Basic Surgical Principles Flashcards

Question

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

Answer 1

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.

Answer 2

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.

Answer 3

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.

Answer 4

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.

Answer 5

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.

Answer 6

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

Answer 7

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

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

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.

Answer 12

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.

Answer 13

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 Printed on: 2/26/2023 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.

Answer 14

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.

Answer 15

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.

Answer 16

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 2. 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

Answer 17

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

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

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.

Answer 31

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.

Answer 32

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.

Answer 33

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.

Answer 34

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.

Answer 35

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 Test Review Report Printed on: 2/26/2023 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.

Answer 36

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.

Answer 37

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.

Answer 38

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.

Answer 39

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.

Answer 40

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

Answer 41

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.

Answer 42

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.

Answer 43

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.

Answer 44

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.

Answer 45

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.

Answer 46

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.

Answer 47

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.

Answer 48

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.

Answer 49

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

Answer 50

The correct response is Option D. The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that mandates the coverage of breast reconstruction after mastectomy as well as coverage of any associated symmetry procedures for the contralateral breast. Although this federal law was enacted more than 20 years ago, there are still significant disparities in access to breast reconstruction and a lack of education regarding the options available for breast reconstruction. The Breast Cancer Patient Education Act of 2015 is a federal law that requires the Secretary of Health and Human Services to implement an educational campaign to inform breast cancer patients about access, availability, and options for breast reconstruction after mastectomy. SB-255 is an amendment in the state of California to the Knox-Keene Health Care Service Plan Act that includes "lumpectomy" for treatment of breast cancer in the definition of "mastectomy" and mandates access to insurance coverage of breast reconstruction after lumpectomy in the state of California. It is important to note that the Test Review Report Printed on: 2/26/2023 Question 137 of 144 WHCRA only mandates coverage of breast reconstruction after mastectomy, not after breast conservation therapies such as lumpectomy. In fact, there is no current legislation mandating insurance coverage for all types of breast reconstruction, including breast reduction, mastopexy, or implant complications after aesthetic surgeries. The Affordable Care Act (ACA) is a comprehensive health care reform law enacted in March of 2010. The three primary goals of the ACA are to make affordable health insurance available to more people, to expand the Medicaid program to cover all adults with income below 138% of the federal poverty level, and to support innovative medical care delivery methods designed to lower the costs of health care generally. There is nothing specifically in reference to breast cancer or breast reconstruction care within the ACA. Reference(s) 1. Berlin NL, Wilkins EG, Alderman AK. Addressing Continued Disparities in Access to Breast Reconstruction on the 20th Anniversary of the Women's Health and Cancer Rights Act. JAMA Surg. 2018;153(7):603-604. 2. Breast Cancer Patient Education Act. Breast Reconstruction Awareness (BRA Day USA). http://www.breastreconusa.org/breast-cancer-patient-education-act. Accessed April 13, 2020. 3. SB-255 Health care coverage: breast cancer. California Legislative Information. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120SB255. Published September 22, 2012. Accessed April 13, 2020.

Answer 51

The correct response is Option A. The first step in managing this patient is biopsy of the wound to rule out cancer recurrence. Although the diagnosis is most likely osteoradionecrosis of the skull, one would not proceed with the next steps of management until recurrence of cancer is ruled out. In this patient, the management sequence would include a biopsy to rule out cancer recurrence, followed by CT scan to delineate the extent of the skull involvement. MRI would not delineate the extent of the bony involvement. The rates of osteoradionecrosis occurrence vary in the literature (from 1.8 to 37%). Although the rate and severity of osteoradionecrosis are most consistently associated with doses of radiation exceeding 50 Gy, there are reports of osteoradionecrosis in patients who received doses as low as 30 Gy. This patient would require extensive craniectomy by a neurosurgeon to debride the wound of necrotic bone and, in most cases, reconstruction with free tissue transfer. Vacuum-assisted closure would not be a viable option for this patient, nor would resection of the scalp with split-thickness skin grafting. Reference(s) 1. Nguyen MT, Billington A, Habal MB. Osteoradionecrosis of the Skull After Radiation Therapy for Invasive Carcinoma. J Craniofac Surg. 2011;22(5):1677-1681. 2. Huang WB, Wong STS, Chan JYW. Role of surgery in the treatment of osteoradionecrosis and its complications after radiotherapy for nasopharyngeal carcinoma. Head Neck. 2017 Oct 9.

Answer 52

The correct response is Option C. Superficial incisional surgical-site infection is defined by the following criteria: Date of event for infection occurs within 30 days of a procedure AND involves only skin and subcutaneous tissue of the incision AND the patient has at least one of the following: A. purulent drainage at incision site B. positive cultures from the incisions or underlying tissue C. superficial incision that is deliberately opened by a surgeon or other designee with the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat D. diagnosis by the surgeon or attending physician designee Reference(s) 1. Centers for Disease Control and Prevention. Surgical Site Infection (SSI) Event. CDC Procedure Assisted Module; January 2016. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Date Accessed: Jan 2018. 2. Institute for Healthcare Improvement. How-to Guide: Prevent Surgical Site Infections. 2012, Cambridge, MA. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventSurgicalSiteInfection.aspx. Date Accessed: 2012

Answer 53

The correct response is Option B. The first step in the management of a newly found palpable breast mass is x-ray imaging to further characterize the tumor. The type of imaging required typically depends on the age of the patient at presentation. In females less than 30 years of age, ultrasound is typically the first (and possibly only) test ordered as the breast tissue is typically denser and mammography is not as effective. In women greater than 30 years of age, mammogram is usually the first test ordered. Mammography can evaluate both breasts for other incidental findings as well as further characterize the mass. Unless the results of the initial mammogram are definitive of a benign etiology of the mass, then an ultrasound is typically necessary as well. Ultrasound can distinguish cystic from solid masses and will help delineate the shape, borders, and acoustic properties of the mass. When the mass is suspicious, biopsy is guided by ultrasonography but this is typically not the initial treatment. Mammography can be used for both screening and diagnosis. Screening mammography consists of two routine views, craniocaudal and mediolateral oblique, and is appropriate for asymptomatic patients. Diagnostic mammography incorporates additional views (e.g. tangential or spot compression views) in order to better delineate the area of concern. The current patient has a new finding of palpable mass on exam and requires a diagnostic mammogram for proper evaluation and management. Given the patient’s age and presentation with newly palpable mass, x-ray imaging prior to any surgery is warranted to rule out malignancy. Proceeding with surgery that would rearrange the breast tissue may compromise the oncologic management of a possible breast cancer with incomplete excision and inability to obtain reliable margins that would require a completion mastectomy instead of the option for breastconserving therapy. Reference(s) 1. Brown AL, Phillips J, Slanetz PJ, et al. Clinical Value of Mammography in the Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older. AJR Am J Roentgenol. 2017 Oct;209(4):935-942. 2. Harvey JA, Mahoney MC, Newell MS, et al. ACR Appropriateness Criteria Palpable Breast Masses. J Am Coll Radiol. 2013 Oct;10(10):742-9.e1-3. 3. Stein L, Chellman-Jeffers M. The Radiologic Workup of a Palpable Breast Mass. Cleve Clin J Med. 2009; 76(3): 175-180.

Answer 54

The correct response is Option A. This patient has the potential to suffer a wrong site surgery if time-out protocols were not established. The surgical preparation error is a near miss. A "near miss" is an unplanned event that does not result in injury, illness, or damage, but has the potential to do so. It is within the standard of care to treat patients who report penicillin antibiotic allergies with a cephalosporin antibiotic. Patient with a true penicillin allergy have about a 10% cross-reactivity with cephalosporin antibiotics. Treating a patient prescribed hydroxyzine with hydralazine is a look-alike, sound-alike medication error. Pneumothorax after central venous catheter placement is a complication of the procedure. Breast implant contracture is an inherent risk of breast implant augmentation. Reference(s) 1. Haugen AS, Murugesh S, Haaverstad R, Eide GE, Søfteland E. A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols. BMC Surg. 2013 Oct 9;13:46.

Answer 55

The correct response is Option B. Epinephrine is the first line of treatment for patients with anaphylaxis and should be administered intramuscularly (anterolateral thigh) as soon as the diagnosis is made. In a setting where an exact dose can be drawn up, the recommended dosage is 0.01 mg/kg (maximum dose of 0.5 mg), administered intramuscularly every 5 to 15 minutes as necessary to control symptoms. It can also be administered more frequently than every 5 minutes if needed. Greater emphasis has been placed on early administration of epinephrine in the management of anaphylaxis. The mean time to cardiac or respiratory arrest from medication-induced anaphylaxis in a hospital setting has been shown in one study to be only 5 minutes, with only 14% of patients receiving epinephrine prior to arrest. Besides intramuscular epinephrine, recommended immediate interventions for anaphylaxis include an assessment of airway, breathing, and circulation; intravenous access; supplemental oxygen; monitoring; and placing the patient in supine position. Depending on the initial response, other interventions include establishing an airway, rapid intravenous fluid infusion, intravenous epinephrine infusion, bronchodilators, steroids, H1/H2 antihistamines, and glucagon. Ketamine and midazolam (versed) are not indicated for the treatment of anaphylaxis. Diphenhydramine (Benadryl) and other antihistamine drugs are recommended as a second line of therapy for anaphylaxis. The same applies to systemic corticosteroids. Reference(s) 1. Kemp SF, Lockey RF, Simons FE, et al. Epinephrine: the drug of choice for anaphylaxis - a statement of the world allergy organization. Allergy. 2008 Aug;63(8):1061-70. 2. Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014 Dec;113(6):599-608.

Answer 56

The correct response is Option A. Perioperative complications arising from intravenous paralytics and inhalational anesthetics may have devastating outcomes including death. Rapid and accurate diagnosis is essential for efficient treatment and maximizing successful outcomes. The paraplegic patient presented in this clinical vignette has developed acute hyperkalemia from the use of succinylcholine. Hyperkalemia after succinylcholine administration may result in paraplegics or any patients with upper or lower motor neuron injury, severe burns, crush injuries, or conditions causing rhabdomyolysis. This phenomenon results from the upregulation of nicotinic acetylcholine receptors in denervated or traumatized muscle. Initial treatment of acute hyperkalemia causing cardiac compromise involves antagonizing the effects of potassium on cardiac conduction and shifting potassium from the extracellular space back into intracellular fluid. Calcium directly antagonizes the hyperkalemia-induced depolarization of resting membrane potential by increasing the threshold potential to stabilize the membrane. Sodium bicarbonate and glucose combined with insulin will promote cellular uptake of potassium. Acidosis enhances the release of potassium from the cell and can be reversed with sodium bicarbonate. In addition, alkalization of plasma decreases levels of ionized calcium permitting the more liberal use of calcium in the treatment of acute hyperkalemia. While hypomagnesemia, hypoglycemia, hypernatremia, and hypocalcemia can all result in electrocardiography changes including tachycardia, prolonged QT interval, shortened PR interval, and ST depression, these electrolyte abnormalities are not the most likely to be associated with the clinical scenario. Reference(s) 1. Katz JA, Murphy GS. Anesthetic consideration for neuromuscular diseases. Curr Opin Anaesthesiol. 2017 June; 30(3): 435-440. 2. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology. 2006 Jan;104(1):158-169. 3. McCullough PA, Beaver TM, Bennett-Guerrero E, et al. Acute and chronic cardiovascular effects of hyperkalemia: new insights into prevention and clinical management. Rev Cardiovasc Med. 2014;15(1):11-23.

Answer 57

The correct response is Option E. Lobular carcinoma in situ (LCIS) has been removed from the staging classification system in the 8th edition and is no longer included in the pathologic tumor in situ (pTis) category. LCIS is treated as a benign entity with an associated risk for developing carcinoma in the future but not as a malignancy capable of metastases. There is a small subset of LCIS that has high-grade nuclear features and may exhibit central necrosis. This subset has been referred to as pleomorphic LCIS and has histologic features that partially overlap the features of ductal carcinoma in situ (DCIS), including the potential to develop calcifications detectable by mammography. The expert panel debated whether to include this variant of LCIS in the pTis category; however, there are insufficient data in the literature regarding outcomes and reproducible diagnostic criteria for this LCIS variant. Cases exhibiting DCIS and LCIS are classified as pTis (DCIS).

Answer 58

The correct response is Option D. A frontal sinus fracture involving the anterior and posterior tables with displacement greater than one table width and associated cerebrospinal fluid (CSF) leak mandates treatment with cranialization and repair of the dural tear. While minimally displaced posterior table fractures with CSF leak may be Test Review Report Printed on: 2/26/2023 Question 124 of 144 observed for spontaneous resolution of the leak, any significant displacement will likely not allow the dural tear to adequately heal and significantly increases the risk for bacterial contamination and meningitis. Accurately diagnosing the presence of a CSF leak in conjunction with significantly displaced posterior table frontal sinus fractures is important in deciding the ultimate management of these complex injuries. The beta-2 transferrin level is the most sensitive test for diagnosis of a true CSF leak. While CSF fluid does tend to have a high glucose content, this could also be seen in bloody rhinorrhea as well and is not as sensitive as a beta-2 transferrin test. Likewise, although CSF rhinorrhea often presents as a salty tasting postnasal drainage, this finding is more subjective and has poor sensitivity. Low hemoglobin concentrations are unlikely after acute fractures but can also be present without CSF leak. High bacterial contamination of the rhinorrhea does not correlate with CSF leak, but the risk for bacterial contamination of the meninges leading to meningitis is the reason for aggressive treatment of displaced posterior table frontal sinus fractures with associated CSF leak. Reference(s) 1. Adepoju A, Adamo MA. Posttraumatic complications in pediatric skull fracture: dural sinus thrombosis, arterial dissection, and cerebrospinal fluid leakage. J Neurosurg Pediatr. 2017;20(6):598-603. 2. Jing XL, Luce E. Frontal Sinus Fractures: Management and Complications. Craniomaxillofac Trauma Reconstr. 2019;12(3):241-248.

Answer 59

The correct response is Option C. Vitamin B12 (cobalamin) deficiency may cause megaloblastic anemia, a type of macrocytic anemia. The process of vitamin B12 absorption is started by gastric acidity, which separates this vitamin from the food proteins it is attached to. Next, before it can be absorbed in the terminal ileum, vitamin B12 needs to be combined with a protein secreted by the stomach, called the intrinsic factor. Bariatric procedures that include partial gastrectomy can substantially decrease the production of hydrochloric acid and intrinsic factor by the stomach, disrupting the absorption of vitamin B12 from one's diet. Thus, at least annual screening is recommended for patients who have undergone Roux-en-Y gastric bypass. Prevalence of vitamin B12 deficiency in the postbariatric population is thought to be as high as 18%. Interestingly, serum measurement alone may not be adequate to identify vitamin B12 deficiency. It is recommended to include the serum concentration of methylmalonic acid (MMA) with or without homocysteine to identify metabolic deficiency of B12 in symptomatic 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 345 of 420 and asymptomatic patients, in patients with history of B12 deficiency, or in patients with preexisting neuropathy. Megaloblastic anemia is characterized by ineffective erythropoiesis resulting from disrupted DNA synthesis, most commonly caused by deficiency of vitamin B12 or folic acid (folate). An incidental finding in routine laboratory testing is the most common presentation, since anemia usually develops gradually and symptoms are present only in severely anemic patients. When caused by vitamin B12 deficiency, neurologic symptoms can be observed, including balance disorder, paresthesias, and lower extremity pain. Diagnostic suspicion should be raised when a complete blood count shows anemia and high mean corpuscular volume or high mean corpuscular hemoglobin. The other vitamins listed are not associated with macrocytic anemias. Iron deficiency anemia may be common in patients with massive weight loss, but it causes a microcytic anemia. REFERENCES: 1. Green R, Datta Mitra A. Megaloblastic anemias: nutritional and other causes. Med Clin North Am. 2017;101(2):297-317. doi: 10.1016/j.mcna.2016.09.013 2. Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. doi: 10.1016/j.soard.2016.12.018 3. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists - executive summary. Endocr Pract. 2019;25(12):1346-1359. doi: 10.4158/GL-2019-0406 4. Toninello P, Montanari A, Bassetto F, Vindigni V, Paoli A. Nutritional support for bariatric surgery patients: the skin beyond the fat. Nutrients. 2021;13(5):1565. https://doi.org/10.3390/nu13051565

Answer 60

The correct response is Option C. Nipple-sparing mastectomy or total skin-sparing mastectomy is becoming an increasingly popular choice for women because of the excellent cosmetic outcomes and the ability to save the nipple-areola complex that may provide psychological benefits with increased patient satisfaction as well. Nipple-sparing mastectomy appears to be oncologically safe with low risks of cancer recurrence in the literature thus far. However, there has been little long-term follow-up, so this approach is still somewhat controversial because the oncologic safety and locoregional recurrence have not been examined definitively. Although certain centers are pushing the envelope regarding the use of this technique in a wide range of patients, the current literature supports the following exclusion criteria: A. Tumor size greater than 5 cm B. Tumor location less than 2 cm from the nipple C. Evidence of axillary disease D. Tumor involvement on retroareolar biopsy E. Lymphovascular invasion, human epidermal growth factor receptor-2 positivity, and/or HER-2/neu positivity on biopsy The current patient’s tumor was found to have a tumor-to-nipple distance of 1.5 cm which is a relative contraindication to nipple-sparing mastectomy in this case. Reference(s) 1. Headon HL, Kasem A, Mokbel K. The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures. Arch Plast Surg. 2016 Jul; 43(4): 328-338. 2. Mallon P, Feron JG, Couturaud B, et al. The Role of Nipple-sparing Mastectomy in Breast Cancer: A Comprehensive Review of the Literature. Plast Reconstr Surg. 2013 May;131(5):969-84.

Answer 61

The correct response is Option A. Traditionally, the need for radiation therapy has been a contraindication for implant-based reconstruction, and autologous reconstruction is the conservative gold standard for women with advanced cancer needing postmastectomy radiation. More recently, there have been reports of successful implant based reconstruction in the setting of postmastectomy radiation that have similar complication profiles and good oncologic outcomes compared with autologous reconstruction. Protocols vary between those that radiate the expander and then expand, and those that expand and then radiate the permanent implant. Being able to anticipate which patient will require postmastectomy radiation is essential for joint decision making about breast reconstruction with the patient prior to her mastectomy. By National Comprehensive Cancer Network (NCCN) guidelines, relative indications for postmastectomy radiation therapy include: positive sentinel node with unknown status of other axillary nodes, one to three positive nodes on permanent histology, and close surgical margins (less than 5 mm). Postmastectomy radiation is recommended as the standard of care in the situations of positive surgical margins with the inability to get clear margins and four or more positive lymph nodes. 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. Ho AY, Hu ZI, Mehrara BJ, Wilkins EG. Radiotherapy in the setting of breast reconstruction: types, techniques, and timing. Lancet Oncol. 2017 Dec;18(12):e742-e753.

