Plastic Surgery Classifications

Question 1

Classification of deep inferior epigastric artery branching pattern.

Answer 1

Question 2

Classification of congenital nevi.

Answer 2

• Small: < 1.5cm^2
• Medium: 1.5 - 20cm^2
• Giant: > 20 cm^2
  
  • Other cut-offs for ‘giant’ include > 1% TBSA or > size of the palm of the hand.

Question 3

Classification of malocclusion.

Answer 3

Angle Classification of malocclusion.

Classification based on the maxillary first molar. In cases where the first molar is missing, canine teeth are used.

ANGLE Class I | NEUTROOCCLUSION: The mesiobuccal cusp of the maxillary first permanent molar occludes with the mesiobuccal groove of the mandibular first permanent molar.

ANGLE Class II | DISTOOCCLUSION (overjet): The molar relationship shows the mesiobuccal groove of the mandibular first molar is DISTALLY (posteriorly) positioned when in occlusion with the mesiobuccal cusp of the maxillary first molar.

ANGLE Class III | MESIOOCCLUSION (negative overjet): The mesiobuccal cusp of the maxillary first permanent molar occludes DISTALLY(posteriorly) to the mesiobuccal groove of the mandibular first molar.

Question 4

Classification of nerve injury.

Answer 4

Seddon classification of nerve injury.

Sunderland classification of nerve injury.

MacKinnon classification of nerve injury.

Question 5

Classification of midface fractures.

Answer 5

LeFort classification of midface fractures.

LeFort I:

• Seperates tooth-bear maxilla from midface.
• Extends from the piriform aperature posteriorly through the nasal septum, lateral nasal walls, anterior maxillary wall, through the maxillary tuberosity or pterygoid plates.
• Upper jaw clinically mobile.

LeFort II:

• Extends through the frontonasal junction along medial orbital wall, usually passing through inferior orbital rim at ZM, continues posteriorly through tuberosity or pterygoid paltes.
• Upper jaw and nasal bones clinically mobile as a single unit.

LeFort III:

• Craniofacial disjunction
• Extends through frontonasal junction along medial orbital wall and inferior orbital fissure and out lateral orbital wall.
• Complete separation of the midface at the level of the NOE and the ZF.

Question 6

Classification of brachial plexus injury (level).

Answer 6

Level 1: Inside the (vertebral) bone (preganglionic root) injury, including spinal cord, rootlet, and root injury.

Level 2: Inside the (scalene) muscle (postganglionic spinal nerve) injury, located at the interscalene space proximal to the suprascapular nerve.

Level 3: Pre- and retroclavicular injury, including trunks and divisions.

Level 4: Infraclavicular injury, including cords and terminal branch injury proximal to the axillary fossa.

Question 7

Classification of infected median sternotomy.

Answer 7

Pairolero classification of infected median sternotomy.

Question 8

Classification of nasoorbital ethoid (NOE) fractures.

Answer 8

Manson-Markowitz classification.

• Type I: A single, non-comminuted, central fragment without medial canthal tendon disruption.
• Type II: Comminuted central fragment without medial canthal tendon disruption.
• Type III: Severely comminuted central fragment with disruption of the medial canthal tendon.

Question 9

Classification of pressure ulcers.

Answer 9

Classification of pressure ulcers:

1. National Pressure Ulcer Advisory Panel Classification.
2. Shea Classification.
3. Yarkony-Kirk Classification.

Question 10

Classification of cleft palate (Veau).

Answer 10

Veau classification of cleft palate.

Question 11

Angiosomes for a unipedicle TRAM.

Answer 11

Question 12

Classification of polydactyly.

Answer 12

Wassel Classification of Polydactyly.

Question 13

Classification of basilar thumb arthritis.

Answer 13

Eaton and Littler Classification of Basilar Thumb Arthritis

Stage I: Subtle carpometacarpal joint space widening.

Stage II: Slight carpometacarpal joint space narrowing, sclerosis, and cystic changes with osteophytes or loose bodies < 2 mm.

Stage III: Advanced carpometacarpal joint space narrowing, sclerosis, and cystic changes with osteophytes or loose bodies > 2 mm.

Stage IV: Arthritic changes in the carpometacarpal joint as in Stage III with scaphotrapezial arthritis.

Question 14

Classification of craniofacial clefts.

Answer 14

Tessier classification of craniofacial clefts.

Within the Tessier clefts, there are 4 sub-groups.

Oral-Nasal Clefts (# 0-3): Oral-nasal clefts occur between the midline and cupid’s bow, disrupting both the lip and nose.

Oral-Ocular Clefts (# 4-6): Clefts connect the oral and orbital cavities without disrupting the integrity of the nose. They occur lateral to cupid’s bow, extend through the soft tissue of the cheek and maxillary process, and are called meloschisis.

Lateral Facial Clefts: Include Treacher Collins Syndrome, Goldenhar’s syndrome, hemifacial microsomia, and necrotic facial dysplasia.

Cranial Clefts: Clefts extend superiorly from the lateral orbit to the midline and proceed through the frontal bone and often into the base of the cranial vault.

COMPLETE TESSIER CLASSIFICATION

Tessier Cleft Number 0: Like cleft number 14, can yield absent or excessmidline skeletal and soft tissue involvement. Cleft begins between the upper incisors, extending through premaxilla, secondary palate (cleft), and nasal bones (potential absence OR potential bifid nose).

Tessier Cleft Number 1: Cleft begins between the lateral and central incisor moving superiorly through the margin of cupid bow and up between the nasal bones and the frontal process of the maxilla.

Tessier Cleft Number 2: Cleft originates at lateral incisor and margin of cupid bow and extends superiorly through the alar rim.

Tessier Cleft Number 3: Cleft begins between lateral incisor and canine and extends superiroly to create communication between oral, nasal, and orbital cavities with disruption of lacrimal system.

Tessier Cleft Number 4: Cleft begins between lateral incisor and canine teeth extending superiorly lateral to the piriform and medial to the infraorbital foramen into the lower eyelid.

Tessier Cleft Number 5: Cleft begins lateral to the canine and courses lateral to infraorbital foramen terminating in the lateral aspect of lower eyelid and orbital floor.

Tessier Cleft Number 6: Cleft extends from the oral commissure along the junction of the maxilla and zygoma into the lower eyelid and inferior orbital fissure.

