Essentials of Plastic Surgery: Q&A Companion E-Book

ALEX Jones

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2023

Beschreibung

A must-have companion resource to test knowledge of plastic surgery essentials

Essentials of Plastic Surgery: Q&A Companion, Second Edition by renowned plastic surgeons Alex P. Jones and Jeffrey E. Janis mirrors expanded content and new chapters in the parent book, Essentials of Plastic Surgery, Third Edition. The third edition of the parent book includes 127 chapters, which reflects the increased scope, breadth, and depth of plastic surgery since publication of the last edition. The companion book employs the same style and formatting, with select illustrations from the parent book, as well as additional unique images created for this text. The print book is accompanied by a complimentary eBook that is accessible on smartphones and tablets.

Key Features

• More than 1600 questions formatted as multiple-choice questions complement and highlight the content contained in the parent book
• Questions specifically designed to test the reader on the clinical application of this knowledge
• Succinct yet detailed answers enhance acquisition and retention of knowledge
• The conveniently compact format fits in a lab coat pocket and is designed and organized to enable quick and easy reading

This is an invaluable, go-to resource for plastic surgeons throughout training and can be used as a refresher and revalidation of knowledge as their careers progress.

This print book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Essentials of

Plastic Surgery

Q&A Companion

Essentials of

Plastic Surgery

Q&A Companion

Second Edition

ALEX P. JONES, FRCS (PLAST), MBCHB, BSC

Consultant Plastic Reconstructive and Aesthetic Surgeon Department of Plastic and Reconstructive Surgery James Cook University Hospital, Middlesbrough;Nuffield Tees Hospital;Norton and Tees Valley HospitalMiddlesbrough, UK

JEFFREY E. JANIS, MD, FACS

ProfessorDepartment of Plastic and Reconstructive Surgery;Chief of Plastic Surgery (University Hospital);Adjunct Professor, Departments of Neurosurgery, Neurology, and Surgery;Co-Director, Center for Abdominal Core HealthThe Ohio State University Wexner Medical Center;Past President, American Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, and Migraine Surgery Society;President, American Hernia SocietyColumbus, Ohio, USA

With the Assistance of Dr. Anna R. Barnard

With Illustrations by:

Brenda L. Bunch, MA, MS; Amanda L. Tomasikiewicz, MA; Sarah J. Taylor, MS, BA; Jennifer N. Gentry, MA, CMI; and Graeme Chambers, BA (Hons.)

395 illustrations

New York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-PublicationData is available from the publisher.

Illustrators: Brenda L. Bunch, MA, MS; Amanda L. Tomasikiewicz, MA; Sarah J. Taylor, MS, BA; Jennifer N. Gentry, MA, CMI; and Graeme Chambers, BA (Hons.)

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.

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Cover design: © Thieme

Cover image source: Picasso, Pablo (1881-1973)

© Artist Rights Society (ARS), NY. Girl Before a Mirror. Boisgeloup, March 1932. Oil on canvas, 64̋ × 51.̋ Gift of Mrs. Simon Guggenheim. (2.1938). The Museum of Modern Art, New York, NY, USA. Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY. © 2006 Estate of Pablo Picasso/ARS, New York.

Typesetting by Thomson Digital, India

Printed in Canada by Marquis Book Printing Inc.

5 4 3 2 1

ISBN 978-1-68420-090-0

Also available as an e-book:

eISBN (PDF): 978-1-68420-091-7

eISBN (epub): 978-1-63853-657-4

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

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This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

To my family and friends for their love and support,

to my mentors for sharing their skills and knowledge,

and to my patients for making the art of plastic surgery so worthwhile.

Alex P. Jones, FRCS (Plast), MBChB, BSc

To my parents and sisters for their unwavering support and love.

To my friends and colleagues for their encouragement and influence.

To my teachers and mentors for their guidance and wisdom.

To my former, current, and future residents for their inspiration.

And most of all to my wife, partner, and best friend, Emily, and our three absolutely incredible children, Jackson, Brinkley, and Holden—for everything.

