Chest Wall / Abdominal Wall / Gynecomastia Flashcards
An 18-year-old woman is evaluated for chest wall and breast asymmetry. She has a history of pectus excavatum and underwent surgery as a child for placement of a correction bar, which was subsequently removed 3 years after insertion. Since the removal of the bar, she has noticed progressive recurrence of her chest wall deformity with associated breast asymmetry. Physical examination shows a thin patient with a 4-cm deep concavity involving the lower end of the sternum and medial distortion of the right breast. The patient denies shortness of breath or chest pain. Which of the following treatment options is the most appropriate recommendation for contour improvement?
A) Autologous transfer of fat tissue to the sternal defect and right breast
B) Implantation of a customized silicone elastomer device with concurrent augmentation mammaplasty
C) Injection transplantation of cultured autologous chondrocytes
D) Placement of bilateral silicone breast implants greater than 550 cc
E) Reinsertion of the correction bar with sternal wiring
The correct response is Option B.
When considering how best to treat pectus excavatum in the female patient, it is important to recognize that the majority of the contour deformity is due to the thoracic concavity with only a small portion of the deformity due to actual breast tissue hypoplasia. However, reinsertion of a correction bar is not always successful in correcting the thoracic deformity in post-adolescent patients whose bones have ossified, and is only done in extreme cases. Augmentation mammaplasty is also unsuccessful, regardless of implant volume, since, as stated above, only a small portion of the defect is actually caused by breast tissue asymmetry. Although some might consider autologous fat grafting a viable option for correcting both the chest wall defect and the hypoplastic breast, there have been reports that indicate that injecting between the tight adhesions of presternal skin and bone is technically challenging and rarely successful. Injection of cultured autologous chondrocytes, which is still in the early stages of research and development, would prove to be equally technically challenging, and at this time, de novo generation of cartilage or fat for injection into soft-tissue defects is still unproven. As a result, customized silicone elastomer implants are commonly used in conjunction with augmentation mammaplasty to provide consistent and reliable correction of pectus excavatum and breast asymmetry in the female patient. Studies have shown that placing a custom sternal prosthesis and bilateral breast implants during one surgery is both safe and effective in producing an improved aesthetic result.
2018
A 5-year-old boy is evaluated for a cerebrospinal fluid leak and a 3 × 3-cm area of wound dehiscence involving the posterior trunk following tethered cord repair. Which of the following is the most appropriate method for reconstructing the wound?
A) Gluteal muscle flap and skin advancement flap
B) Latissimus muscle flap and skin advancement flap
C) Local fascial flap and skin advancement flap
D) Skin advancement flap only
E) Split-thickness skin graft
The correct response is Option C.
The most appropriate method to reconstruct the wound is a local fascial flap and skin advancement flap. The major principle of tethered cord and myelomeningocele repair is to obtain a well-vascularized layer of soft-tissue coverage between the dural and skin closures. The fascia overlying the paraspinous muscles can be turned over as flaps to cover the underlying dural repair. This vascularized soft-tissue layer will minimize the risk of cerebrospinal fluid leak by reinforcing the dural repair. In addition, the fascial flaps will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down.
A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair using skin advancement flaps would place the child at risk for meningitis in the event of a cerebrospinal fluid leak or if wound breakdown occurred along the incision line of the widely undermined skin flaps.
The use of a regional gluteal or latissimus muscle flap to cover the dural repair is unnecessary because local tissue (paraspinous muscle fascia) is available. Harvesting the gluteal or latissimus muscles also may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurological deficit.
2018
A 30-year-old woman is evaluated for a mass on the anterior abdominal wall that has been growing over the past several months. Imaging and examination of the specimen obtained on biopsy confirm a diagnosis of desmoid-type fibromatosis arising from the anterior abdominal musculature. Which of the following is the most accurate statement regarding this condition?
A) It is associated with previous radiation exposure
B) It is locally aggressive with remote risk of metastatic disease
C) It usually arises from an untreated lipoma
D) Primary treatment is combination chemotherapy/radiation
E) There is an autosomal recessive genetic inheritance pattern
The correct response is Option B.
This patient has a desmoid tumor, a rare, locally infiltrative mesenchymal neoplasm that is most commonly found in adolescents and young adults. It does not metastasize but can have a very unpredictable and aggressive natural history. Treatment can range from close observation (as some tumors will self-involute) to radical excision with wide margins. Traditionally, surgical excision can be difficult because of the high risk of local recurrence.
Desmoid tumors are not associated with chemical or radiation exposures, or lipomas.
Metastatic disease is not a characteristic of desmoid tumors.
Although treatment modalities for desmoids are evolving, they are not treated with chemotherapy/radiation therapy as a primary modality. Primary treatment is frequently observation for small or slowly changing tumors. For rapidly growing tumors, radical excision is frequently performed.
There does not appear to be a genetically inherited component for desmoid tumors, although they are associated with random mutations of the ?-catenin (CTNNB1) and adenomatous polyposis coli (APC) genes.
2018
An 18-year-old woman comes to the office to discuss her congenital breast asymmetry. Physical examination shows asymmetry in the size and shape of the right breast and nipple-areola complex compared with the left breast. Additionally, there is an absence of the right anterior axillary fold. A photograph is shown. Which of the following is the most likely origin of the absent muscle in this patient?
A) Ectoderm
B) Endoderm
C) Mesoderm
D) Neuroectoderm
E) Notochord
The correct response is Option C.
The patient above has Poland syndrome. Poland syndrome represents a spectrum of congenital chest wall anomalies ranging from the simple form (depicted in the preoperative photograph) to complex. The pathognomonic feature is the absence of the sternocostal head of the pectoralis major muscle. A variety of other ipsilateral chest wall and upper extremity malformations may be present, including absence of ribs two through five, foreshortening of the limb, brachysyndactyly, hypoplasia/aplasia of the breast and nipple-areola complex, and absence/hypotrophy of various trunk muscles including the latissimus dorsi, serratus anterior and external oblique. Although a few familial cases have been reported, Poland syndrome is believed to be sporadic in nature with an incidence of 1:100,000. There is a male-to-female predilection of 3:1, with a right-sided predominance in boys of 2:1. The patient is shown two months after reconstruction with a right latissimus flap and bilateral silicone gel-filled implants.
The trunk develops from the fusion of the ectoderm/neural crest layer with the somatic mesoderm during the fourth week of gestation. Mesoderm gives rise to somites, which differentiate into the dorsolateral dermomyotome and the ventromedial sclerotome. The dermomyotome gives rise to the musculature of the trunk and extremities. The sclerotome surrounds the developing spinal cord and notochord and forms the vertebral bodies and spinal skeletal structure. The notochord acts as a pathway for the development of the spinal cord and vertebral bodies. The notochord degenerates as the vertebral bodies develop and becomes the nucleus pulposus of the intervertebral disks.
The exact pathophysiology of Poland syndrome has not been elucidated. One theory suggests a mechanical disruption of the embryonic blood supply in the subclavian/vertebral systems during the sixth to seventh week of gestation. Another theory suggests the etiology to be an injury or developmental failure of the mesodermal plate during the third to fourth week of gestation.
Endoderm is the primitive germ layer that gives rise to the epithelium of the respiratory and gastrointestinal tracts. Ectoderm is divided into surface ectoderm and neuroectoderm. Surface ectoderm gives rise to the epidermis, adnexal structures of the skin, and the mammary glands. Neuroectoderm becomes the central nervous system, various neural ganglia, and the branchial arches.
