Past Proc Derm Questions Flashcards
Sharp dissection is performed in the chin
2019 - True - Blunt dissection is often hampered by presence of vertically and diagonally inserting muscle fibres and minimal SC space to dissect within. By contrast, skin of lateral cheek has no direct muscle insertions
Brigham and Women’s Hospital Tumour Classification system for SCC
- based on a total number of criteria
- the following are part of the scale: perineural invasion >0.1mm is equivalent to T3
- invades into SC
- invades into bone in T2b
- larger than 2 cm
- T
- F - bone invasion is equivalent to T3
- T
- F - T3
- T
Desmoplastic SCC is less aggressive than normal cutaneous SCC
F - increased risk of local recurrence and metastasis
Flaps on chin are widely undermined
F - undermining is often difficult and associated with increased bleeding
Chin flaps cross two cosmetic units
?F
Sensory innervation of the ear:
- auricular temple nerve supplies lower part of auricle
- greater auricular supplies conchal bowl
- greater auricular and lesser occipital supplies lower aspect of ear
- the apical triangle exists on the ear
- F —> greater auricular nerve
- F —> auricular branch (Arnold’s nerve) of vagus nerve (CN X)
- T
- F —> refers to superior portion of cutaneous upper lip between medial cheek and ala margin (where crescent in ala crescentic adv flap is taken)
Regarding the nose:
- nasojugal fold is perpendicular to bunny lines
- nasal sill is on the glabella
- soft triangle is inferior to the nose
- False -
- False -
- True -
Cosmetic units
- are anatomical junctions
- anterior hair line is an anatomical junction
- temple and forehead are in same cosmetic unit
- same cosmetic units have the same amount of hair
- F
- F
- T
- F - texture, pigment, pore size, sebaceous quality and hair quality same in a given cosmetic unit
Sebaceous skin
- leaves inverted scars
- is more elastic
- is more compliant
- T
- F
- F
Staples
- cause more skin necrosis than suture
- have more infection
- evert the wound
- can be used for full thickness skin grafts
- true - cause more partial necrosis (Robinson p.200)
- F
- T
- T
- Chalazion clamp is used as a haemostat over the lip
- Local anaesthetic is required for a chalazion clamp to the eyelid for a chalazion clamp to the eyelid
- 0.5% lignocaine is used for the eye
- eye ops for more than 1 hour need drops every 10 min
- True p.230 Robinson
- True
- False, Benoxinate, Tetracaine or Properacaine are used
- True
Tourniquet times:
- arm >60min
- leg >60min
- you should exsanguinate the arm after applying the tourniquet
- F arm 60 min or less p.231
- T leg 1.5-2 hours
- F limb is exsanguinated with a bandage or elastic wrap before tourniquet inflation
Lateral cheek should not be left for secondary intention healing
True
Upper eyelid can be used as FTSG
True
Flaps over the eyelid should be undermined to mid fat
False - above muscle. Layers on eyelid go from dermis to muscle
The dermis of the upper eyelid is attached to orbicularis oculi
True
Rhombic flap used to treat medial canthal areas
True
Banner flap can be used as a lower eyelid repair and causes pincushioning
True
Corrugator supercilii lies superficial to the supratrochlear artery
True
PROCERUS causes inferior movement of the forehead
True
Platysma contributes to lip depression
True - draws corners of mouth inferiorly
Incobotulinumtoxin :
- more potent than onabotulinumtoxin
- does not contain human albumin
- does not need refrigeration
- shelf life >36mo
- equal efficacy when stored in freezer or refrigerator
- F
- F. Does have albumin
- T . Robinson’s states store at <25C ~room temp
- F. 36mo Table 27.1 when unopened
- T
LN2 of face and limbs:
- which causes more swelling?
