All In-service questions Flashcards
A 30-year-old man with a history of radius and ulna midshaft fractures underwent fasciotomies for acute compartment syndrome of the nondominant left volar forearm with immediate return of normal perfusion 4 months ago. He is now pain-free with normal sensation but has persistent stiffness and weakness of the fingers, despite appropriate splinting and physiotherapy. His compartments are soft, and there are no joint contractures. He has full motion and normal strength, except the fingers and thumb can fully extend only with the wrist flexed, and finger and thumb flexion have MRC grade 4/5 strength. Which of the following is the most appropriate next step in management?
A) Dynamic splinting
B) Flexor tendon transfers
C) Intrinsic releases
D) Selective muscle origin slide
E) Strengthening physiotherapy
The correct response is Option D.
The patient is presenting with evidence of Volkmann ischemic contracture of his deep volar forearm compartment musculature, specifically flexor digitorum profundus and flexor pollicis longus. Flexor digitorum superficialis could be minimally involved, but the wrist flexors are spared. Mild median nerve involvement with full recovery and sparing of the ulnar nerve would support this diagnosis. The patient has already undergone appropriate physiotherapy. With persistent findings at 4 months, the most appropriate treatment is surgical exploration, debridement of necrotic muscle, with either selective muscle origin slide or tendon lengthening of preserved but contracted muscle.
Although continued dynamic physiotherapy could potentially provide further improvement in this patient’s muscle tightness, strengthening physiotherapy will not address the problem adequately. Dynamic splinting could complement physiotherapy and be helpful but has likely provided most of its benefit in the 4 months after initial surgery. Intrinsic releases would be indicated in intrinsic muscle contractures; however, this patient has involvement of the extrinsic flexors, not the intrinsic muscles. Finally, flexor tendon transfers would be indicated for more severe cases of Volkmann contractures, where there is no muscle function remaining. This patient’s examination suggests adequate muscle function remains.
References
Gulgonen A, Ozer K. Compartment Syndrome. In, Green’s Operative Hand Surgery, 6th edition. Ed. Wolfe et al. Philadelphia: Churchill Livingstone, 2011. 1929-1948.
Stevanovik MV, Sharpe F. Compartment Syndrome and Volkmann Ischemic Contracture. In, Green’s Operative Hand Surgery, 7th edition. Ed. Wolfe, et al. Philadelphia: Elsevier, 2017. 1763-1787.
Thevenin-Lemoine C, Denormandie P, Schnitzler A, et al. Flexor origin slide for contracture of spastic finger flexor muscles: a retrospective study. J Bone Joint Surg Am. 2013 Mar 6;95(5):446-53.
A 26-year-old man sustained a crush injury to the tip of the left middle finger with an associated fracture at the dorsal base of the distal phalanx with nail bed injury 6 months ago. No treatment was provided. Examination shows non-union of the distal phalanx. Which of the following is the most likely secondary deformity in this patient?
A) Boutonniere deformity
B) Jersey finger
C) Quadriga
D) Swan neck deformity
E) Trigger finger
The correct response is Option D.
The scenario described involves a bony mallet deformity in which a distal phalanx fracture is associated with disruption of terminal extension at the distal interphalangeal joint. If untreated, the DIP extension loss due to a non-union of a bony mallet injury may progress to a swan neck deformity through compensatory proximal phalangeal hyperextension in the setting of continued and persistent flexion at the distal interphalangeal joint (from unopposed pull of the flexor digitorum profundus tendon). A secondary swan neck deformity may occur because of dorsal subluxation of the lateral bands and attenuation of the volar plate and transverse retinacular ligament at the PIP joint level.
A jersey finger is caused by rupture of the terminal flexor digitorum profundus. A boutonniere deformity can be caused by an injury to the central slip (but not the terminal extensor tendon). Quadriga is due to loss of length of a repaired FDP tendon, causing the finger with the repaired tendon to reach terminal flexion sooner than the other fingers whose FDP tendons are of normal length. A trigger finger does not involve a fracture of the DIP joint.
A 30-year-old woman comes to the office because of a mass of the dorsum of the wrist for the past 5 months. She reports that the mass occasionally gets larger and then gets smaller. Physical examination shows the mass is mildly tender and transilluminates. From which of the following articulations is this lesion most likely to arise?
A) Pisotriquetral
B) Radioscaphoid
C) Scapholunate
D) Scaphotrapezial
E) Thumb carpometacarpal (CMC)
The correct response is Option C.
The mass in question is most likely a dorsal ganglion cyst of the wrist. Sixty to 70% of ganglion cysts are found in the dorsal aspect of the wrist. Dorsal wrist ganglion cysts usually communicate with the joint by a stalk. This stalk usually originates at the scapholunate interval, but it can also rarely arise from other aspects of the dorsal wrist joint.
Thirteen to 20% of ganglia are found on the volar aspect of the wrist, and they usually arise from the radioscaphoid, scapholunate, scaphotrapezial, or metacarpotrapezial joint, in decreasing order of frequency.
Ganglia arising from the flexor tendon sheath of the hand account for approximately 10%.
A 35-year-old woman is evaluated because of swelling of the right breast 3 years after undergoing augmentation mammaplasty. The implant type is unknown. Ultrasonography shows a seroma, and a fine-needle aspiration is performed. Which of the following immunohistochemical stains of the aspirate is most appropriate?
A) CCD79a
B) CD30
C) CK20
D) E-cadherin
E) p63
The correct response is Option B.
Patients who present with a late seroma should be evaluated for possible breast implant-associated anaplastic large cell lymphoma (BI-ALCL). A late seroma is usually accepted as occurring 1 year following surgery; however, there are cases of BI-ALCL seromas that have presented as early as 4 months.
The first step in evaluating BI-ALCL is ultrasonography, followed by fine-needle aspiration if indicated. The fluid requires evaluation beyond routine cell cytology. Immunohistochemistry test for CD30 was the most commonly positive marker for BI-ALCL. Immunohistochemistry stains specific antigens in cells by binding to this antigen in an antibody/antigen reaction. The specific stain can then be seen under light microscopy. The CD30 antibody labels anaplastic large cell lymphoma cells. CD30 is a transmembrane cytokine receptor belonging to the tumor necrosis factor receptor family.
CK20 and CCD79a were negative for tested BI-ALCL specimens.
P63 stains myoepithelial cells and is used to rule out invasive breast tumors.
E-cadherin helps distinguish ductal from lobular carcinoma.
A 45-year-old woman who has breast cancer comes to the office for consultation regarding bilateral breast reconstruction. Reconstruction using autologous abdominal tissue is considered. The risk of abdominal morbidity is discussed. Which of the following flap techniques is most likely to result in the lowest level of overall abdominal morbidity?
A ) Deep inferior epigastric artery perforator
B ) Free muscle-sparing transverse rectus abdominis musculocutaneous (TRAM)
C ) Free TRAM
D ) Pedicled TRAM
E ) Superficial inferior epigastric artery flap
The correct response is Option E.
The superficial inferior epigastric artery (SIEA) flap results in the lowest level of overall abdominal morbidity, as the technique used in harvesting this flap leaves the abdominal fascia intact. These vessels are only present in less than one third of patients, and only one half of those patients will have vessels of sufficient diameter to support a free tissue transfer. The SIEA flap is also associated with a higher frequency of total flap loss, in addition to a higher incidence of fatty necrosis.
The deep inferior epigastric artery perforator (DIEAP or DIEP) flap involves dissection of one or two (occasionally more) perforators through the rectus muscle to the inferior epigastric vessels. Although this technique does not include any rectus muscle or sheet/fasica within the flap itself, it does involve moderate-level trauma to those organs and can cause abdominal wall morbidity.
The free TRAM or free muscle-sparing TRAM techniques are free tissue transfer variants of the TRAM, whereby a small amount of the rectus is taken with the flap. In the more advanced MS free TRAM technique, the amount of muscle taken is only enough to allow safe transfer of the perforators. Although this technique is less invasive than the pedicled TRAM, it does still involve removal of a variable portion of the rectus muscle and fascia.
A pedicled TRAM flap technique involves transferring of the flap based on the superficial epigastric vessel that runs within the rectus muscle. Therefore, the entirety of the rectus (unilateral or bilateral) is elevated out of its native abdominal wall location.
Many publications have compared the other modes of breast reconstruction with reference to abdominal wall morbidity. This area remains controversial. The general consensus remains that
in a bilateral reconstruction, pedicled TRAM flaps are associated with higher levels of overall abdominal morbidity (hernias, bulges, weakness, intolerance to exercise, etc) when compared with the use of MS free TRAM, DIEP, or SIEA flaps. The use of SIEA flaps results in minimal to no abdominal wall morbidity.
A 35-year-old man comes to the office for follow-up 3 years after he sustained a scaphoid fracture of the dominant right wrist that was treated in a cast until radiographically healed. Examination shows reduced wrist extension of 35 degrees, weakened grip strength, and dorsoradial wrist pain. Scaphoid malunion is suspected, and an oblique sagittal CT scan is obtained. Which of the following is the minimum intrascaphoid angle at which surgical intervention is required?
A) 10 Degrees
B) 25 Degrees
C) 45 Degrees
D) 65 Degrees
E) 80 Degrees
The correct response is Option C.
Treatment of a scaphoid malunion or “humpback” nonunion deformity by means of an opening interposition wedge bone graft is indicated when the lateral intrascaphoid angle is greater than 45 degrees. The intrascaphoid angle is determined by drawing a line tangent to the dorsal cortex of the distal fragment and the palmar cortex of the proximal fragment. Normally, this angle is 30 to 40 degrees. Amadio and coworkers reported on 45 patients with 46 scaphoid fractures greater than 6 months after healing. There were good clinical outcomes in 83% of those with intrascaphoid angles less than 35 degrees, and posttraumatic arthritis in 22%. In contrast, in those with greater than 45 degrees of lateral intrascaphoid angulation, only 27% had good outcome, and 54% developed posttraumatic arthritis.
Nakamura and colleagues performed volar wedge bone grafting on seven symptomatic patients with scaphoid malunion, and all improved their symptoms.
A 55-year-old woman with a BRCA gene mutation elects to undergo bilateral mastectomy with reconstruction using a deep inferior epigastric perforator flap. BMI is 41 kg/m2. Physical examination shows both supra- and infraumbilical adiposity with excess skin and a mature cesarean delivery scar. This patient has the highest risk for which of the following early postoperative complications?
A) Abdominal wall bulge
B) Abdominal wall hernia
C) Delayed wound healing of donor site
D) Fat necrosis of the flap
E) Flap failure
The correct response is Option C.
The highest risk is for delayed wound healing of the donor site. Because of the patient’s morbid obesity and prior cesarean delivery scar, she has the highest risk for some form of wound breakdown or prolonged wound healing. This risk can be as high as 50 to 60% for morbidly obese patients. These trends are similar in patients following reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap.
To reduce these risks, minimal undermining is recommended and only done if necessary. Techniques to preserve all cutaneous perforators will help reduce the risk associated with closure of the donor sites.
While morbid obesity can be associated with increased abdominal wall thickness, there is no correlation with the occurrence of abdominal wall bulge or hernia. The risks for these complications are less than 2%.
Patients with morbid obesity can have shorter operative times, but there is no correlation with overall flap failure, with rates reported to be less than 1%. This is also seen in pedicled and free TRAM flap reconstructions.
Rates of fat necrosis of the flap can be as high as 10 to 15% in patients undergoing reconstruction, but this risk is not affected by body habitus or body mass index and is lower than the risk for delayed wound healing.
A 45-year-old woman with systemic sclerosis (scleroderma) has severe Raynaud phenomenon. A photograph is shown. Periarterial injection of botulinum toxin type A is being considered for treatment in this patient. This treatment is believed to relieve vasospasm in Raynaud phenomenon by which of the following mechanisms?
A) Blocking fast sodium channels in axonal gap junctions
B) Increasing the activity of chronically down-regulated group C nerve fiber nociceptors
C) Inhibiting Rho/Rho kinase activity
D) Obstructing myofibroblast contractile activity in vascular smooth muscle
E) Promoting substance P secretion/receptor sensitivity
The correct response is Option C.
Several mechanisms have been proposed to explain the effect of botulinum toxin type A (Botox) to inhibit Raynaud phenomenon in patients with scleroderma. Studies have demonstrated inhibition of Rho/Rho kinase activity, inhibition of substance P secretion and receptor sensitivity, and decreasing the activity of chronically up-regulated C-fiber nociceptors all to occur in models of Raynaud phenomenon that responded to Botox treatment. Fast sodium channels conduct axonal signals AT in gap junctions, but have not been shown to be affected by Botox. Myofibroblasts may be involved in late fibrosis of scleroderma patients but do not exist within the vascular smooth muscle.
References
Fonseca C, Abraham D, Ponticos M. Neuronal regulators and vascular dysfunction in Raynaud’s phenomenon and systemic sclerosis. Curr Vasc Pharmacol. 2009;7(1) :34–39.
Iorio ML, Masden DL, Higgins JP. Botulinum toxin A treatment of Raynaud’s phenomenon: a review. Semin Arthritis Rheum. 2012 Feb;41(4):599-603.
Neumeister MW. The role of botulinum toxin in vasospastic disorders of the hand. Hand Clin. 2015 Feb;31(1):23-37.
Uppal L, Dhaliwal K, Butler PE. A prospective study of the use of botulinum toxin injections in the treatment of Raynaud’s syndrome associated with scleroderma. J Hand Surg Eur Vol. 2014 Oct;39(8):876-80.
The metacarpophalangeal (MCP) joint of the thumb is which of the following types of joint?
A) Ball-and-socket
B) Condyloid
C) Hinge
D) Pivot
E) Saddle
The correct response is Option C.
The metacarpophalangeal (MCP) joint of the thumb and interphalangeal joints of the index through little fingers are hinged joints and allow flexion and extension only. Lateral forces can disrupt the collateral ligaments, resulting in partial or full tears.
Condyloid joints allow flexion and extension, abduction and adduction, and circumduction, and they can be seen in the MCP joints of the index through little fingers and in wrist joints. Saddle joints allow flexion and extension, abduction and adduction, and circumduction, and they can be seen in the carpometacarpal joint on the thumb. Ball-and-socket joints allow flexion and extension, abduction and adduction, and internal and external rotation, and they can be seen in the shoulder and hip joints. Pivot joints allow rotation and are seen in the atlas and axis bones.
When considering dislocations of the thumb carpometacarpal (CMC) joint, which of the following is most correct regarding which vector of dislocation would occur with injury to the stabilizing ligament?
Injured LigamentVector of Dislocation
A)Dorsal intercarpalradial
B)Dorsoradialdorsal
C)Intermetacarpalulnar
D)Radiocarpaldorsal
The correct response is Option B.
The CMCJ is very important for hand function and plays a key role in pinch and grasp. The increased range of motion inherent to the thumb CMCJ is attributed to the anatomy of the joint. The biconcave saddle shaped articular surface of the CMCJ also provides some inherent stability. Motion allowed by the joint includes flexion, extension, adduction, abduction, circumduction. Stabilizing ligaments and joint capsule further reinforce the joint, thus thumb CMCJ dislocations are rare injuries. These injuries account for less than 1% of hand injuries.
There are five major stabilizing ligaments to the CMCJ: anterior (volar) oblique, ulnar collateral, intermetacarpal, dorsoradial, and dorsal (posterior) oblique. These ligaments are critical stabilizers during motion. The volar oblique ligament and dorsoradial ligaments are considered to be the most important resistive forces in dislocation in cadaver studies. Reports of traumatic thumb CMCJ dislocation have been in a dorsal vector. The volar oblique ligament was originally thought to be the critical resistive ligament; however, recent literature has supported the dorsal complex (includes the dorsoradial and posterior oblique ligaments) are the most critical for restraint of the joint, thus are injured in dorsal dislocations. Timely recognition is important for these injuries as immediate reduction and casting or splinting for 4 to 6 weeks may be adequate to prevent recurrence. However, these injuries are often missed on radiologic examination or may be persistently unstable. Closed reduction and Kirschner wire fixation may be adequate for treatment in persistently unstable injuries. Some authors advocate for open reduction and ligament reconstruction. Delayed treatment especially beyond three weeks will likely require open reduction and ligament reconstruction. These injuries are often missed on x-ray examination as they can be subtle especially in the setting of more obvious trauma. Inadequate treatment puts these patients at increased risk for subsequent posttraumatic osteoarthritis given the joint malalignment.
The radiocarpal and dorsal intercarpal ligaments are wrist stabilizer not thumb CMCJ stabilizers.
An otherwise healthy 37-year-old woman presents for delayed microsurgical breast reconstruction. Which of the following is associated with use of tamoxifen?
A) Hemodynamic instability
B) Impaired wound healing
C) Increased bleeding
D) Seroma formation
E) Thromboembolic events
The correct response is Option E.
Breast cancers that are estrogen receptor positive may be responsive to adjuvant chemotherapy with selective estrogen receptor modulators such as tamoxifen, which can reduce recurrence and mortality. Tamoxifen is associated with thromboembolic events, such as deep venous thrombosis and pulmonary embolism. This prothrombotic effect has been postulated to be secondary to the effect of tamoxifen on estrogen receptors that are abundant within vascular endothelium.
Tamoxifen has been shown to be associated with increased rates of total flap loss and decreased rates of flap salvage when taken within 28 days of microsurgical breast reconstruction, which represents two half-lives of the active metabolite of tamoxifen (N-desmethyl tamoxifen, t1/2=14 days). It has therefore been recommended that in patients undergoing microsurgical breast reconstruction, tamoxifen be held for at least 28 days preoperatively. Some authors have further advised holding the medication postoperatively in addition to preoperatively.
Tamoxifen is not associated with impaired wound healing, increased bleeding, hemodynamic instability, or seroma formation.
A 55-year-old woman is brought to the emergency department after sustaining mutilating injury to the hand during a motor vehicle collision. Examination shows the hand is unsalvageable. Disarticulation of the wrist is planned. Compared with transradial amputation, which of the following is the most likely benefit of this approach?
A) Better accommodation of a myoelectric unit
B) Better forearm pronation and supination
C) Decreased risk of neuroma formation
D) Decreased risk of prosthetic abandonment
E) More stable soft-tissue envelope
The correct response is Option B.
The choice of wrist disarticulation compared with transradial amputation is a controversial one. The primary benefit of the wrist level disarticulation is preservation of the distal radioulnar joint and consequential improvement in forearm rotation. Preservation of the metaphyseal flare of the radius may aid in prosthetic fit; however, the additional length associated with functional units such as myoelectrics may result in a limb length discrepancy. The prominence of the distal radius and ulna may predispose to pressure-related wound issues associated with prosthetic wear. Patients with wrist level disarticulation are more likely to abandon their prosthesis compared with transradial amputees.
References
Taylor CL. The biomechanics of control in upper-extremity prostheses. Artif Limbs. 1955 Sep;2(3):4-25.
Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg Am. 1995 Jul;20(4):619-22.
Rafael J. Diaz-Garcia and Paul S. Cederna. Major Limb Amputations and Prosthetics. In: Wolfe S, Pederson W, Hotchkiss R, eds. Green’s Operative Hand Surgery. 3rd ed. New York, NY: Churchill-Livingstone; 1993:1753-1762.
A 52-year-old man sustains an amputation of the index finger of his dominant right hand from a table saw. Physical examination shows a sharp amputation immediately distal to the flexor digitorum superficialis insertion. He does not smoke cigarettes. Which of the following factors is the most appropriate indication to perform a replantation?
A) Dominant hand
B) Index finger amputation
C) Level of amputation
D) Nonsmoking status
E) Patient age
The correct response is Option C.
The most appropriate indication to perform a replantation is the level of the amputation. Replantation of an amputation distal to the flexor digitorum superficialis is attempted because the function of the digit is improved with additional length to a normal proximal interphalangeal joint. An amputation in a child is an indication for replantation (adult age is not). Hand dominance is not a major variable in the determination of whether or not to perform a replantation. Replantation of single digits (including the index finger) at the proximal phalanx or proximal interphalangeal joint in adults often is not performed because the limited motion of the digit can inhibit overall hand function. An exception is any level amputation of the thumb, which is a major indication for replantation because the thumb provides 40 to 50% of hand function. Smoking status is not a major variable for the consideration of replantation.
References
Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014 Feb;133(2):333-42.
Jazayeri L, Klausner JQ, Chang J. Distal digital replantation. Plast Reconstr Surg. 2013 Nov;132(5):1207-17.
A 53-year-old man comes to the emergency department because of an avulsion degloving injury to the left nondominant thumb sustained 3 hours ago. The amputated part is not retrievable. Physical examination shows loss of skin from the interphalangeal joint distally on both volar and dorsal surfaces. The distal phalanx and flexor pollicis longus and extensor pollicis longus tendons are intact. He has no other associated injuries. Which of the following is the most appropriate method of reconstruction of the thumb?
A) Amputation revision at the mid-proximal phalanx
B) Great toe wraparound flap
C) Radial forearm osteocutaneous flap
D) Second toe-to-thumb transfer
E) Volar neurovascular advancement flap
The correct response is Option B.
Thumb reconstruction remains a difficult challenge for hand surgeons. Amputations of the skin distally may be covered with palmar advancement flaps; however, this technique is only limited to wounds less than 50% of the palmar surface of the thumb distal to the interphalangeal joint. In order to preserve length and function in more proximal amputations, either a regional or distant flap is required. The toe-to-thumb wraparound flap requires a microvascular anastomosis of digital vessels and nerves, providing excellent sensation and cosmetic results. The toe donor site can be covered with a skin graft in order to preserve length.
The volar neurovascular advancement flap would not adequately cover a defect this size. Amputation at the mid-proximal phalanx would result in a very short thumb with loss of function. The radial forearm flap may be utilized to cover the above defect; however, it would lack adequate sensation. Any osteocutaneous radial forearm flap would not be indicated since there is preservation of the bone. Similarly, a second toe-to-thumb transfer would not be indicated since there is preservation of bone in this patient.
References
Graham DJ, Venkatramani H, Sabapathy SR. Current Reconstruction Options for Traumatic Thumb Loss. J Hand Surg Am. 2016 Dec;41(12):1159-1169.
Del Piñal F, Pennazzato D, Urrutia E. Primary Thumb Reconstruction in a Mutilated Hand. Hand Clin. 2016 Nov;32(4):519-531.
A 25-year-old woman comes to the office because of a 1-week history of erythema and clear drainage from the right breast 6 weeks after undergoing bilateral augmentation mammaplasty. She is afebrile and her vital signs are within normal limits. The drainage from the breast is sent for cultures. Broad-spectrum antibiotics are administered, but no improvement is noted over the next 48 hours. Surgical debridement and explantation of the prostheses are performed. After 7 days, cultures grow Mycobacterium fortuitum. Which of the following is the most appropriate next step?
A) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 weeks
B) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 months
C) Administration of isoniazid, rifampicin, and pyrazinamide for 6 weeks
D) Administration of isoniazid, rifampicin, and pyrazinamide for 6 months
E) No antibiotic therapy is needed because the infected prostheses have been removed
The correct response is Option B.
The most appropriate next step in management is to initiate a 6-month course of ciprofloxacin and trimethoprim-sulfamethoxazole (Bactrim). Mycobacterium fortuitum is an atypical, nontuberculous mycobacterium (NTM), and it is one of the most common causes of NTM soft-tissue infections. It occurs most commonly in the presence of foreign bodies, such as breast prostheses. The incidence of these opportunistic infections has increased over the years. NTM infections can be more indolent and manifest weeks, or even months, following surgery. They occur most commonly with erythema, swelling, and clear drainage, although purulence may be seen. Fever may be absent. On surgical exploration, exuberant granulation tissue and turbid, odorless fluid are often noted. Routine Gram stains and cultures are usually negative. Therefore, it is imperative to request acid-fast bacilli staining and mycobacterial cultures if suspicion of NTM infection is high. Removal of the prosthesis and thorough debridement of the periprosthetic space, followed by long-term (3 to 6 months) antibiotic therapy, is required to treat this infection. Culture sensitivities should guide the antibiotic regimen, but ciprofloxacin, trimethoprim-sulfamethoxazole (Bactrim), clarithromycin, and doxycycline are used commonly for treatment. Reimplantation of the prosthesis should not be considered for a period of at least 6 months.
Isoniazid, rifampicin, and pyrazinamide are standard antibiotics used to treat tuberculosis caused by Mycobacterium tuberculosis, not atypical mycobacteria. Although removal of the affected prosthesis is required, long-term antibiotic therapy is an essential part of the treatment.
A 45-year-old carpenter presents with a six-month history of an ulceration of the ring fingertip and pain at rest. Digital brachial index is 0.45, and angiography demonstrates occlusion of the ulnar artery. The patient has tried three months of calcium channel blockers and aspirin without relief. Which of the following is the most appropriate treatment for this patient?
A) Amputation of the fingertip
B) Chemical sympathectomy
C) Reconstruction of the ulnar artery
D) Stellate ganglion block
E) Surgical sympathectomy
The correct response is Option C.
Conservative treatment includes smoking cessation, calcium channel blockers, anticoagulation therapy, stellate ganglion block, and behavior modification. Nonoperative management is generally considered first-line treatment, because most patients will have at least partial resolution of their symptoms. With that said, 70% of those treated nonoperatively had partial resolution of their symptoms, and only 12% had complete resolution. Of patients treated operatively, 42% had complete resolution of their symptoms and 42% had partial resolution.
For patients with evidence of more advanced disease such as digital ulceration, chronic resting pain, or conservative management failure, operative intervention may be considered. Preoperative noninvasive vascular studies can be used to determine which patients may require reconstruction versus simple excision and ligation. Studies have suggested that a digital brachial index less than 0.7 indicates reconstruction may be warranted. An index of less than 0.5 suggests critical ischemia, which may result in tissue loss.
Surgical options fall into two basic groups: resection of the involved arterial segment with ligation, and vascular reconstruction with or without interposed graft. Graft occlusion is reported in as high as 78% of patients. Despite a high percentage of occlusion, patients remained satisfied. Patients with occluded reconstructions did not experience worsening of symptoms in comparison with the patent reconstructions. Preoperative digital brachial index values, although informative as to the patient’s digital perfusion, do not mandate a particular operative intervention. The general treatment algorithm is to perform surgery on patients who have failed on medical management and local treatment to heal any digital soft tissues. A decision on ligation versus reconstruction can be made with the assistance of information gathered by preoperative angiography and noninvasive vascular studies, as well as intraoperative assessment of ulnar digital perfusion with temporary occlusion of the ulnar artery. Poor perfusion following temporary occlusion mandates reconstruction of the artery, whereas adequate perfusion, despite occlusion, can be treated with simple excision or ligation of the diseased ulnar artery segment.
References
Endress RD, Johnson CH, Bishop AT, Shin AY. Hypothenar hammer syndrome: long-term results of vascular reconstruction. J Hand Surg Am. 2015;40(4):660-665.e2.
Lifchez SD, Higgins JP. Long-term results of surgical treatment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216.
Vartija L, Cheung K, Kaur M, Coroneos CJ, Thoma A. Ulnar hammer syndrome: a systematic review of the literature. Plast Reconstr Surg. 2013;132(5):1181-1191
A 7-year-old patient with a history of submucous cleft palate and persistent severe velopharyngeal insufficiency after Furlow palatoplasty undergoes video nasoendoscopy. An abnormal closure pattern is observed, with excellent movement of the velum and Passavant’s ridge but poor lateral wall motion. On the basis of these findings, which of the following is the most appropriate treatment for this patient’s velopharyngeal insufficiency?
A) Inferiorly based pharyngeal flap
B) Palatal lift appliance
C) Speech therapy
D) Sphincter pharyngoplasty
E) Superiorly based pharyngeal flap
The correct response is Option D.
With a “bow tie” pattern seen on the nasoendoscopy, the patient is an ideal candidate for sphincter pharyngoplasty, which will bring the lateral walls in more centrally, so the velum and pharynx can close off the velopharyngeal port.
Pharyngeal flap surgery is ideal for patients who have a large central gap or sagittal closure pattern caused by palatal hypotonia or shortened palatal length. Palatal soft tissue augmentation is ideal for patients with a very small central gap following adenoidectomy. A palatal lift appliance is typically used in patients with adequate palatal length, but inadequate motor function. The patient described in this scenario has excellent motor function of the velum, but poor lateral wall motion.
Speech therapy does not correct the anatomic deficiency in this patient population.
A patient comes to the office 6 months after undergoing bilateral vertical mastopexy because she is dissatisfied with her postoperative appearance. Height is 5 ft 5 in (165 cm). Physical examination shows the distance from nipple to sternal notch is 16 cm bilaterally, and the distance from nipple to inframammary fold is 14 cm bilaterally. Which of the following is the most appropriate next step in management?
A) Conversion to free nipple grafts
B) Placement of a dual-plane breast implant
C) Placement of a subglandular breast implant
D) Resection of excess skin at the level of the inframammary fold
E) Reassurance, massage, and observation
The correct response is Option D.
This case illustrates superior nipple malposition. The distance from nipple to inframammary (IMF) fold of 14 cm is much too long. The correct answer is to resect the lower pole skin at the IMF in order to move the nipple down. This would create a “T” scar and improve nipple position. Vertical mastopexies and reduction mammaplasties have a learning curve and much of this is predicting the nipple position postoperatively. The nipple should be designed lower on the breast than is done during marking a Wise pattern. At 6 months, it is unlikely the nipple position will change dramatically, so observation is not recommended. Addition of an implant will not help the nipple position. Conversion to free nipple grafts, while possible, will not lead to an aesthetic scar pattern.
A 24-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in subglandular implant placement and would like to discuss the risks of augmentation. Which of the following risks is more likely with smooth round silicone implants compared with textured anatomic silicone implants?
A) Anaplastic large cell lymphoma
B) Capsular contracture
C) Double capsule
D) Late seroma
E) Malrotation
The correct response is Option B.
Capsular contracture is more common in smooth round silicone implants than in textured implants. It is believed that the texturing of the implant is protective against significant capsule formation.
On the other hand, there are several increased risks associated with textured anatomic implants. These include increased risks of late seroma and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), although this is very rare. Double capsule is a complication more recently noted with the introduction of textured anatomic implants. Malrotation can only be seen in an anatomic textured implant, because smooth round implants are symmetric in shape. In addition, it can be difficult to differentiate between anatomic shaped and smooth round implants, with several studies showing their similar cosmetic outcomes.
A 55-year-old woman comes to the office for a second opinion because she is displeased with the results of a recent bilateral mastectomy and breast reconstruction with 800-mL high-profile silicone implants. A photograph is shown. BMI is 35 kg/m2. She repeatedly shows pictures of models with augmented breasts and says that she wants her breasts to be “perkier.” She requests augmentation/mastopexy. Which of the following is the most appropriate next step in management?
A) Augmentation/mastopexy
B) Implant exchange
C) Mastopexy
D) Reassurance
E) Referral to a psychiatrist
The correct response is Option D.
The most reasonable approach in this patient is to offer reassurance and reset her expectations. A patient with a BMI of 35 kg/m2 who undergoes mastectomy and implant reconstruction will never look like a model with augmented breasts. This patient clearly has misguided expectations. Any surgical intervention is unlikely to produce the result she is looking for, when in fact she has a very acceptable result as is. Referral of this patient to a psychiatrist will likely upset the patient and undermine her trust.
A 28-year-old woman, gravida 2, para 2, undergoes augmentation mammaplasty 1 year post partum. On postoperative day 3, the patient comes to the office because of impaired wound healing at the incision site. Physical examination shows white viscous discharge leaking from the edge of the wound consistent with galactorrhea. Which of the following is the most appropriate management?
A) Administration of bromocriptine
B) Administration of metoclopramide
C) Administration of trimethoprim-sulfamethoxazole
D) Application of negative pressure wound therapy
E) Debridement of the wound edges with wet-to-dry dressings
The correct response is Option A.
There are incidents of surgical procedures of the breast associated with galactorrhea leading to skin breakdown, nipple necrosis, and cellulitis. A dopamine agonist such as bromocriptine will cause decreased lactation in cases of galactorrhea/galactocele, thereby improving wound healing. Antibiotics such as sulfamethoxazole and trimethoprim (Bactrim) are generally not required, because the exudate is sterile. There is no need for debridement of the wound edges. Negative pressure wound therapy may increase lactation and galactorrhea, further impairing wound healing. Metoclopramide is a dopamine antagonist used for nausea and vomiting.
A 65-year-old woman comes to the office 1 month before a scheduled mastopexy. Annual mammography shows a 1.5-cm mass in the upper outer quadrant. Core needle biopsy is performed. Pathologic examination of excised tissue identifies papilloma without atypia. Which of the following is the most appropriate next step in management?
A) Bilateral breast sonography
B) Excisional biopsy of needle-localized area
C) Repeat annual mammography in 12 months
D) Repeat mammography at 6-month intervals for 1 year
E) Stereotactic vacuum-assisted biopsy
The correct response is Option B.
Percutaneous biopsy methods are commonly accepted for the initial evaluation of clinically occult breast lesions, although certain nonmalignant lesions pose dilemmas with respect to the most appropriate clinical management. Papillary lesions of the breast can either be benign or malignant, although differentiation is radiologically difficult. Moreover, it is difficult for pathologists to reliably distinguish among benign, atypical, and malignant papillary lesions on the limited fragmented tissue specimens they receive after needle sampling.
