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Surgery > Plastic > Flashcards

Plastic Flashcards

1
Q

Causes of acquired soft tissue defects that are dealt with by plastic surgeon:

A

1) Inflamatory
2) Neoplastic
3) Metabolic
4) Ischemic
5) Traumatic
6) Iatrogenic

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2
Q

Which can heal by regeneration?

A

1) Epithelium
2) Hepatocytes
3) Bone

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3
Q

To be optimal, the tissue transfer (graft or flap) should achieve the following criteria:

A

1) The transferred tissues should be as similar as possible to the lost tissues in the defect (replace like with like)
2) The tissue transfer should achieve maximum benefit to the recipient area.
3) The tissue transfer should achieve minimal harmful effect on the donor area, this is referred to as minimal donor site morbidity
4) The tissue transfer should be safe to patient.

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4
Q

The hierarchy of closure methods includes:

A

1) Direct closure

2) Healing by secondary intention

3) Skin grafting; split thickness, or full thickness

4) Flaps. Local or distant

5) Prosthesis

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5
Q

When do we close the wound?

A

When it is clean:
1) Minimal bacterial load (contamination and infection)
2) Minimal necrotic tissue

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6
Q

What does cleanliness in a wound depend on?

A

1) MECHANISM OF INJURY , AND INSTRUMENT USED: Crushing injuries, and injuries inflicted by blunt instruments are usually associated with a degree of contamination and tissue damage .

2) TIME ELAPSED FROM INJURY TO PRESENTATION: >6 hours = contaminated , an exception to this
rule is the face , in which primary closure could be done within 24 hours.

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7
Q

Why is the face an exception when it comes to primary closure?

A

Due to its excellent vascularity

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8
Q

Depending on the degree of tissue necrosis and contamination, wounds are classified into:

A

1) Incised wound: caused with sharp, relatively clean instruments, like kitchen knife = minimal necrosis and contamination. These wounds are closed primarily if patient arrives within six hours.

2) Lacerated wounds: characterized by jagged edges, caused with blunt instruments,
= moderate degree of necrosis and contamination, if patient arrives within six hours, these wounds are managed by wound excision, (to transform it into an incised wound) and then direct closure.

3) Crushed wounds: seen in industrial and severe road traffic accidents, = heavy contamination and severe tissue revitalization. These wounds are managed by wound opening, cleaning, irrigation and adequate debridement, which means excision of the devitalized tissue. This procedure is repeated daily till the wound is clean with no dead tissue, when it could be closed.

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9
Q

Why is primary closure contra-indicated in crushed wounds?

A

The dead tissue, contamination, and the tissue tension due to inflammatory edema will predispose to infection, especially gas gangrene and tetanus.

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10
Q

When is direct closure used?

A

When there is no or minimal tissue loss so we can approximate the wound edges without tension

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11
Q

When is healing by secondary intention used?

A

1) When the area is of no functional or cosmetic value
2) When other operative methods like grafts or flaps are not safe

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12
Q

Which grafts are used to cover large parts of the body?

A

Split thickness

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13
Q

Why are full thickness grafts better?

A

1) Better texture
2) Better color matching with less pigmentation problems
3) More durable
4) Less wound contraction
5) Better sweat and sebaceous glands function
6) Grows with the child
7) Better final innervation

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14
Q

2 drawbacks of FTSG?

A

1) Less available to cover large areas
2) More difficult to take

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15
Q

Graft take:

A

The process by which the graft is integrated in the recipient site and acquires new blood supply

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16
Q

Skin graft take passes through two stages:

A

1) PLASMATIC CIRCULATION: in the first 1-2 days, the graft is nourished from the underlying recipient site by the process of imbibition or diffusion

2) NEOVASCULARIZATION: within 2-3 days, the graft blood vessels are joined with the recipient site vessels

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17
Q

SIGNS OF SKIN GRAFT TAKE?

A

1) The graft is adherent to the recipient site.
2) The graft is pink in color.
3) The graft blanches with pressure, denoting vasularity.

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18
Q

Factors affecting take?

A

1) Vascularity of the recipient site!
2) Bacterial load (contamination and infection), especially that is caused by GAS.
3) Presence of barriers between the graft and the recipient area, such as hematoma, seroma, debris, or foreign materials.
4) Immobilization, the graft should be fixed to the recipient site

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19
Q

Why must the graft be fixed to the recipient site?

A

Graft mobility hinders imbibition and neovasculaization

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20
Q

Flap vs graft depends on:

A

1) Complexity of the defect
2) Vascularity of the recipient site

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21
Q

The depth (degree of thermal burn) depends on:

A

Quantity of heat:
a) Temperature
b) Duration of exposure

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22
Q

Thermal burns is classified into:

A

1) Dry heat (direct flame burn) direct exposure to fire
2) Moist heat (scald burn), exposure to hot liquids
3) Contact burn. contact with hot metals like an iron
4) Friction burns

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23
Q

Why is direct heat burn serious?

