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Robinsons Flashcards

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Dermatology Board Prep flashcards
1
Q

What are the most common causes of infections and from where

A
  • Most frequent cause of infections: Staph aureus, E coli, Group A Strep, Pseudomonas
  • Most common source: staph aureus from the patient’s anterior nares (85% of isolates are genetically identical)
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2
Q

What % are nasal carriers

A

21.6% of US population are nasal carriers - have a 3-9.6 fold increased risk of SSIs

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3
Q

What is a surgical site infection

A
  • Definition: any surgical wound that produces pus within 30 days of the procedure, even in absence of a positive culture
  • The exception: suture abscess, which suppurates but resolves when removed
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4
Q

Does a positive swab equate an SSI

A

A positive culture may just indicate colonisation. If bacteria per gram of tissue >10^5 then this is more likely infection

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5
Q

Define clean, clean contaminated, and dirty wound

A
  • Clean: elective incisions on non-inflamed tissues under aseptic technique, with no entry into GIT, resp or genitourinary
  • Clean contaminated: minor break in aseptic technique, or entry into a tract, or inflammation but no frank purulence
  • Dirty wound: frank purulent fluid, perforation of a viscus or faecal contamination
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6
Q

Patient factors that increase risk of infection

A
  • Age
  • Malnutrition
  • Obesity
  • Hypothermia
  • Immunosuppressants - including alcohol
  • Length of procedure
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7
Q

What antiseptic agents are there

A

Alcohols
Chlorhexidine gluconae
Povidone iodine
PCMX (not used)

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8
Q

60-95% Alcohol as an antiseptic

A
  • Wide spectrum of action - positive and negative, M tb, fungi, enveloped viruses
  • Fastest onset
  • Drawbacks: flammable, poor cleansing agent
  • Must use liberal amount and allow to dry
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9
Q

Chlorhexidine gluconate - onset, spectrum, activity, drawbacks

A
  • Most common formulation is 4% scrub solution
  • Binds to the stratum corneum, fast onset
  • Spectrum: relatively wide as well, covers M tb, fungi, enveloped viruses, gram pos and negative
  • Sustained activity, additive effect with repeated use. Residual activity in excess of 6 hours, even when wiped off
  • Caution:
    • Ocular toxicity with conjunctivitis and severe corneal ulceration
    • Ototoxicity if it reaches the middle ear through a perforated tympanic membrane. Application to pinna and EAM does not pose risk to patients with in tact TM, but you never know the status really so avoid it
    • Prolonged exposure to middle ear –> deafness.
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10
Q

Povidone-iodine onset, spectrum, activity, drawbacks

A
  • Better spectrum than Clorhex as covers M TB more
  • Fast onset
  • Sustained activity is poor if wiped from skin –> need to leave on
  • Approved for mucosal surfaces - PI 10% aqueous solution commonly used off label around eyes –> there is a lot of data from bacterial enophthalmitis prophylaxis in cataract surgery
  • Caution:
    • Potential systemic toxicity with neonates or large body surface area
    • Rapidly neutralized by blood, serum proteins or sputum
    • Chronic maternal use has been associated with hypothyroidism in newborns
    • Scrub form: has a detergent in it, so shouldn’t make contact with the eyes
    • Prolonged skin contact: irritant and rarely ACD. Once dried generally not irritating
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11
Q

PCMX

A

Parachlorometaxylenol - PCMX

  • Not as good coverage as the others
  • Intermediate onset
  • Sustained activity for several hours
  • Has very poor pseudomonas coverage –> to address this they add EDTA (chelator)
  • We don’t use this
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12
Q

Can you combine anti-septic solutions

A
  • DuraPrep - IP and 74% isopropyl alcohol

- Chloraprep - 2% chlorhex in 70% isopropyl alcohol

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13
Q

Which anti-septic is better

A
  • The jury is still out
  • CHG-alcohol reduces bacterial colonies at the end of surgery and reduced SSIs, but not to stat significance
  • CHG-alcohol was compared to PI and was found better, but they should have put alcohol in the PI for an appropriate comparison
  • CHG and iodophor-alcoholic formulations are likely superior to their aqueous counterparts, and might be preferable for derm surgery in areas with higher rates of infection - like the groin
  • Alcohol based - good to clean skin and fingernails but not that good on its own. Also highly flammable, so need to be careful before electrocautery or laser, make sure its dried.
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14
Q

What is the typical protocol for hand washing for derm procedures

A
  • Remove any visible debris with a single 1 minute handwash with soap at the beginning of the day
  • Follow this with 2 applications of alcohol solution ~4mL to forearms and hands for every procedure or when changing gloves
  • Air dry for 1 minute prior to donning glove
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15
Q

Is there anything that can be done the day before a procedure to reduce infection?

A
  • Night before surgery: preoperative shower with chlorhex or PI has been shown to decrease bacterial colonization and wound infection rates, but meta-analysis does not support this as routine practice –> consider for large surgical fields and those at increased risk of infection (lower legs)
  • Obviously if the eyes use PI solution and half strength (5%)
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16
Q

What is the aim of surgical site preparation?

A

aim is to lower the resident bacterial count as much as possible and limit rebound growth with minimal skin irritation

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17
Q

Tell me about antiseptics and their use around the eye

A
  • Betadine ophthalmic solution: 5% PI, for eye use, cost significantly higher, comes in 30mL single use
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18
Q

Tell me about environmental cleaning of the procedural room and good practices

A
  • Desquamated skin cells disperse and settle on horizontal surfaces, then can be re-aerosolized with movement/breeze
  • To reduce this, keep doors shut, and minimize people walking through as much as possible
  • Disinfection should be done regularly with a quaternary ammonium sanitiser
  • no evidence to thoroughly clean between each patient, but review between patients and make sure is cleaned
  • Terminal clean at the end of each day of use: wet vacuum or 2-mop system: first mop applies disinfectant, and the second mops it up
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19
Q

What is the definition of sterilisation

A

chemical or physical process that completely destroys or removes all forms of viable microorganisms, including spores, from an object

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20
Q

What are the different ways to sterilise?

A 
Autoclave (steam under pressure)
Heated chemical vapour
Dry heat
Gas sterilization
Chemical immersion
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21
Q

Tell me about steam under pressure (autoclave) sterilization

A

most efficient, economical and easy to monitor. Generates pressures of 2 pascals and temp of 121 degs, and maintains that for 15-30 minutes. Good for liquids, glass, metal instruments, paper, cotton. Not good for plastics or oil. Limitation: repeated exposure to high humidity may dull sharp cutting surfaces (particularly high grade carbon steel edges of reusable hair transplant punches)

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22
Q

Tell me about heated chemical vapour sterilization

A

low-humidity method so better for sharp instruments. Doesn’t require drying, and shorter heat-up time. This method uses alcohol and formaldehyde, so you need protective gear, adequate ventilation and safety monitoring

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23
Q

Tell me about dry heat sterilisation

A

prolonged exposure to 121-204 degs, and is humidity free. Good for glass, oils and sharp instruments. Risk of burns, so need protective equipment

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24
Q

Tell me about gas sterilisation

A

With ethylene oxide or formaldehyde, good for heat sensitive and moisture sensitive. These are toxic and known carcinogens. Need really strict monitoring as they’re highly toxic. Rarely done outside of hospital settings.

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25
Q

Tell me about chemical immersion

A
  • immersion in glutaraldehyde or aqueous formaldehyde for heat-sensitive items.
    • For all immersion methods of sterilization, instruments must be used immediately and cannot be wrapped for storage
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26
Q

How can you tell if a steriliser isn’t working?

A

only means of assuring the efficiency of a sterilizer is to perform quality assurance tests with heat-resistant Bacillus spores at regular intervals which confirms the spores’ lack of viability after passing through the process

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27
Q

When should the wound dressing be placed?