Jeffrey E. Janis, MD, FACS

Contents

FOREWORD

Maurice Y. Nahabedian

FOREWORD

Simon Kay

PREFACE

ACKNOWLEDGMENTS

Alex P. Jones

ACKNOWLEDGMENTS

Jeffrey E. Janis

PART I ◆ FUNDAMENTALS AND BASICS

1.WOUND HEALING

2.GENERAL MANAGEMENT OF COMPLEX WOUNDS

3.SUTURES AND NEEDLES

4.BASICS OF FLAPS

5.PERFORATOR FLAPS

6.TISSUE EXPANSION

7.VASCULARIZED COMPOSITE ALLOGRAFTS AND TRANSPLANT IMMUNOLOGY

8.BASICS OF MICROSURGERY

9.BIOMATERIALS

10.NEGATIVE PRESSURE WOUND THERAPY

11.LASERS IN PLASTIC SURGERY

12.ANESTHESIA

13.PAIN MANAGEMENT IN PLASTIC SURGERY

14.PHOTOGRAPHY FOR THE PLASTIC SURGEON

15.DECREASING COMPLICATIONS IN PLASTIC SURGERY

PART II ◆ SKIN AND SOFT TISSUE

16.THE BASICS OF SKIN

17.BASICS OF PLASTIC SURGERY WOUND CLOSURE

18.SCARS AND SCAR MANAGEMENT

19.SKIN GRAFTING

20.BASAL CELL CARCINOMA, SQUAMOUS CELL CARCINOMA, AND MELANOMA

21.BURNS

22.VASCULAR ANOMALIES

23.CONGENITAL MELANOCYTIC NEVI

PART III ◆ HEAD AND NECK

24.HEAD AND NECK EMBRYOLOGY

25.SURGICAL TREATMENT OF MIGRAINE HEADACHES

CONGENITAL CONDITIONS

26.CRANIOSYNOSTOSIS

27.CRANIOFACIAL CLEFTS

28.DISTRACTION OSTEOGENESIS

29.Cleft Lip

30.CLEFT PALATE

31.VELOPHARYNGEAL DYSFUNCTION

32.MICROTIA

33.PROMINENT EAR

TRAUMATIC INJURIES

34.FACIAL SOFT TISSUE TRAUMA

35.FACIAL SKELETAL TRAUMA

36.MANDIBULAR FRACTURES

37.BASIC ORAL SURGERY

ACQUIRED DEFORMITIES

38.PRINCIPLES OF HEAD AND NECK CANCER: STAGING AND MANAGEMENT

39.SCALP AND CALVARIAL RECONSTRUCTION

40.EYELID RECONSTRUCTION

41.NASAL RECONSTRUCTION

42.CHEEK RECONSTRUCTION

43.EAR RECONSTRUCTION

44.LIP RECONSTRUCTION

45.MANDIBULAR RECONSTRUCTION

46.PHARYNGEAL AND ESOPHAGEAL RECONSTRUCTION

47.FACIAL REANIMATION

48.FACE TRANSPLANTATION

PART IV ◆ BREAST

49.BREAST ANATOMY AND EMBRYOLOGY

50.CONGENITAL BREAST DEFORMITIES

51.BREAST AUGMENTATION

52.MASTOPEXY

53.AUGMENTATION-MASTOPEXY

54.BREAST REDUCTION

55.GYNECOMASTIA

56.BREAST CANCER

57.AUTOLOGOUS BREAST RECONSTRUCTION

58.IMPLANT-BASED BREAST RECONSTRUCTION

59.SECONDARY BREAST RECONSTRUCTION

60.NIPPLE-AREOLAR RECONSTRUCTION

PART V ◆ TRUNK AND LOWER EXTREMITY

61.CHEST WALL RECONSTRUCTION

62.ABDOMINAL WALL RECONSTRUCTION

63.POSTERIOR TRUNK RECONSTRUCTION

64.PERINEAL RECONSTRUCTION

65.GENITOURINARY RECONSTRUCTION

66.PRESSURE SORES

67.LOWER EXTREMITY RECONSTRUCTION

68.FOOT ULCERS

69.LYMPHEDEMA

PART VI ◆ HAND, WRIST, AND UPPER EXTREMITY

70.HAND ANATOMY AND BIOMECHANICS

71.BASIC HAND EXAMINATION

72.CONGENITAL HAND ANOMALIES

73.CARPAL BONE FRACTURES

74.CARPAL INSTABILITY AND DISLOCATIONS

75.DISTAL RADIUS FRACTURES

76.METACARPAL AND PHALANGEAL FRACTURES

77.PHALANGEAL DISLOCATIONS

78.FINGERTIP INJURIES

79.NAIL BED INJURIES

80.FLEXOR TENDON INJURIES

81.EXTENSOR TENDON INJURIES

82.TENDON TRANSFERS

83.NERVE TRANSFERS

84.HAND AND FINGER AMPUTATIONS

85.REPLANTATION

86.HAND TRANSPLANTATION

87.TARGETED MUSCLE REINNERVATION

88.HAND REHABILITATION

89.THUMB RECONSTRUCTION

90.SOFT-TISSUE COVERAGE OF THE HAND AND UPPER EXTREMITY

91.COMPARTMENT SYNDROME

92.UPPER EXTREMITY COMPRESSION SYNDROMES

93.BRACHIAL PLEXUS

94.NERVE INJURIES

95.HAND INFECTIONS

96.BENIGN AND MALIGNANT MASSES OF THE HAND

97.DUPUYTREN’S DISEASE

98.RHEUMATOID ARTHRITIS

99.OSTEOARTHRITIS

100.VASCULAR DISORDERS OF THE UPPER EXTREMITY

PART VII ◆ AESTHETIC SURGERY

101.AESTHETIC FACIAL ANATOMY

102.FACIAL ANALYSIS

103.BASICS OF SKIN CARE

104.NEUROTOXINS

105.SOFT-TISSUE FILLERS

106.CHEMICAL PEELS

107.FAT GRAFTING

108.HAIR TRANSPLANTATION

109.BROW LIFT

110.BLEPHAROPLASTY

111.BLEPHAROPTOSIS

112.FACE LIFT

113.NECK LIFT

114.PERIORAL REJUVENATION

115.RHINOPLASTY

116.SECONDARY RHINOPLASTY

117.GENIOPLASTY

118.LIPOSUCTION

119.BRACHIOPLASTY

120.ABDOMINOPLASTY

121.MEDIAL THIGH LIFT

122.BODY CONTOURING IN THE MASSIVE-WEIGHT-LOSS PATIENT

123.BUTTOCK AUGMENTATION

124.MALE AESTHETIC PLASTIC SURGERY

125.FEMALE AESTHETIC GENITAL PLASTIC SURGERY

126.GENDER AFFIRMATION SURGERY

127.NONINVASIVE BODY CONTOURING

INDEX

Foreword

When considering textbooks on plastic, reconstructive, and aesthetic surgery, there are a myriad of choices. The majority of textbooks are beautifully written, nicely illustrated, and take a deep dive into the various aspects of plastic surgery with the goal of facilitating one’s ability to learn and retain complex information. Despite the beautiful construction of these books, it is difficult to assess how effective they are when it comes to knowledge assessment and information retention. The best way to demonstrate learning is via the testing and examination process that is usually in a verbal or written question format. The question then becomes, wouldn’t it behoove us to learn in a question-and-answer format rather than the traditional lecture or textbook format?

In this textbook, Essentials of Plastic Surgery: Q&A Companion, Second Edition, Alex P. Jones and Jeffrey E. Janis have carefully organized and compiled more than 1,600 questions into 127 different chapters focused on the various aspects of plastic, reconstructive, and aesthetic surgery that mirror the content that is contained in the (newly released and long-awaited) parent book, Essentials of Plastic Surgery, Third Edition. These are slated for simultaneous “release,” making them a perfect match for the delivery and testing of the content.

The chapters are arranged into seven sections focused on the different categories that comprise our specialty. These include: Fundamentals and Basics; Skin and Soft Tissue; Head and Neck; Breast; Trunk and Lower Extremity; Hand, Wrist, and Upper Extremity; and Aesthetic Surgery. The ability to prepare such a book requires not only an exceptional grasp of the material at hand, but also a tremendous understanding of what is relevant and important, and to be able to assimilate that information in such a way that the reader is immersed and completely interested in learning the material. Anyone who has prepared questions and answers for examination purposes understands that this is not an easy task. It takes tremendous thought and knowledge to be able to tease out what is important and what is not and to properly format the questions. All of us can attest to the fact that examination questions are effective to assess not only how much we know, but also where we are deficient. The question-and-answer format is a valuable tool for education and learning, especially when the questions are organized into a clinically relevant format. The process of answering the question requires problem solving as we think about the potential possibilities and solutions. Reading Essentials of Plastic Surgery: Q&A Companion, Second Edition is a unique experience because it facilitates the learning process by making it fun, enjoyable, sustainable, and, most importantly, effective.

Determining the ideal format for textbook-based learning is not an easy task, with many theories about what constitutes the most effective method to optimize retention. The unfortunate reality is that most textbooks on plastic surgery do not force us to think and problem solve in the same manner as taking an examination. Test taking is an exceptionally effective learning tool because when posed with a question, we are forced to think critically and explore possibilities. In addition, we process information differently when posed with a question compared to when we are spoon-fed information or when we read an exhaustive amount of material. Learning in a problem-solving format via questions and answers is an active process, whereas traditional didactic learning is passive. Individuals tend to learn more effectively when posed with questions that they have to think about to formulate an answer. When our answers are correct, we can assume that we have a good understanding of the specific topic and the explanation will reinforce it. If our answers are incorrect, then having the ability to immediately review the explanations will facilitate our ability to better comprehend and understand it.

