gastroscesis, prune belly, and omphalocele.
19.
Participate in the evaluation and surgical planning (in concert with other
surgical specialists) of congenital abdominal wall deformities.
71
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives:
1.
Use information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care and the scientific evidence
for that care.
2.
Routinely analyze the effectiveness of own practices in caring for patient
with abdominal wall and trunk plastic surgical diagnoses.
3.
Improve own practices in the care of patient by integrating appropriately
gathered data and feedback.
4.
Educate medical students and other healthcare professionals in the practice
of reconstructive surgery.
5.
Function independently with graduated advancement and appropriate
faculty supervision.
6.
Participate in and appreciate the value of outcome studies as they apply to
abdominal wall and trunk plastic surgical reconstruction.
72
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in post-operative strategies for
reconstructive surgery.
2.
Demonstrate compassion for patients and their families affected by breast
cancer.
3.
Provide adequate counseling and informed consent to patients.
4.
Listen to patients and their families.
5.
Assimilate data and information provided by general surgeons and other
members of the breast care team.
6.
Chart and record accurate information.
7.
Demonstrate appreciation of the psychosocial aspects of breast surgery,
breast deformity, and post mastectomy reconstruction.
73
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Direct the rehabilitation of pressure sore patients following surgery by
partnering with the following:
a.
b.
c.
d.
e.
physical therapy
occupational therapy
prosthetic and orthotics specialists
spina bifida clinic
physical medicine and rehabilitation specialists.
2.
Demonstrate knowledge of cost-effective breast reconstruction and other
breast surgery.
3.
Advocate for breast cancer patients within the health care system.
4.
Refer breast cancer patients to the appropriate practitioners and agencies.
5.
Facilitate the timely discharge of patients undergoing reconstructive
plastic surgery.
6.
Participate in all aspects of breast cancer care, partnering with general
surgeons, radiation oncologists, and other breast care team members in the
complete care of the breast cancer patient.
74
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives:
1.
Develop a sensitivity of the unique stress placed on families under care for
breast cancer.
2.
Exhibit and unselfish regard for the welfare of reconstructive patients.
3.
Demonstrate firm adherence to a code of moral and ethical values.
4.
Be respectful to breast cancer patients and their families, especially in
times of stress to the family unit.
5.
Respect and appropriate integrate other members of the breast care team.
6.
Provide appropriately prompt reconstructive plastic surgery consultations
when requested.
7.
Demonstrate sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to reconstructive plastic surgery.
8.
Be reliable, punctual and accountable for own actions in the OR and
outpatient clinic.
75
PLASTIC SURGERY OF THE
LOWER EXTREMITY
76
A.
Medical Knowledge
I:
Anatomy/Physiology/Embryology
Goal: The resident will obtain comprehensive knowledge of the anatomy, physiology,
and embryology of the lower extremities, and use this information in the management of
a variety of surgical problems of the leg.
Objectives:
1.
Draw the vascular, neural and osseous anatomy of the lower extremity.
2.
Describe the muscular and vascular anatomy of specific flaps including
fascia lata, vastus lateralis, rectus femoris, sartorius, and gracilis flaps.
3.
Describe the boundaries of and vascular anatomy of specific cutaneous
flaps including the lateral thigh, medial thigh, posterior thigh and groin
flaps.
4.
Draw the venous anatomy of the leg including the sapheneous vein.
5.
Describe the muscular, cutaneous, and vascular anatomy of the
gastrocnemius, soleus, and tibialis muscle flaps.
6.
Explain the concept of fasciocutaneous flaps and be able to design them
on the distal lower extremity.
7.
Describe the cutaneous margins and vascular anatomy of foot flaps such
as medical plantar, lateral plantar, V-Y plantar, and dorsalis pedis-based
flaps.
8.
Describe the neuroanatomy of and boundaries of sensate flaps in the lower
extremity.
9.
Explain the physiology of arterial insufficiency, venous hypertension, and
diabetes as they pertain to the lower extremity.
10.
Draw the detailed anatomy of the popliteal artery and its branches.
11.
Describe the normal plantar arch and the fundamentals of normal foot
vasculature.
12.
Discriminate the advantages and disadvantages of the various levels of
lower extremity amputation.
77
13.
Recite the basic lower extremity embryology, abnormal development and
its sequelae.
14.
Describe the anatomy as applied to specific lower extremity flaps
including:
a.
b.
c.
d.
e.
