Poland Grading system:

Thorax

• T1: absence of all or part of pectoralis
• T2: T1 + pectus excavatum or carinatum
• T3: T1 + rib aplasia (usually 3 and 4)
• T4: T1 + T2 + T3

Breast

• B1: hypoplastic breast
• B2: breast alpasia (amastia)

Nipple-areola complex

• N1: hypoplastic NAC less then 2cm displaced
• N2: hypoplastic NAC more then 2cm displaced
• N3: athelia

Posting to social media: a detailed consent documenting the dynamic nature of individual social media sites should be formally discussed and documented in the patient’s medical record prior to proceeding

• there is ultimately no consensus guidelines on ASPS

Allograft transplantation: opportunistic infections are most likely to develop after the first month and within the first year.

• The first month are typical postoperative nocosomial infections
• Peak immunosuppression is between 1-12 months and are prone to opportunistic infections (CMV, HSV, HZ, EBV)
• after 12 months patients can tolerate decreased immunosuppression

Hypovolemic shock: (hemorrhage from trauma); elevation of pulse rate is usually first sign.

• increase in diastolic blood pressure is actually first sign but is not usually noticeable
• other changes at higher rates of loss include decrease in BP, confusion, increase in respiratory rate

Comparative cohort study: investigates particular exposure to determine correlation of disease (implants or no implants with BII)

Case control study: retrospectively identifies cases and controls from the same source population (IE women) to investigate differences in exposures or risk factors (implants vs no implants)

Randomized controlled trial randomly assigns participants into an experimental or control group

Cross sectional study is an observational study that analyzes data from a population at a specific time point

Case series study is one that tracks participants who have received exposure and tracks outcomes

Isofloran dye: allergic reactions can occur in 1.6% of patients, signs can be urticaria, blue hives, skin rash, anaphylaxis

• stop procedure, give fluid bolus followed by BP support (pressor)
• next give steroid and antihistamine to counteract

Sepsis:

Surviving sepsis campaign recommends administration of IV abx ASAP (within 1 hour), increasing delays are associated with increased mortality and detrimental effects (length of hospital stay, AKI, lung injury)

1 hour bundle includes: measuring lactate, obtain blood cultures, administer broad spectrum abx, administer 30ml/kg of crystalloid, apply vasopressors

Inferior oblique: innervation by the oculomotor nerve
Superior oblique: trochlear nerve
Lateral rectus: abducens nerve
– other oculomotor nerve is levator, SR, MR, and IMR

Candidates for board certification with ABPS are responsible for all advertising

Venous couples <2mm have higher rates of thrombosis: surgeon should perform hand sewn anastomosis or find different recipient vessel

Dupuytren’s: disease factor most predictive of recurrence is the degree of PIP contracture

• PIP and younger age
• collagenase is not superior to needle aponeurotomy for PIP contracture

A physician will obtain a higher number of RVUs by performing in a non-facility setting like an office

Maintaining certification: ABPS continuous certification program includes 1) professionalism 2) life long learning and self assessment 3) assessment of knowledge, judgment and skills, 4) improvement in medical practice. Unrestricted medical license is mandatory, and 150 CME credits every three years are needed

PECS ½ blocks: commonly used in ERAS
PECS1: performed between the pectoralis major and pectoralis minor muscles
PECS2: involves injection of anesthesia between pectoralis minor and serratus anterior muslces
Serratus plane block: between serratus anterior and latissimus dorsi

Anticoagulation bridging from warfarin: LMWH briding should begin 3 days prior to the procedure and 2 days after discontinuing warfarin
-should bridge if: embolic event within 3 months, mechanical mitral valve, mechanical aortic valve, Afib with high risk of stroke, VTE in past 3 months, recent coronary stenting (3 months) previous DVT/PE with interruption of anticoagulation

Parkland formula for burn resuscitation: KGXTBSA (determined by second and third degree burns), half is generally given in the first 8 hours of the injury, and the next in 16 hours

Power of attorney document: allows a person to express his or her desires related to end-of-life medical care, allows a person to appoint an individual to make decisions regarding medical care for that person in the event that he/she is no longer able to make decisions for themselves
– living will: outlines a person’s values and preferences for life-sustaining treatments (ventilator, CPR, etc)

AAASF (American association for accreditation of ambulatory surgery facilities) and liposuction
Class A facilities: only 500 of lipo under local or sedation
Class B requires anesthesia provider, no more than 5L aspirate unless patient is monitored overnight in the facility
Class C anesthesia provider and same as above

Burns and integra: decrease in hypertrophic scarring associated with use of bilaminate neodermis and burn reconstruction
– cost is high, needs 2 surgeries, longer hospital stays

Sistrunk procedure: thyroglossal duct cysts, involves resection of cyst, cyst tract, and middle third of the hyoid bone

Equivalent rates of breast cancer mortality between AA and Whites in some states likely due to AA having more access to screening mammography and in situ diagnosis.
– death from breast cancer has declined by 40% in the US since 1989

A single perioperative dose of corticosteroid has been associated with transient hyperglycemia. Long term CS has been associated with increased wound complications. Vitamin A counteracts steroid effects on wound healing.

