Oral Boards Flashcards
Repair A2 or A4 pulley acutely
z-plasty
FDS tail after split at Camper’s chiasm or palmaris longus to reconstruct
Duran early active flexor tendon protocol
Splint wrist 20-30 flexion, MCP 70 flexion, IP’s 0 flexion
start passive flexion, active extension 3-5 days
active flexion at 4 weeks
discontinue splint 6 weeks
strengthening 8 weeks
full activity 12 weeks
Tendon graft
Excise FDP just distal to lumbrical origin in palm and leave 1cm distal. Remove FDS.
Second stage 3 months later.
Veau classification
I Defect soft palate only
II Hard and soft palate
III Soft palate to alveolus, involved lip
IV Complete bilateral clefts
Goldenhar syndrome (oculoauriculovertebral dysplasia)
hemifacial microsomia, defects in eyes (epidbulbar dermoids), ears and spine
Fitzpatrick scale
I white, very fair - always burns, never tans
II white, fair - usually burns, rarely tans
III beige - usually tans, occasionally burns
IV mediterranean - rarely burns, tans easily
V dark brown - rarely burns
VI black - never burns, deeply pigmented
Brow peak
Just lateral to or at lateral limbus
Just superior to supraorbital rim in women and at rim in men
Supratarsal fold evaluation of upper lid
Margin to crease distance should be 7-11mm. If more then concern for levator dehicsence.
Pinch test
If can pull lower lid greater that 6mm from globe then too much laxity and will require canthal procedure.
Also, lateral canthus should attached posterior to orbital rim 2mm superior to the medial canthus.
Snap back test
For ectropion. Pull lower lid away from globe and hold several seconds. If not rebound immediately without blinking then ectropion
Schirmer test
Filter paper into fornix for 5 min and should have >1cm moisture
nasolabial angle
90-100 degrees female
90 degrees
Gustillo classification
I <1cm II >1cm IIIA <10cm IIIB >10cm IIIC major vascular injury
gastrocnemius flap
origin medial and lateral condyle of femur, inserts on calcaneous through achilles tendon.
medial and lateral sural arteries from the popliteal artery enter the deep proximal muscle. Medial and lateral head separated by the sural nerve and lesser saphenous vein. Lateral gastroc beware of peroneal nerve around the fibular neck or can get foot drop. note plantaris will be in plane between gastroc and soleus.
soleus flap
origin head and upper shaft of tibia and insertion on achilles tendon.
incision 2cm medial to tibia or midlateral along border of tibia
posterior tibial artery between soleus and FDL
peroneal artery between soleus and FHL
medial soleus posterior tibial artery and lateral soleus peroneal artery
vastus lateralis flap
descending branch of the lateral circumflex femoral artery. Can be distally based but less reliable than proximally based.
relative indications for amputation
injury to posterior tibial nerve (loss of sensation to sole of foot)
crush injury
warm ischemia >6 hours
timing for skin graft after integra
3 weeks
Grolleau classification of tuberous breast deformity
Type I: Deficiency of lower medial quadrant
type II: Deficiency of entire lower pole of breast
Type III: Deficiency of all quadrants
Characteristics of tuberous breast
elevated IMF
enlarged nipple areola complex with herniated breast tissue
decreased breast diameter
Regnault classification of ptosis
Grade I: nipple at inframammary fold
Grade II: nipple below IMF
Grade III: nipple at lowest post of breast
pseudoptosis: lower-pole breast parenchyma ptosis
Indications for mammagram before breast surgery
age 45 annual
age 55+ every two years until within 10 years of expected death
if family history then 10 years prior to onset of cancer in family member
FDA approval silicone implants
22 years and older
MRI recommendations for implant surveillance
3 years post op then Q 3 years
Baker capsular contracture
Grade I: normal
Grade II: slightly firm, normal appearance
Grade III: firm, appears abnormal
Grade IV: painful, hard, appears abnormal
Medications that cause gynecomastia
marijuana, spironolactone, steroids, HIV medications, diazepam, tricyclic antidepressants, digoxin, calcium channel blockers, furosemide, risperidone, antibiotics
Pressure ulcer stage
I: Nonblanching erythema
II: Partial thickness dermal loss, blister or shallow red wound bed
III: Full thickness skin loss
IV: Injury through fascia
Components separation
Incise the external oblique aponeurosis lateral to the semilunar line and release from the underlying internal oblique. May also release the posterior sheath of the rectus to advance up to 20cm at middle.