- LN2 over neck heals faster than on hand
- DFTC is recommended for Kaposi sarcoma
- suitable for KS lesion >1.5cm
- touch LN2 can be used for KS
- face p.163 - post LN2 oedema on face is most obvious
- T
- T
- ?F ?for small lesions of KS
- T
Keratoacanthomas in subungal location are not associated with bony destruction
False - they are
Persistent erythema is a sign of impending scarring, wrt chemical peels (2014)
True
With 50-70% glycolic acid, significant burning sensation and itching are signs that the peel is penetrating more deeply and peel should be neutralised sooner than anticipated
True
Persistent erythema is a sign of impending scarring, wrt chemical peels (2014)
True
With 50-70% glycolic acid, significant burning sensation and itching are signs that the peel is penetrating more deeply and peel should be neutralised sooner than anticipated
True
Jessner’s solution +15% TCA is medium depth
False. 35% TCA
Incobotulinumtoxin can be stored at room temp
True <25C , does not need refrigeration
Incobotulinumtoxin lasts 36 months unopened
True
Incobotulinumtoxin does not albumin
False , it does
Neurological patients using BoNT-A are less prone to develop antibodies
2015
False - more prone , suggesting relationship of antibody formation with high dose injections and/or frequent intervals
Botox needs to be repeated every 3-6 mo to maintain results
2015
True
Ok to lie down after botox but not manipulate the treated area
False not ok to lie down
2015- darker skin presents with an incr risk of side effects at any given energy, although longer wavelengths offer some degree of protection of epidermal melanin
True
2015 - darker skinned individuals benefit from shorter pulse durations (<30ms) because this allows for simultaneous cooling of the band of melanin at the DEJ
False >30ms longer pulse durations
If erythema from laser removal persists beyond 3 days, topical CS cream should be used
False beyond 10 days
Hair treated by laser continues to grow for a further 3-4 weeks following treatment
False 1-2 weeks
2018 catgut suture is multifilament braided
True
2018 catgut is coated in chromium
True
2018 Chromium coating of catgut suture does not reduce resorption time
TRUE, it does reduce the rate of absorption p.195 HENCE , increases resorption time ie. does not reduce resorption time
Catgut can be used as a superficial suture
True (acts as a deep and superficial suture - UpToDate)
Purse string suture 2018
- reduces size of wound
- threading dermally
- reduces size of wound by 50%
- not cosmetically good for head and neck
- t
- t
- p. 210 - reduces size of defect by 53-70%
- f p.210 - has been showing o have a good cosmetic result for small circular wounds on the face and neck
Suspension sutures:
- involve a dermal component
- need to be fixed to periosteum
- used in inferior orbital rim
- lateral canthopexy is an example
- t p.219 - first throw passes through reticular dermis
- t p.219 - catches a substantial bite of periosteum
- t fig 14.4
- t p.220
Cicatricial ectropion:
- V-Y repair used in severe ectropion
- tacking lower eyelid to eyebrow can be utilised
- thinning the graft helps
- multiple Z-plasty repair is used to repair it
- p.343 false V-Y used for mild ectropion
- p.342 true canthoplasty performed by making a horizontal incision several mm lateral to the lateral canthus, exposing the lateral canthal ligament, then tacking down this ligament to the superior orbital rim, - this results in a tightening of the lower lid skin
- false
- ?false
Regarding anticoagulants:
- pradaxa need to be bridged with LMWH if stopped
- aspirin needs to be stopped 5-7 d prior
- naproxen has an anticoagulant effect
- f?