Tessier Cleft Number 7: Cleft begins at the oral commissure and extends outward affect the ramus/condyle/coronoid of the mandible and include the ear.

Tessier Cleft Number 8: Largely isolated to the orbit with the cleft affecting the frontozygomatic suture with a hypoplastic or absent zygoma with coloboma of the lateral commisure.

Tessier Cleft Number 9: Cleft involves the lateral third of the upper eyelid and brow with a hypoplastic greater wing of the sphenoid; can have encephaloceles.

Tessier Cleft Number 10: Cleft lateral to the supraorbital foramen, yielding encephaloceles and hypertelorism from inferolateral orbital rotation.

Tessier Cleft Number 11: Cleft extending upward from the medial third of the eyelid accompanied by hypertelorism and encephaloceles.

Tessier Cleft Number 12: Cleft lies medial to the medial canthus extending upward and coming out lateral to the cribriform plate, yielding hypertelorism.

Tessier Cleft Number 13: Paramedian cleft with disruption of cribriform plate, hypertelorism, and frontal encephalocele.

Tessier Cleft Number 14: Midline cleft often with significant CNS abnormalities (including holoproencephaly), midline encephalocele and cyclopia - consequently, limited life expectancy often.

Tessier Cleft Number 30: Mandibular cleft originating between the central incisors and extending inferiorly, yielding notching of the lower lip and a bifid tongue.

Question 15

Classification of dorsal PIP Fracture-Dislocations.

Answer 15

Kiefhaber modification of Hastings classification dorsal PIP Fracture-Dislocations.

Type I - Stable fracture-dislocation: Less than 30% articular base of middle phalanx Congruent through full range of motion

Type II - Tenuous: 30% to 50% articular base of middle phalanx, reduces with less than 30 degrees flexion

Type III - Unstable: Mote than 50% of A-P diameter or less than 50% but requires more than 30 degrees PIP flexion to maintain reduction.

Question 16

Classification of cleft lip and palate (Kernahan and Stark).

Answer 16

Kernahan and Stark classification.

Question 17

Classication of Scapholunate Advanced Collapse (SLAC).

Answer 17

Watson Classication of Scapholunate Advanced Collapse (SLAC).

Stage I: Arthritis between scaphoid and radial styloid

Stage II: Arthritis between scaphoid and entire scaphoid facet of the radius

Stage III: Arthritis between capitate and lunate

Question 18

Clark staging of melanoma.

Answer 18

Question 19

Classification of Complex Regional Pain Syndrome (CRPS)

Answer 19

CRPS type I: Causation by an initiating noxious event, such as a crush or soft tissue injury; or by immobilization, such as a tight cast or frozen shoulder. No nerve injury.

CRPS Type II: Presence of a defined nerve injury.

Question 20

Classification of sun reactive skin types.

Answer 20

Fitzpatrick’s classification of sun-reactive skin types.

Question 21

Staging of arteriovenous malformations (AVMs)

Answer 21

Schobinger staging of arteriovenous malformation.

Question 22

Classification of pediatric fractures.

Answer 22

Salter-Harris classification.

Question 23

Classification of wrinkling and photoaging.

Answer 23

Glogau classification: Ranks the degree of skin wrinkling and severity of photoaging. Four stages assessing degree of wrinking, skin damage, keratoses; has typical associated ages with them.

Question 24

Classification of thumb hypoplasia.

Answer 24

Blauth classification of thumb hypoplasia.

Question 25

Scale for predicting pressure sore risk.

Answer 25

**_Braden Scale_** for predicting pressure sore risk. * SEVERE RISK: Total score 9 * HIGH RISK: Total score 10-12 * MODERATE RISK: Total score 13-14 * MILD RISK: Total score 15-18

Question 26

Classification of nasal bone fractures.

Answer 26

**Stranc and Robertson** classification of nasal bone fractures. Fractures are described as "Frontal" or "Lateral" depending on the direction of the force sustained, and based on the 'plane' based on the degree of the fracture. **Plane I:** The caudal end of the nasal bones and the septum are injured. **Plane II:** The entire caudal end of the nasal bones as well as the frontal process of the maxilla at the piriform aperture and the septum. **Plane III:** The nasal bones are fractured and extend to the frontal bone as well as one or both frontal processes of the maxilla extending the orbital rim. These are NOE fractures.

Question 27

Classification of osteoarthritis (all joints).

Answer 27

**Kellgren and Lawrence** classification of osteoarthritis. **_Grade 0:_** no radiographic features of OA are present **_Grade 1:_** doubtful joint space narrowing (JSN) and possible osteophytic lipping **_Grade 2:_** definite osteophytes and possible JSN on anteroposterior weight-bearing radiograph **_Grade 3:_** multiple osteophytes, definite JSN, sclerosis, possible bony deformity **_Grade 4:_** large osteophytes, marked JSN, severe sclerosis and definite bony deformity

Question 28

Classification of **_vaginal defects_**.

Answer 28

Classification of **_vaginal defects_**. **_Type I:_** Partial defect. \> *Type Ia:* Anterior or lateral wall. Partial defect. \> *Type Ib:* Posterior wall. Partial defect. **_Type II:_** Circumferential defect. \> *Type IIa:* Upper two-thirds. Circumferential defect. \> *Type IIb:* Total vaginal defect. Circumferential defect.

Question 29

Classification of ZMC fractures (energy).

Answer 29

**High-energy fractures:** demonstrate comminution at each articulation; therefore they require surgial exposure of each articulation to ensure accurate reduction. **Low-energy fractures:** non-comminuted and generally do not require surgical exposure as aggressively as for high-energy injuries.

Question 30

Classification of abdominal defects.

Answer 30

**Rohrich** classification of abdominal defects (1-6). **Mathes** classification of abdominal defects (I-III).

Question 31

Classification of sensation and motor function on physical examination.

Answer 31

British Medical Research Council (MRC).

Question 32

Classification of ateriovenous malformations (AVMs)

Answer 32

**Schobinger classification** of ateriovenous malformations.

Question 33

Classification of the Scaphoid Non-Union Advanced Collapse (SNAC).