Previous studies have demonstrated high rates of ductal carcinoma in situ (11%) in patients diagnosed with benign papillomas by needle biopsy and who subsequently underwent a surgical excision, although conflicting data suggest an extremely decreased rate of malignancy when histology is benign on needle biopsy.
The management of benign papillary lesions is somewhat controversial. Although conservative follow-up with either yearly mammogram or short-interval follow-up may be appropriate for certain patients diagnosed with benign papilloma, certain features of this patient’s lesion make conservative follow-up inappropriate. Sonographic follow-up in a 65-year-old woman with mature breast parenchyma and a solid mammographically detected mass would not provide much additional information, and a repeat percutaneous biopsy, whether core needle or vacuum-assisted, would also not be effective. Given the size of the lesion and the age of the patient, surgical excision is warranted despite the lack of atypia on needle biopsy. Benign papillomas tend to be smaller than 1 cm and centrally located, whereas malignant lesions are more often greater than 1.5 cm and are peripherally located.
A 48-year-old woman undergoes excision of a 3-cm recurrent keloid of the presternal chest. Immediate reconstruction with a collagen-glycosaminoglycan scaffold dermal regeneration template is performed, followed by thin (0.008-in) epidermal autografting 21 days later. After it has healed completely, punch biopsy is performed. The absence of which of the following histologic features is most likely to indicate regenerated skin in this patient?
A) Capillary loops at the dermal-epidermal junction
B) Elastic fibers
C) Hair follicles
D) Neovascularization
E) Rete ridges
The correct response is Option C.
Regenerated skin is clearly quite different histologically from scar and, in fact, shares many characteristics with normal physiologic skin. Regenerated skin shows mechanical competence, vascularization, and heat and cold sensitivity. Furthermore, the dermal-epidermal junction shows formation of rete ridges and capillary loops. Regenerated skin displays elastic fibers and increased collagen fiber density in the reticular dermis, and it often exhibits nerve fiber regeneration as well. Regenerated skin, even when resurfaced with a split-thickness skin graft, however, does not have the dermal appendages such as hair follicles and sweat glands, that are present throughout normal skin.
A 52-year-old woman receives a diagnosis of invasive ductal carcinoma of the right breast. Which of the following details from this patient’s history is the strongest risk factor for this diagnosis?
A) Early first pregnancy (less than 30 years)
B) Early menarche (less than 12 years)
C) Early menopause (less than 55 years)
D) Multiple episodes of breast-feeding
E) Remote oral contraceptive use
The correct response is Option B.
Early menarche is the highest risk factor for breast cancer of the options listed. Late first pregnancy, late menopause, no breast-feeding, and recent oral contraceptive use are also risk factors for breast cancer but are not as high risk.
A 35-year-old woman comes to the office with her boyfriend for consultation regarding augmentation mammaplasty. She currently wears a size 34B brassiere and is considering having her brassiere size increased to a D cup. She says she is happy with the way she looks in clothes, but the boyfriend indicates he would like to see a little more cleavage when she is in a swimsuit. History includes liposuction of her lateral thighs 6 months ago by a local dermatologist; she was satisfied with the result. She has also had injection of botulinum toxin type A to the glabella 3 times in the last year. Which of the following is the best reason to refuse performing the procedure for this patient?
A) The patient may be being pushed into surgery
B) The patient may be a “surgiholic”
C) The patient may have body dysmorphic disorder
D) The patient may have a personality disorder
E) The patient may have unrealistic expectations
The correct response is Option A.
Most aesthetic surgeons and mental health professionals agree that patients who exhibit even mild signs of psychiatric problems are not good candidates for aesthetic surgery. Many patients present without obvious signs of problems and are unfortunately discovered when postoperative problems arise. However, there are certain groups of patients with easily identifiable characteristics that constitute a red flag: those who are pushed into surgery by others, those with whom you are incompatible, the ?surgiholic? with a long past surgical history, those facing marital or familial disapproval, those with body dysmorphic disorder, the overly demanding patient, and those with unrealistic expectations.
A 54-year-old woman with a history of augmentation mammaplasty with textured silicone implants has histologic confirmation of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). MRI and PET scans show no associated masses, with activity localized to the periprosthetic seroma. Which of the following is the most appropriate next step in management of this patient?
A) Anterior capsulectomy with removal of the implants bilaterally
B) Complete capsulectomy with removal of the implant on the affected side
C) Partial capsulectomy with replacement of the implant
D) Removal of the textured implant and replacement with a smooth implant
E) Sealing of the seroma cavity with fibrin glue
The correct response is Option B.
Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma that has been increasingly recognized as a serious, albeit uncommon, complication associated with the use of textured breast implants. Since the initial case report in 1996, there have been continually increasing reported cases of this rare malignancy and according to the most recent data available, the lifetime risk of association between breast implants and BIA-ALCL is between 1 in 1000 to 1 in 30,000 with the ASPS recognizing nearly 200 cases in the US and nearly 500 cases worldwide.
BIA-ALCL patients typically present with a spontaneously occurring periprosthetic fluid collection or capsule-associated mass approximately 10 years following implantation of the breast implant. To date, all cases have had some association with a textured device. Initial workup includes ultrasound for evaluation of a periprosthetic fluid collection or mass. Periprosthetic fluid collections should undergo fine-needle aspiration in the clinic or ultrasound-guided aspiration by interventional radiology if there is concern for trauma to the implant while masses require tissue biopsy. Specimens should be sent for cytology with immunohistochemistry and flow cytometry for T-cell markers, specifically CD30 cell surface protein. A recent systematic review revealed that 66% of BIA-ALCL patients presented with isolated late-onset seroma while only 8% presented with an isolated new breast mass.
National Comprehensive Cancer Network (NCCN) guidelines for treatment of BIA-ALCL recommend complete removal of the lymphoma (fluid and/or mass), complete capsulectomy, and removal of the implant. More advanced disease may require chemotherapy, radiotherapy, and/or lymph node dissection. Although some surgeons advocate removal of the contralateral breast implant as approximately 4.6% of cases have demonstrated incidental lymphoma in the contralateral breast, this recommendation is controversial. The official NCCN guidelines for treatment only recommend consideration of contralateral breast implant removal but this is not mandated.
A 5-year-old male has a cerebrospinal fluid leak and a 3 x 3-cm area of wound dehiscence involving the posterior trunk following tethered cord repair. Which of the following is the most appropriate method to reconstruct the wound?
A) Gluteal muscle flap and skin advancement flap
B) Latissimus muscle turnover flap and skin advancement flap
C) Local fascial flap and skin advancement flap
D) Skin advancement flap
E) Split-thickness skin graft
The correct response is Option C.
The most appropriate method to reconstruct the wound is a local fascial flap and skin advancement flap. The major principle of tethered cord and myelomeningocele repair is to obtain a well-vascularized layer of soft tissue coverage between the dural and skin closures. The fascia overlying the paraspinous muscles can be turned over as flaps to cover the underlying dural repair. This vascularized soft tissue layer will minimize the risk of cerebrospinal fluid leak by reinforcing the dural repair. In addition, the fascial flaps will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair using skin advancement flaps would place the child at risk for meningitis in the event of a cerebrospinal fluid leak or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a regional gluteal or latissimus muscle flap to cover the dural repair is unnecessary because local tissue (paraspinous muscle fascia) is available. Harvesting the gluteal or latissimus muscles also may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurological deficit.
A 50-year-old woman comes to the office 6 weeks after undergoing right mastectomy and immediate placement of a tissue expander. She reports swelling and redness of the right breast. A photograph is shown. Which of the following factors is most predictive of implant salvage failure in this patient?
A) Culture positive for Pseudomonas species
B) Elevated body mass index
C) Periprosthetic seroma
D) Presence of cellulitis
E) Previous irradiation
The correct response is Option A.
Immediate implant-based reconstruction has become increasingly popular over the past two decades, accounting for over 70% of all reconstructions in the United States. The benefits of immediate reconstruction are numerous, including decreased recovery/number of required procedures and increased patient psychological well-being and aesthetic outcome. However, the complication (seroma, mastectomy flap necrosis, loss of implant, and infection) rates after implant-based reconstruction remain relatively high. Infection rates in the reported literature range from 2.5 to 24%.
Historically, periprosthetic infection or implant exposure mandated immediate implant removal. However, numerous studies over the past several decades have demonstrated implant salvage rates of 37.3 to 73% depending on the methods employed. Several studies have looked at the predictive factors that increase the risk of a failed salvage attempt. Salvage was typically defined as administration of systemic antibiotics (oral or intravenous), removal of the infected implant, partial/total capsulectomy, pocket curettage, implant pocket irrigation with antibiotic solution, and placement of a new device.
Factors associated with implant salvage failure include an elevated white blood cell count, elevated temperature, deep-seated pocket infection (purulent periprosthetic fluid), and atypical pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas species. Spear et al. showed that 93.9% of mild implant infections (localized cellulitis) could be salvaged compared with a 30% salvage rate in the severe infection group. Factors such as smoking, chemotherapy, previous irradiation, mastectomy skin necrosis, increased BMI, and use of acellular dermal matrix (ADM) have demonstrated increased rates of implant-related infections, but these factors have not been demonstrated to increase the risk of implant salvage failure.
A 47-year-old woman who underwent bilateral augmentation mammaplasty with silicone implants to treat mammary hypoplasia 17 years ago is evaluated because of worsening pain, firmness, and distortion of her breasts. Which of the following diagnostic evaluations is most sensitive for evaluating this patient’s silicone breast implants?
A) Breast thermography
B) CT scan
C) Mammography
D) MRI
E) Ultrasonography
The correct response is Option D.
MRI scan would be the most sensitive and specific method for detection of silent rupture of a silicone breast implant in this patient. Classic MRI findings indicating rupture include the linguini sign or the teardrop sign. Current FDA recommendations are to obtain MRI screening for silent rupture three years after placement of silicone implants and every two years after that.
CT scanning can show findings similar to those seen with MRI, but CT involves ionizing radiation, which can be harmful. CT has not been proven to be as sensitive as MRI in evaluating silicone breast implant rupture.
Ultrasonography is a less costly method of implant evaluation but this method is highly operator-dependent. In asymptomatic women, a subsequent MRI scan is generally needed to confirm a positive ultrasound screen.
Mammography is indicated for screening for breast cancer but not for implant rupture.
Breast thermography utilizes digital infrared imaging to evaluate metabolic activity and vascular circulation of the breast to look for suspicious signs of breast cancer. It is not effective in the evaluation of silicone breast implant rupture.
A 40-year-old woman is referred for reconstruction following mastectomy for a peripherally located ductal carcinoma in situ. A nipple-sparing mastectomy with immediate, single-stage prosthesis reconstruction with acellular dermal matrix is planned. Which of the following interventions is most appropriate to ensure that no residual cancer exists?
A) Chemotherapy
B) Ductal washing
C) Radiation therapy
D) Retroareolar frozen section
E) Sentinel lymph node evaluation
The correct response is Option D.
More plastic surgeons are performing reconstruction for women pursuing prophylactic mastectomy, which is requested quite frequently to avoid cancer recurrence and to achieve optimal aesthetic outcome. Exclusion criteria for nipple-sparing mastectomy include tumors greater than 3 cm, clinical invasion of the nipple-areola complex, tumors within 2 cm of the nipple, evidence of multicentric disease, positive intraoperative retroareolar frozen section, or nodal disease. If carcinoma is found in the retroareolar tissue, the nipple-areola complex must be removed. A patient who would require sentinel lymph node evaluation, radiation therapy, or chemotherapy would not be an appropriate candidate for nipple-sparing mastectomy. Annual mammography is recommended for any patient with a history of breast cancer and is not specific to the issue of nipple-sparing mastectomy. Ductal washing is not relevant for this pathology.
A 53-year-old woman is referred for consultation regarding breast reconstruction following mastectomy. Autologous breast reconstruction options are discussed. Which of the following is an advantage of the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap over the free TRAM flap?
A) Decreased complications in patients with a history of smoking
B) Decreased incidence of complete flap loss
C) Decreased risk of abdominal hernia
D) Decreased risk of fat necrosis
E) Ease of insetting and flap shaping
The correct response is Option B.
There is considerable controversy regarding the merits of the pedicled TRAM, free TRAM, free deep inferior epigastric perforator (DIEP), and free superficial inferior epigastric perforator (SIEP) flap reconstructions. Reconstruction with each flap has distinct advantages and disadvantages. Currently, the literature does not clearly favor the use of one procedure over the others.
The pedicled TRAM flap is characterized by a shorter operative time and a decreased risk of complete flap loss when compared to the free flaps. However, the pedicled TRAM flap shows a higher incidence of fat necrosis with partial flap loss, as well as an increased length of stay. Free flaps offer ease of flap shaping and insetting, as well as a decreased risk of abdominal hernia and abdominal wall weakness. Free flaps are more suitable for patients who are diabetic, are overweight, or smoke cigarettes.
Deciding which particular procedure to perform requires assessment on a case-by-case basis and consideration of the surgeon’s level of comfort with the different techniques.
A 29-year-old man undergoes evaluation for nonunion of a scaphoid fracture. Reconstruction with a vascularized osseous flap is planned, and a medial femoral condyle flap is chosen. During harvest, the vascular pedicle for this flap runs between which of the following structures?
A) Anterior to the tensor fascia lata and posterior to the vastus lateralis
B) Anterior to the vastus medialis and anterior to the adductor tendon
C) Anterior to the vastus medialis and posterior to the rectus femoris
D) Posterior to the rectus femoris and anterior to the vastus lateralis
E) Posterior to the vastus medialis and anterior to the adductor tendon
The correct response is Option E.
The medial femoral condyle osseous free flap has become a useful option for reconstruction of bony defects in the extremities, particularly of the scaphoid waist and proximal pole. The vascular supply to this flap is from the descending geniculate artery in the distal medial aspect of the thigh. To explore and identify the pedicle for this flap, the vastus medialis is reflected anteriorly, and the adductor tendon is found posterior to the vessels. The rectus femoris is located anterior to the dissection for this flap.
A 42-year-old woman comes to the office because she is dissatisfied with an obvious step-off between the chest wall and the superior pole of the breast 6 months after she underwent immediate expander reconstruction of the left breast. No further adjuvant therapy was indicated. After full expansion, the tissue expander was removed, and a permanent smooth, round silicone prosthesis was placed. BMI today is 28 kg/m2. Examination shows a well-defined inframammary fold. The volume is matched to the contralateral breast. Which of the following is the most appropriate surgical procedure for correction of this patient’s deformity?
A) Exchange of the silicone prosthesis with a silicone prosthesis of a larger volume and dimension
B) Exchange of the silicone prosthesis with a saline prosthesis of the same volume and dimension
C) Fat grafting to the superior pole and chest wall
D) Placement of acellular dermal matrix as an inferolateral sling
E) Removal of the prosthesis and reconstruction with a deep inferior epigastric perforator flap
The correct response is Option C.
Fat grafting has been shown to successfully address acquired contour deformities in breast reconstruction. Changing the prosthesis to a saline prosthesis of the same size and dimension will not address the problem of the step-off between the prosthesis and the chest wall in this slender patient (BMI 20 kg/m2) which is due to decreased soft-tissue coverage in the superior pole. Likewise, increasing the size and dimensions of the silicone prosthesis would not correct this contour deformity and would also lose the symmetry with the contralateral breast. This patient, without excess lower abdominal skin and subcutaneous fat, is not a candidate for a deep inferior epigastric perforator flap. Placement of acellular dermal matrix as an inferolateral sling is typically performed in the initial stage of tissue expansion and reconstruction. It can help define the inframammary fold, which this patient does not need.
A 53-year-old woman comes to the office because of unilateral swelling of the breast 5 years after undergoing subglandular augmentation mammaplasty. A diagnosis of anaplastic large T-cell lymphoma (ALCL) is established. Which of the following is most likely to represent the progression of this patient’s disease when compared with a patient who has ALCL but no breast prostheses?
A) A more aggressive clinical course and a poorer prognosis
B) A more aggressive clinical course but a more favorable prognosis
C) A more indolent clinical course and a more favorable prognosis
D) A more indolent clinical course but a poorer prognosis
E) The same clinical course and prognosis
The correct response is Option C.
Anaplastic large T-cell lymphoma (ALCL) is a rare (1 per million) non-Hodgkin lymphoma that has been reported in women with and without breast prostheses. However, increasing case reports suggest an association with breast prostheses, although direct causation has not been established. ALCL associated with breast prostheses has malignant cells infiltrating the periprosthetic capsule or in the periprosthetic fluid collection. It is associated with both silicone- and saline-filled prostheses and seen in patients who have had prostheses for augmentation mammaplasty as well as breast reconstruction. Although the cytology is the same between ALCL associated with and without breast prostheses, ALCL that develops around prostheses tend to have an indolent clinical course and favorable prognosis when compared with systemic ALCL.
An otherwise healthy 40-year-old woman comes to the office for augmentation mammaplasty. Mammography 6 months ago showed no abnormalities. Family history is negative for breast cancer. She wants to know if silicone gel implants are safe and what she should do after the procedure to monitor the implant for evidence of rupture. According to the current federal guidelines, which of the following is the most appropriate recommendation to this patient regarding surveillance?
A) MRI 3 years after implantation and every 2 years thereafter
B) MRI every 10 years
C) MRI if symptoms such as chronic myalgia and fatigue develop
D) Yearly mammograms
E) Yearly MRI
The correct response is Option A.
Evidence-based data to confirm the validity of screening patients with silicone implants are lacking. In 2011, the FDA issued recommendations for physicians on the use of silicone gel-filled implants. Recommendations included providing copies of educational brochures, giving appropriate informed consent, maintaining medical vigilance, and reporting adverse events. It also suggested that patients undergoing augmentation mammaplasty get an MRI 3 years after implant placement and every 2 years thereafter. The purpose of these recommendations is not to replace routine cancer surveillance.
A 40-year-old woman presents with small, non-healing ulcers of the right index and middle fingertips. Medical history includes limited scleroderma diagnosed 5 years ago, chronic pain, and color changes of the fingers in cold temperatures. The patient’s symptoms have not improved with administration of nifedipine. Angiography shows diffuse vascular narrowing without any focal lesions. Which of the following is the most appropriate intervention for pain relief and ulcer healing in this patient?
A) Cervical sympathectomy
B) Continuous brachial plexus blockade
C) Digital bypass
D) Onabotulinum toxin A
E) Stellate ganglion block
The correct response is Option D.
This patient has Raynaud’s phenomenon associated with scleroderma. The pathophysiology of Raynaud’s is thought to be related to sympathetic hyperactivity, elevated plasma endothelin, increased peripheral alpha-2 receptors, and possibly abnormal platelet and red cell function. Botulinum toxin type A has been shown to improve digital perfusion on laser Doppler, decrease pain, and result in ulcer healing. In a series of 33 patients injected with 50 to 100 U of onabotulinum toxin A, all patients had ulcer healing by 60 days postinjection. Pain relief typically occurred within 5 to 10 minutes of injection and complication rates were low and limited to injection site reactions. A prospective, randomized, placebo-controlled trial showed patients with limited scleroderma and shorter duration of disease had the best response to onabotulinum toxin A.
Stellate ganglion blocks have been shown to have only variable success for Raynaud’s with only short-term symptom relief and no effect on ulcer healing. Stellate blocks may not disrupt all sympathetic input to the extremity. Brachial plexus blocks may help with perfusion temporarily but are advocated mainly in patients undergoing microvascular surgery. Their use is not recommended in this setting. Surgical bypass to the superficial palmar arch has been shown to increase blood flow to the hand and improve ulcer healing. However, bypass to the digital vessels would not be indicated as the distal target vessels are often diminutive without adequate flow.
References
Bello RJ, Cooney CM, Melamed E, et al. The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud’s Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Arthritis Rheumatol. 2017 Aug;69(8):1661-1669.
Neumeister MW, Chambers CB, Herron MS, et al. Botox Therapy for Ischemic Digits. Plast Reconstr Surg. 2009 Jul;124(1):191-201.
Porter SB, Murray PM. Raynaud Phenomenon. J Hand Surg Am. 2013 Feb;38(2):375-377.
Neumeister MW. Botulinum Toxin Type A in the Treatment of Raynaud’s Phenomenon. J Hand Surg Am. 2010 Dec;35(12): 2085-2092.
Which of the following technical factors has the greatest favorable impact on the final appearance of a surgical scar?
A) Closing the wound in a single layer
B) Use of an absorbable suture
C) Use of topical cyanoacrylate
D) Retention suture
E) Wound-edge eversion
The correct response is Option E.
The two technical factors that increase the likelihood of a “good” scar are placement of sutures that will not leave permanent suture marks and wound-edge eversion. In wounds where the skin is brought precisely together, there is a tendency for the scar to widen. In wounds where the edges are everted or hypereverted in an exaggerated fashion, this tendency is minimized possibly by reducing the tension on the closure. While the most common method of closing a wound is with sutures, there is nothing necessarily superior about sutures or a specific type of suture. Staples, skin tapes, or wound adhesives are also useful in certain situations. Regardless of the method of closure or type of suture used, precise approximation of skin edges without tension is essential to ensure healing with minimal scarring. Simple interrupted suture is the gold standard for suturing wounds closed and everting the skin edges. Retention sutures tend to leave the most obvious and unsightly cross-hatching if they are not removed early. Wounds deeper than the skin are closed in layers. The key is to eliminate the dead space and provide a strong closure to prevent dehiscence and reduce tension. However, not all layers necessarily require separate closure.
A 42-year-old woman with a 3-cm invasive ductal carcinoma of the right breast is evaluated for breast reconstruction. She has not decided how she wants to manage her contralateral breast. Regarding eliciting a family history, which of the following cancers is associated with a mutation in a breast cancer-susceptibility gene?
A) Colon
B) Esophageal
C) Lung
D) Pancreatic
E) Thyroid
The correct response is Option D.
The breast cancer-susceptibility gene types 1 and 2 (BRCA1 and BRCA2) are tumor suppressor genes. Mutations in BRCA1 and BRCA2 are associated with hereditary breast and ovarian cancers. Additionally, they can be associated with increased risks of pancreatic and prostate cancer. Thyroid, lung, esophageal, and colon cancer are not associated with increased risks of BRCA1 and BRCA2 mutations.
A 22-year-old nulliparous woman is evaluated for improvement of breast shape and size. Examination shows bilateral hypoplastic breasts with constricted bases and herniation of breast parenchyma in the areolae. Tuberous breast deformity is diagnosed. Bilateral breast augmentation with smooth, round gel implants via periareolar incisions is planned. Which of the following maneuvers is most likely to decrease the risk for a “double-bubble” deformity?
A) Decreasing the areolar diameter
B) Lowering of the inframammary fold
C) Parenchymal scoring
D) Periareolar incision
E) Subpectoral placement of the implant
The correct response is Option C.
Common hallmarks of tuberous breast deformity include varying degrees of hypoplastic breast parenchyma, deficiencies of the inferior pole, herniation of the parenchyma in the areola, enlarged areolae, superior placement of the inframammary fold, and asymmetry. Surgical goals are to achieve symmetry, sufficient volume (especially in the hypoplastic areas), lowering of the inframammary fold, reduction of areolar tissue herniation, and correction of any ptosis. A double-bubble deformity can occur when the inframammary fold is not sufficiently obliterated. The risk for this is increased with superiorly displaced inframammary folds, as in tuberous breasts. Parenchymal scoring would both release any constricting bands to allow the lower pole tissue to spread over the implant as well as release the superiorly displaced inframammary fold. While decreasing the areolar diameter and lowering of the inframammary fold are goals for breast improvement, neither will treat a double-bubble deformity. A periareolar incision is often advocated in repair of tuberous breasts because of the ability to reduce the areola; it alone, however, will not prevent a double-bubble deformity. Subpectoral placement of implants increases the risk for double-bubble deformity while subglandular placement of implants decreases the risk. Many advocate a dual-plane approach to capitalize on increased upper pole coverage combined with the benefits of a subglandular relationship in the inferior pole.
A 30-year-old man presents to the emergency department with acute left wrist pain after falling 10 feet from a ladder. X-ray studies of the left wrist are shown. After failed closed reduction, the patient reports tingling that progresses to worsening and constant numbness of the left index and long fingers over the course of 6 hours. Which of the following urgent interventions is most appropriate?
A) Aspiration of the wrist
B) Carpal tunnel release
C) MRI of the wrist
D) Open reduction of the scaphoid
E) Repeat closed reduction
The correct response is Option B.
This patient has a type IV perilunate dislocation, or a true lunate dislocation. This represents a complete disruption of the ligamentous stabilizers about the lunate. These injuries are high energy and can be ligamentous only (lesser arc injuries) or include fractures (greater arc) and are then termed perilunate fracture dislocations. Mayfield et al described the stages of injury progressing from radial to ulnar in a type IV dislocation, including injury of the scapholunate ligament, disruption of the lunocapitate joint, injury of the lunotriquetral ligament, and dislocation of the lunate from its fossa at the radiocarpal joint volarly into the carpal tunnel.
On posteroanterior x-ray study of the wrist, there will be disruption of Gilula’s lines. On lateral x-ray study, a “spilled teacup” sign is seen.
Closed reduction with relaxation and traction is important, as the lunate needs to be relocated to its fossa to restore relative alignment of the wrist and to decompress the median nerve in the carpal tunnel. Surgical intervention can then be performed for open reduction of the joints and ligament repair after swelling has improved. However, progression in median nerve symptoms in the setting of successful or failed closed reduction is indicative of acute carpal tunnel syndrome and necessitates urgent surgical intervention.
Advanced imaging such as MRI is not required but may be helpful. Repeat closed reduction is likely to fail at this time, may worsen the swelling, and is unlikely to resolve the carpal tunnel symptoms. Open reduction of the scaphoid is not emergent, and the patient does not have a scaphoid fracture. Aspiration of the wrist will not resolve the inciting etiology of the patient’s carpal tunnel symptoms.
A 39-year-old man comes to the office 3 months after falling 10 feet from a ladder because of persistent radial-sided wrist pain, swelling, decreased grip strength, and a painful clicking in the wrist with moderate activity. Physical examination shows diffuse tenderness of the radial wrist and a painful “clunk” when palpating the scaphoid during radial deviation of the wrist. Initial x-ray studies showed no fracture or dislocation. Recent standard x-ray studies of the wrist show no fracture and normal carpal bone alignment. Which of the following is the most likely diagnosis?
A) de Quervain tenosynovitis
B) Dynamic scapholunate instability
C) Flexor carpi radialis tendinitis
D) Kienböck disease
E) Occult scaphoid fracture
The correct response is Option B.
This patient has dynamic scapholunate instability. These injuries can be difficult to diagnose and require a high index of suspicion. A normal x-ray study at 12 weeks in the setting of these clinical findings suggests there is a disruption of the scapholunate interosseous ligament (SLIL) that is symptomatic only with mechanical loading.
The SLIL is the primary stabilizer of the scapholunate joint, but it is surrounded by multiple secondary stabilizers consisting of the extrinsic wrist ligaments. Normal kinematic motion of the proximal carpal row is controlled by the tough interosseous ligaments. The dorsal component of the SLIL is the primary restraint to distraction, torsion, and translational forces. Disruption of the dorsal SLIL alone will result in changes in wrist mechanics, but the presence of the intact secondary stabilizing ligaments will prevent changes seen on a normal static x-ray study, such as scapholunate dissociation or an increased scapholunate angle.
Stress view x-ray studies, such as the clenched-pencil view, should be obtained when dynamic instability is suspected in the setting of a normal static x-ray study series. These results can be compared with the contralateral normal side. Non-contrast MRI is an advanced imaging modality averaging 71% sensitivity, 88% specificity, and 84% accuracy for SLIL tears. There is improved accuracy with 3.0T MRI machines. Wrist arthroscopy is the gold standard for diagnosis and can be combined with therapeutic procedures such as debridement or thermal shrinkage.
An occult scaphoid fracture should be visible at 12 weeks following the injury. Bone resorption at the fracture site makes the fracture line generally visible within 14 days. If suspicion remains for an occult scaphoid fracture at 2 weeks, additional imaging such as MRI or CT scan is indicated. At 3 months following the injury, any fracture present should be visible and treated as a non-union of the scaphoid.
De Quervain tenosynovitis is defined as tendinitis of the first dorsal extensor compartment. This condition generally presents with pain and tenderness over the radial styloid with a positive Finkelstein test. Tenderness of the carpal bones and carpal bone instability such as a painful “clunk” would not be present. The condition is most associated with repetitive use and not acute trauma.
Kienböck disease involves collapse of the lunate due to vascular insufficiency and avascular necrosis. Etiology is unknown but may involve a combination of anatomic factors and trauma. Early symptoms are similar to a wrist sprain but involve more global wrist pain, loss of dorsiflexion, and tenderness of the dorsal wrist over the lunate. Early stage I disease can have normal x-ray studies but will often show signs of a lunate fracture. Later stage disease shows sclerosis and ultimately fracture or collapse of the lunate.
Flexor carpi radialis (FCR) tendinitis is not a common diagnosis. It presents with wrist pain, crepitus, and point tenderness over the FCR at the wrist flexion crease with flexion and radial deviation. Although it is a cause of radial-sided wrist pain, findings of carpal bone instability on examination are not present.
An 8-year-old girl is brought to the office because of severe, worsening pain as well as finger swelling and numbness three days after she underwent cast placement for a fracture of the left forearm. After removal of the cast, her pain continues and is worsened by passive wrist motion. Which of the following is the most appropriate next step in assessment of this patient’s condition?
A) Angiography
B) CT scan
C) Duplex ultrasound
D) Electromyography
E) Manometry
The correct response is Option E.
The most appropriate next test is manometry. The patient is exhibiting signs of compartment syndrome after swelling due to fracture under a tight restrictive cast. Signs and symptoms of compartment syndrome include pain with passive stretch, increased pressure on palpation, paresthesia, paralysis, pallor, and pulselessness.
Early recognition and treatment are necessary to prevent permanent damage. The pressure within the muscles increases, preventing blood flow to the area and capillary exchange of nutrients. Fasciotomy is recommended if compartment pressure exceeds 30 mmHg, or if the difference between intracompartmental pressure and diastolic blood pressure is less than 30 mmHg. Without treatment, ischemic necrosis to the muscles can result, leading to Volkmann ischemic contracture and causing permanent disability. Scarring and shortening of the muscles can occur, with resultant contracted intrinsic minus appearance of the hand.
Compartment pressures can be measured by handheld manometer (Stryker pen), or needle manometer method (Whitesides) with an arterial line setup. Operative fasciotomy is indicated to release the compartment pressures and prevent tissue loss and muscle necrosis in cases of compartment syndrome. Loss of pulse typically occurs later in the spectrum of findings.
Angiography would be useful in evaluating vasculature and blood flow. Typically pain with passive stretch does not occur in cases of arterial insufficiency.
Duplex ultrasound can evaluate the presence of deep venous thrombosis, which can be a source of pain and swelling. This can occur through compression of the antecubital region, but in this case, the symptomatology would prompt measurement of compartment pressures and urgent fasciotomy.
Electromyography can be used to evaluate nerve function but would not be the next appropriate measure.
CT scan can provide detailed imaging but would not be indicated in this situation and would delay treatment.
References
Hughes T. Compartment Syndrome and Volkmann’s Contracture. In: Trumble T, Rayan G, Budoff, J, et al. Principles of Hand Surgery and Therapy, 2nd ed. Philadelphia, PA: Saunders Elsevier; 2010;8:154-166.
Kistler JM, Ilyas AM, Thoder JJ. Forearm Compartment Syndrome: Evaluation and Management. Hand Clin. 2018;34:53-60.
Leversedge FJ. Compartment Syndromes. In: Hammert W, Calfee RP, Bozentka DJ, et al, eds. ASSH Manual of Hand Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2010;27:483-492.
Stevanovic MV, Sharpe F. Compartment Syndrome and Volkmann Ischemic Contracture. In: Wolfe SW, Hotchkiss RN, Pedersen WC, et al. Green’s Operative Hand Surgery, 7th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2016;51:1763-1787.
Which of the following cell types is most associated with the chronic inflammation that leads to breast implant–associated anaplastic large cell lymphoma?
A) B-cells
B) Monocytes
C) Neutrophils
D) Red blood cells
E) T-cells
The correct response is Option E.
Evidence suggests that chronic inflammation is the stimulus responsible for the development of breast implant–associated anaplastic large cell lymphoma (ALCL) and T-cells are the predominant cell type responding to this antigenic stimulus. B-cells have been implicated in orthopedic implant lymphomas. The other cell types are involved in inflammation, but they are not associated with breast implant-associated ALCL.
An 11-year-old boy is brought to the office with an acute injury of the left small finger. A lateral x-ray study is shown. Which of the following is the most appropriate description of this patient’s injury?
