Plastics in Practice (Resident Review)

A mangled upper extremity can look unsalvageable before resuscitation, perfusion, and debridement reveal what function remains.

In this episode of Plastics in Practice, we build a practical limb-salvage sequence—from life-threatening priorities and early antibiotics to revascularization, compartment assessment, reconstruction, and rehabilitation.

Key takeaways:

• Put life before limb. Complete trauma resuscitation, control hemorrhage, and document perfusion, motor function, and sensation before committing to salvage or amputation.

• A MESS of seven is a risk signal, not an upper-extremity amputation verdict. A 2024 meta-analysis suggested that at least one in...

A normal-looking radiograph can hide a ligament injury that becomes stiffness, deformity, or arthritis if it is missed.In this episode of Plastics in Practice, we connect reduction, stability testing, imaging, early motion, and operative decision points across finger, thumb, carpal, and distal radioulnar joint injuries.Key takeaways:• Treat the PIP joint as a motion emergency: permanent stiffness can develop within about two weeks. After reduction, confirm congruity and stability, then begin early protected motion when the joint is stable.[1]• Use the thirty-fifty rule as a guide for dorsal PIP fracture-dislocations: less than thirty percent articular involvement is usually stable, thir...

A tendon transfer can be perfectly woven and still fail if the joint is stiff, the tissue bed is scarred, or the donor cannot match the lost motion.

In this episode of Plastics in Practice, we build a practical framework for tendon transfers—from donor selection and tensioning to radial, median, and ulnar nerve palsy reconstruction and postoperative retraining.

Key takeaways:

• Make the hand ready first: joints must be supple, and the transfer must glide through a quiet soft-tissue bed. A contracture release and tendon transfer require inco...

Radial wrist pain, a locking digit, and lateral elbow pain can all be called overuse—but a few centimeters can change the diagnosis, treatment, and surgical target.

In this episode of Plastics in Practice, we map de Quervain tenosynovitis, intersection syndrome, trigger finger, and lateral elbow tendinopathy from focused examination through splinting, injection, rehabilitation, and surgical release.

Key takeaways:

• Map radial-sided symptoms by location: de Quervain disease localizes at the radial styloid, while intersection syndrome produces dorsoradial pain and often crepitus four to six centimeters proximal to List...

Extensor tendon injuries are easy to underestimate: a small dorsal wound can conceal a complete laceration, a contaminated MCP joint, or a central slip injury that declares itself later.

In this episode of Plastics in Practice, we review the examination, zone-based repair strategy, rehabilitation, complications, and reconstruction of extensor tendon injuries.

Key takeaways:

• Use the eight-zone map to localize injury and choose a repair and rehabilitation plan; odd-numbered zones lie over joints.

• Test beyond simple active extension: juncturae can mask a complete zone-six EDC laceration, the...

Flexor tendon repair succeeds only when construct strength, tendon glide, pulley preservation, and rehabilitation are planned as one system.

In this episode of Plastics in Practice, we review the evaluation, zone-based strategy, repair principles, rehabilitation, complications, and salvage of flexor tendon injuries.

Key takeaways:

• Detect loss of the normal cascade or tenodesis effect, test flexor digitorum profundus and superficialis independently, and document neurovascular status.

• Let the injury zone drive exposure and repair; zone II demands especially careful sheath and pulley management.

• Build a strong...

Wrist fracture decisions turn on a few measurements, but the right threshold depends on the patient, the image, and the bone.

In this episode of Plastics in Practice, we review distal radius and carpal fractures with an emphasis on reduction, fixation, and the diagnostic traps that change management.

Key takeaways:

• Document median nerve function and distal radioulnar joint stability before and after distal radius reduction.

• In study-defined non-geriatric adults, post-reduction radial shortening greater than three millimeters, dorsal tilt greater than ten degrees, or intra-articular displacement or s...

Hand fracture outcomes often hinge on what radiographs miss — rotation, post-reduction stability, and whether fixation permits early motion.

In this episode of Plastics in Practice, we review metacarpal and phalangeal fracture management — rotational alignment, stability, fixation strategy, early motion, thumb-base injuries, proximal interphalangeal joint fracture-dislocations, and complications.

Key takeaways:

• Examine each injured digit in maximal extension and flexion. Scissoring reveals malrotation; persistent rotation after reduction is operative.³

• Stable, nondisplaced closed fractures usually need splinting or buddy taping, early motion, and radiographs at seven to ten days. Clinical union commonly takes three to four w...

Peripheral nerve deficits are a race against irreversibledenervation — misclassify the lesion or miss the level of compression, and observation becomes lost recovery time.

In this episode of Plastics in Practice, we review traumaticperipheral nerve injury and the compression neuropathies that matter across the median, ulnar, and radial nerves — how to classify the lesion, time electrodiagnostic testing, recognize localization traps, and choose observation versus decompression or repair.