A
  • bandage should be placed over the wound while the sterile field is still in place, and left for at least 48 hours to allow for epithelialization
  • there is no direct evidence supporting this, but might be considered in higher risk locations
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28
Q

Stages of skin grafting

A
  1. Imbibition: ischaemic period for 24-48 hours. Graft increases weight by 40% due to oedema. Fibrin attaches graft to bed. Sustained by plasma exudate and nutrients from passive diffusion. The fibrin glue is then replaced by granulation tissue
  2. Inosculation - revascularisation- begins at 48-72 hours and lasts 7-10 days
  3. Neovascularisation - capillary in growth to the graft, often occurs with stage 2
    Full circulation should be 4-7 days
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29
Q

When does lymphatic flow establish in grafting

A

With blood supply, completed by end of first week. Once returned, graft loses weight

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30
Q

When does reinervation occur in grafts

A

Within 2 months, may not be complete for months - years

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31
Q

Which graft has a higher metabolic demand and increased risk of failure

A

FTSG

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32
Q

What really should be the maximum size of a FTSG re metabolic demand

A

4-5 cm

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33
Q

Sites for FTSG

A 
Nasal tip and ala
Helical convexities
Concavities 
Medial canthus
Digits
Extremities
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34
Q

What % should you oversize a harvested graft

A

10-20 ( this is contentious some people think it should be smaller. Reason for oversizing is due to contracture)

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35
Q

How can you get out a graft

A

Excise

Shave

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36
Q

What do you defat a graft with?

A

Iris scissors

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37
Q

Do you undermine the recipient site with FTSG

A

You can - several mm To prevent pin cushioning

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38
Q

Which cautery system is better for grafts

A

Bipolar: precise pinpoint haemostasis, less char and tissue damage

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39
Q

How to suture a FTSG into place

A

Needle enters the graft first (ship to shore) 2-3 mm from edge and then exits adjacent recipient site skin. Graft first as results in less lifting tendency of graft
Distance between sutures 3-4 mm

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40
Q

When to do basting sutures (center of FTSG)

A

Large grafts
Grafts placed over concave or highly mobile surfaces

Recommend doing them before peripheralnsutures

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41
Q

Pros and cons for bolster dressing

When to use

A

Pro: promotes adherence to bed, minimizes patients touching the graft,
Cons: bulky, time, cost, no evidence it helps

Use it when: unreliable Patient, extremities

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42
Q

Non adherent dressing

A

Adaptic

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43
Q

Define a thin, medium and thick split thickness skin graft

A

Thin: 0.125-.275 mm
Medium: 0.275-0.4 mm
Thick: 0.4-0.75 mm

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44
Q

What to use to cut a split thickness skin graft

A

Weck knife
Zimmer electric dermatome for larger
Blade - no 10, 15 or 20

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45
Q

Meshing with STSG allows to increase coverage by what %

A

25-35%

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46
Q

STSG how does it heal

A

Re epithelializes over 2-3 weeks
Remains pink for several months
Later becomes hypopigmented

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47
Q

Where do composite grafts get their blood supply from

A

Subdermal plexus of wound and graft edges

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48
Q

Maximum size of composite graft

A

1-2 cm to minimize necrosis

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49
Q

Composite graft: when placing graft in alone what % should you oversize by

A

10-15

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50
Q

Can a cartilaginous strut be placed on the ala rim

A

Place 2-3 mm superior to the free rim of the ala to avoid a ridged appearance

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51
Q

Composite graft - give abx?

A

Yes - high risk due to bacteria in nasal mucosa

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52
Q

Indication for delayed graft

A

Significant amount of bone or cartilage exposed, where greater than 25% of the periosteum or perichondrium is lacking
Or- deep primary defect is allowed to granulate and fill the base of the wound with new tissue prior to placement of an FTSG

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53
Q

How long can you leave porcine xenografts on for

A

7-14 days

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54
Q

What are porcine xenografts made out of

A

Domestic swine. Sterilized, packaged and frozen for up to 2 years
So don’t use in pork allergy

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55
Q

Most common complication from a dermal graft

A

Epidermal cyst - 10%

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56
Q

What should a FTSG look like post op

A

Week 1: violaceous
Week 2: pink
4: treat as normal skin

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57
Q

What to do is necrosis at 1 week post FTSG

A

Don’t debride, it acts as biological dressing and deeper components may be fine
Reassure patient
Check for spongy feeling - indicates true necrosis
Review in 5-7 days

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58
Q

FTSG after care

A

Dressing stays on for a week then take off

Then dressing for another 2-3 days with BD cleansing and vaseline

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59
Q

How long does it take for re epithelializstion of fenestrations in STSG

A

6-8 w

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60
Q

Are abx indicated in FTSG

A

No

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61
Q

Which sites are susceptible to graft contracture

A

Near free margins: eyelid, vermilion border, nasal ala

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62
Q

Graft contracture increases as

A

The thickness of the graft decreases

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63
Q

So which grafts require abx regardless

A

Composite

Delayed

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64
Q

Delayed graft: can allow defect to granulate for how long

A

1-3 weeks

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65
Q

TRT of Melania one

A

250-1000 nanoseconds

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66
Q

Tattoo particle size

A

40-300 nm

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67
Q

Picosecond is what

A

A trillionth of a second

100 times shorter than a nano second

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68
Q

Melanin absorption spectrum

A

Within UV, visible and near infrared

Melanin light absorption decreases with increasing wavelengths

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69
Q

For pigment in epidermis (lentigines) what laser to use

A

PDL - 510
KTP - 532
QS ruby - 694

QS alexandrite 755 for both

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70
Q

For pigment in dermis - which laser to use ie naevux of ota

A

NdYag 1064

QS alexandrite 755- can technically be used for superf too

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71
Q

IPL range

A

515-1200 nm

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72
Q

Ablative lasers

A

CO2 10600 nm
ErYag 2940 nm
YSGG 2740

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73
Q

What is pseudomelanoma re lasers

A

Benign appearing naevi that recur following laser may have clinical and histo atypia, but its never been reported as true malignant transformation

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74
Q

Melasma laser options

A

QS lasers: but increase dermal melanophages
QS 1064 Nd Yag, with microdermabrasian and daily topical hydroquinone’
Non ablative fractioanl resurfacing laser
IPL

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75
Q

Tattoo pigment that is red - what causes it and what laser to treat

A

Cinnabar
Cadmium

Laser: QS 510 nm-PDL, QS KTP

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76
Q

Tattoo pigment that is red-brown - what causes it and what laser to treat

A

Iron oxide

QS KTP

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77
Q

Tattoo pigment that is yellow - what causes it and what laser to treat

A

Cadmium sulfide, QS KTP

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78
Q

Tattoo pigment that is green - what causes it and what laser to treat

A

Chromium salts

QS ruby/QS alexandrite/Picosecond alexandrite

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79
Q

Tattoo pigment that is dark blue - what causes it and what laser to treat

A

Cobalt salts
QS ruby, QS alexandrite, Pico alexandrite
1064 NdYag

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80
Q

Tattoo pigment that is black - what causes it and what laser to treat

A

Carbon
QS ruby, QS alexandrite, Pico alexandrite
1064 NdYag

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81
Q

Tattoo pigment that is white - what causes it and what laser to treat

A

Titanium dioxide

Any QS laser

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82
Q

Which part of tattoo pigment is most responsive to laser

A

Carbon (all tattoos contain it, adds the dark hue)

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83
Q

Reduced clinical response to tattoo pigments to laser is associated with what

A 
Smoking
Tattoo larger than 30 cm^2
Older than 36 months
Location on feet or legs
Colours other than black or red - green and yellow had the lowest response
High colour density
Interval of treatment sessions less than 8 weeks
Darkening of the tattoo during treatment
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84
Q

When using QS laser what colour does it make the skin

A

Ash-white - heat induced response causes a scattering of visible light. If the ash white colour isnt there, then you haven’t dosed well enough

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85
Q

QS laser for pigment with excess fluence looks liek what

A 
Thermal burn
Prolonged wound healing
Hypopigmentation
Hyperpigmentation
Textural changes
Scarring
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86
Q

Dermal pigment requires lower fluences true or false

A

False - higher

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87
Q

Fluences that are too low can cause what targeting pigment

A

Paradoxical hyperpigmentation

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88
Q

Why do you put an occlusive dressing on when removing tattoo pigment

A

Acts as a heat sink and may help protect the epidermis, and prevents tissue splatter

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89
Q

Dermal pigment removal - what is the desired response

A

Bright tissue whitening - it is representative of gas bubble formation from rapid heating of particles

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90
Q

Summary of what lasers are best for what tattoo pigments

A

QS ruby and QS or PS alexandrite are best for black, blue, green pigments
QS 1064 NdYag bet for blue and black, but not green
510 PDL, QS532 nm KTP or 532 nm frequency doubled NdYag best for red and yellow pigment

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91
Q

Whats the problem with treating iron oxide or titanium dioxide with laser

A

Immediate irreversible darkening with QS laser - conversion of ferric oxide to ferrous oxide
Beware of the colours white, red, orange, tan, brown - lip liner tattoos etc