A) Displaced Salter Harris fracture of the middle phalanx
B) Displaced Salter Harris fracture of the proximal phalanx
C) Nondisplaced Salter Harris fracture of the distal phalanx
D) Nondisplaced Salter Harris fracture of the middle phalanx
E) Nondisplaced Salter Harris fracture of the proximal phalanx
The correct response is Option A.
This is a displaced growth plate fracture of the small finger middle phalanx. There is a 90% displacement of the metaphysis relative to epiphysis. Although there is no obvious involvement of the metaphysis and, thus, the injury could be interpreted as a Salter Harris I fracture, minor concurrent involvement of some portion of the metaphysis (making it technically a Salter Harris II fracture) cannot be excluded and is quite common. The proximal and distal phalanges of the small finger are not injured.
The mnemonic “SALTER” may be used to recall Salter–Harris fracture types:
Type I: S (Slipped). The fracture occurs through the cartilage of the growth plate (physis) with an incidence of 5-7%.
Type II: A (Above). The fracture occurs above the physis, through the metaphysis. This is the most common type, occurring in 75% of patients.
Type III: L (Lower). The fracture occurs below the physis into the epiphysis. This occurs in 7-10%.
Type IV: TE (Through Everything). The fracture occurs through everything which includes the metaphysis, physis, and epiphysis. This type occurs in 10%.
Type V: R (Rammed or crushed). The growth plate (physis) has been crushed. This occurs in <1%.
A 7-year-old boy presents with a chief complaint of multiple wide and thin scars from skin lesion excisions. The patient’s mother reports a history of late walking, hypermobile joints, and easy bruising. On the basis of these complaints, which of the following is the most likely diagnosis?
A) Capillary fragility syndrome
B) Cutis laxa
C) Ehlers-Danlos syndrome
D) Marfan syndrome
E) Osteogenesis imperfecta
Following a skin-sparing mastectomy, a 39-year-old woman undergoes deep inferior epigastric perforator (DIEP) flap breast reconstruction. To augment flap sensation, the anterior sensory branch of the fourth intercostal nerve is coapted to which of the following nerves within the DIEP flap?
A) Genitofemoral
B) Iliohypogastric
C) Ilioinguinal
D) Intercostal
E) Lateral femoral cutaneous
The correct response is Option D.
The third, fourth, and fifth intercostal nerves are responsible for innervation of the majority of the breast. The anterior branch of the fourth intercostal nerve provides most erogenous sensation to the nipple. Sensation to the lower abdomen arises from segmental cutaneous branches of the intercostal nerve, which travel through the rectus abdominis muscle. T10 provides sensation to the dermatome, including the periumbilical region, and is most commonly used. The iliohypogastric nerve provides sensation to the lateral gluteal region. The ilioinguinal nerve provides sensation to the upper medial thigh. The genitofemoral nerve provides sensation to the upper anterior thigh and mons pubis. The lateral femoral cutaneous nerve provides innervation to the lateral thigh and is not used for this purpose.
A 34-year-old woman with a history of grade I breast ptosis who is 6 years status post-augmentation mammaplasty with subglandular gel-filled implants returns to the clinic. Physical examination shows normal-appearing breasts, but there is mild firmness on palpation. Which of the following Baker grades best describes these findings?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV
The correct response is Option B.
Many classification systems have been used to evaluate the severity of breast capsular contracture, which occurs when the peri-implant capsule undergoes fibrotic change. The most widely employed assessment tool remains the Baker grading system, which takes into account patient signs and symptoms. According to the Baker classification, only the highest degrees of contractures (grades III and IV) require surgical treatment. The descriptors for each grade are listed here:
Grade I: the breast is soft and appears normal in size and shape
Grade II: the breast is a little firm and appears normal
Grade III: the breast is firm and appears abnormal
Grade IV: the breast is firm, appears abnormal, and is painful
Studies note decreased relative risk for Baker grade III to IV capsular contracture in patients who undergo primary breast augmentation through an inframammary fold incision, subpectoral pocket placement, and textured implants. There is an increased relative risk for capsular contracture when patients undergo a periareolar or axillary incision and subglandular placement of smooth implants.
A 35-year-old BRCA-positive woman undergoes bilateral prophylactic nipple-sparing mastectomy via lateral radial incisions with periareolar extensions. She undergoes direct-to-implant reconstruction with an acellular dermal matrix inferior lateral sling. Mastectomy specimens weigh 435 g each, and placement of 450 mL smooth, round, high-profile implants is performed. Postoperatively, 25% partial nipple areolar complex necrosis in both breasts is noted. Which of the following most likely contributed to the necrosis?
A) Bilateral surgery
B) Mastectomy incision
C) Use of acellular dermal matrix
D) Volume of the implants
E) Weight of the mastectomy specimen
The correct response is Option B.
Nipple-sparing mastectomies are becoming more prevalent with the rise of prophylactic mastectomies and increased comfort with performing it in presence of in situ and invasive carcinoma. While universal standards for patient selection do not exist, there is consensus that general recommendations include no inflammatory breast cancers, no pathologic nipple discharge, no Paget’s disease, and for many, a 2-cm distance from the tumor to the nipple. Nipple-sparing mastectomy incisions have been described as radial lateral, lateral inframammary fold, and peri-areolar. Because the entire skin envelope is preserved, direct-to-implant reconstruction is possible with inferolateral support from acellular dermal matrices or other scaffolds. Areolar involvement in mastectomy incisions is associated with increased rates of nipple necrosis. The weight of mastectomy specimen, volume of implants, use of acellular dermal matrices or laterality of surgery have not been shown to be associated with nipple necrosis.
The postoperative CT scan shown is obtained to evaluate a wound dehiscence in a patient who underwent left-sided unilateral reduction mammaplasty for asymmetry six weeks ago. Which of the following upper extremity deformities is most likely to be found in this patient?
A) Contralateral radial club hand
B) Contralateral “pouce flottant” thumb
C) Ipsilateral brachysyndactyly
D) Ipsilateral radial head subluxation
E) Ipsilateral type IV Wassel preaxial polydactyly
The correct response is Option C.
Assessment of the chest CT shows right-sided absence of the pectoralis major and minor muscles and breast hypoplasia. The patient suffers from Poland syndrome, which is a congenital disorder of unknown etiology with the prevailing theory being hypoplasia of the subclavian artery or its branches during the sixth week of embryogenesis. Variability exists in physical findings with the most common being: anterior axillary fold and pectoralis major sternal head absence, breast gland thinning, rib and cartilage hypoplasia, and ipsilateral brachysyndactyly. After local wound care and antibiotic therapy, the patient had resolution of her symptoms.
A type IV Wassel preaxial polydactyly is the most common congenital thumb duplication but is not associated with Poland syndrome. Radial club hand is more common than ulnar club hand, but has no association with Poland syndrome. Both are congenital hand deformities, but unrelated to the pathological condition mentioned. Radial head subluxation is also known as “nursemaid’s elbow.” Nursemaid’s elbow is a common injury of early childhood. It is sometimes referred to as “pulled elbow” because it occurs when a child’s elbow is pulled and partially dislocates. There is no connection between Poland syndrome and increased incidence of radial head subluxation. Type IV Manske modification of the Blauth classification thumbs (the “pouce flottant” thumb) have rudimentary elements and are attached to the hand by a small skin bridge. These thumb anomalies are not associated with Poland syndrome.
A 51-year-old woman is scheduled to undergo needle aponeurotomy for Dupuytren disease of the small finger. A photograph is shown. The addition of lipografting after needle aponeurotomy is most likely to decrease the rate and severity of recurrence in this patient by which of the following mechanisms?
A) Decreasing the proximity of residual cord tissue to the skin
B) Increasing the density of myofibroblast cell-to-cell contact
C) Increasing the density of the residual cord tissue
D) Inhibiting myofibroblast proliferation
E) Providing stem cells to promote collagen production
The correct response is Option D.
Fat grafting (also called lipofilling) has shown promise as a means to improve outcomes after percutaneous needle aponeurotomy for Dupuytren disease. It is believed to work by several mechanisms:
Reducing the density of cell-to-cell myofibroblast contact
Inhibiting myofibroblast proliferation via adipose-derived stem cells
Acting as an interposed tissue graft
Providing passing over the cords to replace native subdermal fat displaced by the nodules and cords
A randomized prospective trial by Kan and colleagues showed that aponeurotomy with lipofilling showed equivalent results at one year out from treatment with a much faster recovery compared with limited fasciectomy.
References
Hovius SER, Kan HJ, Smit X, et al. Extensive percutaneous aponeurotomy and lipografting: a new treatment for Dupuytren’s disease. Plast Reconstr Surg. 2011.128:221-8.
Kan HJ, Selles RW, van Nieuwenhoven CA, et al. Percutaneous aponeurotomy and lipofilling (PALF) versus limited fasciectomy in patients with primary Dupuytren’s contracture: a prospective, randomized, controlled trial. Plast Reconstr Surg. 2016. 137:1800-12.
Murphy A, Lalonde DH, Eaton C, et al. Minimally invasive options in Dupuytren’s contracture: aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014. 134:822e-829e.
Verhoekz JSN, Mudera V, Walbeehm ET, Hovius SER. Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren’s disease. Plast Reconstr Surg. 2013.132:1139-48.
A healthy 45-year-old woman with a history of breast malignancy underwent bilateral mastectomy and reconstruction with tissue expanders followed by exchange for cohesive silicone gel implants eight years ago with routine postoperative MRI surveillance. She comes to the office to report pain and tightness in the right breast that has gradually increased over the past month. On examination, temperature is 36.8°C (98.2°F), blood pressure is 112/76 mmHg, and heart rate is 68 bpm. The right breast appears fuller than the left breast; otherwise, the right implant is in a symmetric position with the left side. The skin is otherwise normal in appearance, and there is no tenderness on palpation. Which of the following is the most appropriate next step in management?
A) MRI of the right breast to assess the integrity of the implant
B) One week of an oral antibiotic and prednisone taper
C) Operative exploration, culture, and replacement of implant
D) Referral of the patient back to her medical and surgical oncologists
E) Ultrasound of the right breast and fine-needle aspiration of any fluid
The correct response is Option E.
Patients that present with a late seroma should be evaluated for possible Breast implant associated Anaplastic Large Cell Lymphoma (BI-ALCL). A late seroma is usually accepted as occurring 1 year following surgery: however there are cases of BI-ALCL seroma that have presented as early as 4 months.
The first step in evaluation for BI-ALCL is an ultrasound followed by fine needle aspiration is indicated. The fluid requires evaluation beyond routine cell cytology. Immunohistochemistry test for CD30 was the most commonly positive marker for BI-ALCL. Immunohistochemistry stains specific antigens in cells by binding to this antigen in an antibody/antigen reaction. The specific stain can then be seen under light microscopy. CD30 antibody labels anaplastic large cell lymphoma cells. CD30 is a transmembrane cytokine receptor belonging to the tumor necrosis factor receptor family and characteristically stains ALCL cells.
MRI for implant integrity and referral to her Oncologist may be needed but it is not the most appropriate next step. BIA-ALCL needs to be ruled out. Immediate operative exploration is not indicated before fluid aspiration and immunohistochemistry evaluation. Antibiotics and prednisone is not indicated in this patient without evidence of infection or inflammation (red breast syndrome).
A 23-year-old woman comes to the office because of a hypertrophic scar after undergoing abdominoplasty 3 months ago. A multimodal approach to improving the appearance of the scar is planned. Which of the following therapies is supported by the highest quality evidence in this patient?
A) Allium cepa extract
B) Fat injection
C) Microneedling
D) Silicone gel
E) Vitamin E
The correct response is Option D.
Silicone gel has demonstrated efficacy in improving hypertrophic scars in a number of studies and is supported by level I evidence. Vitamin E, fat injection, allium cepa extract and microneedling are supported by lesser quality studies in a recent comprehensive review of the literature.
A 23-year-old African-American man presents with a raised thickened scar on his anterior chest that he complains is pruritic and unattractive. It was removed by another provider 4 years earlier and has slowly recurred over the past year. On examination, the lesion extends beyond the initial borders of the scar and is firm and hyper-pigmented. On review of his prior pathology report, which of the following histologic characteristics is most likely?
A) Greater ratio of type III to type I collagen
B) Multitude of myofibroblasts and smooth muscle actin
C) Parallel collagen bundles
D) Thick, wavy, and randomly oriented collagen fibers
The correct response is Option D.
In patients with abnormal or excessive scar tissue formation, treatment and prognosis will be driven by the correct diagnosis of a keloid versus a hypertrophic scar. This patient presents with a recurrent keloid of the chest. His clinical history supports this diagnosis by recurrence after resection, growth extending beyond the original border of the lesion, late recurrence after several years, and continued growth over several years without regression or improvement. Hypertrophic scars are less likely to recur, contained within the original boundaries of the lesion, often regress somewhat within a year, and recur earlier in the postoperative period if they are to recur. Both hypertrophic scars and keloid scars can be pruritic.
Pathologic analysis of keloids reveals more type I collagen than type III collagen, similar to normal skin. Hypertrophic scars will exhibit increased type III collagen and pro-fibrotic collagen cross-linking. Keloid growth is thought to be impacted by cell-signaling between keratinocytes and fibroblasts, but hypertrophic scar production requires an abundance of myofibroblasts expressing smooth muscle actin. While hypertrophic scars have parallel collagen fibrils and bundles, keloids are characterized histologically by thick, randomly oriented collagen fibrils that are not organized into bundles.
Which of the following is most commonly associated with decreased incidence of capsular contracture?
A) Formation of biofilm
B) Placement of textured silicone device
C) Subglandular placement of the implant
D) Use of a periareolar incision
E) Use of a postoperative surgical brassiere
The correct response is Option B.
The rest of the options have been shown to increase the incidence of capsular contracture. Textured silicone implants, inframammary incisions, and submuscular implant placement have been shown to decrease the incidence of capsular contracture. The use of a surgical brassiere postoperatively has not been shown to decrease incidence of capsular contracture as well.
Which of the following structures contributes to the formation of the tragus?
A) First branchial arch
B) First branchial cleft
C) Second branchial arch
D) Second branchial cleft
The correct response is Option A.
The first branchial arch contributes to the formation of the tragus and anterior helix.
The first branchial cleft is incorrect. It gives rise to the external auditory canal.
The second branchial arch is incorrect. It contributes to the formation of the majority of the external ear – the antitragus, remainder of the helix, antihelix, and crura all arise from the second branchial arch.
The second branchial cleft is incorrect. It is typically obliterated during development, but may persist in the form of a second branchial cleft cyst.
References
Adams A, Mankad K, Offiah C, Childs L. Branchial Cleft Anomalies: A Pictorial Review of Embryological Development and Spectrum of Imaging Findings. Insights Imaging. 2016 Feb; 7(1): 69-76.
Schmidt R, Conrad D, Field E, O’Reilly R. Management of First Branchial Arch Anomalies via a Cartilage-Splitting Technique. Otolaryngol Head and Neck Surg. 2015 Jun;152(6):1149-51.
A 35-year-old woman comes to the office to discuss a recent diagnosis of breast cancer. Recent mammography showed diffuse microcalcifications throughout the breast, and needle biopsy showed infiltrating ductal carcinoma. On physical examination, some retraction of the skin in the lower outer quadrant of the breast is noted. She wears a size 36C brassiere. The patient reports that she is currently considering whether to have lumpectomy and radiation therapy or mastectomy. Which of the following features of this clinical scenario is a CONTRAINDICATION to breast conservation therapy?
A) Breast size
B) Mammographic findings
C) Patient age
D) Skin retraction on physical examination of the breast
E) Tumor pathology
The correct response is Option B.
Breast conservation therapy (BCT) refers to breast conserving therapy followed by moderate-dose radiation to eradicate microscopic residual disease. The goal is to provide the equivalent survival of mastectomy while maintaining a cosmetically acceptable appearance with a low rate of recurrence.
When considering breast conservation therapy or mastectomy, the needs and desires of each patient should be addressed. Age alone is not a contraindication to BCT, but overall health and comorbidities should be considered. Histologic subtype and pathology are not contraindications to BCT as long as the tumor is not diffuse and can be safely excised with negative margins. Similarly, breast size needs to be considered along with tumor size and location, but “small” or “large” breasts are not indications or contraindications. While retraction of the skin, nipple, or breast parenchyma is not an absolute contraindication to BCT, as long as negative margins can be safely removed, the cosmetic impact of their involvement should be considered.
There are few absolute contraindications to BCT, but they include:
Multicentric disease with two or more tumors in separate quadrants of the breast such that they cannot be encompassed in a single excision
Diffuse malignant microcalcifications on mammography
A history of prior radiation in the same breast or chest wall
Pregnancy
Persistently positive margins despite re-excision
Which of the following is the most common complication associated with “donut” mastopexy?
A) Boxy breast shape
B) Increased distance from nipple to inframammary fold
C) Loss of nipple sensation
D) Nipple necrosis
E) Widening of the areola
The correct response is Option E.
A common complication of the “donut” (circumareolar) mastopexy is widening of the areola. This can be minimized by using a Gore-Tex suture placed using the “wagon-wheel” technique and limiting the amount of skin resected to a 2:1 ratio of outside diameter to areolar diameter.
Boxy breast shape is associated with Wise pattern mastopexy. Nipple necrosis is associated with combined augmentation and mastopexy. Increased distance from the nipple to the inframammary fold is associated with vertical mastopexies in which the height of the medial and lateral pillars is too tall. Loss of nipple sensitivity is unusual because there is no parenchymal resection.
A 32-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She is concerned about the potential complications with the use of silicone gel prostheses within the first 5 years postoperatively. Which of the following is the most commonly reported complication of the implantation of cohesive silicone gel breast prostheses?
A)Capsular contracture
B)Granuloma
C)Hematoma
D)Infection
E)Rupture
The correct response is Option A.
Cohesive silicone gel is a breast prosthesis option that has been approved by the FDA since 2006. Cohesive gel prostheses have also been called ?gummy bear? prostheses. They maintain their shape because of the increased cross-linking within the silicone gel.
A study by Cunningham followed 1008 patients and 1898 cohesive gel prostheses. Rupture rate was 1.1% for aesthetics and 3.8% for reconstructive procedures. Capsular contracture rates (Baker III/IV) were 9.8/13.7%, and infection was 1.6/6.1%, respectively. Thus, capsular contracture was the most common of the listed complications. The reported incidence of hematoma is approximately 2%.
It should be noted that complications occur more commonly in primary reconstruction as compared to primary augmentation. These findings are important in the preoperative counseling of patients.
A 2-year-old boy is evaluated because of a soft, nontender, noncompressible glabellar mass that has progressively grown since birth. A photograph is shown. Which of the following is the most appropriate next step in management before scheduling surgery?
A) Corticosteroid injections
B) MRI
C) Plain film x-ray study
D) Propranolol trial
E) Observation
The correct response is Option B.
The differential diagnosis for a lesion in this location with the findings described include dermoid cyst, hemangioma, and encephalocele. Osteoma, which is a benign bony tumor, is unlikely because of patient age and examination findings. The noncompressible quality of the lesion makes hemangioma and encephalocele less likely. Propranolol therapy after 12 months of age is unlikely to help, even if the lesion is a hemangioma. If the lesion is a hemangioma, then observation would be appropriate, but because the lesion is still growing, this diagnosis is questionable. Corticosteroid injections are only moderately helpful in treating a hemangioma, but they are contraindicated for dermoid cysts and encephalocele. Diagnosis is the next step with a goal of ruling out intracranial communication, as it will impact the surgical approach. MRI is the best option. Plain x-rays films would not provide adequate information for management.
References
Al-Muhaylib A, Alkatan HM, Al-Faky YH, Alsuhaibani AH. Periorbital lesions misdiagnosed as dermoid cysts. J AAPOS. 2017;21(6):509-511.
Rezaei E, Shams Hojjati Y. Misdiagnosed extranasal mass: report of a 2-year old child with maltreated rare nasal neuroglial heterotopia. World J Plast Surg. 2019;8(1):122-124.
Van Wyhe RD, Chamata ES, Hollier LH. Midline craniofacial masses in children. Semin Plast Surg. 2016;30(4):176-180.
Vincent J, Baker P, Grischkan J, Fernandez Faith E. Subcutaneous midline nasal mass in an infant due to an intramuscular lipoma. Pediatr Dermatol. 2017;34(3):e135-e136.
An active 73-year-old woman comes to the office because of Eaton Stage IV arthritis of the carpometacarpal joint of the dominant thumb (pantrapezial arthritis with carpometacarpal [CMC] joint subluxation). She says she has severe pain when she tries to grip something, such as open a door or twist off the top of a jar. Which of the following is the most predictable procedure to decrease pain and improve hand function in this patient?
A) CMC fusion
B) Metacarpal osteotomy
C) Trapezial hemi-resection and tendon interposition
D) Trapezial resection and silicone implantation
E) Trapezial resection, ligament reconstruction, and tendon interposition
The correct response is Option E.
Thumb basilar joint arthritis is a common debilitating problem. The prevalence in postmenopausal women has been estimated at 33%, although many patients with radiographic evidence of arthritis remain asymptomatic. It more often occurs in the dominant hand. The extent of arthritis and joint deformity dictates the best treatment choice. The most widely used classification is that of Eaton and is based on radiographic findings. Stage I has normal joint contours but possible joint widening due to effusion. Although most patients respond to splinting, anti-inflammatory medications, trapezial hemi-resection, and metacarpal osteotomy have been advocated in very symptomatic patients.
Stage II shows slight trapeziometacarpal (TM) joint narrowing and minimal sclerosis of the articular surface. The indications for operative treatment are more concrete, and surgical options are largely the same as Stage I, with the addition of CMC fusion as an option in a laborer.
Stage III presents as TM joint narrowing with cystic or sclerotic changes in the articular surface. There is variable dorsal subluxation of the TM joint, and adduction contracture may occur. There can be early signs of scaphotrapezial (ST) joint arthritis. If the ST joint is in relatively good condition, some authors still advocate trapezial-sparing procedures such as hemi-resection. Nevertheless, most advocate trapeziectomy with or without ligament reconstruction/tendon interposition (LRTI). There is some evidence that ligament reconstruction preserves the joint space better than no reconstruction, but provides no better clinical outcome and has a higher complication rate. Trapeziectomy ± LRTI provides excellent pain relief and improved function, especially in lower demand patients.
In Stage IV, the TM and ST joints are completely destroyed. In these patients, LRTI is the preferred treatment. Some authors report good early results in selected patients with implant arthroplasty; however, there is a moderately high rate (up to 40%) of instability, dislocation, and implant breakage. The use of silicone as a spacer has fallen into disuse due to the risk of chronic tissue inflammation and resultant bone resorption.
A 21-year-old woman comes to the office for consultation regarding a palpable lump in the left breast that she first noticed 4 months ago. Phyllodes tumor of the breast is diagnosed. Which of the following is the most appropriate management at this time?
A ) Observation and incisional biopsy
B ) Neoadjuvant chemotherapy
C ) Local excision and annual surveillance
D ) Wide local excision and radiation therapy
E ) Mastectomy with immediate reconstruction
The correct response is Option C.
Phyllodes tumors of the breast were once called cystosarcoma phyllodes because of the fleshy nature of the tumor. Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor.
Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast but represents only about 1% of tumors in the breast. It has a sharply demarcated, smooth texture and is typically freely movable. It is a relatively large tumor; the average size is 5 cm. However, lesions greater than 30 cm have been reported. Approximately 90% of phyllodes tumors are benign and approximately 10% are malignant.
In considering excision, the tumor-to-breast ratio should be small enough to allow for segmental excision of the tumor and possible reduction mammaplasty technique (eg, inferior pedicle for a superior tumor or a superior pedicle for an inferior lesion). Annual surveillance and follow-up is recommended because the pathologic appearance does not always predict the clinical behavior.
A 36-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She wears a size 34B brassiere and wants the size increased to a full C cup. Height is 5 ft 6 in (168 cm) and weight is 126 lb (57 kg). She feels her breasts are reasonable in appearance but has been encouraged by her husband, from whom she is separated, to seek enhancement. The risks of the surgery, including loss of nipple-areola sensation and the need for prosthesis maintenance over time, are discussed. She opts to proceed with surgery, and 375-mL saline breast prostheses are placed subpectorally through inframammary fold incisions. Which of the following is most likely to cause patient dissatisfaction after the procedure?
A ) Continued separation from her husband
B ) Deflation of the breast prostheses
C ) Hypertrophy of the breast scars
D ) Inability to breast-feed
E ) Inadequate breast size
The correct response is Option A.
Thorough patient evaluation before surgery, including screening, discussion of risks and complications, and the need for realistic expectations, is necessary to optimize patient satisfaction after surgery. This is especially true of aesthetic surgery.
Despite these efforts, patient dissatisfaction occurs and can be extremely difficult to manage. Patient dissatisfaction is usually associated with failures in communication and patient selection criteria. Determining which patients are unsuitable for operation is a skill acquired with experience. General guidelines include patients who (1) have unrealistic expectations, (2) are excessively demanding, (3) have dissatisfaction with a previous surgical procedure, (4) are psychologically unstable, and (5) have a minimal deformity.
In the scenario described, the patient has an unrealistic expectation that the surgery might save her marriage. Because of her motivation for surgery, she is unlikely to be happy, despite a very good result, unless the expectation of reconciliation has been fulfilled.
The other options are possible causes of postoperative dissatisfaction; however, preoperative counseling and education of the potential complications allow for enhanced acceptance if they do occur.
A 59-year-old woman comes for evaluation because of a 7-month history of pain over the radial aspect of the right wrist that is aggravated with forceful gripping. She denies any history of trauma to the hand or wrist. On physical examination, there is tenderness to palpation over the right anatomic snuffbox and thenar eminence. Axial load and shifting of the basal joint does not result in crepitance or pain. Resisted thumb extension at the metacarpophalangeal joint level is not painful. An x-ray study of the wrist is shown. Which of the following is the most appropriate operative management?
A) Arthrodesis of the scaphotrapeziotrapezoid joint
B) Arthrodesis of the trapeziometacarpal joint
C) Hemi-resection of the distal trapezium and tendon interposition
D) Release of the first dorsal compartment
E) Release of the second dorsal compartment
The correct response is Option A.
Scaphotrapeziotrapezoid (STT) arthritis can often be misdiagnosed on initial presentation as basal joint arthritis. The keys to differentiating the two sites of pain include physical examination, which shows tenderness more proximal than the basal joint and absence of pain with a grind maneuver, coupled with imaging showing osteoarthritic degeneration at the STT rather than the trapeziometacarpal level. Treatment for the arthritic pain can consist of resection arthroplasty or arthrodesis. Both techniques can provide good relief of symptoms. Resection arthroplasty often is used when the scapho-trapezoid articulation is relatively preserved. Regardless of technique chosen, the surgeon should address both the scapho-trapezial and the scapho-trapezoid joints during the procedure.
Release of the first dorsal compartment would address de Quervain tenosynovitis, which could present with pain over the anatomic snuffbox. On examination, however, the patient would typically demonstrate pain with the “resisted Hitchhiker” maneuver (resisted extensor pollicis brevis function at the metacarpophalangeal level). Given the negative findings on examination and the STT arthritis noted on imaging, this patient would not likely respond to treatment directed at the first dorsal compartment.
Second dorsal compartment tenosynovitis can present with distal forearm and wrist pain. The location of the pain is typically more proximal in the forearm and localized to the intersection between the muscle bellies of the first compartment tendons and the radial wrist extensors. This patient’s pain is localized to the STT region rather than the second dorsal compartment.
Hemiresection of the distal trapezium and tendon interposition has been used successfully in the management of trapezio-metacarpal arthritis (basal joint arthritis). In this patient, the location of the pain, absence of pain with a “grinding” type maneuver, and the imaging showing preservation of the basal joint argue against directing treatment at the basal joint itself.
For the same reasons that hemiresection of the distal trapezium is a poor choice for this patient, arthrodesis of the basal joint addresses the wrong site of arthritis. X-ray study and physical examination both indicate STT arthritis as the etiology of the patient’s pain.
A 27-year-old woman who underwent augmentation mammaplasty with 325-mL textured prostheses one year ago comes to the clinic because her breasts look asymmetric and feel hard. Physical examination shows firm asymmetric breasts with palpable capsules. No pain, signs of skin infection, hematoma, or seroma are observed. Hypertrophic scars are seen on the inframammary fold of both breasts. Which of the following factors is the most likely cause of capsular contracture in this patient?
A) Implant size
B) Patient history of hypertrophic scarring
C) Subclinical infection with biofilm formation
D) Submuscular positioning of the implants
E) Textured implants
The correct response is Option C.
On the basis of her clinical presentation, this patient is experiencing Baker Grade III capsular contracture. Capsular contracture is the most common complication after breast implant placement. This is a multifactorial complication; however, only subclinical infection with biofilm formation has a clear correlation with a higher degree of capsular contracture.
Implant size is not directly associated with an increased risk for clinically significant capsular contracture, and it has been established that textured implants are associated with a decreased risk. There is no clear evidence of a relation between a patient’s tendency to scar and an increased risk for capsular contracture. It is accepted that submuscular placement leads to lower rates of capsular contracture than the subglandular technique.
A 50-year-old man comes to the emergency department after sustaining amputation of the right long finger involving an avulsion mechanism. The patient is taken to surgery for replantation. During surgery, extensive vascular injury is seen, and an approximately 2-cm vascular gap of the digital arteries and veins results following excision of injured vessels. Which of the following interventions is most likely to increase the probability of functional digit replantation?
A) Bone shortening
B) Medicinal leech therapy
C) Postoperative warming
D) Systemic heparin
E) Vein grafts
The correct response is Option E.
In patients who sustain digital amputation as a result of an avulsion mechanism, there is often an extensive zone of injury that precludes primary vascular anastomosis. Vein grafts permit vascular anastomosis outside of the zone of injury.
Bone shortening can sometimes allow excision of the injured vasculature and primary anastomosis. However, in this case, bone shortening is unlikely to make up for a 2-cm vascular gap.
Longer vascular gaps can be addressed with vein grafts. Despite the fact that vein grafts involve an additional anastomosis per vessel compared to primary anastomosis, they have been found to exhibit similar rates of thrombosis and replantation survival.
Medicinal leech therapy can help address venous congestion, but is typically considered when venous congestion occurs after attempt at surgical replantation, or if no suitable veins can be found for anastomosis.
While postoperative warming and systemic heparin are often used adjunctively in patients undergoing replantation, they have not been demonstrated to increase the likelihood of survival of the replanted part, and would most likely not have as significant an effect as restoring perfusion to the amputated part using vein grafts.
References
Hyza P, Vesely J, Drazan L, et al. Primary vein grafting in treatment of ring avulsion injuries: a 5-year prospective study. Ann Plast Surg. 2007 Aug;59(2):163-7.
Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014 Feb;133(2):333-42.
Yan H, Jackson WD, Songcharoen S, et al. Vein grafting in fingertip replantations. Microsurgery. 2009;29(4):275-81.
A 43-year-old Caucasian woman is referred to the office because of a mass on her right breast that has been rapidly growing for 8 weeks. Physical examination shows a 4.5-cm, freely movable mass in the right breast. No axillary adenopathy or nipple discharge is noted. Which of the following is the most likely nonepithelial neoplasm in this patient?
A) Fibroadenoma
B) Hamartoma
C) Lipoma
D) Phyllodes tumor
E) Primary breast lymphoma
The correct response is Option D.
Primary breast lymphoma is rare; it constitutes less than 0.6% of all breast malignancies. Phyllodes tumors represent about 1% of tumors in the breast; they are the most commonly occurring nonepithelial neoplasm of the breast. The tumor has a smooth, sharply demarcated texture and is generally freely movable. It is a relatively large tumor, with an average size of 5 cm. A hamartoma is the most common benign tumor of the lung. Hamartomas of the breast are benign tumors composed primarily of dense fibrous tissues with variable amounts of fat and associated ducts. Eighty-five percent of phyllodes tumors are benign, and 15% are malignant. There is no race predilection, but phyllodes tumors occur almost exclusively in women. In young women under age 25 years, asymmetric, tender, and fibrocystic tissues usually point to a fibroadenoma or circumscribed fibrocystic mass. Lipoma of the breast causes diagnostic and therapeutic uncertainty. Clinically, it may be difficult to distinguish a lipoma from other conditions. Fine-needle aspiration cytology is often not helpful. Both mammography and ultrasonography results are often negative. MRI may be overread, but it is useful as a diagnostic tool. This neoplasm can be seen in men and women.
A 47-year-old woman is referred by her primary care physician to evaluate a suspected intracapsular rupture of her prosthesis on the left identified during routine mammography. She underwent primary augmentation mammaplasty with subglandular placement of single-lumen silicone breast prostheses in 1990. Physical examination shows a smaller breast on the left. An MRI is requested. Which of the following findings on MRI is most likely to confirm the diagnosis?
A ) Double wall sign
B ) Linguine sign
C ) Multiple echogenic lines
D ) Reverse double-lumen sign
E ) Snowstorm sign
The correct response is Option B.
MRI, mammography, ultrasonography, and CT scanning have all been used to diagnose silicone breast prosthesis rupture.
Although each modality has specific strengths and weaknesses that may make a particular modality the study of choice for an individual patient, MRI of silicone breast prostheses reports the highest sensitivity and specificity for detection of silicone prosthesis rupture.
