In this week's edition
- ✍️ Letter from P'Fella
You now operate 10% less than 4 years ago - 🤓 The Sunday Quiz
How well do you know angiosomes? - 🚑 Technique Tip
Tip for Z-plasty flap design - 📚 Book Review
A Student Guide by P'Fella - 🎓 theFellow's Corner
This week's feature: Tissue expansion - 📖 What Does the Evidence Say
How much LA can we actually use? - 🔥 Articles of the Week
Quick LA calculation, original angiosomes publication , & the delay phenomenon: 3 articles with 1 sentence summaries. - 💕 Feedback
Suggest ideas & give feedback!
A Letter from P'Fella
You now operate 10% less than 4 years ago.
Looking at the data from the last few years, one thing is clear: Plastic surgery trainees in the UK are operating 10% less than they were in 2019. That’s a significant reduction, and it’s part of a broader trend across various surgical specialties. Let's dive into the numbers and what they really mean.
In 2020, elective surgeries plummeted across the board, with many specialties seeing their operating numbers drop to 60-70% of 2019 levels. This decline is evident in almost all surgical disciplines, and although there’s been some recovery in 2021 and 2022, plastic surgery still lags by about 10% compared to pre-pandemic levels.
Other specialties, like general surgery and orthopedics, have bounced back more effectively, nearing their 2019 levels by 2023. However, plastic surgery, along with a few others, remains behind. The lost experience, represented visually in the data, points to a significant gap in surgical exposure that trainees have yet to fully recover.
Why is this happening?
- Consultant-Centric Operating: With a surgical backlog to clear, consultants are often forced to take on more cases themselves, limiting the number of cases trainees can lead or even assist on. With fewer opportunities to be in the operating room, trainees miss out on the hands-on experience that’s critical to their education.
- Fewer Elective Lists: Many consultants have fewer elective lists compared to four years ago. This could be due to a number of factors, including staffing shortages, bed pressures, and a need to reduce waiting times for essential surgeries. This drop in available lists directly impacts how many cases trainees can participate in.
- Post-COVID Prioritization: During the pandemic, hospitals shifted their focus to urgent and emergency cases. As a result, elective surgeries — which are crucial for trainee development — were drastically cut back. Even now, hospitals are still feeling the pressure to prioritize these urgent cases, leaving less room for elective lists where trainees can gain experience.
So, what can we do about it?
- Incorporate Simulation-Based Training: High-fidelity simulations can help bridge the gap in lost OR time. While nothing replaces real-world experience, advanced simulations can provide critical skills training, especially in complex plastic surgery procedures.
- Maximize the Learning from Each Case: Since the number of elective surgeries isn’t likely to rise quickly, we need to make every case count. Trainees should be involved in every aspect of the surgery — from pre-op to post-op — to ensure they gain as much experience as possible from each case.
- Create Trainee-Focused Lists: We need to push for more operating lists that are specifically designed for trainee development, where trainees take the lead on surgeries under supervision. This will ensure they get the experience they need while still contributing to the hospital’s surgical output.
The numbers show the challenge, but with the right focus, we can turn things around and make sure our future surgeons are ready to lead.
Best,
P'Fella ❤️
The Sunday Quiz
How Well Do You Know Angiosomes?
Welcome to the next round of The Weekly Quiz.
Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher.
Technique Tip
Tip for Z-Plasty Flap Design
When designing a Z-Plasty, ensure the central limb is aligned along the contracture, with two diagonal limbs branching off at angles typically around 60°. This design helps increase the length of the scar while reorienting it. The angle of the limbs determines the amount of length gained, but remember that larger angles may cause more transverse shortening.
For optimal outcomes, ensure there is enough transverse skin laxity and keep the flap base wide to minimize complications like flap necrosis.
👇
Book Review
A Student Guide by P'Fella
We’re launching an initiative targeting medical students with a three-pronged approach: theory, practice, and mentorship. We'd like your support with the first step, a comprehensive plastic surgery student manual/guide.
Let us know your thoughts and experiences with textbooks below 👇
Email tara@theplasticsfella.com if you are interested in getting involved.
If you're interested in building our textbook for students, email tara@theplasticsfella.com.
the Fellows' Corner
This Week's Focus: Tissue Expansion
In case you've missed out, here's a reminder to check out our fresh articles, clinical cases, and surgical techniques.
Read below for an overview of our article on Tissue Expansion.
What Does the Evidence Say?
How much LA can we actually use?
Other methods include a simple formula for bupivacaine (Wilson & Oliver, 2009) and a nomogram for calculating maximum doses (Williams & Walker, 2014). Studies have shown that large volumes of dilute lidocaine can be safely used in liposuction, with mean doses of 33.3 mg/kg reported without complications (Klein, 1993).
In a study of 322 patients undergoing liposuction and abdominoplasty, maximum lidocaine and bupivacaine doses of 3243 mg and 550 mg, respectively, were used without clinical toxicity (Swanson, 2012). For dermatologic procedures, mean lidocaine volumes of 3.44 mL for excision and 11.70 mL for reconstruction were reported, with an extremely low incidence of adverse events (Alam et al., 2016).
These findings suggest that local anesthetics can be safely used in various plastic surgery procedures when appropriate guidelines are followed.
Articles of the Week
3 Interesting Articles with 1 Sentence Summaries
The "WiMP" formula calculates the maximum safe volume of local anesthetic you can use: multiply the patient's weight (in kg) by 0.1, then by the maximum dose of the anesthetic (in mg/kg), and divide by the concentration of the anesthetic solution.
The original publication of angiosomes: The skin and deeper tissues are supplied by a complex, three-dimensional network of vessels, which can map tissue zones for reconstructive surgery.
Pearl’s 1981 study suggests that delaying a surgical flap clears norepinephrine from the tissue, reducing vasoconstriction and improving blood flow during transfer, which enhances flap survival.
