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Plastic Surgery Flashcards

1
Q

Evaluating size of burn

A

Wallace’s rule of 9s
Hand = 1.25%
Palm alone = 1%
ONLY COUNT SUPERFICIAL PARTIAL AND DEEPER (don’t include epidermal burns)

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2
Q

Most common causes of burns

A 
60% scald from oil or water
30% explosion and flame
4% contact burn
3% electrical
3% chemical
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3
Q

Zones of Jackson’s burn model

A
  1. zone of necrosis (dead)
  2. zone of stasis (salvageable)
  3. Zone of hyperaemia - healthy, providing increased circulation to zone of stasis THEREFORE DON”T USE ICE - YOU WILL CONSTRICT THESE VESSELS AN REDUCE BLOOD FLOW
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4
Q

Evaluating depth of burn

A

Epidermal:
epidermal integrity (Nikolsky sign negative)
SUPERFICIAL DERMAL:
Nikolsky +ve, slippery surface, thin walled blisters, blanches with pressure, very painful, oozing
MID DERMAL:
Nik +ve, slippery, thick walled blisters, some mottling, sluggish blanching, dark, red base, less oozy and less painful than superficial dermal
DEEP DERMAL:
Nik +ve, not slippery, red colour, red sensation, absent or red refilling after blanching, mixed mottling, little or no ooze
FULL THICKNESS:
Not painful, no refilling after blanching, white/brown with visible black vessels, hairs fall out easily, dry

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5
Q

Criteria for review of a burn by burns unit (11)

A
  • Adult burn over 10%
  • full thickness burns
  • burns of special areas (face, neck, hands, feet, breasts, genitalia, perineum)
  • Electrical burns
  • Chemical burns
  • Circumferential burns
  • Extremes of age (children or elderly)
  • Comorbid medical illness (Dm, paraplegia)
  • Concomitant trauma
  • Comorbid psychiatric illness
  • Any burn that referring department is not confident to send home
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6
Q

Fluids in burns

A

If over 15% TBSA
MODIFIED PARKLAND FORMULA
First 24h: Hartmann’s solution 4 x %TBSA x weight
give half in first 8 hours, half in next 16 hours

Aim for 0.5mL/kg/hr urine output - CATHETERISE TO MONITOR

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7
Q

Acute complications of burns

A 
Inhalational injury (airway oedema and obstruction, pneumonia, atelectasis)
Acute respiratory distress syndrome
Hypothermia
Hypovolaemia
Renal failure
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8
Q

Subacute complications of burns

A

Secondary infection
Graft loss
Early hypergranulation
Scar contracture/post-burn deformities

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9
Q

Pathogens most likely in secondary infections of brrns

A

First 48h: GRAM +VE - appears of loss of wound granulation

  • staph aureus (from hair follicles)
  • GBS
  • VRE

5-7d: GRAM -VE: appears as surface necrosis and patchy black colouring
- pseudomonas aeruginosa

3-4w: COMPLICATED INFECTIONS AND FUNGUS
Appears as minimal exudate
30-50% mortality!
- Candida
- MRSA
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10
Q

Components of acute respiratory distress syndrome (secondary to burns)

A

Hypoxaemia (due to V/Q mismatch)
Pulmonary HTN (inc. pulmonary oedema)
Bronchoconstriction (systemic inflammatory response)
Reduced lung compliance (secondary to oedema and red. surfactant)

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11
Q

Definition of folliculitis

A

Acute infection of multiple hair follicles

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12
Q

Pathogens in folliculitis

A

Staph aureus

“Hot Tub” version = psudomonas aeruginosa

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13
Q

Clinical features of folliculitis

A

Clusters of multiple lesions
Small, raised, pruritic erythematous lesions +/- central pustule
Each lesion under 5mm (in staph) may be up to 30mm in hot tub version
Frequently observed in areas of repeated shaving (e.g. beard)

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14
Q

Management of folliculitis

A

Usually self-limiting
Warm compresses can be applied TDS
Avoid shaving area
If lesions persist, topical mupirocin for s. aureus version