Answer 33

Watson classification of SLAC often used for classification of the Scaphoid Non-Union Advanced Collapse (SNAC). **Vender classification** is specific to Scaphoid Non-Union Advanced Collapse (SNAC). **Stage I:** Interface between the radius scaphoid fossa and the fractured scaphoid distal fragment interface is affected. **Stage II:** Interface between the fractured scaphoid proximal fragment and capitate is also affected. **Stage III:** Radius-scaphoid, scaphoid-capitate and lunate-capitate interfaces are affected.

Question 35

Classification of dorsal PIP dislocations.

Answer 35

**Eaton-Littler** classification of dorsal PIP dislocation. **Type I:** _Hyperextension injury._ There is an injury to the volar plate, in addition to an *_incomplete_* tear that occurs between the proper and accessory collateral ligaments. The *_joint surface_* remains *_congruent_* after the injury. **Type II:** _Dorsal dislocation._ There is a *_complete disruption of the volar plate_* and a *_complete_* tear between the accessory and proper collateral ligament. The middle phalanx lies on the dorsum of the proximal phalanx in a bayonet fashion. **Type III:** _Fracture dislocation._ There is a *_fracture_* and a *_dislocation_*. The volar plate, accessory collateral ligament, and proper collateral ligament are damaged. The volar margin of the middle phalanx fractures at the site of proper collateral ligament insertion and remains with the proximal phalanx while the middle phalanx moves dorsal and proximal. ***Stable:*** \< 40 % of volar articular surface (dorsal CL still attached, holds reduction) ***Unstable:*** \> 40% of volar articular surface avulsed with VP (no CL attachment)

Question 36

Classification of lower extremity injuries.

Answer 36

Classification of lower extremity injuries: (a) Gustillo, (b) Byrd

Question 37

Perfusion zones TRAM flap (traditional).

Answer 37

Zone I: Ipsilateral to pedicle, overlying rectus muscle. Zone II: Contralateral to pedicle, overlying contralateral rectus. Zone III: Ipsilateral to pedicle, lateral to rectus. Zone IV: Contralateral to pedicle, lateral to rectus.

Question 38

Classification of Mallet Finger injuries.

Answer 38

**Doyle's Classification** of Mallet Finger injuries. **Type I:** Closed injury with or without small dorsal avulusion fracture. **Type II:** Open injury (laceration). **Type III:** Open injury (deep soft tissue abrasion involving loss skin and tendon substance). **Type IV:** Mallet fracture * *A:** distal phalanx physeal injury (pediatrics) * *B:** fracture fragment involving 20% to 50% of articular surface (adult) * *C:** fracture fragment \>50% of articular surface (adult)

Question 39

Classification of Jersey Finger (FDP avulsion).

Answer 39

Leddy-Packer classification of Jersey Finger (FDP avulsion). **Type I:** FDP tendon retracts into the palm with rupture of both vincula (*_no avulsion fragment_*). **Type II:** FDP avulses with *_small bony fragment_* of the distal phalanx. Long vinculum remains intact and tendon retracts to PIP joing (*_A3 pulley_*). **Type III:** FDP avulses with *_large bony fragment_* is avulsed with the tendon and is prevented from retraction beyond the middle phalanx (*_A4 pulley_*). **Type IV:** Avulsion fracture of the distal phalanx combines with *_tendon avulsion from the fragment_* with tendon traction (as in Type I).

Question 40

Classification of Hidradenitis Suppurativa.

Answer 40

**Hurley** Stages of Lesions in Hidradenitis Suppurativa. **Stage I:** Localized and includes the formation of single or multiple abscesses, without sinus tracts and scarring. **Stage II:** Characterized by recurrent abscesses, with sinus tract formation and scarring, occurring as either single lesions or multiple, widely separated lesions **Stage III:** disease, which includes diffuse or nearly diffuse involvement of the affected region, with multiple interconnected tracts and abscesses across the entire area.

Question 41

Perfusion zones DIEP.

Answer 41

Question 42

Classification of Basilar Thumb Arthritis.

Answer 42

**Eaton & Littler** Classification of Basilar Thumb Arthritis. **Burton** Classification of Basilar Thumb Arthritis. **_Eaton & Littler_** **Stage I:** Slight joint space widening (pre-arthritis). **Stage II:** Slight narrowing of CMC joint with sclerosis, osteophytes \<2mm. **Stage III:** Marked narrowing of CMC joint with osteophytes, osteophytes \>2mm. **Stage IV:** Pantrapezial arthritis (STT involved). **_Burton_** **Stage I:** Pain; Positive grind test; Ligamentous laxity; Dorsoradial subluxation of the trapeziometacarpal joint **Stage II:** Instability; chronic subluxation; radiographic degenerative changes. **Stage III:** Involvement of the scaphotrapezial joint or less commonly; the trapeziotrapezoid or trapeziometacarpal joint to the; index finger. **Stage IV:** Stage II or III with degenerative changes at the metacarpophalangeal joint

Question 43

Angiosomes for a free TRAM or DIEP.

Answer 43

Question 44

Classification of facil rhytids.

Answer 44

Classification of facial rhytids (Grade I-V). **Grade I:** No rhytids at rest or animation. **Grade II:** Superficial rhytids on animation only. **Grade III:** Deep rhytids on animation only. **Grade IV:** Superficial rhytids at rest, deep on animation. **Grade V:** Deep rhytids at rest, deeper on animation.

Question 45

Classification of muscle sparing TRAM.

Answer 45

**MS-0:** No muscle spared. **MS-1:** Lateral muscle spared. **MS-2:** Medial and lateral muscle spared. **MS-3:** All muscle spared.

Question 46

Classification of lymphatic malformations.

Answer 46

* **Macrocystic:** composed of cysts \> 1cm. * **Microcystic:** composed of cysts \< 1cm.

Question 47

Classification of abdominal vascular zones.

Answer 47

Huger / Nahai classification of abdominal vascular zones: **Zone 1** – Xyphoid & costal cartilage to line between ASIS, overlying rectus abdominus (Superior & Inferior Epigastric vessels) **Zone 2** – inferior to line between ASIS to the pubis and inguinal crease (circumflex iliac & external pudendal) **Zone 3** – Lateral to zone 1 and superior to zone 2 (intercostal and lumbar vessels – travel between IO & TA)

Question 48

Classification of distal *_unicondylar_* fractures of the proximal phalanx.

Answer 48

**Weiss-Hastings** classification of distal *_unicondylar_* fractures of the proximal phalanx.

Question 49

Classification of condylar fractures of proximal phalanx (P1).

