Lower Extremity Reconstruction: Core Principles

Hand Infections: Diagnosis and Management

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, the high-mortality red flags of nec fasc, and how rising community-acquired MRSA changes empiric antibiotic selection. Key takeaways: • Drainage is non-negotiable for any abscess. Antibiotics are an adjunct, not a substitute. • Never infiltrate local anesthesia into cellulitis — it spreads the infection. Use regional blocks for deep space infections. • Herpetic whitlow is medical, not surgical. Cutting risks systemic viral spread. Confirm with Tzanck smear. • Kanavel's four signs of pyogenic flexor tenosynovitis: semi-flexed digit, fusiform swelling, tenderness along the sheath, pain on passive extension. • Clenched-fist bite injuries seed the MCP joint. Polymicrobial with Eikenella — admit, x-ray, tetanus, and explore in the OR if the extensor mechanism is breached. • Necrotizing fasciitis carries up to 40% mortality. Bright shiny skin, nonpitting edema, violaceous patches — broad-spectrum antibiotics and aggressive debridement now. • Community-acquired MRSA is rising. Culture before empiric antibiotics whenever possible. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #HandInfections #UpperExtremity #SurgicalEducation #PlasticsInPractice #Tenosynovitis

Upper Extremity Anesthesia Essentials

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 always an intravascular accident - aspirate before every injection, and never trust pain as a safety signal in a sedated or proximally blocked patient. - Interscalene for the shoulder, supraclavicular for fast complete arm anesthesia, infraclavicular for elbow and distal, axillary for the hand. - Brachial plexus blocks take 15-25 minutes to mature - perform them in a dedicated block area about 30 minutes before incision. - Bier blocks fit cases under 60 minutes. Keep the tourniquet up for 30 minutes minimum and cycle it down in three releases. - Epinephrine 1:200,000 is safe in fingers and hands - the necrosis fears come from pre-1950s procaine and cocaine reports. - Single subcutaneous volar digital block beats the transthecal block on onset and pain. This content is for educational purposes only and is not medical advice. Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ Free Study Guides: https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #HandSurgery #UpperExtremity #RegionalAnesthesia #BrachialPlexus #SurgicalEducation #PlasticsInPractice

Functional Anatomy and Principles of Upper Extremity Surgery

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 ER reduction; how to image and describe fractures in anatomic terms rather than eponyms; intrinsic plus splinting; safe tourniquet use; Bruner incisions; and why elevation is the single most important postoperative instruction you'll ever give. Key takeaways: * MCP joints have low tolerance for stiffness; the DIP tolerates it well - stability matters more there than motion. * Volar plate disruption at the PIP causes swan-neck; central slip rupture causes boutonniere - opposite mechanisms, opposite deformities. * Scapholunate ligament tear leads to DISI; lunotriquetral tear leads to VISI. The lunate follows the ligament that's still intact. * Tourniquet time should be 90 to 120 minutes max to avoid ischemic reperfusion injury; pressure about 100 mmHg above systolic. * Splint in the intrinsic plus position: wrist in slight extension, MCPs flexed, IPs extended. * Routine soft-tissue cases under 2 hours: postop antibiotics show no clear benefit. Open fractures and bony work: 24 hours of perioperative IV coverage. * Bruner zigzag incisions across the volar finger and palm prevent contracture; never cross flexion creases perpendicularly. This content is for educational purposes only and is not medical advice. Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ [https://www.instagram.com/plasticsinpractice/] Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z [https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z] Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 [https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216] YouTube: https://youtube.com/@plasticsinpractice [https://youtube.com/@plasticsinpractice] Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ [https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/] Free Study Guides: https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ [https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ] #PlasticSurgery #Residency #HandSurgery #UpperExtremity #SurgicalEducation #PlasticsInPractice #HandAnatomy #BoardReview

Lymphedema: Diagnosis and Treatment

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 surgery: physiologic methods like lymphaticovenous bypass and vascularized lymph node transfer, versus reductive options like liposuction and direct excision. We also cover the late complications residents should not miss — recurrent cellulitis, and the rare but devastating Stewart-Treves lymphangiosarcoma. Key Takeaways: * Diagnostic threshold: limb circumference difference > 2 cm or volume increase > 200 ml is clinically significant. * Up to 50% of patients with axillary lymph node dissection develop lymphedema; only 4–7% after sentinel node biopsy. * Complex Decongestive Therapy (CDT) is the gold-standard nonsurgical management — Phase 1 intensive (4–6 weeks), Phase 2 maintenance for life. * ISL staging: Stage 0 latent → Stage I pitting → Stage II non-pitting fibrofatty → Stage III lymphostatic elephantiasis. * Physiologic surgery (lymphaticovenous bypass, vascularized lymph node transfer) can reduce limb volume ~35% at 12 months in selected patients. * Liposuction is the workhorse for non-pitting, fibrofatty lymphedema — requires ≥ 600 ml volume difference, failed 3 months of CDT, and lifelong compression after surgery. * Stewart-Treves lymphangiosarcoma: rare but aggressive — 5-year survival < 10%, average survival 19 months after diagnosis. Always biopsy suspicious nodules in a long-standing lymphedematous limb. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #Lymphedema #BreastReconstruction #SurgicalEducation #PlasticsInPractice #Microsurgery #Liposuction

Pressure Sore Fundamentals

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, and why the recurrence numbers stay high no matter what flap you pick. Key takeaways: - Tissue injury starts deep — muscle over bone fails first, the skin lesion is just the tip of the iceberg. - Capillary perfusion fails above ~32 mm Hg; five minutes of off-loading every two hours is enough to prevent breakdown even at high pressures. - Pressure x time is parabolic: 500 mm Hg for 2 hours or 100 mm Hg for 10 hours both kill muscle. Skin ulcerates last. - Optimize before you operate: albumin >2.0 g/dL, A1c <6%, control spasm (baclofen, dantrolene, botulinum toxin), treat osteomyelitis surgically — not medically. - Avoid primary closure and skin grafts — these wounds have a true tissue deficit. Use flaps. - Fasciocutaneous vs. myocutaneous: in a 94-patient series there was no difference in recurrence, complications, or morbidity — pick the flap that preserves future options. - Avoid radical ostectomy — total ischiectomy redistributes pressure and creates the next ulcer. - Recurrence after flap closure runs ~39%; the most vulnerable window is the first 15–22 months. - Watch for Marjolin ulcer in long-standing wounds — aggressive SCC with metastatic rates over 60%; wide excision is the answer. This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #Residency #PressureSores #WoundCare #SurgicalEducation #PlasticsInPractice #Reconstruction #PressureUlcer