During a ventral hernia repair and abdominal wall reconstruction, a surgeon wishes to achieve full primary fascial closure over an intraperitoneal mesh. However, the fascia is under tension and requires a component separation to achieve full closure with minimal tension. Component separation technique involves which of the following?
A) Incision of the anterior rectus sheath
B) Internal oblique aponeurotomy
C) Ligation of periumbilical perforators
D) Plication of the linea semilunaris
E) Preservation of intercostal nerves
The correct response is Option E.
Preservation of segmental intercostal nerves is a critical aspect of component separation.
Component separation is a powerful technique used during abdominal wall reconstruction to advance the abdominal fascia towards the midline and allow for primary closure with reduced tension.
A component separation is performed by making an incision longitudinally in the external oblique aponeurosis, just lateral to the linea semilunaris. Only the fascia is cut, not the external oblique muscle. This allows for advancement of a myofascial complex consisting of the rectus abdominus muscle, internal oblique muscle and fascia, and transversalis muscle and fascia.
The segmental intercostal nerves that supply the anterior abdominal wall run between the internal oblique and the transversalis muscle. They are deeper than the incision and dissection plane with component separation, and are thus protected from injury. This maintains abdominal wall tone in patients undergoing this procedure.
External oblique aponeurotomy, not internal oblique aponeurotomy, is involved in component separation. Incision of the anterior rectus sheath is not part of component separation, although some modifications include incision of the posterior rectus sheath to release more fascia available for primary closure. Plication of the linea semilunaris is not a part of component separation. Ligation of periumbilical perforators is commonly performed in the standard, open approach to component separation, but it is not considered a critical component of the procedure, as it is possible to perform a perforator-sparing component separation.
2018
An 80-year-old man comes to the office because of recurrent squamous cell carcinoma of the cervical skin. Following reconstruction with a pectoralis myocutaneous flap, the distal half of the skin paddle appears ischemic and eventually exhibits necrosis and full-thickness skin loss. Transection of which of the following structures is most likely responsible for this complication?
A) Lateral thoracic artery
B) Medial pectoral vein
C) Posterior intercostal vasculature
D) Thoracodorsal artery
E) Transverse cervical vessel
The correct response is Option A.
The pectoralis major muscle has three major blood supplies. In general, the internal mammary perforators and the thoracoacromial vessels are dominant, with additional perfusion through the lateral thoracic artery. Turnover pectoralis flaps for sternal reconstruction based on the internal mammary perforators are generally well perfused. Likewise, in most situations a pedicled myofascial or myocutaneous flap based on the thoracoacromial vessels (with the other blood supplies ligated) is robust and can be used for most types of head and neck reconstruction. Although described earlier, the flap became the “workhorse” of head and neck reconstruction after Ariyan’s classic article in 1979. Versus a free tissue transfer, the pectoralis flap has many detractors, including being tethered to its pedicle. In about 6% of cases, the lateral thoracic vessel is the dominant pedicle to the flap and needs to be incorporated for maximal perfusion for head and neck reconstruction. This of course further decreases some of the mobility of the flap. This phenomenon is usually easily discernible by the larger caliber of the lateral thoracic vessels versus the thoracoacromial vessels. In this case, this was the most likely injured vessel, causing the described outcome.
The transverse cervical vessels do supply the posterior thorax, and the intercostal vessels do supply the anterior chest, including breast tissue, but neither gives important perfusion to the pectoralis flap. The lateral pectoral nerve travels with the thoracoacromial vessels and, if not checked when turning the flap, can kink the vascular pedicle and, if not severed, does not allow the flap to decrease in size because of lack of denervation of the muscle. The medial pectoral nerve is another innervation to the pectoralis major muscle and is usually severed during flap elevation. The thoracodorsal artery does not supply the pectoralis muscle.
2018
A 59-year-old man is scheduled for reconstruction of a central abdominal wall hernia measuring 10 cm wide x 30 cm long. A surgical approach using posterior component separation is planned. Which of the following locations for fascial incision most accurately describes the technical considerations of this procedure?
A) Across the lateral intercostal neurovascular bundles
B) Along the mid-axillary line
C) Medial to the linea semilunaris
D) Parallel to the subcostal border
E) Vertical bisection of the rectus muscles
The correct response is Option C.
Component separation of the abdominal wall was initially described for the anterior components, that is, those which are located anterior to the rectus muscle. A more recent development involves component separation of the layers located posterior to the rectus fascia. The technique of posterior component separation begins with a vertical incision of the posterior rectus sheath 0.5 cm medial to the linea semilunaris and continues laterally in the avascular plane posterior to the transversalis muscle. It can extend as far posteriorly as the psoas muscle if needed. In the event that the posterior layer cannot be approximated in the midline, an interposition patch of omental fat, hernia sac, or absorbable mesh is used. Concurrent use of non-absorbable mesh to reconstruct deficient anterior layers may be used in conjunction with the posterior separation technique as long as the mesh is separated from viscera with an intact posterior layer. A benefit of the posterior separation technique is the preservation of the lateral neurovascular bundles preserving the dynamic function of the rectus muscles. The technique may be utilized even when fascial defects are not situated in the midline or are located adjacent to bony landmarks.
2018
A 43-year-old woman, gravida 3, para 3, undergoes a combined panniculectomy and hernia repair. The planned hernia repair is a retrorectus repair without components separation with polypropylene mesh. Which of the following best describes an advantage of using polypropylene mesh compared with a biologic scaffold?
A) Decreased need for components separation
B) Decreased recurrence rate
C) Increased collagen cross-linking
D) Increased resistance to infection
The correct response is Option B.
In general, the indication to use biologic scaffolds in hernia repairs and abdominal reconstruction is in contaminated beds. Biologic scaffolds provide an intact extracellular matrix and support tissue regeneration, and are more resistant to infection than synthetic mesh, likely because of this tissue ingrowth. Biologic scaffolds, unlike synthetic mesh, are degraded over time by collagenase. This accounts for at least some of the higher recurrence rates seen with biologics compared to synthetic mesh. Cross-linking of the scaffold may provide resistance to collagenase and improve long-term stability.
Thus, better resistance to infection is a property of biologic scaffolds, as is collagen cross-linking, although the degree of cross-linking varies based on the particular scaffold. They are associated with a higher cost and an increased recurrence rate. Their high cost compared with synthetic mesh does not justify their routine use, and the recommendation for their use by the Ventral Hernia Working Group is in contaminated fields, with infected mesh and septic dehiscence.
The need for components separation is based on the properties of the hernia itself and is independent of the type of mesh used. Components separation without mesh is, however, associated with a high recurrence rate.
2018
In addition to the typical chest wall deformities, which of the following is the most common associated clinical presentation of patients suffering from Poland syndrome?
A) Dextrocardia
B) Lung hernia
C) Renal malformation
D) Thyroid malignancies
E) Upper extremity anomalies
The correct response is Option E.
Poland syndrome is the rare congenital condition describing the absence of the breast or nipple, hypoplasia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of costal cartilages or ribs 2, 3, and 4 or 3, 4, and 5, occasionally even rib 6. Its aesthetic and functional impairment varies between individuals and highly depends on the severity of the disease. Boys are three times as likely to be affected as girls. Incidence ranges between 1:100,000 to 1:7,000 cases per live births.
Various concomitant anomalies have been published in association with Poland syndrome that typically necessitate a multi-disciplinary approach towards the diagnosis and treatment of this congenital illness. Upper extremity anomalies, renal malformation, lung hernia, and dextrocardia have all been described in literature as related to Poland syndrome. Anomalies of the upper extremity are the most common concomitant malformation besides the chest wall defects.
