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Book Details
Abstract
Plastic Surgery Secrets—the first Secrets Series® title in the PLUS format—offers an easy-to-read, information-at-your-fingertips approach to plastic and reconstructive surgery and hand surgery. Jeffrey Weinzweig has joined forces with world-renowned plastic surgeons Joseph McCarthy, Julia Terzis, Joseph Upton, Fernando Ortiz-Monasterio, and Luis Vasconez, and others to bring you the expert perspective you need to grasp the nuances of this specialty. This new edition features an additional color that highlights tables, legends, key terms, section and chapter titles, and web references. All this, along with the popular question-and answer approach and list of the "Top 100 Plastic Surgery Secrets," make it a perfect concise board review tool and a handy clinical reference.
- Maintains the popular and trusted Secrets Series® format, using questions and short answers for effective and enjoyable learning.
- Provides the most current overview and authoritative coverage of all topics thanks to contributions from an impressive list of over 300 experts in the field of plastic surgery and multiple related specialties.
- Introduces the new PLUS format, with an expanded size and layout and full color for easier review, more information, and more visual elements for an overall enhanced experience.
- Presents enhanced tables, legends, key terms, and section and chapter titles through the use of an additional color that makes finding information quick and easy.
- Contains new full color images and illustrations to provide more detail and offer a clearer picture of what is seen in practice.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Plastic SurgerySecrets | iii | ||
| Copyright Page | iv | ||
| Dedication | v | ||
| Contents | vii | ||
| Contributors | xiii | ||
| Acknowledgments | xxv | ||
| Foreword | xxvii | ||
| Afterword | xxix | ||
| Preface to the first edition | xxxi | ||
| Preface to the Second Edition | xxxii | ||
| Section I: Fundamental Principles of Plastic Surgery | xxxiii | ||
| Chapter 1: The Principles Of Wound Healing | 1 | ||
| 1. What events occur during each of the primary phases of wound healing? | 1 | ||
| 2. What roles do platelet-derived growth factor and transforming growth factor beta play in wound healing? | 1 | ||
| 3. What role do macrophages play in wound healing? | 1 | ||
| 4. Are neutrophils essential for strengthening wounds? | 1 | ||
| 5. How does the wound’s collagen composition compare between the early and late stages of wound healing? | 1 | ||
| 6. When does collagen production peak in a healing wound? | 1 | ||
| 7. During remodeling, no net increase in collagen occurs but wound tensile strength increases greatly. Why? | 2 | ||
| 8. What is the rationale for not allowing patients with hernias to do sit-ups for 6 weeks after a herniorrhaphy? | 2 | ||
| 9. A well-healed wound eventually reaches what percentage of prewound strength? | 2 | ||
| 10. What is the wound healing defect in Ehlers-Danlos syndromes? | 2 | ||
| 11. What is the mechanism of wound contraction? | 2 | ||
| 12. By what three methods can wound healing be achieved? | 2 | ||
| 13. What is contact inhibition and how does it relate to epithelialization? | 2 | ||
| 14. How long should a wound be kept dry after closing a surgical incision? | 2 | ||
| 15. Why do partial-thickness wounds reepithelialize faster than full-thickness wounds? | 2 | ||
| 16. You are about to remove an actinic/seborrheic keratosis from a patient’s face when he asks if there will be any scarring. How do you respond? | 3 | ||
| 17. After giving birth to her first baby, a patient asks if any treatments are available for stretch marks (striae distensae). What causes stretch marks? Are they amenable to treatment? | 3 | ||
| 18. What techniques can be used to optimize healing of surgical wounds? | 3 | ||
| 19. Is a wound less likely to spread if it is closed with intradermal polyglactic acid suture (Dexon, Vicryl) versus a nylon suture that is removed in 7 days? | 3 | ||
| 20. What is the ideal dressing? | 3 | ||
| 21. What are the benefits of occlusive dressings? | 3 | ||
| 22. Which vitamins and minerals affect wound healing? | 3 | ||
| 23. Are there any specific products that help accelerate wound healing? | 3 | ||
| 24. What is the wound vacuum-assisted closure, and how does it accelerate wound healing? | 3 | ||
| 25. You are reluctant to débride a decubitus ulcer with necrotic tissue in a chronically ill patient who has multiple medical problems and a coagulopathy. What are the alternatives to surgical débridement? | 4 | ||
| 26. What is a chronic wound? | 4 | ||
| 27. What factors impair wound healing? | 4 | ||
| 28. What effect does radiation have on wound healing? | 4 | ||
| 29. Why does edema impair wound healing? | 4 | ||
| 30. What factors are responsible for local wound ischemia? | 4 | ||
| 31. Is there a role for hyperbaric oxygen in wound healing? | 4 | ||
| 32. What is the definition of wound infection? | 4 | ||
| 33. What causes hypertrophic/keloid scars? What features distinguish them? | 4 | ||
| 34. A patient has two burns on his chest, one of which epithelialized in 1 week, the other in 3 weeks. The second wound now has a hypertrophic scar. Why? | 5 | ||
| 35. What treatment options are available for hypertrophic scars? | 5 | ||
| 36. What treatment options are available for keloid scars? | 5 | ||
| 37. What effect does aging have on wound healing? | 5 | ||
| 38. You perform a split-thickness skin graft (12/1000ths of an inch) for burns in a young patient and in an elderly patient, using the same technique and equipment. Several weeks later the young patient is doing well, but the elderly patient has blisters fo | 5 | ||
| 39. How does the fetal wound differ from the adult wound? | 5 | ||
| Bibliography | 5 | ||
| Chapter 2: Techniques and Geometryof Wound Repair | 6 | ||
| 1. What are important considerations in surgical wound closure? | 6 | ||
| 2. Why is the choice of suture material critical in the early stages of wound healing? | 6 | ||
| 3. Which layer of a wound repair contributes the most to wound strength? | 6 | ||
| 4. What are the basic principles of suturing skin wounds? | 6 | ||
| 5. What are the different methods of suturing skin wounds? | 6 | ||
| 6. What is the role of immobilization in wound healing? | 7 | ||
| 7. How are suture materials classified? | 7 | ||
| 8. What are the differences among the various absorbable suture materials? | 7 | ||
| 9. What are the differences among the various nonabsorbable suture materials? | 7 | ||
| 10. What influences the permanent appearance of suture marks? | 7 | ||
| 11. What are Langer’s lines? | 8 | ||
| 12. What are relaxed skin tension lines? | 8 | ||
| 13. What is the optimal scar? | 8 | ||
| 14. What causes “stretch” marks? | 8 | ||
| 15. Which excisional methods can be used for removal of skin lesions? | 8 | ||
| 16. What is the purpose of serial excisions? | 8 | ||
| 17. What are the differences among rotation, transposition, and interpolation flaps? | 8 | ||
| 18. What is a bilobed flap? | 8 | ||
| 19. What is a “dog ear”? How can it be eliminated? | 8 | ||
| 20. When should scar revision be performed? What are the goals? | 9 | ||
| 21. What is a Z-plasty? | 9 | ||
| 22. How is a Z-plasty designed? | 9 | ||
| 23. Why are angle size and limb length important in performing a Z-plasty? | 10 | ||
| 24. What is the optimal angle for Z-plasty design? | 10 | ||
| 25. What are the indications for multiple Z-plasties? | 10 | ||
| 26. What is a four-flap Z-plasty? | 10 | ||
| 27. What is a double-opposing Z-plasty? | 10 | ||
| 28. What is a W-plasty? | 10 | ||
| 29. What is the main disadvantage of a W-plasty? | 10 | ||
| 30. What is the V-Y advancement technique? | 10 | ||
| 31. When is a V-Y advancement flap used? | 11 | ||
| 32. What is a rhombic flap? | 11 | ||
| 33. Should lesions be excised to create rhombic defects? | 11 | ||
| 34. What is the Dufourmental flap? | 11 | ||
| Bibliography | 12 | ||
| Chapter 3: Anesthesia For plastic surgery | 13 | ||
| 1. What is the maximal dose of lidocaine that can be safely used for local anesthesia? | 13 | ||
| 2. Which nerves exit the skull through foramina that lie in a sagittal plane? | 13 | ||
| 3. How can the forehead and upper eyelid be blocked to permit excision of a large lipoma? | 13 | ||
| 4. Which nerve provides sensation to the lower eyelid and upper lip? How can it be blocked? | 13 | ||
| 5. How can the lower lip be anesthetized to permit excision of a basal cell carcinoma? | 13 | ||
| 6. How can the masseter muscle be relaxed in cases of trismus? | 13 | ||
| 7. How can adequate regional anesthesia of the nose be obtained before performing a rhinoplasty? | 14 | ||
| 8. How can a regional block of the external ear be obtained before performing an otoplasty? | 14 | ||
| 9. Just before an augmentation mammoplasty, bilateral intercostal nerve blocks are given with 30 mL of a 1% Xylocaine solution. The patient soon appears agitated and her pulse increases. What is the most likely cause? | 14 | ||
| 10. How long should a patient fast before surgery? | 14 | ||
| 11. Why does skeletal muscle contract if stimulated when d-tubocurarine is used as the paralyzing agent in anesthesia? | 14 | ||
| 12. Twenty-four hours after suction-assisted lipectomy of the abdomen and upper thighs, a patient has become confused and somewhat disoriented. She has a petechial rash over the shoulders and anterior chest. Is she possibly allergic to the pain medication? | 14 | ||
| 13. What are the appropriate preoperative preparations and intraoperative and postoperative considerations for a patient with possible sickle cell disease who is to undergo hand surgery? | 15 | ||
| 14. What are the anesthetic considerations for repair of a trochanteric decubitus ulcer in the lateral position? | 15 | ||
| 15. A patient vomits and aspirates during induction of anesthesia. What is the appropriate treatment? | 15 | ||
| 16. What preoperative instructions should be given to a 10-month-old child before cleft lip repair? | 15 | ||
| 17. What is the critical anesthetic problem in a patient with cleft palate? How is it managed? | 16 | ||
| 18. A 10-year-old girl is scheduled to undergo a bilateral otoplasty for prominent ears. The parents are concerned because an uncle died during anesthesia several years ago. During the course of anesthesia the patient develops tachycardia, early cyanosis, a | 16 | ||
| 19. Why is sodium bicarbonate sometimes added to local anesthesia? | 16 | ||
| 20. A patient with 25% total body surface area burn is taken to the operating room for tangential excision and grafting of burn wounds 2 weeks after injury. During induction of anesthesia, succinylcholine is given as a muscle relaxant. The patient begins to | 17 | ||
| 21. During tangential excision of a 30% full-thickness burn, a patient begins to become hypotensive. What are the most likely causes? | 17 | ||
| 22. What is the maximal amount of bupivacaine (Marcaine) that can be safely added to 50 mL of 0.5% Xylocaine in an intravenous regional anesthetic for the upper extremity to prolong duration of action? | 17 | ||
| 23. A 63-year-old man is scheduled to undergo general anesthesia for extensive resection of an oral cancer 4 months after having a myocardial infarction. Should surgery be delayed? | 17 | ||
| 24. When is it usually considered safe to discharge a patient after outpatient surgery under general anesthesia? | 17 | ||
| 25. Does the length of anesthesia increase the risk of complications? | 18 | ||
| 26. If the usual “safe” dose for lidocaine administration is 7 mg/kg, how much can “safely” be given during a suction-assisted lipectomy in tumescent fluid? | 18 | ||
| 27. Are there any dietary supplements that may interact with anesthesia? | 18 | ||
| 28. A patient undergoes outpatient suction-assisted lipectomy of the abdomen and bilateral thighs. A volume of 3500 mL is removed. The patient calls, complaining of significant pain. What are the concerns? | 18 | ||
| Bibliography | 18 | ||
| Chapter 4: Tissue Expansion | 19 | ||
| 1. Is controlled tissue expansion a new concept? | 19 | ||
| 2. Where does the expanded skin come from? | 19 | ||
| 3. What physiologic changes occur in the skin during “creep”? | 19 | ||
| 4. What is the body’s response to the expander? | 19 | ||
| 5. What happens to the cellular growth and mitotic index of expanded skin? | 19 | ||
| 6. What is the effect of expansion on blood flow in the tissues over the expander? | 19 | ||
| 7. What histologic changes occur with expansion? | 20 | ||
| 8. Can the expander envelope rupture because of the internal expander pressure? | 20 | ||
| 9. What limits the rate of expansion? | 20 | ||
| 10. What expanders are available? | 20 | ||
| 11. Does a textured surface on an expander make a difference? | 20 | ||
| 12. What are the new osmotically active hydrogel expanders? | 20 | ||
| 13. In breast reconstruction after mastectomy, what is the most significant advantage of self-filling osmotic tissue expanders over conventional tissue expanders? | 20 | ||
| 14. What are the advantages of the various designs? | 20 | ||
| 15. What are the options for port placement? | 21 | ||
| 16. How many times can an expander be used? | 21 | ||
| 17. What areas are especially suitable for soft tissue expansion reconstruction? | 21 | ||
| 18. Where is it difficult or even inadvisable to use tissue expansion? | 21 | ||
| 19. What are contraindications and relative contraindications to soft tissue expansion? | 21 | ||
| 20. Can tissue expansion be used in reconstruction of soft tissue defects following excision of malignancy? | 21 | ||
| 21. What factors should be considered when selecting a patient for tissue expansion? | 21 | ||
| 22. Where should the expanders be placed? | 22 | ||
| 23. Where do you place the incision for a tissue expander insertion? | 22 | ||
| 24. What technical failure at the time of insertion will cause an expansion to fail? | 22 | ||
| 25. When do you begin filling an expander? How much saline do you add each time? | 22 | ||
| 26. When is the patient ready to return to the operating room for advancement? | 22 | ||
| 27. How long do you keep the expander after the expansion target has been achieved? | 22 | ||
| 28. How do you make the advancement? | 22 | ||
| 29. What aftercare is required? | 23 | ||
| 30. Should families and patients be trusted to do their own expansions at home? | 23 | ||
| 31. How can you—or a child’s family—measure the intraluminal pressure of an expander during a home inflation? | 23 | ||
| 32. What touch-up surgery may be required? | 23 | ||
| 33. What will the future bring in the way of breast reconstruction? Will autogenous tissue reconstruction replace tissue expansion? | 23 | ||
| 34. Is there a role for tissue expansion in treatment of abdominal wall hernias? | 23 | ||
| 35. What are skin stretching devices? | 23 | ||
| 36. What are the common preexpanded flap designs? | 23 | ||
