platic surgery

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collagen normal ratio hypertrophic scar ratio: I:III

normal = 4:1

hypertrophic = 2:1
wound healing inflammatory phase: PMN's and macrophages
% hemangiomas noted in first year of life: 80%
% lidocaine removed by liposuction: 10-30%
drugs associated with gynecomastia: amphetamine,aldactone, antidepressants (tricyclic), digitalis, methyldopa, opiates, tagamet,

NOT ambien
serrtus flap which ribs: ribs 6-8
lateral thigh flap size artey sensorynerve: large
3rd branch of perf femoris
sensate medial and lateral femoral cutaneous nerves
osteo-radionecrosis Rx ?: hyperbaric O2

surgery for pain, fracture, exposure, fistula
Pet scan: resolution = 4-5 mm
specificity = 80-90%
Delay of flap results in: inc capillaries 2-7 days

vasosonstriction early

hypertrophy and reorganization of vessels along the axis of the flap
hydorxyapetite %of skeleton onlay vs inlay cement vs ceramic: 70% of calcific skeleton

inlay = osteoconductive
onlay = non "
cement = resorbable
ceramic = non "
giant hairy nevus: >20 cm diameter

Malig rate = 8 - 10%
scleroderma crest syndrome: calcium soft tissue

calcinosis
reynaud's
esophageal involvement
sclerodactyly
telangiectasia
Surgical delay of flap: choke vessels dilate day 7-8
dil begins day 3

prior to day 3 = vasoconstriction
physical exam false pos or neg for regional lymph nodes: 30%
trapezius flap artery: transverse cervical
integra when to remove silicon layer: 2-3 weeks
Becker nevus: hamartoma (not a nevus)
bipivicaine duration of action related to: protein binding
calciphylaxsis: skin necrosis

hyperparathyroid
dextran actions: decrease factor VIII

decrease platlets

modify fibrin

antigen risk
Mongolian spot Nevus of Ito Nevus of Oto: Mong. = sacrum

Ito = blue nevus, post supraclavicular shoulder

Oto = trigeminal distribution
hemophelia A Rx: factor VIII decreased

operative hemostasis need 80-100% concentration

must maintain 30% for 2 weeks

1/2 life = 12 hrs. --50%gone in 12 hours
burn immunology: dec func leukocytes

dec t lymphocyte and immunoglobulins

inc supresion lymphocyte and complement
gene mutation SCC AK: P53
pectoralis major nerves: medial pectoral nerve = infior and lateral muscle

lateral pectoral nerve = medial muscle
Scorpion bite Rx adult child: adult = observe

child = admit + antivenum (neurotoxin)
rabies bite Rx: wound edge = 1 dose RIG (rabies immune globullin)

vaccine = 5 doses HDCV (human diploid cell vaccine)
bacteria leech human bite cat bite: lee = aeromana hydrophylia Rx = aminoglycocide,trisulfa, 3rd gen. ceph

human = eikonella corrodens Rx= pen/ampicillin

cat = pasturella multicida Rx - pen/amoxicillin
fanconi klippel trinau parks weber maffucci: fan = radial club hand, progressive pancysopenia,life threatening, auto dom

klipp trau = port wine (one extrem) venous and lymphatic

park web = same as klippel trauney + a-v fistula
polands sturge weber: poland = fanconi + syndactyly

sturge weber = port wine stain + siezure
rendu osler weber von hipple landau: rend = hemorraghic telangiectasia in mucous membrane, hematuria etc

von = retina and meningeal hemangiomas
xeroderma pigmentosa malignancy develops when: <10 yrs
indications for radio rx tumor: large

close margin

multiple ln's

extracapsular or perineural involvement
hemangioma (characteristics): plump endothelial cells

inc mast cells

inc 17-beta estradiol

multilaminate basement memb.
madilung's disease: benign symmetric lipomatosis
bone graft osteocyte life advantage vascualr bone effect of radiation: ostercytes die 2 hours

vasc.=less resorp of cort bone
fewer fracture
rapid union
rapid hypertrophy

raadiation = dec bone regeneration by 70%
gracilis flap nerve: obturator
fibular free flap: peroneal artery
posterior medial knee
flexor hallicus longus
classification tibial fractures: I = open 1 cm
II = open >1cm w/o drainage
III = extreme soft tiss. damag
a = able to close
b = loss tissue,
periosteum stripped
bone exposed
c = above + art. injury
BCC second primary: 50% in 5 years
sternocleidomastoid artery: occipital artery

note - spinal acc nerve (XI) runs in the muscle
pectoralis major artery rib complication rate: thoracoacromial artery

