Proc Prep Flashcards

Question

Wart treatments that can be used in pregnancy

Answer 1

TCA (avoid all other topicals) Cryo C+C Surgical excision

Answer 2

Imiquimod 5-FU TCA Podophyllotoxin Cryotherapy Shave C+C

Answer 3

Sal acid Cryo DCP Acitretin Cidofovir IL candida

Answer 4

Inhibits the enzyme dihydrofolate reductase

Answer 5

Pain Bleed Infection Ulcer Necrosis Scar Allergy Cytopaenias Nausea, vomiting, diarrhoea (systemic toxicity) Incomplete response/recurrence

Answer 6

Ensure appropriate indication (biopsy) Ensure no contraindications (allergy, pregnancy lactation, renal failure) Bloods prior (FBE, UEC, LFTs) Consent Skin prep Field block with LA 0.3-2 ml of 25mg/ml MTX intralesionally Inject each quadrant until blanches Final injection in middle of lesions Repeat in 2 weeks Check FBE and UEC at 1 week Simple wound care and dressing Expected response - Involution of tumour Review in 1/12 to ensure involution and exclude recurrence

Answer 7

1-6mg/ml Subjective toxicity Lightheadedness, euphoria, tongue and circumoral paraesthesia, tinnitus, blurred vision 5-9mg/ml Objective toxicity Vomiting, tremors, muscular fasciculations 8-12mg/ml Seizures, cardiopulmonary depression 12-20mg/ml Coma, respiratory and cardiac arrest

Answer 8

Stop injection DRSABC Assess patient, signs/symptoms and baseline obs Oxygen, maintain ventilation Monitor HR, BP Call ambulance Provide reassurance IV access Seizure management - diazepam Hypotension management - fluids Transfer to acute facility ABGs, UECs, MetHb Serial ECGs IV lipid emulsion (intralipid 20%) in severe cardiovascular toxicity or cardiac arrest Methylene blue for methaemoglobinaemia To avoid: Clearly document amount of local anaesthetic used in mls, type and % Staff to verbalise amount used Prior to procedure calculate maximum safe amount for the patient, ensure all staff are aware of this amount (4-5mg/kg) Be aware of drug interactions, liver disease, CCF

Answer 9

Skin Subcutaneous Aponeurosis (galea) Loose connective tissue Pericranium

Answer 10

Side-to-side - ellipse oriented perpendicular to direction of greatest skin laxity (often anterior to posterior) Second intention Advancement flaps Unilateral and bilateral - moreso for frontal scalp - tripolar - bipedicle/bridge - purse-string closure Rotation flaps - single and double - pinwheel Transposition (maybe less common) - rhombic - bilobed Island pedicle - myocutaneous (more for frontal scalp) Burow's FTSG STSG

Answer 11

Wide undermining Relaxing galeotomies Pulley suture Burow's graft Second intention healing

Answer 12

As for regular side-to-side closure, excise standing cones Undermine widely with special emphasis towards area of laxity Close as much as possible with absorbable sutures Draw parallel line on side where most laxity (great variation in length of line and distance from defect 3-20cm Incise down to subgalea and undermine widely around it in subgaleal plane, create a tunnel under the bridge between primary and secondary defects Can make third parallel incision on other side if needed Close with buried absorbable sutures and then superficial sutures

Answer 13

Flap area at least 3 times primary defect area in general, on scalp can be handy to have the flap area even 4-5 times High take-off Arc in direction perpendicular to maximum scalp laxity Burow's triangle or backcut at point of pivotal restraint (not too much to avoid compromising vascular supply) Need to undermine at that area of pivotal restraint Cut defect into an ellipse Second rotation flap from the opposite side of the defect to produce an O to Z closure Other design feature: key suture to create two equal tension defects (close by rule of halves

Answer 14

Side-to-side closure or flap repair if able If too large for that: STSG might take if there is some healing of periosteum, but might not (not guaranteed good outcome) Take a galeal/periostial flap from under the surrounding scalp and suture that over the exposed bone, allowing a graft to be placed over a viable bed Second intention healing Flap repair combined with split graft to secondary defect

Answer 15

Measure defect size Select donor site (usually anterior or lateral thigh) Outline graft on donor site, oversize by 10% Graft harvest options: - Weck knife - Zimmer dermatome Dressing to donor site - absorbant, non-stick, and encourages epidermal regrowth e.g. mepilex Changed 1 week post op or as necessary Place STSG on wound Can place small nicks through graft to prevent any collection Bolster (xeroform or petrolatum gauze) with tie-over silk sutures Alternatives: layered foam dressing e.g. Allevyn secured with staples Or bolster secured with water-repellant adhesive stretchy dressing Hypafix Or chlorsig/bactroban ointment, tefla non-stick dressing, with saline soaked cotton balls over top with tie over dressing, telfa over top followed by gauze (taped on) and crepe bandage

Answer 16

Advantages Suitable for large deep defects Quicker healing than second intention Disadvantages Often leaves poor cosmetic result, depressed and shiny appearance, patch of alopecia, bound down, fragile Needs periosteum present for survival

Answer 17

Advantages Can close medium to large defects Does not leave significant patch of alopecia Ideal for rounded surfaces like the scalp Disadvantages Changed direction of hair growth Large flap requiring extensive undermining in a very vascular area

Answer 18

Advantages Minimal to no change in hair arrangement Redistributes tension equally over 3 areas Can close small to medium defects Disadvantages Multiple scarlines

Answer 19

Advantages Can leave cosemtically pleasing scar in bald scalp Can combine with side-to-side closure and flap repair Scars 30% smaller than original defect Disadvantages Patch of cicatricial alopecia if hair-bearing area Daily wound care 4-6 weeks

Answer 20

Long uninterrupted consult Apologise Allow patient to express concerns and actively listen Acknowledge concerns Answer questions Bulk bill MDO Second opinion Discuss with mentor/senior colleague Documentation Photos Manage expectations +/- MDM Review practices

Answer 21

Topicals and adjuncts: Silicone Gel or dressings Lorsartan (angiotensin II receptor antagonist) Enalapril (ACEi) Pressure garments Massage Potent TCS Intralesional: Increasing triamcinolone to 40mg/ml IL 5-FU injections +/- ILKA Cryotherapy + ILKA Intralesional bleomycin Intralesional interferon IL-MTX Physical: PDL/vascular Fractionated CO2 ErYAG Cryotherapy Non ablative fractional resurfacing Rtx Surgical: Excision

Answer 22

Silicone Imiquimod (prevention, not existing) ILCS Scar massage Taping Compression Botox Laser therapy Radiotherapy

Answer 23

Pre-treatment: Support person present Pre-medicate with benzodiazepines EMLA cream Paracetamol Position patient Reassurance Local anaesthetic first given via a circumferential block Warming the solution Cryotherapy prior Mixed local anaesthetic with the intralesional injectables During treatment: Distraction – talking, nurse holding hands, visualisation, mediation, wiggle toes Relaxing environment – playing music Slow injection but needle inserted quickly Small diameter 30G needle Bevel up Minimise viewing of needle Counter irritation Minimise number of puncture sites Vibration Ice If the injection is LA - buffer with sodium bicarb Penetrate quickly but infiltrate slowly Inject deep to superficial Reintroduce needle to previously anaesthetised sites Nerve block, field block Inject into pore/hair follicle

Answer 24

Treatment failure/ need for multiple treatments/ recurrence Hyperpigmentation Pain and burning Ulceration Cytopenias Eschar formation Purpura Infection Rarely nausea and vomiting, GI symptoms Allergy

Answer 25

Consent, photo Analgesia (not usually required) - comfortable positioning, cryo or ice, EMLA, ring block Alcohol swab Inject 0.05ml of 50mg/ml per 1cm Use small needle e.g 25G, leur locked syringe, bevel up, into mid dermis Max 100mg per session 2 weekly Can combine with triamcinolone e.g. 0.2ml triamcinolone with 0.8ml of 5FU or 0.1ml triamcinolone with 0.9ml 5FU

Answer 26

Fluorinated pyrimidine analog with cytotoxic effects Inhibition of fibroblast proliferation

Answer 27

Pregnancy, lactation Allergy Cytopaenias

Answer 28

Topicals Sal acid (10% on face, but up to 50-60% periungual and palmoplantar) (also lactic) Cantharadin 0.7% Canthardin plus (cantharadin 1%, podophyllin 2%, sal acid 30%) Tretinoin cream 0.05% Trichloroacetic acid (TCA) 70-90% Podophyllotoxin 0.5% solution Podophyllin 10-25% (in clinic) 5-FU Imiquimod DCP Cidofovir Glutaraldehyde soaks 10mg/ml soak BD Formaldehyde 0.7% gel or 3% soaks Injectables Bleomycin 5-FU Interferon Candida antigen Physical Cryo CO2 laser ablation Curette/excision PDT HPV vaccine

Answer 29

Pregnant (cat D), breastfeeding Allergy Immunocompromised Children Peripheral vascular disease Connective tissue disease Raynauds Unable to cope with injection Unsuitable lesion

Answer 30

Painful - can persist for 72 hours Red, swelling, burning feeling Eschar - falls off after ~4 weeks Blister Ulcer Raynauds Gangrene Infection Nail dystrophy Scars - atrophic or hypertrophic Paraesthesias Haematoma if injected too deep Allergy incl anaphylaxis Itch, urticaria Flagellate erythema or hyperpigmentation Pneumonia-like symptoms/ respiratory compromise

Answer 31

Ensure appropriate indication: Used for warts or keloid (or malignancy or vascular malformation) And no contraindication Cytotoxic medication Inhibits DNA synthesis in infected keratinocytes Explain side effects Expected effect Efficacy: 65-80% of lesions clear after 1-2 injections Course (e.g. warts): injection every 3-4 weeks until resolution, usually need 1-3 treatments Consent Photograph Safety - Cytotoxic gloves, gown and sharps disposal (purple coloured) - Protective goggles - Leur lock syringe - Hospital setting, safe environment - Ensure no staff handling drug are pregnant 1U/ml or 1mg/ml concentration (diluted in N Saline, sometimes also with lignocaine 1%, no adrenaline) - prepared by pharmacy Anaesthetic: ring block Warts: Debulk/pare down with scalpel blade Injected into wart bevel up, aiming to see blanching Careful to avoid injecting into nail matrix 0.1ml per wart No more than 2ml per session Dispose of equipment as per cytotoxic protocols Aftercare expect formation of necrotic eschar, fall off at 3-4 weeks Paracetamol or Panadeine Forte for analgesia Cool compression, rest, elevation Time off work Print out and contact details Keloid - 1IU applied to surface of keloid and keloid punctured with 25G needle 2-5 treatments at 1-4 month intervals

Answer 32

Think: PTSD Patient factors: Immunosuppressed Previous wound infections Significant illness T2DM - poorly controlled Smoker Poor hygiene Tropical residence Extensive eczema with bacterial colonisation or impetiginisation Peripheral vascular disease Tumour factors: Ulcerated Infected Site: Lips, ears, nose Axilla Anogenital Groin Hands and feet Lower limbs Defect repair: Prep - sterile instruments, dressings, surgical masks, gloves and gowns Type of procedure - wedge, flaps, graft, long procedures >3hrs, STSG, cartilage graft, under tension Surgical factors - excessive undermining, charring haemostasis, flap or graft design

Answer 33

Quit smoking BSL control Can shower with chlorhexidine night prior (usually only for large procedures) Avoid shaving In scalp where hair can interfere with suturing, sterile hair clips, rubber bands, or a water-soluble gel, such as E-Z Lubricating Jelly. If hair removal is required – clipping at the skin with scissors or electric clippers is recommended prior to establishing sterile field Consider swab of nares for staph and decolonisation if present Can remain in street clothes (Infection rates for same-day surgery are not significantly affected when patients remain fully dressed)

Answer 34

Warn patient Ensure appropriate positioning Protect eyes from light with gauze Avoid Chlohexidine gluconate as can cause ocular toxicity with conjunctivitis and severe corneal ulceration Can use 5% povidone-iodine solution (dilute 10% with normal saline or use opthalmic solution)

Answer 35

Potent TCS Silver nitrate Change to non occlusive dressing Sharp debridement. C+C Electosurgery

Answer 36

Autolytic: body’s own enzymes (enhanced with hydrocolloid dressing) + painless - monitor infection Mechanical: wet to dry - nonselective, painful, maceration Surgical: + rapid, selective Enzymatic: + enhance granulation tissue, reepithelialisation e.g. hydrogel, flaminal Maggot therapy

Answer 37

(Haemostasis first) Inflammatory: minutes to days. Vascular response and cellular (leukocytes, mast cells, chemical mediators) Proliferative: days to weeks. Reepithelialisation, angiogenesis and fibroplasia Remodelling: weeks to months Deposition of matrix materials and the change of these over time

Answer 38

Foams. Alginates (Algisite) Gauze. Hydrofibres (Aquacel) ?Vac dressing

Answer 39

Nutrition - high protein diet Compression - stockings, TEDS, SCUDS Compression bandages - elastic Unna boot Elevation Hyperbaric oxygen Optimise comorbidities

Answer 40

Local: vascular impairment, infection Systemic: systemic medications (steroids), nutritional deficiency Ischaemia: smoking

Answer 41

What to expect after laser resurfacing: First few days - swelling, pain, burning, stinging. Oozing, sloughing, crusting, erythema Apply ice packs - reduce pain, swelling, discomfort Open technique: regular saline or cool water soaks. Apply ointment over the top eg Dermeze + inexpensive, easy, less time consuming - crusting, dessication, prolonged erythema, relies on pt compliance, mild acne Closed technique: cleanse, then occlusive or semi-occlusive dressing. Changed 1-2x daily due to exudate + reduced pain, pruritus, erythema, crusting. Faster reepithlialisation. Decreased scarring - difficult to keep in place, poorly tolerated, time consuming, pt discomfort

Answer 42

Felypressin

Answer 43

Determine nature and history of reaction Type 1 reaction? Immediate, rash/urticaria/angioedema, SOB, anaphylaxis Determine if true allergy vs vasovagal ve adrenaline sensitivity Was it ester or amide? Any cross-reactive allergies e.g. PPD, sulfonylureas, thiazides Collateral history from GP Referral to allergist for testing Is there a local anaesthetic that has been used safely in the past with GP, dentist? Avoid the class of anaesthetics to which allergic Use preservative free if paraben allergy

Answer 44

Ester - tetracaine, benzocaine, procaine Preserved saline Tramadol 5% Benzyl alcohol 0.9% Diphenhydramine 1% Metoclopramide Cryo-anaesthesia Sedation or GA

Answer 45

Eutectic mixture of LA. 2.5mg/ml lignocaine, 2.5mg/ml prilocaine in an oil in water emulsion cream Apply to skin Apply occlusive dressing over top 60 min application period, 3mm depth anaesthesia 25 mins on face 5-15 mins on mucosal surfaces

Answer 46

Infants - risk of methaemoglobinaemia w prilocaine. Use w caution Eyes - can cause alkaline injury to cornea. Avoid use close to eyes

Answer 47

Lidocaine encapsulated in liposomal delivery system. 4% and 5% available Similar effectiveness to EMLA, but LMX has longer duration 30 min application before procedure Does not need occlusion NOT recommended on mucosal or conjunctiva - risk absorption, irritation No risk methaemoglobinaemia Lower risk ACD

Answer 48

Use tetracaine 0.5% or proparacaine 0.5% Place 1-2 drops in conjunctival sac Onset of anaesthesia within 30 seconds Stinging sensation when drops instilled Anaesthesia lasts 15mins or longer Place eye patch after until anaesthesia resolves Proparacaine - slightly less painful, slightly longer duration anaesthesia

Answer 49

Delivery of large volumes of dilute anaesthesia into s/c fat until tissue distends Use 0.5-1.5mm multiport infiltration cannulas or 18-20G blunt tipped spinal needles Pumping devices to aid infiltration large volumes Lignocaine, epinephrine, bicarb 55mg/kg Warm to 40deg; slow rate of infiltration Allows procedures to be performed safely with minimal blood loss without risks of GA; prolonged duration of action - good postop analgesia