Answer 49

**London classification** of condylar fractures of middle phalanx (P2) and proximal phalanx (P1). **Grade I:** Nondisplaced unicondylar fracture. **Grade II:** Displaced unicondylar fracture. **Grade III:** Bicondylar comminuted fracture.

Question 50

Classification of auricular defects.

Answer 50

**Tanzer** classification of auricular defects.

Question 51

Classification of ZMC fractures (Knight and North).

Answer 51

Knight and North classification of ZMC fractures. **Group I:** Non-displaced. **Group II:** Arch fractures. **Group III:** Unrotated body fracture. **Group IV:** Medially rotated body fracture. **Group V:** Laterally rotated body fracture. **Group VI:** Complex fracture.

Question 52

Classification system for labial protrusion.

Answer 52

Classification system for labial protrusion based on the distance of the lateral edge of the labia minora from that of the labia majora (Motakef et al.): Class I: 0 - 2 cm Class II: 2 - 4 cm Class III: \>4 cm \* An "A" is added for asymmetry and a "C" for involvement of the clitoral hood.

Question 53

Classification of cleft lip (clinical).

Answer 53

* Unilateral or bilateral * Complete or incomplete * Complete: extend through lip into nasal floor. * Incomplete: nasal sill intact. * Microform cleft: form fruste

Question 54

Diagrammatic representation of CL/P.

Answer 54

Kerhnahan striped Y.

Question 55

Classification of microtia.

Answer 55

**Nagata** classification of microtia. Name of microtia describes elements that are _present._ * **Anotia:** Absence of auricular tissue. * **Lobular type:** Remnant ear. *Lobule and helix present*. Concha, acoustic meatus, and tragus absent. * **Conchal type:** Remnant ear. *Lobule, concha*, acoustis meatus, tragus *present.* * **Small conchal type:** Remnant ear. Lobule + small indentation of concha present. * **Atpical microtia:** Cases that do not fit into other categories.

Question 56

Classification of Lymphedema.

Answer 56

International Society of Lymphologystaging of lymphedema. **Stage 0:** Latent or *subclinical*. No edema evident, but lymph transport impaired. Can occur months or years before overt edema. **Stage I:** Early accumulation of proteinaceous fluid with edema that *resolves with limb elevation*. Pitting edema can occur. **Stage II:** Pitting edema may or may not be present. Tissue *fibrosis* develops. Does not resolve with limb elevation. **Stage III:** Lymphostatic elephantiasis with absent pitting. Acanthosis, fat deposits, warty growth, and other trophic *skin changes*.

Question 57

Describe normal occlusion and the classification of malocclusion.

Answer 57

Occlusion is defined by the relationship of the first maxillary and mandibular molars. Specifically, the normal relationship is that the mesiobuccal cusp of the first maxillary molar occludes in the buccal grove of the first mandibular molar. *Normal occlusion* exists when the mesiobuccal cusp of the mandibular first molar occludes in the buccal groove of the first mandibular molar **_AND_** there is no malposed or malrotated teeth. **_Angle classification of malocclusion_** * **Class I:** mesiobuccal cusp of the first maxillary molar occludes in the mesiobuccal groove of the mandibular first molar (normal), BUT teeth or malposed or malrotated. * NOTE: Class I is NOT normal occlusion. * **Class II:** The mandibular molar is distally positioned relative to the maxillary molar. Two divisions describe the relationship of the incisor. * **Division I:** Overjet with normal angulation of incisor. * **Division II:** Incisor retroclined to some degree, resulting in less overbite and increased overjet. * **Class III:** The mandibular molar is mesially positioned relative to the maxillary molar.

Question 58

Classification of mandible fractures.

Answer 58

Anatomic classification of mandible fractures. * **Dentoalveolar:** A fracture without disruption of the underlying osseous structures of the mandile and only involving the tooth-bearing area. * **Condyle:** Any fracture the affects the condylar process of the mandible, further classified into: * Intracapsular * Extracapsular * Neck * **Coronoid:** Any fracture that affects the coronoid process. * **Ramus:** *Superior to the gonial angle to the sigmoid notch*. * **Angle:** Region of the *gonial angle* extending to the region of the *third molar*. * **Body:** Any fracture between the *mental foramen* and the *distal aspect of the second molar*. * **Parasymphysis:** Any between the *mental foramen (second premolar)* and the *distal aspect of the lateral incisor*. * **Symphysis:** Fracture in the region of the incisors in a vertical or near-vertical orientation.

Question 59

Classification of congenital hand anomalies.

Answer 59

**International Federation of Societies for Surgery of the Hand Classification** 1. Failure of formation of parts. 2. Failure of differentiation. 3. Duplication. 4. Overgrowth. 5. Undergrowth. 6. Constriction band syndrome. 7. Generalized anomalies and syndromes.

Question 60

Classification of camptodactyly.

Answer 60

* **Type 1:** Apparent during infancy, usually isolated to the small finger. * **Type 2:** Develops during preadolescence and may progress rapidly during growth. * **Type 3:** Severe, involves multiple digits, and is part of a syndrome (most commonly arthrogryposis)

Question 61

Classification of sternal wound infections.

Answer 61

Pairolero and Arnold classification of sternal wounds: **Type 1:** Serosanguineous drainage within first 3 days, negative cultures, no cellulitis or osteomyeltitis. * Tx: Reexplore, debride, reclose. **Type 2:** Purulent mediastinitis occurring within first 3 weeks, positive cultures, and cellulitis and/or osteomyeltitis. * Tx: Reexplore, debride, flap. **Type 3:** Draining sinus tract from chronic osteomyelitis months to years after procedure. * Tx: Reexplore, debride, flap.

Question 62

Classification of sternal defects.

Answer 62

Starzynski classification of sternal defects. * Loss of upper sternal body and adjacent ribs (physiological deficit: minimal) * Loss of entire sternal body and adjacent ribs (physiological deficit: moderate) * Loss of manubrium and upper sternal body with adjacent ribs (physiological deficit: severe)

Question 63

Describe the zones of Guyon's canal.

Answer 63

* Zone I: Proximal to the ulnar nerve bifurcation. * Zone II: surrounds the ulnar nerve deep motor branch as it passes the hamate hook. * Zone III: surrounds the ulnar nerve sensory branch.

