> ## Content Index
> Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt
> Use this file to discover other available public pages before exploring further.

# 2 Tips for Acland's Patency Test, Venous Flaps & ALT Flap in Action
- URL: https://www.theplasticsfella.com/january-19th/
- Published: 2025-01-17T21:11:55.000Z
- Updated: 2025-01-18T17:06:41.000Z
- Description: Also: Last round of the Sunday quiz, evidence on vasopressors, & 3 recommended reads.
- Author: PlasticsFella
- Tags: thePlasticsPaper

#### In this week's edition

1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-19th/#a-letter-from-pfella)  
The shadow economy of plastic surgery is booming.
2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-19th/#the-sunday-quiz)  
How well do you know v**enous flaps*?
3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/january-19th/#image-of-the-week)  
ALT musculocutaneous perforator flap in action.
4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-19th/#technique-tip)  
How to do Allen’s patency test.
5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/january-19th/#what-does-the-evidence-say)  
Vasopressors in microsurgery: Challenging the dogma.
6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-19th/#articles-of-the-week)  
CT Angio before DIEP, why flaps fail, & microsurgical principles: with 1 sentence summaries.
7. 💕 [****Feedback**](https://www.theplasticsfella.com/january-19th/#feedback)  
Suggest ideas & give feedback!

## A Letter from P'Fella

**The Shadow Economy of Plastic Surgery is Booming*

👋

****Hey all!**  
  
Let’s call this what it is: We’ve built a system that’s broken and hypocritical.  
  
In an attempt to reduce stress and level the playing field, medical schools moved away from traditional grades and honors to a pass/fail setup. But instead of fixing the problem, we just shifted the battlefield. 

Now, students are forced into a shadow economy of extracurricular effort to survive an arms race that does nothing to make them better doctors. They’re churning out abstracts, stacking volunteer experiences, and competing on a spreadsheet — not in the clinic, where it actually matters.

Eric Warm’s post on [Twitter](https://x.com/CincyIM/status/1879934709519773910?ref=theplasticsfella.com) brought this to my attention.

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Screenshot-2025-01-18-at-02.52.05.png)

And here’s the dirty truth: None of this insanity predicts who will excel in residency.

**The Reality**  
In 2022, neurosurgery applicants averaged **30** publications per person. The top 10% submitted **58 or more**. For perspective, that’s more than what many full-time academics publish in years. And this isn’t just isolated to the ultra-competitive specialties — plastic surgery is no different. Students are gaming the system because we’ve left them no choice.

We’ve replaced grades with meaningless metrics and called it progress. The result? Students are ditching clinical teaching, their hands-on skills are deteriorating, and burnout is now baked into the process before residency even begins.

**What We’re Really Doing**  
This pass/fail era creates triple harm.

1. **Clinical Excellence is Devalued:** Students are rewarded for looking good on paper, not for being great in practice.
2. **Burnout is Accelerating:** The bar is impossibly high. Even the strongest students are crumbling under the pressure.
3. **Superficial Academia is Thriving:** “Achievements” like mass-producing abstracts aren’t about quality or learning — they’re strategic resume padding.

**A System That Eats Its Young**

Sure, some students feel liberated to pursue meaningful work under pass/fail — but let’s not kid ourselves. Most are just trying to survive. This is not the meritocracy we claim it to be; it’s a system that eats its young and wonders why they’re burnt out by Day 1 of residency.

P'Fella ❤️

## The Sunday Quiz

**How Well Do You Know* ***Venous Flaps?**

****Are you ready to make it to the leaderboard?**  
  
Welcome to ****the last round** of The Weekly Quiz.  
  
Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro.

![Thatte and Thatte Venous Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-10.png)

Thatte and Thatte Venous Flap Classification

## Image of the Week

**ALT Musculocutaneous Perforator Flap in Action*

🖼️

****Image of the Week**   
  
In this section, we feature an anatomical illustration. This week, we’re looking at an intraoperative image of an elevated ALT musculocutaneous perforator flap with the deep fascia.  
  
Read more about the anterolateral thigh flap [here](https://www.researchgate.net/publication/259492840%5FExtended%5FAnterolateral%5FThigh%5FFlaps%5Ffor%5FReconstruction%5Fof%5FExtensive%5FDefects%5Fof%5Fthe%5FFoot%5Fand%5FAnkle?ref=theplasticsfella.com). 

![Intraoperative view after elevation of the ALT musculocutaneous perforator flap with the deep fascia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-11.png)

[Source](https://pubmed.ncbi.nlm.nih.gov/24376731/?ref=theplasticsfella.com)

## Technique Tip

**How to Do A Patency Test*

🚑

****Technique Tip of the Week**   
  
This week’s technique focuses on ****Patency Test**, a useful but minimally traumatic method to assess vessel patency. Use it judiciously to avoid unnecessary vessel trauma.  
  
****Steps:**  
****1\.** Occlude the vessel distal to the anastomosis with forceps.  
****2\.** Use a second pair of forceps to empty a segment of the vessel.  
****3\.** Release the proximal forceps and watch for segment refill.  
  
****Tips:**  
****\-** Use forceps with parallel jaws for reliable occlusion.  
****\-** Perform the test distal to the anastomosis and follow the natural blood flow direction for accuracy.

![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-12.png)

Source: Acland, Principles in Micorsurgery

## What Does the Evidence Say?

**Vasopressors in Microsurgery: Challenging the Dogma*

In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. 

Recent studies challenge the traditional avoidance of ****vasopressors** ****in microsurgery**, with large-scale analyses showing no significant increase in complications or flap failure rates associated with their use. (Chen et al., 2010; Zhu et al., 2023; Goh et al., 2019; Fang et al., 2017). Some studies even reported potential benefits, such as ****reduced fluid administration** and ****improved flap survival** (Zhu et al., 2023; Goh et al., 2019).   
  
Noradrenaline use did not adversely affect free flap survival in microvascular reconstructive surgeries (Rajan et al., 2019). Various vasopressors, including ****phenylephrine**, ****ephedrine**, and ****calcium chloride**, have been safely used in different surgical phases without increasing flap compromise or failure rates (Fang et al., 2017). While some studies noted a slightly ****higher re-exploration rate** with vasopressor use, overall flap outcomes remained unaffected (Rajan et al., 2019).   
  
The judicious use of vasopressors in microsurgery may be safe and potentially beneficial for maintaining hemodynamic stability without compromising flap viability.

## Articles of the Week

**3 Interesting Articles with 1 Sentence Summaries*

✅

****Preoperative CT-Angiography for DIEP Flap Reconstruction** ([Teunis](https://onlinelibrary.wiley.com/doi/10.1002/micr.22119?ref=theplasticsfella.com), 2013)  
  
In DIEP flap breast reconstruction, preoperative CT-angiography significantly reduces both flap loss and operative time compared to Doppler ultrasound.

✅

****What Drives Free Flap Failure? A Multi-Institutional Risk Factor Analysis** ([Wong](https://onlinelibrary.wiley.com/doi/10.1002/micr.22223?ref=theplasticsfella.com), 2014)  
  
microvascular free flaps show a 4.4% failure rate, with operative time exceeding 625 minutes identified as a significant independent risk factor. 

✅

****Reconstructive Microsurgery: Milestones, Principles, and the Road Ahead** ([Armstrong](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2820%2932415-9/abstract?ref=theplasticsfella.com), 2001)  
  
Reconstructive microsurgery has evolved from free flap techniques to advanced procedures such as limb transplantation as its key principles continue to shape complex reconstructions. 

## Feedback

### I hope you enjoyed it 😄

---