Chest/Abdomen/Trunk/Rec/Congenital Flashcards

Question

A 9-year-old boy is referred for evaluation because his breasts have been enlarging during the past six months without pain. Tanner stage is 1. Height and weight are in the 50th percentile. He takes no medications, and his medical history is noncontributory. Which of the following is the most appropriate next step in establishing the diagnosis? A ) Abdominal CT and renal ultrasonography B ) Karyotyping C ) Measurement of serum gonadotropin concentrations D ) Testicular examination and ultrasonography E ) No further testing is necessary

Answer 1

The correct response is Option D. Gynecomastia, defined as benign enlargement of the male breast, can affect as many as 65% of adolescent boys. It is a condition that reflects an elevated ratio of estrogens to androgens caused by age, disease, drugs, or idiopathic factors. Gynecomastia follows a triphasic distribution seen most frequently in the neonate, in early puberty, and with advanced age as a result of normal hormonal shifts that result in a relative preponderance of estrogens over androgens. For this reason, gynecomastia in these patients is considered physiologic and rarely requires workup beyond a careful history and physical examination. The patient described comes to the office with early breast enlargement without other signs of pubertal development. Prepubertal gynecomastia is an uncommon condition, which should prompt a thorough workup for a possible pathologic cause. This is also true for patients of any age with bilateral idiopathic disease. While hormonal screening has previously been considered the first step in evaluating a patient with idiopathic gynecomastia, recent studies have suggested that these tests are rarely cost-effective. If hormone testing does suggest an occult testicular tumor, ultrasonography will be required for confirmation. Ultrasonography is therefore a preferred screening method, as it is cheaper and more accurate than hormone assays. While specific workups have historically been suggested depending on age at presentation, the arbitrary use of screening radiologic or laboratory tests has not been found to be cost-effective. The presence of a feminizing tumor in a patient with idiopathic gynecomastia is extremely rare, affecting fewer than 3% of patients. Moreover, breast hypertrophy is an uncommon sign of testicular neoplasms, occurring in 30% of Leydig cell tumors and less than 10% of beta HCG-producing carcinomas. Feminizing adrenal tumors are even rarer. Adrenal imaging is therefore not warranted. Mammogram and/or ultrasonography of the breast are reasonable choices if history and physical examination are suggestive of breast cancer. Breast cancers usually present as a hard, unilateral mass in an older patient. Karyotype testing would be warranted to rule out Klinefelter syndrome if feminizing characteristics are found on physical examination.

Answer 2

The correct response is Option D. Leuprolide acetate (Lupron) is used in the treatment of certain cancers, including prostate, endometriosis, and precocious puberty. Because it is a synthetic gonadotropin-releasing hormone (GnRH), it acts as an agonist of pituitary GnRH receptors. Its ultimate effect is a lowering of estradiol and testosterone levels through downregulation of luteinizing hormone and follicle-stimulating hormone secretion. Gynecomastia and breast tenderness are known side effects of leuprolide treatment for prostate cancer. Selective estrogen receptor modulators (SERMs), such as tamoxifen, are recommended for the prevention of gynecomastia as a result of antiandrogen monotherapy. Radiation as well has been shown to decrease the breast side effects of leuprolide acetate. Thus, an increase in size, rather than a decrease in size is expected. Darkening of the nipple areolar complex is often associated with pregnancy, but not leuprolide acetate. Galactorrhea is associated with drugs—commonly drugs that contain dopamine depleting agents, such as methyldopa, that cause receptor bock (such as Reglan), and that inhibit release, such as codeine and morphine. Histamine receptor blockade, from drugs such as cimetidine, can also cause galactorrhea. Pituitary tumors are also a cause of galactorrhea. A thorough assessment of all medications and medical history is necessary for evaluation of a patient with gynecomastia and mastodynia.

Answer 3

Correct answer is option D. The most appropriate next step in management is coverage with a local musculofascial flap. The major principle of myelomeningocele repair is to obtain a well-vascularized layer of soft-tissue coverage between the dural repair and skin repairs. The fascia overlying the paraspinous muscles can be turned over as flaps followed by paraspinous muscle advancement flaps to cover the underlying dural repair. This vascularized soft-tissue layer will minimize the risk of contact of cerebrospinal fluid with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. Vacuum-assisted wound therapy over a dural repair would increase the risk of cerebrospinal fluid leak, dural injury, and breakdown of the repair. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair would place the patient at risk for meningitis in the event of a cerebrospinal fluid leak, or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a free flap to cover the dural repair is unnecessary because local tissue (paraspinous muscles and fascia) is available. Harvesting the gluteal muscle(s) may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurologic deficit.

Answer 4

The correct answer is option C. The understanding of human embryology has been developed from research in organisms such as Drosophila melanogaster, chick, and mouse. The development of the musculoskeletal trunk of the human body encompasses the union of skeletal and mesodermal tissues and is initiated by signals from surrounding tissues. This process occurs during the fourth through eighth weeks of gestation.

Answer 5

The correct response is Option D. Component separation for abdominal wall reconstruction involves release of the fascia lateral to the rectus abdominus muscles, just lateral to the semilunar line, dissecting the external oblique off the internal oblique muscles. This creates innervated musculofascial flaps that can be advanced medially for closure of ventral hernias. If the posterior rectus sheath is also dissected free, further advancements can be gained. Per rectus muscle, approximately 4 cm can be gained at the epigastric and suprapubic areas; 10 cm can be advanced at the waist. Therefore, the most advancement can be gained at the umbilicus, which is in the area of the waist. The xyphoid and ligament of Treitz are in the epigastric area, while the arcuate line is in the suprapubic area.

Answer 6

The correct response is Option C. Vaginal reconstruction for congenital vaginal agenesis or after tumor resection remains a challenging reconstructive endeavor. The ideal technique provides a vaginal canal with adequate dimensions, texture, appearance, and sexual function without excessive donor site morbidity. The deep inferior epigastric artery perforator flap as a local regional flap has been described recently for vaginal reconstruction. It is a non-hair-bearing flap that is performed in a single stage but is insensate. Depending on the patient’s body habitus, it is less bulky than the musculocutaneous flaps (gracilis, vertical rectus) used for vaginal reconstruction, but more bulky than the Singapore flap. Two perforators are included in the flap to ensure viability. The major disadvantage is a conspicuous donor site scar. The pudendal thigh flap, commonly referred to as the Singapore flap, is a local fasciocutaneous flap that has been widely used for neovaginal reconstruction. It is a thin, sensate flap based on the posterior labial arteries, which are a continuation of the perineal artery. Modifications of the flap have been described to enhance the viability and reach of the flap. It is a reliable, single-staged operation, but can result in endovaginal hair growth. This can be improved with preoperative electric or laser depilation of the vulvar portion of the flap. Neither flap secretes mucus. Both are single-staged operations.

Answer 7

Correct answer is option C. ' For the definitive diagnosis of Poland syndrome, patients must have absence or hypoplasia of the sternal head of the pectoralis major muscle on the affected side. Other chest wall abnormalities can occur along with the absence of, or hypoplasia of, the ipsilateral breast. These include the latissimus dorsi and serratus anterior muscles. Brachysyndactyly of the ipsilateral upper extremity can be present as well.

Answer 8

Correct answer is option A. Implant infection is a common clinical complication of abdominal hernia repair. Use of biologic mesh in contaminated cases has gained widespread acceptance. The ability of acellular dermal matrix (ADM) to revascularize is most likely the key to its successful application in contaminated scenarios. Revascularization subsequently helps clear bacteria. Contraction is a normal part of wound healing mediated by myofibroblasts, which are not present in polytetrafluoroethylene (PTFE) or ADM. Encapsulation is a foreign body reaction, whereby the organism forms a sterile scar around an alloplastic material. Imbibition is the process by which autogenous grafts perform initial metabolic exchange through diffusion. Inosculation is the first stage of neoangiogenesis, whereby immature vasculature between graft and recipient bed begin to organize in preparation for ingrowth. Neither process occurs in PTFE or ADM, as there is no existing vasculature in either product.

Answer 9

The correct response is Option E. The breast develops as the result of bilateral thickening of ectoderm along the milk line, or mammary ridge, from the axillary to the inguinal region. Mammary buds begin to develop as growths within the epidermis and invade the deeper mesenchyme. Much of the ridge disappears as the embryo develops as the result of apoptosis, except for the primary buds in the pectoral regions. Failure of regression of the mammary ridge can result in accessory breasts (polymastia) or accessory nipples (polythelia). Accessory breast tissue occurs in 1 to 2% of live births and commonly occurs in the axillae. Amastia is the complete absence of the mammary gland. This occurs due to either the failure of the mammary ridge to develop or the complete involution of the mammary ridge. Gynecomastia is defined as benign enlargement of the male breast. While pathologic cases can exist, it is most typically due to a normal response of the breast tissue to circulating levels of estrogen. Inverted nipples are due to failure of the mesenchyme to proliferate above the level of the skin. Poland syndrome can have the following components: hypoplasia of the breast and nipple, absence of the sternocostal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, abnormalities of the chest wall, and anomalies of the upper extremity. Many etiologies have been hypothesized, with the most widely accepted being an interruption of the embryonic blood supply to the upper limb.

Answer 10

Poland syndrome is a congenital condition characterized by complete or partial pectoralis major muscle agenesis, breast and nipple aplasia or hypoplasia, and chest wall and rib malformation. A subset of patients has ipsilateral arm/hand maldevelopment, including brachydactyly and possibly syndactyly. Reconstruction with a deep inferior epigastric artery perforator free (DIEP)flap is the best option from the choices. Because of the chest wall abnormalities, the anatomy of the internal mammary artery should be considered in selecting the recipient vessel. The internal mammary artery may be abnormally small or course retrosternal, and the thoracodorsal artery may need to be considered. The images show a staged postoperative picture following DIEP and before revision. Although expansion of the skin may be a reasonable initial choice, placement of a total submuscular tissue expander would be difficult because of the aplasia of the sternocostal head of the pectoralis major muscle and possibly the entire muscle. While a custom-made silicone implant would be a good choice for this patient, bilateral prophylactic mastectomy is not indicated for Poland syndrome in the absence of breast cancer or genetic elevated risk for breast cancer, such as BRCA. Earlier surgical management is preferred to improve psychosocial development and waiting until age 21 years has no advantage. Left-sided mastopexy alone would not address the volume discrepancy between the right and left breast causing asymmetry.

Answer 11

The correct response is Option E. The congenitally inverted nipple is common and occurs in 4% of infants. It results from the failure of the mesenchyme to proliferate above the level of the skin. Amastia is absence of the entire breast. Athelia is absence of the nipple. Amazia is absence of the mammary gland with an intact nipple and areola. Polythelia, or accessory nipple, results from failure of regression along the milk line.

Answer 12

The correct answer is option a. Umbilical hernias are common occurrences in children where the umbilical ring fails to close. Depending on the severity of the lesion, they may require surgical intervention. However, over time, small umbilical hernias are able to close on their own without the need for surgery. Omphalocele and gastrochisis are open abdominal wall defects that need to be surgically closed and will not close on its own. A diaphragmatic hernia is where the herniation of the abdominal viscera through a defect in the diaphragm requiring surgery. Prune belly syndrome is a defect where there is lack of development of the abdominal wall.

Answer 13

Correct answer is option C. Myelomeningocele is a defect in which there is open dysplasia of the spinal cord and meninges. It is usually not covered with skin and requires immediate surgical intervention to prevent deterioration of neurologic function and risk for infection. Myelocele, meningocele, spina bifida occulta, and spinal teratoma are all usually covered by skin, although in some cases, the skin may be thin, pigmented, covered with hair or depressed.

Answer 14

The correct response is Option C. The patient has Poland syndrome with an unusual axillary web. The defining clinical feature is underdevelopment or absence of the sternal head of the pectoralis major muscles (seen in the photograph), but the deformity can lead to other anomalies such as absence of the nipple, the areola, or portions of the anterior chest wall. Cardiac anomalies may also be present. The ipsilateral extremity and hand are often smaller or hypoplastic, and this finding can be subtle or pronounced. The fingers are typically shorter and smaller than the contralateral side, and there may be webbing between the fingers. In severe forms, the central fingers are mere vestiges. The other choices do not fit with this clinical photograph. Amniotic band syndrome usually leads to amputation or severe constriction of the hand or digits; this is not seen here. Waardenburg syndrome is a genetic condition that causes hearing loss and pigmentation changes to the hair, skin, and eyes. Popliteal pterygium syndrome is a condition associated with cleft lip/palate, webs of the popliteal space, and syndactyly of the toes or fingers. The axillary web seen here is not a described feature. Axillary web syndrome, or cording, is an acquired web that usually follows axillary node dissection in the treatment of breast cancer. This does not fit the clinical scenario.

Answer 15

The correct response is Option D. Larger forms of gynecomastia with significant ptosis present a challenge to plastic surgeons with respect to the size, shape, and position of the nipple on the chest wall. In addition, the nipple-areola complex may need to be reconstructed due to loss from cancer or trauma. Two recent studies investigated the anatomical parameters of the nipple-areola complex in men. These studies demonstrated the following characteristics. More than 90% of the male subjects had nipples that were oval in configuration. The average areolar diameter in one study was 2.8 cm. The average areolar diameter in the other study was 2.7 cm. Furthermore, in men, the position of the nipple on the chest wall is typically 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance in men is 21 cm.

Answer 16

The correct response is Option D. Tidal volume (VT) is the volume of air that is moved into or out of the lungs during quiet breathing. Tidal volume can be measured directly through spirometry or estimated based on a patient’s ideal body mass. It is a key parameter in mechanical ventilation to allow adequate ventilation without causing barotrauma to the lungs. Vital capacity (VC) is the volume of air expired after deepest inspiration. Functional capacity is a physiologic description of an individual’s ability to complete activities of daily living. It can be estimated through exercise treadmill testing and reported in metabolic equivalents (METs). Residual volume (RV) is the volume of air remaining in the lungs after maximal exhalation. Dead-space volume is the volume of air inhaled that does not take part in gas exchange. This volume can include both gas that remains in conducting airways (e.g., trachea, bronchi) during respiration and gas that reaches nonfunctional alveoli (e.g., nonperfused lung parenchyma following pulmonary embolism).

Answer 17

The correct response is Option D. The most effective treatment of the sternal wound infection described is initial debridement to healthy bleeding tissue and bone, removal of all foreign bodies, and immediate closure with bilateral pectoralis major muscle flaps. Post €‘sternotomy wounds are classified according to the duration of time that has elapsed between the sternotomy and the clinical onset of the infection. Type I infections occur within the first week after sternotomy and have no bony involvement. Type II infections occur during the second to fourth weeks after sternotomy. Bony involvement is frequent, but chostochondritis is rare. Type III infections occur months to years after sternotomy and typically involve chronic draining sinus tracts. Osteomyelitis, chostochondritis, and retained foreign bodies are all common. The patient described had a Type III infection with a deep sinus tract as confirmed by CT scan. Although delayed closure had previously been considered the treatment of choice for Type III sternotomy wounds, more recent data suggest that a single-stage approach with bilateral pectoralis major muscle flaps results in quicker recovery, improved cosmesis, and decreased morbidity and mortality compared with staged approaches. Given the chronicity of the wound, all foreign bodies, including retained suture material and wires, should be removed. Pectoralis major turnover flaps provide additional bulk and might therefore be considered preferable. However, the left internal mammary artery has been harvested in this patient, compromising the blood supply to the left pectoralis major turnover flap.

Answer 18

The correct response is Option A. Given the size and history of the defect, the patient described has a significant chance of recurrence of his hernia. To optimize the chances of a functional recovery that is durable and has the lowest chance of recurrence, the component separation technique with mesh reinforcement (synthetic or biologic) is indicated. The component separation technique, originally described by Ramirez et al. in 1990, allows for recruitment of the rectus complex towards the midline to facilitate primary reapproximation (in the best-case scenario) or at least decrease the size of the residual defect. Studies have shown that reinforcement of hernia repairs with mesh decreases recurrence rates by 50 to 75%, even in secondary repairs. It is not clear, however, whether the mesh should be placed as an overlay or underlay. Nonetheless, mesh reinforcement leads to lower recurrence rates, especially if combined with component separation. Specifically, component separation allows for reduction of the hernia defect size after hernia reduction, and leads to lower recurrence rates versus hernia reduction and bridging mesh repair alone. Laparoscopic repair is a useful technique in hernia repairs. However, the complex, large "Swiss cheese–type" defect described lends itself more to open repair in terms of facilitation of reduction, optimization of safety (avoidance of unrecognized bowel injury), and decrease in operative time. A tensor fascia lata flap, originally described for large hernia repairs because it allows transfer of fascia to the abdomen, does not demonstrate superior results compared to available meshes. It also incurs donor site morbidity versus the mesh reinforcement techniques.

Answer 19

The correct response is Option E. The most appropriate next step in management of the exposed titanium is removal of the hardware. The titanium rod or one of the screws likely loosened and subsequently migrated to extrude through the skin. The vertebral column is adequately fused 1 year following the procedure. The orthopedics team should be consulted regarding removal of the hardware. Once the hardware is removed, the wound is easily repaired using delayed primary closure or by allowing it to heal secondarily. Although local skin flaps, skin grafts, regional muscle transfer, and free flaps will provide vascularized soft-tissue coverage over the exposed hardware, these options ultimately will fail. The exposed hardware is much stronger than any soft-tissue coverage and will extrude through a flap, especially when the patient is supine. Definitive management requires eliminating the cause of the problem, which is malpositioned hardware, and not inadequate soft-tissue coverage.