Of the options listed, only the linguine sign is consistent with intracapsular silicone prosthesis rupture and represents the prosthesis shell floating in free silicone gel.
The double wall sign, also known as Rigler sign, is a radiographic sign of pneumoperitoneum.
Snowstorm sign and echogenic lines may be seen on ultrasound examination.
Water suppression or a reverse double-lumen sign would not be expected findings in a single-lumen device but may have a role in double-lumen devices.
A 36-year-old man comes to the office because of a 2-week history of pain of the right wrist after a fall on his outstretched hand. X-ray studies are shown. If this injury is left untreated, which of the following joint surfaces is most likely to develop arthritis first?
A) Capitolunate
B) Lunotriquetral
C) Radiolunate
D) Radioscaphoid
E) Scaphocapitate
The correct response is Option D.
The most likely joint surface to develop arthritis is the radioscaphoid joint. This patient shows evidence of scapholunate ligament tear. There is evidence of widening of the scapholunate interval and increase in the scapholunate angle.
The scapholunate angle is calculated by measuring the angle between a line drawn perpendicular to the distal surface of the lunate and along the axis of the scaphoid on the lateral view. The normal scapholunate angle varies from 30 to 60 degrees. A tear in the scapholunate ligament results in volar flexion of the scaphoid bone and dorsiflexion of the lunate, with a resultant increase in the angle.
If a scapholunate ligament tear is left untreated, a degenerative pattern of changes result. This is known as scapholunate advanced collapse (SLAC) wrist. Over time there is separation of the scaphoid and lunate bones and descent of the capitate into the intervening space.
With scapholunate ligament tears, arthritis occurs in a predictable sequence. This initially begins in the radioscaphoid joint, followed by the scaphocapitate joint and the capitolunate joint. The radiolunate joint is typically spared until advanced stages. The lunotriquetral ligament is intact and arthritis does not occur in this area with SLAC wrist.
A 62-year-old woman with a history of Stage III breast cancer is scheduled for delayed autologous breast reconstruction from the abdominal donor site. She has no other medical problems. BMI is 30 kg/m2. Her mother had a lower extremity deep venous thrombosis in the past. Caprini risk assessment score is 9. Which of the following is the most appropriate method of postoperative VTE risk reduction?
A) Aspirin therapy
B) Early ambulation after surgery
C) Low-molecular-weight heparin therapy
D) Sequential compression device use
E) No VTE prevention is indicated
The correct response is Option C.
Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Plastic and reconstructive surgery patients are known to be at high risk for VTE after surgery. Symptomatic VTE occurs with high frequency after post-bariatric body contouring (7.7%), abdominoplasty (5%), and breast or upper body contouring (2.9%). To fully identify VTE risk in surgical patients, individualized patient assessment is advocated. The Caprini risk assessment model (RAM) is a useful and effective tool to stratify surgical patients for VTE risk. For patients with high Caprini scores, a significantly greater likelihood of VTE events is observed. Approximately 11% of patients with Caprini score >8 will have a VTE within 60 days after surgery.
Based upon recommendations from the ASPS VTE Task Force, patients undergoing elective plastic and reconstructive surgical procedures who have Caprini RAM score of 7 or more should have VTE risk reduction strategies employed, such as limiting operating room times, weight reduction, discontinuation of hormone replacement therapy, and early postoperative mobilization. Patients undergoing major plastic and reconstructive operative procedures performed during general anesthesia that last longer than 60 minutes should receive VTE prevention. For patients with Caprini score of 3 to 6, the use of postoperative low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) should be considered. For patients with Caprini score of 3 or more, use of mechanical prophylaxis throughout the duration of chemical prophylaxis for non-ambulatory patients should be considered. For patients with Caprini score of 7 or more, the use of extended LMWH postoperative prophylaxis should be strongly considered.
Aspirin does not decrease the risk of VTE and may increase the risk of perioperative complications.
A 32-year-old man comes to the emergency department after being hit in the right eye. Examination shows enophthalmos, hyphema, and numbness over the cheek. There is no diplopia. CT scan shows a large orbital floor fracture with herniation of contents into the maxillary sinus. Which of the following findings requires urgent management?
A) Cheek numbness
B) Enophthalmos
C) Hyphema
D) Maxillary sinusitis
E) Orbital floor fracture
The correct response is Option C.
Hyphema is marked by presence of blood in the anterior chamber and is an emergent concern. It can lead to permanent damage to the vision. All the other options are urgent concerns but can be addressed after the hyphema is treated.
A newborn female presents with a large intraoral mass arising from alveolar mucosa of the lower jaw that does not cause any airway obstruction. Photographs are shown. Which of the following is the most likely pathology of the lesion?
A) Congenital epulis
B) Hemangiopericytoma
C) Odontogenic keratocyst
D) Rhabdomyosarcoma
E) Teratoma
The correct response is A.
Congenital epulis is a rare, benign tumor of the oral cavity that is found in newborns. They are considered a form of granular cell tumor that can lead to mechanical obstruction, resulting in respiratory distress or difficulty eating. Surgical excision is the treatment of choice and recurrence after excision is rare. The female-to-male ratio is 10:1. It is observed three times more frequently on the maxilla than the mandible. They are solitary in most cases, but can be large and multiple.
Teratomas and rhabdomyosarcomas of the mandible are even more rare and are usually seen in the older patient population; they are not seen in the neonatal population.
Hemangiopericytomas are rare, vascular neoplasms that originate from vascular pericytes. They can occur anywhere in the body, including the mandible. They are slow-growing and present in the older patient population. The likelihood of presentation in a neonate is exceedingly low.
Odontogenic keratocysts are rare and benign, but locally aggressive lesions of the posterior mandible. They most commonly present in the third decade of life. They make up 19% of jaw cysts.
References
Goldblum JR, Folpe AL, Weiss SW, eds. Enzinger and Weiss’s Soft Tissue Tumors. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:845.
Husain AN, Stocker JT, Dehner LP, eds. Stocker and Dehner’s Pediatric Pathology. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:1027.
Which of the following innervates the nipple-areola complex?
A ) Intercostal
B ) Lateral pectoral
C ) Long thoracic
D ) Supraclavicular
E ) Thoracodorsal
The correct response is Option C.
Two different studies show that prosthesis volume relative to the skin envelope has a potential adverse effect on the sensation of the nipple-areola complex. The type of prosthesis and the pocket placement have no influence on sensitivity. No difference was found between the periareolar and inframammary incision approaches. Other factors, such as a previous history of breast-feeding or minor complications, were not associated with sensory alterations.
In a patient undergoing reconstructive cranioplasty, an increased rate of complications is most likely if which of the following is present?
A) Frontal location
B) Occipital location
C) Parietal location
D) Sphenoidal location
E) Temporal location
The correct response is Option A.
Early decompressive craniectomy is a life-saving maneuver for certain traumatic brain injuries and can be performed far forward in the theater of war. Patients treated with decompressive craniectomy for combat injuries are a unique understudied population. Outcome of treatment of this patient cohort has been previously reported using a standardized cranial defect treatment protocol using custom alloplast implants. Two subgroups of patients (large endocranial dead space and frontal orbital bar injuries) were identified as often having higher rates of complications than other cranial reconstruction cohorts.
An otherwise healthy 38-year-old woman undergoes prophylactic bilateral mastectomy and immediate reconstruction with deep inferior epigastric artery perforator (DIEP) free flaps. Intraoperatively, the left DIEP flap appears congested before the conclusion of the case. The left deep inferior epigastric artery and vein (DIEA and DIEV) were anastomosed to the proximal internal mammary vessels. The vascular pedicle is evaluated and each anastomosis appears patent and not kinked; however, the venous congestion persists. Which of the following is the most appropriate management?
A) Anastomose the superficial inferior epigastric vein to an internal mammary vessel perforator
B) Convert to left prosthetic reconstruction
C) Infuse tissue plasminogen activator (tPA) to the DIEA
D) Initiate leech therapy
E) Revise the DIEV anastomosis to the retrograde internal mammary vessel limb
The correct response is Option A.
Venous drainage of the lower abdominal skin and subcutaneous tissue occurs primarily through the superficial venous system and secondarily through the deep venous system, with perforating veins interconnecting the two systems. These communicating veins have been identified on computed tomography angiography in approximately 90% of abdominal walls in vivo. The majority of the remaining 10% of patients likely have communicating veins that are too small to visualize or are absent. In these cases of anatomical superficial venous system dominance, venous drainage is dependent on the superficial venous system. A recently published 2012 article by Sbitany et al. demonstrated that the incidence of intraoperative venous congestion secondary to persistent superficial venous system dominance was 0.9% in 1201 muscle-sparing transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator free flaps. A free flap that becomes congested after reperfusion in the operating room should be assessed immediately for possible etiologies including twisting, kinking, tension, or vasospasm of the vascular pedicle. If a technical problem is ruled out and the venous anastomosis remains patent, obligatory enhancement of venous drainage with the superficial venous system is necessary to salvage the free flap rather than revision of the original anastamosis. Various methods include an anastomosis of the superficial inferior epigastric vein (SIEV) to the DIEV system or any chest wall vein, including the retrograde limb of the internal mammary vessel, the branch of the internal mammary vessel, or the thoracodorsal system. This requires preemptive planning and sparing of the superficial epigastric vein or SIEV during the dissection of the flap. A vein graft can be utilized if additional length is necessary. Another option is to substitute the DIEV anastomosis with the SIEV.
Tissue plasminogen activator (tPA) would not be indicated in this scenario, as it is used as a thrombolytic and there is no evidence of vascular thrombosis. Revising the DIEV anastomosis would be moot because it is patent and the deep system is being drained. Leech therapy is useful for venous congestion, but primarily as an adjunct after potential surgical etiologies have been addressed. Sacrificing the free flap without first attempting salvage is not warranted, and using a prosthetic would be possible only if prior patient consent were obtained
In embryologic breast development, which of the following best describes the formation of the mammary ridge?
A) Starts at the fifth or sixth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
B) Starts at the fifth or sixth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm
C) Starts at the seventh or eighth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
D) Starts at the seventh or eighth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm
E) Starts at the third or fourth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
The correct response is Option B.
Muntan, et al. described breast development as starting at the fifth or sixth week of development, when outgrowths from the ectodermal skin layer penetrate into the underlying mesoderm, forming the mammary ridge or milk line. The ectodermal thickenings along the mammary line regress between gestational months 2 and 4, except for two of them in the region of the third and fourth ribs. The ectoderm keeps on extending into the underlying mesoderm at the fifth month, and a branching network forms what will eventually become the lactiferous system. The supportive connective and adipose tissue of the breast develops from the surrounding mesenchyme.
A 65-year-old woman with a history of left mastectomy for breast cancer 10 years ago undergoes biopsy of a suspicious lesion of the right breast found on a recent mammogram. Examination of the biopsy specimen confirms a right breast carcinoma. This lesion most likely originated from which of the following structures?
A) Adipose tissue
B) Areolar skin
C) Lactiferous duct
D) Lymph node
E) Pectoralis major muscle
The correct response is Option C.
Women who were previously treated for breast cancer are at increased risk for development of a metachronous lesion of the contralateral breast. Cancers of the breast are typically adenocarcinomas, arising from the glandular tissue such as the ducts or lobules. Paget disease of the breast would involve the areolar skin but is fairly uncommon. Sarcomas arising from the connective tissue (such as adipose or muscle) are also rare. Breast adenocarcinomas do not originate from lymphatic tissue.
Which of the following mechanisms is most likely to inhibit normal wound healing in a patient who smokes cigarettes?
A) DNA strand breaks and helical cross-linking
B) Increased cosubstrate for enzymes involved in collagen production
C) Increased platelet aggregation
D) Increased tissue oxygen delivery
E) Nicotine-induced vasodilation
The correct response is Option C.
The detrimental effects of smoking on wound healing are due primarily to nicotine, carbon monoxide, and hydrogen cyanide. One of the effects of nicotine is increased platelet aggregation due to enhanced adhesiveness of the platelets themselves. This leads to thrombus formation and decreased oxygen delivery. Nicotine does not produce vasodilation, but rather vasoconstriction. Both of these effects can lead to local tissue ischemia, which inhibits the normal wound healing process.
One of the major mechanisms by which ionizing radiation inhibits wound healing is production of DNA strand breaks and helical cross-linking, but smoking is not significantly involved.
Vitamin C is the vitamin which plays the greatest role in wound healing. It is required as a cosubstrate for hydroxylase enzymes, which are involved in the production of collagen. Vitamin C deficiency has long been known to inhibit wound healing (scurvy). However, supplemental vitamin C in the nondeficient patient has not been shown conclusively to produce any beneficial wound-healing effects.
Which of the following comorbidities is associated with the highest risk of digital replant failure?
A) Alcohol abuse
B) Chronic obstructive pulmonary disease
C) Diabetes mellitus
D) Psychotic disorders
E) Tobacco use
The correct response is Option D.
In a study looking at all amputation injuries and digital replantations captured by the National Inpatient Sample from 2001 to 2012, the comorbid conditions associated with the highest risk of replant failure were psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk of replant failure increased 79% in a patient with a psychotic disorder. Alcohol abuse increased the risk of replant failure by 16%, tobacco use by 7%, diabetes by 3%, and chronic obstructive pulmonary disease by 1%. Interestingly, age in and of itself was not associated with a higher chance of replant failure in this and other studies.
References
Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. 2006 Sep;10(3):124-129.
Hustedt JW, Chung A, Bohl DD, et al. Evaluating the effect of comorbidities on the success, risk, and cost of digital replantation. J Hand Surg Am. 2016 Dec;41(12):1145-1152.
Nazerani S, Motamedi MH, Ebadi MR, Nazerani T, Bidarmaghz B. Experience with distal finger replantation: a 20-year retrospective study from a major trauma center. Tech Hand Up Extrem Surg. 2011 Sep;15(3):144-50.
An 80-year-old man sustains an extravasation injury to the dorsum of the arm secondary to administration of a dopamine infusion. Which of the following findings is an indication for a surgical intervention in this patient?
A) Blanching of the skin
B) Blistering
C) Erythema
D) Induration
E) Persistent pain
The correct response is Option E.
The indications for surgery in an extravasation injury include full-thickness skin necrosis, chronic ulceration, and persistent pain. Whereas blistering indicates a partial-thickness skin loss, it is alone not an indication for surgery. Erythema, induration, and poor capillary refill (blanching) are signs of extravasation injury but are not indications for an operative intervention.
References
Al-Benna S, O’Boyle C, Holley J. Extravasation injuries in Adults. ISRN Dermatol. 2013 May 8;2013:856541.
Scuderi N, Onesti MG. Antitumor agents: Extravasation, management, and surgical treatment. Ann Plast Surg. 1994 Jan;32(1):39-44.
A 43-year-old woman would like to discuss plans for breast reconstruction after her upcoming unilateral mastectomy. Postoperative radiation therapy is planned. Which of the following is the most likely benefit of tissue expander–based breast reconstruction compared with immediate autologous breast reconstruction using this patient’s abdominal tissue?
A) Better symmetry
B) Improved postoperative sensation
C) A larger, more ptotic breast reconstruction
D) Lower risk of complications from radiation
E) Preservation of the patient’s options for final reconstruction
The correct response is Option E.
Immediate breast reconstruction with tissue expanders followed by reconstruction of choice preserves the patient’s skin envelope and keeps open options for definitive final reconstruction of choice whether with an implant or autologous tissue.
Tissue expander-based reconstruction is associated with a higher complication rate in the setting of radiation therapy but preserves abdominal and back tissue as options for autologous reconstruction. Implant-based reconstruction does not provide the advantages of improved symmetry, sensation, or breast ptosis.
A 41-year-old woman comes to the office because of an invasive ductal carcinoma of the left breast. On mammography, the tumor is 3 cm from the nipple and measures 4 cm. A left-sided lateral periareolar scar extending from the 12 o’clock to the 3 o’clock position from a previous biopsy is noted. The patient wishes to undergo a nipple-sparing mastectomy. Which of the following findings places the patient at greatest oncologic risk, including risk for de novo or recurrent cancer or inadequate surgical margins, with this procedure?
A) Distance of tumor to nipple
B) Patient age
C) Presence of the periareolar scar
D) Size of tumor
E) Type of tumor
The correct response is Option D.
As surgical approaches to breast cancer treatment have evolved, nipple-sparing mastectomy (NSM) has emerged as an alternative to other approaches. It was initially used for prophylactic mastectomies, and patients reported increased satisfaction and body image with nipple-areola complex (NAC) preservation. The role of NSM has been expanded to therapeutic mastectomy, and with that there has been increased research in the oncologic safety of this approach.
Studies have evaluated therapeutic NSM in the context of invasive ductal carcinoma, invasive lobular carcinoma, and ductal carcinoma in situ. The type of cancer does not appear to be associated with the oncologic safety of NSM. Several studies have demonstrated an inverse association between NAC involvement and distance of the tumor from the nipple. While these studies have varied in their distance cutoffs, nipple involvement is reported to be over 50% when the tumor-nipple distance is less than 2 cm, as noted in one study. There is a direct correlation between tumor size and NAC involvement—the same study cited data that when the tumor was greater than 4 cm, the likelihood of nipple involvement was greater than 50%.
One published screening algorithm for plastic surgery includes tumor size less than 3 cm, and tumor location greater than 2 cm from the nipple as criteria for NSM candidacy.
A periareolar scar, if large, may compromise the blood supply to the NAC. Acceptable incisions for NSM, however, include a periareolar incision of 25 to 50%.
A 52-year-old woman undergoes immediate unilateral breast reconstruction with a free deep inferior epigastric flap. Near completion of the procedure, the flap skin paddle is noted to have venous congestion. On exploration of the pedicle, the anastomosis between the vena comitans and the internal mammary vessel appears patent. Which of the following preventive measures would most likely have averted this issue?
A) Administration of heparin immediately before release of vessel clamps and flap revascularization
B) Anastomosis of the veins using sutures instead of a venous coupling device
C) Preservation and anastomosis of the superficial inferior epigastric vein
D) Routine anastomosis of two venae comitantes per flap
E) Use of near-infrared fluorescence imaging to assess flap blood flow
The correct response is Option C.
Preservation of the superficial inferior epigastric veins (SIEV) during flap harvest is a useful preventive measure in microsurgical free tissue transfer operations. These veins can serve as important lifeboats to augment venous outflow in the setting of venous congestion. Typically, if a free flap demonstrates venous congestion, the inset should be taken down and the pedicle, recipient vessels, and anastomoses interrogated. Simple issues, such as mechanical compression or twisting of the vein should be ruled out. Next, the SIEV should be inspected. If it is engorged, it is likely that the flap is reliant on superficial outflow, and this vein should be connected to a recipient vessel to augment the venous outflow of the flap. Options for recipient veins include an anterograde branch on the pedicle vena comitans, or in a retrograde fashion to the vena comitans that was not used in the initial set of anastomoses.
Near-infrared fluorescence imaging technology can assist with flap design and may be useful for assessing the arterial inflow of the flap, but it has not been shown to correlate with flap loss or venous complications.
The use of one or two veins in microsurgical free tissue transfer is a topic that has been debated for several years. While some studies indicate that the use of two venous connections may decrease the velocity of blood flow across the anatomosis, there are no data to support differences in flap outcomes or thrombotic events. Therefore, the routine use of a second vein is largely up to surgeon preference.
Heparin may be a useful adjunct when thrombosis of the arterial or venous anastomosis is excised and a revision of the anastomosis is performed. Without evidence of thrombosis, it is unlikely to have any added benefit.
For venous anastomoses, the use of venous coupling devices has not been associated with patency issues or increased thrombosis rates. Therefore, a hand-sewn anastomosis is not likely to prevent the issue presented in this question.
A 44-year-old previously healthy woman comes to the clinic because of a 2-week history of a painless mass in the left breast. She initially felt this mass while taking a shower. Her mother was diagnosed with fibrocystic changes. The patient denies alcohol consumption and smoking cigarettes. Examination of the left breast shows a 5-cm mobile, painless mass in the left upper external quadrant without nipple discharge, skin retractions, or color changes. Examination of a specimen obtained on biopsy discloses a phyllodes tumor, and surgical excision of the lesion is planned. Which of the following is the most important factor to prevent local recurrence after surgery?
A) Adjuvant radiotherapy
B) Concurrent axillary node dissection
C) Postoperative chemotherapy
D) Surgical margins less than or equal to 0.5 cm
E) Wide surgical margins
The correct response is Option E.
In a young woman who has no history of breast cancer, presents with a painless mass, and has a mammogram suggestive of fibroadenoma but a core needle biopsy showing stromal hypercellularity with atypical spindle cells and a high mitotic rate, a phyllodes tumor must be suspected.
Phyllodes tumors are uncommon fibroepithelial breast tumors that behave like benign fibroadenomas, although they have a high propensity to recur locally. More aggressive tumors can metastasize distantly. Surgery is the preferred treatment for this condition. In this context, surgical margins greater than or equal to 1 cm have been associated with a lower recurrence rate in borderline and malignant tumors.
Axillary lymph node involvement is rare. Wide local excision or mastectomy with appropriate margins is the preferred clinical intervention.
Based on limited data, the role of systemic chemotherapy in phyllodes tumors is limited. Patients with benign or borderline phyllodes tumors are usually cured with surgery and should not be offered chemotherapy unless they develop unresectable metastases.
Local recurrence rate is higher after excision with narrower margins than broader ones. The efficacy of postoperative adjuvant radiotherapy for a breast phyllodes tumor is not clear. In clinical practice, the utilization of adjuvant radiotherapy for a phyllodes tumor appears to be modest.
A 42-year-old woman comes to the office for treatment after receiving a diagnosis of cancer of the right breast. She has decided to undergo mastectomy of the right breast. Which of the following is a relative CONTRAINDICATION to nipple-sparing mastectomy?
A) Comedo-type breast tumor
B) Invasive lobular carcinoma
C) Subareolar tumor
D) Tumor location 3 cm from the nipple
E) Tumor size of 2.5 cm
The correct response is Option C.
A relative contraindication to nipple-sparing mastectomy is a centrally located tumor. Although various authors have employed different distance criteria, it is generally accepted that patients whose tumors are within 2 cm of the nipple are not candidates for nipple-sparing mastectomy.
Nipple-sparing mastectomy is an appropriate option for high-risk patients undergoing prophylactic mastectomy and for patients diagnosed with breast cancer who meet certain criteria. Those criteria are: tumor size of 3 cm or less, at least 2 cm from the nipple, not multicentric, and with clinically negative nodes.
Comedo carcinoma of the breast is a type of ductal carcinoma in situ. It is considered to be an early stage of breast cancer, is confined to the ducts, and usually does not spread beyond. It is not a contraindication to nipple-sparing mastectomy.
Invasive lobular carcinoma originates from the breast lobules, may form a thickening of the breast tissue rather than a discrete mass, and is often bilateral. As long as it meets the above criteria, it is not a contraindication to nipple-sparing mastectomy.
Inflammatory breast cancer, Paget disease, and tumors infiltrating the skin are also not candidates for skin-sparing or nipple-sparing mastectomy, according to several authors.
In more recent studies, a tumor size of 3 cm or less appears to result in no increase in local or regional recurrence in nipple-sparing mastectomy compared with alternative surgical approaches. A tumor of 2.5 cm is not a contraindication to nipple-sparing mastectomy.
An 18-year-old woman comes to the office for evaluation of her breasts. Photographs of the patient are shown. Which of the following statements most accurately describes the anatomy of this patient’s breasts?
A) The areola is normal size although the breast is small
B) The breast tissue is uniformly distributed throughout the breast pocket
C) The inframammary fold is elevated
D) The skin envelope has greater laxity than in a normal breast
E) The underlying musculature is underdeveloped
The correct response is Option C.
The tuberous breast deformity results in a protruding, oblong shape that resembles a tuberous root plant (Latin derivation tuber = to swell). The features noted in the tuberous breast deformity include a constricted breast base, decreased breast parenchyma, abnormal elevation of the inframammary fold, a decreased skin envelope, and herniation of the breast parenchyma through the central breast and into the areola. The areola is large and lacks firm underlying structure, thus allowing the breast tissue to protrude through this path of least resistance. The deformity is also often referred to as a tubular breast, constricted breast, doughnut breast, nipple breast, breast with narrow base, dome nipple, and snoopy dog breast.
The overall etiologic factors leading to the full expression of the constricted breast deformity are still largely unknown and likely involve a delicate balance of anatomic and endocrinologic forces. A constricting fibrous ring at the level of the areola periphery, representing probably a thickening of the superficial fascia coupled with the normally absent fascial layer in the NAC, has been proposed as a likely cause. The ring is composed of dense fibrous tissue made of large concentrations of collagen and elastic fibers arranged longitudinally. It is usually denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. It has been suggested that a thickening of the superficial fascia combined with the absence of a superficial fascial layer under the NAC is the underlying anatomic/histopathologic cause of the deformity. The cause of the thickened fascia is unknown, although at least one study by Klinger, Caviggioli, et al. demonstrated altered collagen in both disposition and quantity. The same study excluded amyloid deposition as a component of the fibrosis.
The areola in the tuberous breast still contains the normal muscular structures that result in areolar changes with stimulation and temperature changes, although the tissue beneath the areola may be thinned.
A 46-year-old woman who is 5 ft 7 in (170 cm) tall and weighs 135 lbs (61 kg) is evaluated one year following bilateral nipple-sparing mastectomy and immediate reconstruction with placement of 350-mL smooth, round silicone gel implants beneath the pectoralis major muscle. Since the surgery, she has experienced hyperdynamic deformity of her breasts. On physical examination, the breast reconstruction appears natural, and there is significant movement of the breasts when the patient flexes her chest. Which of the following is the most appropriate management for this patient?
A) Inject botulinum toxin into the pectoralis major muscle
B) Inject triamcinolone-40 into the areas of tenderness using ultrasound guidance
C) Move the implants to the prepectoral plane and cover them fully with acellular dermal matrix
D) Perform a breast MRI to assess for rupture of the implants
E) Refer the patient to a physical therapist for range of motion, massage, and ultrasound treatments
The correct response is Option C.
This patient is experiencing significant movement because her implants were placed beneath the pectoralis major muscles. While reconstruction options are limited in this otherwise healthy and very thin patient who is not a good candidate for fat grafting or pedicled or free tissue transfer, placing implants over the pectoralis major muscles and covering the implants fully with acellular dermal matrix would be the most appropriate method of reconstructing her breasts and addressing her concerns.
Physical therapy and muscle relaxants are unlikely to produce long-term improvement. An MRI would likely be nondiagnostic, and even if her implants were ruptured, change to a prepectoral plane is still indicated. Botulinum toxin type A is likely not as effective for long-term significant improvement as reoperation. Triamcinolone would not be effective for hyperdynamic deformity.
A 33-year-old woman comes to the office for consultation because she is dissatisfied with the “sagging” appearance of her breasts. Examination shows grade II ptosis and loss of fullness in the upper pole. A vertical mastopexy is planned. The most common medial innervation to the nipple-areola complex is the anterior cutaneous branches of which of the following intercostal nerves?
A) Second and third
B) Third and fourth
C) Fourth and fifth
D) Fifth and sixth
E) Sixth and seventh
The correct response is Option B.
The most common medial innervation of the nipple-areola complex is mainly 57% from the anterior cutaneous branches of the third and fourth intercostal nerves. The third intercostal nerve accounts for 21.4%. They always reach the areolar edge between 8 and 11 o’clock on the left and 1 and 4 o’clock on the right. The nerve innervation to the nipple-areola complex is important in planning different incisions around the areola in both reduction mammaplasty and mastopexy.
A 45-year-old woman with a T2 N0 M0 invasive ductal carcinoma in the inferior pole of the left breast is scheduled to undergo segmental mastectomy followed by radiation therapy. She currently wears a size 36E brassiere and wants to have any cup size from a C to D. After segmental resection of the tumor, which of the following procedures is most likely to yield the best cosmetic result in this patient?
A) Bilateral reduction mammaplasty
B) Primary closure of the left breast and reduction mammaplasty of the right breast
C) Reconstruction of the left breast with a latissimus dorsi musculocutaneous flap and reduction mammaplasty of the right breast
D) Reconstruction of the left breast with a transverse rectus abdominis musculocutaneous flap and mastopexy of the right breast
E) A single-stage breast reconstruction with placement of a silicone prosthesis in the left breast and reduction mammaplasty of the right breast
The correct response is Option A.
In a patient with large breasts, in whom a partial mastectomy is required, reduction mammaplasty is an appropriate management. This procedure will potentially relieve symptoms of macromastia, reduce the amount of breast tissue present in both breasts, and offer the best aesthetic outcome. Implantation of a prosthesis in a breast that will undergo radiation therapy increases the risk for complications and would likely lead to a less symmetrical result. The latissimus dorsi or transverse rectus abdominis musculocutaneous (TRAM) flaps could be used for immediate partial reconstruction, but they are ideal for delayed reconstruction of partial mastectomy defects. Reduction mammaplasty does not preclude future reconstruction options, but a latissimus flap reconstruction would. With a T2 tumor, a significant portion of the lower pole of the breast is removed to obtain clear margins. Even though the patient described has moderate-to-large breasts, there is a high likelihood that she will develop a deformity of the left breast and asymmetry with the right breast if no reconstruction is performed.
A 20-year-old man is brought to the emergency department after sustaining a stab wound to the neck during a violent assault. Physical examination shows an expanding neck hematoma and stridor. Intraoperative exploration shows a deep laceration to the anterior lateral neck at the level of thyroid cartilage and profuse extravasation of blood from the carotid sheath. According to anatomical zone-based classification of penetrating neck injuries, which of the following zones is involved?
A) Zone 1
B) Zone 2
C) Zone 3
D) Zone 4
The correct response is Option B.
“Penetrating neck injury represents 5-10% of all trauma cases. It is important for clinicians to be familiar with management principles, as mortality rates can be as high as 10%.”
Penetrating neck injury describes trauma to the neck that has breached the platysma muscle. The most common mechanism of injury worldwide is a stab wound from violent assault, followed by gunshot wounds, self harm, road traffic accidents, and other high velocity objects. The neck is a complex anatomical region containing important vascular, aerodigestive, and neurological structures that are relatively unprotected. Arterial injury occurs in approximately 25% of penetrating neck injuries; carotid artery involvement is seen in approximately 80% and vertebral artery in 43%.
Hard signs indicating immediate explorative surgery in penetrating neck injury:
Shock
Pulsatile bleeding or expanding hematoma
Audible bruit or palpable thrill
Airway compromise
Wound bubbling
Subcutaneous emphysema
Stridor
Hoarseness
Difficulty or pain when swallowing secretions
Neurological deficits
The assessment and management of penetrating trauma to the neck has traditionally centered on the anatomical zone-based classification first described by Monson et al. in 1969
Zone 1 extends from clavicles to cricoid, zone 2 from cricoid to angle of mandible, and zone 3 from angle of mandible to skull base.
There are only 3 zones in penetrating neck injuries.
References
Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma. 1969;9(12):987-999.
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018;100(1):6-11.
Saito N, Hito R, Burke PA, Sakai O. Imaging of penetrating injuries of the head and neck: current practice at a level I trauma center in the United States. Keio J Med. 2014;63(2):23-33.
Vishwanatha B, Sagayaraj A, Huddar SG, Kumar P, Datta RK. Penetrating neck injuries. Indian J Otolaryngol Head Neck Surg. 2007;59(3):221-224.
A 47-year-old woman comes to the office after sustaining an injury to the left wrist after falling on her outstretched hand. Examination shows pain of the radial aspect of the left wrist and anatomical snuffbox. Scaphoid fracture is suspected. When obtaining posterior-anterior x-ray studies, which of the following is the optimal positioning of the wrist for evaluation of the entire scaphoid?
A) Wrist in 20 degrees of radial deviation, 20 degrees of wrist extension
B) Wrist in 20 degrees of radial deviation, 20 degrees of wrist flexion
C) Wrist in 20 degrees of ulnar deviation, 20 degrees of wrist extension
D) Wrist in 20 degrees of ulnar deviation, 20 degrees of wrist flexion
E) Wrist in neutral radial/ulnar position, neutral flexion/extension
The correct response is Option C.
Scaphoid fractures are the most common carpal fracture and frequently occur after a fall onto an extended and radially deviated wrist. Initial workup often involves plain x-ray studies, which have a sensitivity of approximately 85%. The optimal position of the wrist when imaging scaphoid fractures includes ulnar deviation and wrist extension, which allows for evaluation of the long axis of the scaphoid. CT scan or MRI may be used as additional imaging if plain x-ray studies do not demonstrate a fracture, yet there is high clinical suspicion.
A 40-year-old woman is evaluated in the emergency department after she fell on her outstretched hand while playing tennis. Examination shows tenderness of the wrist. After the scaphoid, which of the following carpal bones is most likely fractured in this patient?
A) Capitate
B) Hamate
C) Lunate
D) Pisiform
E) Triquetral
The correct response is Option E.
The triquetral is the second most commonly fractured carpal bone. Most triquetral fractures are dorsal ridge fractures that appear as avulsion fractures on lateral view wrist x-ray studies.