Sternal wound acuity
acute < 1 week: dehiscence and sternal instability, take to OR and close
subacute 2-4 weeks: purulence and leukocystosis, debride and local wound care followed by delayed closure when clean
chronic >4 weeks: chronic osteomylitis and sinus tracts, take for debridement, local wound care, delayed closure when clean, may require long term anitbiotics
Pectoralis muscle flap
thoacoacromial vessels. May disinsert the humeral attachment. Can also turnover based on internal mammary. Cover the superior sternal wound
Omental flap
right gastroepiploic vessels. tunnel for sternal wound over costal margin or through diaphragm. Hangs from stomach and transverse colon like an apron.
Gracilis flap
Innervation: branch from obturator nerve
Blood: medial femoral circumflex (off the profunda femoral)
Pedicle length 6 cm
Origin on pubic symphysis, inferior pubic ramus and ischium then inserts on medial condyle of knee
2-3 finger breadths posterior to the adductor longus
pedicle found under the adductor longus and enters muscle 10 cm below ischium.
Preserve saphenous vein
If plan for functional muscle mark 3-4 cm intervals prior to dividing insertion for tension
Drain and ACE wrap. Ambulation ok. Elevate. Ankle splinted in neutral.
Pudendal thigh (Sinapore) flap
Posteriorly based flaps centered on the groin crease
Reconstruct anterior and lateral vaginal defects
posterior labial vessels
sensation from pudendal nerve
Burn estimation
include 2nd and 3rd degree head 9 arm 9 each leg 18 each torso 18 front and 18 back children more head and less leg area singed facial hair or soot in airway - concern inhalation injury
Burn resusciation
1ml/kg hour urine output
Parkland 4mL/kg per % burn over 24 hours (half first 8 and second half next 16)
hand compartments
dorsal interossei (4 compartments) palmar interossei (3 compartments) adductor pollicus thenar hypothenar
lateral arm flap
Innervation: posterior cutaneous nerve
Blood: posterior radial collateral artery off the brachial artery
Flap based over humerus between triceps (posterior) and biceps bracialis, brachioradialis (anterior)
radial nerve is deep. On axis from deltoid insertion to lateral epicondyle.
Start dissection posterior deep to fascia over the triceps to the intermuscular septum. Then dissect anteriorly. The vessels will be in the septum. The radial nerve will come into view proximally.
soft dressing and drain.
latissumus flap
- thoracodorsal nerve
- thoracodorsal artery via subscapular artery via axillary artery (circumflex scapular artery and branch to serratus also come off subscapular artery) enters in posterior axilla 10cm inferior to insertion on humerus
- up to 20x40cm size
- origin iliac crest and thoracolumbar fasica and insert humerus (humeral adductor and internal rotator)
be sure to leave down serratus superiorly, easier to identify plane from starting inferior to scapula and dissecting superior to inferior. - May ligate the serraturs branch and circumflex scapular branch if need more length. May divide nerve to prevent animation deformity.
- Leave 2 JP drains.
- If seroma then aspirate.
plantaris graft
origin lateral supracondylar ridge of femur and insertion posterior calcaneous via calcaneal tendon
missing in 20% people. runs between soleus and gastroc. medial to achilles tendon.