Answer 20

The correct answer is option E. Asphyxiating thoracic dystrophy, Jeune syndrome, is an autosomal recessive disorder in which patients may present with alveolar hypoventilation as a result of short horizontally positioned ribs. Patients are also born with variable short and wide long bones of the extremities. Other findings include irregular costochondral junctions, elevated clavicles, short iliac bones, and hypoplastic phalanges of the hands and feet. Other complications that may develop later in life include renal, hepatic, and pancreatic. Associate position position rips

Answer 21

The correct response is Option C. A comprehensive understanding of the anatomy of the anterior abdominal wall is critical when performing posterior component separation. Above the arcuate line, the anterior rectus sheath is derived from the external oblique aponeurosis and the anterior component of the internal oblique aponeurosis. The posterior rectus sheath is derived from the posterior component of the internal oblique aponeurosis and the aponeurosis of the transversus abdominis muscle. The rectus abdominis muscle sits between the anterior and posterior rectus sheaths superior to the arcuate line. Below the arcuate line, the anterior rectus sheath is derived from the aponeuroses of all three muscles: the external oblique, the internal oblique, and the transversus abdominis muscles. The posterior rectus sheath does not exist below the arcuate line. The rectus muscle is only separated from the abdominal viscera by the transversalis fascia and the peritoneum. References

Answer 22

Correct cancer is option a The trapezius muscle is supplied by the transverse cervical artery, innervated by the accessory nerve (motor) and cervical spinal nerves C3 and C4 (motor and sensory). It arises from the external occipital protuberance and the medial third of the superior nuchal line of the occipital bone (both in the back of the head), from the ligamentum nuchae, the spinous process of the seventh cervical, all the thoracic vertebrae and from the corresponding portion of the supraspinal ligament. It inserts on the posterior border of the lateral third of the clavicle, acromion process and spine of the scapula.

Answer 23

The correct response is Option B. The lesion in this patient is a recurrent desmoid tumor, also known as aggressive fibromatosis. It is a benign tumor, usually found in younger patients between 10 and 40 years of age, and is locally aggressive. It is often associated with pregnancy and previous surgery and can frequently recur. Management is en bloc, full-thickness, wide local excision (usually with frozen section confirmation of negative margins). An aggressive full-thickness abdominal wall resection is standard of care, making reconstruction more challenging. The more durable and functional reconstruction entails complete restoration of the abdominal wall, especially musculofascial components, in a primary reapproximation. However, depending on the size of the tumor and resultant defect, this may not be possible. Basic principles, after obtaining proper margins after resection of the tumor, would then be reduction in defect size to the maximal extent possible and wide bridging underlay of mesh with at least 4- to 5-cm margins in all directions. Bridging inlay, whereby a mesh is simply sewn to the margins of the defect, has clearly been shown to be inferior in terms of recurrence rates. Mesh choice can be either synthetic or biologic, although if significant contamination exists, if soft-tissue coverage is tenuous, or if one desires to decrease the amount of adhesion formation when placing mesh directly against the bowel, one should consider placement of biologic mesh, accepting the fact that there is a higher incidence of postoperative bulges using these materials, by and large. In this case, only a left component separation is possible, given that the tumor has invaded the right rectus muscle and obliques, precluding their use for myofascial advancement. There is no role for chemotherapy or radiation therapy in the treatment of these tumors. Coverage with a right anterolateral thigh flap, with or without rectus femoris, can reconstruct the soft-tissue defect, but avoiding the use of mesh in a defect over 4 cm has a significantly higher chance of a recurrent hernia and would not be standard of care. Primary skin grafting on top of a nonvascularized thick piece of acellular dermal matrix will not “take,” even with use of negative pressure wound therapy.

Answer 24

The correct response is Option C. Patients often come to plastic surgeons with subcutaneous masses. An understanding of the differential diagnosis is helpful to counsel patients. Accessory breast tissue (polymastia) along the milk line is common. This breast tissue is responsive to hormonal influence, and patients will describe cyclical pain and swelling coinciding with menses and with milk letdown. Surgical excision can be performed. Polythelia is the presence of accessory nipples. Lipomas, epidermal inclusion cysts, and sarcomas can occur as subcutaneous masses, but they do not change in character based on hormonal influence.

Answer 25

The correct response is Option C. Component separation of the abdominal wall was initially described for the anterior components, that is, those which are located anterior to the rectus muscle. A more recent development involves component separation of the layers located posterior to the rectus fascia. The technique of posterior component separation begins with a vertical incision of the posterior rectus sheath 0.5 cm medial to the linea semilunaris and continues laterally in the avascular plane posterior to the transversalis muscle. It can extend as far posteriorly as the psoas muscle if needed. In the event that the posterior layer cannot be approximated in the midline, an interposition patch of omental fat, hernia sac, or absorbable mesh is used. Concurrent use of non-absorbable mesh to reconstruct deficient anterior layers may be used in conjunction with the posterior separation technique as long as the mesh is separated from viscera with an intact posterior layer. A benefit of the posterior separation technique is the preservation of the lateral neurovascular bundles preserving the dynamic function of the rectus muscles. The technique may be utilized even when fascial defects are not situated in the midline or are located adjacent to bony landmarks.

Answer 26

Correct answer this option C. The most appropriate method to reconstruct the wound is a local fascial flap and skin advancement flap. The major principle of tethered cord and myelomeningocele repair is to obtain a well-vascularized layer of soft tissue coverage between the dural and skin closures. The fascia overlying the paraspinous muscles can be turned over as flaps to cover the underlying dural repair. This vascularized soft tissue layer will minimize the risk of cerebrospinal fluid leak by reinforcing the dural repair. In addition, the fascial flaps will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair using skin advancement flaps would place the child at risk for meningitis in the event of a cerebrospinal fluid leak or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a regional gluteal or latissimus muscle flap to cover the dural repair is unnecessary because local tissue (paraspinous muscle fascia) is available. Harvesting the gluteal or latissimus muscles also may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurological deficit.

Answer 27

Correct answer is option D. The rectus muscle is the primary flexor of the pelvis. Its segmental nerve supply enters the rectus sheath laterally in a plane between the internal oblique and transversus muscles. Separation of components is a versatile and powerful technique for autologous abdominal wall reconstruction. Along with the ability to close large midline ventral defects primarily, the rectus muscle remains innervated because only the aponeurosis of the external oblique is released. If correctly performed, the internal oblique layer will shield the underlying nerve supply to the rectus and result in a functional abdominal wall repair.

Answer 28

The correct response is Option C. A comprehensive understanding of the anatomy of the anterior abdominal wall is critical when performing posterior component separation. Above the arcuate line, the anterior rectus sheath is derived from the external oblique aponeurosis and the anterior component of the internal oblique aponeurosis. The posterior rectus sheath is derived from the posterior component of the internal oblique aponeurosis and the aponeurosis of the transversus abdominis muscle. The rectus abdominis muscle sits between the anterior and posterior rectus sheaths superior to the arcuate line. Below the arcuate line, the anterior rectus sheath is derived from the aponeuroses of all three muscles: the external oblique, the internal oblique, and the transversus abdominis muscles. The posterior rectus sheath does not exist below the arcuate line. The rectus muscle is only separated from the abdominal viscera by the transversalis fascia and the peritoneum. References

Answer 29

Correct answer is option C. Prehabilitation of the abdominal wall through botulinum toxin type A (BTA) injections into the lateral abdominal wall musculature of patients with large ventral hernias and loss of domain has been demonstrated in multiple studies and meta-analyses to increase the likelihood of primary fascial closure. Advocates for its use have used varying types of BTA, doses, number of injections, and timing of injections, but results have consistently shown that its use has decreased the number of patients requiring bridging of the repair. Based on the mechanism and peak effect of BTA, studies using the injections at the time of repair have been less effective than their use 2 to 4 weeks prior to the planned operation. Radiologic assessment of the patients at the time of injection and immediately prior to surgery have demonstrated a lengthening of the lateral abdominal wall musculature and decrease in the width of the midline hernia. This lengthening and relaxation results in the decreased excursion distance and improved compliance of the abdominal wall, thus allowing for increased numbers of primary fascial closures with or without component separation. Larger scale studies are needed to determine other benefits of its use in this population. There are mixed results related to improved pain control, with some studies reporting a reduction in oral morphine equivalents, while others show no statistical difference. Improvement in complication rates such as hospital stay, and recurrence are not consistent across studies. The use of tissue expanders and progressive preoperative pneumoperitoneum have also shown promise as adjuncts to abdominal wall reconstruction. These have been used alone and in conjunction with BTA injections with improved results regarding achieving primary fascial closure. Since these are more invasive procedures, they do carry unique risks (tissue expander infection/extrusion, intra-abdominal organ injury) that need to be factored into the operative plan. The use of prehabilitation with BTA has not been shown to decrease length of hospital stay or incidence of wound breakdown, nor has it been shown to prolong ventilator dependence or increase infection rate.

Answer 30

The correct response is Option D. Scar minimization is a priority when possible in patients with gynecomastia. The patient’s acceptable BMI, absence of weight change, and physical description imply minimal skin excess, making him a candidate for limited scar techniques. Direct excision of the central gland through periareolar incision with liposuction for marginal contouring would address the patient’s condition without excess scarring. Liposuction alone is unlikely to adequately address the firm central glandular tissue under the nipple-areola complex. The other techniques such as inverted-T pattern breast reduction with inferior pedicle, horizontal scar breast reduction with nipple-areola grafting, and skin-sparing mastectomy with nipple-areola tattoo would all unnecessarily increase scarring.

Answer 31

The correct response is Option A. Ultrasound-assisted liposuction in a dry environment increases the risk of thermal injury and overlying skin necrosis. The introduction of subcutaneous fluid in the wet, superwet, and tumescent techniques helps cool the probe and decreases the risk of injury. Additionally, avoidance of end hits, strict continuous movement of the probe, continuous cold saline irrigation, and use of a probe sheath and a wet towel as a skin guard also protect against thermal injury when ultrasound energy is delivered to the tissues.

Answer 32

The correct response is Option B. Abdominal wall reconstruction after severe trauma involves evaluation of the skin and fascia. First, the surgeon needs to determine if there is sufficient skin and subcutaneous tissue for primary closure. If there is insufficient skin, then tissue expanders, local tissue rearrangement, or distant flaps need to be considered. Second, if there is insufficient fascia, then component separation with primary fascial closure and mesh onlay or a mesh interposition are options for fascial closure. Since the fascial defect is 30 cm, it is unlikely that primary fascial closure can be achieved with component separation alone. An interposition of acellular dermal matrix is appropriate to bridge the fascial gap if primary fascial closure cannot be achieved.

Answer 33

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

Answer 34

The correct response is Option D. The most appropriate next step in management is coverage with a local musculofascial flap. The major principle of myelomeningocele repair is to obtain a well-vascularized layer of soft-tissue coverage between the dural repair and skin repairs. The fascia overlying the paraspinous muscles can be turned over as flaps followed by paraspinous muscle advancement flaps to cover the underlying dural repair. This vascularized soft-tissue layer will minimize the risk of contact of cerebrospinal fluid with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. Vacuum-assisted wound therapy over a dural repair would increase the risk of cerebrospinal fluid leak, dural injury, and breakdown of the repair. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair would place the patient at risk for meningitis in the event of a cerebrospinal fluid leak, or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a free flap to cover the dural repair is unnecessary because local tissue (paraspinous muscles and fascia) is available. Harvesting the gluteal muscle(s) may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurologic deficit.

Answer 35

The correct response is Option D. Several retrospective studies and one randomized trial have shown that when compared to primary closure, the rectus abdominis myocutaneous flap reduces wound healing complications after abdominoperineal resection (APR). Gluteal and gracilis flaps have been used for reconstruction after APR; however, the data supporting their use is not as robust. Split-thickness skin grafting and negative pressure wound therapy are inappropriate for reconstruction of the APR due to the size of the wounds and the risk of evisceration.

Answer 36

Correct answer is option a. Post-sternotomy mediastinitis is a severe complication, with an incidence ranging between 0.2 and 8%. Risk factors include advanced age, diabetes mellitus, morbid obesity, reoperation for bleeding, and use of bilateral internal mammary arteries. Deep sternal wound infections are more serious and have a higher mortality rate than superficial or sterile sternal wounds. The most common organisms are Staphylococcus aureus and Staphylococcus epidermidis, but mixed gram-positive and gram-negative infections are not uncommon. Broad-spectrum antibiotic therapy to include coverage of MRSA infection and Pseudomonas should be instituted. Nevertheless, debridement is the mainstay of therapy. Adequate sternal and soft-tissue debridement is vital and can be combined with immediate sternal closure with delayed primary wound closure versus delayed closure of the entire wound with or without flaps to aid in obliterating any dead space. Many studies have demonstrated that the use of negative pressure wound therapy for wound coverage as a bridging method to final wound closure decreases the morbidity of these patients and is associated with decreased recurrent infection and treatment failure rates compared with conventional therapy, specifically primary rewiring or plating, especially for those at high risk. Flap closure at the time of sternal debridement can be performed; however, if bilateral internal mammary arteries are used for the bypass, a pectoralis turnover flap is not an option because of loss of the internal mammary artery for the pectoralis major. Options would include coverage with the pectoralis transposition flap based on the thoracoacromial artery, an omental flap, or a rectus abdominis flap based on the intercostal artery.

Answer 37

The correct response is Option D. The most appropriate option in the patient described is an omental flap with skin grafting. The defect encompasses the entirety of the sternum, from the sternal notch to the xiphoid. The first-line muscle flaps for this defect would usually be bilateral pectoralis muscle flaps (that do not include a left pectoralis turnover flap option due to the lack of a left internal mammary artery (IMA) used for the coronary graft). However, this option has already been used. An omental flap has an axial blood supply that is not compromised (the gastroepiploic) and the ability to completely span the defect and obliterate the dead space; the skin graft provides the skin coverage needed to complete the reconstruction. Hence, it is the optimal choice in this patient. An adjacent tissue transfer of random skin flaps bilaterally would not obliterate the dead space and would not provide robust axial blood supply to the necessary area, with the tenuous coverage existing along the sternal midline, exactly where the most vital blood supply would be necessary. A left rectus abdominis turnover flap would not be an appropriate option for two reasons: 1) the left IMA has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based; and 2) it would not reach the upper portion of the defect. A left superior epigastric artery perforator fasciocutaneous flap would not be an appropriate option for two reasons: 1) the pedicle is compromised from the left IMA harvest; and 2) muscle flaps have been proven to be optimal for sternal defects more than fasciocutaneous flaps. A right latissimus muscle flap may be a viable choice to get full coverage of the defect with dead space obliteration. However, the option indicates this is a myocutaneous flap, which would not allow for sufficient skin to be harvested to reconstruct the size of this defect.

Answer 38

The correct response is Option A. For most patients with omphaloceles less than 5 cm in diameter, a single operation involving a traditional anterior component separation from costal margin to iliac crest is sufficient to reduce the omphalocele and reapproximate the rectus diastasis. Extended component separations are typically only needed when the omphalocele is large and accompanied by a diaphragmatic hernia. Once the abdominal wall defect extends past 5 cm in diameter, a staged procedure involving the placement of tissue expanders and subsequent flap advancement must be considered. Autologous tissue options, such as the tensor fascia lata flap, may be needed for larger defects that can not be managed with component separation. While prosthetic or biologic mesh placement is used to correct large abdominal wall defects, it is typically used only after autologous options have failed or are not available.

Answer 39

The correct response is Option D. Gynecomastia can occur because of imbalances of estrogen and testosterone, and it can be associated with obesity, certain drugs, and Klinefelter syndrome. It can also be associated with testicular tumors. Therefore, a testicular examination should be performed. Mammography is not necessary for a routine workup if physical examination shows no abnormal masses. A chest x-ray study is not needed for an otherwise healthy 19-year-old. An x-ray study of the hand can evaluate closure of growth plates when determining if puberty has completed. This is unlikely to be necessary for someone who is 19 years old.

Answer 40

The correct response is Option C. The rectus muscle is the primary flexor of the pelvis. Its segmental nerve supply enters the rectus sheath laterally in a plane between the internal oblique and transversalis muscles. Separation of components is a versatile and powerful technique for autologous abdominal wall reconstruction. Along with the ability to close large midline ventral defects primarily, the rectus muscle remains innervated because only the aponeurosis of the external oblique is released. If correctly performed, the internal oblique layer will shield the underlying nerve supply to the rectus and result in a functional abdominal wall repair.

Answer 41

Correct answer is option D The external oblique turnover muscle flap is not commonly used but has the potential to provide adequate coverage of large defects of the back that extend to the midline at the level of T10 to L4. The upper half of the flap is supplied by the 4th through 11th intercostal arteries, whereas the lower half is supplied by one or two vessels from the deep circumflex iliac artery (95%) or the iliolumbar artery (5%). The upper half has a strictly segmental blood and nerve supply, whereas the lower half has segmental innervation but derives its blood supply from one artery.

Answer 42

Correct answer is option C. For the definitive diagnosis of Poland syndrome, patients must have absence or hypoplasia of the sternal head of the pectoralis major muscle on the affected side. Other chest wall abnormalities can occur along with the absence of, or hypoplasia of, the ipsilateral breast. These include the latissimus dorsi and serratus anterior muscles. Brachysyndactyly of the ipsilateral upper extremity can be present as well.

Answer 43

The correct response is Option E. In adults with gynecomastia, thorough medical evaluation is required. History and physical examination should identify new medications, drug and alcohol abuse, and endocrine, hepatic, or pulmonary disease. Laboratory studies should measure electrolytes, blood urea nitrogen, creatinine, testosterone (total and free), estradiol, follicle-stimulating hormone, luteinizing hormone, beta-human chorionic gonadotropin (\_-hCG), prolactin, liver function, and thyroid function. Radiography should also be performed. These tests are intended to rule out germ cell tumors, primary hypogonadism, hyperthyroidism, androgen resistance, pituitary tumors, secondary hypogonadism, and lung cancer. Mammography is not routinely used unless there is a finding on physical examination that shows possible presence of breast cancer; there is no known association between gynecomastia and breast cancer (except in Klinefelter syndrome). Imaging of the brain is not routinely ordered unless there is some other finding suggestive of a brain tumor. If the \_-hCG concentration is increased, ultrasonography of the testes is indicated to rule out germ cell and non–germ cell tumors. CT scan of the abdomen should be ordered only if ultrasonography of the testes is negative.

Answer 44

The correct response is Option A. Post-sternotomy mediastinitis is a severe complication, with an incidence ranging between 0.2 and 8%. Risk factors include advanced age, diabetes mellitus, morbid obesity, reoperation for bleeding, and use of bilateral internal mammary arteries. Deep sternal wound infections are more serious and have a higher mortality rate than superficial or sterile sternal wounds. The most common organisms are Staphylococcus aureus and Staphylococcus epidermidis, but mixed gram-positive and gram-negative infections are not uncommon. Broad-spectrum antibiotic therapy to include coverage of MRSA infection and Pseudomonas should be instituted. Nevertheless, debridement is the mainstay of therapy. Adequate sternal and soft-tissue debridement is vital and can be combined with immediate sternal closure with delayed primary wound closure versus delayed closure of the entire wound with or without flaps to aid in obliterating any dead space. Many studies have demonstrated that the use of negative pressure wound therapy for wound coverage as a bridging method to final wound closure decreases the morbidity of these patients and is associated with decreased recurrent infection and treatment failure rates compared with conventional therapy, specifically primary rewiring or plating, especially for those at high risk. Flap closure at the time of sternal debridement can be performed; however, if bilateral internal mammary arteries are used for the bypass, a pectoralis turnover flap is not an option because of loss of the internal mammary artery for the pectoralis major. Options would include coverage with the pectoralis transposition flap based on the thoracoacromial artery, an omental flap, or a rectus abdominis flap based on the intercostal artery.