Answer 62

The correct response is Option B. Patients with cleft lip and palate frequently have absence of teeth in the alveolar cleft or teeth that may be grossly abnormal or that erupt at an inappropriate angle and require removal. The lateral incisors are most commonly affected, although central incisors and canines may also be affected. Alveolar bone grafting during the mixed dentition phase restores adequate bone support for subsequent placement of an endosseous titanium implant, to which a permanent crown may then be attached. Many studies have reported the efficacy and safety of this approach. This has become the dentofacial prosthetic treatment of choice for the replacement of a single tooth due to its appearance, functionality, and longevity. A removable partial denture is one that rests on the surrounding soft tissues of the alveolar ridge and palate. Although aesthetics may be reasonable, it may cause irritation of the surrounding soft tissues and may produce movement during function. It is often a temporary solution at best. A three-unit fixed partial denture is a prosthesis which spans the gap produced by the missing tooth by anchoring to the adjacent two teeth. However, the abutment teeth often require reduction to permit fixation of the prosthesis. While certainly longer lasting than a removable partial denture, a fixed partial denture will need to be replaced periodically, and therefore would not be the best choice for this young patient. A palatal obturator is a prosthesis used to treat a residual oronasal fistula by physically blocking air escape during speech. This decreases hypernasality. It rests on the soft tissues of the palate and may anchor to the alveolar ridge or teeth. It does not, however, play a role in dental restoration. Nasoalveolar molding is a prosthesis-based treatment used early in life, typically for wide clefts, prior to repair of the lip and palate, but it is not used for dental restoration. Reference(s) 1. Bentz ML, Bauer BS, Zuker RM. Principles &Practice of Pediatric plastic Surgery. St. Louis, MO: Quality Medical Publishing; 2008:651-2. 2. Sowmya S, Shadakshari S, Ravi MB, Ganesh S, Gujjari AK. Prosthodontic care for patients with cleft palate. J Orofac Res. 2013;3(1):22-27.

Answer 63

The correct response is Option E. The indications for surgery in an extravasation injury include full-thickness skin necrosis, chronic ulceration, and persistent pain. Whereas blistering indicates a partial-thickness skin loss, it is alone not an indication for surgery. Erythema, induration, and poor capillary refill (blanching) are signs of extravasation injury but are not indications for an operative intervention. Reference(s) 1. Al-Benna S, O'Boyle C, Holley J. Extravasation injuries in Adults. ISRN Dermatol. 2013 May 8;2013:856541. 2. Scuderi N, Onesti MG. Antitumor agents: Extravasation, management, and surgical treatment. Ann Plast Surg. 1994 Jan;32(1):39-44.

Answer 64

Correct answer is option A. When evaluating any trauma patient, it is essential to assess the ABCs – Airway, Breathing, Circulation. In this patient, the first step is to secure the airway. The other options should be completed after the airway has been secured.

Answer 65

The correct response is Option E. This patient has acute kidney injury (AKI) after a surgical procedure. International practice guidelines recommend insulin therapy for targeted glucose control in critically ill patients. Although the Kidney Disease – Improving Global Outcomes (KDIGO) task force recommended a plasma glucose target of 110 to 149 mg/dL, the latest recommendation by the Surviving Sepsis Campaign is for an upper blood glucose level not higher than 180 mg/dL. Other recommendations for prevention and treatment of AKI by the 2012 KDIGO Clinical Practice Guideline included: Isotonic crystalloids rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for or with AKI; Avoiding restriction of protein intake with the aim of preventing or delaying initiation of renal replacement therapy (RRT); Administration of 0.8 to 1.0 g/kg/d of protein in non-catabolic AKI patients without need for dialysis; 1.0 to 1.5 g/kg/d in patients with AKI on RRT; and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients; Providing nutrition preferentially via the enteral route in patients with AKI; Not using diuretics to prevent AKI; Not using diuretics to treat AKI, except in the management of volume overload; Not using low-dose dopamine to prevent or treat AKI Reference(s) 1. Kellum JA, Lameire N. Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care. 2013; 17(1):204. 2. Lameire N, Kellum JA. Guideline Work Group. Contrast-induced acute kidney injury and renal support for acute kidney injury: a KDIGO summary (Part 2). Crit Care. 2013 4; 17(1):205. 3. 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; 45(3):486-552.

Answer 66

The correct response is Option E. Several studies have compared wet, moist, and dry wound healing following skin surgery without demonstrating an increase in infection rate when washing the wound with tap water at any point postoperatively as opposed to keeping the site dry for various lengths of time. This includes a rigorous randomized control trial in which patients with defects following skin lesion removal were divided into groups with tap water wound washing within 12 hours of surgery versus those asked to keep wound dry for 48 hours, where the incidence of surgical site infection in the wash group was not inferior to the dry group. On the other hand, unrestricted wound washing improves patient comfort, and multiple studies have demonstrated that wet or moist wounds promote reepithelialization and result in reduced scar formation with less inflammatory reaction compared to dry wounds. Reference(s) 1. Harrison C, Wade C, Gore S. Postoperative washing of sutured wounds. Ann Med Surg (Lond). 2016;11:36-38. 2. Heal C, Buettner P, Raasch B, et al. Can sutures get wet? prospective randomised controlled trial of wound management in general practice. BMJ. 2006;332(7549):1053-1056.

Answer 67

The correct response is Option A. The criteria among most insurance plans for coverage of procedures for treatment of gender dysphoria are quite stringent and rely on the concept of medical necessity for the patient. According to the World Professional Association for Transgender Health (WPATH), which is considered the authority on transgender health, standard-of-care guidelines to verify medically necessary procedures include: --the **capacity** of the patient to make a fully informed decision and provide consent (patients who are younger than 18 may provide assent, along with parental consent, for mastectomy) --at least **12 months of hormone therapy** consistent with the individual’s gender goals --**living life fully in the role of the desired sex** for at least **12 months** --psychiatric illnesses must be stable and well-controlled --documentation of gender dysphoria and the potential benefit from surgery by at least **two health-care providers** 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.p df. Accessed May 25, 2018. 3. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7 th ed. The World Professional Association for Transgender Health, 2011.

Answer 68

The correct response is Option B. Atypical ductal hyperplasia (ADH) is a benign proliferative breast lesion involving hypercellularity of the ductal cells. It is linked to a moderate increase in breast cancer risk. Due to this risk, closer follow-up is warranted and may include more frequent physical examinations or imaging. Treatment might also involve hormone therapy. Sclerosing adenosis is a benign proliferative breast condition without atypia. It involves overgrowth of the lobular breast tissue with associated fibrous areas similar to scar tissue. If there is any link to increased risk for breast cancer, it is small. Apocrine metaplasia is a nonproliferative breast disorder characterized by alteration of the ductal epithelium to resemble apocrine sweat glands. It is not associated with an increased risk for breast cancer. Fibrocystic breast change is a benign condition involving the formation of cystic areas and fibrosis. While it may cause symptoms such as pain and swelling, sometimes in response to the menstrual cycle, it does not increase the risk for breast cancer. Flat epithelial atypia is a benign proliferative breast disorder with columnar cell changes and cytologic atypia. It is distinct from atypical hyperplasia (both ductal and lobular), and while there may be a link to a slight increase in breast cancer risk, it is generally agreed that this increase does not even approach that of ADH. REFERENCES: 1. Mastroianni M, Lin A, Hughes K, Colwell AS. Proliferative lesions found at reduction mammaplasty: incidence and implications in 995 breast reductions. Plast Reconstr Surg. 2019 Feb;143(2):271e-275e. doi: 10.1097/PRS.0000000000005192 2. Noorbakhsh S, Koenig ZA, et al. Atypical hyperplasia found incidentally during routine breast reduction mammoplasty: incidence and management. Plast Reconstr Surg Glob Open. 2022;10(2):e4141. doi: 10.1097/GOX.0000000000004141

Answer 69

Correct answer is option B. The first step in the management of acute hemorrhage is to apply direct manual pressure. Subsequent steps include applying a compressive dressing and tourniquet, if available. While surgical intervention are likely required in this patient, these would be performed after initially controlling the hemorrhage with direct pressure.

Answer 70

The correct response is Option B. Rhabdomyosarcomas represent the most common soft-tissue sarcoma of childhood and are responsible for approximately half of all soft-tissue sarcomas in this age group. They are thought to originate from immature cells that are destined to form striated skeletal muscle, although they can arise anywhere in the body. With modern multimodal management, the cure rates for localized disease are generally greater than 70% overall. The primary goal of local tumor control in extremity rhabdomyosarcoma is limb-sparing complete resection where possible. Vascularized bone grafting represents the gold standard for reconstructing segmental bone loss greater than 6 cm associated with a compromised local soft-tissue environment that occurs with radiotherapy and chemotherapy. For large weight-bearing intercalary reconstruction, significant literature supports the combination of a large structural allograft combined with vascularized fibula as described by Capanna in 1980. With this combination, the neoosteogenic properties of the free fibula are supplemented by the immediate structural support of the bulk allograft and provide a durable single-stage biological reconstruction. Distraction osteogenesis is a technique of de novo bone formation that capitalizes on normal bone healing with gradual, surgically controlled distraction of adjacent osteotomy defects and has the advantage of simultaneously expanding surrounding soft-tissue envelopes. The technique requires viable bone in proximity to one another following a latency phase and is useful in limb lengthening and craniofacial procedures but has limited utility in long segmental tumor reconstruction. The induced membrane technique proposed by Masquelet is a two-step procedure where a segment of bone loss is first filled with an acrylic spacer and later replaced by cancellous bone graft in the so-called self-induced reactive “periosteal” membrane. The technique requires two stages and is less favored in the setting of planned radiation or chemotherapy where experience has shown that vascularized flaps or supplemented vascularized allografts are beneficial. The medial femoral condyle flap has been used for small osteoperiosteal, corticoperiosteal, and osteocartilaginous flaps based off either the articular descending genicular or superomedial genicular arteries. It would be insufficient in size for a 20-cm-long bone defect. The Van Ness rotationplasty is a type of autograft where functional limb below the knee is used to reconstruct more proximal defects. It can be a useful “spare part” reconstructive option in composite proximal extremity resections by repurposing a functional ankle joint more proximally in a rotated configuration for preserved gait advantage at the repurposed knee. A rotationplasty would not be indicated for intercalary resections sparing joint and metaphysis. Reference(s) 1. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive technique for intercalary defects of long bones: the association of massive allograft with vascularized fibular autograft. Long-term results and comparison with alternative techniques. Orthop Clin North Am. 2007;38(1):51-60. 2. Dasgupta R, Rodeberg DA. Update on rhabdomyosarcoma. Semin Pediatr Surg. 2012;21(1):68-78. 3. Pappo AS, Dirksen U. Rhabdomyosarcoma, Ewing Sarcoma, and Other Round Cell Sarcomas. J Clin Oncol. 2018;36(2):168-179.

Answer 71

The correct response is Option C. Condylar fractures in children can predispose to facial growth disturbance and temporomandibular joint dysfunction. A condylar fracture with an associated parasymphyseal fracture and an open bite should be treated with arch bars and a period of intermaxillary fixation in a 12-year-old, if possible. Open reduction and plating of the mandible is generally avoided in this age group to avoid injury to tooth buds. It has been demonstrated that arch bars can be used safely and effectively for the injury pattern described during the period of mixed dentition. Delayed sagital split osteotomy is not indicated in a patient with a normal premorbid occlusion. Reference(s) 1. Ghasemzadeh A, Mundinger GS, Swanson EW, et al. Treatment of Pediatric Condylar Fractures: A 20-Year Experience. Plast Reconstr Surg. 2015 Dec;136(6):1279-88. 2. Naran S, Keating J, Natali M, et al. The safe and efficacious use of arch bars in patients during primary and mixed dentition: a challenge to conventional teaching. Plast Reconstr Surg. 2014 Feb;133(2):364-6.

Answer 72

Correct answer is option A. Analysis of radiated tissue will show increased vessel thrombosis. Ionizing radiation directly damages the genome or injures the DNA through free radical production. In acute radiation injury, the skin becomes erythematous and edematous with the dilation of fine blood vessels, endothelial edema, and lymphatic obliteration. Although perfusion of the skin assessed with fluorescein injection appears normal, tissue oxygenation is inadequate. Healing is impaired with slowed fibroblast proliferation and impairment of the acute inflammatory response. Fibroblast defects are the main problem in the inhibited healing of chronic radiation injury. Phagocytosis and bacteriocidal metabolic functions in neutrophils are also impaired. This effect increases after therapy, which cannot be a direct effect of radiation on the neutrophils because their lifespan is too short. The local wound environment and irradiated tissue do not prime the neutrophils with the appropriate cytokines and growth factors needed for activation. This may lead to an increased incidence of postoperative infections in patients with previous radiation. Recent studies have shown promise in the treatment of radiation tissue damage with lipoaspirate transplantation. Adipose-derived stem cells have been hypothesized to target damaged areas, release angiogenic factors, form new vessels, and increase tissue oxygenation.

Answer 73

The correct response is Option C. A comparative cohort study investigates a particular exposure (implants or no implants) to determine correlation to a disease (breast implant illness [BII]). A case-control study retrospectively identifies cases (BII) and controls (no BII) from the same source population (women) to investigate differences in exposures or risk factors (implants or no implants). A randomized controlled trial randomly assigns participants into an experimental or control group. A cross-sectional study is an observational study that analyzes data from a population at a specific time point. A case series study is one that tracks participants who have received an exposure and tracks outcomes. Reference(s) 1. Hatchell AC, Farrokhyar F, Choi M. The misconception of case-control studies in the plastic surgery literature: a literature audit. Plast Reconstr Surg. 2017;139(6):1356e-1363e.

Answer 74

The correct response is Option C. An omphalocele is a congenital abdominal wall defect through the umbilical ring, which contains varying amounts of abdominal viscera and organs covered by a fused membrane of infant peritoneum, Wharton jelly, and amnion into which the umbilical cord inserts. As indicated, giant omphaloceles contain more than intestines and have a large diameter that laterally displaces the rectus muscles as they insert onto the ribs. Once a giant omphalocele is diagnosed, antenatal counseling about the natural history of these malformations is provided. Considerations for the best course for the fetus, pregnancy, delivery, and neonatal period can be determined. Part of that counseling includes the high rate of aneuploidy of autosomes (30%) such as in trisomy 13 in these patients. Pediatric plastic surgeons may be asked to be involved with larger lesions to help reconstruct the abdominal wall. Timing and needs will be determined by pulmonary capacity and maturity, the presence of other anomalies, loss of domain, and reconstructive needs. The plastic surgeon should be conversant with all aspects prior to joining in antenatal or neonatal counseling. 22q11 microdeletion has many syndromic names, including velocardiofacial syndrome or DiGeorge syndrome, and is related to cleft palate. 47,XXY is Klinefelter syndrome and is not associated with omphalocele. Plastic surgeons may see these patients in adolescence with reports of gynecomastia. 5p monosomy is cri du chat syndrome and is also not associated with omphalocele. Plastic surgeons may be asked to evaluate facial differences, including small jaw and hypertelorism. REFERENCES: 1. Shi X, Tang H, Lu J, Yang X, Ding H, Wu J. Prenatal genetic diagnosis of omphalocele by karyotyping, chromosomal microarray analysis and exome sequencing. Ann Med. 2021;53(1):1285-1291. doi:10.1080/07853890.2021.1962966 2. Skarsgard ED. Immediate versus staged repair of omphaloceles. Semin Pediatr Surg. 2019;28(2):89-94. doi:10.1053/j.sempedsurg.2019.04.010 3. Wagner JP, Cusick RA. Paint and wait management of giant omphaloceles. Semin Pediatr Surg. 2019;28(2):95-100. doi:10.1053/j.sempedsurg.2019.04.005 4. Khan FA, Hashmi A, Islam S. Insights into embryology and development of omphalocele. Semin Pediatr Surg. 2019;28(2):80-83. doi:10.1053/j.sempedsurg.2019.04.003

Answer 75

The correct response is Option B. Hematoma is the most common early complication following rhytidectomy. Resorption of adrenalin in the early postoperative period can lead to rebound hypertension and subsequent hematoma. The incidence of hematoma after rhytidectomy in nonhypertensive patients is approximately 3%, but the incidence rises approximately 8% in hypertensive patients and, in male patients, the risk seems to be even greater. The most common cause of hematoma is related to uncontrolled acute postoperative hypertension (defined by values of systolic hypertension greater than 190 mmHg with or without a diastolic blood pressure greater than or equal to 100 mmHg in at least two consecutive measurements, reported in the postsurgery time). Patients who preoperatively have a history of hypertension should be instructed to take their blood pressure medications on the morning of surgery. As an adjunct, oral clonidine (0.1 to 0.3 mg) or a transdermal patch (0.1 to 0.2 mg) can be administered preoperatively or intraoperatively, respectively, to keep blood pressure low in the perioperative period, especially as the injected adrenalin absorbs. Intraoperative hypertension should be well controlled, and maintenance of postoperative systolic blood pressure below 140 mmHg is desirable. Injected adrenalin from the local anesthetic solution is slowly absorbed, such that postoperative hematomas usually occur 4 to 10 hours after surgery. Postoperatively, blood pressure can be controlled with beta blockade (100 mg of oral labetalol) or an alpha agonist (0.1 to 0.3 mg of clonidine). Increased intraoperative fluid could account for increased postoperative blood pressure but is less likely than inadequate preoperative treatment of blood pressure. Nausea and poor pain control can also certainly contribute to increased blood pressure and hematoma but are less likely the cause in this particular patient who has baseline hypertension. Multiple studies have shown no increased risk for postoperative hematoma with use of ketorolac. Reference(s) 1. Barton FE Jr. Aesthetic surgery of the face and neck. Aesthet Surg J. 2009 Nov-Dec;29(6):449-463. 2. Sansone P, Pace MC, Passavanti MB, et al. Postoperative hypertension: novel opportunities in the treatment of a common complication. J Hypertens. 2015;4:202. 3. Wan D, Small KH, Barton FE. Face lift. Plast Reconstr Surg. 2015 Nov;136(5):676e-689e.

Answer 76

Correct answer is option E. This patient has hemorrhagic shock. Initial management should include assessing the patient’s ABCs, placing large bore IVs and starting crystalloid resuscitation and possibly blood transfusion. Next a CXR and FAST exam (and possibly pelvic XR, if indicated) can be performed rapidly in the trauma bay to identify injuries and potential sources of hemorrhage. In this patient with a widened mediastinum and positive FAST exam, bilateral chest tubes should be placed and the patient should be taken for an emergent laparotomy. As the patient is unstable, it would be unsafe to perform angiography or computed tomography. While monitoring intracranial pressure may be necessary, that would not address the patient’s hemodynamic instability. A thoracotomy may be needed, but would not be the next step in this patient with blunt trauma.