| 37. Where and when do preexpanded transposition flaps play a role? | 23 | ||
| 38. Which patients are the candidates for pretransfer tissue expansion of free flaps? | 24 | ||
| 39. What are the advantages of reconstruction with preexpanded free flaps? | 24 | ||
| 40. Which free flaps have been preexpanded? | 24 | ||
| 41. What are the disadvantages of pretransfer tissue expansion of free flaps? | 24 | ||
| 42. What is the role of intraoperative tissue expansion? | 24 | ||
| 43. What are the complications of tissue expansion? | 24 | ||
| 44. What are some of the inherent advantages of tissue expansion? | 25 | ||
| Bibliography | 25 | ||
| Chapter 5: Alloplastic Implantation | 26 | ||
| 1. What are the advantages of alloplastic materials? | 26 | ||
| 2. How are biomedical alloplants classified? | 26 | ||
| 3. What are properties of the “ideal” implant? | 26 | ||
| 4. What is the goal of alloplastic implantation? | 26 | ||
| 5. What is the Oppenheimer effect? | 26 | ||
| 6. What are bioabsorbable plates and screws? | 27 | ||
| 7. Which metals are suitable for implantation in plastic surgery? | 27 | ||
| 8. What is hydroxyapatite? | 27 | ||
| 9. How is HA used in plastic surgery? | 27 | ||
| 10. How is synthetic HA used in plastic surgery? | 28 | ||
| 11. Which polymer is most often used for facial augmentation? Why? | 28 | ||
| 12. What are the physical properties of silicone? | 28 | ||
| 13. What are the disadvantages of using silicone? | 28 | ||
| 14. Are there alternatives to silicone gel for breast implants? | 29 | ||
| 15. What is methylmethacrylate used for in plastic surgery? | 29 | ||
| 16. What is cyanoacrylate? How is it used? | 29 | ||
| 17. Which fluorocarbon polymers are used in plastic surgery? | 30 | ||
| 18. What are osseointegrated implants? | 30 | ||
| 19. What is AlloDerm? | 30 | ||
| 20. Should patients with implants undergo antibiotic prophylaxis? | 30 | ||
| Bibliography | 30 | ||
| Chapter 6: The Problematic Wound | 31 | ||
| 1. What is a problematic wound? What causes it? | 31 | ||
| 2. What are primary, secondary, and tertiary wound closure? | 31 | ||
| 3. What systemic problems may make a wound problematic? | 31 | ||
| 4. What local factors may make a wound problematic? | 31 | ||
| 5. What are the guidelines for handling ischemic wounds? | 31 | ||
| 6. What are the guidelines for handling pressure wounds? | 31 | ||
| 7. How are radiated wounds managed? | 32 | ||
| 8. What about traumatic wounds? | 32 | ||
| 9. Which irrigation fluid should be used? How much? | 33 | ||
| 10. What about bacterial contamination? | 33 | ||
| 11. What is quantitative microbiology? | 33 | ||
| 12. Does quantitative microbiology make a difference? | 33 | ||
| 13. Should quantitative microbiology be used before closing all wounds? | 33 | ||
| 14. What is the value of antibacterial agents in problematic wounds? | 34 | ||
| 15. My laboratory does not perform quantitative microbiology. Please comment. | 35 | ||
| Bibliography | 35 | ||
| Chapter 7: Principles and Applications ofVacuum-Assisted Closure (VAC) | 36 | ||
| 1. What is vacuum-assisted closure (VAC)? | 36 | ||
| 2. How is the VAC applied and managed while treating a wound? | 36 | ||
| 3. How does the VAC work? | 36 | ||
| 4. What have laboratory studies shown? | 36 | ||
| 5. What are the indications for use of the VAC? | 37 | ||
| 6. What are contraindications to VAC? | 37 | ||
| 7.What are the complications of vacuum-assisted therapy? | 38 | ||
| 8.What role does the VAC have in the management of chronic nonhealing wounds? | 38 | ||
| 9. What is the role of the VAC in the management of acute wounds? | 38 | ||
| 10.Is the VAC system efficacious in the management of wounds in children? | 38 | ||
| 11.How is the VAC used to treat acute wounds with exposure of bone, tendon, and vital structures? | 38 | ||
| 12.How is the VAC used to salvage exposed orthopedic hardware? | 39 | ||
| 13.How is the VAC used to manage the open abdominal wound and abdominal compartment syndrome? | 39 | ||
| 14. What is the role of the VAC in the management of sternal wounds? | 39 | ||
| 15.What is the role of the VAC in extravasation injuries and toxic bites? | 39 | ||
| 16.How does the VAC benefit patients requiring decompression fasciotomy? | 40 | ||
| 17.What role can the VAC play in skin grafting? | 40 | ||
| 18. How is the VAC helpful in managing wounds with artificial dermal substitutes such as Integra? | 40 | ||
| 19. How is the VAC used in the management of acute burns? | 40 | ||
| 20.Can the VAC be placed over a fresh wound closure or fresh flap? | 40 | ||
| 21.Does the VAC require prolonged hospitalization and how is it used in outpatient management? | 41 | ||
| 22.Is VAC management of a wound cost-effective? | 42 | ||
| Bibliography | 42 | ||
| Chapter 8: The Fetal Wound | 43 | ||
| 1. What is the major phenotypic difference that distinguishes fetal from adult wound healing? | 43 | ||
| 2. How was scarless fetal wound healing discovered? | 43 | ||
| 3. What surgical approaches are used to access the fetus? | 43 | ||
| 4. What potential complication is considered the major limiting factor to fetal surgery, and what is done to attempt to prevent it? | 43 | ||
| 5. Does the process of fetal wound healing follow the same patterns as adult wound healing? | 43 | ||
| 6. Is the ability of the fetus to heal without scar purely a function of being in the womb, bathed by amnionic fluid? | 43 | ||
| 7. Is there a time limit to the process of fetal cutaneous wound healing? | 43 | ||
| 8. Do all fetal cutaneous wounds heal without scar? | 44 | ||
| 9. How do the inflammatory cell mediators differ in fetal and adult wound healing? | 44 | ||
| 10. What effect does inflammation have on the fetal wound? | 44 | ||
| 11. How does collagen synthesis differ within the fetal wound? | 44 | ||
| 12. What are the differences between fetal fibroblasts and adult fibroblasts? | 44 | ||
| 13. What is the role of the extracellular matrix in fetal wound healing? | 44 | ||
| 14. How may HA provide the matrix signal that coordinates healing by regeneration rather than by scarring? | 44 | ||
| 15. Do all fetal tissues heal scarlessly? | 44 | ||
| 16. Do fetal wounds heal differently in congenital models versus surgically created models? | 44 | ||
| 17. Does amniotic fluid play a role in wound contraction? | 45 | ||
| 18. Is the lack of wound contracture in the fetus due to lack of myofibroblasts in the skin? | 45 | ||
| 19. Can adult skin placed into a fetal environment heal without scar? | 45 | ||
| 20. How do growth factor profiles differ between fetal and adult wounds? | 45 | ||
| 21. What is the role of cyclooxygenase-2 and prostaglandin E2 in fetal wound healing? | 45 | ||
| 22. How do the levels of the growth factors, interleukins, collagen, ECM modulators, and cell types involved in wound healing differ between fetal and adult wounds? | 45 | ||
| Controversies | 45 | ||
| 23. What regulates the process of fetal wound healing? | 45 | ||
| 24. What is the potential advantage of scarless fetal wound healing in the treatment of congenital craniofacial anomalies? | 45 | ||
| 25. Can scarless healing after in utero repair of cleft lip and palate completely eliminate the facial growth abnormality associated with postnatal, surgically induced scar formation? | 45 | ||
| Bibliography | 46 | ||
| Chapter 9: Liability Issues in Plastic Surgery | 48 | ||
| 1. What makes plastic surgeons such frequent targets for malpractice lawsuits? | 48 | ||
| 2. Can you enumerate those qualities that make one doctor less prone to lawsuit than others? | 48 | ||
| 3. Can you expound on what constitutes “competence”? | 48 | ||
| 4. What about “communication”? That covers a lot of ground, doesn’t it? | 48 | ||
| 5. Can you explain the rules of the game in “patient selection”? | 48 | ||
| 6. Are there any reliable signs by which one can identify potentially problematic patients? | 49 | ||
| 7. One hears so much about the importance of “informed consent.” What does that mean, and how different is that from plain vanilla consent? | 49 | ||
| 8. Just how much and what sort of information is needed to fully qualify the consent as “informed”? | 50 | ||
| 9. Can you specify how a surgeon’s personality and attitude are factors in malpractice claims? | 50 | ||
| 10. What can be done to prevent things going from bad to worse? | 50 | ||
| 11. If you were offering claims avoidance “pearls” to surgeons new to practice, what would they be? | 53 | ||
| Bibliography | 53 | ||
| Chapter 10: CPT Coding Strategies | 54 | ||
| 1. What is the appropriate CPT coding for the excision of a 10-mm basal cell carcinoma of the cheek with 2-mm margins followed by a layered closure of 3cm? | 54 | ||
| 2. Three full-thickness ragged lacerations of the face are repaired. Each requires débridement of contused tissues, undermining, and layered closure: 3cm on the nose, 2cm on the lip, and 4cm on the cheek. How is this procedure reported? | 54 | ||
| 3. A 10-cm basal cell carcinoma of the scalp extends into the skull. The lesion is excised with 1-cm margins, and the outer table of the skull is removed. Does the malignant lesion excision code (11646) include the bone resection? | 54 | ||
| 4. How is the removal of an injection port of a permanent expander reported? | 54 | ||
| 5. Is “division and inset” of the flap included in the cross finger flap code? | 54 | ||
| 6. When a transverse rectus abdominis myocutaneous flap is harvested, how is closure of the abdominal fascia with synthetic | 55 | ||
| 7. When several skin lesions are removed, why does the insurance company reimburse for only one lesion and disallow the rest? | 55 | ||
| 8. How many CPT codes are required to report the open reduction internal fixation of a comminuted malar complex fracture with reconstruction of an orbital floor blowout fracture using an implant? | 55 | ||
| 9. Is there a code for the “separation of components” technique of abdominal wall reconstruction? | 55 | ||
| 10. Can add-on codes ever be used alone? | 55 | ||
| 11. When more than one muscle flap is used to close a single defect, should each muscle flap be reported separately? | 55 | ||
| 12. What is considered global in free flap coding? | 56 | ||
| 13. The CPT code for tissue expander placement (11960) reads “Insertion of tissue expander(s) for other than breast, including subsequent expansion.” If two expanders are placed in two different areas, should the code be reported only once? | 56 | ||
| 14. Medicare does not reimburse for excisions of benign lesions. How does one code these procedures so that Medicare will pay? | 56 | ||
| 15. How does one code for repeated skin grafts that are performed during the global postoperative period? | 56 | ||
| 16. A Dupuytren’s contracture requires a fasciectomy of the palm, middle, ring, and small fingers. Y-V flaps are performed to provide extra skin length. How is this coded? | 56 | ||
| 17. A pediatrician refers a child to the plastic surgeon with a Salter fracture of the index finger. The plastic surgeon assumes treatment that requires 3 weeks of splinting. Is this considered a consultation? | 57 | ||
| 18. When multiple tendons are repaired in the hand, should each tendon repair be reported separately? | 57 | ||
| 19. A 1-cm basal cell carcinoma below the eyelid margin is excised with 5-mm margins. An inferomedially based rotation flap measuring 5 × 5cm is used to reconstruct the defect. How is the proper code selected? | 57 | ||
| 20. A sacral decubitus is débrided, including bone débridement, and the defect is reconstructed with bilateral gluteus maximus V-Y flaps. What codes are used? | 57 | ||
| 21. If wound edges are undermined and then advanced to close a defect, is this a flap reconstruction? | 57 | ||
| 22. In a carpal tunnel release, can incision of the fascia proximally be reported separately with 25020? | 57 | ||
| 23. How long has CPT coding been in existence? | 58 | ||
| Bibliography | 58 | ||
| Chapter 11: Ethics in Plastic Surgery | 59 | ||
| 1. What is ethics? | 59 | ||
| 2. What do you mean by a “profession”? | 59 | ||
| 3. What specifically is meant by a “practice”? | 59 | ||
| 4. What is meant by “internal goods” or virtues? | 60 | ||
| 5. What are the “external goods”? | 60 | ||
| 6. What are the “rules” of ethical care? | 61 | ||
| 7. This sounds like the Hippocratic Oath! | 61 | ||
| 8. What is meant by “autonomy”? | 61 | ||
| 9. How does “justice” apply to these ethical principles? | 62 | ||
| 10. How is it determined what is ethical? Who says? | 62 | ||
| 11. How does one apply ethical issues to practice? | 63 | ||
| 12. What is the role of “impartiality” in the ethical process? | 63 | ||
| 13. Is “discernment” an important component of the ethical process? | 63 | ||
| 14. What is meant by “precedent-setting,” and what does that have to do with ethics? | 63 | ||
| 15. How do the “three steps of ethical process” apply to providing expert testimony? | 63 | ||
| 16. What are the three levels of professional contact? | 64 | ||
| 17. What about human experimentation? | 64 | ||
| 18. What is the most important ethical challenge to plastic surgeons? | 64 | ||
| 19. Elaborate on these “ethical criteria.” | 65 | ||
| 20. Does the use of implant materials present a special ethical situation for plastic surgeons? | 65 | ||
| 21. Do international surgery programs that provide care in developing countries have special ethical considerations? | 66 | ||
| 22. Where does one find ethical standards for plastic surgery? | 66 | ||
| 23. What are the most common ethical violations? | 66 | ||
| 24. How does one categorize the “impaired surgeon”? | 66 | ||
| 25. What about advertising? | 67 | ||
| 26. Are there ethical concerns for plastic surgery education? | 67 | ||
| 27.Case analysis: A 17-year-old female requests that you implant a tennis ball in the middle of her forehead. What is your response, and what are the ethical issues? | 68 | ||
| 28. You have said that “Ethics is like manure!” What do you mean? | 68 | ||
| Bibliography | 68 | ||
| Chapter 12: Advances in Basic Science Research | 70 | ||
| Distraction Osteogenesis | 70 | ||
| 1. How is distraction osteogenesis used to generate new bone? | 70 | ||
| 2. What are the phases of distraction osteogenesis? | 70 | ||
| 3. What are common complications associated with craniofacial distraction osteogenesis? | 70 | ||
| 4. Describe the mechanical forces involved in distraction osteogenesis | 70 | ||
| 5. Can the period of latency be potentially reduced to shorten the overall course of distraction osteogenesis? | 70 | ||
| 6. How can the period of consolidation be shortened? | 70 | ||
| 7. How may bone morphogenetic proteins improve results of distraction osteogenesis? | 71 | ||
| 8. Which pro-angiogenic cytokines are involved in distraction osteogenesis? | 71 | ||
| 9. How critical is angiogenesis for successful bone formation during distraction osteogenesis? | 71 | ||
| Craniosynostosis | 71 | ||
| 10. Mutations in which growth factor receptors have been implicated in several forms of syndromic craniosynostosis? | 71 | ||
