Surgery AAD Questions Flashcards
(186 cards)
1
Q
What agent if used for cleaning to the eye can cause corneal damage, sensorineural deafness, severe allergic reaction
A
Chlorhexidine gluconate
2
Q
Corneal damage via what: corneal de-epitheliazation, conjunctival chemosis, anterior stromal edema
A
Chlorhexidine
3
Q
How does chlorhexidine cause damage to the ear
A
damage to the chochlea resulting in sensorineural hearing loss
-typically in setting of prolonged exposure of chlorhexidine to the tympanic membrane rupture
4
Q
T/F: You can use fractional ablative lasers on the neck and chest with altered settings
A
True (you cannot use fully ablative lasers)
5
Q
What is seen on histological examination of skin after fractional ablative laser
A
collagen remodeling, neocollagenesis
6
Q
What can you treat with fractional ablative laser
A
scars, photo damage, rhytides
7
Q
Mental nerve: sensory or motor
A
sensory
8
Q
Common complication (4%) of deoxycholic acid injections for submental fat
A
marginal mandibular nerve paresis
9
Q
What is the safe dose of plain lidocaine?
How much lidocaine is in each cc of 1%?
A
4.5 mg/kg
10 mg
10
Q
What is the max safe dose of lidocaine with epi?
A
7 mg/kg
11
Q
What is the max safe dose of tumescent anesthesia lidocaine with epinephrine?
A
55 mg/kg
12
Q
What do you do if you drop a graft on the floor?
A
Inform the patient, lavage the graft in chlorhexidine or povidone iodine for 60 seconds and proceed with the procedure
13
Q
What layer are virtually all fillers injected into
A
subcutis or deeper tissue layers
14
Q
Injections into what plain can lead to violaceous nodules
A
dermis (Tyndall effect)
15
Q
What is the cause of darkening after Q switched laser for brown, red and pink pigments
A
Reduction of ferric oxide to ferrous oxide (similar rxn in titanium dioxide in white and flesh colored pigments)
16
Q
If you have paradoxical darkening with red/brown tattoo removal, what laser can nearly or completely treat
A
Nd:YAG laser
17
Q
What is the treatment for eyelid ptosis from botox
A
apraclonidine
18
Q
Primary artery for a nasolabial interpolation flap
A
angular artery
19
Q
How much tumescent anesthesia can you use in a 75 kg person?
A
4125 mg (55 mg/kg)
20
Q
What organ metabolizes lidocaine
A
Liver (CYP3A4 pathway)
21
Q
What is the function of an M plasty
A
Decrease the length of a scar
22
Q
Name the types of advancement flaps (7)
A
- Unilateral Burow’s advancement (A to L or O to L)
- Unilateral crescentic advancement (cheek to nose crescentic)
- Unilateral O to U advancement (helical rim advancement)
- Bilateral A to T or O to T
- bilateral O to H
- Island pedicle, ‘kite’ flap renamed V to Y
- Mucosal advancement
23
Q
What type of flap: redirect a scar and lengthen a scar?
A
Z plasty
24
Q
What are the WLE margins for DFSP?
A
2-4 cm to the superficial muscular fascia (WLE with 4 cm margins to 95% clearance in tumors <3x3cm)
25
Name the artery: approximated by the most prominent glabellar frown lines near the medial eyebrow
Supratrochlear
26
Name the syndrome: sebaceous neoplasms +/- keratoacanthomas and visceral malignancies (GU and colorectal cancers)
Muir Torre Syndrome (MLH1, MSH2, MSH6)
27
Next steps if suspect Muir Torre (3)
1. Perform immunohistochemistry to evaluate for mismatch repair proteins
2. Refer for age appropriate cancer screenings
3. Take a detailed personal and family hx
28
What two sources are common for cartilage to support the nasal ala?