Answer 77

The correct response is Option B. Contrast-induced nephropathy (CIN) is a significant problem in patients undergoing procedures that require contrast administration. The mechanism is believed to be an ischemic injury to the renal medulla. Test Review Report Printed on: 2/26/2023 Question 92 of 144 It is the third most common cause of hospital-acquired renal failure. Independent of renal failure, the development of even mild CIN is associated with increased rates of morbidity and mortality. The major risk factor for developing CIN is pre-existing renal dysfunction. This is particularly associated with patients with diabetes and those who have a creatinine clearance less than 60. The best method of prevention is appropriate risk stratification, intravenous hydration with normal saline and withholding of nephrotoxic medications. Intravenous fluid hydration with normal saline is the mainstay of practice in the prevention of CIN. It is low-risk, carries few side effects, and is cost-effective. Randomized trials have found intravenous hydration with normal saline to be consistently effective. The administration of intravenous fluids increases intravascular volume, promotes diuresis, diminishes the overall intravascular contrast load and supports vasodilation. Although intravenous administration of sodium bicarbonate has also gained popularity in the prevention of CIN, recent publications have demonstrated mixed results. The use of N-acteylcysteine, statin drugs and ascorbic acid are not recommended for the prevention of CIN. Reference(s) 1. Brar SS, Shen AY, Jorgensen MB, et al. Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial. JAMA. 2008 Sep 3;300(9):1038-46. 2. Goldfarb S, McCullough PA, McDermott J, Gay SB. Contrast-induced acute kidney injury: specialtyspecific protocols for interventional radiology, diagnostic computed tomography radiology, and interventional cardiology. Mayo Clin Proc. 2009 Feb;84(2):170-9. 3. Gupta RK, Bang TJ. Prevention of contrast-induced nephropathy (CIN) in interventional radiology practice. Semin Intervent Radiol. 2010 Dec;27(4):348-59.

Answer 78

The correct response is Option B. Consensus guidelines recommend a 2-mm minimum margin for patients undergoing breast-conserving therapy. Margins over 2-mm are not associated with further risk of local recurrence. Primary treatment options for women with ductal carcinoma in situ (DCIS) are lumpectomy plus whole breast radiation with or without boost, total mastectomy - with or without SLNB with optional reconstruction, or lumpectomy alone. For patients with DCIS treated with breast conserving therapy, which includes lumpectomy followed by radiation, margins of at least 2-mm are associated with a reduced risk of ipsilateral breast tumor recurrence relative to narrower negative margin widths. However, a negative margin widths wider than 2 mm is not supported by the evidence. An analysis of specimen margins and specimen radiographs should be performed to ensure that all mammographically detectable DCIS has been excised. In addition, a postexcision mammogram should be considered where appropriate. Reference(s) 1. Barrio AV, Van Zee KJ. Ductal carcinoma in situ of the breast: controversies and current management. Adv Surg. 2019;53:21-35. doi: 10.1016/j.yasu.2019.04.002. 2. Pilewskie M, Morrow M. Margins in breast cancer: how much is enough? Cancer. 2018;124(7):1335- 1341.

Answer 79

The correct response is Option A. The use of hormone replacement therapy for medical transitioning in transgender individuals is considered generally safe in the short- and medium-term settings, but many answers about lifetime therapy remain unknown, particularly in the arenas of cancer and aging effects. When counseling patients about the benefits, risks, and consequences of medical transitioning, it is essential that the practitioner is honest about the limitations of knowledge at this time. Most guidelines for the use of testosterone in transgender men note that there are short-term changes in BMI, systolic blood pressure, and, potentially, liver chemistry that should be watched closely initially. Long-term monitoring centers on lipids (HDL, LDL) and polycythemia. The initial virilizing effects of testosterone manifest in lowering of the voice, increased muscle mass with decreased body fat, development of acne, cessation of menses, and development of increased body hair and facial hair. While changes can start to appear in 3 to 6 months, it may take up to 5 years for the full post-puberty male phenotype to be achieved. Removing testosterone at this point is not generally recommended and continued hormone therapy for life is considered reasonable. If hormones are stopped after reaching post-pubertal male phenotype, lowering of voice, growth of clitoris, increased hair distribution, and male pattern hair loss that have occurred will not be reversed. Menstruation can resume. Long-term effects on fertility are unknown, but pregnancy has been achieved by transgender men in their late 20s. Use of testosterone and cessation of menses IS NOT sufficient birth control to prevent pregnancy. Reference(s) 1. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-7.

Answer 80

Correct answer is option D. As surgical approaches to breast cancer treatment have evolved, nipple-sparing mastectomy (NSM) has emerged as an alternative to other approaches. It was initially used for prophylactic mastectomies, and patients reported increased satisfaction and body image with nipple-areola complex (NAC) preservation. The role of NSM has been expanded to therapeutic mastectomy, and with that there has been increased research in the oncologic safety of this approach. Studies have evaluated therapeutic NSM in the context of invasive ductal carcinoma, invasive lobular carcinoma, and ductal carcinoma in situ. The type of cancer does not appear to be associated with the oncologic safety of NSM. Several studies have demonstrated an inverse association between NAC involvement and distance of the tumor from the nipple. While these studies have varied in their distance cutoffs, nipple involvement is reported to be over 50% when the tumor-nipple distance is less than 2 cm, as noted in one study. There is a direct correlation between tumor size and NAC involvement—the same study cited data that when the tumor was greater than 4 cm, the likelihood of nipple involvement was greater than 50%. One published screening algorithm for plastic surgery includes tumor size less than 3 cm, and tumor location greater than 2 cm from the nipple as criteria from NSM candidacy. A periareolar scar, if large, may compromise the blood supply to the NAC. Acceptable incisions for NSM, however, include a periareolar incision of 25 to 50%.

Answer 81

The correct response is Option C. Numerous healthcare reform acts have been recently enacted as legislation. Many of these involved improved patient access to care as well as providing additional benefits to patient safety and privacy. While the Health Insurance Portability and Accountability Act (HIPAA) was the first to institute regulations for protected health information through its privacy rules, this legislation also guarantees the transferability of a patient’s healthcare insurance coverage from one job to another. The Patient Safety and Quality Improvement Act protects healthcare workers who report unsafe conditions and encourages reporting of medical errors. The Health Information Technology for Economic and Clinical Health Act promotes the expansion and adoption of health information technology while updating both the privacy rules as well as an individual’s right to access their electronic health information (EHR). The 21st Century Cures Act helps define the specifics of EHR interoperability and increases a patient's access to a broadened scope of their medical record in a timely fashion. The Women's Health and Cancer Rights Act mandates insurance coverage of breast reconstruction after cancer treatment. REFERENCES: 1. 8 Health Care Regulations in United States. Regis College. Accessed March 3, 2022. https://online.regiscollege.edu/blog/8-important-regulations-united-states-health-care/ 2. Rosenbloom ST, Smith JRL, Bowen R, Burns J, Riplinger L, Payne TH. Updating HIPAA for the electronic medical record era. J Am Med Inform Assoc. 2019;26(10):1115-1119. doi:10.1093/jamia/ocz090 3. Kauk J, Hill A, Althausen P. Healthcare Fundamentals. J Orthop Trauma. 2014;28(7 Suppl):S25-41. doi: 10.1097/BOT.0000000000000140.

Answer 82

The correct response is Option B. Aspirin causes an increase in bleeding time through the inhibition of prostaglandin biosynthesis and platelet secretion reaction. Platelet function is altered, but not the platelet count. Prothrombin time/International Normalized Ratio, activated partial thromboplastin time, and D-dimer concentration are unaffected by routine aspirin use. REFERENCES: 1. Wan D, Small KH, Barton FE. Face lift. Plast Reconstr Surg. 2015;136(5):676e-689e. doi:10.1097/PRS.0000000000001695 2. Mielke CH Jr, Kaneshiro MM, Maher IA, Weiner JM, Rapaport SI. The standardized normal Ivy bleeding time and its prolongation by aspirin. Blood. 1969;34(2):204-215. doi:https://doi.org/10.1182/blood.V34.2.204.204

Answer 83

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.

Answer 84

The correct response is Option D. The ASPS recently published the first consensus statement/guidelines for antibiotic prophylaxis in plastic surgery which is based on comprehensive systematic review of the available evidence. Systemic antibiotic prophylaxis is recommended for clean-contaminated, contaminated, or dirty plastic surgery of the head and neck, orthognathic/mandibular, septoplasty/rhinoplasty, hand and upper limb, and skin. Antibiotic prophylaxis is also recommended to reduce surgical-site infection for clean plastic surgery of the breast. Antibiotic prophylaxis is not recommended to reduce surgical-site infection in clean surgical cases of the head and neck, orthognathic/mandibular area, hand and upper limb, skin, and abdominoplasty. With the exception of cosmetic breast surgery, clean operations have not been shown to benefit from routine antibiotic prophylaxis. Clean-contaminated and contaminated plastic surgical procedures do benefit from the use of antibiotic prophylaxis. The duration of antibiotic use should generally be limited to a single preoperative dose because studies have generally showed no benefit for longer term antibiotic prophylaxis. As far as choosing the antibiotic, it should have activity against the most frequently encountered microorganisms in postoperative surgical-site infections. Cefazolin as a single dose preoperatively is the most commonly recommended agent and would be considered appropriate in most cases. In the event of allergy or intolerance, clindamycin or vancomycin may be appropriate alternatives. Reference(s) 1. Ariyan A, Martin J, Lal A, et al. Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery: An Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015 Jun;135(6):1723-39.

Answer 85

The correct response is Option E. The most likely pathology of this mass is a schwannoma of the median nerve. These benign nerve tumors are typically painless proximal to the wrist. Schwannomas of the digits tend to be painful. Tinel sign can often be demonstrated. Nerve function typically is not disturbed. Because of the size and location, MRI is effective in characterizing and localizing the mass. With magnification, marginal excision of schwannomas is easily performed because they are almost self-extruding from the nerve. Compared with neurofibromas, schwannomas are noninfiltrative. The recurrence rate is approximately 4%. The risk of nerve deficit is higher for excision after recurrence. An enchondroma would be apparent on a plain x-ray study and would reveal a mass with cortical thinning. A lipoma would likely be present within the carpal tunnel and would not be in continuity with the nerve. It is also unlikely to have positive Tinel sign. An aneurysm of the radial artery presents as a pulsatile mass. Vasospastic or thromboembolic findings may be present. The median nerve may be compressed by the aneurysm. Reference(s) 1. Forthman CL, Blazar PE. Nerve tumors of the hand and upper extremity. Hand Clin. 2004 Aug;20(3):233-242, v. 2. Furniss D Swan MC, Morritt DG, et al. A 10-year review of benign and malignant peripheral nerve sheath tumors in a single center: clinical and radiographic features can help to differentiate benign from malignant lesions. Plast Reconstr Surg. 2008 Feb;121(2):529-533. 3. Rockwell GM, Thoma A, Salama S. Schwannoma of the hand and wrist. Plast Reconstr Surg. 2003 Mar;111(3):1227-1232.

Answer 86

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 one 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 increased mortality and detrimental effects on secondary end points, 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, one hour was recommended as a reasonable shortest target, considering multiple patient and organizational factors that may cause delay. In the Campaign’s 2018 update, the Hour-1 Bundle was modified to reflect the need to begin resuscitation and management of patients with sepsis and septic shock immediately upon presentation. The Hour-1 bundle includes: Measure the lactate level. Remeasure if initial lactate is more than 2 mmol/L Obtain blood cultures prior to administration of antibiotics Administer broad-spectrum antibiotics Rapidly administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L Apply vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain a mean arterial pressure greater than or equal to 65 mmHg 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;42(8):1749-55.

Answer 87

The correct response is Option B. The medication that is used to reverse the effects of epinephrine is phentolamine, which is an alphaadrenergic receptor blocker. The wide-awake Hand Surgery is well described by Donald Lalonde and utilizes the effects of local anesthesia to perform a wide variety of hand-surgical procedures without general anesthesia. An alpha-adrenergic receptor activator, such as epinephrine, could increase vasoconstriction and worsen the scenario, as could a beta-adrenergic receptor blocker. Sodium channel blockers and potassium channel blockers are not indicated for reversal of epinephrine effect. Reference(s) 1. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010 Sep;126(3):941-945. 2. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie project clinical phase. J Hand Surg Am. 2005 Sep;30(5):1061-1067.

Answer 88

The correct response is Option E. This patient will have increased overall survival compared with a patient who does not have elective neck dissection. The patient described has Stage II (T2 N0 M0) oral cancer (larger than 2 cm but not larger than 4 cm, has not spread to lymph nodes with no metastatic disease). There has been much debate regarding management of the neck in patients with early-stage oral cancers. The two primary options include elective neck dissection (ie, at the time of the primary tumor resection) versus therapeutic neck dissection in the case of nodal relapse. In a prospective, randomized, controlled trial study of patients with T1 or T2 node-negative oral squamous cell carcinoma, patients received either elective neck dissection at the time of primary tumor resection or therapeutic neck dissection after nodal relapse. At 3 years, patients who underwent elective neck dissection had a higher rate of survival compared with the therapeutic surgery group (69.5 vs. 45.9%, P<0.001). Patients who undergo elective neck dissection at the time of primary tumor resection have an increased number of postoperative complications and decreased nodal recurrence. Distant metastasis was the same between the two groups. Reference(s) 1. D'Druz AK, Vaish R, Kapre N, et al. Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer. N Engl J Med. 2015;337(6):521-529. 2. Thiagarajan S, Nair S, Nair D, et al. Predictors of prognosis for squamous cell carcinoma of oral tongue. J Surg Oncol. 2014 Jun;109:639-644.

Answer 89

The correct response is Option A. On auscultation a muffled heart sound and pericardial friction rub is heard and would direct the clinician to decompress tamponade. Patient is demonstrating Beck's triad and has reason for possible cardiac tamponade. Immediate chest x-ray can be ordered to help rule out pneumothorax, but with normal oxygenation, the chance of a pneumothorax is lower on the differential, and there are other better initial diagnostic and therapeutic steps. ECG can help support the diagnosis of pericardial effusion, but this is not diagnostic and is only used as an adjunct. Ultrasonography of the heart can confirm the existence of pericardial effusion, as well as allow needle drainage for immediate treatment. However, this would be performed after auscultation. Reference(s) 1. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003; 349:684. 2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015; 36:2921.

Answer 90

The correct response is Option D. There is an increased risk of deep venous thrombosis associated with autologous breast reconstruction. Studies have tried to correlate autologous breast reconstruction with decreased venous return and stasis. When compared with baseline levels, the common femoral veins have increased diameter and decreased flow velocity. These changes persist through the day of discharge. Since lower abdominal tissue is harvested and tight abdominal closure is performed in both unilateral and bilateral autologous breast reconstruction, there is no difference in venous stasis postoperatively when comparing both groups.

Answer 91

Correct answer is option B. Muscle wasting is common in critically ill patients, due to increased muscle protein catabolism in the setting of inflammation. While the daily protein intake recommended for healthy adults is **0.8 g/kg per day**, critically ill patients require **1.5 g/kg per day**. The total calorie requirement for critically ill patients is **25-30 kcal/Kg/day**.

Answer 92

The correct response is Option E. Systematic review drawing from 30 studies and more than 14,000 patients undergoing minor cutaneous surgery firmly supports continuation of aspirin therapy in all minor cutaneous surgery, as patients on aspirin monotherapy are at no greater risk of hemorrhagic complications than those on no agents. While a case-by-case risk profiling in all patients on aspirin therapy is prudent, the preponderance of evidence favors meticulous hemostasis over aspirin cessation in prevention of bleeding complications in minor cutaneous surgery. There is no reported association between aspirin utilization and increased risk of wound dehiscence, wound infection, or cosmetic outcome.

Answer 93

The correct response is Option D. Venous thromboembolism (VTE) is a major complication following orthopedic injury. For patients who undergo major orthopedic surgery, it is suggested that dual prophylaxis with compression devices and antithrombotic agents be used while hospitalized. It is also suggested to extend venous thromboembolism prophylaxis, in the form of low-molecular- weight heparin, to a period of up to 35 days from the day of surgery rather than for only 10 to 14 days. Aspirin is more commonly used in total joint arthroplasty and currently not recommended as VTE prophylaxis in orthopedic trauma patients. REFERENCES: 1. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2):e278s-e325s. doi: 10.1378/chest.11-2404 2. Kahn SR, Shivakumar S. What’s new in VTE risk and prevention in orthopedic surgery. Res Pract Thromb Haemost. 2020;4(3):366-376. doi:10.1002/rth2.12323

Answer 94

Correct answer is option C. In the scenario described, the most important consideration is the patient’s choice. In several studies, patients who underwent prophylactic mastectomy at the suggestion of the physician were generally more regretful than those who underwent the procedure following a patient-initiated discussion. The lack of perioperative emotional support also affected these patients. Lack of nipple sensation and inability to breast-feed are two factors leading to patients’ regret about their decision. Factors influencing a patient’s decision to choose bilateral mastectomies include BRCA gene status, family history, previous biopsies, dense breasts, and hard-to-read mammograms. Reconstructive options are important to explore with the patient, but ultimately the patient’s wishes are most predictive of patient satisfaction in prophylactic mastectomy. Radiation and tumor burden do not affect the treatment of the contralateral breast.