- f, 1-2 wk in robinson
- true
Digital nerve blocks:
- blocks 2 pairs of nerves on either side of digit
- the level of the injection is when you hit bone with time of needle
- circumferential ring block can result in skin necrosis
- avoid in Raynaud’s
- True - dorsal and ventral paired digital nerves
- true
- true due to compartment syndrome
- true? (0.5mL lignocaine is preferred)
Superior eyelid surgery
- need to anaesthetise cornea when using chalazion clamp
- used as a donor site for full thickness skin graft
- secondary intention healing (ciliary border) is contraindicated
- undermine in fat area if below orbital rim
- T
- T
- T
- F
Tetracaine eye drops
- anaesthesia onset in 30 sec
- works for 15 min
- need to use chlorsig during or after tetracaine use
- not used in long Surg
- keep eye covered until anaesthetic wear off
- T
- T, lasts 15 min or longer , up to 45 min on mucous membranes p. 48
- F
- T
- T
Haematoma
- haematoma and infection should not be opened up
- treatment of choice for a large haematoma within 6 hrs of surgery is to insert a Penrose drain
- is an indication for antibiotic use,
F
F
T
Clonidine
- lowers BP through its alpha agonist effect,
- reduces analgesia requirement after surgery
- reduces heart rate, contraindicated if SBP >180mmHg
- has an anti-anxiolytic effect
- T
- T
- F
- T
Primary closure
- crescentic closure cannot be used on the cheek, -angle greater than 45 degrees likely to result in a dog ear,
- M plasty can be used to reduce the length of the scar
- F
- T
- T
Surgery on the forehead
- small defect on central forehead prefers to be closed horizontally
- bilateral advancement flap can result in neuralgia,
- risk of danger to superior trochlear nerve if operating in mid fat on forehead,
- having a fascia on the middle of the forehead gives a surgical challenge
- T
- T
- T
- ?F
Mucosal advancement flap
- indicated for broad lip defect,
- will result in 2 surgical lines,
- is a form of bipedicle flap
- loss of sensation is rare
- is a two-staged flap
- T
- F
- F
- ?F
- F
Flaps
- dorsonasal flap is a rotation flap
- Tenzel flap is a rotation flap,
- Mustarde flap is a transposition flap
- T
- T
- F - rotation
Dorsonasal root rotation flap
- is a rotation flap,
- secondary defect is along the nasofacial sulcus,
- defect size can be up to 3cm
- T
- T
- F 2cm
Banner flap
- transposed 90 degrees or more,
- length ratio used is 2:1
- can be used on the inferior eyelid,
- preauricular skin is the donor site for superior helical rim,
- T
- F 3:1
- T
- T
Interpolation flaps
- spear flap
- Abbe flap,
- two-staged paramedian forehead plan
- Karapandzic flap
- F
- T
- T
- F - rotation + advancement for Lower lip
Axial flaps
- are random flaps
- dorsonasal flap is a two-staged flap
F
F
Abbe flap
- width of the flap should be smaller than the defect,
- height of the flap should be same as the defect
- flap is rotated around 180 degrees,
- the donor site is closed first,
- flap is from the contralateral lip
- T p.298 - flap width usually 50-75% width of defect
- T vertical height of flap equals vertical height of defect
- T p.298 - incised end of non pedicle side of flap is rotated 180degree toward the primary defect
- T ?
- True
Flaps used on perioral skin
- Rieger flap,
- double advancement peng variant,
- Abbe flap,
- F (nose)
- T
- T
Delayed grafting
- for wounds too deep,
- 4 wks later
- chlorhexidine should not be used at the base
- not suitable for a FTSG
- T
- F 1-3 weeks
- F
- F
FTSG
- becomes anhidrous (F),
- higher metabolic demand will limit the size of the graft,
- will not do well when placed on exposed cartilage,
- basting sutures are used to tie over the graft (F)
- F
- T
- T not ideal over exposed bone or cartilage
- F
FTSG on ear
- flap atrophy is common
- tie over suture not required
- notching on the rim can be prevented by pexing the cartilage,
- conchal bowl retains its shape,
- T
- ?F
- T
- T
lipoma
- usually not incapsulated,
- can be inmeshed with frontalis muscle on the forehead,
- those infiltrating muscles on arms usually painful,
- incision should be shorter than the diameter of the lipoma,
- infiltrative lipomas can occasionally metastasise
- T
- T
- T
- T
- F
Body dysmorphic disorder
- cannot pinpoint exact problem,
- tends to want a particular procedure,
- cosmetic surgery is usually contraindicated,
- social phobia develops after BDD
- often have co-existing psychological issues
- T
- T
- T
- F (before)
- T
Hyaluronic acid
- should be refrigerated
- nitrite glycerine paste should be used in intrarterial injection,
- optimal result can be seen after 3 days
- lasts for up to 4 months
- should not be mixed with propylene glycol containing saline
- F
- T
- F
- F 4-6 mo
- F doesn’t need mixing
superficial chemical peels
- includes 25% TCA,
- can be used for PIH,
- useful for solar lentigines,
- should not be used if skin type VI
- T
- T
- T
- T?