A

Because it may be associated with inhalation injury

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24
Q

GENERAL THERMAL BURNS MANAGEMENT:

A

1) Maintaining adequate oxygenation

2) Proper fluid resuscitation to maintain adequate perfusion, management of electrolytes and acid-base derangements

3) Treatment of anemia

4) Nutritional support

5) Minimizing tissue edema which has a negative effect on micro-circulation and decreases tissue perfusion.
a) Proper fluid resuscitation (avoid over-resuscitation)
b) Elevation of injured limbs

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25
Q

Acids usually produce ___ necrosis, while alkalis usually produce ___ necrosis.

A

Coagulative; liquefactive

26
Q

The primary management of chemical burns is:

A

Irrigation of the area affected by
water to dilute the chemical agent, (2-4 hours = alkaline burn, 30 minutes = acidic burns)

27
Q

Why don’t we apply acids to neutralize alkalis and vice versa?

A

Because adding acid to alkali results in harmful heat production

28
Q

Which tissues and stuff have the least resistance?

A

1) Nervous tissues + nerves
2) Muscular tissues
3) Blood
4) Blood vessels

29
Q

Severity of electrical burns depends on:

A

1) Voltage >1000
2) Resistance

30
Q

Which is most affected by electrical burns and why?

A

Muscles, because of their bulk (NOT NERVES)

31
Q

MANAGEMENT OF ELECTRIC BURNS:

A

1) Head injury and peripheral nerves damage.
2) Involvement of cardiac muscles may lead to cardiac arrythmias.
3) Due to the skeletal muscle damage, myoglobin is released from the damaged muscles leading to myoglobinemia and myoglobinuria that causes acute kidney injury. Good hydration, and alkalization of urine are measures to be used to prevent this renal impairment.
4) Also, due to the muscle damage, compartment syndrome.
5) Due to severe muscle contraction patients may have bone fractures.

32
Q

ASSESSMENT OF THE SEVERITY OF BURN (Depth and Percentage):

A

1) The depth of burn damage (degree) = local management and
outcome
2) The surface area involved in burn = prognosis (mortality rate) and the systemic management and complications

33
Q

Classification of the depth of burn injury:

A

1) First degree burn
2) Second degree burn (partial thickness)
3. Third degree burn (full thickness)

34
Q

Characteristics of first degree burns?

A

1) Thermal necrosis is limited to the epidermis
2) Pain + erythema
3) 1-6 days to heal and leaves no scars

35
Q

Characteristics of second degree burns?

A

1) Necrosis of the epidermis and a varying depth of the dermis
2) Pain (due to irritation of the
dermal sensory nerves), erythema, blisters (bullae), the burned area is wet with exudate (weeping), blanching denoting intact dermal vascularity, and preservation of skin elasticity
3) 1-4 weeks to heal and leaves minimal scarring

36
Q

Characteristics of third degree burns?

A

1) Necrosis of the whole skin (epidermis and dermis) and its skin appendages

2) Eschar (the burned necrotic skin), it is insensitive, leathery, hard, inelastic, and may show
thrombosed dermal vessels. NO PAIN BECOMES DAMAGED NERVES

3) It takes months to heal and leaves significant scarring and post burn joint contractures.

To avoid scarring it should be skin grafted after removal of the necrotic skin (the eschar).

37
Q

The percentage of burn determines:

A

1) The mortality rate (mortality rate increases as percentage increases)

2) Degree of hypovolemic shock (fluid deficit) and hence the fluid resuscitation

3) Degree of malnutrition, Hypermetabolism, catabolism and protein breakdown

4) The probability of decreased immunity, sepsis, septic shock and their systemic complications as multi-organ failure increases with the increase in burn percentage

38
Q

Rule of nines:

A

1) Head & neck (9%)
2) Upper limbs (9% each)
3) Anterior trunk (18%)
4) Posterior trunk (18%)
5) Lower limbs (18% each)
6) Genitals (1%)
7) Palms (1% each)

39
Q

Signs of impending airway obstruction include:

A

1) Tachycardia
2) Progressive hoarseness
3) Difficulty clearing bronchial secretions

40
Q

Laboratory examination: significant ECF losses may be associated with:

A

1) Elevated blood urea nitrogen level.
2) Urine osmolality usually will be higher than serum osmolality.
3) Urine sodium will be low, typically <20 mEq/L.