Answer 45

The correct response is Option D. The most appropriate next step in management is referral to a psychiatrist for evaluation. Gender identity disorder, formerly known as transsexualism, should ideally be managed by a multidisciplinary team. Ideal management includes psychotherapeutic, hormonal, and surgical treatments. Initial care involves a diagnostic phase in two stages. The goal of the first stage is to establish the diagnosis according to well-defined criteria and to rule out other psychiatric disorders. The second stage of the diagnostic phase is a ?real-life test,? in which the patient assumes the role of the opposite sex. Ongoing supportive psychotherapy is often required. Some centers begin hormonal therapy during the ?real-life test? to assist the transition and to make the test more realistic. Most centers defer hormonal therapy until 1 year following initial contact with the patient; surgery is deferred for 2 years following contact. There are no well-established protocols to guide the surgical sequence.

Answer 46

The correct response is Option E. What follows is the description from the original records found in Paris, France: "In 1841, Alfred Poland, a 19-year-old medical student at Guy's Hospital in London, England, published the classic description of the syndrome that bears his name. Serving as an anatomy demonstrator, Poland recorded that, in his subject: 'the whole of the sternal and costal portions of the pectoralis-major muscle were deficient; but its clavicular origin quite normal. In the left hand, the middle phalanges were absent. The web between the fingers extended to the first articulation the hand was shorter than the right the left thumb was quite normal.' In a footnote, he indicated that 'the hand has been deposited in the Museum of Guy's Hospital.' Poland was a popular teacher and later pursued a distinguished surgical career." (Charlier P, Deo S, Galassi FM, Benmoussa N. Poland syndrome before Alfred Poland: the oldest medical description [Paris, France, 1803]. Surg Radiol Anat. 2019;41[10]: 1117-1118.) Today, Poland syndrome presents a spectrum of chest wall anomalies ranging from simple to complex. These deficiencies are largely cosmetic, with the most common (simple) form presenting as a unilateral absence of the sternocostal head of the pectoralis major muscle. The deformity can also be complex, with ipsilateral absence of ribs, axillary webbing, and foreshortening of the hemithorax. Reconstructive options for the chest wall depend on anatomical severity, gender, associated anomalies, and, of course, the patient's preference. Clavicular head of pectoralis major muscle is generally present in these patients. Pectoralis minor, absence of serratus anterior, and rib absence may or may not be present in patients with Poland syndrome.

Answer 47

The correct response is Option D. The principles of management of this recurrent right breast cancer include radical resection of all involved tissues (including ribs) and reconstruction with well vascularized flaps. In this case, a right latissimus muscle flap and skin graft was used for reconstruction. No alloplastic material was placed or skeletal thoracic cage reconstruction performed. This is common in these types of patients, because excessive fibrosis caused by the radiation to the chest wall prevents loss of respiratory efficiency through paradoxical motion which otherwise occurs in patients who have more than four ribs involved or a defect larger than 5 cm.

Answer 48

The correct response is Option E. The posterior components separation technique involves dissection in the retro-rectus plane to release the transversus abdominis muscle medial to the linea semilunaris, allowing medialization of the posterior rectus sheath-transversalis fascia complex. This fascial layer is approximated to form the posterior layer of closure. The anterior layer, consisting of abdominal wall musculature, is approximated at the linea alba. Mesh is usually placed in between these two layers. In the more commonly performed anterior components separation technique, the external abdominal oblique is released lateral to the linea semilunaris to permit medialization of the rectus abdominis muscle for abdominal closure. The internal abdominal oblique is not released in anterior component separation. The internal abdominal oblique fascia is released medial to the semilunaris in posterior component separation. References

Answer 49

The correct response is Option E. Gynecomastia is benign enlargement of the glandular breast tissue in a man. It is often related to factors that either results in an increase in estrogen production, or a decrease in androgen production. This can be due to the transient imbalances during puberty, or secondary to medication use, drug use (such as marijuana), testicular pathology, thyroid disease, liver disease, breast cancer, etc. This is in contrast to pseudogynecomastia, which is enlargement of the breast due to fat deposition in the absence of glandular hypertrophy. Pseudogynecomastia is typically seen in the patient who is overweight or obese. Pseudogynecomastia is distinguished from gynecomastia by physical examination. In true gynecomastia, one will palpate enlarged firm glandular breast tissue, as opposed to in pseudogynecomastia, where palpation will reveal a soft fatty breast throughout with no enlargement of the subareolar tissue. History may suggest a pathologic etiology that will be confirmed on laboratory testing. Medication and drug use questioning will show if the gynecomastia is pharmacologic in origin. Mammography and MRI will aid in determining if there is a malignant etiology causing the breast tissue enlargement. However, it is not standard for gynecomastia evaluation.

Answer 50

Correct answer is option C. Separation of components of the abdominal wall is fast becoming a first-choice procedure for large ventral defects. The procedure involves medial advancement of the rectus abdominis muscle flap after division of the aponeurosis or fascia of the external oblique muscle layer. Properly identifying the correct fascia to incise is a critical step in the procedure, and it relies on knowledge of the abdominal wall anatomy. The rectus abdominis muscles are separated by the midline linea alba, and each rectus muscle is medial to the layered triad of muscles—the external oblique, internal oblique, and transversus. Division of external oblique fascia is properly performed lateral to the linea semilunaris, which represents the lateral border of the rectus sheath, which is formed by the contributions of the external oblique, internal oblique, and transversus layers as the envelope of the rectus abdominis muscle. Above the arcuate line, the later layers split around the rectus muscle at the level of the internal oblique, forming both the anterior and posterior rectus sheaths; however, below the arcuate line, all layers travel anteriorly, forming the anterior sheath but no distinct posterior rectus sheath. The inguinal ligament exists between the anterior superior iliac spine and the pubic symphysis and should not be divided in component separation. Transverse tendinous inscriptions interrupt the rectus sheath, and division of the anterior rectus sheath or the inscriptions is not part of the classic component separation.

Answer 51

Correct answer is option C. The latissimus dorsi myocutaneous flap is one of the most commonly used flaps for anterior and anterolateral chest wall reconstruction. However, the thoracodorsal pedicle may have been ligated in a previous axillary dissection. Patency of the thoracodorsal pedicle can be confirmed with angiography, CTA or MRA. However, in a patient with stage 4 chronic kidney disease, there is a high risk for contrast induced nephropathy with iodinated contrast material, and nephrogenic systemic fibrosis with gadolinium. Furthermore, radiation may make dissection and creation of a tunnel around the area of the axilla and lateral chest wall difficult. In an elderly patient with medical comorbidities, a quick, safe and reliable operation is desirable. The external oblique myocutaneous flap provides good soft tissue coverage of the lower anterior chest wall. The TRAM flap the most common method of autologous breast reconstruction. However, patients with COPD rely on abdominal wall musculature as accessory muscles of respiration. The omental flap provides well vascularized soft tissue for anterior and lateral chest wall defects. However, it requires an intra-abdominal operation, which will increase the risk of post-operative respiratory complications in a patient with COPD . Free flaps are used when local flaps options are not available or not sufficient for reconstructive needs. Moreover, a long operation with the added risks of free flap associated complications would not be desirable in this patient in the presence of a simple reliable pedicled flap option. correct answer is option C.

Answer 52

The correct response is Option B. This patient €™s mother should be counseled that a strong association exists between renal disease and polythelia. Kidney abnormalities such as cysts, duplications, or unilateral renal agenesis can be found in 14% of sporadic and 32% of familial cases compared with those seen in 1% to 2% of the general population. Nineteen percent of patients with adenocarcinoma of the kidney have polythelia and 16% of patients with end-stage renal disease have polythelia. In addition, other organ systems can have abnormalities, including conduction disturbances of the heart and congenital heart and gastrointestinal and central nervous system anomalies. Due to the significant incidence of congenital and acquired disorders in patients with polythelia, patients and families should be aware of the need for complete physical examination, urinalysis, and renal ultrasonography. The presence of extra nipples in children should heighten suspicion for possible renal and other anomalies.

Answer 53

Correct answer option D. The triceps, teres major, and teres minor muscles comprise the borders of the triangular space. A knowledge of this region is essential to harvest the scapular and parascapular flaps, which receive their blood supply from the circumflex scapular artery. The pedicle of the parascapular flap arises from the triangular space and enters the deep surface of the flap. The other muscles listed above can be identified in the region of the shoulder and trunk but do not define the triangular space.

Answer 54

The correct response is Option C. A retrospective chart review of 77 patients was conducted over a 7-year period, focusing on patients with sternum dehiscence who underwent pectoralis major transposition for sternal reconstruction. Female sex, smoking, detachment of the humeral insertion, and operation time are associated with postoperative wound complications. Breast size in women was previously found to be a risk factor for the development of post-sternotomy mediastinitis. Jones et al. found that recurrent dehiscence after tissue-flap coverage of the sternum occurs more frequently in obese women with large pendulous breasts. An association between female sex and recurrent wound dehiscence was also found in the study. This might have been caused by traction of large breasts on the wound edges or devascularization of mammary tissue. Due to the retrospective nature of this study, breast size as a cofactor could not be included in the analysis. Age, pectoralis major harvest, hypertension, and coronary artery disease are not independent risk factors for recurrent sternotomy dehiscence.

Answer 55

The correct response is Option E. Postnatal repair of myelomeningocele is performed within the first 48 hours of life. Later repair is associated with worse outcomes. Myelomeningocele is a protrusion of the meninges and spinal cord via a defect in the caudal neural tube. The higher the level of the defect, the more severe the associated abnormalities, such as bowel and bladder dysfunction, lower limb sensory and motor abnormalities, and structural abnormalities (eg, club feet). Central nervous system problems include hindbrain herniation (Chiari II malformation), tethered cord and hydrocephalus. MRI can be performed to further delineate fetal central nervous system abnormalities. Gadolinium is not given in pregnancy as it is associated with fetal morbidity and mortality. The neurologic abnormalities caused by myelomeningocele are described by the "two-hit" hypothesis. The failure of the neural tube to close (first hit) results in exposure of the neural elements to amniotic fluid (second hit). Prenatal closure is thought to improve neurologic outcomes by decreasing the duration of exposure of neural elements to amniotic fluid. The management of myelomeningocele study (MOMS) is the only randomized-controlled trial that evaluated the outcomes of fetal surgery for myelomeningocele. The trial was stopped early because of improved outcomes in the prenatal correction group. The biggest difference was in the incidence of shunt-dependent hydrocephalus, which was 82% in the postnatal group and 40% in the prenatal group. The prenatal group also had better outcomes for mental development and motor function. However, there was a higher incidence of preterm labor and uterine dehiscence at delivery in the prenatal surgery group. Prenatal repair is performed between 19 and 27 weeks’ gestation. Cesarean delivery is the preferred method of delivery for fetuses with myelomeningocele at many centers. This is performed when the fetus reaches term (i.e., 37 weeks' gestation). Cesarean delivery avoids trauma to the neural tube, maintains an aseptic environment, and allows elective scheduling of meningomyelocele surgical correction.

Answer 56

The correct answer is option E. This patient has Poland syndrome, which is characterized by unilateral breast or nipple hypoplasia, unilateral absence of the sternal head of the pectoralis major muscle, absence of the pectoralis minor muscle, and ipsilateral syndactyly or hypoplasia of the ipsilateral extremity. In severe Poland syndrome, rib anomalies also occur. Ambiguous genitalia, craniosynostosis, microtia, and pectus excavatum are not associated with Poland syndrome.

Answer 57

The correct response is Option B. Anabolic steroids have sex-specific adverse effects. Development of breast tissue in men, a condition called gynecomastia (which is usually caused by high levels of circulating estradiol), may arise because of increased conversion of testosterone to estradiol by the enzyme aromatase. Decreased sexual function and temporary infertility can also occur in men.

Answer 58

Correct answer option E. Exposure of the donor muscle to radiation is most likely to result in the development of total muscle necrosis. Although there can be many causes of flap failure, a history of radiation is associated with a significant risk for complete necrosis. Previously irradiated muscle should not be used for flap transfer. A history of smoking is associated with an increased incidence of complications following surgery because microcirculation is affected. This is especially true in a patient who regularly smokes cigarettes at the time of the procedure. However, total muscle necrosis is unlikely; partial muscle necrosis is more common. Patients with hypertension and/or diabetes mellitus are not at increased risk for development of total muscle necrosis. Previous irradiation of the wound is not a risk factor for development of muscle necrosis because it does not affect the donor muscle. Complete debridement of all the necrotic and nonviable tissue found in the wound should be performed prior to flap transfer.

Answer 59

The correct response is Option A. Accessory mammary structures are found along the embryonic milk line, which forms on the ventrolateral body wall from the axilla to the groin. These structures include most supernumerary breasts, which are most often found in the axilla just above or below the normal breast or in the groin. True accessory mammary structures occur less frequently in the inner surface of the upper arm and/or the inner surface of the thigh or the vulva. Ectopic mammary structures are found outside of the embryonic milk line and represent either the ectopia or displacement of the milk line. Ectopic breast tissue has been reported in the midline of the face, ear, neck, back, buttock, and outer thigh.

Answer 60

Correct answer is option A. Blood is supplied to the abdominal wall both by direct cutaneous vessels and musculocutaneous vessels. Haddad demonstrated the exact locations of these vessels using arteriography. Huger later classified the vascular supply into simple zones for use in abdominal lipectomy. This classification can be applied to abdominal reconstruction. The mid-abdomen is supplied primarily by the deep epigastric arcade. The superior epigastric artery arises from the internal thoracic artery and descends with the posterior rectus sheath. The deep inferior epigastric artery arises from the external iliac artery and ascends with the posterior rectus sheath. Each of these vessels supplies branches to the rectus muscle and overlying skin. The lower abdomen is supplied by branches of the epigastric arcade and the external iliac artery. The superficial epigastric and superficial external pudendal arteries originate from the femoral artery running superficial to the fascia to supply the overlying skin. The inferior epigastric artery on the posterior rectus sheath supplies the underlying muscle in this zone. The deep circumflex iliac artery supplies the muscles in the area of the anterior iliac spine. The flanks and lateral abdomen are supplied by the intercostal, subcostal, and lumbar arteries. These vessels arise from the aorta and give off perforators to the back and flank. They travel circumferentially on the transversus abdominis, perforating the oblique muscles and supplying the overlying skin.

Answer 61

Correct answer is option D. The most appropriate option in the patient described is an omental flap with skin grafting. The defect encompasses the entirety of the sternum, from the sternal notch to the xiphoid. The first-line muscle flaps for this defect would usually be bilateral pectoralis muscle flaps (that do not include a left pectoralis turnover flap option due to the lack of a left internal mammary artery (IMA) used for the coronary graft). However, this option has already been used. An omental flap has an axial blood supply that is not compromised (the gastroepiploic) and the ability to completely span the defect and obliterate the dead space; the skin graft provides the skin coverage needed to complete the reconstruction. Hence, it is the optimal choice in this patient. An adjacent tissue transfer of random skin flaps bilaterally would not obliterate the dead space and would not provide robust axial blood supply to the necessary area, with the tenuous coverage existing along the sternal midline, exactly where the most vital blood supply would be necessary. A left rectus abdominis turnover flap would not be an appropriate option for two reasons: 1) the left IMA has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based; and 2) it would not reach the upper portion of the defect. A left superior epigastric artery perforator fasciocutaneous flap would not be an appropriate option for two reasons: 1) the pedicle is compromised from the left IMA harvest; and 2) muscle flaps have been proven to be optimal for sternal defects more than fasciocutaneous flaps. A right latissimus muscle flap may be a viable choice to get full coverage of the defect with dead space obliteration. However, the option indicates this is a myocutaneous flap, which would not allow for sufficient skin to be harvested to reconstruct the size of this defect.

Answer 62

The correct response is Option B. When considering how best to treat pectus excavatum in the female patient, it is important to recognize that the majority of the contour deformity is due to the thoracic concavity with only a small portion of the deformity due to actual breast tissue hypoplasia. However, reinsertion of a correction bar is not always successful in correcting the thoracic deformity in post-adolescent patients whose bones have ossified, and is only done in extreme cases. Augmentation mammaplasty is also unsuccessful, regardless of implant volume, since, as stated above, only a small portion of the defect is actually caused by breast tissue asymmetry. Although some might consider autologous fat grafting a viable option for correcting both the chest wall defect and the hypoplastic breast, there have been reports that indicate that injecting between the tight adhesions of presternal skin and bone is technically challenging and rarely successful. Injection of cultured autologous chondrocytes, which is still in the early stages of research and development, would prove to be equally technically challenging, and at this time, de novo generation of cartilage or fat for injection into soft-tissue defects is still unproven. As a result, customized silicone elastomer implants are commonly used in conjunction with augmentation mammaplasty to provide consistent and reliable correction of pectus excavatum and breast asymmetry in the female patient. Studies have shown that placing a custom sternal prosthesis and bilateral breast implants during one surgery is both safe and effective in producing an improved aesthetic result.