Answer 95

The correct response is Option D. Striae can be associated with Cushing disease, exogenous steroid administration, obesity, pregnancy, and rapid growth in adolescence. They are all situations involving hormonal excess (physiologic or nonphysiologic) as part of the presumed cause. Exogenous steroid use and Cushing disease would also be associated with central obesity. The patient's BMI does not indicate obesity. Addison disease is not associated with stretch marks. The rise in hormones and rapid growth in height seem to leave the lumbar area, buttocks, and calves susceptible to stretch marks in adolescent boys. The natural history of striae is to present with an inflammatory phase (striae rubrae), during which they are red and may be itchy and slightly raised. With time, the inflammatory aspects subside, leaving hypotrophic-appearing white striae (striae albae). There are multiple approaches to management of striae that include strategies to decrease vascularity, increase collagen production, and increase melanin deposition. These approaches individually and in combination can produce incremental improvement in appearance, but none are curative. Striae are associated with weight gain, not weight loss. REFERENCES: 1. Borrelli MR, Griffin M, Ngaage LM, Longaker MT, Lorenz HP. Striae distensae: scars without wounds. Plast Reconstr Surg. 2021;148(1):77-87. doi:10.1097/PRS.0000000000008065 2. Seirafianpour F, Sodagar S, Mozafarpoor S, et al. Systematic review of single and combined treatments for different types of striae: a comparison of striae treatments. J Eur Acad Dermatol Venereol. 2021;35(11):2185-2198. doi:10.1111/jdv.17374 3. Elsedfy H. Striae distensae in adolescents: a mini review. Acta Biomed. 2020;91(1):176-181. doi:10.23750/abm.v91i1.9248

Answer 96

The correct response is Option C. The pectoral nerve (PECS) 1 and PECS 2 anesthetic blocks have become increasingly common methods for regional anesthesia to decrease postoperative pain in many early recovery after surgery (ERAS) protocols. The PECS blocks are thoracic regional fascial plane blocks that typically require ultrasound guidance for proper infiltration of the anesthetic between the muscles of the thoracic wall. A PECS 1 block is performed between the pectoralis major and pectoralis minor muscles and anesthetizes the lateral and medial pectoral nerves. A PECS 2 block, in addition to the PECS 1 block, involves an additional injection of anesthetic between the pectoralis minor and serratus anterior muscles and blocks the intercostal and intercostobrachial nerves. The serratus plane block is another thoracic regional fascial plane block requiring injection of local anesthetic between the serratus anterior and latissimus dorsi muscles in order to block the long thoracic and thoracodorsal nerves. Reference(s) 1. Al Ja'bari A, Robertson M, El-Boghdadly K, Albrecht E. A randomised controlled trial of the pectoral nerves-2 (PECS-2) block for radical mastectomy. Anaesthesia. 2019;74(10):1277-1281. 2. Wang K, Zhang X, Zhang T, Yue H, Sun S, Zhao H, Zhou P. The Efficacy of Ultrasound-guided Type II Pectoral Nerve Blocks in Perioperative Pain Management for Immediate Reconstruction After Modified Radical Mastectomy: A Prospective, Randomized Study. Clin J Pain. 2018;34(3):231-236.

Answer 97

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

Answer 98

The correct response is Option D. Virchow recognized a triad of factors that predispose to intravascular thrombosis. These are stasis in blood flow, endothelial (intimal) damage, and intrinsic hypercoagulability. One recent review identifies a personal history of prior thrombotic event as perhaps the single greatest risk factor of a hypercoagulable state. Other known hypercoagulable disorders that can be identified by specific blood test include Factor V Leiden mutation, prothrombin gene (20210A) mutation, protein C deficiency, protein S deficiency, antithrombin III (AT3) deficiency, lupus anticoagulant, anticardiolipin antibodies, and anti-beta-2 glycoprotein 1 antibodies. These appear to increase the risk of microsurgical thrombotic complications as well. However, the severity of the increased risk for each remains to be fully elucidated. Another published series of 41 patients, showed an 80% free flap success rate in patients with identified hypercoagulable states. Therefore, a thorough preoperative evaluation of patients for microvascular procedures may help to identify those at increased risk for thrombotic complications, guiding patient selection and perioperative anticoagulation therapy. The Caprini Risk Assessment Model (RAM) is used to assess venous thromboembolism (VTE) risk, and its use has been validated in plastic and reconstructive surgery patients. The Caprini RAM score for the patient in this question is 5 (2 risk factor points for major surgery over 45 minutes, 2 points for presence of malignancy, and 1 point for ages 41 to 60). According to the recommendations of the American Society of Plastic Surgeons VTE Task Force Report, one should consider postoperative chemoprophylaxis for VTE for this patient who is at intermediate risk. However, data are lacking, which would support the use of the Caprini Risk Assessment Model as a tool to stratify risk of microvascular thrombotic complications. BRCA-2 genetic mutation is a heritable condition that significantly increases lifetime risk for breast and ovarian cancer. However, it has not been shown to play any role in risk for thrombotic events. Similarly, sickle cell trait (heterozygous carrier of the sickle cell mutation in the hemoglobin-beta gene) has not been shown to increase risk for microsurgical thrombotic complications. While chest wall irradiation might negatively impact the recipient chest wall vessels for deep inferior epigastric perforator (DIEP) flaps, the impact of radiation following a lumpectomy is very unlikely to be as significant as that of a prior personal thrombotic event. Reference(s) 1. Murphy RX Jr, Alderman A, Gutowski K, et al. Evidence-based practices for thromboembolism prevention: summary of the ASPS venous thromboembolism task force report. Plast Reconstr Surg. 2012;130:168e-75e. 2. Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg. 2011;212:105-12. 3. Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist's perspective. Plast Reconstr Surg. 2015;136(4):545e-52e. 4. Wang TY, Serletti JM, Cuker A, et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg. 2012;129:443-53.

Answer 99

The correct response is Option D. The literature states that there is a decrease in hypertrophic scarring associated with the use of bilaminate neodermis with burn reconstruction. The cost of the product is high. Use of the product requires a second surgery for the skin graft. There has not been any literature supporting improved sensation following use of the graft. The downside to the graft is that it can result in longer hospital stays for the patient in order to get the second surgery completed. Reference(s) 1. Heimbach DM, Warden GD, Luterman A, et al. Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment. J Burn Care Rehabil. 2003;24(1):42-8.

Answer 100

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.

Answer 101

The correct response is Option A. Pilomatrixoma (also known as pilomatricoma or calcifying epithelioma of Malherbe) is a benign, slowgrowing skin tumor of the hair follicle. These tumors are most commonly found in children, although they have been increasingly found in patients of all ages. They tend to develop in the head and neck region but can also be found in the trunk and extremities, and they are usually not associated with any other isolated signs and symptoms. Pilomatrixomas can rarely become cancerous via transformation to the malignant pilomatrix carcinoma. Mutations in the CTNNB1 gene have been found in at least 75% of isolated pilomatrixomas. The CTNNB1 gene is needed to regulate cell growth and attachment, and mutation in this gene directly implicates beta-catenin/LEF dysregulation as the major cause of hair matrix cell tumorigenesis in this condition. The GLUT1 gene mutation is associated with infantile hemangioma, while the NF1 and p57 gene mutations are associated with neurofibromatosis 1 and Beckwith-Wiedemann syndrome, respectively.

Answer 102

The correct response is Option C. Meningomyelocele is the most common neural tube defect. It involves dorsal herniation of the meninges and spinal cord through the vertebrae and may produce motor and sensory nerve deficits. It is often diagnosed prenatally by elevated maternal serum alpha fetoprotein and ultrasonography. Treatment of larger defects often involves both neurosurgery and plastic surgery teams. After repair of the neural placode, the goals of soft tissue reconstruction are to cover and protect the neural element, prevent infection, and avoid any cerebrospinal fluid leak. Ideally this is performed within the first 24 to 48 hours of life. Larger defects are often best reconstructed with muscle flaps, fasciocutaneous flaps, or a combination of both. Many different flaps have been described, but considerations for adequate vascularity (such as inclusion of perforator blood vessels within geometrically designed flaps) and closure without tension are paramount. While hydrocephalus is a common finding in patients with meningomyelocele, it is treated with cerebrospinal fluid shunting if required. Meningomyelocele repair does not regain or improve neural abilities that are not present at birth, such as bowel and bladder function, and lower extremity motor and sensory function. Symptoms related to tethering of the spinal cord may develop as the patient grows in as many as 20 to 50% of children who undergo meningomyelocele repair shortly after birth and many may require surgery to release the scar tissue attached to the cord. However, this condition is not prevented by meningomyelocele repair. Reference(s) 1. Rodriguez ED. Craniofacial, head and neck surgery. In: Rodriguez ED, ed. Craniofacial, Head and Neck Surgery and Pediatric Surgery; vol 3.

Answer 103

The correct response is Option B. Hemorrhage is one of the most common causes of shock in trauma and it is important to recognize early hemodynamic changes and warning signs of shock. Among the signs of hemorrhagic shock listed in the question, elevation of pulse rate is usually the first one to be noticeable. Although difficult to document in the usual clinical setting, studies have shown that typically the first clinical sign of hypovolemia is an increase in the diastolic blood pressure causing narrowing of the pulse pressure (systolic minus diastolic pressures). Skin vasoconstriction, decrease in blood pressure (systolic and diastolic), confusion, and increase in respiratory rate are all associated with higher blood volume loss. Reference(s) 1. Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378(4):370-379. 2. Mutschler M, Paffrath T, Wölfl C, et al. The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge? Injury. 2014;45(suppl 3):S35-S38.

Answer 104

The correct response is Option D. Merkel cell carcinoma (MCC) is an uncommon and extremely aggressive cutaneous malignancy that is challenging to diagnose. Up to one half of patients will eventually develop a recurrence or a metastasis. There are approximately 2500 cases of MCC diagnosed per year in the United States. Eighty percent of MCCs are caused by the Merkel cell polyomavirus and the remaining 20% by extensive ultravioletmediated damage. MCC is most common on sun-damaged areas, with half located on the head and neck and nearly 40% on the extremities. They usually present as nontender, rapidly growing, painless, single, red to violaceous, firm intradermal papules or nodules. The epidermis overlying the tumor is usually preserved, but ulceration or crusting is not uncommon. Their doubling time can be as short as 12 days. The clinical features of MCC are summarized in the acronym AEIOU: asymptomatic, expanding, immunosuppressed, older than 50 years, and ultraviolet-exposed fair skin. They are differentiated histologically by the small, round, blue cells that stain positive for cytokeratin 20. The surgical treatment of MCC consists of wide local excision with one to two centimeter margins, inclusive of the underlying fascia. Management of regional disease is critical with this tumor. A clinically negative nodal basin will be evaluated with a sentinel node biopsy while a patient with a clinically positive nodal basin will be offered a therapeutic complete lymph node dissection. Postoperative radiation is offered to patients with tumors greater than 1 cm, close/positive margins, or nodal involvement. Melanoma cells stain positive for S100 and HMB-45. Basal cell carcinomas stain positive for Ber- EP4. Squamous cell carcinomas stain positive for AE1/AE3.

Answer 105

The correct response is Option B. Rabies is a preventable disease, as long as the victim is treated as soon as it is determined that either this was a high risk exposure or the animal is confirmed to have rabies. Left untreated, rabies is uniformly fatal In the United States of America with few exceptions.1 While domestic animals now rarely cause transmission of rabies and most exposures come from wild animals such as bats and raccoons, transmission is still possible in an attack. As well, even though the rabies vaccine in domesticated animals is very effective, there are case reports noting rabies developing in vaccinated animals, albeit quite rare.2 Regulations can vary state to state on reporting requirements; however, it is always a good idea to contact local authorities. Rabies prophylaxis, while life-saving, can have significant discomfort and side effects during and after administration, thus should not be given lightly. As well, local authorities will be able to help assess risk for rabies in the patient’s location and how to best proceed. A 10-day quarantine has been very effective and to date, there is no report of an animal observed to be healthy for 10 days and actually transmitting rabies. Only in situations where the risk is determined to be high or the animal cannot be found should prophylaxis be given. Thus, the correct answer is to seek guidance from local authorities and a 10-day observation or humane euthanization of the animal with pathology would be the appropriate answer. In this case, the animal is in possession of the friend and can be safely observed for 10 days.1,3 Reference(s) 1. Qasim AM, Obadua AA, Okewole PA, Tekki IS, Omoleye OS. Rabies in a Vaccinated 9-Month-Old German Shepherd Dog, Akure, 2010: A Case Report. Case Reports in Veterinary Medicine. 2013;2013:1-3. doi:10.1155/2013/280603. 2. Rabies. Centers for Disease Control and Prevention. https://www.cdc.gov/rabies/index.html. Published September 17, 2019. Accessed January 27, 2020. 3. World Health Organization. Rabies vaccines: WHO position paper, April 2018 - Recommendations. Vaccine. 2018;36(37):5500-5503. doi: 10.1016/j.vaccine.2018.06.061.

Answer 106

The correct response is Option B. The direct anticoagulation agent rivaroxaban (Xarelto) is a direct anticoagulant, which acts within the clotting cascade by blocking Factor Xa, which, along with Factor Va, helps convert prothrombin to thrombin. This step in the cascade is where the intrinsic and extrinsic pathways intersect and the common pathway that leads to fibrinogen being cleaved to fibrin and stabilized by factor XIIIa as a crosslinked clot. Aspirin is a drug that interferes with platelet function. Coumadin affects the vitamin K dependent factors II (prothombin), VII, IX and X. Heparin prevents clot propagation by blocking thrombin-mediated activation of fibrinogen to fibrin. The primary benefits of the direct anticoagulation agents over coumadin include no need for monitoring and equivalence in efficacy across many clinical situations. It is excreted by the kidney, so dosages must be altered or the drug avoided in renal failure. A U.S. Food &Drug Administration–approved reversal agent, recombinant coagulation factor Xa (Andexxa), is now available on the market for life-threatening or uncontrolled bleeding in patients using direct anticoagulants affecting factor Xa, like rivaroxaban. Prior to this, administration of fresh frozen plasma (FFP) was the antidote of choice. Reference(s) 1. Munson CF, Reid AJ. Novel oral anticoagulants in plastic surgery. J Plast Reconstr Aesthet Surg. 2016 May;69:585-593. 2. Rogers KC, Winks SW. A new option for reversing the anticoagulant effect of Factor Xa inhibitors: Andexanet alfa (ANDEXXA). Am J Med. 2019 Jan;132:38-41.

Answer 107

The correct response is Option C. Obtaining a serum lactate level is the most appropriate next step for the diagnosis of septic shock in this scenario. Patients with septic shock can be clinically identified by having both of two criteria: 1) Vasopressor requirement to maintain a mean arterial pressure of 65 mmHg or greater and 2) Serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. In 1991, a consensus task force developed initial definitions that focused on the prevailing view at the time that sepsis resulted from a host’s systemic inflammatory response syndrome (SIRS) to infection. SIRS was defined by the presence of two or more of four criteria, including body temperature, heart rate, respiratory rate, and white blood cell count. Despite their known limitations, these definitions remained mainly unchanged for almost three decades. In 2016, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine sponsored a task force to review the definition of sepsis and its management guidelines (Sepsis-3). Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. This organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of two points or more. Another measure called quick SOFA (qSOFA), although less robust, may be more practical for providers diagnosing sepsis in the non-ICU setting. qSOFA incorporates altered mentation (GCS <15), systolic blood pressure of 100 mmHg or less, and respiratory rate of 22/min or greater. Septic shock is a subset of sepsis with profound circulatory and cellular/metabolic dysfunction, associated with a higher risk of hospital mortality than with sepsis alone (40% versus 10%, respectively). The term “severe sepsis,” previously defined as sepsis complicated by organ dysfunction, has been incorporated into the current definition of sepsis and abandoned. Reference(s) 1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8): 801-810. 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; 45(3): 486-552. 3. Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. 23; 315(8): 775-787.

Answer 108

The correct response is Option B. While advanced age has been historically considered a risk factor for increased postoperative complications, this idea has been challenged in the literature, particularly in plastic surgery where many procedures are elective and patients can be functionally optimized for surgery. More recently, the concept of frailty has been suggested as an alternative and better predictor for poor surgical outcomes. While the original Canadian Study of Health and Aging Frailty Index consisted of 70 items, the modified 5-Item Frailty Index has shown similar predictive value with increased simplicity. The components of the modified 5-Item Frailty Index include the following: • Functional status before surgery • Diabetes mellitus • Chronic obstructive pulmonary disease • Congestive heart failure • Hypertension requiring medication REFERENCES: 1. Magno-Pardon DA, Luo J, Carter GC, Agarwal JP, Kwok AC. An analysis of the modified five-item frailty index for predicting complications following free flap breast reconstruction. Plast Reconstr Surg. 2022;149(1):41-47. doi:10.1097/PRS.0000000000008634 2. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor modified frailty index using American College of Surgeons NSQIP Data. J Am Coll Surg. 2018;226(2):173-181.e8. doi:10.1016/j.jamcollsurg.2017.11.005

Answer 109

The correct response is Option B. Multiple studies have shown the benefits of negative pressure wound therapy (NPWT) when used in conjunction with skin grafts, both as a bolster over a skin graft as well as wound bed preparation. NPWT has been shown to decrease the risk of infection in complex and traumatic wounds in some studies, while others have shown no difference in infection rates in complex wounds when the patient has multiple comorbidities or when used to cover uncomplicated incisions for elective orthopedic operations. However, there is no evidence to suggest NPWT increases infection risk compared with standard wound dressings. NPWT reduces both inflammatory response and edema formation. When used for damage control laparotomy and abdominal compartment syndrome, studies have failed to show any benefit of NPWT over standard dressings. Furthermore, at least one study has suggested an increased rate of enteric fistula formation is associated with NPWT. NPWT has been shown to decrease both the number of postoperative dressing changes and the number of additional operative interventions in complicated diabetic wounds. Reference(s) 1. Anghel EL, Kim PJ. Negative-pressure wound therapy: a comprehensive review of the evidence. Plast Reconstr Surg. 2016 Sep; 138(3 Suppl): 129S-37S. 2. Evangelista MS, Kim EK, Evans GRD, Wirth GA. Management of skin grafts using negative pressure therapy: the effect of varied pressure on skin graft incorporation. Wounds. 2013;25(4):89-93.

Answer 110

The correct response is Option C. Poland syndrome is likely a multifactorial genetic syndrome related to the embryologic timing and development of the subclavian arch. Its unifying finding is absence of the pectoralis major muscle but is variable in other manifestations of underdevelopment of the chest wall, breast, and ipsilateral upper extremity. Poland syndrome is most often reported as more frequent in males, but some series show equal expression in males and females. Additionally, up to 10% of patients may have associated dextrocardia. Having a way to describe or classify a deformation in an organized fashion is helpful in planning reconstruction, determining results and outcomes, and discussing cases with colleagues. The thorax, breast, nipple-areola complex (TBN) system was proposed and published by Romanini et al. to do just that. Since that publication, further research by the group based on the TBN classification has been published and others have suggested modifications to include the presence or absence of ipsilateral upper extremity anomalies. Thorax T1: absence of all or part of pectoralis T2: T1 + pectus excavatum or carinatum T3: T1 + rib aplasia (usually 3 and 4) T4: T1 + T2 + T3 Breast B1: hypoplastic breast B2: breast aplasia (amastia) Nipple-areola complex N1: hypoplastic NAC less than 2 cm displaced N2: hypoplastic NAC more than 2 cm displaced N3: athelia The patient in the scenario is best described by the TNB classification as T2 (no pectoralis, pectus excavatum), B1 (breast hypoplasia) and N2 (hypoplastic NAC greater than 2 cm displaced). According to this classification, she is probably best served by correction of the pectus first, then correction of the Test Review Report Printed on: 2/26/2023 breast. Reference(s) 1. Manzano Surroca M, Parri F, Tarrado X. Poland sequence: retrospective analysis of 66 Cases. Ann Plast Surg. 2019;82(5):499-511. 2. Romanini MV, Calevo MG, Puliti A, et al. Poland syndrome: a proposed classification system and perspectives on diagnosis and treatment. Seminars in Pediatric Surgery. 2018;27(3):189-199. 3. Romanini MV, Torre M, Santi P, et al. Proposal of the TBN classification of thoracic anomalies and treatment algorithm for Poland syndrome. Plast Reconstr Surg. 2016;138(1):50-58.

