Chest Wall/Abdominal Wall/Gynecomastia 06-22, 24 Flashcards

Question

A 52-year-old woman with cancer of the right breast undergoes mastectomy and axillary node dissection, complicated by mastectomy flap necrosis requiring skin grafting. She completes adjuvant chemoradiation. One year later, she comes to the office with a fungating mass growing through the skin graft. Imaging demonstrates involvement of the fourth and fifth ribs with an anticipated skeletal defect of 4 × 4 cm. A photograph is shown. Which of the following is the most appropriate treatment for the skeletal reconstruction? A) High-density porous polyethylene B) Methyl methacrylate with mesh C) 2.4-mm Titanium plate D) No skeletal reconstruction E) Vascularized rib

Answer 1

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 2

The correct response is Option D. The treatment of gynecomastia is based on the degree of breast enlargement and the extent of ptosis that is noted on examination. Grade 1 gynecomastia is minimal breast hypertrophy without ptosis. Grade II gynecomastia is moderate hypertrophy without ptosis. Grade III gynecomastia is severe hypertrophy with moderate ptosis. Grade IV gynecomastia is severe hypertrophy with severe ptosis. The treatment of mild to moderate gynecomastia without ptosis is suction-assisted lipectomy. Direct periareolar excision with skin excision and subcutaneous mastectomy are not indicated for gynecomastia without ptosis. Mastopexy and free nipple grafting techniques are indicated for gynecomastia with severe ptosis.

Answer 3

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 4

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 5

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 6

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 7

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 8

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 9

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 10

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 11

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 12

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 13

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 14

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 15

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 16

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 17

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 18

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 19

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 20

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 21

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 22

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 23

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 24

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 25

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 26

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 27

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 28

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 29

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 30

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 31

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 32

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 33

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 34

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 35

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 36

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 37

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 38

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 39

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 40

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 41

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 42

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 43

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 44

The correct response is Option B. 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 45

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 46

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 47

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 48

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 49

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 50

The correct response is Option B. 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 51

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 52

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 53

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 54

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 55

The correct response is Option E. 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 56

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 57

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 58

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 59

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 60

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 61

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 62

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 63

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 64

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 65

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 66

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 67

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 68

The correct response is Option B. 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 69

The correct response is Option A. 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.

Answer 70

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 71

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 72

The correct response 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 73

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 74

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 75

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 76

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 77

The correct response is Option D. The principle of component separation is that the layers of the abdominal wall are able to be mobilized to a greater degree when they are separated from one another. In a ventral hernia repair, the bowel is freed from the fascial edges. Large skin flaps are developed that expose the abdominal fascia. The external oblique layer is separated from the internal oblique layer just lateral to the rectus sheath. Incising the posterior rectus sheath can add 1 to 2 cm of additional mobilization if necessary. 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 78

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 79

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 80

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 81

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 82

The correct response is Option C. 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. Needle decompression with a large-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. The diagnosis of tension pneumothorax is confirmed by a rush of air escaping the chest on needle decompression. In tension pneumothorax, the negative pressure caused by inspiration draws air through the wound, and the injured tissue acts as a one-way valve. This pressure accumulation in the chest causes collapse of the lungs and impedes cardiovascular filling. Administration of vasopressors would not be a first-line means of increasing blood pressure in this patient. Decompression of the compressed atria and thoracic vessels along with fluid and blood replacement are the first resuscitative measures required. Vasopressors may play a role for hypotension after appropriate fluid resuscitation fails to normalize pressure. Diagnostic peritoneal lavage is an emergency department technique for rapid diagnosis of occult abdominal injury. While the patient described is at risk for intra-abdominal trauma, the rapid oxygen desaturation and large chest injuries suggest a thoracic source of injury. Line placement is needed for ongoing monitoring and care of the critically injured patient described but would not be the initial procedure. Large-bore peripheral intravenous catheters for rapid fluid infusion would be optimal for the early treatment phase of the trauma patient. A repeat radiograph of the chest may be helpful in establishing a diagnosis, although in the unstable patient with suspected tension pneumothorax, emergent decompression is required. The patient would not likely survive the time interval from ordering a radiograph until the results were made available.

