All right, I see people are coming in. I would like to wish everyone a nice evening or morning, wherever you may be logging on from, and welcome you to the first resident-run ASPS Global Partners webinar that will feature plastic surgery trainee experiences from around the world. My name is Lisa Kfera. I'm a current chief resident in the Mass General Brigham Harbor Plastic Surgery Program and the current resident representative to the board of ASPS and the PSF. I look forward to moderating three exciting talks from resident experiences in COVID over burn reconstruction and simulation training. Next slide, please. I wanna remind everyone to please submit your questions throughout the presentations using the QA feature at the bottom of your screen, and we will answer questions after each presentation. Today's webinar is being recorded and it will be posted to the ASPS EdNet forum. You have access to the forum if you are an active ASPS member, and if you wish to become a member and view this talk later on, please get in contact with Romina, whose email address is here on the screen, and she will be happy to help you. Next slide, please. I will introduce all of our speakers before they give talks, but I am excited that we have residents from three different regions of the world, from Belgium, Argentina, and Chile, who will present today. The first talk this evening will be given by Ayush Kapila from Belgium. He completed his medical school training at King's College in London and the Imperial College London, and he's currently a PGY-4 resident in the plastic surgery program at the University of Brussels in Belgium. And he will be speaking about the Belgian experience that residents had during COVID. So I want to invite Dr. Kapila to share his screen, please. Thanks very much, Lisa, for the kind introduction. Okay, can you guys all see my screen? So we'll start the presentation somewhere in the middle. All right, so here we go. So first of all, hello, everyone. Thank you to ASPS for organizing this. It's really, really great to be part of this. And I look forward to all the upcoming talks on this series. My name's Ayush Kapila. I'm a resident in the Department of Plastic and Reconstructive Surgery at the University Hospital, Brussels, which is led by Professor Mustafa Hamdi. My talk is on making the most of residency during the pandemic, and really highlighting a little bit about the Brussels experience. So I'm from Belgium. We call it the capital of Europe. It's a population of 11.5 million people, and it's quite a small country. Capital is Brussels, and we've also got Ghent and Bruges as two beautiful medieval cities. So do visit when you get time. We've got seven residency programs, two in Brussels, two in Leuven, one in Ghent, Antwerp, and Liege. And it's usually about a six-year residency for all of us. So I train at the Vrije Universiteit in Brussels, which is in Brussels. This is our hospital, as you can see. And usually we approximately cover about 1,500 cases every year. We've got two full-day operating rooms, and also daily staff member consultations. We've also got resident consultations four times a week in addition to this, as well as resident operating lists do three times a week, and also one in three, two, one in four on call. So it can get quite busy at times. Trying to get past my slide, yeah. So we're quite a tight-knit department. These are all photos taken before the pandemic arrived. And really, we had no idea what would hit us. And it was last year on the 12th of March, 2020 that we had the first COVID briefing in our hospital. And this really significantly impacted on our activity. So we studied this. And looking at the first wave of the pandemic on the 15th of March and the 3rd of May in Belgium, we noticed that our surgical activity in this period had fallen by about 81% when we compared it to 2019. Similarly, for consultations, we saw a similar trend of about a reduction of 80%. And then looking at financial revenue, we again noticed that an 81% reduction was noticed. So this was really quite significant. And we're only speaking about a six-week period here. So we've had a second wave after this. We've also had a third wave as well. So you can imagine the impact. Of course, it was not only on surgical activity and revenue, but also on education as well. We're all residents, and this is normally how we would learn. And so we studied this in quite a lot of detail, actually. We published a few studies in the BGS and also in PRSCO looking at perspectives from residents all across surgical specialties, even medical students, but specifically for plastic surgery residents. We had a very representative group from Belgium responding, and 86% experienced a decline of more than 75% in activity. Furthermore, 86% also felt an actual effect on their surgical skills training. 