antihelix and conchal bowl
29
Name the high risk cardiac people that need abx prior to surgery (4)
1. prosthetic valve
2. hx of infective endocarditis
3. unrepaired congenital heart disease
4. cardiac transplant patients with cardiac valvulopathy
30
Name the joint people that need abx before surgery
1. within 2 years of replacement
2. previous joint infx
3. type 1 DM, immunosuppressed or hemophilia
31
What areas deemed consideration of abx prior to surgery (5)
1. oral mucosa
2. groin/leg
3. wedge excision of lip or ear
4. nasal flaps
5. all grafts
32
What type of skin graft has greater metabolic demand, retains adnexal structures and contracts less
Full thickness skin graft (FTSG)
33
Monomorphous small round nuclei around vascular spaces
Glomus tumor
34
Crateriform lesion lined by a hyperplastic epithelium with atypical keratinocytes with abundant eosinophilic cytoplasm
Keratoacanthoma
35
Cyst lined by keratinizing squamous epithelium
Epidermal infundibular cyst
36
Digitated lesion with a fibrovascular core
Wart
37
Full thickness epidermal atypia
SCC
38
What part of the nail develops melanoma
nail matrix
39
What does the distal matrix give rise to
ventral (inferior) nail plate
40
What does the proximal matrix give rise to
superficial (dorsal) nail plate
41
What part of the matrix should be biopsied to prevent dystrophy of the nail
distal matrix via a horizontal or tangential biopsy for sufficient tissue sample without disrupting the proximal matrix
42
True or False: A biopsy of the nail bed would allow for a dx of subungal melanoma
False: A biopsy of the nail bed would not allow for a diagnosis of subungual melanoma
43
What lasers can result in delayed hypopigmentation
Erbium:YAG or CO2
- fully ablative lasers
- mechanical dermabrasion
44
Name the flap: camouflage a scar by breaking it up into smaller components, improve a postprocedure web, release tension surrounding a free margin and reorient a scar
Z-plasty: transposition flap based on a 60 degree Z with central limb oriented across the long axis of the scar and two limbs oriented at 60 that are transposed
45
Tip of nose sensation
anterior ethomoidal nerve
46
What ganglia results in trigeminal trophic syndrome
geniculate ganglion or gasserian ganglia (trigeminal ganglia)
47
What innervates the tip of the nose
medial nasal branch of the anterior ethmoidal nerve
48
What is the correct plane to undermine for eyebrow repair?
Subcutaneous below the follicular unit (above the muscles to avoid injury to sensory nerves)
49
During what trimester should non-urgent procedures be done
Second trimester
50
What is an allergic contact allergen found in hydrocolloid dressings
Colophony: hydrogenated resin
51
Name the allergen: found in the rubber in elastic dressings
Carba
52
What are the high risk factors in SCC (BWH)
1. diameter >2 cm
2. poorly differentiated histology
3. perineural invasion of at least 0.1 mm
4. invasion beyond subq fat
53
BWH T1-T3 SCC
T1: 0 high risk factors
T2a: 1 high risk factor
T2b: 2-3 high risk factors
T3: 4 high risk factors
54
SCC AJCC8 Staging
T1 <2 cm
T2 >2 cm but <4 cm
T3 Tumor >4 cm or minor bone invasion or perinueral invasion or deep invasion
T4a Tumor with gross cortical bone and/or marrow invasion
T4b Tumor with skull bone invasion and/or skull base foramen involvement
55
Name the term: suture's ability to transfer fluid along its' strand by wicking fluid from an immersed end to a dry end
Capillarity: as it increases, bacterial load increases
56
What are initial sx of lidocaine toxicity (5)?
1. tinnitus
2. lightheadedness
3. circumoral numbness
4. metallic taste
5. double vision
57
What are late sx of lidocaine toxicity?
1. nystagmus
2. speech slurring
3. muscle twitching
4. fine tremors
Later: respiratory depression, coma
58
What two mutations can cause basal cell nevus syndrome?
| What mutation does NOT result in odontogenic keratocysts
PTCH1, SUFU
| SUFU does NOT have odontogenic keratocysts, but still has a 20x increased risk of medulloblastoma
59
Damage to what nerve: inability to raise the eyebrow, and drooping of the ipsilateral eyebrow
temporal branch of facial (innervation of frontalis)
60
Damage to what nerve: result in asymmetry with a crooked smile and drooling on the affected side due to injury of muscles that innervate the lip depressors
Marginal mandibular (branch of facial)
61
Damage to what nerve: shoulder drooping, winged scapula, inability to abduct the arm
spinal accessory nerve
62
Name the species that silk comes from
Bombyx mori (family bombycidae)
63
Name the suture: high tissue reactivity to lots of inflammation, high tissue capillarity (high infx), soft/pliable and good for mucosal surfaces
Silk
64
Polyglactin 910
vicryl
65
Poliglecaprone 25
monocryl
66
Why would you not want to treat verrucous carcinoma with radiation
fear of anaplastic transformation
67
What is the muscle that allows the eyelid to open fully
levator palpebrae superioris
68
What muscle may be affected if botox is injectect less than 1 cm above the eyebrow or lateral to the midpupillary line
levator palpebrae superioris
69
Name the med: alpha-2 adrenergic agonist that causes Muller muscles to contract and provide some compensation for the weakened levator
Apraclonidine
70
What is the most common complication of an interpolation flap
Bleeding 9%
| infection 1-3%, dehiscence 0.5%, necrosis 3%
71
Trichilemmomas--name the ds and the associated cancers
Cowden: breast, thyroid (some melanoma)
72
Fibrofolliculomas, acrochordons, trichodiscomas--name the ds and the systemic associations
Birt-Hogg-Dube: renal cancer, pulmonary cysts (pneumothorax)
73
CK20
Merkel Cell Carcinoma
74
What is the most common virus a/w merkel cell carcinoma
polyomavirus
75
What type of virus is polyomavirus
nonenveloped, ds DNA virus
76
What type of virus is parvovirus
single stranded DNA virus
77
What 2 viruses are enveloped, double stranded DNA viruses
Herpes and pox
78
Name (6) nonenveloped, single stranded RNA viruses
1. Norwalk virus
2. Coxsackievirus
3. Hepatitis A
4. Hepatitis E
5. Poliovirus
6. Rhinovirus
79
Name (5) enveloped, single stranded RNA viruses
1. Hepatitis C
2. Yellow fever
3. Dengue virus
4. West Nile
5. Rubella
80
Damage to what part of the eye with PDL can lead to permanent damage
Retina
81
What part of the eye is damaged with ablative lasers?