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15
Q

definition of furuncle

A

AKA boil

An acute infection of a single hair follicle

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16
Q

Definition of carbuncle

A

Multi-loculated furuncle (coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles)

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17
Q

Pathogen involved in furunculosis/carbuncles

A

Staph aureus almost always

If use foot baths at nail salons, at risk for myobacterium

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18
Q

Management of furunculosis and carbuncles

A

Small: warm compresses to promote drainage
Larger/carbuncles: incision and drainage, MCS of material drained
If at risk of endocarditis: antibacterial prophylaxis prior to I/D (vancomycin preferred)

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19
Q

Definition of impetigo

A

Superficial bacterial infection involving the epidermis proper

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20
Q

Age group impetigo most commonly seen in

A

2-5y

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21
Q

Pathogens in impetigo

A

Classic impetigo: strep pyogenes

Bullous impetigo: Staph aureus (exofoliative A toxin - loss of cell adhesion in superficial epidermis - bullae)

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22
Q

Features of non-bullous impetigo

A

Lesions begin as papules - vesicles surrounded by erythema - become pustules - thick adherent crusts with golden appearance
typically involves face and extremities

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23
Q

Features of bullous impetigo

A

Vesicles enlarge to form flaccid bullae with clear-yellow fluid - becomes darker and more turbid - ruptures - thin brown crust
Trunk more frequently affected than in non-bullous

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24
Q

Management of impetigo

A

Soak moist or crusted areas with water/white vinegar
Antiseptic/antibiotic ointment
(Betadine, OH, chlorhexadine, mupirocin etc.)
Oral Fluclox 7d
Cover affected areas, avoid close contact with others, stay home until crusts have dried out, change and wash clothes and linen daily

