Board Review Flashcards
My total review for PRS boards 2016
1
Q
Blepharophimosis syndrome triad
A
ptosis, telecanthus, phimosis of lid fissure
2
Q
Marcus Gunn jaw-winking syndrome
A
synkinesis of upper lid with chewing
aberrant innervation from fifth cranial nerve, seen in 2-6% of congenital ptosis
3
Q
Marcus Gunn pupil
A
during the swinging flashlight test,
- when the light is flashed on the unaffected eye, the pupils constrict normally
- when the light is swung to the affected eye, the pupils dilate
= afferent pupillary defect from optic nerve injury
4
Q
McCune-Albright Syndrome
A
Fibrous dysplasia, precocious puberty, cafe au lait spots
5
Q
Klippel-Feil syndrome
A
congenital fusion of any two of the sever cervical vertebrae; short neck, low occipital hairline, restricted mobility of the upper spine
6
Q
Paget disease of the bone
A
enlarged deformed bones
7
Q
Proteus syndrome
A
atypical bone development and skin overgrowth
8
Q
Renal osteodystrophy
A
bone mineralization deficiency resulting from electrolyte and endocrine abnormalities associated with chronic kidney disease
9
Q
difference between hypertelorism and telecanthus
A
telecanthus = the intercanthal distance is increased, but the interorbital distance is normal; hypertelorism = both the intercanthal and interorbital distances are increased
10
Q
coup de sabre deformity is pathognomic for…
A
Romberg disease AKA progressive hemifacial atrophy
11
Q
Medial nasal prominences form
A
primary palate, midmaxilla, midlip, philtrum, central nose, and septum
12
Q
Lateral nasal prominences form…
A
nasal alae
13
Q
Maxillary prominences form…
A
secondary palate, lateral maxilla, and lateral lip
14
Q
Muscles of mastication
A
4 muscles;
Masseter, medial pterygoid, lateral pterygoid, temporalis
15
Q
Romberg disease
A
progressive facial atrophy
16
Q
Lateral arm flap - vascular supply
A
- posterior radial collateral artery (terminal branch of deep brachial artery)
- for reverse flap: radial recurrent
2012 2.22
17
Q
Posterior interosseous artery flap
A
based on communication between the AIA and PIA just proximal to the distal radioulnar joint. Can be based distally 2012 2.22
18
Q
ALT flap pedicle
A
Pedicle is descending branch of the lateral femoral circumflex artery off the profunda 2012 2.23
19
Q
TFL flap pedicle
A
Ascending branch of the lateral femoral circumflex artery 2012 2.23
20
Q
Gracilis pedicle
A
Ascending branch of the medial femoral circumflex artery 2012 2.23
21
Q
Critical size bone defect of the hand
A
6-8 cm
22
Q
Definition of osteogenesis
A
Provides the cells needed for bone growth (vascularized bone graft, bone graft)
23
Q
Definition of osteoconductive
A
Some thing that promotes bone ingrowth but doesn’t provide growth factors or stimulant (ex/ inert scaffolding, calcium phosphate cement)
24
Q
Definition of osteoinductive
A
Promotes bone formation - BMP2, demineralized bone
25
Gustilo fracture classification
3 components: wound size, contamination, bony injury
I: 1cm, contaminated, moderate communition
ii: wound >1cm, soft tissue isn't extensive
IIIa: >10cm, highly contaminated, severe communition, can be addressed with local flaps, grafting
IIIb: >10cm, ,Involves extensive soft tissue damage with high-energy fracture pattern; soft tissue requires free tissue transfer or regional tissue transfer for coverage, periosteal stripping and bone exposed
IIIc: Major vascular injury requiring repair for salvage
26
mass with foamy histiocytes and hemosiderin deposits on the hand
giant cell tumor of the tendon sheath
27
Most common tumor of the hand
Ganglion cysts - cystic in character
28
second most common tumor of the hand
Giant cell tumor (AKA localized nodular synovitis, fibrous xanthoma, pigmented villonodular tenosynovitis)
29
Elson test for central slip disruption
central slip disruption = PIP joint is flexed and DIP can extend independently
30
Pathophys of swan neck deformity
Terminal extensor tendon disruption
31
Risks of free fibula flap
damage to peroneal nerve, destabilization of the ankle, damage to the posterior tibial nerve
32
Interval to approach the median nerve in the forearm
between FCR and pronator teres
33
Interval to approach the radial nerve in the forearm
Between the EDC and ECRB
| 2014 #59
34
Interval to approach the radial nerve in the upper arm
Between the brachialis and triceps
35
Inability to flex the elbow with the forearm supinated = injury to ____ nerve
Musculocutaneous (Brachialis)
36
Inability to flex the elbow with the forearm pronated = injury to the _____
radial nerve (brachioradialis)
37
7 requirements for tendon transfers
1. functional
2. expendable
3. Excursion
4. Strength
5. travels in a straight line
6. Performs 1 function
7. supple joints
38
Which tendons have the greatest excursion/amplitude for tendon transfer? The least?