Answer 63

The correct response is Option C. The patient above has Poland syndrome. Poland syndrome represents a spectrum of congenital chest wall anomalies ranging from the simple form (depicted in the preoperative photograph) to complex. The pathognomonic feature is the absence of the sternocostal head of the pectoralis major muscle. A variety of other ipsilateral chest wall and upper extremity malformations may be present, including absence of ribs two through five, foreshortening of the limb, brachysyndactyly, hypoplasia/aplasia of the breast and nipple-areola complex, and absence/hypotrophy of various trunk muscles including the latissimus dorsi, serratus anterior and external oblique. Although a few familial cases have been reported, Poland syndrome is believed to be sporadic in nature with an incidence of 1:100,000. There is a male-to-female predilection of 3:1, with a right-sided predominance in boys of 2:1. The patient is shown two months after reconstruction with a right latissimus flap and bilateral silicone gel-filled implants. The trunk develops from the fusion of the ectoderm/neural crest layer with the somatic mesoderm during the fourth week of gestation. Mesoderm gives rise to somites, which differentiate into the dorsolateral dermomyotome and the ventromedial sclerotome. The dermomyotome gives rise to the musculature of the trunk and extremities. The sclerotome surrounds the developing spinal cord and notochord and forms the vertebral bodies and spinal skeletal structure. The notochord acts as a pathway for the development of the spinal cord and vertebral bodies. The notochord degenerates as the vertebral bodies develop and becomes the nucleus pulposus of the intervertebral disks. The exact pathophysiology of Poland syndrome has not been elucidated. One theory suggests a mechanical disruption of the embryonic blood supply in the subclavian/vertebral systems during the sixth to seventh week of gestation. Another theory suggests the etiology to be an injury or developmental failure of the mesodermal plate during the third to fourth week of gestation. Endoderm is the primitive germ layer that gives rise to the epithelium of the respiratory and gastrointestinal tracts. Ectoderm is divided into surface ectoderm and neuroectoderm. Surface ectoderm gives rise to the epidermis, adnexal structures of the skin, and the mammary glands. Neuroectoderm becomes the central nervous system, various neural ganglia, and the branchial arches.

Answer 64

The correct response is Option E. The patient described meets criteria for Poland syndrome. This complex includes breast and/or nipple-areola complex hypoplasia, absence of the sternal head of the pectoralis major, rib abnormalities, and syndactyly or symbrachydactyly, fused and shortened digits. Polydactyly (multiplication of digits), macrodactyly (overgrowth and enlarged digits), arachnodactyly (long fingers), and acrosyndactyly (fusion of distal aspects of digits only) are not usually associated with Poland syndrome.

Answer 65

Correct answer is option E Fillet flaps utilize an amputated part for reconstruction, which minimizes donor site morbidity, as there are no additional flap harvest sites. The forearm tissue is typically not involved with tumors around the shoulder girdle and can be used to reconstruct the lateral thoracic defect in forequarter amputations. Flap pedicle is an astomosed to suitable chest or neck vessels. A full thickness skin graft will not take over a non-vascularized structure like a prolene mesh. The ipsilateral latissimus dorsi pedicle is frequently sacrificed in an extensive forequarter defect. A free latissimus or ALT flap would incur an additional donor site.

Answer 66

The correct response is Option E. Gynecomastia, enlargement of the male breast, may occur as physiologic temporary overgrowth of the adolescent breast or it may appear during adulthood as a result of numerous etiologies. It can consist of various proportions of excess subareolar fibrous breast tissue and adipose tissue in the periphery, with the extent often depending upon the habitus of the individual. Appearing at about age 14 in more than 65% of healthy boys, gynecomastia will typically resolve within 2 years of onset in otherwise healthy males. Persistence of adolescent-onset gynecomastia after age 21 is unlikely to resolve with conservative measures. Hormone blockers have no place in the management of persistent breast tissue in otherwise healthy individuals. A wide variety of surgical treatment options for resection of redundant male breast tissue have been published. These include direct excision through a number of described incisions, traditional and ultrasound-assisted liposuction, and recently, use of an arthoscopic shaver. Ultrasound-assisted liposuction may have an advantage in stimulating skin retraction for cases where mild to moderate ptosis exists when scar minimization is desired. For otherwise uncomplicated gynecomastia, excision of fragmented subareolar tissue via a limited areolar border incision with the pull-through technique is the most appropriate choice of therapy. When redundant skin exists in addition to excess male breast tissue, immediate skin resection via periareolar, transverse lenticular, omega-shaped, or Wise (inferior pedicle) incision are among the numerous methods described. Regardless of the resection method, an evolving trend favors allowing skin to retract for 6 to 9 months before determining whether there is a need to subject the individual to additional incisional scarring.

Answer 67

The correct response is Option C. Before the advent of microsurgical techniques, the procedure to replant a penis was rudimentary – surgeons would simply suture the approximate corporal bodies and the overlying tunica. Although successful occasionally, this technique was prone to partial necrosis of the glans or shaft and was associated with sexual and erectile dysfunction. The use of microsurgical techniques has allowed surgeons to repair transected structures more precisely and achieve significantly improved results. A review of the current published literature on penile replantations finds that, in addition to repair of the urethra, the three neurovascular structures that are repaired consistently are the dorsal nerves, dorsal veins, and the deep dorsal artery. Generally, a suprapubic catheter is placed to divert urinary flow for 2 to 3 weeks while the urethral repair heals. The cavernous artery is buried within the substance of the corpus cavernosum and is technically difficult to repair. The circumflex artery runs circumferentially through collateral circulation and would not be repaired normally. The pudendal artery is a branch of the internal iliac vessels and is located much more proximally in the pelvis. It gives rise to the inferior rectal artery, perineal artery, posterior scrotal artery, and the deep dorsal artery. The subtunical venous plexus is extremely small and would be technically difficult to repair.

Answer 68

The correct response is Option C. The component separation technique can be used to achieve medial transposition of the rectus muscle and overlying anterior fascia. The surgery involves division of the external oblique fascia and muscle lateral and parallel to the linea semilunaris. The plane deep to the external oblique muscle, which is relatively avascular, is then dissected laterally. The rectus muscle is also separated off of the posterior rectus sheath (using access from the medial laparotomy or hernia incision). This allows for medial advancement of the rectus muscle, overlying anterior rectus sheath, internal oblique muscle, and transversus muscle as a unit. The segmental neurovascular bundles course deep to the internal oblique muscle and penetrate into the rectus muscle 10 to 25 mm medial to its lateral margin. The component separation technique, when performed in the scenario described, can give unilateral advancement toward the midline approximately 10 cm at the level of the umbilicus, which equates to a bilateral advancement of 20 cm. The least amount of advancement is in the subxiphoid and subcostal regions, often making more cranially located defects more difficult to close. Since it was originally reported in 1990, several modifications and variations of this technique have been described in the literature. These include perforator-preserving and/or endoscopic techniques to methods that describe additional maneuvers to increase mobilization or improve durability with the addition of biologic or prosthetic meshes.

Answer 69

Correct answer is option D. Patients with extensive comorbidities, post-surgical systemic complications, visceral edema with loss of domain, and extensive infection or tissue loss may be managed with a delayed abdominal wall repair. The timing of such is debatable however early abdominal closure is preferable to delayed closure (> 6 mos) in order to avoid the obligate hernia defect and large scale secondary hernia repair.

Answer 70

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.

Answer 71

The correct response is Option A. The number of male body contouring procedures performed in the United States has been steadily increasing over recent years, and correction of high-grade gynecomastia remains one of the most challenging procedures performed by plastic surgeons today. A grading system for gynecomastia was originally described in 1973 and later modified in 2003. Pseudogynecomastia after massive weight loss, in which the redundant breast tissue consists primarily of fat and skin, has been separately classified, and a grading system was published in 2008. Although there are minor differences between the varying classification schemas, it is generally agreed that high-grade gynecomastia, with severe ptosis and a large amount of redundant skin, may require skin resection and movement of the nipple-areola complex using either a pedicled or free nipple grafting technique. The proper position, shape, and viability of the nipple-areola complex remain the major factors in successful outcome after mastectomy and free nipple grafting in the correction of gynecomastia. Many studies have evaluated these parameters with results that are fairly consistent, although recommendations can be somewhat formulaic and cumbersome. In the simplest of schema, 100 normal male volunteers were measured to determine the appropriate anatomical parameters for nipple position and areolar diameter. It was found that patient height was the most important fixed parameter from which nipple position should be calculated. The average diameter of the nipple-areola complex in men was found to be 28 mm, and the sternal notch-to-nipple distance was found to be 20 cm. These numbers may, however, apply less in the setting of obesity or severe weight loss. One consistent finding with respect to nipple-areola configuration in men is the shape. In one study of 100 healthy male subjects performed in 2001, it was found that 91% had an oval-shaped complex with a mean ratio of horizontal-to-vertical diameter of 27:20 mm. The mean nipple-areola diameter of the 9% of patients who had a round complex was 2.3 cm. It was also found that the center of the nipple-areola complex was in the fourth intercostal space in 75% of patients and in the fifth intercostal space in 23% of patients. Unsatisfactory results after surgical correction of gynecomastia are largely secondary to improper nipple placement, with the nipple-areola complex being placed too low and close to the sternum. Moreover, to avoid a €œstuck-on € appearance, use of a small oval, rather than a perfectly round shape, will result in a more natural appearance.

Answer 72

The correct response is Option D. Although recurrence rates are generally very high for large ventral hernias, placement of mesh in the retrorectal position appears to have the most decreased rate of recurrence compared with other methods. Placement above the plane of the rectus muscle requires division of vascular perforators that traverse the rectus muscle and perfuse the overlying skin flaps. These perforating branches of the epigastric circulation are most dense in the periumbilical zone. Preservation of the perforators has been shown to be beneficial in a number of case series reports. Placement of mesh between the oblique muscles in this case would not provide support for the midline hernia because these muscles are more lateral. Hernia recurrence rates are generally more increased in the presence of infection, with large defects when the rectus muscles cannot be advanced back together in the midline, in obese patients, and in patients with multiple medical comorbidities. Patients with several risk factors can expect recurrence rates in the range of 20 to 40%, whereas patients with few risk factors have recurrence about 5% of the time.

Answer 73

Correct answer is option D. The most effective treatment of the sternal wound infection described is initial debridement to healthy bleeding tissue and bone, removal of all foreign bodies, and immediate closure with bilateral pectoralis major muscle flaps. Post‑sternotomy wounds are classified according to the duration of time that has elapsed between the sternotomy and the clinical onset of the infection. Type I infections occur within the first week after sternotomy and have no bony involvement. Type II infections occur during the second to fourth weeks after sternotomy. Bony involvement is frequent, but chostochondritis is rare. Type III infections occur months to years after sternotomy and typically involve chronic draining sinus tracts. Osteomyelitis, chostochondritis, and retained foreign bodies are all common. The patient described had a Type III infection with a deep sinus tract as confirmed by CT scan. Although delayed closure had previously been considered the treatment of choice for Type III sternotomy wounds, more recent data suggest that a single-stage approach with bilateral pectoralis major muscle flaps results in quicker recovery, improved cosmesis, and decreased morbidity and mortality compared with staged approaches. Given the chronicity of the wound, all foreign bodies, including retained suture material and wires, should be removed. Pectoralis major turnover flaps provide additional bulk and might therefore be considered preferable. However, the left internal mammary artery has been harvested in this patient, compromising the blood supply to the left pectoralis major turnover flap.

Answer 74

Correct answer is option A. The omentum has dual major pedicle blood supply through the right gastroepiploic and left gastroepiploic arteries. It provides bulk and can adequately cover lower sternal defects. Typically, skin grafting may be required over the omentum. The pectoralis major muscle flap can be used as an advancement flap (thoracoacromial artery pedicle) or as a turnover flap based on the internal mammary perforators. A pectoralis major muscle turnover flap can potentially reach a lower sternal defect, whereas this can be challenging for a pectoralis advancement flap. The thoracoacromial artery is the pedicle for the pectoralis major muscle advancement flap. It would be difficult for the pectoralis major muscle advancement flap to reach a lower sternal defect. A vertical rectus abdominis muscle flap can be used, particularly for lower sternal defects, but it is based on the superior epigastric artery, not the inferior epigastric artery, when it is pedicled for chest reconstruction. A left pectoralis major muscle turnover flap would reach the lower sternal defect. However, it is based on the internal mammary artery perforators and cannot be used in this patient due to his history of using the left internal mammary artery for coronary artery bypass. The transverse cervical artery supplies the trapezius muscle and supraclavicular flap. Neither flap would reach the lower sternal defect. References: 1. Izaddoost S, Withers EH. Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases. Ann Plast Surg. 2012;69(3):296-300. doi:10.1097/SAP.0b013e31822af843 2. Hamaguchi R, Shekar PS, Johnson JA, Orgill DP. Current management of sternal wounds. Plast Reconstr Surg. 2021;148(6):1012e-1025e. doi:10.1097/PRS.0000000000008510 3. Isaac KV, Elzinga K, Buchel EW. The best of chest wall reconstruction: principles and clinical application for complex oncologic and sternal defects. Plast Reconstr Surg. 2022;149(3):547e-562e. doi:10.1097/PRS.0000000000008882

Answer 75

The correct response is Option E. Implant infection is a common clinical complication of abdominal hernia repair. Use of biologic mesh in contaminated cases has gained widespread acceptance. The ability of acellular dermal matrix (ADM) to revascularize is most likely the key to its successful application in contaminated scenarios. Revascularization subsequently helps clear bacteria. Contraction is a normal part of wound healing mediated by myofibroblasts, which are not present in polytetrafluoroethylene (PTFE) or ADM. Encapsulation is a foreign body reaction, whereby the organism forms a sterile scar around an alloplastic material. Imbibition is the process by which autogenous grafts perform initial metabolic exchange through diffusion. Inosculation is the first stage of neoangiogenesis, whereby immature vasculature between graft and recipient bed begin to organize in preparation for ingrowth. Neither process occurs in PTFE or ADM, as there is no existing vasculature in either product.

Answer 76

The correct response is Option C. A component separation procedure allows for the primary closure of central abdominal wall musculofascial defects without excessive tension. In the classically described procedure, the external oblique aponeurosis is released lateral to the linea semilunaris, allowing for medial advancement of the rectus abdominis along with the internal oblique and transversus muscles. The innervation and vasculature to these structures are preserved in order to maintain functional integrity of these abdominal wall muscles. The vertical and transverse rectus abdominus musculocutaneous flaps along with the anterolateral thigh flaps are primarily used to reconstruct soft-tissue defects but are unlikely to result in a functional abdominal wall.

Answer 77

The correct response is Option E. The lesion in this patient is a desmoid tumor, also known as aggressive fibromatosis. It is a benign tumor, usually found in younger patients between 10 and 40 years old, and is locally aggressive. It is oftentimes associated with pregnancy and prior surgery, and can frequently recur. Treatment is en bloc full-thickness wide local excision (usually with frozen section confirmation of negative margins). As aggressive full-thickness abdominal wall resection is standard of care, reconstruction is more challenging. If midline fascia can be reapproximated, it should be, as primary fascial closure is associated with the lowest hernia recurrence rates. Reinforcement with mesh has been prospectively demonstrated to reduce recurrence rates even further, especially in defects over 4 cm. If midline fascial reapproximation is not possible, reduction in the size of the defect is crucial to decrease recurrence rates. This is done by component separation. However, in this case, only a right component separation is possible, given that the tumor has invaded the left rectus muscle and obliques, precluding their use for myofascial advancement. If the obliques had been spared, a component separation could still have been attempted even if there were violation of the rectus. The most durable reconstruction would be achieved if midline fascial reapproximation were possible with mesh reinforcement. Second best would be reduction in the size of the defect with a right component separation and placement of mesh as a bridging underlay. There is no role for neoadjuvant chemotherapy or radiation therapy in the treatment of these tumors.

Answer 78

The correct response is Option D. Scar minimization is a priority when possible in patients with gynecomastia. The patient’s acceptable BMI, absence of weight change, and physical description imply minimal skin excess, making him a candidate for limited scar techniques. Direct excision of the central gland through periareolar incision with liposuction for marginal contouring would address the patient’s condition without excess scarring. Liposuction alone is unlikely to adequately address the firm central glandular tissue under the nipple-areola complex. The other techniques such as inverted-T pattern breast reduction with inferior pedicle, horizontal scar breast reduction with nipple-areola grafting, and skin-sparing mastectomy with nipple-areola tattoo would all unnecessarily increase scarring.

Answer 79

The correct response is Option C. The most appropriate reconstructive option is to place a subcutaneous expander on the left side and perform a reduction of the right breast. This patient is still going through puberty and has a few years of growth left. However, her breast asymmetry is severe, symptomatic, and negatively impacting her life. Additionally, she has a good social support system with parents who are actively engaged in her well-being. Surgery that can potentially have permanent changes in a person’s physical anatomy (e.g., scars), and potentially negative consequences (e.g., inability to breast-feed) must be performed with very detailed and complete informed consent, especially in minors. On the other hand, doing nothing could also lead to potentially negative social, emotional, psychological, and physical consequences. Therefore, if the patient and parents understand the risks and benefits, and are fully informed, surgical treatment is warranted in situations such as the one described. In this situation, simply placing an expander on the left side and not addressing the symptomatic right breast does not take care of all of her issues. A reduction of the right breast will not only help with her symptoms of breast hypertrophy, but will also enable a more symmetric reconstruction. Using a prosthesis to mimic an E cup breast is not ideal and will not succeed. Reducing the breast to about a C cup will allow the surgeon a realistic chance to reconstruct the left side to mimic the right breast. The expansion process on the left side would then continue until volume symmetry is attained compared with the right side. Through her growing years, the expansion process could continue. When she stabilizes in terms of her breast growth, the expander can then be substituted with a permanent prosthesis. A contralateral further reduction/lift can also be performed as needed. An ipsilateral latissimus muscle flap can also be performed simultaneously to recreate the anterior axillary fold or fill the infraclavicular space if grossly concave. However, the latissimus muscle flap in and of itself does not have the amount of tissue needed for larger breast reconstructions, as in this case, and needs a simultaneous expander placed under it for that reason.

Answer 80

The correct response is Option E. The chest findings described are consistent with Poland syndrome with absence of the sternocostal head of the pectoralis major muscle. Poland syndrome can be associated with hand abnormalities, including shortened digits. Cleft lip, accessory nipple, clubfoot, and microtia are not known to be associated with Poland syndrome.

Answer 81

The correct response is Option C. Assessment of the chest CT shows right-sided absence of the pectoralis major and minor muscles and breast hypoplasia. The patient suffers from Poland syndrome, which is a congenital disorder of unknown etiology with the prevailing theory being hypoplasia of the subclavian artery or its branches during the sixth week of embryogenesis. Variability exists in physical findings with the most common being: anterior axillary fold and pectoralis major sternal head absence, breast gland thinning, rib and cartilage hypoplasia, and ipsilateral brachysyndactyly. After local wound care and antibiotic therapy, the patient had resolution of her symptoms. A type IV Wassel preaxial polydactyly is the most common congenital thumb duplication but is not associated with Poland syndrome. Radial club hand is more common than ulnar club hand, but has no association with Poland syndrome. Both are congenital hand deformities, but unrelated to the pathological condition mentioned. Radial head subluxation is also known as "nursemaid's elbow." Nursemaid's elbow is a common injury of early childhood. It is sometimes referred to as "pulled elbow" because it occurs when a child's elbow is pulled and partially dislocates. There is no connection between Poland syndrome and increased incidence of radial head subluxation. Type IV Manske modification of the Blauth classification thumbs (the "pouce flottant" thumb) have rudimentary elements and are attached to the hand by a small skin bridge. These thumb anomalies are not associated with Poland syndrome.