Pilomatrixoma: slow growing tumor of the hair follicle. Develop in head and neck region, mutation in CTNNB1 (regulates cell growth and attachment)

ACOSOG trial: If staging of the axilla cannot be obtained via sentinel lymph node biopsy, level 1 and 2ax dissection should be performed for staging purposes
NCCN (national comprehensive cancer network) protocol recommends excisional biopsy following detection of high risk lesions including: papillomas WITH atypia, atypical ductal hyperplasia, atypical lobular hyperplasia, ductal carcinoma in situ

Afib: irregularly irregular QRS complexes without P waves. Can occur in 5-10% of patients undergoing non cardiothoracic surgery.
-rate vs rhythm control: rhythm control associated with greater number of hospitalizations, torsades de pointes, pulmonary events, GI, bradychardia etc.
Rate control is treatment strategy of choice (80-100)
First choice is metoprolol, diltiazem second line therapy.

Hyperkalemia: IV calcium gluconate (to stabilize myocardium) given first followed by dextrose/insulin orbeta2agonist

Patients should stop ACE inhibitors (lisinopril) the night prior to surgery. Patients can continue statins, beta blockers, SSRIs, sleeping medications

Most sensitive test for CSF leak is beta 2 transferrin. Remember that displaced posterior table fractures require cranialization

Risk of surgical site occurrence is 12 weeks after any CSI (for hand surgery). Should wait 12 weeks minimum prior to OR

P value: calculated value that quantifies the probability of obtaining data equal to or more extreme than the data observed on a study should the null hypothesis be true

Type I error: the erroneous rejection of a true null hypothesis (study that shows drug is more efficacious than placebo)

Alpha: probability of making type I error (rejecting a true null hypothesis). Typically set by the researcher at 5%)

Type II error: failure to reject false null hypothesis
Power of a test of statistical significance is the probability that it will reject a false null hypothesis. Decreases as beta increases.

Breast conservation therapy: 2mm minimum margin (options for DCIS include lumpectomy plus radiation, mastectomy and SLNB, or lumpectomy alone)

Cleft palate team: American cleft palate craniofacial association requires minimum core of providers include surgeon, speech and language pathologist, and orthodontist. Must have ACCESS (but not core providers to social work, audiology, genetics, general and pediatric dentistry, ENT and pediatrics primary care)

Zones of penetrating neck injuries: Zone 1: extends from clavicles to cricoid, 2: from cricoid to angle of mandible, and 3 from angle of mandible to skull base

HPV oropharyngeal SCC have better prognosis stage for stage than other head and neck SCCs

For noninfected non ischemic neuropathic diabetic foot ulcers, pressure reduction and offloading measures are of critical importance. Recommend use of non-removable knee high offloading booth as first line treatment (total contact casting knee high)

Facial resurfacing: post-inflammatory hyperpigmentation is of greatest concern for those with darker skin color (Fitzpatrick IV-V)

CPT code of TMR: 64905 Nerve pedicle transfer, first stage (involves transecting major sensory or mixed nerve and transferring it end-to-end fashion to the small motor nerve in a nearby muscle

Elective hand surgery (soft tissue surgery) does not require prophylactic antibiotics (per SOME studies) even for patients with diabetes

Hormone replacement therapy for gender reaffirming: for femae to male (transgender men): changes in BMI, BP, liver chemistry, lowering of voice, increased muscle mass, increased body hair
-non reversible changes include lowering of voice, growth of clitoris, increased hair distribution, male pattern hair loss
-Menstruation may resume

There is an increased risk of DVT associated with free flap breast reconstruction. Common femoral veins have increased diameter, and decreased flow velocity indicating persistent venous stasis through the day of discharge

Women’s Health and Cancer Rights Act: federal law that mandates the coverage of breast reconstruction after mastectomy as well as coverage for associated symmetry procedures

For conscious sedation: IV regimen that will reduce pain and anxiety while minimizing risk for respiratory depression is fentanyl /midazolam

Rabies: should contact local authorities, if animal already has rabies vaccination should be quarantined and observed for 10 days (particularly if unprovoked)

Merkel cell carcinoma: nontender raplidly growing, single in head and neck red to violaceous, firm intradermal papules or nodules. Histologically appear to be small, round blue cells that stain for CD20
-treatment includes WLE of 1-2 cm margins including the fascia
-postoperative radiation is offered to patients with tumors greater than 1cm, positive margins or nodal involvement

Compartment syndrome: deep volar compartment most likely to develop highest pressures in traumatic distal radius fractures

Von Willebrand disease: VWF is deficient, works by mediating the adherence of platelets and binds factor VIII
-most common inherited bleeding disorder; presents as easy bruising, bleeding after dental work, heavy menstruation, prolonged nose bleeds
-recommended treatment is desmopressinworks by inducing release of VWF from endothelial cells

Malignant hyperthermia: mechanism includes accelerated release of calcium from the sarcoplasmic reticulum. Symptoms include high end tidal CO2, tachycardia, increase in temperature and muscle rigidity. First step in treatment includes discontinuing volatile agents THEN administering dantrolene

Posterior mandibular fractures like subcondylar fractures cause shortening of vertical height of the mandible and early contact of molar teeth on the affected ipsilateral side (results in anterior open bite on contralateral side)