41
Q

Causes of fluid losses in surgical patient:

A

1) Loss of GI fluids from nasogastric suction, vomiting, diarrhea, or enterocutaneous fistula (MOST COMMON)

2) Sequestration (third space losses) secondary to soft tissue injuries and inflammation burns, and intra-abdominal processes such as peritonitis, pancreatitis, intestinal obstruction, or prolonged surgery

  1. Hemorrhage
42
Q

In burns, there is a major shift of fluids from the __ compartment,
which is responsible for direct tissue perfusion, to the ___ compartment. Why?

A

Intravascular; Interstitial

Because of the increase capillary permeability, or loss of the capillary integrity

43
Q

Burn shock is seen in adults with burns greater than ___ and in children with burn more than ___.

A

15-20%; 10-15%

44
Q

How do we ensure that the optimal amount of fluid is given?

A

1) Clinically by observing, the general condition of the patient, and the vital signs

2) Urine output (most sensitive indicator of tissue perfusion) should be 0.5-1 ml/kg/hour, higher urine output may indicate that, extra fluid is given, that increases tissue edema.

3) Serial PCV readings, in which, high PCV indicates, hemoconcentration, where more fluid is to be administered, and low PCV means, hemodilution, in
which the rate of fluid administration is to be lowered.

4) Swan-Gans or CVP lines may be indicated in some patients, especially those with border line cardiac reserve, like the elderly.

45
Q

Parkland formula states that:

A

Fluid in the first 24 hours = 4 X Weight X % of burn

46
Q

Prophylactic antibiotics are contra-indicated in burns. Why?

A

1) Studies did not prove that prophylactic antibiotics decrease the incidence of sepsis.
2) Antibiotics increase the incidence of fungal infections.
3) Antibiotics increase the incidence of bacterial resistance.

47
Q

INDICATIONS OF ADMISSION TO HOSPITAL:

A

1) Burns that need fluid resuscitation: Adults>15%, children>10%).
2) Full-thickness burns> 2%
3) Burns of special areas: face, hands, perineum.
4) Electric and chemical burns.
5) Inhalation injury.
6) Old age and co-morbidity.
7) Suspected child abuse.

47
Q

INDICATIONS OF ADMISSION TO HOSPITAL:

A

1) Burns that need fluid resuscitation: Adults>15%, children>10%).
2) Full-thickness burns> 2%
3) Burns of special areas: face, hands, perineum.
4) Electric and chemical burns.
5) Inhalation injury.
6) Old age and co-morbidity.
7) Suspected child abuse.

48
Q

Which side and gender more common in cleft lip?

A

Left; males

49
Q

Causes of cleft lip?

A

1) Genetics
2) Vitamin deficiency in pregnancy (folic acid)
3) Drugs as steroids
4) Gestational viral infections or irradiation
5) Loss of amniotic fluids

50
Q

Cleft palate problems:

A

1) Feeding (suckling)
2) Speech
3) Regurgitation of food from nose
4) Hearing loss due to recurrent ear infections

SWALLOWING IS NORMAL

51
Q

MOST COMMON CAUSE OF VELOPHARYNGEAL INCOMPETENCE?

A

Cleft palate, which causes:
1) Mechanical defect of the cleft
2) Hypoplasia of the palate
3) Abnormal insertion of the palatal muscles

52
Q

When to repair cleft palate?

A

Speech therapists believe that, the earlier the cleft palate repair is, the better the outcome of speech would be, so they encourage early repair, but the facial surgeons
think that early surgical repair would interfere with the facial bony growth leading to retardation of maxillary growth ( dish face). So the compromise between these two opinions is to operate at 1 year of age.

53
Q

Features of infantile hemangiomas?

A

1) Localized/diffused
2) Histologically share features of placental tissue
3) Expression of glucose transporter protein GLUT-1
4) PHACE association

54
Q

Active hemangioma intervention is necessary in the presence of
complications such as:

A

1) Large size or disfigurement
2) Multiple lesions causing high-output cardiac failure
3) Obstruction of vital structures (vision, airway)
4) Persistent ulceration.

55
Q

First line hemangioma treatment:

A

Propranolol

56
Q

Second line hemangioma treatment:

A

Steroids

57
Q

Genetic abnormalities associated with venous malformations:

A

1) Krit-1
2) TIE-2
3) Glomulin genes
4) Blue rubber bleb syndrome

58
Q

Kaposiform hemangioendothelioma (KHE) treatment?

A

MTOR+: Sirolimus

59
Q

Management of ischemic ulcers?

A

1) Revascularization
2) Wound care

60
Q

Where do venous stasis ulcers tend to occur?

A

At the sites of incompetent
perforators, the most common being above the medial
malleolus, over Cockett’s perforator

61
Q

Pressure ulcer formation is accelerated in the presence of:

A

1) Friction
2) Shear forces
3) Moisture

Surgery (7 decks)

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