2018
A 22-year-old man comes to the office reporting breast enlargement that began 7 years ago. Physical examination shows bilateral breast enlargement. Testicular examination is normal. BMI is 27 kg/m2. Which of the following evaluations is best for distinguishing gynecomastia from pseudogynecomastia in this patient?
A) History of medication use
B) Laboratory testing
C) Mammography
D) MRI
E) Physical examination
The correct response is Option E.
Gynecomastia is benign enlargement of the glandular breast tissue in a man. It is often related to factors that either results in an increase in estrogen production, or a decrease in androgen production. This can be due to the transient imbalances during puberty, or secondary to medication use, drug use (such as marijuana), testicular pathology, thyroid disease, liver disease, breast cancer, etc.
This is in contrast to pseudogynecomastia, which is enlargement of the breast due to fat deposition in the absence of glandular hypertrophy. Pseudogynecomastia is typically seen in the patient who is overweight or obese.
Pseudogynecomastia is distinguished from gynecomastia by physical examination. In true gynecomastia, one will palpate enlarged firm glandular breast tissue, as opposed to in pseudogynecomastia, where palpation will reveal a soft fatty breast throughout with no enlargement of the subareolar tissue.
History may suggest a pathologic etiology that will be confirmed on laboratory testing. Medication and drug use questioning will show if the gynecomastia is pharmacologic in origin. Mammography and MRI will aid in determining if there is a malignant etiology causing the breast tissue enlargement. However, it is not standard for gynecomastia evaluation.
2018
Which of the following surgical options is most important for gynecomastia patients with significant glandular hypertrophy?
A) Areolar reduction
B) Excess skin removal
C) Lateral lipectomy
D) Subtotal glandular resection
E) Ultrasonic liposuction
The correct response is Option D.
In patients with a significant glandular component, it is important to do a subtotal glandular resection to prevent recurrence and provide the best chance at adequate contour. Ultrasonic liposuction has been used to attempt subtotal removal of gland tissue, but it does not reliably produce a subtotal resection. Areolar reduction is usually not necessary due to the contractile nature of the tissue. Skin resection may be necessary, most commonly in the massive weight loss patient, but does not necessarily play a role in the glandular component of the resection. Lateral suction lipectomy does not correct glandular hypertrophy.
2018
A 48-year-old man undergoes revision ventral hernia repair. Medical history includes poorly controlled type 1 diabetes mellitus and liver transplantation 3 years ago. The duration of the operation is 6 hours and the procedure is complicated by extensive lysis of adhesions. Three days postoperatively, the patient is noted to have decreased urine output and hypotension despite crystalloid and colloid fluid resuscitation. Intrinsic renal failure is suspected. On analysis of serum and urinary electrolytes, which of the following values is expected to be normal with intrinsic renal failure in this patient?
A) BUN:serum creatinine ratio
B) Fractional excretion of sodium (FENa)
C) Urinalysis
D) Urinary sodium concentration
E) Urine osmolality
The correct response is Option A.
Assessment of renal failure begins with a thorough history and physical examination as well as evaluation of key laboratory measurements including complete blood count, metabolic panel, coagulation profile, urinalysis, and urine electrolytes. Early signs of renal failure may include orthostatic hypotension, tachycardia, and dry mucous membranes on examination.
Renal failure may be divided into three categories: prerenal (causes include hypovolemia, cardiac failure, sepsis), renal/intrinsic (causes include disorders of the renal parenchyma, glomerular disease, acute tubular necrosis), and postrenal (causes included renal vein occlusion, urinary tract obstruction).
Assessment of serum and urinary electrolytes and a urinalysis aid with the identification of the cause of renal failure. In prerenal failure, the urinalysis is normal, the ratio of blood urea nitrogen (BUN) to serum creatinine is elevated above 20:1, the urinary sodium concentration is less than 20 mEq/L, urine osmolality is higher than 500 mOsmol/kg H2O, and the fractional excretion of sodium (FENa), which compares the differences of the sodium and creatinine in the plasma and urine, is less than 1%.
Intrinsic renal failure usually presents with a normal BUN and serum creatinine, urinary sodium concentration higher than 40 mEq/L, urine osmolality less than 350 mOsmol/kg H2O, and an abnormal urinalysis.
Postrenal failure typically has an elevated BUN to serum creatinine, a FENa greater than 1%, and a normal urinalysis.
2018
A 2-year-old boy with a history of omphalocele presents for correction of a 5-cm abdominal bulge with a 3-cm widened scar over the bulge. Which of the following is the most appropriate next step in management of the bulge?
A) Anterior component separation
B) Interposition acellular dermal matrix placement
C) Interposition prosthetic mesh placement
D) Tensor fascia lata flap
E) Tissue expander placement
The correct response is Option A.
For most patients with omphaloceles less than 5 cm in diameter, a single operation involving a traditional anterior component separation from costal margin to iliac crest is sufficient to reduce the omphalocele and reapproximate the rectus diastasis. Extended component separations are typically only needed when the omphalocele is large and accompanied by a diaphragmatic hernia. Once the abdominal wall defect extends past 5 cm in diameter, a staged procedure involving the placement of tissue expanders and subsequent flap advancement must be considered. Autologous tissue options, such as the tensor fascia lata flap, may be needed for larger defects that can not be managed with component separation. While prosthetic or biologic mesh placement is used to correct large abdominal wall defects, it is typically used only after autologous options have failed or are not available.
2017
The plastic surgeon is called to the neonatal unit to evaluate a newborn with a myelomeningocele. There is an intact 4 × 4-cm sac at the lumbosacral area with minimal fluid oozing from the area. Early operative repair is indicated for which of the following reasons?
A) To decrease the need for cerebrospinal fluid shunt placement
B) To decrease the need for folic acid supplementation
C) To improve motor function return
D) To prevent bacterial meningitis
E) To prevent cerebrospinal fluid leakage
The correct response is Option D.
The major indication to repair a myelomeningocele defect in the early postnatal period is to prevent infection and bacterial meningitis. Great care is taken to keep the sac sterile and hydrated. Further cardiac, orthopedic, and urologic workup is often necessary, as well as evaluation for hydrocephalus. Although improvement in the return of motor function with early repair has not been shown, neurogenic bladder prognosis is improved. Leakage of cerebrospinal fluid is commonly observed regardless of timing of closure. Although folic acid supplementation has been shown to decrease the neural tube defects and myelomeningocele formation, postnatal supplementation has not been shown to be effective.
Approaches to surgical therapy for the treatment of these defects have seen a shift toward prenatal, fetal reconstructive surgery. A recent study by Adzick et al. in the New England Journal of Medicine examined the use of prenatal surgery versus postnatal surgery. In this randomized trial, the authors found a decreased need for cerebrospinal fluid shunt placement and improved motor function outcomes.
2017
A 10-year-old boy is brought to the office because of the findings shown in the photograph. Which of the following is the most likely diagnosis?
A) Amniotic band syndrome
B) Axillary web syndrome
C) Poland syndrome
D) Popliteal pterygium syndrome
E) Waardenburg syndrome
The correct response is Option C.
The patient has Poland syndrome with an unusual axillary web. The defining clinical feature is underdevelopment or absence of the sternal head of the pectoralis major muscles (seen in the photograph), but the deformity can lead to other anomalies such as absence of the nipple, the areola, or portions of the anterior chest wall. Cardiac anomalies may also be present. The ipsilateral extremity and hand are often smaller or hypoplastic, and this finding can be subtle or pronounced. The fingers are typically shorter and smaller than the contralateral side, and there may be webbing between the fingers. In severe forms, the central fingers are mere vestiges.