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92
Q

Risk factors for scarring or permanent hypopigmentation in pigment removal

A 
Excessive fluence
Tattoos containing double ink
Pulse stacking
Treating too frequently
Tattoos in areas more prone to scar: ankle, deltoid, chest areas
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93
Q

Where are suspension sutures

Placed

A

Between deep fascia or periosteum and overlying dermis

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94
Q

Classification of chemical peels

A

Superficial: epidermis to pap dermis
Medium: pap dermis to upper reticular 0.45-0.6 mm
Deep: mid reticular dermis 0.6-0.8 mm

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95
Q

Contraindications for peels

A
  1. Isot last 6-12 m - atrophies pilosebaceous unit, can re epithelialize properly
  2. Previous radiation - increase risk of scarring
  3. Blood supply compromise
  4. Active HSV, bacterial or other viral infection
  5. Dermal - recent facial surgery
  6. Smoking - relative
  7. Non compliant with priming
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96
Q

Time of year to do a chemical peel

A

Winter or when indoors

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97
Q

How to classify photoaging

A 
Glogau class:
Mild - 28-35 y
Mod - 36-50 early AKs and wrinkling
Advanced - 51-65 wears make up always
Severe 66-75 wrinkling cutis laxa gravity ++ make up
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98
Q

Pre op prep for chemical peeling

A

Avoid sun - for 3 m before
Tretinoin/ taza rótenes and or alpha hydroxy acids - at least 6 weeks before
Hydroquinone
Anti viral

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99
Q

What are the alpha hydroxy acids most commonly used

A

glycolic acid: smaller, penetrates better

Lactic acid

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100
Q

Hydroquinone MOA

A

Hydroxyphenolic chemical - inhibits tyrosinase enzyme, DNA and RNA synthesis in melanocytes - degradation of Melanosomes and destruction of melanocytes but NOT keratinocytes
Available 2-4%

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101
Q

Hydroquinone A/E

A 
ACD
Nail discolouration
PIh 
Despigmentación
Exogenous ochronosis
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102
Q

When to give antivirals for chemical peel

A

Medium or deep peel - day prior and for 10-14 days after

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103
Q

expected a/e of chemical peels

A

Stinging, burning, visible peeling, scaling

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104
Q

Unwanted a/e of chemical peel

A 
Milia
Pigment
Persistent erythema
Infectious
Scarring
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105
Q

Purpose of priming in chemical

Peels

A

Melanocytes suppression and uniform penetration

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106
Q

Indication for superficial peel

A 
Non inflam acne
PIH
Melisma
Ephelides 
Solar lentigines 
Photoaging
Fine rhytides
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107
Q

Superficial peeling agents

A 
TCA 10-25%
Jessners: resorcinol/sal acid/ lactic
Modified Unna’s resorcinol 
Solid CO2 slush
Sal acid
AHA
Tretinoin
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108
Q

Degreasing before a peel - what do you use

A

Acetone (flammable though)
Alcohol
Septisol
Chlorhexidine

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109
Q

Order to apply chemical peel

A 
Forehead
Lateral aspects
Nose
Cheeks
Peri oral
Infra orbital last
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110
Q

What to use to apply chemical peel

A

Thanks referred us rung out gauze for TCA or Jessners
Saturated cotton balls for glycolic
Indra orbital: saturated cotton ripped applicators

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111
Q

TCA in chemical peels

A

No systemic toxicity
Dissolved in distilled water 10-25% - ie25 g in 100 mL
Stable for 23 weeks in amber bottles at room temp, not light or heat sensitive
Stronger than AHA
Causes epidermal protein coagulation and cell necrosis

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112
Q

End point of a TCA peel

A

Skin turns whitish gray - frost

Resolves within 1-2 hours

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113
Q

Type of pain in chemical peel

A

Crescendo

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114
Q

What is sal acid

A

Ortho hydroxybenzoic acid
Beta hydroxy acid

Causes immediate white precipitation
Self limiting - no need to neutralize
Anaesthetic property: minimal pain
Strong comedolytic

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115
Q

What is salicylism

A

Tinnitus headache dizziness
Unusual in peels
Drink water to improve sx

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116
Q

Glycolic acid as a chemical peel

A

Not a true peel
Removes epidermal corneocytes to produce exfoliation
Short lived smoother skin
Most use 70% un buffered and un neutralized

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117
Q

AHA peel - how do you carry it out

A

Clean and de grease
Leave on for 15 second - 3 minutes for first peel, can be longer for subsequent
You must stay and watch
If hot spot erythema - then neutralise
Neutraliza with 5% sodium bicarb and wash face
Neutralize at end of time, if red, if uncomfortable
Give topical hydrocort to minimise PIH

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118
Q

Factors that affect penetration of AHA

A 
PH
Bioavailability 
Degree of buffering
Volume of agent applied
Duration of time on skin
Condition of epidermal barrier
Extent of degreasing
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119
Q

Jessners formula

A

Resorcinol 14 g
Sal acid 14 g
Lactic acid 14 g
Ethanol 95% 100 mL

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120
Q

End point of Jessners

A

Erythema and white speckling

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121
Q

Jessners séquenlas

A

Light desquamation for 2-3 days

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122
Q

Pros and cons of pyruvic acid

A

Alpha keto acid
Pro: small, deep penetration
Con: scarring risk, neutralize with 10% sodium bicarb

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123
Q

What is the Klingon formula

A

Melasma treatment
Hydroquinone 4%
Tretinoin 0.5%
Steroid

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124
Q

Ideal peel for melasma

A

Combination peel

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125
Q

Indications for medium depth peels

A

Epidermal growth: AK, seb k, lentigines

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126
Q

Medium depth chemical peeling agents

A 
TCA 50%
Solid CO2 + 35% TCA
70% glycolic acid + 35% TCA
88% phenol 
Pyruvic acid
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127
Q

Care for eyes when doing medium peel

A

Assistant hold 2 dry cotton tipped applicators at medial and lateral canthus of eye to catch tears

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128
Q

What is CROSS

A

Chemical reconstruction of skin scars

Focal application of high concentration TCA 65-100% - press into scar

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129
Q

Post op care for medium peel

A

Within 30 mins: sunburn like,
First 24 hours oedema
After 24 hours light brown appearance
Desquamation begins around mouth and central face - last area to peel is the hairline, starts on day 3 done by day 7
Erythema fades 2-4 weeks
Keep greasy with petrolatum ointment or LanRoche Posay cold cream multiple times a day within 5-7 days
Can use acetic acid 0.25% and cool water soaks 3-5 times a day for first few days
Don’t scrub at skin
Make up within 7-10 days
Re start AHA on week 3 and Tretinoin 4-6

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130
Q

Adjuvant treatment for peels

A

Botox

Laser resurfacing to rhytides

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131
Q

Possible deep peel ingredients

A 
Phenol
Croton - deepens penetration 
Swptisol 
Water
Vegetable oils
Bakers Gordon the most common:
Please don’t stop cooking 
Phenol USP 88% 3 mL
Distilled water 2 mL
Septisol liquid soap 8 drops
Croton oil 3 drops
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132
Q

Deep peel end point

A

Ivory white to gray white colour

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133
Q

Deep peel healing

A

Re epithelialize day 8

Erythema gradually subsided

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134
Q

Chemical peel complications

A
  1. cardiac arrhythmia - phenol directly toxic to myocardium so need CPR monitoring if use phenol, hydrate and diurese if occurs
  2. Dyspigmentation - need to prime before, hyperpigmentation more common, hypo with deeper peels
  3. Infection - HSV most common. Toxic shock reported
  4. Milia - up to 20% post peel, 8-16 weeks post procedure. Can treat with electrosurgery
  5. Acneiform dermatitis immediately after re epithelialization - rx abx
  6. Scarring - commonly lower face
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135
Q

Contraindications for sclerotherapy

A

Absolute: Known allergy
DVT or PE
Local infection or severe generalised infection
Permanent immobility of patient with confinement to bed
Foam sclero: known right to left shunt - patent foramen ovale
Relative:
Pregnancy
Breastfeeding - interrupt for 2-3 days
Severe PAD
Poor health
Strong allergies
High thromboembolic risk
Acute superficial venous thrombosis
Foam: visual disturbances or neuro disturbances following previous foam sclerotherapy

