pimp questions

Question 1

Why leave the fascia on the muscle during the dissection?

Answer 1

So you will have a strong layer of tissue to suture too.

Question 2

What suture style do you use for weaker tissue?

Answer 2

Figure of 8 because it has greater surface area and won’t “cheese wire” the tissue.

Question 3

What is Red Breast Syndrome?

Answer 3

Type IV hypersensitivity (delayed) reaction to acellular dermal matrix.

Question 4

What is the incidence of Tissue Expander infections?

Answer 4

7-10%

Question 5

What is the blood supply to the pectoralis major muscle?

Answer 5

Type V Mathes and Nahai flap. Dominant supply pectoral branch of thoracoacromial trunk. Segmental supply of IMA perforators.

Question 6

Mathes and Nahai type 1

Answer 6

Single Vascular Pedicle
ex: gastrocnemius, tensor fascia lata

Question 7

Mathes and Nahai type 2

Answer 7

Dominant Vascular Pedicle(s) and Minor Vascular Pedicle(s)
ex: gracilis, hamstring (biceps femoris), rectus femoris, soleus, sternocleidomastoid, trapezius, triceps, and vastus medialis

Question 8

Mathes and Nahai type 3

Answer 8

Two Dominant Pedicles
ex: gluteus maximus, rectus abdominis, serratus, and temporalis

Question 9

Mathes and Nahai type 4

Answer 9

Segmental Vascular Pedicles
ex: sartorius, tibialis anterior

Question 10

Mathes and Nahai type 5

Answer 10

Dominant Vascular Pedicle and Secondary Segmental Vascular Pedicles
ex: internal oblique, latissimus dorsi, pectoralis major

Question 11

What is Pitanguy’s line?

Answer 11

topographic marking for the frontal branch of the facial nerve
0.5 cm inferior to the tragus to a point 1.5cm superior and lateral to the eyebrow​

Question 12

What is Pitanguy’s point?

Answer 12

transposition of inframammary fold [IMF] to anterior breast

Question 13

Why smooth expanders?

Answer 13

ALCL linked to previous textured tissue expanders

Question 14

What are the aesthetic units of the breast?

Question 15

Primary venous drainage system of abdomen?

Answer 15

superficial system

Question 16

Why wait after infiltrating to start liposuction?

Answer 16

For the onset of epinephrine. Onset time 8 minutes. Peak effect 26 minutes.

Question 17

What does 1% solution mean?

Answer 17

This is 1000 milligrams in 100 milliliters of water. Which converts down to 10 mg per cc of solution.

Question 18

How much epinephrine can you use?

Answer 18

This is an important question for cleft palate. It is a highly vascular region and absorbs quickly. It is rec that 10 μg/kg at 30 minute intervals be used.

Question 19

How much lidocaine can you infiltrate?

Answer 19

5mg/kg without epi
7mg/kg with epi

Question 20

Strongest suture technique?

Answer 20

Vertical mattress

Question 21

Best suture tech for everting?

Answer 21

Horizontal mattress

Question 22

Most ischemic stitch?

Answer 22

Horizontal mattress

Question 23

Clip the artery or vein first on a flap?

Answer 23

The artery first so the flap isn’t engorged with blood.

Question 24

How can you prevent new capsular contracture after breast implant exchange?

Answer 24

Switch planes from sub-glandular to sub-muscular. Alloderm can also decrease the chance of capsular contracture.

Question 25

What are the grades of capsular contracture?

Answer 25

Grade I — the breast is normally soft and appears natural in size and shape
Grade II — the breast is a little firm, but appears normal
Grade III — the breast is firm and appears abnormal
Grade IV — the breast is hard, painful to the touch, and appears abnormal.

Question 26

When you are making the keyhole for the new nipple in a breast reduction, why de-epilthelize?

Answer 26

In case the nipple becomes ischemic, you can thin it and graft it onto that surface.

Question 27

What are the rates of capsular contracture?