Answer 50

Local injections of phentolamine 0.5mg/ml (alpha adrenergic blocker) Topical application nitroglycerin

Answer 51

Intravascular injection; administering excess amounts; rapid drug absorption (eg highly vascular area, mucous membranes); abnormal drug metabolism (liver disease, med interactions - amides are metabolised by CYP450 - so CYP450- inhibitors may increase levels)

Answer 52

Disorder with genetic predisposition skin cancer (Gorlin's, albinism) Genodermatoses with photosensitivity (XP, Cockayne, Trichothiodystrophy, Bloom, Rothmund Thomson) Concurrent AZA, CsA, MMF, tacro Unable to stand in booth safely Relative: Hereditary dysplastic naevus syndrome Lupus Phototoxic medications Hx melanoma, NMSC Prev arsenic or ionising radiation Prev excessive sunexposure/phototherapy/sunbeds Prev significant use of oral immunosuppressives Strong fam hx skin cancer at a young age Current pre-malignant skin lesions

Answer 53

Consent Photograph 0.6mg/kg 8MOP orally with food, 2 hrs prior Wear UV blocking clothing and wraparound sunglasses as soon as ingested (remove sunscreen and protective clothing prior to treatment) UVA 0.5J for skin PT I 2.5J for skin PT V Increase by 0.5-1.5J increments Expose affected areas (must be same areas every time) Continue wearing UV blocking sunglasses Cover face (if not affected) and wear underwear Schedule Clearance: 2-3 times per week at least 48hrs apart When >95% clear change to maintenance Maintenance: hold dose and reduce frequency (4 treatments per fortnight, then 4 treatments every 3 weeks, then 4 treatments every 4 weeks, then monthly or stop) Aftercare: Wear sunglasses until sundown that day Strict sunprotection and sunscreen 6-12 monthly skin checks If slow responder can increase dose or add acitretin

Answer 54

Personal or family hx melanoma Significant NMSC Significant past phototherapy Pregnancy (cat C) and lactation Severe liver, renal or cardiac disease Photosensitive disorders (lupus, XP) Photosensitive medications Cataracts Concurrent immunosuppressants

Answer 55

Oral: Psoriasis, MF Vitiligo, eczema - more treatments needed, use lower dose Topical: Palmoplantar eczema, psoriasis, pustulosis

Answer 56

Erythema, oedema, blistering Tanning Pruritus Flare of skin condition Inadvertent burn or blister Nausea (take with high fat food)* Photo-onycholysis Headache* Ankle oedema* Increase in NMSC (esp >150 treatments) Photoageing PUVA lentigines (large, dark, irregularly shaped) Hypertrichosis Cataracts Hepatotoxicity* Lack of effect/need for multiple treatments/recurrence *oral

Answer 57

Photochemical interaction between a psoralen (photosensitiser derived from plants) and UVA (320-400nm)

Answer 58

Consent Photograph Sunscreen dorsal hands if not involved 30mL of 1% 8-MOP solution in 100mg WSP applied to affected areas (same area every time) Apply 1 hour prior UVA 0.1-0.5J Increase with 0.1-0.5J increments Wear UV goggles Treat 2-3 times per week at least 48 hours apart Wash hands after treatment Strict sunprotection FSE every 6-12 months RV in 8 weeks

Answer 59

Consent Photograph 5mL 1% 8-MOP lotion in 100L of water Bathe for 15 minutes, swish around Dry off Wear UV goggles during treatment Sunscreen or clothing for unaffected areas UVA Starting dose 0.25-0.5J Increments 0.25-0.5J Treat 2-3 times per week At least 48hrs apart

Answer 60

Allergy/hypersensitivity Pregnancy, breastfeeding Neuromuscular disease (myasthenia gravis, Lambert Eaton syndrome) Infection at injection site Medications - calcium channel blockers, penicillamine, aminoglycosides, NSAIDs Coagulation disorders, anticoagulants Needle phobia Unrealistic expectations Jehova's Witness (human albumin) If hands - muscle atrophy (occupation, pianist?) Age <12 years

Answer 61

Wisdom spots from growing a little older Common in darker skin types Genetic or familial tendency Progressive Not dangerous Will not resolve spontaneously Treatment may improve cosmesis, will not prevent future lesions or recurrence and there are side effects including hyperpigmentation

Answer 62

Consent Photograph Cleanse makeup/sunscreen Bed 45 degrees Eye protection Mask Smoke evacuator Lighting Surgical scrub with saline Personal protective equipment Hyfrecator low frequency ~4 watts Wipe off char with wet gauze Avoid contact with grounded metal objects Dress with petrolatum

Answer 63

Contact patient Apologise Open disclosure Check procedure log book - investigate how specimen was lost Check with courier Contact MDO Speak to senior colleague/mentor Bulk bill Invite to return for repeat biopsy AUDIT Review policy and processes Educate staff, updater courses Time out checklist Ensure pots are pre-labelled, specimens immediately potted and lids closed, nurses verbalise 'specimen in pot' Minimise distractions during procedures

Answer 64

Rare but significant: Anaphylaxis, tissue necrosis and ulceration, stroke and TIA, DVT, PE, motor nerve injury Other: Telangiectatic matting (10%) Hyperpigmentation (1-2%) - lasts 6-12 months Visual disturbance <1% Headaches and migraines <1% Local allergic reactions Urticaria Superficial thrombophlebitis Sensory nerve injury Chest tightness, dry cough Failure to be effective/need for multiple treatments/recurrence Expected: erythema, oedema, transient bruising

Answer 65

Position patient so comfortable but can hold the cryotherapy upright Debulk Ensure bloodless field Divide lesion into sections e.g. 4 quadrants or 3 rings, also mark my margin (5mm) Cryotherapy gun - size B nozzle Open spray technique Held 1cm away from skin surface Spray continuously until an ice ball forms and expands to encompass entire lesion and desired margin Stop the spray and palpate between thumb and forefinger to ensure frozen solidly Begin timing, intermittently spray centre of lesion to keep ice ball Aim for it to be frozen for 30 seconds Allow to thaw, consider repeat Local anaesthetic option of pain Cover with dressing 24 hrs AFTERCARE (for every procedure)

Answer 66

Field damage: 5-Fluorouracil 5% cream BD for 3 weeks (BE SPECIFIC!) Imiquimod cream 5% - M/W/F for 4 weeks, stop for 4 weeks, repeat if necessary Photodynamic therapy (MAL - methyl aminolevulinate - with daylight or red light) Peels - trichloroacetic acid or Jessner solution Diclofenac gel 3% BD for 3 months Topical tirbanibulin daily for 5 days Radiotherapy For individual AKs including hypertrophic AKs: Shave, curette, electrocautery, excision

Answer 67

Imbibition - 1st stage - ischaemic period - 24-48hrs - fibrin attaches graft to bed - graft sustained by plasma exudate from wound bed, passive diffusion of nutrients Inosculation - 2nd stage - revascularisation - linking graft dermal vessels with those in recipient bed - lasts 7-10 days Neovascularisation - final stage - often occurs in conjunction with inosculation - capillary ingrowth to graft from recipient base and sidewalls Lymphatics usually restored within 1 week

Answer 68

Waxing, shaving, bleaching, threading Depilatory creams Investigate for potential PCOS - spironolactone, OCP Topical eflornithine cream Galvanic electrolysis, thermolysis Long pulsed ndYAG 1064nm Diode 800-810nm Alex 755nm Ruby 694nm IPL

Answer 69

Lupus erythematosus Isotretinoin in last 6 months Suntan (6 weeks) Pregnancy Keloids Koebnerising conditions - psoriasis Doxycycline (ensure have been worked up for causes hirsutism) Past or current gold treatment Unrealistic expectations

Answer 70

PEER LIT TRESD Photo Prep Eyes Environment Respiratory (ventilation, o2 leak if GA) Laser settings - check input settings Ice/cool/water (including for ablative lasers having moist towels/wetting of hair) Tip (cleaned) Tight (all cords attached, no frays) Ready - warn about to fire, will see brightness despite eyes closed and protected, sound, discomfort Endpoint Standby Document

Answer 71

Lignocaine 1% - 50mL Adrenaline 1:1,000,000 - 0.5mL Sodium bicarbonate 8.5% - 10mL All in 1L normal saline

Answer 72

PHOTO of what nose previous looked like to sculpt Safety checklist - protective eyewear (metal goggles for patient) REMEMBER: CO2 laser higher risk of fire - nearby extinguisher Clean with saline (not alcohol) Check laser settings INFILTRATE WITH LOCAL ANAESTHETIC (tumescent anaesthesia used) Warn about noise Test on paddle pop stick Test patch ENDPOINT (always mention): tissue vaporisation To reduce risk of excessive thermal injury, partially desiccated tissue should be removed manually with wet gauze after each laser pass to expose the underlying dermis Document laser parameters used Dressings Vaseline, Jelonet, Melolin, Micropore Analgesia Ice Prophylactic antivirals Head elevated, avoid excessive talking Photoprotection Expectations of recovery - crusting/weeping for 7-10 days, then pink for several weeks Close follow up - 1 day, then 7 days Contact details and warning signs

Answer 73

Assess for appropriate indication No contraindications Explanation to patient: this is a focused light that makes pigment particles shatter Expectations: Multiple treatments, 10-12 weeks apart Multiple lasers if different colours Difficult to treat Consent, medical financial Photograph Anaesthetic - topical, sometimes local infiltrated (1% lignocaine with adrenaline) Laser safety: Signage, cover reflective surfaces, goggles, eye protection patient, laser smoke plume removal Warn about noise Select and document settings Removal of all makeup/cream/sunscreen/topical anaesthetic Administer and check endpoint Expected response - immediate whitening, mild pinpoint bleeding Aftercare: Cooling with ice/cool compresses Emollients Strict sunprotection Gentle cleaning Side effects Discomfort, swelling, redness, urticaria Blistering, infection Hyper/hypopigmentation Scar Failure to be effective/need for multiple treatments

Answer 74

1. QS Ruby (694), KTP (532), Alexandrite (755) IPL not so commonly used Ash white colour (resolves in 20 mins) 2. QS ndYAG 1064nm QS Ruby (694), Alexandrite (755) Petechiae

Answer 75

Better response - Amateur - Dark - Uniformly coloured - Red colour Worse response - Professional - Older tattoo (>36 months) - Location on feet or legs - Green and yellow colours/ colours other than black and red - Dense pigment - Smoker - Immediate pigment darkening - Larger tattoos (>30cm) - Interval of treatment sessions <8 weeks

Answer 76

Excessive fluences and small spot sizes Tattoos with double ink Pulse stacking Too frequent treatments Sites: ankle, deltoid, chest

Answer 77

Light energy is absorbed by colour targets in your skin, converted to heat energy and that heat destroys those colour targets Treatment lasts about 20mins, minimal down time Usually 4-6 treatments, 3-6 weeks apart Not very painful, like snap of rubber band, topical anaesthetic not usually required Special laser safe room Remove all makeup, creams, sunscreen Goggles/protective eyewear Noise (warn) Cold gliding gel applied to skin and smooth glass surfeca of IPL treatment head is applied to skin Skin turns pink, sensation of mild sunburn (red, peeling, swelling), may last a few days Afterwards – wash off gel, regular moisturizer/emollient, photoprotection Can return to work same day Pre and post treatment with hydroquinone if concern about hyperpigmentation Risks/ side effects: blistering, hyper/hypopigmentation (incl melasma), bruising (10%), alopecia, scarring, ocular damage if close to eye, fails to be effective, multiple treatments, recurrence, HSV reactivation

Answer 78

sodium tetradecyl sulphate, polidocanol foam, liquid

Answer 79

Flush artery with dextran Consider hospitalisation Consider therapeutic heparin (7-10 days) Procaine if STS Hyaluronidase if detergent Normal saline if hypertonic saline GTN High flow O2 Analgesia

Answer 80

Mutual agreement regarding which product/procedure would best suit patient's needs Taking into consideration down-time and risk tolerance Set realistic patient expectations May need combination of different treatments for different issues (e.g. filler, botox) Temporary, repeat 4-6 monthly Side effects (expected, short term, long term, serious)

Answer 81

Mark - aim incision length 1/2 to 1/3 of the lipoma diameter Local anaesthetic - over, around, under Take care to avoid damage to supratrochlear and supraorbital neurovascular bundles If dissecting frontalis muscle should be dissected VERTICALLY Suture the submuscular fascia and then then the frontalis 5.0 monocryl, 5.0 nylon (specify) Pressure dressing Keep elevated Handout, contact details Review within 1 week

Answer 82

No active treatment, medical monitoring Electrosurgery Shave excisions/biopsy Targeted ablative laser eg CO2 or erbium YAG There are other options eg: Cryotherapy Curettage (C+C) Although they would be less favourable in a patient with a darker skin type ndYAG laser

Answer 83

Disadvantages: FUE takes longer Increased risk of transecting hairs Requires larger donor area Can be more difficult for subsequent sessions (fibrosis from secondary intention healing) Advantages: FUE better than FUT if concerned about scarring (can wear hair shorter) FUE is better than FUT if it is a very loose or very tight scalp. - Although can be difficult in a loose scalp - follicular units may shed during extraction - Tight scalps will have a more limited donor supply

Answer 84

Quit smoking Bloods for chronic infections - hepatitis, HIV Assess adequate donor density, lax but not too lax >25 Assess contraindications - diffuse unpatterned alopecia Realistic expectations Bleeding disorders, immunodeficiency Keloids, CTD, major psychiatric disorder, unstable arrhythmias Sensitivity to anaesthetic or adrenaline Back and neck problems Side effects High or low hairline Unnatural look Ongoing progression Failure of grafts Dehiscence Bleeding Infection

Answer 85

Expectations: Transplanted hair sheds around 2-6 weeks after the procedure First signs of new growth at around 10 weeks, can take longer Second session would usually be 12 months later This procedure moves rather than creates hair It is the patient's own hair from the sides and back of head that will be transplanted Therefore the resulting transplanted density will be significantly less than the person's non-balding density Results are not guaranteed Risks: Allergy Sterile folliculitis Infection Cyst formation at graft site Scarring in donor area Hair loss related to procedure Hair texture changes Failure of transplanted hair to grow Numbness, paraesthesia Temporary swelling or bruising Alternatives: Doing nothing Changing hairstyles (lightening, shortening) Medical therapy Wearing a hair piece

Answer 86

Position with incline to avoid getting in eyes (45 degrees) Protect the eyes with gauze Wear gloves Wipe away any tears throughout to avoid wicking Facial cleansing, degreasing - acetone rubbing alcohol, chlorhexidine Apply peel with wrung out gauze Forehead, lateral face, nose, cheeks, periorbital and then infraorbital Feather application at edges Endpoint - speckling and erythema for Jessners, white frosting for TCA - appears after 1-2 minutes Analgesia - fan/cold air Give antivirals Careful not to pass over patient's eyes With TCA - consider test patch first on lateral part of face with 50% strength, then uptitrate Expectations: Medium depth - erythema sunburn within 30 minutes - oedema within 24 hours - light brown appearance - day 3-7 desquamation Keep skin greasy post op (petrolatum applied multiple times per day), avoid scrubbing/peeling/picking Careful sunprotection Erythema should fade after 2-4 weeks Makeup can be worn by day 7 No tretinoin for 4-6 weeks

Answer 87

Advantages: No surgery No scars, good cosmesis Tissue preserving Not painful Clearance ~70% Can include generous margins Can be used in patients who may be medically inoperable Outpatient procedure Disadvantages: Increased risk recurrence, lower cure rate, secondary skin cancers in treated area No histological confirmation of clearance Post radiation complications including dermatitis, ulcer, reduced quality of irradiated skin (atrophy, telangiectasias, alopecia, hypopigmentation or pink) - Can mean that subsequent surgery same site may be difficult Protracted treatment course, many visits Cannot have radiation in the future at the same site