The other choices do not fit with this clinical photograph. Amniotic band syndrome usually leads to amputation or severe constriction of the hand or digits; this is not seen here. Waardenburg syndrome is a genetic condition that causes hearing loss and pigmentation changes to the hair, skin, and eyes. Popliteal pterygium syndrome is a condition associated with cleft lip/palate, webs of the popliteal space, and syndactyly of the toes or fingers. The axillary web seen here is not a described feature. Axillary web syndrome, or cording, is an acquired web that usually follows axillary node dissection in the treatment of breast cancer. This does not fit the clinical scenario.
2017
An otherwise healthy 14-year-old boy is evaluated because of bilateral breast enlargement over the past 3 months. He is worried that his friends will notice. He reports no illicit drug use and takes no medications. Physical examination shows normal hair distribution for the patient’s age, no testicular masses, and firm discs of tissue under the areola of each breast. Which of the following is the most appropriate next step in treatment?
A) Direct excision in the subareolar area, leaving a small button of tissue, and marginal breast liposuction
B) Liposuction of entire breast with use of cutting cannula under the areola
C) Reassessment in 9 months
D) Testosterone replacement
E) Wise pattern skin excision with nipple grafting
The correct response is Option C.
The patient appears to have benign pubertal gynecomastia, and many of these cases resolve spontaneously. The recommended treatment is observation and reassessment. Early surgery in these circumstances is usually reserved for patients experiencing more extreme psychological impact. Testosterone replacement would not be useful since by examination the patient appears to have an otherwise normal physiology. The three surgical interventions are all potential treatments for gynecomastia, but surgery is usually not recommended within the first six months of onset of gynecomastia in a pubertal male. The skin excision and nipple grafting option would be most useful if the patient had large quantities of fat and skin. The two techniques employing liposuction both might be adequate surgical techniques to address the type of gynecomastia this patient demonstrates, should surgery eventually become recommended.
2017
A 50-year-old man with a BMI of 36 kg/m2 comes to the office for consultation regarding gynecomastia. He takes no medications. Physical examination shows no other abnormalities. Which of the following is the most likely cause of this patient’s gynecomastia?
A) Decreased circulating estrogen
B) Decreased estrogen receptors
C) Excessive androgen receptors
D) Excessive aromatization of androgen to estrogen
E) Increased circulating androgen
The correct response is Option D.
Gynecomastia is benign proliferation of breast tissue in men. It is present in 40 to 50% of men over 40 years of age. It can manifest in pubertal boys and in men of advanced years. The etiology can be variable and may be due to excess circulating estrogen, decreased circulating androgens, or a deficiency of androgen receptors. However, in middle-aged and older men, it is most commonly due to the excessive aromatization of androgens to estrogens. Initial evaluation requires a detailed history and physical examination to differentiate between fatty tissue, parenchymal enlargement, and a tumor. Mammography may be useful and biopsy may be indicated in some cases.
2017
A 65-year-old man is prescribed leuprolide acetate for prostate cancer. Which of the following is the most likely effect the drug will have on this patient’s breasts?
A) Darkening of the nipple-areola complex
B) Decrease in size
C) Galactorrhea
D) Mastodynia
E) Petechiae
The correct response is Option D.
Leuprolide acetate (Lupron) is used in the treatment of certain cancers, including prostate, endometriosis, and precocious puberty. Because it is a synthetic gonadotropin-releasing hormone (GnRH), it acts as an agonist of pituitary GnRH receptors. Its ultimate effect is a lowering of estradiol and testosterone levels through downregulation of luteinizing hormone and follicle-stimulating hormone secretion.
Gynecomastia and breast tenderness are known side effects of leuprolide treatment for prostate cancer. Selective estrogen receptor modulators (SERMs), such as tamoxifen, are recommended for the prevention of gynecomastia as a result of antiandrogen monotherapy. Radiation as well has been shown to decrease the breast side effects of leuprolide acetate. Thus, an increase in size, rather than a decrease in size is expected. Darkening of the nipple areolar complex is often associated with pregnancy, but not leuprolide acetate. Galactorrhea is associated with drugs—commonly drugs that contain dopamine depleting agents, such as methyldopa, that cause receptor bock (such as Reglan), and that inhibit release, such as codeine and morphine. Histamine receptor blockade, from drugs such as cimetidine, can also cause galactorrhea. Pituitary tumors are also a cause of galactorrhea.
A thorough assessment of all medications and medical history is necessary for evaluation of a patient with gynecomastia and mastodynia.
2017
In bilateral component separation for abdominal wall reconstruction, which of the following points is most likely to be the area of greatest advancement?
A) Arcuate line
B) Ligament of Treitz
C) Suprapubic
D) Umbilicus
E) Xyphoid
The correct response is Option D.
Component separation for abdominal wall reconstruction involves release of the fascia lateral to the rectus abdominus muscles, just lateral to the semilunar line, dissecting the external oblique off the internal oblique muscles. This creates innervated musculofascial flaps that can be advanced medially for closure of ventral hernias. If the posterior rectus sheath is also dissected free, further advancements can be gained. Per rectus muscle, approximately 4 cm can be gained at the epigastric and suprapubic areas; 10 cm can be advanced at the waist. Therefore, the most advancement can be gained at the umbilicus, which is in the area of the waist. The xyphoid and ligament of Treitz are in the epigastric area, while the arcuate line is in the suprapubic area.
2017
A 25-year-old man returns to the operating room for closure of the abdomen 2 weeks after undergoing small-bowel resection. The abdomen was left open after the resection and treated with abdominal negative pressure wound therapy. The bowel wall edema has improved, and the fascia and rectus muscles are 30 cm apart at the level of the umbilicus. There is no evidence of contamination. Abdominal wound closure is planned. There is adequate skin for primary closure. Which of the following methods is most appropriate for fascial closure?
A) Acellular dermal matrix and negative pressure wound therapy
B) Component separation and acellular dermal matrix interposition
C) Skin grafting and negative pressure wound therapy
D) Subcutaneous tissue expansion, staged closure of skin flaps
E) Submuscular tissue expansion, staged closure of fascial flaps
The correct response is Option B.
Abdominal wall reconstruction after severe trauma involves evaluation of the skin and fascia. First, the surgeon needs to determine if there is sufficient skin and subcutaneous tissue for primary closure. If there is insufficient skin, then tissue expanders, local tissue rearrangement, or distant flaps need to be considered. Second, if there is insufficient fascia, then component separation with primary fascial closure and mesh onlay or a mesh interposition are options for fascial closure. Since the fascial defect is 30 cm, it is unlikely that primary fascial closure can be achieved with component separation alone. An interposition of acellular dermal matrix is appropriate to bridge the fascial gap if primary fascial closure cannot be achieved.
2017
A 64-year-old man is brought to the emergency department after collapsing at home. Examination shows a ruptured abdominal aortic aneurysm and hemodynamic instability. The patient is taken to the operating room to undergo open repair of the aneurysm. Postoperatively, urine output decreases despite aggressive fluid resuscitation, and urinary bladder pressure is greater than 30 mmHg. Increased peak airway pressures are noted. Which of the following is the physiologic effect of increased intra-abdominal pressure in this patient?
A) Direct organ compression leads to decreased systemic afterload
B) Elevation of the diaphragm leads to decreased preload
C) Elevation of the diaphragm leads to increased flow in the inferior vena cava
D) Vascular compression leads to increased flow in the inferior vena cava
E) Vascular compression leads to decreased renal vascular resistance
The correct response is Option B.