chemical peels
- stinging is expected,
- light peeling is expected,
- milia is expected
- persistent erythema is expected
- use of sunscreen for 3 months prior can reduce risk of PIH)
- T
- T
- F , a side effect
- F , a side effect
- T
Botox
- resistance usually develops more for those used for cosmetic than cervical dystonia
- requires an anaesthetic
F
F
Photoepilation should be withheld in those who :
- has a suntan,
- used a hair lightening cream in the last 4 weeks,
- has lentigines over the area to be treated
- took gold in the last 12 months
- T
- T
- F
- T
Tattoo laser removal
- response to professional tattoo is unpredictable,
- older faded ones respond better than new fresh ones,
- red response better than green
- yellow is hard to treat,
- use with caution laser that destroys cadmium salt pigment in those who have cadmium allergy
- T
- T
- F
- T
- ?T
HOI and PDL
- proliferating ones respond better than deep,
- ulcerated haemangioma should not be treated
- treating early prevents deep invasion of the vessels
T
F
F
Port wine stain
- with hypertrophy lesions in pts less than 18yo
- usually affects V1,
- there is bony hypertrophy underneath (F),
- treatment should be withheld until 6 yoa (F).
- hypertrophic lesions should not be excised yet
T T F F T?
Sclerotherapy
- Imaging for excluding patent foramen ovale is mandatory before foam sclerotherapy,
- Polidocanol injection is relatively painless,
- Sodium tetradenyl sulphate is for spider and small veins only,
- patient needs to walk around post procedure to prevent DVT
- F
- T
- F
- T
Sclerotherapy SEs - matting occurs in 10-15% of patients
<10% hence false. From table in sclerotherapy chapter if side effects and incidence
Keloid
- dosage IL bleomycin 100
- 5FU can be safely given 50mg/ml equally mixed with 1% lignocaine
- PDL does not help
F
F
F
Compression therapy for hypertrophic scar -increases skin cellularity
- should be higher than SBP
- need to have a break for minimum 6 hrs
- needs to be on for at least 18 hrs per day,
??F. Book states it does increase collagen age activity by inhibiting a-microglobulin s, and decrease tissue metabolism. Causes fibroblast and collagen degeneration
F
F
T
Post-surgical hypertrophic scar
- recommended dose is triamcinolone acetonide 20mg/ml,
- usually only need about 0.3ml per treatment,
- space treatment monthly until effect,
- should be injected into superficial dermis
- T
- T
- T
- F
Mohs
- recurrence usually due to poor surgical clearance
- primary tumours are not cost effective as opposed to recurrent tumours
- the deep and horizontal margins are assessed separately
- tissue is frozen in liquid nitrogen,
- chemohaemostasis should be avoided in Mohs defect until finished)
- F
- F
- F
- T
- T
Mohs more painful if:
- more cuts are done,
- took longer,
- fingers and toes more than facial sites,
-true all?
Biopsies
- scalp biopsy parallel to the direction of hair growth prevents alopecia,
- IF should be transported in glutaraldehyde
- EM should be transported in Michel’s medium
T
F
F
Hypertensive pt more risk of bleeding post op
T
hypertensive pt
-hypertension in known HT pt has less bleeding effect than in normal hx of BP
T as controlled?
Anatomical names
- soft triangle on the nose,
- supratip on the nose,
- anterior triangle on the ear
- white roll on the ear
- tubercle on the lip
T T F - landmark on neck F - on lip T
Cosmetic junctions
-are fixed anatomical landmarks,
forehead and temples are one unit
melolabial fold divides the nose from the upper lip
- T
- F
- F
EMLA cream
- contraindicated in infants,
- contraindicated on mucosal surfaces,
- contraindicated use near the eyes,
- contraindicated to leave on for longer than 120 minutes,
- cannot be used in those with lignocaine allergy
- T
- T
- T
- T
- T
Imaging
- Perineural invasion is best visualised with MRI - lymphatic spread should be assessed with PET,
- high frequency USS is best in visualising the depth of a BCC
- F, PET
- T
- F
Resident flora in different anatomical sites
- strep viridans on ears
- pseudomonas in axillae
- staph aureus on glaborous skin,
- corynebacterium in groin
- F, mouth
- F
- T
- F
Allergic reactions
- a PPD reaction may indicate an allergy to prilocaine, - it is reasonable to use a preservative-free anaesthetic of the other class in someone with a documented local anaesthetic allergy,
- pts with lignocaine allergy is usually allergic to prilocaine,
- amides are more likely to cause allergy than esters,
- T, prilocaine is an ester, which is metabolised to PABA which cross-reacts with PPD
- T
- T
- F
nbUVB therapy
- Burn occurs in 12-24 hours, if more severe burn it occurs earlier than mild reactions
- if just erythema keep the same dose
- if missed 10 days reduce dose by 25%
- if missed 3-4 weeks reduce dose by 50%
- F
- F
- F
- F - start again
PUVA
- need to protect eyes during bath in severe psoriasis patients
- bath needs to be soaked for 30 minutes,
- need to be exposed to light within 30 mins
- on commencing a repeat course, the response rate drops from the first course
T
T
F 2 hr
F?