Answer 88

Location: radiation oncology department Multiple treatments - attending 5 days per week for ~4 weeks Consultation prior to the treatment commencing Template is made of the lesion, with a margin 5-15mm Photographs Works by causing damage to the DNA of the cancer cells Treatment is not painful Safety - eye shields and thyroid shield, shield around template Lie still and will be alone in the room for at least 5 minutes while the treatment takes place (radiotherapist leaves the room) Expect - erythema, oedema, crusting, desquamation, discomfort Risks/complications - ulcer, slow healing, infection, mucositis Longer term - alopecia, atrophy, telangiectasia, hyper/hypopigmentation, risk of secondary malignancy (1-2% over 20 years), anhidrosis, necrosis of tissue, cartilage or bone, cataracts Failure of effective/recurrence Aftercare - cool compresses, emollients No limitations to your contact with other people while you're having the treatment

Answer 89

Be specific/detailed Positioning Airway - clear secretions, chin lift, jaw thrust, laryngeal airway if not intubated Circulation - CPR 30 compressions every 2 breaths IVC Bolus saline Adrenaline 1mg Amiodarone depending on rhythm Contact next of kin

Answer 90

Winter/spring 50-100mJ/cm^2 2 per week Increase by 50mJ/cm^2 per session For 4-6 weeks Patient review Flare: Well or unwell and extent/severity - do they need hospital admission Assess for complications - secondary infection requiring treatment Apologise for inconvenience Reassure Will manage together Oral prednisolone Potent TCS Optimise general skincare measures Analgesia - paracetamol Pruritis - antihistamines Halt UV treatment until recovered If and when recommencing consider lower dose e.g. 50% and slower increments to increase

Answer 91

Assess extent of burn If mild/moderate, cool compresses, topical corticosteroids (say which, wet wrap), NSAIDs, PO pred if more severe (25mg daily for 5 days, 12.5mg daily for 5 days) If very severe (blisters, deep burns) - hospital admission Liberal dermeze Assess for signs of secondary infection Swabs for bacterial MCS, viral PCR and prophylactic antibiotics/antivirals Review reasons why burn has occurred - machine settings, frequency of treatments, doses, other light exposure, any photosensitising medications or topicals

Answer 92

Expected Discomfort, erythema, oedema Short term Folliculitis, acne Blister, ulceration, scar Hyperpigmentation Hypopigmentation, leukotrichia Long term Permanent removal of ephelides in treatment area Increased hair growth, conversion of vellus hairs to terminal hairs Failure to clear completely, need for multiple treatments, recurrence

Answer 93

Primary/direct side-to-side Flaps: Keystone flap Bridge flap Tripolar (Mercedes) advancement flap Rotation flap Rhombic transposition flap Subcutaneous island pedicle (if on hand and feet then bilobed/trilobed transposition flaps and Burow's exchange advancement flaps are other options) Combination repairs with Burow's graft or second intention FTSG STSG - if large defect, or if over shin

Answer 94

Long lasting suture for deep layers - PDS or Maxon Tension-relieving and apposition-enhancing techniques - Bootlace suture - Subcutaneous inverted cross mattress suture (SCIM) - Haneke-Marini suture (partially buried horizontal or vertical mattress sutures) - Running subcuticular to reduce track marks

Answer 95

Orient long axis of ellipse parallel to direction of vessels and nerves Draw keystone on side of greatest laxity At least 1:1 flap width:defect width Angle adjacent to ellipse is 90 degrees Incise down to fascia Use vertical scissors to tease flap pedicle away from surrounding fat; can later loosen as needed with blunt dissection using vertical scissors Undermine all around the flap Move flap into place with skin hooks Haemostasis Absorbable sutures to close 2 trailing edge corners in a V-Y fashion Advantages: Good colour and texture match No secondary donor site Disadvantages: Deep undermining Obvious geometric scar

Answer 96

Supine position, foot on padded support Foot extended and externally rotated USS can be used to identify correct site of injection Place needle at level of the upper half of medial malleolus, and posterior to posterior tibial artery pulse and anterior to the calcaneal tendon Advance needle towards posterior tibia and inject 3-4 ml of lignocaine

Answer 97

From sciatic nerve: Tibial/post tibial - plantar foot Branches of posterior tibial nerve: medial plantar nerve, lateral plantar nerve, tibial nerve Superficial peroneal/fibular - most of dorsum foot Deep peroneal/fibular - first web space Sural - lateral foot From femoral nerve: Saphenous nerve - medial foot

Answer 98

Flexor carpi ulnaris, palmaris longus, median nerve, flexor carpi radialis Put 5th finger and thumb together to bring out palmaris longus For median nerve – inject between palmaris longus and median nerve For ulnar nerve - inject just radial to flexor carpi ulnaris at the ulnar styloid process For radial nerve – inject lateral to the radial artery, lateral border of the radius, just dorsal to radial styloid Inject 3-5mL

Answer 99

Side-to-side closure Burow's exchange advancement flap (ideal for small defects just lateral to midline) Rotation flaps - Dorsal nasal - Double (Peng) rotation flap - Advancement and Inferior Rotation of the Nasal Sidewall (AIRNS) flap Transposition flaps - Bilobed, trilobed Island pedicel flaps - Subcutaneous - Myocutaneous (unilateral, bilateral) Interpolation flaps - Paramedian forehead - Nasolabial FTSG

Answer 100

Conchal bowl Glabella Nasolabial folds (pre/post auricular)

Answer 101

Advantages: May repair defects up to 2cm Well vascularised Utilises skin laxity from upper nose Good colour and texture match Majority of scar in natural cosmetic junctions (alar crease, nasofacial sulcus, glabellar lines) Disadvantages: Large flap, requiring elevation of entire nasal skin and musculature Risk nasal tip elevation (if defect too lateral or large, or nose too short) Distal anaesthesia from severing external nasal branch of anterior ethmoidal nerve Transverse line at nasal tip may be obvious in sebaceous noses

Answer 102

If defect is to one side, rotation arc will be on other side Burow's triangle (!!!) in oposite direction of arc Flap length approximately 4x greater than width of defect Glabellar back cut 30 degrees inverse V Incise flap to perichondrium and periosteum (but above muscles at glabellar area) First suture to close back-cut at glabellar Second buried suture to close primary dfeect

Answer 103

Advantages: - Utilises skin from more lax area at upper and lateral nose - Well vascularised (especially if tip defect) - infratrochlear arteries and branches of angular arteries - Good tissue match - Medium to large defects (esp if at tip) - Single staged procedure - Scarlines hidden in cosmetic junction lines, scar lateral rather than central Disadvantages - Alar or tip elevation - Uneven distortion of nostril shape - Not suitable if defect is very proximal - May not be preferred if very deep defect (paramedian forehead or delayed FTSG preferred) - Large flap requiring elevation of entire nasal skin - Scars on both sides of nose - Flap tip necrosis (moreso when more proximal defect?) - May accentuate dorsal nasal convexity (if more proximal) - Distal anaesthesia if severing of external nasal branch of anterior ethmoidal nerve (can take 6-12 months to return)

Answer 104

Start incisions from distal edge of defect, into alar grooves and nasofacial sulcus up to lower medial canthus Undermine in submuscular layer Initial buried absorbable suture to bring flap arms together to cover defect Inset flap leading edge with buried sutures from central to lateral alternating side to side Repair central standing cone Close secondary defects, may need to remove Burow's triangle from medial canthi

Answer 105

Advantages: - Allows movement of more lax skin from higher up nose - Good match - Can close defects up to 1.5cm Disadvantages: - Pincushioning - Elevation alar rim - Buckling alar cartilage and mucosa, may cause reduced airflow - Technically difficult

Answer 106

Spider veins Reticular veins Varicose veins Venous leg ulcers with poor healing Venous malformations

Answer 107

Absolute: Allergy Pregnancy Significant peripheral arterial disease PFO (known) - symptomatic right to left shunt Bed bound/ non ambulatory patient Pregnancy Acute DVT or PE Infection Imminent travel Relative: Leg oedema Poor general health Known hypercoagulable state Breastfeeding (interrupt 2-3 days) Note history of DVT, obesity, saphenofemoral reflux are not absolute CIs (although may be relative) Thrombophilia, high risk of thromboembolism and neuro symptoms post previous treatments are things that can be discussed/worked around

Answer 108

History - contraindications Examination - assess for saphenofemoral incompetence; palpate peripheral arterial pulses Doppler USS Document CEAP classification of venous disease severity (Clinical, Etiologic, Anatomic, Pathophysiologic)

Answer 109

Pt lying down supine or on non-treated side Single leg at a time Prep entire leg with 70% isopropyl alcohol Loupes and good lighting 1% polidocanol 2ml syringe 30G needle for reticular veins, 32G for spider veins/telangiectasias Start with large vessels first Use veinlite for good visualisation and 2.5x magnification loupes Hand traction to keep skin taut Draw back then inject slowly a small amount of sclerosant until vessel filled (0.1-0.2ml), repeat at 3cm intervals Repetitive punctures, slow injections, small volumes Gradiated compression stockings immediately Aftercare discussion, written instructions, contact details

Answer 110

Principles: Transform vein into fibrous cord Inject sclerosant to damage vessel wall and cause sclerosis Aim to collapse vessel Expected outcome: Veins collapse, fade from view Often multiple treatments required Can get worse before gets better, may take several months

Answer 111

poorly differentiated perineural invasion >0.1mm or named nerve location (head and neck, especially ears, lips) diameter >2cm recurrence level of invasion (subcutis, muscle, bone) previous radiation at site lymphovascular invasion Thickness >4mm (very high risk if >6mm) Very high risk if high grade histological subtype – adenosquamous, desmoplastic, spindle, sarcomatoid, metaplastic Tumour arising within scar or chronic inflammation In transit metastases (very high risk) Plentiful mitoses Infiltrative growth patten

Answer 112

Wavelength: 340-400nm Indications: sclerosing dermatoses, atopic dermatitis, CTCL, UP, GVHD Course: 5 times per week for 3-4 weeks Dosing regimens: Low dose UVA1 refers to 10-20 J/cm2 Medium dose UVA1 refers to 50-60 J/cm2 High dose UVA1 refers to 130 J/cm2

Answer 113

70% isopropyl alcohol - prep whole leg to be treated 3-5ml syringes 30-32G 1/2 inch needles Loupes or magnifying lens Veinlite USS Sclerosant (polidocanol 0.5, 1, 2%) Graduated compression stockings Anaphylaxis kit with adrenaline GTN paste

Answer 114

Pretreat with keratolytic for 2 weeks e.g. sal acid, urea, AHAs 5-FU days prior to PDT treatment Immediately prior to PDT Acetone wipe Curettage Fractionated ablative CO2 laser Ensure adequate concentration (16%), adequate amount (0.1-0.5mL thick)

Answer 115

Indications: Poorly defined tumours Recurrent tumours Regions with high anatomic risk (mid face, ears) Lesions with aggressive histology Areas needing tissue conservation (eyelid, nose, face) Perineural invasion >2cm diameter Aggressive tumours or tumours with high risk of recurrence - MAC, DFSP, EMPD, MCC, BCC morphoeic, infiltrative, micronodular Contraindications: Non-contiguous tumour Invading bone, cartilage, or repair that would require GA Pt inability to tolerate, multiple needles, long wait, no GAs When less costly and time consuming procedures are appropriate

Answer 116

No international flights for 12 weeks Short haul flights 6 hours okay after 6 weeks Compression 24hrs per day for 7 days Brisk 30min walk daily for 7 days Set realistic expectations - multiple treatments required, perfection not guaranteed

Answer 117

Sclerotherapy (USS guided) Endovenous laser ablation (large refluxing saphenous veins) Venaseal adhesive closure (glue) - large saphenous veins Vein stripping

Answer 118

Occurs in ~10% May occur days to months after treatment Usually resolves within 3-12 months, can be permanent in 10-20% Risk factors: obesity, OCP, pregnancy, inadequate compression, fam hx telangiectatic veins Technique to minimise risk: Ensure optimal weight, Not on OCP Treat proximal dz first Low concentrations Low injection pressure Low volume Strict compression post for 2 weeks Daily mobilisation Pentoxyfilline Antihistamines Treatment: Further sclerotherapy with either same or alternative sclerosant PDL or IPL

Answer 119

USS can help confirm diagnosis Digital block Visualisation of the connection between cyst and DIP joint via methylene blue injection (inject into joint on palmar surface DIP) Reflect nail fold Use nail elevator, remove nail plate Excision of cyst and close off connection (ligate with silk suture) Take care to avoid underlying nerves, tendon Send for histology Place nail plate back Close with vicryl rapide/nylon Reconstruction of skin may require a flap

Answer 120

palmoplantar eczema/ psoriasis PRP GA thicker stage MF

Answer 121

Neurotoxin derived from Clostridium botulinum Selectively and irreversibly binds to cholinergic receptors Blocks release of acetylcholine through enzymatic cleavage of protein (SNAP25 for BoNT-A) Prevents muscle depolarisation and contraction

Answer 122

What to expect: muscle paralysis appears within 72 hours reaches max level at 2 weeks lasts 4-6 months (longer for anhidrotic, 6-9) dynamic rhytides (not deep and static) Avoid: lying down, massaging or manipulating the area, sauna 24/24 no physical activity for 4 hours

Answer 123

MICE SPPD MADREA Medical and financial consent Indication Contraindications Education - written and verbal Set realistic expectations Pretreatment Photos Documentation MOA Alternatives Dose/duration Risks/side effects Expected effects/endpoint Aftercare

Answer 124

Glabellar frown lines Periorbital rhytides Forehead lines Perioral rhytides Bunny lines Nasal tip droop Dimpled chin Marionette lines Gingival smile Neck and chest - platysmal bands Facial asymmetry Masseteric hypertrophy Hyperhidrosis Rosacea Keloid prevention Other: migraine, muscle spasm

Answer 125

Assess vision and function Exclude other neurological causes Reassure will gradually resolve over 2-12 weeks Apraclonidine 0.5% eye drops TDS 1-2 drops in affected eye

Answer 126

Reconstituted in 0.9% normal saline Insert needle into vile (gentle introduction, very slow, avoid bubble formation) Gentle swirl Can be stored for 2-6 weeks Store in fridge (unless INCO), avoid freezing Cold chain should not be broken

Answer 127

Lateral pterygoid

Answer 128

ONA (botox), ABO (dysport), INCO ONA = INCO ONA : ABO 1:2-2.5 (ABO needs more, not as strong)

Answer 129

Severe primary axillary hyperhidrosis Previously failed aluminium chloride hexahydrate for 1-2 months or did not tolerate Age >12 Dermatologist, neurologist or paediatrician Max 3 treatments per year, must be at least 4 months apart

Answer 130

Opening: used to identify areas of hyperactive sweat glands Clean thoroughly Apply iodine 4-5% Allow to dry Dust evenly with starch powder Allow pt to sweat Wait 10 minutes Areas that turn black identify hyperactive glands Outline with skin marker and document with photo for record

Answer 131

Upper eyelid ptosis (levator palpebrae superioris) Exaggerated bunny lines (recruitment of nasalis) "Spock brows" - excessive elevation of eyebrow tails

Answer 132

Pain, bruising, heamatoma Headache Treatment failure Erythema, oedema Asymmetry Vasovagal Anaphylaxis Antibody formation Short term hyperaesthesia

Answer 133

Pre-auricular - ample skin laxity if older - may have more photoaging changes and not be as good skin match - risk of hair transfer Post-auricular - good match, scar hides well, good laxity Conchal bowl - good match for sebaceous nose - often left to heal by second intention which can be slow/uncomfortable Nasolabial fold or glabellar skin - Good match - Scar on face (but can hide in folds) - Risk of hair transfer with glabellar, esp males

Answer 134

Prevents graft contraction and notching, recreates alar contour Repairs full thickness alar rim defects Avoids complex and 2-stage flap repairs Maintains patency of nostril Disadvantages: Size limitation ~1cm Higher risk graft necrosis Pt discomfort with nasal packing until ROS Donors: Helical crus on ipsilateral ear Conchal bowl (better if needing more cartilage)