46% felt that training should be prolonged if lockdown remains. And 46% of residents were also reassigned to the emergency department COVID wards, so really completely out of surgery. We also studied the mental health consequences, which was published in the European Journal of Psychiatry. And there was 56% that felt a psychological strain as a result of the pandemic, and also expressed concern about welfare and future. We also had 20% of all doctors feeling that they need some form of psychological support. So in summary, up till now, we know that the surgical caseload was greatly reduced in the first wave by more than 80%. And the education opportunities were less as well with an 86% impact, or 86% of residents feeling an impact on residency, and of course, a mental health impact as well. Now, how do we cope with this? And this is really the crux of my presentation today. So in July last year, we published suggestions. We sat down, and of course, with Professor Hamdi, our training supervisor, and we came up with three main facets that we can divide our training into. And this was surgical skills, surgical knowledge, and of course, academia. So first of all, looking at surgical skills. Now, in the midst of the pandemic, operating never completely stops. We still have urgent cases. You've got traumas, infections, cancers just still coming in, but you need to understand that there's less nursing staff, there's less anesthetists, people are redeployed, and it can be quite a struggle to plan things and to get things done. And especially free flap surgery is not always possible because there's a lack of a high care bed. It's all reserved for COVID patients. There's also a lack of close monitoring as well. So we need to start looking at alternatives. So I'll start with a very simple case. This is a case that very often you'd see in a residence consultation, but we had to manage this differently during the pandemic. Reason is these are often elderly patients with relatively quite a few comorbidities, and you don't want to expose them to be in hospital for a long period of time with COVID. So what we did for this chap was to do a rotation flap under local anesthesia. Often some of us would do this under general, but here we really went for the local option to do it under a day case. And we also limited the post-operative consultations as well. Again, a similar case, which we've done under local. This is an 85-year-old gentleman. And here I did a cheek, we said a cheek advancement flap. Again, often we prefer to do this under general, just, well, for our own comfort, but also for the comfort of the patient. During the pandemic, we found ourselves doing these cases under local, purely because, well, we didn't have the nursing staff, we didn't have the anesthetists, and we wanted to get these patients home maybe sooner. This is a case Professor Handley did. So this is an 80-year-old lady who had a mix of fibrosarcoma, already had six procedures, and the last procedure being two months prior to this photo. Unfortunately, she had exposure of a scapula and also of a vertebra. Now, generally we would consider three flap options, but really doing the first wave, it was quite difficult to get this arranged. So we did multiple pedicle flaps, scapular keystone flap, a dorsal intercostal artery perforator, latissimus dorsi flap as well. We had a reasonably good result to really cover these chronic defects. This was a 46-year-old chap who had a motorbike accident at the same night. He was washed out by the orthopedic surgeons for his right knee wound and suture. Unfortunately, there was a lot of tension, so he developed a full thickness necrosis down to the patella, which we had to reconstruct. This is about 14 by 10 centimeters. Again, we went for a pedicled reverse ALT in this case and had quite a decent result. This is just to illustrate the pedicled options that we had to opt for. Of course, I'm sorry about the post-op photo. I didn't have the long-term one, but we were lucky in Belgium that we were still able to do immediate breast reconstruction straight after the mastectomy. I know that in other countries, plastic surgeons were asked to put in expanders to really minimize operating times and save the beds. But fortunately, we still had some continuity in our microsurgical breast reconstructions. We were quite fortunate that way. Of course, we also saw new injury patterns. So we recently published this as well, really seeing atypical evolutions of simple sacral pressure injuries related to the disease pathology that COVID brings with it. We saw an association with pyelonegragnosis. We saw slow evolutions. And of course, we also saw the effect of prone ventilation. So our wound care team was really fantastic, and they came up with a very nice protocol, which they also presented internationally. Now, the second point is also the catch-up in surgical activity. So you can see that we had an initial period of lockdown between March and May, which I presented earlier, and we had a reduction in operation activity and revenue. However, when we were finally allowed to resume our activity between May and July of last year, we, in comparison to 2019, did have an increase of 22% in operations and an increase of 18% in revenue, really showing that we pulled our socks up, went to seventh or eighth day, and really worked hard to catch up as much as we could. Now, as I said, we also had a second and a third wave afterwards, but in between, we always had these resumption of normal activity periods. And again, you would find similar trends where we are increasing our output. So everyone has been working double as hard. And of course, this is just to illustrate, now, when there's no patients, you always have each other to operate on. This is my chief resident, who's entrusted me in performing an operation for him, but this is just to illustrate that there's always each other. Now, a second important point is the skills-based learning, and specifically a focused and structured skills-based learning. And to illustrate this, I would like to just speak about our microsurgery lab. So these are my colleagues, Maxime Guéron is on the left, and Caro Barquette. So we really set out to formalize our training in the microsurgery lab. So what we did is we organized seminars together, and we presented these in a hybrid format with a live audience, our staff members, and also a virtual presence with people from different hospitals, giving feedback, our colleague residents