Plastics in Practice (Resident Review)

Pedicled or free TRAM? This is one of the classic decision points in autologous breast reconstruction, and it still matters. In this episode, we break down the practical tradeoffs between pedicled TRAM, free TRAM, and DIEP-based thinking: flap perfusion, donor-site morbidity, operative complexity, and patient selection. For residents, this is the real question: when should you preserve muscle, whe...

This long-form episode is a high-yield, start-to-finish in-service review. We cover the main topics: core principles → wounds/flaps/grafts → burns/skin cancer → CMF trauma + vision threats → hand infections/tendon zones → breast/implants + complications → trunk/LE coverage logic → last-minute algorithms. #PlasticSurgery #PSITE #InService #PlasticsInPractice #SurgeryResident #BoardPrep #Microsurger...

Autologous reliability with prosthetic precision— the latissimus dorsi flap (LDF) is back for a reason. In this episode we break down how to optimize LD flap breast reconstruction using “volume-added” harvest and smart expander/implant strategy. We cover the operative setup from markings and skin paddle design to subfascial dissection to capture deep fat , high axillary tunneling , and inset strat...

Prosthetic breast reconstruction looks “simple” until you chase symmetry, fight the inframammary fold, and add radiation into the mix. This episode is a practical walkthrough of the two-stage expander–implant pathway —what actually matters, what fails, and how to plan it cleanly. Episode overview We cover patient selection , immediate vs delayed timing , modern biodimensional expanders , the expan...

Breast cancer management isn’t “mastectomy vs lumpectomy.” It’s risk → imaging → tissue diagnosis → staging → locoregional control → systemic therapy , all tailored to tumor biology and patient goals. In this episode, we walk through the modern evidence base that moved us from Halsted-era radical surgery to breast-conserving therapy + targeted systemic therapy , while keeping oncologic safety fron...

Gynecomastia isn’t “just fat.” It’s a spectrum—ductal tissue, stroma, and fat—driven by hormonal shifts across life stages. In this episode, we walk through a clean clinical framework : etiology → pathology timeline → exam/workup → severity grading → surgical plan , with pearls that prevent the most common aesthetic failures. We cover when you can stop the workup , how to interpret florid vs fibro...

Vertical reduction mammaplasty represents a fundamental shift in breast reduction philosophy. Instead of relying on skin tension to maintain shape, the vertical approach prioritizes internal parenchymal architecture to create durable projection, narrower bases, and reduced scarring. In this episode of Plastics in Practice , we break down the core principles of Hall-Findlay’s vertical reduction mam...

Macromastia reduction is where reconstructive principles collide with aesthetic outcomes— and the inverted-T (Wise) pattern stays dominant because it’s predictable. In this episode, we walk through the anatomic “non-negotiables” for NAC perfusion + sensation , then translate that into practical pedicle selection (inferior, superomedial, central mound, and vertical bipedicle) for the real cases: la...

Ptosis + volume loss is the classic “deflated upper pole in a stretched envelope” problem—and mastopexy-augmentation is where planning mistakes become revisions . This episode breaks down how to choose the right mastopexy pattern , when augmentation alone is enough, and the technical pitfalls that drive complications (especially scarring, malposition, and ischemic risk). We’ll walk through ptosis...

Breast augmentation is one of the most performed aesthetic operations—and still one of the most revised. This episode is a practical, surgeon-to-surgeon breakdown of how to drive reoperations down by treating planning as the operation. We walk through a tissue-based philosophy : objective measurements (not cup-size promises), pocket selection that matches coverage needs, and operative decisions th...

In this episode of Plastics in Practice , we break down one of the most enduring debates in reconstructive microsurgery: Muscle vs. Fasciocutaneous (FC) flaps for lower limb trauma. For decades, residents were taught that muscle was mandatory for open fractures and osteomyelitis due to its superior vascularity and dead-space obliteration. But does the modern evidence support this? We analyze landm...

Foot and ankle reconstruction is a battlefield of function and form. Every subunit has its own demands — the dorsum needs thin, pliable coverage; the heel demands durable, glabrous-like skin. In this landmark PRS 2010 paper, Hollenbeck et al. applied the subunit principle to 165 free flaps, giving surgeons a blueprint for tailored, long-term reconstruction success. Summary: This episode breaks dow...