Answer 135

Make template and mark out donor site (conchal bowl or helical crus or ipsilateral ear) Anaesthetise donor site, incise graft and cartilage Cutaneous component should match defect, cartilaginous component needs to be 2-3mm longer than skin component on each end - these cartilaginous pegs will slot into small incisions made in each side of defect to hold graft in place Helical crus donor site closed primarily or with flap Create small pockets at medial and lateral edge of alar defect (stab incision) Suture mucosal surface in place first, then cartilage into pockets (absorbable sutures), then suture skin surface Pack nostril with petrolatum gauze - pressure dressing

Answer 136

Side-to-side Unilateral single sided advancement flap - Burow's exchange advancement flap (with Burow's triangle hidden in superior end of nasolabial fold) - or just L-plasty, with the L along the alar crease i.e. PACA flap - perialar crescentic advancement flap Nasolabial advancement flap Back-cut (Hatchet) rotation flap Subcutaneous island pedicle Others (not preferred, but possible): Transposition - rhombic, bilobed, nasolabial Myocutaneous island pedicle FTSG

Answer 137

Side-to-side Back-cut (glabellar) rotation flap Transposition flaps - Rhombic > bilobed Others (not preferred, but possible): Advancement flap - Tripolar (Mercedes) or Bipedicle (bridge) Island pedicle flaps

Answer 138

- first incision lateral, incise to fat keeping muscle intact - then incise medial flap down to perichondrium or periostium - first absorbable suture is drawing flap across defect - ensure eversion at leading edge (mattress sutures good) - second absorbable suture is to close secondary defect at tail - tip stitch to ensure appropriate tip placement

Answer 139

Advantages: Good vascular supply Good tissue match Large, deep defects Disadvantages: Pincushioning Triangular shaped scar Marked bruising and swelling

Answer 140

Advantages: Utilises skin laxity from glabella Good skin match Scars hide well in natural rhytides Disadvantages: Pincushioning Small to medium defects only Potential blunting of nasal root concavity Movement of eyebrow hair onto nose Geometric scar

Answer 141

Advantages - Can close larger defects - Some of the scar hides in nasolabial fold Disadvantages Potential for: - Blunting across nasofacial sulcus - Tension on lower eyelid - Elevation of alar rim - Asymmetry (of nasolabial fold) - Webbing of medial canthus - Draw line from inferomedial aspect of defect around alar crease and down nasolabial fold - Incise flap and undermine widely in subcutaneous plane - Strict haemostasis - First suture = absorbable pexing suture from middle of underside of flap to nasofacial sulcus - Second pexing suture 5mm behind the advancing corner of the flap to the periosteum, under the superior edge of the defect - Closure by rule of halves - Trimming to fit - When suturing cheek flap to alar area, take deep bite on perialar skin and superficial bite on flap, to ensure flap is tucked down around the alar groove - Remove standing cone/burow's triangle - Surface sutures

Answer 142

Side-to-side Advancement flaps - Especially: Unilateral single-sided eg perialar crescentic advancement flap (PACA) - Others: Burow's exchange; unilateral double-sided (Rintala); bilateral single-sided (T-plasty); Bipedicle/bridge Rotation flaps - Especially: Back-cut/ hatchet - Others: Double/Peng Island pedicle flaps Subcutaneous > myocutaneous or transposed Transposition flaps less preferred, rhombic, bilobed, trilobed, nasolabial FTSG

Answer 143

Side-to-side Second intention Transposition flaps Especially: bilobed, nasolabial Other: rhombic Island pedicle flaps Subcutaneous, myocutaneous, transposed, shark Two-stage nasolabial interpolation flap Spiral rotation flap FTSG

Answer 144

Nasolabial turnover island pedicle (Spear) flap Composite graft Combined procedure - mucosa, cartilage, skin

Answer 145

Consider each cosmetic defect separately e.g. nasal sidewall repaired with cheek advancement and Burow's graft for nasal dorsum Muscle hinge flap for deeper defects Delayed grafts for deep wounds or where bone or cartilage is exposed

Answer 146

Mucosal layer - side-to-side if <5mm - bipedicle mucosal advancement flap from immediately above defect - second intention if smaller defect/higher up - composite grafts from ear - STSG - FSTG - myocutaneous hinged flap Cartilage layer - helical crus, conchal bowl Skin - need flap (blood supply) usually 2 stage interpolation (from forehead or cheek) but if smaller defect can use other random pattern flaps

Answer 147

Advantages: - Full-thickness reconstruction of ala, including when there has been loss of alar base and perialar skin - Large defects - Single stage Disadvantages: - Difficult to design and perform - Bulky ala may require surgical revision later - Change of nasal alar contour

Answer 148

Outline flap - width of flap = horizontal measurement of widest portion of defect - length of flap = at least 2x vertical measurement of defect (mucosal + cutaneous/ala) - superior end of flap will be at horizontal level equal to the superior edge of the mucosal defect - lower end of flap 30 degree angle down nasolabial fold Incise and undermine flap Produce a narrow and deep muscle and fatty pedicle Proximal end will turn over 180 degrees and fit into mucosal defect so proximal flap skin forms nasal lining Suture mucosal aspect with absorbable suture (vicryl rapide) Complete deep and superficial sutures

Answer 149

Advantages Large, deep defects Good match Full-thickness Can be placed over bare cartilage Random pattern allows for flexibility in design Smaller wound bandage area compared to paramedian (if for nasal tip) Disadvantages 2 stage, at least 2 weeks with obvious pedicle Daily wound dressings Pincushioning, requiring debulking Risk of nasal valve insufficiency or collapse Hair bearing skin may be moved to nose

Answer 150

Create defect template Use ruler or gauze to measure how far to travel then mark template on cheek Flap along nasloabial fold Width of pedicle should equal width of flap Turns 90 degrees Trim/shape/thin to fit, suture in place Pedicle wrapped in petrolatum-impregnated gauze ROS after 5-7 days Pedicle then divided at 2-4 weeks Check perfused by clamping pedicle Remove redundant part of flap/pedicle, trim and shape ROS again 5-7 days

Answer 151

Advantages: Utilises redundant skin from cheek Good match Turnover variant can be used to repair full thickness defects Single stage Disadvantages: Trapdoor Obscuring alar groove

Answer 152

Draw flap - line along nasolabial fold - width of defect = width of flap superiorly, then extend down to meet nasolabial fold line at 30 degree angle Triangle above defect also 30 degree apex Anaesthetise Incise and undermine flap in subcutaneous plane Close secondary defect first, pushing flap into place Pexing suture to recreate alar crease Ensure no blanching/flap ischaemia - if so, remove suture

Answer 153

Advantages - Robust blood supply (supratrochlear artery) - Reaches distal nose and columella - Large defects, deep or full thickness - Good tissue match Disadvantages - At least 2 weeks with obvious and unsightly pedicle - Cannot wear glasses - Donor site on forehead may require graft or to heal with second intention - Not suitable if prior radiation or surgeries on forehead compromising vascular supply - Trapdoor - Bulbous looking nasal tip

Answer 154

Consider enlarging defect to fill cosmetic subunit of nasal tip Template defect Use ruler or stretched gauze to measure distance pedicle, use this to find best location for donor Width of pedicle 1.5-2.5cm Centre of pedicle over supratrochlear artery Pedicle should begin 3.5cm above orbital rim (supratrochlear artery ascends to subut fat) Portion of flap to be placed on nose in subcutaneous plane; pedicle portion is submuscular Suture 50% of defect circumference in place Pedicle wrapped with non stick gauze Repair donor site - primarily, second intention, graft Pt return in 24/24 for dressing change and wound check 3 weeks later - pedicle division Clamp pedicle to check flap well perfused Then severe, shape/debulk and suture ROS 5-7 days 6 week review for ILCS

Answer 155

Draw standing cone in lateral direction with tip 30-45 degrees Mark a line superiorly, to make a right angle with the central longitudinal axis of the defect's standing cone Draw outer arc and inner arc semi-circles centred on pivot point of standing cone triangle Primary lobe fits in these perimeters, same width as defect but can oversize slightly Secondary lobe is triangle with 30 degree apex, 1/3 to 2/3 wide as primary lobe Incise and undermine above perichondirum First suture to either close tertiary defect first; or to position tip of flap in primary lobe Tacking suture to help minimise pincushioning but monitor for any blanching and whether you need to remove that Attention to wound eversion ROS 5-7 days Regular massage (1 week after ROS), 6 weeks later ILCS

Answer 156

Side-to-side Advancement flaps (unilateral or T plasty) (modified O to Z) Transposition flaps (rhombic or bilobed) - less likely to cause tenting than advancement or rotation Skin grafts

Answer 157

Side-to-side - in or parallel to posterior sulcus if possible; horizontal mattress sutures for haemostasis and eversion Second intention Advancement - O to L or O to T - Or tripolar Rotation Transposition - Rhombic or bilobed Grafts Note: generally extensive undermining required in this area; cautious haemostasis

Answer 158

Lesser occipital Provides sensation to mastoid area and superior ear

Answer 159

Side-to-side Wedge Advancement - superior helical rim - T plasty Helical crus rotation flap (pulls the ear forward a little) Transposition flap - banner (risks: tip necrosis, pincushioning, hair transfer) - bilobed (risks: pincushioning, notching, haematoma) FTSG (may be good option if prone to bleeding)

Answer 160

Advantages - normal ear shape, structure - cannot be too large Disadvantages - decreased size of ear - risk buckling, cupping, notching - risk of cartilaginous prominences and over time chondrodermatitis

Answer 161

Incise anterior skin with scalpel Then use surgical scissors or scalpel to cut through cartilage and posterior ear skin Can remove two perpendicular wedges from superior and inferior edges of wedge (three-pronged stellate variation) Absorbable monofilament sutures for precise approximation of cartilage, knots on posterior side Non-absorbable mattress sutures at helical rim for hypereversion (minimise notching risk)

Answer 162

Flap same width or slightly larger than defect *Mark cone of redundant skin/Burow's (at primary defect)* Incise flap and undermine in subcutaneous plane Thin flap Close donor site/secondary defect first Then suture flap into place Mattress sutures for eversion, prevent notching

Answer 163

Advantages utilises skin from pre or post auricular Good colour texture match Can be used for larger defects Well vascularised Disadvantages risks: tip necrosis, pincushioning/bulky, hair transfer

Answer 164

Side-to-side Second intention Wedge Advancement helical rim - full thickness and partial thickness variants Interpolation flap FTSG

Answer 165

Draw flap - line along sulcus of helical rim from inferior border of defect to the ear lobe Draw Burow's triangle anterior ear lobe Incise full thickness flap down to superior edge ear lobe Burow's triangle is excised (on anterior ear lobe only) Haemostasis Key suture - pull primary defect closed Horizontal mattress at helical rim Finish surface sutures - anterior and then posterior

Answer 166

Flap marked and incised along inside border of helical rim sulcus down to the ear lobe - incision made through anterior ear skin and cartilage but posterior ear skin remains intact Flap widely undermined on posterior ear Need meticulous attention to haemostasis Standing cone of skin redundancy on posterior ear adjacent to defect Burow's triangle anterior surface of ear lobe may also be required Pressure dressing - ointment, non-adherent dressing, damp cotton balls, compression bandage - to remain intact for 48 hours Post ob abx (cephalexin, ciprofloxacin) Review at 48 hours for dressing removal, clean, wound review, redressing

Answer 167

Draw flap like an O to U on the mastoid, lined up with ear defect, leading edge in postauricular sulcus Width of flap = height of defect Incise, undermine Careful haemostasis Elevate flap onto defect, trim Basting sutures through flap to cartilage to recreate natural helical contour (check no ischaemia) Superficial sutures Wrap pedicle with petroleum impregnated gauze 3 weeks later, amputate posterior aspect of flap and thin/shape and suture Secondary defect can be closed with flap, second intention, rarely graft

Answer 168

Advantages - Can close larger defects >2cm and full thickness - Can recreate the helix Disadvantages - 2 stages - Bulky - Risk hair transfer

Answer 169

Advantages - Restores normal contour - Defects 1.5-2.5cm Disadvantages - Rim notching, cupping - Needs to be middle third of helical rim

Answer 170

Advantages - Restores normal anatomy - Good viability (rim remains attached to skin on posterior ear) - Can be used for defects slightly higher on the helical rim (where the full thickness pedicle would be too long) Disadvantages - Risk of haematoma with undermining at posterior ear - Cartilage buckling, minor contour changes

Answer 171

During surgery, cotton ball or petrolatum impregnated gauze placed in EAC to prevent blood collection Flush canal with sterile saline prior to closing Can again pack the canal with petrolatum-impregnated gauze, change 5 days post op, then every 2 days

Answer 172

Second intention Banner transposition flap Pull through island pedicle flap FTSG, STSG

Answer 173

Outline and anaesthetise donor site in retroauricular groove Incise donor site, leaving attached to fatty base At least 1/3rd of the pedicle needs to remain attached Pedicle should be adjacent to full thickness window of defect Pull flap through conchal bowl and suture into place Close donor site - primarily, flap (island pedicle) or partial closure/second intention

Answer 174

Advantages - Well vascularised - Large defects - Missing cartilage Disadvantages - Bulky - Auricle may be pinned back

Answer 175

Side-to-side Second intention Chondrocutaneous rotation flap Rhombic transposition Pull through island pedicle FTSG, STSG

Answer 176

Side-to-side Second intention Advancement flaps - Burow's exchange Rotation flaps - Single, double (these may be better than side-to-side when it comes to glasses, hearing aids) Rhombic transposition or bilobed Island pedicle (incorporate fibres of auricularis posterior muscle) FTSG, STSG If very large - STSG, 2 stage interpolation, large myocutaneous pedicle or bilobed from mastoid/upper cervical area

Answer 177

Side-to-side Wedge Purse-string Transposition Banner, bilobed Island pedicle

Answer 178

Assess for skin necrosis - pain, blanching, dusky, cool Stop treatment Massage Warm compresses Inject hyaluronidase - 500-1000 units widely in the area If vision loss - 1500 units in 2 mL xylocaine 1% Otherwise - 1000 unit pulse, repeat hourly until resolution, up to 3 pulses Nitroglycerine paste topically (2%) 300mg aspirin stat, then 75mg daily (not good evidence for eyes) Oral abx Photos, document timing Call MDO If eyes - examine each eye separately (read text, number of fingers holding up, detect movement of hand) pupillary reactions, eye movements Ophthalm emergency - call in advance, urgent transfer, do not delay transfer with assessments Hx of migraines Neuro exam associated cutaneous signs of impending skin necrosis eye massage eye patch warm compress sublingual GTN Timolol 0.5% drops (1-2 drops each eye) Apology MDO

Answer 179

Know anatomy (avoid danger zones), depth of injection (periosteum) Inject very slowly, low pressure Cannulae safer than needles in most areas (brow, cheeks, not nose) Micro-boluses, small aliquots LA with adrenaline to constrict local vessels Regular movements Direction of injection away from eye Inject perpendicular to vessels Use of HA (because can dissolve) No evidence to support aspiration USS guided

Answer 180

Site - high risk anatomic area (eyelids, nose, ears, lips) Histology Staging Is it recurrent Treatments so far What are the treatment goals - primary or adjuvant? Definitive or palliative? Any previous radiation and where Comorbidities, overall health? Conditions that may be exacerbated by radiation (systemic sclerosis, other sclerodermatous condition, lupus erythematosus) Patient expectations

Answer 181

Chemical peel Fractional Co2 laser resurfacing Fractional Er:YAG laser resurfacing Microneedling Dermabrasion Dermal filler Subscision Punch elevation