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136
Q

So what are the two particular contraindications for foam sclerotherapy

A

Known symptomatic right to left shunt - patent FO - absolute

Visual disturbances or neuro sx from previous foam - relative

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137
Q

Sclerotherapy is performed in what order

A

Larger veins to smaller varicose veins

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138
Q

Maximum dose of polidocanol

A

2 mg/kg body weight

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139
Q

Excessive doses of sodium terradecyl sulfate can lead to what

A

RBC haemolysis-

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140
Q

Maximum dose of STS for sclerotherapy

A

No more than 4 mL of 3% solution, and not more than 10’mL of all other concentrations per session

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141
Q

For telangiectasias, sclerotherapy volume and concentration

A

Up to 0.2 mL, POL 0.25-0.5% and STS 0.1-0.2%

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142
Q

Reticular varicose veins sclerothetapy measurements

A

Volume up to 0.5 mL

0.5-1 % POL or up to 0.5% STS

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143
Q

Varicose veins volume injected of sclerotherapy

A

Up to 2 mL

If large go up to 3% of POL or STS otherwise 1% for small and 2-3 for medium

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144
Q

Post liquid sclerotherapy care

A

Local compression - removal depends on diameter and location of varicose vein
Walk around immediately after - physical thromboprophylaxis
Avoid sport, hot baths, saunas and strong UV radiation in the initial days after sclerotherapy

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145
Q

What is the mixing ratio for sclerosant plus gas

A

1+ 4 to 1 + 5 - liquid to gas

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146
Q

What gas is used for sclerosing foam

A

Room air

You can also use CO2 or oxygen

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147
Q

Maximum foam volume per leg in a given foam slcerotherapy session

A

10 mL

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148
Q

What are the duplex grades of successfulness in sclerotherapy

A

2: successful - complete disappearance of vein
1: partial successful, reflux <1 second - diameter reduction
0: unsuccessful, reflux >1 second or unchanged

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149
Q

Safety measures for foam sclerotherapy for GSV AND SSV

A

Avoid immediate compression
Use USS to monitor foam distribution
Inject a highly viscous foam
Ensure there is no patient or leg movement for ~ 5 minutes, no Valsalva maneuver or other mm movement

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150
Q

Adverse effects from sclerotherapy

A

Allergy: anaphylaxis, allergic dermatitis, contact urticaria, erythema
Clots: stroke and Tia (v rare) DVT, PE (v rare)
Necrosis: large tissue (rare) and skin necrosis
Neuro: visual disturbances headaches and migraines <1%, nerve injury, motor nerve injury v rare
Skin: matting <10%, residual pigment <10%, embolia cutis medicamentosa , superficial phlebitis
Resp: dry cough and chest tightness <0.01%

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151
Q

What % of the population has a patent foramen ovale

A

25%

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152
Q

Foam sclerotherapy has higher risk of what side effects

A

Pigmentation and inflammation
Transient neuro
Visual disturbances transient
Triggering migraine

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153
Q

Caput medusae indicates what

A

Superficial epigastric vein insufficiency

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154
Q

How deep can a Doppler penetrate

A

Up to 8 cm

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155
Q

Three types of sclerosants

A
  1. Hyperosmotic agents - causes endothelial cell damage via dehydration
  2. Chemical irritants - act as corrosives
  3. Detergent sclerosants - these are STS and polidocanol
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156
Q

Which sclerosant won’t cause pain

A

Polidocanol- lowest risk

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157
Q

Which sclerosanrs have a low incidence of allergic reactions

A

STS and polidocanol

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158
Q

What does making a foaming sclerosant achieve

A

Increases potency two fold, decreases adverse effects four fold

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159
Q

How is using CO2 different to room air in foaming sclerosant

A

CO2 allows the Gas sclerosant bubble to break down more quickly - minimizing possibility of gas embolisation

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160
Q

How can you treat telangiectasias procedurally

A

Microsclerotherapy
IPL
Laser - PDL and NdYag 1064

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161
Q

At what measurement interval in centimetres should you sclerose a vein

A

3-6 cm

162
Q

How often should you do sclerotherapy

A

6-8 w

163
Q

How long does pigmentation from sclerotherapy last

A

6-12 months

164
Q

What increases risk of pigment in sclerothetapy

A

Defect in iron transport
Use of minocycline, aspirin, NSAIDs
Hypercoagulability
Vessel fragility - elderly

165
Q

Risk factors for telangiectasias post sclerotherapy

A

Obesity
Oestrogen
Pregnancy
Fhx

166
Q

How can you prevent ulceration with sclerotherapy

A

Rub 2 % nitroglycerin ointment in until reactive hyperaemia seen

167
Q

How to manage arterial injection in sclerotherapy

A

Procaine 1% is administered peri-arterially, forming a complex with STS making it inactive
It doesn’t work for polidocanol though
Cooking of the limb to minimise tissue anoxia, followed by immediate heparinization for 7-10 days and administration of IV dextran 10% 500 mg daily for 3 days
Consider thrombolysis and long term vasodilation

168
Q

High risk spots for nerve damage in sclerotherapy

A

Saphenous and sural veins

169
Q

How to manage superficial thrombophlebitis in sclerotherapy

A

Arises 1-3 weeks after
Prevented with compresison
If occurs: evacuate and compress, frequent ambulation, aspirin, NSAID
Consider DVT

170
Q

Complications from ambulatory phlebectomy

A 
Most common: lymphocele 
Allergy
Púrpura, bleeding, séroma, superficial thrombophlebitis 
DVT and PE
Telangiectasia 
Oedema 
Nerve damage, traumatic neuroma
Skin: necrosis, infection, dyspigmentation, dimpling, tattoo, talc granulosa
171
Q

Target of endogenous laser ablation

A

Haemoglobin: 810-1064 nm
Water: 1320, 1440, 1550 nm

172
Q

How can you target the saphenofemoral junction

A

Endovenous laser ablation
Endovenous radiofrequency ablation

Then can do USS guided sclerotherapy and EV steam ablation

173
Q

What temperature does endovenous radiofrequency go to

A

120 degrees

174
Q

Length: width ratio for simple excision

A

3-4:1

Angles 30-75 degrees

175
Q

How should you hold the blade when excising

A

Angled approximately 10 degrees to the outside of the wound

176
Q

Where are good sites for running locking sutures

A

Ear or genitals

177
Q

Which suture is helpful for eversión

A

Vertical mattress sugure

178
Q

What are the angles in an M plasty

A

45 degrees

179
Q

Why pick an S plasty

A

Minimizes buckling of a scar - lengthens the scar

180
Q

All scars can contract up to what %

A

30%

181
Q

How long you leave a pulley stitch in to allow for creep

A

20 minutes

182
Q

What is a hockey stick repair

A

It’s a curved method of repair

Like standing cone but curved

183
Q

What is an L shaped and T shaped repair

A

L shaped: standing cone is 90 degree angle from the original suture line
T shaped is the same but bilateral to form a T

184
Q

Where to use an S plasty

A

Jaws or extremities

185
Q

If you open a wound after closing it, can you re suture

A

Yes if it’s in the first 24 hours

186
Q

How to deal with a Haematoma a few days postoperativelt

A

If small and stable can observe
If concerned is compromising wound healing either: 18 g needle to aspirate, or open and evacuate. If you open then it needs to be left by secondary intention

187
Q

When do spitting sutures become apparent

A

3-6 weeks post op

188
Q

When closing a wound against the relaxed skin tension lines this results in a wound with how much times the tension if was done along Langers

A

Twice

189
Q

How to tell the difference between keloids and scars

A

Keloids grow slowly, continue to grow for an extended period, exceed the site of trauma, occur in areas with little motion, recur after therapy, often done shaped or pedunculated
Hypertrophic are quick, stay within initial wound, occur in areas of motions

190
Q

Classification of earlobe keloids

A 
Anterior button
Posterior button
Dumbbell -core component within the lobe
Wraparound
Lobular - entirely replace the fatty lobe
191
Q

List common therapies for keloids

A

Topical: steroids, retinoids, imiquimod, vitamin E
Injections: steroids, 5FU, interferons, verapamil, bleomycin
Surgical: debulking, laser debulking
Physical: laser, radiation, compression, silicone sheeting, cryotherapy

