Quick Hits

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Cervicofacial flaps: used for moderate to large defects of the cheek with tension free repair (avoids eyelid complications)

-less optimal choices would include primary closure (ok if small), STSG (causes contracture and overall mismatch), FTSG (may appear patch like), and tissue expanders (not idea in an open wound)

Hidradenitis: serial flares and cutaneous eruptions associated with apocrine sweat glands. FDA approved treatment includes Humira (adalimumab), a TNF-alpha inhibitor

Z-plasties: theoretical gain in z plasty angles

Angle Gain in Length
30 degrees 30%
45 degrees 50%
60 degrees 75%
75 degrees 100%
90 degrees 125%

Mycobacterium infections: specifically mycobacterium marinum can occur in patients with frequent contact of water, can be frequently misdiagnosed. These cultures should be sent in a Lowenstein-Jenson medium

Penicillin allergy and cross-over: Pen allergy reported in 10% of patients, cross reactivity with cephalosporins are 3% cross reactivity (less than 8% previously reported)

Lymphedema: patients with morbid obesity frequently present with lymphedema (b/l LE, pannus etc). Stemmer sign indicates inability to pinch skin at base of second toe.

-in patients with morbid obesity <50 BMI, 50% will resolve with weight loss alone (IE bariatric surgery)

Wound Care:

  • Highly exudative wounds: hydrofibers
  • Mild to moderately exudative: hydrocolloid and foam dressings
  • No exudate: hydrogels

Heterotopic Ossification: frequent complication in burns (elbow most common site of occurrence). Can result in wounds and poor range of motion. Prevention includes radiation therapy and NSAIDs. Surgical excision is the procedure of choice. (Will see soft tissue lamellar calcification on Xrays)

Penile inversion vaginoplasty: appropriate plane of dissection is the retroprostatic fascia (denomvilliers’ fascia)

Vasopressors have no effects on overall success of DIEP flap breast reconstruction (not contraindicated) Flap monitoring near infrared spectroscopy has been shown to detect vascular compromise before it becomes clinically obvious (improved salvage rates in studies)

Radial forearm adipofascial perforator flap: reliably thin and pliable flap. Can be used for distal upper extremity reconstruction (hand coverage, revision carpal tunnel surgery, radio/ulnar synostosis).

  • other advantages include avoiding the need to sacrifice the radial artery
  • most distal perforator arises 1.5cm proximal to the radial styloid -> safe pivot point is 4cm proximal to radial styloid

TAP block: transversus abdominus plane block -> blocks abdominal fibers from T7-L1. T10 demonstrates highest level of anesthesia

– remember that sensory nerves travel between internal oblique and transversus abdominus muscle

Botox dosage for axillary hyperhidrosis is 50 units per side, palmar hyperhidrosis is 100, plantar 150. Can give relief for 2 months Vitamin C: Deficiency can cause impair of collagen cross-linking via lysyl oxidase

Pressure Sores: Risks of recurrence – hemoglobin A1c > 6, age less than 45. Osteomyelitis at the time of surgery is not a predictor as well as prealbumin <20

Myelomeningocele: protrusion of the meninges and spinal cord via a defect in the caudal neural tube, higher defects have more severe abnormalities should repair within the first 48 hours of life. Prenatal closure in second trimester has better outcomes on hydrocephalus.

Preference of C section over vaginal delivery

Paradoxical adipose hyperplasia: rare side effect of cryolipolysis, treatment includes liposuction after 6-9 months

Anterior rectus sheath: above the arcuate line formed by external oblique aponeurosis and anterior internal oblique aponeurosis

  • Posterior rectus sheath derived from posterior internal oblique aponeurosis and transversus abdominus
  • below the arcuate line the anterior rectus sheath is derived from aponeurosis of all three and the posterior rectus sheath does not exist. (rectus muscle separated from abdominal viscera by transversalis fascia and peritoneum

Xanthelasmata: local accumulation of lipid deposits on the eyelids. Treatment includes surgical excision (benign no need for margins)

WPATH: all patients considering transgender surgery require a psychologic evaluation to determine appropriateness for surgery

  • for minors- patient, care team, psychologist, and guardians should believe that delay of top surgery would cause harm
  • year of hormone therapy for top surgery suggestion not requirement

Nerve gaps longer than 3cm should undergo autologous nerve grafts over conduits

Least resistance for electrical burns is muscle, highest resistance is cortical bone

BMP-2 vs iliac crest in alveolar bone grafting: equivalent results, increased severe edema with use of BMP2

Stacked flap reconstruction should use antero and retrograde ipsilateral vessels; thoracoacromial can be used as a life boat for venous outflow

Cranioplasty options: HA (hydroxyapatite) has osteoconductive properties and can be used with titanium to increase strength. Polyetheretherketone can be used for custom cranioplasty, polymethylmethacrylate is the most commonly used