15.
skin flaps
muscle and skin-muscle flaps
fascial and fasciocutaneous flaps
sensate flaps
flaps which include bone
Describe the biomechanics of the lower extremity including:
a.
b.
c.
function of specific muscles and muscle groups
gait
functional consequences of use of specific muscles as flaps
78
II:
Trauma/Reconstruction of the Lower Extremity
Goal: The resident will obtain the principles of management of trauma related problems
of the lower extremity and carry out surgical management in the reconstruction of such
problems.
Objectives:
1.
Recite the indications for and timing of closure of soft tissue defects of the
lower extremity.
2.
Describe coverage techniques (including skin grafts, flaps, distant flaps,
musculocutaneous flaps, and free flaps) for soft tissue closure of the lower
extremity.
3.
Describe the management of infectious processes (including
osteomyelitis) related to traumatic injuries of the lower extremity.
4.
Describe the pathophysiology of and techniques for nonoperative and
operative management of traumatic, ischemic, venous stasis, hypertensive
and infectious ulcers.
5.
Recite the etiology and treatment of lymphedema (including non operative
measures).
6.
Recite the basis for classification of tibial fractures and the treatment
modification appropriate for injuries of varying severity.
7.
Understand the orthopedic management of long-bone injuries including
internal and external fixation, leg lengthening, and standard techniques for
replacement of bone defects.
8.
Recite the common congenital deformities of the lower extremity
(including constriction defects and syndactyly) and their management.
9.
Describe the indications of and techniques for replantation or
revascularization of lower extremity devascularizing or amputative
injuries.
10.
Recite the principles and techniques of aesthetic contouring of the lower
extremity (including excisional and liposuction techniques).
79
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of lower extremity diagnoses.
Objectives:
1.
Perform cadaver dissection of the lower extremity.
2.
Apply anatomic and biomedical knowledge to the choice of procedures for
lower extremity reconstruction.
3.
Classify lower extremity tibial fractures.
4.
Participate in the orthopedic management of lower extremity trauma.
5.
Participate in the reconstruction of congenital deformities of the lower
extremity.
6.
Participate in the reconstruction of major vascular lesions or injuries of the
lower extremity.
7.
Perform reconstructions of major tendon or nerve injuries of the lower
extremity.
8.
Participate in the surgical and nonsurgical multidisciplinary care of left
ulcers.
9.
Evaluate and treat patients with lower extremity ulceration of different
etiologic origins.
10.
Undertake perioperative management and surgical treatment of patients
with devascularizing injuries or conditions of the lower extremity.
11.
Evaluate and treat patients with lymphedema of the lower extremity.
12.
Perform aesthetic reconstruction and liposuction of the lower extremities.
80
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives:
1.
Use information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care for patients with lower
extremity diagnoses and the scientific evidence for that care.
2.
Routinely analyze the effectiveness of own practices in caring for lower
extremity patients.
3.
Improve own practices in the care of lower extremity patients by
integrating appropriately gathered data and feedback.
4.
Educate medical students and other healthcare professionals in the
practices of lower extremity reconstruction.
5.
Function independently with graduated advancement and appropriate
faculty supervision in the evaluation and treatment of patients with lower
extremity diagnoses.
81
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in post-operative care of lower extremity
diagnoses.
2.
Demonstrate compassion for patients and families with congenital and
acquired anomalies of the lower extremity.
3.
Provide adequate counseling and informed consent to patients.
4.
Listen to patients and their families.
5.
Assimilate data and information provided by therapists and other members
of the health care team.
82
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Function within the organization of specialty clinics (diabetic clinic,
venous stasis clinic, amputation clinic) including the coordination of all
special services in the evaluation of lower extremity lesions.
2.
Coordinate the nonsurgical treatment of patients with lower extremity
lesions among contributing specialists (prosthetics, orthotics and wound
care specialists).
3.
Understand and function within a team approach to treat patients with
lower extremity diagnoses.
4.
Participate in multidisciplinary planning and treatment for patients with
lower extremity amputations.
5.
Direct the rehabilitation of lower extremity patients by partnering with the
following:
a.
b.
c.
6.
physical therapy
occupational therapy
prosthetic and orthotics specialists
Demonstrate knowledge of cost-effective lower extremity reconstruction.
83
F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives:
1.
Develop a sensitivity of the unique stress placed on families under care for
traumatic lower extremity injuries.
2.
Exhibit and unselfish regard for the welfare of lower extremity patients.
3.
