Plastic and Reconstructive Surgery

CHAPTER 26
Plastic and Reconstructive Surgery


Ramon Garza III


Test Taking Tips


Review innervation and blood supply to pectoralis major, pectoralis minor, serratus, and latissimus dorsi.


There is always a question about topical antimicrobials such as silver nitrate or sulfamylon. Review their side effects and what organisms they best cover.


SKIN


What type of UV radiation is linked with skin cancer?


UVB


What is the most common skin malignancy in the United States?


Basal cell carcinoma


What are the classic physical findings of basal cell carcinoma?


Pearly appearance with rolled edges, +/- telangiectasia


What type of basal cell carcinoma is the most aggressive?


Morpheaform type (produces collagenase)


What margins are appropriate for basal cell?


3 mm margins are acceptable and frozen section can be used intraoperatively.


What is the most common physical finding of squamous cell carcinoma?


Scaly appearance, papulonodular, ulceration


What is the name of the cancer associated with a previous burn injury?


Marjolin ulcer; can also develop in areas of chronic inflammation, that is, enteric fistula.


What are appropriate margins for squamous cell carcinoma?


0.5 to 1.0 cm margins


What are risk factors for the development of squamous cell carcinoma?


Actinic keratosis, arsenics, atrophic dermatitis, Bowen disease, chlorophenols, fair skin, HPV, immunosuppression, nitrates, previous skin cancer, radiation exposure, sun exposure, xeroderma pigmentosum


What is the natural history of squamous cell carcinoma?


Actinic keratosis, Bowen disease (squamous cell carcinoma in situ), squamous cell carcinoma


Aside from sun exposure, what is classically a risk factor for squamous cell carcinoma?


History of organ transplantation, or any other immunocompromised state


Can squamous cell carcinoma metastasize?


Yes, it is uncommon, but it can metastasize to lymph nodes. Regional adenectomy should be performed.


When can Mohs surgery be used for basal cell or squamous cell carcinoma?


Delicate areas that include perioral, perioccular, perinasal, ears, hands, and genitalia


What is the most common melanoma site on the skin in men? In women?


Men—back


Women—legs


What is the most common location for distant melanoma metastasis?


The lung (surgery can help relieve pain caused by metastatic melanoma to the lung, but is not a cure)


What is the most common metastasis to the small bowel?


Melanoma


What margins are recommended for a melanoma skin lesion with thickness of 1 mm?


1 cm margins are recommended; for lesions greater than 2 mm a 2 cm margin is recommended. 0.5 cm margins are acceptable for thin lentigo maligna melanomas or melanoma in situ.


Can electrocautery be used for excisional biopsy of melanoma?


No, cold knife excision should be used so as to not disturb the deep margin with burn artifact.


What types of melanoma are there?


Superficial spreading, lentigo maligna, acral lentiginous, nodular


What is the most common type of melanoma?


Superficial spreading


image


FIGURE 26-1. Although Breslow thickness has traditionally been used to anticipate clinical outcomes based on the depth of melanoma invasion, more recent staging criteria advanced by the American Joint Committee on Cancer (AJCC) are today’s standard of care. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)


What is the least aggressive type of melanoma?


Lentigo maligna


What is the most aggressive type of melanoma?


Nodular, but acral lentiginous is also aggressive and presents late because of location on feet/hands.


If a melanoma lesion is less than 1 mm thickness and no lymphadenopathy is palpated, does any additional workup need to be performed?


No. Optional CXR, liver function test (LFT’s), and sentinel lymph node biopsy (SNLB) can be performed for lesions greater than 1 mm thickness. If SNLB is positive, then all the above workup and an MRI of brain and CXR should be performed. If there are palpable nodes present, a formal lymph node dissection should be performed.


Can Mohs surgery be used for melanoma?


No, never!


Can frozen sections be used to determine if margins are negative for melanoma?


No, frozen sections have no role in the management of melanoma (permanent section only).


What is the difference between a keloid and hypertrophic scar?


A hypertrophic scar does not extend beyond the borders of the original scar.


What is the treatment for a keloid?


First-line therapy for most keloids is intralesional corticosteroids. They can also be treated with radiation, silicone sheets, surgery with interferon or triamcinolone injections, and pressure garments.


What is the treatment for a hypertrophic scar?


Intralesional corticosteroids, silicone sheets, pressure garments


What is the treatment for hidradenitis?


Improve hygiene, antibiotics, surgery to remove infected tissue and apocrine sweat glands


WOUND HEALING


What is the reconstructive ladder?


It is a way of organizing approaches to reconstruction and wound healing. The first step of the reconstructive ladder is the simplest and least invasive method progressing to the most complex method at the top of the ladder.


What are the general categories in the steps of the reconstructive ladder in order from simple to complex?


Healing by secondary intention


Healing by primary intention/tertiary (delayed primary) intention


Split-thickness/full-thickness skin graft (STSG/FTSG)


Local flap


Regional flap


Distant flap


Free flap


What patient factors are important when evaluating a wound?


Immune deficiency/suppression


Nutritional status/obesity


Diabetes


Smoking


Healing disorders


Age


How can you diagnose a skin infection in a burn patient?


Biopsy the skin; if bacteria are present on deep dermis, then the patient likely has an infection.


How do you obtain a sample of bone for biopsy to evaluate for osteomyelitis?


A separate incision is made, away from open wound, and bone biopsy is performed through this incision.


What is the utility of imaging in evaluating osteomyelitis?


MRI is a good modality to evaluate extent of osteomyelitis, plain film will not show osteomyelitis changes for 2 weeks, and bone scan is not specific in the face of an open wound or a fracture.


True or false: A moist environment is key for a clean wound to heal.

Aug 13, 2019 | Posted by in ABDOMINAL MEDICINE | Comments Off on Plastic and Reconstructive Surgery
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