Abdominal compartment syndrome (ACS) may develop rapidly after an increase in intra-abdominal pressure. Chronic causes of elevated intra-abdominal pressure (such as central obesity or large abdominal tumors) may be compensated for, but acute elevations as a result of trauma, bleeding, burn, or abdominal surgery may lead to life-threatening failure of multiple organ systems.
Three mechanisms present in ACS lead to multiple organ failure: vascular compression, elevation of the diaphragm, and direct organ compression. These three forces and their interactions create a constellation of physiologic effects that lead to the circulatory collapse at the center of ACS. Vascular compression results in decreased flow to the inferior vena cava and an increase in renal vascular resistance. Diaphragmatic elevation results in decreased flow to the inferior vena cava and an increase in intrathoracic pressure and decreased cardiac pre-load. Direct organ compression leads to an increase in systemic afterload. Left untreated, these forces eventually lead to renal failure, respiratory failure, intracranial hypertension, and intestinal and hepatic ischemia.
2017
An 83-year-old woman comes to the office for repair of a deep sternal wound infection after undergoing open single-vessel coronary artery bypass grafting using the left inferior mammary artery. Medical history includes cancer of the left breast for which she underwent wide excision with oncoplastic reconstruction followed by adjuvant radiation therapy to the breast and axilla. She does not smoke cigarettes. The patient’s infection resolves with aggressive debridement and culture-guided antibiotics. A photograph is shown. Which of the following is the most appropriate reconstructive option?
A) Left pectoralis turnover flap coverage with skin graft resurfacing
B) Left vertical rectus abdominis musculocutaneous flap coverage
C) Right latissimus dorsi musculocutaneous flap coverage
D) Right pectoralis advancement flap with skin readvancement closure
E) Right vertical rectus abdominis musculocutaneous flap coverage
The correct response is Option E.
Deep sternal wound infections represent life-threatening infections whose most frequent etiology in contemporary cases is surgical site infection following open heart surgery, with a reported incidence of 0.2 to 3% of patients undergoing median sternotomy. Risk factors in adults include diabetes mellitus, obesity, peripheral arterial disease, tobacco use, reoperation, and other surgical complications such as prolonged operative time and postoperative bleeding. Published mortality rates range from 8.1 to 14.8%. Once a diagnosis is made, initial treatment in cases of deep infection typically involve a combination of antimicrobial therapy and staged surgical debridement followed by delayed closure.
Sternotomy wounds can be complex problems because of their proximity to heart and lungs and exposure of these vital organs following debridement. Principles of reconstruction once a healthy wound bed has been obtained include durable coverage of vital structures with obliteration of dead space with a view to retaining or restoring optimal form and function.
In the case scenario described, a right superiorly based rectus abdominis myocutaneous flap provides the most reliable, well vascularized and non-irradiated option for regional soft tissue reconstruction of the composite chest wall defect (shown). A left vertical rectus abdominis myocutaneous flap is suboptimal in the setting of a relatively compromised superior epigastric vascular pedicle in the setting of known sacrifice of its parent left internal mammary artery (IMA). Latissimus and pectoralis flaps in any form are less reliable in their ability to fully cover inferior third sternectomy defects. While a turnover pectoralis flap can reach the inferior sternum, a left pectoralis turnover flap is furthermore less reliable in the setting of known sacrifice of its inferior segmental internal mammary perforators in the setting of known IMA sacrifice. Skin re-advancement in the setting of prior radiation and distorted perfusion from prior reduction mammoplasty also invites further unnecessary risk.
2017
A 55-year-old man who underwent abdominal surgery 10 years ago undergoes lysis of adhesions for treatment of ongoing intermittent bowel obstruction symptoms. He does not smoke cigarettes and has a history of hypertension and diabetes mellitus. A single enterotomy is made and repaired primarily. During abdominal wall closure after the intra-abdominal procedure, the fascial edges cannot be approximated without marked tension with a relaxed defect diameter maximum of 7 cm. Which of the following is the best method of repair?
A) Bioprosthetic mesh bridging
B) Component separation and bioprosthetic mesh underlay
C) Component separation and synthetic mesh underlay
D) Component separation with no mesh
E) Synthetic mesh bridging
The correct response is Option B.
Given the size of the defect, the patient’s comorbidities, and bowel violation, the best method to optimize results is a component separation with a bioprosthetic mesh underlay.
The use of bridging mesh without approximation of the fascia is not recommended due to a high recurrence rate. Instead the Ventral Hernia Working Group (VHWG) recommends reapproximation of the rectus muscle at the midline whenever possible without undue tension. This can be done by using the component separation technique originally described by Ramirez. The procedure calls for a release of the external oblique aponeurosis 1 cm lateral to the linea semilunaris, which allows for medialization of the rectus abdominis and underlying lateral musculature for primary approximation.
Given the enterotomy, a bioprosthetic mesh would be recommended as opposed to a synthetic mesh, because it is likely more resistant to infection and does not necessarily need removal in a contaminated wound. It is the VHWG’s preferred method to place mesh in an underlay manner, because intra-abdominal pressure pushes the mesh against the native abdominal wall instead of away from it. It also adds another layer of tissue over the prostatic material and would be preferred with a bioprosthetic because of decreased risk for bowel adhesions.
Additionally, lower rates of hernia recurrence have been shown in patients who underwent component separation with mesh as opposed to those without.
2016
A) Advancement of the vertical rectus abdominis musculocutaneous flaps
B) Release and advancement of the external oblique muscles
C) Release and advancement of the rectus, internal oblique, and transversus abdominis muscles
D) Rotation of the anteriolateral thigh flaps
E) Rotation of the transverse rectus abdominis myocutaneous flaps
The correct response is Option C.
A component separation procedure allows for the primary closure of central abdominal wall musculofascial defects without excessive tension. In the classically described procedure, the external oblique aponeurosis is released lateral to the linea semilunaris, allowing for medial advancement of the rectus abdominis along with the internal oblique and transversus muscles. The innervation and vasculature to these structures are preserved in order to maintain functional integrity of these abdominal wall muscles.
The vertical and transverse rectus abdominus musculocutaneous flaps along with the anterolateral thigh flaps are primarily used to reconstruct soft-tissue defects but are unlikely to result in a functional abdominal wall.
2016
A 66-year-old man with a history of adenocarcinoma of the lung undergoes a left pneumonectomy using a posterolateral thoracotomy incision. Postoperatively, he receives radiation therapy. The patient subsequently develops a nonhealing ulcer of the chest wall measuring 5 × 6 cm in the region of the nipple-areola complex. Which of the following is the most appropriate option for reconstruction?
A) Negative pressure wound therapy
B) Pedicled intercostal muscle flap and a split-thickness skin graft
C) Pedicled latissimus dorsi musculocutaneous flap
D) Pedicled vertical rectus abdominis musculocutaneous flap
E) Split-thickness skin graft only
The correct response is Option D.
Tissue injury from radiation results in irreversible damage that limits the ability of wounds to heal with skin grafts or by secondary intention, such as using negative pressure wound therapy. Tissues within the field of radiation are also generally affected, which would limit use of an intercostal muscle flap. Although a latissimus dorsi musculocutaneous flap would provide an adequate amount of tissue from outside of the field of radiation, it would be unreliable in the setting of prior posterolateral thoracotomy, unless there is documentation that the latissimus was spared. A vertical rectus abdominis musculocutaneous flap would provide sufficient tissue from outside of the field of radiation and would not have been affected by the patient’s prior surgery.