Answer 111

Correct answer is option E. Total parenteral and enteral nutrition are both options for supplementary nutrition; however, enteral nutrition is preferred when possible. Total parenteral nutrition is associated with increased infectious and increased ICU length of stay. Enteral nutrition is more physiologic and has a trophic effect on gastrointestinal cells. In the absence of enteral nutrition, gastrointestinal mucosa atrophies, resulting in impaired gastrointestinal barrier function, increased epithelial inflammation and decreased regulation of immune receptors.

Answer 112

Correct answer is option D. More plastic surgeons are performing reconstruction for women pursuing prophylactic mastectomy, which is requested quite frequently to avoid cancer recurrence and to achieve optimal aesthetic outcome. Exclusion criteria for nipple-sparing mastectomy include tumors greater than 3-cm, clinical invasion of the nipple-areola complex, tumors within 2-cm of the nipple, evidence of multicentric disease, positive intraoperative retroareolar frozen section, or nodal disease. If carcinoma is found in the retroareolar tissue, the nipple-areola complex must be removed. A patient who would require sentinel lymph node evaluation, radiation therapy, or chemotherapy would not be an appropriate candidate for nipple-sparing mastectomy. Annual mammography is recommended for any patient with a history of breast cancer and is not specific to the issue of nipple-sparing mastectomy. Ductal washing is not relevant for this pathology.

Answer 113

The correct response is Option A. Minors are neither eligible for nor able to receive organ donation without the consent of a parent or guardian. Creutzfeldt-Jakob disease or any other prion disease is a contraindication for organ donation of any kind. Metastatic cancer is a contraindication for organ donation. HIV status is no longer a contraindication to donate or receive an organ, provided the donor and recipient are both HIV positive. Reference(s) 1. U.S. Government Information on Organ Donation and Transplantation. Www.Organdonor.gov. Accessed May 25, 2018. 2. Malani PN. New law allows organ transplants from deceased HIV-infected donors to HIV-infected recipients. JAMA. 2013; 310:2492.

Answer 114

The correct response is Option E. This patient has a high risk for venous thrombosis given that the 1.5-mm anastomotic coupler was used. In a large retrospective study, Hansen et al, found that based on 5643 reconstructions, the 1.5-mm diameter coupler had an overall thrombosis rate of 6.9%. This is significantly higher than all other coupler sizes. In another study, Jandali et al, found that using the anastomotic coupler in breast reconstruction is safe. In fact, these authors demonstrated a 0.6% flap loss rate in 1000 cases of autologous breast reconstruction. When encountered with a recipient vein that is less than 2.0 mm, the surgeon should either perform a hand-sewn anastomosis or find different recipient vessels. Reference(s) 1. Hanson SE, Mitchell MB, Palivela N, et al. Smaller Diameter Anastomotic Coupling Devices Have Higher Rates of Venous Thrombosis in Microvascular Free Tissue Transfer. Plast Reconstr Surg. 2017;140(6):1293-1300. 2. Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg. 2010;125(3):792-8.

Answer 115

The correct response is Option C. All the medications listed are safe for use the night before surgery with the exception of an ACE inhibitor. While there have been some questions in the past regarding the safety of selective serotonin reuptake inhibitors (SSRIs) like sertraline due to bleeding concern, the current consensus is that it is safe to take.1 Beta blockers can have a beneficial effect for the cardiovascular system before surgery and thus, patients may take them even the morning of surgery.2 Lisinopril, however, can lead to hypotension during surgery and anesthetic management, and should be stopped the night before surgery. As an ACE inhibitor, it may counter the medications the anesthesiologist uses for blood pressure control. Reference(s) 1. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Before Noncardiac Surgery: An Analysis of the Vascular events In Noncardiac Surgery Patients Cohort Evaluation Prospective Cohort. Anesthesiology. 2017;126(1):16-27.

Answer 116

The correct response is Option D. The p value is defined as the probability of getting a difference at least as large as that observed if the null hypothesis is true. The larger the p value, the more likely the observed difference is due to sampling error (and therefore one accepts the null hypothesis of no difference). The smaller the p value, the more likely the observed difference is not due to sampling error (and therefore one rejects the null hypothesis of no difference). In patients who suffer from moderate to severe migraine headaches from a single or predominant trigger site, 84% of patients that underwent surgical decompression of that trigger point experienced reduction in migraine symptoms by more than 50%, compared to 58% of those who underwent sham surgery. Reference(s) 1. Guyuron B, Reed D, Kriegler JS, et. al. A Placebo-Controlled Surgical Trial of the Treatment of Migraine Headaches. Plast Reconstr Surg. 124:461, 2009. 2. Ruffenburgh RH. Statistics in Medicine. 3 rd edition. San Diego, California; Elsevier Inc; 2012.

Answer 117

The correct response is Option D. The advantage of using this combination is that midazolam has excellent anxiolytic and amnestic effects, whereas fentanyl is an excellent short-acting analgesic. A recent multicenter, randomized study demonstrated that the combination of fentanyl and midazolam is superior to midazolam alone in decreasing the patient’s subjective report of pain and anxiety. The main drawback of fentanyl is respiratory depression; however, it does have a very short half-life. Midazolam, in contrast, has minimal effects on the respiratory system except in some older patients, in whom lower doses must be used. Continuous oxygen saturation monitoring and checking the patient's respiratory status and other vital signs every 5 minutes are important for patient safety. Medications are only administered in small doses at each 5-minute interval (no more than 50 mg of fentanyl and 2 mg of midazolam at a time). This helps achieve a steady-state effect. Both of these medications have antagonists that are able to reverse their effects. Flumazenil and naloxone, the antagonists of midazolam and fentanyl, respectively, should be readily available in the operating room. The surgeon should be familiar with their dosage and administration. Ketamine would not resolve anxiety in this patient. Use of propofol in combination with an opiate and benzodiazepine can be used for conscious sedation; however, the disadvantage of this combination is the higher risk of respiratory depression and the lack of a reversing agent for propofol. Because a deeper level of sedation can be maintained, this technique is preferable for selected patients who are very anxious. A recently published series of abdominoplasty with sedation using propofol used monitored anesthesia care by an anesthesiologist or nurse anesthetist. Propofol and benzodiazepines have no significant analgesic effect. Test Review Report Printed on: 2/26/2023 Reference(s) 1. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non- Anesthesiologists. Practice guidelines for sedation and analgesia by non- anesthesiologists. Anesthesiology.1996;84(2):459-471. 2. Dionne RA, Yagiela JA, Moore PA, Gonty A, Zuniga J, Beirne OR. Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients. J Am Dent Assoc. 2001;132(6):740-751. 3. Rosenberg MH, Palaia DA, Bonanno PC. Abdominoplasty with procedural sedation and analgesia. Ann Plast Surg. 2001;46(5):485-487.

Answer 118

The correct response is Option B. Absolute stability is achieved by interfragmentary compression, which allows for direct bone healing without the formation of a callus. Forms of this osteosynthesis include lag screws, compression plates, and tension banding. Relative stability does not have interfragmentary compression at the fracture site, and healing is achieved through callus formation. Types of relative stability include intramedullary nailing, bridge plating, external fixation, and splinting/casting. In minimally invasive plate osteosynthesis (MIPO), the preferred stability is typically relative stability as it allows for controlled motion at the fracture site, promoting better bone healing by encouraging callus formation, which is the primary principle of this technique; in contrast, absolute stability limits micromovement, potentially hindering the natural healing process. *Key points to remember:* **Relative stability:** Achieved using a bridge plate, which provides some stability but allows for a degree of movement at the fracture site, leading to callus formation and bone healing. **Absolute stability:** Achieved with a neutralization plate and lag screws, providing near complete immobilization at the fracture site, often resulting in faster union but with potential drawbacks like decreased vascularity and impaired bone healing in certain situations. Why is relative stability preferred in MIPO? *Preserves blood supply:* By minimizing soft tissue disruption, MIPO aims to preserve the blood supply to the fracture site, which is crucial for optimal bone healing. *Biological healing:* Relative stability encourages the natural process of bone healing with callus formation, which is considered more advantageous in many fracture scenarios. REFERENCES: 1. Baumgaertel F. Bridge plating, In: Ruedi TP, Murphy WM, eds. AO Principles of fracture management. 2000; 221-231. 2. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-1110. doi: 10.1302/0301-620x.84b8.13752 3. Wenger R, Oehme F, Winkler J, Perren SM, Babst R, Beeres FJP. Absolute or relative stability in minimal invasive plate osteosynthesis of dimple distal meta or diaphyseal tibia fractures? Injury. 2017;48(6):1217-1223. doi: 10.1016/j.injury.2017.03.005

Answer 119

The correct response is Option E. The targeted muscle reinnervation procedure involves transecting a sensory or mixed motor nerve and transferring it in an end-to-end fashion to the smaller motor nerve in a nearby muscle. Since the surgeon is connecting two different nerves together, this is treated as a nerve transfer procedure. The suture of a major peripheral nerve is used to code for a repair of a laceration of nerve. While the common peroneal neuroma is being transected, the proximal stump of the nerve is not being buried in an innervated muscle; therefore, the burial of the neuroma code is not appropriate. Also, while the surgeon is transecting the common peroneal nerve to resect the neuroma, the transection code cannot be billed, since it would be included in the nerve transfer code. Also, the neuroplasty code is bundled in the nerve transfer code under normal circumstances. Reference(s) 1. CPT Professional 2018. Chicago, IL: American Medical Association; 2017. 2. Souza JM, Cheesborough JE, Ko JH, et al. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res.2014;472(10):2984-90.

Answer 120

The correct response is Option D. In this scenario, the physician should rule out compartment syndrome for several reasons: the crush injury, the reperfusion state, and pain unrelieved by pain medications prior to providing more pain relief. Pain that is out of proportion to the expected level or out of proportion to examination findings should alert the clinician to the possibility of compartment syndrome. The only study option provided that would give the clinician the ability to rule out compartment syndrome is the direct measurement of compartment pressures, which is recommended by several authors. Loss of peripheral artery pulses or perfusion to the distal skin would be very late presentations of the ischemic process, at a point where intervention, such as fasciotomy may not be effective. Missing this diagnosis in a patient such as this one, may lead to loss of muscular function (ischemic muscle contracture) even if the limb as a whole is salvaged. The presence of palpable pulses is reassuring evidence for the patency of the bypass graft but does not tell the clinician about the perfusion in the capillary beds of the muscle. Similarly, perfusion of the skin and the digits does not guarantee flow in the muscle that was reperfused. Reference(s) 1. Kistler J, Ilyas A, Thoder JJ. Forearm Compartment Syndrome Evaluation and Management. Hand Clin. 2018 Feb;34(1):53-60. 2. Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg. 2011 Jan;19(1):49-58.

Answer 121

The correct response is Option A. The pH is low, indicating an acidosis, while the bicarbonate is high, indicating that a respiratory acidosis with metabolic compensation is present. The pH is low so the primary problem is an acidosis and is likely to be respiratory in nature. The PaCO2 is very high and indicates a respiratory acidosis is present. The very high PaCO2 level seen here is typical of a person with respiratory disease that results in retention of CO2, (ie, the primary clinical problem is respiratory failure due to chronic obstructive pulmonary disease).The most likely cause for this acid-base abnormality is an acute exacerbation of chronic obstructive pulmonary disease. Reference(s) 1. Hamilton PK, Morgan NA, Connolly GM, et al. Understanding Acid-Base Disorders. Ulster Med J. 2017;86(3):161-166.

Answer 122

The correct response is Option E. Epinephrine is the initial drug of choice in the acute management of this patient with pulseless electrical activity (PEA). Desirable effects of epinephrine in the treatment of cardiac arrest include vasoconstriction (alpha-1 adrenergic) and increase in cardiac output (beta-1 adrenergic). According to current Advanced Cardiac Life Support guidelines, epinephrine should be administered to a patient in cardiac arrest as soon as the electrocardiographic diagnosis of either PEA or asystole is made. The intravenous dose is 1 mg every 3 to 5 minutes, always followed by a 20 mL normal saline flush. Cardiopulmonary resuscitation should not be halted for drug administration. The drug can also be administered via intraosseous access or through the endotracheal tube. The other drugs listed are not indicated in the initial treatment of PEA.

Answer 123

The correct response is Option E. White phosphorus is sustained in both military and civilian circumstances. It is commonly found in fireworks, fertilizers, and pesticide. It is extremely volatile and can ignite spontaneously upon exposure to air. Additionally, phosphoric acids form during combustion and further injure tissues. Treatment mainstays include: 1. Immediate debridement of visible debris 2. Copious irrigation 3. Keep the area wet and covered with saline-soaked gauze 4. Cardiac monitoring and electrolyte evaluation. Profound hypocalcemia, hyperphosphatemia, and sudden death have been associated with this injury. Calcium gluconate gel is used in the management of hydrofluoric acid burns. Polyethylene glycol is used in the management of phenol and cresol burns. Mineral oil is used to isolate potassium, sodium, and magnesium from water, with which they react explosively. Mafenide (Sulfamylon) has no role in the immediate management of white phosphorus burns. Reference(s) 1. Renz E, Cancio L. Chapter 12, Acute Burn Care. In: Combat Casualty Care. Falls Church, VA: Office of the Surgeon General of the United States Army; 2012: 596-631. 2. Hardwicke J, Hunter T, Staruch R, Moiemen N. Chemical burns-an historic comparison and review of the literature. Burns. 2012 May;38(3):383-7. 3. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn center for over a 51 year period. Burns. 2004 Aug;30(5):448-52.

Answer 124

The correct response is Option D. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) is an accrediting body that certifies that an accredited facility meets nationally recognized standards for safety. The facility is surveyed every 3 years. There are different classes of facilities. According to their Basic Mandates: In a Class A facility, procedures "may be performed under topical or local anesthesia only; only minimal sedation levels are permitted, and no more than 500 cc’s of aspirate can be removed via liposuction." In a Class B facility, "parenteral sedation, field and peripheral nerve blocks and dissociative drugs (excluding propofol) may be administered by a/an physician, certified registered nurse anesthetist (CRNA) with physician supervision, anesthesia assistant under direct supervision of an anesthesiologist or registered nurse (RN) under qualified physician supervision. The use of propofol, spinal and epidural anesthesia, endotracheal intubation, laryngeal mask airway, and/or inhalation general anesthesia is prohibited. No more than 5L of aspirate can be removed via liposuction unless the patient is monitored overnight in the facility." In a Class C facility, "all types of anesthesia listed above can be administered including general anesthesia (with or without endotracheal intubation or laryngeal mask airway), and propofol can be administered by a/an physician, CRNA with physician supervision, anesthesia assistant under direct supervision of an anesthesiologist or RN under qualified physician supervision. No more than 5L of aspirate can be removed via liposuction unless the patient is monitored overnight in the facility." Certificate of need relates to insurance cases and is not a mandate of the AAAASF. There is no mandate requiring pathologic examination availbility. American Association for Accreditation of Ambulatory Surgery Facilities, Inc. Regular standards and checklist for accreditation of ambulatory surgery facilities: version 14.5. https://www.aaaasf.org/wpcontent/ uploads/2019/09/Standards-and-Checklist-Manual-V-14.5.pdf. Revised March 2017. Accessed December 30, 2019. 2. Pearcy J, Terranova T. Mandate for accreditation in plastic surgery ambulatory/outpatient clinics. Clin Plast Surg. 2013;40(3):489-492.

Answer 125

The correct response is Option A. Patients receiving immunosuppressive therapy after allograft transplantation are most likely to develop infections caused by opportunistic pathogens after the first month and within 1 year after transplantation. Classically, infections in immunosuppressed patients after organ transplantation occur in three distinct time periods. 1) During the first month after transplantation, most infections are typical postoperative nosocomial infections, although donor-derived and pre-existing recipient infections can also occur. 2) During the period of peak immunosuppression, typically between 1 and 12 months after transplantation, most infections are classic opportunistic infections, including cytomegalovirus, herpes simplex virus, herpes zoster, Epstein-Barr virus, Aspergillus, Nocardia, and Pneumocystis. Use of prophylaxis may result in a later onset of opportunistic infections. 3) After 12 months posttransplantation, recipients with satisfactory allograft function will tolerate decreased maintenance immunosuppression, with a lowered risk for developing infections by classic opportunistic agents, although they may still occur. Community-acquired infections are most typical during this period, as healthy recipients suffer community-based epidemiological exposures. These infections may be more prolonged and result in more complications than in otherwise healthy patients. Reference(s) 1. Fishman JA. Infection in Organ Transplantation. Am J Transplant. 2017;17(4):856-879. 2. Kumar R, Ison MG. Opportunistic Infections in Transplant Patients. Infect Dis Clin North Am. 2019;33(4):1143-1157.

Answer 126

The correct response is Option A. In severe burn scar contractures, adjacent tissue transfer (Z-plasty, VY-plasty) and skin grafts are not indicated. Perforator-based local flaps have low recurrence rates but one limitation of this technique is the availability of local normal skin. In this specific case, no normal skin is available. Free tissue transfer is the best option. Perforator vessels are normally protected and can serve as recipient vessels for the free flap transfer. Reference(s) 1. Hayashida K, Akiti S. Surgical treatment algorithms for post-burn contractures. Burns Trauma. 2017; 5:9. 2. Stekelenburg CM, Marck RE, Tuinebreijer WE, et al. A systemic review on burn scar contracture treatment: searching for evidence. J Burn Care Res. 2015 May-Jun;36(3):e153-61.

Answer 127

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.