Key takeaways:

· Neurapraxia is a conduction block with intactaxons and expected recovery within two to three months; axonotmesis regeneratesat roughly one millimeter per day under ideal c...

Hand infections deteriorate fast — the same anatomy that gives the hand its function turns ordinary swelling into ischemia, tendon necrosis, and permanent loss of motion. This episode walks through how to recognize and manage everything from paronychia and felon to pyogenic flexor tenosynovitis, deep space infections, bite injuries, and necrotizing fasciitis — with the surgical pitfalls every resident needs to know cold.

In this episode of Plastics in Practice, we cover the anatomy that makes the hand vulnerable, when to splint and when to cut, the Kanavel signs you'll be quizzed on, the herpetic whitlow trap...

Upper extremity surgery is, at its core, a regional anesthesia specialty. Choose the right block in the right place and most hand and arm cases never need general anesthesia.

In this episode of Plastics in Practice, we work through the practical anesthesia decision tree for the upper extremity: brachial plexus block locations and their trade-offs, peripheral nerve blocks at the elbow and wrist, the Bier block, digital block techniques, and the modern, evidence-based truth about epinephrine in the finger.

Key takeaways:

- Severe systemic toxicity is almost...

Every hand case rests on the same foundation: knowing which joints need mobility, which need stability, and how to run an acute hand with a trauma-first mindset. Get this layer right, and every chapter after it makes sense.

In this episode of Plastics in Practice, we cover the foundational anatomy and operative principles of the upper extremity: how the thumb, finger, and wrist joints differ in their tolerance for stiffness and instability; the classic deformities (swan-neck, boutonniere, DISI, VISI) and the ligaments that produce them; the acute hand workup from "life over limb" through...

Lymphedema is the chronic disease plastic surgeons are best positioned to treat — and the most commonly mismanaged. After axillary node dissection, up to 50% of breast cancer patients develop it, and most never get the early, disciplined care that prevents progression to fibrofatty disease.

In this episode of Plastics in Practice, we review the essentials of lymphedema management — from how the lymphatic system fails to the diagnostic threshold (2 cm or 200 ml difference), staging by the International Society of Lymphology, the role of Complex Decongestive Therapy as the gold-standard nonsurgical approach, and how to think about surg...

Pressure sores are the wound the plastic surgeon gets consulted on after everything else has gone wrong — and the recurrence rate is brutal if you skip the basics. The lesson nobody teaches you in residency is that the surgery is the easy part.

In this episode of Plastics in Practice, we review the basics of pressure sore management: the pathophysiology of pressure-time injury, the six-stage NPUAP system, what you absolutely have to optimize preoperatively (albumin, A1c, spasm, contractures, osteomyelitis), how to choose between fasciocutaneous and musculocutaneous flaps for ischial, sacral, and trochanteric defects, an...

Few regions punish poor planning like the perineum — the pelvic outlet sits at the crossroads of the urinary, gynecologic, and GI tracts, and the wrong flap choice in an irradiated or contaminated field gets you back in the OR fast.

In this episode of Plastics in Practice, we walk through the core principles of perineal reconstruction: anatomy and vascular supply, the reconstructive ladder, pelvic dead-space management, and the workhorse flaps you actually need to know — VRAM, gracilis, posterior thigh, Singapore, and the greater omentum. We finish with functional restoration in both female and male patients, including the Cord...

Saving a foot is rarely about the flap. It's about the angiosome you re-perfuse, the millimeters of debridement you take, and whether you lengthen a tight Achilles before you ever think about closure.

In this episode of Plastics in Practice, we cover the principles of foot and ankle reconstruction: the six angiosomes and how they should drive every revascularization, incision, and flap design; the role of the multidisciplinary team in salvaging a limb that traditionally would have been amputated; and the practical algorithm for moving a chronic wound to closure — debridement, NPWT, dermal templates, an...

Lower extremity reconstruction is the most unforgiving testing ground in plastic surgery — every decision is graded by whether the patient can bear weight, walk, and protect a sensate foot for the rest of their life.

In this episode of Plastics in Practice, we walk through the core principles of lower extremity salvage: the zone-of-injury concept, when to fix vs. amputate, fracture management, soft-tissue coverage by leg third, and the trade-offs between limb salvage and a well-fit below-knee amputation.

Key takeaways

Abdominal wall reconstruction is where plastic surgery principles get tested in real time — and it's where most failures start with one wrong assumption about force distribution.

In this episode of Plastics in Practice, we review the basics of abdominal wall reconstruction: how to think about the abdomen as a pressurized cylinder, why supported repairs beat bridged repairs almost every time, how to read the components separation technique like a physiology problem instead of a memorization problem, and how to choose between synthetic and bioprosthetic mesh in a contaminated field. We close with soft tissue strategy — when to skin...