The art of preparing questions that are conducive to the learning process cannot be overemphasized. The best questions are those in which the important principles and concepts are embedded and also where the readers can place themselves in the clinical situation being described. This is essentially how board examination and in-service examination questions are created, and also how the Essentials of Plastic Surgery: Q&A Companion, Second Edition is created. The clinical situation usually piques our interest; we think about the possibilities and review the choices. This is in contrast to traditional textbook learning in which the material is presented in a structured format that sometimes lacks clinical relevance.

In conclusion, Essentials of Plastic Surgery: Q&A Companion, Second Edition is an excellent textbook for students, residents, and practicing clinicians and should be included in the armamentarium of plastic surgeons on our shelves and computers. It is organized so that it covers each section from the basics to the nuances and provides a strong foundation for focused learning, and at the same time preparatory learning with the goal being to obtain a superb understanding of the essential educational aspects of our specialty. This textbook is an effective means to assess one’s knowledge, to acquire new knowledge, and for exam preparation focused on plastic, reconstructive, and aesthetic surgery. 

Maurice Y. Nahabedian, MD FACS

Professor of Plastic Surgery

VCU College of Medicine - Inova Branch

National Center for Plastic Surgery

McLean, Virginia, USA

Foreword

Most of us love a quiz, whether to test our knowledge privately or to compete as a team. The satisfaction of knowing an answer is balanced by dismay at failing on a question while not understanding why. This volume is comprehensive not only in its scope but in the excellent explanations of the answers, each of which is clearly delineated and referenced.

By this method, the pleasure of quizzing is combined with the joy of learning, and any candidate for any higher exam in the specialty who can master these questions need not fear their future inquisitors. The scope goes beyond the essentials of our specialty to test and provide a breadth of knowledge and insight which I believe surpasses that of most practicing surgeons. I doubt many will resist the impulse to follow up some of the references that appear at the end of each answer and so take their learning further. Moreover the subject matters also serve as an excellent portal to new advances in our specialty for more senior surgeons to refresh their knowledge. A book this enjoyable and instructive deserves a place in every surgeon’s library.

Simon Kay, OBE, FRCS

Professor of Hand Surgery

University of Leeds, UK

Consultant Plastic Surgeon

Leeds Teaching Hospitals NHS Trust

Leeds, UK

Preface

Almost a decade has passed since we first discussed producing a Q&A companion to the second edition of the popular Essentials of Plastic Surgery. We felt there was a paucity of texts available for self-assessment and that the market could benefit from a comprehensive, clinically oriented Q&A book to help readers cement the core principles covered within the Essentials text.

The third edition of Essentials has grown considerably over time, going from 88 to 102 to 127 chapters, paralleling the increased scope, breadth, and depth of plastic surgery.

The second edition of the Q&A companion has also grown, mirroring the equivalent chapters from Essentials,third edition, with the same style and format and pertinent illustrations reproduced as well as some additional images created for this text.

The new edition of the Q&A companion book contains more than 1,600 questions, all of which are now formatted as multiple-choice questions (MCQ) to match the style used in most international, professional examinations.

The questions are specifically designed to test the reader on the content of each source Essentials chapter, with key emphasis on clinical application of the knowledge.

This learning resource is accompanied by an electronic version (e-book), which means that it can be readily accessed on smartphones and tablets.

For those who prefer traditional books, the format is both compact and portable and presented with high-quality production.

We hope that readers find this second edition to be an even more useful and clinically relevant adjunct to the third edition of Essentials on which it is based, and that it can be used to assess one’s knowledge base of the spectrum of plastic surgery as presented in the parent book. We hope it will prove useful through your training and revalidation and in developing career as a plastic surgeon.

Alex P. Jones, FRCS (Plast), MBChB, BSc

Jeffrey E. Janis, MD, FACS

Acknowledgments

The creation of this book has required teamwork by a significant number of talented people, and I would like to express my gratitude for each person’s part in its development.

First, my appreciation to Dr. Jeff Janis for providing us with the superb Essentials of Plastic Surgery, now in its third edition, as the source text and inspiration for this Q&A Companion. I would like to thank him for his great teamwork, insightful collaboration, commitment, dedication, and enthusiasm throughout the development of both editions of the Q&A Companion book. It has been a real pleasure working with him. I would also like to thank all of the original contributors to the source text for providing such a wealth of information on which to base questions.

A particular thank you is also due to Karen Berger and her team, who first expressed their belief in and support for the first edition.

Anna Barnard has been a significant contributor to both editions, providing feedback and editing advice throughout and for this am I truly grateful. Furthermore, she provided specific expert inputs in the upper limb sections, for which she created and updated the majority of questions alongside juggling our baby twins, clinical work, and our 4-year-old daughter. Our excellent colleague Donald Dewar also provided insightful feedback for some of the early chapters. With infinite patience and tenacity, developmental editor Judith Tomat spent endless hours keeping us on track, while shaping the book into a cohesive whole. Most impressively, she achieved this while simultaneously doing the same for the parent book to ensure close alignment in content and completion time between the two. The size of this task is not to be underestimated. Praise must also be given to Brenda Bunch and her team for providing such high-quality illustrations. A special thank you to the illustrators including Sarah Taylor, Amanda Tomasikiewicz, and Graeme Chambers. My thanks also go to the many members of the Thieme editing and production team, fully supported by Sue Hodgson and Karen Edmonson.

Our goal was to produce a valuable resource for the plastic surgeons of today and tomorrow as they expand and refine their knowledge of our ever-growing field. The nature of plastic surgery demands innovators, and it is our hope that through Essentials of Plastic Surgery and this Q&A Companion, readers will reinforce their mastery of the fundamentals, which may prove necessary for the very next patient they see.

Alex P. Jones, FRCS (Plast), MBChB, BSc

Acknowledgments

A tremendous debt of gratitude is owed to a great number of people who put an incredible amount of time, energy, and effort into the creation, editing, and production of this second edition of the Q&A Companion to the third edition of Essentials of Plastic Surgery.

It goes without saying that there could not be a companion book without a parent book, and to that end, I would like to thank the authors of the original chapters on whose work these questions were crafted and founded.

I also acknowledge with sincere appreciation Alex Jones, who once again poured his heart and soul into this new edition, just as he did in the first. As you will see from the quality of the book, these questions and answers were not written overnight, but rather were painstakingly written over a long period of time with many meticulous revisions and modifications. Alex’s dedication, time, sweat, and passion come through in the final result, and it has been a distinct pleasure to work closely with him. His European perspective gives international flavor and relevance to the book and the types of questions it contains to make it applicable to plastic surgeons worldwide. Credit clearly is also due to Anna Barnard, who helped Alex on many of the chapters and whose work and effort absolutely need to be recognized.