as well. And the idea was to really go through the basics, and then of course, go into more complex animal models, animal experiments, and to set up a more kind of formalized training for each one of us, where you could all revise the simple things, go into a bit more complex things. We also started using this structured assessment scale from the University of Iowa. Iowa, I can't pronounce it very well. And we set up also a stepwise progression for all of us to initially go through these presentations, do initial steps, initial training on inanimate objects, move over to animal training models. So this is just to illustrate one of these presentations. So you can see it's really simple things, like how do you pick up your needle? And you can see that we've got like 15 slides explaining that how you push a needle through the vessel. And it's just gonna illustrate the detail and the depth that we tried to go into so that we can really hone our skills. And so during these periods that we're not in the operating theater, we spent a lot of time in our microsurgery lab to really improve our skills, hone our skills. And actually, when we started operating again, we found ourselves being better, being well-trained and not actually losing the skill that we could because of the pause. Of course, we also saw a real boom in virtual seminars, webinars, and journal clubs. And we all know that this existed before. But as a result of the pandemic, this really has become embedded in the way we do things. Every single journal club that we do now is hybrid. You've got live audiences, you've got a virtual audience. This is my colleague, Caroline Denise, who's presenting on propeller flaps. And you can see there's a virtual audience as well. And we're all sitting there listening to her with a lot of attention. So we organized an international robotic plastic surgery webinar, which was really a big success. We had about 500 people attending. And this was actually quite early in June last year. Of course, on the left, you can see the master's in microsurgery that was organized by Dr. Santa Maria's department, which was huge. But it just illustrates how amazing the virtual field can be for surgical conferences. This is the PRS Resident Advisory Board meeting. Again, all virtual. This is a seminar we gave on breast augmentation guidelines nationally. And this was really well-received. It was a journal club at Assist University organized. Of course, we also got a podcast from our wound care team. Now, I'm nearly at the end. So at the same time, when we're not operating, there was also more time for academia. And again, one of our studies showed this, that during times of reduced surgical activity, 65% of residents were able to increase their research output. Just put my Google, a screenshot of my Google Analytics to show you some of my research. And this has really increased in 2020 and 2021, simply because we've had time to be able to complete pending things, stuff that was in the pipeline, has all been able to be done. The same time, 81% had increased time to improve theoretical knowledge, and 36% of department heads were actually providing continuous education, which 70% was by virtual learning. Of course, going beyond plastic surgery. Now, our department was also really keen to spread awareness on the pandemic. You've got last year's chief resident, Ben de Broeckhoff, who spearheaded the national campaign of Action Health for Life, and actually raised a lot of funds for protective equipment. And I'm just speaking to the media about the COVID pandemic in our hospital. So in summary, how did I make the most of this period? Well, just to go back to the table I presented earlier. First point, surgical skills. So really, the structured skills-based learning, been specifically in our microsurgery lab. Also making the most of different types of reconstructions, learning to do things more on the local anesthetic, looking at pedicle flap options. Of course, catch up, work like we've never worked before when operating was allowed. Second point, surgical knowledge, of course, the virtual journal clubs, seminars, webinars, continuing to read. I actually did read a lot during this period of break simply because I had more time. And of course academia, so with research. So thank you very much. I'm very happy to answer any questions you may have and also if you want to email me, I'm happy to answer through email as well. Thanks. Thank you, Dr. Kapila. That was an excellent talk. And you know, it really shows you how many good things can come out of something this bad. And it's really amazing what you were able to set up in Brussels. So congratulations. That's fantastic. I have a question for you. You know, one of the things that we kind of implemented in our program that we thought was a good thing during the pandemic was that the residents were part of virtual consultations. You know, to kind of not miss out on the clinic experience and also learn about how to do a virtual consultation because that's becoming a more, you know, prevalent thing. Do you think there's value in learning that as a resident? Should that be part of our curriculum now that we're kind of going online more? Or how do you think about that? Thanks for your question. First of all, I do agree that the pandemic does bring some silver lining for us. And yeah, I think I really agree that as residents, we have to try and maximize these little slivers of hope that we might have. With regards to virtual consultations, now, what we did, and this was really spearheaded by our staff members, we had the tele consultations. And that kind of worked well, but of course, it's with a