Greatest: FDP > FDS > FPL> digital extensors
Least: Wrist flexors and extensors
(This is proportional to how distal they are)
39
Options for opponensplasty
```
Camitz: PL + palmar fascia to APB
Bunnel: FDS ring through FCU pulley to APB
Burkhalter: EIP to ADQ or APB
Huber: ADM to APB
BR to FPL
```
40
Nerve compression syndromes:
Median (3):
Ulnar (2):
Radial (3):
Median: CTS, AIN syndrome, pronator syndrome
Ulnar: Cubital, guyon's
Radial: radial tunnel, PIN, wartenberg
41
Innervated by the median nerve (not AIN)
```
LOAF muscles:
Lumbricals 2/3
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
```
42
Innervated by AIN
FPL, 2/3 FDP, FDS, FCR (Think of everything near the carpal tunnel)
43
Options for tendon transfer for high median nerve palsy
1. EIP to APB (EIP is PIN innervated)
2. BR to FPL (BR is PIN innervated)
3. ADM to APB (ADM is ulnar innervated)
4. for IF/LF DIP flexion - tenorrhaphy betwen IF/LF FDP and RF/SF FDP (ulnar innervated)
(thumb opposition, thumb flexsion, dip flexion)
44
Tendon transfers for claw hand
Low injury will have more clawing than high ulnar due to muscle imbalance
1. ECRB or ECRL to radial lateral bands
2. Lasso FDS over A1 or A2
3. Split FDS to lateral bands or proximal phalanx
* in high ulnar nerve injury cannot use FDS of RF and SF due to palsy of FDP in RF and SF
45
Common tendon rupture in RA
EPL
46
Common tendon rupture in distal radius fx
EPL
47
Tendon transfer for radial nerve palsy
```
wrist = PT to ECRB
Fingers = FCU, FCR, or FDS to EDC
Thumb = PL or EIP to EPL
```
48
Approach to dissect the radial nerve (PIN) in the forearm
between the ECRB and EDC
49
Approach to dissect the radial nerve in the upper arm
between brachialis and triceps
50
Approach to dissect the median nerve in the forearm
between the pronator teres and the FCR
51
What are superficial vs. medium vs. deep peels?
| AHA, BHA, Jessner, 20%TCA, Phenol-croton oil
Superficial: AHA, BHA, Jessner
Medium: 20% TCA
Deep: Phenol-croton
52
Characteristics of a tuberous breast
constricted breast and high inframammary crease, herniation of breast parenchyma into NAC, large diametere areola
53
Layers of tears
1. precorneal - mucin secreting goblet cells in conjuctiva - promotes dispersion of aqueous layer
2. middle = tear layer from lacrimal gland - promotes osmotic regulation and control of infectious agents
3. meibomian glands - prevents evaporation of tear film
2014 #168, 2015#184
54
Role of estrogen and progesterone in breast function
Estrogen = ductal proliferation
Progesterone = glandular proliferation, periductal stromal development
2014 #169
55
Symptoms of lidocaine toxicity
-- dizziness, agitation, lethargy, slurred speech, euphoria,
-- tinnitus, metallic taste, perioral paresthesia,
-- hypotension, bradycardia, asystole
- hypotension may be refractory to ACLS resus
- treat with lipid emulsion
2014 #174, 2013 #181 2016
56
Layers of the epidermis
Stratum corneum, stratum lucidem, stratum granulosum, stratum spinosum, stratum basale
57
```
Epidermal response to tissue expansion
Dermal response to tissue expansion
Muscle response to TE
Fat response to TE
Capsule response to TE
Vascular response to TE
```
epidermis - thickens, normalizes after 6 months
dermis - thins 30-50%, increase fibroblasts and myofibroblasts, sweat glands and hair further apart
Muscle - decreased thickness and mass, function unchanged
Fat - decreased thickness and mass
Capsule - forms within days 4 layers, thick layer of collagen parallel to the surface of the expander
Vascular - angiogenesis occurs, highest density at junction of capsul and host tissue
58
4 layers of a capsule
1. inner layer - synovial -like lining
2. central layer - elongated fibroblasts and myofibroblasts
3. transitional layer - loose collagen
4. outer layer - vasculature and collagen
59
What is the amount of surface area gained with a
1. round expander
2. crescent expander
3. rectangular expander
```
round = 25%
Crescent = 32%
Rectangular = 38%
```
60
Absolute contraindications to tissue expansion
- near malignancy
- under skin graft
- open infection
- already tight tissue
61
Rule for Tissue Expander base diameter size
2-2.5 times the diameter of the defect to be covered
| - the tissue available for expansion is = circumference minus the base width
62
Placement of tissue expander and incision
Incision is perpendicular of the direction of expansion
63
Frankfort plane
Orbitale - tragion horizontal like (notch above tragus along infraorbital rim)
64
Treatment of chemotherapy IV infiltrate
"A" drugs (anthracycline "rubicins", Abx, Alkylating agents) = dry cold compress, neutralize with DMSO topical or IV dexrazoxane
"Vinka, taxanes, platins" = dry warm compress to disperse, dilute with hyaluronidase
65
At ___ weeks of embryologic life, male or female differentiation begins
6 weeks
66
Paramesonephric ducts (mullerian) regression
- influenced by
- produced by
- develop into
- influenced by mullerian inhibiting substance
- produced by sertoli cells
- develop into fallopian tubes, uterus, and upper part of vagina in the absence of mullerian inhibiting substance
= female is the default and occurs in the absence of mullerian inhibiting substance
67
Masculine development of mesonephric (wolffian) ducts
- influenced by
- produced by
- develops into
- influenced by testosterone analog
- produced by the interstitial cells of Leydig
- develops into the epididymis, vas deferens, and seminal vesicles
68
innervation in the genital region
Pudendal nerve, perineal nerve, dorsal nerve of the penis/clitoris, posterior scrotal/labial nerves, inferior anal nerves; ilioinguinal nerve, anterior scrotal/labial nerve
69
What is Mayer-Rokitansky-Kuster-Hauser Syndrome?