I would also like to recognize Judith Tomat, the Developmental Editor for both this book and its parent book, Essentials of Plastic Surgery. Through her experience, expertise, and indefatigable work ethic, she simultaneously worked on both titles to make them fully and seamlessly integrated—a true companion volume! Massive credit is also due to Brenda Bunch, who managed all artwork associated with both titles. With the incredible number of tables and figures, this was no small task! And finally, I would also like to recognize Sue Hodgson and Karen Edmonson from Thieme Publishing, whose leadership and oversight, and most importantly support, were invaluable. Without each of these individuals, this project simply could not have come to fruition. Their skill and expertise are clearly represented in every page.

Most of all, I would like to deeply and sincerely thank my wife, Emily, and our beautiful children, Jackson, Brinkley, and Holden. Their love, support, patience, and understanding is unequaled and unparalleled and is the only reason a book like this is possible in the first place. I owe them more than I could ever hope to repay, and I take nothing for granted.

Jeffrey E. Janis, MD, FACS

PART I

Fundamentals and Basics

1.Wound Healing

See Essentials of Plastic Surgery, third edition, pp. 3-11

PHASES OF WOUND HEALING

1.Which one of the following statements is true of the process of wound healing?

A.It is comprised of five key phases.

B.Vasodilatation is the initial response after injury.

C.Each of the key phases are distinct entities.

D.Each of the phases are of similar duration.

E.The wound healing process differs in fetal tissue.

CELLS IN WOUND HEALING

2.In the first 24 hours after a soft tissue injury, which one of the following represents the dominant cell type?

A.The neutrophil

B.The macrophage

C.The lymphocyte

D.The fibroblast

E.The myofibroblast

COLLAGEN SUBTYPES

3.Which one of the following collagen subtypes is most commonly found in the skin?

A.Type I

B.Type II

C.Type III

D.Type IV

E.Type V

WOUND HEALING

4.Which one of the following is true in a 6-week-old healing wound?

A.Net collagen production is positive.

B.Net glycosaminoglycan production is positive.

C.Net vasculogenesis is positive.

D.Net glycosaminoglycan production is static.

E.Net collagen production is static.

COLLAGEN SUBTYPES

5.Which one of the following collagen subtypes predominates in a 3-week-old healing wound?

A.Type I

B.Type III

C.Type V

D.Type VII

E.Type IX

WOUND HEALING STRENGTH

6.After 10 weeks of direct closure of a wound to the forearm, what proportion of preinjury tensile strength can be expected across the scar?

A.20%

B.40%

C.60%

D.80%

E.100%

GROWTH FACTORS IN WOUND HEALING

7.A patient sustains a wound to the right arm following trauma. After wash-out in the emergency department, the wound is left to heal by secondary intention. Which one of the following is correct regarding the effect of growth factors in this process?

A.Fibroblast growth factor (FGF) will decrease fibroblast proliferation.

B.Transforming growth factor (TGF)-beta promotes fibroblast migration and proliferation.

C.Vascular endothelial growth factor (VEGF) is produced by endothelial cells.

D.Epidermal growth factor (EGF) promotes endothelial proliferation.

E.Platelet-derived growth factor (PDGF) promotes keratinocyte proliferation.

CELL TYPES IN WOUND HEALING

8.Which one of the following cell types is chiefly responsible for reducing the surface area of a granulating wound because of its contractile properties?

A.Fibroblast

B.Keratinocyte

C.Macrophage

D.Lymphocyte

E.Myofibroblast

CELLULAR PROCESS IN EPITHELIALIZATION

9.Which one of the following is an important cellular process that facilitates mobilization of keratinocytes during healing of a split-thickness skin graft donor site?

A.Diapedesis

B.Margination

C.Loss of contact inhibition

D.Differentiation

E.Epithelialization

TYPES OF WOUND HEALING

10.Which one of the following most accurately defines whether primary or secondary healing occurs within a cutaneous wound?

A.The mechanism of injury

B.The amount of tissue damage

C.The time healing takes to occur

D.The method of wound closure

E.How closely the wound edges are apposed

FACTORS AFFECTING WOUND HEALING

11.In which one of the following conditions is normal wound healing expected after surgery?

A.Ehlers-Danlos

B.Progeria

C.Werner syndrome

D.Cutis laxa

E.Smokers

VITAMINS IN WOUND HEALING

12.Which one of the following vitamins can be particularly useful to help wound healing in patients on long-term steroids?

A.Vitamin A

B.Vitamin B

C.Vitamin C

D.Vitamin D

E.Vitamin E

FAILURE OF WOUND HEALING

13.What is the single most important cause of a wound to fail to heal?

A.Poor oxygen supply

B.Denervation

C.Dry wound base

D.Radiation injury

E.Poor nutrition

SMOKING CESSATION

14.A 35-year-old lady is planning to undergo augmentation mastopexy on the understanding that she will have to stop smoking preoperatively. Which one of the following tests would be most useful to assess her compliance with smoking cessation?

A.Platelet count

B.Blood nicotine

C.Exhaled carbon dioxide

D.Urine cotinine

E.Blood hydrogen cyanide

EFFECTS OF NICOTINE ON WOUND HEALING

15.You see a patient who wishes to undergo a face lift. She has given up smoking after your advice and now uses only nicotine replacement medications. Which one of the following represents a well-recognized effect of nicotine on tissues?

A.Reduced oxyhemoglobin concentrations

B.Reduced platelet adhesion

C.Reduced local inflammation

D.Reduced local blood supply

E.Toxic effects on keratinocytes

CHEMOTHERAPY AND WOUND HEALING

16.You have a patient with a large wound to the calf after a fall and have closed this directly. He is due to start chemotherapy very soon. When can the chemotherapy be started without detrimental effects on healing of this wound?

A.Immediately

B.In 3 days

C.In 14 days

D.In 1 month

E.There is no evidence to guide this decision

BIOFILMS

17.When considering the formation of a biofilm around a breast implant, which one of the following is true?

A.Its presence can be detected with routine blood or wound cultures.

B.It would probably respond well to systemic antibiotic therapy.

C.It is associated with an acute inflammatory reaction with release of histamine.

D.It would be effective at evading a host immune response.

E.It would be unlikely to reform following thorough debridement.

ABNORMAL SCARRING

18.When examining a patient with an abnormally thickened scar, what is the key factor that will differentiate a keloid from a hypertrophic scar?

A.Elevation of the scar

B.Erythema within the scar

C.Growth beyond the original wound borders

D.A biopsy of the scar tissue is the only way to differentiate

E.The shape of the scar

TREATMENT FOR KELOID SCARS

19.A 23-year-old lady presents with a 1-cm keloid scar to the left pinna following ear piercing 12 months before. Which one of the following approaches to treatment would be optimal for scar reduction with least risk of recurrence?