Answer 82

The correct response is Option C. Abnormal breast development may affect the psychological progress of a teenaged girl. If the definitive reconstruction is performed too early, additional growth may result in asymmetry. If intense anxiety is encountered in a young female patient, early intervention can be considered. In the patient described, a subcutaneous tissue expander can be placed because the sternal portion of the pectoralis is missing. Subsequent expansion can be performed as the opposite breast develops. The soft-tissue envelope will expand to eventually allow placement of a permanent prosthesis under a latissimus dorsi muscle flap. Placement of a saline breast prosthesis covered by a latissimus dorsi flap is not appropriate because additional development will likely require a larger prosthesis. Furthermore, as the patient grows, the latissimus with fat added or buried skin paddle may be required to further enhance areas of soft-tissue deficiency. Injection of autologous fat is not currently accepted for breast augmentation. Placement of a tissue expander covered by a latissimus dorsi flap is also not appropriate because expansion will attenuate the muscle. Reconstruction with a TRAM flap is not appropriate because the patient will not have a definitive reconstruction with a matching breast. In addition, TRAM flaps are contraindicated prior to childbearing.

Answer 83

The correct response is Option D. Hernia repair is associated with a high rate of recurrence, approaching 20% in many studies. Recurrence rates are lowest when primary fascial closure of the abdominal wall is reinforced with mesh placement as an underlay. Primary fascial closure alone or with component separation results in a higher recurrence rate than primary fascial closure with mesh reinforcement. In this example, it is unlikely that primary fascial closure would be possible, given a 10-cm hernia defect. With regard to mesh placement, there are multiple planes at which the mesh can be placed. Using a bridging repair, the mesh is used to bridge across a fascial defect and is associated with the highest rates of recurrence. In a retrorectus repair, the mesh is placed deep to the rectus (Rives-Stoppa technique) or below the transversus abdominis (transversus abdominis release technique). This is performed underneath a primary fascial closure. Conversely, in an overlay repair, the mesh is secured superficial to the abdominal wall repair. Retrorectus placement of a mesh is associated with a significantly lower recurrence rate than placement of the mesh in another position.

Answer 84

The correct response is Option C. Component separation for closure of large abdominal wall defects was first described by Ramirez in 1990. The purpose of the surgery is to achieve abdominal wall closure with well-vascularized, innervated muscle flaps. The muscles of the abdominal wall are innervated by the intercostal nerves from T7-L4. The plane below the external oblique and above the internal oblique is an avascular plane that will allow for medial advancement of the rectus muscle flaps while protecting the intercostal nerves that run under the internal oblique.

Answer 85

Correct answer option D. The external oblique turnover muscle flap is not commonly used but has the potential to provide adequate coverage of large defects of the back that extend to the midline at the level of T10 to L4. The upper half of the flap is supplied by the 4th through 11th intercostal arteries, whereas the lower half is supplied by one or two vessels from the deep circumflex iliac artery (95%) or the iliolumbar artery (5%). The upper half has a strictly segmental blood and nerve supply, whereas the lower half has segmental innervation but derives its blood supply from one artery.

Answer 86

The correct response is Option D. A tuberous breast is classically defined as hypoplastic with a constricted and elevated base, insufficient inferior skin, and a herniated nipple-areola complex. Amastia would manifest without a nipple. Poland syndrome is classically described as missing the pectoralis muscle with variable breast and nipple effects. A constricted base and herniated areola are not usually associated with Poland syndrome. Hypertrophy would likely present with a broader base and increased volume. Micromastia would not manifest with a herniated areola.

Answer 87

The correct response is Option A. The lateral breast is mobile, unlike the inframammary fold. Therefore, the footprint can vary slightly and be just behind the anterior axillary fold, but it does not extend to the midaxillary line. The breast footprint is not described as relating to either the latissimus dorsi or the clavicle.

Answer 88

The correct response is Option C. The most appropriate method to reconstruct the wound is a local fascial flap and skin advancement flap. The major principle of tethered cord and myelomeningocele repair is to obtain a well-vascularized layer of soft tissue coverage between the dural and skin closures. The fascia overlying the paraspinous muscles can be turned over as flaps to cover the underlying dural repair. This vascularized soft tissue layer will minimize the risk of cerebrospinal fluid leak by reinforcing the dural repair. In addition, the fascial flaps will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair using skin advancement flaps would place the child at risk for meningitis in the event of a cerebrospinal fluid leak or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a regional gluteal or latissimus muscle flap to cover the dural repair is unnecessary because local tissue (paraspinous muscle fascia) is available. Harvesting the gluteal or latissimus muscles also may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurological deficit.

Answer 89

The correct answer is option B. The patient has pectus excavatum, which is characterized by a deformity causing a concave appearance to the anterior chest wall. This is the most common congenital chest wall deformity and is more common in males. Symptoms include difficulty breathing, embarrassment, exercise intolerance, and decreased endurance. A defect greater than 2.5cm is usually indicative of surgical intervention. Poland syndrome also causes chest wall depression, most commonly due to the absence of the pectoralis muscles. However, in addition, there is usually syndactyly of the ipsilateral hand. Rotation of the sternum and difficulty breathing are not typical symptoms of Poland syndrome. Pectus carinatum and ectopia cordis would not cause a concave appearance. Amastia is the absence of the nipple areola complex and glandular tissue.

Answer 90

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.

Answer 91

The correct response is Option E. Deep sternal wound infections represent life-threatening infections whose most frequent etiology in contemporary cases is surgical site infection following open heart surgery, with a reported incidence of 0.2 to 3% of patients undergoing median sternotomy. Risk factors in adults include diabetes mellitus, obesity, peripheral arterial disease, tobacco use, reoperation, and other surgical complications such as prolonged operative time and postoperative bleeding. Published mortality rates range from 8.1 to 14.8%. Once a diagnosis is made, initial treatment in cases of deep infection typically involve a combination of antimicrobial therapy and staged surgical debridement followed by delayed closure. Sternotomy wounds can be complex problems because of their proximity to heart and lungs and exposure of these vital organs following debridement. Principles of reconstruction once a healthy wound bed has been obtained include durable coverage of vital structures with obliteration of dead space with a view to retaining or restoring optimal form and function. In the case scenario described, a right superiorly based rectus abdominis myocutaneous flap provides the most reliable, well vascularized and non-irradiated option for regional soft tissue reconstruction of the composite chest wall defect (shown). A left vertical rectus abdominis myocutaneous flap is suboptimal in the setting of a relatively compromised superior epigastric vascular pedicle in the setting of known sacrifice of its parent left internal mammary artery (IMA). Latissimus and pectoralis flaps in any form are less reliable in their ability to fully cover inferior third sternectomy defects. While a turnover pectoralis flap can reach the inferior sternum, a left pectoralis turnover flap is furthermore less reliable in the setting of known sacrifice of its inferior segmental internal mammary perforators in the setting of known IMA sacrifice. Skin re-advancement in the setting of prior radiation and distorted perfusion from prior reduction mammoplasty also invites further unnecessary risk.

Answer 92

Correct answer is option a The blood supply to the abdominal wall is diverse, arising from multiple sources uncluding the Superior and Inferior Epigastrics, Superficial and Deep Circumflex Iliacs Intercostals,Subcostals, Superficial External Pudendals and Lumbar Vessels. The blood supply is further divide into zones , referred to as Hugers Zones. Zone 1 is the midabdomen supplied by the deep epigastric arcade. Zone 2 represents the lower abdomen and is supplied by the Superficial Epigastrics and Deep Circumflex Iliac Artery. Zone 3 represents the flanks and lateral abdomen and is supplied by the Intercostal, Subcostal and Lumbar vessels. An avascular plane exists between external and internal oblique muscles and is an important anatomic detail in the components separation performed for the repair of complex abdominal wall hernias.

Answer 93

The correct response is Option D. Adult gynecomastia occurs because of drugs, unresolved pubertal gynecomastia, and unknown causes (idiopathic gynecomastia). Tamoxifen and raloxifene, both selective estrogen receptor modulators (SERMs), can be used for the treatment of male gynecomastia. Indeed, the use of SERMs is recommended to prevent gynecomastia as a result of antiandrogen monotherapy for treatment of prostate cancer. They are most effective, however, when used to treat gynecomastia that has been present for less than 1 year. Anastrozole, an aromatase inhibitor, is recommended for the treatment of breast cancer and as a preventative measure in high-risk women. Surgical resection is the appropriate treatment for painful gynecomastia that has been present for greater than 1 year. Both open resection and liposuction are appropriate techniques. Radiation therapy is indicated to prevent gynecomastia as a result of prostate cancer treatment. Spironolactone is a cause of—not a treatment for—gynecomastia.

Answer 94

The correct response is Option A. Although surgery remains the mainstay of treatment for gynecomastia in this country, results have been inconsistent, with reported dissatisfaction rates as high as 50%. Common aesthetic problems reported after surgery include unacceptable scarring and nipple and areolar deformities such as tethering and malposition. As a result, less invasive techniques have evolved and are now the mainstay of treatment for all but the most severe forms of gynecomastia. The use of ultrasound-assisted lipectomy has improved the outcomes in the treatment of all grades of gynecomastia. In the more severe grades, certain maneuvers will improve skin retraction and redraping and may thus eliminate the need for a subsequent procedure for skin excision. While fatty and fibrous tissue is best approached from a deeper subcutaneous plane, transition to a subdermal plane can allow for greater skin retraction. Moreover, disruption of the inframammary fold is essential in that it allows the skin to drape more naturally onto the abdomen, which is typical of a male breast. The use of wetting solutions is imperative with ultrasound-assisted lipectomy to avoid burns. Both superwet (1:1) and tumescent (3:1) techniques are acceptable. The power of the unit should generally not exceed 90% to avoid burns and dermal injuries. Peripheral feathering improves contour, providing a smoother transition to the outer border of the breast, but does not specifically address skin excess.

Answer 95

The correct response is Option D. Gynecomastia is defined as the benign proliferation of male glandular breast tissue. The most common symptom of gynecomastia is painless breast enlargement in adolescent and elderly men. Examination of a breast biopsy specimen may be necessary to exclude breast cancer if mammography and/or breast ultrasonography are suggestive of malignancy. Microscopic findings include ductal epithelial hyperplasia with proliferation of stroma and fibroblasts. Pseudogynecomastia is defined as breast enlargement secondary to fat deposition without glandular proliferation. Fibroadenoma are the most common benign tumor of the female breast. They are most often diagnosed in women between the ages of 20 and 35 years. Fibroadenomas are often ovoid or spherical, freely movable, and often well circumscribed. Microscopic findings include ductal tissue with proliferation of stroma surrounded by fibroblasts. Ductal carcinoma accounts for the majority of breast cancers. Ductal carcinoma is characterized microscopically by cords and nests of tumor cells with varying amounts of gland formation, and cytologic features that range from bland to highly malignant. Epidermal cysts are inclusion cysts lined by well-differentiated epidermis filled with keratin. Lymphangiomas of the breast are distended lymphatic channels interspersed with breast lobules.

Answer 96

The correct response is Option C. For the definitive diagnosis of Poland syndrome, patients must have absence or hypoplasia of the sternal head of the pectoralis major muscle on the affected side. Other chest wall abnormalities can occur along with the absence of, or hypoplasia of, the ipsilateral breast. These include the latissimus dorsi and serratus anterior muscles. Brachysyndactyly of the ipsilateral upper extremity can be present as well.

Answer 97

Correct answer is option C The arterial supply of the pectoralis muscle is the pectoral branch of the thoracoacromial trunk. It is innervated by the lateral and medial pectoral nerves. It originates from the clavicle , sternum, superior six costal cartilage and the aponeurosis of the external oblique muscle. It also inserts on the intertubercular groove of the humerus.

Answer 98

The correct response is Option B. This patient has class IIAii gynecomastia per the McMaster classification of gynecomastia. To treat this degree of gynecomastia, in which there is 250 to 500 g of tissue that is primarily glandular and associated with marked skin redundancy, direct gland and skin excision with nipple transposition (with or without liposuction) is indicated. Skin excision patterns include a boomerang pattern to correct vertical and horizontal skin excess primarily in patients with massive weight loss. Transverse incisions are used to remove vertical excess. Liposuction would not address the glandular tissue, and skin excision is needed to treat the skin redundancy. Liposuction combined with direct gland excision also does not correct the skin redundancy. Cryolipolysis is indicated for fat reduction, which would not treat the primarily glandular component. Direct gland and skin excision with liposuction does not correct the nipple position.

Answer 99

The correct response is Option D. Meningocele and myelomeningocele are neural tube defects resulting in spinal dysraphism. Both are forms of spina bifida, with myelomeningocele being more severe due to the protrusion and underdevelopment of neural structures and meningocele only involving the meninges, commonly referred to as spina bifida occulta. Cerebellar tonsillar herniation with attendant hydrocephalus is part of myelomeningocele only. Because only the dural sac is involved in meningocele, neural deficits are milder. Alpha-fetoprotein concentration is tested in the first trimester of pregnancy. REFERENCES: 1. Avagliano L, Massa V, George TM, Qureshy S, Bulfamante GP, Finnell RH. Overview on neural tube defects: From development to physical characteristics. Birth Defects Res. 2019;111(19):1455-1467. doi: 10.1002/bdr2.1380 2. Shaer CM, Chescheir N, Schulkin J. Myelomeningocele: A review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals. Obstet Gynecol Surv. 2007;62(7):471-479. doi: 10.1097/01.ogx.0000268628.82123.90

Answer 100

The correct response is Option B. Labioplasty is a common surgical procedure used to reduce the size of excessively protruding or enlarged labia. The condition can result in discomfort or irritation with exercise or intercourse. Frequently, surgery is sought for cosmetic reasons alone. The goal of surgery is to reduce the size of the labia so that they become closer to the level of, or posterior to, the labia majora. Direct amputation-excision should be avoided, as an anterior scar line can cause postoperative discomfort in clothing or with sexual activity. Effective surgical methods use incisions that place the scars inferior, interior, or transverse, such as the inferior wedge resection with superior flap technique. When the surgery is performed properly, long-term sexual complaints are rare. The condition is sporadic in nature and does not seem to be associated with endocrinopathy. The most frequent postoperative complaint is incomplete correction, wherein the patients are not completely satisfied with the aesthetic result (about 15% of cases). Group B streptococcal infection is associated with postpartum infections, not routine genital surgery. Scars typically heal very well, and keloid formation is not a common concern.

Answer 101

The correct response is Option D. The most appropriate next step for the patient described, who is young with a long history of bilateral gynecomastia since puberty, is surgical excision. The onset of gynecomastia correlates with transient elevations of plasma estradiols prior to the completion of puberty so that the androgen-to-estrogen ratio is altered. Suction lipectomy can also be used as surgical treatment for gynecomastia. Most cases of gynecomastia present at puberty, with an incidence as high as 65% in boys 14 to 15 years of age. The condition disappears during the late teens, with only 7.7% remaining at age 17 years. The incidence rises again with progressive age. The condition is often a normal finding, even though it may be associated with a more serious disease in occasional cases. In certain cases, systemic causes — such as liver disease, lung carcinoma, testicular carcinoma, adrenal tumors, thyroid disease, testosterone imbalance, and Klinefelter syndrome — or drugs like marijuana, should be considered. For instance, a prepubescent boy presenting with gynecomastia would cause concern. Another example would be if an adult man presented with a 6-month history of unilateral gynecomastia. A work-up including liver function test, urine studies, testicular examination, endocrinology evaluation, and possibly mammography should be done if there is a possibility of cancer (ie, patients with Klinefelter syndrome).

Answer 102

The correct response is Option A. The pectoralis major muscle has three major blood supplies. In general, the internal mammary perforators and the thoracoacromial vessels are dominant, with additional perfusion through the lateral thoracic artery. Turnover pectoralis flaps for sternal reconstruction based on the internal mammary perforators are generally well perfused. Likewise, in most situations a pedicled myofascial or myocutaneous flap based on the thoracoacromial vessels (with the other blood supplies ligated) is robust and can be used for most types of head and neck reconstruction. Although described earlier, the flap became the "workhorse" of head and neck reconstruction after Ariyan’s classic article in 1979. Versus a free tissue transfer, the pectoralis flap has many detractors, including being tethered to its pedicle. In about 6% of cases, the lateral thoracic vessel is the dominant pedicle to the flap and needs to be incorporated for maximal perfusion for head and neck reconstruction. This of course further decreases some of the mobility of the flap. This phenomenon is usually easily discernible by the larger caliber of the lateral thoracic vessels versus the thoracoacromial vessels. In this case, this was the most likely injured vessel, causing the described outcome. The transverse cervical vessels do supply the posterior thorax, and the intercostal vessels do supply the anterior chest, including breast tissue, but neither gives important perfusion to the pectoralis flap. The lateral pectoral nerve travels with the thoracoacromial vessels and, if not checked when turning the flap, can kink the vascular pedicle and, if not severed, does not allow the flap to decrease in size because of lack of denervation of the muscle. The medial pectoral nerve is another innervation to the pectoralis major muscle and is usually severed during flap elevation. The thoracodorsal artery does not supply the pectoralis muscle.

Answer 103

The correct response is Option E. In the clinical scenario described, the vertical rectus abdominis musculocutaneous (VRAM) flap is the most appropriate choice. This approach can provide enough tissue to resurface the vaginal vault and fill dead space. For posterior defects of the vaginal vault, abdominal-based flaps are usually preferable. They can provide a large amount of vascularized tissue that rotates easily into the defect. Bilateral gracilis muscle flaps alone would offer less soft tissue, and mucosalization in a radiated field is unpredictable. A deep inferior epigastric artery perforator flap is far more complicated than a VRAM flap, and the donor site is problematic in patients with a history of smoking. Primary closure of a large vaginal defect would likely cause significant stenosis and poor healing because of previous radiation. A skin graft with obturator is not likely to be successful given her radiation and tobacco history and violation of the rectum.

