Basic Surgical Principles Flashcards
Comprehensive Principles
A 36-year-old health-care worker sustains a needle-stick injury from a hepatitis C–seropositive patient.
Immediate testing for anti-HCV antibodies and confirmatory immunoassays for HCV-RNA are performed.
Initial follow-up testing after exposure should be performed at which of the following time periods?
A) 1 week
B) 3 weeks
C) 6 weeks
D) 12 weeks
E) 24 weeks
The correct response is Option C.
It is recommended that follow-up retesting be done at 6 weeks, 3 months, and 6 months in known HCV
exposure cases. Tests at 1 or 3 weeks would possibly lead to false negative results. There is no
advantage in waiting beyond 6 weeks.
Reference(s)
1. Waljee J, Malay S, Chung K. Sharps Injuries: the Risks and Relevance to Plastic Surgeons. Plast
Reconstr Surg. 2013 Apr;131(4):784-91.
2. Pappas N, Lee DH. Hepatitis C and the Hand Surgeon: What You Should Know. Journal of Hand
Surgery. J Hand Surg Am. 2012 Aug;37(8):1711-3; quiz 1714.
A right-hand–dominant, 72-year-old man presents with clicking, locking, and pain deep to the distal
palmar crease of the right ring finger. Four weeks prior he had a 40 mg triamcinolone injection with
incomplete resolution of his symptoms. How long should he wait after the corticosteroid injection before
performing an A1 pulley release in order to mitigate the increased risk of surgical site occurrence?
A) 1 week from injection
B) 4 weeks from injection
C) 8 weeks from injection
D) 12 weeks from injection
E) There is no increased risk of surgical site occurrence
The correct response is Option D.
The risk of surgical site occurrence is mitigated at approximately 80 days (~12 weeks) from corticosteroid
injection. In a retrospective review of 999 patients who underwent corticosteroid injection for trigger digit
and subsequently underwent surgery, they carefully scrutinized rates of surgical site occurrence. Charts
were queried for infection/occurrence by identifying “infection,” “suture abscess,” “worrisome for
infection,”, or “return to the operating room for infection.” Those who did not develop an infection had a
significantly longer time between corticosteroid injection and surgery (mean 260 days vs mean 79 days,
p less than 0.05). There were no differences in infection rates between those who underwent one or
multiple corticosteroid injections prior to surgery (Ng et al.).1
In male patients with a single involved digit, the average success rate for corticosteroid injection alone is
low (35%). One may suggest that surgery is indicated in this patient population prior to attempting
corticosteroid injection. When evaluating the treatment of trigger digit from a cost perspective, males with
single digit involvement or multiple digit involvement and women with multiple digit involvement should
forgo corticosteroid injection because of low success rates (35%, 37%, and 56%, respectively)
(Brozovich et al. and Wojahn et al).2,3
The decision to treat trigger digit with corticosteroid injection versus surgery may also be a personal
decision by the patient after informed discussion with the surgeon. It is important to remember that
corticosteroid injection preceding surgery may increase the risk for surgical site occurrences.
Reference(s)
1. Brozovich N, Agrawal D, Reddy G. A Critical Appraisal of Adult Trigger Finger: Pathophysiology,
Treatment, and Future Outlook. Plast Reconstr Surg Glob Open.2019;7(8):e2360.
2. Ng WKY, Olmscheid N, Worhacz K, et al. Steroid Injection and Open Trigger Finger Release
Outcomes: A Retrospective Review of 999 Digits. Hand (NY). 2018:1558944718796559.
3. Wojahn RD, Foeger NC, Gelberman RH, et al. Long-term outcomes following a single corticosteroid
injection for trigger finger. J Bone Joint Surg Am. 2014;96(22):1849-54.
A 64-year-old, left-hand–dominant man presents with Dupuytren contracture of the hand. Physical
examination shows joint contractures of the small finger metacarpophalangeal (MCP) joint (35 degrees),
proximal interphalangeal (PIP) joint (30 degrees); and ring finger MCP joint (30 degrees) and PIP joint
(15 degrees). Needle aponeurotomy is planned to correct the deformity. Which of the following diseaserelated
factors is most predictive of re-intervention following this procedure?
A) Dominant hand involvement
B) MCP contracture severity
C) Older age
D) PIP contracture severity
E) Presence of a natatory cord
The correct response is Option D.
The disease-related factor most strongly predictive of recurrence is the degree of PIP contracture. In a
retrospective review of 848 interventions for Dupuytren contracture, authors noted that degree of PIP and
a younger age at time of initial intervention were most predictive of re-intervention. They looked at a
cohort of 350 patients over an 11-year period in which multiple surgeons performed interventions for
varying degrees of contracture of both the MCP and PIP joints. Comparisons between needle
aponeurotomy, collagenase, and partial fasciectomy were performed. They reported 2-year reintervention
rates of 24%, 41%, and 4% respectively. Based on cumulative number of re-intervention,
total direct surgical costs were $1,540, $5,952, and $5,507 respectively (Leafblad et al.).[1]
MCP contracture severity was not an independent predictor of re-intervention. Natatory cords are
responsible for webspace contractures and do not independently result in MCP or PIP contractures.
Younger age at time of initial intervention was predictive of re-intervention and older age was
preventative. They found no differences in contracture re-intervention when comparing dominant to nondominant
hand.
In a prospective, randomized trial, investigators compared needle aponeurotomy to collagenase in
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Question 105 of 144
patients with isolated PIP joint contracture. Patients were followed for 2 years following intervention.
Primary outcome was reduction in contracture by at least 50%. At 2-year follow-up, 7% of collagenase
patients had maintained improvement as compared to 29% of patients who underwent needle
aponeurotomy, suggesting that collagenase treatment of Dupuytren disease leading to PIP contracture is
not superior to needle aponeurotomy (Skov et al.).[2]
Reference(s)
1. Leafblad ND, Wagner E, Wanderman NR, et al. Outcomes and Direct Costs of Needle Aponeurotomy,
Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture. J Hand Surg Am
.2019;44(11):919-927.
2. Skov ST, Bisgaard T, Søndergaard P, et al. Injectable Collagenase Versus Percutaneous Needle
Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled
Trial. J Hand Surg Am.2017;42(5):321-328.e3.
Which of the following is the most common type/location of salivary gland cancer in the pediatric
population?
A) Acinic cell carcinoma/submandibular glands
B) Adenoid cystic carcinoma/submandibular glands
C) Carcinoma ex pleomorphic adenoma/minor salivary glands
D) Cystadenocarcinoma/parotid gland
E) Mucoepidermoid carcinoma/parotid gland
The correct response is Option E.
The most common type/location of salivary gland cancer in the pediatric population is mucoepidermoid
carcinoma of the parotid gland. There are three sites of salivary gland carcinoma in this population
including the parotid gland, submandibular glands, and minor salivary glands. In a systematic review and
meta-analysis, Zamani et al. identified the frequency of various types of salivary cancer in children
including the location and type. Their findings indicate that the most common site of salivary gland
cancers occur in the parotid gland (72%), followed by the minor salivary glands (21%) and the
submandibular glands (8%). The most common types of salivary gland cancers are mucoepidermoid
carcinoma, adenoid cystic carcinoma, and acinic cell carcinoma. In all locations, mucoepidermoid cancer
is the most common type (53% for parotid, 55% for submandibular gland, and 63% for minor salivary
glands).
Reference(s)
1. Yoshida AJ, Garcia J, Eisele DW, Chen AM. Salivary gland malignancies in children. Int J Pediatr
Otorhinolaryngol. 2014;78:174-178.
2. Zamani M, Gronhoj C, Jensen JS. Survival and characteristics of pediatric salivary gland cancer: a
systematic review and meta-analysis. Pediatr Blood Cancer. 2018;e27543.
A 30-year-old woman undergoes augmentation mammaplastyin an office-based operating room.
Intravenous midazolam and fentanyl are used, and a lidocaine field block is administered. An hour later,
while in the recovery room, the patient experiences disorientation, muscle twitching, and lightheadedness.
Administration of which of the following drugs is the most appropriate next step in
management?
A) Dantrolene
B) Fat emulsion
C) Flumazenil
D) Naloxone
E) Propofol
The correct response is Option B.
This patient is experiencing symptoms of lidocaine toxicity. Lidocaine toxicity occurs within a few minutes
after injection but can occur up to 60 minutes after injection. The maximum dose of lidocaine without
epinephrine is 4.5 mg/kg and with epinephrine is 7 mg/kg. Symptoms of lidocaine toxicity can range from
central nervous system (CNS) excitement (circumoral/tongue numbness, metallic taste, lightheadedness,
dizziness, visual and auditory disturbances, disorientation, drowsiness), and at higher
doses CNS depression (muscle twitching, convulsions, unconsciousness, coma, respiratory depression
and arrest, cardiovascular depression and collapse). Cardiovascular manifestations include chest pain,
shortness of breath, palpitations, hypotension, and syncope. Of the options presented, fat emulsion
(Intralipid) is the treatment of choice. Flumazenil is the treatment for benzodiazepine overdose, naloxone
is for opioid overdose, dantrolene is for malignant hyperthermia, and propofol is used for induction and
maintenance of general anesthesia.
Reference(s)
1. Mustoe TA, Buck II DW, Lalonde DH. The safe management of anesthesia, sedation, and pain in
plastic surgery. Plast Reconstr Surg. 126:165e, 2010.
2. Failey C, Aburto J, Garza de la Portilla H, et. al. Office-based outpatient plastic surgery utilizing total
intravenous anesthesia. Aesth Surg J. 33(2) 270-274, 2013.
A 22-month-old female infant presents with a large mixed micro- and macrocystic lymphatic malformation of the left upper extremity. A photograph is shown. Medical history includes two rounds of sclerotherapy for the macrocystic component at 6 and 12 months of age and repeated infections, requiring a long hospital stay for intravenous antibiotic therapy 4 months ago. Which of the following is the most
appropriate therapy for this patient?
A) Amputation
B) Embolization
C) Power-assisted liposuction
D) Repeated sclerotherapy
E) Surgical debulking
The correct response is Option E.
This 22-month-old female has undergone treatment of the macro cystic component of the lymphatic malformation and continues to present with complication secondary to the disease. In addition to difficulty of mobilization, fitting of regular clothes, nutrition problems due to repeated infections, there is also significant life threatening risk of severe infection. Even though compression garment and repeated sclerotherapy are potential options, there will be no control of the disease. The best next step is surgical debulking. Embolization is not appropriate for a lymphatic malformation, and amputation is not indicated at this time. Power-assisted liposuction would be indicated for lymphedema, not for a lymphatic malformation.
Reference(s)
1. Defnet AM, Bagrodia N, Hernandez SL, et al. Pediatric lymphatic malformations: evolving
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Question 74 of 144
understanding and therapeutic options. J Pediatr Surg Int. 2016 May;32(5):425-33. doi: 10.1007/s00383-
016-3867-4. Epub 2016 Jan 27.
2. Kanth AM, Krevalin M, Adetayo OA, Patel A. Surgical Management of Pediatric Lymphedema: A
Systematic Review. J Reconstr Microsurg. 2019 Feb 27. doi: 10.1055/s-0039-1681068.
Which of the following factors has been shown to have the greatest impact on infection reduction in
trauma patients with a lower-extremity open fracture?
A) Definitive irrigation and debridement, and initiation of negative pressure wound therapy within 12 hours of injury
B) Early intramedullary reaming and nail fixation
C) Evaluation of the patient at a level I trauma center
D) Initial debridement of the wound by a senior surgeon
E) Intravenous administration of an antibiotic within 3 hours of injury
The correct response is Option E.
Early administration of antibiotics (less than 3 hours after injury) has been shown to be the most
important determinant of infection prevention after traumatic open fractures of the lower extremity; this is
more influential than other factors including time to initial washout, seniority of surgeon involved, as well
as severity of the extremity trauma. Guidelines differ by institution but at least a cephalosporin is
advocated with consideration given to additional gram-negative plus or minus anaerobic coverage in
grossly contaminated wounds.
In a large multi-institutional study of open fractures, Pollak et al, showed a significant decrease in
infection rate with either early direct admission (<2 hours) or transfer (<11 hours) to a level I trauma
center, though this was only true for the Gustilo Type III open tibial fracture subgroup and not all open
fractures. The authors hypothesized that early transfer resulted in earlier administration of antibiotics, though this was not directly compared.
While prompt debridement is important in obtaining wound control in traumatic lower-extremity open
fractures, no clear advantage has been shown to debridement within 6 hours versus 24 hours, with the
accepted standard that this can typically wait until daylight hours in the setting of timely prophylactic
antibiotic administration.
Intramedullary reaming has not been shown to decrease infection risk in open tibial fractures, although
early skeletal reduction and stability will minimize ongoing soft tissue damage.
Reference(s)
1. de Mestral C, Sharma S, Haas B, et al. A contemporary analysis of the management of the mangled
lower extremity. J Trauma Acute Care Surg. 2013;74(2):597-603.
2. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures.
Cochrane Database Syst Rev. 2004(1):CD003764.
3. Park JJ, Campbell KA, Mercuri JJ, Tejwani NC. Updates in the management of orthopedic soft-tissue
injuries associated with lower extremity trauma. Am J Orthop. 2012;41(2):E27-35.
A 63-year-old woman presents with a 2.3-cm moderately differentiated infiltrating ductal carcinoma of the
left breast and clinically negative axilla. Partial mastectomy and sentinel lymph node biopsy are planned.
Preoperative injection is performed with blue dye and technetium sulfur colloid. Intraoperatively, no
sentinel lymph node is identified. Which of the following is the most appropriate next step in
management?
A) Closure of the axilla and continuous surveillance
B) Intraoperative ultrasonography and excision of any enlarged nodes
C) Level I and II axillary node dissection
D) Reinjection with technetium sulfur colloid and blue dye
E) Total mastectomy
The correct response is Option C.
Recent data from the ACOSOG Z0011 trial and others have diminished the role of axillary node
dissection in the treatment of breast cancer. Yet at times it is still the appropriate choice. Proper staging
of the axilla is very important, and when it cannot be obtained via sentinel lymph node biopsy, per the
updated National Comprehensive Cancer Network (NCCN) guidelines, level I and II axillary dissection
should be performed for staging purposes. Total mastectomy would not provide nodes for staging. The
remaining options are not standard approaches per the NCCN guidelines.
A 48-year-old man who sustained severe traumatic brain injury and extensive facial fractures in a motor
vehicle collision 2 weeks ago is receiving ventilatory support and enteral nutrition via feeding tube. An
indirect calorimetry assessment shows a respiratory quotient (RQ) value of 1.3. This value is most closely
associated with which of the following types of metabolism?
A) Carbohydrate oxidation
B) Ketosis
C) Lipid oxidation
D) Lipogenesis
E) Protein oxidation
The correct response is Option D.
Indirect calorimetry measurements, or a metabolic cart, are used to help calculate the resting energy
expenditure (REE) and respiratory quotient (RQ) as a means to help determine the caloric needs of a
patient as well as optimize the patient’s nutrition. Indirect calorimetry measures the amount of oxygen
consumed (VO2) and the amount of carbon dioxide produced (VCO2) by the patient. REE is calculated
by the Weir equation [REE = (3.94 x VO2) + (1.1 x VCO2)] while the RQ is calculated as VCO2 / VO2.
The calculated values of the respiratory quotient are reflections of what fuels are being oxidized by the
patient with typical values as follows:
Fat oxidation RQ 0.7
Protein oxidation RQ 0.8
Carbohydrate oxidation RQ 1.0
Lipogenesis RQ 1.3
Optimal values of RQ for nutrition assessment are between 0.8 and 0.9, representing a balance between
lipid and glucose oxidation. Values below 0.8 suggest underfeeding, while values greater than 1.0
suggest overfeeding. A value of 1.3 in this patient suggests significant overfeeding and lipogenesis and
the enteral nutrition should be adjusted based on the current energy expenditure obtained from indirect
calorimetry.
Ketosis is not measured by RQ.
Reference(s)
1. Maxwell J, Gwardschaladse C, Lombardo G, et al. The impact of measurement of respiratory quotient
by indirect calorimetry on the achievement of nitrogen balance in patients with severe traumatic burn
injury. Eur J Trauma Emerg Surg. 2017; 43(6): 775-782.
2. Oshima T, Berger MM, De Waele E, et al. Indirect calorimetry in nutritional therapy. A position paper
by the ICALIC study group. Clin Nutr. 2017; 36(3): 651-662.