A.Silicone sheeting

B.Steroid injection

C.Radiation

D.Combination therapy

E.Surgical excision

Answers

1.Wound Healing

PHASES OF WOUND HEALING

1.Which one of the following statements is true of the process of wound healing?

E.The wound healing process differs in fetal tissue.

Fetal wound healing during the first two trimesters differs from the normal wound healing process and is the subject of much research because of the perceived potential for scarless healing. The process is more of a regenerative process than a repair process often with the absence of an inflammatory phase.1

Wound healing after birth represents a highly evolved and complex defense mechanism that helps to limit infection and further injury. The normal wound healing process is comprised of three (not five) phases. These are the inflammatory, the fibroproliferative, and the remodeling phases. The phases are not distinct entities and have overlap both in terms of timing and function. Each phase has a different duration and it can be quite variable. The inflammatory phase typically lasts for 1 week, the fibroproliferative phase lasts for 2–3 weeks, and the remodeling phase lasts for up to 1 year. Vasoconstriction is the initial response to injury in order to limit blood loss and lasts for 5–10 minutes after injury. Vasodilatation and increased tissue permeability follow this as part of the inflammatory phase to promote cellular access to the injured area. Knowledge of the key processes in wound healing is often tested in examinations and a solid understanding of these principles is important for clinical practice with respect to the management of different wound types.2–5

REFERENCE

1.Hu MS, Maan ZN, Wu JC, et al. Tissue engineering and regenerative repair in wound healing. Ann Biomed Eng 2014;42(7):1494–1507

2.Broughton G, Rohrich RJ. Wounds and scars. Sel Read Plast Surg 2005;10(7):1–56

3.Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997

4.Janis JE, Kwon RK, Lalonde DH. A practical guide to wound healing. Plast Reconstr Surg 2010;125(6):230e–244e

5.Janis JE, Harrison B. Wound healing: Part I. Basic science. Plast Reconstr Surg 2016;138(3, Suppl):9S–17S

CELLS IN WOUND HEALING

2.In the first 24 hours after a soft tissue injury, which one of the following represents the dominant cell type?

A.The neutrophil

There are a number of key cell types involved in the wound healing process and they are generally specific to a particular phase of wound healing. For example, the neutrophil is the dominant cell type in the first 24 hours after injury. It serves to produce inflammatory mediators and undertake phagocytosis of damaged cells but is not actually critical to wound healing. After 48 hours the macrophage becomes the dominant cell type. In contrast to neutrophil, this is critical to wound healing because it orchestrates growth factors such as TGF-beta, which promotes collagen production, remodeling, epithelialization, and chemotaxis. Lymphocytes are involved in the inflammatory phase, although their role is poorly defined. They are typically present toward the end of the first week after injury. The fibroblast is key to wound healing and moves into the wound after 48 hours. By the end of the first week, it represents the dominant cell type. Along with the myofibroblast, it has a key role in the fibroproliferative phase with the production of collagen.1

REFERENCE

1.Janis JE, Harrison B. Wound healing: Part I. Basic science. Plast Reconstr Surg 2016;138(3, Suppl):9S–17S

COLLAGEN SUBTYPES

3.Which one of the following collagen subtypes is most commonly found in the skin?

A.Type I

Collagen is a protein that forms the key building block for skin, bone, cartilage, and tendon. The basic structure consists of three left-handed polypeptide helices wound together to form a right-handed helix. It comprises two alpha-1 and one alpha-2 chains; each of these are formed by amino acid sequences: glycine-prolene-X and glycine-X-hydroxyprolene. There are more than 20 different collagen subtypes and type I is the most common in humans, representing 90% of all body collagen. It predominates in the skin, tendon, and bone. Type II is found in the cornea and articular cartilage. Type III is found in the vessel and bowel walls. Type IV is found in the basement membrane only.

WOUND HEALING

4.Which one of the following is true in a 6-week-old healing wound?

E.Net collagen production is static.

At 6 weeks, the healing wound should be in the remodeling phase of wound healing. During this phase, net collagen production is static because an equilibrium is reached between collagen breakdown and collagen synthesis. Although there is no change in quantity, collagen continues to undergo remodeling with increased organization and formation of stronger cross-links. The ratio of different collagen subtypes also changes. Glycosaminoglycan production and vasculogenesis decrease as does the water content and cellular population.1,2

REFERENCE

1.Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith’s Plastic Surgery, 5th ed. Philadelphia: Lippincott-Raven; 1997

2.Janis JE, Harrison B. Wound healing: Part I. Basic science. Plast Reconstr Surg 2016;138(3, Suppl):9S–17S

COLLAGEN SUBTYPES

5.Which one of the following collagen subtypes predominates in a 3-week-old healing wound?

B.Type III

There are more than 20 different types of collagen with type I representing 90% of all total body collagen. The normal adult ratio of type I to type III collagen within the skin is around 4:1. However, in the healing wound, type III collagen is made first and this subtype predominates in the proliferation and early remodeling phases until it is gradually replaced by type I collagen.

WOUND HEALING STRENGTH

6.After 10 weeks of direct closure of a wound to the forearm, what proportion of preinjury tensile strength can be expected across the scar?

D.80%

In spite of the impressive ability of wounds to heal, tissues never regain 100% of their preinjury tensile strength. It is estimated that a completely healed wound will have, at best, around 80% of its preinjury tensile strength and this will be achieved between 60 days and 1 year after the injury, typically around 90 days. The evidence for this stems from a 1965 study by Levenson et al1 where healing in rat skin wounds was assessed at various time intervals. Knowledge of skin strength at various time points following repair is clinically useful when considering suture selection, such that the suture is able to satisfactorily support the wound until adequate strength has been regained. For example, placement of buried dermal sutures in the face allows for external skin sutures to be removed at 5 days although the repair will still be weak at this stage. It also helps guide the clinician and patient with regard to resumption of normal activities following surgery.1

REFERENCE

1.Levenson SM, Geever EF, Crowley LV, Oates JF III, Berard CW, Rosen H. The healing of rat skin wounds. Ann Surg 1965;161:293–308

GROWTH FACTORS IN WOUND HEALING

7.A patient sustains a wound to the right arm following trauma. After wash-out in the emergency department, the wound is left to heal by secondary intention. Which one of the following is correct regarding the effect of growth factors in this process?

B.TGF-beta promotes fibroblast migration and proliferation.

Many growth factors are involved in the wound healing process and most of these positively influence cell proliferation and migration. Similarly, TGF-beta will promote fibroblast migration and proliferation. FGF will increase both fibroblast and keratinocyte proliferation. It also affects fibroblast chemotaxis. VEGF will promote endothelial cell proliferation and is produced by many different cell types in response to hypoxia or injury. EGF promotes keratinocyte and fibroblast division rather than endothelial cell proliferation. PDGF promotes fibroblast, endothelial cell, and smooth muscle proliferation rather than keratinocyte proliferation.