2016
A 24-year-old man is evaluated because of a 15-month history of painful idiopathic gynecomastia. Which of the following is the most appropriate treatment?
A) Anastrozole
B) Radiation therapy
C) Spironolactone
D) Surgical resection
E) Tamoxifen
The correct response is Option D.
Adult gynecomastia occurs because of drugs, unresolved pubertal gynecomastia, and unknown causes (idiopathic gynecomastia). Tamoxifen and raloxifene, both selective estrogen receptor modulators (SERMs), can be used for the treatment of male gynecomastia. Indeed, the use of SERMs is recommended to prevent gynecomastia as a result of antiandrogen monotherapy for treatment of prostate cancer. They are most effective, however, when used to treat gynecomastia that has been present for less than 1 year. Anastrozole, an aromatase inhibitor, is recommended for the treatment of breast cancer and as a preventative measure in high-risk women.
Surgical resection is the appropriate treatment for painful gynecomastia that has been present for greater than 1 year. Both open resection and liposuction are appropriate techniques.
Radiation therapy is indicated to prevent gynecomastia as a result of prostate cancer treatment.
Spironolactone is a cause of—not a treatment for—gynecomastia.
2016
An otherwise healthy 25-year-old man comes to the office with concerns about recent enlargement of his breasts. BMI is 28 kg/m2 and has not changed during the past year. He does not take any prescription or illicit drugs. He has no nipple discharge. Examination of which of the following is most appropriate?
A) Cervical lymph nodes
B) Cranial nerves
C) Peripheral pulses
D) Prostate
E) Scrotum and testes
The correct response is Option E.
The patient described is likely to have gynecomastia, which can occur in up to 30% of men. In the younger, postpubertal patients, testicular cancer may be a cause. Examination of the scrotum and testes to rule out any testicular masses has to be included in the physical examination and documented. Measurement of beta-human chorionic gonadotropin concentration can also be effective.
The other examinations listed do not directly contribute to the assessment of gynecomastia.
2016
Which of the following is the most appropriate term for the amount of air that is inspired and expired with a single breath during normal resting respiration?
A) Dead-space volume
B) Functional capacity
C) Residual volume
D) Tidal volume
E) Vital capacity
The correct response is Option D.
Tidal volume (VT) is the volume of air that is moved into or out of the lungs during quiet breathing. Tidal volume can be measured directly through spirometry or estimated based on a patient’s ideal body mass. It is a key parameter in mechanical ventilation to allow adequate ventilation without causing barotrauma to the lungs.
Vital capacity (VC) is the volume of air expired after deepest inspiration.
Functional capacity is a physiologic description of an individual’s ability to complete activities of daily living. It can be estimated through exercise treadmill testing and reported in metabolic equivalents (METs).
Residual volume (RV) is the volume of air remaining in the lungs after maximal exhalation.
Dead-space volume is the volume of air inhaled that does not take part in gas exchange. This volume can include both gas that remains in conducting airways (e.g., trachea, bronchi) during respiration and gas that reaches nonfunctional alveoli (e.g., nonperfused lung parenchyma following pulmonary embolism).
2016
A 27-year-old woman is evaluated for a recurrent abdominal desmoid tumor. CT scan shows a mass that occupies the full-thickness right musculofascial abdominal wall, involving the rectus abdominis muscle and oblique muscles, including lateral to the semilunar line. Resection is performed. Photographs of the defect are shown. Which of the following is the most appropriate management?
A) Bilateral component separation, primary skin closure with incisional topical negative pressure wound therapy, adjuvant chemotherapy
B) Left component separation, bridging wide intraperitoneal underlay biologic mesh, primary closure skin
C) Pedicled right anterolateral thigh flap with rectus femoris, no mesh
D) Placement of a bridging inlay of biologic mesh with primary split-thickness skin grafting and negative pressure wound therapy
E) Placement of a bridging inlay of uncoated heavyweight polypropylene mesh with adjuvant radiation therapy
The correct response is Option B.
The lesion in this patient is a recurrent desmoid tumor, also known as aggressive fibromatosis. It is a benign tumor, usually found in younger patients between 10 and 40 years of age, and is locally aggressive. It is often associated with pregnancy and previous surgery and can frequently recur. Management is en bloc, full-thickness, wide local excision (usually with frozen section confirmation of negative margins). An aggressive full-thickness abdominal wall resection is standard of care, making reconstruction more challenging.
The more durable and functional reconstruction entails complete restoration of the abdominal wall, especially musculofascial components, in a primary reapproximation. However, depending on the size of the tumor and resultant defect, this may not be possible. Basic principles, after obtaining proper margins after resection of the tumor, would then be reduction in defect size to the maximal extent possible and wide bridging underlay of mesh with at least 4- to 5-cm margins in all directions. Bridging inlay, whereby a mesh is simply sewn to the margins of the defect, has clearly been shown to be inferior in terms of recurrence rates.
Mesh choice can be either synthetic or biologic, although if significant contamination exists, if soft-tissue coverage is tenuous, or if one desires to decrease the amount of adhesion formation when placing mesh directly against the bowel, one should consider placement of biologic mesh, accepting the fact that there is a higher incidence of postoperative bulges using these materials, by and large.
In this case, only a left component separation is possible, given that the tumor has invaded the right rectus muscle and obliques, precluding their use for myofascial advancement.
There is no role for chemotherapy or radiation therapy in the treatment of these tumors.
Coverage with a right anterolateral thigh flap, with or without rectus femoris, can reconstruct the soft-tissue defect, but avoiding the use of mesh in a defect over 4 cm has a significantly higher chance of a recurrent hernia and would not be standard of care.
Primary skin grafting on top of a nonvascularized thick piece of acellular dermal matrix will not “take,” even with use of negative pressure wound therapy.
2015
(Please note that this pictorial appears in color in the online examination)
A 57-year-old woman undergoes resection of a squamous cell carcinoma of the vagina, resulting in a defect of the posterior two thirds of the vaginal vault from the introitus to the dome. A small portion of the rectum is involved in the resection and primarily repaired. The patient has a history of pelvic radiation therapy and tobacco use. Which of the following is the most appropriate approach for closure of this defect?
A) Bilateral gracilis muscle flaps
B) Deep inferior epigastric artery perforator flap
C) Primary repair of the vaginectomy defect
D) Split-thickness skin grafting with obturator
E) Vertical rectus abdominis musculocutaneous flap
The correct response is Option E.
In the clinical scenario described, the vertical rectus abdominis musculocutaneous (VRAM) flap is the most appropriate choice. This approach can provide enough tissue to resurface the vaginal vault and fill dead space.
For posterior defects of the vaginal vault, abdominal-based flaps are usually preferable. They can provide a large amount of vascularized tissue that rotates easily into the defect. Bilateral gracilis muscle flaps alone would offer less soft tissue, and mucosalization in a radiated field is unpredictable. A deep inferior epigastric artery perforator flap is far more complicated than a VRAM flap, and the donor site is problematic in patients with a history of smoking.
Primary closure of a large vaginal defect would likely cause significant stenosis and poor healing because of previous radiation. A skin graft with obturator is not likely to be successful given her radiation and tobacco history and violation of the rectum.
2015
A 62-year-old woman presents with a new-onset draining sinus of the left thoracic cage with associated indurated skin. Medical history includes bilateral breast cancer that was managed with bilateral radical mastectomy with radiation therapy 27 years ago. On CT scan, the image (shown) is consistent with osteoradionecrosis. Resection of affected skin, soft tissue, and thoracic cage produces a 35 × 20-cm soft-tissue defect and a skeletal defect spanning five ribs. A photograph of the defect is shown. The thoracic cage is fibrotic and noncompliant because of previous radiation. Which of the following approaches is most appropriate for reconstruction?