telephone. But we unfortunately did not have virtual video consultations. And I do think there is room for that. But that would require a hospital wide approach. I think it's a little bit difficult to organize that through one department, specifically with the IT department, and making sure that we've got the required approvals. But it's a really good idea. I think I'll propose it. Yeah, you should, I think. Yeah. And if anyone who's watching this, you know, webinar right now has any suggestions on what other programs could do, what went well in your own program, please share in the chat, because we'd be very interested. And I think we can all learn from each other. You know, I had another question for you along the lines of surgical simulation, but because that is going to be answered by our next speaker, I'll introduce him and let him expand on that subject. So our second speaker is Dr. Alfonso Navia. He's a fully trained general surgeon, and also a chief resident in the plastic surgery program at the Pontifical, you have to help me here. How do you pronounce your university? Well, in English, it would be Pontifical Catholic University of Chile. In Spanish, it's Pontificio Universidad Católica de Chile, but I translated it to be a little easier. That's exactly what I said. So. All right, so he also completed a research fellowship and a master in science degree at the same university, and really focused on research in plastic surgery simulation training, which he will be talking about today. So I'm very excited to hear his talk. Please go ahead and share your screen. Great. Well, thank you so much for the introduction and for the invitation. This is actually a really special and emotional webinar for me because actually tomorrow I end my residency is my last day of training. So this pretty much sums everything up about my experience during my training and also during the pandemic. So what about my country? Many of you may not know too much. Chile is a long and thin country at the most southern part of South America. We have a population of 19 million people. The capital is Santiago, and we are, well, actually neighbors of Argentina. Esteban and Helena will talk about that. And we are surrounded by the Andes Mountains. We have great desertic landscapes at the north, as well as great national parks at the south. We also have all the Polynesian culture at the eastern island with the Moais that you may that you may know. And we also have the dramatic landscapes of the Chilean Antarctic. What about some famous Chileans? Maybe you know Don Francisco. He's a famous anchorman. Also some soccer players like Alexis Sanchez, Arturo Vidal, Marcelo Rios, who was the one of tennis at the 90s. But probably nowadays the most famous Chilean would be Pedro Pascal, who is the star of the Mandalorian. What about training in Chile? Well, medical school last seven years. Then we have to do a general surgery specialty of three years to then be able to apply to a subspecialty in plastic surgery, which last two years in UCI Chile and three years at my university. There are only two or three maximum positions per university per year. So you can sum it up. And there are usually no more than 10 or 12 residents in all Chile. And there's also an additional option of a four-year program with one year of research fellow and a master in science degree prior to the clinical residency, which this is the pathway that I took. So I will talk about that. About the research fellow experience, my personal lines of research are focused on residence training and education and also plastic surgery simulation and the development and validation of training models. During my residence, I got a total of 19 articles published. Some of them, well, here we analyze the transfer from presentation to publication among research on plastic surgery residents and surgeons, where we saw that there was a higher transfer to publication rate on a static research with 36% compared to reconstructive research with 11%. We got a couple of publications with the experience of residents doing research during the residency. One's some national and Latin American experience, but this recent article published in Annals of Plastic Surgery, where we need a service study in more than 100 residents. We could saw some different things. Well, the acronym for the study is PRESS, for Plastic Surgery Residents Research Effort Service Study. And we saw that the main declared barrier for doing research during the residency was lack of time with more than 70% and followed by lack of motivation or mentoring from senior staff with more than 50%. And we also analyzed the publication rate of those residents with a prior research fellowship compared to those that didn't have a research fellowship before the clinical residency. And you can clearly see that those with a research fellowship published more, and that was statistically significant. And also, I'm pretty convinced that the best way nowadays with all the technology and social media is to do collaborative research. So I encourage every one of you to join ICOPLUS trainees, which is the worldwide biggest trainees network. You can contact me or contact directly to the ICOPLUS trainees social media. And we recently published this article at PRESS introducing this community. What about plastic surgery simulation? Well, this article published by a group where we analyze the difference of published simulators either on aesthetic topics or reconstructive topics. And you can clearly see in blue that most of the topics of reconstructive areas are covered. However, there are few published simulators on aesthetic surgery. We've got some of a little