Congenital Vaginal Agenesis;
70
Flap options for vaginal reconstruction
Singapore flaps, vertical rectus flap, bilateral gracilis flaps, colon transfer,
71
Techniques for scrotal reconstruction
```
superiomedial thigh flaps
skin grafts
pedicled ALT flaps
Gracilis flap with STSG
tissue expansion of perineal skin or remaining scrotal tissue
```
72
Techniques for penile reconstruction
Most popular; radial forearm flap
Free sensate osteocutaneous fibular flap
Scapula flap +/- latissimus dorsi
abdominal flaps (VRAM or DIEP flaps)
73
Treatment of hypospadias
- treat between 6-9 months
- release chordee
-meatal advancement and glanuloplasty
-Urethral advancement
-tubularized incised plate (TIP) urethroplasty for distal defects
-Flip flap technique (distal)
Proximal: FTSG, Preputial flap urethroplasty
74
Hypospadia repair complications
fistula, glands dehiscence, urethral stenosis
75
Epispadia repair techniques
- young (penile skin makes neourethra)
- cantwell-ransley (shaft degloved, lateral incision of urethra and tubularized)
- W-flap (bilateral superiorly based groin flaps)
76
Epispadias are commonly seen with _____
bladder exstrophy
77
Excision margins for melanoma
```
insitu: 0.5mm
<1mm = 1cm
1-4mm = 2cm
>4mm = 2cm
don't include fascial layer
```
78
SCIP protocol
Do not use razors
Abx 30-59 minutes before incision
Postop abx for 24 hours
HgA1c
79
Mustarde sutures for correction of
- conchoscaphoid permanent sutures to CREATE ANTIHELICAL FOLD
80
How to create an antihelical fold
Mustarde conchoscaphoid sutures
81
How to correct moderate prominence of posterior wall of concha
Furnas Conchomastoid sutures
82
Reduce conchal projection
resection of conchal cartilage
83
causes of prominent ears
1. Conchal hypertrophy
2. Effaced antihelix
3. Conchoscaphal angle >90degrees
84
Spinal accessory nerve innervates
SCM, trapezius
| - may presend as drooping of the shoulder with scapular winging
85
wavelength and laser good for treating vascular lesions
wavelength = 585 nm
| Pulsed-dye laser
86
Lasers that are absorbed by water
CO2, Er:YAG
87
Lasers to treat acne scarring
Nd:YAG, diode, erbium lasers
| - wavelengths 1064-1540
88
Tattoo lasers
Q-switched ruby laser at 694nm (blk, blu, grn)
Q alexandrite 755 (black, blue, green)
KTP: red
89
Measurements for ptosis and levator function
Degree of Ptosis
1-2 mm = mild
3mm = moderate
4mm or more = severe
Levator Function
>10mm = Good
5-10mm = Fair
90
Seven indications for head and neck cancer adjuvant radiation
1. high grade malignancies
2. residual disease
3. recurrent disease
4. invasion of adjacent structures/extraglandular extension
5. close or positive margins
6. perineural invasion
7. T3 or T4 parotid malignancies
91
Indications for a neck dissection
- Failed XRT
- Recurrent tumors
- clinically or radiologically positive nodes
- large or rapidly growing tumors
- extraglandular extension, facial nerve palsy
- Involvement of spinal accesory n. or SCM
- aggressive tumors (SCC, adenoid cystic, malignant mixed, high-grade mucoepidermoid, adenocarcinoma)
92
What are high grade Head and Neck malignancies?
- high-grade mucoepidermoid carcinoma
- adenoid cystic carcinoma
- SCC
- Adenocarcinoma
- Carcinoma ex-pleomorphic adenoma
- undifferentiated
93
Branches of the external carotid artery?
```
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Maxillary
Superficial temporal
```
94
Prelaminated versus prefabricated flaps
```
prelaminated = adding additional tissue to a flap still attached to its axial blood supply;
Prefabricated = introduction of a vascular pedicle to a desired donor tissue that on its own does not possess an axial blood supply
```
95
How does aproclonidine work to relieve post-botox ptosis?
stimulation of alpha-andrenergic receptors in Muller muscle
96
most common benign tumor of the nasopharynx?
juvenile angiofibroma
97
MC malignant tumor of the nasopharynx?
Nasopharyngeal carcinoma, ass'd with Asian, diet, EPV; most present with nodal mets
98
MC cancer of the oropharynx?
SCC
99
MC cancer of the hypopharynx?
SCC - has the worst outcome of the head and neck cnacers
100
4 stages of swallowing
1. oral preparatory
2. oral (CN IX triggers pharyngeal swallowing)
3. pharyngeal - airway protection too; most important part
4. esophageal
101
Superior orbital fissure syndrome
SOF runs between greater and lesser wings of sphenoid (CN III, IV, VI, V1 ophtho)
- paresthesia of upper forehead, brow, lid, cornea
- pupil fixed and dilated
- ptosis
- proptosis
- paralysis of III, IV, VI
102
Orbital apex syndrome
5P's of SOFS + blindness
103
Limits of primary closure for lip defects?
Upper lip 25%
| Lower lip 40%
104
methods of closure for lip defect 25-80%
Estlander, Abbe, karapandzic, Bernard/nasolabial
central: abbe
commissure: estlander
105
method of closure for lip defect > 80%
bilateral bernard/NL flaps, or free flap (radial forearm)
106
Indications for replantation
1. child
2. thumb
3. multiple digits
4. distal amp (zone 1), simple and straight
5. hand amputation
107
Contraindications for replantation
1. patient cannot undergo surgery
2. Multiple levels
3. Zone 2 to a single digit
4. severe crush/mangle
108
Order of repair for a replant
1. bone
2. tendon
3. nerve
4. artery or vein
109
Indications for pharyngeal flap for VPI treatment?
