Intensive Final Exam Review

Definitions:

• Plastic: Derived from the Greek word plastikos meaning to remold or reform.
• Cosmetic Surgery: Deals with reshaping normal structures of the body to improve appearance.
• Reconstructive Surgery: Deals with repairing or reshaping abnormal structures to improve function and approximate normal appearance.

Preoperative Optimization:

• Setting Expectations: The surgeon must inform the patient that function will never be completely "normal" and that asymmetry and scars will permanently persist.
• Modifiable Factors: Do not operate until social and modifiable factors are optimized. Complete smoking cessation is absolutely mandatory before reconstruction.

The Reconstructive Ladder:

Concept of planning from simple to complex to ensure a "lifeboat" if the procedure fails. The exact order is highly tested:

• 1. Secondary Intention (allowing the wound to heal on its own).
• 2. Direct Tissue Closure (Primary intention).
• 3. Skin Graft.
• 4. Local Tissue Transfer (Local Flap).
• 5. Regional Tissue Transfer.
• 6. Free Tissue Transfer (Microsurgery).
• Core Principle: Replace Like with Like (use tissue similar in color, thickness, and pliability).

Intraoperative Surgical Principles:

• Tissue Handling: Dissect sharply with a scalpel. Avoid crushing or pinching tightly with forceps.
• Hemostasis: Must be achieved at the patient's baseline blood pressure (normotensive). Note for MCQs: Drains do NOT prevent hematomas.
• Obliterate Dead Space: Potential spaces collect fluid and form seromas.
• Incision Planning: Scars are optimized by planning incisions parallel to the Relaxed Skin Tension Lines (RSTL).

Closure & Excision Techniques:

• Wound-Edge Eversion: Achieved successfully using the Vertical Mattress Suture.
• Subcuticular Suture: Used specifically to avoid external "hatch marks" on the skin.
• Elliptical Excision: The correct length of the ellipse must be at least three times the width (3:1 ratio) to prevent the formation of "dog-ears".

Dressings & Pain Control:

• Semiocclusive & Hydrocolloids (e.g., Duoderm): Strictly contraindicated in infected wounds.
• Foam (Mepilex) & Alginates: Highly absorptive (alginates absorb 20x their weight). Indicated for highly exudative wounds.
• Negative Pressure Wound Therapy (NPWT) / VAC: Absolute Contraindications: Malignant wounds, Ischemic wounds, and Inadequately debrided tissues.
• Pain Control: Add Bicarbonate to reduce injection pain. Add Epinephrine to reduce bleeding and lengthen the duration of the anesthetic effect.

Definition & Requirements for Survival:

A graft is completely detached from its blood supply. Its survival depends entirely on the recipient site vascularity. The critical process where capillary connections form is called Inosculation and occurs by Day 3.

• Strict Contraindications: Avascular beds will fail. These include Denuded Bone (without periosteum), Denuded Cartilage (without perichondrium), and Denuded Tendon (without paratenon).
• Graft Failure: Hematoma is the single most common cause of graft failure. Infection and shearing forces are also major causes.

Classifications by Thickness:

• Split-Thickness Skin Graft (STSG): Contains epidermis and varying parts of the dermis. Higher "take" rate, but causes more severe secondary wound contracture.
• Full-Thickness Skin Graft (FTSG): Contains epidermis and the entire full dermis. Better color/texture match, less contracture, but has a lower take rate.

Definition & Flap Monitoring:

A flap is a unit of tissue that maintains its own blood supply during transfer. Clinical evaluation is the gold standard for monitoring:

• Arterial Insufficiency: Flap is cold, pale, capillary refill > 2 seconds, absent point bleeding.
• Venous Congestion: Flap is warmer than expected, blue/purple hue, brisk dark bleeding, and highly characteristic: tense and swollen (increased turgor).

Tissue Rearrangement Geometry:

• Z-Plasty: Transposition of two triangular flaps specifically to increase length. The elongation depends on the angle:
  • 60° = 75% elongation (This is the classic/typical Z-plasty).
• W-Plasty: Used purely to break up a straight-line scar to improve aesthetics. Unlike Z-plasty, W-plasty does NOT lengthen tissue.

Initial Trauma Management:

• Secure the airway, and crucially, assume a Cervical Spine (C-spine) injury until proven otherwise.
• Debridement of devitalized tissue should be very conservative in the face due to its extremely rich blood supply.

Repair of Aesthetic Units:

• Lip: Precisely align the white roll and vermilion border first, then repair the orbicularis oris muscle.
• Eyebrow: Never shave the eyebrow. The muscle division under the brow must be repaired to prevent a spreading scar.
• Ear: Suture in one layer (skin only). Firm adherence aligns the cartilage. Must drain hematomas to prevent severe chondritis (Cauliflower Ear).