Corneal or scleral burns
82
What areas of the eye are damaged by pigmented lesion laser?
Retina or choroid
83
What is contraindicated with an allergy to bee stings
Hyaluronidase
84
True/False: there is no evidence to justify delaying tx with hair removal, lasers, lights, vascular lasers, nonablative fractional and fractional devices in patients who are receiving isotretinoin or have received it in the last 6 months
True
85
T/F: Topical abx may impair wound healing
True
86
T/F: there is no difference in infection rates for mohs or reconstruction with sterile or non sterile glove use
True
87
Plane to undermine in the scalp
sub galea aponeurotica in the loose connective tissue
88
What part of the eye can be damaged by the CO2 laser
Cornea
89
What type of laser damages the retina
visible near infrared spectrum (180-400 nm)
90
What light spectrum is UVA
315-400
91
What type of sclerosing agent induces endothelial cell damage via alterations in surface tension around endothelium
Detergents (ethanolamine oleate, polidocanol, sodium tetradecyl sulfate)
92
What type of slcerosing agent causes direct injury via corressive action to endothelial cells
Chemical irritants (glycerin, polyiodide iodine)
93
Damage to what nerve: inability to raise the eyebrow, drooping of the ipsilateral eyebrow, inability to close eye completely
Temporal branch of facial nerve--innervation of frontalis
94
Damage to what nerve: asymmetry with a crooked smile, drooling on the affected side due to injury of muscles that innervate the lip depressors
Marginal Mandibular branch of facial nerve
95
Motor or sensory: greater auricular, lesser occipital, transverse cervical
sensory
96
What nerve is damaged and what is it a branch of in Frey's syndrome?
Auriculotemporal branch of cranial nerve V in the parotid region (vasodilation and hyperhidrosis of the ipsilateral cheek when eating)
97
Buccal nerve--sensory or motor
senosory (buccal branch of facial is motor)--decreased sensation of the skin over the cheeks
98
Injury to the mental nerve
decreased sensation of the front of the chin and lower lip
99
Name the sensory nerves of the zygomatic arch and upper cheek
Zygomaticofacial and zygomaticotemporal nerves
100
What is best for margin control in MIS
Mohs and staged excision
101
Name high risk features of SCC (5)
1. poorly differentiated, undifferentiated
2. sclerosing
3. invasive with a Breslow depth of 2 mm or greater
4. Clark level IV or greater
5. perineural or perivascular invasion
102
T/F: Any active viral or bacterial infx is a contraindication to ablative laser treatment
True
103
Contraindications to ablative surgery (2)
1. hx of keloid formation (hypertrophic scar ok)
| 2. personal hx of lupus or scleroderma or active inflammatory ds (family hx is ok)
104
How long to wait for isotretinoin to be complete before pursuing fully ablative laser
6 months
105
What is the artery for an Abbe flap
inferior labial artery
106
Paranuclear dot positivity with cytokeratin (CK20) antibodies
Merkel Cell Carcinoma
107
What is the use of CK20
distinguish MCC from metastatic small cell carcinoma of the lung, neuroblastoma, melanoma
108
What is cutaneous lymphocyte associated antigen used for
positive in lymphoma cutis and absent in MCC
109
rare, slow-growing sweat gland tumor eccrine (or apocrine?) differentiation
primary cutaneous mucinous carcinoma
110
what is the most common location for primary cutaneous mucinous carcinoma
eyelid
111
What additional work up is recommended in primary cutaneous mucinous carcinoma
Need to differentiate from metastatic ds: total body CT, mammogram, colonoscopy
112
surgical tx of primary cutaneous mucinous carcinoma
excision--mohs is ineffective
113
type of flap: recruitment of excess tissues, limite in their ability to redirect tension vectors
advancement and rotation flaps
114
Injection into what muscle when trying to inject the depressor anguli oris can lead to asymmetric smile
Depressor labii inferioris
| -avoid this via injecting laterally to the nasolabial folds to avoid overlapping
115
AE a/w injection into what muscle: upper lip drop, phonation problems