Which of the following best describes the type and level of evidence in a Plastic
and Reconstructive Surgery paper evaluating a retrospective series of surgical
outcomes in 13 patients over 8 months?
A) Diagnostic, Level II
B) Diagnostic, Level III
C) Diagnostic, Level IV
D) Therapeutic, Level II
E) Therapeutic, Level III
F) Therapeutic, Level IV
The correct response is Option F.
The paper would fall into the therapeutic category, not diagnostic or risk, because the authors
are discussing a surgical intervention. It is a case study looking at a result and would therefore
be considered level IV evidence.
In early 2011, Plastic and Reconstructive Surgery unveiled their new program of a specialty-
wide evidence-based initiative. From that time forward, level of evidence had to be listed on
any and all articles that were amenable to such grading. This was believed to be a
straightforward and visible way of promoting and advancing evidence-based medicine in the
practice of plastic surgery. The three types of clinical questions addressed are diagnostic,
therapeutic, and risk. Each article should fall into one of the three groups.
There are five levels of evidence, ranging from I being the most stringent, highest degree of
evidence to V being mostly expert opinion-based. Level I studies are high-quality, multicenter
or single-center, randomized controlled trials with adequate power or systematic reviews of
these trials. Level II are lesser-quality randomized controlled trials or systematic reviews of
these studies. Level III are retrospective cohort or case-controlled studies. Level IV are case
studies with pre/post-test or only post-test outcomes. Level V studies encompass expert
opinion developed by consensus, case reports, and clinical examples. The long-term goal of
this process is to elevate the level of evidence of articles in Plastic and Reconstructive
Surgery.
REFERENCES:
1. Burns PB, Rohrich R, Chung KC. The levels of evidence and their role in evidence-based
medicine. Plast Reconstr Surg. 2011;128:305-310. doi:10.1097/PRS.0b013e318219c171
2. Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level of evidence pyramid:
indicating levels of evidence in Plastic and Reconstructive Surgery articles. Plast Reconstr
Surg. 2011;128(1):311-314. doi:10.1097/PRS.0b013e3182195826
A 52-year-old woman comes to the office after undergoing uncomplicated rhytidectomy 1 week ago. The
patient reports that she cannot feel her left earlobe. Damage to a sensory nerve is suspected. The
affected nerve was most likely injured intraoperatively in which of the following locations?
A) Along a line from the external auditory canal to the lateral edge of the inferior orbit
B) At the anterior border of the sternocleidomastoid muscle
C) Half the distance from mastoid process to the clavicular origin of the sternocleidomastoid muscle
D) One centimeter caudal to the external jugular vein as it crosses the sternocleidomastoid muscle
E) One-third the distance from external auditory canal to the clavicular origin of the sternocleidomastoid
muscle
The correct response is Option E.
The great auricular nerve (GAN) is the most commonly injured nerve in rhytidectomy. The GAN
complication rate is approximately 6.5%. GAN injury can result in pure anesthesia, partial parasthesia, as
well as painful neuromas in the distribution of the nerve. Permanent complete numbness has been
reported in up to 5% of patients. This may cause difficulty wearing earrings, using the telephone, shaving,
or combing one’s hair. Although not as catastrophic as a facial nerve injury, this complication can present
as a functional impairment and nuisance to the patient and surgeon alike.
It is critical to be aware of this nerve when embarking upon rhytidectomy in order to prevent iatrogenic
injury. Once the GAN emerges onto the anterior surface of the sternocleidomastoid muscle, it resides in a
superficial plane and is vulnerable to injury during elevation of facial flaps. The GAN is found at its most
superficial location approximately one third the distance from the external auditory canal to the clavicular origin of the sternocleidomastoid (SCM). A similar distance ratio exists from the mastoid process to the
clavicular origin of the SCM. It also lies approximately one centimeter cranial to the external jugular vein
on the anterior surface of the sternocleidomastoid muscle. With these anatomical landmarks, the surgeon
can accurately predict the location of the GAN at its most vulnerable site and reliably proceed with flap
dissection in the lateral neck during rhytidectomy procedures.
Frankfort’s line is a cephalometric measurement that runs from the external auditory canal to the lateral
edge of the inferior orbit and would be too cranial a location to find the GAN.
Reference(s)
1. Murphy R, Dziegielewski P, O’Connell D, et al. The great auricular nerve: an anatomic and surgical
study. J Otolaryngol Head Neck Surg. 2012 Apr;41 Suppl 1:S75-7.
2. Ozturk CN, Ozturk C, Huettner F, et al. A Failsafe Method to Avoid Injury to the Great Auricular Nerve.
Aesthet Surg J. 2014 Jan 1;34(1):16-21.
3. Rohrich RJ, Taylor NS, Ahmad J, et al. Great auricular nerve injury, the “subauricular band”
phenomenon, and the periauricular adipose compartments. Plast Reconstr Surg. 2011;127(2):835-843.
A 54-year-old woman undergoes lipoabdominoplasty under general anesthesia.
She is positioned supine with arms abducted for 4 hours. Compression
neuropathy of which of the following nerves is most likely in this patient?
A) Long thoracic
B) Median
C) Musculocutaneous
D) Radial
E) Ulnar
The correct response is Option E.
Eighty percent of surgical procedures take place supine. The most common postoperative
neuropathy following these procedures is ulnar (28% of closed claims in 1999) followed by
brachial plexus (20% of closed claims in 1999). They most commonly arise from improper
padding and positioning.
Compressive neuropathy of the radial nerve, long thoracic nerve (with its location on the
chest wall), musculocutaneous nerve, and median nerve is less common as a result of
inadequate positioning or padding during surgery.
Nerve injury may be avoided by abducting the arms no more than 60 to 90 degrees,
maintaining supination when arms are abducted, maintaining neutral positioning when arms
are tucked at the patient’s side, proper padding on the arm board, and the surgeon not leaning
on the extremities throughout the case.
REFERENCES:
1. Poore SO, Sillah NM, Mahajan AY, Gutowski KA. Patient safety in the operating room: I.
Preoperative. Plast Reconstr Surg. 2012;130(5):1038-1047.
doi:10.1097/PRS.0b013e31826945d6
2. Souba W. ACS Surgery: Principles and Practice 2006. RN. 2006;69:59-63.
A 65-year-old woman remains intubated in the intensive care unit after undergoing a prolonged
operation. Arterial blood gas analysis shows respiratory acidosis. An increase in respiratory minute
ventilationis planned. Minute ventilation is calculated by multiplying the respiratory rate and which of the
following parameters?
A) Inspiratory capacity
B) Residual volume
C) Tidal volume
D) Total lung capacity
E) Vital capacity
The correct response is Option C.
Minute ventilation is calculated by multiplying respiratory rate and tidal volume. Tidal volume is the
amount of air/gas displaced during each quiet breath, using no extra inspiratory (“deep breath”) or
expiratory effort.
Minute ventilation is an important concept in mechanical ventilation because of its inverse relationship
with blood carbon dioxide levels. The caveat of this relationship is that not all inhaled air/gas takes part in
gas exchange, whether because it remains in the conductive airways (ventilator tubing, endotracheal
tube, trachea, etc) or it reaches alveoli that are not adequately perfused. The volume of air/gas that does
not take part in gas exchange is called dead space. Residual volume is the volume of air still remaining in the lungs after the most forcible expiration possible.
Inspiratory capacity is the volume of air that enters the lungs during the most forcible inspiration possible,
starting at rest. Inspiratory reserve volume equals inspiratory capacity minus tidal volume, or the
difference between the deepest breath and a quiet breath.
Expiratory reserve volume is the amount of air that can still be expired after a quiet expiration ends. It
requires contraction of expiratory chest wall muscles, as opposed to quiet expiration, which is passive.
Vital capacity is the total amount of air that can be forcefully expired from the lungs after the most forcible
inspiration possible. It represents the addition of inspiratory reserve, tidal, and expiratory reserve
volumes.
Total lung capacity is the combination of vital capacity and residual volume.
Reference(s)
1. Hall, JE, Guyton AC. Pulmonary Ventilation. In: Hall, JE, ed. Guyton and Hall Textbook of Medical
Physiology, 13 th ed. Philadelphia, PA: Elsevier; 2016. Chapter 38: 497-507.
2. Rodriguez-Roisin R, Ferrer A. Chapter 37: Effect of Mechanical Ventilation on Gas Exchange. In:
Tobin, MJ, ed. Principles and Practice of Mechanical Ventilation, 3 rd ed. New York, NY: McGraw-Hill
Medical; 2013.
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 zonebased
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.
Reference(s)
1. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma.1969;9(12):987-999.
2. 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.
3. 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.
A 29-year-old right-hand–dominant man presents with a right distal radius fracture after falling on his
outstretched hand. He reports increasing pain and a pins-and-needles feeling in the right hand and
fingers. Distal capillary refill is less than 2 seconds, and radial and ulnar arteries are readily palpable, but
the patient has severe pain on passive extension of the fingers. Early compartment syndrome is
suspected. Which of the following compartments is most likely to have the most increased measured
pressures in this case?
A) Deep volar
B) Dorsal
C) Lateral
D) Superficial volar
The correct response is Option A.
Compartment syndrome is a devastating condition in which bleeding and/or edema within a muscle
compartment surrounded and restricted by fascia can result in increased pressures leading to
neurovascular compromise and muscle death. Sequelae of compartment syndrome include loss of
function, Volkmann ischemic contracture, and even amputation. It typically presents with pain out of
proportion to clinical examination, as well as increased pain with passive extension of the muscle bellies
within the affected compartment. Signs of neurovascular compromise are often not seen until much
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Question 141 of 144
later in the process. Compartment syndrome is most commonly associated with traumatic fractures.
Distal radius fractures are the most common cause of compartment syndrome in the forearm. The
forearm musculature is contained in four separate compartments: dorsal, lateral (or mobile wad),
superficial volar, and deep volar. The deep volar compartment is the most likely to develop the highest
interstitial pressures early in acute compartment syndrome after traumatic distal radius fracture. This
compartment houses the flexor digitorum profundus and flexor pollicis longus muscles, which are the
muscles most likely to be affected with untreated compartment syndrome and responsible for distal
interphalangeal flexion of the phalanges and interphalangeal flexion of the thumb, respectively.
Reference(s)
1. Hanandeh A, Mani VR, Bauer P, Ramcharan A, Donaldson B. Identification and Surgical Management
of Upper Arm and Forearm Compartment Syndrome. Cureus. 2019;11(10):e5862.
2. Kistler JM, Ilyas AM, Thoder JJ. Forearm Compartment Syndrome: Evaluation and Management.
Hand Clin.2018;34(1):53-60.
The patient is a 26-year-old white male with gunshot wound to the mouth to left tonsillar fossa with profuse bleeding. GCS 7, Immediate management:
A) resuscitation
B) intubation
C) CT scan of the head
D) transport to OR
Correct answer is option B.
The ABCs should guide the initial management of all trauma patients. In this patient with an injury to the airway and GCS score less than 8, it is essential to secure the airway first. The other options listed can be completed after the airway has been secured.
A 72-year-old man undergoes wide local excision of a T2 N0 squamous cell
carcinoma in the left lateral border of the tongue, along with left cervical
lymphadenectomy including sublevels IB and IIA and levels III and IV. The left
internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve are
preserved. Which of the following is the most appropriate classification of this neck
dissection?
A) Extended
B) Modified radical
C ) Radical
D) Selective
The correct response is Option D.
Removal of sublevels IB and IIA and levels III and IV is classified as a selective neck dissection.
Radical neck dissection was first described in 1906 by Dr. George Crile. It includes removal of
cervical lymph nodes from levels I through V, along with the ipsilateral internal jugular vein,
sternocleidomastoid muscle, and spinal accessory nerve.
Modified radical neck dissection refers to the removal of all cervical lymph nodes routinely
included in a radical neck dissection (levels I through V), while preserving at least one of the
nonlymphatic structures (internal jugular vein, sternocleidomastoid muscle, or spinal accessory
nerve).
Selective neck dissection refers to a cervical lymphadenectomy that preserves at least one of the
lymph node levels that are routinely removed in a radical neck dissection (I through V). Levels
and sublevels are selected for removal based on the expected drainage pattern determined by the
location of the primary tumor. Since many different selective neck dissections are possible, the
recommended name of the procedure should include “selective neck dissection” followed by the
list of levels or sublevels to be removed, as in: “left selective neck dissection (sublevels IB and
IIA and levels III and IV).”
Extended neck dissection refers to the removal of additional lymph node groups (eg,
paratracheal) or nonlymphatic structures (eg, hypoglossal nerve) that are not routinely included in
a radical neck dissection.
REFERENCES:
1. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions
proposed by the American Head and Neck Society and the American Academy of
Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg.
2002;128(7):751-758. doi: 10.1001/archotol.128.7.751
2. Robbins KT, Shaha AR, Medina JE, et al. Consensus statement on the classification and
terminology of neck dissection. Arch Otolaryngol Head Neck Surg. 2008;134(5):536-538. doi:
10.1001/archotol.134.5.536
A 44-year-old woman presents in evaluation for breast reconstruction with biopsy-proven left breastinfiltrating
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.
Reference(s)
1. Gradishar WJ, Anderson BO, Abraham J, et al. NCCN Clinical practice guidelines in oncology - breast
cancer. National Comprehensive Cancer Network Web
site.https://www.nccn.org/professionals/physician_gls/default.aspx. Updated February 8, 2019. Accessed
February 11, 2019.
2. Man VC, Cheung PS. Neoadjuvant chemotherapy increases rates of breast-conserving surgery in
early operable breast cancer. Hong Kong Med J. 2017 Jun;23(3):251-257.
The physiologic hypervolemia of pregnancy has clinical significance in the management of the severely injured, gravid woman by:
A) reducing the need for blood transfusion
B) increasing the risk of pulmonary edema
C) complicating the management of closed head injury
D) reducing the volume of crystalloid required for resuscitation
E) increasing the volume of blood loss to produce maternal hypotension
Correct answer is option E>
Recognition of hypovolemia in pregnant patients is complicated by changes in normal physiological parameters during pregnancy. Initially, mean blood pressure decreases due to maternal systemic vasodilation and from the high-flow, low-resistance circuit in utero-placental circulation. Later, blood pressure normalizes again. In addition to changes in vascular tone and resistance, circulating blood volume increases by as much as 50%.
An 81-year-old man with peripheral vascular disease undergoes coverage of exposed vascular
prosthesis in the groin with a rectus femoris muscle flap. On postoperative day 2, the patient has sudden
onset of chest tightness and becomes unresponsive, with no palpable pulse. CPR is promptly initiated.
The defibrillator monitor shows ventricular fibrillation. Which of the following is the most appropriate next
step after shock delivery (electrical defibrillation)?
A) Capnometry
B) Chest compressions for 2 minutes
C) Endotracheal intubation
D) Intravenous administration of adenosine
E) Pulse/rhythm check
The correct response is Option B.
According to current Advanced Cardiac Life Support (ACLS) guidelines, CPR should be resumed
immediately after shock delivery, without pausing for a rhythm or pulse check. It should begin with chest
compressions and continue for 2 minutes, after which the rhythm should be checked and the cycle
(shock/CPR 2 min/check) repeated if there is no return of spontaneous circulation (ROSC).
Increasing emphasis has been placed on the importance of continuous “high-quality” chest compression
(5 cm sternal depression, 100 to 120/min), to maximize tissue perfusion and probability of ROSC. A 30:2
compression:ventilation rate is recommended in the absence of an endotracheal or supraglottic airway.
Otherwise, 10 breaths per minute should be delivered with continuous chest compressions.
There are no studies directly addressing the timing of advanced airway placement and outcome during
resuscitation from cardiac arrest. Although insertion of an endotracheal tube during ongoing chest
compressions is possible, in most instances intubation is associated with interruption of compressions for
many seconds. Particularly, patients with witnessed cardiac arrest from ventricular fibrillation or pulseless
ventricular tachycardia may benefit from a few uninterrupted cycles of CPR prior to placement of an
advanced airway.
Adenosine is not indicated in the treatment of adult cardiac arrest.
Capnometry/capnography requires placement of an endotracheal tube.
Reference(s)
1. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015
American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444-64.
2. Bobrow BJ, Ewy GA, Clark L, et al. Passive oxygen insufflation is superior to bag-valve-mask
ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009; 54:
656-662.
3. Zhan L, Yang LJ, Huang Y, et al. Continuous chest compression versus interrupted chest compression
for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Database
Syst Rev. 2017;3:CD010134.