| 11. What is the role of fibroblast growth factors in cranial suture fusion? | 71 | ||
| 12. What role does Noggin play in the maintenance of suture patency? | 71 | ||
| 13. What is BMP-3, and how may this protein affect suture fate? | 71 | ||
| 14. What is the role of transforming growth factor beta in cranial suture biology? | 72 | ||
| 15. What role does the dura mater play in cranial suture biology? | 72 | ||
| Tissue Engineering/Regeneration | 72 | ||
| 16. What are current techniques used to treat large bone defects, and what are their disadvantages? | 72 | ||
| 17. What cellular options exist for cell-based approaches to tissue engineering? | 72 | ||
| 18. Mesenchymal stem cells have the capacity to differentiate into which lineage-specific tissue types? | 72 | ||
| 19. What are the three broad types of scaffolds used in bone tissue engineering? | 72 | ||
| 20. Neovascularization is the process of new blood vessel formation. How does angiogenesis contribute to new blood vessel growth, and how does it differ from vasculogenesis? | 72 | ||
| 21. Describe the steps involved in the process of angiogenesis | 73 | ||
| 22. Describe the process of vasculogenesis | 73 | ||
| 23. What are the cytokines that stimulate angiogenesis to occur? | 73 | ||
| 24. Are there any cytokines that inhibit angiogenesis? | 73 | ||
| 25. Why is the process of angiogenesis important to the field of plastic and reconstructive surgery? | 73 | ||
| 26. How else does the decrease in angiogenesis contribute to disease pathology? | 73 | ||
| 27. If a decrease in angiogenesis is associated with a propensity to develop these multiple disease processes, is an increase in angiogenesis always beneficial to the health of the patient? | 73 | ||
| 28. What treatment modalities are available to treat these defects in angiogenesis? | 73 | ||
| 29. What is therapeutic neovascularization? | 73 | ||
| Bibliography | 74 | ||
| Section II: Integument | 77 | ||
| Chapter 13: Malignant Melanoma | 79 | ||
| 1. What are the essential facts about cutaneous melanoma? | 79 | ||
| 2. What is the basis for classifying melanoma? | 79 | ||
| 3. What are the major forms of cutaneous melanoma? | 79 | ||
| 4. What are the general clinical features of cutaneous melanoma? | 80 | ||
| 5. What are the general histopathologic features of cutaneous melanoma? | 80 | ||
| 6. What are the clinical and histopathologic features of melanomas of intermittently sun-exposed skin? | 84 | ||
| Clinical Features | 84 | ||
| Histopathologic Features | 84 | ||
| Invasive Component in Dermis | 85 | ||
| 7. What is the differential diagnosis of melanomas of intermittently sun-exposed skin? | 85 | ||
| 8. What are the clinical and histopathologic features of lentigo maligna melanomas? | 85 | ||
| Clinical Features | 86 | ||
| Histopathologic Features (Figs. 13-11 and 13-12) | 86 | ||
| 9. What is the differential diagnosis of lentigo maligna melanoma? | 87 | ||
| 10. What are the clinical and histopathologic features of acral (and mucosal) melanomas? | 87 | ||
| Clinical Features | 87 | ||
| Histopathologic Features (Figs. 13-13 to 13-15) | 88 | ||
| 11. What is the differential diagnosis of acral (and mucosal) melanoma? | 89 | ||
| 12. What are the clinical and histopathologic features of nodular melanomas? | 89 | ||
| Clinical Features | 89 | ||
| Histopathologic Features (Fig. 13-16) | 89 | ||
| 13. What is the differential diagnosis of nodular melanomas? | 90 | ||
| 14. What are the most important unusual variants of melanoma? | 90 | ||
| 15. What are the clinical and histopathologic features of desmoplastic neurotropic melanoma? | 90 | ||
| Section III: Craniofacial Surgery I-Congenital | 131 | ||
| Chapter 20: Principles of Craniofacial Surgery | 133 | ||
| 1. What is the specialty of craniofacial surgery? | 133 | ||
| 2. What three types of pathology can be treated by the craniofacial surgeon? | 133 | ||
| 3. What are the goals of craniofacial surgery in patients with craniosynostosis or faciocraniosynostosis? | 133 | ||
| 4. What is the incidence of craniosynostosis? | 133 | ||
| 5. What is the pathogenesis of craniosynostosis? | 133 | ||
| 6. How is craniosynostosis classified? | 133 | ||
| 7. What is the main feature of faciocraniosynostosis compared with craniosynostosis? | 134 | ||
| 8. Are all craniosynostoses or faciocraniosynostoses present at birth? | 134 | ||
| 9. What is the main functional risk of craniosynostosis? | 134 | ||
| 10. In acrocephalosyndactyly (such as Apert’s syndrome), which factors may be associated with a better mental outcome? | 134 | ||
| 11. Describe the preoperative evaluation of the craniofacial patient | 134 | ||
| 12. Which imaging studies are necessary before surgery? | 134 | ||
| 13. What are the principles of frontoorbital remodeling in craniosynostosis? | 135 | ||
| 14. Compare the growth of the brain and skull in the first 2 years of life | 135 | ||
| 15. What is the main factor responsible for frontal sinus growth after frontocranial remodeling? | 135 | ||
| 16. What complications are associated with craniofacial surgery? How can they be prevented? | 135 | ||
| 17. Can surgery improve the mental outcome of craniosynostotic patients? | 135 | ||
| 18. What is the most common type of craniosynostosis? | 135 | ||
| 19. Is blood transfusion frequently required in craniofacial surgery? | 135 | ||
| 20. What is the mortality rate in craniofacial surgery? | 135 | ||
| 21. Is distraction always osteogenic? | 135 | ||
| 22. What is the current safe strategy for treatment of faciocraniosynostosis? | 135 | ||
| 23. Is frontofacial monobloc advancement a safe procedure? | 136 | ||
| 24. Is it possible to correct an abnormally shaped skull in an adult who has not undergone surgery in childhood for craniosynostosis? | 136 | ||
| Bibliography | 136 | ||
| Chapter 21: Craniofacial Embryology | 137 | ||
| Facial Prominences/Branchial Arches | 137 | ||
| 1. The face originates from how many prominences? What are they? | 137 | ||
| 2. Which branchial arches give rise to the five facial prominences? | 137 | ||
| Maxillary Prominence | 137 | ||
| 3. What structures do the maxillary prominences give rise to? | 137 | ||
| 4. What structures give rise to the nasolacrimal duct? | 137 | ||
| Mandibular Prominence | 137 | ||
| 5. What structures contribute to formation of the lower jaw? | 137 | ||
| 6. By what type of ossification does the lower jaw form? | 137 | ||
| 7. Does the mandible form before, during, or after development of the mandibularbranch of the trigeminal nerve? | 139 | ||
| Palatal Fusion | 139 | ||
| 8. What four structures contribute to the formation of the palate? | 139 | ||
| 9. Are the terms hard and soft palate synonymous with primary and secondary palate? | 140 | ||
| 10. What is the mechanism underlying the formation of cleft palate? | 141 | ||
| 11. What is a submucous cleft? | 141 | ||
| 12. What is the etiology of cleft palate in Pierre Robin sequence? | 141 | ||
| Lip Fusion | 141 | ||
| 13. What is the most common mechanism underlying cleft lip? | 141 | ||
| 14. Is the incidence of cleft palate higher in males or females? What about cleft lip? | 141 | ||
| 15. Are cleft lips more common than cleft palates? | 141 | ||
| Craniofacial Clefts | 141 | ||
| 16. What is the most common classification system of craniofacial clefts? | 141 | ||
| 17. Which craniofacial cleft results from failed fusion of the mandibular and maxillary prominences at the lateral commissure? | 141 | ||
| 18. What are the midline clefts in the Tessier system, and how do they form? | 142 | ||
| Frontonasal Development | 142 | ||
| 19. What structures give rise to the nasal cavity? | 142 | ||
| 20. Do paranasal sinuses form during fetal or postnatal development? | 142 | ||
| Cranial Suture Development/Fusion | 142 | ||
| 21. What is the distinction between neurocranium and viscerocranium? | 142 | ||
| 22. By what type of ossification does the neurocranium form during development? | 142 | ||
| 23. Will calvarial intramembranous bone formation occur in the absence of an underlying brain? | 142 | ||
| 24. What is the clinical significance of cranial sutures during fetal and adult life? | 142 | ||
| 25. What is posterior deformational plagiocephaly, and how does it occur? | 143 | ||
| 26. Do the neurocranium and facial skull maintain a similar proportion duringdevelopment? | 143 | ||
| 27. Does the relative thickness of calvarial bone change following birth? | 143 | ||
| Eye | 143 | ||
| 28. What structures give rise to the eye? | 143 | ||
| Bibliography | 143 | ||
| Chapter 22: Cleft Lip | 144 | ||
| 1. What is the cause of a cleft of the lip and palate? | 144 | ||
| 2. What is the cause of clefting in a specific case? | 144 | ||
| 3. What is the anatomy of a cleft? | 144 | ||
| Unilateral Clefts | 144 | ||
| 4. What is the key factor involved in the treatment of a unilateral cleft? | 144 | ||
| 5. Summarize the evolution of unilateral cleft surgery | 144 | ||
| 6. What is the Mirault-Blair-Brown method of lip repair? | 144 | ||
| 7. What is the Hagedorn-Le Mesurier method? | 144 | ||
| 8. What is the Tennison-Randall method? | 144 | ||
| 9. What is the rotation-advancement method? | 144 | ||
| 10. What are the most common mistakes made in the rotation-advancement method? | 144 | ||
| 11. What are the recent advances in unilateral cleft lip surgery? | 146 | ||
| 12. At what age are the various stages of lip construction accomplished? | 146 | ||
| 13. Why is the lip adhesion used? | 146 | ||
| 14. What are the key deformities in the unilateral cleft lip nose? How are they corrected? | 146 | ||
| 15. Why is the rotation-advancement lip operation the method of choice? | 146 | ||
| Bilateral Clefts | 146 | ||
| 16. What are the specific deformities in a bilateral cleft? | 146 | ||
| 17. What one aspect of the bilateral cleft is sometimes an advantage? | 146 | ||
| 18. Summarize the evolution of bilateral cleft surgery | 146 | ||
| 19. How is maxillary alignment maintained? | 147 | ||
| 20. What is the major risk of early alveolar construction? | 147 | ||
| 21. Can this risk be avoided? | 147 | ||
| 22. What are the advantages of early orthodontic manipulation and gingivoperiosteoplasty of the alveolar cleft? | 147 | ||
| 23. How are the soft tissues treated in bilateral clefts? | 147 | ||
| 24. What is the key to correction of the nose? | 147 | ||
| 25. What is the best method of action? | 147 | ||
| 26. How is the forked flap used? | 147 | ||
| 27. How is the lip of a bilateral cleft closed? | 147 | ||
| 28. What is important to the future treatment of clefts? | 147 | ||
| Bibliography | 148 | ||
| Chapter 23: Cleft Palate | 149 | ||
| 1. What is a cleft palate? | 149 | ||
| 2. Explain the terms primary and secondary palate, and prepalatal and palatal structures | 149 | ||
| 3. What is the premaxilla? | 149 | ||
| 4. When is a cleft palate associated with a cleft lip? What is the overall incidence? | 149 | ||
| 5. How can clefts be classified? | 149 | ||
| 6. What is the etiology of cleft palate? | 149 | ||
| 7. How does a primary or prepalatal cleft form? | 150 | ||
| 8. Why are left-sided secondary or palatal clefts more common than right-sided clefts? | 150 | ||
| 9. What is Simonart’s band? | 150 | ||
| 10. Which muscles are the most important for achieving velopharyngeal closure? | 150 | ||
| 11. Do any other muscles contribute to velopharyngeal closure? | 150 | ||
| 12. What is the most important anatomic abnormality seen with a cleft palate? | 151 | ||
| 13. What is an intravelar veloplasty? | 151 | ||
| 14. What is Passavant’s ridge? | 151 | ||
| 15. How can a mother know if her child has a cleft palate? | 151 | ||
| 16. How should a mother feed a child with a cleft palate if the child cannot suck? | 151 | ||
| 17. Who should evaluate a newborn with a cleft palate? | 152 | ||
| 18. What disciplines should be available on a cleft palate team? | 152 | ||
| 19. What are the major sequelae of an unrepaired cleft palate? | 152 | ||
| 20. At what age should the palate be surgically repaired? | 152 | ||
| 21. What is the benefit of earlier closure? | 152 | ||
| 22. What is the von Langenbeck operation? | 152 | ||
| 23. What is the Furlow double-opposing Z-plasty technique? | 152 | ||
| 24. What is the Wardill-Kilner-Veau operation? | 153 | ||
| 25. What is a vomer flap? | 153 | ||
| 26. Is there an alternative to surgical repair? | 153 | ||
| 27. What is velopharyngeal incompetence? How soon after surgery should a child be evaluated for velopharyngeal incompetence? | 153 | ||
| 28. Who should decide to operate on an incompetent palate? | 153 | ||
| 29. What can be done about residual speech problems after cleft palate repair? | 153 | ||
| 30. Why do children with palatal clefts have ear problems? | 154 | ||
| 31. What is the likelihood of a cleft in another child from the same parents? | 154 | ||
| 32. Is there a way to decrease the incidence of clefts? | 154 | ||
| Bibliography | 154 | ||
| Chapter 24: Correction of Secondary Cleft Lip and Palate Deformities | 155 | ||
| 1. In a newborn infant with cleft lip and palate, what are the number and the timing of surgical procedures that can be anticipated? | 155 | ||
| 2. are the etiologies of residual lip deformities following primary cleft lip repair? | 155 | ||
| 3. When and how should deformities of the vermilion–white roll junction be addressed? | 156 | ||
| 4. What treatment options are available for midline vermilion deficiencies? | 156 | ||
| 5. When should secondary cleft septorhinoplasty be performed? | 156 | ||
| 6. What are the etiologies of palatal dysfunction following primary cleft palate repair? | 156 | ||
| 7. What techniques are available for assessing velopharyngeal insufficiency? | 157 | ||
| 8. What patterns of velopharyngeal closure are commonly seen in cleft palate patients with velopharyngeal insufficiency? What is the treatment of each? | 157 | ||
| 9. What procedures are available for closure of palatal fistulae? | 161 | ||
| 10. What special considerations must be observed in patients with velocardiofacial syndrome? | 161 | ||
| 11. What is the purpose of alveolar cleft bone grafting? When is it performed and what donor site bone is preferred? | 161 | ||
| Bibliography | 161 | ||
| Chapter 25: Dental Basics | 163 | ||
| 1. How are teeth identified? | 163 | ||
| 2. How are the surfaces of the teeth described? | 163 | ||
| 3. What is the Angle classification? | 164 | ||
| 4. Describe the anatomy of a tooth | 164 | ||
| 5. What are the names of the teeth? | 164 | ||
| 6. What is the nerve supply to the teeth? | 164 | ||
| 7. What are natal and neonatal teeth? | 164 | ||
| 8. What is a supernumerary tooth? | 165 | ||
| 9. What is the most common congenitally missing tooth, and what are the syndromes associated with developmentally missing teeth? | 165 | ||
| 10. What is the difference between overbite, overjet, and anterior openbite? | 165 | ||
| 11. What is a posterior dental crossbite? | 165 | ||
| 12. What is an anterior dental crossbite? | 166 | ||