orbicularis oris--lip sphincter weakness and incompetence in the ability to adequately purse the lips
116
What muscle to inject to fix a gummy smile
levator labii superioris alaeque nasi
117
Best way to remove hair if needed for surgery
Remove via clipping with scissors just prior to surgery
118
What is the target of proteolysis in onabotulinumA (botox) and E
the light chain of botox catalyzes the proteolysis of one of the three synaptosomal-associated protein receptors 25 kd
119
What is the heavy chain of botox responsible for
attachment to the motor nerve axon terminal and translocation across the cell membrane
120
What serotype of botulinum toxin cleaves syntaxin-1
C
121
What serotypes of botox cleave vesicle associated membrane protein
B, D, F, G
| synaptobrevin
122
What is the only absorbable suture from natural materials
surgical gut (sheep or cow intestines)
123
What stains are positive in Merkel Cell Carcinoma
cytokeratin 20 positive in paranuclear dot pattern, synaptophysin positive, chromogranin positive, CAM 5.2 positive, PanCK positive, neuron enolase positive, thyroid transcription factor-1 negative (to rule out small cell carcinoma)
124
Is SNLB recommended in Merkel?
Yes--all cases (1/3 of cases have micrometastatic disease)
125
What chemotherapy is FDA approved for tx of metastatic merkel
PD-L1 inhibitor (pempbrolizumab or avelumab)
126
What would you like the apices of surgery angles to be
Less than 30 degrees
127
What are the advantages of a split thickness skin graft over a full thickness skin graft (5)
1. decreased metabolic demand
2. ability to place over a recipient bed with diminished vascular supply (periosteum or perichondrium)
3. ability to place at a recipient site at high risk of tumor recurrence (can detect this)
4. ease of application
5. ability to cover large defects
128
Disadvantages of spit thickness skin graft compared to full thickness skin graft
1. suboptimal cosmetic outcome
2. loss of adnexal structures
3. increased graft contraction
4. presence of a granulating donor site in the post op period
129
What is the cause of transient post-inflammatory hyperpigmentation in laser tx
inadequate cooling (skin types III-V)
130
Pre and post tx with what can prevent PIHyper
hydroquinone, sunscreen
131
What nerve damage causing flattening of the forehead and drooping on the affected side eyebrow
Temporal nerve (care to undermined the superficial subcutaneous plane and to avoid extensive cautery)
132
Preferred level of undermining for nasal bilobed flap
subnasalis (submuscular)
133
CD34 and CD31 positive
Kaposi's sarcoma
134
S100+, vimentin+, HLA-DR, FcC3b, CD1a
Langerhan's cell histiocytosis (histiocytosis X)
135
CD30+
Lymphomatoid papulosis
136
CK20+, ethidium monazide synaptophysin, neuron-specific enolase and neurofilaments
Merkel Cell Carcinoma
137
What two conditions are CD34+
DFSP, Kaposi's sarcoma
138
Stain to use on Mohs for melanoma
MART-1
139
How many mg is in 1% lidocaine
10 mg/mL
140
What is the thermal relaxation time of a given target equal to
square of the diameter of the target, expressed in seconds
141
Name the nerve: frontalis, upper orbicularis oculi, corrugator supercilii muscles
Temporal branch of facial
142
What wave length of laser is most likely to cause damage to the retina
400-1400 nm
143
Damage to what: Q switched laser to a 'popping' sound by the patient
due to photoacoustic disruption of the retina
144
What is the medium of an excimer laser
xenon and chloride gas
145
Innervation of levator palpebrae superioris
oculomotor nerve III--lifts the upper eyelid
146
Path of temporal branch of facial nerve
Crosses the zygomatic arch and travels along the deep surface of the temporoparietal fascia and under the superficial musculoaponeurotic system (SMAS)
147
Take another layer or close: Folliculocentric basaloid proliferations (FBP) are irregular strands of basaloid cells emanating from the upper portion of hair follicles
Close: reactive phenomenon--normal skin, margins of BCC, various neoplastic and non-neoplastic skin conditions
148
Key stitch in rhombic transposition
closes secondary defect (end of the curve)
149
What meds in HIV to lipoatrophy