1. good lateral wall movement
| 2. circular or sagittal port on nasoendoscopy
110
Indications for sphincter pharyngoplasty for VPI treatment?
large posterior gap with coronal, circular or bowtie patterns with poor lateral wall movement
111
Age at which pollicization is performed for thumb hypoplasia
3months to 3 years
112
Management of RA swan neck
1. flexible PIP joint
2. PIPJ limited due to intrinsic tightness
3. PIPJ limited in all MCP positions
4. PIPJ destruction
1. figure of 8 splinting
2. Intrinsic release
3. translocation of lateral bands, PIPJ capsulectomy and collateral ligament release
4. Arthrodesis or arthroplasty
113
Responsible for lateral leg sensation and eversion of the foot
Superficial peroneal nerve
| - lateral compartment with peroneus brevis and longus
114
Responsible for dorsiflexion and sensation at the 1st dorsal webspace
Deep peroneal nerve
| - anterior compartment with TA, EHL, EDL/B, peroneus tertius
115
Responsible for innervation of the anterior thigh and leg extension
Femoral nerve
116
Transfers for radial nerve palsy
```
Wrist extension (to ECRB): PT
Finger extension (to EDC): FCUor FCR or FDS
Thumb extension/abduction (to EPL): PL
```
117
Transfer for chronic EPL rupture
EIP or EDQ or ECRL
118
Things that can cause radial nerve compression
- Leash of Henry
- Arcade of Frohse (fibrous edge of supinator)
- Radial tunnel (fibrous edge of ECRB)
- Distal edge of supinator
119
Areas of ulnar nerve compression in cubital tunnel
- arcade of struthers
- heads of FCU
- Osborne ligament
- Medial epicondyle
- Medial intermuscular septum
- Anconeus
120
Rate of cure of arteriovenous malformations:
| Stage i, ii, iii
Schobinger stages
I: quiescent (75%)
II: enlarging (67%)
iii: ulcerating (48%)
121
Most common malignancy of parotid?
| 2nd most common?
1. mucoepidermoid carcinoma
| 2. Warthin tumor
122
Mechanism of action for aproclonidine?
alpha-2 adrenergic stimulation of the Muller muscle
123
Cyanosis that improves with crying
choanal atresia
124
CD4 counts for HIV
>200 cells/mm3 = risk same as general population
AIDS when CD <200 cells/mm3
high viral loads = therapy no longer effective, Increases risks
125
Keloids vs. hypertrophic scars
1. fibroblast density
2. ratio of collagen III:I
3. collagen fibers
Keloids have:
1. both have increased fibroblast density but keloids have increased fibroblast proliferation rates
2. more collagen I than HTS
3. thicker, large, and more randomly oriented collagen fibers
126
Review the rule of 9's for burns
see chart
127
In electrical injuries, what areas are the most affected?
Areas of less cross-sectional area. Tissue resistance is lowest in nerves, highest in bone. Deeper tissues will be more injured than superficial tissues.
128
When is rigid stabilization needed in chest reconstruction?
1. without rads: >3 ribs
2. with rads: >5 ribs
3. worse with loss of lateral ribs
4. diameter is >5cm
129
What is the tensile strength of wounds at
1. 2 weeks
2. 3 weeks
3. 4 weeks
4. 6 weeks
5. 12 weeks
1. 10%
2. 20%
3. 40%
4. 80%
5. full strength
130
Signs of involutional ptosis
high skin crease (>7mm), thinned upper eyelid, lid drop on downward gaze
131
Causes of neurogenic ptosis
oculomotor nerve palsy, horner syndrome, marcus gunn jaw-winking syndrome
132
Causes of myogenic ptosis
myasthenia gravis, myotonic dystrophy, mitochondriopathy
133
Where do the abdominal intercostals run?
BELOW THE INTERNAL OBLIQUE
- Between the transversus abdominis and internal oblique muscles. They enter the internal oblique fascia, divide into two branches and enter the posterior rectus sheath.
- abdominoplasty block using a TAP block
134
Where do the iliohypogastric and ilioinguinal branch?
Between the oblique muscles
135
Where is the arcuate line found?
At the level of the ASIS
136
Where do the intercostal neurovascular bundles run?
Between the internal and innermost intercostals. There are 3: external, internal, and innermost
137
Indications for chest wall reconstruction
>4 ribs, >5cm, flail chest
138
Mesonephric duct develops into...
epididymus, vas deferens, seminal vescicles
139
Paramesonephric ducts develop into...
fallopian tubes, uterus, and upper portion of the vagina
140
Methods for female to male surgery
fibula osteocutaneous free flap, ALT with prosthetic
141
Options for coverage of Sacral ulcers
```
Lumbosacral flap (requires backgrafting)
These can be re-rotated:
-Gluteal FC flap
-Gluteal musculocuatenous flap
-Uni- or bi-lateral V-Y flap
```
142
Options for coverage of ischial ulcers
Gluteal flaps
Posterior hamstring myocutaneous V-Y advancement flaps
posterior FC thigh flap
TFL flap
143
Options for coverage of trochanteric ulcers
TFL +/- vastus lateralis
| Girdlestone procedure
144
Symptoms of lidocaine toxicity
neuro and cardiac toxicity
Early: neuro - slurred speech, restlessness, tinnitus, and a metallic taste, numbness in the mouth;
Late: muscle twitching, seizures, and cardiac arrest
145
Symptoms of Fat embolism
petechial rash, respiratory dysfunction, cerebral dysfunction that appears 24-48 hours after surgery
146
If a transaxillary aug is done, what is the worst new pedicle you could do for a revision aug?