Answer 104

The correct response is Option E. The patient described will have a 10 × 16-cm, full-thickness defect of the abdominal wall in the setting of previous radiation. A full-thickness defect this large in the setting of past radiation makes primary closure alone and primary closure with interpositional mesh a poor choice. Bilateral component separation will not be possible because the rectus muscles will be resected with the specimen. A pedicled anterolateral thigh flap will offer well-vascularized, nonradiated tissue that will include soft-tissue coverage as well as fascia for abdominal wall reconstruction. A free latissimus muscle flap, while providing well-vascularized tissue, would involve the increased risks of microsurgery and not provide fascia for closure. Therefore, Option E is most appropriate.

Answer 105

The correct response is Option A. Blood is supplied to the abdominal wall both by direct cutaneous vessels and musculocutaneous vessels. Haddad demonstrated the exact locations of these vessels using arteriography. Huger later classified the vascular supply into simple zones for use in abdominal lipectomy. This classification can be applied to abdominal reconstruction. The mid-abdomen is supplied primarily by the deep epigastric arcade. The superior epigastric artery arises from the internal thoracic artery and descends with the posterior rectus sheath. The deep inferior epigastric artery arises from the external iliac artery and ascends with the posterior rectus sheath. Each of these vessels supplies branches to the rectus muscle and overlying skin. The lower abdomen is supplied by branches of the epigastric arcade and the external iliac artery. The superficial epigastric and superficial external pudendal arteries originate from the femoral artery running superficial to the fascia to supply the overlying skin. The inferior epigastric artery on the posterior rectus sheath supplies the underlying muscle in this zone. The deep circumflex iliac artery supplies the muscles in the area of the anterior iliac spine. The flanks and lateral abdomen are supplied by the intercostal, subcostal, and lumbar arteries. These vessels arise from the aorta and give off perforators to the back and flank. They travel circumferentially on the transversus abdominis, perforating the oblique muscles and supplying the overlying skin.

Answer 106

The correct response is Option A. The patient described has amastia, a congenital condition that involves absence of the nipple €‘areola complex and glandular tissue. Amazia is the absence of glandular tissue only. Athelia is the absence of the nipple alone. Pectus excavatum is a congenital defect of the thoracic wall, consisting of a concave deformity of the mid thorax. Reconstruction is indicated for aesthetic reasons or, in severe cases, for relief of cardiorespiratory dysfunction. Poland syndrome is characterized by absent sternal head of the pectoralis major, hypoplasia of the breast or nipple, deficiency of subcutaneous fat and axillary hair, absence of the pectoralis minor, syndactyly or hypoplasia of the ipsilateral extremity, and shortening of the forearm.

Answer 107

The correct response is Option E. The patient described meets criteria for Poland syndrome. This complex includes breast and/or nipple-areola complex hypoplasia, absence of the sternal head of the pectoralis major, rib abnormalities, and syndactyly or symbrachydactyly, fused and shortened digits. Polydactyly (multiplication of digits), macrodactyly (overgrowth and enlarged digits), arachnodactyly (long fingers), and acrosyndactyly (fusion of distal aspects of digits only) are not usually associated with Poland syndrome.

Answer 108

Correct answer is option E. The rectus sheath is the semifibrous compartment that encompasses the rectus abdominis muscle and consists of an anterior and posterior sheath created by the aponeurotic extensions of the external oblique, internal oblique, and transversus abdominis muscles. Proximal to the arcuate line, which is located approximately at the level of the anterior superior iliac spine, the anterior rectus sheath comprises the aponeuroses of the external oblique and the anterior leaf of the internal oblique. The internal oblique has two leaves, the deeper of which contributes to the posterior rectus sheath along with the transversus abdominis and transversalis fascia. At the level of the arcuate line, the posterior leaf of the internal oblique aponeurosis and the transversus abdominis aponeurosis travel superficially to the rectus abdominis, making the posterior sheath very weak. When the anterior rectus sheath is defective at this level, the likelihood for bulging or hernia is high. The level of the arcuate line is not always clear from topographical landmarks, which can make the planning of a transverse rectus abdominis musculocutaneous (TRAM) flap more difficult and increase the risk for a hernia complication.

Answer 109

The correct response is Option E. Acellular human dermal matrix, which is commercially available as AlloDerm or FlexHD, has emerged as a versatile material for abdominal wall reconstruction. Because of retained vascular channels, this material revascularizes rapidly and resists infection. In addition, the matrix serves as a soft-tissue scaffold, retaining its original strength and becoming incorporated with minimal scar or adhesion formation. These materials are more expensive than alloplastic mesh, although a formal cost analysis has not yet been published.

Answer 110

The correct response is Option D. The nerve that gives sensation to the posterior thigh flap is the posterior femoral cutaneous nerve (S1 to S3). This fasciocutaneous flap is based on the descending branch of the inferior gluteal artery and provides an abundant and reliable amount of available soft tissue for transfer from the posterior aspect of the thigh. Because of the proximal vascular pedicle, this flap can easily reach high within the pelvis and can be rotated to provide closure to both anterior and posterior vaginal defects. In addition, the flap can also be harvested with relative technical ease in a short period of time, and the donor site can typically be closed without the need of skin grafts. The skin is innervated by the posterior femoral cutaneous nerve (S1 to S3), which allows this flap to be used as a sensate flap when indicated. There are several other advantages to the posterior thigh flap that make it ideal for complex perineal reconstruction. The inferior gluteal artery is a terminal branch of the internal iliac artery.

Answer 111

The correct response is Option A. Assessment of renal failure begins with a thorough history and physical examination as well as evaluation of key laboratory measurements including complete blood count, metabolic panel, coagulation profile, urinalysis, and urine electrolytes. Early signs of renal failure may include orthostatic hypotension, tachycardia, and dry mucous membranes on examination. Renal failure may be divided into three categories: prerenal (causes include hypovolemia, cardiac failure, sepsis), renal/intrinsic (causes include disorders of the renal parenchyma, glomerular disease, acute tubular necrosis), and postrenal (causes included renal vein occlusion, urinary tract obstruction). Assessment of serum and urinary electrolytes and a urinalysis aid with the identification of the cause of renal failure. In prerenal failure, the urinalysis is normal, the ratio of blood urea nitrogen (BUN) to serum creatinine is elevated above 20:1, the urinary sodium concentration is less than 20 mEq/L, urine osmolality is higher than 500 mOsmol/kg H2O, and the fractional excretion of sodium (FENa), which compares the differences of the sodium and creatinine in the plasma and urine, is less than 1%. Intrinsic renal failure usually presents with a normal BUN and serum creatinine, urinary sodium concentration higher than 40 mEq/L, urine osmolality less than 350 mOsmol/kg H2O, and an abnormal urinalysis. Postrenal failure typically has an elevated BUN to serum creatinine, a FENa greater than 1%, and a normal urinalysis.

Answer 112

The correct response is Option B. Component separation is a well-described technique for repairing midline abdominal wall hernias. Originally described by Ramirez et al. in 1990, the technique involves incising the external oblique fascia lateral to the rectus muscle. The external oblique is elevated off of the internal oblique muscle in a loose areolar plane that is largely avascular, except for the intercostal branches to the external oblique muscles that are located far posteriorly. The posterior rectus sheath can be incised longitudinally to provide an additional 1 to 2-cm mobilization if needed. The attachments of the internal oblique to the rectus muscle are preserved, as are the intercostal neurovascular bundles that supply the rectus muscle. Hence, the rectus muscle is kept innervated and functional. Under ideal conditions, mobilization of the rectus-internal oblique muscle flap on both sides allows for closure of defects at the epigastrium, mid abdomen, and low abdomen of 10, 20, and 6 cm, respectively. A component separation repair alone would be insufficient because the defect described is 28 cm wide. There would still be a persistent defect in the fascia. Therefore, component separation with supplemental mesh would be required to adequately close this defect. Component separation mobilizes functional muscle medially to help restore abdominal wall integrity and minimizes the amount of bridging that would be repaired with mesh. A mesh repair alone would close the fascial defect but would do nothing to restore the functionality of the abdominal wall. Large defects repaired with mesh can be associated with hernia recurrence and long-term bulging. Tissue expansion can be useful in situations where skin coverage may be lacking. Tissue expansion is unnecessary in the patient described because skin coverage is not an issue. Free flap reconstruction, such as with a tensor fascia lata flap, has been described for abdominal wall defects and can provide vascularized fascia. There are even case reports of innervated free flap reconstructions. However, failure to maintain sufficient muscular tone in the long term leads to eventual attenuation of the fascia and abdominal wall bulging.

Answer 113

The correct response is Option C. Separation of components of the abdominal wall is fast becoming a first-choice procedure for large ventral defects. The procedure involves medial advancement of the rectus abdominis muscle flap after division of the aponeurosis or fascia of the external oblique muscle layer. Properly identifying the correct fascia to incise is a critical step in the procedure, and it relies on knowledge of the abdominal wall anatomy. The rectus abdominis muscles are separated by the midline linea alba, and each rectus muscle is medial to the layered triad of muscles—the external oblique, internal oblique, and transversus. Division of external oblique fascia is properly performed lateral to the linea semilunaris, which represents the lateral border of the rectus sheath, which is formed by the contributions of the external oblique, internal oblique, and transversus layers as the envelope of the rectus abdominis muscle. Above the arcuate line, the later layers split around the rectus muscle at the level of the internal oblique, forming both the anterior and posterior rectus sheaths; however, below the arcuate line, all layers travel anteriorly, forming the anterior sheath but no distinct posterior rectus sheath. The inguinal ligament exists between the anterior superior iliac spine and the pubic symphysis and should not be divided in component separation. Transverse tendinous inscriptions interrupt the rectus sheath, and division of the anterior rectus sheath or the inscriptions is not part of the classic component separation.

Answer 114

The correct response is Option E. The original description of component separation technique of the abdominal wall by Ramirez includes the following maneuvers: elevation of the skin and subcutaneous fat off of the sheath and oblique fascia, division of the external oblique aponeurosis with elevation of the external oblique laterally, and selective scoring of the posterior rectus sheath. Important modifications to this technique, which can provide up to 10 cm of advancement per side, include preservation of the periumbilical perforators, endoscopic release of the external oblique, laparoscopic release of the transversalis only, and anterior sheath fascial flap to provide additional midline reach. Harvesting the rectus muscle as a turnover flap will provide additional vascularized tissue medially, but this maneuver divides the intercostal nerves that travel between the internal oblique and transversalis muscle, providing motor supply to the rectus. The denervated muscle loses its previous advantage as an innervated, functional flap.

Answer 115

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.

Answer 116

The correct response is Option C. The patient appears to have benign pubertal gynecomastia, and many of these cases resolve spontaneously. The recommended treatment is observation and reassessment. Early surgery in these circumstances is usually reserved for patients experiencing more extreme psychological impact. Testosterone replacement would not be useful since by examination the patient appears to have an otherwise normal physiology. The three surgical interventions are all potential treatments for gynecomastia, but surgery is usually not recommended within the first six months of onset of gynecomastia in a pubertal male. The skin excision and nipple grafting option would be most useful if the patient had large quantities of fat and skin. The two techniques employing liposuction both might be adequate surgical techniques to address the type of gynecomastia this patient demonstrates, should surgery eventually become recommended.

Answer 117

The correct response is Option B. In general, the indication to use biologic scaffolds in hernia repairs and abdominal reconstruction is in contaminated beds. Biologic scaffolds provide an intact extracellular matrix and support tissue regeneration, and are more resistant to infection than synthetic mesh, likely because of this tissue ingrowth. Biologic scaffolds, unlike synthetic mesh, are degraded over time by collagenase. This accounts for at least some of the higher recurrence rates seen with biologics compared to synthetic mesh. Cross-linking of the scaffold may provide resistance to collagenase and improve long-term stability. Thus, better resistance to infection is a property of biologic scaffolds, as is collagen cross-linking, although the degree of cross-linking varies based on the particular scaffold. They are associated with a higher cost and an increased recurrence rate. Their high cost compared with synthetic mesh does not justify their routine use, and the recommendation for their use by the Ventral Hernia Working Group is in contaminated fields, with infected mesh and septic dehiscence. The need for components separation is based on the properties of the hernia itself and is independent of the type of mesh used. Components separation without mesh is, however, associated with a high recurrence rate.

Answer 118

The correct response is Option B. The area below the umbilicus and above the incision is most likely to have decreased sensation in the long term (after more than 3 years). This is true for superficial touch, superficial pain, temperature (hot and cold), and vibration. The area above the umbilicus recovers sensation to touch, pain, and vibration within 3 years; sensation to hot and cold temperatures recovers beyond 3 years. The suprapubic area has decreased sensation to temperature; however, touch, pain, and vibration recover in the short term. The areas below the xiphoid, at the lateral abdomen, as well as all other areas on the abdomen, have decreased sensation to pressure, although the infraumbilical region had the greatest change. The anterior nerve branches of the 6th to 12th intercostal nerves travel in a plane between the transversus abdominis and internal oblique muscles. They enter the internal oblique fascia, divide into two branches, and enter the posterior rectus sheath. One branch ascends 3 cm from the lateral edge of the rectus muscle to supply sensation to the skin over the lateral half of the rectus muscle. The other branch travels between the rectus and the posterior sheath before penetrating the linea alba and supplying sensation to the medial half of the rectus muscle. These nerves are divided during undermining from the abdominoplasty.

Answer 119

The correct response is Option E. Preservation of segmental intercostal nerves is a critical aspect of component separation. Component separation is a powerful technique used during abdominal wall reconstruction to advance the abdominal fascia towards the midline and allow for primary closure with reduced tension. A component separation is performed by making an incision longitudinally in the external oblique aponeurosis, just lateral to the linea semilunaris. Only the fascia is cut, not the external oblique muscle. This allows for advancement of a myofascial complex consisting of the rectus abdominus muscle, internal oblique muscle and fascia, and transversalis muscle and fascia. The segmental intercostal nerves that supply the anterior abdominal wall run between the internal oblique and the transversalis muscle. They are deeper than the incision and dissection plane with component separation, and are thus protected from injury. This maintains abdominal wall tone in patients undergoing this procedure. External oblique aponeurotomy, not internal oblique aponeurotomy, is involved in component separation. Incision of the anterior rectus sheath is not part of component separation, although some modifications include incision of the posterior rectus sheath to release more fascia available for primary closure. Plication of the linea semilunaris is not a part of component separation. Ligation of periumbilical perforators is commonly performed in the standard, open approach to component separation, but it is not considered a critical component of the procedure, as it is possible to perform a perforator-sparing component separation.

Answer 120

The correct response is Option B. The most appropriate flap to reconstruct the wound is omentum. Because of the large extent of the wound, the only flap listed that can adequately fill the defect and eliminate the dead space is the omentum. Pectoralis major flaps would not adequately fill the defect, particularly the inferior aspect of the wound. Pectoralis minor flaps are not used for sternal reconstruction and would not provide adequate tissue. The latissimus dorsi flap would not be able to fill the large sternal wound. Serratus flaps can be used for posterior chest wounds, but would not be able to reconstruct the large anterior chest wound.

Answer 121

The correct response is Option C. The most likely factor to indicate rigid chest wall reconstruction in this very large anticipated chest wall defect is the total area of the bony chest wall that is resected. Generally, reconstruction of the lateral bony chest wall seems necessary if four or more consecutive ribs are resected or if the diameter of the total defect is larger than 5 cm. Historically, protection of a flail segment of chest wall was based on the pendelluft principle, a phenomenon in which there is airflow back and forth between the lungs, resulting in underventilated segments of lung. This out-of-phase movement of the airway gas between the intact and flail-chest-side lungs was long believed to be the major contributor to respiratory dysfunction in patients with flail chest but has failed to be proven and appears to be a flawed hypothesis. In patients who have had radiation therapy, larger defects may be tolerated without rigid chest wall stabilization owing to fibrosis. As many as five ribs may be resected in patients who have undergone radiation therapy before reconstruction is considered because increased fibrosis produces chest wall stiffness. Anterior and posterior defects are typically better tolerated than lateral defects.

Answer 122

The correct response is Option C. Three months is considered a relatively short duration for gynecomastia. Rohrich advocates waiting 12 months prior to considering surgery in the absence of other findings. Gynecomastia during puberty is common, and arbitrary use of laboratory tests in the absence of any clinical history or physical findings is not recommended. Careful history and physical examination are all that is required to identify pubertal gynecomastia. Reassurance and reassessment at 12 months are the most reasonable alternatives. If the patient still had gynecomastia that is not receding at 12 months, then surgery or liposuction would be a reasonable option. The use of other tests or biopsy is unnecessary and possibly dangerous.

Answer 123

The correct response is Option E. The most appropriate pedicled flap for this particular defect is a latissimus flap, shown in the photograph, supplied by the thoracodorsal artery. The latissimus flap is a Mathes/Nahai type V flap that can be transferred on its dominant pedicle (thoracodorsal artery) or on multiple segmental paraspinal perforators. The internal mammary artery terminates as the superior epigastric artery, which would provide blood supply for a superiorly based vertical rectus flap. The rectus flap is a Mathes/Nahai type III flap, with two dominant pedicles. However, this pedicle is not available because of the radical resection and prior irradiation. The lateral thoracic artery is one of two dominant pedicles supplying the serratus anterior muscle (Mathes/Nahai type III). This flap is an option, but it would not provide enough bulk necessary for the defect in this situation. The deep inferior epigastric artery (DIEA) supplies the DIEA perforator flap, which would be an option as a free tissue transfer but not as a pedicle flap for this situation.

Answer 124

The correct response is Option E. It is very common for nipples to be inverted at birth and concerned parents often discuss the condition with pediatricians and practitioners. The mammary ridge begins to develop in the fourth week of development, and produces the primary and secondary buds. The mammary pit is a small depression present at birth into which the lactiferous ducts open. After birth, proliferating mesoderm during the first several weeks of life will cause the inverted nipple to protrude. In some cases, the inverted nipple persists. Although there may not be a functional consequence, it can lead to difficulty with lactation. Han and Hong described a grading system for inverted nipple: grade I, in which the nipple can be made to protrude manually and can maintain position without traction; grade II, in which the nipple fails to maintain projection after manipulation; and grade III, in which the nipple cannot be pulled out manually. Treatment is based on the grade. In some cases, breast-feeding or use of a breast pump is sufficient to correct the variation. Surgical intervention can be approached in several ways. Constricting the base of the inverted nipple can create projection, severing the ducts can cause projection, and myotomy can cause projection. Any division of the ducts will compromise a patient’s ability to breast-feed.