The most common carpal bone fracture incidences in order of frequency are scaphoid, triquetral, trapezium, lunate, and hamate.
A 27-year-old man sustained multiple facial fractures when he was involved in a motorcycle collision. On arrival to the emergency department, blood pressure is 80/50 mmHg and heart rate is 150 bpm. Significant retropharyngeal bleeding is noted. Trauma workup reveals no other injuries. CT angiography shows active bleeding from the right maxillary artery. Angioembolization is planned and massive transfusion protocol is initiated. Which of the following is the most appropriate intravenous resuscitation in this patient?
A) Fresh frozen plasma (FFP) and packed red blood cells (pRBC) in a 1:1 ratio; discontinuation of crystalloids
B) FFP and pRBC in a 1:1 ratio; crystalloids via rapid transfuser (max rate)
C) FFP and pRBC in a 1:4 ratio; crystalloids at 125 cc/h
D) FFP and pRBC in a 1:4 ratio; discontinuation of crystalloids
E) FFP and pRBC in a 4:1 ratio; crystalloids via rapid transfuser (max rate)
The correct response is Option A.
For initiation of a massive transfusion protocol, transfusing fresh frozen plasma (FFP) and packed red blood cells (pRBC) at a 1:1 ratio and discontinuing intravenous crystalloids is the most appropriate next step in patient management.
Massive Transfusion Protocol guidelines have been set forth by the American College of Surgeons through its Trauma Quality Improvement Program (TQIP). Recommendations for initiating a massive transfusion protocol include:
Beginning universal blood product infusion rather than crystalloid or colloid solutions,
Transfusing universal pRBC and FFP in a ratio between 1:1 and 1:2 (FFP:pRBC),
Transfusing one single donor apheresis or random donor platelet pool for each six units of pRBC.
It is also suggested to deliver PRBC and FFP by a rapid transfuser and through a blood warmer, and that the initial rate of transfusion should restore perfusion while allowing for “permissive hypotension” until the operation or angioembolization to stop the bleeding begins.
A 28-year-old woman comes to discuss primary augmentation mammaplasty options and is deciding between form-stable shaped implants and less cohesive round silicone gel implants. She inquires about the benefits of each type of implant. Compared with smooth round silicone gel implants, highly cohesive form-stable gel implants have a decreased incidence of which of the following?
A) Capsular contracture
B) Implant malposition
C) Infection
D) Seroma
The correct response is Option A.
Form-stable silicone gel implants are fifth-generation, shaped, and textured implants that have additional cross-linking between molecules. They are purported to have several advantages over other round saline and silicone gel implants because they retain their shape and decrease the incidence of folding and rippling. This has translated into significantly lower capsular contracture rates.
However, they do have some disadvantages. Because they are shaped and maintaining orientation is critical, they have a higher incidence of malposition. They are also more prone to seroma formation, which may be associated with their textured surface.
Infection and resorption rates remain similar.
A 22-year-old man who has consumed alcoholic beverages punches a concrete wall with both hands and sustains multiple metacarpal fractures. Which of the following will cause the most significant long-term hand impairment in this patient?
A ) Fifth metacarpal neck fracture with 40-degree angulation
B ) Fourth metacarpal neck fracture with 35-degree angulation
C ) Fourth metacarpal shaft fracture with 10-degree angulation
D ) Third metacarpal neck fracture with 25-degree angulation
E ) Third metacarpal shaft fracture with 0-degree angulation
The correct response is Option D.
Angulation is better compensated for in the ring and little fingers. The carpometacarpal (CMC) joints of these digits have 20 to 30 degrees of mobility in the sagittal plane. Angulation deformities in the little finger up to 40 to 70 degrees have been followed and found to have no functional impairment.
However, because of the lack of compensatory CMC motion in the index and long metacarpal neck fractures, there is universal agreement that residual angulation greater than 10 to 15 degrees should not be accepted.
Metacarpal shaft fractures generally require reduction for angulation greater than 30 degrees in the little finger, 20 degrees in the ring finger, and any angulation in the long and index fingers.
A 36-year-old woman with genetic susceptibility to breast cancer is scheduled to undergo bilateral prophylactic mastectomy. She has elected to proceed with immediate single-stage reconstruction using permanent silicone implants and acellular dermal matrix. Which of the following is the most sensitive method to detect implant rupture in this patient?
A) CT scan
B) Mammography
C) MRI
D) Physical examination
E) Ultrasonography
The correct response is Option C.
Implant rupture is one of the most common reasons for implant removal. While implant rupture can be associated with symptoms such as capsular contracture, it is often completely asymptomatic or “silent.” For this reason, screening imaging to detect such ruptures has been recommended.
According to the 2011 Update on the Safety of Silicone Gel-Filled Breast Implants published by the U.S. Food and Drug Administration, it is currently recommended that women with silicone implants get their first MRI 3 years after they receive the implants and every 2 years thereafter to detect silent ruptures.
Since the rate of rupture increases the longer an implant is in place, not screening is unacceptable.
Mammograms can detect extracapsular silicone when an implant ruptures, but they do not detect intracapsular ruptures.
The accuracy of ultrasound largely depends on the skill of the ultrasound technologist, the type of equipment used, and the experience of the interpreting physician. Furthermore, ultrasound is limited in its ability to detect ruptures in the back wall of the implant and in the breast tissue behind it.
CT scans can detect intracapsular silicone gel-filled breast implant rupture, but they are limited in their ability to detect extracapsular ruptures.
A 48-year-old woman, gravida 3, para 3, who wears a size 36B bra comes to the physician for evaluation of breast ptosis. BMI is 24 kg/m2. Physical examination shows the distance from sternal notch to nipple is 28 cm, and there is grade 2 breast ptosis with skin laxity. A combined augmentation/mastopexy is planned. Which of the following is the biggest risk of combining the procedures rather than staging them?
A) Hematoma
B) Need for revision procedure
C) Nipple-areola complex necrosis
D) Seroma
E) Transection of lateral intercostal nerves
The correct response is Option B.
Combining an augmentation with a mastopexy has long been considered risky because the surgeon is addressing two opposing forces during the same operation: the ptosis and volume, for which the placement of additional weight may exacerbate ptosis. Studies have shown, however, that the two operations can safely be combined. During the planning, particularly for severe ptosis, the surgeon must be careful not to overresect skin that will be critical for closure over an implant.
Compared with staged procedures, mastopexy-augmentation has a higher rate of need for revision procedures. Patients should be counseled about the potential need for revisions.
Seroma and hematoma are not increased when combining the procedures, and nipple-areola complex necrosis is a function of pedicle size and patient-specific factors such as obesity and tobacco use, rather than the combination of procedures. Similarly, transection of intercostal nerves is associated more closely with pedicle type than with combining procedures.
The use of routine systemic antibiotic prophylaxis is indicated in which of the following procedures?
A) Abdominoplasty
B) Carpal tunnel release
C) Excision of squamous cell carcinoma of the skin
D) Reduction mammaplasty
E) Rhytidectomy
The correct response is Option D.
Systemic antibiotic prophylaxis is recommended in clean breast surgery. Studies have shown that the use of antibiotic prophylaxis in patients undergoing breast surgery (with or without implant) significantly reduces the risk of surgical site infections. The benefit from routine antibiotic prophylaxis is greater in individuals receiving tissue expanders or breast implants for reconstruction, but patients undergoing breast augmentation or reduction mammaplasty also benefit from antibiotic prophylaxis. With the exception of cosmetic breast surgery, clean operations have not been shown to benefit from routine antibiotic prophylaxis. Therefore, the use of routine antibiotic prophylaxis is not indicated in clean surgical cases of the hand (carpal tunnel release), skin (squamous cell carcinoma of the skin), head and neck, or abdominoplasty. It is indicated in contaminated surgery of the hand or face.
A 24-year-old man is scheduled to undergo reconstruction for avascular necrosis of the proximal pole of the scaphoid with a free osteochondral bone flap. Which of the following arteries is the most commonly encountered vascular pedicle for the medial femoral condyle free bone flap?
A) Anterior tibial recurrent
B) Descending genicular
C) Popliteal
D) Saphenous
E) Superficial femoral
The correct response is Option B.
The medial femoral condyle free bone (corticocancellous) flap has been shown to be an excellent option for treatment of complicated degenerative bone pathology in the wrist, particularly scaphoid avascular necrosis. The Mayo group has also shown improved outcomes for scaphoid nonunion with humpback deformity compared with pedicled flaps from the distal radius. The same group has shown more consistent presence of supply from the medial superior genicular artery, which can be used in cases where the descending genicular artery is insufficient, although the pedicle length of the medial superior genicular artery is generally shorter. More recent anatomic analysis has shown this vessel can supply flaps up to 11 cm in length.
The (superficial) femoral and popliteal arteries are larger, regional vessels, with the superficial femoral artery being the immediate source vessel for the descending genicular artery. The popliteal artery is the source vessel for the medial superior genicular artery. The anterior tibial recurrent artery is distal and lateral, lying over the lateral aspect of the tibial plateau, and does not supply the medial femoral condyle. The saphenous artery has been described as a branch of the superficial femoral supplying the skin paddle overlying the medial femoral condyle but does not supply the bone.
A 46-year-old woman with ductal carcinoma in situ is scheduled to undergo right mastectomy. Immediate reconstruction with a tissue expander and acellular dermal matrix (ADM) is planned. Which of the following is an expected outcome with use of ADM?
A) Decreased formation of seroma
B) Decreased incidence of hematoma
C) Decreased risk of infection
D) Increased capsule contracture
E) Increased initial fill of the expander
The correct response is Option E.
According to Sbitany, et al, acellular dermal matrix (ADM) allows for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. Sbitany, et al, concluded that ADM-assisted prosthesis breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.
ADM has enhanced prosthesis-based reconstruction and remains useful in immediate prosthetic breast reconstruction. However, it has been found to have higher rates of postoperative seroma and infection. It has also been reported to decrease capsule contracture.
A 27-year-old woman comes to the office for evaluation of bilateral hand pain. The patient reports worsening pain when she retrieves items from the freezer and says that in the winter she experiences pain in her fingers unless she wears electric, heated gloves and on occasion her fingers will turn white and blue. Medical history includes no personal or family history of joint or skin problems. Physical examination shows the patient’s fingers are warm, and wrist pulses are palpable. Which of the following is the most appropriate initial management of this patient’s symptoms?
A) Botulinum toxin type A injection
B) Oral nifedipine
C) Temperature biofeedback
D) Thoracoscopic sympathectomy
E) Topical nitroglycerin
The correct response is Option B.
Patients presenting with Raynaud syndrome fall into two classic categories: primary (traditionally referred to as Raynaud disease) and secondary (Raynaud phenomenon, associated with an underlying condition, most commonly involving an autoimmune process). In this woman presenting without an underlying etiology for her vasospastic symptoms, primary treatment should be directed at managing the vasospasm. Although a plethora of interventions have been tried, recent reviews show the calcium-channel blockers, such as nifedipine, to be the optimal first-line intervention.
Temperature biofeedback has shown variable effect in multiple small trials, and, consequently, it is not recommended as a primary intervention for vasospasm.
Topical nitrates can assist with vasodilation in the digits, making them an occasional adjunct treatment for symptoms not completely managed by calcium channel blockers. In isolation, topical nitrates have been ineffective for managing Raynaud syndrome.
Multiple small trials have demonstrated successful relief of pain and digital ulcers in a mixed group of both primary and secondary Raynaud syndrome with injection of botulinum toxin around the digital vessels in the palm. The cost and risk of temporary paralysis to intrinsic muscles, however, renders this a second-line treatment for refractory pain or nonhealing ulcers. Treatment of digital vasospasm is still considered an “off-label” use of botulinum toxin and may not be covered by insurance.
Surgical sympathectomy, either proximally through a thoracoscopic approach or peri-arterially in the wrist and hand, represents the most aggressive treatment and would typically be reserved for patients with nonhealing wounds or chronic ischemic changes. These procedures are gradually being supplanted by injection of botulinum toxin type A.
References
Butendieck RR, Murray PM. Raynaud Disease. J Hand Surg Am. 2014 39 (1):121-4.
Wigley FM, Flavahan NA. Raynaud’s Phenomenon. N Engl J Med. 2016 Aug 11;375(6):556-65.
Valdovinos ST, Landry GL. Raynaud Syndrome. Tech Vasc Interv Radiol. 2014 Dec;17(4):241-6.
A 77-year-old man undergoes wide local excision of a melanoma on the posterior shoulder. Concomitant sentinel lymph node biopsy is positive for metastasis. Completion axillary lymph node dissection and adjuvant radiation therapy to the axilla are performed. Metastatic workup shows no abnormalities. Postoperatively, the patient develops chronically draining seroma and open wound to the axilla. He is referred for management of the radiation wound after it fails to improve with conservative local wound care. Physical examination shows a 2-cm open wound to the axilla, which tunnels 5 cm into the apex and is surrounded by extensive fibrosis and erythema. Which of the following interventions is most likely to result in a definitive closure?
A) Administration of 30 hyperbaric oxygen treatments at 2.4 ATA
B) Application of negative pressure wound therapy
C) Excision of the wound cavity and full-thickness skin graft reconstruction
D) Excision of the wound edges and application of acellular dermal matrix
E) Wide excision of the irradiated soft-tissues and repair with a thoracodorsal artery perforator flap
The correct response is Option E.
Radiation damage produces a hypoxic, hypovascular, and hypocellular environment that can lead to delayed healing and even ulcer formation. Principles of management once a chronic radiation wound has developed include aggressive surgical removal of the entire zone of injury, which is sometimes larger than initially anticipated, and repair with well-vascularized tissue. A thoracodorsal artery perforator flap will provide sufficient healthy and supple soft tissue to cover the entire axilla. The thoracodorsal pedicle should be intact as it is not regularly divided during axillary lymph node dissection.
Negative pressure wound therapy would be contraindicated in this wound because of the potential for exposure of blood vessels in the axilla as well as for sponge retention in the tunneled wound and is, therefore, incorrect.
Excision of the wound edges only may be inadequate treatment of the zone of injury, and it is not the best choice. Furthermore, acellular dermal allograft plays no role, aside from possibly a temporizing measure, in the treatment of radiation ulcers.
Hyperbaric oxygen therapy is indicated for soft tissue radionecrosis. This delivers increased levels of oxygen to the hypoxic, irradiated wound and establishes a steeper oxygen gradient between the wound and surrounding tissues. The cellular response to this gradient stimulates neovascularization and can improve or even heal some wounds. However, with this large, cavitary wound, hyperbaric oxygen therapy, as a single-line treatment, would be unlikely to heal the wound completely.
Excision of the wound cavity and full-thickness skin graft reconstruction is not the best option for two reasons. First, the excision may lead to exposure of neurovascular structures that should not be covered with a skin graft. Second, risk of partial or total loss of a full-thickness skin graft may be unacceptably high in an irradiated wound bed.
A 45-year-old woman comes to the office 10 years after undergoing subglandular implantation of textured silicone implants for augmentation mammaplasty. Physical examination shows swelling of the left breast. She is concerned about cancer. Increased incidence of which of the following malignancies is associated with breast implants?
A) Acute myeloid leukemia
B) Anaplastic large cell lymphoma
C) Angiosarcoma
D) Infiltrating ductal carcinoma
E) Malignant fibrous histiocytoma
The correct response is Option B.
Several reports have suggested an association between breast implants and anaplastic large cell lymphoma (ALCL), which is an extremely rare malignancy. In these cases, ALCL has usually occurred several years after implantation as swelling or a mass around the implant and is often associated with a periprosthetic seroma. Treatments have included capsulectomy with implant removal and chemotherapy and/or radiation therapy, though there is no defined consensus regimen. Despite evidence of an increased risk of ALCL in breast implant patients, the absolute risk remains extremely low.
Several large epidemiologic studies have demonstrated a similar or lower incidence of breast cancer (infiltrating ductal carcinoma) among patients who have undergone prosthetic augmentation mammaplasty surgery compared with those who have not. Most cases of ALCL have been in textured implants.
Angiosarcoma and malignant fibrous histiocytoma are two sarcomas that may arise in the breast. Angiosarcoma may be caused by radiation therapy for breast cancer. Neither of these sarcomas has been associated with breast implants.
Acute myeloid leukemia may be associated with radiation treatment to the breast but has not been associated with breast implants.
A 28-year-old postpartum woman comes to the office for evaluation of breast asymmetry with pain and enlargement of the right breast for 2 months. Medical history includes augmentation mammaplasty 4 years ago. She denies fever or chills. She was previously breast-feeding but stopped this 1 month ago. Physical examination shows the right breast is significantly larger than the left breast. A well-healed peri-areolar incision is present and no evidence of infection is noted. Ultrasound shows a complex cyst, which yields 150 cc of milky fluid. A drain is placed. The most appropriate next step is administration of which of the following medications?
A) Bromocriptine
B) Cephalexin
C) Fluconazole
D) Prolactin
E) Trimethoprim-sulfamethoxazole
The correct response is Option A.
This postpartum patient is presenting with a symptomatic galactocele after breast-feeding. Galactoceles are benign breast cysts containing milk. They typically occur in women of childbearing age in the setting of active lactation, recent pregnancy, or the use of hormonal medications such as oral contraceptives. The galactocele is thought to occur from ductal obstruction. Although the presence of a breast implant and the respective pocket placement is unknown to have an effect on the development of galactoceles, there is some thought that peri-areolar incisions may contribute to the ductal obstruction. There are, however, documented cases of post-augmentation galactocele without peri-areolar incisions.
Treatment for a galactocele is typically medical with the initiation of oral bromocriptine. Bromocriptine is a dopamine receptor agonist and causes inhibition of prolactin secretion, which is the primary hormone responsible for milk production. Dosage is titrated to effect. Incision and drainage of the cyst, particularly in the setting of implants, is often performed as well to rule out the possibility of infection.
Cephalexin and trimethoprim-sulfamethoxazole are antibiotics and are not indicated in this case because there is no active infection. Fluconazole is indicated for the treatment of fungal infections. Prolactin would actually stimulate milk production and would worsen the patient’s symptoms.
A 40-year-old man comes to the office for evaluation of a nonhealing scaphoid fracture. History includes bone grafting for avascular necrosis of the proximal pole, but there is evidence of nonunion. Carpal collapse and humpback deformity are also noted. Reconstruction with a vascularized medial femoral condyle flap is scheduled. Which of the following arteries provides the blood supply to this flap?
A) Descending genicular artery
B) Lateral circumflex femoral artery
C) Medial circumflex femoral artery
D) Peroneal artery
E) Profunda femoris artery
The correct response is Option A.
The descending genicular artery supplies the medial femoral condyle flap. The descending genicular artery is a branch of the superficial femoral artery. This corticoperiosteal flap has been used with increasing frequency for small bony defects and the treatment of nonunion. A cutaneous component can also be harvested based on a saphenous artery branch.
The anterolateral thigh flap is based off the lateral femoral circumflex artery perforators. The gracilis muscle flap is based off vessels from the medial circumflex femoral artery; perforator flaps can also be designed based off this vascular system. The profunda femoris supplies the posterior thigh flap. The peroneal artery provides the vascular supply to the fibula flap.
The stylopharyngeus muscle is innervated by which of the following nerves?
A) Facial (VII)
B) Glossopharyngeal (IX)
C) Hypoglossal (XII)
D) Trigeminal (V)
E) Vagus (X)
The correct response is Option B.
The pharyngeal muscles are all innervated by the vagus (X) nerve, except the stylopharyngeus muscle, which is innervated by the glossopharyngeal nerve (IX).
The trigeminal nerve (V) is responsible for facial and oral sensation. The maxillary branch (V2) is responsible for sensation of the upper teeth, upper lip, hard palate, cheeks, and nasopharyngeal mucosa. The mandibular branch (V2) provides sensory fibers for the lower teeth, lower mucosa of the mouth and the anterior two-thirds of the tongue. The facial nerve (VII) provides motor innervation of the muscles of facial expression and the posterior bellies of the stylohyoid and digastric muscles. The vagus nerve (X) provides motor innervation to all of the pharyngeal muscles except the stylopharyngeus muscle. The hypoglossal nerve (XII) provides motor innervation to the intrinsic and extrinsic tongue muscles and also provides motor innervation to the geniohyoid muscle through the ansa cervicalis.
References
Costa MMB. Neural control of swallowing. Arq Gastroenterol. 2018 Nov;55 Suppl 1(Suppl 1):61-75.
Netter FM. Glossopharyngeal nerve: schema [print]. In: Netter FM. Atlas of Human Anatomy. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010:plate 119.
A 54-year-old woman undergoes bilateral immediate tissue expander–based breast reconstruction. BMI is 36 kg/m2. On postoperative day 10, examination shows bilateral breast erythema; empiric antibiotics are started. In addition to Staphylococcus species, which of the following bacteria should be treated as the next most likely pathogen?
A) Bacteroides fragilis
B) Enterococcus faecalis
C) Mycobacterium marinum
D) Pasteurella multocida
E) Pseudomonas aeruginosa
The correct response is Option E.
After Staphylococcus aureus and S. epidermidis, Pseudomonas aeruginosa is among the the next most common sources of breast infections. It is common in hospitalized or immunocompromised patients, as well as patients with foreign body devices such as catheters or implants. It is a gram negative rod, and common antibiotic treatments include advanced β-lactams (piperacillin, ceftazidime), carbapenems, quinolones, and aminoglycosides. Dual coverage is often recommended in severe infections. In the case of breast implant infections, if there is not rapid improvement on antibiotic therapy, or if significant systemic symptoms develop (vital sign instability, high white blood cell count, fever, renal impairment), then surgical washout and device removal is mandatory. In patients without systemic symptoms, wash out and new implant placement can be an option in carefully selected and counseled patients. Other breast pathogens include Escherichia coli, Propionibacterium, and Corynebacterium.
More than 300,000 breast implant procedures are performed each year in the United States. In reconstructive cases, the infection rate averages 6% and the explantation rate 3% (range, 1.5 to 8%). Preventative measures include proper patient selection, preoperative MRSA management when carriers are suspected, routine presurgery chlorhexidine washes, proper antibiotic timing presurgery and continuation of antibiotics in implant reconstruction cases for at least 24 hours (though the optimal treatment duration has not yet been determined).
None of the other bacteria listed are common in breast infections, though all are common pathogens. Bacteroides are anaerobic gram-negative rods that are common in gut flora and feces.
Enterococcus faecalis is a frequent cause of nosocomial infection, with a high prevalence of multi-drug resistance. It is a gram-positive coccus, and is not commonly seen in breast surgery patients as it primarily colonizes the digestive tract.
Mycobaterium marinum is a rare pathogenic cause of hand infections from injuries that occur in aquatic environments.
Pasteurella multocida is a frequent cause of animal bite infections, particularly from cats and dogs.
When performing immediate breast reconstruction, it is important to reconstruct the lateral inframammary fold. This is because the oncologic extirpation of the breast is carried out to which of the following anatomic landmarks?
A) Anterior edge of the latissimus dorsi muscle
B) Anterior edge of the serratus muscle
C) Lateral edge of the pectoralis major muscle
D) Lateral edge of the pectoralis minor muscle
E) Posterior edge of the serratus muscle
The correct response is Option A.
For modified radical and simple mastectomies, the landmarks of dissection are: superiorly to the clavicle, medially to the sternum, inferiorly to the inframammary fold, and laterally to the border of the latissimus dorsi muscle. The pectoralis major muscle fascia is resected with the specimen.
The recreation of the inframammary fold is important for shaping in breast reconstruction and care must be taken to evaluate and repair both the inferior and lateral components of the inframammary fold.
A 28-year-old man is brought to the emergency department after sustaining injury during a motor vehicle collision. Cranialization of the frontal sinus is planned. Which of the following best describes the components of cranialization?
A) Removal of the anterior table, reconstruction of the posterior table with a titanium plate, and closure of the dura
B) Removal of the posterior table, sinus mucosa, and closure of the sinonasal tract
C) Repair of both the posterior and anterior tables with bioabsorbable plates, and obliteration of the frontal sinus
D) Repair of the anterior table and obliteration of the frontal sinus
E) Repair of the posterior table with bioabsorbable plates, removal of the sinus mucosa, and closure of the dura
The correct response is Option B.
Cranialization involves removal of the posterior table (not repair), closure of the dura, sinonasal tract, and obliteration of the sinus mucosa. Management of the anterior table is as indicated.
Surgical repair of the anterior table is indicated if there is nasofrontal duct involvement, or, in the absence of nasofrontal duct involvement (such as a minimally displaced anterior table), patient desire for a better aesthetic outcome. If there is nasofrontal duct involvement, the nasofrontal duct and frontal sinus can be obliterated (repair of the anterior table and obliteration of the frontal sinus).
Bioabsorbable or titanium plates can be used to fixate the fractured anterior table. It is not used for the posterior table.
A 49-year-old woman is evaluated because of a traumatic laceration of the right lower eyelid and cheek. Physical examination shows difficulty with eyelid closure, voluntary squinting, and animation. Which of the following branches of the facial nerve is most likely injured?
A) Buccal
B) Cervical
C) Marginal mandibular
D) Temporal
E) Zygomatic
E) Zygomatic
The correct response is Option E.
Anatomically, the orbicularis oculi muscle is divided into three segments: pretarsal, preseptal, and orbital. However, functionally, the orbicularis oculi muscle is divided into the medial inner canthal orbicularis and the extracanthal orbicularis. The medial inner canthal orbicularis is responsible for blinking, lower lid tone, and the pumping mechanism of the lacrimal system. Innervation to the inner canthal orbicularis is from the buccal branches of the facial nerve. The zygomatic branch of the facial nerve innervates the extracanthal orbicularis, which controls eyelid closure, voluntary squinting, and animation. The temporal, marginal mandibular, and cervical branches do not provide innervation to the orbicularis oculi muscle.
A 68-year-old woman comes to the office for a delayed breast reconstruction. She had right breast cancer and a mastectomy followed by chemotherapy and radiation therapy 1 year ago. BMI is 35 kg/m2. Medical history includes well-controlled type 2 diabetes mellitus, a previous cesarean section through a low transverse incision, and an open cholecystectomy through a subcostal incision. The patient requests autologous reconstruction, but the surgeon is not comfortable performing a free flap. Which of the following is the most appropriate method for reconstruction?
A) Bipedicled transverse rectus abdominis musculocutaneous (TRAM) flap
B) Contralateral pedicled TRAM flap
C) Ipsilateral pedicled TRAM flap
D) Surgical delay procedure followed by contralateral pedicled TRAM flap
E) Surgical delay procedure followed by ipsilateral pedicled TRAM flap
The correct response is Option D.
In this obese patient with right breast cancer and a previous subcostal incision, a delay procedure with a contralateral transverse rectus abdominis musculocutaneous (TRAM) flap is the most appropriate method for reconstruction. Although a contralateral TRAM flap can be performed without a delay procedure, it has been shown that the addition of a delay procedure decreases risks of ischemia to the flap. In addition, a delay procedure may also reduce risks of abdominal wall complications. In this patient, the subcostal incision excludes right-sided pedicled flap reconstruction, so an ipsilateral pedicled TRAM would not be the right choice, nor would a bipedicled TRAM flap.
Although there is controversy on which patients should have a delay procedure, the use of this technique has usually been limited to high-risk patients and to those requiring large amounts of tissue. Multiple reports have shown that obese patients undergoing a delay can decrease the risks of tissue related ischemia. In a paper by Wang et al., the delay procedure was performed at least 14 days prior to the reconstruction; however, other studies have shown improvements at 7 days. The procedure described consists of ligation of both deep inferior epigastric arteries and veins bilaterally accessed from an inferior flap incision. This can also be done laparoscopically. Some authors advocate more extensive incisions and elevating portions of the flap; however, there is little data to show that this is effective or necessary.
A 30-year-old man is scheduled to undergo transhumeral amputation after unsalvageable brachial artery occlusion. A photograph is shown. Use of targeted muscle reinnervation may allow improved functional recovery by which of the following means?
A) Better bulk and durability by preventing denervation atrophy of muscles at the amputation stump
B) Better prosthesis control by input from median and ulnar nerve signals
C) Better sensory detection in the prosthesis by positioning amputated nerve stumps closer to the skin closure
D) More precise control of an osseointegrated body-powered prosthesis
E) Preservation of greater bony length in the amputation stump
The correct response is Option B.
A body-powered prosthesis uses motion of remaining joints, such as the gleno-humeral and scapulo-thoracic joints, to control an upper extremity prosthesis.
Targeted muscle reinnervation (TMR) would not affect function of a body-powered prosthesis. TMR positions amputated nerve stumps well within the remaining muscle and far from the cutaneous closure. Current prosthetics are not yet able to detect sensation and transmit this to the patient. Having nerve stumps near the amputation closure site increases the risk for neuroma pain.
TMR has not been shown to decrease denervation atrophy of residual upper extremity muscles. TMR has gained increasing acceptance in the treatment of patients who have undergone or will undergo upper extremity amputation. Resected nerves, such as the median and ulnar nerves, can be coapted to nerve branches to remaining muscles, such as the pectoralis and deltoid. Transcutaneous EMG detectors are positioned over these reinnervation sites to detect nerve signal, which a myoelectric prosthesis can then use to better control distal joints.
TMR does not affect the amount of bony length that can be preserved in an amputation.
References
Dumanian GA, Ko JH, O’Shaughnessy KD, et al. Targeted reinnervation for transhumeral amputees: current surgical technique and update on results. Plast Reconstr Surg. 2009 Sep;124(3):863-9.
Souza JM, Cheesborough JE, Ko JH, et al. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014 Oct;472(10):2984-90.
Hijjawi JB, Kuiken TA, Lipschutz RD, et al. Improved myoelectric prosthesis control accomplished using multiple nerve transfers. Plast Reconstr Surg. 2006 Dec;118(7):1573-8.
Solarz MK ,Thoder JJ, Rehman S. Management of Major Traumatic Upper Extremity Amputations. Orthop Clin of North Am. 2016; 47(1):127–36
A 27-year-old woman is evaluated because of pain 2 weeks after undergoing subglandular augmentation mammaplasty. She has no history of fever, chills, or drainage. Physical examination discloses a painful, tender cord in the inframammary region of the left breast. Which of the following is the most appropriate next step in management?
A) Administration of an antibiotic
B) Administration of an anticoagulant
C) Administration of an anti-inflammatory agent
D) Duplex ultrasonography
E) Removal of the implant
The correct response is Option C.
Mondor disease of the breast is a benign, self-limiting thrombophlebitis of the inframammary veins. Clinically, Mondor disease usually occurs 2 to 3 weeks postoperatively as a painful, tender cord within the superficial veins of the thoracoepigastric system. Management is observation and includes the use of warm, moist dressings and anti-inflammatory agents for symptomatic relief. The use of anticoagulation, antibiotics, or steroids is not indicated. Implant removal is not indicated in the absence of infection. Duplex ultrasonography is not required for management.
Nipple-sparing mastectomy is CONTRAINDICATED in which of the following women considering mastectomy and immediate breast reconstruction?
A) A 21-year-old with BRCA1 mutation and grade I breast ptosis
B) A 31-year-old with BRCA2 mutation; subglandular augmentation mammaplasty 1 year ago
C) A 45-year-old with unilateral breast cancer and need for postoperative radiation therapy
D) A 50-year-old with unilateral breast cancer in the tail of Spence
E) A 61-year-old with unilateral breast cancer; tumor-to-nipple distance of 1 cm
The correct response is Option E.
Nipple-sparing mastectomy is increasingly prevalent owing to perceived improvement in reconstructive outcome and patient satisfaction. Prevalence of nipple ischemia, which can vary in severity from incomplete, partial-thickness epidermolysis to total nipple loss, ranges from 2 to 60% depending on the definition used. A recent pooled analysis found a cumulative prevalence of 7%. Most cases respond to local wound care; reoperation for total nipple loss is relatively infrequent.
Patient selection remains paramount to successful nipple preservation. Typically, thin, non-smoking patients with small, non-ptotic breasts are considered ideal candidates. Severe macromastia and ptosis may not only increase risk of poor nipple vascularity, but also contribute to nipple malposition. Oncologic determinants of the safety of nipple preservation should also be considered. Noninflammatory cancers located in excess of 2 cm from the nipple can generally be safely extirpated without removal of the nipple. Usually, an intraoperative frozen section biopsy of the retroareolar tissue (“doughnut”) is performed after excision of the main mastectomy specimen to demonstrate nipple margins free of tumor. Patients undergoing prophylactic mastectomy in the setting of high genetic predisposition are also considered good candidates. Successful nipple preservation has also been described in patients with a history of reduction mammaplasty or mastopexy.
Successful nipple-sparing mastectomy with implant reconstruction has been described recently in patients who require postoperative radiation, albeit with higher risk of capsular contracture and nipple malposition. Prior augmentation in the subglandular or subpectoral positions does not contraindicate nipple-sparing mastectomy; rather, the latter group may present opportunities for direct-to-implant reconstruction. Location of a breast cancer in the tail of Spence (axillary extension of breast tissue) should not contraindicate nipple-sparing mastectomy, as it is likely to be far enough from the nipple to safely spare it.