Answer 83

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 84

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 85

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 86

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 87

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 88

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 89

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 90

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 91

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 92

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 93

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 94

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 95

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 96

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 97

The correct response is Option B. 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 98

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 99

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 100

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 101

The correct response is Option E. Tuberous breast deformity is a rare congenital condition that results in aberrant breast shape due to a constricting ring at the breast base. Abnormal development results in breast tissue deficiency, herniation of breast tissue into the nipple-areola complex, areolar enlargement, and breast asymmetry. Although latissimus flaps could be used for severe primary cases or reoperative secondary cases, such an aggressive intervention would not be warranted in the patient described. Surgical correction is challenging, but it can be achieved in a single-stage operation. This procedure should include submuscular placement of silicone or saline prostheses, mastopexy with areolar reduction, and scoring of the gland to relieve the constricting tissue. Postoperative results are depicted in the photograph shown.

Answer 102

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 103

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 104

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 105

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 106

The correct response is Option B. Accessory breast tissue is most commonly located in the axilla, but other locations including milk line, face, posterior neck, chest, middle back, buttock, vulva, flank, hip, shoulder, and upper extremity have been reported.

Answer 107

The correct response is Option E. 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.

Answer 108

The correct response is Option B. Mediastinitis, along with purulent material from the mediastinum, constitutes a deep sternal wound infection. It is a potentially life-threatening complication following cardiac surgery involving a sternotomy. Surgical management includes drainage of purulent material, debridement of devitalized tissue, appropriate antibiotic therapy, and removal of contaminated foreign material such as sternal wires. The resultant defect can present reconstructive challenges, and proper flap selection is critical. A pectoralis major muscle turnover flap is based on the perforators arising from the internal mammary vessels. In this patient, the left internal mammary regional pedicle is unavailable since it has been redirected to the coronary circulation as part of the patient's initial surgery. Therefore, a left pectoralis major turnover flap is contraindicated. The pedicle for a right pectoralis major advancement flap is the right thoracoacromial artery. The pedicle for a right rectus abdominis flap is the right superior epigastric artery. The pedicle for an omental flap is the right omental artery via the right gastroepiploic artery. The pedicle for a left pectoralis major advancement flap is the left thoracoacromial artery. None of these pedicles has been disrupted by a previous surgery. Therefore, these others would be reasonable flap options for the obliteration of dead space and soft-tissue coverage of the defect.

Answer 109

Correct answer is D 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 110

E 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 have 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 111

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.

Answer 112

D The most appropriate next step in management is to plan a staged, implant-based reconstruction. Poland syndrome is a congenital disorder involving the chest wall. The sequence of findings may vary but typically involves absence of the sternal portion of the pectoralis major muscle and lack of development of the soft tissue of the chest, including the breast in female patients. This may include partial or complete absence of the breast or musculature and structure of the arm. This patient has demonstrated that the abnormality is significantly affecting her quality of life and may further impact her social and emotional development. It is reasonable to consider starting reconstruction at this time. Given that her right breast is very large, at some point she may benefit from a reduction mammoplasty to help balance the dramatic difference of her chest size. Placing a tissue expander is ideal since it may be adjusted over time as she further develops on the right side. In addition to breast asymmetry, there may also be poor soft-tissue quality of the chest wall, necessitating additional procedures like a latissimus dorsi flap or fat grafting. Once the expander is successfully placed and expanded, the patient can decide when she would like to have definitive reconstruction and at what size. This should be done when she has stopped developing on the right side. Definitive reconstruction can be done with either autologous tissue or an implant depending on the patients body habitus and wishes. Delaying her reconstruction until she has fully grown is likely to cause the patient to undergo a prolonged period of emotional suffering that may not be easily overcome. Performing definitive reconstruction at this time is not advisable since the patient has not fully developed.

Answer 113

E The transversus abdominis release technique involves incision of the transversus abdominis muscle medial to the neurovascular bundles. Dissection continues between the transversus abdominis muscle and the transversalis fascia above the arcuate line and between the transversus abdominis and the peritoneum beneath the arcuate line. The plane between the external oblique and internal oblique muscles is the plane for an anterior component separation. The plane between the rectus abdominis muscles and transversalis fascia describes the retrorectus plane, which is medial to the semilunar line. The plane between the transversus abdominis and the internal oblique muscles is the plane for anesthetic infiltration for transversus abdominis plane blocks. This plane contains neurovascular bundles and would risk denervation of the rectus abdominis muscles. Dissecting between the neurovascular bundles and the semilunar line would also risk denervation of the rectus abdominis muscles.