Demonstrate firm adherence to a code of moral and ethical values.
4.
Be respectful to patients and their families, especially in times of trauma and
stress to the family unit.
5.
Provide appropriately prompt consultations when requested.
6.
Demonstrate sensitivity to the individual patient’s profession, life goals, and
cultural background as they apply to lower extremities diagnoses.
7.
Be reliable, punctual, and accountable for own actions in the OR and clinic.
84
AESTHETIC PLASTIC SURGERY
85
A.
Medical Knowledge
I.
Aesthetic Surgery of the Breast and Trunk
Goal: The resident will be thoroughly familiar with aesthetic surgery of the trunk and
breast, and undertake comprehensive surgical management of such diagnoses.
Objectives:
1.
Draw the normal anatomy of the breast and axillae.
2.
Describe the pathologic anatomy and histology of the breast as it relates to
mammary hyperplasia and hypoplasia.
3.
Discuss the various surgical techniques for breast reduction, the
indications for and contraindications to the procedures.
4.
Discuss the complications of breast reduction, their prevention and
management.
5.
Describe the various surgical techniques for breast augmentation, the
indications for an contraindications to the procedures.
6.
Discuss the complications of augmentation mammoplasty, their prevention
and management.
7.
Discuss the different types of breast implants and the reasons for choosing
a particular type for a particular problem.
8.
Describe the basic techniques for mastopexy, the indications for and
contraindications to these procedures.
9.
Discuss the complications of mastopexy, their prevention and
management.
10.
Discuss techniques for treatment of aesthetic trunk deformity such as
panniculectomy and abdominoplasty, the indications for them and
contraindications to the procedures.
11.
Discuss the complications of panniculectomies and abdominoplasties and
their prevention and management.
12.
Discuss the treatment options for congenital breast anomalies such as
Pollands syndrome.
86
13.
Describe the techniques of suction lipectomy as applied to aesthetic
deformities of the trunk, as well as anesthetic management for these
procedures.
14.
Recite the principles of selection of mastopexy vs. augmentation
mammoplasty.
15.
Recite the principles of selection of abdominoplasty vs. liposuction.
16.
Explain the basic principles and techniques for treating other aesthetic
deformities of the breast and drunk such as inverted nipples, localized
lipodystrophy, tubular breast deformity, etc.
17.
List the long-term consequences of augmentation mammoplasty such as
capsular contraction and its treatment as well as methods for follow-up
including special techniques for mammography.
18.
Discuss the post-obesity deformity and the options for body contouring
surgery.
87
II.
Aesthetic Surgery of the Head and Neck
Goal: The resident will be familiar with aesthetic diagnoses of the head and neck and
understand the principles of surgical treatment of such problems.
Objectives:
1.
Discuss the concepts of beauty and aesthetic principles of the facial
structures.
2.
Identify the principles and techniques of aesthetic rhinoplasty as well as
the differences in approach between primary and secondary rhinoplasty.
3.
Recite the diagnostic and therapeutic techniques in the management of
nasal airway obstruction.
4.
Discuss the application of aesthetic principles to the cleft patient.
5.
Explain the complications of rhinoplasty and septoplasty, their prevention
and treatment.
6.
Discuss the varying effects of aging and sun exposure on the facial
structures.
7.
Demonstrates the techniques of rhytidectomy, suction lipectomy,
genioplasty, blepharoplasty, and other methods for treatment of the aging
face.
8.
Discuss the complications of facial aesthetic surgery, their prevention and
treatment.
9.
Draw the various aesthetic deformities of the ear and know the techniques
of their correction.
10.
Discuss the aesthetic and functional problems of the eyelid, including
blepharochalasis and ptosis; knows the treatment for these diagnoses,
complications and prevention.
11.
Discuss the diagnostic methods and treatment options for the patient with
facial palsy.
12.
Describe the diagnostic principles and treatment techniques for alopecia
pattern baldness including tissue expansion, scalp flaps, and hair
transplantation.
88
13.
Discuss the principles and techniques of orthognathic surgery for the
treatment of craniofacial skeletal dysharmony.
14.
Discuss the various ancillary techniques for management of the aging
face, including chemical peel, Retin A, dermabrasion, collagen injection,
laser resurfacing, injection of filling material, botulinum toxin,
hydroxyapatite, hyaluronic acid, and skin care products.
15.
Discuss the use of lasers for the treatment of unwanted hair, tattoo
removal, and facial resurfacing, include laser biophysics and safety.