CELL TYPES IN WOUND HEALING

8.Which one of the following cell types is chiefly responsible for reducing the surface area of a granulating wound because of its contractile properties?

E.Myofibroblast

Fibroblasts are the key cells responsible for forming extracellular matrix and collagen. They are present in both the early and late stages of wound healing and have a permanent presence in the dermis. Myofibroblasts are specialized fibroblasts that have contractile cytoplasmic microfilaments and distinct cellular adhesion structures. They are present in the early stages of wound healing and serve to collectively decrease the size of a wound. They usually remain within the wound for the first few weeks following injury. Keratinocytes are the major cells of the epidermis and are involved in wound healing and normal skin cell turnover. Macrophages and lymphocytes are both inflammatory cells that are involved in the orchestration of wound healing.

CELLULAR PROCESS IN EPITHELIALIZATION

9.Which one of the following is an important cellular process that facilitates mobilization of keratinocytes during healing of a split-thickness skin graft donor site?

C.Loss of contact inhibition

The process of healing a split-thickness skin graft donor site is termed reepithelialization. This involves a series of cellular processes that enable keratinocytes from the wound edges to proliferate and move toward the center of the wound. Cells are usually held at the wound edge by contact inhibition and this must be lost to enable cells to mobilize. Following a loss of contact inhibition, cells move across the wound until they meet cells from the other side and contact inhibition is reestablished. While cells at the wound edge are migrating, basal cells further back from the wound edge proliferate to support the cell numbers required to bridge the wound. Differentiation of keratinocytes subsequently occurs to reestablish normal epithelial layers from basal layer to stratum corneum. Margination refers to the process of leukocytes moving from the axial zone (central higher flow zone) to the plasmatic zone (peripheral lower flow zone) within blood vessels and adhering to the vessel walls in order to exit the blood stream. Diapedesis refers to the process of cells passing through vessel walls once margination has taken place during the inflammatory phase of wound healing.

TYPES OF WOUND HEALING

10.Which one of the following most accurately defines whether primary or secondary healing occurs within a cutaneous wound?

E.How closely the wound edges are apposed

Healing is defined as primary, secondary, or tertiary (delayed primary). The key factor that differentiates whether primary or secondary healing occurs is how closely the wound edges are apposed. When the wound edges are reapproximated, such as when an incised wound is sutured, primary healing can occur. This results in the least amount of scar tissue production. In contrast, where there is a gap between the wound edges, such as when a finger pulp injury with tissue loss is left open, secondary wound healing will occur in order to fill in the missing tissue. More scar tissue is formed and the process involves a combination of contraction and epithelialization. Neither the mechanism of injury, the amount of tissue damage, nor the method of wound closure, per se, define whether healing by primary or secondary intention occur, only the reapproximation of the wound edges. Even when tissue loss has occurred, primary healing is possible providing that the wound edges are debrided and well apposed. Complete healing is normally achieved most quickly in wounds that are closed primarily, but this is not a defining factor. Wound closure can be satisfactorily achieved with sutures, staples, or glue, and each of these techniques allows primary healing to take place. Tertiary healing and delayed primary healing are the same thing. They refer to wounds that are initially left open and then closed after debridement at a later stage. This is an approach commonly employed in infected wounds where closure is delayed until the infection has been satisfactorily treated.

FACTORS AFFECTING WOUND HEALING

11.In which one of the following conditions is normal wound healing expected after surgery?

D.Cutis laxa

Cutis laxa is a condition where there is a mutation in elastin fibers and this results in loose wrinkled skin and hypermobile joints. Some patients can benefit from resection of excess skin and this is safe as wound healing is normal.

The other conditions are all associated with abnormal wound healing. Ehlers-Danlos syndrome is also known as cutis hyperelastica and is a genetic connective tissue disorder with abnormal collagen cross-linking. The condition is associated with thin friable skin, poor wound healing, hypertrophic scarring, and hypermobile joints. Progeria is also known as Hutchinson-Gilford syndrome and is also a genetic condition observed in children. Patients have premature aging with skin laxity and poor wound healing. Werner syndrome is adult progeria with similar features to Hutchinson-Gilford syndrome. In each of these conditions, surgery is best avoided where possible.

It is well accepted that there is an association between smoking and delayed wound healing, although the precise mechanism is not well understood. The constituents implicated within tobacco smoke include nicotine, carbon monoxide, and hydrogen cyanide. Sørensen undertook a systematic review in 20121 to consider the effects of smoking on wound healing and found that smoking temporarily decreases tissue oxygenation and aerobic metabolism, while it also attenuates both the inflammatory and proliferation phases of wound healing, thereby decreasing collagen production. Cessation of smoking for 4 weeks before surgery appears to reverse some, but not all, of the processes described.

REFERENCE

1.Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012;255(6):1069–1079

VITAMINS IN WOUND HEALING

12.Which one of the following vitamins can be particularly useful to help wound healing in patients on long-term steroids?

A.Vitamin A

Vitamins are vital to normal wound healing processes, but supplements typically help wound healing only when there is a deficiency present. Vitamin A is also known as retinol and has important functions in immunity, vision, and wound healing. It can help reverse delayed wound healing due to steroids and increase epithelialization in healing wounds. It is well accepted that steroids delay wound healing and animal and human studies have shown these negative effects to be reversed when vitamin A is used either topically or systemically. The mechanism is not well understood, and the benefit of using vitamin A is absent when steroids are not being given. Given this evidence, it may be particularly useful to prescribe vitamin A during the perioperative period in patients on long-term steroids such as for rheumatoid arthritis or ulcerative colitis.1

There are a number of different B vitamins including thiamine, folic acid, pyridoxine, and cobalamin which have important roles in metabolism and oxygen transport. Deficiencies of the B vitamins can therefore result in a broad range of conditions. Vitamin C is vital for hydroxylation reactions in collagen synthesis and a deficiency leads to scurvy, with immature fibroblasts, deficient collagen synthesis, capillary hemorrhage, and decreased tissue strength. Vitamin D is important for calcium regulation and a deficiency can lead to rickets in children or osteomalacia in adults. Vitamin E is an antioxidant that stabilizes membranes. Large doses inhibit healing and may cause dermatitis.

REFERENCE

1.Hunt TK, Ehrlich HP, Garcia JA, Dunphy JE. Effect of vitamin A on reversing the inhibitory effect of cortisone on healing of open wounds in animals and man. Ann Surg 1969;170(4):633–641

FAILURE OF WOUND HEALING

13.What is the single most important cause of a wound to fail to heal?

