Plastic and Reconstructive Surgery

What type of UV radiation is linked with skin cancer?

• UVB

What is the most common skin malignancy in the United States?

• Basal cell carcinoma

What are the classic physical findings of basal cell carcinoma?

• Pearly appearance with rolled edges, +/− telangiectasia

What type of basal cell carcinoma is the most aggressive?

• Morpheaform type (produces collagenase)

What margins are appropriate for basal cell?

• 3 mm margins are acceptable and frozen section can be used intraoperatively.

What is the most common physical finding of squamous cell carcinoma?

• Scaly appearance, papulonodular, ulceration

What is the name of the cancer associated with a previous burn injury?

• Marjolin ulcer; can also develop in areas of chronic inflammation, that is, enteric fistula.

What are appropriate margins for squamous cell carcinoma?

• 0.5 to 1.0 cm margins

What are risk factors for the development of squamous cell carcinoma?

• Actinic keratosis, arsenics, atrophic dermatitis, Bowen disease, chlorophenols, fair skin, HPV, immunosuppression, nitrates, previous skin cancer, radiation exposure, sun exposure, xeroderma pigmentosum

What is the natural history of squamous cell carcinoma?

• Actinic keratosis, Bowen disease (squamous cell carcinoma in situ), squamous cell carcinoma

Aside from sun exposure, what is classically a risk factor for squamous cell carcinoma?

• History of organ transplantation, or any other immunocompromised state

Can squamous cell carcinoma metastasize?

• Yes, it is uncommon, but it can metastasize to lymph nodes. Regional adenectomy should be performed.

When can Mohs surgery be used for basal cell or squamous cell carcinoma?

• Delicate areas that include perioral, perioccular, perinasal, ears, hands, and genitalia

What is the most common melanoma site on the skin in men? In women?

• Men—back

• Women—legs

What is the most common location for distant melanoma metastasis?

• The lung (surgery can help relieve pain caused by metastatic melanoma to the lung, but is not a cure)

What is the most common metastasis to the small bowel?

• Melanoma

What margins are recommended for a melanoma skin lesion with thickness of 1 mm?

• 1 cm margins are recommended; for lesions greater than 2 mm a 2 cm margin is recommended. 0.5 cm margins are acceptable for thin lentigo maligna melanomas or melanoma in situ.

Can electrocautery be used for excisional biopsy of melanoma?

• No, cold knife excision should be used so as to not disturb the deep margin with burn artifact.

What types of melanoma are there?

• Superficial spreading, lentigo maligna, acral lentiginous, nodular

What is the most common type of melanoma?

• Superficial spreading

What is the least aggressive type of melanoma?

• Lentigo maligna

What is the most aggressive type of melanoma?

• Nodular, but acral lentiginous is also aggressive and presents late because of location on feet/hands.

If a melanoma lesion is less than 1 mm thickness and no lymphadenopathy is palpated, does any additional workup need to be performed?

• No. Optional CXR, liver function test (LFT's), and sentinel lymph node biopsy (SNLB) can be performed for lesions greater than 1 mm thickness. If SNLB is positive, then all the above workup and an MRI of brain and CXR should be performed. If there are palpable nodes present, a formal lymph node dissection should be performed.

Can Mohs surgery be used for melanoma?

• No, never!

Can frozen sections be used to determine if margins are negative for melanoma?

• No, frozen sections have no role in the management of melanoma (permanent section only).

What is the difference between a keloid and hypertrophic scar?

• A hypertrophic scar does not extend beyond the borders of the original scar.

What is the treatment for a keloid?

• First-line therapy for most keloids is intralesional corticosteroids. They can also be treated with radiation, silicone sheets, surgery with interferon or triamcinolone injections, and pressure garments.

What is the treatment for a hypertrophic scar?

• Intralesional corticosteroids, silicone sheets, pressure garments

What is the treatment for hidradenitis?

• Improve hygiene, antibiotics, surgery to remove infected tissue and apocrine sweat glands

What is the reconstructive ladder?

• It is a way of organizing approaches to reconstruction and wound healing. The first step of the reconstructive ladder is the simplest and least invasive method progressing to the most complex method at the top of the ladder.

What are the general categories in the steps of the reconstructive ladder in order from simple to complex?

• Healing by secondary intention

• Healing by primary intention/tertiary (delayed primary) intention

• Split-thickness/full-thickness skin graft (STSG/FTSG)

• Local flap

• Regional flap

• Distant flap

• Free flap

What patient factors are important when evaluating a wound?

• Immune deficiency/suppression

• Nutritional status/obesity

• Diabetes

• Smoking

• Healing disorders

• Age

How can you diagnose a skin infection in a burn patient?

• Biopsy the skin; if bacteria are present on deep dermis, then the patient likely has an infection.

How do you obtain a sample of bone for biopsy to evaluate for osteomyelitis?

• A separate incision is made, away from open wound, and bone biopsy is performed through this incision.

What is the utility of imaging in evaluating osteomyelitis?

• MRI is a good modality to evaluate extent of osteomyelitis, plain film will not show osteomyelitis changes for 2 weeks, and bone scan is not specific in the face of an open wound or a fracture.

True or false: A moist environment is key for a clean wound to heal.

• True. Clean wounds heal faster and with less scarring if the wound is kept moist.

What adverse side effect is associated with silver nitrate? Silvadene? Sulfamylon?

• Silver nitrate = hypo-(calcium, sodium, potassium, chloride)

• Sulfamylon = metabolic acidosis

• Silvadene = neutropenia and thrombocytopenia

What is the strength layer in closing an incision?