Inferior because the inferior pole gets stretched out ....
147
Innervation to the orbicularis oculi
Orbic has three parts: pretarsal, preseptal, orbital
| 2 functional parts: extracanthal (zygomatic) and medial inner canthal (buccal)
148
What does the extracanthal orbic control?
eyelid closure, voluntary squinting, animation *(zygomatic br)
149
What does the medial inner canthal orbic control?
blinking, lower lid tone, pumping mechanism of the lacrimal system (buccal br)
150
Criteria for nipple sparing mastectomy
1. tumor 2cm from nipple
2. <2cm
3. not multicentric
4. clinically negative nodes
5. no nipple discharge, no inflammatory breast cancer, no Paget's
151
What causes the tear trough deformity?
osteocutaneous ligament betwen the palpebral and orbital portion of the muscle. It extends from the medial canthus and connects with the bilayered orbicularis retaining ligament mid-pupil
152
Most common inherited thrombophilia
factor V Leiden
153
Risks for breast cancer
Early menarche, late first pregnancy, late menopause, no breast-feeding, recent oral contraceptive use
154
Treatment of biopsy papilloma in the breast
excision - difficult for distinguishing between benign and malignant on biopsy only. Malignant features include >1cm, peripherally located,
155
Components of bleph/ptosis examination
Palpebral fissue height, marginal reflex distance, levator function or excursion, scleral show, lid crease height and contour, superior sulcus depth and contour, lagophthalmos, Bell phenomenon, ocular deominance, and eyelid laxity
156
MRD1 values - normal?
Normal is between 3.5-4.5
| Ptosis is
157
Tensilon test for ptosis
used when myasthenia gravis is suspected. mg neostigmine injected IM and ptosis should improve if MG is the cause
158
Phenylephrine test for ptosis
- phenylephrin 2.5% drops stimulate Muller muscle and results in 2-3mm of lid elevation
159
Treatment of phyllodes tumor
wide local excision with 1cm margins
160
Evaluation of gynecomastia
always check the scrot and testicles for testicular tumors.
| can be related to obesity, drugs, Klinefelter
161
Structures that affect nasal airflow
internal and external nasal valves, inferior turbinates, nasal septum
162
What cancers are also associated with BRCA?
BRCA - pancreatic and prostate
| - NOT thryoid, lung, esophageal, or colon
163
Tear layers
1. precorneal - mucin secreting goblet cells in conjuctiva - promotes dispersion of aqueous layer
2. middle = tear layer from lacrimal gland - promotes osmotic regulation and control of infectious agents
3. meibomian glands - prevents evaporation of tear film
2014 #168, 2015#184
164
Depth of peels from superficial to deep
Salicyclic 20-30%; jessner/Glycolic acid; TCA 35 to 50%
165
Tuberous breast deformity treatments
constricted IMF - radial scoring
| short IMF to nipple distance - lower the IMF
166
Risk of breast cancer
all: 8%
mother/sister: 15%
premenopausal/bilateral 1st degree: 45%
BRAC1: 50-80%
167
Difference in asian eyelids
absent or low lid crease, shorter tarsus, descending pre-aponeurotic fat, minimal or absent connection between the levator and upper lid dermis
168
Quadrangular space - boundaries and contents
Boundaries: teres minor, teres major, long head of triceps, surgical neck of humerus (and lateral head of triceps)
Contains: Axillary nerve, posterior circumflex humeral artery
169
Triangular space
1. teres minor, teres major, long head of triceps - contains the circumflex scapular artery
170
```
Pharyngeal pouches
1:
2:
3:
4:
```
```
Pharyngeal pouches
1 - eustachian, mastoid, tympanic cavity
2 - tonsil
3 - thymus, lower parathyroids
4 - upper parathyroids
```
171
Branchial arches: nerves, bones, muscles, vessels,
1 (mandibular): CN5; maxilla & mandible; muscles of mastication, mylohyoid, tensors, TENSOR VELI PALATINI, anterior belly digastric; maxillary artery, anterior 3 hillocks of his
2 (hyoid): CN7; hyoid, stapes; platysma, stylohyoid, facial muscles, POSTERIOR belly of the digastric; stapedial artery; posterior 3 hillocks of his
3: CN9; lower part of hyoid; stylopharyngeus; common carotid, ICA;
IV/VI: CN10; laryngeal cartilage, pharyngeal constrictors, levator veli palatini; palate muscles; aortic arch, right subclavian, ductus arteriosus
172
Most common parotid malignancy?
Mucoepidermoid carcinoma
173
Parotid malignancy most likely to present with distant mets?