Answer 128

The correct response is Option A. Postoperative surgical site infection (SSI) following implant-based breast reconstruction is a major complication that can mandate device removal and thereby result in reconstructive failure. As such, meticulous technique, maintenance of a sterile surgical field, and perioperative antibiotic prophylaxis are of utmost importance in decreasing postoperative infection rates. Historically, antibiotics were used quite liberally following implant-based breast reconstruction with prophylaxis implemented for an extended duration, frequently until drain removal. More recent studies, however, have demonstrated that extended postoperative systemic antibiotics have no significant effect on decreasing the incidence of SSI. Importantly, Phillips et al demonstrated that antibiotic prophylaxis for an extended duration, versus less than 24 hours, was associated with a greater rate of expander loss. Therefore, contemporary recommendations call for antibiotic prophylaxis limited to the perioperative period only, for less than 24 hours. As to antibiotic choice, the use of beta-lactam antibiotics (eg, cefazolin) was recently demonstrated as superior to alternative antibiotics with a bacteriostatic mechanism of action (eg, vancomycin, clindamycin) in regards to rates of postoperative infection and reconstructive failure following immediate implant-based breast reconstruction. Trimethoprim-sulfamethoxazole would be contraindicated in this patient given her sulfonamide allergy. Since perioperative antibiotic prophylaxis is predominantly targeted against gram-positive bacteria (skin flora), intravenous piperacillin/tazobactam would not be an appropriate choice. REFERENCES: 1. Hai Y, Chong W, Lazar M. Extended prophylactic antibiotics for mastectomy with immediate breast reconstruction: A meta-analysis. Plast Reconstr Surg Glob Open. 2020;8(1):e2613. doi: 10.1097/GOX.0000000000002613 2. Miller TJ, Remington AC, Nguyen DH, Gurtner GC, Momeni A. Preoperative β-lactam antibiotic prophylaxis is superior to bacteriostatic alternatives in immediate expander- based breast reconstruction. J Surg Oncol. 2021;124(5):722-730. doi: 10.1002/jso.26599 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;222(6):1116-1124. doi: 10.1016/j.jamcollsurg.2016.02.018

Answer 129

The correct response is Option C. Risk factors for postoperative nausea and vomiting fall into four categories: patient-related, anesthesia-related, surgery-related, and other factors. Patient-related predictors are: female sex, non-smoking status, history of postoperative nausea and vomiting/motion sickness, genetics, age of 50 years or younger, and obesity (BMI greater than 30 kg/m2). Anesthesia-related predictors are: postoperative opioids, inhalational anesthetics, and nitrous oxide. Surgery-related predictors are: surgery duration and surgery type. Other factors including high patient anxiety and postoperative pain. Reference(s) 1. 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.

Answer 130

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.

Answer 131

The correct response is Option D. Isosulfan blue has many uses. It is used to identify sentinel nodes in melanoma and Merkel cell skin cancer as well as in breast cancer. It is used in reverse axillary mapping in order to preserve extremity lymph nodes while harvesting those that drain the breast. Allergic reactions to this dye occur in up to 1.6% of patients. These adverse events are unexpected and occur with unpredictable severity. There is no current validated method to detect or decrease the risk of allergic reaction. It is important for the plastic surgeon to be able to quickly recognize and treat complications. The most common allergic reactions are urticaria, blue hives, and skin rash. Anaphylaxis has been reported, but much less commonly. In this scenario, the first sign of anaphylactic reaction is the sudden and severe drop in blood pressure. Test Review Report Printed on: 2/26/2023 Question 100 of 144 This can occur immediately or unexpectedly later during the surgical procedure. After halting the operation and starting a fluid bolus, a vasopressor should be administered to counteract the hypotension. Once this is done, both a corticosteroid (dexamethasone) and an antihistamine (diphenhydramine) should be given to counteract the allergic reaction. Changing the fraction of inspired oxygen will not help the allergic reaction. A needle thoracostomy would be indicated if dissection high in the axilla resulted in a tension pneumothorax, but that is not the case here. Administration of lipid emulsion is appropriate for local anesthetic toxicity. A commonly suggested alternative to isosulfan blue, without the risk of anaphylaxis, is methylene blue. However, there is a significantly higher rate of wound healing complications with the use of methylene blue, which is why isosulfan blue is preferred in plastic surgical procedures, specifically skin grafting. Reference(s) 1. Dayan JH, Dayan E. Smith ML. Reverse lymphatic mapping: new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135(1):277-285. 2. Knackstedt T, Knackstedt RW, Couto R, Gastman B. Malignant melanoma: diagnostic and management update. Plast Reconstr Surg. 2018;142(2):202e-216e. 3. Neves RI, Reynolds BQ, Hazard SW, Saunders B, Mackay DR. Increased post-operative complications with methylene blue versus lymphazurin in sentinel node biopsies for skin cancers. J Surg Oncol. 2011;103(5):421-425. 4. Ortiz D, Alvikas J, Riker AI. A case of severe anaphylactic reaction secondary to isosulfan blue dye injection. Ochsner J. 2015;15(2):183-186.

Answer 132

The correct response is Option E. While there are different resuscitation formulas for initial burn resuscitation, such as the Brooke formula or the Parkland formula, they rely on giving a certain amount of fluid multiplied by total body surface area (as determined by partial- and full-thickness burns) and weight in kilograms of the patient. The fluid is then given initially as determined from time of injury, and divided into half given in the first 8 hours of injury and then half in the next 16 hours. This is a guideline only and resuscitation can be altered based on physiologic response, such as urine output. Gender and age are not a consideration and first-degree burns are not used in the calculation of total body surface area. Reference(s) 1. Shah A, Pedraza I, Mitchell C, Kramer GC. Fluid volumes infused during burn resuscitation 1980-2015: A quantitative review. Burns. 2019. pii: S0305-4179(19)30443-7.

Answer 133

The correct response is Option D. Brain death is a criteria for nonliving organ donation. Absence of all brain stem reflexes needs to be present for brain death to occur. Absence of corneal reflex demonstrates an absence of brain stem reflexes. Presence of pupillary reflex and nystagmus during caloric test demonstrates a positive finding and presence of brain stem reflex. Mild cough or gag during tracheal manipulation demonstrates presence of brain stem reflex. Any respiratory rate during apnea test is seen as a sign of brain stem function. Evaluation of deep tendon reflexes is not part of assessing brain death. Reference(s) 1. Charpentier J. Diagnosis of brain death, back to medical diagnosis! Anaesth Crit Care Pain Med. 2019 Apr;38(2):117-118. doi: 10.1016/j.accpm.2019.02.003. Epub 2019 Feb 14.

Answer 134

The correct response is Option D. A randomized clinical trial of safety and efficacy of 1-year oxandrolone administration to severely burned children (over 30% total body surface area burns) demonstrated significant benefits of this medication. Improvements were noted in height, bone mineral content (BMC), cardiac work, and muscle strength, and were statistically higher compared to the control group. Mechanism of action is not totally clear but increased in insulin-like growth factor-1 secretion during the first year after burn injury, and, in combination with exercise, considerable increase in lean body mass and muscle strength has been demonstrated. The maximal effect of oxandrolone was found in children aged 7 to 18 years. No deleterious side effects were attributed to long-term administration. Oxandrolone, a synthetic oral nonaromatizable testosterone derivative, has only 5% of the virilizing activity and low hepatotoxicity when compared with testosterone administration. Oxandrolone reaches peak serum concentrations within 1 hour and is excreted through the urine. Oxandrolone binds to androgen receptors in the skeletal muscle to initiate protein synthesis and anabolism. Because oxandrolone cannot be aromatized to estrogen, the likelihood of estrogen-dependent bone-age advancement is reduced, making oxandrolone a safe therapeutic approach for growing children. Testosterone is not currently approved for treatment of burned children due to increased risks of virilization in female patients and aromatization effects among other health risks. Glutamine and ascorbic acid supplementation can aid in burn recovery; however, it has not shown to have similar effects on bone density as oxandrolone. Several studies support the use of enteral glutamine supplements in the adult burn population. Research has also shown that glutamine supplementation is favorable as it has the potential to decrease length of stay and associated costs through improving wound healing and decreasing rates of infection and mortality. Antioxidant therapies including: ascorbic acid; glutathione; N-acetyl-L-cysteine; vitamins A, C, and E; alone or in combination have been previously shown to protect microvascular circulation, mitigate Test Review Report Printed on: 2/26/2023 changes in cellular energetics, decrease tissue lipid peroxidation, and decrease the volume of fluid required for resuscitation. Insulin is used to treat hyperglycemia and primarily used in diabetic patients. It may have limited use in burn care patients but has not shown to increase bone mineral density. Reference(s) 1. Hall KL, Shahrokhi S, Jeschke MG. Enteral nutrition support in burn care: a review of current recommendations as instituted in the Ross Tilley Burn Centre. Nutrients. 2012 Oct 29;4(11):1554-1565. 2. Porro LJ, Herndon DN, Rodriguez NA, et al. Five-year outcomes after oxandrolone administration in severely burned children: a randomized clinical trial of safety and efficacy. J Am Coll Surg. 2012 Apr;214(4):489-502.

Answer 135

The correct response is Option C. This patient is suffering from a bleeding disorder called von Willebrand disease (VWD), which occurs when the von Willebrand factor (VWF) is deficient or qualitatively abnormal. Von Willebrand factor (VWF) works by mediating the adherence of platelets to one another and to sites of vascular damage. It also binds to Factor VIII, keeping it inactive while in circulation since Factor VIII rapidly degrades when not bound to VWF. VWD is the most common of the inherited bleeding disorders, with an estimated prevalence in the general population of 1 percent by laboratory testing. Patients will often present with signs of easy bruising, extensive bleeding after dental work, heavy or long menstrual periods, and prolonged nose bleeds. Patients with a history of abnormal bleeding should always be properly worked up prior to surgery. There has been an extensive discussion over the years about the treatment of patients suffering from von Willebrand’s disease and rhinoplasty procedure. The recommended treatment of patients suffering from VWD undergoing rhinoplasty procedure is 0.3 μg/kg of 1-deamino-8-D-arginine-vasopressin (Desmopressin). Desmopressin is an analogue of vasopressin that exerts a substantial hemostatic effect, by inducing the release of von Willebrand factor from its storage sites in endothelial cells. Patients with the mild form of VWD have lower than normal levels of VWF, and the release of the additional proteins from the endothelial cells aids with clotting. Factor V Leiden is a mutated form of human Factor V, which condition that result in a hypercoagulable state. Due to this mutation, Protein C, an anticoagulant protein which normally inhibits the pro-clotting activity of factor V, is not able to bind normally to Factor V, leading to a hypercoagulable state. Desmopressin does not have a direct interaction on this molecule. Thrombin is an enzyme that converts fibrinogen to fibrin, and a reaction that leads to the formation of a fibrin clot. There are several thrombin products commercially available. Hemophilia is a condition that is deficient in Factor VII. Recombinant activated factor VII. Aspirin irreversibly blocks the formation of thromboxane A2 in platelets, producing an inhibitory effect on platelet aggregation. Reference(s) 1. Ozgönenel B, Rajpurkar M, Lusher JM. How do you treat bleeding disorders with desmopressin?. Postgrad Med J. 2007;83(977):159–163.

Answer 136

The correct response is Option B. Postoperative delirium is an acute brain dysfunction that is characterized by changes in levels of consciousness, inattention, and disorganized thinking. There are two types of delirium. Delirium can manifest with hyperactive signs (agitation, restlessness), or hypoactive signs (lethargy, inattentiveness). It is very common in hospitalized patients, with 60 to 80% of mechanically ventilated patients and 20 to 50% of patients with a lower severity of illness developing delirium at some point during their hospitalization. For patients at risk of postoperative delirium, benzodiazepines and antihistamines should be avoided, as these medications could exacerbate the symptoms. Reference(s) 1. Card E, Pandharipande P, Tomes C, et al. Emergence from general anaesthesia and evolution of delirium signs in the post-anesthesia care unit. Br J Anaesth. 115(3):411-7, September 2015. 2. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 215(4):453-66, October 2012. 3. Moskowitz EE, Overbey DM, Jones TS, et al. Post-operative delirium is associated with increased 5- year mortality. Am J Surg. 214(6):1036-1038, December 2017.

Answer 137

The correct response is Option B. Adipose-derived stems cells (ADSC) have had extensive study in vitro and in vivo because there are ready sources of them from adult patients, which bypasses many ethical and regulatory issues of embryonic stem cells. ADSC have both direct structural and paracrine roles in wound healing. They can directly differentiate into keratinocytes, endothelial cells, and dermal fibroblasts. ADSCs, through paracrine phenomena, are modulators of the inflammatory environment of the wound healing milieu but are not involved in the immediate chemotaxis during the inflammatory period nor do they function as a scaffold during the proliferative phase. Lysyl oxidase is the extracellular enzyme responsible for final alignment of collagen fibrils. Presence of skin adnexa such as hair follicles and sweat glands are hallmarks of scarless, fetal healing. Hair follicle formation typically only occurs during embryonic development and involves interaction of ectodermal and mesenchymal cells influenced by signaling pathways including Wnt/b-catenin and BMPl but not ADSCs. Reference(s) 1. Hassan WU, Greiser U, Wang W. Role of adipose-derived stem cells in wound healing. Wound Repair Regen. 2014 May-Jun;22(3):313-325. 2. Philips BJ, Marra KG, Rubin JP. Healing of grafted adipose tissue: current clinical applications of adipose-derived stem cells for breast and face reconstruction. Wound Repair Regen. 2014 May;22 Suppl 1:11-13. 3. Takeo M, Lee W and Ito M. Wound healing and skin regeneration. Cold Spring Harb Perspect Med. 2015:5:a02367:1-12.

Answer 138

The correct response is Option D. Atrial fibrillation manifests as irregularly irregular QRS complexes without P waves on ECG. Postoperative atrial fibrillation (POAF) is multifactorial in origin, and occurs in 5 to 10% of patients undergoing non-cardiothoracic surgery. In the largest trial to date comparing rate versus rhythm control (Atrial Fibrillation Follow-Up Investigation of Rhythm Management [AFFIRM]), rhythm control was associated with a greater number of hospitalizations, torsades de pointes, pulmonary events, gastrointestinal events, bradycardia, and QT prolongation events. Rate control is the treatment strategy of choice, with the goal of 80 to 100 bpm. Metoprolol is the preferred beta blocking agent due to its efficient conversion between IV and oral routes, low cost, and clinician familiarity. Diltiazem (nondihydropyridine calcium channel blocker) is a second-line therapy, and is intended for use if first-line therapy is ineffective at rate control at maximum doses or the first-line therapy is contraindicated. Digoxin is considered when other options are ineffective or contraindicated because of its narrow therapeutic window. Amiodarone has both beta-blocking and calcium channel blocking properties in addition to its antiarrythmic effects. Amiodarone can be used in patients with decreased ejection fractions. It is associated with acute pulmonary toxicity. Test Review Report Printed on: 2/26/2023 Question 119 of 144 Reference(s) 1. Danelich IM, Lose JM, Wright SS, et al. Practical management of postoperative atrial fibrillation after noncardiac surgery. J Am Coll Surg. 2014;219(3):831-841. 2. Kanji S, Williamson DR, Yaghchi BM, Albert M, McIntyre L; Canadian Critical Care Trials Group. Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients. J Crit Care. 2012;27(3):326.e1-326.e8. 3. Seguin P, Signouret T, Laviolle B, Branger B, Mallédant Y. Incidence and risk factors of atrial fibrillation in a surgical intensive care unit. Crit Care Med. 2004;32(3):722-726.

Answer 139

The correct response is Option D. All of the deficiencies listed are common in massive weight loss patients who present for plastic surgery. It is critical to identify that this woman is exhibiting signs of Wernicke encephalopathy (WE). It is characterized by the classic triad of ataxia, eye movement disorders, and mental status change. This acute neuropsychiatric syndrome results from a deficiency of thiamine. The total number of reported post-bariatric WE cases is growing, and it is important to keep this in the differential for plastic surgery patients. Vomiting is the most frequently described presenting symptom. However, the most profound characteristic of WE identified is ataxia, which often presents itself as gait abnormalities up to the full inability to walk or move. Altered mental status manifests as delirium, confusion, and problems in alertness or cognition. Lastly, eye movement disorders, including nystagmus and ophthalmoplegia, resulting from extraocular muscle weakness, are seen in the majority of cases as well. Adequate and timely thiamine treatment in patients who have undergone bariatric surgery is required to prevent the development of WE, which is a rare but severe complication. Calcium deficiency presents more slowly, due to decreased absorption, and results in bone density loss, causing an increased risk for fracture. Folate deficiency also presents slowly secondary to decreased absorption. It results in anemia and can cause abnormal embryogenesis in pregnant women. Iron deficiency also presents slowly from a lack of adequate absorption and clinically causes anemia. Vitamin B12 requires stomach acid for it to be released from dietary protein. With a paucity of gastric tissue to produce that acid, this vitamin is also frequently deficient, resulting in a microcytic anemia. REFERENCES: 1. Bossert RP, Rubin JP. Evaluation of the weight loss patient presenting for plastic surgery consultation. Plast Reconstr Surg. 2012;130(6):1361-1369. doi:10.1097/PRS.0b013e318273e5f5 2. Oudman E, Wijnia JW, van Dam M, Biter LU, Postma A. Preventing wernicke encephalopathy after bariatric surgery. Obes Surg. 2018;28(7):2060-2068. doi:10.1007/s11695-018-3262-4 3. Sebastian JL, V JM, Tang LW, Rubin JP. Thiamine deficiency in a gastric bypass patient leading to acute neurologic compromise after plastic surgery. Surg Obes Relat Dis. 2010;6(1):105-106. doi:10.1016/j.soard.2009.04.017

Answer 140

The correct response is Option B. Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma that has been increasingly recognized as a serious, albeit uncommon, complication associated with the use of textured breast implants. Since the initial case report in 1996, there have been continually increasing reported cases of this rare malignancy and according to the most recent data available, the lifetime risk of association between breast implants and BIA-ALCL is between 1 in 1000 to 1 in 30,000 with the ASPS recognizing nearly 200 cases in the US and nearly 500 cases worldwide. BIA-ALCL patients typically present with a spontaneously occurring periprosthetic fluid collection or capsule-associated mass approximately 10 years following implantation of the breast implant. To date, all cases have had some association with a textured device. Initial workup includes ultrasound for evaluation of a periprosthetic fluid collection or mass. Periprosthetic fluid collections should undergo fine-needle aspiration in the clinic or ultrasound-guided aspiration by interventional radiology if there is concern for trauma to the implant while masses require tissue biopsy. Specimens should be sent for cytology with immunohistochemistry and flow cytometry for T-cell markers, specifically CD30 cell surface protein. A recent systematic review revealed that 66% of BIA-ALCL patients presented with isolated late-onset seroma while only 8% presented with an isolated new breast mass. National Comprehensive Cancer Network (NCCN) guidelines for treatment of BIA-ALCL recommend complete removal of the lymphoma (fluid and/or mass), complete capsulectomy, and removal of the implant. More advanced disease may require chemotherapy, radiotherapy, and/or lymph node dissection. Although some surgeons advocate removal of the contralateral breast implant as approximately 4.6% of cases have demonstrated incidental lymphoma in the contralateral breast, this recommendation is controversial. The official NCCN guidelines for treatment only recommend consideration of contralateral breast implant removal but this is not mandated. Reference(s) 1. Clemens MW, Horwitz SM. NCCN Consensus Guidelines for the Diagnosis and Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma. Aesthet Surg J. 2017 Mar 1;37(3):285-289. 2. Leberfinger AN, Behar BJ, Williams NC, et al. Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Systematic Review. JAMA Surg. 2017;152(12): 1161-1168.