192
Q

What concentration of steroid to use in keloids

A

40 mg/mL

Often <10 is sub therapeutic

193
Q

What is the maximum dose of kenacort to inject

A

40 mg so you don’t suppress the HPA axis

194
Q

How often should you treat keloids

A

Every 2 - 4 weeks and not earlier

195
Q

Is topical EMLA before keloid injection

A

No, the pain is deeper. Do a block

196
Q

How do you use steroids for keloid prevention

A

Inject wound margins with kenacort 40 on day of surgery, at 2, 4 and 6 weeks
Then at 2 months, and every month thereafter, injections are given as clinically necessary
Best to be carried out for 1 fully year

197
Q

How can you treat a pedunculated keloid <1 cm base

A

Excise with close primarily

198
Q

How long should you wear pressure earrings for with keloid treatment

A

6-18 months

199
Q

What can you give after keloid ear lobe treatments

A

RT, silicone gel, steroid injections and IFN injection

200
Q

What laser can you use for keloid treatment

A

Pulsed dye laser
Pulsed CO2 láser
NdYag

201
Q

What application of pressure should be used for keloid treatment and for how long

A

Between 20 and 30 mmHg (above capillary pressure), for 18-24 hours a day, for at least 4-6 months and up to 2 years

202
Q

How long should you wear silicone sheets for to prevent scarring

A

12-24 hours a day for 2 months

203
Q

Can imiquimod be used to treat keloids

A

No - only for prevention - BD from day of surgery for 8 weeks

204
Q

How many sessions of cryotherapy do you need for keloid treatment and how do you do it

A

Usually 8-10 visits every 3 weeks

2-3 prolonged large bore tip spray or contact freeze thaw cycles of 15-30 s each

205
Q

On the face, where are hypetrophic scars more likely to occur

A

Convexities: mandible, zygomatic arch, clavicle

206
Q

When should you discontinue aspirin pre-operatively

A

If it is being taken for primary prevention only

207
Q

What vascular system supplies random pattern flaps

A

The subdermal plexus (the intradermal plexus is not enough)

208
Q

Which two factors are accurate predictors of flap survival

A

Torsion

Tension

209
Q

What is the largest length to width ratio banner flaps can be designed

A

6:1 to 7:1 if the arterial supply isn’t twisted or kinked

210
Q

Where is the best place to use an H plasty (bilateral advancement flap)

A

Eyebrow defects

Otherwise it is not used in many places

211
Q

How are the A-T and O-T flaps different

A

A-T relies on linear tissue advancement

O-T relies on flap rotation

212
Q

Commonly used sites for advancement f;aps

A

Nasal sidewall superior to the vermillion border
Supraorbital forehead lateral to the midpupillary line
Upper lateral lip superior to the vermilion border

213
Q

What is another name for the traditional island pedicle flap

A

V-Y flap

214
Q

What size can the defect be to carry out an island pedicle flap

A

Perinasal area can be 2 cm or even larger

Nose tends to be smaller though due to poor compliance

215
Q

Particularly complication to the subctuaneous island pedicle

A

Pin cushioning - particularly when medial cheek and lip

216
Q

How to prevent pincushioning in a subcutaneous island pedicle flap

A

Design a flap with a smaller breadth than diameter of the primary surgical defect –> places tension on the lateral aspects of the island pedicle flap

217
Q

Where is the primary area of restraint that inhibits subcutaneous island pedicles mobility

A

Tapering tail - make sure you free deeply and laterally

May also need to undermine the leading edge of the island pedicle flap

218
Q

Where do you undermine to in a subctuaneous island pedicle

A

Just above the superficial fascia

219
Q

What is the Rieger flap?

A

Dorsal nasal rotation flap

220
Q

What is the Limberg flap

A

rhomboid transposition

221
Q

Where do you undermine in a mucosal advancement flap

A

Between the plane of the minor salivary glands and the underlying orbicularis oris musculature
Undermining is generally extended to the area where the mucosa reflects onto the mandible

222
Q

A/E of moving mucosal lip onto exposed pink portion of the lip

A

long-term peeling from metaplasia

223
Q

Where are rotation flaps commonly used

A

Cheek - particularly medial
Scalp
Temple

224
Q

What size defects are dorsal nasal rotation flaps used for

A

Medium sized defects - up to 2 cm in diameter

225
Q

Dissection plane for dorsal nasal rotation flap

A

Elevated at level of perichondrium and periosteum, but as you go superiorly you change to S/C fat to avoid procerus and corrugator supercilli

226
Q

What is the classic Mustarde flap

A

Large rotation of cheek and temple skin

227
Q

What is the Tenzel flap

A

Semi-circular flap - rotation of skin and orbicularis oculi muscle from the temple and lateral canthal areas
Also incorporates a cantholysis of one crus of the lateral canthal tendon to promote easier flap rotation
Actually involves an advancement and rotation around a pivot point on the zygomaq

228
Q

What is the modified Tenzel flap

A

Combines features of rotation and advancement, in an infra-orbital site
Its horizontally oriented to prevent ectropion

229
Q

Possible complications from the modified Tenzel flap

A

Oedema temporarily due to obstruction of laterally draining lymphatics
Ectropion if vertical tension at all

230
Q

Good sites for transposition flap

A

Ala
Lip
Proximal helix
Eyelid

231
Q

Angles for rhomboid transposition flap

A

120 and 60 degrees

232
Q

What is the rhomboid transposition flap good for (location)

A 
Medial canthus
Upper Nose
Lower eyelid
Temple
Peripheral cheek
233
Q

Angles of modified rhomboid flap

A

135 and 45 degrees

234
Q

What is the size of the defect in a bilobed transposition flap

A

Up to 1.5 cm

235
Q

What level do you undermine at for a bilobed transposition

A

Perichondrium and periosteum

236
Q

Where else is good for the bilobed transposition flap

A 
Nose
Chin
Lateral cheek
Hand
Posterior ear
237
Q

What are the angles in the tri-lobed transposition flap

A

45-50 degrees

238
Q

What is the width ratio for banner flaps

A

3:1-5:1

239
Q

Angle for banner flap

A

Up to 90 degree transposition

240
Q

Sites for banner flaps

A 
Upper helical rim
Proximal nasal bridge
Nasal sidewall
Medial canthal defects
Medial lower eyelid
Upper cheek
Lateral lower eyelid
241
Q

Angle for nasolabial transposition flap

A

Superior dog ear should be less than 30 degrees, tall and narrow

242
Q

Where do you anchor in the nasolabial transposition flap

A

Pivot point of the flap - superolaterally baseed - to the piriform aperture near the junction of the lateral ala to the isthmus of the upper lip

243
Q

Complications from the nasolabial transposition flap

A

Potential to place bear hair onto the nose
Flattens the alar groove
Pin cushioning if you don’t thin the distal portion

244
Q

If you think a procedure is going to be lengthy, what local anaesthetic can you use

A

Bupivacaine

245
Q

Preferred site of undermining for location with structure to be aware of: nose

A

Submuscular fascia/perichondrium/periosteum

Nasociliary nerve and angular artery

246
Q

Preferred site of undermining for location with structure to be aware of: lip

A

Just above the orbicularis oris

Multiple branches of labial artery

247
Q

Preferred site of undermining for location with structure to be aware of: Ear

A

Just above perichondrium

248
Q

Preferred site of undermining for location with structure to be aware of: Eyelid

A

Just above orbicularis oris

Lacrimal gland and drainage system

249
Q

Preferred site of undermining for location with structure to be aware of: scalp

A

Just above or beneath the galea

250
Q

Preferred site of undermining for location with structure to be aware of: cheek

A

Mid to deep subcutaneous fat

Parotid duct, buccal branches of facial nerve

251
Q

Preferred site of undermining for location with structure to be aware of: forehead

A

Just above frontalis

Supraorbital and supratrochlear arteries and nerves

252
Q

Preferred site of undermining for location with structure to be aware of: temple

A

Just above superficial temporal fascia

Temporal branch of facial nerve, superficial temporal artery

253
Q

Common sites for tacking sutures

A 
Frontal bone
Lateral orbital wall
Zygomatic arch
Nasal bones
Medial maxilla
254
Q

When can scar massage be started

A

1 month post operatively

255
Q

What causes flap necrosis with a haematoma

A

Accumulated blood is an abundant source of iron, which catalyzes the formation of tissue injuring free radicals