Relative indications intervension Dupuytrens
MCP conrcture 30 degrees
PIP contracture
Adduction thumb interferes with activities
Relative indications intervention Dupuytrens
MCP contracture 30 degrees
PIP contracture
Adduction thumb interferes with activities
Timing syndactyly release
12-18 months
6 months if border digit due to differential growth
matacarpal and phalangeal fracture surgery indications
metacarpal neck angulation: 15 degrees index and middle, 30-40 degrees ring, 40-50 degrees small
intraarticular step off > 2mm and/or >30% articular surface
bony shortening > 3mm
open fracture
rotation
tendon transfer thumb opposition (low median)
extensor indicis proprius to abductor pollicis brevis
tendon transfer thumb flexion (high median)
brachioradialis to FPL
tendon transfer thumb extension
EIP to EPL
if radial nerve palsy then can use PL (if don’t have then FDS of middle)
Tendon transfer finger flexion
ECRL to FDP
tendon transfer finger extension (low radial)
FCU or FCR to EDC
tendon transfer wrist extension (low radial)
PT to ECRB
tendon transfer for claw (low ulnar)
FDS of the middle to the radial lateral bands of the middle, ring and small or ECRL with grafts to the radial lateral bands.
tendon transfer elbow extension
posterior deltoid
tendon transfer elbow flexion
pectoralis major, triceps, latissimus, forearm flexor mass (steindler)
margins for skin cancer
low risk has 95% BCC and 92% SCC disease free 5 years
BCC 4mm
SCC 4-6mm
high risk BCC/SCC
> 2cm in trunk, extremities
1cm scalp, forehead, cheeks, neck, pretibia, genitals, hands, feet
mask area ( periorbital, nose, lips, chin, mandible, ears, temple)
actinic keratosis
5-fluorouracil and imiquimod promote apoptosis of malignant skin cells by inhibition of DNA synthesis and activation of cell-mediated immune response or cryotherapy
apex of orbit
44-50mm posterior to orbital rim
Superior orbital fissure syndrome
Near orbital apex. Compression or fracture causes:
Oculomotor - upper eyelid ptosis, fixed dilation, weakness of superior, inferior and medial rectus and inferior oblique
Trochlear - superior oblique weakness
Abducens - lateral rectus weakness
Ophthalmic division of V1 - numbness forehead and upper eyelid
Superior and inferior ophthalmic veins - proptosis
orbital apex syndrome
superior fissure syndrome with involvement of the optic canal that includes the optic nerve and ophthalmic artery through the greater wing of the sphenoid. This adds blindness.
enophthalmos
posterior displacement of globe in AP axis
detectable at 2mm
measure with Hertel exophthalmometer
increase in globe by 5% will cause enophthalmos
hypoglobus
inferior displacement of globe
evaluate by light reflex
indications for orbital floor surgery
enophthalmos > 2mm
defect > 1-2cm2 or 50% floor
entrapment
reverse sural flap
artery: sural branches from the peroneal (medial superficial sural artery)
veins: branches lesser saphenous
nerve: sural cutaneous
covers the heel and ankle
pivot point 5 cm above the lateral malleolus
instep flap, medial plantar
artery: medial plantar artery from posterior tibial.
vein: vena commintantes or greater saphenous vein
nerve: medial plantar nerve
medial plantar artery runs between abductor halluces and flexor digitorum brevis
Keinbocks stage and treatment
Stage I: no visible changes on xray but seen on MRI - immobilization and NSAIDS
Stage II: sclerosis of the lunate - joint leveling (ulnar negative), radial wedge osteotomy or STT fusion (ulnar neutral), distal radius core decompression, revascularization
Stage IIIA: lunate collapse, no scaphoid rotation - same as stage II
Stage IIIB: lunate collapse, fixed scaphoid rotation - PRC, STT fusion, SC fusion
Stage IV: degenerated adjacent intercarpal joints - wrist fusion, PRC, limited intercarpal fusion
transcuruncular incision
in fold (plica semilunaris) posterior to lacrimal system.
posterior interosseous flap
flap marking: axis from lateral epicondyle to DRUJ
PIA bewteen EDM and ECU
cross finger flap
volar defects, skin graft dorsum of donor
reverse flap for dorsal defects and skin graft recipient
divide pedicle at 10-14 days
mesh options
Phasix is poly-4-hydroxybuterate and is absorbable monofilament. Prolene is permanent.
nutrition labs
prealbumin >15
albumin >3.4
ALT
markings: ASIS to superolateral patella. mark 1/2 way and then 5cm on either side. These are anticipated perforators 1.5cm posterior to line.
vessels: descending branch lateral femoral circumflex off the produnda femoral
pedicle runs between vastus lateralis and rectus femorus
Iliac crest flap (deep circumflex iliac artery)
blood supply: deep circumflex iliac system from external iliac.