The inferior oblique muscle of the orbit is innervated by which of the following cranial nerves?
A) Oculomotor (III)
B) Trochlear (IV)
C) Trigeminal (V)
D) Abducens (VI)
E) Facial (VII)
The correct response is Option A.
The inferior oblique muscle receives its nerve supply from the oculomotor nerve, or cranial nerve III. The
other voluntary muscles within the orbit that receive their innervation from the oculomotor nerve are the
levator palpebrae superioris, superior rectus, medial rectus, and inferior medial rectus muscles. The
superior oblique muscle is innervated by the trochlear nerve (cranial nerve IV). The lateral rectus muscle
is innervated by the abducens nerve (cranial nerve VI).
The inferior oblique is the only one of these muscles that does not arise from the apex of the orbit. It
originates from the medial floor of the orbit just posterior to the infraorbital rim. It runs laterally,
posteriorly, and upward, crossing inferior to the inferior rectus, and inserting on the posterior half of
the globe beneath the lateral rectus insertion. Its action is to elevate the globe, producing upward gaze of
the pupil. Risk of iatrogenic injury to the inferior oblique is greatest with transconjunctival surgical
approach to the orbit. Therefore, with this procedure, care must be exercised to place the periosteal
incision along the anterior aspect of the infraorbital rim.
1-year-old boy presents with a 3-cm mass on the cheek. Which of the following characteristics is most
likely to support a diagnosis of lymphatic malformation in this patient?
A) Firm and rubbery to palpation
B) History of recurrent infections
C) Presence of a bruit
D) Presence of calcified phleboliths
E) Rapid growth followed by involution
The correct response is Option B.
Lymphatic malformations (LM) are benign masses of abnormal lymphatic vessels. There are many
historic classifications, such as microcystic and macrocystic, as well as historic terms for specific areas affected, such as cystic hygroma, found in the head and neck. Cystic hygromas may lead to airway
compromise in the newborn. LM often fluctuate in size and are frequently associated with recurrent bouts
of infection. They tend to be soft and compressible on palpation, not firm and rubbery. LM are present at
birth, although they might not become evident until a little later in life, especially in the lower extremities.
However, they do not follow the growth pattern of hemangiomas, specifically rapid growth (proliferation)
followed by a period of involution. Treatment of LM may include observation for asymptomatic lesions,
surgical resection, sclerotherapy for larger cystic structures, or laser treatment for small, superficial
lesions. More recently, a mutation in the PIK3CA gene, which affects a tyrosine kinase cellular signaling
pathway, has been linked to lymphatic malformations.
Further elucidation of this genetic link may lead to improved understanding and directed treatments in the
future.
The presence of phleboliths is a common finding in venous malformations.
The presence of a bruit suggests the turbulent flow of an arteriovenous malformation.
Reference(s)
1. Bentz ML, Bauer BS, Zuker RM. Principles &Practice of Pediatric Plastic Surgery. St. Louis, MO:
Quality Medical Publishing; 2008.
Compared with oropharyngeal squamous cell carcinomas associated with tobacco and alcohol, which of
the following is true about oropharyngeal squamous cell carcinomas associated with human papillomavirus (HPV)?
A) They are associated with active HPV infection in the partner
B) They are more resistant to radiation therapy
C) They have a better prognosis, stage for stage
D) They more frequently occur in the hypopharynx
E) They occur more frequently in women
The correct response is Option C.
An estimated 53,260 cases of head and neck squamous cell carcinomas (HNSCCs) were anticipated in
2020 in the United States. 70% of the cases (38,380) will be in men. More cases in both women and men
will be associated with human papillomavirus (HPV), and it is anticipated that HNSCCs associated with
HPV will soon outnumber cases of HPV-associated cervical cancer.
Interestingly enough, partners of patients with HPV-associated HNSCCs screened for the HPV16
subtype have the same occurrence rate as the general population (1.2 to 1.3%). HPV-associated
HNSCCs are associated with a greater number of lifetime sexual partners (N 9) and a greater number of
partners involved with orogenital sex (N 4).
HPV-associated HNSCCs typically occur in the oropharynx, whereas lesions on the larynx and
hypopharynx are associated with the larger field affected by tobacco smoke and alcohol.
Stage for stage, the prognosis is better for HPV-associated HNSCCs. To prevent over-treatment (or to
encourage less aggressive treatment), the eighth edition of the Cancer Staging Manual of the American
Joint Committee on Cancer has revised the tumor, node, metastasis (TNM) classification of HNSCCs to
differentiate between HPV-positive and HPV-negative tumors.
Reference(s)
1. Lydiatt WM, Patel SG, O’Sullivan B, et al. Head and neck cancers-major changes in the American
Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):122-137.
A 19-year-old man presents to the emergency department with malocclusion sustained during an assault.
Examination shows isolated mandibular subcondylar fracture. A photograph is shown. Which of the
following is the most likely location of the mandibular fracture?
A) Left
B) Right
C) Bilateral
D) Not possible to determine with information provided
The correct response is Option A.
Posterior mandibular fractures, such as those of the subcondylar subunit, cause foreshortening of the
vertical height of the mandible and early contact of the molar teeth on the ipsilateral side of the fracture.
This results in an open bite on the anterior contralateral side of the fracture as demonstrated in the
picture (right open bite).
A displaced right subcondylar fracture usually presents with a left open bite.
The malocclusion pattern from bilateral subcondylar fractures is more difficult to predict. If displaced, they
may present with an anterior open bite, caused by early contact of the molar teeth on both sides of the
face.
Reference(s)
1. Fractures of the condylar process and head. AO Surgery Reference.
https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2D
Dbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?bone=CMF&segment=Mandible&soloState=fbo
x&teaserTitle=&contentUrl=srg/91/01-Diagnosis/ao_srg_diag_condyle_all.jsp. Accessed January 29,
2020.
2. Howlader D, Ram H, Mohammad S, et al. Surgical Management of Mandibular Subcondylar Fractures
Under Local Anesthesia: A Proposed Protocol. J Maxillofac Surg 2019 May;77(5):1040.e1-1040.
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.
Reference(s)
1. Molnar JA, Vlad LG, Gumus T. Nutrition and chronic wounds: improving clinical outcomes. Plast
Reconstr Surg. 2016 Sep;138(3 Suppl):71S-81S.
2. Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: clinical considerations in
the perioperative period. Am J Surg. 2013;206:410-7.
A 69-year-old man is brought to the emergency department because of acute onset of excruciating pain
of the left forearm and a pale, pulseless, cool left hand. Medical history includes atrial fibrillation and
steroid-dependent chronic obstructive pulmonary disease (COPD). Physical examination and hand-held
Doppler interrogation are consistent with acute arterial blockage in the left ulnar artery. In addition to
aspirin, which of the following therapeutic interventions should be administered promptly while assessing
the patient’s ability to withstand surgery?
A) Apixaban
B) Clopidogrel
C) Heparin
D) Recombinant tPA
E) Verapamil
The correct response is Option C.
Iannuzzi and colleagues have summarized the treatment for acute arterial thrombosis of the hand.
Prevention of further damage should be the first line of treatment while completing work-up of the patient.
They recommend that heparin and aspirin should be administered to prevent propagation of further
arterial occlusion. While the idea of reducing vasospasm in the surrounding vessels is appealing,
Iannuzzi’s review of the literature is inconclusive of any benefit for tissue salvage outcomes. The article is
also useful for comparison of the various imaging modalities for definitive diagnosis and approach to
treatment.
In their meta-analysis for the Cochrane library, Berridge et al. surveyed the literature and came to the
conclusion that distal limb salvage was similar at 30 days, 6 months, and 1 year with either surgical
extraction of clot or thrombolysis by direct delivery of the agent to the artery in question. Bleeding and
distal embolization were more common after use of thrombolytic agents at 30 days.
Robertson et al, also in meta-analysis for the Cochrane library, found some differences favoring tissue
plasminogen activator (tPA) in initial vessel patency, but there were no differences in limb salvage
outcomes with intra-arterial delivery of tPA or urokinase. In the streptokinase vs tPA studies, there were
increased bleeding complications noted with streptokinase.
Reference(s)
1. Robertson I, Kessel DO, Berridge DC. Fibrinolytic agents for peripheral arterial occlusion. Cochrane
Database Syst Rev. 2010 Mar 17;(3):CD001099.
2. Iannuzzi NP, Higgins JP. Acute Arterial Thrombosis of the Hand. J Hand Surg Am. 2015
Oct;40(10):2099-106.
3. Berridge DC, Kessel DO, Robertson I. Surgery versus thrombolysis for initial management of acute
limb ischaemia. Cochrane Database Syst Rev. 2013 Jun 6;(6):CD002784.
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.
Reference(s)
1. Yannas IV, Orgill DP, Burke JF. Template for skin regeneration. Plast Reconstr Surg. 2011 Jan; 127(1Suppl):60S-70S.
2. Moiemen N, et al. Long-term clinical and histological analysis of integra dermal regeneration template.
Plast Reconstr Surg. 2011 Mar; 127(3):1149-54.
A 31-year-old man presents with a posterior fracture to the body of the mandible involving the alveolus of
the first molar sustained during an assault. Open reduction and internal fixation of the fracture is
performed. Intraoperatively, the position of the mandibular first molar in the fracture prevents an
adequate reduction, and it must be extracted. Removal of how many intact tooth roots is most likely to
indicate complete extraction of the mandibular molar in this patient?
A) One
B) Two
C) Three
D) Four
The correct response is Option B.
Anatomy of the mandibular first molar is relatively consistent in that the vast majority will have two
roots. Knowledge of the number of roots is important in the setting of extraction to ensure complete
removal. If either the injury or the reduction of the mandible fracture had caused a fracture of the tooth
root itself, then complete removal of the fractured root would involve either exploration at the time of open
reduction and internal fixation or postoperative referral to an oral surgeon. A retained tooth root would
place the patient at high risk for abscess formation that could require additional treatment. Incisors,
canines, mandibular premolars, and maxillary second premolars usually have one root. Maxillary first
premolars and mandibular molars usually have two roots. Maxillary molars usually have three roots.
Reference(s)
1. Nelson SJ. Wheeler’s Dental Anatomy, Physiology, and Occlusion. 10th ed. St. Louis, MO: Elsevier
Saunders; 2015.
2. Netter FH. Atlas of Human Anatomy. 4th ed. Philadelphia, PA: Elsevier; 2006:plate 57.
A 26-year-old woman with a strong family history of breast cancer undergoes genetic testing. She is found to have a deleterious mutation of the BRCA1 gene. Which of the following best describes her lifetime risk for the development of breast cancer when compared with women without this mutation?
A) Two times greater
B) Six times greater
C) Ten times greater
D) Fifteen times greater
E) Twenty times greater
Correct answer is option B.
A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits an altered BRCA1 or BRCA2 gene. Women with an inherited alteration in one of these genes have an increased risk of developing these cancers at a young age (before menopause) and often have multiple close family members with the disease. These women may also have an increased chance of developing colon cancer.
Men with an altered BRCA1 or BRCA2 gene also have an increased risk of breast cancer (primarily if the alteration is in BRCA2) and possibly prostate cancer. Alterations in the BRCA2 gene have also been associated with an increased risk of lymphoma, melanoma, and cancers of the pancreas, gallbladder, bile duct, and stomach in some men and women.
According to estimates of lifetime risk, approximately 13.2% (132 of 1000 individuals) of women in the general population will develop breast cancer, compared with estimates of 36 to 85% (360 to 850 of 1000) of women with an altered BRCA1 or BRCA2 gene. In other words, women with an altered BRCA1 or BRCA2 gene are 3 to 7 times more likely to develop breast cancer than women without alterations in those genes. Lifetime risk estimates of ovarian cancer for women in the general population indicate that 1.7% (17 of 1000) will get ovarian cancer, compared with 16 to 60% (160 to 600 of 1000) of women with altered BRCA1 or BRCA2 genes. No data are available from long-term studies of the general population comparing the cancer risk in women who have a BRCA1 or BRCA2 alteration with women who do not have an alteration in these genes. Therefore, these figures are estimated ranges that may change as more research data are added.
A 165.3-lb (75-kg), 76-year-old woman is scheduled to undergo wide local excision of a large, invasive
basal cell carcinoma of the cheek with flap reconstruction during general anesthesia. Medical history
includes nonvalvular atrial fibrillation, hypertension, and an embolic stroke 3 months ago. Current
medications include warfarin. Renal function is normal. Which of the following is the most appropriate
preoperative anticoagulation management for this patient?
A) Discontinue warfarin 5 days prior to the procedure and initiate low-molecular-weight heparin bridging 3
days prior to the procedure
B) Discontinue warfarin 5 days prior to the procedure without bridging
C) Discontinue warfarin 7 days prior to the procedure and initiate low-molecular-weight-heparin bridging 3 days prior to
the procedure
D) Immediately initiate low-molecular-weight heparin bridging and discontinue warfarin 5 days prior to the procedure
E) Do not discontinue warfarin
The correct response is Option A.
This patient has a very high thromboembolic risk and a high bleeding risk. Recommended heparin
bridging is 3 days before a planned procedure (ie, two days after discontinuing warfarin), when the
prothrombin time and international normalized ratio (PT/INR) has started to drop below the therapeutic
range.
Atrial fibrillation accounts for the highest percentage of patients for whom perioperative anticoagulation
questions arise. Importantly, patients with atrial fibrillation are a heterogeneous group; risk can be further
classified according to clinical variables such as age, hypertension, congestive heart failure, diabetes,
prior stroke, and other vascular disease.
Bridging anticoagulation may be appropriate in patients who will have a very high thromboembolic risk
with prolonged interruption of their anticoagulant (generally a vitamin K antagonist). Individual patient
comorbidities that increase bleeding risk may also need to be considered because an increased
postoperative bleeding risk may be a reason to avoid bridging. Suggested use of bridging in individuals
taking warfarin includes:
Test Review Report
Printed on: 2/26/2023
Question 109 of 144
*
*
*
*
*
*
*
Embolic stroke or systemic embolic event within the previous three months
Mechanical mitral valve
Mechanical aortic valve and additional stroke risk factors
Atrial fibrillation and very high risk of stroke (eg, systemic embolism within the previous 12 weeks,
concomitant rheumatic valvular heart disease with mitral stenosis)
Venous thromboembolism (VTE) within the previous three months (preoperative and postoperative
bridging)
Recent coronary stenting (e.g. within the previous 12 weeks)
Previous thromboembolism during interruption of chronic anticoagulation
The other answer choices are not appropriate strategies for this patient.
Reference(s)
1. Douketis JD. Perioperative management of patients who are receiving warfarin therapy: an evidencebased
and practical approach. Blood. 2011;117(19):5044-5049.
2. Gallego P, Apostolakis S, Lip GY. Bridging evidence-based practice and practice-based evidence in
periprocedural anticoagulation. Circulation. 2012;126(13):1573-1576.
3. Jaffer AK. Perioperative management of warfarin and antiplatelet therapy. Cleve Clin J Med.
2009;76(suppl 4):S37-S44.
4. Kakkar VV, Cohen AT, Edmonson RA, et al; Thromboprophylaxis Collaborative Group. Low molecular
weight versus standard heparin for prevention of venous thromboembolism after major abdominal
surgery. Lancet.1993;341(8840):259-265.
5. Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or
surgery. Blood. 2012;120(15):2954-2962.
6. Torn M, Rosendaal FR. Oral antic
A plastic surgery residency program director is developing criteria for allowing
postgraduate year 1 and 2 residents to perform laceration repairs in the emergency
department without direct supervision by a more senior resident. In addition to at least 2
months on a plastic surgery rotation and 10 repairs observed and coached directly by a
senior practitioner, the program director decides that the resident must submit a video
of the resident repairing a standard laceration on a facial laceration model, which will be
graded against a published rubric. In this scenario, which of the following is the purpose
of the simulation of a facial laceration repair?
A) Certification to practice
B) Deliberate practice
C) Technique training
D) Verification of proficiency
The correct response is Option D.
For psychomotor skills like surgical skills, simulations can be used for training, practice,
assessment, and certification. When simulation is part of a curriculum, its purpose must be
clear to all stakeholders: the trainee, the instructor, the program, and the public.
Following adult learning principles, simulation used for training and instruction should be
done in a low-stakes situation where the trainee has opportunity to try to a new skill without
worrying about causing harm to another or being judged. For more basic skills with
inexperienced individuals, low-fidelity experiences can inexpensively provide large gains in
proficiency. As the complexity of the skill and the sophistication of the trainee increase,
higher-fidelity experiences become more useful.