Answer 141

The correct response is Option D. In collaboration with the Centers for Medicare &Medicaid Services (CMS), The Joint Commission developed the following recommendations: - All health care organizations should have policies prohibiting the use of unsecured text messaging—that is, short message service (SMS) text messaging from a personal mobile device—for communicating protected health information. Organizations are expected to incorporate limitations on the use of unsecured text messaging in their policies protecting the privacy of health information. This policy should be routinely discussed during orientation of all practitioners and staff working in the facility. - Computerized provider order entry (CPOE) should be the preferred method for submitting orders as it Test Review Report Printed on: 2/26/2023 Question 72 of 144 allows providers to directly enter orders into the electronic health record (EHR). CPOE helps ensure accuracy and allows the provider to view and respond to clinical decision support (CDS) recommendations and alerts. - In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable and it should allow for a real-time, synchronous clarification and confirmation of the order as it is given by the ordering practitioner. - HIPAA compliance can also be maintained by deidentifying information before it is transmitted. Under the Safe Harbor Method, health information is no longer linked to an individual when 18 types of patient identifiers have been removed. Reference(s) 1. Text Messaging and Protected Health Information: What Is Permitted? Drolet BC1. JAMA. 2017 Jun 20;317(23):2369-2370. doi: 10.1001/jama.2017.5646. 2. What is accreditation? The Joint Commission website. https://www.jointcommission.org/accreditation/accreditation_main.aspx. February 26, 2019.

Answer 142

The correct response is Option D. This patient is experiencing nephrotoxicity and chronic kidney disease (CKD) from tacrolimus. Calcineurin inhibitor nephrotoxicity is a well-known phenomenon posttransplantation, and close monitoring of kidney function is essential. There are multiple described pathways of kidney damage secondary to calcineurin inhibitors including irreversible damage to all compartments of the kidney (glomeruli, arterioles, and tubule-interstitium). Krezdorn et al. evaluated 99 recipients of facial or extremity transplantation and concluded that kidney dysfunction represents a major complication posttransplantation in vascularized composite allografts and recommends pretransplant, peritransplant, and posttransplant strategies to reduce kidney damage. These include identifying patients at risk for CKD. Pretransplantation recommendations include treating existing renal conditions, avoiding hypotension and hypertension, limiting nephrotoxic drugs, limiting intravenous contrast, and avoiding hypovolemia. Peritransplantation recommendations include minimizing use of nephrotoxic agents, avoiding hypovolemia, and limiting ischemia time. Postoperative recommendations include minimizing tacrolimus exposure including reduction of trough levels, treating hypertension, treating hyperglycemia, treating dyslipidemia avoiding intravenous contrast, and limiting potentially nephrotoxic drugs such as nonsteroidal anti-inflammatory drugs. Therefore, in this patient, tacrolimus troughs should be reduced. Initiation of oral corticosteroids is not appropriate. The patient should remain on antihypertensive and dyslipidemia drugs. Reference(s) 1. Krezdorn N, Tasigiorgos S, Wo L, et al. Kidney dysfunction after vascularized composite allotransplantation. Transplant Direct. 2018 Jun 1;4(7):e362. 2. Naesens M, Kuypers DRJ, Sarwal M. Calcineurin inhibitor nephrotoxicity. Clin J Am Soc Nephrol. 2009 Feb;4(2):481-508.

Answer 143

The correct response is Option E. Understanding the potential complications after facial resurfacing is important to know, especially those complications that occur in patients with darker skin. Traditionally, the Fitzpatrick Scale is used to assess skin tone and risk for both the development of skin cancer and also response to post-treatment pigmentation issues. Herpetic lesions can develop in individuals with any skin color after laser treatment. While hyperemia can develop in any patient after laser resurfacing, post-inflammatory hyperpigmentation is of greatest concern in those with darker skin color, especially in an individual like the one described, who has a Fitzpatrick Type IV skin type. While there are different ways to mitigate the issue of pigmentation both before and after treatment, it is a risk factor that should be discussed with patients undergoing skin resurfacing, especially in darker skin individuals. Laser therapy has been used to treat hypertrophic scars and freckles. Reference(s) 1. Sanniec K, Afrooz PN, Burns AJ. Long-Term Assessment of Perioral Rhytide Correction with Erbium: YAG Laser Resurfacing. Plast Reconstr Surg. 2019;143(1):64-74. 2. Patel SP, Nguyen HV, Mannschreck D, Redett RJ, Puttgen KB, Stewart FD. Fractional CO2 Laser Treatment Outcomes for Pediatric Hypertrophic Burn Scars. J Burn Care Res. 2019 Jun 21;40(4):386- 391. 3. Kung KY1, Shek SY1, Yeung CK1, Chan HH1,2. Evaluation of the safety and efficacy of the dual wavelength picosecond laser for the treatment of benign pigmented lesions in Asians? Lasers Surg Med 2019 Jan;51(1):14-22. Epub 2018 Oct 25.

Answer 144

Correct answer is option B. Among familial breast cancers, 5 to 10% are considered to be hereditary. These familial breast cancers are linked to specific mutations on a cancer susceptibility gene. The breast cancer susceptibility genes (BRCA) belong to a class of genes known as tumor suppressors. In normal cells, BRCA1 and BRCA2 genes stabilize the DNA and prevent uncontrolled cell growth. A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a mutation on BRCA1 or BRCA2 genes. BRCA1- and BRCA2-related breast cancers occur in younger women and are often associated with estrogen receptor-negative tumors.

Answer 145

The correct response is Option C. Omphalocele (OC) and gastroschisis (GS) represent the two most common congenital abdominal wall defects, with a prevalence of approximately 3 to 4 per 10,000 live births/fetal deaths/stillbirths/pregnancy terminations each. Precise pathoetiologies are unclear, but developmental pathways and characteristics at the time of birth are notably distinct. OC is characteristically a midline partial-thickness abdominal wall defect covered by a membrane of amnion and peritoneum occurring within the umbilical ring and containing abdominal contents. GS is characteristically a full-thickness, paraumbilical abdominal wall defect associated with eviscerated bowel. Both OC and GS are associated with elevated maternal serum alpha fetoprotein (MSAFP). For comparison, MSAFP values average twice that recorded in pregnancies with open spina bifida, and similar to values recorded with anencephaly. An elevated MSAFP is an indication for thorough ultrasound examination of the fetus for anatomical abnormalities. Multiple chromosomal abnormalities have been associated with at least 60% OC cases, including trisomy -18, -13, -21, Turner syndrome, and triploidy. By contrast, GS is associated with abnormal karyotype in about 1% of cases, usually in the setting of other congenital abnormalities. The definite treatment of both OC and GS is surgical once optimal resuscitation is achieved. Primary closure is associated with better survival rates if it can be achieved without compromise of intestinal blood flow or other hemodynamic or respiratory embarrassment. Large defects are frequently managed with temporary abdominal silos which are gradually reduced over the course of days to weeks in a form of visceral tissue expansion followed by delayed abdominal wall closure. The long-term outcome in isolated cases of OC and GS are generally good, although they can be associated with gut motility impairment, gastroesophageal reflux, ventral hernias, and late obstructive episodes. Constriction rings with limb and digital amputations are found in amniotic band sequence but are not characteristic of OC or GS. GS is not characteristically associated with hypoglycemia, macrosomia, or macroglossia. Reference(s) 1. Stephenson CD, Lockwood CJ, MacKenzie AP. Omphalocele. Wilkins-Haug L &Levine D, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed January 1, 2018.

Answer 146

The correct response is Option C. A cleft palate and craniofacial team accredited by the American Cleft Palate-Craniofacial Association (ACPA) must have, as a minimum core, health care providers from the speech-language pathology, surgery, and orthodontics specialties. These providers must participate in team meetings as appropriate for specific patient needs. The participation of these individuals should be documented in each patient’s team reports. The ACPA team must also have access to professionals in the disciplines of psychology, social work, audiology, genetics, general and pediatric dentistry, otolaryngology, and pediatrics/primary care. Test Review Report Printed on: 2/26/2023 Question 128 of 144 However, these providers are not considered core providers. Reference(s) 1. Alleyne B, Okada HC, Leuchtag RM, Rowe DJ, Soltanian HT, Becker DB, Lakin GE. Cleft and Craniofacial Clinic Formats in the United States: National and Institutional Survey. J Craniofac Surg. 2017;28(3):693-695. 2. Standards of Approval for Team Care. ACPA. https://acpa-cpf.org/team-care/standardscat/standardsof- approval-for-team-care/. Accessed January 29, 2020.

Answer 147

The correct response is Option C. Brain death is a permanent and irreversible state. There will be no return of cerebral or cortical function. Hypothermia is not required for brain death examination; it needs to be reversed for at least 4 hours (up to 24 hours) to establish brain death. Neuromuscular blockade must be reversed and patient must have normal peripheral muscle response to peripheral nerve stimulus in order to undergo brain death examination. Brain death examination includes elicitation of brain reflexes, which can be muted by neuromuscular blockade. Anoxic brain injury must be observed for at least 24 hours prior to beginning brain death examination. Cause or reason for brain death must be established prior to beginning brain death examination. Absence of deep tendon reflexes is not required to initiate the examination. Reference(s) 1. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. American Academy of Neurology. Neurology. 2010;74(23):1911. 2. Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1995;45(5):1012.

Answer 148

The correct response is Option A. This patient has androgenic alopecia. Androgenetic alopecia, or patterned alopecia, is the most common form of hair loss in both men and women and is characterized by a progressive loss of hair diameter, length, and pigmentation. The genetic inheritance of androgenetic alopecia is well known, although the causative genes have yet to be elucidated. In genetically predisposed males and females, androgenetic alopecia is caused by progressive shortening of the anagen stage and an increase in the number of hair follicles in telogen. Follicular unit hair transplantation is the gold standard, because it preserves the natural architecture of the hair units and gives natural results The follicular unit (FU) was first described by Headington in 1984 and was shown to include 1 to 4 terminal follicles, 1 or 2 vellus follicles, and perifollicular vascular and neural plexi, all surrounded by concentric layers of collagen fibers. Seager later showed that when single-hair micrografts were generated by breaking up larger FUs, their growth was less than when the FUs were kept intact, supporting the concept of the FU as a physiologic entity, rather than just an anatomic one. This gave rise to the FU transplant era, in which grafts are single FU or multi FU (2–3 FU). It was found that peripheral areas such as the hairline naturally have 1- and 2-hair FUs, whereas the more central regions have more 3- and 4-hair FUs. "Micrografts” (1–2 hairs) and “minigrafts” (3–6 hairs) have been used in the past for hair transplantation but are not quite as effective as follicular unit transplantion and produce less natural appearing results. Tissue expansion and scalp flaps are generally reserved for scalp burn wounds or wounds of traumatic nature with significant hair loss. They generally leave long scars and may require multiple stages and prolonged recovery which would likely not be acceptable for this patient. Reference(s) 1. Gordon KA, Tosti A. Alopecia: evaluation and treatment. Clin Cosmet Investig Dermatol. 2011;4:101- 106. 2. Jandali S, Low DW. From surgery to pharmacology to gene therapy: the past, present, and future of hair restoration. Ann Plast Surg. 2010 Oct;65(4):437-442.

Answer 149

carriers and approximately 49% in BRCA2 mutation carriers. The risk for developing cancer and associated mortality decreases with age. For example, a 55-year-old woman has an approximately 35% risk for developing breast cancer and a 6% mortality, compared with a 25- year-old woman who has a 65% chance of developing breast cancer with a 14% mortality. This being said, it is important to consider to benefits of prophylactic mastectomies beyond mortality, including patient-specific factors such as the desire to decrease screening and seeking peace of mind. REFERENCES: 1. Giannakeas V, Narod SA. The expected benefit of preventive mastectomy on breast cancer incidence and mortality in BRCA mutation carriers, by age at mastectomy. Breast Cancer Res Treat. 2018;167:263-267. doi: 10.1007/s10549-017-4476-1 2. Ludwig KK, Neuner J, Butler A, Geurts JL, Kong AL. Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review. Am J Surg. 2016;212:660-669. doi: 10.1016/j.amjsurg.2016.06.010 3. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol. 2007;25(11):1329-1333. doi:10.1200/JCO.2006.09.1066

Answer 150

The correct response is Option E. Radial longitudinal deficiency may present as an isolated condition but is often associated with an underlying syndrome. The frequency of association with a syndrome has been reported to range from 33 to 44%. Hypoplastic thumb can be present in isolation or in combination with any radial deficiency. Hypoplastic thumb is the second most frequently encountered thumb anomaly. Commonly associated syndromes with radial longitudinal deficiencies include Holt-Oram, Fanconi anemia, thrombocytopeniaabsent radius, and VACTERL association (a sporadic collection of anomalies consisting of the vertebral deformity, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal agenesis, and limb deformities). Holt-Oram is a syndrome passed in an autosomal dominant fashion and presents with both radial longitudinal deficiency and a cardiac anomaly, most commonly a ventricular septal defect. Both thrombocytopenia-absent radius syndrome and Fanconi anemia are transmitted in an autosomal recessive pattern. Thrombocytopenia absent radius syndrome consists of thrombocytopenia that manifests itself during infancy and can be fatal; however, it usually resolves spontaneously with age. In contrast, Fanconi anemia presents after 3 years of life, commonly around 8 to 9 years, with aplastic anemia. Historically this condition was fatal, with no method of altering the course of the anemia. Recently, however, bone marrow transplants have been performed successfully to treat the anemia and prolong the life expectancy of these patients. Lastly, the final condition seen commonly with radial longitudinal deficiency is VACTERL association. Anorectal malformations (ARM) often co-occur with upper limb anomalies, mainly of pre-axial origin. ARM patients with a major upper limb anomaly—with or without other congenital anomalies—have a twofold greater chance of a genetic disorder than have nonisolated ARM patients without upper limb anomalies. Not all upper limb anomalies in ARM patients are part of the VACTERL association. Fetal alcohol syndrome causes brain damage and growth problems, however it is not associated with thumb hypoplasia. Reference(s) 1. Oda T, Pushman AG, Chung KC. Treatment of Common Congenital Hand Conditions. Plast Reconstr Surg. 2010;126:121e-133e. 2. van den Hondel D, Wijers CH, van Bever Y. Patients with anorectal malformation and upper limb anomalies: genetic evaluation is warranted. Eur J Pediatr. 2016;175:489-97. 3. Wall LB, Ezaki M, Oishi SN. Management of Congenital Radial Longitudinal Deficiency: Controversies and Current Concepts. Plast Reconstr Surg. 2013;132:122-128.

Answer 151

The correct response is Option A. There is level II evidence provided by Winocour et al in 2017 by querying the Cosmetassure database of more than 129,000 patients that body procedures such as lower body lift and abdominoplasty have higher risk than breast, liposuction, or facial procedures. More specific level II evidence about abdominoplasty and venothromboembolism (VTE) was published in 2018 Keyes et al. after querying the Internet Based Quality Assurance Program database, that BMI greater than 25 kg/m2 and age greater than 40 were independent predictors of VTE risk. Most of the patients in this study who had VTE had preoperative Caprini scores of 2 to 8, which would not typically make these patients recipients of chemoprophylaxis against VTE. Although operating in the area of the calf muscles seems like a good source of potential VTE, there is no reference to calf implants in these large database studies, and a PubMed search of VTE and calf implants returns no literature. For a generalized summary of risk stratification, consult the Pannucci et al. article. Reference(s) 1. Pannucci CJ, Swistun L, MacDonald JK, et al. Individualized Venous Thromboembolism Risk Stratification Using the 2005 Caprini Score to Identify the Benefits and Harms of Chemoprophylaxis in Surgical Patients: A Meta-analysis. Ann Surg. 2017 Jun;265(6):1094-1103. 2. Winocour J, Gupta V, Kaoutzanis C, et al. Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients. Aesthet Surg J. 2017 Mar 1;37(3):337-349. 3. Keyes GR, Singer R, Iverson RE, Nahai F. Incidence and Predictors of Venous Thromboembolism in Abdominoplasty. Aesthet Surg J. 2018 Feb 17;38(2):162-173.

Answer 152

The correct response is Option B. 5-Fluorouracil has been used as an effective and safe treatment for hypertrophic scar and keloid injections. Studies have largely shown 5-fluorouracil to be safe and efficacious with a comparable or lower recurrence rate when compared with intralesional steroid injections. The mechanism of action is inhibition of fibroblast proliferation with a decrease in collagen synthesis, thereby causing scar degradation. Intralesional steroid injections decrease leukocyte and monocyte migration and phagocytosis, and laser therapy acts by protein denaturation and tissue coagulation, as well as by coagulation in microthermal zones and preserving the integrity of the epidermis. Localized hypoxia and increased collagenase activity is associated with pressure therapy. REFERENCES: 1. Shah VV, Aldahan AS, Mlacker S, Alsaidan M, Samarkandy S, Nouri K. 5-Fluorouracil in the treatment of keloids and hypertrophic scars: a comprehensive review of the literature. Dermatol Ther (Heidelb). 2016;6(2):169-183. doi:10.1007/s13555-016-0118-5 2. Ibrahim A, Chalhoub RS. 5-fu for problematic scarring: a review of the literature. Ann Burns Fire Disasters. 2018;31(2):133-137. 3. Bijlard E, Steltenpool S, Niessen FB. Intralesional 5-fluorouracil in keloid treatment: a systematic review. Acta Derm Venereol. 2015;95(7):778-82. doi: 10.2340/00015555-2106 4. Li K, Nicoli F, Cui C, et al. Treatment of hypertrophic scars and keloids using an intralesional 1470 nm bare-fibre diode laser: a novel efficient minimally-invasive technique. Sci Rep. 2020;10:21694. doi: 10.1038/s41598-020-78738-9 Havel M, Betz CS, Leunig A, Sroka R. Diode laser-induced tissue effects: in vitro tissue model study and in vivo evaluation of wound healing following non-contact application. Lasers Surg Med. 2014;46(6):449-55. doi: 10.1002/lsm.22256 6. Morelli Coppola M, Salzillo R, Segreto F, Persichetti P. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives. Clin Cosmet Investig Dermatol. 2018;11:387-396. doi: 10.2147/CCID.S133672 7. Acosta S, Ureta E, Yañez R, Oliva N, Searle S, Guerra C. Effectiveness of intralesional triamcinolone in the treatment of keloids in children. Pediatr Dermatol. 2016;33(1):75-9. doi: 10.1111/pde.12746 8. Hackert I, Aschoff R, Sebastian G. Keloide und ihre Therapie [The treatment of keloids]. Hautarzt. 2003;54(10):1003-1015; quiz 1016-1017. doi: 10.1007/s00105-003-0573-7 9. Mustoe TA, Cooter RD, Gold MH, et al. International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560-571. doi: 10.1097/00006534-200208000-00031

Answer 153

The correct response is Option D. For the noninfected, nonischemic, neuropathic diabetic foot ulcer, pressure reduction through offloading measures is of critical importance. The International Working Group on the Diabetic Foot strongly recommends the use of a non-removable knee-high offloading device as first line treatment. This is supported by high-level quality evidence and multiple studies. These non-removable knee-high offloading devices include the use of total contact casts and non-removable knee-high walker devices. Removable offloading devices, such as custom molded and other therapeutic shoe inserts, as well as multiple therapeutic shoe designs, have consistently been shown to be less effective in healing chronic wounds than non-removable devices. This may be largely because of patient non-compliance. Surgical interventions that may decrease plantar pressures, such as Achilles tendon lengthening, metatarsal head resection, and metatarsal-phalangeal joint arthroplasty, may be of less utility and should only be considered when nonsurgical methods have failed. Hyperbaric oxygen therapy may play a significant role in Wagner grade III (bone involvement) or greater diabetic foot wounds in terms of increased healing and Test Review Report Printed on: 2/26/2023 Question 131 of 144 decreased amputation rate; however, evidence is lacking to suggest its routine use in soft-tissueonly diabetic foot ulcers. Reference(s) 1. Bus SA. The role of pressure offloading on diabetic foot ulcer healing and prevention of recurrence. Plast Reconstr Surg. 2016;138(suppl 3):179S-187S. 2. Bus SA, Armstrong DG, Gooday C, et al; International Working Group on the Diabetic Foot. IWGDF guideline on offloading foot ulcers in persons with diabetes. https://iwgdfguidelines.org/wpcontent/ uploads/2019/05/03-IWGDF-offloading-guideline-2019.pdf. Published 2019. Accessed January 8, 2020. 3. Huang ET, Mansouri J, Murad MH et al; UHMS CPG Oversight Committee. A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. Undersea Hyperb Med. 2015;42(3):205-247.