Markings: finger breadth above and parallel to inguinal ligament
identify the superficial and dee circumflex iliac vessels and follow the deep vessels in transversalis fascia. Protect the lateral cutaneous nerve. Vessels will lie on surface of iliacus muscle as continue to iliac crest. take portion of iliacus muscle with the bone graft (usually one cortex). suture iliacus muscle to internal oblique to prevent hernia or pelvis.
midline mass
dermoid - squamous epithelium lining with adnexal structures and caseous material. dimple.
gliomas - glial tissue without CSF
encephaloceles/meningoceles - protrusion of intracranial contents
all form from fonticulus nasofrontalis which is a temporary fontanelle between the paired nasal nd frontal bones
intercanthal distance
28-32mm, equal to palpebral fissure width
coronal synostosis syndromes
apert syndrome - AD, brachycephaly, midface hypoplasia, brachysyndactyly, mental deficiency, cleft palate
crouzon - AD, brachycephaly, midface hypoplasia
pfeiffer - AD, brachycephaly, midface hypoplasia, broad thumbs and toes
saethre-chotzen - brachycephaly, midface hypoplasia, narrow or cleft palate, prominent ear crus, brachysyndactyly
treatment coronal synostosis
8-10 months
blood available, can treat erythropoietin, recycle blood in OR
Fronto-orbital advancement with neurosurg, overcorrect frontal bone bandeau. secure with resorbable polylactic plates and screws.
ICU post op. Monitor sodium.
evaluation of head shape
Hx: pregnancy complications, prematurity deformity at birth, getting better/worse developmental delay PE: palpable ridges head circumference papilledema syndromic? hands, feet, cardiac, urologic, clefts, hyperterlorism, midface retrusion, ears, heart sternocledomastoid, torticollis
sagittal craniosynostosis
pi cranioplasty with barrel stave osteotomies, prone position
6 months strip with springs or helmet
head and neck cancer staging
Tis - in situ T1 - less than 2cm T2 - 2-4cm T3 - >4cm T4 - invades adjacent structures N0 - no mets N1 - single ipsilateral node N2 - single ipsilateral node 3-6cm, multiple ipsilateral, or contralateral nodes N3 - node > 6cm M0 - no mets M1 - mets
tetanus recommendations
protect against clostridial infection
fully immunized but no booster within 5 years then tetanus toxoid IM
if not fully immunized then also get human tetanus immune globulin IM
temporoparietal fascia flap
blood supply: posterior branches of the superficial temporal artery from the external carotid system.
TPF is extension of the SMAS inferiorly and the galea superiorly. The temporalis is deep.
frontal branch of facial nerve runs in line from inferior tragus to lateral brow
auriculotemporal branch of maxillary nerve posterior to pedicle and sacrificed resulting in numbness.
ptosis etiology
senile - disinsertion or laxity of levator aponeurosis from tarsal plate
myasthenia gravis - better in morning, improves with phenylephrine, treat with cholinesterase inhibitors
horner syndrome - also miosis and anhydrosis due to loss of sympathetic innervation
trauma or surgery - scarring
congenital
levator function
block eyebrown and measure excusion with upward and downward gaze
>8mm good - advance levator and sutured to suprior border of tarsal plate with 5-0 vicryl
5-7mm moderate - levator resection and resuspension
<4mm poor - suspend levator to frontalis with fascia lata or silicone
at rest eyelid should be 102 mm below superior limbus
may give phenylephrine to stumulate mullers because sympathomimetic
margin reflex distance
distance between eyelid margin and light reflex.