Question 64

What are the cut offs for median nerve sensory and motor latencies in CTS?

Answer 64

Operative intervention for CTS indicated with median nerve sensory latencies greater than 3.5 msec and median nerve motor latencies greater than 4.5 msec.

Question 66

Stages of breast development.

Answer 66

* **Stage 1:** Preadolescent elevation of nipple only; no palpable glandular tissue or areolar pigmentation. * **Stage 2:** Presence of glandular tissue in the subareaolar region; nipple and breast project as single mound. * **Stage 3:** Further increase in glandular tissue with enlargement of breast and nipple but continued contour of nipple and breast in single plane. * **Stage 4:** Enlargement of areola and increased areolar pigmentation with secondary mound formed by nipple and and areola above level of breast. * **Stage 5:** FInal adolescent development of a smooth contour with no projectio of the areola and nipple.

Question 67

Describe the levels of axillary lymph nodes.

Answer 67

* **Level I:** Lateral to the lateral border of pectoralis minor. * **Level II:** Behind pectoralis minor and below axillaru vein. * **Level III:** Medial to medial border of pectoralis minor.

Question 68

Classification of dual plane.

Answer 68

**Type I:** * Complete division of pectoralis from its origin at the level of the IMF with subpetoral dissection. * NO dissection in the retromammary plane to free the breast parenchyma-muscle interface * Indications: * Most 'routine breasts' * All breast parenchyma located above the IMF * Tight attachments at the parenchyma-pectoralis inerface. * Minimally stretch lower pole (NAC-IMF 4-6 cm) **Type II:** * Complete division of pectoralis from its origin at the IMF. * Pectoralis separated from breast parenchyma in the retromammary plane to ***inferior to the NAC***. * Indications: * 'highly mobile parenchyma' * Most parenchyma located above IMF * Looser parenchyma-pectoral attachments (breast tissue much more mobile relative to pectoralis major) * Moderate lower pole stretch (NAC-IMF distance 5.5-6.5 cm). **Type III:** * Complete division of pectoralis from its origin at the IMF. * Pectoralis separated from breast parenchyma in the retromammary plane to ***superior to the NAC***. * Indications: * "Glandular ptotic" and "constricted lower pole breasts" including tuberous breasts. * Breasts with glandular ptosis or true ptosis when a third or more of parenchyma is below the projected IMF. * Very loose parenchyma-pectoral attachments (parenchyma readily slides off pectoralis surface) * Markedly stretch lower pole (NAC-IMF distance 7-8cm). * Tight, contricted lower breast with short, tight IMF * Parenchymal maldistribution, tightly concentrated centrally leading to narrow base width * Short NAC-IMF distance (tuberous breasts)(2-5cm) * Use radial and concentric scoring through breast parenchyma

Question 69

Classification of double-bubble deformity.

Answer 69

* **Type A Double-Bubble Deformity ('Waterfall deformity'):** * Implant is above breast mound * Implant held high onc chest wall by pectoral coverage or contracture, and loose parenchyma slides off pectoral muscles inferior to the axis of the implant. * **Type B Double-Bubble Deformity:** * Implant is below breast mound. * With significant overdissection of IMF implant can slide caudal to the breast mound and create a second IMF below the native IMF and breast mound.

Question 70

Classification of capsular contracture.

Answer 70

* **Grade I:** No palpable capsule. The augmented breast feels as soft as an unoperated breast. * **Grade II:** Minimal firmness. Breast is less soft, and the implant can be palpated but not visible. * **Grade III:** Moderate firmness. The breast is harder, the implant can be palpated easily and it can be seen. * **Grade IV:** Severe contracture. The breast is hard and tender. Associated with pain.

Question 71

Classification of ptosis.

Answer 71

**Regnault classification** of ptosis. * **Grade I ptosis (mild ptosis)** * NAC *_at the level_* of the IMF. * **Grade II ptosis (moderate ptosis)** * NAC lies *_below level_* of IMF but remains above the most dependent portion of the breast. * **Grade III ptosis (severe ptosis)** * NAC lies well below the level of the IMF at the most *_dependent part of the breast_* along the inferior contour of the fold. * **Pseudoptosis or glandular ptosis** * NAC is above or at the level of the inframammary fold, but most of the breast parenchyma has descended below the fold. * Nipple to IMF distance has increased.

Question 72

Classification of tuberous breast deformity.

Answer 72

Von Heimburg classification of tuberous breast deformity. * Type I. Hypoplasia of the lower medial quadrant. * Type II. Hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region. * Type III. Hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region. * Type IV. Severe breast constriction, minimal breast base.

Question 73

Classification of the vascularity of abdominal wall.

Answer 73

Huger classification of the vascular supply to the abdominal wall: * **Zone I:** * Bounded superiorly by the costal margin, laterally by the lateral borders of the rectus sheath, and inferiorly by a line drawn between the ASIS bilaterally. * Supplied primarily by *superficial branches of the superior and inferior epigastric systems*. * **Zone II:** * Bounded superiorly by a line connecting the bilateral ASIS and laterally/inferiorly by the inguinal creases. * Supplied by the *superficial branches of the circumflex iliac and external pudenal vessels*. * **Zone III:** * Superior to Zone II and lateral to Zone I. * Supplied by the intercostals, subcostals, and lumbar vessels.

Question 74

Describe the classification of perilunate instability.

Answer 74

MAYFIELD CLASSIFICATION OF PERILUNATE INSTABILITY * Mayfield et al. performed an anatomic study on 32 cadaveric wrists loaded to failure in a position of *_wrist extension_*, *_ulnar deviation_*, and *_intercarpal supination_*. This produced 13 perilunate dislocations and two lunate dislocations. Through radiographic evaluation and dissection of the specimens, four distinct stages of injury emerged. The progressive ligamentous injury around the lunate was referred to as progressive perilunar instability. * *_Stage 1:_* In the first stage, **scapholunate articulation is disrupted**. Ligaments injured included the radioscaphoid, radiocapitate, and scapholunate interosseous ligaments. Radiographically, this was associated with scaphoid rotation and **scapholunate dissociation**. * *_Stage 2:_* Second stage progresses to include **capitolunate** as well as scapholunate disruption. Radiographs may show capitate suluxation or dissocation. * *_Stage 3:_* Progression to ****_peri_**lunate dislocation**. In addition to the scapholunate, capitolunate, the lunotriquetral joint is now disrupted. Radiographically, the capitate is dislocated dorsally, the triquetrum and scaphoid are malrotated, there may be triquetrolunate diastasis, and there may be a volar triquetral fracture. In addition to the previously described ligaments, the palmar radiotriquetral ligament is torn and the ulnotriquetral ligament injured to a variable extent. * Stage 4: Progression to **lunate dislocation**. This entails disruption of the dorsal radiocarpal ligament. Notably, the capitate is still dislocated dorsally from the lunate. But in a lunat dislocatin, the lunate is also dislocated volarly from its articulation with the radius. Cadaveric dissection shows all the previously described ligament injuries with the addition of **dorsal radiocarpal ligament** tear.