5th rib (or sternum)

60% complication rate
melanoma prognosis factor stains risk of 2nd primary: ulcer decreases prognosis

s100 and hmb45

2nd prim = 2-3%
atypical mole syndrome risk melanoma: 10%
lymphatic laser: ErbYag
saphenous aretery branch of: genicular
hydradenitis organism(s): staph

strep viredens
brown recluse spider Rx: dapsone

(not with G-6-Phos deficiency)
gracilis located: immediatley posterior to adductor magnus
heterotopic calcificatio Rx: etidronate

pamidronate

(does not effect bone healing)
purpura fulminans: toxic shock syndrome

staph aureus (include pneumonia)
nissseria meningitis
hemophilus influenza

remove implant
amputation lower ext. absolute indication: complete division post. tib n.

crush with warm ischemia > 6 hrs.
acute burn neutrophil function: inc chemotaxsis

inc degranulation therefore tissue necrosis
cultured allgenic keratocytes survival: 30 months
av malformation effect on bone: destruction
pressure ulcer stages: I skin intact

II blister skin

III into muscle no infection

IV involves bone or joint
lidocaine peaks a ______ hours: 12
ISLE immediate physical change: reallign collagen
local anesthetic mech of action: Na+ transport
defect lower extremity primary choice of closure: fasciocutaneous flap
cidex: gluturaldehyde
xylocaine (lidocaine): dose4.5 mg/kg
Maffucci syndrome: multiple enchondromas and hemangiomas
1st Rx of expanding hemangioma: oral conticosteriods
Carcinoma caused by chronis exposure to nickel: SCC nasal sinuses
scapula free flap bone: augment using angular artery (branch of thoracodorsal)
Actinic Keratosis to SCC: 10% in 5 years
presure ulcer recurrence post repair (in paraplegia): 80%
gracilis flap: type II

prim, art = medial circumfles

second art = superficial fem.
saphenous flap artey: saphenous art.

branch of genicular artery
fibular flap bone: 25 cm

maintain 6 cm prox and dist.
lower ext. flap choice prox 1/3 middile 1/3: grastocnemius

soleus
Flap types: I one dom

II one dom several minor

III two dom

IV mult segmental

V one dom several segmental
eg. flap type I: TFL
gastrocnemius
vastis lateralis
flap type II: gracilis
soleus
flap type III: gluteus
rectus
serratus
flap type IV: ext hall longus
serratus
tib ant
flap type V: lat dorsi
pect major
reverse sural flap: 5 cm above lat malleous
center over saph vein
width = 2 cm
contains lesser saph vein
deep fascia
sural n.
superfic sural art.
gastrocnemius flap art: sural
dx osteomylitis in pressure ulcer: MRI
contraindication to hyperbaric O2: optic neuritis

existing neoplasm

active virus
deep peroneal nerve: sensory to 1st web space

travels with ant tib/dor ped artery
arterial supply rectus femoris TFL vastus lateralis: lateral femoral circumflex
gracilis artery: medial femoral circumflex
sartorius flap artery: superficial circumflex iliac
superficial femoral
cover heel lateral ankle medial ankle: flex. dig brevis

abductor dig minimi

abductor hallicus
collagen production/degredation equlibrium: 21 days
which skin flap provides maximun latitude in positioning the skin paddle?: scapula
muscle radiation transfer risk =: necrosis
tissue expansion in children highest rate of complication occurs where: lower extremity
burn patients most common cause of death: pneumonia
dog bite: capnocytophaga carnivorsus