<4 or 5mm then ptosis
rhinoplasty evaluation
frontal: skin thickness and Fitzpatrick facial proportions (1/3) dorsal aesthetic lines bony vault midvault tip - boxy, pinched, supratip break alar rims and base upper lip lateral: nasofrontal angle dorsal hump supratip break tip projection (1/3 nose length) nasolabial angle (100) columellar show mental projection basal: nasal projection alar base columella nostril Internal: with and without vascoconstruction assess turbinates and valves perform cottle manouver
rhinoplasty evaluation
frontal: skin thickness and Fitzpatrick facial proportions (same as forehead and lower face height) dorsal aesthetic lines bony vault midvault tip - boxy, pinched, supratip break alar base width line up with medial canthi (nose similar width to palpebral fissure) columella should have gull wing appearance upper lip lateral: nasofrontal angle (115-130 degrees) dorsal hump supratip break tip projection (2/3 nose length) nasolabial angle (100ish, more in women) nostril 50% length to tip mental projection within 3mm of line from frankfort plane through upper lip basal: equilateral triangle 2:1 columellar to lobular portion nostrils teardrop shaped Internal: with and without vascoconstruction assess turbinates and valves perform cottle manouver
rhinoplasty surgical approach
- local anesthetic injection 1% lidocaine with epi, nasal packing affrin for vasoconsriction and throat pack
- stairstep transcolumellar and infracartilaginous incision
- skin elevation for exposure of lower and upper lateral cartilages
- intraoperative evaluation
- assessment of tip projection
- component dorsal hump reduction (bony with rasp and cartilagenous with scissors)
- septal reconstruction/graft harvest with 1.5cm L strut using septal elevator to remove off the perpendicular plate
- augmentation of dorsum/internal nasal valves with spreader grafts
- cephalic trim of lower lateral cartilage (leave 8mm)
- final tip projection with sutures, columellar strut, tip grafts
- alar rim grafts
- inspect
- inferior turbinoplsty or outfracture
- osteotomies (internal) feel along piriform aperture where nasal bones meet the maxilla, low to low with guarded 2mm osteotome
- final evaluation and close
- doyle splints and denver splint and dressing
- remove splints at POD 7 and keep on abx until then
nasolabial flap
based superiorly or inferiorly on the angular branch of the internal maxillary artery
cleft lip repair
C flap - columellar fill upper portion of lip
L flap - lining nasal lining
M flap - mucosal gingivobucal sulcus
Abbe flap
based on labial artery
called estlander when at teh commisure
Karapandzic flaps
superior labial arteries
mark along meliolabial crease
incise skin and divide obicularis from surrounding tissues
maintain facial nerve and V2 and V3 and facial artery/labial branch
maintain most of the mucusa
brow lift
sentinal vien 1.5 cm lateral and superior to lateral brow and frontal branch 1cm above it.
brow to hairline
5cm women and 6cm men
temporal brow lift incision
over temporalis muscle
dissect just above the deep temporal fascia (protect frontal branch of facial nerve between deep temporal fascia and TPF.
mandibular distraction
submandibular incision. protect facial vessels. Inverted L posterior to inferior alveolar nerve entering mandibular foramen. coutner incision post auricular. activation on POD 1 at 2 mm/day then consolidation for 6 weeks.
treacher collins
chromosome 5q
lower lid colobomas, zygomatic hypoplasia, microtia, mandibular hypoplasia, cleft palate
embryology ear
anterior hillocks-helical root and tragus
posterior hillocks-helix, antitragus, triangular fossa, scapha, concha, lobule
adult ear dimensions
height 6cm and width half of that
superior in line with brown and inferior in line columellar base
posteriolateral axis 15-30 degrees
specific ear dimensions
conchal boal <1.5cm deep
helical rim to mastoid: 10mm lobule, 16mm mid, 20mm upper
blood supply and innervation ear
posterior auricular and superficial temporal arteries auriculotemporal nerve (anterior) greater auricular and lesser occipital (posterior)
correct prominent ear age
90% growth by 3 years
6 years cartilage hardens
repair 3-6 years before school
concha too deep
furnas conchomastoid sutures
use methalyne blue to mark points
make posterior incision 2.5 cm lateral to sulcus
divide the postauricular muscle
suture conchal cartilage to mastoid fascia with nonabsorbable suture. include anterior and posterior cartilage but not anterior skin.
