Chest and Abdominal Wall Reconstruction Flashcards

Question

How much can be mobilized in a components separation

Answer 1

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. The posterior rectus sheath can be incised longitudinally to provide an additional 1 to 2-cm mobilization if needed.

Answer 2

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.

Answer 3

B ) Incomplete correction

Answer 4

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.

Answer 5

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.

Answer 6

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.

Answer 7

The most frequent postoperative complaint is incomplete correction, wherein the patients are not completely satisfied with the aesthetic result (about 15% of cases).

Answer 8

E ) Revascularization

Answer 9

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

Answer 10

D ) Internal oblique and transversus abdominis

Answer 11

The internal oblique muscle is usually not separated from the transversus abdominis muscle because it contains the intercostal nerves and blood vessels. This makes dissection difficult, bloody, and heightens the risk of denervating the rectus abdominis muscle.

Answer 12

C ) Observation and follow-up in 12 months

Answer 13

Rohrich advocates waiting 12 months prior to considering surgery in the absence of other findings.

Answer 14

A ) Oval; placement at the fourth-to-fifth intercostal space

Answer 15

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

Answer 16

It has been 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

Answer 17

E ) Use of a rectus muscle medial turnover flap

Answer 18

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 19

Important modifications to this technique, which can provide up to 10 cmof 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.

Answer 20

C ) Needle decompression

Answer 21

The most likely diagnosis for a precipitous drop in oxygenation and blood pressure in the setting of a large open wound of the chest is tension pneumothorax.

Answer 22

Needle decompression with alarge-bore intravenous catheter is performed in the second intercostal space in the midclavicular line.

Answer 23

Needle decompression with alarge-bore intravenous catheter is performed in the second intercostal space in the midclavicular line. This procedure is followed by tube thoracostomy for stable decompression of the thoracic cavity, thereby allowing lung inflation

Answer 24

E ) Urachal sinus

Answer 25

A urachal sinus 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.

Answer 26

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.

Answer 27

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

Answer 28

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 29

B ) Renal anomalies

Answer 30

Supranumary nipples

Answer 31

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.

Answer 32

D ) Testicular examination and ultrasonography 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. 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 33

Ultrasonography is the preferred screening method, and is cheaper and more accurate than hormone assays.