Answer 182

MoA: Needles create micro-channels through epidermis and dermis Controlled wounds induce the inflammatory cascade Collagen synthesis reduces the appearance of atrophic scars Spring loaded pens or cylindrical rollers with embedded needles Different needle lengths (1-2mm) Best for rolling and boxcar scars Potential side effects: Infection HSV - prophylaxis Process: Topical lignocaine prior Prep skin with alcohol Hyaluronic acid applied to the treatment area can help the device glide Non treatment hand applies gentle traction to skin Endpoint is uniform pinpoint bleeding Need 3-5 treatments at 2-4 week intervals Expect erythema, dryness Aftercare: Need sunscreen and emollients Safe in skin of colour Can be used as monotherapy or in combination with radiofrequency, fillers, peels, PRP for acne scars

Answer 183

Pre-op Oral analgesia – 1g paracetamol, 400mg ibuprofen 60 mins prior Lignocaine without adrenaline IL Nerve block NOT EMLA Intra-op Distraction, talking, squeeze stress ball, music, counter stimulation/vibration Reassurance, reinforce that pain is appropriate reaction Cold air/fan, zimmer cooler, water mist Pause illumination/ interrupting treatment Lower fluence (with increased time) Choose daylight PDT instead Other: nitrous oxide Post-op Cool compresses, icepacks Sun avoidance Oral analgesia

Answer 184

Maternal age >30 Mother identifies as ATSI Diabetes Obesity High alcohol Past hx of NTDs Smoking Poor nutrition Reduced folic acid intake

Answer 185

Inform theoretical risk of NTD with nbUVB (UVA degrades folic acid > UVB) Weigh risks and benefits, calculate cumulative dose, document Contact obstetrician, USS monitoring Contact medical insurer Check part of consent process

Answer 186

"Just START" Jessners Sal acid TCA (10-25%, 30% if one coat) AHAs, e.g. GA (20-30%) Resorcinol (modified Unna's resorcinol paste) Tretinoin solution (+solid CO2 slush)

Answer 187

TCA 50% TCA 35% + Jessners 70% GA + 35% TCA 88% phenol Pyruvic acid Solid CO2 + 35% TCA

Answer 188

Baker's phenol/ Phenol croton oil

Answer 189

Isotretinoin 6-12 months HSV (active) Radiation Facial surgery Smoking Minocycline Keloid Immunosuppression PIH Unrealistic expectations BDD Pregnancy/lactation Skin PT

Answer 190

Peel itself - agent - conc - number of coats - technique of application (cotton tips, gauze) - pressure exerted - duration of contact Patient factors - pre-treatment preparation/priming - skin type - sebaceous, anatomic location

Answer 191

QS ndYAG 1064 or pico Consent Explain possible side effects - discomfort, blisters, infection, dyspigmentation, scar, hairloss, suboptimal response Anaesthesia - topical ot infiltrate. tetracaine eye drops for eyeshield Safety measures - eyeshield, goggles, close windows, laser safety light Prep skin - remove sunscreen, cosmetics Expect - erythema, oedema, bruising Aftercare - simple analgesia, strict photoprotection Multiple treatments required at least 4, usually about 6-12 weeks apart

Answer 192

Consent - medical and financial Photograph Position, lighting Anaesthetise - ring block, 2% lidocaine 1-2ml each side, wing block Prep (chlorhex soak, prep whole hand) Glove for torniquet, record time Use elevator to lift cuticle and nail fold Bilateral incisions at junction of lateral and proximal nail fold Reflect nail fold with skin hooks Proximal nail fold avulsed to expose matrix Take biopsy from matrix - punch, excisional, or shave Replace nail fold Close skin with 5.0 nylon Remove tourniquet, check timer (document) Dressing with iodosorb, jelonet, gauze, soft padded crepe, crepe (buddy dressing) Post op care - analgesia - elevate, restrict activity - warn of infection - follow up 24-48 hours for wound check and dressing change

Answer 193

Facial cleansing, degreasing - acetone rubbing alcohol, chlorhexidine Apply peeling agent - saturated cotton balls with GA - rung out gauze for TCA or Jessners - cotton tip applicator for intraorbital region Careful to wipe any tears so no wicking Forehead, lateral face, nose, cheeks, periorbital and then infraorbital Feather application at edges Look for frosting endpoint (unless Jessners) GA - neutralise after time or if discomfort, erythema Analgesia - fan/cold air Expectations: Medium depth - erythema sunburn within 30 minutes - oedema within 24 hours - light brown appearance - day 3-7 desquamation Keep skin greasy post op, avoid scrubbing/peeling Careful sunprotection Erythema should fade after 2-4 weeks

Answer 194

Pre-procedure Ensure correct indication No CIs (meds, smoking, HSV, immunosuppression, keloid, pregnancy, PIH etc) Sunprotecting 3 months prior, topical retinoid and hydroquinone 6 weeks prior, stop 3 days before Medical and financial consent Aims, options, expected result, adverse outcomes, costs Photography Degrease face - acetone, cleanser Comfortable position, 45 degree angle, hand held fan Saturated cotton ball Forehead, lateral face, nose, cheeks, periorbital and then infraorbital Feather application at edges Endpoint: frosting, pseudofrost Post procedure: Contact if any concerns Expect dyschromia to be worse before better Erythema fades after 2-4 weeks Strict photoprotection Can wear makeup again after about 1 week Can recommence TOP retinoid after 4-6 weeks

Answer 195

Atrophic scarring Rhytides (glabellar furrows, lower eyelid, nasolabial folds, marionette lines) Volume loss Lipoatrophy Contour defects

Answer 196

Consent - medical and financial Photograph Indications - restore symmetry, volume loss Check for CIs - BDD, hypersensitivity, keloid, bleeding diathesis/ blood thinners, pregnancy, active infection Logistics/explanation of the procedure: - different fillers will last different amounts of time, often HA is used lasts 6-12 months - remove makeup, prep area - anaesthesia: topical, injected locally, nerve blocks - serial puncture with small volume of filler injected - massage - ice - if hx of HSV, prophylactic antivirals - no strenuous activity 24/24, no travel/flights - red flags, contact details Side effects/risks - discomfort - bruising, swelling - haematoma - uneven/asymmetry - beading - tyndall effect - overcorrection - nodule formation - hypersensitivity reaction - HSV reactivation - atypical infection - paraesthesia/nerve injury - scarring - rare but important: intravascular injection - necrosis, blindness

Answer 197

Side to side closure Second intention (if <1cm^2) Advancement flap Rotation flap Transposition flaps - rhombic* (also: bilobed; trilobed - ideal for if both upper and lower eyelid involved) Rotating island pedicle flap - inferiorly based subcutaneous fat pedicle FTSG

Answer 198

Advantages Able to utilise skin laxity from temple Can close larger defects Disadvantages Pincushion effect Tension on lateral canthus Risk of damage to temporal branch of facial nerve when undermining

Answer 199

Side to side *Wedge (defect must be <25% eyelid) *Unilateral single sided advancement flap Rotation flap Transposition flaps (banner, rhombic) Subcutaneous island pedicle FTSG *NB - pre-op evaluation of lower lid laxity (excessive laxity = higher risk lower lid eversion) - main risks of lower lid repair = notching lid margin, misalignment of lash line, entropion and ectropion

Answer 200

Canthopexy - lateral canthal tendon of inferior lid is dissected - 5.0 polypropylene suture to hold and anchor tendon to periosteum of superolateral orbital rim Canthoplasty - lateral canthal tendon is released and trimmed 2-5mm, denuded of its epithelium and secured to periosteum at Whitnall's tubercle (where superior and inferior grey lines meet)

Answer 201

4.0 non absorbable suture - passed through tarsus twice, creating a 'W' with 3 suture strands pulled up and attached above the eyebrow (suture or adhesive strips) Careful to avoid puncta inferiorly and neurovascular bundles superiorly

Answer 202

Defect must be <25% lid margin, lateral to punctum Draw a pentagon around defect with acute angle facing inferiorly (lower eyelid) Haemostasis 6.0 vicryl to suture both sides of lid margin - not yet tied but left long and taped to forehead (or cheek if doing upper eyelid) Close in 2 layers for anterior and posterior lamellae (tarsal plate and muscle) Extreme care to avoid corneal contact with needle Knots tied externally Superficial sutures 6.0 soft e.g. silk - passed and tied through the grey line, left long and placed inferior to eye (can also do lateral canthoplasty of needing extra movement)

Answer 203

Advantages - Ideal for full thickness defects or where there has been loss of structural rigidity of lid Disadvantages - cannot do on medial eyelid (disruption of lacrimal drainage apparatus), or if defect >25% - notching

Answer 204

Side to side Second intention - if <10mm and centrally positioned Rotation flaps (back-cut: glabella, nasofacial) *Transposition flaps (banner, rhombic or bilobed) Island pedicle flaps (esp myocutaneous* - procerus based, but also subcutaneous, transposed or tunnelled) *FTSG, STSG NB: can help to insert probe to better visualise the lacrimal puncta and canaliculi Webbing also common

Answer 205

Heamostasis, cleanse Ointment (WSP/ petrolatum ointment) Apply pressure dressing 48 hours Cleanse area twice daily and apply ointment RV after 2 weeks, change to hydrocolloid dressing (duoderm) Change dressing on alternate days Wound care for up to 6 weeks

Answer 206

Acne scarring Actinic keratoses Actinic cheilitis Benign epidermal growths (AN, epidermal naevus, sebaceous naevus) Photorejuvenation Rhytides Rhinophyma

Answer 207

Infectious Carcinogenic Chemical hazards Direct physical hazards

Answer 208

Extractor, mask, shield

Answer 209

Light is absorbed by water leading to thermal damage Results fully realised 3-6 months after Effects: Short term - raw, ozzing, swollen with slough, tenderness taking 7-10 days to heal Medium term (2 weeks - 3 months) - erythema, mild swelling, pruritus Long term - healthy skin with improved colour rhytides and texture

Answer 210

10,600nm CO2 (chromophore water) 2940nm

Answer 211

400nm - 1400nm

Answer 212

Wavelength and optical density and colour

Answer 213

Expected: - post operative pain - oozing - crusting Short term: - bleeding - delayed healing - granulation - infection (HSV, bacterial) Long term: - scarring - hyper and hypopigmentation - recurrence (uncommon) - development of SCC (up to 5%) - needs careful follow up given ack of histology

Answer 214

Camouflage Sunprotection (reduce contrast) Treat background to reduce contrast Excimer laser Lotanoprost Bimatoprost 0.03% gel (came up in acne scarring JAAD for hypopigmented, along with tretinoin cream 0.025% at night) - bimatoprost can be used in combination with non-ablative fractional laser and CO2 lasers Melanocyte grafting

Answer 215

Erbium YAG - disadvantages: bleeding - advantages: less downtime/quicker recovery; narrower heat zone, less pigmentation CO2 - advantages: haemostasis - disadvantages: increased risk depigmentation, scarring, longer downtime

Answer 216

Need grade 2 compression socks 24 hours for 7 days, then daily for 7 weeks 30 minutes mobilising per day Nothing vigorous exercise Can continue to work, does not need time off work No international flights for 12 weeks Avoid iron supplements and blood thinners Avoid: waxing wearing high heels saunas Worse before better, can take months Top up treatments 3 yearly reviews due to recurrence

Answer 217

Pregnancy and lactation History of IHD, cardiac arrhythmia, glaucoma Epilepsy Pacemaker, defibrillator, deep brain stimulator, cochlear implant, braces Metallic prosthesis

Answer 218

Same for psoriasis, eczema and vitiligo SPT 1-2 = 100mJ/cm^3 SPT 3-4 = 200mJ/cm^3 SPT 5-6 = 300mJ/cm^3

Answer 219

Linear increments of 50-100mJ/cm^3 per visit for all skin types OR 20% for psoriasis and vitiligo; and 15% for eczema

Answer 220

For eczema: SPT 1-2 = 1500mJ/cm^3 SPT 3-4 = 2500mJ/cm^3 SPT 5-6 = 3500mJ/cm^3 For psoriasis and vitiligo: SPT 1-2 = 2000mJ/cm^3 SPT 3-4 = 3000mJ/cm^3 SPT 5-6 = 4000mJ/cm^3

Answer 221

Body SPT 1-2 = 2000mJ/cm^3 SPT 3-4 = 3000mJ/cm^3 SPT 5-6 = 4000mJ/cm^3 Hands and feet SPT 1-2 = 3000mJ/cm^3 SPT 3-4 = 4000mJ/cm^3 SPT 5-6 = 5000mJ/cm^3 Face SPT 1-2 = 1000mJ/cm^3 SPT 3-4 = 2000mJ/cm^3 SPT 5-6 = 3000mJ/cm^3

Answer 222

1 week - HOLD at previous dose (unless burns) 2 weeks - reduce dose by 25% 3 weeks - reduce dose by 50% 4 weeks - review and restart

Answer 223

Attend for review Apologise Review chart - What were the doses - What were the increments - Were there missed treatments (without dose alteration) - Has patient noticed longer duration in machine - Check treatment log book Check when machine was last calibrated Patient factors - Recent tanning - Other sun exposure - New medications - New topical regimens - New medical problems Has the same site always been exposed Document, photographs Exclude infection Topical steroids Bland emollient Miss phototherapy until this is completely settled And reduce dose when recommencing according to how long they have been off treatment for and at what point this reaction occurred If severe - inform MDO Follow up

Answer 224

What to expect: Red, inflamed, swollen for ~24/24 That will settle, left with little black dots/scabs - moisturiser, avoid picking/exfoliation/loufering Watch out for signs of infection Skin care, sunprotection, vaseline, soap substitutes, emollients, avoid other skin procedures Call if any issues Follow up 4-8 weeks

Answer 225

Risk factors: Increased vessel diameter Below the knee treatment Increased concentration of sclerosant Darker skin type High ferritin Other medications (iron supplements, minocycline) Venous insufficiency Techniques: Injecting with minimal pressure Draining any blood clots Compression stockings Excluding CIs prior to treatment Treatments: Hydroquinone Tretinoin cream Azelaic acid Combination creams QS ndYAG, QS Ruby, pico Alexandrite

Answer 226

Ensuring cannula adequately placed in vein (USS) Pain is a warning sign (burning, redness, swelling, feeling of pressure, prickling) QS ndYAG, QS Ruby, pico Alex, pico 1064

Answer 227

Red 24 hours Avoid picking/scrubbing Photoprotection, sunscreen Soap substitute, emollient Avoid other procedures PRN paracetamol Call if any blisters, infection Follow up at 8 weeks and option to retreat Endpoint - mild transient greying

Answer 228

Patient - no contraindications Room/environment - windows covered, plume extractor, saftey eyewear, laser appropriate marks, light signage, hearing protection Laser - settings - documentation

Answer 229

Darker, thicker/dense hair (terminal responds better than vellus hairs) PCOS (more treatments required) Between treatment intervals shaving is best (avoiding plucking and waxing) Treatment intervals every 6 weeks Correct laser settings, desired endpoint

Answer 230

Pregnancy, breastfeeding Known allergy Infection at site Pain intolerance, needle phobia Unable to attend multiple appointments Poorly controlled diabetes for large areas being injected

Answer 231

Cosmetic Medical Artistry - professional or amateur Traumatic

Answer 232

Time required to dissipate 50% of the heat that a chromophore gets after laser exposure

Answer 233

Heating of the selected chromophore such that the surrounding tissue is not destroyed

Answer 234

Paradoxical hyperpigmentation with QS laser Ferric to ferrous oxide conversion Treat with single pass ablative laser

Answer 235

Different methods Tap water wetted pads in direct contact with treatment sites for 20 minutes, 3 times weekly for 3 weeks, then reduce frequency to as required Also can do with glycopyrrolate 0.05% 1x weekly, then every 2 weeks then gradually to every 3-4 weeks (less frequently than water)

Answer 236

Tingling Pain Blistering Excess dryness Hyperaesthesia Anticholinergic effects from systemic absorption of the glycopyrrolate - dry mouth, blurred vision, palpitation, cardiac arrhythmias, urinary retention, constipation

Answer 237

Kirby Desai scale Fitzpatrick skin type Location of tattoo Type of tattoo (professional, amateur) - ink intensity Colours (black is best, multiple is worst) Number of layers - layering tattoos Scar tissue in area