bit of everything in our group. We have this, for example, really novel low-cost method that we published to teach breast reduction markings in the context of the COVID-19 pandemic and social distancing. We basically used some breast prosthesis usually used by transgender people and use it to teach markings to residents. And it was pretty useful. We also got this otoplasty model, which was handcrafted, but really low cost, about $5 each. It's published in the Latin American Simulation Journal. It's in Spanish, unfortunately, but here you can see that we also validated the method by training medical students. And you can see the pre and post-training results. We also have a rhinoplasty simulator that we haven't published yet. And we also have this, our latest minimal invasive placation rectus of the diastasis of the rectus abdominis model. As you saw, we are all general surgeons, so we have a lot of laparoscopic abilities. So we are currently validating this method for training. What about reconstructive surgery simulators that we have? We have a lot from really basic suture skill paths focused for medical students, to the use of pig skin to train local labs, to the microsurgery with this, the published in PRS by our group that probably is the basis of our experimental microsurgery research, where we validated a training curriculum, which was based on non-living models, mainly chicken thigh and chicken wing. And the skill gain was comparable to experts and comparable to traditional training courses. And it had transfer of skills to the live rat model, which is probably the gold standard nowadays. With that, then we started using a lot of the chicken leg, chicken thigh and chicken wing. We've got a couple of publications describing perforator flaps, the use of super microsurgical skills. And also this article that I published last year, I encourage you to read it, to take the most advantage of the chicken wing anatomy with in-depth nomenclature review and anatomy description of it. Some articles coming soon, this is using 3D printing technology. We printed a modeled mandible where we mount a sciatic chicken nerve that you can use to practice intraoral nerve repair using either a training microscope or using the loops. And you can put the model in a dental phantom. What about my experience in the clinical residency? This is the general distribution of our rotations. We get to rotate pretty much on everything. And as Chile is a small country and pretty much centrated in Santiago, we get to go to the different referral centers of every specialty and topic. I got to operate on my personal count, almost 350 surgeries as a first surgeon and probably about 200 more as a first or second assistant. And we got to get to do everything. That's something that I like a lot about my training from non-invasive laser spillings, Botox fillers, hair grafting techniques, facial aesthetic surgery, like blepharoplasties, fat grafting, cervical facial liftings, otoplasties, lots of rhinoplasties too, all of the static breast procedures, segmentation, mastopexies, reductions, a lot of body contour. We do a lot of post-bariatric surgery from traditional abdominoplasty for the least body lifts, liposuctions. In the reconstructive part, we do a lot of skin grafting, but also, well, we also see a lot of burns, either minor or major burns. And also in the acute and the sequelae settings, we also get to see a lot of pressure surges, especially with those that went high during the pandemic. Also a lot of head and neck surgery from small local flaps on the context of mass surgery, regional flaps like a frontal flap, or a more complex reconstruction like this microsurgical reconstruction of the maxilla. A lot of breast reconstructions from implants to expander techniques to all of the autologous techniques. For example, these two DEP cases, also second procedures of symmetrization and nipple reconstruction. We also get to do a lot of genital and perineal reconstruction like this perforator flaps reconstructions, also transgender surgery, a lot of lower extremity reconstruction, microsurgically, skip ALT flaps, combined reconstruction, and also complex reconstruction like this skip flap in a pediatric patient, a seven-year-old year for heel reconstruction. So we get to be hands-on some super microsurgery techniques, like some perforator flaps. I did a couple of them, and also the opportunity to resolve a LVA anastomosis for lymphedema. And microsurgery is a topic that I like the most, so I did my elective rotations in microsurgery. So in my personal account, I did a total of 29 free flaps as a first surgeon, probably about 20 more as a first or second assistant, most of them ALT, followed by DEP and skip flaps. What about how COVID-19 has affected our training? Well, we have this published last year in aesthetic plastic surgery. We also, similarly to Dr. Kabila, saw a 60 to 80% decrease of elective surgery, especially during the heavy quarantine times, with a great increase in pressure shorts, as I told you. We first did a strategic reorganization of rotations, obviously prioritizing reconstructive trauma and oncological rotations that didn't stop too much, at least during the heavy quarantine times. We also stimulated research, because we finally have the time that we didn't have before, and that we have it studied and published, as I mentioned. All of the webinars and journal clubs that we all know, and we are actually now in one, we have this study, too, and we, from the declaration of the COVID-19 as a pandemic at the beginning of March to the first wave, it actually has the same trend as the first wave of COVID, the peak that the webinars