Deliberate practice is used to improve performance. Deliberate practice is directed at a
specific aspect of performance and is observed and coached at the time of practice, such as
having a golf professional coach by watching and redirecting performance of a player after
each drive. Practicing by oneself is not deliberate practice. Self-directed practice has the
potential to habituate and propagate mistakes. The repetition with immediate feedback by a
mentor allows correct habits to develop and extinguishes bad habits.
Simulation can be used to verify that a trainee has learned the steps of a basic task such as
laceration repair. The simulation can include the entire task (anesthetizing, cleansing,
American Society of Plastic Surgeons
In-Service Examination
This examination contains test materials that are owned and copyrighted by the American Society of
Plastic Surgeons. Any reproduction of these materials or any part of them, through any means, including
but not limited to, copying or printing electronic files, reconstruction through memorization or dictation,
and/or dissemination of these materials or any part of them is strictly prohibited. Keep printed materials in
a secure location when you are not reviewing them and discard them in a secure manner, such as
shredding, when you have completed the examination.
Page 343 of 420
draping, repairing, and dressing) or can be limited to any step of the test. This model works
well when the learner has an opportunity for observed practice and unobserved practice. It
allows an element of self-evaluation as the resident has the rubric and submits the video when
they feel they’ve achieved the criteria.
Simulation is being incorporated into surgical certification rapidly. A prominent example is
the requirement to have passed Fundamentals of Laparoscopy Surgery and Fundamentals of
Endoscopic Surgery during residency as prerequisite for the board certification process by the
American Board of Surgery.
REFERENCES:
1. Higgins M, Madan CR, Patel R. Deliberate practice in simulation-based surgical skills
training: a scoping review. J Surg Educ. 2021;78(4):1328-1339.
doi:10.1016/j.jsurg.2020.11.008
2. Toale C, Morris M, Kavanagh D. Perceptions and experiences of simulation-based
assessment of technical skill in surgery: A scoping review. Am J Surg. 2021;222(4):723-
730. doi:10.1016/j.amjsurg.2021.03.035
3. Beason AM, Hitt CE, Ketchum J, Rogers H, Sanfey H. Verification of proficiency in basic
skills for PGY-1 surgical residents: 10-year update. J Surg Educ. 2019;76(6):e217-e224.
doi:10.1016/j.jsurg.2019.08.019
4. Training & Certification. The American Board of Surgery. Updated 2022.
https://www.absurgery.org/default.jsp?certgsqe
5. Fundamentals of Laparoscopic Surgery. Updated 2022. https://www.flsprogram.org
6. Fundamentals of Endoscopic Surgery. Updated 2022. https://www.fesprogram.org
A 10-year-old boy undergoes surgical repair of microtia of the right ear. During cartilage rib harvest, the
right thorax is damaged with visualization of the lung. After repair of the pleura, Valsalva maneuver is
performed with no evidence of an air leak. An intraoperative chest x-ray is negative for pneumothorax.
Several minutes later in the PACU, the patient becomes hypotensive and tachypneic, and his oxygen
saturation decreases to the mid-80s, despite use of a non-rebreather mask.Which of the following is the
most appropriate next step in management?
A) Draw arterial blood gas
B) Intubation
C) Needle decompression of the right chest
D) Open the chest incision
E) Portable chest x-ray study
The correct response is Option C.
The patient shows all the signs of tension pneumothorax, and although the precise etiology is unclear,
the patient requires decompression.
Intubation will not help relieve the tension and pressure, with decreased venous return jeopardizing
hemodynamic stability.
Immediate chest x-ray is inappropriate because of the time required.
Opening the chest incision is not a good option because it requires surgical equipment, general
anesthesia, and cannot be completed in a timely fashion.
Needle decompression at the second intercostal is the standard of care to decompress a tension
pneumothorax. After oxygen saturation and hemodynamics are stabilized, definitive treatment of
pneumothorax can be pursued. This would include placement of chest tube to low suction and serial
chest x-ray to monitor the progress of the lung inflation.
Arterial blood gas will not help make the diagnosis and potentially will delay the appropriate intervention.
Reference(s)
1. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000; 342:868.
2. Dotson K, Johnson LH. Pediatric spontaneous pneumothorax. Pediatr Emerg Care. 2012; 28:715.
3. Romo T, Baratelli R, Raunig H. Avoiding complications of microtia and otoplasty. Facial Plast Surg.
2012 Jun;28(3):333-9.
A 63-year-old man undergoes ventral hernia repair with component separation. On the third
postoperative day, his serum potassium level is 6.7 mEq/L. Vital signs are stable. Electrocardiography
discloses sinus rhythm with flattened P waves and peaked T waves. Initial therapy should include the
administration of which of the following drugs?
A) Albuterol
B) Calcium gluconate
C) Dextrose and insulin
D) Furosemide
E) Sodium bicarbonate
The correct response is Option B.
Intravenous calcium gluconate should be given to this patient with severe hyperkalemia and associated
electrocardiographic changes.
Hyperkalemia causes a decrease in the resting membrane potential, leading to increased myocardial
excitability and cardiac arrhythmias, including ventricular fibrillation and asystole. Electrocardiographic
changes associated with progressive hyperkalemia include peaked T waves, prolonged P-R segment,
flattening/loss of P waves, widening of QRS complex, ectopic beats, ventricular fibrillation, conduction
blocks, and asystole.
Neither a specific serum potassium level threshold nor an electrocardiographic pattern that predisposes
patients to life-threatening cardiac arrhythmias has been well established. However, the initial therapy for
patients presenting with a serum potassium level greater than 6 mEq/L and hyperkalemia-related
electrocardiographic changes should focus on stabilizing the myocardium to prevent or reverse cardiac
arrhythmias by intravenous administration of a calcium salt (gluconate or chloride). The onset of action is
nearly immediate, but the duration of the protective effect is only 30 to 60 minutes. Therefore, repeat
administration may be required.
Interventions to shift potassium intracellularly (intravenous dextrose and insulin, with or without nebulized
albuterol/beta-2 agonist; intravenous sodium bicarbonate) or eliminate it from the body (intravenous
furosemide, rectal or oral potassium-binding agents, hemodialysis) should be carried out as soon as
possible after intravenous administration of calcium.
A 2-year-old boy is brought to the office for evaluation of unilateral blepharoptosis. Examination shows a
2-mm eyelid ptosis of the right eye with 7-mm of upper eyelid excursion without visual obstruction. The
left side shows no abnormalities. Which of the following is the most appropriate treatment in this patient?
A) Frontalis suspension
B) Lenticular skin excision
C) Levator palpebrae advancement
D) Tarsoconjunctival Müllerectomy (Fasanella-Servat procedure)
E) Observation and re-evaluation at age 3
The correct response is Option E.
Correction of mild to moderate eyelid ptosis in children should be delayed until the child can cooperate
with the preoperative assessment and post operative care. This would not be reliably possible for a 2-
year-old patient. Intervention before age 3 should be considered if there is significant obstruction of the
visual axis. Levator advancement provides appropriate correction in pediatric patients with fair to good
levator function. Frontalis suspension is generally reserved for instances when levator function is poor
(less than 4 mm). Lenticular skin excision will have no reliable effect on lid position.
Reference(s)
1. Harvey D J, Iamphongsai S, Gosain A K. Unilateral congenital blepharoptosis repair by anterior levator
advancement and resection: an educational review. Plast Reconstr Surg. 2010;126(4):1325-1331.
2. Hornblass A. Eyelids. In: Oculoplastic, Orbital and Reconstructive Surgery. Vol 1. 1988:121.
A 24-year-old man who is hearing impaired requests to be evaluated for left cubital tunnel syndrome. The
patient currently lives 2 hours away, and his mother, who usually helps interpret for him, is unable to
attend the appointment. The office does not have anyone who is capable of interpreting sign language.
Which of the following is the most appropriate next step?
A) Arrange a video interpreter to be available during the appointment at the office’s expense
B) Decline to schedule an appointment because the office does not offer the language services requested
C) Help the patient arrange for an interpreter to be present at the appointment at his expense
D) Require the patient bring a friend or family member to help interpret during the appointment
The correct response is Option A.
The Americans with Disabilities Act (ADA) requires that reasonable accommodations are provided by
businesses and in public areas to allow people with disabilities to participate in daily activities. Public
places include doctors’ offices. The building and spaces should accommodate all individuals regardless
of disability. As a business and a public space, a doctor’s office must be in compliance with the ADA.
Services cannot be denied to a patient with a disability because of the disability if services could
otherwise be provided. Accommodations should be made to examine the patient with a disability as any
other.
In this case, treatment for a cubital tunnel syndrome, something offered routinely by this office, cannot be
declined based on the patient’s hearing deficit.
In this case of a patient with a hearing issue, an interpreter must be provided to help with the
appointment upon the patient’s request. This does not necessarily need to be in-person; a video
interpreter can be acceptable. The patient cannot be charged for the interpreter services whether inperson
or by video. The health care provider is expected to make a reasonable effort to provide the
service. While having the patient bring a friend or family member to the appointment would make the
appointment easier for the physician, a patient is not required to bring anyone to help interpret for
him/her.
Reference(s)
1. Evelth PA, Sherer RB. Office of compliance - fast facts. United States Congress Office of Compliance
Web site. https://www.compliance.gov/sites/default/files/wp-content/uploads/2010/03/fastfacts_ada.pdf.
Updated February 2008. Accessed February 12, 2019.
2. Hearing Loss Association of America. ADA - Americans with Disabilities Act. Hearing Loss Association
of America Web site. https://www.hearingloss.org/programs-events/advocacy/know-your-rights/ada/.
Accessed February 12, 2019.
A 69-year-old woman presents to the emergency department because she has had increasing redness
and pain in her left reconstructed breast for the past 24 hours. Blood pressure is 80/40 mmHg, heart rate
is 130 bpm, and respiratory rate is 32/min. Initial plasma lactate level is 5.2 mmol/L. Ultrasonography
shows no fluid collections within the breast. Intravenous fluid resuscitation is started. Administration of
intravenous antibiotics is most appropriate within how many hours?
A) 1
B) 3
C) 6
D) 12
E) 24
The correct response is Option A.
The 2016 Surviving Sepsis Campaign guidelines strongly recommend that administration of intravenous
antibiotics be initiated as soon as possible after recognition and within 1 hour for both sepsis and septic
shock.
In the presence of sepsis or septic shock, increasing delays in administration of appropriate antibiotics
are associated with increasing mortality and detrimental effects on secondary endpoints, such as length
of hospital stay, acute kidney injury, acute lung injury, and the Sepsis-Related Organ Assessment score.
Although data suggest that optimal outcomes are achieved by the earliest possible administration of
appropriate antibiotics following recognition of sepsis, 1 hour was recommended as a reasonable minimal
target, considering multiple patient and organizational factors that may cause delay.
Reference(s)
1. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe
sepsis and septic shock from the first hour: results from a guideline-based performance improvement
program. Crit Care Med. 2014 Aug;42(8):1749-1755.
2. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for
management of sepsis and septic shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552.
A 25-year-old man presents with partial-thickness burns involving 15% of the total body surface area that
he sustained during a house fire. The patient is stabilized and resuscitated. Topical 1% silver sulfadiazine
cream is applied to the burns. Which of the following properties is most characteristic of this antimicrobial
agent?
A) Greatly enhanced efficacy when compounded with thiol chelators
B) Metabolic acidosis
C) Poor capacity for wound bed penetration
D) Poor efficacy against Candida albicans
E) Potential for transient leukocytosis
The correct response is Option C.
In the United States, silver is the most commonly used topical antimicrobial. It is available as a liquid
solution of AgNO3 or ointments such as silver sulfadiazine (Silvadene). Despite its many advantages, its
Test Review Report
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Question 87 of 144
capacity to penetrate into the wound bed is limited to the surface epithelium, particularly in the presence
of eschar because of the binding of silver ions to surface proteins. In this setting, different modalities
should be used for optimal effects.
Silver sulfadiazine is not only effective against Pseudomonas species and enteric bacteria, but it also
provides coverage against fungi, including Candida albicans, with antimicrobial effects lasting up to 24
hours.
Enhanced efficacy when compounded with thiol chelators is consistent with bismuth compounds, not
silver. Bismuth is another heavy metal with antimicrobial properties.
The most commonly used formulation of bismuth for wound care is bismuth subgalactate, found in
xeroform (Covidien) gauze. This heavy metal disrupts biofilm formation by inhibiting polysaccharide
capsule production in bacteria. Bismuth’s antibacterial activity is enhanced when compounded with thiol
chelators.
Regarding the potential for transient leukocytosis, silver sulfadiazine has been shown to cause reversible
neutropenia, which usually improves within a few days after discontinuation of the agent.
Metabolic acidosis is associated with mafenide acetate use.
Reference(s)
1. Cambiaso-Daniel J, Boukovalas S, Bitz GH, Branski LK, Herndon DN, Culnan DM. Topical
Antimicrobials in Burn Care: Part 1-Topical Antiseptics. Ann Plast Surg. 2018 Jan 9.
2. Greenhalgh DG. Topical antimicrobial agents for burn wounds. Clin Plast Surg. 2009 Oct;36(4):597-
606.
A 28-year-old woman presents with a 4-cm mass of the left breast. Examination of
a specimen obtained on biopsy discloses a benign phyllodes tumor. Which of the
following is the most appropriate treatment for this lesion?
A) Intensity-modulated radiation therapy
B) Mastectomy with sentinel lymph node biopsy
C) Neoadjuvant chemotherapy
D) Wide local excision
E) Observation
The correct response is Option D.
Phyllodes tumors are uncommon fibroepithelial masses. They are classified as benign,
borderline, or malignant based on histology. Local recurrence risk is not insignificant. The
standard of care includes wide local excision with a clear margin. Although the recommended
surgical margin is an area of some controversy, many authors suggest at least a 1-cm rim of
normal tissue surrounding the tumor. Very large phyllodes tumors might necessarily lead to
mastectomy. However, the patient in this question has a smaller tumor, which would not
require mastectomy. Sentinel lymph node biopsy might be considered for a malignant
phyllodes tumor, but it is not indicated for a benign tumor. Surgical extirpation of phyllodes
tumors may be quite extensive and therefore can present significant challenges to the
reconstructive surgeon. There are no data to recommend chemotherapy or radiation therapy in
the setting of a benign phyllodes tumor. Observation of the primary tumor is not recommended.
REFERENCES:
1. Tsuruta Y, Karakawa R, Majima K, et al. The reconstruction after a giant phyllodes tumor
resection using a DIEP flap. Plast Reconstr Surg Glob Open. 2020;8(4):e2760. doi:
10.1097/GOX.0000000000002760
2. Pitsinis V, Moussa O, Hogg F, McCaskill J. Reconstructive and oncoplastic surgery for giant
phyllodes tumors: a single center’s experience. World J Plast Surg. 2017;6(2):233-237.
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:
1. Beginning universal blood product infusion rather than crystalloid or colloid solutions,
2. Transfusing universal pRBC and FFP in a ratio between 1:1 and 1:2 (FFP:pRBC),
3. 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 23-year-old man is brought to the trauma bay with a stab wound to the neck.
Physical examination shows a 3-cm laceration deep to the platysma, just lateral to
the thyroid cartilage. Blood pressure is 125/80 mmHg, heart rate is 80 bpm, and
respiratory rate is 16/min. Pulse oximetry shows oxygen saturation is 95%. There
is no focal neurologic deficit. Which of the following is the most appropriate next
step in management?
A) Cervical collar stabilization
B) CT angiography of the neck
C) Endoscopy of the upper aerodigestive tract
D) Laceration repair
E) Surgical exploration in the operating room
The correct response is Option B.
Classically, management of penetrating neck trauma was based on anatomic zones, with
mandatory operative exploration for Zone II injuries (between the cricoid cartilage and the
angle of the mandible). This led to many nontherapeutic operations, as well as risk for
iatrogenic injury. With the advent of high-resolution, noninvasive imaging techniques,
management has evolved into one of selective exploration.
This patient is hemodynamically stable. The most appropriate next step is CT angiography of
the neck to evaluate for vascular injury. Once vascular injury is excluded, further evaluation
can be tailored to other symptoms. For the unstable patient, or one who presents with hard
signs of injury such as uncontrollable hemorrhage, respiratory distress, or expanding
hematoma, appropriate management is operative exploration without delay.