Question 75

Describe the classification of SL injury.

Answer 75

**Geissler Arthorscopic Grading System of SL Injury** * **Grade I:** * **​**Attenuation/hemorrhage of the SLIL (viewed from radiocarpal space). * No midcarpal malalignment. * **Grade II:** * Attenuation/hemorrhage of the SLIL AND stepoff/incongruency of carpal alignment (viewed from radiocarpal). * Slight gap between S and L ( * **Grade III:** * Attenuation/hemorrhage of the SLIL AND stepoff/incongruency of carpal alignment (viewed from radiocarpal and midcarpal). * AND scapholunate gap large enough to pass probe between carpals. * **Grade IV:** * Attenuation/hemorrhage of the SLIL AND stepoff/incongruency of carpal alignment (viewed from radiocarpal and midcarpal). * Gross instability * AND 2.7mm arthroscope can pass through the gap bewteen the scaphoid and lunate ('positive drive through sign').

Question 76

Describe a classification of axial fracture-dislocations of the carpus (6).

Answer 76

* Generally speaking these injuries involve an axial dislocation (potentially combined with fracture) through the carpus - one part remains aligned with the radius/ulna and the other part is dislocated along with the associated metacarpals. * There are THREE radial sided sub-groups and THREE ulnar sided subgroups **AXIAL-RADIAL FRACTURE DISLOCATIONS** * Peritrapezoid peritrapezium * Peritrapezium * Transtrapezium (trapezium fractured) **AXIAL-ULNAR FRACTURE DISLOCATIONS** * Transhamate peripisiform (hamate fractured) * Perihamate peripisiform * Perihamate transtriquetrum

Question 77

Describe the classification of TFCC injuries.

Answer 77

* **Class I: Traumatic (acute)** * **A:** central performation * **B:** Ulnar avulsion, with or without ulnar styloid fracture * **C:** Distal avulsion from carpus * **D:** Radial avulsion, with or without sigmoid notice fracture * **Class II: Degenerative (chronic)** * ​**A:** TFCC _wear_ * **B:** TFCC _wear_ * + lunate and/or ulnar head chondromalacia * **C:** TFCC _perforation_ * + lunate and/or ulnar head chondromalacia * **D:** TFCC _performation_ * + lunate and/or ulnar head chondromalacia * + lunotriquetral ligament perforation * **E:** TFCC _performation_ * + lunate and/or ulnar head chondromalacia * + lunotriquetral ligament performation * + ulnocarpal arthritis

Question 78

Classification of medial thigh skin laxity and adiposity for NON-MASSIVE-WEIGHT-LOSS PATIENTS.

Answer 78

Classification essentially moves from lipodystrophy with no skin laxity to quantifying the extent of medial thigh skin laxity begining with the superior third. * **Type I:** Lipodystrophy with no sign of skin laxity. * **Type II:** Lipodystrophy and skin laxity _confined to the upper third_ of the thigh. * **Type III:** Lipodystrophy and skin laxity that extends beyond the upper third of the thigh. * **Type IV:** Moderate skin laxity that extend the length of the thigh. * **Type V:** Severe medial thigh skin laxity with lipodystrophy.

Question 79

Classification of medial thigh adiposity / laxity for MASSIVE-WEIGHT-LOSS PATIENTS

Answer 79

Essentially just differentiates whether there is skin and fat excess. * Type I: * Deflated: Skin laxity over the entire thigh without significant residual lipodystrophy. * Type II: * Non-deflated: Skin laxity and significant lipodystrophy.

Question 80

Pittsburgh Rating Scale for medial thigh adiposity.

Answer 80

Question 81

Classification of labia minora enlargement.

Answer 81

**Felicio classification** of labia minora enlargement. * Type I: \< 2cm * Type II: 2-4 cm * Type III: 4-6cm * Type IV: \>6cm

Question 82

Classifcation of upper arm contouring.

Answer 82

* Type i: Minimal skin excess with moderate fat excess. * Type II: Moderate skin excess with minimal fat excess. * Type III: Moderate skin excess with moderate fat excess. \*\* Subgroups defined by location of SKIN excess \*\*\*

Question 83

Describe 6 classifications of carpal instability.

Answer 83

Question 84

Describe the dissociative and nondissociative classifcation of carpal instability.

Answer 84

* **Carpal Instability Dissociative (CID):** Instability WITHIN a carpal row. * **Carpal Instability Nondissociative (CIND):** Instability BETWEEN carpal rows or BETWEEN radius and proximal row. * **Carpal Instability Complex (CIC):** Elements of CID and CIND. * **Carpal Instability Adaptive (CIA):** Reason for malalignment is not located within the wrist but there have been adaptive changes secondary.

Question 85

Describe the classification of SLAC wrist and differentiate that with the classification of SNAC wrist.

Answer 85

**_Scapholunate Advanced Collapse_** * **Stage I SLAC:** Isolated radial styloid-scaphoid impingement / OA. * **Stage II SLAC:** Complete radioscaphoid OA. * **Stage III SLAC:** Midcarapal arthritis (capitolunate arthritis) * **Stage IV SLAC:** Pancarpal arthritis. **_Scaphoid Non-Union Advanced Collapse_** * **Stage I SNAC:** Isolated radial styloid-scaphoid impingement / OA (same as SLAC). * **Stage II SNAC:** Scaphocapitate articulation OA + radial styloid (DIFFERENT from SLAC) * **Stage III SNAC:** Midcarapal arthritis (capitolunate arthritis) + radial styloid + scaphocapitate (DIFFERENT from SLAC) * **Stage IV SNAC:** Pan carpal arthritis.