Answer 125

Correct answer is option C Unlike the other tissues, the trapezius muscle is based on the transverse cervical artery (based on the thyrocervical trunk in 80% of cases or the subclavian artery in 20% of cases). The subscapular system allows for the creation of chimeric flaps that can include bone, muscle, fascia, fat, and skin. Flaps that have been used include the serratus anterior muscle and fascia, latissimus dorsi muscle and fascia, scapular and parascapular fascia and overlying skin, and scapular and rib bone. Such combinations allow for versatility in reconstructing complex three dimensional defects that are often encountered in the face. Unlike the other tissues, the trapezius muscle is based on the transverse cervical artery (based on the thyrocervical trunk in 80% of cases or the subclavian artery in 20% of cases). The subscapular system allows for the creation of chimeric flaps that can include bone, muscle, fascia, fat, and skin. Flaps that have been used include the serratus anterior muscle and fascia, latissimus dorsi muscle and fascia, scapular and parascapular fascia and overlying skin, and scapular and rib bone. Such combinations allow for versatility in reconstructing complex three dimensional defects that are often encountered in the face.

Answer 126

The correct response is Option A. Radiation causes production of reactive oxygen species, which causes injury to tissues and progenitor cells. Cytokine release results in chronic inflammation and ongoing tissue damage. Radiation therapy can cause soft-tissue ulcerations, osteoradionecrosis, and radiation-induced sarcomas. If a patient presents with a late ulcer after radiotherapy, malignancy needs to be ruled out. A biopsy of the ulcer edge should be performed. Once malignancy has been ruled out, excision of all radiation-damaged tissue, rather than just the ulcer, will result in more durable reconstructive outcomes. Osteoradionecrosis of the chest wall presents as full-thickness chest wall ulcers and the involved ribs should be resected. The underlying pleura and lung may be adherent and, thus, limited lung resection may need to be performed. Reconstruction is performed with well-vascularized tissue, either local pedicled flaps or free flaps. Negative pressure therapy utilizes subatmospheric pressure for local wound care. It provides local wound care by controlling exudate and, thus, keeping the wound clean. It is thought to promote wound healing by inducing cellular proliferation and increasing capillary blood flow. Malignancy in the wound is a contraindication to negative pressure therapy. Therefore, if suspected, malignancy should be ruled out prior to initiation of negative pressure therapy. Hyperbaric oxygen is the administration of 100% oxygen in a pressurized chamber. This results in high tissue concentrations of oxygen, which promote neovascularization and wound healing. Hyperbaric oxygen has been shown to improve healing in soft-tissue radionecrosis and osteoradionecrosis. It can be used as an adjunct, especially when radical excision and reconstruction of radiation damaged tissue is not possible.

Answer 127

The correct response is Option A. The child described has Poland syndrome, which is characterized by anomalies of the upper limbs and torso. The most common finding in patients with Poland syndrome is absence of the sternal head of the pectoralis major muscle. Other muscles, including the external oblique, latissimus dorsi, pectoralis minor, and serratus muscles, may be absent or hypoplastic. The rectus abdominis muscle is not involved. Ribs and costal cartilages of the affected side may be absent. Other anomalies of the chest include athelia and hypoplastic skin covering the chest wall. Anomalies of the ipsilateral upper extremity include brachysyndactyly as well as foreshortening and hypoplasia of the forearm. Correction of the breast deformity is not recommended until the patient has reached full breast maturity.

Answer 128

The correct response is Option B. The most appropriate management is reconstruction with bilateral pudendal fasciocutaneous flaps. These flaps are based on the branches of the superficial perineal vessels, which are the terminal branches of the internal pudendal vessels. The course of the superficial perineal nerve follows these vessels; therefore, this flap can be raised as a sensate flap. These are relatively simple flaps to raise, and they are reliable and completed in one stage. They are thin, sensate flaps and are ideally suited for vaginal reconstruction. The donor site can be closed primarily and the scar is well hidden within the inner groin crease. The McIndoe procedure involves a split-thickness skin graft reconstruction of the vagina using a mold, followed by the continued use of a vaginal dilator to prevent constriction. The skin graft donor site scar is not as inconspicuous as a linear scar in the groin crease. Extended groin flaps have been described for vaginal reconstruction; however, these flaps are insensate. Gracilis and rectus abdominis musculocutaneous flaps are workhorse flaps for vaginal and pelvic reconstruction. However, they too are insensate and have large, conspicuous donor site scars.

Answer 129

The correct response is Option E. The most likely diagnosis for the patient described is an urachal sinus, which is derived from a persistently patent urachus with a sinus that drains to the umbilicus. Intermittent drainage is often the result of infections from this sinus tract. Surgical excision is recommended to avoid future infections and potential malignant degeneration. Omphalitis is an infection of the umbilical stump that presents as cellulitis. It is rare in industrialized countries but can be a common cause of neonatal mortality in developing areas. The source of infection is polymicrobial. An umbilical hernia usually presents as a mass at the umbilicus with no drainage. An umbilical granuloma or pyogenic granuloma is a benign inflammatory reaction to a healing umbilicus. This bright red, friable lesion does not have a sinus tract or drainage of fluid. An urachal cyst is a fluid-filled structure that is also a remnant of a patent urachus; however, the two ends (umbilicus and bladder) are obliterated. They are rarely symptomatic in early childhood; however, in adolescence they can present as an abdominal mass and cause pain. These cysts can also develop infections as well.

Answer 130

The correct response is Option C. The goals of skeletal chest wall reconstruction are restoration of chest wall stability and protection of intrathoracic structures. Large chest wall defects can result in flail segments with impairment of ventilatory mechanics. The lateral thoracic wall is most susceptible to such alterations since it the most mobile part of the chest wall. There is general consensus that skeletal chest wall reconstruction is indicated if four or more ribs are resected or if lateral defects are ? 5 cm. Total sternectomy defects disrupt the chest wall ring and increase dependence on abdominal breathing and may cause chronic chest wall pain; as such, they are considered by some to be indications for skeletal reconstruction. Posterior chest wall defects under the scapula (above the fourth rib) and anterior chest wall wounds under the pectoralis major do not require skeletal reconstruction since sufficient rigidity and protection is provided by these structures. Posterior defects around the area of the scapular tip may cause scapular entrapment and thus require skeletal reconstruction. Radiation fibrosis renders the chest wall stiff, and thus larger skeletal defects are well tolerated. Oncologic resections are not a contraindication for skeletal reconstruction. Skeletal reconstruction is most commonly performed with prosthetic materials, like synthetic meshes, biologic meshes and osteosynthesis materials. Radiation is not a contraindication for skeletal chest wall reconstruction. Reconstruction is performed at the same time as resection.

Answer 131

Correct answer is option C. The sacrum is the central “universal joint” of the body. A total sacrectomy essentially detaches the torso from each of the lower extremities. Without rigid stabilization of this defect with both bone and instrumentation, patients have a very low chance of ever walking without assistance again. A total sacrectomy also creates a massive, high volume wound that is prone to wound healing complications if a large volume flap is not employed to obliterate the dead space and provide durable coverage to the underlying spino-pelvic instrumentation. Finally, the bony defect spanning the lumbar spine to iliac bones is large. Non-vascularized bone grafts spanning large distances experience lower fusion rates compared to vascularlized bone flaps. For these reasons, choice C is the reconstruction that provides all of the elements required for optimal reconstruction of a total sacrectomy defect. Choice A is incorrect because gluteal flaps do not provide sufficient soft tissue bulk to obliterate the high volume wound created by a total or sub-total sacrectomy. Choice A is also incorrect because no spino-pelvic instrumentation is provided. Choice B is incorrect because no bony reconstruction is provided. Over time, spinal instrumentation alone fatigues and will fail. Hardware failure often results in compromised ambulatory status. Choice D is incorrect because a non-vascularlized tibia allograft is less likely to achieve fusion, is more prone to partial or total resorption, and has less strength in comparison to a vascularized bone flap.

Answer 132

Correct answer is option E. The arcuate line, also known as the linea semicircularis, is about 1/3 of the distance from the umbilicus to the pubis at the level of the anterior superior iliac spine. Anatomically, it represents the lower limit of the posterior rectus sheath and is approximately where the inferior epigastric vessels perforate the rectus muscle posteriorly.

Answer 133

The correct response is Option E. Options for reconstruction of this irradiated, complex, three-dimensional defect include various flaps, but the best choice is the vertical rectus abdominis myocutaneous (VRAM) flap, due to its ease of harvest, minimal donor-site morbidity, large skin paddle (which can resurface both the perineum and the vagina), reliable blood supply, and favorable arc of rotation. Although the pedicled ALT flap has recently been described for vaginoperineal defects, the VRAM flap remains the gold standard. Primary repair, even if technically possible, would be associated with unacceptable risk of wound-healing problems.

Answer 134

The correct response is Option A. Acellular dermal matrices (ADM) have been advocated for the past decade as an important adjunct in the complex field of abdominal wall reconstruction. Many studies have verified the use and general safety of ADM in abdominal wall reconstruction, but conclusive evidence of its advantages over other techniques is still lacking. What can be inferred is its advantage over prosthetic mesh in contaminated fields. Polypropylene mesh would be contraindicated in the infected wound in this example. After adequate debridement and appropriate antibiotics in an optimized patient, ADM can be used for hernia repair or reconstruction along with component separation. Postoperative infections can be as common as 40%, but conservative management measures often suffice, rather than reoperation and graft explantation, which are required with prosthetic mesh. One recognized drawback in the stretchable nature of dermal matrix grafts is that they can often stretch under tension to 50% or more of their initial dimensions. Postoperative bulging without true herniation is common. Strategies for prevention include suturing the graft under maximal stretch and use of porcine dermal grafts rather than human grafts. Hernia recurrence in the complex abdominal wall reconstruction remains a common event, regardless of technique. Although some studies assert a strong advantage with ADM, others report a similar or increased recurrence rate. As successful operative techniques become more standardized, perhaps more uniform success will be demonstrated in future studies. Skin necrosis and hematoma are common surgical complications that should not vary between choice of graft material. Fistula rates are decreased with ADM versus prosthetic mesh reconstruction.

Answer 135

Correct answer is option C. The most likely diagnosis is a Morel-Lavallée lesion (MLL). This lesion is caused by a shearing injury that separates the fascia from the overlying subcutaneous tissues, creating a prefascial potential space. Disruption of lymphatic vessels and capillaries leads to persistent fluid accumulation in this space. In the initial CT, the space appears filled with a hematoma, common in such injuries. Over time, the blood typically resorbs, but the leaking lymphatic fluid can persist, leading to enlargement of the lesion, surface damage, and potential skin necrosis. Explanation of options: • Fat necrosis: Though it may occur in these injuries and can calcify, it does not enlarge or cause progressive fluid accumulation over time. • Hemorrhage: While present initially, hemorrhages resolve over time and are unlikely to cause worsening skin necrosis months after the injury. • Lymphatic disruption: This is the correct answer, as leaking lymphatic vessels are the most likely cause of the enlarging fluid collection and fluctuant mass. • Postoperative seroma: Seromas usually occur after surgical intervention and do not typically enlarge months later without an underlying cause. • Sarcoma: Sarcomas are more fixed, non-fluctuant masses and are not associated with fluid collections as seen in this patient. Treatment of Morel-Lavallée lesions involves early conservative measures, such as aspiration, and surgical excision for lesions that fail to resolve. References: 1. Molina BJ, Ghazoul EN, Janis JE. Practical review of the comprehensive management of Morel-Lavallée lesions. Plast Reconstr Surg Glob Open. 2021;9(10):e3850. doi:10.1097/GOX.0000000000003850 2. Singh R, Rymer B, Youssef B, Lim J. The Morel-Lavallée lesion and its management: a review of the literature. J Orthop. 2018;15(4):917-921. doi:10.1016/j.jor.2018.08.032

Answer 136

The correct response is Option E. Reconstruction of the vagina after oncologic resection can be challenging for plastic surgeons, as restoration of form and function must be considered. Restoration of form is often achievable by a variety of procedures, including the vertical rectus musculocutaneous flap, gracilis musculocutaneous flap, pudendal artery fasciocutaneous flap, skin grafting, and interpositional colonic grafts. Restoration of functional outcome, however, is controversial. Return of sexual activity across multiple studies shows wide variability from 31 to 100% (53.8% pooled data). A recent survey study found that 50% of responders were sexually active and were able to achieve orgasm after reconstruction. However, a majority of responders reported wishing that they had been given more information on the procedure before surgery. The most common long-term complication from total reconstruction of the vagina is stenosis with rates reported from 18 to 22%. This requires regular use of obturators for dilatation and this should be clearly discussed with patients preoperatively. Abdominal hernia, rectovaginal fistula, pelvic abscess, and small-bowel obstruction are less common complications.

Answer 137

The correct response is Option B. Given the size of the defect, the patient’s comorbidities, and bowel violation, the best method to optimize results is a component separation with a bioprosthetic mesh underlay. The use of bridging mesh without approximation of the fascia is not recommended due to a high recurrence rate. Instead the Ventral Hernia Working Group (VHWG) recommends reapproximation of the rectus muscle at the midline whenever possible without undue tension. This can be done by using the component separation technique originally described by Ramirez. The procedure calls for a release of the external oblique aponeurosis 1 cm lateral to the linea semilunaris, which allows for medialization of the rectus abdominis and underlying lateral musculature for primary approximation. Given the enterotomy, a bioprosthetic mesh would be recommended as opposed to a synthetic mesh, because it is likely more resistant to infection and does not necessarily need removal in a contaminated wound. It is the VHWG’s preferred method to place mesh in an underlay manner, because intra-abdominal pressure pushes the mesh against the native abdominal wall instead of away from it. It also adds another layer of tissue over the prostatic material and would be preferred with a bioprosthetic because of decreased risk for bowel adhesions. Additionally, lower rates of hernia recurrence have been shown in patients who underwent component separation with mesh as opposed to those without.

Answer 138

The correct response is Option D. Metformin is an oral hypoglycemic used in the treatment of type 2 diabetes mellitus. Metformin must be discontinued two days prior to surgery to avoid untreatable lactic acidosis and death. It has not been reported to have gynecomastia as a side effect. Therapy with estrogen or androgen can produce gynecomastia. Estradiol is a metabolic product of testosterone and this fact might explain this phenomenon. Carcinoma of the prostate is treated with stilbestrol, an estrogen that causes gynecomastia. Other pharmacologic agents that may cause gynecomastia include antiandrogens, chorionic gonadotropin, spironolactone, reserpine, phenothiazines, methyldopa, meprobamate, ergotamine, diazepam, hydantoin, hydroxyzine, marijuana (Cannabis sativa), digitalis, isoniazid, and anabolic steroids.

Answer 139

The correct answer is option D. Omphaloceles are abdominal wall defects in which there is herniation of the bowel, and other organs into an intact umbilical cord. Unlike gastrochisis, the omphalocele defect is always covered by a sac, although the membrane may rupture. Immediate surgery is recommended to close the defect.

Answer 140

Correct answer is option C. Spinal metastasis can produce intractable pain, paralysis, and incontinence not manageable with conservative, non-surgical modalities. Select patients experience a significant quality of life improvement with operative resection of metastatic spinal tumors. Selection criteria for spinal metastasectomy include symptoms not responsive to non-operative therapy and a minimum life expectancy of 3-6 months. Choice A is incorrect because the spine is the 3rd most common site of solid tumor metastasis. Choice B is incorrect because the spine is the most common site of bony metastasis. Choice D is incorrect because prior radiotherapy does not represent an absolute contraindication to metastasectomy. Radiotherapy does increase the chances of wound healing complications postoperatively and, therefore, strong consideration should be given to preemptively placing a muscle or musculocutaneous flap at the time of resection to minimize the chances of a major postoperative complication.

Answer 141

The correct response is Option E. The patient described is likely to have gynecomastia, which can occur in up to 30% of men. In the younger, postpubertal patients, testicular cancer may be a cause. Examination of the scrotum and testes to rule out any testicular masses has to be included in the physical examination and documented. Measurement of beta-human chorionic gonadotropin concentration can also be effective. The other examinations listed do not directly contribute to the assessment of gynecomastia.

Answer 142

Correct answer is option B. The latiisimus dorsi muscle is a superficial muscle of the back and receives its blood supply from the thoracodorsal branch of the subscapular artery. Innervation is via the thoracodorsal nerve (C6-C8). It originates from the spinous process of the T7-T12 vertebrae, thoracolumbar fascia, the iliac crest, the inferior 3 ribs and the inferior angle of the scapula; its insertion is the intertubercular groove of the humerus.

Answer 143

Correct answer is option D The transverse cervical artery, which provides the primary vascular supply to the trapezius flap, is typically divided during an ipsilateral radical neck dissection. Therefore, the trapezius flap cannot be used for coverage of a defect in a patient who has undergone an ipsilateral radical neck dissection because its primary vascular supply may have been compromised. The anterior branch then courses toward the shoulder, while the posterior branch courses beneath the central portion of the trapezius along its main axis, continuing to supply blood to this flat, triangularly shaped type II muscle. The occipital artery is a secondary source of vascularity for the trapezius muscle flap. However, in looking at the specific location and depth of this patient's defect, it appears that the portion of the muscle supplied by the occipital artery has been resected. The medial edge of the trapezius flap also receives some blood from posterior thoracic intercostal perforators along the medial edge of the flap. Because carotid endarterectomy is performed at or close to the bifurcation of the common carotid artery, it does not disrupt the thyrocervical trunk. The circumflex scapular vessels and vertebral arteries are not involved in supplying vascularity to the trapezius flap.