Rx = amoxicillin, clavulanic
lateral thigh flap artery: 3rd branch of profundus femoris

originates immediately caudad to adductor brevis
salmon eggs & caviar spots: lymphangioma (assoc. with bine overgrowth)
dural space ends: S 2-3
carbonaceous tatoo (residual of burn) Rx: Nd:YAG

(also asphalt, ink from amateur tatoo)
multiple treatments
dermabrasion end point for reticular dermis: confluent bleeding with coarse tissue background
z plasty theoretical gain: dergees percent
30 25
45 50
60 75
75 100
90 120
botox mech of action: inhibition of acetycholine release at neuromuscular junction
which contain only human dirived material alloderm apligraf biorane integra transcyte: alloderm
apligraf biorane integra transcyte: apligraf cultured neonatal epidermocytes and bovine collagen

biorane synthetic nylon/silicone

integra bovine collagen and silicone

transcyte neonatal dermal fibroblasts and silicone/nylon mesh with bovine collagen
which is more likely with erb:yag as opposed to co2 erythema scar skin tightening transudate: transudate

erb:yag absorb in water
burn cardiac output: decreased 40-60%
(hypovolemia)
male pattern baldness anogen telogen: anogen (active)decreased

telogen (resting) increased
parkland formula: 4cc/kg/%burn

give 50% in first 8 hours
calculated from time of burn
bipivercaine longer acting because: protein binding
Agdiazine adverse effect: neutropenia
extremity mass decomrpesses when elevated: venous malformation
wave lengths erb:yag pulse dye nd:yag co2: erb:yag 2940

pulse dye 585

nd:yag 1064

co2 10,600
hemorrhagic necorsis of skin dissem intravasc coagulation fever shock: purpura fulminans

60% mortality
vascular lesion with central arteiole: spider hemangioma
hair donor dominence: hairs have individual specific genetically definedlife spans

therefore occipital hair is preferred donor site
toxic eipdermal necrosis scar residua: none = epidermis only
mechanism of action silicone scar/scar: increasing the static electronegative field
preferred reconstruction of 1cm alar defect: composite graft from ear
primary benefit of using integra for cover full thickness burn: thinner donor site harvest
results from sun exposure: lentigines
in addition to scc,bcc,ak,
painful lesion on margin of ear: chondrodermatitis nodularis helicic
histologic examination of a proliferating hemangioma: decreased 17-beta estradiol binding sites
scar evaluation: RSTL (relaxed skin tension
lines) vs. ATL (anti-
tension lines)

width
color
copntour
landmark allignment (i.e.
mucocutaneous roll)
contracture
dextran: increased complications

no inc. flap survival
pressure ulcer grades: I = skin not broken

II = full thickness skin

III = to underlying muscle

IV = bone or joint involved
augmentation pocket irrigation: not betadine
(providone-iodine)

ans = bacitracin, cefazolin, gentamycin
spastic paraplegia wound closure protection: intrathecal baclofen pump
burn admission: 2nd 3rd > 20% any age
" " > 10% under 10 over
50 yrs
sig burn face perineum,
3rd deg > 5% any age
inhalation component
burn reconstruction: look carefully at the % tba burn, may preclude flap
avm leg initial step: mri/mra

rx = surgery for symptomatic lesions or those fairly easily resectable
melasma in fitzpatrick V skin type rx: 1% tretinoin
6 mo. old with vascular lesion rt. temple and calcification of outer tempmoral cortex: capillary hemanioma
(V1 dermatome)

sturge-weber syndrome

inc.risk siezure, devel delay, hemiplegia, glaucoma, retina detach, blindness
silversulfadiazine causes ?: decrease in granulocytes
hyaluronic acid dermal fillers: said to prolong effect by

molecular cross linking
adding albumin at 24hrs post parkland burn resuscitation =: maintenance intravasc volume
interga when to remove silicone layer: 21 days
anhydrous amonia burn to cornea: results in liquifaction necrosis - can progress for 2 days even with irrigation
ALA 5-aminolevulinic acid: used topically

activated by pulse dye laser

rx for aging and acne
keratoacanthoma: scc
stsg donor site best for multiple harvest: thick skin