Adenoid cystic carcinoma
174
Most common minor salivary gland maligancy
Adenoid cystic carcinoma
175
Most common parotid tumor in children
Hemangiomas
176
Treatment for parotid tumors with cervical mets
1. resect tumor
2. parotidectomy
3. post-op XRT vs MRND
4. Radical neck when extracapsular disease
177
Bilateral parotid masses
Warthin's tumor AKA papillary cystadenoma lymphomatosum
178
Treatment of nasopharyngeal carcinoma
xrt
179
Indications for adjuvant XRT in head and neck cancers
1. any stage III or IV (III = >3cm or with a node) (IV = growing into other structures and/or large nodes)
2. single node >3cm
3. multiple nodes
4. extracapsular disease
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taste and Sensation to the anterior 2/3 of the tongue
sensation via lingual nerve V3, taste via chorda tympani (VII)
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taste and sensation to the posterior 1/3 of the tongue
glossopharyngeal (IX) for both taste and sensation
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Treatment of SCC of the lip
SCC of the lip is RADIOSENSITIVE. most will regress with XRT only, if >6cm, shrink with XRT first
- consider surgical excision if it looks like you will have an easily cosmetic resection
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Palisading odontogenic epithelial cells
Ameloblastoma of the mandible
184
Cystic fluid containing keratin in mandible
Odontogenic keratocyst
185
Treatment of odontogenic keratocyst
enucleation, curettage, peripheral ostectomy - need to rule out Gorlin's syndrome
186
Treatment of unicystic ameloblastoma
Enucleation and curettage only
187
Treatment of "soap bubble" ameloblastoma
marginal mandibular resection with immediate recon. If cortical spread, 1cm margins
188
Treatment of peripheral or extraosseous ameloblastomas
Radial resection and/or hemimandibulectomy, 20% recurence rate
189
Treatment of cyst at the apex of a non-vital tooth
Radicular cyst: treat with root canal
190
Treatment of giant cell tumor of the mandible
benign (as opposed to malignant in long bones); curettage if small, excision and recon if large
191
Approaches to reducing a zygomatic arch fracture
Gilles - elevate immediately beneath DEEP temporal fascia (superficial to temporalis muscle)
Keen - intraoral incision - lateral maxillary vestibular incision
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Cranial nerves
???
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What are the structure continuous with the SMAS?
Galea--> superficial temporal fascia --> SMAS --> platysma --> superficial cervical fascia
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Was is the continuous structure with the parotidomasseteric fascia?
deep cervical fascia
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What facial muscles are innervated on their superficial surface?
mentalis, levator anguli oris (LAO), buccinator = the deepest layer of muscles
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Most superficial facial muscles?
DAO, zyomaticus minor, orbicularis oris
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2nd layers of facial muscles?
Depressor labii inferioris, risorius, platysma
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3rd layer of facial muscles?
Zyomaticus major, levator labii superioris alaeque nasi
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Buccal branch of the facial nerve innervates all mid and lower facial muscles except?
DAO, DLI, mentalis --> marginal mandibular
| Orbic oculi --> zygomatic part (lateral), deep buccal branch innervates the medial aspect
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7 orbital bones
zygoma, maxilla
ethmoid
lacrimal, palatine, frontal, sphenoid
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Lateral orbital wall bones
Zygoma, greater wing of the sphenoid
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Inferior orbital bones
maxilla, zygoma,
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Medial orbital bones
ethmoid, palatine, lacrimal
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Superior orbital bones
frontal, greater wing of the sphenoid
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How does a CN III present?
eyeball is "down and out". All EOM are innervated by CN 3 except lateral rectus (CN6) and superior oblique (CN4)
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Trauma to the lower eyelid with epiphora - jones testing and tx?
Jones testing - for checking for obstruction of lacrimal system. Positive = it is open (no obstruction)
- I = fluorescein into eye, check for fluor in inferior meatus in nose,
- II = saline into ducts, check for saline in nose
Tx: Dacryocystorhinostomy = makes a connection between the lacrimal sac and nose
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Structures that lie superficial to posterior belly of the digastric
1. facial nerve
| 2. external jugular vein
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Structures that lie deep to the posterior belly of the digastric
vagus, spinal accessory, hypoglossal, sympathetic trunk, IJ, ICA, ECA, facial artery, lingual artery
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First permanent tooth to erupt
Mandibular first molar = start of mixed dentition phase
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Arcade of Frohse
radial tunnel syndrome, PIN palsy
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Leash of Henry
radial tunnel syndrome/PIN
212
lacertus fibrosis
pronator syndrome
213
ligament of struthers
pronator syndrome
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arcade of struthers
cubital tunnel
215
Osborne's ligament
cubital tunnel
216
MOA of aspirin
Cyclooxygenase inhibitor which then inhibits thromboxane which is a platelet aggregator and vasoconstrictor
217
MOA of Dextran
decreases platelet aggregation via altering electric charge of platelets and decreases blood viscosity
218
MOA of Heparin
binds to antithrombin III to inhibit thrombin and factors 9, 10, 11, 12
219
MOA of Hirudin
directly inhibits thrombin
220
MOA Streptokinase
thrombolytic agent the activates plasminogen
221
EMG normal motor finding
no sharp waves, no fasciculations
latency <4.0ms
amplitude 15-25 uV
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EMG normal sensory findings
latency <3.5 ms
| amplitude 15-25uV (abnormal is <15 uV)
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Presentation of volkmann's contracture
pseudo-claw position with intact ulnar nerve function
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Cause of boutonniere deformity
central slip disruption resulting in volar subluxation of lateral bands
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Causes of swan-neck deformity
Dorsal subluxation of lateral bands, laxity of volar plate at the PIP joint, MCP volar dislocations, DIP extensor injury, Rheumatoid arthritis
226
What are the strongest donor tendons?