Answer 144

The correct answer is C. Plane between the transversus abdominis muscle and transversalis fascia The posterior component separation with transversus abdominis release technique (TAR) is a method used in complex abdominal wall reconstructions. It involves incising the posterior rectus sheath and entering the plane between the transversus abdominis muscle and the transversalis fascia. This approach allows for significant medial mobilization of the abdominal wall musculature, facilitating tension-free midline closure and placement of a large prosthetic mesh in the retromuscular space. Dissecting in this specific plane provides a wide, well-vascularized space for mesh placement, reducing the risk of complications associated with other planes. References: • Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204(5):709-716. doi:10.1016/j.amjsurg.2012.02.008 • Jones CM, Winder JS, Potochny JD, Pauli EM. Posterior component separation with transversus abdominis release: technique, utility, and outcomes in complex abdominal wall reconstruction. Plast Reconstr Surg. 2016;137(2):636-646. doi:10.1097/01.prs.0000475778.45783.e2

Answer 145

The correct response is Option E. Poland syndrome was described by Sir Alfred Poland in 1841 after a cadaver dissection while he was a medical student. His initial report described the absence of pectoralis major and minor musculature and upper extremity anomalies. Absent in his account were other components of the syndrome; these have been added by others. These anomalies include the absence of subcutaneous tissue; anterior rib abnormalities; subclavian venous aberrancies; and dysplasia of the latissimus dorsi, deltoid, external oblique, serratus, rectus abdominis, supraspinatus, and infraspinatus musculature. The most consistent of these components is partial or total absence of the pectoralis major muscle. Other additions to the constellation include upper extremity anomalies apart from syndactyly, including hypoplasia of the hand, forearm, and fingers (brachy-symphalangism). Breast anomalies, including amastia and hypomastia, have also been frequently associated with Poland syndrome. One of the main ways to approach breast reconstruction in these patients is to utilize the latissimus muscle. However, the latissimus dorsi muscle can be hypoplastic or even missing completely. This fact has rarely been reported in literature. In the few published reports in which the latissimus dorsi muscle was found to be hypoplastic, the precise extent of the latissimus deformity could not be judged adequately by physical examination alone because the results of the usual tests for functioning of the muscle (ie, the resistance test, the scapula test, the cough test) were normal. During these operations, however, the latissimus dorsi muscle was found to be grossly attenuated or highly hypoplastic. Poland syndrome occurs in a predominantly sporadic fashion; however, familial kindreds have been infrequently identified. Associations with other congenital defects have been linked with Möbius syndrome, neuroblastoma, Wilms tumor, myelomeningocele, leukemia, and non-Hodgkin lymphoma. The exact cause of Poland syndrome is unknown, but it is most likely a vascular anomaly. The leading theory is that the manifestations result from subclavian artery ?kinking? during the sixth week of gestation, with subsequent hypoplasia leading to distal musculoskeletal malformation. This has been termed a subclavian artery supply disruption sequence and is supported by Merlob et al’s evaluation of subclavian artery diameter and flow. They found that these values were consistently decreased by 50% in affected individuals.

Answer 146

Correct answer is option E. Spina bifida occulta is a posterior torso defect where there is incomplete fusion of the neural arch of the vertebra, usually in the lumbosacral region. This defect is usually benign and most often does not produce any disability for the patient. Those with spina bifida occulta may not show any external manifestation or may often present with a hairy patch, dimple, pigmented area or hemangioma.

Answer 147

The correct response is Option B. This patient has a desmoid tumor, a rare, locally infiltrative mesenchymal neoplasm that is most commonly found in adolescents and young adults. It does not metastasize but can have a very unpredictable and aggressive natural history. Treatment can range from close observation (as some tumors will self-involute) to radical excision with wide margins. Traditionally, surgical excision can be difficult because of the high risk of local recurrence. Desmoid tumors are not associated with chemical or radiation exposures, or lipomas. Metastatic disease is not a characteristic of desmoid tumors. Although treatment modalities for desmoids are evolving, they are not treated with chemotherapy/radiation therapy as a primary modality. Primary treatment is frequently observation for small or slowly changing tumors. For rapidly growing tumors, radical excision is frequently performed. There does not appear to be a genetically inherited component for desmoid tumors, although they are associated with random mutations of the ?-catenin (CTNNB1) and adenomatous polyposis coli (APC) genes.

Answer 148

The correct response is Option D. Gynecomastia is benign proliferation of breast tissue in men. It is present in 40 to 50% of men over 40 years of age. It can manifest in pubertal boys and in men of advanced years. The etiology can be variable and may be due to excess circulating estrogen, decreased circulating androgens, or a deficiency of androgen receptors. However, in middle-aged and older men, it is most commonly due to the excessive aromatization of androgens to estrogens. Initial evaluation requires a detailed history and physical examination to differentiate between fatty tissue, parenchymal enlargement, and a tumor. Mammography may be useful and biopsy may be indicated in some cases.

Answer 149

The correct response is Option B. Abdominal compartment syndrome (ACS) may develop rapidly after an increase in intra-abdominal pressure. Chronic causes of elevated intra-abdominal pressure (such as central obesity or large abdominal tumors) may be compensated for, but acute elevations as a result of trauma, bleeding, burn, or abdominal surgery may lead to life-threatening failure of multiple organ systems. Three mechanisms present in ACS lead to multiple organ failure: vascular compression, elevation of the diaphragm, and direct organ compression. These three forces and their interactions create a constellation of physiologic effects that lead to the circulatory collapse at the center of ACS. Vascular compression results in decreased flow to the inferior vena cava and an increase in renal vascular resistance. Diaphragmatic elevation results in decreased flow to the inferior vena cava and an increase in intrathoracic pressure and decreased cardiac pre-load. Direct organ compression leads to an increase in systemic afterload. Left untreated, these forces eventually lead to renal failure, respiratory failure, intracranial hypertension, and intestinal and hepatic ischemia.

Answer 150

The correct answer is option a. The child described has Poland syndrome, which is characterized by anomalies of the upper limbs and torso. The most common finding in patients with Poland syndrome is absence of the sternal head of the pectoralis major muscle. Other muscles, including the external oblique, latissimus dorsi, pectoralis minor, and serratus muscles, may be absent or hypoplastic. The rectus abdominis muscle is not involved. Ribs and costal cartilages of the affected side may be absent. Other anomalies of the chest include athelia and hypoplastic skin covering the chest wall. Anomalies of the ipsilateral upper extremity include brachysyndactyly as well as foreshortening and hypoplasia of the forearm. Correction of the breast deformity is not recommended until the patient has reached full breast maturity.

Answer 151

The correct response is Option D. Tissue injury from radiation results in irreversible damage that limits the ability of wounds to heal with skin grafts or by secondary intention, such as using negative pressure wound therapy. Tissues within the field of radiation are also generally affected, which would limit use of an intercostal muscle flap. Although a latissimus dorsi musculocutaneous flap would provide an adequate amount of tissue from outside of the field of radiation, it would be unreliable in the setting of prior posterolateral thoracotomy, unless there is documentation that the latissimus was spared. A vertical rectus abdominis musculocutaneous flap would provide sufficient tissue from outside of the field of radiation and would not have been affected by the patient's prior surgery.

Answer 152

Correct answer is option A. Given the size and history of the defect, the patient described has a significant chance of recurrence of his hernia. To optimize the chances of a functional recovery that is durable and has the lowest chance of recurrence, the component separation technique with mesh reinforcement (synthetic or biologic) is indicated. The component separation technique, originally described by Ramirez et al. in 1990, allows for recruitment of the rectus complex towards the midline to facilitate primary reapproximation (in the best-case scenario) or at least decrease the size of the residual defect. Studies have shown that reinforcement of hernia repairs with mesh decreases recurrence rates by 50 to 75%, even in secondary repairs. It is not clear, however, whether the mesh should be placed as an overlay or underlay. Nonetheless, mesh reinforcement leads to lower recurrence rates, especially if combined with component separation. Specifically, component separation allows for reduction of the hernia defect size after hernia reduction, and leads to lower recurrence rates versus hernia reduction and bridging mesh repair alone. Laparoscopic repair is a useful technique in hernia repairs. However, the complex, large “Swiss cheese–type” defect described lends itself more to open repair in terms of facilitation of reduction, optimization of safety (avoidance of unrecognized bowel injury), and decrease in operative time. A tensor fascia lata flap, originally described for large hernia repairs because it allows transfer of fascia to the abdomen, does not demonstrate superior results compared to available meshes. It also incurs donor site morbidity versus the mesh reinforcement techniques.

Answer 153

The correct answer is D) To prevent bacterial meningitis This clinical scenario describes a myelomeningocele, resulting from neural tube closure failure during the fourth week of gestation. The exposure of the spinal canal and neural elements increases the risk of cerebrospinal fluid leakage and infection. The primary indication for early surgical intervention is to prevent bacterial meningitis, which is life-threatening. Explanation of options: • A) To improve motor function of the lower extremities: Early intervention does not restore motor function but may help preserve bladder function. • B) To prevent hydrocephalus: Hydrocephalus often coexists with myelomeningocele and requires a separate procedure, such as a ventriculoperitoneal shunt. • C) To decrease cerebrospinal fluid leakage: While surgery addresses cerebrospinal fluid leakage, this is not the primary indication. • E) To repair the defect with a skin graft: Skin grafts may be used as temporary measures in specific cases but are not the initial priority in this situation. Management: Immediate management includes keeping the sac sterile and hydrated while stabilizing other conditions. Definitive repair involves dura repair to prevent cerebrospinal fluid leakage and using a well-vascularized tissue layer to protect the dura and skin repair, preventing bacterial contamination and subsequent meningitis. References: 1. Crowe CS, Hauptman JS, Lee A, Ellenbogen RG, Ettinger RE, Susarla SM. Progressive-tension sutures in reconstruction of posterior trunk defects in pediatric patients: a prospective series. Plast Reconstr Surg. 2022;150(2):435e-438e. doi:10.1097/PRS.0000000000009331 2. Mohan AT, Sur YJ, Zhu L, et al. The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg. 2016;138(4):710e-729e. doi:10.1097/PRS.0000000000002610

Answer 154

Correct Answer: C. Rupture of the amniotic membrane along the right side of the umbilical cord. Abdominal wall defects occur in up to 1 in 2000 live births. The two most common are omphalocele and gastroschisis. In an omphalocele, the abdominal wall defect is in the central abdomen in the umbilical region, and the intestinal contents are covered with a membrane. In gastroschisis, the defect is to the right of the umbilicus and intestinal contents are not covered by a membrane. There is no clear consensus about the exact etiology of these abdominal wall defects. Omphalocele is thought to be caused by failure of intestines to return to the abdominal cavity. During gestational week 6, the intestines herniate into the umbilical cord because of rapid intestinal elongation. They return to the abdominal cavity at 10 weeks. Failure of this return results in an omphalocele. One of the most widely accepted theories about the pathogenesis of gastroschisis is that it occurs because of rupture of the amniotic membrane along the right side of the umbilical cord. This allows evisceration through the abdominal wall defect. Incomplete closure of the fascia of the umbilical ring leads to infantile umbilical hernias; most of these close spontaneously. The processus vaginalis is a protrusion of the peritoneum into the scrotum. Failure of obliteration results in hydroceles or inguinal hernias. The pleuroperitoneal folds separate the pleural and abdominal cavities. Failure of fusion of these folds results in congenital diaphragmatic hernias. References: 1. Pechriggl E, Blumer M, Tubbs RS, et al. Embryology of the abdominal wall and associated malformations-a review. Front Surg. 2022;9:891896. doi:10.3389/fsurg.2022.891896 2. Khan FA, Raymond SL, Hashmi A, Islam S. Anatomy and embryology of abdominal wall defects. Semin Pediatr Surg. 2022;31(6):151230. doi:10.1016/j.sempedsurg.2022.151230 3. Mowrer AR, DeUgarte DA, Wagner AJ. Abdominal wall defects: a review of current practice guidelines. Clin Perinatol. 2022;49(4):943- 953. doi:10.1016/j.clp.2022.07.004

Answer 155

The correct response is Option B. Although not commonly used, the thoracic intercostal nerves can provide graft material up to 12 cm in length. Harvest of the intercostal nerve has minimal donor site numbness and can be harvested through an open or endoscopic approach. The intrinsic chest muscles include (from superficial to deep) the external intercostal, internal intercostal, innermost intercostal, and transverse thoracis muscles. The external intercostal muscle is most active during inspiration. It functions to stiffen the chest wall during descent of the diaphragm to prevent paradoxical collapse of the chest. The other more internal intercostal muscles are weaker and are more involved in expiration. The intercostal nerve emerges from the spinal cord and immediately splits into a dorsal ramus (that innervates the back) and ventral ramus. The ventral ramus runs between the internal and innermost internal intercostal muscles before crossing over the internal thoracic vessels and penetrating through the intercostal muscles to supply the anterior chest skin.

Answer 156

The correct response is Option D. In patients with a significant glandular component, it is important to do a subtotal glandular resection to prevent recurrence and provide the best chance at adequate contour. Ultrasonic liposuction has been used to attempt subtotal removal of gland tissue, but it does not reliably produce a subtotal resection. Areolar reduction is usually not necessary due to the contractile nature of the tissue. Skin resection may be necessary, most commonly in the massive weight loss patient, but does not necessarily play a role in the glandular component of the resection. Lateral suction lipectomy does not correct glandular hypertrophy.

Answer 157

The correct response is Option E. Poland syndrome is the rare congenital condition describing the absence of the breast or nipple, hypoplasia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of costal cartilages or ribs 2, 3, and 4 or 3, 4, and 5, occasionally even rib 6. Its aesthetic and functional impairment varies between individuals and highly depends on the severity of the disease. Boys are three times as likely to be affected as girls. Incidence ranges between 1:100,000 to 1:7,000 cases per live births. Various concomitant anomalies have been published in association with Poland syndrome that typically necessitate a multi-disciplinary approach towards the diagnosis and treatment of this congenital illness. Upper extremity anomalies, renal malformation, lung hernia, and dextrocardia have all been described in literature as related to Poland syndrome. Anomalies of the upper extremity are the most common concomitant malformation besides the chest wall defects.

Answer 158

Correct answer is option B. The musculoskeletal system develops from the ectodermal neural crest and the paraxial and lateral plate (somatic layer) mesoderm. Approximately 40 segmental tissue blocks alongside the neural crest caudal to the head region, known as somites, differentiate into 2 parts. The dorsolateral subpopulation of somatic cells is called the dermomyotome, and the ventromedial subpopulation of cells is known as the sclerotome. The dermomyotome eventually forms the musculature of the trunk, whereas the sclerotome develops into the skeletal framework.

Answer 159

The correct response is Option D. The major indication to repair a myelomeningocele defect in the early postnatal period is to prevent infection and bacterial meningitis. Great care is taken to keep the sac sterile and hydrated. Further cardiac, orthopedic, and urologic workup is often necessary, as well as evaluation for hydrocephalus. Although improvement in the return of motor function with early repair has not been shown, neurogenic bladder prognosis is improved. Leakage of cerebrospinal fluid is commonly observed regardless of timing of closure. Although folic acid supplementation has been shown to decrease the neural tube defects and myelomeningocele formation, postnatal supplementation has not been shown to be effective. Approaches to surgical therapy for the treatment of these defects have seen a shift toward prenatal, fetal reconstructive surgery. A recent study by Adzick et al. in the New England Journal of Medicine examined the use of prenatal surgery versus postnatal surgery. In this randomized trial, the authors found a decreased need for cerebrospinal fluid shunt placement and improved motor function outcomes.

Answer 160

Correct Answer: b) Descending branch of the lateral femoral circumflex artery. Descending branch of the lateral femoral circumflex artery and hip flexion and knee extension represent the blood supply to and function of the rectus femoris muscle flap, one of the predictable, workhorse flaps for groin wound reconstruction. After supplying the rectus femoris muscle, the lateral femoral circumflex artery continues on to supply the anterolateral thigh flap. The rectus femoris muscle crosses both the hip joint and the knee joint, and as such functions to both flex the hip and extend the knee. Option A refers to the hamstring muscles, which are on the posterior thigh and would not be an appropriate choice for groin wound reconstruction. Option C refers to the tensor fascia lata muscle. This muscle is used for lateral hip wounds but not typically for groin wound reconstruction. Option D refers to the adductor longus muscle. This muscle is not used in groin wound coverage. Option E refers to the sartorius muscle, but it has already been used in this patient’s previous surgery, and it is therefore not available for this reconstruction. The sartorius muscle is preferred for smaller wounds and is often used for prophylactic coverage in complex groin cases. 1. Landry GJ, Carlson JR, Liem TK, Mitchell EL, Edwards JM, Moneta GL. The sartorius muscle flap: an important adjunct for complicated femoral wounds involving vascular grafts. Am J Surg. 2009 May;197(5):655-659. doi:10.1016/j.amjsurg.2008.12.020 2. Mirzabeigi MN, Fischer JP, Basta MN, et al. Managing groin wounds after infrainguinal vascular procedures: examining the reoperative events and complication profile of muscle flap reconstruction. Ann Vasc Surg. 2017;43:232-241. doi:10.1016/j.avsg.2017.02.010 3. Fischer JP, Mirzabeigi MN, Sieber BA, et al. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg. 2013;66(10):1396-1404. doi:10.1016/j.bjps.2013.06.014

Answer 161

The correct answer is option B. The association between some congenital disorders and the development of cancer is well recognized. Poland syndrome is frequently associated with Hodgkin disease, some types of leukemia or leiomyosarcoma, renal tumors, and lung tumors, but there are few reports on the association between Poland syndrome and breast cancer. The low incidence of Poland syndrome (1 in 30,000 live births) and the sex ratio (boys to girls = three to one) also makes statistical correlation between Poland syndrome and breast cancer difficult. Despite the presence of less breast tissue with hypoplastic breast status, women with Poland syndrome are not at decreased risk for breast cancer either. In addition, researchers have shown that the hypoplasia of the breast does not make the discovery of the breast tumors easier. In this sense, it seems that the risk for breast cancer in Poland syndrome mimics that of the general population, and screening recommendations should follow accordingly. Mammography (along with ultrasonography and MRI, if indicated) should be given consideration before any decision is made for breast surgery or reconstruction in a patient with Poland syndrome. No studies to date have shown a significant increase in the risk for breast cancer in women with a history of silicone implants or autologous fat grafting. Reference(s) Mojallal A, La Marca S, Shipkov C, Sinna R, Braye F. Poland syndrome and breast tumor: a case report and review of the literature. Aesthet Surg J. 2012;32(1):77-83. doi:10.1177/1090820X11430499 Myckatyn TM, Wagner IJ, Mehrara BJ, et al. Cancer risk after fat transfer: a multicenter case-cohort study. Plast Reconstr Surg. 2017;139(1):11-18. doi:10.1097/PRS.0000000000002838 Noels EC, Lapid O, Lindeman JH, Bastiaannet E. Breast implants and the risk of breast cancer: a meta-analysis of cohort studies. Aesthet Surg J. 2015;35(1):55-62. doi: 10.1093/asj/sju006. PMID: 25568234

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