Answer 27

Rates are lower sub-pectoral (3-4%) compared to pre-pectoral (12%). Smooth implants are higher than textured implants (1% sub-pectoral). The mechanism is perhaps thought to be from micro-motion.

Question 28

Advantage of pre-pectoral?

Answer 28

Able to place TE more medially, less pain, no animation deformity, may be faster if you wrap.

Question 29

Disadvantage of pre-pectoral?

Answer 29

Only being held by skin, subq so that breast implant may drop. You can also see the contour of the implant more easily.

Question 30

Why use ADM (acellular dermal matrix)?

Answer 30

decreased capsular contracture, ?may decrease bottoming out of implant

Question 31

Disadvantage of ADM (acellular dermal matrix)?

Answer 31

seroma formation

Question 32

What must you do if the patient wants a larger breast size?

Answer 32

Be sure to have the incision low at the IMF. If the incision is too high, the NAC will be distorted during filling of the TE. (ie the nipple will point downward because the expander will be too high).

Question 33

Unilateral DIEP Flap: where is the ideal perforator?

Answer 33

From the medial row (more centrally) so it can perfuse more of the flap. A lateral row might not perfuse the contralateral side of the flap as well.

Question 34

DIEP Flap: what perforator is more morbid, medial, middle or lateral row?

Answer 34

The lateral row perforators much more morbid because you’re going to transect nerves more laterally and this is going to deinnervate more muscle.

Question 35

You have a tourniquet up, but a half an hour into the case you start seeing dark blood seeping out from the wound. What’s happening?

Answer 35

You have a venous tourniquet and the buildup of pressure is forcing the blood out through the path of least resistance which is the capillaries in your wound bed. This tends to happen with calcified vessels.

Question 36

How to identify EIP?

Answer 36

Deep and ulnar (compared to EDC to index finger in both hand and at 4th dorsal compartment). Most distal muscle belly in forearm. No juncturae tendinae.

Question 37

How to identify motor recurrent branch of median nerve?

Answer 37

It is approximately where the index finger naturally flexes to the thenar eminence.

Question 38

What is Kaplan’s cardinal line?

Answer 38

It is a line from the the apex of the first web space to the hook of hamate and represents the vascular palmar arch. The hook of hamate can be difficult to palpate and transposing a line parallel to the mid-palmar crease to the apex of the first webspace.

Question 39

What is an intrinsic plus finger?

Answer 39

Force along FDP tendon is instead directed through lumbricals to lateral bands. This causes paradoxical extension of IPs during flexion. This sometimes occurs during OT sessions after FDP repair or after revision amps that remove the FDP insertion.

Question 40

What is quadrigia?

Answer 40

Adjacent finger cannot flex completely because of a shortened tendon and a common FDP muscle belly. Term comes from chariots in ancient Rome with reins going to 4 horses.

Question 41

What is the nutrition supply to tendons?

Answer 41

Vincula, direct diffusion through tendon sheath and from digital arteries.

Question 42

Where does FPL lay in hand?

Answer 42

Between adductor and abductor policis brevis.

Question 43

For thigh lifts or mass excisions, how do you prevent labial spreading?

Answer 43

Suture advanced dermis to Colle’s fascia.

Question 44

For mandibular contouring, what structure on buccal mucosa near the first molar must avoid

Answer 44

Stenson/parotid duct

Question 45

Approaching the end of cleft lip surgery, the patient begins to bleed while final sutures are placed. Why?

Answer 45

The cleft palate is a highly vascular region, and blood pressure rises as anesthesia becomes less deep.

Question 46

At what age does the sphenoid sinus complete pneumatization?

Answer 46

7-8 years; MRI after this age will show complete pneumatization.

Question 47

What are the layers of the scalp?

Answer 47

S Skin
C Connective Tissue
A Aponeurosis of Galea
L Loose Areolar Tissue
P Periosteum/Pericranium

Question 48

When reflecting the scalp for calvarial procedures, what layer is separated?

Answer 48

Separate at layer of loose areolar tissue, reflect the scalp, then elevate the pericranium.