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25
Definition of erysipelas
Superficial skin infection involving the upper dermis with deeper layers not affected
26
Pathogen of erysipelas
ALWAYS streptococcus pyogenes
27
Clinical features of erysipelas
most commonly lower extremities Lesions raised above level of surrounding skin Clear line of demarkation Milians ear sign - involvement of ear (has no deeper tissue therefore must be cellulitis) Butterfly involvement of face Acute systemic symptoms (fever, chills)
28
Management of erysipelas
Non-pharm: elevation, hydration Parenteral ABx if systemic manifestations (ceftriaxone or cephazolin) Mild infection - oral amoxicillin
29
Definition of cellulitis
Bacterial infection of the deep dermis and subcutaneous fat
30
Pathogens in cellulitis
Staph OR strep pyogenes (less unwell) Water related: Fresh water- - aeromonas hydrophilia Salt water - vibrio species (vulnificus) Dog/cat bites: pasteurella Human bite: mixed oral flora
31
Clinical features of cellulitis
Redness, swelling, warmth, tenderness More indolent course of disease than erysipelas +/- purulent drainage/exudate
32
Management of cellulitis
``` Oral flucloxacillin (IV if severe) If purulent: clindamycin, bactrim or doxycycline ```
33
Definition of necrotising fasciitis
An infection of the deeper tissues that results in progressive destruction of the muscle fascia and overlying subcutaneous fat; muscle tissue frequently spared because of its generous blood supply
34
Types of necrotising fasciitis
Type I: polymicrobial Type II: Streptococcal (pyogenes) Type III: Gas gangrene - clostridium perfringens
35
Clinical features of necrotising fasciitis
Acute rapid progression over several days (usually appear within 24h of minor injury) Flu-like sx Intense thirst (dehydrated) Erythematous without sharp margins Swollen, warm, shiny, exquisitely tender Pain out of proportion to physical exam findings Red-purple skin - patches of blue-grey 3-4d: large dark marks, skin breakdown with bullae and frank cutaneous gangrene 4-5 days: severely unwell, high fever, v low BP, toxic shock Gas gangrene has subcutaneous crepitus
36
Investigations in necrotising fasciitis
Surgical exploration - cultures of deep specimens | Radiographic imaging ?muscle involvement
37
Management of necrotising fasciitis
Surgical emergency - aggressive debridement of all necrotic tissue - Cover with sterile dressing - re-evaluate in 24 hours Antibiotic: Empirical - meropenem IV + clindamycin Type II: BenPen, clindamycin, IVIG +/- amputation Type III: hyperbaric O2 +/- amputation
38
Basal cell carcinoma definition
a non-melanoma skin cancer which arises from the cells in the basal epithelium layer of the skin
39
From which cells to BCCs arise
Pluripotential cells of basaly layer of epithelium OR from hair follicle
40
Types of BCC
``` nodular (50-60%) Superficial spreading (10-15%) Infiltrative (7%) Pigmented (6%) Morpeaphorm (sclerosing/fibrosing) (2-3%) ```
41
Clinical features of nodular BCC
Well defined borders Fleshy coloured, pearly nodule Overlying telangiectasia May ulcerate - rodent ulcer
42
On which surfaces do BCCs NOT occur
MUCOSAL
43
Clinical features of superficial spreading BCC
In epidermis, no dermal invasion Flat, pink, scaly ulcerations +/- crusting Usually on trunk May be misdiagnosed as fungus, psoriasis, eczema etc.
44
Clinical features of infiltrative BCC
opaque, yellow-white | Blends well with surrounding skin
45
Clinical features of morephaephorm BCC
"enlarging scar" indurated, flat/slightly elevated papule White-yellow scarlike appearance High i
46
Investigations for BCCs
Punch biopsy 3-4mm - scar, but not a problem if excised after histology Shave biopsy cause minimal scarring, therefore may be good for facial lesions, but may be difficult to localise later
47
Management options for BCC
``` Medical: Imiquimod 5% (Aldara) Radiotherapy: - if not fit for surgery - risks: osteitis, skin necrosis Destructive: - curettage and electrodissection - cryosurgery (esp good for nodular) - laser (CO2) ablation Surgical: - +/- flap - Moh's surgery if central face, or recurrent tumours, OR high risk histological type, large or ill defined ```
48
Margins for BCC excision
Low risk lesions on face: 2-5mm | High risk/larger tumours: 10mm
49
Definition of SCC
Squamous cell carcinoma: a non-melanoma tumour of the skin arising in the squamous cells of the epithelium
50
Genetic mutation associated with high risk of SCCs
MC1R gene
51
Types of SCC
``` Verrucous ulcerative Marjolin's ulcer Subungal SCC Metastasis ```
52
Clinical features of SCC
predominantly head/neck, dorsum of hands and forearms tender, painful, hyperkeratotic growing nodule in area of sun damage Squeezing causes pain May ulcerate
53
Histology of SCC
Lobular proliferations of keratinocytes | Intradermal invasion of keratinocytes with prominent keratin production
54
Prognosis of SC with distant nodal involvement
35% 5 year survival
55
Management of SCC