Answer 238

Isotretinoin Keloid Allergy to tattoos previously e.g. allergy to red tattoo Infection Recent physical therapy in zone - chemical peel, dermabrasion RadTx Blood clotting abnormalities

Answer 239

Banner or rhombic transposition flaps Advantages: - able to utilise redundant skin from glabella or nasal root - scar hides well in glabellar rhytides or nasal root crease Disadvantages: - pincushioning - webbing (pexing suture helps) - may bring eyebrows together

Answer 240

Advantages: - robust flap, good blood supply - ideal for deep defects and if flap needs to be moved longer distance - good tissue match Disadvantages: - Pincushioning - Triangular shape - Bruising, swelling over nose and bilateral infraorbital area

Answer 241

Triangle drawn medially towards opposite medial canthus (width slightly wider than defect) First incision superior, to subcut Glabella undermined in this plane Second incision inferior, down to periosteum Undermining in superior direction Cut vertically through procerus to narrow the superior muscle pedicle Thin flap leading edge to go on medial canthus Haemostasis First suture pulls flap into position, second suture pulls trailing edge together behind the flap Pexing suture to keep concavity at medial canthus Try to maximise eversion, mattress sutures Trim flap corners

Answer 242

Side-to-side (horizontal curvilinear (belpharoplasty)) Wedge repair Advancement flaps* - including unilateral single-sided L plasty or Burow's exchange; blepharoplasty exchange; blepharoplasty myocutaneous Rotation flap Transposition flaps (rhombic, banner) Subcutaneous island pedicle* FTSG Cautions: Avoid lagophthalmos, ectropion, eyebrow distortion, notching

Answer 243

Advantages - Blepharoplasty exchange advancement flap is ideal for broad-based anterior lamellar defects between lash line and eyelid crease - Blepharoplasty myocutaneous advancement flaps are for defects up to 1cm in pretarsal eyelid ideally in middle thirs of eyelid from marginal zone to palpable crease - Good functional and cosmetic outcomes Disadvantages - Need sufficient skin laxity to avoid lagophthalmos and maintain brow position - May have loss of some eyelashes

Answer 244

Medical hx - Allergies - LA, abx, latex, dressings - Blood disorders - Malnutrition - Poor general health - Poorly controlled diabetes Surgical hx - Past surgical and dental hx - Excessive bleeding - Bad scar/keloid formation, adverse wound healing - Wound infections - Local anaesthetic reactions - Prior surgery or radiotherapy in area Social hx - Smoking - ETOH - Occupational requirements - Geographical distance - Language difficulties

Answer 245

Cardiac: - prosthetic valve - previous endocarditis - heart transplant with abnormal valve function - congenital heart disease: unrepaired or partially repaired cyanotic defects; or complete repair within 5 months Joint replacement: - within last 2 years - prior history of prosthetic joint infection - immunosuppression Vascular grafts: - within past 4 months

Answer 246

Frontalis - raises eyebrows - temporal branch of facial nerve Corrugator supercilii - brow medial and down - temporal branch of facial nerve Procerus - forehead and brow inferiorly - temporal branch of facial nerve Orbicularis oculi - closing eye - zygomatic and temporal branch facial nerve Levator palpebrae superioris - opening eye - zygomatic branch facial nerve Orbicularis oris - draws lips together, puckers mouth - buccal and marginal mandibular branches facial nerve Buccinator - flattens cheeks against teeth - buccal branch facial nerve Lip elevators - zygomatic branch facial nerve Levator labii superioris Levator labii superioris alaeque nasi Zygomaticus major Zygomaticus minor Other lip elevators - buccal branch facial nerve Levator anguli oris Risorius Lip depressors - marginal mandibular branch facial nerve Depressor anguli oris Depressor labii inferioris Platysma (cervical branch of facial nerve) Mentalis - lower lip elevation and protrusion - marginal mandibular

Answer 247

Superficial musculoaponeurotic system Superficial layer of fascia, invests nearly all the muscles of facial expression, esp lower face, mid-face and forehead Binds all muscles of fascial expression together, allowing them to work in unison Joins with superficial temporal/temperoparietal fascia superiorly and with platysma inferiorly (Deters spread of infection from superficial to deep areas of face) Motor nerves are deep to the SMAS

Answer 248

0.5cm below tragus, 1.5cm superior to lateral eyebrow, draw line

Answer 249

Frontalis - raises eyebrows Orbicularis oculi - closes eye Corrugator supercilli - wrinkles brow Ear

Answer 250

Postauricular nodes - posterior ear, parietal, mastoid and temporal area of the scalp Occipital nodes - muscular layers of the neck and posterior aspect of the scalp Parotid nodes - Lateral cheek, anterior ear, forehead, frontolateral scalp, lateral canthus (upper and lateral face) Submental - Central lower face, medial 2/3 lip, chin, floor of mouth, anterior tongue Submandibular - Lower eyelids, medial cheeks, nose, rest of lips, gingiva

Answer 251

Temporal branch - 0.5cm below tragus, 1.5cm superior to lateral eyebrow, draw line Zygomatic - just lateral to the zygomatic eminence (over the zygoma) Marginal mandibular - as it emerges from the inferoanterior margin of the parotid gland, at the mandibular angle; and in the neck below the mandible; Crosses mandibular ramus anterior to facial artery (pulse can be palpated at the anterior border of the masseter, helping to identify the danger zone)

Answer 252

Auriculotemporal - upper ear Lesser occipital - mid-lateral (and posterior ear) Greater auricular - lobe/lower ear Auricular branch of vagus nerve - conchal bowl

Answer 253

Labial artery at LIP Angular artery as it courses near the NOSE Facial artery as it crosses mandibular rim Superficial temporal artery superior to ear

Answer 254

Becomes facial artery after crosses mandibular rim Facial a. then takes anterosuperior course in direction of oral commissure Branches inferior and superior into labial arteries Also courses along medial cheek to nose making angular artery - enters orbit to anastamose with ophthalmic artery branches Superficial temporal artery behind parotid (psoteroinferior aspect), after zygomatic arch it enters subcutaneous fat

Answer 255

Can be damaged at fibular head, easily palpable, injury leads to loss of dorsiflexion (foot drop)

Answer 256

Scars should be oriented perpendicular to lower lid margin (therefore not following relaxed skin tension lines) Choice of repair to minimise any downward pull e.g. Tenzel advancement flap from lateral or rhombi transposition flap from inferior Oversize grafts up to double defect size Size flaps generously in order to push up inferior lid Periosteal tacking/suspencion suture to suspend flap to bony orbit/temple and prevent pull on lower lid If lower lid laxity - full thickness triangular wedge Canthoplasty/canthopexy - horizontal incision several mm lateral to the lateral canthus, exposing lateral canthal ligament, which is then tacked to superior orbital rim Frost suture, taping, lower eyelid splinting

Answer 257

Paralysis of upper lid Epiphora Exposure keratitis

Answer 258

Inability to smile, whistle Grimace - affected side lower lip will not go down as much as it does on the other side when smiling (because depressor labii superioris isn't working)

Answer 259

<1min 30-120 mins (1-6.5hrs with adrenaline) Max: 5mg/kg without adrenaline 7mg/kg with adrenaline Kids: 1.5-2 mg/kg without adrenaline 3-4.5mg/kg with adrenaline

Answer 260

30-60 mins for LMX - quickest tetracaine 60-90 EMLA 60-120

Answer 261

LMX more effective than EMLA, even if unoccluded vs occluded LMX = lidocaine 5% EMLA = prilocaine 2.5%, lidocaine 2.5% LMX quicker, EMLA slower LMX longer duration EMLA should not be used near the eyes - caustic/alkaline injury to cornea

Answer 262

Advantages - decreased tissue reactivity - decreased tissue strangulation - excellent wound edge eversion Disadvantages - patient discomfort - staple extractor required

Answer 263

Ring (very sharp) Oval head Spoon curettes Sizes 1-9mm

Answer 264

Indications: Benign - soft epidermal lesions (seb k, AK, molluscum) - easy cleavage plane between lesion and dermis Superficial low grade akin cancer eg sBCC Debulking prior to Mohs Contraindications: Lax skin Invasive tumours

Answer 265

Mark out lesion with margin Shave saucerisation first for histopathological analysis Steady surrounding skin Firm downward motion of curette Obtain multiple fragments Multiple curette cycles (serial curettage) for malignant lesions Haemostasis - chemical, electrosurgical or haemostatic dressings Warn risk depigmented and hypertrophic scarring

Answer 266

Execution: - debulk thick flap or graft - suture to open nasal valve/ affix it to underside of flap or graft - pexing suture to bring out the ala - use nasal packing for 48hours post op (xeroform, jelonet), gadel airway - work combined with plastics or ENT - ala batten grafts to improve structural support Once complication has occurred: - apologise - conservative measures - watch and wait, breathe rite strips to open nasal valve (especially useful at night) - refer to plastics or ENT - ala batten grafts, rhinoplasty, ala rim grafts Close follow up +++

Answer 267

NEET NOCH FAIR NEET - heals well with second intention Concave surfaces of Nose Ear Eye Temple NOCH - heals poorly Convex surfaces of Nose Oral lips Cheek/chin Healix FAIR - might heal well, unpredictable Flat surfaces of Foreahead Antihelix ear (I)Eyelids and the Rest of nose, lips, cheeks

Answer 268

Planning: - Appropriate closure type - Long acting local anaesthetic - Could you use a graft/Burow's graft for part of it to reduce tension - Regular analgesia from the outset - paracetamol/codeine - Warn about pain so they can get on top of it early and expect some discomfort - Ice area hourly - Minimise physical activity, rest - Contact details including after hours and ability to walk-in if needed and be seen by self or nurse if increased pain Other methods post: - Pain relief, ice, clinic review - Consider removing some sutures where there is highest tension (some areas can be left to heal by secondary intention) - Check if any other factors playing a role - infection, bleeding/haematoma, nerve entrapment, social situation - Or if headache any other cause eg stroke or other - Regular close follow up

Answer 269

PDL/vascular for erythematous/telangiectatic scars Fractional resurfacing lasers for hypopigmented/atrophic scars Pulse ablative lasers for thickened/irregular scars (note: dermabrasion similar effect as this)

Answer 270

With UVB, you start at 70% MED MED testing is done on sunprotected skin You read MED at 24/24

Answer 271

Broadband UVB 290-320nm nbUVB 311-313nm UVA 320-400nm UVA1 340-400nm

Answer 272

Anticoagulation e.g. heparin (to prevent clotting in the tubing system) 2 consecutive days each month, assess response after 3 months Takes 2-4 hours Blood is drawn, white cells are separated White cells are treated with PUVA (methoxypsoralen + UVA) Then re-infused back into patient Indications: MF, Sezary, GVHD, SSc

Answer 273

Low BP, dizziness Fever (2-12 hrs) Red, itch (6-8 hrs) Photosensitivity/light sensitivity Anaemia, thrombocytopaenia Heart failure Take antihypertensive post if needed Fast if hypertriglyceridaemia Sunglasses 24hrs

Answer 274

Vascular lesions Some pigmented lesions and photoaging (ephilides, lentigines, rhytides) Hair removal

Answer 275

fine lines, wrinkles stretch marks scars (incl acne scars) hyperpigmentation melasma

Answer 276

Indications - Acne scars - Fine lines and wrinkles - Skin laxity - Other scars (surgical or trauma) - Striae - Hyperhidrosis Contraindications: - Pregnancy or breastfeeding - <18yo without parental consent - BDD, unrealistic expectations - Koebnerising skin disease - Tendency for keloid scars - Active infection

Answer 277

Usually 5 treatments, 1-2 months apart Targets collagen with aim of remodelling and tightening, new elastin production Expectations: 50% improvement after 5 treatments Consent - medical and financial Photograph Remove makeup Topical anaesthetic Micro needle cartridge/handpiece applied in direct contact with skin Then needles penetrate the skin with minimal epidermal trauma Bipolar radiofrequency energy denaturalises the tissue around the microneedles Needles are removed Slight discomfort during treatment, minimal Mild tight tingling for few hours post Swelling and redness 1-2 days Other risks Oozing, weeping, scabs, broken skin Excessive swelling, redness, discomfort Bruising Infection (HSV) PIH Hypopigmentations SCarring Failure to be effective Aftercare: Gentle moisturiser Regular sunprotection

Answer 278

Pre-op consult and assessment, appropriate patient and site for flap or graft Selection and design of appropriate flap or graft Execution: - gentle handling with skin hooks or fine toothed Adson forceps (preventing damage to tissue and blood supply) - haemostasis sufficient but not excessive - correct sizing to reduce tension - use fine sutures to reduce trauma - for graft - basting sutures and bolster tie over dressing (increasing contact of graft with base, and preventing external trauma)

Answer 279

Exits anterior parotid Superficial to masseter Pierces through buccinator Drains into mouth at 2nd molar Most vulnerable as emerges from parotid gland and over buccal fat pad Chronic draining sinus if injured, required intervention, will NOT heal on its own (unlike parotid gland)

Answer 280

Darkening/greying centrally and disappearance of feeder vessel

Answer 281

Whitening and pinpoint purpura/petechiae

Answer 282

Immediate whitening and some mild pinpoint bleeding

Answer 283

Mild erythema

Answer 284

Sezary GVHD Nephrogenic systemic fibrosis Systemic sclerosis

Answer 285

Pregnancy, breastfeeding Allergy Hypotension Anaemia CHF

Answer 286

liquor picis carbonis

Answer 287

Anthralin 0.5% cream applied to affected areas scalp Wash with shampoo/soap and water Initial application time 10 minutes Increase that time by 10 minute increments every 4-5 days Aim for slight irritation (erythema, scale, pruritus) If able to tolerate for 60 minutes, increase concentration to 1% anthralin and start at 10 minutes contact time, increasing same way If tolerating 1% anthralin for 60 minutes then can try overnight If excess irritation at any stage, then can withhold for a few days and recommence at the toleratable contact duration Response over 12-24 weeks Beware/expect: - Brown staining scalp and hair (also furniture, bedding, clothing if not careful) - Avoid getting in eyes - do not apply to eyelids or lashes

Answer 288

Goekerman's = tar bath, UVB, tar Ingram's = tar bath, UVB, dithranol Day unit admission Multiple consecutive days for 1-2 weeks Coal tar bath 20% (20 minutes)/ pinetarsol bath Olive oil to help remove dithranol from night before Sorbolene after bath nbUVB TCS after nbUVB eg elocon Dithranol (starting at 0.1% slow increase by 0.25% every 2 days as tolerated to max 1%) in Lassar's paste (= 2% SA, 24% zinc, 24% starch, 50% WSP) (or (Zn 96%, sa 2%, paraffin 2%)) Talcum powder/corn starch to set paste Crepe bandage/tubigrip Leave on overnight Options for long contact (24 hours) Or short contact (20-30 minutes then wipe off, no covering) Followed by TCS eg diprosone

Answer 289

Cryoglobulinaemia Young children Skin phototype darker Aggressive/invasive tumours High risk sites of tumours (perioral, ear, perinasal, periocular)

Answer 290

Open spray technique Closed technique with: chamber, probe Forceps application

Answer 291

Pain, discomfort Bleeding Erythema, oedema, blister Exudation Ulceration Poor healing Infection Hyper/hypopigmentation Milia Pseudoepitheliomatous hyperplasia Cold urticaria Scarring, hypopigmentation Retraction/notching of free margins Alopecia Nail dystrophy Paraesthesia Headache if on scalp or face

Answer 292

Side-to-side* (can do also with Burow's graft) Nasolabial advancement flap* Rotation flap Transposition flap Subcutaneous island pedicle flap*

Answer 293

Incision down nasolabial sulcus and down melolabial/nasolabial fold (defect may need to be extended slightly medially) Undermining at level of subcutaneous fat, fair degree required Haemostasis Inset flap with skin hooks First suture a pexing/suspension suture - deep down to periosteum of nasal bone and in dermis of flap (~5-10mm back from the advancing tip) Finish deep sutures (rule of halves) Trim excess tip of flap Rotation pucker/redundant cone removed from under eye - in cosmetic junction line between cheek and eyelid Superficial sutures