thymidine analogs, nucleoside reverse transcriptase inhibitors in combination with protease inhibitors
150
What are the FDA approved fillers for HIV lipoatrophy
poly-l-lactic acid (Sculptra; Galderma) and calcium hydroxylapatite filler (Radiesse)
151
What are hyluronic acid fillers FDA approved for
injection into the mid-to-deep dermis for the correction of moderate to severe facial wrinkles and folds
152
Nonabsorbable microspheres that stimulate fibroblasts to encapsulate each microsphere and augment tissue volume by fibroplasia
Polymethylmethacrylate filler
153
FDA approved silicone oil
Only for intraocular ophthalmic use--not approved for filling face or body contouring
154
Tx of AFX
Mohs
155
What strength of salicylic acid is safe to use in skin of color
up to 30% without PIPA
156
Glycolic up to what percent is superficial
50%
157
TCA peel of what percent is deeper superficial peel
10-30% (over 35% medium to deep)
158
Common cause of standing cones (dog ears)--4
1. large apical angles
2. excision on a convex surface
3. excess subq tissue at the apical edges
4. sides of unequal length during surgical planning
159
What abx can coat sutures
Triclosan (does not cross react with penicillin)
160
What is the only biterminal device
Electrosection
161
What is the key stitch in advancement flaps
Closure of the primary defect
162
What makes incobotulinum toxin A unique
Prior to opening--no refrigeration and it does not contain complexing proteins
163
Why would onabotulinum toxin A be good in DM patients
no sugar moiety
164
What botox contain dried serum albumin
inco, abobo, onabotulinum
165
Name the toxin: inhibit the release of acetylcholine at neuromuscular junctions by cleaving SNAP-25
A
166
Name the toxin: inhibits the release of acetylcholine through cleavage of synaptorbrevin
B
167
Name 2 deep peels
Jessner solution TCA>50% and Baker Gordon phenol-croton oil peel
168
Medium depth Jessner-TCA peel
35%
169
Name the paramedian forehead flap artery
supratrochlear artery
170
Next step to dx as met of BCC
biopsy (ie core bx of iliac crest lesion)
171
Mohs to the scalp (name the dx): SOB, confusion, HA, seizures, loss of consciousness, neurologic sx (facial droop, hemiplegia, hemiparesis)
Air embolism-exposed bone to negative pressure gradient to pull air into the diploic spaces
172
Name the sclerosing agent: works through formation of amphiphilic micelles that cause death to endothelial cells by extracting and denaturing their cell surface proteins
polidocanol--a detergent
173
Name two chemical irritants
Glycerin and polyiodinated iodine
174
What is the most important factor affecting full thickness skin graft: diabetes, nutritional deficiency, HTN, atherosclerosis, cigarette smoking
Smoking
175
What is contraindicated in surgery with uncontrolled hyperthyroidism and pheochromocytoma
Epinephrine--causes dysrhythmias, tachycardia, thyrotoxic crises
176
What type of sclerosant is contraindicated in a patent symptomatic foramen ovale
Foam sclerotherapy
177
What is the preferred lenght: width ration for a elliptical excision
3:1 and 4:1
178
What muscle can be affected leading to eyebrow ptosis with injections to frontalis
Diffusion into the levator palpebrae superioris
179
What is the result of rare injection into the superior rectus muscle
Impaired gaze and diplopia
180
How deep should a nail matrix bx extend
to the periosteum
181
Where does the artery come from for an Abbe flap
Pedicle is created from the contralateral lip and sutured into place (axial flap)
182
What two stitches for wounds under tension
Pulley stitch
| Subq inverted cross mattress stitch
183
Laser for solar lentigo
QSwitched Nd:YAG 532 nm (could also do QSwitched ruby 694 nm, Q Switched alexandrite 755 nm, or IPL)
184
What do you tx with the excimer laser
Inflammatory skin conditions--psoriasis and vitiligo
185
What is the safest hair removal laser for darker skin types
1064 nm Nd: YAG laser
186
Where is Erb's Point? What is there?
Midpoint of the posterior border of the sternocleidomastoid--superficial branches of the cervical plexus (greater auricular nerve, lesser occipital, transverse cervical, supraclavicular)