Laceration repair should only be performed once other significant injuries have been fully
evaluated. Endoscopy can evaluate for injury of the esophagus, pharynx, larynx, and trachea.
A hard collar may be useful for cervical spine stabilization for trauma patients and is usually
indicated in all high-energy head and neck injuries.
REFERENCES:
1. 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. doi: 10.1308/rcsann.2017.0191
- Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in
trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936-940. doi:
10.1097/TA.0b013e31829e20e3
Which of the following forms of communication is compliant with the Health Insurance Portability and
Accountability Act (HIPAA)?
A) E-mailing the confidential information using an encrypted patient portal server
B) Leaving protected information on the patient’s voicemail
C) Placing a sealed folder with patient records under the attending physician’s office door
D) Texting medical information to a password protected smart phone
E) Transferring the patient records via a non-encrypted flash drive
The correct response is Option A.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is United States legislation that
provides data privacy and security provisions for safeguarding medical information. Unauthorized release
of any confidential or identifying information, which can be linked to an individual patient, is considered a
violation of the law, with penalties ranging from fines to incarceration. The secure, private transmission of
Protected Health Information (PHI) is allowed between two treating health-care professionals, provided
that the communication is confidential and not at significant risk of breach or theft. Transmission of PHI
via social media, e-mail, and other electronic methods must be done through a combination of
safeguards that involves encryption. Although the legal understanding of how to communicate PHI
continues to evolve, these devices must meet institutional requirements for security.
Reference(s)
1. Lifchez SD, McKee DM, Raven RB 3rd, et al. Guidelines for ethical and professional use of social media in a hand surgery practice. J Hand Surg Am. 2012 Dec;37(12):2636-41.
2. Drolet BC, Marwaha JS, Hyatt B, et al. Electronic Communication of Protected Health Information:
Privacy, Security, and HIPAA Compliance. J Hand Surg Am. 2017 Jun;42(6):411-416.
3. Gordon CR, Rezzadeh KS, Li A, et al. Digital mobile technology facilitates HIPAA-sensitive
perioperative messaging, improves physician-patient communication, and streamlines patient care.
Patient Saf Surg. 2015 May 23;9:21. Healthcare reimbursement: 13.I.1
A 62-year-old woman with invasive ductal carcinoma of the left breast is
scheduled to undergo a left-sided mastectomy with immediate reconstruction
using a free deep inferior epigastric perforator flap. BMI is 30.2 kg/m2.
Preoperative examination shows bilateral lower extremity varicose veins. She has
a right chest port that has been used for neoadjuvant chemotherapy.
Chemoprophylaxis using a weight-based dose adjustment of which of the
following drugs is most appropriate to decrease this patient’s risk for postoperative
venous thromboembolism?
A) Intravenous heparin
B) Oral apixaban
C) Oral rivaroxaban
D) Subcutaneous enoxaparin
E) No chemoprophylaxis is indicated
The correct response is Option D.
Venous thromboembolism (VTE) is a life-threatening postoperative complication. Numerous
studies have demonstrated that chemical prophylaxis is impactful for high-risk plastic surgery
inpatients. The patient presented here is a high-risk patient, given that she is an obese woman
with a cancer diagnosis, varicose veins, and central venous access, and she is scheduled to
undergo a surgical procedure lasting several hours. Hence, chemical prophylaxis is indicated.
Enoxaparin, a low-molecular-weight heparin, has been demonstrated to prevent VTE in high-
risk plastic surgery patients. However, it has not been uniformly effective with breakthrough
VTE events occurring in 4 to 10% of the highest risk patients. This has been attributed to the
“one-size-fits-all” approach to enoxaparin prophylaxis (ie, the same dose is administered in
all patients), irrespective of body weight and extent of surgery.
Recent level I evidence demonstrated that for plastic surgery inpatients, weight-based
enoxaparin administration showed superior pharmacokinetics for avoidance of both under-
anticoagulation and over-anticoagulation in postoperative patients receiving prophylactic enoxaparin. Intravenous heparin is not indicated for VTE prophylaxis, nor do studies support its use for
routine management in free flap surgery.
Apixaban and rivaroxaban are not indicated for VTE chemoprophylaxis in plastic surgery
patients. Indications for their use include:
• Decrease in the risk for stroke and systemic embolism in nonvalvular atrial fibrillation
• Prophylaxis of deep venous thrombosis following hip or knee replacement surgery
• Treatment of deep venous thrombosis/pulmonary embolism
• Decrease in the risk for recurrence of deep venous thrombosis/pulmonary embolism
REFERENCES:
1. Pannucci CJ, Fleming KI, Bertolaccini C, et al. Optimal dosing of prophylactic enoxaparin
after surgical procedures: Results of the double-blind, randomized, controlled Fixed or
Variable Enoxaparin (FIVE) trial. Plast Reconstr Surg. 2021;147(4):947-958. doi:
10.1097/PRS.0000000000007780
2. Pannucci CJ, Fleming KI, Varghese TK, et al. Low anti-factor Xa level predicts 90-day
symptomatic venous thromboembolism in surgical patients receiving enoxaparin
prophylaxis: a pooled analysis of eight clinical trials. Ann Surg.
2020:10.1097/SLA.0000000000004589. doi: 10.1097/SLA.0000000000004589. Epub
ahead of print.
A 12-year-old boy with a thyroglossal duct cyst undergoes a Sistrunk procedure. Which of the following
structures are resected during this procedure?
A) Cyst and cyst tract only
B) Cyst, cyst tract, and middle third of the cricothyroid cartilage
C) Cyst, cyst tract, and middle third of the hyoid bone
D) Cyst, cyst tract, and middle third of the thyroid cartilage
E) Cyst, cyst tract, and the pyramidal lobe of the thyroid
The correct response is Option C.
The Sistrunk procedure is the operation of choice for thyroglossal duct cysts. This operation involves
resection of the cyst, the cyst tract, and the middle third of the hyoid bone. In the Sistrunk procedure, the
thyroid cartilage is not removed, nor is the cricothyroid cartilage. If, upon exploration, the distal tract is
found to be in communication with the pyramidal lobe of the thyroid, then the communication should be
excised. Despite this, resection of the pyramidal lobe of the thyroid is not a standard component of the
Sistrunk procedure.
Reference(s)
1. LaRiviere CA, Waldhausen JH. Congenital cervical cysts, sinuses, and fistulae in pediatric surgery.
Surg Clin North Am. 2012;92(3):583-597.
2. Povey HG, Selvachandran H, Peters RT, Jones MO. Management of suspected thyroglossal duct
cysts. J Pediatr Surg. 2018;53(2):281-282.
For a trauma patient intubated in the field who presents with absent Right-sided breath sounds what could be done in the field?
A) needle decompression
B) thoracotomy
C) thoracostomy tube
D) re -Intubation
Correct answer is option A.
In a trauma patient with decreased breath sounds, one should suspect a pneumothorax. In the field, this can be treated with needle decompression, while tube thoracostomy can be performed in the trauma bay. A thoracotomy would not be the initial management in the field. You should check for endotracheal tube position and breath sounds after intubation and adjust the endotracheal tube as needed.
A 54-year-old woman with a history of left mastectomy for breast cancer presents for right reduction
mammaplasty for symmetry. In this patient, the incidence of occult breast cancer discovered incidentally
in tissue specimens at the time of reduction mammaplasty is approximately which of the following?
A) 0.4 %
B) 1 %
C) 5 %
D) 15 %
E) 23 %
The correct response is Option C.
There have been multiple studies on the incidence of breast cancer discovered in reduction
mammaplasty specimens. The incidence of occult cancer detected in reduction mammaplasty specimens
is typically very low (0.06 to 5.45%) but varies depending on the patient’s age and history of breast
cancer. One specific study compared women undergoing reduction mammaplasty for symptomatic
macromastia with women undergoing reduction mammaplasty for symmetry after mastectomy with or
without reconstruction. Incidentally discovering occult breast cancer was much higher in women
undergoing symmetry procedures (5.5 vs. 0.4%) versus those undergoing reduction mammaplasty for
symptomatic macromastia. The important distinction in this clinical vignette is that the woman has had a
mastectomy for breast cancer, and highlights several important points including:
1) The importance of a thorough history before reduction mammaplasty 2) Preoperative clinical
examination 3) Screening mammography prior to the reduction mammaplasty 4) Pathologic examination
of reduction mammaplasty specimens
Based on multiple studies, the other percentages listed are either too high or too low.
The treatment of occult cancers discovered during reduction mammaplasty depends on several factors
including family history and evaluation of surgical margins.
Reference(s)
1. Carlson GW. The Management of Breast Cancer Detected by Reduction Mammaplasty. Clin Plastic
Surg. 2016:43:341-347.
2. Tadler M, Vlastos G, Pelte MF et al. Breast lesions in reduction mammoplasty specimens: a
histopathological pattern in 534 patients. Br J Cancer. 2014;110(3):788-91.
A 67-year-old woman is scheduled to undergo carpal tunnel release under monitored anesthesia care
with local anesthetic. Her comorbidities include type 1 diabetes mellitus (recent hemoglobin A1c is 7.4%),
current everyday smoking, and rheumatoid arthritis, for which she takes methotrexate. Which of the
following is the most appropriate antibiotic therapy to reduce this patient’s risk for surgical site infection?
A) Intravenous cefazolin, 30 minutes prior to induction, cephalexin 500 mg four times a day for 7 days postoperatively
B) Intravenous cefazolin, 30 minutes prior to induction, with no postoperative therapy
C) Intravenous cefazolin, 60 minutes prior to induction, cephalexin 500 mg four times a day for 7 days postoperatively
D) Intravenous cefazolin, 60 minutes prior to induction, with no postoperative therapy
E) No antibiotics indicated
The correct response is Option E.
Several studies have shown that timing of antibiotic delivery does impact the rate of surgical site infection
(SSI). Current recommendations suggest that, when indicated, antibiotics should be given between 1 and
2 hours before surgery. There are no data to support a reduction in SSI risk when antibiotics are given
within 30 minutes of surgery.
In the retrospective review by Bykowski et al, authors reported the SSI rates in patients undergoing
elective soft-tissue surgery. Rates of SSI did not differ between patients who received preoperative
antibiotics and those who did not (0.54% versus 0.26%, p less than 0.05). When a subgroup analysis
was performed, SSI infection rates for patients who were active smokers, diabetics, and with procedure
length greater than 60 minutes showed no difference with or without antibiotic administration.
Traditionally, patients with rheumatoid arthritis are viewed to be at higher risk for infection following
surgery. There are no data to suggest that there is a risk reduction with the use of preoperative and/or
postoperative antibiotics. Also, methotrexate does not increase one’s SSI risk and is therefore not an
indication for perioperative antibiotic therapy.
Reference(s)
1. Bykowski MR, Sivak WN, Cray J, et al. Assessing the impact of antibiotic prophylaxis in outpatient
elective hand surgery: a single-center, retrospective review of 8,850 cases. J Hand Surg Am.
2011;36(11):1741-1747.
2. de Jonge SW, Gans SL, Atema JJ, et al. Timing of preoperative antibiotic prophylaxis in 54,552
patients and the risk of surgical site infection: A systematic review and meta-analysis. Medicine
(Baltimore). 2017;96(29):e6903.
A 33-year-old transfeminine (male-to-female) patient with gender dysphoria presents for consultation
regarding bilateral breast enlargement with silicone implants. Which of the following is the most
appropriate CPT code for this procedure?
A) 19324-50: mammaplasty, augmentation; without prosthetic implant
B) 19325-50: mammaplasty, augmentation; with prosthetic implant
C) 19342-50: delayed insertion of prosthesis in breast reconstruction
D) 19357-50: immediate insertion of a tissue expander
E) 19366-50: breast reconstruction with other technique
The correct response is Option B.
Breast surgery for treatment of gender dysphoria is a recognized therapeutic option, which is covered by
the Centers for Medicaid and Medicare Services, military health maintenance organizations, and most
private payers. Because breast reconstruction with implants is a defined, covered benefit for women with
breast cancer, as mandated by federal legislation, the US judicial system has ruled that this procedure
should also be available to transgender women who desire breast reconstruction. Because this benefit is
available for some women, this benefit should be available for all women, including transgender women.
Withholding a medically necessary procedure for treatment of gender dysphoria would represent a form
of gender discrimination.
The CPT code recognized by both private and public health insurance companies is 19325-50 for
bilateral augmentation mammoplasty with prosthetic implant. Even though this code is most often used in
the aesthetic setting, the procedure is considered to be reconstructive in transgender women with gender
dysphoria.
Reference(s)
1. CPT corner: Coding for sex-reassignment surgery is evolving. Plastic Surgery News, March 2015,
page 14.
2. CMS.gov. Gender Reassignment Surgery Model NCD. Page 6.
https://www.cms.gov/medicare/coverage/determinationProcess/downloads/Kalra_comment_01022016.pdf.
A 43-year-old woman who is BRCA-positive is scheduled to undergo bilateral mastectomy. Tissue
expander–based reconstruction is planned. Which of the following is the optimal duration of antibiotic
prophylaxis for this patient?
A) No preoperative antibiotic
B) One preoperative antibiotic dose and another dose duringskin closure
C) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital
D) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital and then discharge on oral
antibiotics until drains are removed
E) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital and then maintenance on
oral antibiotics until tissue expanders are exchanged
The correct response is Option C.
The overall complication rate in breast reconstructive surgery is as high as 60%. Infection rates can
exceed 20%, much higher than in clean elective surgery. The CDC guidelines suggest only 24 hours of
peri-operative antibiotics beginning thirty minutes prior to skin incision. However, not all plastic surgeons
agree with this. A 2013 meta-analysis found when comparing combined patient cohorts receiving no
antibiotics, antibiotics for less than 24 hours, and antibiotics for greater than 24 hours, the average
infection rates were 14.4, 5.8, and 5.8%, respectively. This demonstrated that the administration of
antibiotics made a difference, however duration beyond 24 hours did not.
A study was published in 2013 evaluating the difference in surgical site infection between two different
prophylactic antibiotic durations (24 hours and until drain removal). In this prospective, randomized,
controlled non-inferiority trial, 24 hours of antibiotics is equivalent to extended oral antibiotics for surgicalsite
infection in tissue expander immediate breast reconstruction patients.
Reference(s)
1. Phillips BT, Bishawi M, Dagum AB, et al. A systematic review of antibiotic use and infection in breast
reconstruction: what is the evidence? Plast Reconstr Surg. 2013;131:1-13.
2. Phillips BT, Bishawi M, Dagum AB, et al. A systematic review of infection rates and associated
antibiotic duration in acellular dermal matrix breast reconstruction. Eplasty. 2014;14:e42.
3. Phillips BT, Fourman MS, Bishawi M, et al. Are Prophylactic Postoperative Antibiotics Necessary for
Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial. J Am Coll Surg.
2016 Jun;222(6):1116-24.
A 68-year-old woman presents with multiple injuries sustained during a motor vehicle collision that
require reconstructive surgery. She will require a stay in a skilled nursing facility following her initial
hospitalization. Which of the following parts of Medicare covers this service?
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
The correct response is Option A.
Medicare Part A covers services and supplies considered medically necessary to treat a disease. These
services include inpatient hospital care, skilled nursing facility care, and hospice environments. In
addition, when appropriate, home health services are covered by Part A.
Medicare Part B covers medically necessary services and preventative care services. Physician services,
durable medical equipment, and mental health services are included in Part B coverage.
Medicare Part C is also known as Medicare Advantage. Part C allows for a Medicare-eligible individual to select an approved private health insurance plan.
Medicare Part D offers prescription drug coverage to original Medicare. Part D can be added to a Medicare Advantage Plan if prescription drug coverage is not included.
A 45-year-old man comes to the office for consultation regarding breast cancer after undergoing gene testing and learning that he is a carrier of the BRCA2 gene mutation. He has a strong family history of breast, prostate, and ovarian cancers. Which of the following best represents his lifetime risk for developing breast cancer?
A) 6%
B) 15%
C) 30%
D) 60%
E) 85%
Correct answer is option A.
Since the identification of the first breast cancer gene in 1990, the field of molecular breast cancer testing has grown enormously. It is estimated that approximately 5% to 10% of patients diagnosed with breast cancer last year carry highly penetrant cancer susceptibility genes. It is important to identify these patients early, as the presence of genetic mutations or other high-risk factors may alter management strategies for patients, both prior and subsequent to the diagnosis of breast cancer.