A.Poor oxygen supply

The single most common reason for a wound not to heal is tissue hypoxia. This can occur secondary to a number of causes such as poor vascularity, smoking, previous injury, or radiation therapy. The presence of infection with microorganisms greater than 105 per gram of tissue will decrease oxygen tension, lower the pH, and increase collagenase activity. Denervation of a wound will make it more susceptible to pressure damage and is a major factor in the development of sacral sores in paraplegic patients and foot ulcers in diabetic patients. A moist wound is thought to be beneficial to healing so wounds are often kept moist until reepithelialization is complete, but a dry wound is not the most significant factor in failure of a wound to heal. Radiation injury is a significant factor in wound healing and results from damage to blood vessels, which in turn causes poor oxygen supply to local tissues.

Nutritional status is a key component in wound healing and needs to be considered pre- and postoperatively, with dietician support requested in more complex cases.

SMOKING CESSATION

14.A 35-year-old lady is planning to undergo augmentation mastopexy on the understanding that she will have to stop smoking preoperatively. Which one of the following tests would be most useful to assess her compliance with smoking cessation?

D.Urine cotinine

Cotinine is the body’s key metabolite of nicotine and is considered the gold standard biomarker for smoking assessment. It has a half-life of up to 20 hours in contrast to nicotine which has a half-life of up to 2 hours. Measurement of nicotine itself is therefore less useful than cotinine because it is more rapidly metabolized from the body, so would only be measurable very shortly after a recent cigarette. In contrast, cotinine levels would remain elevated some weeks following a patient’s last cigarette if he or she is a regular smoker. Cotinine levels can be measured in the urine, blood, saliva, or hair follicles. Urine testing is generally preferred because blood testing of cotinine can be affected by diet due to the presence of thiocyanate, which is found in green vegetables such as broccoli and cabbage. Hair or saliva testing of cotinine is less commonly used. One advantage of the hair sampling over saliva is that longer exposure estimates may be obtained.1

Exhaled carbon monoxide (not carbon dioxide) is another useful measurement for assessing smoking. It is recorded in parts per million (ppm). It is generally accepted that a level of 7 ppm is the upper limit to show evidence of recent smoking. Measurement of exhaled carbon monoxide has some drawbacks including the fact it is not specific to tobacco intake as it is influenced by atmospheric carbon monoxide, passive smoking, occupational exposure, or smoke from biomass or coal burning. It too has a short half-life so tends to provide an assessment of smoking behavior primarily over a 6–8 hours period.2

Smoking can lead to increased platelet adhesiveness due to nicotine itself; however, the platelet count would not be expected to be measurably altered. Some other blood parameters can be affected by smoking and these include hemoglobin, white cell count, and mean corpuscular volume.3 Hydrogen cyanide inhibits oxygen transport and is increased in smokers. However, it is not routinely measured in relation to smoking cessation.

REFERENCE

1.Miron R, Trofor L, Bucur D, Man M, Cernat R, Trofor A. Biomarkers of tobacco exposure-relevant diagnostic implications in daily practice. Romanian Journal of Oral Rehabilitation 2014;6(1)

2.Cope GF, Wu HHT, O’Donovan GV, Milburn HJ. A new point of care cotinine test for saliva to identify and monitor smoking habit. Eur Respir J 2012;40(2):496–497

3.Malenica M, Prnjavorac B, Bego T, et al. Effect of cigarette smoking on haematological parameters in healthy population. Med Arh 2017;71(2):132–136

EFFECTS OF NICOTINE ON WOUND HEALING

15.You see a patient who wishes to undergo a face lift. She has given up smoking after your advice and now uses only nicotine replacement medications. Which one of the following represents a well-recognized effect of nicotine on tissues?

D.Reduced local blood supply

Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and the potential for impaired healing of injured tissues. Nicotine also increases platelet adhesiveness (not decreases it), raising the risk of thrombotic microvascular occlusion and further tissue ischemia. In addition, it can reduce red blood cells, fibroblast, and macrophage proliferation. Nicotine is therefore one of the components within cigarette smoke that may be responsible for the increased risk of wound complications associated with tobacco smoking.

There have been a number of studies to explore the precise role of nicotine in wound healing, both as a single agent and as part of cigarette smoking. However, the mechanisms involved are complex and remain incompletely understood. At present, in spite of the effects of nicotine on wound healing, there is no clinical evidence to show that nicotine replacement therapy in patients abstaining from smoking will significantly affect their wound healing. In high-risk procedures such as face lifting, it is still probably best to avoid both smoking and nicotine replacement therapy in order to minimize risk of wound complications. Other products in cigarette smoke such as carbon monoxide and hydrogen cyanide are responsible for reduced oxyhemoglobin concentrations, altered inflammation, and toxic cellular effects.1–3

REFERENCE

1.Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012;255(6):1069–1079

2.Silverstein P. Smoking and wound healing. Am J Med 1992;93(1A):22S–24S

3.Warner DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology 2006;104(2):356–367

CHEMOTHERAPY AND WOUND HEALING

16.You have a patient with a large wound to the calf after a fall and have closed this directly. He is due to start chemotherapy very soon. When can the chemotherapy be started without detrimental effects on healing of this wound?

C.In 14 days

It is well accepted that antineoplastic agents affect wound healing. This evidence is based on both lab-based animal studies and clinical studies in humans. However, there is unlikely to be any significant effect on wound healing, providing that chemotherapy treatment is delayed for 10–14 days after the wound has been closed. This makes sense given the anticipated healing time for a typical soft tissue wound.1,2

REFERENCE

1.Falcone RE, Nappi JF. Chemotherapy and wound healing. Surg Clin North Am 1984;64(4):779–794

2.Shamberger RC, Devereux DF, Brennan MF. The effect of chemotherapeutic agents on wound healing. Int Adv Surg Oncol 1981;4:15–58

BIOFILMS

17.When considering the formation of a biofilm around a breast implant, which one of the following is true?

D.It would be effective at evading a host immune response.

Biofilms have a significant role in plastic surgery, particularly where implants are used. They can be a major saboteur to wound healing and the reconstructive process. In addition, there has been much debate as to their importance in formation of capsular contracture in breast augmentation, where their presence has been implicated as a key causal factor.1

One of the most challenging factors in managing biofilms is their effectiveness at evading the host’s immune system. Biofilms are fundamentally different from free floating bacteria (termed the planktonic state). They require a surface for growth, which can be either a prosthetic implant or one occurring within the body’s own soft tissues. They are difficult to detect and treat. Routine culture is not effective at detection of biofilms and they are recalcitrant to treatment with systemic antimicrobials. Even following debridement, they have a tendency to recur.

REFERENCE

1.Barker JC, Khansa I, Gordillo GM. A formidable foe is sabotaging your results: what you should know about biofilms and wound healing. Plast Reconstr Surg 2017;139(5):1184e–1194e

ABNORMAL SCARRING

18.When examining a patient with an abnormally thickened scar, what is the key factor that will differentiate a keloid from a hypertrophic scar?