| 13. What is the occlusal plane? | 166 | ||
| 14. What is the difference between centric relation and centric occlusion? | 166 | ||
| 15. Describe the most common injuries involving the teeth | 166 | ||
| 16. When do the primary teeth erupt? | 167 | ||
| 17. When do the permanent teeth erupt? | 167 | ||
| 18. What is a mamelon? | 167 | ||
| 19. Describe the embryology of teeth | 167 | ||
| 20. What is the process of dental decay? | 167 | ||
| 21. What are the muscles of mastication? | 168 | ||
| 22. How do the muscles of mastication move the mandible? | 168 | ||
| 23. What are the average measurements of mandibular movement in an adult? | 168 | ||
| 24. What is a dental implant? | 168 | ||
| 25. What is Invisalign? | 168 | ||
| 26. What is periodontitis? | 168 | ||
| 27. What drugs may cause gingival hyperplasia (overgrowth of gingival tissue)? | 168 | ||
| 28. What is endodontics? | 168 | ||
| Bibliography | 168 | ||
| Chapter 26: Orthodontics for Oral Cleft Craniofacial Disorders | 169 | ||
| Passive Prosthetics \n(Neonatal Period) | 169 | ||
| 1. What is a passive infant oral prosthesis? | 169 | ||
| 2. What does the prosthesis do? | 169 | ||
| 3. Does a prosthesis affect growth? | 169 | ||
| 4. When is the prosthesis worn? | 169 | ||
| 5. How long does it take before a prosthesis is outgrown? | 169 | ||
| 6. Does extension of the prosthesis over the alveolar structures restrict normal development of the lateral dental segments? | 170 | ||
| Presurgical Orthopedic Correction (Neonatal Period) | 170 | ||
| 7. What is presurgical orthopedic correction? | 170 | ||
| 8. How does POC apply to oral cleft patients? | 170 | ||
| 9. What problems attend oral cleft treatment without POC? | 170 | ||
| 10. What are the benefits of POC? | 170 | ||
| 11. What are the various techniques used in POC? | 170 | ||
| 12. What techniques use passive retention? | 170 | ||
| 13. How effective are passive techniques? | 170 | ||
| 14. What techniques use pinned retention? | 171 | ||
| 15. How effective are pinned techniques? | 171 | ||
| 16. How is POC used in UCLP and BCLP treatment? | 171 | ||
| 17. How does the UCLP device produce orthopedic correction? | 171 | ||
| 18. How long does it take before a patient with UCLP is ready for reconstructive surgery? | 172 | ||
| 19. How does the BCLP device produce orthopedic correction? | 172 | ||
| 20. How long does it take before a patient with BCLP is ready for reconstructive surgery? | 172 | ||
| 21. What are the significant treatment effects in BCLP? | 172 | ||
| 22. What is the incidence of postalveolar cleft palate fistulation in patients treated withand without POC? | 172 | ||
| 23. Do pinned POC devices stimulate maxillary growth? | 172 | ||
| 24. Does pinned POC treatment adversely affect maxillary growth? | 172 | ||
| Orthodontic Management | 173 | ||
| Primary Dentition (Age 3 to 6 Years) | 173 | ||
| 25. What is the primary dentition? | 173 | ||
| 26. Why is orthodontic treatment important at this age? | 173 | ||
| 27. What is achieved with orthodontic treatment? | 173 | ||
| 28. What physical signs are most important? | 173 | ||
| 29. What procedures are undertaken at this age? | 173 | ||
| 30. What kinds of devices are used for maxillary expansion? | 173 | ||
| 31. How long of a rest period is needed after expansion? | 173 | ||
| 32. How much expansion is necessary? | 173 | ||
| 33. When was maxillary expansion first used? | 174 | ||
| 34. What other use do expansion devices have? | 174 | ||
| 35. During primary dentition, when is the best time for maxillary protraction? | 174 | ||
| Mixed Dentition (Age 7 to 11 Years) | 174 | ||
| 36. What is mixed dentition? | 174 | ||
| 37. What are the succedaneous or successional teeth? | 174 | ||
| 38. What are the accessional teeth? | 174 | ||
| 39. What is achieved by orthodontic treatment of mixed dentition? | 174 | ||
| 40. What treatment procedures are used? | 174 | ||
| 41. Why is this period critical for the alveolar bone graft? | 174 | ||
| 42. Why is it important to graft the alveolar defect when the canine root is less than 50% formed? | 175 | ||
| Adolescent and Adult Dentition (Age 12 to 17 Years and Beyond) | 175 | ||
| 43. What is adolescent dentition? | 175 | ||
| 44. What orthodontic appliances are used during this period? | 175 | ||
| Controversy | 175 | ||
| 45. Is alveolar bone grafting a definitive procedure? | 175 | ||
| Facial Growth In Oral \nCleft Patients | 175 | ||
| 46. Is craniofacial morphology of parents related to susceptibility for oral cleft in offspring? | 175 | ||
| 47. How is the craniofacial status of adult patients with isolated unilateral cleft lip/alveolus surgically treated in childhood different from that of normal samples? | 175 | ||
| 48. How is the craniofacial status of adult patients with isolated UCLP surgically treated in childhood different from that of normal samples? | 175 | ||
| 49. How is the craniofacial status of adult patients with isolated BCLP surgically treated in childhood different from that of normal samples? | 175 | ||
| 50. How is the craniofacial status of infants with isolated CP different from that of the CLA sample? | 176 | ||
| 51. How is the craniofacial status of adult patients with isolated CP treated and untreated in childhood different from that of normal samples? | 176 | ||
| 52. How does a pharyngeal flap affect facial development? | 176 | ||
| Bibliography | 176 | ||
| Chapter 27: Cephalometrics | 177 | ||
| 1. What is cephalometrics? | 177 | ||
| 2. How is cephalometric analysis performed? | 177 | ||
| 3. How is a standard cephalogram obtained? | 177 | ||
| 4. Why is a cephalostat used? | 177 | ||
| 5. How do you trace a cephalogram? | 177 | ||
| 6. What are the requirements for a landmark? | 177 | ||
| 7. What are the most commonly used landmarks? | 179 | ||
| 8. What is a cephalometric plane? | 180 | ||
| 9. What are the components of cephalometric analysis? | 180 | ||
| 10. What is the purpose of skeletal analysis? | 181 | ||
| 11. What does the dental analysis indicate? | 181 | ||
| 12. What does the profile analysis assess? | 181 | ||
| 13. What is the Holdaway ratio? | 182 | ||
| 14. What are the applications of cephalometrics? | 182 | ||
| 15. How is the STO carried out? | 182 | ||
| 16. How do you evaluate the effect of treatment? | 182 | ||
| 17. Have there been any recent advancements in cephalometrics? | 182 | ||
| 18. What is digital imaging? | 182 | ||
| 19. What are the advantages of digital imaging? | 182 | ||
| 20. What are the disadvantages of digital imaging? | 182 | ||
| 21. What is computerized cephalometrics? | 182 | ||
| 22. What is the advantage of computerized cephalometrics? | 184 | ||
| 23. What are the disadvantages of morphing a picture? | 184 | ||
| 24. What is cone beam CT? | 184 | ||
| Bibliography | 184 | ||
| Chapter 28: Principles of Orthognathic Surgery | 185 | ||
| 1. What is the Angle classification? | 185 | ||
| 2. What do the terms centric occlusion and centric relation mean? | 185 | ||
| 3. What do the cephalometric relationships SNA, SNB, and mandibular plane angle signify? | 186 | ||
| 4. What is the normal amount of incisor show with the lips in repose and during smiling? | 186 | ||
| 5. Describe the classic vertical proportions of the face in profile | 186 | ||
| 6. What is the value of a surgical splint in an orthognathic procedure? How are splints made? | 186 | ||
| 7. What is the rationale behind orthodontic preparation prior to orthognathic surgery? | 187 | ||
| 8. What are the most common osteotomies used to perform mandibular repositioning? | 187 | ||
| 9. Classify chin deformities | 187 | ||
| 10. What is the long face syndrome? Suggest a basic surgical approach | 188 | ||
| 11. What is the short face syndrome? Suggest a basic surgical approach | 188 | ||
| 12. Describe the vascular supply of the mobilized Le Fort I maxillary segment | 188 | ||
| 13. What are the risks of nerve injury during orthognathic surgery? | 188 | ||
| 14. What is the normal range of vertical mandibular opening in adults? Describe the normal motion of the TMJ | 189 | ||
| Controversies | 189 | ||
| 15. Does orthognathic surgery improve TMJ symptoms? | 189 | ||
| 16. What is progressive condylar resorption? What is its cause? How is it treated? | 189 | ||
| Bibliography | 189 | ||
| Chapter 29: Cleft Orthognathic Surgery | 190 | ||
| 1. What are the maxillomandibular abnormalities in cleft lip and palate patients? | 190 | ||
| 2. Do surgical procedures on the lip and palate contribute to these abnormalities? | 190 | ||
| 3. What can we do to prevent these abnormalities? | 190 | ||
| 4. How often is orthognathic surgery needed in cleft patients? | 190 | ||
| 5. Is orthognathic surgery avoidable in cleft patients? | 190 | ||
| 6. What are the most frequent orthognathic procedures performed in cleft patients? | 190 | ||
| 7. How does one prepare a cleft patient for orthognathic surgery? | 190 | ||
| 8. What is the optimal timing to perform orthognathic surgery in cleft patients? | 191 | ||
| 9. What are the goals when performing a maxillary osteotomy? | 191 | ||
| 10. What is the basic technique for a Le Fort I maxillary osteotomy? | 191 | ||
| 11. Is the Le Fort I maxillary osteotomy technique performed differently in cleft patients? | 191 | ||
| 12. What is the main indication for two-jaw surgery? | 191 | ||
| 13. How do you select the optimal technique for mandibular osteotomies? | 191 | ||
| 14. What is the aesthetic effect of mandibular retropositioning? Is it enough? | 192 | ||
| 15. What is the indication for a maxillary segmental osteotomy? | 192 | ||
| 16. Is velopharyngeal closure affected by a Le Fort I maxillary advancement? | 193 | ||
| 17. Is the presence of a pharyngeal flap a limiting factor when performing a maxillary advancement? | 193 | ||
| 18. Are the results of orthognathic surgery in cleft patients permanent? | 193 | ||
| 19. What are the complications of orthognathic surgery in cleft patients? | 193 | ||
| 20. How do you treat relapse of a maxillary advancement? | 193 | ||
| Bibliography | 193 | ||
| Chapter 30: Craniosynostosis | 194 | ||
| 1. What is craniosynostosis? Who first described it? | 194 | ||
| 2. What structure is currently believed to be the primary site of abnormality responsible for craniosynostosis? | 194 | ||
| 3. What structure is critical to suture patency? | 194 | ||
| 4. How are cranial bones formed? | 194 | ||
| 5. What are the two regions of the skull? | 195 | ||
| 6. What is the primary stimulus for growth at the cranial suture? | 195 | ||
| 7. At what age are brain volume and cranial capacity approximately 50% that of the adult? | 195 | ||
| 8. In which direction does cranial growth occur with relation to a synostotic suture? What is Virchow’s law? | 195 | ||
| 9. What is the incidence of craniosynostosis? | 195 | ||
| 10. What is syndromic craniosynostosis? How common is it? | 195 | ||
| 11. Are growth factors involved in syndromic craniosynostosis? | 195 | ||
| 12. What is “functional” synostosis? | 195 | ||
| 13. What is the incidence of increased intracranial pressure with single-suture and multiple-suture involvement? | 195 | ||
| 14. What is the pathognomonic ophthalmologic sign of increased ICP? | 196 | ||
| 15. What does “thumb printing” or a “copper-beaten” appearance indicate? | 196 | ||
| 16. What is the most common isolated, nonsyndromic, single-suture synostosis? | 196 | ||
| 17. Which type of craniosynostosis is most often associated with hypotelorism? | 196 | ||
| 18. When does the metopic suture normally fuse? | 196 | ||
| 19. What is a “metopic notch”? | 197 | ||
| 20. What is a “metopic groove”? | 197 | ||
| 21. What are the different types of nonsyndromic isolated craniosynostoses? | 197 | ||
| 22. To which multiple-suture synostoses do the terms “tower skull,” “pointed head,” and “cloverleaf skull” refer? | 197 | ||
| 23. What characteristics differentiate Crouzon syndrome from Apert syndrome? | 199 | ||
| 24. Name three syndromes associated with hand anomalies | 199 | ||
| 25. What is secondary craniosynostosis? | 199 | ||
| 26. What is “slit ventricle syndrome”? | 199 | ||
| 27. What is “postshunt craniosynostosis”? What causes it? | 200 | ||
| 28. How is postshunt craniosynostosis treated? | 201 | ||
| 29. How does one differentiate between deformational and synostotic plagiocephaly? Which is more common? | 201 | ||
| 30. Once the diagnosis of deformational plagiocephaly is made in a 2-month-old infant with a pronounced posterior head shape abnormality, what is the appropriate management? | 202 | ||
| 31. What is the harlequin deformity? | 202 | ||
| 32. What is torticollis? | 202 | ||
| 33. Is there an association between deformational plagiocephaly and torticollis? | 202 | ||
| 34. What are the two goals of surgery for patients with craniosynostosis? | 202 | ||
| 35. What is the ideal timing for correction of craniosynostosis? | 202 | ||
| 36. When can defects of the skull be expected to spontaneously heal? How does this affect reconstructive plans? | 202 | ||
| 37. Which reconstructive procedures are performed before 1 year of age? Which are performed after 1 year of age? | 203 | ||
| 38. Is a strip craniectomy sufficient treatment for sagittal synostosis? | 203 | ||
| 39. Is the treatment strategy for sagittal synostosis different in older children? | 203 | ||
| 40. How is metopic synostosis corrected? | 203 | ||
| 41. What is the appropriate treatment of an infant with bilateral coronal synostosis and a moderate degree of exorbitism? Is this approach useful in an infant with syndromic synostosis (Crouzon or Apert syndrome)? | 203 | ||
| 42. How does treatment of unilateral coronal synostosis (plagiocephaly) differ from treatment of bilateral coronal synostosis (brachycephaly)? | 203 | ||
| 43. What is a Le Fort III advancement osteotomy? | 205 | ||
| 44. When should a Le Fort III advancement osteotomy be performed with a simultaneous Le Fort I osteotomy or frontal bone advancement? | 206 | ||
| Controversies | 206 | ||
| 45. What is a monobloc advancement? Is it safe? | 206 | ||
| 46. Is there a role for alloplastic bone substitutes during craniosynostosis reconstruction? | 206 | ||
| 47. Is there a role for the endoscopic approach to craniosynostosis reconstruction? | 206 | ||
| Bibliography | 209 | ||
| Chapter 31: Principles of Distraction Osteogenesis | 210 | ||
| 1. What is distraction osteogenesis? | 210 | ||
| 2. How long has the concept of skeletal molding been in use? | 210 | ||
| 3. Who performed the first distraction? | 210 | ||
| 4. What are the phases of distraction? | 210 | ||
| 5. What are the four zones of tissue generation in the intercalary gap? | 210 | ||
| 6. What are the three types of distraction? | 210 | ||
| 7. Can distraction be performed without an osteotomy? | 211 | ||
| 8. What is distraction histogenesis? | 211 | ||
| 9. What is “molding of the generate”? | 212 | ||
| 10. What is tensile stress? Tensile strain? Young’s modulus of elasticity? | 212 | ||
| 11. What is the range of nominal strain in the mandibular distraction gap? | 212 | ||