Male breast cancer accounts for less than 1% of all breast cancer cases in the United States and is more common in men with a family history of breast cancer. The relationship between male breast cancer and a deleterious BRCA2 mutation has been well established. In the largest study to date, the lifetime risk of developing breast cancer in a BRCA2 male carrier is approximately 7%. The correlation with BRCA1 and male breast cancer is less clear, but it seems that the presence of BRCA1 mutation confers a lower lifetime risk of developing breast cancer than a BRCA2 mutation. The relative risk of developing breast cancer is highest for men in their 30s and 40s, and it decreases with increasing age.
The lifetime risk for the development of breast cancer in female carriers of BRCA1 and BRCA2 mutations is significantly higher than for males. Female BRCA1 carriers have an 85% risk of developing breast cancer and a 62% risk of developing ovarian cancer. Female BRCA2 carriers have an 85% risk of developing breast cancer and a 25% risk of developing ovarian cancer.
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
Correct answer 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 recent graduate of an ACGME-accredited plastic surgery residency has set up a private practice for
herself. She has applied for and received hospital privileges, state licensure, and malpractice insurance,
and has started seeing patients in her clinic and is advertising her practice. In terms of advertising, which
of the following aligns with the guidelines and values set forth by the ABPS?
A) ABPS does not have established guidelines
B) A candidate for Board Certification with the ABPS is responsible for all advertising, including third-party
employers or physician rating websites
C) Active practice websites are permitted prior to graduation of residency
D) Alcoholic beverages are permitted at marketing events where injectables, procedures, or operations are performed
E) Candidates are permitted to advertise as board eligible for 10 years
The correct response is Option B.
In keeping with the values established and published by the ABPS in the Booklet of Information,
candidates for board certification with the ABPS are responsible for all advertising, including third-party
employers or physician rating websites. All other answers do not align with the values set by the ABPS.
Reference(s)
1. Booklet of Information. ABPlasticsurgery.org. “Booklet of Information.” ABPlasticsurgery.org, The
American Board of Plastic Surgery, 1 July 2019, www.abplasticsurgery.org/media/17328/2019-2020-
ABPS-Booklet-of-Information-web-copy.pdf. Published July 1, 2019.
A 38-year-old woman is undergoing a routine abdominoplasty at an outpatient surgery center under
general anesthesia. Thirty minutes into the operation, the anesthesiologist reports high end-tidal CO2
production and tachycardia. Which of the following is the most appropriate first step in management?
A) Administer dantrolene
B) Discontinue volatile anesthetic agents
C) Infusion of lipid emulsion
D) Switch to total intravenous anesthesia
E) Treatment of arrhythmia
The correct response is Option B.
Malignant hyperthermia is an anesthetic crisis that is potentially fatal if not appropriately managed. The
mechanism of malignant hyperthermia is an accelerated release of calcium from the sarcoplasmic
reticulum. The increasing release of calcium surpasses uptake and leads to an inability to control the
intracellular calcium level. The symptoms of malignant hyperthermia include unexplained high end-tidal
CO2 levels, tachycardia, increasing body temperature, masseter muscle rigidity, and skeletal muscle
rigidity. The first step in the management of malignant hyperthermia is discontinuing the volatile
anesthesia. The subsequent steps in management include administering dantrolene, switching to IV
anesthesia, and treatment of arrhythmia. Depolarizing muscle relaxants can cause malignant
hyperthermia and these drugs should be immediately discontinued and not administered. Infusion of lipid
emulsion is done for lidocaine toxicity.
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.
Reference(s)
1. Janis JE, Harrison B. Wound Healing: Part I. Basic Science. Plast Reconstr Surg. 2016 Sep; 138(3
Suppl):9S-17S.
2. Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1A):22S-24S.
A 30-year-old woman with a history of Crohn disease undergoes ventral hernia repair. BMI is 31 kg/m2.
Which of the following is the greatest risk factor for postoperative nausea and vomiting in this patient?
A) Elevated body mass index
B) Perioperative fasting
C) Placement of nasogastric tube
D) Supplemental oxygen
E) Young age
The correct response is Option E.
Postoperative nausea and vomiting remains a significant problem after cosmetic and reconstructive
plastic surgery. Reported studies on the condition list incidences as high as 56%, whereas a metaanalysis
found that the overall incidence was 28.3%.
For many plastic surgery procedures, general inhalational anesthesia and narcotic pain control are
required and may predispose patients to postoperative nausea and vomiting (PONV).The effects can be
disastrous including hematoma, incisional dehiscence, respiratory compromise, pain, longer hospital
stay, slower recuperation, and patient dissatisfaction.
A number of risk factors have been associated with a positive overall incidence of PONV. Patient-specific
risk factors for PONV in adults include female sex, a history of PONV, non-smoking status, young age,
general versus regional anesthesia, postoperative opioids, and type of surgery.
obesity, and supplemental oxygen.
Reference(s)
1. Gan TJ, Diemuncsh P, Habib AS, et al. Consensus guidelines for the management of postoperative
nausea and vomiting. Anesth Analg. 2014 Jan;118(1):85-113.
2. Lee YZ, Lee RQ, Thinn KK, et al. How patients fare after anaesthesia for elective surgery: a survey of
postoperative nausea and vomiting, pain and confusion. Singapore Med J. 2015 Jan;56(1):40-6.
3. Manahan MA, Johnson DJ, Gutowski KA, et al. Postoperative nausea and vomiting with plastic
surgery: a practical advisory to etiology, impact, and treatment. Plast Reconstr Surg. 2018
Jan;141(1):214-222.
A 36-year-old woman with a confirmed diagnosis of ductal carcinoma in situ is considering skin-sparing mastectomy and immediate reconstruction. The patient should be informed that her risk of developing recurrent ipsilateral breast cancer over the next four years is approximately which of the following?
A) 2%
B) 5%
C) 10%
D) 15%
E) 20%
Correct answer is option A.
Several studies support skin-sparing mastectomy as an oncologically safe technique, based on the absence of breast ductal epithelium at the margin of the native skin flaps. A recurrence rate of less than 2% at 45 months is quoted in a study by Slavin and colleagues.
A 33-year-old woman comes to the office with a 6-cm rapidly growing tumor of the left breast. She wears a size 36C brassiere. The tumor has a bluish hue and skin veins are dilated. A phyllodes tumor is diagnosed, and surgical excision is planned. Which of the following is the most appropriate surgical procedure to treat this patient?
A) Excision with 1-cm margin
B) Excision with 2-cm margin
C) Excisional biopsy
D) Modified radical mastectomy
E) Radical mastectomy
Correct answer is option A.
Phyllodes are large benign tumors that occur primarily in the perimenopausal patient. Previously, they were referred to as cystosarcoma phyllodes, a term coined in 1838 because the tumors are fleshy and have a gross leaf-like intracanalicular growth pattern. However, this is a misnomer because these tumors do not behave like sarcomas and are rarely malignant. The histologic characteristics that separate fibroadenomas from phyllodes tumors are not well defined and have been somewhat controversial. Nevertheless, phyllodes tumors typically are large fibroadenomas that histologically have more stromal cellularity than that seen in the typical fibroadenoma. The classification of benign versus malignant phyllodes tumors is not sharply delineated, and the term borderline lesion may be more appropriate. Borderline lesions have more mitoses per high-power field and moderate nuclear pleomorphism. They have a tendency to recur after local excision but do not demonstrate true malignant behavior. When metastases of a phyllodes tumor have been reported, there have been obvious sarcomatous elements such as liposarcoma or rhabdomyosarcoma in the lesion.
The surgical treatment of phyllodes tumors has recently been redefined. In the past, simple or radical mastectomies were recommended for the treatment of large phyllodes tumors. Currently, most surgeons perform more conservative surgery. Several clinical studies have recommended the excision of tumors with 1-cm clear margins or mastectomy if breast conservation is impossible.
A newborn male is brought to the tertiary multidisciplinary referral center for evaluation of anorectal
malformation, tracheoesophageal fistula and absent right thumb. Which of the following associated
VACTERL diagnoses is the best predictor of inpatient mortality?
A) Aniridia with brain stem hypoplasia
B) Anomalies of spine or vertebrae
C) Cardiac disease
D) Renal or urinary anomaly
E) Tracheal stenosis with stridor
The correct response is Option C.
Anomalies of the spine or vertebrae (V), anorectal malformations (A), congenital cardiac anomalies (C),
esophageal atresia/tracheoesophageal fistula (TE), renal and urinary abnormalities (R), and limb lesions
(L) frequently co-occur and are recognized as VACTERL anomalies. VACTERL association is typically
diagnosed in the presence of at least three characteristic features in the absence of evidence for an
overlapping condition, and is estimated to occur in approximately 1 in every 10,000 to 40,000 live births.
The presence of either anorectal malformation or esophageal atresia alone generally triggers a workup
for associated VACTERL diagnoses because of their significant impact on morbidity and mortality. For
example, in a large cohort of children undergoing surgical repair of anorectal malformations, Lautz et al.
found associated VACTERL diagnoses including congenital heart disease in 40.4%, renal or internal
urinary disease in 34.7%, spinal or vertebral anomalies in 31.4%, esophageal atresia/tracheoesophageal
fistula in 7%, and limb defects in 5.6%. The most common limb defects in VACTERL association include
poorly developed or missing thumbs, or underdeveloped forearms and hands, polydactyly, syndactyly,
and reduction deformities of the lower limb.
Independent predictors of mortality in any patient with VACTERL association include congenital heart
disease (greatest for those who require cardiac surgery than those with a diagnosis but no operation),
birthweight <2 kg, and black race. Of note, the association between cardiac disease and higher mortality
has been reproduced in several studies.
Aniridia, brain stem hypoplasia, and tracheal stenosis with stridor are not primary characteristics of
VACTERL association.
Reference(s)
1. Lautz TB, Mandelia A, Radhakrishnan J. VACTERL associations in children undergoing surgery for
esophageal atresia and anorectal malformations: Implications for pediatric surgeons. J Pediatr Surg.
2015;50(8):1245-1250.
2. Olgun H, Karacan M, Caner I, Oral A, Ceviz N. Congenital cardiac malformations in neonates with
apparently isolated gastrointestinal malformations. Pediatr Int. 2009;51(2):260-262.
Totonelli G, Catania VD, Morini F, et al. VACTERL association in anorectal malformation: effect on the outcome. Pediatr Surg Int. 2015;31(9):805-808.
52-year-old woman undergoes preoperative mammogram. Medical history includes symptomatic
macromastia. Suspicious calcifications are identified, and a core-needle biopsy is performed. Which of
the following results necessitates an excisional biopsy prior to proceeding with the reduction
mammaplasty?
A) Atypical lobular hyperplasia
B) Fibroadenoma
C) Papilloma without atypia
D) Pseudoangiomatous stromal hyperplasia
E) Radial scar
The correct response is Option A.
National Comprehensive Cancer Network (NCCN) protocol recommends excisional biopsy following
detection of the following high risk lesions: papillomas with atypia, atypical ductal hyperplasia (ADH),
atypical lobular hyperplasia (ALH), and ductal carcinoma in situ (DCIS). These lesions, initially diagnosed
on vacuum-assisted core-needle biopsy, progress to carcinoma of the breast on excisional biopsy in 10%
to 39% of cases. Also, any proliferative lesion with atypia or any biopsy result that is discordant with its
radiologic image should also undergo excisional biopsy. If a radial scar has been completely excised and
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Question 120 of 144
definitively diagnosed, it does not require an excisional biopsy.
Once a lesion has been confirmed benign, it is safe to proceed with reduction mammaplasty. It is
important to note that a woman with a history of ADH, ALH, or lobular carcinoma in situ (LCIS) will have
an increased risk for developing in situ or invasive breast carcinoma over her lifetime. These patients
should, at a minimum, undergo yearly mammographic screening as well as possible breast magnetic
resonance imaging and risk reducing strategies including endocrine therapy.
Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast lesion characterized histologically by
dense collagenous stroma with spindle cell-lined spaces that appear like capillaries. Microscopic disease
may be found incidentally, or it may be associated with a palpable mass. It has not been demonstrated to
increase risk for subsequent breast carcinoma development.
Reference(s)
1. Allen A, Cuthen A, Dale P, Jean-Louis C, Lord A, Smith B. Evaluating the frequency of upgrade to
malignancy following surgical excision of highrisk breast lesions and ductal carcinoma in situ identified by
core needle biopsy. Breast J. 2019;25(1):103-106.
2. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: breast
cancer screening and diagnosis. https://www.nccn.org/professionals/physician_gls/pdf/breastscreening.
pdf. Accessed December 3, 2019.
3. Thomas PS. Diagnosis and management of high-risk breast lesions. J Natl Compr Canc Netw.
2018;16(11):1391-1396.
A 9-month-old female infant with severe metopic craniosynostosis requires bifrontal craniotomy and a
fronto-orbital advancement. The anesthesiologist is concerned about intraoperative blood loss and the
need for blood transfusion. Which of the following drugs administered by intravenous infusion at the time
of cranial reconstruction is most likely to reduce both intraoperative and postoperative bleeding?
A) Aprotinin
B) Erythropoietin
C) Fibrinogen
D) Protamine
E) Tranexamic acid
The correct response is Option E.
Acute blood loss and the need for autologous blood transfusions are common in infants undergoing
craniofacial procedures. Techniques to limit blood loss and transfusions have been studied extensively in
craniosynostosis surgery. Tranexamic acid (TXA) is a synthetic analog of the amino acid lysine, which
inhibits the conversion of plasminogen to plasmin when intravenously administered. TXA inhibits the
proteolytic action of plasmin, thus inhibiting fibrinolysis. It has been shown in multiple studies to reduce
both intraoperative and postoperative blood loss.
Aprotinin is a small protein bovine pancreatic trypsin inhibitor with anti-thrombolytic potential. It was
taken off the market in the United States in 2007 as its use was associated with increased complications
and death. It has since been reapproved in Canada and Europe but remains banned in the United
States. Protamine is a drug used to reduce the effects of heparin toxicity and of no benefit in this clinical
scenario. Erythropoietin is a recombinant glycoprotein cytokine that stimulates red cell production. When
given preoperatively, it has been shown to reduce the need for blood transfusion (not necessarily acute
blood loss) in craniosynostosis surgery. Fibrinogen is not administered intravenously. Fibrin glue does
reduce blood loss in craniosynostosis procedures, but it is administered topically, not intravenously.
Reference(s)
1. Hansen JK, Lydick AM, Wyatt MM, Andrews BT. Reducing postoperative bleeding after
craniosynostosis repair utilizing a low-dose transexamic acid infusion protocol. J Craniofac Surg. 2017
Jul;28(5):1255-1259.
2. Kurnik NM, Pflibsen LR, Bristol RE, Singh DJ. Tranexamic acid reduces blood loss in craniosynostosis
surgery. J Craniofac Surg. 2017 Jul;28(5):1325-1329.
3. White N, Bayliss S, Moore D. Systematic review of interventions for minimizing perioperative blood
transfusion for surgery for craniosynostosis. J Craniofac Surg. 2015 Jan;26(1):26-36.
A 48-year-old man presents to the emergency department because of spontaneous progressive pain,
swelling, cyanosis, and edema of the left lower extremity for the past 24 hours. A photograph is shown.
Medical history includes prophylactic inferior vena cava (IVC) filter placement in the setting of prolonged
immobilization secondary to traumatic closed head injury sustained 2 years ago. Physical examination
shows no dyspnea. Oxygen saturation is 98% on room air. Venous ultrasonography and CT scan show
total left deep femoral thrombosis extending into the lower IVC at the indwelling filter. Which of the
following is the most appropriate next step in management?
A) Catheter-directed thrombolysis
B) Femoral vein to IVC vascular bypass
C) Isolated extracorporeal membrane oxygenation (ECMO) support to the affected extremity
D) Open thrombectomy
E) Oral anticoagulation
The correct response is Option A.
The patient is presenting with extensive acute thrombotic occlusion resulting in clinically evident
symptomatic venous insufficiency of the extremity. If the occlusion is left untreated, progressive cyanosis
and secondary ischemia followed by gangrene develop. Locally delivered thrombolytic agents via
catheter-directed thrombolysis with or without percutaneous transluminal angioplasty is an effective first
line of treatment in this scenario where the patient presents within a few days of symptom onset (ie, prior
to clot fibrosis) and is not high-risk for bleeding. In patients who are high-risk for bleeding (eg, acute
intracerebral hemorrhage, gastrointestinal bleeding), alternative methods of restoring venous outflow
include clot retrieval through other percutaneous or open techniques (eg, transluminal aspiration
thrombectomy, open inferior vena cava (IVC) thrombectomy with or without temporizing groin
arteriovenous fistula creation). Systemic thrombolysis can be considered when other first line therapies
are not available but has been associated with high frequency of major bleeding complications in several
randomized trials (14% for streptokinase).