(dermis never recovers)
maximal tensile strength in repaired skin wound\ results from: molecular cross linking
melena - vasc malformation mucous membrane, lung, abdomenal visera: rendu-osler-weber
cell - wound contraction: myofibroblast
active hair growth phase: anogen

(telogen = resting phase)
best bone graft inductive quality: autologous cancellous
pectoralis major artery: thoracoacormial
most abundant collagen in healed scar: type I
black and red tatoo: Q-switched Nd:YAG
(switchable)

(532 = red, 1064 = black)
burn - inhalation injury 30% co2 or higher: intubate

40-50% = coma, resp depression and deathe
predom cell respons for wound healing day 2 - 21: fibroblast
integra: said to improve cosmesis

when compared to stsg
meibobian gland malignancy: sebaceous carcinoma
merkel cell carcinoma origin: neuroendocrine cells in epidermis
2 month old with circumferential subglottic hemangioma mild stridor = rx: corticosteriod
35% tbsa burn cause of shock via what mechanism: hypovolemia
large a-v malformation h&n with multiple episodes of bleeding rx: excison and immediate flap reconstruction
port wine stain best laser wave length: 585 nm

(532 = superficial vasc lesion)
most effective rx for ischemic flap: insure adequate fluid resuscitation
post op alopecia with repeated breakdown best rx: tissue expansion
local anesthetic allergy: esters (ester cross linked)
benzocaine
cloroprocaine
procaine
tetracaine
amide local anesthetics: not assoc. with true allergies

when present related to preservatives PABA
"doughy" mass grown comsenurate with child enlarges with viral infections: lymphangioma
most comm. cause of male pattern baldness: inheritance

only cause (X-linked autosomal dominent gene)
cap hemangioma in 6 mo. old rx: observation

(yellow pulse-dye laser only effective early in prolif phase)
grade IV pressure ulcer with communication with hip joint rx: resection femoral head and flap reconstr

(vastus lateralis into acetabular fossa)
artecol permanent?: said to be permanent

(methylmethacrylate beads in a collagen matrix)
not avail in u.s.
bone, cartilage, fat, muscle least graft resorption: cartilage
noncoherant light: intense pulse

(not a laser)
nevus most difficult to distinguish form melanoma (clinically and histoloigically): spitz nevus
least sensative to inc lidocaine levels bp, hr, cns, muscle tone: blood pressure
vitamin E: no proof of improving hypertrophic scars
creeping substitution in bone grafting: in all except ftt
thigh/buttock lift prevent scar widening/recur etc.: suspension superficial fascial

anchor skin to colle's fascia
deep devision of supraorbial nerve supplies: central scalp
vertical scar reduction mammoplasty: central vertical gland resection
shortening or ectropion lower lid post op/trauma: shortening posterion lamella (capsulopapebral fascia)
1.5 cm defect on nose location for best 2nd healing: medial canthal area

(test answer, be careful with this one)
galactorrhea evaluation: prolactin level and thyroid function

(also tricyclic antideprss)
dr.'s company most common procedure resulting in malpractice suit: periqreolar mastopexy

(widening of the areola)
suction lipectomy most common cause of death: thromboembolism
botox time of onset of action: 2 weeks
brachioplasty most common complication: widening scar
blepharochalasis: painless edema of lower lids leading to permanent bags
hair transplant growth pattern: growth 1 month
hair loss
normal growth after 3 months
microtia rx: autologous reconstruction age 7 - 8 years.
retinoids mech of action on skin: dec. activation
metalloproteases
2 week old with prominent ears rx: molding ears with splint and tape.
ear, third crus: stahl's ear
miosis, anhidrosis, blepharoptosis: horner's syndrome
dermabrasion good for: graumatid tatoo and perioral rhytids
most common branching pattern for 4th intrcostal n. to nac: lateral
blepharoplasty pain, vomiting, visual disturbances: retrobulbar hematoma
retrobulbar hematoma rx: exploration and latreal canthotomy
smoking and mastectomy: risk for native skin flap loss
smoking and tram flap: not assoc. with inc risk of
thrombosis
fat necrosis
flap loss
infection
gynecomastia least appropriate rx: wise pattern