if severe may need to excise cartilage
antihelical deformity
mustarde horizontal mattress scaphconchal sutures
include post and anterior cartilage but not anterior skin
if rigid cartilage anterior scoring
enlarged lobule
suture helical tail to concha cavum
posterior skin and subcutaneous tissue excision in a V or ellipse.
associated anomalies with microcia
oculo-auriculo-vertebral spectrum cervical spine heart (murmurs, septal defects, tetralogy) facial microsomia fascial clefts hairline GU (kidneys) abdomen
nagata technique
> 10 years
synchondrosis of 6-7 base
free floating 8 rib helical rim
fill defect with saline and valsalva to make sure no leak. if air bubbles then small red rubber catheter and repair parietal pleural defect the valsalva and remove.
repair rectus fascia and skin to close.
place framework and suction drain.
Stage 2 2 months later transpose the lobule with z plasty and elevate the postauricular sulcus.
right chest to avoid heart
bank cartilage under chest skin at first stage from 5th rib.
blue rubber bleb syndrome
skin and intestine venous malformations
may have GI bleed
klippel-trenaunay syndrome
venous malformation and limb hypertrophy
maffucci syndrome
venous malformations and enchondromas
parks weber syndrome
AV malformations and soft tissue hypertrophy of the extremity
proteus syndrome
vascular malformations and asymmetric gigantism, macrocephaly, epidermal nevi, lipomas
groin flap
superficial circumflex vessels from external iliac system. Perforate fascia just medial to sartoreus at the inguinal ligament.
medial femoral condyle flap
blood supply descending genicular artery from the superficial femoral artery. Runs deep to vastus medialis.
TFL flap
blood supply: ascending branch of the lateral femoral circumflex.
origin anterior iliac crest and insert iliotibial tract (lateral patella).
pedicle come in 1/3 down.
markings - draw line from ASIS to lateral patella and axis of femur and TFL is between.
can pivot flap 8 cm below the ASIS
parotid tumors
benign pleomorphic adenoma - mobile and painless
warthins - benign, males, may be bilateral
malignant mucoepiermoid most common and adenoid cystic carcinoma
course of facial nerve
exit the stylomastoid foramen
landmarks to find: pointer of the tragal cartilage, tympanomastoid suture line and anterior border of the sternocleidomastoid muscle and posterior belly of digastric muscle. Will be adjacent to the tympanomastoid suture line
frey syndrome
parotid receives parasympothetic fibers from the auriculotemporal nerve which triggers saliva when chewing. Transection of these and reinnervation to overlying sweat glands causes sweating when eating.
starch iodine will turn blue on cheek
topical anticholinergices such as atropine, botox
neck dissection
1 submandibular
2 superior jugular: skull base to inferior border of hyoid
3 middle jugular: inferior hyoid to cricoid
4 lower jugular: inferior cricoid to clavicle
5 posterior: SCM to trap
6 anterior: common carotid to midline
collagen disorders
cutis laxa: degeneration of dermal elastic fibers. surgery ok
ehlers danlos: joint hypermobility, thin, fragile, hyperextensible skin. Wound healing problems. no surgery
great auricular nerve anatomy
crosses superficial SCM 6.5cm below external auditory canal. just posterior to jugular vein. Lie deep to SMAS/platysma layer
facial nerve anatomy
frontal branch from parotid gland on line from 0.5cm below tragus of ear to 1.5cm above lateral brow. Deep to SMAS over zygomatic arch. enter frontalis deep.
gold weight
1 g pretarsal via lid crease incision under local. may still need to tape at night.
cross face nerve graft
redundant branches to zygomaticus used as donors. 6-9 months later repair to zygomaticus major, obicularis occuli and depressor anguli oris.
hypoglossal nerve transfer
can use for facial nerve or as a babysitter nerve.
static fascial slings
temporalis: central 1/3 of muscle reflected inferiorly and inset into the modiolus and corner of upper and lower lips. Will activate while eating.
masseter
> 3 hemangiomas
neonatal hemangiomatosis - concern for visceral hemangiomas. May have congestive heart failure or liver enlargement. abdominal US.
vascular malformation in V1 or V2
sturge-weber - evaluate eyes and brain.