256
Q

Most common post flap complication

A

Difficulties with haemostasis

257
Q

Dehiscence definition

A

Separation of previously apposed wound edges

258
Q

What flaps are at highest risk for pin cushioning

A

Transposition flaps

259
Q

Why does pin cushioning occur and when

A

Usually 3-6 weeks post procedurally

Circumeferential contraction of the scar surrounding the flap’s recipient - the flap decompresses anteriorly

260
Q

How to prevent or treat pin cushioning

A

Trim flap to size, good flap design
Widely undermine the flaps recipient site, squaring off the flaps edges

Post op: IL steroids every 2-3 months (usually need high dose if trying to cause s/c fat atrophy), aggressive massage at scar line
Rarely surgical revision procedure

261
Q

Ideal time to abrade a wound

A

4-8 weeks post op

262
Q

Which procedure can effectively re-orient wound tensions if not happy with a flap

A

Z-plasty

263
Q

What is an Abbe flap

A

A full thickness composite flap (lip)

264
Q

What is a dufourmental flap

A

A rhombic transposition flap

265
Q

What is a Peng flap

A

Double rotation

266
Q

Time you should wait between isotretinoin and laser

A

6-12 months

267
Q

What lasers selectively target water
And which is more precise
And which has better haemostasis

A

CO2 10600

Er Yag 2940- more precise and better haemostasis

268
Q

Where should you ablate to with CO2 laser

A

Papillary dermis

269
Q

With Er yag what colour does the skin go

A

White

270
Q

Features of Er Yag 2940

A

So better haemostasis and more precise
Rapid recovery time: re epithelialize wi th in 5.5 days
Less thermal injury and trauma to skin so reduction in pigment changes
Less impressive cosmetic outcome than CO2 which is better at targeting rhytides

271
Q

Side effects and cx of ablative laser skin resurfacing

A

Expected: erythema, oedema, itch
Mild: extended erythema, milia, acne, contact dermatitis
Moderate: infection (HSV 7% so everyone needs anti virals), hyperpigmentation
Severe: hypopigmentation, hypertrophic scarring, ectropion

272
Q

IPL range

A

515-1200

273
Q

Where can you find the supra trochlear artery Pedicle most reliably

A

Within 3 mm medial or lateral to the medial canthus

274
Q

For the forehead flap what is a safe pedicle base width

A

1.1-1.4 cm

275
Q

When to cut the STA in a forehead interpolation flap

A

1-3 weeks

276
Q

What is the Abbe flap

A

Cross lip axial flap with a pedicle based on either the superior or inferior labial artery

277
Q

Ideal pedicle flap width for Abbe flap

A

1 cm

278
Q

How to avoid cutting the contralaterql DNA in the dorsonasal rotation flap

A

Do not put the back cut within 7 mm of the contralaterql medial canthal tendon

279
Q

Dosage of fluclox for kids

A

> 1 month
12.5-25 mg/kg every 6 hours, use up to 1 g every 6 hours
For IV 25 mg/kg QID, maximum is 50 mg/kg QID

280
Q

Dosage of clindamycin

A

Adult: 150-450 mg QID
IV 600-2700, usually 450-900 TDS

Kids over 1 month
Oral 5-10 mg/kg max 450 TDS
IM or IV 5-15 mg/kg TDS

281
Q

What nerves are needed to be anaesthetized to block a nerve

A

Infra trochlear
External nasal branch/anterior ethmoidal
Infraorbital
Spinus (does the columella and tip)

282
Q

What are the grades of acne scarring

A

1: just pigment change, macular disease - so erythema, hyperpigmented or hypopigmented
2. mildly abnormal contoured disease: mild atrophy or hypertrophy that may not be obvious at distances of more than 50 cm - i.e. mild rolling atrophic and small soft papular scars
3. moderate atrophic or hypertrophic scarring obvious at conversational distance, but able to be flatted through manual stretching of the skin - i.e. rolling and superficial box car scarring
4. severe atrophic or hypertrophic scarring obvious at conversational distance >50 cm and not able to be flatted by manual stretching of the skin

283
Q

How long can the needles be in manual skin rolling

A

3 mm - this depth usually requires local anaesthesia

284
Q

What dosage fluouracil to use for steroid injection

A

Low strength intralesional steroid 50 mg/mL, mixed 80:20 steroid, usually fortnightly. often 0.1-0.3 mL is all that is needed

285
Q

What strength of TCA in the CROSS technique

A

60-100%

286
Q

Types of procedural surgical options for acne scarring

A 
Up to 3-4 cm in diameter:
Punch excision
Punch replacement grafting
Punch elevation
 (should be down outside of the scar, never inside or just on the scar edge)
Atrophic scarring: subcision

Excision: usually if severe atrophic facial scars or hypertrophic scars (may cause cyst activation)

287
Q

Type of acne scarring that is most amenable to filler

A

Atrophic or rolling

288
Q

Main types of filler

A

Poly-l-lactic acid - PLLA
Hyaluronic acid - HA
Calcium hydroxylapatite - CaHA
Polymethylmethacrylate - PMMA

289
Q

How is hyaluronic acid gel filler cleared

A

Gradual absorption of water as the filler degrades

290
Q

With hyaluronic acid, which is more safe to inject: supra-periosteal or subcutaneous

A

Supra-periosteal

291
Q

Where to inject filler in the mucosal lip

A

Submucosally above the orbicularis muscle

292
Q

What is the point of a blunt cannula with fillers

A

Minimizes the bruising and swelling compared to sharp needles

293
Q

How does the tower technique work with fillers in the NL folds and marionnette lines

A

Needle is delivered perpendicular and goes down to deep subcutaneous fat
HA is delivered as the needle is withdrawn
You need to massage it, and then patient holds firm pressure for 5-10 minutes

294
Q

Which sites are the most painful with filler

A

Peri-oral

Peri-ocular

295
Q

Adverse effects (some expected0 of hyaluronic acid

A
  1. Redness - for a few hours to overnight - expected
  2. Swelling - lasts up to 1-2 days - expected, use ice and minimise injections to help
  3. Bruising - takes 5-10 days to resolve
  4. Frank bleeding - firm pressure
  5. Injection site necrosis: angular artery or supratrochlear arteries most common, bluish grey discolouration, pain, erosion, ulceration. Treat with nitroglycerin paste
  6. Nodule formation: immediately after or a few weeks later, from superficial injection, excess injection, granulomatous or inflammatory - treat with hyaluronidase, or just massage and monitor
  7. Local hypersensitivity - red indurated bumps, can occur after up to 3 months after
  8. Itch, acne, herpes labialis - consider anti virals
296
Q

If I wanted to see calcium hydroxylapatite injections on imaging what image would I pick

A

MRI

you can’t see it on X-ray

297
Q

How it calcium hydroxylapatite degraded

A

When injected it becomes integrated into the surrounding soft tissue - provides long lasting effects, but palpability diminishes over time as it is integrated into soft tissues
It is gradually phagocytosied and degraded, and elininated as calcium and phosphate ions via the urinary system

298
Q

Where should you not inject calcium hydroxylapatite

A

The lips
The lower eyelid skin
The dermis

Only do subcutaneous in the peri-ocular area, everything else is supra-periosteal

299
Q

Can you mix calcium hydroxylapatite with lignocaine

A

Yes 0.3 cc 2% plain lignocaine with 1.5 cc CaHA

300
Q

Safety of calcium hydroxylapatite

A

The usual
lip nodules - remove with active extrusion with a needle or slit excision
Transient lumpiness –> massage

301
Q

PLLA - how to reconstitute, store

A

Distributed as freeze dried
Stored at room temp
Re-consitute with sterile water 2-24 hours prior to use: do with 7 mL sterile water night before, then on day of procedure add 2 mL of plain 2% lignocaine, draw into a 3m L syringe with 25 gauge needle for injection (don’t use a cannula)
Shake before use, and shake during if worried sediment is beginning to occur

302
Q

How long does PLLA last

A

2-3 years with eventual breakdown into lactic acid

303
Q

CI for PLLA

A

Blood thinners

Active skin infection or inflammation

304
Q

A/E particular to PLLA use

A

Asymmetry of volume when one vial is split between 2 sides and the product settles out of the suspension during reconstitution

305
Q

What does PMMA come in in terms of syringes

A

0.8 and 0.4 mL fill volumes

306
Q

How long does PMMA last

A

Permanent (or very long lasting)

307
Q

Who is PMMA good to use in

A

Really deep facial wrinkle lines with minimal skin laxity

308
Q

Who is PMMA bad to use in

A

Sebaceous skin
Large pore size
Extremely thin and loose skin

People who want their lips done - don’t do it in the lips as can get undesired fullness