Question 86

Classification of scapholunate dissociation.

Answer 86

* Stage I: Partial SL Ligament Injury * Stage II: Complete SL Ligament Injury, Repairable * Stage III: Complete SL Ligament Injury, Non-Repairable * Stage IV: Complete SL Ligament Injury, Non-Repariable, Reducible Subluxation. * Stage V: Complete SL Ligament Injury, Irreducible Subluxation, Normal Cartilage * Stage VI: Complete SL Ligament Injury, Irreducible Malaignment, Cartilage Degeneration

Question 87

Classification of Scaphoid Non-Union Advanced Collapse (SLAC).

Answer 87

* Stage 1: * Arthritis between scaphoid and radial styloid * Stage 2: * Arthritis between scaphoid and entire scaphoid facet of the radius * Stage 3: * Arthritis between capitate and lunate

Question 88

Classification of masseter hypertrophy.

Answer 88

* **Type I:** minimal bulging, no obvious bulge * **Type II:** mono, local, single longitudinal bulge * **Type III:** Double, two seperate longitudinal bulges * **Type IV:** Triple, three longitudinal bulges * **Type V:** Excessive, massive single bulge

Question 89

Classification of microtia.

Answer 89

* **Anotia:** absence of auricular tissue. * **Lobular type:** remnant ear _with lobule and helix_, but without concha, acoustic meatus, or tragus. * **Conchal type:** remnant ear and lobule with concha, acoustic meatus, and tragus. * **Small conchal type:** remnant ear and lobule with small indentation of concha. * **Atypical microtia:** cases that do not fall into the previous categories.

Question 90

Classification of facial nerve function / dysfunction.

Answer 90

**House-Brackmann Scale** * 6 point scale that goes from normal to complete paralysis. Grade I is normal and grade VI is complete paralysis. The remainder of the grades are determined by GROSS appearance and MOTION. * Notable transition point is between Grade III and Grade IV, where grade III still has the ability to have complete eye closure. * Complete scale attached, simplified scale below: * Grade I: Normal. * Grade II: Almost imperceptible assymtery at rest with mild distrubances with motion. * Grade III: Noticable assymetry at rest. ABLE to close eye. * Grade IV: Disfiguring assymetry. UNABLE to close eye. * Grade V: Disfiguring assymetry. Barely perceptible movement. UNABLE to close eye. * Grade VI: Complete paralysis.

Question 91

Describe four tests that can be used to assess the facial nerve in the context of paralysis?

Answer 91

* **Nerve Excitability Test (NET)** * Measures minimum stimulus required to create a twitch of facial musculature * Difference of 3.0 milliamps or more is abnormal * **Maximal Stimulation Test (MST)** * Assess degree of facial movement with stimulus level creates discomfort * Difference from side to side is abnormal * Becomes positive before NET * **Electroneurography (ENoG)** * Current applied to stylomastoid formaen and maximal action potentials recorded at nasolabial fold * Most accurate and reproducible test to determine prognosis * **Electromyography (EMG)** * Traditional EMG, looking for fibs and positive sharp waves as signs of denervation.

Question 92

Broadly describe the three categories of surgical management in facial reanimation.

Answer 92

1. **Reinnervation procedures** * Can be used when facial muscles are still within window that they will accept reinnervation (\<36 months, but ideally the sooner the better). 2. **Dynamic procedures** * Procedures using free or regional muscle transfers to regain dynamic facial function. 3. **Static procedures** * Essentially resuspension procedures.

Question 93

Describe FOUR reinnervation procedures for facial reanimation.

Answer 93

1. **Primary nerve repair** * Tension free nerve coaptation 2. **Nerve repair with interpositional nerve graft** * Coaptation with interpositional graft 3. **Cross-face nerve graft (a contralateral nerve transfer)** * Indicated when distal muscles susceptible to reinnervation, distal facial nerve available, but proximal facial nerve not available. * Uses branches of contralateral functioning facial nerve. * Sural nerve grafts are used to connect contralateral side to branches on ipilateral side. * Can be done in one stage or two stages 4. **Nerve transfer** * Nerve transfer with ipsilateral hypoglossal (XII), masseteric (V), glossopharyngeal (IX), spinal accessory (XI), phrenic, C7 roots, cervical plexus motor nerves, recurrent laryngeal * Most common is hypoglossal nerve transfer.

Question 94

Describe FOUR options for DYNAMIC reconstruction for facial reanimation (3 regional, 1 free).

Answer 94

_Indications:_ Absent mimetic muscles after long-standing atrophy with no potential for reinnervation. **REGIONAL MUSCLE TRANSFERS** * **Temporalis transfer** * Originates from temporal fossa and superior temporal line to insert on the coronoid process. Innervated by the mandibular branch of the trigeminal nerve. Blood supply from the anterior deep temporal artery, posterior deep temporal artery, and medial temporal artery. * Can transfer flips of muscle to: eyelids, ala of nose, oral commisure, upper and lower lips. * Can perform temporalis tendon transfer, where muscle disinserted from coronoid and reinserted at oral commisure. * **Masseter transfer** * Technique to give motion to the lower half of the face. * Take three slips of the muscle and suture them to the lower lip, upper lip, commisure * **Digastric transfer** * Anterior digastric tendon mobilized and inserted into orbicularis oris at inferior vermillion border, medial to oral commisure. * Can be used in marginal mandibular nerve injury. **FREE FUNCTIONAL MUSCLE TRANSFER** * **Gracilis** * Typically combined with cross face nerve graft (first stage) followed by free functional muscle (second stage). * **Other options:** pectoralis minor, serratus anterior, abductor hallucis, partial lat, partial rectus abdominus, extensor digitorum brevis, rectus femoris, platysma

Question 95

What are options for STATIC procedures for facial paralysis?

Answer 95

**BROW** * Brow lift (direct, indirect) **UPPER EYELID** * Lid loading (gold or platinum under skin of upper lid) * Tarsorrhaphy (not a permanent solution) * Adjucts: supportive therapy with lubrication, taping, botox for denervation of levator palbebrae and mullers in nonpermanent facial paralysis. **LOWER EYELID** * Ectropion can be treated with tarsal strip and canthopexy **MIDFACIAL PTOSIS** * Suture suspension **NASAL VALVE STENOSIS** * Multivectored suture suspension * Fascial slings * Functional rhinoplasty **ORAL COMMISSURE** * Fascial sling * Sling from preauricular zygomatic arch and split to insert on upper and lower lip. * Passed in subcutaneous tunnel from zygoma and secured to orbicularis. * Multivector suture technique * Stab incisions made at lateral orbital rim and three locations on nasolabial fold (nasal ala, mid fold, oral commisure). Suture passed with Keith needle.