had, with a 3,250% increase, and probably now it's a lot more. We also get to be lucky to have a lot of access to an anatomy cadaver lab, so we pretty much have open access to pretty much every cadaver we want, and we combine that with a lot of the simulation training that I already showed you. Some other things that we published is, for example, here we compare three different points of views of recording video images of intraoral surgeries using a GoPro, mostly to optimize the video recordings for residence training in the context of that intraoral surgeries have higher risk of COVID transmission, and therefore we're more limited to access for residents during the pandemic. And finally, we also do a lot of microsurgery training. We have courses, and it's included in our curriculum, and we are currently soon to publish, I hope, it's under review, this microsurgical training kit to train at home. Here is a little sneak peek, but it's basically a kit that includes everything from the carrying bag to the microscope, the instruments, sutures, clamps, vessels, either synthetic or the dissection guide for chicken wing vessels, and it's a full training kit to train microsurgery at home. It's really low cost. We are hopefully soon to publish it. The idea is to be open source, so everybody can buy it and develop it at their own countries and homes, and we not only develop it, but also we did the validation of the process, and we saw that in a group of general surgery residents with no prior abilities in microsurgery, they had the same gain in skills compared to those that make a formal training course at our microsurgery lab, and it was comparable to the skill of experts. So that's pretty much my experience, and thank you very much. Wow, I'm very impressed how many different simulation models you have, and especially how far you've carried the microsurgery simulation, which I think it would be fantastic if we could all have access to an at-home training kit that doesn't exist in this form right now. So that's really impressive, and thank you for that great innovation and contribution. There was a question from Dr. Kapila about whether you have any ideas of doing kind of in vitro perfusion-based models, so instead of, you know, having just like a vessel that doesn't have blood flow, to have a system where you can like see blood flow, etc. Yeah, we have that incorporated at our lab. We use it not all the time because it's more tough to mount, but usually you do use some pumps that actually have a pulsatile blood flow, and you can do it from in a chicken wing to also perfused cadavers. So we've got that implemented in our simulation lab. Yes, it's really cool, but as you don't have always a monopolar coterie, sometimes it actually makes it a little messy when you train in that way, but of course it's a higher fidelity way of training indeed. Yeah, that's fantastic. I think Dr. Kapila might want to come visit you to bring it back to Belgium. So, you know, another question that I have is all these things are so great. And Angelo from Johns Hopkins also in the chat mentioned that they had other simulation training for clefts, for example, or microtia. But a lot of these things are sometimes cost prohibitive and not available across the board. Do you have any suggestions on how to change that and make all this available to every one of us? Yeah, probably the glue there is creativity. At our research fellowship, we have really scarce financial support. Most of it is resident-based. So we have to be creative to take more advantage of it. So taking low-cost materials and maybe sometimes sacrificing some of the face validity of the model to be able to learn some skills. But most of it is being creative and using low-cost things that are easily accessible and available for everyone. So have you used any 3D printing or anything like that or more basic? I don't know. Yeah, we actually have a 3D printer available at our lab from about a couple of years ago. So actually, the model that I presented, which is a 3D-printed mandible to train into inferior alveolar nerve repair during orthognathic surgery that you can mount it in a dental phantom, for example. So actually, that makes the things a lot easier. But you have to have the 3D printing technology available. 3D printing, depending on the material that you use, can be pretty cheap. So the main cost there, a main barrier, is to have the access to a 3D printer. Yes. OK, and then my other question was, what areas do you think, like, if you're a residency program and you only have one area or two areas that you can focus on with simulation training, what do you think are the things that people should focus on that are most beneficial to residents? Wow, that's a tough question. Probably, it will depend on every program, on which areas they do less things on their clinical residency. As I mentioned, in our residency, we have the luck that maybe we don't do a lot of everything. But at least we have the opportunity to do at least a little of everything. And you have the opportunity to spend your elective rotations to deepen a little bit more those areas. Probably, in our reality, it would be a little bit of hand surgery. In Chile, at least, most hand surgery is performed by orthopedic surgeons and not too much by plastic surgeons. So maybe that would be an area that, in our reality, we could focus. And actually, we are now working with them. And we are doing some implant, some re-implant finger model to train, and another couple more, yes. OK, wonderful. And then one thing I want to share that Angelo just posted in our chat is that he says that Johnson & Johnson and other big companies