A) Free omental flap with skin graft over titanium mesh and reconstruction plates
B) Left latissimus dorsi muscle flap with skin graft over acellular dermal matrix
C) Left rectus abdominis turnover flap with skin graft over methyl methacrylate sandwich
D) Reverse abdominoplasty advancement over ePTFE patch
E) Right pectoralis muscle turnover flap over polypropylene mesh
The correct response is Option B.
(Please note that this pictorial appears in color in the online examination)
The most appropriate option for this patient is a left latissimus dorsi muscle flap with skin graft over acellular dermal matrix, given the alternatives listed. Basic principles of thoracic reconstruction include: debridement of devitalized tissue, removal of foreign bodies, establishment of healthy wound bed, restoration of stability/structure (generally reconstruction of skeleton if more than four ribs or a greater than 5-cm-diameter defect is involved), restoration of normal respiratory mechanics, protection of vital structures/organs, obliteration of dead space, provision of durable coverage, and delivery of an aesthetic result. However, if a patient has been previously irradiated, and therefore loses compliance of the thoracic cage because of radiation-induced fibrosis, skeletal reconstruction may not be mandatory if there is no paradoxical motion of the thoracic cage upon respirations and there is preservation of respiratory efficiency. Such is the case with this patient.
A left rectus turnover flap would not be a good option for two reasons: 1) as can be seen in the image, the left internal mammary artery has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based, and 2) it is insufficient to provide enough soft-tissue coverage of a defect this size. Furthermore, as indicated above, methyl methacrylate would not be mandatory in this patient.
A right pectoralis turnover flap is insufficient to cover a defect this size.
A free omental flap can be used to reconstruct this defect (as can a pedicled omental flap), but again, thoracic skeletal reconstruction would not be mandatory in this previously irradiated patient; furthermore, even if it were, titanium mesh and reconstruction plates would not be utilized.
A reverse abdominoplasty flap (Ryan procedure) would not be able to cover a defect this size.
A 56-year-old man is evaluated for a ventral hernia after undergoing midline laparotomy for diverticulitis. BMI is 38 kg/m2. Physical examination shows midline fascial defect measuring 20 × 15 cm; there is no evidence of infection and skin coverage is stable. Repair with rectus advancement and polypropylene mesh is planned. Placement of mesh between which of the following planes is most likely to decrease this patient’s risk of hernia recurrence?
A) Anterior rectus sheath and rectus muscle
B) Internal and external oblique muscles
C) Medial edges of rectus muscle
D) Rectus muscle and posterior sheath
E) Skin and anterior rectus sheath
The correct response is Option D.
Although recurrence rates are generally very high for large ventral hernias, placement of mesh in the retrorectal position appears to have the most decreased rate of recurrence compared with other methods. Placement above the plane of the rectus muscle requires division of vascular perforators that traverse the rectus muscle and perfuse the overlying skin flaps. These perforating branches of the epigastric circulation are most dense in the periumbilical zone. Preservation of the perforators has been shown to be beneficial in a number of case series reports. Placement of mesh between the oblique muscles in this case would not provide support for the midline hernia because these muscles are more lateral.
Hernia recurrence rates are generally more increased in the presence of infection, with large defects when the rectus muscles cannot be advanced back together in the midline, in obese patients, and in patients with multiple medical comorbidities. Patients with several risk factors can expect recurrence rates in the range of 20 to 40%, whereas patients with few risk factors have recurrence about 5% of the time.
2015
A 60-year-old man undergoes sigmoid resection and colostomy for management of ruptured diverticulitis. The patient has smoked one pack of cigarettes daily for the past 35 years. BMI is 36 kg/m2. After colostomy reversal, he has an abdominal wound infection and fascial dehiscence. Reconstruction with a bridging human acellular dermal matrix is planned. Compared with traditional polypropylene mesh repair, which of the following complications is more likely with the planned approach?
A) Abdominal bulge
B) Fistula
C) Hematoma
D) Infection
E) Skin necrosis
The correct response is Option A.
Acellular dermal matrices (ADM) have been advocated for the past decade as an important adjunct in the complex field of abdominal wall reconstruction. Many studies have verified the use and general safety of ADM in abdominal wall reconstruction, but conclusive evidence of its advantages over other techniques is still lacking. What can be inferred is its advantage over prosthetic mesh in contaminated fields. Polypropylene mesh would be contraindicated in the infected wound in this example. After adequate debridement and appropriate antibiotics in an optimized patient, ADM can be used for hernia repair or reconstruction along with component separation. Postoperative infections can be as common as 40%, but conservative management measures often suffice, rather than reoperation and graft explantation, which are required with prosthetic mesh.
One recognized drawback in the stretchable nature of dermal matrix grafts is that they can often stretch under tension to 50% or more of their initial dimensions. Postoperative bulging without true herniation is common. Strategies for prevention include suturing the graft under maximal stretch and use of porcine dermal grafts rather than human grafts.
Hernia recurrence in the complex abdominal wall reconstruction remains a common event, regardless of technique. Although some studies assert a strong advantage with ADM, others report a similar or increased recurrence rate. As successful operative techniques become more standardized, perhaps more uniform success will be demonstrated in future studies.
Skin necrosis and hematoma are common surgical complications that should not vary between choice of graft material.
Fistula rates are decreased with ADM versus prosthetic mesh reconstruction.
2015
A 40-year-old man undergoes ventral hernia repair with biologic mesh and fascial closure at the midline. A bilateral component separation technique with incision of the external oblique fascia and muscle lateral to the linea semilunaris and dissection in the plane between the external and internal oblique muscles, and separation of the rectus muscle off of the posterior rectus fascia is performed. At which of the following levels can the least amount of advancement of the medial fascial edges be expected?
A) Midway between the umbilicus and pubis
B) Midway between the umbilicus and subcostal margin
C) Subcostal margin
D) Suprapubic
E) Umbilicus
The correct response is Option C.
The component separation technique can be used to achieve medial transposition of the rectus muscle and overlying anterior fascia. The surgery involves division of the external oblique fascia and muscle lateral and parallel to the linea semilunaris. The plane deep to the external oblique muscle, which is relatively avascular, is then dissected laterally. The rectus muscle is also separated off of the posterior rectus sheath (using access from the medial laparotomy or hernia incision). This allows for medial advancement of the rectus muscle, overlying anterior rectus sheath, internal oblique muscle, and transversus muscle as a unit. The segmental neurovascular bundles course deep to the internal oblique muscle and penetrate into the rectus muscle 10 to 25 mm medial to its lateral margin.
The component separation technique, when performed in the scenario described, can give unilateral advancement toward the midline approximately 10 cm at the level of the umbilicus, which equates to a bilateral advancement of 20 cm. The least amount of advancement is in the subxiphoid and subcostal regions, often making more cranially located defects more difficult to close. Since it was originally reported in 1990, several modifications and variations of this technique have been described in the literature. These include perforator-preserving and/or endoscopic techniques to methods that describe additional maneuvers to increase mobilization or improve durability with the addition of biologic or prosthetic meshes.
2015
A 29-year-old woman comes to the office because of a firm, mildly tender, well-circumscribed mass of the abdomen. A photograph is shown. The mass has been slowly increasing in size for the past 6 months. CT scan shows a mass that occupies the left musculofascial abdominal wall, including the rectus, external, and internal oblique muscles, and penetrates through the anterior rectus sheath. Which of the following is the most appropriate management?