Question 96

Describe Synkinesis, its pathophysiology and its treatment.

Answer 96

* **Definition:** Unintentional motion in one area of teh face produced during intentional movement in another area. * **Pathophysiology:** Aberrent generation of axons with reinnervation of non-native muscle groups. * **Treatment:** Facial muscle retraining, botux

Question 97

Classification of proximal phalnx head fractures.

Answer 97

Weiss and Hastings classification of phalangeal head articular fractures.

Question 98

Grading of collateral ligament sprain.

Answer 98

* **Grade I:** Gross stability with microscopic tear. * **Grade II:** A groslly intact ligament with some abnormal laxity when joint is stressed. * **Grade III:** Complete tear of collateral ligament with gross instability.

Question 99

Classification of dorsal dislocation of PIP.

Answer 99

Eaton classification of dorsal PIP dislocation. * Eaton Type I: Essentially a hyperextension injury with no dislocation. Volar plate avulsion (no fracture), with longitudinal split of the collaterals. * Eaton Type II: Dorsal dislocation. Volar plate avulsion (no fracture). The base of the middle phalanx rests dorsally on the condyles of the proximal phalanx, with no contact between the articular surfaces. * Eaton Type III: Volar plate avulsion with FRACTURE. Can be divided into stable (\<40% of articular surface) and unstable (\>40% articular surface). The reason the stability is impact is because as the 40% increases there is a decreased amount of residual collateral ligament attaching the proximal phalanx head to the volar aspect of the middle phalanx.

Question 100

Classification of osteomyeltitis.

Answer 100

**Cierney** classification of **osteomyelitis**. Defines two dimensions: host susceptibility and anatomic location.

Question 101

Describe the Gustilo classification of open fractures.

Answer 101

* **Gustilo I:** Open fracture + clean laceration \<1cm * **Gustilo II:** Open fracture + clean laceration \>1cm WITHOUT extensive soft tissue injury, flaps, or avulsions * **Gustilo III:** Open fractures with extensive soft tissue damage to soft tissue, including muscle, skin, and neurovascular structures * **A:** Adequate coverage despite extensive damage * **B:** Extensive injury with PERIOSTEAL STRIPPING, BONE EXPOSURE, and/or MASSIVE CONTAMINATION * **C:** Open fracture with arterial injury requiring repair

Question 102

Describe the classificaiton of congenital hand anomalies.

Answer 102

**International Federation of Societies for Surgery for the Hand Classification** 1. Failure of formation of parts * Transverse arrest * Longitudinal arrest * Examples: phocomedilia, hypoplastic thumb, radial/central/ulnar longitudinal deficiency. 2. Failure of differentiation of parts * Soft tissue * Osseous * Examples: synostosis, syndactyly, radial head dislocation, symphalangism, camptoactyly, Kirner's deformity 3. Duplication * Examples: Polydactyly, mirrior hand, duplicate thumb 4. Overgrowth * Examples: macrodactyly 5. Undergrowth 6. Constriction band syndrome 7. Generalized anomalies and syndromes

Question 103

Classification of ULNAR-SIDED POLYDACTYLY (postaxial).

Answer 103

* **Type A:** Supernumerary digit is *_well developed_*. * **Type B:** Digit is rudimentary and *_pedunculated_*.

Question 104

Classification of thumb duplication (preaxial).

Answer 104

There are two classifications: The **Wassel** classification of thumb duplication and the **Zuidam** classification. Wassel classification moves stepwise from partial to complete duplicate of each bone (from distal to proximal). It then also includes a Type VII which is a duplicate thum that is triphalangeal. Zuidam classification still uses the **levels** as described by Wasell but adds a modifier to describe the complexity of the extra digit: * **Type T:** Triplication * **Type Tph:** Triphalangism in which one of the digits is triphalangeal. * **Type H ulnar** or **Type H radial:** Hypoplastic extra digit. The 'ulnar' or 'radial' describe the hypoplastic side. * **Type D:** Deviation / angulation at the IP joint. * **Type S:** Symphalangism or osseous union between two bones.

Question 105

Classification of Macrodactyly.

Answer 105

**Classification (Upton)** * **Type I:** Macrodactyly with lipofibromatosis of nerve * **Type II:** Macrodactyly associated with neurofibromatosis(von Recklinghausen's disease) * **Type III:** Macrodactyly with hyperostosis(excessive bone growth) * **Type IV:** Macrodactyly with hemihypertrophy

Question 106

Classification of radial club / radial longitudinal deficiency.

Answer 106

Original classification from Bayne and Klug: * **Type I deficiency -** The mildest type, this is characterized by *mild radial shortening* of the radius without considerable bowing; minor radial deviation of the hand is apparent, though considerable thumb hypoplasia may be evident * **Type II deficiency -** This is characterized by a *miniature radius* with *distal and proximal physeal abnormalities* and moderate deviation of the wrist * **Type III deficiency -** This is characterized by a *partial absence of the radius* (most commonly the distal portion) and severe wrist radial deviation * Type IV deficiency - The most common variant, this is characterized by a *complete absence of the radius*; the hand tends to develop a perpendicular relation to the forearm. There has since been a global classification to incorporate the entire radial side of the hand, including the thumb and carpus. It simply adds 'N' to denote isolate thumb hypoplasia or absence and stage 0 to be isolate carpal deficiency.

Question 108

What is the classification of THUMB HYPOPLASIA and the typical treatment for each type?

Answer 108

Question 109

What is the classification of CENTRAL LONGITUDINAL DEFICIENCY (CLEFT HAND)?

Answer 109

* Classification largely based on degree of first webspace deficiency. * **Type 1:** Normale first web space. * **Type 2a:** MIldly narroweb web space. * **Type 2b:** Severely narrowed web space. * **Type 3:** Thumb/index syndactyly * **Type 4:** Index raw supressed, thumb web space merged with cleft. * **Type 5:** Thumb elements supressed.