Antiseptics
Cadexomer Iodine is cytotoxic
Povidone-Iodine should not be used in those with iodine allergy,
Cadexomer Iodine should be avoided in neonates ?Or maybe it was children
F, it is slowly released through beads
T
?T - thyrotoxic
Monocholoroacetic acid questions
- more effective than cryotherapy
- pain starts within 1 hour after application
- works better for certain types of verruca
- equivalent to placebo
- F, similar efficacy
- T
- ?T
- F
What is the Brigham and women’s hospital staging for SCC
T1 - 0 high risk factors
T2a - 1 high risk factor
T2b - 2-3 high risk factors
T3 - 4 or more high risk factors or bone invasion
High risk factors include tumour diameter >=2cm , Poorly differentiated PNI >=0.1mm, Invasion beyond fat (excluding bone) Bone upgrades to T3
Age and sun exposure can accentuate wrinkles that appear along course of relaxed skin tension lines - 2012
T
2019 V-Y flap over the lip :
- apical margin posterior
- crosses vermillion
- True
- False
2019
V-Y repair is helpful for severe ectropion
False - mild ectropion
Banner flap can be used as a lower eyelid repair and causes pin cushioning
True p. 313 Paver
Regarding eyelid repairs:
- upper eyelid can be used as FTSG
- flaps over eyelid should be undermined to mid fat
- dermis of upper eyelid is attached to the orbicularis oculi
- corrugator supercilii lies superficial to the supratrochlear artery
- T
- F - above muscle
- T - Dermis—> muscle
- T
PROCERUS causes inferior movement of the forehead
True
Platysma is a lip depressor
True
Regarding botox:
- INCO is more potent than ONA
- INCO does not contain human albumin
- INCO does not need refrigeration
- shelf life for INCO is >36 mo
- storage of freezing vs. refrigerated
- F
- F , it does. Page 429
- T, all except INCO need to be stored in the refrigerator
- F, shelf life 36mo
- false, all botox should avoid being frozen after reconstitution
Regarding electron beam:
- requires a booster (?bolus)
- requires eye protection
- requires margin >1-2cm
- F, not always
- F, depending on site
- ?depend on lesion
For hypertrophic acne scars:
- intralesional 5-FU 50mg/mL
- bleomycin
- TCA 60-80%
- subcision
- True. Robinson p.330. Mix 80:20 with steroid fortnightly
- True
- False, for atrophic scars
- False, subcision for tethered scars
Regarding hair transplant:
- punch biopsy in line with hair follicles prevent alopecia
- the strip is 25-30cm
- strip overlies occipital prominence
- follicular unit transplantation results in linear scars
- loose scalp better than non loose scalp
- T
- F 32-35cm (p.484)
- T
- T, whilst FUE results in circular scars
- T? (However too loose leads to distended scars)
Injectables:
- botox mixed with normal saline containing benzyl alcohol preservative is more painful
- 200U botox will last longer than 50U botox for axillary hyperhidrosis
- mixing lignocaine with triamcinolone reduces pain of injection
- Bleomycin + lignocaine incr uptake
- False, less painful with preservatives
- F
- F pain of injection the same as lignocaine doesn’t have a chance to work yet
- T
ABO botox diffuses more than INCO botox
True
2% ALA for Ak’s
Green light can be used for PDT
p. 530 Robinson
- false, 20%
- true