309
Q

What are the most concerning a/e with PMMA

A
  1. Granuloma formation - can be years after - heard texture and blue, can inject with steroids but can be very resistant to therapy
  2. It is less forgiving given it is long-lasting
  3. Papules and areas of excessive fullness –> can be due to too much injection, or incorrect placement or granulomas –> injected with Kenacort carefully
  4. Undesired fullness due to too frequent injections (more than every 8-16 weeks) or too much injection
310
Q

What should you do with someone before you inject PMMA

A

Skin test prior:
0.1 mL intradermal injection into volar forearm, monitor for 4 weeks –> if positive such as redness then can’t use
If equivocal - no rash at site but symptoms elsewhere like rash or myalgias then do another test on other arm

311
Q

Is PMMA combined with local

A

Yes lignocaine 0.3%

312
Q

What angle do you inject PMMA

A

20-40 degree angle beneath the wrinkle. Better to go too deep than too superficial

313
Q

Pitfalls of soft tissue augmentation

A 
1. Acute: discomfort, bruising, swelling, haematoma, hypersensitivity
Infection
Blindness
Skin necrosis
2. Vasovagal reaction
3. Long term:
Bluish discolouration (tyndall effect)
Beading
Granuloma formation
Cosmetic: asymmetry, incomplete correction, scarring
Palpability in skin
Neuropraxia
Extrusion
314
Q

What is a wing block

A

A distal digital block
Inject 1 cm lateral and proximal to the junction of the proximal and lateral folds to knock out the dorsal nerve branch, and then move towards palmar surface to do the palmar nerve branch
Good for nail stuff

315
Q

Where is stensons duct

A

Mid third of tragolabial line
Like from tragus to mid point of lateral commisure and nasal alar
Pierces buccinator at 2nd molar

316
Q

Loss of spinal accessory nerve (hitting Erbs point)

A

Winging of scapula
Inability to shrug the shoulder
Difficulty initiating abduction
Chronic shoulder pain

317
Q

Max dose of STS

A

4 mL of 3%

318
Q

Max dose of polidocanol

A

2 mg/kg/day

319
Q

Max dose of foam STS

A

10 mL

320
Q

Glycopyrrolate for iontophoresis make up

A

0.05% of 500 mL with positive electrode, and warm tap water 1.5 L

321
Q

Max dose for tumescent anaesthesia

A

50 mg/kg

322
Q

Post procedural liposuction

A

Abx

Heavy comprsssion for 24 hours, then mild for another 2-4 weeks

323
Q

Contraindications to laser

A 
IBLOODYKTPU
Infection
Inflammation
Isot/mino/gold last 6 months
Bleeding diatheses
Keloid scarring
Tan
Pregnancy, photosensitising drugs
Unrealistic expectations, BDD
324
Q

Efficacy of IL 5FU with its indications

A

SCC/KA 96% clearance, nBCC 91%

Keloid 50% improve

325
Q

A/E of IL 5FU

A 
Pain erythema oedema crusting
Ulceration 
Depressed scarring
Transient hyperpigmentation 
Leukopaenia and thrombocytopaenia
326
Q

How to treat with IL5FU

A 
Treat with chemo precautions
Conc 50 mg/mL
Inject 0.5-2 mL 1-2 X a week for 4-8 treatments
Blanch 
Weekly bloods
Expect necrosis, crust and involución
327
Q

How to inject IL steroid

A
  • Intradermal at level of mid dermis injection 0.1ml solution at 1cm apart
    • Inject slowly
    • Skin raises slightly and blanches
    • Avoid injection into subcutaneous tissue => injected solution flows easily
    • Note – pre-treatment of keloid with LIN2 for 5-20 seconds softens lesion to assist injection
328
Q

Max IL kenacort dose

A

40 mg/mL is equivalent to 50 mg pred

329
Q

Conc of IL MTX

A

<1 cm 12.5 mg/mL

>1 cm 25 mg/mL

330
Q

How to inject IL MTX for KA

A

0.3-2 mL
If >1 cm aim for 4 quadrants
If <1 cm do centre of lesion
Aim tumour blanching

331
Q

IL MTX for KA

A

Complete response 92%
Pre bloods and weekly bloods
1-4 treatments 4 weeks a part

332
Q

Max dose of IL MTX

A

50 mg - 2 mL of 25 mg/mL

333
Q

Max dose of IL 5FU

A

50 mg a session, do every 4-6 weeks

334
Q

Pregnancy plans with IL 5FU

A

Don’t fall pregnant for 120 days after

335
Q

IL bleomycin dosage

A

1 IU, Max 2 per session
Comes in pre made 1 IU/mL
Administer in tuberculin syringe

For SCC/KA: max 0.6 mL weekly for up to 8 weeks
For wart: aim to blanch, 0.2-2 mL/ session, average number of injections is 4, review in 4 weeks

336
Q

Bleomycin contraindications

A

Pregnancy
PVD
Raynauds
CT disease

337
Q

IL bleomycin a/e

A

Acute: erythema, oedema, pain, burning
Painful for 72 hours
Necrotic/eschar in 2 days- good sign, goes in 4 weeks

Rare: onychodystrophy, Raynauds, hypopgimentation, hyperpigmentation, atrophy, gangrene, anaphylaxis, flagellate erythema, itch, urticaria

338
Q

Dose for deoxycholic acid

A

10 mg/mL
Pre made 2 vials
At least 2 doses, 2 months a part

339
Q

Treatment options for fat reduction

A 
Liposuction 
1060 sculptura 
Radiofrequency 
Cryolipolysis 
USS
340
Q

CI for belkyra

A 
Dysphagia
Over 65
Previous sx 
Thinners 
Infection
BDD
341
Q

Belkyra dosage to inject

A

0.2 mL 1 cm a part into the fat, avoid 1.5 cm below the mandible to avoid the marginal mandibular nerve

342
Q

Treatment for bruising post vascular laser

A

Hirudoid cream 0.3% cream

Arnika cream

343
Q

PWS indicators of better response to laser

A 
Young age 3 m - 6 yr
No nodules
Small
Facial > centrofacial > peripheral
Superficial
Red > pink > purple
344
Q

Aim for vascular laser

A

Minor púrpura, no epidermal damage

345
Q

Treatment options for melasma

A 
Photoprorection 
Kligman 
Tranexamic acid
Peels
Cryotherapy
Derm abrasion 
Laser/IPL
346
Q

How many treatments are needed to remove tattoos

A

For professional up to 15 treatments

347
Q

Chromophores for hair removal

A

Endogenous: melanin
Exogenous: ALA, carbon, meladine

348
Q

Lasers for hair removal

A 
Alexandrite 755
Nd Yag 1064
Ruby 694
IPL difficult in curved areas
Diode 810
349
Q

If red gray hair what laser for removal

A

964 nm and 755 nm

350
Q

Blonde or white hair laser removal

A

Ruby 694

351
Q

Cooling systems for laser hair remova

A 
Aqueous gel
Water encased in glass housing
Water in sapphire housing
Dynamic active cooling with cryogenic spray
Forced air cooling
352
Q

Botox reconstitution

A

Cosmetic: 100 units in 2.5 mL normal saline, so that 0.1 mL is 4 units
Hyperhidrosis: 100 units with 4 mL normal saline, so 0.1 mL is 2.5 units, and use 0.3 mL syringe

353
Q

Post op ablative laser care

A

Open technique Vaseline and saline baths every 2 hours
Valtrex
Abx

Closed technique: occlusive or semi automatic cclusice changing 1-2 X a day, less pain but incr risk infection

354
Q

Fractionated non ablative lasers

A

1440 and 1540
Er Glass 1550 - Fraxel
Thulium 1927

355
Q

Recovery time for ablative laser

A

Non ablative face 3-7 days, neck, chest limbs 5-10 days

Ablative face 10-14 days, other areas >14

356
Q

Retinal hazard wavelength with lasers

A

400-1400 nm

357
Q

Cooling techniques with laser

A

Cooling spray - liquid fluorocarbon
Water in sapphire/glass window
Cool air - Zimmer
Cold gels

358
Q

Hyperhidrosis treatment options

A 
Aluminium chloride 20%
Topical glycopyrrolate 1-2%
Iontophoresis
Oxybutynin 1.25-5 mg BD
Botox
Sympathectomy
359
Q

