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					          CORE OF
KNOWLEDGE/GENERAL PLASTIC
  SURGICAL PRINCIPLES AND
        TECHNIQUES
           PGY I
                              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:

       1.     Recite the physiology and biochemistry of normal healing.

       2.     Discuss the physiology and biochemistry of abnormal wound healing
              including hypertrophic scars and keloids.

       3.     Discuss common agents and processes which result in abnormal healing.

       4.     Identify the pharmacologic agents and other nonsurgical methods for
              treatment of abnormal healing.

       5.     Describe the management of dressings, splints and other techniques
              utilized in wound management.

       6.     Explain the differences in the healing of cortical and cancellous,
              membranous and endochondral bone.

       7.     Draw and plan techniques of scar revision (such as Z-plasty and W-
              plasty).

       8.     Describe the various lines of the skin (such as relaxed skin tension) and
              their importance in placement of incisions for maximum aesthetic result.

       9.     Discuss the role of nutrition in the wound healing process and the standard
              methods for diagnosis and treatment of nutritional deficiencies.

       10.    Discriminate the pathologic processes involved in keloid formation and
              the methods available to treat keloids.

       11.    Understand the differences in suture materials and indications for the use
              of different materials.

       12.    Discuss the basic science of healing, including the anatomy, physiology,
              biochemistry, microbiology, immunology, wound healing for:

              a.     skin and soft tissue
              b.     tendon



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              c.      bone (different types)
              d.      nerve
              e.      cartilage.

       13.    Discuss abnormal wound healing, including:

              a.      delayed healing – physiology and treatment
              b.      excessive healing (hypertrophic scars and keloids).



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.




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       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.


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.


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       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.

       13.    Discuss the principles and techniques of hematologic manipulation of
              abnormal vascular flow characteristics.

       14.    Discuss the technical aspects of microsurgery including:

              a.     microscopes – principles, usage
              b.     sutures – types, indications\
              c.     microvascular coupling devices
              d.     suturing techniques.

       15.    Discuss the use of electrophysiologic tools in the evaluation of nerve
              injury (EMG, NCS).




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 non-
              vascularized 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.




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       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.

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 and for 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.




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       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.

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.




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       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.



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.     digital block
               b.     wrist block
               c.     brachial block
               d.     bier block
               e.     ankle block

       6.      Discuss the principles of spinal and epidural anesthesia.




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       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.      mode of action
              b.      duration of action
              c.      dosage and toxicity
              d.      side effects
              e.      antidotes.

       9.     Discuss the general principles and techniques for general anesthesia,
              including:

              a.      patient monitoring
              b.      airway management
              c.      preoperative mediations
              d.      intravenous agents
              e.      inhalation agents
              f.      muscle relaxants
              g       antiemetics.

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.


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       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.      autoimmune disease
               b.      immunology of skin transplantation
               c.      interrelationship of transplantation and microsurgery.

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.




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       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      skin infection
              b.     breast infections
              c.     surgical wound infections
              d.     hand infections
              e.     special problems
                     1. animal bites
                     2. human bites
                     3. farm injuries.

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.     equipment
              b.     laboratory evaluation
              c.     patient records
              d.     patient monitoring


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              e.      AAAAPSF standards
              g       risk management.

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.      surgical techniques (Z-plasty, W-plasty, etc)
              b.      nonsurgical techniques
              c.      camouflage techniques.

       2.     Evaluate patients and their nutritional status as related to wound healing,
              including:

              a.      diagnosis of deficiency
              b.      treatment of deficiency

       3.     Participate in planning surgical incisions, with respect to:

              a.      selection in relation to skin lines
              b.      techniques for closure
              c.      suture materials – types and uses.

       4.     Participate in wound management, including:

              a.      debridement
              b.      use of splints, dressings, casts, topics agents
              c.      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.




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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.

11.   Participate in the surgery of grafts and flaps including: skin, dermis,
      cartilage, bone, tendon, muscle, fascia, combined tissue; specifically:

      a.     grafting techniques
      b.     instruments for harvesting grafts
      c.     graft preservation techniques
      d.     donor site management
      e.     recipient site management
      f.     special techniques
      g.     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.


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21.   Manage long-term aspects, including rehabilitation, of patients who have
      undergone replantation and revascularization procedures.

22.   Prepare methyl methacrylate prostheses.

23.   Perform surgical procedures using solid implant materials including:

      a.     cranioplasty
      b.     silicone implantation to breasts, orbital floor, malar area, chin or
             joints
      c.     bone substitution for small defects, such as orthognathic
             advancements
      d.     non-vascularized bone grafts for a variety of defects:
      e.     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.


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36.   Participate in the critical care management/emergency management of
      burn and trauma patients, including:

      a.     initial care
      b.     diagnosis
      c.     preparation for the operating room
      d.     postoperative care.

37.   Participate in the management of ICU patient, including:

      a.     monitoring
      b.     respiratory management
      c.     cardiovascular management
      d.     fluid management
      e      management of infection and sepsis
      f.     management of nutrition.

38.   Participate in the care of surgical patients with complications including:

      a.     respiratory failure
      b.     cardiovascular problems (arrhythmia, DVT, PE)
      c.     sepsis
      d.     bleeding
      e.     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.


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       47.     Utilize steroids for treatment of a variety of plastic surgical problems and
               in the postoperative care of steroid-dependent patients.

       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.



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.




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       5.      Function independently with graduated advancement and appropriate
               faculty supervision in the evaluation and treatment of patients.



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.


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.



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       4.      Direct the overall care of patients with complicated wounds by partnering
               with the following:

               a.      nutritionalists
               b.      wound care specialists
               c.      occupational therapists

       5.      Demonstrate knowledge of cost-effective surgical care.

       6.      Advocate for patients within the health care and insurance system.



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 council patients regarding risks and
               complications of breast implant surgery.

       10.     Effectively deal with dissatisfied patients.



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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.




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