have several unrestricted educational grants that everyone can apply to and that can fund these projects. So thank you for that piece of advice. I think that's wonderful. Yeah, good advice. Thanks. Yeah. All right. And if anyone else has advice on simulation training or how to get funded, just type it into the chat. And we can all benefit from that. All right. Well, thank you so much, Dr. Navia. It was very nice to see you. And I think you've got a lot of invitations waiting from different places. I would be happy to be there. Yeah, all right. So our third speaker tonight is Dr. Scarafoni from Argentina, who is a chief resident at the Hospital for Burns in Buenos Aires. And he will be speaking about when microsurgery is not an option and surgical alternatives have to be found. So please go ahead. Hi, everybody. Do you listen? Can you see my presentation? OK. First of all, thank you to the ESPS for the invitation. It's a great honor to be part of this webinar and to share our experience. My name is Esteban Lelina. I'm a plastic surgeon in Buenos Aires, Argentina. This is my hospital, a public burn health institution, and the primary burn referral center in the city. This is part of our team. Nowadays in Argentina, we have a seven-year plastic surgery resident program, which includes a four-year general surgery residency, and afterwards, a three-year plastic surgery residency. And so as a burn center, we face every day with this type of burn sequels. We know that burn injuries to the neck can lead to significant functional impairment and major aesthetic problems, and that burn neck can be constructed with a wide range of surgical treatments. Skin graft has been the mainstay treatment for this type of reconstruction. However, it requires long-term immobilizations and it has a high recurrency rate. Local flaps, although we see most of the time they are involved in the injury, so we have to get used to regional flaps or free flaps. If we look a little bit in the literature, we see that the use of free flap composite tissue transfer for burn deformities is pretty new. The first description is in 1975 by Harry Anomori from the Tokyo Metropolitan Hospital, which they presented 85 cases for burn reconstruction and baldness due to burns and neck contractures were the main indications, and the groin flap was the most used flap, and has been a workhorse flap for this type of reconstructions until in 1994, Claudia Grishani, a microsurgeon from Argentina, described the extended parascopular free flap based on the descendant branch of the circumflex scapular artery to reconstruct the burn sequels. And afterwards, three years later, basing on both subscapular arteries, he described a total face reconstruction with one free flap in six cases. We know that the role of free tissue transfer in head and neck reconstruction is important. In this paper, we see that there are three main indications. First of all, the exposed bone or cartilage. Second, the failure of previous treatments. And first of all, the extensive neck contractures. However, in Argentina, this type of reconstructions, most of the time it's not possible due to lack of resources and lack of formal training in microsurgery. So we have to deal with other options and we have to find another treatments for this type of reconstructions. So for us, the work of flap for burn neck treatment is the supracavicular flap, as it's versatile and has an acceptable match in the color and texture of the recipient area. It's a simple operative procedure which is performed by second year plastic surgery residency. It has a reliable pedicle and minimal donor site morbidity when closed primarily. This supracavicular flap was described by Lamberti in 1976, in 1979, sorry, but it is an evolution of the Charretera flap which was described by Kassanjian and Converse and in our country was very popularized by Simon Kirschbaum from Cordoba and Hugo Arrufe and Victor Nassif Cabrera in Buenos Aires, both who work in our institution. So as for our experience between 2010 and 2020, we have performed 102 supracavicular flaps for neck scar contracture and 21 cases involved bilateral reconstruction for extensive neck contracture. We use bilateral supracavicular flaps when 60% of the neck unit is involved by the injury. In our experience, 85% were female patients and 15% were male patients with an average age of 33.7 years. The burn cause was fire in 85% of cases and 15% was scar burns and the median follow-up time was 8.3 months and the mean surgical time was 2.5 hours. As for the surgical technique, we use the works of Norbert Palua. In the preoperative time, we use a Doppler probe to find the pedicle, which is also the time two finger breasts behind the sternocleidomastoid and two finger breasts above the clavicle and afterwards we design the flap variable in length and width. We try not to exceed the distal insertion of the deltoid muscle and we try not to exceed the 10 centimeter width to avoid rafting the donor side. As for the lateral aspect of the design, we can do it in an elliptical manner or as the right side image as a fishtail design to gain height in the lateral aspect of the neck so we can avoid recurrency in the long-term. In the intraoperative, we start by releasing the neck contracture while the second team start elevating the supracavicular flap from distal to proximal. We can elevate it in a suprafacial or a subfacial manner. In our experience, there is no difference between these two planes and it depends on the surgeon's experience and preferences. After we find and identify the pedicle, we release it from the medial side and we transfer it to the neck. This is a case