Orbital floor fractures are among the most common midfacial injuries—and understanding when and how to operate is key for every resident. In this episode, we break down the anatomy, evaluation, and evidence-based management of orbital blowout fractures, based on Gart & Gosain’s Plastic and Reconstructive Surgery 2014 review. We cover: Mechanisms — buckling vs. hydraulic theory, and why both ma...

Mandible fractures are the most common indication for surgical repair of facial fractures, and their management continues to evolve with modern plating systems and imaging. In this episode of Plastics in Practice, we break down the key anatomy, causes, diagnostic pearls, and surgical strategies you need to know for the boards and the operating room. We start with the anatomy of the mandible — from...

Frontal sinus fractures are among the most challenging maxillofacial injuries — rare but high-stakes, with potential for meningitis, brain abscess, and lifelong sinus complications if mismanaged. In this episode of Plastics in Practice , we break down the stepwise algorithm for diagnosis and management of frontal sinus trauma. We’ll walk through the embryology and anatomy that make these fractures...

Zygoma fractures are among the most common midfacial injuries, directly impacting both function and aesthetics. For plastic surgery residents, mastering the anatomy, evaluation, and surgical management of these fractures is essential. In this episode of Plastics in Practice , we break down the essentials of zygoma fractures. From the quadripod anatomy of the zygomaticomaxillary complex to the clin...

Middle and distal leg defects can be among the most challenging reconstructive problems in plastic surgery. But what if you could avoid microsurgery and still achieve reliable “like-with-like” coverage? In this episode, we break down the principles, technique, and outcomes of perforator propeller flaps for lower extremity reconstruction. Drawing from the landmark PRS Global Open article by Mendiet...

When faced with high-energy lower extremity trauma, the question of salvage versus amputation is one of the toughest decisions in reconstructive surgery. This episode breaks down the evidence and provides practical pearls for plastic surgery residents and trainees. We walk through the landmark LEAP study and subsequent meta-analyses comparing functional outcomes between limb salvage and early ampu...

Lower extremity reconstruction is one of the most challenging areas of plastic surgery, where surgeons must decide between limb salvage and primary amputation. This episode breaks down the principles from the PRS CME article by Reddy and Stevenson, giving residents and fellows a clear roadmap for evaluation, decision-making, and flap selection. We start with preoperative assessment : patient comor...

Major upper extremity amputation is one of the most devastating injuries a patient can face. Unlike lower extremity amputations where prosthetics may restore function, the upper limb remains uniquely challenging. That’s why every effort should be made to replant the amputated extremity. But replantation is only the beginning — secondary reconstructive surgery is often required to optimize function...

Hand trauma with vascular compromise demands fast and accurate decision-making. In this episode of Plastics in Practice , we review two pivotal studies shaping how we triage and manage these patients: the use of pulse oximetry for objective assessment of vascular injuries and the role of IV heparin following digital replantation . Traditional bedside exam—capillary refill, Doppler signals, pinpric...

Distal fingertip amputations are among the most common hand injuries, yet whether to replant or revise remains one of the most debated questions in hand surgery. In this episode, we break down “A Systematic Review of the Outcomes of Replantation of Distal Digital Amputation” (Sebastin & Chung, PRS 2011). Thirty studies encompassing 2,273 distal replantations give us the best available evidence...

Upper limb replantation remains one of the most challenging — and rewarding — procedures in plastic and reconstructive surgery. From fingertip injuries to major limb salvage, success depends not only on microsurgical skill but also on sound decision-making, efficient technique, and anticipating complications. In this episode, we break down the essential principles every trainee should know when fa...

Hand and upper extremity amputations are devastating injuries — but modern microsurgery has transformed outcomes. Not every part should be replanted, and today’s decisions balance survival, function, and efficiency. In this episode of Plastics in Practice , we dive into the current concepts of upper extremity replantation. Since the first successful thumb replantations in the 1960s, the field has...

What if you could fix hand fractures without sedation, tourniquet pain, or costly OR time? Welcome to the era of wide-awake, local anesthesia, no tourniquet (WALANT) surgery. In this episode, we unpack the principles, technique, and rehab pearls behind wide-awake surgical management of hand fractures. WALANT challenges long-held beliefs about epinephrine use in the finger and empowers surgeons to...