| 12. What is mechanical transduction? What are the mechanicobiologic principles thought to guide mesenchymal tissue differentiation? | 212 | ||
| 13. What is the theoretical mechanism for new bone formation? | 212 | ||
| 14. What are the molecular signals that play a role in distraction osteogenesis? | 212 | ||
| 15. What are the two basic types of distraction devices? | 213 | ||
| 16. What are the advantages of distraction osteogenesis compared with traditional surgical movements of the craniofacial skeleton? | 213 | ||
| 17. What are the disadvantages of craniofacial distraction? | 213 | ||
| 18. Are there age limits on distraction? | 213 | ||
| 19. Can irradiated bone be distracted? | 213 | ||
| 20. Can craniofacial distraction treat obstructive sleep apnea? | 213 | ||
| 21. When would you perform mandibular distraction? | 214 | ||
| 22. When would you perform alveolar ridge distraction? | 214 | ||
| 23. When would you perform maxillary distraction? | 214 | ||
| 24. When would you perform midface distraction? | 214 | ||
| 25. When would you perform frontoparietal (monobloc) distraction? | 214 | ||
| 26. What are the critical factors for successful distraction? | 214 | ||
| 27. What is the optimal latency? | 215 | ||
| 28. What is the optimal activation rate of distraction osteogenesis? | 215 | ||
| 29. How do you determine when the activation phase is complete? | 215 | ||
| 30. What is the optimal length of consolidation? How do you determine when consolidation is complete? | 215 | ||
| 31. How does distraction fail? | 215 | ||
| 32. What are the most common complications following distraction osteogenesis? | 216 | ||
| Bibliography | 216 | ||
| Chapter 32: Distraction Osteogenesis of the Mandible | 217 | ||
| 1. What are the causes of a hypoplastic mandible? | 217 | ||
| 2. What is Pierre Robin sequence? | 217 | ||
| 3. What is craniofacial microsomia? | 217 | ||
| 4. What are the differences in the mandibles in patients with Robin sequence and those with craniofacial microsomia? | 217 | ||
| 5. What is the Pruzansky classification of mandibular deformities? | 217 | ||
| 6. What are the indications for mandibular distraction? | 217 | ||
| 7. Can mandibular distraction treat obstructive sleep apnea? Can mandibular distraction prevent tracheostomy or allow for removal of an existing tracheostomy? | 218 | ||
| 8. How do you assess the mandibular deformity preoperatively? | 218 | ||
| 9. What is the preoperative workup for a patient undergoing mandibular distraction? | 218 | ||
| 10. Which areas of the mandible can be distracted? | 219 | ||
| 11. How do you decide when to distract the neonate or infant with mandibular deficiency and respiratory insufficiency or sleep apnea? | 219 | ||
| 12. What are the options when a Pruzansky III mandible is present? What if the tooth follicle is in the way? | 219 | ||
| 13. What are the vectors of distraction? | 219 | ||
| 14. How do you choose from among an extraoral, intraoral, or semi-buried approach? | 219 | ||
| 15. What is the utility of a multiplanar device? | 219 | ||
| 16. When is transport distraction helpful for mandibular deformities? | 220 | ||
| 17. Does skeletal elongation with distraction osteogenesis have an impact on the associated soft tissue? | 222 | ||
| 18. Which incisions can be used? | 222 | ||
| 19. What orthodontic measures can be practiced during activation and consolidation to achieve the optimal occlusion? | 222 | ||
| 20. How is the progress of mandibular distraction monitored clinically and radiographically? | 222 | ||
| 21. What are the endpoints of unilateral distraction? | 222 | ||
| 22. What are the endpoints of bilateral distraction? | 222 | ||
| 23. When do you remove the distraction device? | 222 | ||
| 24. What are the most common complications following mandibular distraction? How are they treated? | 222 | ||
| 25. Is the distracted mandible stable? Does the distracted mandible grow? | 223 | ||
| 26. Does mandibular distraction affect the TMJs? | 223 | ||
| Bibliography | 223 | ||
| Chapter 33: Distraction Osteogenesis of the Midface | 224 | ||
| 1. What is distraction osteogenesis? | 224 | ||
| 2. Which patients are potential candidates for maxillary distraction osteogenesis? | 224 | ||
| 3. What are some physical deformities and functional deficits exhibited by patients with severe maxillary hypoplasia? | 224 | ||
| 4. How does rigid external distraction work? | 224 | ||
| 5. Is autogenous or alloplastic bone grafting or internal skeletal fixation used with the rigid external distraction device? | 224 | ||
| 6. Why is internal fixation and autogenous bone grafting not needed? | 224 | ||
| 7. What is the latency period for midface distraction? | 224 | ||
| 8. What is the activation period? | 224 | ||
| 9. What is the period of rigid retention? | 225 | ||
| 10. How is the distraction vector determined? | 226 | ||
| 11. What is the rate of distraction during the activation period? | 226 | ||
| 12. What are the postoperative instructions for patients after the osteotomies and placement of the distraction device? | 226 | ||
| 13. What is the mean horizontal maxillary advancement in patients treated with a traditional Le Fort I advancement? | 226 | ||
| 14. What is the long term relapse in horizontal maxillary advancement in patients treated with a traditional Le Fort I advancement? | 226 | ||
| 15. What is the complication rate of traditional Le Fort I maxillary advancement in cleft patients? | 226 | ||
| 16. What is the mean horizontal maxillary advancement in patients undergoing rigid external distraction? | 226 | ||
| 17. What is the mean horizontal relapse in patients undergoing rigid external distraction? | 226 | ||
| 18. What is the complication rate in cleft patients undergoing rigid external distraction? | 226 | ||
| 19. Where is the area of most bone formation after maxillary distraction? | 226 | ||
| 20. What are some advantages of rigid distraction osteogenesis? | 226 | ||
| 21. Are all surgeons currently using distraction osteogenesis to advance the maxilla in cleft patients? | 226 | ||
| Bibliography | 227 | ||
| Chapter 34: Distraction Osteogenesisof the Cranium | 228 | ||
| 1. Briefly describe the history of craniofacial distraction osteogenesis | 228 | ||
| 2. Is special equipment required to perform DOG? | 228 | ||
| 3. Describe the technique for cranial DOG | 228 | ||
| 4. What are the DOG periods? | 228 | ||
| 5. Is there an “ideal” distraction device? | 229 | ||
| 6. What is the distraction vector? Why is it important? | 229 | ||
| 7. What craniofacial disorders have been successfully treated with DOG techniques? | 229 | ||
| 8. What are the advantages of cranial vault distraction? | 230 | ||
| 9. What are the disadvantages of cranial vault distraction? | 230 | ||
| 10. What is the optimal timing for cranial vault DOG? | 230 | ||
| 11. Describe spring-mediated craniofacial distraction | 230 | ||
| 12. What craniofacial disorders can be corrected with spring-mediated distraction? | 230 | ||
| 13. What are important factors to take into account for spring-mediated distraction? | 230 | ||
| 14. What is combined distraction–compression cranial vault remodeling? | 230 | ||
| 15. What are the complications of cranial vault DOG? | 231 | ||
| 16. What is the frequency of complications in cranial DOG? | 231 | ||
| 17. What special considerations are needed when performing DOG for Apert syndrome? | 231 | ||
| 18. What is the future direction for cranial DOG? | 231 | ||
| Bibliography | 232 | ||
| Chapter 35: Orbital Hypertelorism | 233 | ||
| 1. What is orbital hypertelorism? | 233 | ||
| 2. How do you measure IOD? | 233 | ||
| 3. What is the significance of pseudohypertelorism? | 233 | ||
| 4. Why is interpupillary distance not used to measure OHT? | 233 | ||
| 5. Describe the changes that occur in IOD with age | 233 | ||
| 6. Describe the two classifications of OHT | 233 | ||
| 7. What causes OHT? | 233 | ||
| 8. What is an encephalocele? | 233 | ||
| 9. Describe the various types of encephaloceles | 234 | ||
| 10. How does the level of the cribriform plate compare between people with OHT and those with a normal IOD? | 234 | ||
| 11. How is OHT surgically managed? | 234 | ||
| 12. What are “box osteotomies” of the orbit? | 234 | ||
| 13. A “U-shaped” osteotomy is performed with which type of OHT reconstruction? | 234 | ||
| 14. What is a facial bipartition? | 234 | ||
| 15. What steps must be taken to preserve olfactory function during surgical correction of OHT? | 234 | ||
| 16. What effect does the intraorbital/intranasal exoneration have on future growth of the midface? | 234 | ||
| 17. After correction of OHT, what is done with the excess interorbital skin? | 234 | ||
| 18. Why is proper management of the medial canthal tendon important in OHT repair? | 235 | ||
| 19. What is the role of the lateral orbital wall in OHT repair? | 235 | ||
| 20. What are the key steps to keep in mind during surgical planning for OHT correction? | 235 | ||
| 21. What are the most common complications following OHT repair? | 235 | ||
| 22. What is Cohen craniosynostosis syndrome? | 235 | ||
| Bibliography | 235 | ||
| Chapter 36: Craniofacial Syndromes | 236 | ||
| 1. What is a syndrome? What are craniofacial syndromes? | 236 | ||
| 2. What is the difference between malformation, deformation, and disruption? | 236 | ||
| 3. What is craniosynostosis? Do all patients with craniosynostosis have syndromes? | 236 | ||
| 4. How does cranial growth occur, and what are the theories regarding the etiology of sutural synostosis? | 236 | ||
| 5. How is cranial growth affected by suture synostoses? | 237 | ||
| 6. Which sutures are most commonly involved in craniofacial syndromes? | 237 | ||
| 7. Why do most patients with syndromic craniosynostosis have some level of midface hypoplasia (midface underdevelopment)? | 237 | ||
| 8. Which type of suture synostosis relates to which morphologic appearance? | 237 | ||
| 9. List some common craniofacial syndromes and their distinguishing features, frequency, mode of inheritance, and associated genetic abnormalities | 237 | ||
| 10. What is acrocephalosyndactyly? | 237 | ||
| 11. What are the goals in the treatment of patients with craniofacial syndromes, and what procedures are commonly used? | 237 | ||
| Form | 237 | ||
| Function | 239 | ||
| 12. What is normal ICP, and are craniofacial syndromes always associated with increased ICP? | 240 | ||
| 13. Are craniofacial syndromes associated with mental retardation or learning deficiencies? | 240 | ||
| 14. Which craniosynostosis syndromes involve the limbs? Is there a difference in themagnitude of limb involvement? | 240 | ||
| 15. Name a few facial syndromes and their main characteristics | 240 | ||
| 16. In patients with velocardiofacial syndrome, what presurgical consideration is important prior to treatment of velopharyngeal insufficiency? | 240 | ||
| 17. Is Pierre Robin syndrome truly a syndrome? | 240 | ||
| 18. Can craniofacial anomalies be treated anywhere? What is the importance of a multidisciplinary team? | 240 | ||
| Bibliography | 241 | ||
| Chapter 37: Craniofacial Clefts | 242 | ||
| 1. When does the embryologic development of the face take place? | 242 | ||
| 2. When does the most rapid phase of facial development occur? | 242 | ||
| 3. Morphogenesis of the craniofacial skeleton begins with the formation of which bone? | 242 | ||
| 4. Why do craniofacial clefts occur? | 242 | ||
| 5. What are the two leading theories of facial cleft formation? | 242 | ||
| 6. What is the incidence of craniofacial clefts? | 242 | ||
| 7. Who was the first to recognize the three-dimensional complexity of craniofacial clefts? | 243 | ||
| 8. How is the Tessier classification of craniofacial clefts structured? | 243 | ||
| 9. Can a patient have more than one type of craniofacial cleft? What are the rules? | 243 | ||
| 10. What is internasal dysplasia? To which Tessier cleft does this term apply? | 243 | ||
| 11. Which craniofacial clefts begin at Cupid’s bow? | 244 | ||
| 12. What is nasoschizis? To which clefts does this term refer? | 244 | ||
| 13. What is an oronasoocular cleft? | 244 | ||
| 14. What are colobomas? Where are they found in relation to the punctum in the no. 3 cleft? | 245 | ||
| 15. Why is the no. 4 cleft also called meloschisis? | 245 | ||
| 16. Which of the oblique facial clefts may permit orbital content prolapse into the maxillary sinus? | 246 | ||
| 17. Which cleft represents an incomplete form of the Treacher Collins anomaly? | 246 | ||
| 18. Which is the least rare of the craniofacial clefts? With which more familiar anomaly is it associated? | 246 | ||
| 19. When was hemifacial microsomia first described? | 246 | ||
| 20. What syndrome is closely related to hemifacial microsomia but has the additional features of epibulbar ocular dermoids and vertebral anomalies? | 247 | ||
| 21. Which craniofacial cleft is often occupied by a dermatocele? | 247 | ||
| 22. The bilateral combination of no. 6, 7, and 8 clefts represents the complete form of which syndrome? (Hint: The zygomas are absent.) | 247 | ||
| 23. Which is the rarest of the craniofacial clefts and the first to involve the superior hemisphere of the orbit? | 247 | ||
| 24. Which cleft is the cranial extension of the no. 4 facial cleft and is often occupied by a frontoorbital encephalocele? | 247 | ||
| 25. Which cleft is usually found in combination with the no. 3 cleft? When is it associated with orbital hypertelorism? | 247 | ||
| 26. Why is orbital hypertelorism usually associated with the no. 12 cleft? | 247 | ||
| 27. Which cleft is associated with transverse widening of the cribriform plate? | 248 | ||
| 28. “The face predicts the brain.” Explain | 248 | ||
| 29. In addition to the no. 0 cleft, which other cleft is associated with both hypotelorism and hypertelorism? | 248 | ||
| 30. Which structures must be considered in the reconstruction of a craniofacial cleft? | 248 | ||
| 31. What is a no. 30 cleft? | 248 | ||
| Controversy | 249 | ||
| 32. What other congenital anomalies have been associated with craniofacial clefts? | 249 | ||
| 33. Are the location and complexity of craniofacial clefts affected in patients with concomitant limb ring constrictions? | 249 | ||
| 34. What about an association between rare craniofacial clefts and craniosynostosis? | 249 | ||
| Bibliography | 249 | ||
| Chapter 38: Craniofacial Microsomia | 251 | ||
| 1. What is craniofacial microsomia and how frequently does it occur? | 251 | ||
| 2. Does craniofacial microsomia and hemifacial microsomia represent the same entity? | 251 | ||
| 3. What are the current theories of the pathogenesis of craniofacial microsomia? | 251 | ||
| 4. Are any genetic or familial factors believed to play a role in craniofacial microsomia? | 251 | ||
| 5. Describe the typical clinical appearance of a patient with craniofacial microsomia | 251 | ||
| 6. What is Goldenhar syndrome? | 251 | ||
| 7. What is the role of prenatal ultrasound in diagnosing conditions affecting development of the first and second branchial arches? | 251 | ||