In women with breast ptosis, which of the following is an advantage of performing combined one-stage augmentation mammaplasty with mastopexy compared with mastopexy alone?
A) Better predictability of cosmetic outcome
B) Decreased complication rates
C) Decreased revision rates
D) Improved upper pole projection
E) Lower operative costs
The correct response is Option D.
Early reports have raised concerns about the safety of combined augmentation mammaplasty with mastopexy surgeries. However, in patients who wish to correct their breast ptosis these two procedures are often combined to a one-stage surgery and can show favorable outcomes. Nevertheless, plastic surgeons advocate that these cases should only be performed by experienced physicians.
Reasons are that the overall aesthetic results are harder to predict in one-stage augmentation/mastopexy procedures compared to mastopexy alone or even the two-stage augmentation mammaplasty followed by mastopexy. Both complication and revision rates are highest in the one-stage approach that combines augmentation mammaplasty with mastopexy. Longer operative time and the need for implants naturally increase operative costs.
The advantage of the simultaneous insertion of implants is the improved superior pole projection that cannot be achieved by mastopexy alone.
A 34-year-old woman is scheduled to undergo bilateral prophylactic mastectomy because of a strong family history of breast cancer. Reconstruction with free flaps from the upper inner thigh is planned. Which of the following is the pedicle to these flaps?
A) Ascending branch of the lateral femoral circumflex artery
B) Descending branch of the lateral femoral circumflex artery
C) Medial femoral circumflex artery
D) Superficial circumflex iliac artery
E) Superficial femoral artery
The correct response is Option C.
The transverse upper gracilis (TUG) flap is a free flap that can be used in breast reconstruction. It is particularly useful in cases where the abdominal donor site is not available or not desired. The flap incorporates the skin and subcutaneous tissues of the upper inner thigh, in the region of the medial thigh lift. The TUG flap is based on the gracilis vessels and perforators from the descending branch of the medial femoral circumflex artery, which forms the dominant pedicle. This arises from the profunda femoris artery. Modifications of this flap have been proposed to increase the volume available for free tissue transfer.
The ascending branch of the lateral femoral circumflex artery provides blood supply to the tensor fascia lata flap.
The descending branch of the lateral femoral circumflex artery forms the pedicle for the anterolateral thigh flap.
The superficial circumflex iliac artery forms the pedicle for the groin flap.
Branches from the superficial femoral artery provide minor pedicles to the distal portion of the gracilis muscle, but are less important and distal to the area of the TUG flap.
Which of the following best represents the likelihood that a patient with a frontal sinus fracture would have a concurrent intracranial injury?
A) 1%
B) 15%
C) 30%
D) 55%
E) 90%
The correct response is Option D.
In an acute trauma setting, the recognition of mild traumatic brain injury (mTBI) is a diagnostic challenge as there are often competing diagnoses that take immediate priority. Furthermore, within this cohort, patients with craniofacial fractures have been shown to be at risk for delayed or missed diagnosis for all degrees of TBI, although with a higher likelihood of missed or delayed diagnosis for mTBI compared with moderate to severe TBI. Previously, it was hypothesized that facial fractures buffered the forces transmitted during blunt head trauma, thereby protecting intracranial structures. This conceptual framework has since been questioned as evidence has mounted that individuals with facial fractures are at increased risk for head injury. The biomechanics resulting in different types of facial fractures and the amount of force required to fracture the different components of the facial bony structure have been well described. The nasal bone has the lowest tolerance for fracture at 25 to 75 lbs, while the frontal bone has the highest tolerance at 800 to 1600 lbs. Recent studies have proposed that craniofacial fractures can serve as clinical markers for brain injury and Mulligan et al. suggest that the prevalence of overall head and cervical spine injuries in the setting of facial fractures is high enough to warrant a change in current protocols.
In this context, the prevalence of mTBI and moderate to severe TBI in patients with isolated facial fractures in the National Trauma Databank (NTDB) was evaluated, and further characterized the association of isolated facial fractures with different degrees of TBI in patients with mild, moderate, and severe TBI. Facial fractures can serve as objective clinical markers for the potential presence of mTBI and moderate to severe TBI in trauma patients. As mTBI patients have been shown to benefit from simple, easy-to-administer educational interventions, trauma patients with facial fractures may benefit from automatically receiving education about mTBI and TBI recovery, given the clinically meaningful prevalence of mTBI and TBI in this population. As one moves up the craniofacial skeleton, the forces are transmitted more reliably to the intracranial space. Therefore, a frontal sinus fracture is at extremely high risk (usually a 45 to 65% chance) of having an associated intracranial injury.
A 30-year-old man is evaluated for a hand injury after punching a wall. X-ray study shows a fracture of the fifth metacarpal neck. Which of the following findings is most likely to require surgical intervention?
A) Angulation
B) Callus formation
C) Impaction
D) Malrotation
E) Shortening
The correct response is Option D.
Malrotation causes scissoring of the affected digit, which will adversely affect neighboring digits. This will affect activities of daily living and is an indication for operative intervention. Other indications for operative intervention include displaced intra-articular fractures, severe soft-tissue injury, unstable open fractures, segmental bone loss, and multiple fractures. Angulation is usually dorsal tip–oriented because of intrinsic and extrinsic muscle pull. A good rule of thumb is the 10, 20, 30, 40 for digits two, three, four, and five. The fourth and fifth digits have carpometacarpal joint mobility and can tolerate larger angulation. The fifth digit metacarpal may even tolerate up to 70 degrees of angulation as long as there is no extensor lag. Impaction can lead to shortening and/or angulation, which is tolerated more than rotational deformities. Similarly, shortening is well tolerated as long as there is no extensor lag. Nonoperative complications include aesthetic with loss of knuckle and possible pain in the palm from the metacarpal head. Callus formation is indicative of an old, healed fracture.
An otherwise healthy, nonsmoking 30-year-old mechanic has the long, ring, and little fingers amputated sharply through Zone II of the right hand. The amputated digits are stored appropriately, and he is rushed to surgery within 2 hours of the accident. Which of the following sequences is the best method of replantation?
A) Digit by digit: bone, tendons, arteries, nerves, veins
B) Digit by digit: bone, tendons, arteries, veins, nerves
C) Structure by structure: bone, nerves, tendons, arteries, veins
D) Structure by structure: bone, tendons, arteries, nerves, veins
E) Structure by structure: tendons, bones, veins, arteries, nerves
The correct response is Option D.
The most efficient sequence to perform the replantation is structure by structure: bone, tendons, arteries, nerves, and then veins. It has been shown that the time to complete the procedure is significantly shorter if the same anatomic structure on each severed digit is fixed before repairing the next structures, as opposed to completing all aspects of the replantation one digit at a time. With respect to the sequence of repair of the severed structures, the general thought is to have a stable construct prior to starting the delicate microscopic repairs. However, the technical sequence used by microsurgeons varies greatly.
The only consistent agreement is starting with bony shortening and fixation. The traditional sequence that follows is extensor and flexor tendon repair, and then vessel/nerve repair. However, individual surgeon preference and patient circumstances dictate the usual sequence thereafter. Some surgeons like to start dorsally and complete the extensor tendon, venous, and skin repair first, and then complete the volar structures next. On the volar side, some surgeons repair the tendon first, followed by the artery and nerve, while others fix the artery and nerve first, followed by the tendon. There are those who believe that the nerve is better repaired in a bloodless field, so that should be done first. Others feel that repairing the vein first reduces blood loss and keeps a bloodless field more reliably for better vision. In patients who present with long ischemia time, it may be beneficial to anastomose the artery first, because this provides the advantages of earlier revascularization and allows easier detection of the most functional veins by their spurting backflow. In short, any of these sequences is fine, as long as it follows the bony fixation.
The other options are incorrect sequences for the above reasons.
References
Maricevich M, Carlsen B, Mardini S, Moran S. Upper extremity and digital replantation. Hand (NY). 2011; Dec; 6(4):356–363.
Prucz RB, Friedrich JB. Upper Extremity Replantation: Current Concepts. Plast Recon Surg. 2014;133(2):333-342.
Walaszek I, Zyluk A. Long term follow-up after finger replantation. J Hand Surg Eur Vol. 2008;33(1):59–64.
Breast implant–associated anaplastic large cell lymphoma is most closely associated with which of the following implant characteristics?
A) High-profile dimensions
B) Saline filling
C) Silicone gel filling
D) Smooth shell
E) Textured shell
The correct response is Option E.
The overwhelming majority of reported cases of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) have been associated with textured surface implants.
Anaplastic large cell lymphoma in association with breast implants is a rare occurrence; however, when it does appear, the course is usually less aggressive with a better prognosis than when it is unrelated to breast implants. Recent studies suggest that the breast implant shell causes a chronic T-cell stimulation. This reaction is thought to be caused by an interaction of textured surface characteristics and associated biofilm.
BIA-ALCL associated with smooth shell implants has occurred; however, it is disproportionately rare.
ALCL is seen with both silicone- and saline-filled implants. These numbers are highly influenced by the specific popularity of each implant. Specific implant dimensions, be it projection or width, are not uniquely associated with ALCL.
A 35-year-old woman comes to the office for consultation because she is dissatisfied with the appearance of her “deflated” and “saggy” breasts. Augmentation/mastopexy is planned. Compared with placement of the implant in the subglandular position, placement of the implant in the subpectoral space will preserve blood supply to the breast tissue and skin through which of the following arteries?
A) Internal thoracic
B) Lateral thoracic
C) Superficial superior epigastric
D) Thoracoacromial
E) Thoracodorsal
The correct response is Option D.
The perfusion of the nipple-areola complex is a major concern during breast procedures involving periareolar and intraparenchymal incisions. The nipple-areola complex has a very rich and overlapping perfusion through multiple sources. This fact allows the design of various pedicles to carry the nipple and areola with different techniques. The blood supply through the internal thoracic vessels reaches the breast, nipple, and areola through the intercostal perforators, which may be divided during both subpectoral and subglandular implant placement.
The location of the implant deep or superficial to the pectoralis muscle will not change the perfusion through the superficial epigastric vessels. The same is true for the blood supply through the lateral thoracic vessels. However, the flow through the thoracoacromial vessels to the breast parenchyma will be preserved by placement of the implant deep to the pectoralis muscle. Creation of a subglandular pocket above the muscle will interrupt the collaterals from the thoracoacromial vessels through the muscle to the parenchyma.
The thoracodorsal artery is not a major source of blood supply to the breast and the position of the implant will not affect it.
In augmentation mammaplasty, which of the following is the ideal upper pole to lower pole anatomic ratio?
A) 25:75
B) 35:65
C) 45:55
D) 50:50
E) 55:45
The correct response is Option C.
Studies have demonstrated the ideal anatomical characteristics of the breast to include: an upward pointing nipple, a straight or mildly concave upper pole slope, smooth lower pole convexity and fuller lower pole compared to upper pole. Breasts with an upper pole-to-lower pole ratio of 45:55 were identified as defining the ideal breast. The ratio was defined ideal by respondents including women, men, plastic surgeons, and individuals of ethnic diversity.
A 23-year-old woman undergoes augmentation mammaplasty with round, smooth silicone implants placed in the dual-plane position. Postoperatively, unilateral erythema and warmth are noted, and they slowly resolve over 10 days of oral antibiotic treatment. The patient asks what this might mean for future satisfaction with the outcomes. Which of the following is the most likely sequela of this patient’s clinical course?
A) Breast gland ptosis
B) Capsular contracture
C) Double-bubble appearance
D) Implant rupture
E) Nipple numbness
The correct response is Option B.
One of the most often mentioned potential risk factors for capsular contracture is biofilm, and this may be related to bacterial contamination. History of infection is unlikely to impact nipple sensation, implant rupture, true breast gland ptosis, or effacement of the inframammary fold with downward descent of the implant.
A 55-year-old postmenopausal woman desires improvement in the appearance of her breasts. Change in which of the following levels of hormones is most likely responsible for postmenopausal involution of breast tissue?
A) Estrogen
B) Growth hormone
C) Oxytocin
D) Prolactin
E) Testosterone
The correct response is Option A.
Estrogen is the primary hormone in promoting the development of the breast epithelium and ductal tissue. Progesterone acts in combination with estrogen to regulate breast development. With the onset of menopause, there is a decrease in the secretion of estrogen and progesterone. As a result of the decrease in the circulating levels of these hormones, the breast undergoes regression and atrophy of the glandular elements.
Oxytocin and prolactin are hormones involved in the physiology of lactation. Growth hormone and testosterone may have an effect on breast tissue, but they are not primary factors in the physiology of the female breast.
A 28-year-old woman is evaluated for micromastia. During consultation, she reports that her best friend underwent breast augmentation that was complicated by painful capsular contracture. Which of the following measures is most likely to prevent this complication in this patient?
A) Initiation of implant massage on postoperative day 5
B) Placement of a closed suction drain for prevention of postoperative hematoma
C) Use of a surgical support bra postoperatively for 2 weeks
D) Use of a subglandular, smooth, round implant via periareolar incision
E) Use of a subpectoral, textured implant via inframammary incision
The correct response is Option E.
Capsular contracture occurs when there is fibrosis of the peri-implant capsule. The severity is typically described by the Baker Grade classification.
Grade 1: the breast is soft and appears normal in size and shape
Grade 2: the breast is a little firm and appears normal
Grade 3: the breast is firm and appears abnormal
Grade 4: the breast is firm, appears abnormal, and is painful
Studies have shown a decreased relative risk for Baker grade 3-4 capsular contracture in primary breast augmentation associated with inframammary fold incision, textured implants, and subpectoral placement. The relative risk for capsular contracture was increased with periareolar or axillary incision, smooth implants, and subglandular placement. There is no evidence that wearing a support bra or implant massage will decrease the risk for capsular contracture. While hematoma is linked to capsular contracture, the presence of a drain does not prevent hematoma.
A 40-year-old man and his 80-year-old father are assaulted. They both have facial fractures. The older victim is more likely to have which of the following?
A) Decreased chance of noncraniofacial injuries
B) Higher mortality
C) Less severe injuries
D) Mandibular body fracture
E) Shorter hospital stay
The correct response is Option B.
In recent years many publications focused on craniofacial injury in the elderly as not only the mode of trauma differs compared with the younger population, but also the associated injuries and morbidities. In general, most related comorbidities in patients older than 60 to 65 (depending on the study) versus those younger are worse, including: longer hospital stays, need for assistance upon discharge, more severe injuries, likely to have noncraniofacial injuries like limb and spine fractures, and, of greatest concern, a much higher death rate. In a recent article though, Mundinger et al, showed that panfacial and mandible fractures were more common in the nongeriatric population, whereas mid face, orbital, and condylar fractures were more common in those older than 60 years of age.
A 28-year-old woman desires augmentation mammaplasty with silicone implants. Physical examination shows tuberous breast deformity with an elevated inframammary crease. Sternal notch to nipple distance is 21 cm bilaterally. Nipple to inframammary crease distance is 3.5 cm bilaterally. Periareolar mastopexy with 350-mL silicone implants is planned. Which of the following operative plans will most effectively minimize the likelihood of a double-bubble deformity?
A) Lower the inframammary crease by 3 cm
B) Perform radial release of the lower pole breast fascia
C) Place implants in subparenchymal pocket
D) Reinforce the inframammary crease with acellular dermal matrix
E) Use highly cohesive gel implants
The correct response is Option B.
The tuberous breast is a developmental deformity characterized by a constricted inframammary fold, short nipple to inframammary crease distance, and both horizontal and vertical deficiencies. The pathophysiology of the tuberous breast predisposes the patient to develop a double-bubble deformity. In this patient, the inframammary crease must be lowered to accommodate the implant and improve the vertical skin deficiency. Radial release of the lower pole breast fascia is done with either a cautery or a knife. Multiple radial incisions are made, thereby allowing the tight crease to expand and decrease the chance for a double-bubble deformity.
Lowering the crease is necessary but will increase the chances of a double-bubble deformity. Subparenchymal implant placement and use of highly cohesive gel implants may help but are not the essential procedures required. The use of acellular dermal matrix can help secure the position of the inframammary crease in a patient who develops a double-bubble deformity secondary to an inferior migration of the implant below the inframammary crease. This does not apply in the patient described.
A 44-year-old woman presents in evaluation for breast reconstruction with biopsy-proven left breast-infiltrating ductal carcinoma after routine mammography discovered a 7-cm lesion. She has been referred to medical oncology and genetic testing is pending. Her past medical history is significant for hypertension and scleroderma. On examination, she has grade I ptosis and wears a size 34A brassiere. During the consultation, the patient reports a strong preference for lumpectomy and oncoplastic reconstruction over total mastectomy. Which of the following is most likely to increase this patient’s chances of qualifying for breast-conserving therapy?
A) Active scleroderma
B) BRCA-1 gene mutation
C) Multicentric tumor
D) Preoperative chemotherapy
E) Small-sized breasts
The correct response is Option D.
Preoperative chemotherapy could increase this patient’s chances of qualifying for locoregional treatment (partial mastectomy or lumpectomy). Studies have shown that breast conservation rates are improved with preoperative systemic therapy, which can also render inoperable tumors resectable. Other potential benefits of preoperative (neoadjuvant) chemotherapy include providing important prognostic information based on response to therapy, minimizing the extent of axillary surgery, and allowing time for genetic testing and reconstructive planning prior to surgery. A small-sized breast would likely provide insufficient uninvolved breast tissue for breast-conserving therapy after resection of a large (7 cm) mass. The same applies to multicentric tumors.
Whole breast irradiation is strongly recommended after lumpectomy, with studies showing a favorable effect in reducing the 10-year risk of recurrence (19% versus 35%) and the 15-year risk of breast cancer death (21% versus 25%). Therefore, patients with (relative) contraindications to radiation therapy, such as lupus or scleroderma (connective tissue disease involving the skin), should ordinarily be offered total mastectomy, particularly if this resolves the need for radiation therapy. While radiation therapy would likely still be considered for this particular patient even after total mastectomy (tumor size greater than 5 cm), the diagnosis of scleroderma itself does not increase her chances of qualifying for breast conservation surgery. BRCA-1 gene mutation and other genetic predispositions to breast cancer are relative contraindications for breast-conserving therapy. These patients may be considered for prophylactic bilateral mastectomy for risk reduction.
A 6-year-old boy presents with a supracondylar fracture sustained during a fall on an outstretched hand. A splint with the elbow flexed less than 90 degrees is placed. The patient is screaming in pain. Examination shows the affected hand has a 3-second capillary refill. Which of the following is the most appropriate next step in management?
A) Closed reduction
B) Continued observation and application of ice packs
C) Elevation of the arm
D) Exploration of the brachial artery
E) Replacement of the current splint with an elbow extension splint
The correct response is Option A.
Supracondylar fractures are one of the most common traumatic fractures seen in children. It occurs most commonly in children 5 to 7 years of age with similar male and female incidence. The mechanism is usually from a fall onto an outstretched hand. The fracture can lead to severe forearm edema, then ischemia leading to Volkmann’s contracture.
Immobilization would be long arm casting with the elbow flexed at less than 90 degrees. Arm elevation would decrease tissue perfusion and would therefore be contraindicated. Immediate bedside closed reduction by gentle traction and elbow flexion to 20 to 40 degrees would be indicated in this case as a next step. If the closed reduction is unsuccessful or ischemia persists after reduction or recurs, urgent operative closed reduction with percutaneous pinning is required. Pins are placed to prevent recurrence. Brachial artery exploration could be required if ischemia has not resolved even after successful reduction, but not initially.
A 56-year-old man is evaluated because of gynecomastia. Physical examination shows mild, diffuse breast enlargement with no visible inframammary fold or ptosis. Which of the following is the most appropriate surgical correction of this patient’s condition?
A) En bloc resection of skin and breast tissue with free nipple grafting
B) Open excision of breast tissue with mastopexy
C) Subcutaneous mastectomy with nipple preservation
D) Suction-assisted lipectomy
E) Superior periareolar excision with skin excision
The correct response is Option D.
The treatment of gynecomastia is based on the degree of breast enlargement and the extent of ptosis that is noted on examination. Grade 1 gynecomastia is minimal breast hypertrophy without ptosis. Grade II gynecomastia is moderate hypertrophy without ptosis. Grade III gynecomastia is severe hypertrophy with moderate ptosis. Grade IV gynecomastia is severe hypertrophy with severe ptosis. The treatment of mild to moderate gynecomastia without ptosis is suction-assisted lipectomy. Direct periareolar excision with skin excision and subcutaneous mastectomy are not indicated for gynecomastia without ptosis. Mastopexy and free nipple grafting techniques are indicated for gynecomastia with severe ptosis.
A 23-year-old man is brought to the emergency department after twisting the long finger of his dominant right hand while playing basketball. Physical examination shows dorsal instability of the proximal interphalangeal (PIP) joint. X-ray study shows a volar buttress fracture involving 40% of the articular surface of the base of the middle phalanx. X-ray joint reduction is attained by passively flexing the PIP joint to 30 degrees. Which of the following is the most appropriate management? A ) Dynamic force-coupler external fixation
B ) Extension block splinting
C ) Hemi-hamate reconstruction of the volar buttress
D ) Open reduction and internal fixation of the fracture fragments
E ) Volar plate arthroplasty
The correct response is Option B.
If the PIP fracture/dislocation can be maintained stable with 30 degrees of flexion, then this is suitable to treat by extension block splinting. This will be the case with an approximate 40% volar articular fracture of the base of the middle phalanx. There is a risk of late flexion contracture if greater than 30 degrees of flexion is required to maintain PIP joint stability. More complex injuries may be treated with force-coupler dynamic splinting or with hemi-hamate reconstruction. For a larger fracture fragment with greater instability, open reduction and internal fixation may be required. Volar plate arthroplasty may be suitable with more chronic injuries and is limited to 60% of the articular surface.
A 54-year-old man comes to the office because of an injury to the long finger of the dominant right hand sustained when it was pinched in a machine at work. Physical examination shows a 1.3-cm loss of pulp tissue with no exposed bone. To preserve function and sensation in the digit, which of the following is the most appropriate intervention?
A) Amputation at the distal interphalangeal joint
B) Cross-finger flap
C) Moist dressings
D) Thenar flap
E) Volar V-to-Y advancement flap
The correct response is Option C.
Fingertip injuries are one of the most common problems encountered in hand surgery. The long finger is the most common finger involved. The patient’s age, occupation, and compliance with treatment should be considered when determining treatment. When possible, if the patient has no exposed bone or only a small area of exposed bone, treatment with dressing changes offers excellent results. There is no donor site morbidity, scarring is often minimal, and return of sensation is generally excellent. Patients, however, need to be cautioned that a prolonged period of dressing changes is required, often lasting 3 to 6 weeks.
Amputation at the distal interphalangeal joint would result in loss of function of the profundus tendon and grip weakness. Neurovascular island flaps and V-to-Y advancement flaps offer excellent closure options when digital length needs to be preserved and there is significant exposure of bone. However, with these flaps there is a donor defect and decreased sensation. Care must be taken when using a cross-finger flap or thenar flap in older patients to avoid contractures and stiffness of the digits.
References
Panattoni JB, De Ona IR, Ahmed MM. Reconstruction of fingertip injuries: surgical tips and avoiding complications. J Hand Surg Am. 2015 May;40(5):1016-24.
Krauss EM, Lalonde DH. Secondary healing of fingertip amputations: a review. Hand (N Y). 2014 Sep;9(3):282-8
A 40-year-old woman who underwent a subglandular augmentation mammaplasty with smooth round silicone breast implants 5 years ago returns to the office for evaluation of an increasingly firm left breast. Surgical revision of the left breast is planned. Which of the following measures is most likely to decrease the recurrence of the symptoms?
A) Conversion to a new plane or pocket
B) Performing a total capsulectomy
C) Using botulinum toxin type A in and around the implant pocket
D) Using fat grafting in and around the implant pocket
The correct response is Option A.
Site change and implant exchange are the only factors that have consistently been shown to decrease recurrence of capsular contracture, although other factors including use of a textured implant and fat grafting used are in augmentation mammoplasty revision. Botulinum toxin type A has been described for prevention of capsular contracture however; no consensus that these treatments decrease recurrence of capsular contracture exists.
Furthermore, there are no data to support performing total versus partial capsulectomy, or even the superiority of capsulectomy over capsulotomy.
A 62-year-old woman undergoes breast reconstruction using autologous tissue from the abdomen. Intraoperatively, use of a perforator flap is found to be impossible because of multiple small nondominant perforators. Conversion to a delayed pedicled transverse rectus abdominis muscle flap is planned. Ligating which of the following vessels in this stage will best facilitate future viability of the tissue transferred in the next stage?
A) Deep inferior epigastric
B) Hypogastric
C) Internal mammary
D) Superficial inferior epigastric
E) Superior epigastric
The correct response is Option A.
Pedicled transverse rectus abdominis muscle (TRAM) flaps are based on the superior epigastric system, which is often less robust than the deep inferior epigastric system. Therefore, surgical delay by ligation of the deep inferior epigastric system may facilitate overall viability of the transferred tissue. Ligation of the superior epigastric system would make a pedicled TRAM flap unlikely to survive. The internal mammary ligation may also interrupt blood supply to the superior epigastric system, and even if the tissue is fed through collaterals, it would not strengthen the flap. Division of the superficial inferior epigastric system might also help, but it is not as critical as ligation of the deep inferior epigastric system. The hypogastric system does not have a direct impact on the pedicled TRAM tissues.
A 36-year-old woman, gravida 3, para 3, comes to the physician because she desires larger breasts. She has breast-fed three children. Physical examination shows grade 3 ptosis and loss of superior pole volume. The distance from nipple to sternal notch is 26 cm. Result of upper pole pinch test is 1.5 cm. A dual-plane augmentation/mastopexy is planned. Which of the following is the strongest indicator for subpectoral placement of the implant in this patient?
A) Concurrent mastopexy
B) Grade 3 ptosis
C) Loss of superior pole volume
D) Nipple to sternal notch distance of 26 cm
E) Pinch test result of 1.5 cm
The correct response is Option E.
A dual-plane approach is subpectoral in the superior pole and subglandular in the inferior pole. This is to afford more subcutaneous coverage in the superior pole. Tebbetts recommends pinching the skin and subcutaneous tissues of the superior pole for a “pinch test.” For thickness less than 2 cm, he recommends a dual-plane placement for adequate soft tissue coverage. This is not affected by the grade of ptosis, need for mastopexy, history of loss of superior pole volume, or nipple to notch distance.
A 52-year-old man presents with a chronic ulcer of the lower extremity. Current medications include prednisone for management of rheumatoid arthritis. In addition to standard local wound care, which of the following treatments is most appropriate?
A) Folate
B) Hyperbaric oxygen therapy (HBOT)
C) Long-acting insulin
D) Vitamin A
E) Vitamin C
The correct response is Option D.
Malnutrition is a well-established risk factor for the development of chronic wounds. Vitamin A has been shown in multiple studies to offset the detrimental effects of corticosteroids on wound healing.
Appropriate glucose management is critical to the treatment of diabetic ulcers, but insulin would not be indicated in the absence of uncontrolled diabetes mellitus.
Vitamin C is required as a cosubstrate for enzymes involved in collagen production, and its supplementation is recommended for the nutritionally deficient. However, vitamin C has not been shown to be of any benefit to wound healing in the setting of chronic corticosteroid therapy per se.
Hyperbaric oxygen therapy delivers oxygen to tissues by both hemoglobin-dependent transport and vastly increased dissolved oxygen content in blood when a patient breathes 100% oxygen at pressures well above atmospheric level. This improves wound healing by multiple cellular mechanisms in select wounds. However, benefits in treatment of chronic corticosteroid use have not been demonstrated.
Elevated serum homocysteine has been associated in multiple studies with impaired wound healing and increased risk of coronary and cerebrovascular disease due to its enhancement of clotting pathways. Folate supplementation is often used to treat hyperhomocysteinemia, but conclusive benefit in chronic wounds is not as well-established.
A 32-year-old man comes to the emergency department after a motorcycle collision. Examination and x-ray studies show an isolated injury to the left wrist consistent with a perilunate dislocation. In perilunate dislocations, dislocation of which of the following is the initial injury that leads to lunate dislocation?
A) Dorsal carpal ligaments
B) Lunocapitate junction
C) Lunotriquetral ligaments
D) Scapholunate ligament
E) Triangular fibrocartilage complex
The correct response is Option D.
All the other answers are incorrect due to incorrect sequence of force transmission across the wrist. Furthermore B and E are wrong due to incorrect mechanism, as well.
Wagner and Mayfield conducted classic studies on carpal dynamics and anatomy to determine the progression of stresses across the wrist in severe hyperextension injuries. They determined that there is a reliable and predictable pattern to these injuries, which is described as Progressive Perilunate Instability (PLI). There are four stages of PLI, corresponding to the degree of stress applied in the injury. The mildest form is the isolated scapholunate dissociation: PLI stage 1. As the forces continue in an ulnar and distal direction, the distal row and scaphoid progress dorsally, and the capitate separates from the lunate: PLI stage 2. As the force continues in an ulnar direction, the lunotriquetral ligaments separate, and if the lunate is still in place, this is the full Midcarpal Dislocation: PLI stage 3. Finally, in the most severe cases, the dorsally dislocated capitate will dislodge the lunate and push it volarly, creating the true lunate dislocation: PLI stage 4.
A 47-year-old woman, gravida 3, para 3, is evaluated for improvement of breast appearance. She breast-fed all three of her children for 1 year each. Examination shows the distance from nipple to sternal notch is 27 cm bilaterally; decreased superior pole volume, and striae are also noted. There is Grade 3 ptosis bilaterally. The pinch of the superior pole soft tissue is 1 cm. Which of the following procedures is most likely to improve superior pole volume and breast shape in this patient?
A) Dual-plane implant augmentation
B) Mastopexy with dual-plane implant augmentation
C) Mastopexy with subglandular implant augmentation
D) Subglandular implant augmentation
E) Vertical mastopexy
The correct response is Option B.
Goals of improvement would be upper pole fullness and a coned, rounded breast, with raising the nipple. Because the superior pole thickness is less than 2 cm, a subglandular implant is not recommended. A dual-plane implant would not address the ptosis and would likely leave persistent ptosis. Vertical mastopexy alone would require some modification to address the excess vertical skin with some element of horizontal inferior excision. This would not address the lack of upper pole volume in the long term. The striae indicate poor tissue strength. Staged implant placement would have the fewest risks.
A 10-year-old girl is brought to the office by her mother because of difficulty using her hand. Medical history includes supracondylar fracture 6 months ago treated with a closed reduction and casting. The fingers of the affected hand are held in the intrinsic minus position. Volkmann ischemic contracture following the fracture is suspected. Which of the following muscles is LEAST likely to be affected by Volkmann contracture?
A) Brachioradialis
B) Flexor digitorum profundus
C) Flexor digitorum superficialis
D) Flexor pollicis longus
E) Pronator teres
The correct response is Option A.
Volkmann ischemic contracture results from forearm muscle shortening and fibrosis as a result of ischemia of forearm muscles during increased compartment pressures. Common reasons for increased compartment pressures include gunshot wounds and fractures, particularly supracondylar pediatric fractures. The radial artery is superficially located, whereas the ulnar artery is deeply positioned, traversing deep to the pronator teres muscles. The ulnar artery becomes the common interosseous artery, which divides immediately into anterior and posterior interosseous branches. The muscles dependent on this deep circulatory pattern are more likely to be affected by ischemia during increased compartment pressures. Flexor muscles commonly involved in this process are the flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and pronator teres. The brachioradialis is not typically affected due to its more superficial radial artery circulation. Patients with significant functional loss may require surgical procedures such as a free gracilis functioning muscle transfer.
References
Fischer JP, Elliott RM, Kozin SH, Levin LS. Free function muscle transfers for upper extremity reconstruction: a review of indications, techniques, and outcomes. J Hand Surg Am. 2013;38(12):2485-2490.
Harris IE. Supracondylar fractures of the humerus in children. Orthopedics. 1992;15(7):811-817.
Stevanovic M, Sharpe F. Management of established Volkmann’s contracture of the forearm in children. Hand Clin. 2006;22(1):99-111.
Zuker RM, Bezuhly M, Manktelow RT. Selective fascicular coaptation of free functioning gracilis transfer for restoration of independent thumb and finger flexion following Volkmann ischemic contracture.J Reconstr Microsurg. 2011 Sep. 27(7):439-44.
Brahmamdam P1, Plummer M, Modrall JG, Megison SM, Clagett GP, Valentine RJ. Hand ischemia associated with elbow trauma in children. J Vasc Surg. 2011 Sep;54(3):773-8.
A 63-year-old man undergoes microdermabrasion for scar irregularity following treatment of facial skin cancer. Which of the following intraoperative findings signals the endpoint of treatment?
A) Cobblestoned, yellow adiposity
B) Confluent patches of bleeding lakes on a yellowish background
C) Minimal dermis with visible subdermal plexus
D) Pinpoint, punctate bleeding on a white background
E) Thinned but present epidermis
The correct response is Option D.