Side to side closure for Philtral defect - what size should defect be

A

<50% of philtral width

360
Q

When to use a two sided advancement flap in the Phil trim

A

Small defects immediately above the vermilion which involve the full width of the philtrum

361
Q

SCIP in philtral defect

A

Defect needs to be 50-100% of the philtral width
Only use for defects immediately above the vermilion or below the columella
Eclabium May occur if defect more than 50% of philtral height or the flap is in sufficiently mobilised

362
Q

Mucosal advancement flap key points

A

Score vermillion
4:1 horizontal ellipse with superior border on vermillion
Undermine below level of minor salivary glands but above OO muscle
Undermine until minimal tension to close defect

363
Q

Key points re bilateral vermilion rotation flap

A

Repair entirely within mucosa and no skin needs to be sacrificed
Must be <40% of lip

Central triangle of redundancy will be on mucosal surface

364
Q

Closure options for vermillion upper lip

A

Mucosal advancement
Double rotation
Wedge excision
Mucosal V to Y

365
Q

Wrinkles scale

A 
Glogau scale 
1- mild
2- dynamic 
3- at rest 
4- wrinkles
366
Q

Steps for wedge excision

A 
Mark the vermillion marker and nick
Gauze in mouth
Draw wedge <30% of entire lip, oblique angle of lateral to make re approximation easier
Assistant to hold edges
Incise
Tie off labial aa or lígate 
T plasty if close to mental crease
Close layers: internal mucosa, OO, mucosa
367
Q

Main features to remember for mucosal advancement flap (surgical vermillionectomy)

A

Mark vermillion botder
Elilipse - line along vermillion border
Can extend 5 mm past the lateral commissures onto the buccal mucosa to prevent puckering or troughing
Undermine in submucosal plane down to apex of labial sulcus
Labial mucosa is advanced from inside the oral cavity out and over the defect

Lip will have deeper, red colour after and more rounded appearance
May pull the lip inward
May affect sensation

368
Q

For bilateral vermilion rotation flap, what % should the defect be of the lip

A

Less than 50%

369
Q

Closure options for the chin

A

Rotation: single or double
Rhombic transposition
Side to side

370
Q

Cosmetic subunits of the cheek

A

Medial
Central
Mandibular
Pre-auricular

371
Q

Path of stensons duct

A

Exits anterior apex of triangular parotid gland, courses over buccal fat pad, then turns 90 degrees over the anterior margin of the masseter muscle to drain into the mouth at the level of the second upper molar

372
Q

Principles of NL advancement flap

A

For medial cheek - can either pull from skin laterally, or pull inferiorly
Laterally: standing cone will be inferior to defect, and when draw line make sure it goes superiorly once past the lateral canthus
Inferiorly: standing cone will be underneath the eye in cosmetic junction between cheek and eyelid, and the arc will be drawn down the nasofacial sulcus

Tacking sutures:
Under flap to nasal bone, placed ~ 5 mm back from advancing tip
Can also re-created nasofacial sulcus if needed too

373
Q

Negatives of a rotation flap on the cheek (Mustarde)

A

Lymphoedema
Ectropion
Extensive undermining required

374
Q

Main points of rotation flap on cheek (Mustarde)

A

Design: curvilinear line: lateral side of defect to lateral canthus, subciliary line, past lasteral canthus arc superiorly and above the zygomatic arch
Anchoring sutures: underside of flap to periosteum at orbital rim and nasal bone
Standing cone inferior to the defect excised

375
Q

SCIP for medial cheek: what does the length of the triangle need to be

A

2-3 X the length of the defect

Can do lenticular

376
Q

Ideal closure for pre auricular site

A

Burrows advancement flap

377
Q

When to use weck knife versus electric dermatome

A

Weck knife for <4 cm

Electric dermatome for larger

378
Q

STSG - oversize donor site by how much

A

10%

379
Q

Closures for mandible area

A

STS

Rhombic transposition

380
Q

Key points of wedge excision on ear

A 
Cannot involve conchal bowl 
Cut from anterior, thru cartilage and posterior
Ant and post edges exactly matching
Knots on post surface
Mattress suture to hyper every
381
Q

Key points banner transposition flap on ear, negatives

A

Width of flap = width of defect
Donor can be ant or post, post easier
Close donor site first
Tip of flap - suture in horizontal mattress suture

Risks: tip necrosis if >3:1, pin cushioning, notching

382
Q

Superior helical rim advancement flap key points

A

Draw arc along edge of helical rim from defect down to superior border of tragus
Back cut on pre-auricular region
Triangulate on posterior ear, with apex toward retroauricular sulcus
Incise in S/C plan above perichondreium
Absorbable suture to close back cut, second absorbable to pull flap across defect
Excise back cut triangle
Close with interrupted, horizontal mattress suture to hyper-evert to prevent notching

383
Q

what do you do if ftsg on ear cartilaginous base but no perichondrium

A

several small punch excisions through cartilage to help nourish the graft, place every 5 mm of exposed cartilage

384
Q

closures for upper third of helical ear

A 
s2s
wedge excision
banner flap
bilobed transposition
helical advancement
helical crus rotation
FTSG
385
Q

Wedge excision for mid third of helical rim

A

<1 cm

386
Q

Two stage post auricular pedicle interpolation - key features

A

Used for large defects >2 cm
Can recreate the helix
Draw flap like an O to U flap on the mastoid, lined up with the ear defect
Leading edge in post-auricular sulcus
Undermine, elevate and lift up over the ear
Pexing suture into cartilage
Amputate 1-3 weeks later

387
Q

Pull through flap principles

A

For conchal bowl defect, can make conchal bowl thick and can pull ear back a bit
Donor site: retroauricular groove, should be adjacent to full thickness window of defect
1/3 of the pedicle remains attached
Suture pedicle in place
Close donor site primarily

388
Q

Second intention healing - how much does it contract by

A

30%

389
Q

Dressing for second intention

A

Abx ointment
Nonstick dressing with light pressure
After 1-2 days, cleanse and use baseline BD
Review 1 week then 6 weeks

390
Q

Dressing for STSG donor site

A

Mepilex

391
Q

Concerns when closing things close to the lower eyelid

A

Notching
Ectropion
Entropion
Affecting the hair lashes

392
Q

Ways to prevent ectropion

A

Frost suture - passes through tarsus twice and then attached to skin above eyebrow for 3 days
Splinting - vaseline gauze - extends between canthi, 2 mm below ciliary margin, sutured to lower eyelid, then suspension sutures at each canthal tendon

393
Q

Principles of wedge excision on lower eyelid

A

<25%
Draw V shape, excise
Suture through lid margins - don’t tie, leave long
Then close tarsal plate to reapproximate lid margins
Reapproximate muscle
Knots on external surface
Superficial sutures with 6-0 Vicryl, pass through grey line but leave long

+/- lateral cantheroplasty

394
Q

Upper eyelid closures

A 
Subcutaneous island pedicle
Wedge excision
Side to side
Advancement
Rotation
FTSG
395
Q

Repair options for the neck

A 
S2S
A to T
Rhombic transposition
Bilobed transposition
Grafts
396
Q

Mastoid closures

A 
S2S
Rotation
Transposition
T plasty or Burrows exchange
FTSG
Second intention
397
Q

Keystone principles

A

Short ellipse around defect
Keystone on side with greatest skin laxity
Incise to fascia
Undermine all the way around
Leave central pedicle
Move flap with skin hooks, if need more movement can blunt dissect vertically or release opposite deep fascial margin

398
Q

Cost of Efudix

A

$60 for a tube

399
Q

Efudix chemo wrap regime

A

Chemo wraps – apply 10-20g/limb and add zinc paste bandage – remove 1 week later, as long as tolerated, keep dry 

Keep dry and pre tx, jelonet, combine/guaze/sinc or glad wrap 4-7 days (depends on response, repeat 1-4 weekly

400
Q

Surface area to use efudix

A

Maximum 23 X 23 cm

401
Q

What percentage of the population have a DPD deficiency

A

5%

402
Q

Expected effect of Efudix

A

Expected effect - very selective of the abnormal cells in skin

Erythema, irritation, burning, pain, pruritus will begin around day 5-7 

Tightness and soreness for the 2-3 weeks, aiming for superficial graze look and redness for 2 weeks 

Photosensitivity and residua erythema Week 6 

Pink with smooth skin at week 12 – good point to assess for NMSC unmasked by treatment 

Derm (57 decks)

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