| 8. What diagnostic tests, in addition to physical examination, are useful tools in the assessment of patients with craniofacial microsomia? | 251 | ||
| 9. Are clinical ear findings of craniofacial microsomia associated with hearing loss? | 251 | ||
| 10. Classify the mandibular malformations associated with craniofacial microsomia | 252 | ||
| 11. What classification systems have been used in an attempt to encompass the range of abnormalities found in craniofacial microsomia? | 252 | ||
| 12. What orthodontic treatment is used in patients with craniofacial microsomia? | 253 | ||
| 13. What are the goals of surgical treatment in craniofacial microsomia? | 253 | ||
| 14. What surgical methods are available to reconstruct the mandibular ramus and increase the size of the mandible? | 253 | ||
| 15. What new surgical treatments are being used for type III mandibular deformities? | 253 | ||
| 16. What structure is subject to anatomic variation in patients with craniofacial microsomia and is of special concern during mandibular surgery? | 253 | ||
| 17. What are the indications for maxillary operation? | 253 | ||
| 18. What are the goals of mandibular distraction? | 253 | ||
| 19. How do you know when mandibular distraction is adequate? | 253 | ||
| 20. What surgical methods are used for treatment of deformities of the nose and chin after completion of bony reconstruction? | 253 | ||
| 21. What is the sequence of reconstructive surgery in children with craniofacial microsomia? | 253 | ||
| 22. What are the methods of soft tissue deficiency treatment? | 253 | ||
| 23. What is the most common postoperative complication after sagittal split osteotomy? | 254 | ||
| 24. In patients with craniofacial microsomia, which cranial nerve is most frequently involved? | 254 | ||
| 25. How does distraction osteogenesis differ from sagittal split osteotomy for treatment of mandibular hypoplasia? | 254 | ||
| 26. In a sagittal split osteotomy of the mandible, the neurovascular bundle should remain in which of the following segments of the mandible? | 254 | ||
| 27. What is the optimal daily rate of distraction? | 254 | ||
| Bibliography | 254 | ||
| Chapter 39: Skull Base Surgery | 255 | ||
| 1. What are the anatomic divisions of the cranial base? | 255 | ||
| 2. List the foramina found in each segment of the cranial base and their contents | 255 | ||
| 3. What tumors (malignant and benign) are commonly found in the cranial base? | 255 | ||
| 4. What are the common clinical findings associated with tumors of the skull base? | 256 | ||
| 5. How has the development of transfacial approaches to the cranial base enabled more successful skull base surgery? | 256 | ||
| 6. What are the advantages of transfacial approaches? | 257 | ||
| 7. What are the disadvantages of transfacial approaches? | 257 | ||
| 8. Why is the team approach important in conducting cranial base surgery? | 257 | ||
| 9. What diagnostic tests are most commonly used in the diagnosis of skull base tumors? | 257 | ||
| 10. What is the role of tumor biopsy in diagnosing lesions of the skull base? | 257 | ||
| 11. How do you prepare a patient for cranial base surgery? | 257 | ||
| 12. What transfacial surgical approach is used to access tumors of the anterior cranial fossa and tumors that extend into the superior orbital region? | 257 | ||
| 13. What are the variations of the transfrontal approach, and what are indications for their use? | 257 | ||
| 14. What transfacial surgical approach is used to expose the anterior cranial fossa, nasopharynx, clivus, orbit, and tumors that grow anteriorly? | 258 | ||
| 15. What are the variations of the transfrontal nasal approach and indications for their use? | 258 | ||
| 16. What transfacial surgical approach is used for resection of large anterior cranial fossa or nasopharyngeal lesions and clival lesions with anterior extension? | 258 | ||
| 17. What are the variations of the transfrontal nasal-orbital approach and indications for their use? | 258 | ||
| 18. What transfacial surgical approach is used for wide exposure of the entire midline skull base region and large nasopharyngeal and clival lesions that extend in all four directions? | 259 | ||
| 19. What are the variations of the transnasomaxillary approach and indications for their use? | 259 | ||
| 20. What transfacial surgical approach is used for small clival lesions with superior, posterior, and inferior extensions, and small to moderate nasopharyngeal lesions? | 259 | ||
| 21. What are the variations of the transmaxillary approach, and what are the indications for their use? | 260 | ||
| 22. What transfacial surgical approach is used to expose the lower clival and upper cervical region for resection of small tumors? | 260 | ||
| 23. What are the variations of the transpalatal approach and indications for their use? | 260 | ||
| 24. What are the important aspects of closure and reconstruction of the cranial base? | 261 | ||
| 25. What are the options for flap reconstruction? | 261 | ||
| 26. What are the indications for use of free flaps in skull base reconstruction? | 263 | ||
| 27. What is the postoperative management protocol for a patient who has undergone skull base surgery? | 263 | ||
| 28. What complications may occur after skull base surgery? | 263 | ||
| 29. What improvements in survival rates after skull base surgery have been seen over the past 4 decades? | 265 | ||
| Bibliography | 265 | ||
| Chapter 40: Conjoined Twins | 266 | ||
| 1. What is the incidence of conjoined twins? | 266 | ||
| 2. What are the types of conjoined twins? | 266 | ||
| 3. What are the relative percentages of each type of conjoined twin? | 266 | ||
| 4. What percentage of conjoined twins are the same sex? | 266 | ||
| 5. What are the embryologic issues that lead to the formation of conjoined twins? | 266 | ||
| 6. How did conjoined twins become known as “Siamese twins”? | 266 | ||
| 7. Who were some of the historically noted conjoined twins? | 268 | ||
| 8. What were some of the historical separations? | 268 | ||
| 9. If not separated, why does the surviving twin die soon after the first dies? | 269 | ||
| 10. What is the plastic surgical technique that has allowed the most reliable separation and reconstruction of conjoined twins? | 269 | ||
| 11. Why is ethics concerning the possible separation of conjoined twins a particularly difficult issue? | 269 | ||
| Bibliography | 269 | ||
| Section IV: Craniofacial Surgery II-Traumatic | 271 | ||
| Chapter 41: Assessment and Management of Facial Injuries | 273 | ||
| 1. What are life-threatening facial injuries? | 273 | ||
| 2. The presence of fat in a periorbital laceration should mandate what examination? | 273 | ||
| 3. The presence of a Marcus Gunn pupil implies what cranial nerve injury? | 273 | ||
| 4. The presence of nasal bleeding implies fracture of what craniofacial structure? | 273 | ||
| 5. Numbness in the infraorbital division of the trigeminal nerve is consistent with what fracture? | 273 | ||
| 6. The presence of cyanosis, drooling, and hoarseness implies damage to what structures and the necessity for operative intervention in what area? | 274 | ||
| 7. Cervical spine fractures accompany what maxillofacial injury? | 274 | ||
| 8. Which maxillofacial fractures are more difficult to localize in computed tomographic scans? | 274 | ||
| 9. Panorex examination of the mandible is likely to miss fractures in what mandibular region? | 274 | ||
| 10. Split palate and alveolar fractures have what symptoms in contrast with a Le Fort fracture? | 274 | ||
| 11. Which nasoethmoidal fractures do not display telecanthus? | 274 | ||
| 12. Cerebrospinal fluid fistulas can be detected by what examinations? | 275 | ||
| 13. Subcondylar fractures of the mandible generally present with what occlusal disturbance? | 275 | ||
| 14. Untreated Le Fort II and III fractures generally present with what changes in facial structure and occlusion? | 275 | ||
| 15. Incomplete or greenstick Le Fort fractures present with what symptoms and are characteristically found at what level? | 275 | ||
| 16. The presence of an anterior cranial fossa fracture is suspected by what clinical signs? | 275 | ||
| 17. What is the difference between enophthalmos and ocular dystopia? | 275 | ||
| 18. How are injuries of the parotid duct detected? | 275 | ||
| 19. Blunt craniofacial injuries accompanied by facial nerve palsy are generally due to fracture of what bone structure? | 276 | ||
| 20. Subluxation of the condylar head anterior to the glenoid fossa produces what symptom? | 276 | ||
| 21. Transection of the lacrimal system is suggested by what physical signs? | 276 | ||
| 22. Facial lacerations rarely require débridement because the blood supply is good and the tissue will usually heal. True or false? | 276 | ||
| 23. Three-dimensional CT scans are indicated in what kind of fracture evaluation? | 276 | ||
| 24. What potentially lethal facial fracture emergency is commonly overlooked? | 276 | ||
| 25. What disastrous complications result from instrumentation or unrecognized fractures of the anterior cranial fossa? | 276 | ||
| 26. Numbness of the lower lip usually accompanies what type of mandibular fracture? | 276 | ||
| 27. Acutely, orbital floor fractures present with what symptoms? What criteria should be used to establish the need for operative reduction? | 277 | ||
| 28. A young boy is watching a football game in a grandstand when he is pushed forward and falls several rows, breaking his nose. He is bleeding profusely from his nose, says he blacked out for a brief period, and has pain when he turns his head side to side | 277 | ||
| 29. In secondary facial reconstruction, is one most likely to have difficulty with bone repositioning, soft tissue repositioning, or retained plates? | 277 | ||
| 30. Following bone grafting, what “take” of a bone graft is generally expected? | 277 | ||
| 31. What is the most frequent reason for failure of alloplastic cranioplasty in the skull? | 277 | ||
| 32. What is the best material for frontal sinus obliteration? | 277 | ||
| 33. Osteomyelitis is common after frontal sinus repair. True or false? | 277 | ||
| 34. Supraorbital fractures usually displace the eye in which direction? | 277 | ||
| 35. In many nasoethmoidal fractures, the medial canthal ligament may be left attached to what structure during reduction? | 278 | ||
| 36. A Stranc plane II nasal fracture would be expected to require what type of reconstruction? | 278 | ||
| 37. The majority of zygomatic fractures require what type of surgical approach? | 278 | ||
| 38. In a patient with 6 mm of enophthalmos, 20/20 vision, and diplopia looking upward, will correction of the enophthalmos correct the diplopia? | 278 | ||
| 39. A Le Fort fracture doesn’t exist if the maxilla is not mobile. True or false? | 278 | ||
| 40. Rigid fixation of a Le Fort fracture allows the patient to return to a regular diet following the operation. The rigid fixation makes it unnecessary to observe the occlusion. True or false? | 278 | ||
| 41. How should split palate fractures be treated? | 278 | ||
| 42. In a subcondylar mandibular fracture that has healed following closed reduction with a shortened ramus height but has good condylar motion, how should a premature contact in the molar dentition and an anterior openbite be managed? | 279 | ||
| 43. What is the optimal treatment of a comminuted parasymphysis fracture? | 279 | ||
| 44. In a close-range, self-inflicted shotgun wound of the central midface and mandible, what is the most appropriate approach to managing the resultant complex injuries? | 279 | ||
| Bibliography | 279 | ||
| Chapter 42: Radiologic Examination of the Craniofacial Skeleton | 280 | ||
| 1. When should x-rays be obtained for patients with suspected nasal fractures? | 280 | ||
| 2. What is the best way to evaluate the orbit for potential fractures? | 280 | ||
| 3. Is there a role for plain x-rays in facial trauma? | 280 | ||
| 4. What is the best way to diagnose single sutural craniosynostosis? | 280 | ||
| 5. What is the best examination to evaluate a child with positional plagiocephaly? | 281 | ||
| 6. What is the best way to determine ideal cranial bone graft harvest sites? | 281 | ||
| 7. In determining increased intracranial pressure, how reliable is a copper-beaten skull appearance, or Lückenschädel? | 282 | ||
| 8. For infants and children with one of the craniofacial dysostoses (e.g., Apert syndrome, Crouzon syndrome, Pfeiffer syndrome), what radiologic studies need to be performed? | 282 | ||
| 9. Are there any risks of performing a CT scan in infants and small children? | 282 | ||
| 10. Aside from CT scans, are there any other ways to assess sutural patency? | 282 | ||
| 11. What studies need to be obtained prior to orthognathic surgery? | 282 | ||
| 12. it necessary to obtain an x-ray prior to performing a genioplasty? | 283 | ||
| Bibliography | 283 | ||
| Chapter 43: Pediatric Facial Fractures | 284 | ||
| 1. What is the most common type of pediatric facial fracture? | 284 | ||
| 2. What are the growth patterns of the pediatric craniofacial skeleton? | 284 | ||
| 3. Where are the growth centers of the pediatric craniofacial skeleton? | 284 | ||
| 4. What is the sequence of frontal and maxillary sinus pneumatization? | 284 | ||
| 5. What is the epidemiology of pediatric facial fractures? | 284 | ||
| 6. What are the common pediatric facial fracture patterns? | 284 | ||
| 7. What are the advantages and disadvantages of open versus closed treatment of pediatric facial fractures? | 284 | ||
| 8. Should absorbable or metallic fixation be used when treating pediatric facial fractures? | 285 | ||
| 9. How do you diagnose pediatric facial fractures? | 285 | ||
| 10. What radiographic studies should be obtained in pediatric patients with facial fractures? | 285 | ||
| 11. How common are pediatric frontal sinus fractures? | 285 | ||
| 12. What is a “growing skull fracture”? | 285 | ||
| 13. What are the principles of treating pediatric orbital fractures? | 285 | ||
| 14. How do you treat pediatric nasal fractures? | 285 | ||
| 15. How do you treat pediatric mandible fractures? | 286 | ||
| 16. What are some issues surrounding maxillomandibular fixation in pediatric patients? | 287 | ||
| 17. What pediatric facial fracture is considered a true surgical emergency? | 287 | ||
| 18. What is the concern for associated injuries in patients with pediatric craniofacial fractures? | 288 | ||
| 19. What are the effects of pediatric facial fractures on facial growth? | 288 | ||
| 20. What is the follow-up for pediatric facial fracture patients? | 288 | ||
| Bibliography | 288 | ||
| Chapter 44: Fractures of the Frontal Sinus | 289 | ||
| 1. What are the most common causes of frontal sinus injury? | 289 | ||
| 2. How common are fractures of the lower frontal bone compared with other facial bones? | 289 | ||
| 3. Is frontal sinus injury typically associated with other maxillofacial injuries? | 289 | ||