Diagnostic Imaging:

The gold standard study of choice for evaluating facial trauma is the Maxillofacial Computed Tomography (CT) Scan.

Specific Bone Fractures:

• Mandibular Fractures: The most common site is the condylar neck. Clinical signs include malocclusion, trismus, and numbness in the mental nerve distribution.
• Maxillary Fractures (Le Fort): Classified into Le Fort I, II, and III.
• Orbital Fractures: Inferior and medial walls are most frequently involved. Presents functionally with diplopia (double vision) and enophthalmos.
• Zygomatic Fractures: An isolated zygomatic arch fracture can impinge on the coronoid process, causing limitation of mandibular movement.

Etiology & Morbid Anatomy:

• Risk Factors: Maternal smoking, alcohol, isotretinoin. Folate and Vitamin B6 are protective.
• Associated Syndromes: Primary retrognathia is highly associated with Pierre Robin sequence.
• Anatomy: The fundamental disruption is in the orbicularis oris muscle sphincter, causing an upward rotation of Cupid's bow.

Surgical Timing (Crucial for MCQs):

• Historical "Rule of Tens": Fitness for surgery was defined as 10 weeks of age, 10 pounds of weight, and 10 mg/dL of Hemoglobin.
• Timeline Protocol:
  • 3 Months: Primary cleft lip repair + tip rhinoplasty.
  • 12 Months: Primary cleft palate repair (using intravelar veloplasty).
  • 3-4 Years: Assess for Velopharyngeal Insufficiency (VPI).
  • 7-9 Years: Secondary alveolar bone graft.

Cleft Lip Repair Techniques:

• Straight-line: Rose-Thompson.
• Quadrangular Flap: Le Mesurier method.
• Triangular Flap: Randall-Tennison, Trauner, Skoog.
• Rotation Advancement: Millard's technique (The most universally utilized method).

Pathophysiology & Risk Factors:

• Mechanism: Prolonged immobility creates pressure that exceeds the capillary perfusion pressure (~32 mmHg). This induces severe ischemia leading to necrosis.

Clinical Staging (MCQ Core):

• Stage 1: Intact skin with non-blanchable erythema.
• Stage 2: Partial-thickness skin loss (involving epidermis/dermis).
• Stage 3: Full-thickness tissue loss, subcutaneous fat is visible.
• Stage 4: Deep full-thickness loss where bone or tendon is visible or palpable. Highly associated with osteomyelitis.

Conservative Protocol:

• Systematic Repositioning: Reposition the patient every 2 hours using a 30-degree lateral position. Never use donut-shaped cushions as they concentrate pressure.
• Nutritional Support: Target a high-protein intake of 1.25 to 1.5 g/kg/day to support collagen synthesis.

Surgical Intervention & Complications:

• Surgery involves radical debridement, bursectomy, bone contouring, and flap-based reconstruction.
• Complications: Recurrence is the most common long-term complication overall.

Epidemiology & Characteristics:

• Onset: Appear after birth (unlike malformations). Most common tumor of infancy (Incidence: 1:10 infants).
• Demographics: More common in females (3:1) and premature/low-birth-weight infants (23%). Most common location is the Head/Neck region.

The 3 Phases of Hemangiomas:

• 1. Proliferating Phase: Rapid growth in the first 6-8 months. Tumor has a florid crimson presentation.
• 2. Involuting Phase: The crimson color fades to a dull purplish hue. Lasts anywhere from 2 to 10 years.
• 3. Involuted Phase: Loose fibrofatty tissue replaces the parenchymal tissue. Regression is complete in 50% of children by 5 years, and 70% by 7 years.

Associated Syndromes & Rare Presentations:

• PHACES Syndrome: Posterior fossa anomalies, Hemangiomas, Cardiac anomalies, Eye abnormalities, Sternal cleft.
• Kasabach-Merritt Syndrome: Hemangioma combined with life-threatening thrombocytopenia (Platelets < 10,000, normal PT/PTT).
• Spina Bifida Occulta: Highly associated with lumbar hemangiomas.
• Cutaneous Visceral Hemangiomas: Presence of >5 skin hemangiomas raises concern for visceral (liver) involvement, which can cause Congestive Heart Failure, Hepatomegaly, and Anemia.