Answer 34

D ) Metformin

Answer 35

``` Therapy w/ estrogen or androgen Stilbestrol Antiandrogens Chorionic gonadotropin Sprironolactone Reserpine Phenothiazines Methyldopa Meprobamate Ergotamine Diazepam Hydantoin Marijuana Digitalis Isoniazid Anabolic steroids Chorpromazine ```

Answer 36

(E)Resistance to infection Because of retainedvascular channels, this material revascularizes rapidly and resists infection.

Answer 37

The matrix serves as a soft-tissue scaffold, retaining its original strength and becoming incorporated with minimal scar or adhesion formation.

Answer 38

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 39

(A)Amastia

Answer 40

Amastia: a congenital condition that involves absence of the nipple-areola complex and glandular tissue.

Answer 41

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

Answer 42

(C)Absence of the sternal head of the pectoralis major muscle

Answer 43

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.

Answer 44

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 belowthe normal breast or in the groin.

Answer 45

(C)Placement of an adjustable subcutaneous tissue expander In the patient described, a subcutaneous tissue expander can be placed because the sternal portion of the pectoralis is missing. 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

Answer 46

contraindicated prior to childbirth

Answer 47

(D)Pectoralis major muscle flaps The patient described had a Type III infection with a deep sinus tract as confirmed by CT scan. 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 arteryhas been harvested in this patient, compromising the blood supply to the left pectoralis major turnover flap.

Answer 48

Type I infections occur within the first week after sternotomy and have no bony involvement.

Answer 49

Type II infections occur during the second to fourth weeks after sternotomy. Bony involvement is frequent, but chostochondritis is rare.

Answer 50

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

Answer 51

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.

Answer 52

(E) Ultrasonography of the testes

Answer 53

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). I

Answer 54

Imaging of the brain is not routinely ordered unless there is some other finding suggestive of a brain tumor.

Answer 55

If the B-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 56

(D) 3 cm, oval

Answer 57

(A) Absence of the 12th rib 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.

Answer 58

Ipsilateral

Answer 59

B) Left component separation, bridging wide intraperitoneal underlay biologic mesh, primary closure skin 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 60

E) Vertical rectus abdominis musculocutaneous flap 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 61

B) Left latissimus dorsi muscle flap with skin graft over acellular dermal matrix The most appropriate option for this patient is a left latissimus dorsi muscle flap with skin graft over acellular dermal matrix, given the alternatives listed. Basic principles of thoracic reconstruction include: debridement of devitalized tissue, removal of foreign bodies, establishment of healthy wound bed, restoration of stability/structure (generally reconstruction of skeleton if more than four ribs or a greater than 5-cm-diameter defect is involved), restoration of normal respiratory mechanics, protection of vital structures/organs, obliteration of dead space, provision of durable coverage, and delivery of an aesthetic result. However, if a patient has been previously irradiated, and therefore loses compliance of the thoracic cage because of radiation-induced fibrosis, skeletal reconstruction may not be mandatory if there is no paradoxical motion of the thoracic cage upon respirations and there is preservation of respiratory efficiency. Such is the case with this patient. A left rectus turnover flap would not be a good option for two reasons: 1) as can be seen in the image, the left internal mammary artery has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based, and 2) it is insufficient to provide enough soft-tissue coverage of a defect this size. Furthermore, as indicated above, methyl methacrylate would not be mandatory in this patient. A right pectoralis turnover flap is insufficient to cover a defect this size. A free omental flap can be used to reconstruct this defect (as can a pedicled omental flap), but again, thoracic skeletal reconstruction would not be mandatory in this previously irradiated patient; furthermore, even if it were, titanium mesh and reconstruction plates would not be utilized. A reverse abdominoplasty flap (Ryan procedure) would not be able to cover a defect this size.

Answer 62

D) Rectus muscle and posterior sheath 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 63

A) Abdominal bulge 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 64

C) Subcostal margin 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 65

B) Infraumbilical 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 66

C) Total area of the chest wall defect 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 67

A) Anterior axillary line 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 68

E) Observation 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 69

B) Estradiol 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 70

E) Shortened right-hand digits 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 71

D) Testicular examination 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 72

B) External iliac 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 primary vascular supply to the rectus muscles are the deep inferior epigastric artery and vein, which arise from the external iliac vessels. The internal mammary vessels give rise to the superior epigastric arteries and veins, which is a secondary, nondominant vascular supply of the rectus muscles. The femoral vessels give rise to the superficial inferior epigastric artery and vein, which perfuse the skin and subcutaneous fat of the inferior lateral abdomen.

Answer 73

D) Gynecomastia 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 74

E) Wide local excision, right component separation, mesh reinforcement 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 75

C) Polymastia 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 76

E) Subareolar tissue ressection via pull-through excision technique 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 77

E) Nipple inversion 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 78

C) Placement of a subcutaneous left-sided tissue expander and right-sided reduction mammaplasty 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 79

B) Paraspinous musculofascial flap and skin advancement flap The most appropriate method to reconstruct the wound is a local musculofascial flap and skin advancement flap. The major principle of myelomeningocele repair is to obtain a well-vascularized layer of soft-tissue coverage between the dural 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 cerebrospinal fluid 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 muscles and 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 neurologic deficit.

Answer 80

E) Vaginal stenosis 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 81

B) Innermost intercostal and internal intercostal muscles 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 82

C) Less vaginal hair growth 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 83

E) Pudendal nerve In women, the pudendal nerve terminates in the dorsal nerve of the clitoris, which is responsible for most erogenous sensation. Neurorrhaphy to this nerve has been shown to result in superior sensory outcomes in phalloplasty. The dorsal nerve of the clitoris is analogous to the dorsal nerve of the penis, which is used as a target for neurorrhaphy during penile reconstruction for amputation or congenital microphallus. Other branches of the pudendal nerve include the inferior rectal and perineal nerves. The ilioinguinal nerve supplies sensation to the skin of the upper medial thigh and to the skin of the mons pubis and labia majora. The genitofemoral nerve also provides sensation to the labia majora and skin of the femoral triangle. The posterior femoral cutaneous nerve innervates the skin of the posterior surface of the thigh as well as part of the perineum. The iliohypogastric nerve innervates the skin above the pubis and in the gluteal region.

Answer 84

C) Below external oblique, above internal oblique 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

E) Use of a pedicled anterolateral thigh flap 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 86

C ) Deep dorsal artery 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 87

D) Psychiatrist for evaluation 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 88

D) Coverage with a local musculofascial flap 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 89

A) Debridement and negative pressure wound therapy 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 90

D ) Coverage with omental flap and skin grafting 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 91

D ) Posterior femoral cutaneous 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 92

B ) Bilateral pudendal fasciocutaneous flaps 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 93

C ) Linea semilunaris 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 94

C ) Preservation of the nerves between the internal oblique and transversalis muscles 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 95

A ) Deep epigastric 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 96

A ) Disruption of the inframammary fold 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 97

B ) Gynecomastia Breast anomalies in children are a relatively common finding. A recent study showed that hyperplastic abnormalities were the most common category, with the most common anomalies being gynecomastia, followed by juvenile hypertrophy or hyperplasia. The average age at initial surgery for the group was age 17.4 years; the average number of operations per patient was 1.14. Patients most likely to require revisional surgery were those with giant fibroadenoma.

Answer 98

A ) 1% A literature search yielded over 2000 articles in total; however, only 36 articles have discussed cases of adolescent gynecomastia and the associated pathologic results, resulting in data for 615 individuals. Of these 615 individuals, there have been six cases of cancer and five cases of atypical ductal hyperplasia associated with adolescent gynecomastia. Specific patient information was only available for seven of the individuals (six breast cancer and one atypical ductal hyperplasia), which revealed that the average age of patients involved was age 17.4 years (range, age 16 to 20 years), 43% of cases had symptoms of unilateral gynecomastia, and an abnormal physical examination was present in only one case. In the cases with histologic characterization, five cases were ductal carcinoma in situ with low to intermediate grades, and the other case had been diagnosed as invasive carcinoma of the secretory carcinoma type. Sixty percent of the cases of ductal carcinoma in situ had associated atypical ductal hyperplasia as well.