16.
Discuss the various techniques used for face lifting, including the role of
platysma, SMAS, subperiosteal, deep plan, composite, etc.
17.
Discuss the different types and appropriate uses of liposuction.
89
B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment 0f aesthetic patients.
Objectives:
1.
Perform complete assessment of patients presenting for facial plastic
surgery.
2.
Perform the following breast surgeries with graduated operative
independence including:
a.
b.
c.
3.
reduction mammoplasty
augmentation mammoplasty
ptosis correction and mastopexy.
Perform the following surgeries including pre-operative markings with
graduated operative independence, including:
a.
b.
c.
d.
e.
f.
suction lipectomy
panniculectomy
abdominoplasty
body lifts
brachioplasties
thigh lifts
4.
Perform preoperative markings for reduction mammoplasty.
5.
Perform a comprehensive (internal/external) nasal exam and participate in
surgery of the nose including:
a.
b.
c.
d.
6.
primary and secondary rhinoplasty
cleft lip nasal deformity
airway obstruction
septoplasty.
Participate in facial aesthetic surgery including:
a.
b.
c.
d.
e.
f.
rhytidectomy
brow lift
facial liposuction
blephanoplasty
gennioplasty
jaw disharmony
90
7.
Perform both open and endoscopic surgical therapy for patients with aging
face including rhytidectomy and brow lift.
8.
Perform ancillary procedures for the aging face such as chemical peels,
skin care, injection of fillers and botox, etc.
9.
Participate in the treatment of patients with facial nerve palsy including:
a.
b.
c.
d.
e.
10.
nerve grafts
placement of gold weights
suspensory static procedures
dynamic procedures
free tissue transfer.
Evaluate the psychosocial status of the patient presenting for aesthetic
plastic surgery and determine whether the patient is an appropriate
candidate for surgery.
91
C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives:
1.
Uses information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care and the scientific evidence
for that care.
2.
Routinely analyzes the effectiveness of own practices in caring for
aesthetic and breast patients.
3.
Improve own practices in the care of aesthetic and breast patients by
integrating appropriately gathered data and feedback.
4.
Educate medical students and other healthcare professionals in the
practices of aesthetic and breast surgery.
5.
Function independently with graduated advancement and appropriate
faculty supervision.
6.
Continue to keep apprised of new techniques used in facial aesthetic
surgery.
92
D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives:
1.
Educate patients and families in operative strategies for aesthetic surgery.
2.
Provide adequate counseling and informed consent to patients.
3.
Listen to patients and their families.
4.
Chart and record accurate information.
5.
Accurately assess patient’s expectations of aesthetic plastic surgery and
honestly educate them on appropriate surgical intervention.
93
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives:
1.
Demonstrate knowledge of cost-effective strategies for breast surgery.
2.
Facilitate the timely discharge of aesthetic and breast patients.
3.
Understand the state, local and specialty requirements for outpatient
surgical centers utilized in the care of aesthetic surgery patients.
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F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles and sensitivity to a diverse patient
population.
Objectives:
1.
Exhibit an unselfish regard for the welfare of patients presenting for
cosmetic surgery.
2.
Demonstrate firm adherence to a code of moral and ethical values.
3.
Respect and appropriately integrate other member of the breast care team.
4.
Demonstrate sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to aesthetic and breast surgery.
5.
Is reliable, punctual, and accountable for own actions in the OR and clinic.
6.
Provide non-biased consultations for patients presenting for aesthetic
surgery.
7.
Understand the impact of psychological issues, such as body dysmorphic
disorder and psychosocial stressors, in patients who present for cosmetic
surgery.
8.
Participate in the Chief Resident’s Aesthetic Clinic, adhering to strict
ethical principles and professionalism specifically with respect to
advertising, recruiting, educating and treating patients.
9.
Appreciate the potential conflict of interest that exists in the practice of
aesthetic plastic surgery with respect to patient’s surgical needs and
expectations and the surgeon’s financial rewards.
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BURN SURGERY
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A.
Medical Knowledge
Goal: The resident will achieve a detailed knowledge of the evaluation and management
of burn patients.
Objectives:
1.
Discuss the techniques of resuscitation of major burns.
2.
Recite the criteria for superficial and deep partial thickness, as well as fullthickness classification of burns.
3.
Discuss the three zones of a burn wound.
4.
Discuss the properties of split thickness vs. full thickness skin grafts, as
meshed and sheet grafts.
5.