PHACE
posterior cranial fossa malformation (dandy-walker), facial hemagiomas, arterial abnormalities, coarctation of aorta, eye abnormalities.
kasbach merritt
consumptive coagulopathy with hemangiomas where platelets low. May need to treat with steroids, vincristine
pectus excavatum
may have marfan syndrome - tall and thin, joint laxity, scoliosis.
check PFT’s
ravitch procedure - remove cartilage lower 4-5 ribs, osteotomy through anterior sternum and greenstick, place bar or plate for 6 months. Can used vascularized 7th rib on anterior intercostal artery
Nuss ages 8-12. bilateral transverse incisions. subcutaneous dissection and substernal. pre-bent meval fixation bar put across ribs and rotated 180.
medical conditions cause gynecomastia
liver disease, lung cancer, testicular cancer, adrenal or pituitary tumors (test visual fields), colon or prostate cancer, thyroid disease, testosterone imbalance, klinefelter syndrome, breast cancer (feel axilla)
medications that cause gynecomastia
spironolactone, marijuana, cimetidine, digoxin, reserpine, estrogens, theophylline, diazepam (pneumonic: some men can develop rather excessive throacic diameters) also steroids and antipsychotics
brachioplasty
mark apex of deltopectoral groove and bicipital groove. Pinch to see how much can be removed.
liposuction first
start anterior incision
as get within 13cm medial epicondyle stay superficial to protect MABC (and bascilic vein)
tack to clavipectoral fascia
z plasty across axilla
cut posterior and close over drain.
liposuction
tumescent 1L NS with 1 amp epi and 10 mL 1% lidocaine
large volume is >4-6 Liters. Must be in accredited facility and stay overnight
resuscitate.
nutrition labs
albumin > 3gm/dL
prealbumin > 16
prealbumin responds to improved diet within 48 hours. Takes 14 days to drop.
25 cal/kg non protein cal per day
1.3-3 cal/kg protein per day
for burns will need 25 cal/kg + 40 cal/TBSA
posterior thigh flap
include biceps femoris, semi membranosus, semitendinosus. V-Y allow to readvance.
pressure sore beds
low-air loss
air and sand most effective at reducing pressure but can cause pulmonary problems and electrolyte and water loss
innervation lower extremity
posterior tibial nerve - plantar foot sensation and plantar flexion, relative contraindication for limb salvage
peroneal nerve - foot drop and loss sensation dorsum
lower extremity length
try to maintain >6cm below tibial tubercle
free flap lower extremity recipient vessels
anterior tibial artery and vein through the tibialis anterior and EHL
posterior tibial artery and vein medially deep to soleus
holt-oram syndrome
TBX5 mutation
radial longitudinal defects
heart disease
oral-facial-digital syndrome
females. cerebellar/brain, hypertelorism, cleft palate, micrognathia, dental anomalies, syndactyly, polycystic kidneys
popliteal pterygium syndrome
web behind knee, cleft palate, genitalia and mouth problems
prader-willi
AD, low muscular tone, obesity, mental retardation, short, hypogonadotropic hypogonadism, small hands and feet
fanconi anemia
pancytopenia and thumb deficiency
thrombocytopenia absent radius (TAR)
develop thrombocytopenia first year of life
VACTERL
vertebral malformation anal atresia cardiac tracheoesphageal fistula renal limb (radial dysplasia)
timing hand surgery
syndactyly - 6 months if boarder and if middle then 12-18 months
pollicization - 1-2 years
giant congenital nevi
20 cm diameter as adult
2-40% melanoma
half develop by 3 years and 70% by puberty
thumb hypoplasia
type 1: small - no treatment
type 2: first webspace narrow - four-flap z plasty
absent thenar muscles - abductor digiti minimi
opposition transfer
UCL instability - repair or reconstruction
type 3A: all of type 2 and transfer EIP for EPL and reconstruct FPL (may need to reconstruct pulley system)
type 3B: unstable CMC joint - pollicization at 1-2 years. base on ulnar (need to divide branch to middle) and radial neurvascular bundles. metacarpal head becomes trapezium. 45 degrees abduction and 100-140 pronation. EIP to EPL, EDC for abductor pollicis longus, palmer interosseus to adductor, dorsal interosseus as abductor pollicis brevis.