Pre-requisite is a healthy and well-perfused soft tissue envelope with no contact with paranasal sinuses (high risk of infection)

In patients with a risk of flap failure or thrombosis (connective tissue disease, lupus etc) should obtain preoperative hypercoagulability work up first

Mafenide acetate: carbonic anhydrase inhibitor, can be used for cartilage burns of the ear and eschar penetration. Carries the risk of metabolic acidosis particularly in those with respiratory tract injury

  • Silver sulfadiazine (leukopenia, hyperosmolarity)
  • Silver nitrate: electrolyte imbalances (hyponatremia) and methemoglobinemia

Posterior component separation: dissection of retrorectus plane to release the transversus abdominus muscle medial to the linea semilunaris (allows for medialization of posterior rectus sheath transversalis fascia complex) and subsequent closure. Mesh is typically used for the anterior component of closure

PAP flap (profundal artery perforator flap) perforators typically course through the adductor magnus muscle

Preoperative CT scan recommended due to perforator variability

Spiroademoma: treatment includes reassurance and observation after excisional biopsies (benign neoplasms)

Gracilis flap: pedicle found between the adductor longus and magnus muscles 7cm distal to the pubic symphysis

Keloid: treatment with radiation should begin within 24 hours after surgery (predictors of relapse include male gender, younger age <29), large keloids, high tension areas, and skin grafts for reconstruction

Ulnar artery perforator flap: typically more likely to be able to be closed primarily, and less risk for tendon exposure when compared to radial forearm flap (radial artery has longer pedicle and able to incorporate bone more reliably)

Aging process: aged skin has epidermal thinning, decreased cellular turnover, undergoes considerable atrophy, keratinocyte proliferation declines, dermal epidermal junctions flatten, collagen fibrils become disorganized

Pressure ulcer:

  • Sacral wounds are best reconstructed with gluteal VY advancement flaps
  • Pedicled tensor fascia lata used for trochanteric culers
  • Biceps femoris VY for deep ischial ulcers

Cutaneous melanomas: develop in the stratum basale (layers from superficial to deep, corneum, granulosum, spinosum, basale)

Basal cell carcinomas also arise from in the stratum basale

Dog bites: most common pathogen is pasturella, staph, strep, and capnocytophaga caminorsus. First line therapy is augmentin (amoxicillin/clavulanate), second choice clinda/Bactrim in those with a penicillin allergy

-flouroquinolones/doxy carry risk of bone discoloration and tendon rupture in pediatric patients

Exposed TE: should undergo TE removal in the operating room particularly if the patient receives post mastectomy radiation as this doubles risk of complications (do not attempt to salvage)

BIA-ALCL: breast implant associated lymphoma, CD30 +, ALK negative. Disease typically contained within the capsule and fluid immediately adjacent to the implant

-patients typically present with delayed seroma, more common in textured devices, workup with aspiration and ulntrasound, wright geisma stain
(systemic ALCL Is ALK positive, breast is ALK negative- anaplastic lymphoma kinase)

Pre-pectoral implant reconstruction vs submuscular: prepectoral associated with more rippling of upper pole that may require fat grafting, less pain/ and earlier return of function; submuscular is more camoflauged but will have animation deformity

-ideal candidate for prepectoral is BMI <30 (nothing else has been proven)

Infantile hemangiomas: characterized by rapid growth and increased cellular proliferation. Clinical course includes rapid proliferation during the first 9 months of life followed by gradual involution until 2.4 years of age (more common in females). Herald patch will present first in up to 50% of cases

Facial burns: lagophthalmos and patient complaints warrant intervention  contracture release and full thickness skin grafts even if early. Consider possible donor sites and their involvement

Giant melanocytic nevi risk of melanoma now 0.7-2.9% risk. Risk of malignant transformation higher in trunk lesions, and can occur in satellite lesion as well as main lesion

Lentigo meligna: most common melanoma in situ. Arises in chronically sun exposed areas. Treatment is excision with 5-10mm margins (treatment of choice)
-second line treatment is topical 5% imiquimod and radiation

Vaginoplasty options: inversion vaginoplasty with penile scrotal flaps most commonly used, size of neovaginal canal depends on penile size and may be smaller if on hormonal therapy. For penetrative sex require length of 4.5-11cm, otherwise intestinal vaginoplasty may be used which does not depend on penile size

Scalp closure: release of galeal aponeurosis is important for scalp advancement, performed in parallels of 1cm to provide adequate release
-rememver layers skin, dense connective tissue, galeal aponeurosis, loose areolar tissue, and pericranium (SCALP)

Late seroma in implant cases: require work up with ultrasound (rupture vs late seroma)

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