Answer 294

Advantages - using skin laxity from cheek - portion of scar hides well in nasolabial fold - tension directed towards the nose Disadvantages - ectropion (if not performed correctly) - can have long lasting lower eyelid oedema from scar along inferior eyelid

Answer 295

Draw long inverted triangle from inferior border of defect Place one side in nasofacial sulcus and nasolabial fold Length of triangle 2-3x length of defect Lenticular shaped variant works well here Incise and undermine in subcutaneous plane As needed, pedicle can be loosened by blunt dissecting with scissors in vertical manner to avoid damage to nerves and vessels Haemostasis First suture - absorbable suture to pull leading edge across the defect Second suture - to close resultant secondary defect

Answer 296

Advantages: Good blood supply Can close large and deep defects Half of scar disappears well in the nasolabial fold Disadvantages: Triangular scar can be obvious, especially lateral arm Flap oedema (can persist) Scar troughing

Answer 297

Side-to-side Advancement flap Rotation flap Tranposition flap - rhombic, bilobed Subcutaneous island pedicle flap (+rotating variant) 'Reading man' flap

Answer 298

Advantages - ideal for defects in malar and infraorbital areas - minimal dog-ear deformities due to rotation angles <90 degrees - minimal eyelid retraction and ectropion risk - good tissue match and reduced scar area Disadvantages - defect limited in size to <2cm for infraorbital and <4cm for malar - if suboptimal design then dog ears can ocur - some scar lines will cross relaxed skin tension lines and be more obvious

Answer 299

Side-to-side Second intention Burow's exchange advancement flap Transposition flaps (rhombic) Subcutaneous island pedicle Skin grafts

Answer 300

Frey's syndrome (gustatory sweating) Salivary fistula Sialocele (salivary gland cyst)

Answer 301

Outline flap by drawing a line from inferolateral border of defect down preauricular fold (line extends beyond earlobe) Draw standing cone medial to defect Design so vertical line can sit in preauricular fold Incise and undermine in subcutaneous plane Haemostasis Absorbable sutures to advance flap superiorly over defect Excise standing cone and close Burow's triangle from beneath ear lobe Close

Answer 302

Advantages - suitable for larger defects in this region - utilises redundant skin from cheek and jowls - preserves hairless zone Disadvantages - Horizontal scar from removing standing cone medial to defect may be noticeable - not suitable for very large vertically oriented defects - can cause reorientation of the skin rhytides

Answer 303

Side-to-side Advancement/rotation flap* Rhombic transposition flap

Answer 304

Head in neutral position when marking flap Draw triangle from superior end of defect, conforming with RST lines on cheek Draw line from inferolateral border of defect along mandibular margin, with Burow's triangle at angle of mandible/infra-auricular or submandibular Excise standing cone Incise flap and undermine widely in subcutaneous plane Haemostasis Advance flap, suture with absorbable sutures Remove burow's triangle Insert superficial sutures

Answer 305

Advantages - Scarlines conform to relaxed skin tension lines of cheek and junction line of mandibular margin - Burow's triangle is hidden in infra-auricular or submandibular area - Avoids crossing mandibular margin Disadvantages - Burow's triangle may produce some troughing across mandibular margin

Answer 306

Electrodessication - tip in contact with skin - superficial tissue dehydryation through water vaporisation - monoterminal - alternating current - voltage high - amperage low - waveform damped - good for superficial, not very vascular - slightly higher risk dermal damage c/w electrofulguration Electrofulguration - tip not in contact with skin (spark) - superficial tissue carbonisation or charring - monoterminal - alternating current - voltage high - amperage low - waveform damped - good for superficial, not very vascular Electrocoagulation - tip in contact with skin - deeper tissue, through thermal denaturation - biterminal (therefore need to ensure indifferent electrode is attached to patient) - alternating current - voltage low - amperage high - waveform moderatley damped Electrosection - cuts through tissue by causing tissue vaporisation - alternating current - voltage low - amperage high - undamped or slightly damped - superior speed and haemostasis Electrocautery - hot tip, no electrical current - safe with PM and defib - tissue charring - voltage low - amperage high - pinpoint haemostasis (otherwise not great)

Answer 307

Fixed rate No effect Demand: ventricular inhibited Bradycardia Asystole Ventricular triggered Extrasystole Tachyarrhythmia VF

Answer 308

Effective for skin-limited MF - MF stage IA–B disease - complete response rates of >80% - Tumour stage MF response rates ~40% total dose is 36 Gy administered in fractions of 1.5–2 Gy over 8–10 weeks can do lower doses 10-22 Gy, allowing for re-treatment perineum, plantar surfaces & scalp receive supplemental “boosts” as not adequately treated in standing position Side effects mild, including: erythema, scaling, and temporary loss of hair, nails and sweat gland function (hypohidrosis) NO other systemic side effects, NO nausea/vomiting Can do adjunct PUVA

Answer 309

- Electrical burns - Electric shock - Patients remove all jewellery - Patients (and staff) avoid contact with grounded metal objects - Avoid solutions containing alcohol (ignition risk) - Avoid moist packing around anus (risk of methane ignition) - Account for the possibility of interference with cardiac pacemaker, implantable cardioverter-defibrillator, deep-brain stimulator - Eye injury - eye protection if near eye - Plume safety - extractor and masks - Infection trasnmission HPV, Hep B

Answer 310

- Haemostasis control (electrodessication or electrocoagulation) - Treatment of benign lesions (acrochordon, sebaceous hyperplasia, rhinophyma, verrucae) - Treatment of pre-malignant lesions (AK) and some malignant lesions (sBCC)

Answer 311

Not absolute contraindication but rather need to practice extreme caution with patients with implantable devices - liaise with relevant specialists and technicians PPM Type of pacemaker Fixed rate - no effect Demand: ventricular inhibitor - can cause bradycardia or asystole Ventricular triggered - can cause tachyarrhythmia, VF Ensure cautery not too close to site > 5 cm Short bursts < 5 seconds Low power settings Bipolar Perform in hospital or consider other treatments Consider hot wire electrocautery instead Liaise cardiology to change PPM into fixed rate mode Post op cardiology consult Place grounding plat not directly in path between treatment and indifferent electrode, and not over bony prominence and make sure well adhered

Answer 312

Application of low level electric current to skin surface Results in reduced sweat production, possibly due to the production of a physical blockage at the level of the stratum corneum

Answer 313

Palmoplantar hyperhidorsis Axillary hyperhidrosis (Drionic) Delivery of drugs (lignocaine/adrenaline)

Answer 314

Known hypersensitivity/allergy Active infection at the site Pregnancy and lactation Body dysmorphic disorder Unrealistic expectations Relative: bleeding diathesis, keloid scarring Unable to consent, <18 years NOT be used simultaneously with laser, deep chemical peels or dermabrasion Previous fat transfer Autoimmune disease - relative

Answer 315

Hyaluronic acid Poly L lactic acid Calcium hydroxylapatite (CaHA) Polymethylmethacrylate (bovine collage, requires skin test)

Answer 316

Discomfort Redness, bruising, swelling immediately post (Redness lasts 1-2 days) (Bruising lasts 5-10 days) Incomplete, uneven, asymmetry Beading and nodule formation Bluish discolouration (Tyndall) Hypersensitivity reaction (red bumps) Atypical infection Granuloma formation Neuropraxia Haematoma Scarring Skin necrosis (intra-arterial injection) Vision loss Short term/early - Infection - Vascular compromise - Injection site reactions (redness, bruising, welling) - Hypersensitivity - Technical placement errors - asymmetry, contour irregularity Long term/late - Biofilm - Migration of filler - Immune reaction - Granuloma - Nodules, abscesses - Persistent discolouration

Answer 317

HA Periorbital rhytids - superficial dermis Deep perioral rhytids - mid dermis Nasolabial furrows - deep dermis Autologous fat Subdermal plane for lipoatrophy

Answer 318

Chemical peels Dermabrasion Ablative laser therapy Non-ablative laser therapy Indications: Photoageing AKs Benign epidermal growths Scarring Rhytides Rhinophyma Contraindications: BDD Keloid scarring tendency Active infection at treatment site Isotretinoin therapy Immunosuppression Previous facelift surgery Previous radiotherapy

Answer 319

microdermabrasion - non-invasive, minimal clinical benefit mechanical dermabrasion - hand engine which powers an abrasive endpiece (diamond fraise or wire brush) - very bloody, risk of airborne blood particles Or No 80-120 sandpaper Side effects: dyspigmentation, milia, infection

Answer 320

Resorcinol 14g Sal acid 14g Lactic acid 14g Ethanol 95% 100ml Endpoint is erythema and speckling, not frosting

Answer 321

Chemical reconstruction of skin scars For atrophic acne scars TCA 65-100% Sharpened wooden applicator (or paint brush) Best to treat rest of face with superficial peel (e.g. TCA 10-15%) 2-6 treatments

Answer 322

Sunscreen - 3 months prior, indefinitely afterwards Tretinoin - pre and post - 6 weeks prior, minimum, restart post re-epithelialisation AHAs (GA or LA) Hydroquinone +/- antiviral

Answer 323

TCA 50% TCA 35% + Jessners 70% GA + 35% TCA 88% phenol Pyruvic acid Solid CO2 + 35% TCA

Answer 324

"Just START" Jessners Sal acid TCA (10-25%, 30% if one coat) AHAs, e.g. GA (20-30%) Resorcinol (modified Unna's resorcinol paste) Tretinoin solution (+solid CO2 slush)

Answer 325

Baker's phenol/ Phenol croton oil

Answer 326

Peel itself - agent - conc - number of coats - technique of application (cotton tips, gauze) - pressure exerted - duration of contact Patient factors - pre-treatment preparation/priming - skin type - sebaceous, anatomic location

Answer 327

Fraxel 1550nm Less complicated, less painful, shorter recovery time, minimal complications Need for multiple treatments, inferior overall results

Answer 328

Acute/short term 7-10 days Raw, oozing, red, swollen, slough, tender Medium term 2 weeks - 3 months Erythema, mildly swollen, pruritic (but fully resurfaced) Long term Post 3-6 months Healthy skin with improved colour, rhytides, texture

Answer 329

Infection (viral, bacterial, fungal) Milia Acne Contact dermatitis Persistent erythema or pruritus Hyperpigmentation Hypopigmentation Atrophy and textural changes Scarring (incl hypertrophic) Ectropion Incomplete clearance/recurrence

Answer 330

pre-op dose ~1 hour Staph aureus: Cephalexin 1-2g Clindamycin 300-600mg Strep viridans (oral): Amoxicillin 1-2g Clindamycin 300-600mg Gram negative/pseudomonas: Ciprofloxacin 500mg BD

Answer 331

Consent - medical and financial Photograph - dermoscopy and clinical Chlorhexidine soak 10-15 mins Digital nerve block Inject 1.5 ml of 2% lignocaine without adrenaline each side, dorsolateral approach Advance needle until hit bone, then slightly retract, inject both dorsal and ventral nerves Wait 10-15 mins Can inject small amount of LA near nail plate Prep whole hand Tourniquet on Cut finger off of sterile surgical glove Exsanguinate while rolling back cuff proximally Document time Limit 15 mins Use nail elevator to lift the nail cuticle and fold off the nail plate Further retract nail fold by performing bilateral parallel/oblique incisions at junction of proximal and lateral nail folds with 15 blade and reflect with fine skin hooks - remove nail plate as a trap door proximal nail fold is avulsed to expose matrix Identify origin of pigment Perform biopsy (excision or shave or punch if <3mm) Mark specimen with ink to orientate and send in cassette to preserve orientation and prevent loss of tissue - send for histology Use 6-0 absorbable vicryl rapide sutures (if needed), replace nail plate and proximal nail fold with 5-0 nylon Wrap buddy dressing with adjacent finger - iodosorb, xeroform, gauze, softban padding, micropore Tourniquet off and document time Ensure brisk capillary refill Sling for elevation Restrict activity Analgesia with Panadeine forte Review 24 hours Warn about infection - red flags, contact details

Answer 332

Adrenaline Ring block technique (circumferential anaesthesia) Excessive tourniquet pressure Post-operative burns from hot soaks to anaesthetised fingers Injecting excessive volumes (>8ml) Infection avoid the use of adrenaline especially in patients with PVD use small needles (30 gauge) to avoid vessel injury limit volume of anaesthetic used to 1–2 mL Dorsal approach avoid circumferential block of the digits block at the level of the metacarpal heads do not use digital block if there is infection or trauma of the proximal phalanx (distal to the injection site) ensure bandages are not too constrictive / use buddy dressing counsel patients to avoid postoperative hot soaks

Answer 333

Nail dystrophy Bleeding Pain Infection Osteomyelitis / septic arthritis Necrosis / digital ischaemia (amputation) Extensor tendon injury DIP joint stiffness Reflex sympathetic dystrophy Inadequate sample/sampling error

Answer 334

Removal of nail plate Can be complete or partial Can be proximal or distal Can be surgical or medical (main ingredient medically is urea 40%) Both distal and proximal approach begin with sepeartion of nail plate from proximal nail fold Indications: Onyhcomycosis, onychogryphosis, onychocryptosis (ingrown)

Answer 335

Definition: nail matrix destruction Can be partial - treatment for ingrown nails, onychomycosis Or total - treatment for pincer nails, onychogryphosis, onychomycosis Different techniques: Scalpel excision - partial (wedge excision lateral horns) Scalpel excision - total/complete Chemical - phenolisation Electrosurgically (with curettage) CO2 laser ablation

Answer 336

Active infection Anticoagulated/bleeding diathesis Raynaud's Peripheral vasopasm PVD Smoking T2DM

Answer 337

Appropriate footwear Trimming Chemical softeners - urea (40%), potassium iodide, sal acid Burring down with podiatrist

Answer 338

Conservative - warm water soaks - Cotton-wick insertion in the lateral groove corner – gently lift the edge of the nail that is digging into the skin and place a small piece of rolled cotton, gauze, dental tape or floss, between the nail and the skin to keep it elevated - clip toenails straight across - wear good shoes - keep feet clean and dry - stretching skin/keeping away from nail folds Topical or oral antibiotics Surgical: Lateral nail avulsion plus matricectomy/ lateral wedge resection

Answer 339

Consent - medical and financial Need to wear open toe shoes on day and have family/friend drive home Photo Explain risks, expectations post op Exclude contraindications - PVD, scleroderma, diabetes, active infection Digital nerve block + local infiltration around nail plate Soak with chlorhexidine for 10 mins Tourniquet on (penrose drain for feet, twist and use suture holder) Exsanguinate while rolling back cuff proximally Document time Limit 15 mins Clean and prep Test LA Use nail Freer Elevator to avulse nail plate off nail bed Use nail splitter/scissors to cut through nail plate Remove nail plate with artery forceps Gently curette any granulation tissue Ensure all nail spicules and lateral horn is completely removed Sterile Vaseline around non-treated areas Apply 88% phenol via cotton bud wrapped around forceps to epithelium of matrix and horns, 4 min contact, avoid dripping/spills, twist over nail Other options: TCA, CO2 laser, electroradiosurgery Suture nail fold Buddy dressing Torniquet off Ensure brisk capillary refill Review 24-48 hours Analgesia Elevation

Answer 340

Assess neurovascular status - sensation, movement Assess capillary refill Assess peripheral pulses Complete set of observations Swab bacterial MC+S and viral PCR Antibiotics empirically Take history for other possible causes Infection - bacterial, viral, fungal, atypical mycobacterial, septic arthritis Gout Trauma PVD Recurrence Reflex sympathetic dystrophy Nail spicules growing inward Hypergranulation tissue Implanted epidermoid cyst