Answer 114

C Failure of the neural tube to close during the fourth week of gestation results in a myelomeningocele. There is exposure of the spinal canal and neural elements, allowing for cerebrospinal fluid leakage and risk for infection. The primary indication for early intervention is to prevent bacterial meningitis. Initial care involves keeping the sac sterile and hydrated. Many of these patients have hydrocephalus and will require a shunt to decrease intracranial pressure and cerebrospinal fluid leakage. Further workup for cardiac, urologic, orthopedic, and other neurologic abnormalities is required, with many of these patients requiring multiple future surgeries. Early intervention has not been shown to improve the return of motor function but may improve bladder function. After stabilization of other medical conditions, some authors have proposed placement of a temporary split-thickness skin graft until definitive repair is undertaken. Definitive correction will require repair of the dura to prevent further cerebrospinal fluid leakage, followed by placement of a well-vascularized layer of tissue between the dura and skin repair. Various flaps have been used for providing vascularized coverage of the dura. These include paraspinous fascia turnover flaps, paraspinous muscle advancement flaps, local/regional fasciocutaneous flaps, gluteal advancement flaps, and latissimus turnover flaps. The vascularized layer will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural or skin repairs fail.

Answer 115

D This patient has osteoradionecrosis of the right fifth and sixth ribs associated with a nonhealing wound and superimposed infection. In order to eradicate the infection and allow for wound healing, resection of the involved ribs will be necessary. Local wound care or debridement of soft tissues alone will leave devitalized bone in place and likely lead to eventual failure of any closure with a local flap. Furthermore, skin substitutes such as bilaminate neodermis are not suitable options in the setting of persistent infection and are less likely to be effective in the setting of severe radiation-induced soft-tissue injury. Therefore, management involving complete resection of the necrotic ribs is the only suitable option for eradicating infection and providing a wound bed capable of healing. Although it is generally accepted that defects resulting from resection of fewer than four ribs do not necessitate rigid or semi-rigid chest wall reconstruction, this patient's CT scan demonstrates elevation of the right hemidiaphragm with abdominal contents immediately beneath the involved ribs (fifth and sixth). As such, closure of this wound without some form of chest wall reconstruction will necessarily lead to hernia formation. Therefore, management involving reconstruction of the chest wall as well as soft-tissue coverage for wound closure is the most suitable answer. Phrenic nerve dysfunction can be caused by severe radiation injury, and although this is more commonly reported in the setting of stereotactic radiotherapy to the diaphragm and/or mediastinum, it can also occur in the setting of postmastectomy radiation therapy. This can lead to worsening pulmonary function and may benefit from operative plication of the diaphragm to restore higher lung volumes.

Answer 116

D 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 that 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 because of his history 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.

Answer 117

D Performing a definitive hernia repair at the time of explantation for mesh infection would be best suited via the use of a xenograft biologic mesh and placement in the sublay position without a bridge. This patient has a Grade 4 hernia based on the Ventral Hernia Working Group classification system. In Grade 4 hernias, permanent synthetic mesh is currently thought to be contraindicated because of the high infection rate and need for explantation. Based on the classification system, Grade 1 hernias are those with low risk for complications and no history of infection, Grade 2 hernias have comorbidities that increase the risk for complication, Grade 3 hernias have discontinuity of their gastrointestinal tract or a history of wound infection, and Grade 4 hernias have a mesh infection. There is debate as to the contraindication of synthetic mesh in Grade 2 and 3 hernias, and different studies have demonstrated superior outcomes with synthetic and biologic mesh. While human-derived mesh continues to be widely used in breast reconstruction, early experience in abdominal wall reconstruction demonstrated a lack of durability and high hernia recurrence rate. As a result, the use of human biologics was replaced by xenograft biologics in the form of porcine, bovine, or ovine-derived products with better outcomes. There have been multiple studies looking at the position of the mesh and the long-term outcomes. Bridged repairs, where the mesh is placed in a gap between the edges of the soft tissue, carry a much higher hernia recurrence rate when compared with other repairs. The sublay or underlay position where the mesh is placed in the abdomen, preperitoneal space, or retrorectus space has a more favorable hernia-free survival comparatively. Performing this type of repair in someone with a history of major abdominal injury often requires the use of bilateral component separation to approximate the abdominal wall over the mesh to prevent the need for bridging.

Brainscape's Knowledge GenomeTM

Chest Wall/Abdominal Wall/Gynecomastia 06-22, 24 Flashcards

Brainscape's Knowledge Genome^TM