Systemic anticoagulation infusion helps prevent progression but does not restore acute compromised
ischemic limb secondary to venous outflow obstruction. Oral anticoagulation is not indicated for acute
management of a limb-threatening thrombosis. Femoral vein to IVC vascular bypass is not a described
procedure for venous insufficiency. Limb-threatening thrombo-occlusive venous insufficiency resulting in
a painful swollen blue leg, such as that pictured (also known as “phlegmasia cerulea dolens,” literally
“painful blue edema”) was first described with heparin-induced thrombocytopenia. It has also been
associated with cancer or life-threatening critical illness. More recently, a growing population of patients
are at risk due to unretrieved IVC filters. While IVC filter placement may protect the pulmonary vascular
bed, it does not lessen thrombotic predisposition or incidence in the lower extremities, and IVC
thrombosis with or without phlegmasia cerulea dolens has been reported to occur in 3 to 30% of patients
following IVC filter placement. Filter retrieval following its initial indicated need can lessen secondary
thrombotic complications, but data suggest that only a fraction of retrievable filters are later removed. In a
systemic review, overall retrieval was 34% with a high percentage of nonretrieval occurring for a variety
of reasons, including loss to follow up (particularly in trauma centers), limited life expectancy, and/or
unresolved underlying conditions.
Reference(s)
Test Review Report
Printed on: 2/26/2023
1. Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior vena cava thrombosis. JACC Cardiovasc
Interv. 2016;9(7):629-643.
2. Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava
filters. J Vasc Interv Radiol. 2011; 22:1522.
3. Fedullo PF, Roberts A. Placement of vena cava filters and their complications. UpToDate website.
https://www.uptodate.com/contents/placement-of-vena-cava-filters-and-their-complications. Updated
October 5, 2017. Accessed January 8, 2019.
4. Heilman J. Phlegmasia cerulea dolens. In: WikiMedia website.
https://commons.wikimedia.org/w/index.php?curid=49299938. Created June 7, 2016. Accessed January
8, 2019. Courtesy J Heilman.
An otherwise healthy 62-year-old woman presents with mild edema, some hemosiderin deposition, and a
clean, shallow, painful ulcer about 2 cm in size above the left medial malleolus. Medical history includes a
left ankle fracture 15 years ago. She does not smoke cigarettes. She has a job which requires that she
stand for 8-hour shifts. Distal pulses are present and ankle brachial index is .94. Which of the following is
the most appropriate initial management?
A) Debride the wound and apply a split-thickness skin graft
B) Elevate and apply serial compression dressings (Unna boot)
C) Hyperbaric oxygen therapy (HBOT)
D) Optimize the wound bed with bilaminate neodermis (Integra)
E) Strip the greater saphenous vein and ligate the perforators
The correct response is Option B.
Venous insufficiency is staged using the CEAP (clinical, etiologic, anatomical, and pathophysiologic)
classification. The patient presented in this scenario meets the criteria for C6 (Clinical 6) criteria with the
presence of an active ulcer. Compression and keeping the wound clean are the initial, primary, and
mainstay therapies for healing venous ulcers. The only option listed that provides compression and
wound care is to clean the wound, elevate, and apply serial compression dressings (Unna boot). After a
trial of compression and wound bed optimization, closure can be considered. The literature does not
provide conclusive evidence that skin grafting is a superior or desired closure. There are studies that
demonstrate the superiority of Apligraf in achieving wound closure. If the perforators are found to be the
source of the issue, ligation may reduce the recurrence of ulcers in the area but studies comparing
ligation and wound care do not show earlier closure of ulcers present. Hyperbaric oxygen therapy
(HBOT) is not indicated in this situation.
Reference(s)
1. Ratliff CR, Yates S, McNichol L, Gray M. Compression for Primary Prevention, Treatment, and
Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care
Across the Continuum. J Wound Ostomy Continence Nurs. 2016 Jul-Aug;43(4):347-64.
2. Game FL, Jeffcoate WJ. Dressing and Diabetic Foot Ulcers: A Current Review of the Evidence. Plast
Reconstr Surg. 2016 Sep;138(3 Suppl):158S-64S.
3. Pascarella L, Shortell CK. Medical management of venous ulcers. Semin Vasc Surg. 2015
Mar;28(1):21-8.
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 showsthe right breast is significantly larger than the left breast. A well-healed periareolar
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 administrationof 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.
Reference(s)
1. Rosique RG, Rosique MJ, Peretti JP. Postaugmentation Galactocele Without Periareolar Incision and
8 Years after Pregnancy. Plast Reconstr Surg Glob Open. 2016; 4(3): e644.
2. Tung A, Carr N. Postaugmentation Galactocele: A Case Report and Review of the Literature. Ann
Plast Surg. 2011; 67(6): 668-670.
Which of these situations is best suited for the use of a topical skin adhesive (polymerizing
cyanoacrylate) for closure?
A) Burst laceration along the eyebrow
B) Over an intradermal repair of a vertical forehead laceration
C) Over a suture repaired dog bite of the ear
D) Straight line laceration on the cheek with 4 mm of separation
E) Well apposed lip laceration crossing the vermilion cutaneous border
The correct response is Option B.
Cyanoacrylate skin adhesives are sold as monomers that polymerize by an exothermic reaction on
contact with air and fluids. They can be used in conjunction with other skin closure mechanisms such as
sutures or as a primary skin closure device. There is evidence across multiple surgical specialties and
situations that skin glues can save time in the operating room. When used correctly, the cosmesis is
similar or better than external suturing. There are in vitro studies suggesting inhibition of Gram-positive
cocci and clinical anecdotal evidence of decreased infection.
There is evidence that when wounds are closed with skin glue as the only closure device that dehiscence
rates are increased.
If the adhesive leaks below the skin when applied, it can hold the edges open and delay or prevent
healing with increased scarring or poorer cosmesis. Adhesives should be applied to well apposed skin edges only.
The U.S. Food &Drug Administration–approved package insert for a major brand of skin adhesive
(eg, Johnson &Johnson, Ethicon Dermabond) specifically indicates use on mucosa and over dirty
wounds such as dog bites to be contraindicated.
A burst laceration along the eyebrow and a straight line laceration on the cheek with 4 mm of separation
would be contraindicated because of the lack of excellent epithelial continuity. Adhesive over a suture repaired
dog bite of the ear and a well-opposed lip laceration crossing the vermilion cutaneous border are
specifically contraindicated on the package insert. Studies across multiple surgical specialties are
supportive of cyanoacrylate skin adhesives over an intradermal repair of a vertical forehead laceration.
Reference(s)
1. Bartenstein DW, Cummins DL, Rogers GS. A prospective, randomized, single-blind study comparing
cyanoacrylate adhesives to sutures for wound closure in skin cancer patients. Dermatol Surg. 2017
Nov;43(11):1371-1378.
2. Dumville JC, Coulthard P, Worthington HV, et al. Tissue adhesives for closure of surgical incisions.
Cochrane Database Syst Rev. 2014 Nov 28;(11):CD004287.
3. Halli R, Joshi A, Kini Y, Kharkar V, Hebbale M. Retrospective analysis
A study compares a new injectable neuromodulator drug against placebo for the treatment of glabellar
lines. The authors of the study report that if this drug performs no differently than placebo, there is a 0.4%
chance that repeating the study will show the same or greater calculated differences between the two
groups. Which of the following terms refers to this concept?
A) Alpha
B) p-value
C) Power
D) Type I error
E) Type II error
The correct response is Option B.
The p-value is a calculated value that quantifies the probability of obtaining data equal to or more
extreme than the data observed on a study, should the null hypothesis be true (eg, the new drug in reality
is NOT more efficacious than placebo).
Type I error is the erroneous rejection of a true null hypothesis (eg, a study shows that a new drug is
more efficacious than placebo, when in reality it is not).
Alpha is the probability of making a type I error (rejecting a true null hypothesis). It is an assigned value
determined by the researcher. A value of 5% is often chosen in medical literature.
Type II error is the failure to reject a false null hypothesis (eg, a study shows that a new drug is no
different than placebo, when in reality it is more efficacious). Beta is an assigned value by the researcher
that represents the probability of making a type II error.
Power of a test of statistical significance is the probability that it will reject a false null hypothesis. It
decreases as beta increases (power = 1–beta). Power of a test may be influenced by multiple factors,
including sample size and magnitude of the measured effect.
A 46-year-old woman undergoes a fleur-de-lis abdominoplasty following successful gastric bypass
surgery. She has a 94-lb (43-kg) weight loss and current BMI is 28 kg/m2. To ensure the best outcome for wound healing, which of the following is the recommended postoperative daily intake of protein for this
patient?
A) 20 to 30 g/day
B) 40 to 50 g/day
C) 60 to 70 g/day
D) 80 to 90 g/day
E) More than 100 g/day
The correct response is Option C.
Nutritional status in postbariatric subjects is essential in achieving successful healing of surgical
wounds. Anatomical changes to the gastrointestinal tract following bariatric surgery can exacerbate
nutritional deficiencies and inadequacies. Reduced protein intake has been associated with significantly
lower healing rates in massive weight loss patients. It is recommended that postbariatric patients
consume 60 to 70 g/day of protein 2 to 4 weeks prior to surgery and for 1 to 2 months postoperatively.
Reference(s)
1. Michaels J 5th, Coon D, Rubin JP. Complications in postbariatric body contouring: postoperative
management and treatment. Plast Reconstr Surg. 2011 Apr;127(4):1693-1700.
2. Small KH, Constantine R, Eaves FF 3rd, Kenkel JM. Lessons learned after 15 years of circumferential
bodylift surgery. Aesthet Surg J. 2016 Jun;36(6):681-692.
A 37-year-old woman comes to the office desiring breast augmentation mammaplasty, mastopexy, and
abdominoplasty. The surgeon is trying to promote “mommy-makeover” procedures and asks the patient if
she would be willing to participate in a video recording of her operation to be posted on social media.
Which of the following statements is correct regarding the informed consent process when obtaining and
posting a video to social media that includes protected health information and reveals patient identity?
A) ASPS guidelines recommend that surgeons should not participate in the posting of sensitive content via social
media because of the inherent risks to patient privacy
B) A detailed consent documenting the dynamic nature of individual social media sites should be formally
discussed and documented in the patient’s medical record prior to proceeding
C) Standard hospital or surgery center consent can be modified to include language about social media and should
release the physician for unrestricted use of content on any platform
D) Verbal consent should be obtained the day of the operation and must be witnessed by a nurse
The correct response is Option B.
The most correct answer is that a detailed consent documenting the dynamic nature of individual social
media sites should be formally discussed and documented in the patient’s medical record prior to
proceeding.
Test Review Report
Printed on: 2/26/2023
Question 96 of 144
1.
2.
3.
4.
5.
In the systematic review and ethical analysis of current plastic surgery publications regarding posting of
online video content, Dorfman et al. describe in detail their recommendations for posting sensitive
content online.
Although there are no consensus guidelines documented in the American Society of Plastic Surgeons
(ASPS) Code of Ethics, social media continues to evolve as an important part of a plastic surgery
practice, as more patients report searching online to find their physicians.
Authors document five ethical principles to follow when posting content online in order to “protect
patients, surgeons, and the public perception of our specialty:”
Ask the patients about posting the content online and obtain a formal written consent. Full disclosure
with the patient must involve specific social media sites and that the patient will have the ability to
withdraw consent at any time. Legal advice may improve the quality of the consent form.
In understanding the dynamic between the physician and patient and possibility for coercion, the
patient must be made aware that they may refuse consent without any punishment, penalty, and
delivery of an inferior product, i.e., worse operative result.
The patient must be made aware of the dynamic nature of social media platforms, and must be fully
aware that their videos will become public and permanent at the time of publishing online. Withdrawal
of consent does not equate to removal of online content because even if the surgeon removes the
video, it may persist online indefinitely.
Always follow the standards of professionalism published by the ASPS Code of Ethics.
The surgeon is ultimately responsible for all content disseminated online.
Reference(s)
1. Bennett KG, Berlin NL, MacEachern MP, et al. The Ethical and Professional Use of Social Media in
Surgery: A Systematic Review of the Literature. Plast Reconstr Surg. 2018;142(3):388e-398e.
2. Dorfman RG, Vaca EE, Fine NA, et al. The Ethics of Sharing Plastic Surgery Videos on Social Media:
Systematic Literature Review, Ethical Analysis, and Proposed Guidelines. Plast Reconstr Surg.
2017;140(4):825-836.
A 45-year-old man presents with significant closed head injury. Maintenance fluids are initiated because
of progressive nausea with reduced oral intake. CT scan of the head shows diffuse cerebral edema.
Administration of which of the following solutions is most appropriate in this patient?
A) Dextrose 5% in water
B) Hypertonic (3%) saline
C) Hypotonic (0.45%) saline
D) Physiologic (0.9%) saline
E) Ringer’s lactate
The correct response is Option B.
The patient is showing signs of symptomatic progressive intracranial pressure following head trauma.
Hypertonic infusion therapy can be used in this scenario to decrease intracranial pressure and curtail
progressive cerebral edema. Hypertonic (3%) saline fits into conventional algorithms for treatment of
symptomatic acute intracranial hypertension along with hyperventilation, mannitol, diuretics, and surgical
decompression. Hypertonic solutions have been shown to decrease intracranial pressure with greater
efficiency than mannitol in early stages of trauma for patients with evolving brain injury.
Ringer’s lactate and physiologic (0.9%) saline solution would not prevent or counteract progressive
cerebral edema following head trauma. Hypotonic solutions (such as dextrose 5% in water and 0.45%
saline solutions) are broadly contraindicated in patients who suffer severe traumatic brain injury, because
they may lower serum osmolarity and exacerbate cerebral edema.
Reference(s)
1. Agró FE. Body Fluid Management: From Physiology to Therapy. Berlin, Germany: Springer;
2013:xii,274.
2. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain
injury: II hyperosmolar therapy. J Neurotrauma. 2007;24 Suppl 1:S14-S20.
3. Mangat HS, Härtl R. Hypertonic saline for the management of raised intracranial pressure after severe
traumatic brain injury. Ann N Y Acad Sci. 2015 May;1345:83-8.
A 45-year-old woman undergoes abdominoplasty in an ambulatory surgery center. After induction of
general anesthesia, the patient’s end tidal carbon dioxide level increases, her heart rate increases to 160
bpm, and her arms become rigid. Which of the following are the physiologic abnormalities associated with this condition?
A) Hyperkalemia, hyperphosphatemia, metabolic acidosis
B) Hyperkalemia, hyperphosphatemia, metabolic alkalosis
C) Hyperkalemia, hypophosphatemia, metabolic acidosis
D) Hypokalemia, hyperphosphatemia, metabolic acidosis
E) Hypokalemia, hyperphosphatemia, metabolic alkalosis
The correct response is Option A.
Malignant hyperthermia is an inherited myopathy that is autosomal dominant with variable
penetrance. Anesthetic agents that trigger malignant hyperthermia include halothane, enflurane,
isoflurane, desflurane, sevoflurane, and succinylcholine. These agents trigger an earlier calcium release
into the skeletal muscle, resulting in an abnormal buildup of calcium in the myoplasm. This flood of
calcium causes the muscle to remain in a contracted state, producing high levels of lactic acid, carbon
dioxide, phosphate, and heat. The resulting physiologic changes are metabolic acidosis, hypercapnia,
hyperphosphatemia, and fever in a patient experiencing malignant hyperthermia. The treatment of
malignant hyperthermia is discontinuation of volatile agents and succinylcholine, dantrolene, treatment of
hyperkalemia and metabolic acidosis, and transfer to an acute care hospital.
Reference(s)
1. Gurunluoglu R, Swanson JA, Haeck PC. Evidence-based patient safety advisory: malignant
hyperthermia. Plast Reconstr Surg. 124(Suppl.):68S, 2009.
2. In J, Ahn EJ, Lee DK, et al. Incidence of malignant hyperthermia in patients undergoing general
anesthesia. Medicine. 96(49):e9115, December 2017.
Hyperbaric oxygen therapy (HBOT) is most appropriate for a patient with which of the following
conditions?