Brachioradialis and Flexor carpi ulnaris = 2
FCR, wrist extensors, finger flexors, and PT = 1
finger extensors = 0.5
palmaris longus, thumb extensors and abductors = 0.1
227
Radial nerve palsy effects on UE function
loss of wrist extension, finger MCP extension, thumb abduction, thumb extension and thumb retropulsion, decrease in grip strength
228
Tendon transfer for radial nerve palsy
Wrist: PT to ECRB
MCP: FCR, FDS, or FCU to EDC
Thumb: EIP or PL to EPL
229
How to distinguish between high and low median nerve palsy
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low = loss of thenar function and opposition
high = loss of thenar function PLUS loss of FDS to all fingers, loss of FPL, and index FDP (AIN innervated)
```
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What is innervated by the AIN?
think carpal tunnel
| FDS, FDP (2/3), FPL + FCR
231
Tendon transfer for low median nerve palsy
Restore thumb opposition (opponensplasty to APB)
- Camitz (PL)
- Huber (ADM)
- EIP
- FDS
232
Tendon transfer for high median nerve palsy
Restore thumb opposition, +FPL, and index FDP
- Thumb: EIP or ADM to APB
- FPL: brachioradialis
- FDP 4/5 side to side with FDP 2/3
233
Effects of ulnar nerve palsy
CLAWING IS WORSE IN LOW VS HIGH ULNAR NERVE PALSY
low: loss of key pinch and clawing and loss of integration of flexion
high: FCU, FDP 4/5 also lost
234
Goals of tendon transfers for ulnar nerve palsy
restore key pinch, correct clawing, integrate finger flexion, and restore FDP 4/5
235
Tendon transfer for ulnar nerve palsy
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Clawing corrections: FDS, BR, FCR, ECRL, ECRB
1. ECRL or ECRB to lateral bands (BRAND)
2. FDS lasso
3. FDS to lateral bands or P1
4.
```
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PIN innervation
all extensors except ECRL/ECRB
237
Indications for ORIF of scaphoid fracture
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>1mm displacement, comminution, angulation (intrascaphoid angle greater than 35 degrees), open fracture,
carpal instability (scapholunate angle> 60 degrees, radiolunate angle >15 degrees)
```
238
X-rays to get for scaphoid fractures
usual 3 view plus PA clenched fist view in ulnar deviation
239
Nerve transfer for AIN palsy
brachialis br of musculocutaneous nerve to AIN in the upper arm
240
Nerve transfer for ulnar nerve injury
AIN to ulnar nerve in forearm
241
Nerve transfer for axillary nerve injury resulting in loss of deltoid, shoulder abduction and external rotation
triceps branch of the radial nerve to axillary nerve
242
when do limb buds appear?
day 26
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When does digital separation occur?
between days 44-54
244
Treatment of Head and neck cancer?
Stage I
Stage II
Stage III and IV
Stage I: surgical resection or XRT
Stage II: surgical resection or XRT + neck dissection
Stage III and IV - surgical resection + XRT + Neck dissection
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General order of tooth eruption
first molar --> central incisor --> lateral incisor --> first premolar --> canine
246
Treatment of BRONJ
stage 1 - antiseptic rinses
stage 2 - rinse and superficial debride, abx
stage 3 - surgical debridement, rinse, abx
2016 #122
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Arterial supply of the trapezius
dorsal scapular and transverse cervical
248
Margins for BCC
- 3 to 4 mm for BCC <2cm on face or low-risk
| - 10mm if >2cm, morpheaform, high risk, recurrent, on trunk/extremiteis
249
Margins for SCC
4-6mm
<2cm = 4mm
>2cm, high-risk, goes to subQ = 6mm
250
Margins for melanoma
```
insitu: 0.5mm
<1mm = 1cm
1-4mm = 2cm
>4mm = 2cm
don't include fascial layer
```
251
VPI with coronal gap
sphincer pharyngoplasty
252
VPI with minimal circular gap and good lateral wall movement
pharyngeal flaps
253
Indications for approval for panniculectomy
1. inability to walk normally
2. Chronic pain and ulceration in the skin fold
3. Pannus is below the pubis
4. Intertrigo of the pannis over 3 months with treatment
5. Stable weight for at least 6 months and 18 months after gastric bypass
254
Poiseuille law
(viscosity x length)/radius^4
255
Causes of gynecomastia
drugs, unresolved pubertal gynecomastic, idiopathic.
256
Treatments of gynecomastia
Tamoxifen, raloxifene - gynecomastia <1 year
| Surgical - painful, present > 1year
257
Eyelid reconstruction techniques for defects > 60%
Upper lid: Bridge (Cutler-Beard) flap; Tenzel flap, Temporal (Fricke) flap
Lower lid: hughes tarsoconjunctival flap, tripier flap, Mustarde flap, temporal (fricke flap)
258
Eyelid reconstruction techniques up to 60%
Upper lid: Tenzel flap, lower lid-sharing flap (Mustarde), direct closure up to 30%
Lower lid: primary up to 20%, Tenzel, vertical myocutanouse cheek lift,
259
Eyelid recons that supply both anterior and posterior lamella
Cutler-beard, Tenzel, primary closure, lid-sharinge (Mustarde), Fricke flap
260
Partial thickness eyelid recon
Tripier flap, forehead flap, Hughes,
261
Guideline for cardiac clearance
1. Is there need for emergency NCS? If yes, proceed with surgery.
2. Are there active cardiac conditions (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease)? If yes, evaluate and treat per specific guidelines before considering NCS.
3. Is the NCS considered low risk (e.g., superficial and ophthalmologic procedures)? If yes, proceed with low-risk NCS.
4. Does the patient have good functional capacity (METs >= 4) without symptoms? If yes, proceed with NCS.
Is there need for emergency NCS? If yes, proceed with surgery.