| 4. Is frontal sinus injury typically associated with other bodily injuries? | 289 | ||
| 5. Who is at a much higher risk for involvement of the frontal sinuses in craniofacial fractures: children or adults? | 289 | ||
| 6. What are the initial signs of frontal sinus fracture? | 289 | ||
| 7. What radiographic modality best detects and delineates the presence and extent of frontal sinus fractures? | 289 | ||
| 8. What are the anatomic boundaries of the frontal sinus? | 290 | ||
| 9. What are the foramina of Breschet? | 290 | ||
| 10. What complications are associated with frontal sinus fractures? What causes them? | 290 | ||
| 11. What is the function of the frontal sinuses? | 290 | ||
| 12. Are frontal sinus fractures a surgical emergency? | 290 | ||
| 13. How can frontal sinus fractures be classified? | 290 | ||
| Controversies | 292 | ||
| 14. What are the indications for surgery? | 292 | ||
| 15. What are the surgical approaches to exploration and repair of frontal sinus fractures? | 292 | ||
| 16. How does frontonasal duct injury impact the surgical treatment? | 292 | ||
| 17. What are the indications for cranialization? | 292 | ||
| Bibliography | 292 | ||
| Chapter 45: Fractures of the Nose | 293 | ||
| 1. The nose is composed of which five bones? | 293 | ||
| 2. What are the cartilaginous structures of the nose? | 293 | ||
| 3. Which structures contribute to the internal nasal valve? | 293 | ||
| 4. Numbness of the nasal tip after trauma results from injury to which nerve? | 293 | ||
| 5. Where do nasal bones most commonly fracture? | 294 | ||
| 6. What is the role of radiographs in the diagnosis and treatment of nasal fractures? | 294 | ||
| 7. What is the rhinion, and what is its role in nasal fractures? | 294 | ||
| 8. A patient with severe nasal trauma resulting in comminution of the entire bony skeleton underwent repair 4 days after injury. He now complains of epiphora. What has caused this? | 294 | ||
| 9. How is the medial interorbital distance affected by nasal fractures? | 294 | ||
| 10. Why is it critical to perform an intranasal examination for patients with nasal trauma? | 294 | ||
| 11. How are septal hematomas treated acutely? | 294 | ||
| 12. What is the incidence of septal fracture in simple nasal bone fractures? | 294 | ||
| 13. What is the management of nasal fractures? | 294 | ||
| 14. What is the treatment of severely comminuted nasal fractures? | 295 | ||
| 15. What is the ideal timing of closed reduction in adult and pediatric patients? | 295 | ||
| 16. What are the indications for septoplasty at the time of closed reduction? | 295 | ||
| 17. Can a septoplasty be performed in the pediatric patient as either early or late treatment of nasal septal fractures? | 295 | ||
| 18. What is the cause of the saddle nose deformity? | 295 | ||
| 19. What is the incidence of posttraumatic nasal deformity? | 295 | ||
| 20. What are late complications of nasal fractures? | 295 | ||
| 21. When is secondary treatment of nasal fractures indicated? | 296 | ||
| Bibliography | 296 | ||
| Chapter 46: Fractures of the Orbit | 297 | ||
| Anatomy | 297 | ||
| 1. The orbit is composed of how many bones? | 297 | ||
| 2. The orbital rims are composed of which bones? | 297 | ||
| 3. The orbital walls are composed of which bones? | 297 | ||
| 4. Which is the only bone that exists entirely within the orbital confines? | 297 | ||
| 5. What is the relationship between the anterior cranial fossa and the orbit? | 298 | ||
| 6. Which nerve traverses the floor of the orbit? | 298 | ||
| 7. The orbit is best described by which geometric shape? | 298 | ||
| 8. Through which bone do all neurovascular structures pass into the orbit? | 298 | ||
| 9. How deep is the orbit? | 298 | ||
| 10. Where is the optic foramen located? What about the optic canal? | 298 | ||
| 11. Where is the superior orbital fissure located? Which structures pass through it? | 298 | ||
| 12. Nothing passes through the inferior orbital fissure. True or false? | 298 | ||
| 13. What is Tenon’s capsule? | 298 | ||
| 14. What is the annulus of Zinn? | 298 | ||
| 15. What are the functions of the extraocular muscles? | 299 | ||
| 16. Why is the medial canthal tendon so important? | 299 | ||
| 17. Distinguish between intraconal and extraconal fat. Which is important for globe support? | 299 | ||
| Pathology | 299 | ||
| 18. What is the most common orbital fracture? | 299 | ||
| 19. What is the most common site of an isolated intraorbital fracture? | 299 | ||
| 20. What is a “blowout” fracture? What is the responsible mechanism? | 300 | ||
| 21. What is the difference between pure and impure blowout fractures? | 300 | ||
| 22. What key findings should be sought on physical examination in a patient with a suspected orbital fracture? | 300 | ||
| 23. What physical findings suggest an orbital fracture? | 300 | ||
| 24. Hypoesthesia or anesthesia in the distribution of which nerve is seen in 90% to 95% of orbital floor fractures? | 301 | ||
| 25. How can entrapment of orbital contents be diagnosed? | 301 | ||
| 26. What is a Marcus Gunn pupil? | 301 | ||
| 27. What is the superior orbital fissure syndrome? | 301 | ||
| 28. What is the orbital apex syndrome? | 301 | ||
| 29. What is the best radiographic study for diagnosis of an orbital fracture? | 301 | ||
| 30. What are the goals of surgical treatment of orbital fractures? | 301 | ||
| 31. What are the principles of orbital fracture management? | 301 | ||
| 32. What materials are used to reconstruct the orbital floor? | 302 | ||
| 33. What are the most frequent sequelae of inadequately treated fractures of the orbital floor? | 302 | ||
| 34. What is the principal mechanism responsible for posttraumatic enophthalmos? | 302 | ||
| 35. What is diplopia? Is it always an indication for surgery? | 302 | ||
| 36. What are the major surgical indications for orbital fracture repair? | 302 | ||
| 37. What complications are associated with fractures of the orbital roof? | 302 | ||
| 38. Which fracture may result in an antimongoloid slant of the palpebral fissure? Why? | 302 | ||
| 39. What incisions are used to approach the orbit? | 302 | ||
| 40. Which incision has the greatest propensity for complications such as scleral show or ectropion? | 303 | ||
| 41. Is the Caldwell-Luc approach to the orbital floor a wise one? | 304 | ||
| 42. What is an NOE fracture? | 304 | ||
| 43. What classic clinical findings are associated with an NOE fracture? | 304 | ||
| 44. How can the intercanthal distance be preserved after an NOE fracture? | 304 | ||
| 45. What is the surgical approach to treatment of an NOE fracture? | 304 | ||
| Bibliography | 305 | ||
| Chapter 47: Fractures of the Zygoma | 306 | ||
| 1. Describe the anatomy of the zygoma | 306 | ||
| 2. What different terms have been used to describe fractures of the zygoma? | 306 | ||
| 3. What is the pattern of the typical zygoma fracture? | 306 | ||
| 4. Why is the commonly used term tripod fracture a misnomer for zygomatic complex fractures? | 306 | ||
| 5. Which muscles attach to the zygoma? | 307 | ||
| 6. What are the signs and symptoms of zygomatic fractures? | 307 | ||
| 7. What is the mechanism of trismus caused by fracture of the zygoma? | 307 | ||
| 8. Which diagnostic images provide the most information in evaluating and formulating a treatment plan for zygomatic fractures? | 307 | ||
| 9. How many points must be evaluated by a surgeon when evaluating a fracture of the zygoma? | 308 | ||
| 10. What are the surgical principles for reconstruction of zygomatic fractures? | 308 | ||
| 11. When is the optimal time to operate on zygomatic fractures? | 309 | ||
| 12. Name the four points at which the zygoma can be fixated | 309 | ||
| 13. Which anatomic structure is most useful when assessing whether the zygomatic complex is appropriately reduced? | 309 | ||
| 14. How are isolated, displaced zygomatic arch fractures treated? | 310 | ||
| 15. Describe the temporal (Gillies) approach to the zygomatic arch | 310 | ||
| 16. Name the three standard approaches to the infraorbital rim and orbital floor | 310 | ||
| 17. What are the common approaches to the lateral orbital rim? | 310 | ||
| 18. How is access obtained for manipulation and reduction of the ZM buttress? | 310 | ||
| 19. What are the advantages of the coronal incision for reduction of zygomatic fractures? | 310 | ||
| 20. Describe the approach to the zygomatic arch from a coronal incision | 310 | ||
| 21. Summarize the commonly used incisions for surgical exposure | 312 | ||
| 22. A patient appears to have an increase in facial width after complex facial injuries requiring plating of the zygomatic arch. What went wrong? | 312 | ||
| 23. What is the dreaded OIF? | 312 | ||
| 24. What is the most feared complication after surgical treatment of the zygoma fractures? | 312 | ||
| 25. How is malunion of the zygoma treated? | 312 | ||
| 26. What are the common late sequelae of inadequate fracture reduction? | 312 | ||
| 27. A patient demonstrates facial asymmetry and an inferiorly displaced malar mound on the affected side despite anatomic reduction of a zygoma fracture. What was forgotten? | 312 | ||
| 28. During reconstruction of a comminuted ZMC fracture, three-point fixation was established and the soft tissues were resuspended. However, the patient continues to have facial asymmetry. What fracture could have been missed? | 312 | ||
| Bibliography | 313 | ||
| Chapter 48: Fractures of The Maxilla | 314 | ||
| 1. What are the buttresses of the maxilla? | 314 | ||
| 2. At what age does the maxillary sinus become mature? | 314 | ||
| 3. Who was Le Fort? What are Le Fort fractures? | 314 | ||
| 4. What is the difference between a Le Fort fracture and a Le Fort osteotomy? | 314 | ||
| 5. How do you clinically diagnose a midface fracture? | 315 | ||
| 6. What is the characteristic deformity associated with an untreated Le Fort I fracture? | 315 | ||
| 7. What if loose teeth are associated with a maxillary fracture? | 315 | ||
| 8. What should one do with a tooth that has been completely pulled out of its socket? | 315 | ||
| 9. What imaging test should be obtained in patients with a suspected maxillary fracture? | 315 | ||
| 10. What are the goals of panfacial fracture management? | 315 | ||
| 11. What incisions are necessary for adequate fracture exposure? | 315 | ||
| 12. What would you do if you were operating on a patient with a displaced, impacted Le Fort I fracture that could not be reduced? Why is it important to reduce it? | 316 | ||
| 13. What is the order of fixation of multiple fractures of the mandible, maxilla, and orbit? | 316 | ||
| 14. When should bone grafts be used in the treatment of maxillary fractures? | 316 | ||
| 15. What are the indications for exploration and repair of orbital floor fractures? | 316 | ||
| 16. What material should be used for reconstruction of internal defects in the orbital cavity, such as the medial orbital wall and orbital floor? | 316 | ||
| 17. What is the preferred donor site for bone grafts for the orbit and maxilla? | 316 | ||
| 18. When is intermaxillary fixation properly required after a maxillary fracture? | 316 | ||
| 19. When miniplates and screws are used to obtain rigid internal fixation for maxillary and orbital fractures, should they be removed later? | 316 | ||
| 20. What is the cause of permanent diplopia after orbitozygomatic fractures? | 317 | ||
| 21. What are the causes of late enophthalmos? | 317 | ||
| 22. What is the treatment of progressive loss of vision after blunt facial trauma? | 317 | ||
| 23. What are the contraindications to immediate treatment of panfacial fractures? | 317 | ||
| Bibliography | 317 | ||
| Chapter 49: Fractures of the Mandible | 318 | ||
| 1. What is the anatomy of the mandible? | 318 | ||
| 2. What are the five Ps of mandible fractures? | 318 | ||
| 3. List the clinical signs that may be associated with mandibular fractures | 318 | ||
| 4. Why does ecchymosis occur in the floor of the mouth in mandible fractures? | 319 | ||
| 5. What percentage of mandibular fractures are multiple? | 319 | ||
| 6. What percentage of patients with mandibular fractures present with concomitant cervical spine injuries? | 319 | ||
| 7. Describe the biomechanical response of the mandible to trauma | 319 | ||
| 8. What is the concept of favorable and unfavorable fractures? | 319 | ||
| 9. How is the interocclusal distance measured? | 320 | ||
| 10. Why is Angle classification of malocclusion so important? | 320 | ||
| 11. How is malocclusion classified? | 320 | ||
| 12. Does mixed dentition play a role in mandible fractures? | 320 | ||
| 13. How do pediatric mandibular fractures differ from adult mandibular fractures? | 320 | ||
| 14. What is intermaxillary fixation? | 320 | ||
| 15. What is the basic sequence of treatment in mandibular fractures? | 320 | ||
| 16. What is the spherical sliding principle in rigid osteosynthesis of mandible fractures? | 320 | ||
| 17. What are the concepts of “zone of compression” and “zone of tension” in the treatment of mandible fractures with internal fixation? | 320 | ||
| 18. What is the incidence of fractures in the different areas of the adult mandible? | 321 | ||
| 19. What complications are associated with repair of mandibular fractures? | 321 | ||
| 20. What risk factors increase the possibility of infection with mandibular fractures? | 321 | ||
| 21. What role does dentition play in mandibular fractures? | 321 | ||
| 22. What treatments are ideal for symphyseal and parasymphyseal fractures? | 321 | ||
| 23. What techniques are used for fractures of the condyles? | 321 | ||
| 24. What muscle is primarily responsible for condylar displacement in patients with a subcondylar fracture? | 321 | ||
| 25. What are the indications for open reduction internal fixation of condylar fractures? | 322 | ||
| 26. How do you repair edentulous mandible fractures? | 322 | ||
| 27. Before the application of MMF, how do you establish a patient’s pretraumatic occlusion? | 322 | ||
| 28. What are the indications for removal of teeth involved in fracture lines in the mandible? | 322 | ||
| Bibliography | 322 | ||
| Chapter 50: Management of Panfacial Fractures | 324 | ||
| 1. What is a panfacial fracture? | 324 | ||
| 2. Describe the mechanisms of injury necessary to produce panfacial fractures | 324 | ||
| 3. What are the main support structures in the facial skeleton, and how do they relate to panfacial fractures? | 324 | ||
| 4. Discuss the types of imaging studies available for the diagnosis and treatment of panfacial fractures | 324 | ||
| 5. What is the optimal timing for repair of panfacial fractures? | 325 | ||
| 6. Explain the preoperative planning necessary for successful treatment of panfacial fractures | 325 | ||
| 7. What soft tissue considerations are necessary in the management of panfacial fractures? | 325 | ||
| 8. What sequence is used in the surgical approach to panfacial fractures? | 325 | ||
| 9. List the types of incisions that provide access for rigid fixation in the craniofacial skeleton | 326 | ||