Medical - Retinoic acid (activates tumour suppression genes) - Fluorouracil (5FU) cream for premalignant lesiosn - chemotherapy (cisplatin) Destructive: - curretage and electrodessication for small superficial lesions Surgical: - 4-6mm margins
56
Margins for SCC
4mm if under 2cm diameter
57
Definition of melanoma
A skin malignancy arising from the malignant degeneration of melanocytes
58
How common is melanoma
less than 5% of all skin cancers | but causes most amount of deaths
59
Risk factors for melanoma
``` Large number of naevi Atypical mole syndrome Sun exposure Family history transplant recipients Xeroderma pigmentosum ```
60
Clinical features of melanoma
``` ABCDE Asymmetry Border irregularity Colour variation Diameter over 6mm Evolving (enlarging, changing) ```
61
Types of melanoma
Superficial spreading (70%) Nodular (15%) Lentigo maligna/ melanoma in situ (5-10%) Acral lentiginous melanoma (5-10%)
62
Clinical features of superficial spreading melanoma
Peaks 30-50y Can arise in pre-existing naevus Pigment varies from black and blue-grey to pink or grey-white Irregular borders
63
Nodular melanoma clinical features
``` Peak in 50s Uniform blue-black, blue-red or red nodule Rapidly growing 5% are amelanotic Mostly on trunk, head, neck ```
64
Lentigo maligna clinical features
Irregular tan-brown macule | Slowly expanding on sun-damaged skin of elderly
65
Acral lentiginous melanoma clinical features
``` Peak in 60s On palms, soles or under nails 3cm diameter on average at diagnosis tan, brown-to-black, flat macule with colour variation and irregular borders Not linked to sun exposure ```
66
Grading of melanoma and margins for excision
``` Breslow thickness:: Melanoma in situ: 5mm under 1mm: 1cm 1-4mm: 1-2cm Over 4mm: 2cm ```
67
Excisional depth in melanoma
Muscle fascia | + sentinel node biopsy
68
Definition of actinic/solar keratosis
Abnormal skin cell development due to exposure to UV radiation which are considered to be pre-cancerous
69
Rates of transformation of solar keratosis to SCC
0.1-2% per year
70
Percentage of SCCs that arise from pre-existing solar keratoses
60%
71
Clinical features of solar keratosis
Adjacent skin shows signs of solar damage (yellow or pale, spotty hyperpigmentation, telangiectasias, xerosis) Classic: erythematous, scaly macule plaque or papule Hypertrophic: thick adherent scale on erythematous base Atrophic: scale absent, lesions smooth red macules With cutaenous horn: keratotic projection of height at least half the largest diameter (spicule or cone)
72
Management of solar keratosis
``` Cryotherapy Curettage and cautery Excision biopsy 5-fluorouracil cream (Efudix) - 2 weeks Imiquimod Photodynamic therapy ```
73
Hutchinson's melanotic freckle AKA
Lentigo maligna (melanoma in situ)
74
Features suspicious of progression of lentigo maligna into invasive melanoma
Thickening of part of the lesion Increasing number of colours (esp. blue or black) Ulceration or bleeding itching or stinging
75
Management of lentigo maligna
diagnostic biopsy with 5mm margin Radiotherapy Cryotherapy Imiquimod cream
76
What is Bowen's disease
AKA SCC in situ | A common type of skin cancer arising from epidermal squamous cells that is confined to the epidermis
77
Clinical features of bowen's disease
1+ irregular, flat, red, scaly patches of up to several cm in diameter May arise on any area of skin most often diagnosed on sun exposed areas (ears, face, hands, lower legs)
78
Management of bowen's disease
``` cryotherapy superficial skin surgery Fluorouracil cream (Efudix) Imiquimod cream photodynamic therapy ```
79
What is a keratoacanthoma
A skin lesion that erupts in skin damaged skin, growing rapidly over a few months, then may shrink and resolve itself. Considered to be a variant of SCC and cannot reliably be distinguished from SCC clinically
80
Clinical features of keratoacanthoma
May first appear as small pimple/boil but found to have solid core when squeezed Grows rapidly May be up to 2cm diameter by time it presents Diagnose as keratoacanthoma with biopsy or after regression
81
Management of keratoacanthoma
``` Obtain pathology (ensure not invasive SCC) Treat as if SCC unless horn has already fallen off ``` Cryotherapy Curettage and cautery Excision Radiotherapy
82
Signs of melanoma on dermoscopy
Reticular lines (not crossing, just growing out) Multiple colours Pseudopods Blue-grey veil
83
Intermittent bleeding on face with incomplete healing
Nodular BCC until proven otherwise
84
EFG for nodular melanomas
Elevation Firm to touch Growing persistently for more than 1 month
85
investigations if suspect melanoma
Excisional biopsy with 2mm margins
86
Management of melanoma
Excision with appropriate margins +/- sentinel node biopsy regular full skin examination + LN palpation (6, monthly, annual, 2, yearly) Counsel to present immediately if worrying spots
87
Adverse effects of imiquimod/Aldara
Flu-like symptoms for duration of treatment (occur in 5%) | No long-lasting side effects
88
Congenital spots with high risk of melanoma
LARGE congenital naevi Giant (over 20mm) 5-10% lifetime risk higher in lesions that cross the spine!

Surgery (8 decks)

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