Discuss the treatment of inhalation injuries.
6.
Describe the resuscitation and management of electrical burns.
7.
Describe the indications of fasciotomies and escharotomies.
8.
List the details regarding the use of skin substitutes, biological dressings,
and xenografts in the treatment of the burn patient.
9.
Discuss the reconstruction for burn contractures.
10.
Recite the use of pressure garments and silicone therapy in the prevention
of abnormal scars.
11.
Describe the pathology and management of thermal, chemical, and
electrical injury and inhalation injury and relationship to mortality,
morbidity, and course of patient recovery.
12.
Outline the principles of burn shock, immunologic alteration, and
bacteriologic pathology of the burn wound.
13.
Discuss the epidemiology, prevention,
psychological impact of burns.
14.
Recite the physiologic response to thermal, chemical, and electrical burn
injuries, including the micro and macro disruption of normal skin anatomy
and physiology.
and
socioeconomic
and
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B.
Patient Care
Goal: The resident will provide patient care that is compassionate, appropriate, and
effective for the treatment of burn patients.
Objectives
1.
Evaluate the appearance of the burn wound in relation to its depth,
bacteriologic condition, healing potential, and requirement for
intervention.
2.
Perform burn wound debridement and preparation for skin grafting.
3.
Perform split thickness skin grafts.
4.
Perform full thickness skin grafts.
5.
Utilize skin substitutes, biological dressings, and xenografts in the
treatment of burn wounds.
6.
Utilize splinting and pressure garments to minimize scar formation and
post burn contractures.
7.
Perform the surgical treatment of post-burn contractures with releases, zplasties, and grafting.
8.
Participate in the acute resuscitation and care of the burned patient.
9.
Treat patients who are victims of electrical burns.
10.
Perform escharotomies and fasciotomies when indicated.
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C.
Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices,
appraise and assimilate scientific evidence, and improve patient care practices.
Objectives
1.
Uses information technology to prepare for surgical cases, bringing to the
OR the knowledge of current modalities of care and the scientific evidence
for that care.
2.
Routinely analyzes the effectiveness of own practices in caring for burn
patients.
3.
Improves own practices in the care of burn patients by integrating
appropriately gathered data and feedback.
4.
Educates medical students and other healthcare professionals in the
practices of burn surgery and reconstruction.
5.
Functions independently with graduated advancement and appropriate
faculty supervision.
6.
Uses library sources to perform research and perform literature searches.
7.
Understands the principles of clinical research and the application of
biostatistics.
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D.
Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result
in effective information exchange and teaming with patients, their families, and
professional associates.
Objectives
1.
Educates patients and families in post operative and rehabilitative
strategies for burn patients.
2.
Demonstrates compassion for patients and families afflicted with trauma.
3.
Provides adequate counseling and informed consent to patients.
4.
Listens to patients and their families.
5.
Assimilates data and information provided by other members of the health
care team.
6.
Charts and records accurate information.
100
E.
System Based Practice
Goal: The resident will demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
Objectives
1.
Coordinates all aspects of the rehabilitation of the burn surgery patient.
2.
Direct the rehabilitation of burn surgery patients by partnering with the
following:
a.
b.
c.
d.
e.
Physical Therapy
Occupational Therapy
PRM physicians
social workers
nutritionalists
3.
Demonstrates knowledge of cost-effective burn surgery care.
4.
Advocates for burn surgery patients within the health care system.
5.
Refers orthopedic patients to the appropriate practitioners and agencies.
6.
Facilitates the timely discharge of burn surgery patients
7.
Works with paramedical professionals in the prehospital care of trauma
patients.
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F.
Professionalism
Goal: The resident will demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
Objectives
1.
Develops a sensitivity of the unique stresses placed on families under care
for burn injuries.
2.
Exhibits an unselfish regard for the welfare of burn surgery patients.
3.
Demonstrates firm adherence to a code of moral and ethical values.
4.
Is respectful to burn patients and their families especially in times of
trauma and stress to the family unit.
5.
Respects and appropriately integrates other members of the burn surgery
team.
6.
Provides appropriately prompt consultations when requested.
7.
Demonstrates sensitivity to the individual patient’s profession, life goals,
and cultural background as they apply to burn care.
8.
Is reliable, punctual, and accountable for own actions in the OR and clinic.
9.
Understands the concepts of autonomy, beneficence, nonmaleficence,
justice, and respect for life.
10.
Maintains patient confidentiality.
102