Medical & Surgical Management:

• Pharmacologic: Indicated for aggressive/life-threatening tumors. Options include Corticosteroids (topical/intralesional/oral), Propranolol, Interferon Alpha, and Vincristine.
• Lasers: Pulsed Dye Laser (PDL) for flat, superficial hemangiomas.
• Surgical Indications (Complications): Ulceration (most common complication), Bleeding, Infection, Kasabach-Merritt syndrome, High-output heart failure, Skeletal distortion (pressure deformity), and emotional distress.

Core Differences from Hemangiomas:

Always present at birth, grow proportionately with the child, do NOT regress, and have an equal Male:Female ratio.

Types of Malformations:

• Capillary Malformations: e.g., Port-wine stains.
• Lymphatic Malformations: Slow-flow lesions. Divided into Macrocystic and Microcystic. They are the most common cause of macroglossia (enlarged tongue) and macrocheilia. Mainstay treatment: Sclerotherapy.
• Venous Malformations: Blue/purple spongy texture. Uniquely, they swell in a dependent position and deflate when elevated. They are hormone sensitive (enlarge during puberty/pregnancy). Treated via Sclerotherapy or Nd:YAG/Argon lasers.
• Arteriovenous Malformations (AVMs): Pulsatile high-flow lesions. Diagnosed via angiography; MRI used for extent.
  Schobinger Clinical Stages:
  • Stage 1 (Quiescent): Warm pink/bluish stain.
  • Stage 2 (Expansion): Thrill and dilated venous network.
  • Stage 3 (Destruction): Ulcers, necrosis, bleeding.
  • Stage 4 (Decompensation): Cardiac decompensation (Heart failure).
  Treatment: Preoperative embolization followed strictly by surgical resection within 72 hours.

Classification, Treatment & Differential:

• Classification: Small (< 1.5 cm²), Medium (1.5 - 20 cm²), Giant (> 20 cm²).
• Treatment Timing: Intervention must be performed early because the risk of malignant transformation is greatest in the first decade of life. Surgery ideally starts at 6 months of age.
• Management: Only complete excision addresses the malignant potential. Non-excisional methods (lasers, dermabrasion) exist but are inferior for cancer prevention.
• Differential Diagnosis: Cafe au lait spot, Nevus spilus, Epidermal nevus, Atypical/Dysplastic nevus, Blue nevus, Becker's nevus, Mongolian spot, Nevus of Ota.

Look & Feel:

• Functions of Hand: Fine pinch, Power grip, Key grip, Chuck grip, Hook grip.
• Look (Inspection): Look for tight bands in the palm indicating Dupuytren Contracture. An abnormally extended digit at rest strongly suggests a ruptured flexor tendon.
• Circulation (Feel): Allen's Test assesses radial and ulnar collateral arterial blood flow.

Move (Tendon Examination):

• Tenodesis Effect: Passive wrist extension normally and automatically causes finger flexion.
• Flexor Digitorum Profundus (FDP) Test: Hold the PIP joint strictly extended, and ask the patient to flex the DIP joint alone.
• Flexor Digitorum Superficialis (FDS) Test: Hold all other non-tested fingers in strict extension, and ask the patient to flex the PIP joint of the target finger.

Management Protocols:

• Rest: Minimizes the opening of tissue planes to prevent spread.
• Splinting (The Safe Position): To prevent ligament shortening, splint the hand in: Wrist extension, Metacarpophalangeal (MCP) joint flexion, Interphalangeal (IP) joint extension.
• Elevation: The hand must be elevated above the level of the right atrium of the heart.
• Heat Application: Moist heat is more effective than dry heat for vasodilation.

Initial History & General Trauma:

• Golden Period: Contamination is usually low in the first 6 hours after injury.
• Nailbed Injury: If the subungual hematoma constitutes greater than 50% of the nail area, the nail plate must be removed to repair the matrix with 6-0 absorbable suture.

Flexor Tendon Injuries:

• Zones: Zone 2 extends from the proximal reflection of the synovial sheath to the FDS insertion. It is termed "No man's land".
• Repair Principles:
  • Core Repair: Uses 4 to 6 strands.
  • Epitendinous Repair: Increases strength by 10% to 50%.
  • Pulleys: Meticulously preserve the A2 and A4 pulleys to prevent tendon bowstringing.

Clinical Presentation & Quick Motor Exam:

• Median Nerve Lesion: Causes devastating loss of thenar function. Classically presents as the "Apelike Hand". Tested by the "OK" sign.
• Ulnar Nerve Lesion: Loss of intrinsic muscle function. Tested by asking the patient to abduct/adduct/cross their fingers.
• Radial Nerve Lesion: Presents dramatically as Wrist Drop. Tested by the "Thumbs up" sign.