(looks like a female)
gracilis immediate posterior to ?: adductor longus
groin flap artery: superficial circumflex iliac

artery 45-50% common origin with superficial inferior epigastric
z-plasty theoretical gain: 30 deg = 25%
45 deg = 50%
60 deg = 75%
75 deg = 100%
90 deg = 120%
3rd degree burn mech assoc with progession to tissue destruction: increased chemotaxis
chondrodermatitus helicus rx: excision
tram flap delay =: increaded diameter of superion epigrastic artery
stsg immediate graft survival: plasmatic imbibition
HFl burn rx: 10% calcium gluconate

inject or topical
most common unfavorable result from augmentation with acellular dermal homograft: resorption
holo nevus reason to treat: only when the nevus resembles a melanoma
Dapsone complication: hemolysis

(used to rx brown spider bite)
silicone implant rupture when: mean = 13 years
multiple keratoacanthomas (or scc/bcc) assoc with viseral malignancy: Muir-torre syndrome

colon,kidney,bladder, ovary, pancreas, breast
lidocaine, max safe dose in child: 4.5 mg/kg
best test to see avm assoc with surrounding tissue: mri
sclerosing bcc best rx: moh's
(test answer)
autologous fat injection and blindness +/- cns cmplx: glabellar injection
vit c deficiency results in decreased: hydroxylation of amino acids (lysine and proline)
% hemangiomas noted in 1st month of life: 80%
accelular dermal sheet lip augmentation anatomic placement: subcutaneous
along wet/dry vermillion border
spitz nevus most common location: head and neck
Hutchin's melanotic freckle: lentigo maligna melanoma
(melanoma in situ)
topical reversing potential of developing premilagnant skin lesions: retinoids
fracture not visable on initial x-ray Dx: wait 2 weeks and repeat x-ray
dysplastic nevus and melanoma: very few dysplastic nevi go on to become melanoma

cancer65:12321,1990
most effective method of clearing bone adherent bacteria in an open wound: surgical soap
melanoma biopsy lesion size: lesions less than 1.5 cm should be completely excised
melonma biopsy thickness of biopsy: always full thickness skin
melanoma sentinel lymph node indications: breslow 1.0 - 3.99mm
male trunk lesion breslow
>.76mm
thin melanoma with the following
regression, lymphocytic infiltrate, ulceration, clark level III
doughy mass growing comensurate with the child: lymphangioma
saphenous artery is a branch of ?: genicular
dermabrasion end point bleeding papillary dermis reticualar dermis: pap = sparse pin point

retic = confluent
mech of action of botox: inhibits acetylcholine release at neuromusc. junction
organisms in hydradenitis: staph aureus
strep viridans
becker nevus Misnomer?: yes
is smooth muscle therefore a hamartoma
vascular lesion with central arteriol: spider hemangioma
epidermolysis bullosum need for splinting to prevent contracture: none
advantage of using "Integra" in full thickness skin loss: able to use thinner autograft
test dose of Zyderm (bovine collagen) delay time to second injection: 4 weeks
gracilis blood supply: medial femoral circumflex

secondary for superficial fem.
lentigo - etiology: caused by sun exposure
mathes/nehai classification: I one dom. ped
II one dom and mult minor
III dual dom ped
IV segmental'
V one dom and mult segmental
oral splinting for electrical burn to commisure length of time ?: 6 months
SENSATE flap with bone for oral reconstruction: lateral arm flap

(bone = 10-15x1-2cm)
black widdow spider venum: name = latrodectus mactans

neurotoxin
black widdow spider Rx: methocarbamol or valium

antivenum in immunocompromised patient only
brown recluse spider vinus: sphyngomyelinate (dermonecrotic factor, hemolysis, platelet aggrigation, coagulation)
wolf's law and bone graft survival: stress is necessary
periosteum and bone graft survival: preservation of periosteum increases bone survival at all stages
membraneous vs enchondral bone: membranous bone inc survival
stsg grows proportional with the child true or false: false only ftsg
bovine collagen most effective when injected into which site: dermis
hydroxyapatite osteo inductive or conductive: osteoconductive
hydroxyapatite effect on ct scan: none

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