A) Neoadjuvant chemotherapy
B) Radiation therapy
C) Wide local excision, bilateral component separation, adjuvant chemotherapy
D) Wide local excision, mesh placement, radiation therapy
E) Wide local excision, right component separation, mesh reinforcement
The correct response is Option E.
The lesion in this patient is a desmoid tumor, also known as aggressive fibromatosis. It is a benign tumor, usually found in younger patients between 10 and 40 years old, and is locally aggressive. It is oftentimes associated with pregnancy and prior surgery, and can frequently recur. Treatment is en bloc full-thickness wide local excision (usually with frozen section confirmation of negative margins). As aggressive full-thickness abdominal wall resection is standard of care, reconstruction is more challenging.
If midline fascia can be reapproximated, it should be, as primary fascial closure is associated with the lowest hernia recurrence rates. Reinforcement with mesh has been prospectively demonstrated to reduce recurrence rates even further, especially in defects over 4 cm. If midline fascial reapproximation is not possible, reduction in the size of the defect is crucial to decrease recurrence rates. This is done by component separation. However, in this case, only a right component separation is possible, given that the tumor has invaded the left rectus muscle and obliques, precluding their use for myofascial advancement. If the obliques had been spared, a component separation could still have been attempted even if there were violation of the rectus. The most durable reconstruction would be achieved if midline fascial reapproximation were possible with mesh reinforcement. Second best would be reduction in the size of the defect with a right component separation and placement of mesh as a bridging underlay.
There is no role for neoadjuvant chemotherapy or radiation therapy in the treatment of these tumors.
2014
A 75-year-old woman with a history of right mastectomy and irradiation therapy presents with a sarcoma that requires radical resection and partial sternectomy. A photograph is shown. A pedicled flap is planned to repair the defect. Which of the following arteries supplies the most appropriate flap in this situation?
A) Deep inferior epigastric
B) Internal mammary
C) Lateral thoracic
D) Thoracoacromial
E) Thoracodorsal
The correct response is Option E.
The most appropriate pedicled flap for this particular defect is a latissimus flap, shown in the photograph, supplied by the thoracodorsal artery. The latissimus flap is a Mathes/Nahai type V flap that can be transferred on its dominant pedicle (thoracodorsal artery) or on multiple segmental paraspinal perforators. The internal mammary artery terminates as the superior epigastric artery, which would provide blood supply for a superiorly based vertical rectus flap. The rectus flap is a Mathes/Nahai type III flap, with two dominant pedicles. However, this pedicle is not available because of the radical resection and prior irradiation. The lateral thoracic artery is one of two dominant pedicles supplying the serratus anterior muscle (Mathes/Nahai type III). This flap is an option, but it would not provide enough bulk necessary for the defect in this situation. The deep inferior epigastric artery (DIEA) supplies the DIEA perforator flap, which would be an option as a free tissue transfer but not as a pedicle flap for this situation.
A 52-year-old woman with cancer of the right breast undergoes mastectomy and axillary node dissection, complicated by mastectomy flap necrosis requiring skin grafting. She completes adjuvant chemoradiation. One year later, she comes to the office with a fungating mass growing through the skin graft. Imaging demonstrates involvement of the fourth and fifth ribs with an anticipated skeletal defect of 4 × 4 cm. A photograph is shown. Which of the following is the most appropriate treatment for the skeletal reconstruction?
A) High-density porous polyethylene
B) Methyl methacrylate with mesh
C) 2.4-mm Titanium plate
D) No skeletal reconstruction
E) Vascularized rib
The correct response is Option D.
The principles of management of this recurrent right breast cancer include radical resection of all involved tissues (including ribs) and reconstruction with well vascularized flaps. In this case, a right latissimus muscle flap and skin graft was used for reconstruction. No alloplastic material was placed or skeletal thoracic cage reconstruction performed. This is common in these types of patients, because excessive fibrosis caused by the radiation to the chest wall prevents loss of respiratory efficiency through paradoxical motion which otherwise occurs in patients who have more than four ribs involved or a defect larger than 5 cm.
2019
The postoperative CT scan shown is obtained to evaluate a wound dehiscence in a patient who underwent left-sided unilateral reduction mammaplasty for asymmetry six weeks ago. Which of the following upper extremity deformities is most likely to be found in this patient?
A) Contralateral radial club hand
B) Contralateral “pouce flottant” thumb
C) Ipsilateral brachysyndactyly
D) Ipsilateral radial head subluxation
E) Ipsilateral type IV Wassel preaxial polydactyly
The correct response is Option C.
Assessment of the chest CT shows right-sided absence of the pectoralis major and minor muscles and breast hypoplasia. The patient suffers from Poland syndrome, which is a congenital disorder of unknown etiology with the prevailing theory being hypoplasia of the subclavian artery or its branches during the sixth week of embryogenesis. Variability exists in physical findings with the most common being: anterior axillary fold and pectoralis major sternal head absence, breast gland thinning, rib and cartilage hypoplasia, and ipsilateral brachysyndactyly. After local wound care and antibiotic therapy, the patient had resolution of her symptoms.
A type IV Wassel preaxial polydactyly is the most common congenital thumb duplication but is not associated with Poland syndrome. Radial club hand is more common than ulnar club hand, but has no association with Poland syndrome. Both are congenital hand deformities, but unrelated to the pathological condition mentioned. Radial head subluxation is also known as “nursemaid’s elbow.” Nursemaid’s elbow is a common injury of early childhood. It is sometimes referred to as “pulled elbow” because it occurs when a child’s elbow is pulled and partially dislocates. There is no connection between Poland syndrome and increased incidence of radial head subluxation. Type IV Manske modification of the Blauth classification thumbs (the “pouce flottant” thumb) have rudimentary elements and are attached to the hand by a small skin bridge. These thumb anomalies are not associated with Poland syndrome.
2019
A 44-year-old woman comes to the clinic because of chronic intermittent infection, pain, and drainage of the right axilla. History is significant for obesity, type 2 diabetes, and smoking, as well as multiple courses of antibiotic therapy and abscess drainage. A photograph is shown. Which of the following skin appendages is most likely involved in the disease process in the photograph?
A) Apocrine glands
B) Eccrine glands
C) Hair follicles
D) Sebaceous glands
E) Stratum spinosum
The correct response is Option A.
This patient has hidradenitis suppurativa, which is an inflammatory disease that arises in the apocrine glands. Apocrine sweat glands are primarily located in the axilla, perineum, groin, and inframammary region. These glands produce a viscid, lipid-rich, milky fluid that functions primarily as a pheromone and produces body odor. Occlusion of the glands results in inflammation and subcutaneous abscess formation with resultant odor, pain, and drainage. Early disease is typically treated with antibiotic therapy, local and systemic steroids, antiandrogen therapy, and botulinum toxin injections. More severe cases may benefit from tumor necrosis factor alpha inhibitors, such as infliximab or etanercept. Surgical treatment is common and may range from simple drainage of the abscess to wide excision with skin graft or flap reconstruction.
Eccrine glands are found throughout the body and are responsible for thermoregulation by secretion of a thin, clear, hypotonic fluid during sweating. There is some recent data that suggests hair follicle occlusion and folliculitis may lead to apocrine occlusion; however, hair follicles are found throughout the body without evidence of clinical hidradenitis in those locations. Sebaceous glands are found throughout the skin except for the palms and soles and produce sebum, which is an oily substance that lubricates skin and hair follicles. These glands are particularly abundant in the head and neck region. The stratum spinosum is a layer of the epidermis located between the stratum granulosum and stratum basale.
2023