A) Acute osteomyelitis of the tibia
B) Anaerobic necrotizing soft-tissue infection
C) Chemical burn because of lye exposure
D) Stevens-Johnson syndrome
E) Wagner grade 2 diabetic foot ulcer
The correct response is Option B.
Hyperbaric oxygen therapy (HBOT) is an accepted adjunct to surgical debridement, appropriate antibiotic
therapy, and indicated critical care measures for necrotizing soft-tissue infections such as necrotizing
fasciitis and Fournier gangrene. The increased oxygen delivery of HBOT improves leukocyte function and
can enhance penetration of certain antibiotics such as aminoglycosides. The clinical effects include
slowing of the progress of the infection and decreased risk of both amputation and mortality.
There is not adequate evidence to justify HBOT in diabetic foot ulcers (DFUs) with Wagner grade 2
(extension to bone, tendon, or capsule) or less. However, there is moderate evidence to suggest benefit
in DFUs with Wagner grade 3 (deep ulcer with osteomyelitis or abscess) or greater.
HBOT may be indicated in the treatment of chronic osteomyelitis but not in the acute setting. It plays no
role in the treatment of Stevens Johnson syndrome, and may be beneficial in acute thermal burns but is
not indicated for chemical burns.
The complete list of approved indications for HBOT, as determined by the Undersea and Hyperbaric
Medical Society and the U.S. Food and Drug Administration, includes the following:
1. Air or gas embolism
2. Carbon monoxide poisoning
3. Clostridial myositis and myonecrosis (gas gangrene)
4. Crush injury, compartment syndrome, and other acute traumatic ischemias
5. Decompression sickness
6. Arterial insufficiency
7. Severe anemia
8. Intracranial abscess
9. Necrotizing soft-tissue infections
10. Refractory osteomyelitis
11. Delayed radiation injury (soft tissue and bony necrosis)
12. Compromised grafts and flaps
13. Acute thermal burn injury
14. Idiopathic sudden sensorineural hearing loss
Reference(s)
1. Fife CE, Eckert KA, Carter MJ. An update on the appropriate role for hyperbaric oxygen: indications
and evidence. Plast Reconstr Surg. 2016 Sep; 138(3 Suppl):107S-16S.
2. Weaver LK, ed. Hyperbaric Oxygen Therapy Indications, 13 th edition. Durham, NC. 2014:1-240.
A multi-institutional clinical trial is gathering data on the ability of a test to determine the number of
women who develop a new breast disease, and comparing this with age-matched controls. The
specificity of the test is defined as which of the following?
A) The ratio of healthy subjects diagnosed as negative and the total number of healthy patients
B) The ratio of healthy subjects diagnosed as positive and the total number of sick patients
C) The ratio of sick patients diagnosed as negative and the total number of healthy patients
D) The ratio of sick patients diagnosed as negative and the total number of sick patients
E) The ratio of sick patients diagnosed as positive and the total number of sick patients
The correct response is Option A.
The sensitivity of a test is defined as the ability of a test to correctly classify an individual as diseased
(positive in disease).
Sensitivity = a / a + c
The specificity of a test is the ability of a test to correctly classify an individual as disease free.
Specificity = d / b + d
Reference(s)
1. Kirkwood BR and Stern JAC. Essential Medical Statistics. 2nd edition. Malden, Massachusetts:
Blackwell Sciences Ltd; 2003.
Data collection is complete in a study examining Patient-Reported Outcomes
Measurement Information System Upper Extremity (PROMIS UE) scores following
intramedullary screw placement in the treatment of an isolated proximal phalanx
fracture. Which of the following is the most appropriate statistical test to compare
the mean PROMIS UE scores at 2 weeks with those at 12 weeks?
A) Independent samples t-test
B) One-sample t-test
C) One-way analysis of variance
D) Paired samples t-test
The correct response is Option D.
Understanding appropriate statistical analysis is essential for conducting and reviewing
research. There are four main ways in which means can be compared, assuming that the data
are normally distributed.
An independent samples t-test is a comparison of the mean for two different data sets that are
independent from each other. For example, an independent samples t-test might be used to
compare PROMIS UE scores at the end of healing between male and female patients, where
male versus female is the independent variable.
A paired samples t-test is a comparison of two measurements on the same subject at two
different time points. The paired sample t-test is appropriate in this scenario because
researchers are looking for differences in PROMIS UE scores at two discrete times after
surgery.
A one-sample t-test is used when a mean is compared with a specified constant, such as
comparing PROMIS UE scores at one time point with the expected PROMIS UE score in the
general adult population.
One-way analysis of variance is used to compare the means in more than two groups.
REFERENCES:
1. Everitt BS, Skrondal A. The Cambridge Dictionary of Statistics. Cambridge University
Press; 2010.
In the design of a proper randomized clinical trial, concerns about a selection bias
confounder are best addressed at which of the following stages?
A) Data analysis
B) Data collection
C) Data publication
D) Initial literature search
E) Study design
The correct response is Option E.
Confounders are extraneous risk factors associated with both causal factors and disease-
related entities that can influence accurate data analysis. These can result in overestimation or
underestimation of the study effect. The five main parts of a well-designed clinical trial study
are the initial literature review, study design and execution, data collection, data analysis, and
data publication. Examples of confounders that may negatively impact these specific stages
include publication bias (initial literature review), selection bias (study design and execution),
and information bias (data collection).
REFERENCES:
1. Yang LJ, Chang KW, Chung KC. Methodologically rigorous clinical research. Plast
Reconstr Surg. 2012;129(6):979e-988e. doi:10.1097/PRS.0b013e31824eccb7
2. Stewart LA, Parmar MK. Bias in the analysis and reporting of randomized control trials.
Int J Technol Assess Health Care. 1996;12:264-275. doi: 10.1017/s0266462300009612
A study is conducted to evaluate the association between diabetes and postoperative infection in patients
undergoing implant-based breast reconstruction with acellular dermal matrix. Which of the following
statistical tests is most appropriate to supply the data for this study?
A) Analysis of variance (ANOVA)
B) Linear regression analysis
C) Pearson’s chi-squared test
D) Unpaired T test
E) Wilcoxon rank-sum test
The correct response is Option C.
Selecting an appropriate statistical test is critical for accurate data analysis. Determining the optimal
method for a given data set must take into account several factors including the limitations and
distributional properties of the variables under study.
Statistical variables may be defined as either categorical or numerical. Categorical variables typically
represent qualitative observations (eg, postoperative infection, diabetes, obesity) while numerical
variables refer to quantitative observations (eg, body mass index, HgbA1c). Additionally, it is important to
distinguish between independent (predictive) and dependent (predicted) variables. These variables can
also be categorical or numerical. Dependent variables are typically the measured endpoints of the study
(eg, postoperative infections – categorical versus operative times – numerical) while independent
variables are hypothesized to have an influence over the measured endpoints (eg, diabetes/obesity –
categorical versus HgbA1c / BMI – numerical).
Studies, such as this one examining only categorical variables (diabetes and postoperative infection), are
best analyzed using Pearson’s chi-squared test. In contrast, a study evaluating only numerical variables
is best analyzed using regression analysis.
The unpaired T test and analysis of variance (ANOVA) are best used as statistical tests to analyze
independent numerical and dependent categorical data. The tables shown help to provide a general
outline for statistical test selection based on the different types of statistical variables being studied
including categorical or numerical variables, independent or dependent variables, number of groups
being studied, and whether the variables are normally distributed or not.
These statistical tests make assumptions of the parameters of the population distribution and are
considered parametric tests. Non-parametric tests, including the Wilcoxon rank-sum and Kruskal-Wallis
tests, are used when the data does not meet the assumptions required for parametric tests.
A pair of conjoined twins is evaluated to determine the surgical plan for soft-tissue coverage after their separation. The twins face one another and are conjoined from the sternum to the umbilical area. Which of the following terms best describes this type of conjoined twins?
A) Cephalopagus
B) Craniopagus
C) Omphalopagus
D) Parapagus
E) Thoracopagus
The correct response is Option E.
Conjoined twinning is an extremely rare phenomenon. They are monoamniotic and
monochorionic twins that can be adjoined symmetrically, asymmetrically, ventrally, dorsally,
laterally, or caudally. There is debate in the literature whether the phenomenon occurs
because of fission of a single embryo at day 13 or fusion of two embryos between days 13
and 17 to create the single amnion/chorion.
In the United States, Willobee et al interrogated the Kids’ Inpatient Database and identified
240 conjoined twin pairs born between 1997 and 2012, for an incidence of 1 per 100,000 live
births. Approximately 60% of those pairs died in the perinatal period. Only 28% were able to
be separated in the neonatal period. The 2020 Great Ormond Street study by Frawley reported
the following incidences:
* Craniopagus – dorsal conjoined at the cranium – 5%
* Cephalopagus – ventral fusion from vertex to umbilicus – 3.4%
* Thoracopagus – ventral fusion of chest and thorax to umbilicus – 42%
* Omphalopagus – ventral fusion of lower chest to umbilicus – 5.5%
* Parapagus – lateral fusion of lower abdomen and pelvis – 14.5%
All studies emphasize the need for interdisciplinary management of these patients and
stressed the use of imaging, model surgery, simulation surgery, and teamwork. The ethics of
these cases can be very opaque with the high mortality for one or both twins, the intensive
resources needed, and the highly publicized nature of these cases.
REFERENCES:
1. Frawley G. Conjoined twins in 2020 - state of the art and future directions. Curr Opin
Anaesthesiol. 2020;33(3):381-387. doi:10.1097/ACO.0000000000000864
2. Willobee BA, Mulder M, Perez EA, et al. Predictors of in-hospital mortality in newborn
conjoined twins. Surgery. 2019;166(5):854-860. doi:10.1016/j.surg.2019.06.028
3. Jackson OA, Low DW, LaRossa D. Conjoined twin separation: lessons learned. Plast
Reconstr Surg. 2012;129(4):956-963. doi:10.1097/PRS.0b013e3182442323
A previously healthy, 70-kg man suffers an estimated acute blood loss of 2 liters. Which one of the following statements applies to this patient?
A) his pulse pressure will be widened
B) his urinary output will be at the lower limits of normal.
C) he will have tachycardia, but no change in his systolic blood pressure.
D) his systolic blood pressure will be decreased with a narrowed pulse pressure.
E) his systolic blood pressure will be maintained with an elevated diastolic pressure.
Correct answer is option D.
This patient has lost 2 liters of blood, which is associated with the development of class III shock. In class III shock, patients develop an increased pulse rate, hypotension, and decreased urine output below normal levels. Both blood and crystalloid is required for resuscitation in class III shock. A widened pulse pressure may be seen in class I shock. Urine output may be at the lower limits of normal and patients become tachycardic with a normal blood pressure in class II shock.
An 85-year-old woman underwent left modified radical neck dissection for stage III metastatic cutaneous
melanoma. The procedure and immediate recovery were uneventful. On postoperative day 2, the base of
the neck was noted to be erythematous with 300 mL/24 hours output of milky fluid emanating from closed
suction drainage. A photograph is shown. Which of the following is the most appropriate next step in
management?
Figure 64-1
A) Bed rest and pressure dressing
B) Dietary modification and octreotide therapy
C) Immediate general surgery consultation for occult esophageal injury repair
D) Initiation of total parenteral nutrition
E) Laparoscopic thoracic duct ligation
The correct response is Option B.
The patient is demonstrating an iatrogenic chyle leak (CL). CL has been reported to occur in 2 to 8% of
neck dissections secondary to thoracic duct injury, which frequently goes unrecognized intraoperatively
because of the relatively low volume and clear output seen in the immobile and fasted operative
patient. Postoperatively, CL manifests as the sudden appearance of creamy white fluid drain output
associated with overlying inflammatory skin erythema following resumption of enteral feeds containing
fat. Confirmation can be made by testing drain triglyceride levels greater than serum levels, absolute
drain triglyceride level greater than 100 mg/dL, or with the presence of chylomicrons.
The majority of CL occur in the base of the left neck where the thoracic duct is largest and carries up to
75% of the body lymphatic fluid plus protein, electrolytes, and fatty acid-containing chylomicrons formed
by breakdown of long-chain fatty acids in the proximal small bowel.
Dietary modification is important to CL management. Patients commonly transition to nonfat/low-fat diets
or medium-chain fatty acid diets (which are largely water soluble and absorbed via portal venous
circulation rather than small bowel lymphatics), resulting in decreased chyle flow. Coupled with this, for
low-output (less than 500 cc/day) CL, octreotide has been shown to be a cost-effective therapy that
significantly decreases morbidity, length of stay, and need for further surgical intervention. In a study of
low-output leaks, CL typically stopped after 2 to 4 days of octreotide therapy. Octreotide is a somatostatin
analogue with a relatively long half life that inhibits chyle production by reducing gastric, pancreatic, and
intestinal secretions.
Bed rest may be helpful for CL, as activity encourages chyle return through the thoracic duct. Pressure
dressings are of equivocal efficacy and may compromise cervical skin flap perfusion. Both methods are
largely nondefinitive without concomitant dietary modification to reduce chyle flow.
Total parenteral nutrition (TPN) can also be employed to decrease chyle production by completely
bypassing the fatty acid uptake through the small bowel lymphatic system. However, TPN utilization must
be weighed against its need for central venous access, elevated risk of bacteremia, impaired wound
healing, metabolic disturbance, and high cost.
For high-output (greater than 1000 cc/day) CL or CL that fails to diminish with octreotide therapy, surgical
intervention is frequently indicated. This includes cervical reexploration although success can be variable
because of a relatively hospitable operative field secondary to local inflammation generated by
extravasated chyle. Alternatively, thoracoscopic ligation of thoracic duct has proven to be successful
intervention in high-output leaks through mass ligation of ductal tissue as it travels through the
diaphragmatic hiatus between the azygous vein and the aorta.
Iatrogenic esophageal injuries are a significant cause of morbidity and mortality. The patient is not
presenting with cervical esophageal injury, which may be associated with dysphonia, hoarseness,
cervical dysphagia, and/or subcutaneous emphysema.
There is no indication for empiric broad spectrum antibiotics in the absence of infection or in the routine
management of CL.
Reference(s)
1. Delaney SW, Shi H, Shokrani A, Sinha UK. Management of chyle leak after head and neck surgery:
review of current treatment strategies. Int J Otolaryngol. 2017;2017:8362874.
2. Ilczyszyn A, Ridha H, Durrani AJ. Management of chyle leak post neck dissection: a case report and
literature review. J Plast Reconstr Aesthet Surg. 2011;64(9):e223-e230.
3. Jain A, Singh SN, Singhal P, Sharma MP, Grover M. A prospective study on the role of octreotide in
management of chyle fistula neck. Laryngoscope. 2015;125(7):1624-1227.
4. Swanson MS, Hudson RL, Bhandari N, Sinha UK, Maceri DR, Kokot N. Use of octreotide for the
management of chyle fistula following neck dissection. JAMA Otolaryngol Head Neck Surg.
2015;141(8):723-727.
A 10-year-old boy with osteosarcoma is undergoing resection of 8 cm of proximal tibia. Reconstruction
with a vascularized bone flap is planned. Which of the following arteries is the primary blood supply for
this flap?
A) Anterior tibial
B) Dorsalis pedis
C) Peroneal
D) Popliteal
E) Posterior tibial
The correct response is Option C.
The peroneal artery is adjacent to the fibula. It arises from the tibioperoneal trunk, immediately distal to
the takeoff of the anterior tibial artery. It perforates the interosseous membrane. The peroneal artery also
gives perforators to the skin of the lower leg. The length of the pedicle is usually short, but can be
increased substantially by dissecting the peroneal artery from the fibula and using the distal bone for
reconstruction.
The popiteal artery is proximal to the other arteries mentioned. After crossing the knee, it branches into
the anterior and posterior tibial arteries. The posterior tibial artery then gives off the peroneal artery.
Reference(s)
1. Al Deek NF, Kao H, Wei FC. The fibula osteoseptocutaneous flap: concise review, goal-oriented
surgical technique, and tips and tricks. Plast Reconstr Surg. 2018 Dec;142(6):913e-923e.
2. Sainsbury DC, Liu EH, Alvarez-Veronesi M, et al. Long-term outcomes following lower extremity
sarcoma resection and reconstruction with vascularized fibula flaps in children. Plast Reconstr Surg.
2014 Oct;134(4):808-20.
3. Taylor GI, Corlett RJ, Ashton MW. The evolution of free vascularized bone transfer: a 40-year
experience. Plast Reconstr Surg. 2016 Apr;137(4):1292-305.