type 4: pounce flotant
type 5: aplasia
toe to thumb transplant
first doral metatarsal artery off dorsalis pedis (or the first plantar metatarsal artery). If injury at CMC then need to pollicize.
cords in dupytrens
pretendinous - MCP
spiral bands (pretendinous, spiral, lateral, graysons) - PIP (also central)
natatory - webspace
retrovascular - DIP
increase in type III rather than type II collagen.
migrane triggers
test with botox
supraorbital nerve pass through suprorbital notch (foraminotomy) within corrugator (resect).
supratrochlear nerve through corrugator
zygomaticotemporal (avulse)
occipital 3cm below and 1.5 cm lateral to occipital protuberance can be compressed by trapezius, splenius capitis, semispinalis capitis, rectus capitis, oliquus capitis or occipital artery. Release and fat flap.
brow lift
must release the temporal ligamentous adhesion (temporal fusion line) at the temporal crest and the supraorbital ligamentous adhesion. protect the frontal branch of the facial nerve that will be 1.5cm above and lateral to the lateral canthus.
incision in front of hairline as long as not a short forehead (normal 5cm women and 6cm men)
incision is medial to temporal crest and above the periosteum (under the galea/frontalis) to 2cm above the orbital rim
then must release retaining ligaments.
if temporal release then go in plane over the superificial deep temporal fascia.
skin excision to brow elevation is 2:1 ratio (may over correct)
suture galea.
upper bleph
lower incision is 1cm above the lash line and leave 1cm from brown. pinch how much can take. Laterally go into a rhytid. Skin only.
note the lateral fat pad is actually the lacrimal gland. May need to pexy.
lower bleph
can pinch skin from subcilliary incision 2mm below the lash line. release the orbicularis retaining ligament if tear trough
if scleral show or ectropian then will need canthal procedure. grasp the lateral tarsal plate with double armed suture and attach to the periosteum of the superiolateral orbital rim.
transcong incision 5mm below tarsal plate and antior to tarsal plate
arcus marginalis incised keeping the obicularis intact.
dissect 5-10 mm inferior to the tear trough deformity
interior oblique muscle will be between the nasal and central fat pads.
may remove fat through the septum or mobilize
be sure to preserve 5mm preseptal obicularis to preserve spontaneous blink
upper eyelid reconstruction
<25% primary closure
<60% tenzel semicircular myocutaneous with cantholysis
cutler beard is full thickness lid from lower passed beneath lid margin. requires cartilage graft between conjuctiva and muscle
mustarde (like an abbe flap)
temporal forehead flap from above eyebrow
lower eyelid reconstruction
<25% direct closure
bipedicled myocutaneous flap from upper lid (tripier)
<60% tenzel semicircular flap with canthotomy
hughes tarsoconjunctival with FTSG
cheek advancement (mustarde) need lateral canthal fixation and inner and middle lamella graft
staged procedures generally divide at 3-6 weeks
sphincter pharyngoplasty
palatopharyngeal flaps rotated 90 degrees and sutured to eachother and the posterior pharyngeal wall
posterior pharyngeal flap
elevate posterior pharyngeal wall (constrictor muscles) to the prevertebral fascia (make sure carotid arteries not medialized). soft palate opened like a book and the flap sutured to the posterior palate.
airway monitoring and ensure taking nutrition before discharge.