Three or more clinical risk factors undergoing vascular surgery: consider testing if it will change management
One or two clinical risk factors undergoing vascular surgery or one or more clinical risk factors undergoing intermediate-risk surgery: either proceed with surgery with heart rate control (beta blockade) or consider noninvasive testing if it will change management
262
Tx for injury to motor branch after endo CTR resulting in loss of opposition?
camitz opponensplasy = PL to APB
| PL is median innervated but only motor branch is gone in this scenario
263
Tx for loss of thumb opposition after combined high median and ulnar nerve palsy?
Burkhalter opponensplasty = EIP to APB
| Median is gone so cannot use PL which is median innervated
264
Tx for high median nerve injury resulting in loss of FPL
brachioradialis to FPL
265
transfers for EPL rupture
EIP or
EDQ or
ECRL
266
Thenar muscles
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Innverated by median except deep FPB (ulnar)
267
Innervation of the anterior hard palate
Sphenopalatine
268
Innervation of the soft palate and uvula
lesser palatine
269
Use for a lateral crural turnover flap
pinched tip due to crural deformity, deformed ala, external valve stenosis
- addresses convex or concave lower lateral crura
270
Treatment for bulbous nose
Lateral crural strut
Cephalic trim
Transdomal suture
271
Treatment for boxy tip
domal sutures, do transdomal first, then interdomal
272
Technique for more tip rotation
cephalic trim, lateral crura shortening
273
Technique for less tip rotation
spreader grafts, medial crura shortening
274
Treatment for hanging columella
Transfixation incision to access the columella, then perform caudal septum resection
275
Treatment for tongue cancer >3cm
surgical excision, XRT, regional lymphadenectomy
276
General rules for Head and Neck XRT
1. Recurrence
2. Residual disease
3. Perineural invasion
4. extracapsular extension
5. T3 T4
6. 2 or more nodes
277
Up to how much tongue can be closed primarily?
50%
278
Sensation to the anterior 2/3 of the tongue
lingual nerve (V3), taste via chorda tympani (VII)
279
Sensation and taste to the posterior 1/3 of tongue
glossopharyngeal (IX)
280
What muscle dilates the nostrils
Levator labii superioris
281
What is the nasal tip angle of divergence
What is normal?
What makes a boxy tip?
What makes a bulbous tip?
- angle between the middle crura
- normal is 30-60 degrees
- boxy tip is >60 degrees
- bulbous is flat
282
Correction of internal valve collapse
- butterfly graft
- spreader grafts
- flaring sutures
- splay grafts
283
Correction of external valve collapse
- Alar batten grafts
| - lateral crural struts/turnover
284
Nerve responsible for plantar flexion, foot inversion, and plantar sensation?
Tibial nerve (innervated the superficial and deep posterior compartments)
285
Nerve responsible for leg abduction
Superior gluteal nerve
286
Nerve responsible for leg adduction
Obturator nerve
287
Predicted recurrent of Cleft lip AND Palate
a. 1 sibling
b. 1 parent
c. 2 siblings
d. 1 parent, 1 sibling
a. 4%
b. 4%
c. 9%
d. 16%
288
Predicted recurrent of Cleft palate alone
a. 1 sibling
b. 1 sibling + FHx
c. 1 sibling + another anomoly
d. 2 siblings
e. 1 parent
f. 1 parent, 1 sibling
a. 4%
b. 7%
c. 2%
d. 1%
e. 2-6%
f. 15%
289
Embryology of cleft lip
Failure of medial nasal and maxillary prominences to merge
290
Embryology of cleft palate
a. primary palate
b. secondary palate
a. failure of fusion of medial and lateral palatine processes
b. failure of fusion of lateral palatine processes with each other and the nasal septum
291
a. what does the frontonasal prominences become?
b. Maxillary prominence?
c. Medial nasal prominence?
d. Lateral nasal prominence?
e. Mandibular prominence?
a. divides into the medial and lateral nasal process --> forehead, nose, and top of the mouth
b. lateral lip elements that fuse with philtrum
c. nose, septum, philtrum, cupid's bow, premaxilla to incisive foramen
d. alae
e. mandible
292
How to determine between sphincteroplasty vs. pharyngeal flaps?
Satisfactory lateral pharyngeal wall movement and sagittal or circular velopharyngeal closure patterns should be treated with a pharyngeal flap. A large posterior gap with coronal, circular, or bowtie patterns of closure and good velar elevation, but poor lateral wall motion, should be treated with a sphincter pharyngoplasty
293
Sensation to the posterior and inferior nasal septum, premaxilla palate extending back to maxillary cuspid
Nasopalatine (v2)
294
Sensation to the palate except the premaxilla palate
Anterior palatine (greater palatine) nerve (v2)
295
SEnsation to the maxillary sinus, cuspid, and incisor region
Anterior superior alveolar n (V2
296
Sensation to the floor of the mouth
Lingual (v3) and chorda tympanii (CN7)
297
Sensation to the cheeck
Buccal nerve (V3)
298
Innervation of the parotid
Auricuotemporal nerve (V3)
299
INnervation of the meibomian glands
lacrimal nerve (V1)
300
Innervation of the lacrimal gland
facial nerve parasympathetics travelling with lacrimal nerve (v1)
301
Innervation of nasal and palatal secretory glands
Facial nerve parasympathetics travel with pterygopalatine (V2)
302
taste for anterior 2/3 of tongue, sublingual and submandibular glands
Linguinal nerve (V3) and chorda tympanii (7)
303
Main characteristics of Goldenhar (Oculoauriculovertebral spectrum)
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Epibulbar dermoids
Varied microsomia
Hemifacial microsomia
Colobomas (upper eyelid)
Vertebral/rib anomalies
frontal bossing, low hairline
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Associated with agenesis of the sphenoid wing
Neurofibromatosis