• Dermis

How does a Z-plasty work?

• It increases length by rearranging the tissues and borrowing from the width.

What are the angles of a Z-plasty that would give you a theoretical increase in length of 75%?

• 60 degrees

How do you design a Z-plasty?

• The common limb of the Z-plasty is in the direction to be lengthened. All the limbs should be the same length.

What is a STSG?

• Its components include all of the epidermis and a portion of the dermis. STSG vary in thickness depending on how much dermis is included.

What is a FTSG?

• Its components include all of the epidermis and all of the underlying dermis.

How do skin grafts survive?

• Within the first 24 to 48 hours, skin grafts survive on nutrients that diffuse from the surrounding tissue to the dermis of the skin graft (plasmatic imbibition). After this occurs, revascularization of the skin graft occurs (inosculation).

Can a skin graft survive on exposed tendon or bone?

• Yes, as long as the peritenon and periosteum are in place, respectively.

What is the difference between a flap and a graft?

• A flap has its own inherent blood supply. A graft receives its nutrition from the recipient tissue until revascularization occurs.

What is a random skin flap?

• It is a flap that does not have a large-bore artery as its arterial supply (axial blood supply).

• It receives its blood supply from a random subdermal arterial plexus.

What is a pedicle?

• It is the vascular supply to a flap that is left intact when mobilizing a flap.

What is surgical delay with regard to skin flaps?

• It is the process in which there is a partial interruption of the skin flap's blood supply to build a more robust arterial supply from the other feeding vessels (likely the future pedicle).

What is the safe (flap length):(base width) for a random skin flap? For the face?

• 1:1; 1:1.5 for face

What is an axial skin flap?

• It is a skin flap that is fed by a named or clearly identifiable artery.

What is the (flap length):(base width) for an axial skin flap? For the face?

• 3:1; 6:1

What is a fasciocutaneous flap?

• Fascia + skin; can be used as a pedicled flap or as a free flap.

What is a myocutaneous flap?

• Muscle + skin; can be used as a pedicled flap or as a free flap.

What is meant by major vascular pedicle in the Mathes and Nahai muscle classification system?

• It is a vascular pedicle able to maintain adequate perfusion to the entire muscle if its other arterial supplies were interrupted.

What is the blood supply to pectoralis major?

• Major blood supply from pectoral artery from thoracoacromial vessel and minor blood supply from segmental branches from internal mammary

What is the blood supply to Latissimus Dorsi?

• Major blood supply from thoracodorsal artery, minor contributions from intercostal and lumbar arteries

What is the blood supply to gracilis?

• Ascending branch from medial circumflex femoral artery

What is the blood supply to the rectus abdominis?

• The inferior epigastric and superior epigastric arteries

What is the success rate of a free flap surviving?

• Greater than 90%

What is the most common reason for free flap failure?

• Venous thrombosis

What is the most sensitive way to determine pedicle/free flap viability?

• Clinical monitoring

What are signs of a viable flap?

• Warm flap, pink in color, cap refill <2 to 3 seconds

What are the various methods for postmastectomy breast reconstruction?

• Tissue expander with subsequent breast implant, pedicled autologous tissue (TRAM/latissimus dorsi), free flap (free TRAM, DIEP, SIEA, SGAP)

What do TRAM, DIEP, SIEA, and SGAP stand for?

• TransRectus abdominis myocutaneous flap, deep inferior epigastric artery perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap

What is a perforator?

• It is an arterial branch from a larger artery that travels through a muscle ("perforates") to supply the overlying fascia and skin with blood.

What is the first stage of a tissue expander breast reconstruction?

• Placement of the expanders in a subpectoral pocket with minimal inflation of the expander.

• The expander will be slowly filled over the next several weeks/months until the tissue has expanded enough to accept the final implant at a second stage procedure.

What is the blood supply to a pedicled TRAM flap?

• Superior epigastric artery

Where does the superior epigastric artery come from?

• It is the distal extent of the internal mammary.

What is the blood supply for a DIEP flap?

• It is a perforator from the deep inferior epigastric artery that travels through the rectus abdominis muscle to supply the overlying fascia, fat, and skin

How many phalanges are located in the digits of one hand?

• 14; all of the digits have 3 phalanges (proximal, middle, and distal) with the exception of the thumb, which has 2 (proximal and distal).

What is a quick way to assess function of the median nerve in an injured hand/forearm?

• Ask the patient to make an "Ok" sign.

What muscles are innervated by the ulnar nerve in the hand?

• Palmar and dorsal interossei, opponens digiti minimi, flexor digiti minimi, abductor digiti minimi, palmaris brevis, deep portion of flexor pollicis brevis, adductor pollicis, lumbricals to ring and small finger

What is Allen test?

• It is a way to assess the patency of the ulnar and radial artery to the hand.

What are the indications for replantation?

• Thumb replantation, multiple finger amputations, single digit distal to flexor digitorum superficialis (FDS) insertion (zone I), hand amputation through palm, hand amputation through distal wrist, any part in a child, distal forearm

What are the structures in the carpal tunnel?

• There are 9 tendons and one nerve (median nerve). Tendons from FDS and flexor digitorum profundus plus the flexor pollicis longus

How do you diagnose carpal tunnel syndrome?

• Nerve conduction tests that show motor latency greater than 4.5 msec and sensory latency greater than 3.5 msec

How do you surgically treat carpal tunnel?

• Complete release of transverse carpal ligament with care to avoid median recurrent motor branch of median nerve.

Which 2 nonthumb fingers are needed for grip strength?

• Little and ring fingers