Answer 154

The correct response is Option D. Social determinants of health include where a person resides, what exposures are present, what diet is eaten, how much stress is present, and other lifetime experiences. Social determinants of health affect who gets disease and how well they can be cared for when they have disease. According to the 2020 cancer statistics, death from female breast cancer has declined overall by 40% in the United States since 1989. The 2017 breast cancer statistics look at breast cancer in a state-by-state fashion demonstrating that those gains in survival have not been uniformly spread among the populations, with non-Hispanic African American women suffering higher death rates by age group, staging, and oncotyping groups. While there are no data to discuss why non-Hispanic African American women tend to develop cancer younger or develop more “triple negative” breast cancers, there has been evidence presented in the 2017 breast cancer statistics that better access to care may improve the stage at diagnosis. In seven states, the mortality rates were statistically the same. In three of those states—Massachusetts (an early state to establish mandatory health insurance), Connecticut, and Delaware—there were sufficient cohort numbers of non-Hispanic African American women with an in situ diagnosis, which is used as a proxy for access to screening mammography. In the four other states, there was statistical equivalence, but they were underpowered. The implication of these data is that better access to mammography/care lowers mortality for non-Hispanic African American women with breast cancer. These studies did not address affluence, but they did rule out age as a factor.

Answer 155

The correct response is Option A. Traumatic placental injury can cause maternal-fetal hemorrhage in 10 to 30% of pregnant trauma patients. The majority of these are subclinical, without measurable effects to the fetus. However, as little as 0.001 milliliter of Rh-positive fetal blood can cause alloimmunization of an Rh-negative mother. Therefore, determination of Rh status is mandatory for all pregnant trauma patients and all Rh-negative of these should be given anti-D immune globulin (IgG). A single dose administered within 72 hours from injury may provide protection against sensitization in up to 90% of the cases. Higher doses may be necessary if it is determined that transplacental hemorrhage was in excess of 30 milliliters. Simply discharging the patient for a future obstetric follow up is not acceptable. At least 4 hours of electronic fetal monitoring should be provided to all pregnant trauma patients with >= 23 weeks gestation. Internal electronic fetal heart rate monitoring (with an electrode in the scalp) is not indicated at this time. Instead, external monitoring could be done using a dedicated Doppler ultrasound device. MRI of the abdomen/pelvis and diagnostic peritoneal lavage are not indicated in the scenario described. Radiographic imaging generally indicated for trauma evaluation, including abdominal computed tomography, should not be deferred or delayed due to concerns of fetal exposure to radiation. Ultrasonography (FAST) should be part of the secondary survey in all pregnant trauma patients. Reference(s) 1. American College of Surgeons' Committee on Trauma. Advanced Trauma Life Support (ATLS). 9th ed. Chicago, IL: American College of Surgeons; 2013. 2. Goodwin TM, Breen MT. Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma. Am J Obstet Gynecol. 1990 Mar;162(3):665-671.

Answer 156

The correct response is Option B. The effects of corticosteroids on wound healing have been extensively studied. A single perioperative dose has not been associated with wound healing problems or complications. There is, however, a mild increase in glycemia, even in patients without diabetes. The long-term use of corticosteroids has been associated with increased wound complications in susceptible individuals. It depends on the dose and duration of corticosteroid treatment. The use of vitamin A, not E, has been shown to counteract the negative effects of corticosteroids on wound healing. Reference(s) 1. Polderman JA, Farhang-Razi V, Van Dieren S, et al. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev. 2018;8:CD011940.

Answer 157

The correct response is Option A. Malignant hyperthermia is an autosomal dominant trait, thus, based on Mendelian Genetics, if one parent has a confirmed diagnosis, their biological children will have a 50% chance of inheritance of the affected gene. Malignant hyperthermia is a potentially life-threatening condition. Individuals with this inherited myopathy present with a hypermetabolic reaction to potent volatile anesthetic gases, such as halothane, enflurane, isoflurane, sevoflurane, and desflurane. Individuals are also susceptible to the depolarizing muscle relaxant succinylcholine. The preoperative workup for an individual with suspected malignant hyperthermia is the Caffeine-Halothane Contracture Test. In this test, a piece of skeletal muscle is excised, and its contractile properties are determined when exposed to the ryanodine receptor agonist halothane and/or caffeine. Abnormal contractile activity is indicative of susceptibility. Based on basic Mendelian Genetics, the risk of inheritance is 50%. Given this pattern of inheritance, x-linked, autosomal and mitochondrial inheritance are incorrect answers. Reference(s) 1. Gurunluoglu R, Swanson JA, Haeck PC, et al. Evidence-based patient safety advisory: malignant hyperthermia. Plast Reconstr Surg. 2009;124 (Suppl.);68S-81S. 2. Riazi S, Kraeva N, Hopkins, PM. Updated guide for the management of malignant hyperthermia. Can J Anaesth. 2018 Jun;65(6):709-721. doi: 10.1007/s12630-018-1108-0. Epub 2018 Mar 29.

Answer 158

The correct response is Option E. A physician will obtain a higher number of relative value units (RVUs) for a specific medical procedure by performing it in a "non-facility" or "office" setting, such as a physician’s office, compared with performing it Test Review Report Printed on: 2/26/2023 Question 106 of 144 1. 2. 3. in a "facility" setting (hospital, ambulatory surgical center, community mental health center, etc.), according to the fee schedule by the Centers for Medicare &Medicaid Services (CMS). Physician services are described by CPT codes and Healthcare Common Procedure Coding System codes. CMS determines the number of RVUs assigned for each physician service by adding three subcategories of RVUs: Physician Work RVUs: reflect the relative time and intensity associated with furnishing a specific medical service. It may reflect not only the "intra-service" time, but also the time needed to prepare for the service beforehand and to document it afterwards. Practice Expense RVUs: reflect the costs of maintaining a practice (such as renting office space, buying supplies and equipment, and staff costs). Malpractice RVUs: reflect the costs of medical liability insurance. When a physician provides a service in a facility (eg, hospital, ambulatory surgical center), the costs of clinical personnel, equipment, and supplies are incurred by the facility, not the physician’s practice. Therefore, CMS assigns to these services a "facility-based" Practice Expense RVU amount that excludes the practice expenses and is typically lower than the "office-based" Practice Expense RVUs for the same service. CMS uses a formula to determine payment amounts for each covered medical service. First, each of the three RVU subcategories is multiplied by the corresponding geographic practice cost indices, which are designed to account for geographic variations in the costs of practicing medicine in different areas of the country. Then the three adjusted RVU subcategories are added together and multiplied by a conversion factor in dollars. Reference(s) 1. Medicare Physician Fee Schedule. Centers for Medicare &Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/MedcrePhysFeeSchedfctsht.pdf. Published February 2017. Accessed January 23, 2020. 2. Revised and Clarified Place of Service (POS) Coding Instructions. Centers for Medicare &Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7631.pdf. Published December 18, 2012. Accessed January 23, 2020.

Answer 159

The correct answer is option C. This patient underwent liposuction and autologous fat grafting for gluteal augmentation and now presents with signs and symptoms consistent with microscopic fat embolism syndrome. While further laboratory and imaging workup is pending as an inpatient, cardiopulmonary supportive care measures should be instituted immediately. Fat embolism syndrome occurs when fat emboli enter the bloodstream and systemic circulation. Large particles of fat can directly occlude critical blood vessels, leading to acute cardiorespiratory failure and often death (macroscopic fat embolism). In contrast, smaller emboli that do not directly occlude critical vasculature incite an inflammatory response due to hydrolysis by lipase enzymes and release of free fatty acids that are toxic to alveolar and endothelial cells (microscopic fat embolism). The presentation of macroscopic fat embolism occurs intraoperatively and necessitates immediate transfer to a tertiary care center for intensive care and any hope of patient survival. The signs and symptoms of a microscopic fat embolus syndrome will usually present 48 to 72 hours after surgery as the process of inflammation and alveolar edema develop. The treatment is supportive and consists of rehydration, oxygenation/mechanical ventilation, and maintenance of blood pressure, as indicated. Infusion of a lipid emulsion would be indicated if lidocaine toxicity was suspected; however, the patient does not have the hallmark neurologic presentation of lidocaine toxicity (dizziness, light-headedness, circumoral numbness, tinnitus, etc.), and her presentation falls outside of the peak of lidocaine absorption from liposuction. In the absence of other signs of infection, antibiotics would not be indicated. Heparin anticoagulation therapy is also not indicated as the first-line treatment in this situation. Reference(s) Cárdenas-Camarena L, Durán H, Robles-Cervantes JA, Bayter-Marin JE. Critical differences between microscopic (MIFE) and macroscopic (MAFE) fat embolism during liposuction and gluteal lipoinjection. Plast Reconstr Surg. 2018;141(4):880-890. doi:10.1097/PRS.0000000000004219 Habashi NM, Andrews PL, Scalea TM. Therapeutic aspects of fat embolism syndrome [published correction appears in Injury. 2007;38(10):1224]. Injury. 2006;37(suppl 4):S68-S73 . doi:10.1016/j.injury.2006.08.042 Safran T, Abi-Rafeh J, Alhalabi B, Davison PG. The potential role of corticosteroid prophylaxis for the prevention of microscopic fat embolism syndrome in gluteal augmentation. Aesthet Surg J. 2020;40(1):78-89. doi:10.1093/asj/sjz166

Answer 160

The correct answer is option C. “Of those listed, the most appropriate pre- and intraoperative dosages of cefazolin for this patient is an initial intravenous dose of 2 g followed by redosing every 4 hours. According to current guidelines by the Centers for Disease Control and Prevention, dosing of prophylactic antimicrobials should be adjusted based on patient weight. Recommended doses for cefazolin are: • 30 mg/kg for pediatric patients • 1 g for adult patients with weight less than 176 lb. (80 kg) • 2 g for adult patients with weight greater than or equal to 176 lb. (80 kg) and less than 264.6 lb. (120 kg) • 3 g for adult patients with weight greater than or equal to 264.6 lb. (120 kg) Redosing of the antibiotic agent should occur at intervals of 2 half-lives, measured from the time of initial administration. Shorter redosing intervals should be considered when excessive blood loss occurs. Longer intervals should be considered for renal impairment. The half-life of cefazolin in adults with normal renal function is approximately 1.8 hours (mostly ranging from 1.2 to 2.2 hours). Content Description: Surgical site infections and prophylaxis (10.E.07) ECOSystem Description: Milestone Description: Patient Care 7: Wound, Burn, and Infection Exam Year: 2024 Reference(s) 1. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904 2. Karamian BA, Toci GR, Lambrechts MJ, et al. Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection. Spine J. 2022;22(9):1442-1450. doi:10.1016/j.spinee.2022.05.018 3. Dorn C, Petroff D, Stoelzel M, et al. Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid. J Antimicrob Chemother. 2021;76(8):2114-2120. doi:10.1093/jac/dkab143”

Answer 161

The correct answer is option C. “While antibiotic prophylaxis in orthopedic, cardiac, and other procedures is supported by robust scientific evidence, data to support routine use specifically in plastic surgery is lacking. There is a general consensus for administering an intravenous dose of prophylactic antibiotic in clean breast surgery to decrease the risk for postoperative surgical site infection. This should be given within 60 minutes prior to skin incision. The choice of antibiotic should cover skin flora, primarily gram-positive organisms such as Staphylococcus aureus, Streptococcus pyogenes, Cutibacterium acnes, diphtheroids, lactobacilli, and Bacillus spp. The first choice of antibiotic is typically a first-generation cephalosporin, such as cefazolin. However, this patient has a previous anaphylactic reaction to penicillin. While reported cross-reactivity between cephalosporins and penicillins is only 1 to 10%, due to the severity of the prior reaction, cefazolin is not the best choice. When a first-generation cephalosporin is not an option due to allergy or another reason, then clindamycin, vancomycin, and fluoroquinolones represent other acceptable choices. The other antibiotic options are not as effective against skin flora and therefore are not the best choices. Ceftriaxone is a third-generation cephalosporin, which has broader gram-negative coverage but is worse against skin flora, including Staphylococcus aureus. Furthermore, the severe penicillin allergy argues against use of any cephalosporin. Gentamicin is much more effective against gram-negative organisms. Toxicity can affect renal function as well as the inner ear. Piperacillin is a synthetic penicillin which is often combined with the beta-lactamase inhibitor tazobactam, giving it a broader spectrum effect against both gram-positive and gram-negative organisms. It is commonly used for serious infections, such as pneumonia and peritonitis. However, severe hypersensitivity to penicillin for this patient precludes its recommended use. Reference(s) 1. Ariyan S, Martin J, Lal A, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015;135(6):1723-1739. doi:10.1097/PRS.0000000000001265 2. American Society of Plastic Surgeons. Evidence-based clinical practice guideline: breast reconstruction with expanders and implants. American Society of Plastic Surgeons; 2013. Accessed January 5, 2023. https://www.plasticsurgery.org/documents/medical-professionals/quality-resources/guidelines/guideline-2013-breast-recon-expanders-implants.pdf”

Answer 162

The correct answer is option D. Obesity is a global epidemic. Efforts to treat it include behavior modifications with diet and exercise, bariatric surgery, and pharmacologic interventions. Semaglutide is a glucagon-like peptide-1 (GLP-1) analogue that is administered subcutaneously once weekly. It acts by stimulating insulin production, inhibiting glucagon release, and delaying gastric emptying. Traditionally used for its glycemic control in patients with type 2 diabetes, recent studies demonstrate a 15% weight loss in patients with obesity. There are multiple pharmacologic approaches to weight loss on the market. Orlistat induces weight reduction by the inhibition of lipases in the mucous membranes of the stomach, small intestine, and pancreas. This reduces lipid absorption by preventing the breakdown and absorption of triglycerides in the intestines. Naltrexone extended-release/bupropion extended-release acts as an appetite suppressant. By inhibiting the reuptake of norepinephrine and dopamine, it activates pro-opiomelanocortin, a neuropeptide that decreases appetite when its concentration increases in the hypothalamus, and supplements dopamine activation, which is lower among patients with obesity. Phentermine also acts as an appetite suppressant. It increases the secretion of epinephrine in the hypothalamus. Topiramate is a gamma-aminobutyric acid agonist, glutamate antagonist, and carbonic anhydrase inhibitor. It is conventionally used to treat epilepsy and prevent migraine headaches. Although its mechanism for obesity treatment is uncertain, it exerts weight reduction effects through increased satiety, increased energy expenditure, decreased caloric intake, and taste disturbances. It is typically combined with phentermine. Reference(s) 1. Son JW, Kim S. Comprehensive review of current and upcoming anti-obesity drugs. Diabetes Metab J. 2020;44(6):802-818. doi:10.4093/dmj.2020.0258 2. Wilding JPH, Batterham RL, Calanna S, et al; STEP 1 Study Group. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183

Answer 163

The correct answer is option D. While recent guidelines suggest most oral diabetic medications, including metformin, can be continued until the day before surgery, SGLT2 inhibitors like dapagliflozin require special consideration. The U.S. FDA and American College of Cardiology have issued warnings about the risk of euglycemic diabetic ketoacidosis (DKA) associated with perioperative use of SGLT2 inhibitors, which can occur despite normal blood glucose levels. This complication is a form of metabolic acidosis and necessitates discontinuation 3–4 days preoperatively. Metformin discontinuation 24–48 hours before surgery remains debated but is no longer universally recommended. Stopping glipizide or insulin glargine risks hyperglycemia, not hypoglycemia, as hyperglycemia is the primary concern when withholding glucose-lowering agents. References support perioperative cessation of SGLT2 inhibitors due to DKA risk, while other agents are generally safe to continue.

Answer 164

The correct answer is option C. The first-line radiographic examination for women 35 years of age or older who present with a breast mass is mammography. This involves x-ray imaging in both the craniocaudal and mediolateral oblique planes to make sure that all breast tissue has been captured. Mammography has a higher sensitivity and specificity than ultrasonography. Ultrasound imaging is useful in younger women who have a denser breast and less fatty tissue. MRI is also useful but is a more expensive diagnostic tool with a longer waiting time. Breast imaging reports are standardized using the Breast Imaging Reporting and Data System (BI-RADS). This allows each radiologic breast examination to be described by density of breast tissue, presence and location of mass(es), calcifications, asymmetry, and any associated features. This system divides patients into seven categories. In mammography, to be considered a mass, the finding must be visible in two projections, have convex outer borders, and be denser centrally. • BI-RADS 0 insufficient or incomplete study • BI-RADS 1 normal study • BI-RADS 2 benign features • BI-RADS 3 probably benign (less than 2% risk for malignancy) • BI-RADS 4 suspicious features (4A: low 2 to 9% suspicion of malignancy; 4B: moderate 10 to 49% suspicion of malignancy; 4C: high 50 to 94% suspicion of malignancy) • BI-RADS 5 probably malignant (greater than 95% chance of malignancy) • BI-RADS 6 malignant (proven on tissue biopsy) In this case, the mass is categorized as BI-RADS 4B, indicating a moderate (10 to 49%) suspicion of malignancy. The most appropriate next step is tissue biopsy for histopathological evaluation to confirm the diagnosis and guide further management. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. 5th ed. American College of Radiology; 2013. Magny SJ, Shikhman R, Keppke AL. Breast imaging reporting and data system. StatPearls. StatPearls Publishing; 2022. Updated August 29, 2022. https://www.ncbi.nlm.nih.gov/books/NBK459169/

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