Chest wall reconstruction is where rigid skeletal support and versatile soft tissue coverage meet — and where a wrong flap choice or a missed debridement step turns a small defect into a respiratory disaster.

In this episode of Plastics in Practice, we review the basics of chest wall reconstruction: the anatomy that drives every decision, when you actually need to rebuild the skeleton, how to classify and treat sternal wound infections, and how to pick the right flap based on the location and depth of the defect.

Key takeaways:

Hair restoration is one of the most planning-dependent procedures in plastic surgery — a single wrong call on the hairline or the donor strip can show up for the rest of the patient's life.

In this episode of Plastics in Practice we walk through what residents actually need to know about modern hair transplantation: how to evaluate the donor area, how to think about lifetime donor yield, the trade-offs between strip excision and FUE, graft preparation and the out-of-body clock, recipient site design (hairline placement, angle and direction, ethnic and gender variations), postoperative management, and where finasteride, minoxidil, an...

Osseous genioplasty is the most versatile tool the plastic surgeon has for the lower face — and the most commonly mis-planned. In this episode of Plastics in Practice, we review the basics of chin surgery: when to pick the osteotomy over an implant, the five-pillar physical exam, the technical steps that decide your aesthetic result, and the pitfalls that cause the bizarre "overadvanced" chin we've all seen on revision.Key takeaways:• The lower lip rule: never advance the chin past a vertical line dropped from the lower lip. Cross it, and the result looks artificial every time.¹• 3-D versatility: implants only co...

Facial implants can dramatically change facial balance, but the difference between a natural result and an operated look comes down to planning, positioning, and fixation. In this episode, we break down the core principles of facial skeletal augmentation with implants for the plastic surgery resident.

We review the major implant materials, the anatomic targets across the midface and mandible, and the operative concepts that matter most in real cases. This includes why subperiosteal placement is preferred, why screw fixation remains a key technical principle, and how to think through chin augmentation versus sliding genioplasty. We also cover...

Prominent ears are not one deformity. They are usually a combination problem involving the antihelix, concha, and lobule. In this episode, we break down a practical, anatomy-first approach to otoplasty that helps you create a natural setback without a sharp, overdone, or obviously operated appearance.

We review the major causes of auricular prominence, the aesthetic goals of correction, and the core maneuvers every plastic surgery resident should know. The focus is on reliable, cartilage-sparing principles: Mustarde sutures for antihelical recreation, Furnas sutures and selective conchal reduction for conchal excess, and deliberate management of the...

Rhinoplasty is not a reductive operation anymore. Modern rhinoplasty is about precision, preservation, and structure. In this episode, we break down a practical framework for analyzing the rhinoplasty patient, protecting the airway, and executing reproducible tip and dorsal maneuvers with fewer long-term problems.

We cover the anatomy that actually matters in the OR: skin/soft tissue envelope behavior, the bony and cartilaginous vaults, the internal nasal valve, and the ligamentous support structures that determine projection, rotation, and long-term stability. We also walk through systematic nasofacial analysis, component dorsal hump reduction, algorithmic tip refinement, spreader graft logic, osteotomy...

Master the principles behind modern facelifting.

This episode breaks down the core concepts of rhytidectomy, focusing on high-yield surgical principles, SMAS manipulation, and complication avoidance. We move beyond outdated skin-tension techniques and focus on what truly matters: volume restoration, anatomic precision, and hemodynamic control.

You’ll learn how to think about facelifts like a surgeon—not just perform steps. From SMAS strategies to neck management and hematoma prevention, this is a practical, resident-level deep dive.

Blepharoplasty looks simple—but it’s one of the easiest ways to create devastating complications if you don’t respect the anatomy.

This episode breaks down the high-yield principles of modern blepharoplasty, focusing on what actually prevents bad outcomes: proper evaluation, conservative technique, and understanding lid support.

We cover upper and lower lid strategy, when to preserve vs remove fat, and how to avoid classic complications like ectropion, scleral show, and retrobulbar hematoma.

The brow lift has evolved. What used to rely on long coronal incisions has shifted toward anatomically precise, minimally invasive endoscopic approaches designed to restore brow position while avoiding the over-elevated, unnatural “surprised” look.

In this episode of Plastics in Practice, we break down the modern principles of forehead and brow rejuvenation with a resident-focused review of upper facial aging, brow aesthetics, relevant anatomy, retaining ligaments, and operative strategy. We cover how the frontalis acts as the sole brow elevator, why the corrugator, procerus, orbicularis, and depressor supercilii matter clinically, and how selective ligament release with controlled fixa...

Fat grafting is no longer just filler—it’s a cornerstone of modern plastic surgery. In this episode, we break down the principles that actually determine graft survival, contour outcomes, and safety across facial and mega-volume applications.