Answer 341

Baseline photography Consent - medical and financial Vital signs Correctly identify site of tumour with use of previous photos, dermoscopy and magnification Mark out tumour Outline landmarks and borders of cosmetic subunits as LA may distort anatomy Infiltrate with LA 1-2% lidocaine with adrenaline or bupivacaine / ropivacaine (longer acting) Prep with povidone-iodine or chlorhexidine gluconate and drape If tumor is thick or large, debulk using a curette or blade Incise along the marked margin with no. 15 blade Score edges to orientate specimen Remove saucer shaped specimen with 30o beveled edges Hemostasis with direct pressure, electrocoagulation Place pressure dressing and patient can wait in waiting room 2 dimensional map is created with aid of a photograph Specimen is divided into sections to fit on a microscope slide Number sections, clockwise pattern, 1 starting at 1 o'clock Ink specimens - non-epidermal edges are stained to allow orientation Each layer may require 1-2 hours for processing and reviewing Highly trained technologist Flattening of the specimen Cut in horizontal section Tissue cryostat/frozen section Slides and stained with H+E +/- immunostains Slides are rinsed Coverslip is applied Microscopic review Multistage progress until complete tumour extirpation has occurred Examine vertical specimen of debulked tumor first Interpretation - Mohs surgeon is also pathologist Patients with CLL and solid organ transplant have increased risk of prominent inflammatory foci on Mohs sections making interpretation more difficult Cut further excisions at areas where tumor is still present with 2-5 mm margins Repair with above, flap or graft, may require plastics/oculoplastics Key points: utilises horizontal sections Equipment: cryostat, highly trained histotechnicians, stains

Answer 342

"I assume the options have already been discussed with the patient, and the patient and I have jointly decided to move forward with DCP" Photos Educate Consent Sensitise: - In office - Comfortable position, role up sleeve - Wearing gloves - Applicator stick/ toothpick - Apply 2% to inner arm - Dressing (tegaderm), keep dry - Leave in place for 2-3 days/ 48 hours - Wash off with water and soap TCS as rescue in case needed Warn about what to expect, blisters Wait 2 weeks Look for reaction Then commence therapy At home application: - Safe environment, away from children - Starting at 0.1% - Pt apply after washing hands, wearing gloves, use toothpick, apply to affected area - Apply vaseline ointment around the affected area - Avoid contact with non-affected areas

Answer 343

- Review in person - Apologise for experience, reassure - Stop application - Swabs bacterial and viral - Cover abx - Potent TCS such as diprosone - Analgesia (1 full mark) - Check concentration of script/on bottle - any error - Check how they have been applying - Small risk PIH/scar - Likely treatment will work

Answer 344

topical brimonidine (3.3%), topical oxymetazoline (1%) oral beta-blockers (carvedilol), oral clonidine

Answer 345

Too high fluence, wrong wavelength, no cooling, accidental pulse stacking, longer pulse duration Malfunction machine Treated a darker skin type

Answer 346

In-built cryogen spray Contact - ice, gel Air - zimmer Laser - sapphire plates

Answer 347

Tetrafluoroethane

Answer 348

Sunprotect Cool packs Sleep on 1-2 pillows Avoid heavy exercise Gentle skin care Will get some bruising, don't be alarmed Watch for signs of infection Given written information Contact if concerns, number to call Review 6-8 weeks

Answer 349

PDL 595, 585 KTP 532 For central papular component - LP ndYAG 1064

Answer 350

Hardening, popping

Answer 351

Celestone chronodose

Answer 352

TCA 50-90% Ablative laser Electrodessication Cryotherapy Curettage Shave excision Serial punch excisions (~every 4 weeks)

Answer 353

Less frequent and not as short haircuts, avoid shaving and tight collars Can swab pustules Topical steroids, antibiotics and retinoid Oral tetracycline or retinoid ILCS Excision CO2/erbium laser Laser hair removal Cryotherapy

Answer 354

Consent and photos Positioning Lighting Clean face - remove makeup, sunscreen Curette (LA if needing to curette more hyperkeratotic lesions) Apply MAL 16% - 5mm margin, 1mm thick Opaque dressing over top leave on 3 hours, keep sunprotected Return, remove cream Protective goggles Red light 630nm, 8 minutes, 8cm away Pain Vaseline Opaque dressing back on (48 hours) Analgesia Second cycle 1-2 weeks later Expected effect: Photosensitive 48 hours Pain, red, swelling, crusting, scale - 1 week to heal Side effects: severe pin, redness, swelling blistering, burns infection hypo/hyperpigmentation scar incomplete treatment/recurrence hypersensitivity macular degeneration with light

Answer 355

Early or late complications (>4 weeks) Mild, moderate, severe Vascular, non-vascular OR ischaemic, non-ischaemic

Answer 356

Prevent: Using less reactive resorbable sutures (monocryl, Maxon, PDS II) Not too superficial placement Higher risk with inflammatory skin conditions like rosacea Manage: Reassure If suture abscess - then incise and drain, remove suture material If more of a solid papular granulomatous reaction (later onset), then will take time to resolve (up to 6 months) Avoid overzealous extraction If suture is protruding, can be gently extracted or otherwise snipped off at level of wound

Answer 357

Prevent - prevent haemorrhage, haematoma and infection - adequate design, minimising tension - slowly resorbing absorbable deep sutures (Maxon, PDS II) - supportive dressings (steri strips, Hypafix, supportive stockings) - instructions to patients regarding movements Manage - treat any infection or haematoma - give abx - delay suture removal for double usual time - re-suturing can be difficult, should not be done if infection - usually heal by second intention with regular review - supportive dressings (can dehisce further) - may require scar revision in future

Answer 358

Energy is administered to the skin, absorbed by DNA and preferentially causes cell death of abnormally dividing cells

Answer 359

Grenz rays - benign disease Superficial xrays - skin cancers Electron beam therapy - large skin cancers, especially overlying bone or cartilage Brachytherapy - for areas with poor healing Also can divide into: definitive, adjuvant and palliative radiotherapy

Answer 360

Psoriasis Keloids Lymphocytoma cutis/pseudolymphoma BCC SCC MCC KS Cutaneous lymphomas LM Patients >60 Head and neck (eyelid, nose, ear, lip) When surgery may result in significant morbidity, impaired function, or poor cosmesis Surgery/needle phobic or refusal Adjuvant radiotherapy, where positive surgical margins not amenable to further resection Palliative radiotherapy

Answer 361

Absolute: Gorlin's XP Pregnancy Patient unable to cooperate with technique Age <50 Certain locations - below knee, scrotum Relative: CTDs (scleroderma, LE) Chronic ulceration Poorly vascularised, oedematous tissues Trauma, thermal burns Prior field of radiation

Answer 362

Acute radiodermatitis Chronic radiodermatitis Radiation induced poikiloderma Radiation recall phenomenon Recurrence of tumour Radiation induced tumour Expect: erythema, oedema, crusting, desquamation, discomfort Risks/complications: ulcer, slow healing, infection, mucositis Longer term: alopecia, atrophy, telangiectasia, hyper/hypopigmentation, risk of secondary malignancy (1-2% over 20 years), anhidrosis, necrosis of tissue, cartilage or bone, cataracts Failure to be effective/recurrence

Answer 363

Ideal treatment for cutaneous malignancies <5mm thick Energy source is electron delivered through a linear accelerator Uses megaelectron volt (MeV) Requires margin of 1-2cm Needs a bolus (of gelatin like material) to deliver 100% of designated dose at skin surface (thus minimising tissue damage including to bone and cartilage)

Answer 364

Uses low energy photons produced by 10-30 kilovolt Xray machine Radiation is absorbed within first 2mm of tissue Xrays used instead of linear accelerator Bolus not required

Answer 365

Limited to irradiation sites - AIBD - Comedonal acne, folliculitis - EM - GVHD - Digitate keratosis - Grovers - LP - LS - Morphoea - Sclerosing post-irradiation panniculitis - Recall - UP - Vitiligo Not confined to sites of irradiation - Herpes zoster - EM - AIBD - Eosinophilic polymorphic and pruritic erruption associated with radiotherapy syndrome Spare irradiation - Exanthematous drug eruption

Answer 366

- dose range 12–16 Gy in 3–4 fractions to 20 Gy in 5 fractions - not as monotherapy (ineffective) - begin within 24–48 hours following surgery, or at least 2 weeks - recurrence rate 10% - avoid neck - side effects: atrophy, pigmentation, dermatitis, alopecia - not in children

Answer 367

Dose (Gy) Number of fractions Total time of radiation course

Answer 368

50-55Gy can be divided into 20 daily fractions Monday through Friday for 4 weeks (2.5-2.75Gy per fraction)

Answer 369

Autologous blood product Centrifuged to enrich the plasma concentration Has 3-8 x the plasma concentration of native plasma

Answer 370

Critical thrombocytopenia (low platelet count) Hypofibrinogenaemia Haemodynamic instability (collapse) Sepsis (infection) Acute and chronic infections Chronic liver disease Anti-coagulation therapy (warfarin, dabigatran, heparin)

Answer 371

Male pattern hair loss Scar revision, especially in combination with other treatments such as fractional CO2 laser, or in combination with subscision Wound healing/ulcers

Answer 372

For depressed scars (rolling or box car) Free fibrous bands tethering base of scar Leading to elevation of depressed area and neocollagenesis during healing How to do: Prep LA Needle inserted into upper subcut tissue at periphery of scar Blade parallel to epidermis Maintain the horizontal orientation Break fibrous connections to underlying tissue May have popping sound May require multiple entry points and directions Multiple treatments spaced at least 3 weeks apart SEs: Bruising, hypertrophy, cyst formation, infection, worsening of scar

Answer 373

Erythematous - skin care, retinoids, vascular laser, fractionated non-ablative 1550nm Hyperpigmented - sunprotection, bleaching agents (hydroquinone), light peels, microdermabrasion, pigment laser, IPL Hypopigmented - sunprotection, pigment transfer, bleaching to limit contrast, fractionated non-ablative 1550nm

Answer 374

Mild rolling - skin needling, rolling, microdermabrasion, laser resurfacing (fractionated non ablative), dermal filler Small papular - fine wire diathermy

Answer 375

Significant rolling Superficial box car - fractionated resurfacing - ablative lasers - dermabrasion - chemical peels - dermal filler - botox - subscision Mild-mod hypertrophic - intralesionals, PDL

Answer 376

Ice pick - TCA CROSS - punch techniques - float, elevation, excision, grafting Deep box car - above Marked atrophy - fat transfer and dermal filler Significant hypertrophy or keloid Bridges, tunnels, dystrophic scars - excisions (botox if movement related)

Answer 377

Retinoids: Tretinoin 0.05% Adapalene 0.3% Trifarotene 0.005% (Aklief) Tazarotene 0.1% Azeleic acid Clindamycin lotion Benzoyl peroxide Salicylic acid Combinations: Epiduo - 0.1% adapalene/2.5% benzoyl peroxide Acnatac - (clindamycin) 1% with tretinoin 0.025% Duac - (clindamycin) 1.2% along with 5% benzoyl peroxide Chemical peels - sal acid

Answer 378

Similar to ultraviolet radiation (like what you get from the sun) It is a very superficial radiation, penetrating mostly (90%) just to 5mm depth in the skin, not below your skin It has an anti-inflammation effect It is not painful Given weekly or twice weekly for total 3-4 sessions

Answer 379

Mild sunburn reaction Tan/darkening of skin NMSC

Answer 380

Are you very worried about your appearance? Do these concerns preoccupy you? Do they cause you a lot of distress, torment or pain? Do they cause social, occupational or other functional impairment? Do they interfere with social life? Do you avoid doing anything because of your appearance concerns?

Answer 381

Follow PROTOCOL of the healthcare establishment, which should include details around: - appropriate SKILLED OFFICER with expertise for assessment (may require referral to local hospital or ID department) - LABORATORY to process emergency specimens - PHARMACY which stocks prophylactic medication REDUCE RISK - eye protection - gloves - safe disposal of sharps - hep B immunity POST EXPOSURE MANAGEMENT - seek care immediately, report immediately to supervisor - wash with soap and water - rinse mucous membranes (if affected) with saline or water) - do not squeeze affected area - risk assessment of exposure - type of exposure, type and amount of fluid, infectious status of source, susceptibility of exposed healthcare worker - if source known, then HBV surface antigen, HCV antibody and HIV antibody testing - healthcare worker baseline testing - counselling and follow up to healthcare worker - If source is HBVsAg, HIV or HCV antibody positive, contact ID department at nearest hospital - Recognising that post exposure prophylaxis is most effective if implemented soon after exposure - Injured worker to have baseline serology and repeat in 3 months - Offer pregnancy testing - accident/incident report form (documenting date and time, how it happened) - post exposure counselling and follow up with ID physician

Answer 382

Side-to-side Second intention Wedge Advancement (esp crescentic, also can do L or T plasty or Burow's exchange) Rotations flaps (with arc along nasolabial fold) (can also combine with a wedge if large defect) Transposition flaps Subcutaneous island pedicle

Answer 383

Can do 3 types - With Burow's triangle in lip rhytides - With wedge repair (when large, deeper and on lower half of upper cutaneous lip) - With horizontal cut along vermilion border (when large and involving most of the lateral upper cutaneous lip) Design with crescent around alar groove (~2mm outside the groove) Advantages: - Portion of scar hidden along alar groove and in vertical rhytides upper lip or along vermillion border - Design allows tension to run horizontally, minimising possible deformity of the vermillion border Disadvantages: - Vertical scar on upper cutaneous lip - Upper lip eversion, effacement and retraction may occur

Answer 384

Side-to-side Wedge *Advancement (unilateral single sided crescentic; bilateral single sided advancement; unilateral and bilateral two sided advancement; "gullwing" mucosal advancement flap) If philtrum only: Side-to-side Advancement (bilateral one sided and two sided) Island pedicle flaps FTSG

Answer 385

Side-to-side Second intention Wedge Mucosal advancement Bilateral vermilion rotation flap Submucosal V-Y island pedicle flap If cutaneous and vermilion lip both involved in defect then can either close together in a wedge; or do a combination repair e.g. mucosal advancement flap (in combo with cutaneous advancement)

Answer 386

Advantages: Scar line hides in vermilion border Can close long horizontal defects Can be used in combination with cutaneous repairs Disadvantages: Vermilion border contour may be altered, loss of cupid's bow May have persistent hypoaesthesia Misaligned beard hairs may pierce the lip (if upper lip?)

Answer 387

Prior to anaesthesia, identify vermilion border and mark each side with a marker pen Once anaesthetised, vermilion can be scored with scalpel blade or marked with sutures Mark a long horizontal ellipse around defect (at least 4:1) with one ellipse line along the vermilion border Undermine below the level of the minor salivary glands, but above the orbicularis muscle Haemostasis Close with silk sutures

Answer 388

Side-to-side Wedge Advancement (Burow's exchange; bilateral one-sided/T-plasty) Rotation flap Subcutaneous island pedicle NB: wedge if <50% of lip But if >50%, combination wedge/flap Preserve mental crease where possible (W-plasty or advancement flap along the crease)

Answer 389

Wear gloves Apply with toothpick or finger Apply thin layer Remove gloves and wash hands

Answer 390

Short term - vitiligo Long term

Answer 391

Avoid overlap Ensure correct filters

Answer 392

Prison incarceration - current or past Blood transfusion prior to 1990 Tattoos or piercings not performed professionally Current or past injecting drug use Household member with HBV Sexual partner with HBV, HCV, HIV Infants of mothers with HBV, HCV, HIV Persons born in regions with >/=2% prevalence of chronic HBV infection

Answer 393

HBV - test source for HBsAg as soon as possible - if injured person is immune, no need for further action - if not immune (or unknown), give HBVIg within 48-72 hours of exposure - give HBV vaccine within 7 days, repeat at 1 month and 6 months HIV - test source for HIV antibody as soon as possible - test injured person, repeat test at 1, 3 and 6 months if source is positive or has recently engaged in at-risk behaviour - if source is positive, consult with ID - considering ART - if decision to commence prophylaxis ideally will be within 2hours from injury - therapy continues for 4 months HCV - if source positive, test HCV PCR (transmission less likely if negative) - repeat at 1, 3 and 6 months - test injured person at 1, 3 and 6 months - consult ID