C.Growth beyond the original wound borders

Keloid and hypertrophic scars each represent abnormal scarring processes and are differentiated clinically. The key defining feature of a keloid scar is that it grows beyond the original scar border, whereas a hypertrophic scar does not. Both keloid and hypertrophic scars are typically elevated and erythematous. The histological appearances are similar with high concentrations of type III collagen in each. Keloid scars are only seen in humans, and typically observed in younger patients, i.e., 10–30 years of age. They can occur spontaneously or secondary to injury or infection. They tend to affect patients with darker skin tones most commonly. Females are more commonly affected than males. They commonly occur on the ear or anterior chest and rarely regress spontaneously. Hypertrophic scars have an equal sex ratio, are typically seen in younger age groups (less than 20 years of age), and appear soon after injury such as in children who have sustained a burn. All skin tones can be affected (Fig. 1.1).1,2

Fig. 1.1 Keloid scar.

REFERENCE

1.Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am 2011;19(3):505–515

2.Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg 2009;23(3):178–184

TREATMENT FOR KELOID SCARS

19.A 23-year-old lady presents with a 1-cm keloid scar to the left pinna following ear piercing 12 months before. Which one of the following approaches to treatment would be optimal for scar reduction with least risk of recurrence?

D.Combination therapy

Keloid scars can develop following body piercings, as in this case, following tattoos, acne, insect bites, vaccinations, trauma, or surgery. Effective management of them can be challenging. There are a number of potential options for treatment including silicone sheeting, corticosteroids, interferon, radiation, surgical excision, and cryotherapy. Recurrence rates tend to be high in many cases, so multimodality or combination therapy is generally accepted as the best practice approach for their treatment.1,2

Recurrence rates tend to be high in many cases, so multimodality or combination therapy is generally accepted as the best practice approach for their treatment.In this case, initial treatment with steroid injection followed by surgical excision or debulking may be effective. Additional scar management therapies such as silicone sheeting or pressure may also be helpful. Alternatively, surgical excision combined with radiotherapy may provide the most effective solution if this treatment is available. Radiation treatment for keloids is typically commenced on the same day as surgery with dose ranges of 12–30 gray (Gy), delivered over 5–7 days.3,4

Silicone sheeting would be recommended for wounds as soon as epithelialization is complete so it would be too late for this duration of scar as primary treatment and would be unlikely to show any effect. Steroid injections can reduce collagen synthesis and inflammatory mediators to soften keloid scars. Radiation inhibits angiogenesis and fibroblasts and can be associated with lower rates of recurrence than some treatments.

REFERENCE

1.Sidle DM, Kim H. Keloids: prevention and management. Facial Plast Surg Clin North Am 2011;19(3):505–515

2.Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg 2009;23(3):178–184

3.Zainib M, Amin NP. Radiation Therapy in the Treatment of Keloids. StatPearls; 2019

4.Mankowski P, Kanevsky J, Tomlinson J, Dyachenko A, Luc M. Optimizing radiotherapy for keloids: a meta-analysis systematic review comparing recurrence rates between different radiation modalities. Ann Plast Surg 2017;78(4):403–411

2.General Management of Complex Wounds

See Essentials of Plastic Surgery, third edition, pp. 12–20

BLOOD GLUCOSE CONTROL

1.A diabetic patient is scheduled to undergo abdominal wall reconstruction. Preoperative hemoglobin A1C is 12% and random blood glucose (RBG) level is 200 mg/dL. Which one of the following is correct?

A.A normal A1C should be 8.5 when expressed as a percentage of glycosylated hemoglobin.

B.The A1C represents the patient’s average glucose control over the previous 180 days.

C.Postoperative infection risk is significantly increased for this patient because the blood glucose level is higher than 180 mg/dL.

D.Tight blood glucose control (<70 mg/dL) during the perioperative period will reduce the postoperative mortality risk.

E.An elevated A1C level linearly correlates with an increased risk of surgical site infections.

PREOPERATIVE ASSESSMENT OF NUTRITION

2.When assessing a patient’s preoperative nutritional status before major surgery by monitoring blood albumin levels, which one of the following is correct?

A.The half-life of albumin is 3 days.

B.A preoperative value of 4.3 g/dL is outside the normal range.

C.Assessment is based on the “rule of fives.”

D.Severe malnutrition would be suggested by preoperative values less than 3.0 g/dL.

E.A low preoperative level is a strong predictor for postoperative mortality risk.

IMAGING IN COMPLEX WOUNDS

3.A 67-year-old smoker has exposed hardware after a wound breakdown over his tibial fracture. The hardware has been removed, but his wound is not progressing. His dorsalis pedis pulse is not palpable, and the posterior tibial pulse is weak. Which one of the following modalities is the most accurate and least harmful for imaging of this patient’s peripheral arterial disease status and leg vessel anatomy?

A.Magnetic resonance angiography (MRA)

B.Plain radiographs

C.Computerized tomography angiography (CTA)

D.Ultrasound

E.Contrast angiography

VASCULAR ULCER MANAGEMENT

4.After assessing a patient who is malnourished and has a punched-out ulcer on the lower lateral leg, you decide to perform an ankle-brachial pressure test, which shows a value of 0.4. What does this result suggest?

A.Normal lower limb vasculature.

B.Imminent ischemic gangrene is likely.

C.Critical stenosis is present that warrants further intervention.

D.Vessels are significantly calcified.

E.Predominantly venous disease.

TISSUE RECONSTRUCTION AND WOUND CLOSURE

5.What was the main limitation of the original reconstructive ladder concept?

A.It did not include free tissue transfer.

B.The concept could only be practiced by plastic surgeons.

C.It did not include dermal matrices or negative pressure therapy.

D.The reconstructive process was performed in a stepwise manner.

E.Primary closure was the first rung on the ladder.

NEGATIVE PRESSURE WOUND THERAPY

6.You are planning to temporize an abdominal wound with a negative pressure dressing after debridement. Which one of the following is correct regarding negative pressure wound therapy?

A.It increases local blood flow and granulation tissue production.

B.It reduces fluid exudate.

C.It is contraindicated in recently debrided wounds.

D.It can be useful for treating fistulas.

E.It reduces mitotic activity in the wound.

WOUND DEBRIDEMENT

7.A 47-year-old paraplegic patient presents with a grade 3 sacral pressure sore. Examination shows a 7 ᵡ 8 cm chronic wound with eschar, fibrinous exudate, and granulation in the wound bed. In order to optimize accuracy at the time of surgical debridement, which one of the following adjuncts would be most useful intraoperatively?

A.Quantitative tissue cultures

B.Frozen section biopsy

C.Iodine brown solution

D.Methylene blue dye

E.Indocyanine green dye

COMPLICATIONS OF RADIOTHERAPY

8.A 68-year-old male has undergone postsurgical radiotherapy to the right side of the neck and mandible for management of an intraoral squamous cell carcinoma (SCC). He now presents with symptoms of pain and swelling over the mandible and has reduced mouth opening. Examination shows bone exposed through the skin surface (sequestrum).