From the Coleman technique to BRAVA-assisted breast reconstruction, this is a high-yield, resident-focused deep dive into what matters in real cases.

Fat graft “take” is ~40–60% → technique + vascularization are everything

Small vs large volume = completely different strategies (micro-aliquots vs slurry + expansion)

Best facial survival: deep, low-motion compartments (malar, cheek)

Golden rule: V/C ra...

Botulinum toxin is simple—until you actually try to use it well. This episode breaks down what most people get wrong: it’s not about units, it’s about functional anatomy and precision.

We walk through the true mechanism (SNAP-25 cleavage → presynaptic blockade), why Botox affects nerves—not muscle or skin, and how that translates into real-world injection strategy. From glabella to platysma, this is a high-yield, resident-focused guide to getting consistent results while avoiding classic complications.

If you’re still thinking in “standard dosing,” you’re already behind.

BoNTA works v...

Dermal fillers are more than just wrinkle tools. In this episode, we break down the science that actually drives filler performance: rheology, particle behavior, tissue planes, facial fat compartments, and complication management.

This is a high-yield review of dermal and soft-tissue fillers for plastic surgery residents, fellows, and aesthetic surgeons. We cover how G′ (elastic modulus) and viscosity influence lift, spread, and extrusion; why cross-linking matters more than concentration alone for HA longevity; how facial aging reflects compartmentalized volume loss rather than uniform descent; and how these concepts translate into agent selection, injection plane, and technique. We al...

Skin resurfacing is one of those topics that looks simple on the surface but gets very nuanced once you start thinking about depth, target tissue, endpoint recognition, and complication profile. In this episode, we break down the science of skin resurfacing in a way that actually matters for plastic surgery trainees.

We cover the core anatomy behind resurfacing, why the dermal-epidermal junction matters, and how different modalities—chemical peels, dermabrasion, CO2 laser, Erbium:YAG, and fractional photothermolysis—produce different patterns of injury and healing. The real clinical question is not just what device or agen...

Congenital breast anomalies are more than aesthetic diagnoses—they carry major psychosocial weight and demand a thoughtful reconstructive plan. In this episode, we break down the high-yield clinical framework for evaluating and surgically correcting congenital breast deformities, with a focus on tuberous breast deformity, developmental asymmetry, and Poland syndrome.

This is the resident-level overview you actually want before clinic, consults, or conference: embryology, Tanner staging, classification systems, timing of intervention, and the operative principles that drive reconstruction. We cover why “improvement, not perfection” is the right counseling framework, why bilateral procedures are often necessary for symmetry, and how mo...

Nipple reconstruction is not the “small final step” of breast reconstruction—it is the focal point. A great breast mound can be undermined by poor nipple position, poor projection, or a mismatch in size and symmetry. In this episode, we break down the high-yield principles that actually matter when planning and performing nipple-areola complex reconstruction.

We cover how to mark the nipple thoughtfully rather than relying on rigid measurements alone, why patient input matters more than many residents realize, and how technique selection changes depending on whether the breast mound is autologous or implant-based. We als...

Free flap breast reconstruction is one of the most technically demanding and rewarding procedures in reconstructive microsurgery. In this episode, we break down flap selection, donor-site strategy, recipient vessel choice, perfusion monitoring, and the key complications every plastic surgery resident needs to know.

We focus on why the abdomen remains the preferred donor site for most patients, how DIEP, free TRAM, and SIEA differ in muscle preservation and vascular reliability, and when to move to secondary donor sites like SGAP, IGAP, or TUG/TMG. We also review why the internal mammary system is usually the recipient vessel...

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, when should you prioritize perfusion, and when is the “simpler” flap actually the smarter flap? We walk through the muscle-sparing classification, high-risk patient considerations, recipient vessel choices, and the aesthetic plus functional consequences that actually drive decision-making in the OR.<...

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 #Microsurgery #HandSurgery #Craniofacial

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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 strategies that improve contour while protecting the pedicle. We also clarify when to use expander as an intelligent spacer vs. immediate implant—and how Stage 2 refinement (4–6 months) improves final implant selection and symmetry.

Key Takeaways...

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 expansion protocol, and the exchange operation with an emphasis on IMF positioning, inferior pole projection/ptosis, and strategies to optimize symmetry. We also break down ADM use (what it helps, what it costs), and why radiation changes complication risk and revision...

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 front and center.

Key takeaways:

Screening: Average risk = annual mammography starting at 40; high-risk patients may add MRI starting ~30.

Pathology framework: DCIS (basement membrane) vs LCIS (risk marker) vs invasive (ductal most common; lobular often occult on mammo).

Breast conser...

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 fibrous disease by duration, and how Simon grading dictates whether you’re doing lipo, excision, pull-through, or formal skin resection. Then we get practical: incision placement, contour strategy, compression, drains, and how to avoid the nightmare complication...