When performing microdermabrasion, the most appropriate endpoint is removal of soft tissue into the papillary dermis. The appropriate level in the papillary dermis is visualized as pinpoint bleeding in a white dermal background. Epithelial removal would be insufficient. Removal of tissue into the reticular dermis, either superficial or deep, increases the risk for scarring. The superficial reticular dermis demonstrates a yellowish white coloration and would reinforce the need to discontinue treatment before deeper injury occurs. Furthermore, dermal excisional depth would manifest as confluent red bleeding in a yellowish background of dermis or nearly complete dermal removal with a visible subdermal vascular plexus. If a full-thickness skin removal is performed (into the subcutaneous adipose layer), significant deformity could result. Preservation of adnexal structures to allow reepithelialization is a key tenet in determining the appropriate depth of treatment. Posttreatment changes include thickened epidermis and increased elastin and collagen.
A 45-year-old woman who underwent bilateral breast augmentation mammaplasty returns to the office after a motor vehicle accident with deployment of airbags. Physical examination shows point tenderness over the chest with an obvious “seat belt” sign along the left breast. The immediate diagnostic workup of the implants shows no rupture. Six months later, the patient returns with distortion of the left breast over the implant with a cleft formation. Which of the following is the most appropriate next step in assessing the integrity of the implants?
A) Chest x-ray study
B) CT scan with intravenous contrast
C) Mammography
D) MRI
E) Ultrasound
The correct response is Option D.
The patient has a late presentation of seat belt syndrome, which requires an MRI to assess the integrity of the breast implants. Patients with seat belt syndrome may present with a cleft or a mass. It is important to rule out invasive ductal carcinoma located in the line of the diagonal contracture. An intracapsular seroma can form gradually over time as well. Reconstructive options include unilateral capsulectomy and implant exchange.
Chest x-ray study can be used in a more immediate setting to rule out any bony injury to the chest wall. Mammography is an appropriate choice in patients who have a palpable mass in an initial assessment; however, this does not rule out implant rupture. In the event that there is an expanding breast in the immediate setting, CT scan with intravenous contrast can be used to rule out possible arterial extravasation or pneumothorax. Ultrasound can be used to assess implant or capsule rupture, but MRI is the most definitive investigative study.
A 52-year-old woman undergoes autologous breast reconstruction with unilateral deep inferior epigastric perforator (DIEP) flaps. According to the Hartrampf model of perfusion zones, if the lateral row perforator vessels are used, in which chronological order will the flap zones be perfused?
A) I – II – III – IV
B) I – III – II – IV
C) II – I – III – IV
D) II – I – IV – III
E) IV – III – II – I
The correct response is Option B.
In medial perforator-based flaps, the zones are perfused in the order I – II – III – IV (A) as shown in the image. In lateral perforator-based flaps, however, the zones are perfused in the order I – III – II – IV (B).
After a nipple-sparing mastectomy, which of the following branches of an intercostal nerve predominantly provides remaining sensation to the nipple-areola complex?
A) Anterior branch of the fifth
B) Anterior branch of the fourth
C) Lateral branch of the fifth
D) Lateral branch of the fourth
E) Lateral branch of the third
The correct response is Option B.
The cutaneous innervation of the female breast is derived medially from the anterior cutaneous branches of the first to sixth intercostal nerves and laterally from the lateral cutaneous branches of the second to seventh intercostal nerves. The nipple-areola complex is physiologically innervated by the lateral and anterior branches of the third to fifth intercostal nerves. The fourth intercostal nerve has further shown to be most consistent in various anatomical studies.
However, the anterior branches take a superficial course within the subcutaneous tissues of the medial breast while the lateral branches take a deep course within the pectoral fascia and reach the nipple via the breast parenchyma. Therefore, the lateral branches are most likely resected during mastectomy and contribute little to the postoperative innervation of the nipple-areola complex.
A 23-year-old woman with micromastia and bilaterally tuberous breasts comes to the office to discuss augmentation mammaplasty and improving the overall appearance of her breasts. Physical examination shows bilateral mildly ptotic breasts with glandular tissue herniating through the nipple-areola complex. The lower pole appears mildly deficient in the lower medial and lateral quadrants, and the distance from the nipple to the inframammary crease is 5.5 cm on stretch. Which of the following is the most appropriate operative approach for this patient?
A) Implant placement with circumareolar mastopexy
B) Implant placement without mastopexy
C) Implant placement with vertical mastopexy
D) Implant placement with Wise-pattern mastopexy
E) Two-stage reconstruction with tissue expander, followed by placement of a permanent implant
The correct response is Option A.
The tuberous breast deformity was first described by Aston and Rees in 1976. While most of the surgical approaches listed, with the exception of implants together with Wise-pattern mastopexy, have been described for the spectrum of tuberous breast deformities, the key is to select the right procedure for the right patient. In this case, a mild form of the deformity is described. Implant placement alone, even with parenchymal scoring and lowering of the inframammary crease, is unlikely to correct the deformity of the nipple-areola complex. In cases of severe ptosis, vertical mastopexy may be used but would be unnecessary in this patient with mild ptosis. In severely deficient cases, a two-stage approach with tissue expansion may be necessary, but it would be over-operating in this mildly deficient patient. Recently, fat grafting has also been advocated for this procedure.
In the case described, which is a common presentation, a periareolar approach is typically used to place the implant in a dual-plane configuration. Subglandular placement is also described. The inframammary crease is commonly adjusted downward. Radial scoring of the parenchyma and a circumareolar mastopexy are typically performed.
In the recent review by Kolker and Collins, 92% of tuberous breast patients had a one-stage procedure. Ninety-six percent of these were treated with implant placement and circumareolar mastopexy, combined with inframammary crease adjustment and radial scoring of the parenchyma.
A 40-year-old woman comes to the office for consultation on an augmentation mastopexy 2 years after giving birth to her second child. She is back to her pre-pregnancy weight. Physical examination shows involutional changes contributing to a deflated appearance of the breasts. This appearance is most likely due to a histologic decrease in which of the following?
A) Area composed of stromal matrix
B) Number of differentiated lobules
C) Thickness of dermis
D) Thickness of pectoralis muscle
E) Volume of adipose tissue
The correct response is Option B.
Postpartum involutional changes can manifest clinically as breasts that appear deflated, commonly due to a loss of volume and skin that has been stretched. On a histologic level, these clinical manifestations occur due to a decrease in the number and area of differentiated lobules that were enlarged and specialized for milk production. As this occurs, it is hypothesized that the lobular area is then replaced by stromal matrix and eventually fat. Involutional changes do not refer to changes in the dermis, pectoralis muscle or chest wall structures.
A 19-year-old woman with a medical history significant for Poland syndrome and a BMI of 19 kg/m2 undergoes first-stage breast reconstruction with a tissue expander that is complicated by extrusion and infection 40 days after implantation. A photograph is shown. Attempts at implant salvage are made. The presence of which of the following factors is most likely to lead to decreased salvage rates?
A) BMI of 19 kg/m2
B) Culture-positive Staphylococcus sp
C) Hemoglobin A1c of 6.5%
D) Prepectoral placement of the device
E) Use of acellular dermal matrix
The correct response is Option B.
It has been shown that successful breast device salvage in breast reconstruction is possible if caught early. However, there are associated factors with failure, including culture-positive Staphylococcus (epidermidis or aureus), as demonstrated by several studies. Other associated risk factors for failure include obesity, poorly-controlled diabetes, smoking, history of radiation therapy, postoperative seroma, and early contamination of the implant with biofilm formation. Therefore, prompt and aggressive intervention is warranted in these situations where the device is threatened by either infection and/or exposure. This includes both surgical and antimicrobial options.
In a 2017 study, prepectoral and subpectoral placement demonstrated comparable complications. Acellular dermal matrix did not increase failure rates.
An 11-year-old boy is brought to the emergency department after sustaining an injury to the tip of the left long finger while playing baseball. The long fingertip is held in a flexed position. The proximal nail plate is slightly visible superficial to the eponychial fold, and a small subungual hematoma is noted. An x-ray study is shown. Which of the following is the most appropriate management?
A) Closed reduction and distal interphalangeal joint extension splinting for 6 to 8 weeks
B) Closed reduction, removal of nail plate, and percutaneous pinning
C) Open reduction, repair of nail bed, and Kirschner wire fixation
D) Repair of zone I flexor tendon avulsion
E) Suture repair of lacerations and observation for 6 weeks
The correct response is Option C.
This patient has a Seymour fracture, or an open physeal/juxta-epiphyseal fracture of the distal phalanx. These injuries present as mallet-like injuries, but they are open fractures by definition. The treatment of choice is open reduction, debridement of the fracture site, repair of associated nail bed laceration, and Kirschner wire fixation of the fracture across the distal interphalangeal (DIP) joint. The injury is secondary to hyperflexion and is essentially a Salter I or Salter II fracture of the distal phalanx. The flexed posture occurs because the terminal extensor tendon inserts on the proximal dorsal epiphysis, while the flexor digitorum profundus inserts on the metaphysis of the bone distal to the fracture site. These injuries can often be mistaken for mallet injuries or DIP dislocations. Often a flap of nail bed matrix becomes interposed between the fracture fragments, preventing closed reduction. This must be repaired. It is recommended to not discard the nail plate, because it helps maintain bone reduction. Dorsal physeal widening and flexion of the distal fracture fragment is seen on lateral x-ray studies.
Observation alone for a Seymour fracture, mallet finger, or DIP dislocation is inappropriate.
Closed reduction and DIP extension splinting is generally the treatment of choice for mallet-type injuries. These can be purely soft-tissue mallet fingers or osseous mallet fractures. Initial treatment should include closed reduction by extension or hyperextension and splinting that isolates the DIP joint in extension. Generally, the splint is worn for 6 to 8 weeks continuously, and then for a period of time at night as indicated. Compliance may be an issue with the pediatric or adolescent population, and the patient should be seen regularly to assess splint fit and skin integrity.
Closed reduction and pinning may be necessary for osseous mallet fingers with associated volar subluxation of the distal phalanx. Several techniques have been described, but this is not appropriate for a Seymour fracture. The nail bed tissue must be reduced from the fracture site to achieve anatomic reduction in this case. Also, closed treatment has an unacceptable incidence of infection, residual finger deformity from incomplete reduction, and nail deformity.
A zone I flexor tendon avulsion, or jersey finger, would present with the DIP joint held in extension. This is opposite to the presentation of this patient. In that case, the patient would require open exploration and reinsertion of the profundus tendon to the distal phalanx via bone tunnels or suture anchor.
A 25-year-old man is brought to the emergency department after falling down a staircase and landing on his outstretched hand. X-ray studies show a perilunate dislocation. The scapholunate and which of the following ligaments must be ruptured for this dislocation to occur?
A ) Dorsal intercarpal
B ) Dorsal radiotriquetral
C ) Lunotriquetral
D ) Radioscaphocapitate
E ) Ulnotriquetral
The correct response is Option C.
Perilunate dislocation is the most common form of carpal dislocation. There is disruption between the ligamentous connections of the lunate and other carpal bones and radius. In the scenario described, rupture of the scapholunate and lunotriquetral ligaments is the most likely cause of the dislocation. These ligaments are usually repaired, followed by open reduction and internal fixation.
The dorsal intercarpal, dorsal radiotriquetral, radioscaphocapitate, and ulnotriquetral ligaments are not appropriate choices because they do not connect to the lunate.
A 36-year-old woman is evaluated because of spontaneous galactorrhea 6 days after undergoing augmentation mammaplasty. Which of the following factors most likely contributed to this outcome?
A) Inframammary placement of the incision
B) Subglandular versus dual-plane position of the device
C) Surgical interruption of the intercostal nerves
D) Use of silicone versus saline breast implants
The correct response is Option C.
Although no one knows exactly what leads to postoperative galactorrhea, it is observed to occur more often in parous women and theorized to occur due to a combination of factors which simulate suckling or change in the innervation of the chest wall and nipple-areola complex. This would include increased tissue pressure related to the implant placement and interruption of intercostal nerves. No relationship has been identified between incision placement (peri-areolar, inframammary, transaxillary, or even peri-thelial) and postoperative galactorrhea. Similarly no relationship has been identified between device positioning (dual-plane, subglandular, and submuscular) and postoperative galactorrhea. Again, no relationship has been observed in implant type, saline versus silicone, and postoperative galactorrhea.
A 38-year-old woman reports decreased areola sensitivity after undergoing mastopexy. Intraoperative injury to which of the following nerves is the most likely cause of this patient’s reduced sensitivity?
A) Intercostobrachial nerve
B) Lateral cutaneous branch of the fourth intercostal nerve
C) Lateral cutaneous branch of the sixth intercostal nerve
D) Medial cutaneous branch of the fifth intercostal nerve
E) Medial cutaneous branch of the third intercostal nerve
The correct response is Option B.
The lateral cutaneous branch of the fourth intercostal nerve is most commonly responsible for nipple and areola sensitivity. The other intercostal nerve branches listed do contribute to breast sensitivity but are less often thought to be the primary innervation to the nipple and areola. The intercostobrachial nerve supplies innervation to the upper medial arm.
In women undergoing prosthetic breast reconstruction complicated by an expander/implant infection, which of the following is the most common gram-negative bacteria isolated from cultures?
A) Escherichia coli
B) Klebsiella
C) Proteus
D) Pseudomonas
E) Serratia
The correct response is Option D.
Tissue expander/implant-based breast reconstruction remains the most common form of reconstruction after mastectomy. One of the most potentially devastating complications of this form of breast reconstruction is an implant infection with need for removal of the expander/implant. The mean reported incidence of implant infection after breast reconstruction is 8%, with a range of 1 to 35%. When cultures are obtained, the most common causative bacteria on microbiology examination are gram-positive organisms (41 to 83%), specifically, Staphylococcus species (56 to 76.5%). Gram-negative bacteria accounted for 15.3 to 28.6%, with Pseudomonas (10.7 to 14%) being the most common gram-negative bacteria present on microbiology examination.
A 28-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in silicone implants, specifically highly cohesive gel shaped implants. Which of the following is the most likely result of increasing the cross-linking in these implants?
A) Decreased risk of gel fracture
B) Decreased risk of shell delamination
C) Improved form stability
D) Increased risk of folds
E) Softer implants
The correct response is Option C.
Increasing the cross-linking in a highly cohesive gel shaped silicone implant improves form stability. This allows for the creation of shaped implant designs that persist despite position or external forces on the implant.
The current, fifth-generation silicone breast implants derive their cohesiveness from the cross-linking of the silicone. Increasing the amount of cross-linking leads to an increase in cohesiveness and a firmer implant. This may lead to less rippling and folding because of resistance to collapse; however, recent MRI studies have shown folds and distortions are still possible. Increasing cohesiveness, however, does have some disadvantages with potential risks for gel fracture and delamination of the implant shell.
A 24-year-old woman comes to the office 8 months after undergoing a circumareolar mastopexy/augmentation. She is concerned because her areolas are now asymmetric. They were symmetric preoperatively. Physical examination shows that the right areola diameter is 7 cm and the left areola diameter is 4 cm. The most likely cause of this asymmetry is a failure of which of the following?
A)Breast pillar approximation
B)Periareolar de-epithelialization
C)Prosthesis pocket
D)Purse-string suture
E)Skin envelope tailor tacking
The correct response is Option D.
The most likely cause of nipple-areola asymmetry in the patient described is failure in the purse-string suture. Periareolar mastopexy/augmentation has been plagued with inconsistent control of the nipple-areola complex diameter. This mastopexy technique creates concentric resection of periareolar epithelium to elevate the nipple-areola complex and reduce the skin envelope. The etiology of this areola-spreading is the tension of the closure intrinsic to the technique. Use of a permanent suture for the purse-string helps limit the postoperative spreading of the areolar diameter. Introduction of the interlocking polytetrafluoroethylene (GORE-TEX) suture has allowed improved control of areolar shape and diameter. If one of the purse-string sutures breaks or pulls through its dermal attachments, that areola will be subject to the forces of tension and expand in diameter. In the patient described, operative correction involves either replacing the purse-string on the widened side or removing the purse-string on the smaller diameter areola.
Periareolar de-epithelialization is the cause of the tension and is an essential part of the procedure. In patients who are significantly asymmetric, tension of the areolas will also be asymmetric; however, a permanent purse-string suture is crucial in these cases.
Prosthesis pocket and parenchyma shaping sutures will not have the impact on areolar diameter that is described in this scenario.
Envelope tailor tacking relates to final adjustments in periareolar de-epithelialization.
An otherwise healthy 54-year-old perimenopausal woman is scheduled for a mastectomy for biopsy-proven right-sided grade 2 ductal carcinoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, postmastectomy radiation therapy will be the standard of care for this patient if she has which of the following surgical outcomes?
A) 1-cm surgical margins, four positive axillary lymph nodes
B) 1-cm surgical margins, one positive axillary sentinel node
C) 1-mm surgical margins, no positive axillary nodes
D) 5-mm surgical margins, no positive axillary nodes
E) 5-mm surgical margins, three positive axillary nodes
The correct response is Option A.
Traditionally, the need for radiation therapy has been a contraindication for implant-based reconstruction, and autologous reconstruction is the conservative gold standard for women with advanced cancer needing postmastectomy radiation. More recently, there have been reports of successful implant based reconstruction in the setting of postmastectomy radiation that have similar complication profiles and good oncologic outcomes compared with autologous reconstruction. Protocols vary between those that radiate the expander and then expand, and those that expand and then radiate the permanent implant. Being able to anticipate which patient will require postmastectomy radiation is essential for joint decision making about breast reconstruction with the patient prior to her mastectomy.
By National Comprehensive Cancer Network (NCCN) guidelines, relative indications for postmastectomy radiation therapy include: positive sentinel node with unknown status of other axillary nodes, one to three positive nodes on permanent histology, and close surgical margins (less than 5 mm). Postmastectomy radiation is recommended as the standard of care in the situations of positive surgical margins with the inability to get clear margins and four or more positive lymph nodes.
Which of the following characteristics is correlated with increased risk of nipple-areola complex necrosis in nipple-sparing mastectomies with immediate reconstruction?
A) Autologous tissue reconstruction
B) Direct to implant reconstruction
C) Patient age
D) Periareolar incision
E) Small breast size
The correct response is Option D.
Nipple-sparing mastectomies (NSMs) are becoming more common for both therapeutic and prophylactic mastectomies. Nipple-areola complex (NAC) necrosis can imperil reconstructive efforts, as well as negatively affect patients emotionally. It is important to maximize perfusion to the mastectomy skin flaps and NAC while still performing an oncologically sound procedure. There are multiple different incisions for performing NSM. Periareolar, inframammary-fold, radial, and vertical incisions are the most common. Periareolar incisions are associated with an increased risk of NAC necrosis in NSMs. Type of reconstruction, small breast size, and patient age have not been shown to be linked to increased rates of NAC necrosis.
A 35-year-old woman with tuberous breast deformity is scheduled to undergo augmentation/mastopexy. A smooth, round, cohesive gel implant will be used. This patient is at higher risk for which of the following complications when compared with augmentation/mastopexy performed on a patient without a tuberous breast?
A) Capsule contracture
B) Double bubble
C) Hematoma
D) Nipple-areola depigmentation
E) Rippling
The correct response is Option B.
The classic features of a tuberous breast deformity include a constricted base with a high inframammary crease and herniation of breast parenchyma into the nipple-areola complex producing a large-diameter areola. Variable extent of micromastia is associated as well as breast asymmetry. When a patient has a high and tight inframammary crease, this crease must be released to accommodate an implant and allow correction of the deformity. If this native crease does not fully expand, then a double bubble will occur. Over time, the lower pole skin stretches in response to the implant and this double bubble often improves spontaneously. The incidence of capsule contracture, hematoma, nipple-areola depigmentation, and rippling should be similar to a patient who undergoes periareolar augmentation/mastopexy without a tuberous breast.
A 60-year-old woman comes to the office because of a 2-year history of disabling pain in the carpometacarpal joint of the thumb of the nondominant left hand. Physical examination shows swelling and tenderness. Grind test results are positive. X-ray study shows osteoarthritis with subluxation of the joint. Which of the following types of biomaterial is most appropriate for arthroplasty?
A ) Expanded polytetrafluoroethylene (GORE-TEX)
B ) Polypropylene (Marlex)
C ) Polyurethaneurea (Artelon)
D ) Porcine dermal collagen xenograft (Permacol)
E ) Silicone trapezial implant arthroplasty
The correct response is Option C.
Polyurethaneurea (Artelon) implants typically biodegrade by hydrolysis and are described as causing minimal giant cell and foreign body reaction. Although long-term studies are still pending, they currently appear to be the best biomaterial for this application.
The use of silicone trapezial implants was, at one time, a common procedure, but the long-term results of silicone arthroplasty wear and deformation led to multinucleated giant cell reactions with silicone granulomas and synovitis. This resulted in about a 25% failure rate with this modality.
Similarly, a study by Greenberg, et al, showed an incidence of 80% osteolysis and a high failure rate with GORE-TEX implants. A biopsy specimen of one retrieved implant showed giant cell reactions. Marlex implants also showed foreign body reactions and synovitis. A study by Belcher, et al, on Permacol implants was terminated prematurely because of adverse reactions to the implant in 6 of 13 patients, with significant pain and evidence of multinucleated giant cells.
Which of the following is the arterial supply of the flap for digital tip reconstruction shown?
A) Distally based from the contralateral digital artery
B) Dorsal perforating vessels
C) Perineural perforating vessels
D) Proximally based from the ipsilateral digital artery
The correct response is Option A.
A reverse homodigital island flap is shown. It is a distally based flap that is useful in the repair of fingertip injuries. Arterial inflow is based upon the contralateral digital artery in the crossing ladder vessels of the palmar digital arch that lie just dorsal to the volar plate at each joint. The flap requires sacrifice of the ipsilateral digital artery and care must be taken to preserve the digital nerve during elevation of the skin paddle. Typically, the donor site is grafted.
References
Regmi S, Gu JX, Zhang NC, Liu HJ. A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps. Aesthetic Plast Surg. 2016 Apr;40(2):277-83.
Foucher G and Khouri RK: Digital reconstruction with island flaps. Clin Plast Surg. 1997 Jan;24(1):1-32.
A 37-year-old man who works as a laborer sustains a saw injury to the non-dominant left hand. X-ray studies are shown. Which of the following is the most appropriate functional option for reconstruction of this thumb defect?
A) Metacarpal lengthening
B) Osteoplastic reconstruction
C) Pollicization
D) Prosthesis
E) Toe transfer
The correct answer is Option C.
The x-ray study shows a carpometacarpal-level amputation of the thumb. Toe transfer, osteoplastic reconstruction, and metacarpal lengthening require part or most of the thumb metacarpal to be present. A thumb prosthesis would have limited functionality and be insensate.
Pollicization would potentially allow a sensate, functional index finger to accomplish some of the functions of the thumb. It is, however, not without its drawbacks because it is technically demanding and has a high likelihood of requiring secondary procedures. For a carpometacarpal-level amputation, pollicization provides the best option for function.
References
Graham D, Bhardwaj P, Sabapathy SR. Secondary thumb reconstruction in a mutilated hand. Hand Clin. 2016 Nov;32(4):533-547.
Muzaffar AR, Chao JJ, Friedrich JB. Posttraumatic thumb reconstruction. Plast Reconstr Surg. 2005 Oct;116(5):103e-122e.
Pet MA, Ko JH, Vedder NB. Reconstruction of the traumatized thumb. Plast Reconstr Surg. 2014 Dec;134(6):1235-1245.
Graham DJ, Venkatramani H, Sabapathy SR. Current reconstruction options for traumatic thumb loss. J Hand Surg Am. 2016 Dec;41(12):1159-1169.
A 12-month-old boy presents for evaluation of a soft, fixed lateral brow mass that has been enlarging since it was first noted at 2 months of age. A photograph is shown. The parents report that the mass does not change in size during crying or activity, nor did it change in size during recurrent pink eye infections. Which of the following is the most likely diagnosis?
A) Branchial cleft cyst
B) Dermoid cyst
C) Hemangioma
D) Lacrimal gland
E) Lymphatic malformation
The correct response is Option B.
Dermoid cyst is the correct answer and the most common cause of a lateral brow mass in an infant. If it were a hemangioma, its size would change during crying or any activity that increases blood flow. Lacrimal gland ptosis is unlikely in a child but can be seen in the adult population, and can be ruled out if the mass is above the orbital rim, as seen in the photograph. The mass is not in the distribution of any of the different types of branchial cleft cysts. Lymphatic malformations typically change in size during infections.
References
Al-Muhaylib A, Alkatan HM, Al-Faky YH, Alsuhaibani AH. Periorbital lesions misdiagnosed as dermoid cysts. J AAPOS. 2017;21(6):509-511.
Rezaei E, Shams Hojjati Y. Misdiagnosed extranasal mass: report of a 2-year old child with maltreated rare nasal neuroglial heterotopia. World J Plast Surg. 2019;8(1):122-124.
Van Wyhe RD, Chamata ES, Hollier LH. Midline craniofacial masses in children. Semin Plast Surg. 2016;30(4):176-180.
Vincent J, Baker P, Grischkan J, Fernandez Faith E. Subcutaneous midline nasal mass in an infant due to an intramuscular lipoma. Pediatr Dermatol. 2017;34(3):e135-e136.
A 35-year-old woman presents with a fixed adduction contracture of the first web space that has not improved with splinting and hand therapy for 4 months. Medical history includes a crush injury with complex laceration to the first web and dorsal hand and index finger five months ago. A photograph is shown. Which of the following is the most appropriate plan for reconstruction of the first web space contracture in this patient?
A) First dorsal metacarpal artery flap
B) Flexor carpi ulnaris flap
C) Posterior interosseous artery flap
D) Thenar flap
E) Split-thickness skin grafting
The correct response is Option C.
Contracture of the first web space may be secondary to cutaneous scarring, skin deficiency, fibrosis of the fascia and thenar muscles, or joint contractures. Mild contractures may be isolated to the skin; however, deeper structures are most likely involved as the contracture becomes more severe. It is important to understand the mechanism of injury, length of time the contracture has been present, and any prior treatments.
Reconstruction of the first web space involves complete contracture release and resurfacing with adequate vascularized tissue. The dissection should be carried out palmarly and dorsally with release of the palmar fascia and adductor aponeurosis as needed. Intrinsic muscle and joint contractures should be addressed at this time, and a trapeziectomy may be needed to restore carpometacarpal (CMC) motion.
This patient has a severe contracture that likely involves multiple structures given her history of deep lacerations and bony injury. This requires resurfacing with thin, pliable vascularized tissue. In this setting, the posterior interosseous artery (PIA) flap is the best choice. This flap is outside the zone of injury and provides an adequate amount of vascularized tissue for resurfacing of the web space. The PIA runs between the extensor carpi ulnaris and extensor digit quinti and forms an anastomosis with the anterior interosseous artery 2cm proximal to the distal radioulnar joint.
Skin grafting alone, either split-thickness or full-thickness, should be avoided because of the inherent tendency for secondary contracture. Skin grafts may be combined with local flaps such as a 4-flap or 5-flap z-plasty in mild to moderate contractures.
Tissue flaps from the dorsum of the hand such as the first dorsal metacarpal artery fasciocutaneous flap or dorsal hand transposition flap may be good options in some patients with small- to moderate-sized skin deficits. However, this patient sustained trauma to the dorsal hand with dorsal skin lacerations. This makes a random-pattern transposition flap unreliable. The defect in question is also too large to be completely resurfaced with a first dorsal metacarpal artery (FDMA) flap. The flexor carpi ulnaris flap is useful for elbow coverage as a turn-over flap but will not reach the hand.
References
Moody L, Galvez M, Chang J. Reconstruction of First Web Space Contractures. J Hand Surg Am. 2015 Sept;40:1892-95.
Cavadas P et al. The Simplified Posterior Interosseous Flap. J Hand Surg Am. 2016 Sep;41(9):e303-7.
A 58-year-old woman with moderate ptosis is evaluated for mastopexy. According to Regnault classification, which of the following best describes the location of the nipple-areola complex in type II breast ptosis?
A) 1 to 3 cm inferior to the inframammary fold
B) 4 cm inferior to the inframammary fold
C) 6 cm inferior to the inframammary fold
D) At or 1 cm inferior to the inframammary fold
E) Superior to the inframammary fold
The correct response is Option A.
Regnault classification of breast ptosis, based on the position of the nipple-areola complex (NAC) relative to the inframammary fold (IMF):
The type of mastopexy performed will depend on the degree of breast ptosis. Breast ptosis is graded using Regnault classification. Type I can be treated with a crescent mastopexy, when the degree of nipple-areola complex elevation does not exceed 1 cm. Type I or II ptosis can be treated with a periareolar mastopexy, when the distance of nipple-areola complex elevation ranges from 1 to 2 cm. Type II and III ptosis is amenable to the inverted-T technique, where the horizontal incision will reduce the distance from the nipple-areola complex to the inframammary fold, while the vertical incision will reduce the base diameter.
A 20-year-old rugby player is evaluated for an acute thumb injury 4 hours after falling onto his outstretched hand while being tackled. X-ray study is shown. Surgical intervention is planned. Which of the following is the most appropriate force to apply to the thumb metacarpal during reduction?
A) Abduction
B) Axial compression
C) Flexion
D) Supination
The correct response is Option A.
In a Bennett fracture, the smaller volar-ulnar fragment is retained by the anterior oblique (beak) ligament, while the abductor pollicis longus, thumb extensor tendons, and the adductor pollicis combine to distract the base of the larger shaft fragment radially, dorsally, and proximally. These distracting forces create joint incongruity, which is a relative indication for fracture reduction. These forces must be countered to reduce the fracture, thus, requiring axial distraction, pronation, and abduction of the metacarpal shaft, while simultaneously applying external pressure at the radial base of the metacarpal.
Axial compression will worsen proximal migration of the metacarpal shaft. Extension will worsen dorsal displacement, and supination will further distract the volar surfaces of the fracture fragments. Application of these forces will not promote fracture reduction.
An 86-year-old farmer is brought to the emergency department because of a large dorsal wound of his nondominant left hand sustained when his hand was caught in a flail mower. After debridement is performed, examination shows normal volar structures, including nerve and tendon function, and loss of dorsal skin and tendons. Medical history includes myocardial infarction 1 month ago. An x-ray study and photograph are shown. Which of the following is the most appropriate method of reconstruction for this patient?
A) Bilaminate neodermis (Integra) and skin grafting with delayed bone grafting
B) External fixator and posterior interosseous artery flap
C) Finger fillet flaps of index and middle finger
D) Free anterior lateral thigh flap with secondary bone grafting
E) Pedicle radial forearm flap with secondary bone grafting
When caring for patients with mangling hand injuries, it is imperative to consider all aspects of the patient’s history and future goals. This patient would be at risk for cardiac complications if a longer procedure such as a free flap were chosen. The amount of bone loss in the index and middle metacarpals is also problematic and would most likely require multiple procedures. Just placing an external fixation and covering the wound with a local flap is also possible but will require several procedures. Bone grafting while receiving bilaminate neodermis (Integra) and skin grafts is not recommended because of the lack of subcutaneous tissue and poor blood supply. The most expeditious method of covering this patient’s wounds in one procedure is finger fillet flaps of the injured digits. Finger fillet flaps can cover a large area for reconstruction as shown.
References
Leunam S, Prugsawan K, Kosiyatrakul A ,et al. Neural anatomy of the anterolateral thigh flap. J Hand Microsurg. 2015;7:49-54.
Lachia RD. Evidence-Based medicine: management of acute lower extremity trauma. Plast Reconstr Surg. 2017;139:287-301e.
A 9-year-old boy is brought to the office for evaluation of a nodule on the neck that appeared 1 week ago. The nodule measures 2 cm and is slightly to the right of midline. A photograph is shown. The lesion is slightly tender. Which of the following is the most appropriate management of this lesion?
A) Excision of lesion with any tract and a section of hyoid bone
B) Excision of lesion with any tract and a section of thyroid cartilage
C) Excision of lesion with any tract only
D) Fine-needle aspiration with cytology
E) Intralesional sclerotherapy under image guidance
The correct response is Option A.
Thyroglossal duct cysts are neck lesions that usually present during childhood, often after a localized inflammation or infection. They are usually neck lesions near the midline. Some may move with swallowing if they are close to the base of the tongue, but not all exhibit this finding. The congenital thyroglossal duct is the remnant of the descent of the developing thyroid gland, and it runs from the foramen cecum of the base of the tongue, down to the thyroid. Imaging is typically by ultrasound, but other modalities, including radioisotope scans to rule out ectopic thyroid tissue or confirm the location of the normal thyroid gland, have been suggested to avoid excising ectopic thyroid gland.
The Sistrunk procedure shows less recurrence and is a complete excision, including any associated tract, and about a 1-cm section of hyoid bone. Although proposed in 1928, this is still the most commonly recommended approach for thyroglossal duct cysts.
Fine-needle aspiration is appropriate for thyroid nodules, which are unlikely to present in an acute manner in this population.
Sclerotherapy is used for vascular anomalies and likely would have presented earlier on in childhood.
References
Sistrunk WL. Technique of removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol Obstet. 1928;46:109–112.
Galluzzi F, Pignataro L, Gaini RM, et al. Risk of recurrence in children operated for thyroglossal duct cysts: A systematic review. J Pediatr Surg. 2013 Jan;48(1):222-7.