of the simple or unilateral supracavicular flap and this is a case of the bilateral supracavicular flap. In this type of reconstructions, we try to use the biggest flap in the neck, just inserting and fixing it to the joint bone and the smallest flap in the thorax. This is the postoperative, the medial postoperative. We leave just a simple drainage which is removed at 24 hours postoperative and the patient is discharged at 24 hours. This is the first patient with a simple supracavicular flap and this is the second patient with a bilateral supracavicular flap at one year postoperative which shows an acceptable aesthetic result and acceptable donor side mobility. So as for the result, average size of the flaps were 17.5 in length and seven centimeters in width with a 90% donor side closed primarily and a 5% complication rate most of the time due to some dehiscence in the donor side which can be treated in a conservative way. No numbers of the shoulder or functional problems were observed in the donor side and the appearance of the scar was acceptable in most of the cases. So here are some cases to show you. This is a 33 year old woman with a burned neck injury which was solved with a bilateral supracavicular flap. This is a one year postoperative result showing a good functional outcome and an acceptable scar. This is a 10 year old boy with a severe burned neck injury. I think that if I ask here the panelists, most of them would perform a pre-flap. We solved this with a bilateral supracavicular flap. This is a six months post-op result and this is a one year post-op result showing a good functional outcome and an acceptable aesthetic result also. So as to conclude, we can say that the supracavicular flap is a recommended alternative when microsurgery is not an option. It's an easily and quickly harvest flap. It has a reliable pedicle, matches in color and thickness and has minor donor side mobility and for us is a really workhorse flap. So I recommend it to you. Thank you very much. Thank you, Esteban. That's really fantastic results with this flap. We use this flap way less often than you do, but I think we should because it seems to be a very unreliable flap that is a great option for the entire head and neck area essentially. So Angelo has a question. He says, great results. What is your second choice option? Should the supraclavicular area be burned? And what's interesting to me is that right after he posted that question, you showed this kid that had burns bilaterally and you still did it. So. Yeah, yeah. We can, I mean, we have performed some supracavicular flaps with burn injuries in the shoulder area with good results. If not, we have to try maybe a trapezium flap or something like that depending on the donor side available or well, there are some cases that there are not donor side available and we have to go for a free flap, but we try to employ it every time we can. But it seems like in some cases you're able to use the burned skin and include it in your flap. Is that correct? Yeah, yeah, yeah. With good results and we haven't seen, I mean, some problems with that. Wow. And so, you know, out of curiosity, when you do transfer burned skin, do you have to like do other maneuvers like Z-plasties that break up the scar more or can you just transfer it the way it is? No, no. When I experienced just transfer it, nothing, nothing else. Wow. No, that's fantastic to know because we oftentimes like shy away from using burned skin, but maybe that's not, you know, warranted. Angelo also says that oftentimes when there's no good donor site, they use Integra. I don't know if you've heard about that, but it's a skin substitute that- Yeah, yeah. We don't have that much experience because we are like in a public health. So Integra for us is very expensive. So in that case, instead of using Integra, we use a simple skin graft and we try to split it for a long time. I know it's not the best, but well, it works sometimes. No, definitely. I was curious, you know, if you are a resident and you're doing this surgery for the first time, what are your tips for, you know, how can you make this work? Are there any challenges that you faced raising this flap that we should all know about? I mean, it's not that difficult. Of course, it has a learning curve. You can go in a subfacial and a suprafacial. I prefer to go in a subfacial plane because you can see the, I mean, the artery goes in the subcutaneous area. So that way you don't have, or you have less chances of damaging the artery. The first third or the first half of the flap is pretty straightforward. And then in the inner third, yes, you have to be more careful, but not much for us. Okay, that's good to know. And when you do have problems with the flap, what is the most common thing? Is it venous congestion or, you know, when it fails, like why does it fail in your opinion? Yes, most of the time it's venous congestion, but we have distal necrosis maybe of doing it very long, but not other problems. Okay, that's wonderful. Yeah. All right. So, you know, I think it was a very successful first resident run webinar. I think it's just wonderful to learn from different regions of the world. And I think we should do more at least. I mean, I learned so much from you and thank you also for the audience for tuning in and asking questions. I think we're gonna all just be on the screen and, you know, say bye to our audience. I really appreciate everyone joining and thank you for spending the time with us. Do the speech. Thank you very much. Final comments. Thank you very much. Thanks very much. It was great. Thank you everyone.

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