Li WY, Reinisch JF. Cysts, pits, and tumors. Plast Reconstr Surg. 2009 Jul;124(1 Suppl):106e-116e.
A healthy 11-year-old boy is brought to the emergency department because of worsening redness and pain around the site of an injury to the middle finger of the left hand. The patient sustained the original injury 3 weeks ago while wrestling with his brother. The patient had swelling and pain of the finger, but the pain resolved quickly, so no medical care was sought. The patient’s mother reports that she noticed a small bump on the dorsum of the finger since then. However, the patient developed redness and pain 2 days ago at the same site, both of which have worsened. An image and x-ray studies are shown. Which of the following is the most likely cause of this patient’s symptoms?
A) Biting of nails
B) Exposure to Pasteurella species
C) Flexor tendon avulsion
D) Immunocompromised state
E) Trapped germinal matrix
This patient has a Seymour fracture—a juxta-epiphyseal open fracture—of the distal phalanx as evidenced by the eponychial disruption and fracture pattern on x-ray study. These are open fractures traditionally frequently with associated nail bed transection. Unfortunately, secondary to delay in treatment, the patient developed osteomyelitis.
These patients often present with a mallet-appearing deformity from flexion of the distal fracture segment, the nail may be disrupted (with the distal nail bed) and lay superficial to the eponychial fold, while the transected nail bed proximally (germinal matrix) becomes entrapped within the fracture, making closed reduction prone to failure. Acute treatment in the emergency department or operating room consists of nail plate removal, reduction of the trapped nail bed, irrigation and debridement of the fracture site, reduction of the fracture, nail bed repair, nail plate replacement, and immobilization. Instability or inadequate reduction warrants operative intervention and may require Kirschner wire fixation. Inadequate reduction and/or delayed treatment are critical influences of infection rates. In a study by Reyes and Ho in the Journal of Pediatric Orthopaedics, investigators reviewed acute appropriate reduction, acute partial treatment, and delayed treatment. No infections occurred in the acute appropriately managed group, whereas 15% of the patients developed infections in the partially treated group, and 45% of the delayed treatment group developed infections. Biting of nails has been associated with nontraumatic paronychial infections. There is no history of immunocompromised state, and healthy children can acquire infections with these injuries. This patient sustained the injury wrestling his brother as opposed to from an animal bite. Pasteurella is not the most frequent bacteria associated with infections in patients who have sustained Seymour fractures. Flexor tendon avulsions, also known as jersey fingers, are traditionally closed and would demonstrate lack of flexion of the distal interphalangeal joint.
A 74-year-old woman comes to the office because of a 2-month history of increasing soreness over the left lateral chest wall. History includes bilateral radical mastectomy and adjuvant radiation to the left chest 30 years ago because of left-sided breast cancer. On examination, a small, nonhealing 1 × 2-cm wound is visible in the subaxillary region within an area of dense fibrotic skin. A photograph is shown. Which of the following is the most appropriate next step?
A) Biopsy of the nonhealing wound
B) Coverage with a left latissimus muscle flap and skin grafting
C) LHyperbaric oxygen treatment
D) MRI of the chest wall
E) Oral administration of antibiotics for 7 days
The correct response is Option A.
This patient’s presentation is consistent with late radiation tissue injury (LRTI), which occurs in 5 to 15% of long-term cancer survivors who have received radiation and can occur months to years (even decades) after treatment. It can vary significantly with age, dose, and site of treatment. Characteristics include progressive tissue deterioration secondary to decreased vascularity followed by replacement of normal soft-tissue architecture by dense fibrotic tissue until there is insufficient oxygen delivery to sustain normal function. When LTRI of the chest wall progresses to skin breakdown and ulceration, as has happened in this patient, a biopsy is always required to rule out recurrence of the primary tumor or a radiation-induced squamous cell carcinoma or soft-tissue sarcoma.
Hyperbaric oxygen therapy has been proposed as a treatment modality that can improve tissue quality and prevent tissue breakdown in irradiated areas. While most data on this relate to treatment of osteoradionecrosis of the mandible, there have been some reports of its use on the chest wall after irradiation due to breast cancer. However, the question specifically asks for the most appropriate next step, which would be biopsy rather than hyperbaric oxygen therapy.
The principles of management once malignancy has been ruled out include debridement of necrotic tissues (including ribs) and reconstruction with well-vascularized flaps. In this case, a left latissimus muscle flap and skin graft was used for reconstruction after aggressive debridement. No alloplastic material was placed or thoracic cage reconstruction performed. This is common in these types of patients as excessive fibrosis caused by the radiation to the chest wall prevents loss of respiratory efficiency through paradoxical motion.
CT scan or MRI may be useful in evaluating the size, extent, and nature of the problem, but does not take priority over tissue biopsy.
The redness that is visualized on the patient’s skin in the case is related to post-radiation changes and telangiectasias, which are common in LTRI, and is not infection. Therefore, antibiotics would be unnecessary.
A 37-year-old man who works as a carpenter is brought to the emergency department after falling 10 ft from a scaffold. He says he has pain in the left wrist and numbness of the thumb, index, and long fingers of the left hand. Trauma screening shows no other injury, and x-ray studies of the left wrist are obtained (shown). Which of the following is the most appropriate treatment?
A ) Application of finger traps and placement in traction
B ) Closed reduction and carpal tunnel release
C ) Open reduction and internal fixation
D ) Splinting of the wrist in 30 degrees of extension
E ) Total wrist fusion
The correct response is Option C.
Perilunate dislocations are relatively uncommon injuries that typically follow high-energy impact to the wrist. The pattern of injury traverses both the greater and lesser carpal arcs, disrupting the lunotriquetral ligament and either the scapholunate ligament or the body of the scaphoid (trans-scaphoid, perilunate dislocation). Although controversy surrounding the need for operative intervention existed in the past, poor long-term outcomes from closed reduction alone have showed the importance of early restoration of carpal alignment with repair of the injured ligaments. In the setting of trans-scaphoid, perilunate dislocation, this would include rigid internal fixation of the scaphoid.
Application of finger traps and placement in traction may assist in reduction of the dislocated lunate but will not, by itself, reduce the lunate and remove the need for internal fixation and repair of the injured ligaments.
Proximal row carpectomy and wrist function play a role in long-term salvage of the painful wrist following perilunate dislocations. Only in rare circumstances, such as nonreconstructible fractures of the proximal row bones, should acute proximal row carpectomy be considered.
Splinting of the wrist in extension often provides relief in the setting of idiopathic carpal tunnel syndrome; however, in the setting of lunate dislocation, the presence of the lunate in the carpal tunnel necessitates reduction of the lunate for relief of symptoms
A 50-year-old woman comes to the office for consultation about improving the appearance of her “saggy” breasts. She has lost 100 lb (45 kg) during the past 18 months by diet. Photographs are shown. Physical examination shows breast deflation and marked ptosis. A Wise pattern mastopexy with augmentation mammaplasty is planned. Which of the following arteries is most likely to provide circulation to the breast gland and nipple during submuscular augmentation in this patient?
A)Intercostal
B)Pectoral
C)Superior epigastric
D)Thoracoacromial
E)Thoracodorsal
The correct response is Option D.
The thoracoacromial artery and vein travel just deep to the pectoralis major muscle, supplying circulation to the overlying breast tissue and skin. Subglandular augmentation mammaplasty disrupts the connection between the thoracoacromial vessels and the overlying breast. This leads to a higher risk of wound-healing complications when placing the prosthesis in the subglandular plane. The submuscular plane of dissection maintains the connection between the thoracoacromial vessel and overlying breast and skin, allowing better potential healing.
Intercostal arteries are multiple and are not completely disconnected with either subglandular or subpectoral augmentation mammaplasty.
The superior epigastric artery provides circulation to the rectus abdominis muscle and abdomen. This artery would be injured with the mastopexy procedure.
The thoracodorsal artery supplies the latissimus dorsi muscle and not the chest.
A 23-year-old male rugby player is evaluated because of the inability to flex the ring finger at the distal interphalangeal (DIP) joint 2 days after injuring the finger during a match. The patient reports tenderness over the pulp and distal flexion crease. A clinical photograph and x-ray studies are shown. Which of the following is the most appropriate management?
A ) Closed reduction and percutaneous pin fixation
B ) DIP arthrodesis
C ) Extension block splinting
D ) Open reduction and internal fixation
E ) Volar plate arthroplasty
The correct response is Option D.
The clinical scenario, photograph, and x-ray studies demonstrate classic symptoms of a ?jersey finger,? or avulsion of the insertion of the flexor digitorum profundus (FDP) tendon. In this instance, the rupture involves a large bone fragment to which the FDP tendon remains attached (Type III). The large size of the bone fragment lends itself to repair via open reduction and internal fixation of the fracture. Use of mini-screws or transosseous wiring will provide suitable internal fixation. Type II (retraction of the tendon to the proximal interphalangeal [PIP] joint) and Type I (retraction to the palm) injuries can be addressed through transosseous suture reattachment or suture anchor.
Inadequate closed reduction would make percutaneous pin fixation a poor choice of treatment.
Arthrodesis offers a salvage procedure for failed or unrepaired FDP avulsion injuries. In this young patient with an acute condition, arthrodesis would be too aggressive an intervention.
Extension block splinting can be useful in volar plate injuries, which are often identified by a small, palmar avulsion fragment seen on the lateral x-ray study. This fracture would not be successfully reduced by attempts at flexion or splinting.
Volar plate arthroplasty can restore a functional articular surface following intra-articular fractures of the PIP joint but are not useful in the DIP.
A 22-year-old man comes to the emergency department after falling onto his outstretched left hand. An x-ray study and a clinical photograph are shown. Attempted reduction is unsuccessful. Reduction is most likely blocked by which of the following anatomical structures?
A) Central slip
B) Dorsal capsule and collateral ligaments
C) Flexor tendons and intrinsic muscles
D) Lateral bands
E) Sagittal bands
The correct response is Option C.
Dorsal metacarpophalangeal joint (MCP) dislocations are relatively uncommon. They occur with forced hyperextension injuries. The digit involved most commonly is the index finger, followed by the little finger.
With complete dislocation, the volar plate ruptures in the membranous proximal portion and becomes interposed in the joint. If this were the only structure blocking reduction, traction on the joint would be sufficient to draw the proximal edge of the volar plate over the metacarpophalangeal head. This is not possible in an irreducible MCP dislocation because additional taut medial and lateral structures are drawn around the narrow metacarpophalangeal neck. At the index finger, the structures include the lumbrical on the radial side and the flexor tendons on the ulnar side. At the little finger, the structures are the common tendon of the abductor digiti minimi and flexor digiti minimi on the ulnar side and the lumbrical and flexor tendons on the radial side. Central slip remains dorsal at the proximal interphalangeal joint and is not associated with the metacarpophalangeal joint. The other structures at the MCP joint would not result in a noose around the metacarpal neck and block reduction.S
A 78-year-old woman has a 6.5-cm defect of the right cheek (shown) just below the lower eyelid after wide local excision for a lentigo maligna melanoma. All final pathologic margins are negative. Which of the following is the most appropriate management?
A ) Cervicofacial flap closure
B ) Full-thickness skin grafting
C ) Healing by secondary intention
D ) Internal mammary artery perforator flap closure
E ) Primary closure
The correct response is Option A.
Optimal color and texture matches for cheek reconstruction are obtained from using local cheek tissues (see photograph below). The cervicofacial flap is classically an inferomedially based flap that allows for transfer of large amounts of cutaneous and subcutaneous soft tissues from the loose preauricular and neck regions to the medial cheek. The incision begins at the superior margin of the defect and extends along the outer canthus toward the zygoma and down the preauricular crease. The incision ends in the retroauricular hairline or curves anteriorly in the region of the neck, preferably within a cervical rhytid. The flap is advanced and rotated into the defect, and primary closure of the donor site can usually be achieved via wide subcutaneous undermining. Anchoring of the flap to the zygoma is recommended to reduce tension on the lower eyelid that could lead to ectropion.
Full-thickness skin grafts tend to appear shiny and patch-like with a poor contour match. Split-thickness or very thin full-thickness grafts are also associated with graft contracture. Split- or full-thickness skin grafts are sometimes used as a ? emporary. method of reconstruction during a period of tumor surveillance to rule out early recurrence prior to definitive reconstruction.
Closure by secondary intention would require a prolonged period of healing and result in a poor final appearance with significant scar contracture, resulting in lower lid ectropion and possibly an upper lip deformity.
The internal mammary artery perforator (IMAP) flap is based on perforating blood vessels from the internal mammary artery and vein. The IMAP flap is an island variant of the deltopectoral flap and can be transferred as a free flap with good color match to the cheek compared with more distant tissues, such as the thigh or forearm. Use of the IMAP flap may result in breast distortion in a female and would require a microvascular anastomosis while not necessarily resulting in a superior cosmetic outcome to the cervicofacial flap.
Primary closure is often the reconstructive method of choice for small defects with excellent cosmetic results when the scar can be oriented along lines of minimal tension or natural cheek borders. However, for such a large defect, primary closure cannot be achieved without significant wound tension and excessive distortion of surrounding structures.
A 4-year-old boy is seen following a pitbull bite to his face. The periorbital findings are shown in the photograph. A stent is placed and the ends of the stent are advanced across the canaliculus. The ends of the stent will enter the nasal cavity in which of the following locations?
A) Above the superior turbinate
B) Below the superior turbinate
C) Above the middle turbinate
D) Below the middle turbinate
E) Above the inferior turbinate
F) Below the inferior turbinate
The correct response is Option F.
Reconstruction of the lacrimal apparatus is a critical step in addressing this patient’s periorbital wounds. Failure to properly manage this aspect of the injury will lead to epiphora and the inevitable need for a secondary procedure to manage tear drainage. Delayed reconstruction of this injury would likely require a conjunctivodacryocystorhinostomy, a surgically created conduit between the eyelid and the nose. The best initial management of this lacrimal apparatus disruption is as described—placement of a stent through the canaliculi, into the lacrimal duct (contained within the maxillary bone), and into the nose. The exit point of the nasolacrimal duct is via the valve of Hasner, below the inferior turbinate. It is here that the ends of the stent can be identified and retrieved, although this is often quite challenging.
The frontal, maxillary, and anterior ethmoid sinus cells drain into the middle meatus, just below the middle turbinate. The sphenoid sinus and posterior ethmoid sinuses drain into the sphenoethmoid recess, between the nasal septum and the superior turbinate.
References
Netter, F. H. Atlas of Human Anatomy. Lacrimal apparatus. Ciba-Geigy. 1989.
Drake, R., Vogl, W., Mitchell. A.W.M., Tibbitts, R. and Richardson, P. Gray’s Atlas of Anatomy. 3rd. Edition. Churchill Livingstone. 2021.
A 25-year-old man comes to the office 48 hours after “jamming” the right index finger while playing volleyball. The patient reports pain and swelling around the proximal interphalangeal (PIP) joint that prevents him from flexing the digit. Examination does not show malrotation or angulation of the fingertip, but range of motion is limited at the PIP joint because of pain. X-ray studies are shown. Which of the following is the most appropriate next step in management?
A) Arthrodesis of the PIP joint
B) Dorsal block splinting
C) Dynamic traction reduction
D) Hemi-hamate arthroplasty
E) Splint immobilization for 4 weeks
The correct response is Option C.
Dislocations of the proximal interphalangeal joint may be treated with splinting, typically dorsal block splinting, and early motion. In the setting of a volar dislocation, where injury to the central slip is suspected, splinting for 3 to 6 weeks in extension may be necessary. Splinting alone is inadequate treatment for fracture dislocations where the middle phalanx remains subluxed dorsally compared with the proximal phalanx condyles. This particular injury requires reduction prior to splinting or other methods of maintaining the joint congruity. Fracture/dislocations of the proximal interphalangeal joint that can be reduced and maintained with joint flexion can be successfully treated with either dorsal block splinting or percutaneous pinning as a dorsal block. Injury patterns amenable to this treatment typically involve <40% of the volar articular surface. The lateral radiograph demonstrates a comminuted fracture of 50 to 60% of the volar articular surface of the middle phalanx with the presence of a centrally depressed fragment; which is too large for a hemihamate graft. The AP radiograph shows comminution extending obliquely as well as in the sagittal plane, suggesting a pilon-type injury. This pattern of injury would not be reduced adequately with dorsal blocking alone. Complex fractures/dislocations of the base of the middle phalanx prove challenging to treat. Keys to success involve reduction of the dorsally dislocated middle phalanx base, restoration of articular congruity, and provision of early motion.
One useful approach to these injuries involves application of a dynamic traction device. Commercial devices are available; however, a construct composed of pins and rubber bands, described by Suzuki, allows creation of a dynamic traction device with materials available at any hospital. Outcomes from this treatment can achieve anywhere between 70 to 90% of the motion of the uninjured joint. When unstable, simple fracture/dislocations of the proximal interphalangeal joint can be treated with open reduction and internal fixation. Multiple techniques have been employed including dorsal, palmar, and midlateral approaches. Screws, cerclage wires, and even miniplates have been used. The lateral radiograph demonstrates this with the depressed articular fragment in the volar half of the joint surface. When severe comminution destroys enough of the volar half of the middle phalanx base so as to make restoration of stability unlikely, an osteochondral graft from the dorsum of the hamate between the little and ring finger metacarpal bases can be harvested and used to replace the lost articular surface. Use of this procedure requires the presence of a dorsal articular segment with some stability, to which the graft may be affixed. The AP radiograph demonstrates fracture lines extending through the dorsoradial articular surface of the middle phalanx, making hemi-hamate grafting difficult if not impossible. Arthrodesis is reserved as a salvage repair after attempts at primary repair have failed
A 27-year-old man is brought to emergency department because of a thumb avulsion injury measuring 3 × 3 cm. A photograph is shown. Which of the following is the best option for sensate, soft-tissue coverage?
A) Cross-finger flap
B) First dorsal metacarpal artery flap
C) Moberg flap
D) Pedicled groin flap
E) Skin grafting
The correct response is Option B.
There are several sensate options for thumb pulp deformities. These include neurovascular island flaps, Moberg flaps, free toe pulp flaps, and the first dorsal metacarpal artery flap (FDMA). Cross finger flaps, skin grafts, and pedicle groin flaps do not have innate innervation. The defect in the question involves the entire pulp of the thumb overlying the distal phalanx and is too large for a Moberg advancement flap.
The FDMA flap is supplied by its eponymous artery, which travels in the fascia overlying the index metacarpal and supplies the skin overlying the dorsum of the proximal phalanx. The vessel is accompanied superficially by a branch of the radial nerve that provides neural activation to the skin overlying the proximal phalanx of the index finger. The flap can be transposed to provide sensate coverage of the tip of the thumb, and can provide sufficient size to resurface relatively large defects.
Cortical reorientation is the fact that the brain recognizes a stimulus from the flap area as a stimulus from the thumb, and not from the index finger. This process takes some time, but is usually complete after 2 years. Average static two-point discrimination in these flaps utilized for thumb resurfacing is 10 to 11 mm.
Use of the FDMA flap for resurfacing of the thumb pulp has been compared to heterodigital island flaps in several studies. Both remain options to be considered, but the ease of elevation, limited dissection, and acceptable donor site morbidity make the FDMA flap a common primary option for thumb tip resurfacing.
References
Tränkle M, Sauerbier M, Heitmann C, Germann G. Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap. J Hand Surg Am. 2003; 28(5):758–766.
Muyldermans T, Hierner R. First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strat Traum Limb Recon. 2009; 4:27.
Delikonstantinou IP, Gravvanis AI, Dimitriou V, Zogogiannis I, Douma A, Tsoutsos DA. Foucher first dorsal metacarpal artery flap versus Littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects. Ann Plast Surg. 2011 Aug;67(2):119-22.
An otherwise healthy 28-year-old woman comes to the physician requesting removal of bilateral axillary masses. She states that the masses fluctuate in size and tenderness with her menstrual cycle. She reports that the masses have not had discharge or drainage. Physical examination shows smooth, spongy masses in both axillae. A photograph is shown. Which of the following is the most appropriate next step in management of this patient?
A) Excise the bilateral axillary masses and skin
B) Obtain bilateral mammograms of the axillary masses
C) Order an MRI of the chest
D) Perform a core biopsy of both axillary masses
E) Perform liposuction
The correct response is Option A.
This patient presents with ectopic breast tissue. In utero, the milk line (galactic band) forms at 5 weeks of gestation. This bilateral structure courses from the axillae to the groin, and normal breasts form in the prepectoral region after there has been regression of the rest of the galactic band. When there is failure of this regression, breast tissue remains in locations outside of the normal breast. The most common location for ectopic breast tissue is in the axillae, although it can be found anywhere along the milk line from the axillae to the groin. Ectopic breast tissue outside of the milk line has been described and is termed aberrant breast tissue.
The tissue found in these ectopic locations is breast tissue with the same characteristics and propensity for disease as normally located breast tissue, and breast cancer has been described in these tissues. In the absence of pathologic findings such as a mass, pain, and skin changes that are associated with breast cancer, there is no strong oncologic indication for excision. If there are findings concerning for a neoplasm, then work-up should be initiated and might include further imaging, core biopsy, and surgery. However, most cases present without pathologic findings and are excised to achieve a more reasonable appearance for the patient, the ability to don clothing more comfortably, and for the obvious social advantages.
In this case, the patient is young, has no complaints, and has no physical findings to suggest a neoplasm. Excision should be offered.
Obtaining bilateral mammograms is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination. In addition, mammograms of axillary breast tissue are technically unfeasible.
Performing a core biopsy is incorrect as there is no concern for malignancy in this case. In the case of a mass noted within the ectopic axillary breast tissue, then an oncologic workup should be initiated which might include a core biopsy.
An MRI of the chest is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination.
Reassuring the patient with no further action is not the most appropriate management, as it will not address the patient’s concerns and desires. In the patient who does not request excision or is not an appropriate surgical candidate, then reassurance and surveillance are appropriate.
As this is a young female with axillary breast tissue, liposuction will not improve the excess breast tissue or skin.
A 62-year-old woman is evaluated because of a new 2 × 2-cm open area near her left axillary fold. Medical history is significant for left breast cancer previously treated with bilateral mastectomies, left axillary node dissection, and adjuvant chemoradiation 10 years ago. A photograph is shown. She has been compliant with postoperative oncologic surveillance and has had no recent trauma. Which of the following underlying conditions is most likely responsible for her current presentation?
A) Empyema with spontaneous drainage
B) Lymphedema drainage tract
C) Osteoradionecrosis of the underlying rib(s)
D) Recurrent breast cancer
E) Skin ulceration from intertriginous shearing forces
The correct response is Option C.
The effects of ionizing radiation are permanent and may present either acutely or in delayed fashion, even years after the original radiation insult. The mechanism of injury from this radiation is through free radical production which, in turn, directly damages the DNA. In the acute period, the effects of radiation may manifest themselves as erythema and edema of the skin, vasodilation with endothelial edema, and lymphatic obliteration. This eventually leads to capillary thrombosis and subsequent inadequate tissue oxygenation. Over time, nonhealing ulcers can spontaneously develop, sometimes years later.
Although recurrent cancer is always a concern in patients with a personal history of cancer, proper, regular, and thorough surveillance can often detect recurrences early, especially in compliant patients. Most recurrences occur within the first 5 years.
Abscesses usually present initially with pain, erythema, and localized fluctuance, and often with associated fever and/or malaise. Spontaneous necessitation to the skin would also result in purulent drainage.
Lymphedema can be a chronic condition after mastectomy and axillary node dissection, and is usually manifested as generalized edema of the ipsilateral upper extremity. Sinus tract formation is rare.
Intertriginous shearing would most often present as superficial epidermal loss with possible superinfection with yeast due to moisture.
A 30-year-old woman comes to the office because she is unable to flex the distal interphalangeal (DIP) joint of the right long finger. An x-ray study is shown. She reports that she injured the finger 2 days ago when attempting to restrain her dog. Physical examination shows no active flexion of the DIP joint; however, the DIP joint can be passively flexed from 0 to 80 degrees. During surgical exploration, the distal end of the flexor digitorum profundus tendon is most likely to be found at the level of which of the following structures?
A ) A4 pulley
B ) Camper chiasm
C ) Central slip
D ) Sagittal band
E ) Terminal tendon
The correct response is Option A.
The injury to the patient described is commonly referred to as a €œjersey finger. € Patients have the sudden failure of fingertip-level grasp, like a football player attempting to tackle an opponent by the jersey. Injury may involve a pure soft-tissue rupture of the flexor digitorum profundus (FDP) tendon, or a portion of the volar proximal aspect of the distal phalanx may be avulsed along with the tendon. Injuries are classified based on the type of fracture and how proximally the FDP tendon has retracted. In the patient described, a large fragment of the distal phalanx base remained attached to the FDP tendon. The tendon and fragment are held in this position by the A4 pulley.
Camper chiasm is where the flexor digitorum superficialis (FDS) tendon splits to pass dorsal to the FDP tendon en route to its insertion at the base of the middle phalanx. Camper chiasm does not exist distal to the proximal interphalangeal (PIP) joint. The sagittal band is a stabilizer of the extrinsic extensor tendons over the dorsum of the metacarpophalangeal (MCP) joint. It also does not contact the FDP tendon. The terminal tendon and central slip are components of the finger extensor mechanism. They do not contact the FDP tendon.
The postoperative x-ray study shown demonstrates reduction of the bone fragments to the shaft of the distal phalanx. A Bunnell suture was used to capture the tendon and the multiple bone fragments. This suture was then passed through the distal phalanx and tied dorsally over a button.
A 12-year-old girl with Beckwith-Wiedemann syndrome develops profound breast enlargement at the onset of puberty. Physical examination shows two distinct masses in the right breast and severe hyperplasia consuming the left breast. A photograph is shown. Which of the following is the most appropriate surgical management?
A) Hormone suppression therapy
B) Right lumpectomies; left mastectomy with skin reduction with application of nipple as skin graft
C) Right simple mastectomy; left mastectomy with skin reduction with application of nipple as skin graft
D) Right simple mastectomy; left simple mastectomy with sentinel lymph node biopsy
E) Right total mastectomy; left modified radical mastectomy
The correct response is Option B.
Epithelial hyperplasia is a benign pathological process. Therefore, modified radical mastectomy or sentinel lymph node biopsy would not be indicated in the absence of cancer. Mastectomy on the right is not indicated because the masses are discrete and separate from the normal breast parenchyma. As such, a viable breast mound can be preserved in this 12-year-old girl. Because of the expansive nature of her hyperplasia on the left, skin reduction is required to ensure smooth contour of her skin flaps. The nipple may be spared because of the benign disease. Reconstruction can be performed in a delayed fashion after development is complete. An adjustable expander/prosthesis can also provide a reasonable breast mound until definitive reconstruction is performed.
Hormone suppression therapy may temporarily slow the growth of the hyperplasia but could adversely affect this child’s normal development. It would not comprise definitive management.
A 38-year-old man comes to the office because of central wrist pain 7 months after falling on his outstretched right hand. He did not seek treatment at the time of his original injury. An anteroposterior x-ray study is shown. In a lateral x-ray study view, the scapholunate angle is most likely to be which of the following?
A) Less than 20 degrees
B) 20 to 40 degrees
C) 41 to 60 degrees
D) Greater than 60 degrees
The correct response is Option D.
The patient described has scapholunate separation that results not only in widening of the gap between the scaphoid and the lunate, as depicted in the x-ray study shown (Terry-Thomas sign), but also in flexion of the scaphoid. This is seen on the anteroposterior x-ray study as a ?ring sign? as a result of the distal pole of the scaphoid moving relatively closer to the proximal scaphoid cortex and being viewed end-on.
Carpal bone malalignment is also determined by angles on lateral x-ray studies. As the scaphoid flexes progressively, the lunate (still tethered to the triquetrum) goes into an extension dorsal intercalated segment instability deformity.
In a patient with rotary subluxation at the scaphoid, the scapholunate angle is expected to be increased on lateral x-ray study. Normal values range from 30 to 60 degrees. Angles greater than 80 degrees are considered a definite indication of scapholunate dissociation.
A 54-year-old woman is evaluated for an injury to the proximal interphalangeal (PIP) joint of the long finger of the left hand that she sustained during a motor vehicle collision. X-ray study is shown. Which of the following methods is the most appropriate surgical management of this patient’s fracture?
A) Dynamic external fixation
B) Hemihamate arthroplasty
C) Lag screw fixation
D) PIP joint arthrodesis
E) Volar plate arthroplasty
This patient presents with an intra-articular, or pilon, fracture of the middle phalanx base. Typically, pilon fractures are axial load injuries to the finger resulting in impaction, comminution, central depression, and splaying of the middle phalanx fracture fragments both volarly and dorsally.
Fractures involving the proximal interphalangeal (PIP) joint are generally divided into three categories: volar rim fractures, dorsal rim fractures, and pilon fractures (volar and dorsal rim) with or without joint dislocation. Joint dislocation occurs secondary to ligamentous injury and correlates to the amount of articular surface involved in the fracture. Management of these injuries depends on the fracture type, severity, degree of articular surface involvement, extent of dislocation, and associated soft-tissue injuries. Pilon fractures due to the comminution and crush component of the middle phalanx base can be very difficult to treat. Post-traumatic osteoarthritis causing stiffness, impaired function, and pain is a known complication.
Multiple different types of dynamic external fixation devices have been described in the literature. These are mostly fabricated from K-wires with or without a rubber band traction system. The devices work by the principles of a lever and ligamentotaxis to maintain fracture reduction and joint congruency and to allow early motion for joint surface remodeling. The devices are inexpensive and relatively easy to place with experience, and can be placed using local anesthesia. Dynamic distraction external fixation has been indicated for use in pilon fractures and unstable PIP joint fracture dislocations. The constructs are usually removed 4 to 6 weeks after fracture consolidation and clinical healing is present. Most studies report 60 to 88 degrees of PIP motion with good patient satisfaction and return of function. The presence of arthritic changes on x-ray studies is common after these injuries. Pin tract infections up to 40% have been reported in retrospective studies; however, these seem to be treated with oral antibiotics alone and do not require pin removal. They do not progress to osteomyelitis.
PIP joint arthrodesis is an option for treatment in very severe pilon fractures or crush injuries with severe soft-tissue involvement; however, this sacrifices motion and should be reserved for cases where there are no other viable treatment options.
Hemi-hamate arthroplasty and volar plate arthroplasty are operations described to treat PIP joint fracture dislocations with isolated volar rim involvement. These procedures require an intact dorsal cortex of the middle phalanx base to achieve stable fixation. Both procedures are indicated for comminuted fractures involving 30 to 50% of the articular surface of the middle phalanx base.
Open reduction and internal fixation of pilon fracture with locking plates has been described, but is technically challenging and requires significant soft-tissue dissection compared with percutaneous dynamic external fixation. Lag screws are inadequate fixation in general for pilon fractures. Isolated volar rim fractures with a larger fracture fragment can be treated successfully with lag screws.
A 48-year-old woman undergoes radical resection of the left breast, left hemisternectomy, four-rib resection, and visceral pleurectomy because of invasive inflammatory breast cancer extending through the thoracic wall into the mediastinum and chest. Examination of specimens obtained from intraoperative frozen section biopsies shows no residual disease. Postoperative adjuvant chemotherapy and radiation therapy to the area are planned. An intraoperative photograph of the 17 × 17-cm defect is shown. Which of the following is the most appropriate technique for soft-tissue reconstruction?
A) Left latissimus muscle flap with skin graft
B) Left rectus muscle turnover flap and skin graft
C) Omental flap and skin graft
D) Reverse abdominoplasty flap
E) Right transverse rectus abdominis musculocutaneous (TRAM) flap
The correct response is Option E.
The most appropriate option for this patient would be a right TRAM flap. The defect encompasses a composite defect of the left side of the sternum, including the left internal mammary artery, four contiguous ribs, and the entire left breast. The question specifically asks for soft-tissue thoracic reconstruction. The analysis of the defect yields a very large soft-tissue requirement. Given this, the most logical choice of flaps to provide this amount of soft tissue on a reliable pedicle would be a right (contralateral) TRAM flap. Furthermore, this flap could also be shaped to provide a breast mound versus all the other choices.
A left latissimus muscle flap with skin graft is not the optimal choice as it would not provide sufficient soft-tissue coverage with its associated skin paddle without undue donor site morbidity in this particular patient with a large defect that spans parasternal and lateral chest wall. As a muscle-only flap with skin graft, however, it may be considered as a backup option in case of primary flap failure.
An omental flap with skin graft is an option for reconstruction of this defect; however, it would not be the most appropriate option in this case as it would necessitate an otherwise unnecessary intra-abdominal procedure and would not reshape a breast mound. It has been shown, however, to be optimal in contaminated areas due to its associated lymphatic vessels and nodes associated with its pedicle, so in different circumstances, this may be a preferred choice.
A left rectus turnover flap with skin graft would not be a good option for two reasons: the left internal mammary artery has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based; and it would not cover the entirety of the defect.
A reverse abdominoplasty flap would not be able to reach the full superior extent of the defect.