| 10. What types of fixation are available for treatment of maxillofacial fractures? | 326 | ||
| 11. Describe the types of splints that may be useful in the management of panfacial fractures | 326 | ||
| 12. What long-term deformities are potential undesirable outcomes of panfacial fractures? | 326 | ||
| 13. What functional problems may persist even after satisfactory treatment of panfacial fractures? | 326 | ||
| 14. Discuss the role of tracheotomy in the management of patients with panfacial fractures | 327 | ||
| Bibliography | 327 | ||
| Chapter 51: Secondary Management OfPosttraumatic Craniofacial Deformities | 328 | ||
| 1. What is enophthalmos? | 328 | ||
| 2. How does posttraumatic enophthalmos occur? | 328 | ||
| 3. What is the treatment of posttraumatic enophthalmos? | 328 | ||
| 4. Does correction of established enophthalmos improve diplopia? | 329 | ||
| 5. What is telecanthus? | 329 | ||
| 6. What are the features of the secondary deformity from an untreated NOE fracture? | 331 | ||
| 7. How do you treat the secondary deformities of a NOE fracture? | 331 | ||
| 8. Following treatment of a NOE or medial orbital fracture, what happens to the lacrimal drainage system? | 331 | ||
| 9. What is a growing skull fracture? | 331 | ||
| 10. Discuss the pathophysiology of the posttraumatic temporal contour deformity | 332 | ||
| 11. What are the possible long-term complications following a frontal sinus fracture? | 332 | ||
| 12. What is a frontal sinus mucocele? | 333 | ||
| 13. Classify posttraumatic cranial vault defects | 333 | ||
| 14. Describe the management of posttraumatic cranial vault defects | 333 | ||
| 15. What is the pathophysiology of cheek ptosis following open reduction internal fixation of orbital and midfacial fractures? | 333 | ||
| 16. What are the late features of an untreated healed OZC fracture? | 334 | ||
| 17. How do you treat a healed displaced OZC fracture? | 334 | ||
| 18. In an untreated Le Fort I midface fracture, what are the biomechanical forces on the maxilla, and what type of facial deformity may exist? | 334 | ||
| 19. What are the long-term risks of titanium fixation used in facial fracture management? | 334 | ||
| 20. What is a saddle nose deformity, and why is it called that? | 335 | ||
| 21. What is a posttraumatic carotid cavernous sinus fistula? | 335 | ||
| 22. What are the clinical findings of CCF? | 335 | ||
| 23. How common is mandibular nonunion? How is it categorized? | 336 | ||
| 24. What is the treatment of mandibular nonunion? | 336 | ||
| Bibliography | 337 | ||
| Chapter 52: Reconstruction of ComplexCraniofacial Defects | 338 | ||
| 1. What are the causes of complex craniofacial defects? | 338 | ||
| 2. What is the most debilitating aspect of posttraumatic deformity? | 338 | ||
| 3. How is diplopia evaluated? | 338 | ||
| 4. What is the best approach to the orbit in such a situation? | 338 | ||
| 5. What is the treatment of isolated orbital floor fracture with enophthalmos? | 338 | ||
| 6. What is the treatment of a displaced lateral wall fragment causing enophthalmos? | 338 | ||
| 7. What is the treatment of an acute, complex lateral inferior rim and floor fracture with severe displacement and significant comminuted bony injury? | 338 | ||
| 8. Discuss the management of an established posttraumatic deformity of the orbitozygomatic complex with enophthalmos | 338 | ||
| 9. What is the best method of performing a medial canthopexy? | 339 | ||
| 10. What are the causes of posttraumatic enophthalmos with and without vertical displacement of the globe? | 339 | ||
| 11. Discuss the treatment of posttraumatic frontal bone deformity without cerebrospinal fluid leak | 339 | ||
| 12. What is the best method for reconstruction of the flat nose of either congenital or posttraumatic origin? | 339 | ||
| 13. What foreign materials are useful in head and neck reconstruction and why? | 339 | ||
| 14. Discuss the types of cranial bone grafts available for skull defect reconstruction | 340 | ||
| 15. What are the most useful materials for skull reconstruction? | 340 | ||
| Cranial Bone | 340 | ||
| Foreign Materials | 340 | ||
| 16. What is the treatment of a fracture of the zygomatic arch? | 341 | ||
| 17. What is the treatment of an orbitozygomatic fracture? | 341 | ||
| 18. What is the treatment of an orbital floor blowout fracture when isolated? In conjunction with an orbitozygomatic fracture? | 341 | ||
| 19. Describe the treatment of a severely displaced maxillary fracture in conjunction with a nasoorbitoethmoidal fracture and a mandibular fracture | 341 | ||
| 20. What is the sequence of treating a displaced three-level (skull, maxilla, mandible) fracture with a cerebrospinal fluid leak? | 341 | ||
| 21. A patient presents with a full-thickness frontal bone defect following tumor resection. The skin cover is satisfactory. What is your next step in this patient’s reconstruction? | 341 | ||
| 22. A large full-thickness scalp defect results after tumor resection or trauma, with a skull defect that requires reconstruction. How can this best be managed? | 341 | ||
| 23. Discuss methods of filling small, medium, and large full-thickness bone defects | 342 | ||
| 24. How should a defect of the cribriform plate area after tumor excision with direct opening into the nasal cavity be reconstructed? | 342 | ||
| 25. What is the best reconstruction for an established posttraumatic flat nose? | 342 | ||
| Bibliography | 342 | ||
| Section V: Head and Neck Reconstruction | 343 | ||
| Chapter 53: Head and Neck Embryologyand Anatomy | 345 | ||
| 1. What is a branchial arch? | 345 | ||
| 2. Describe the derivatives of the branchial arches and pouches | 345 | ||
| 3. A 12-year-old boy has a draining sinus at the anterior upper one-third border of the sternocleidomastoid muscle. What is the likely source? | 345 | ||
| 4. How would you treat this patient? | 345 | ||
| 5. A 6-month-old infant has had a mass of the nasal root since birth. On physical examination, the mass measures 1.5 cm, it is firm, noncompressible... | 346 | ||
| 6. A young boy presents with a small mass in the midline of the neck below the hyoid bone. The mass has been present since birth. What is this finding consistent with? | 346 | ||
| 7. Are any preoperative tests important? | 346 | ||
| 8. From which embryologic structure does the external auditory meatus develop? | 346 | ||
| 9. Describe the function of the facial nerve | 347 | ||
| 10. Define the surface anatomy of the facial nerve | 347 | ||
| 11. A patient presents with a deep facial laceration in the emergency department. Clear fluid is draining from the wound. What structure was most likely damaged? | 347 | ||
| 12. How do you diagnose and treat this injury? | 348 | ||
| 13. You receive another consult from the emergency room. The patient has a superficial laceration to the neck but complains of numbness of the earlobe. What is the cause? | 348 | ||
| 14. A 50-year-old man has gustatory sweating and flushing of the right cheek after undergoing superficial parotidectomy for removal of a parotid tumor. What is the most likely cause of his current symptoms? | 348 | ||
| 15. A 45-year-old woman develops left shoulder pain and weakness after undergoing a left neck lymph node biopsy. What is her diagnosis? | 349 | ||
| 16. A 20-year-old man has suffered a full-thickness injury to the scalp and is bleeding profusely. What are the layers and blood supply of the scalp? | 349 | ||
| 17. Your patient has a neoplastic lesion of the posterior third of the tongue and is experiencing ear pain. Describe the phenomenon of referred pain | 349 | ||
| 18. List the layers of the eyelid | 349 | ||
| 19. Which palatal muscle acts to close off the nasopharynx from the oropharynx? | 350 | ||
| 20. Describe the nasolacrimal drainage system | 350 | ||
| 21. What other structures empty into the nasal cavity? | 350 | ||
| 22. After downfracture of the maxilla during a Le Fort I osteotomy, profuse bleeding is seen. What vessel is most likely responsible? | 350 | ||
| 23. You plan a radial forearm free flap to reconstruct a floor of mouth defect for squamous cell carcinoma (SCCA). During dissection of the external carotid artery you... | 350 | ||
| 24. What major congenital syndromes are associated with first and second branchial arch abnormalities? | 350 | ||
| 25. Developmental embryologic clefts result as a failure of fusion between adjacent structures. Describe the processes responsible for the major facial clefts | 351 | ||
| 26. What are the foramina of the 12 cranial nerves? | 351 | ||
| 27. What is the motor function of the trigeminal nerve? | 351 | ||
| 28. Describe the action of the muscles of mastication on the mandible. | 351 | ||
| Bibliography | 352 | ||
| Chapter 54: Head and Neck Cancer | 353 | ||
| 1. A patient returns 6 years after having a resection of a T1 squamous cell carcinoma of the floor of mouth with a biopsy-proven cancer in close proximity to the lesion... | 353 | ||
| 2. What is field cancerization? | 353 | ||
| 3. What are the relative contraindications to resecting a head and neck cancer? | 353 | ||
| 4. What is the appropriate evaluation of a lateral neck mass present in an adult for at least 3 weeks? | 353 | ||
| 5. What is the classification of lymph node regions in the neck? | 353 | ||
| 6. What are the differences among radical, modified radical, and selective neck dissections? | 354 | ||
| 7. What are the principal indications for adjuvant postoperative external beam radiation therapy for patients with squamous cell carcinoma of the head and neck? | 354 | ||
| 8. What are the most common benign and malignant tumors of the nose and paranasal sinuses? | 354 | ||
| 9. Where do nasal and sinus tumors originate? | 356 | ||
| 10. Describe the lymphatic drainage of the oral tongue | 356 | ||
| 11. What is the role of elective neck dissection in the management of patients with early (stages I and II) squamous cell carcinoma of the oral tongue? | 356 | ||
| 12. What is the role of elective radiation therapy in oral tongue cancer? | 356 | ||
| 13. What methods are available for assessing mandibular bony invasion with carcinomas of the oral cavity? | 357 | ||
| 14. What surgical techniques are appropriate for management of oral cavity cancers that are adjacent to or invade the mandible? | 357 | ||
| 15. What are the subsites of the oropharynx? | 357 | ||
| 16. What is the role of surgery versus radiation in the treatment of early (T1 and T2) squamous cell carcinomas of the oropharynx? | 357 | ||
| 17. How is the oropharynx accessed surgically? | 357 | ||
| 18. What are the major differences in clinical behavior between cancers of the glottic and supraglottic larynx? | 357 | ||
| 19. What is the role of a larynx preservation strategy using radiotherapy with or without chemotherapy in advanced laryngeal cancers? | 357 | ||
| 20. What methods are currently available for speech rehabilitation in patients who undergo total laryngectomy? | 358 | ||
| 21. What is the role of laser surgery in the treatment of early laryngeal cancer? | 358 | ||
| 22. Name the most common benign and malignant tumors of the parotid gland. | 358 | ||
| 23. What is the biopsy technique for a lesion of the parotid gland? | 358 | ||
| 24. What are the major indications for facial nerve sacrifice during surgery for parotid gland neoplasms? | 358 | ||
| 25. What is the appropriate initial management of patients with a thyroid nodule? | 359 | ||
| 26. What are the major prognostic factors that predict clinical outcomes for patients with differentiated thyroid (papillary and follicular) cancers? | 359 | ||
| 27. What is the appropriate surgical margin for resection of cutaneous melanomas in the head and neck region? | 359 | ||
| 28. What is the role of elective neck dissection in the management of melanomas of the head and neck? | 359 | ||
| 29. What are the indications for a selective neck dissection versus modified radical neck dissection in patients with squamous cell carcinoma? What if the tumor is papillary thyroid cancer or melanoma? | 359 | ||
| Bibliography | 360 | ||
| Chapter 55: Local Flaps of the Head and Neck | 361 | ||
| General Principles | 361 | ||
| 1. What are the advantages of using local flaps in the head and neck? | 361 | ||
| 2. Full-thickness defects up to what width can be repaired with composite grafts? | 361 | ||
| 3. What are the major problems with the use of local flaps? | 361 | ||
| 4. In the planning of local flaps, what are the two main vasoelastic biomechanicalproperties of the skin of which the surgeon must be aware? | 361 | ||
| 5. Where should incision lines for local flaps and donor areas be placed? | 361 | ||
| 6. In the design of a rotational flap the defect should be excised in what shape? | 361 | ||
| 7. In a rotation flap, where is the line of greatest tension? | 361 | ||
| 8. In an advancement flap, what is excessive skin at the base called? | 362 | ||
| 9. How many potential flaps can be designed from each rhomboid defect? | 362 | ||
| 10. What are the common angels of the rhomboid defect created for flap closure? | 362 | ||
| 11. Large circular defects can be converted into a hexagon to facilitate closure. Howmany rhomboid flaps are available for closure of this defect? | 362 | ||
| 12. How many rhomboid flaps are most commonly used for closure of a hexagonaldefect? | 362 | ||
| 13. What are the angles used for a Dufourmental flap? | 363 | ||
| 14. What are the major indications for performing a Z-plasty? | 363 | ||
| 15. In the design of a Z-plasty, what angles yield what percent gain in length? | 363 | ||
| 16. What is the major indication for a W-plasty? | 363 | ||
| 17. What are the causes for local flap failure in the head and neck include? | 363 | ||
| 18. Describe the fallacy of the length-to-width ratio in designing skin flaps in the headand neck. | 363 | ||
| Forehead | 364 | ||
| 19. Much of the forehead can be anesthetized by infiltration of local agents aroundwhich nerves? | 364 | ||
| 20. The key concept in forehead reconstruction is a firm knowledge of which structures? | 364 | ||
| 21. Which area of the forehead has thinner and more pliable skin? | 364 | ||
| 22. What is the motor supply to the forehead musculature? | 364 | ||
| 23. Where are the lines of minimal tension in the forehead? | 364 | ||
| 24. To avoid pin cushioning, how should incisions be placed? | 364 | ||
| 25. What are the four aesthetic units of the forehead? | 364 | ||
| 26. Which technique allows additional rotational length for flaps on the forehead and scalp? | 364 | ||
| 27. When scalp mobility and galeal scoring are not sufficient, which technique allows forclosure of difficult defects? | 364 | ||
| 28. How is supra eyebrow reconstruction best achieved? | 364 | ||
| 29. How is the eyebrow best reconstructed? | 364 | ||
| 30. Because of the limited amount of forehead skin, epidermolysis can occur. Howshould it be treated? | 364 | ||
| Lips | 364 | ||
| 31. What are the major functional muscles of the lips and cheeks? | 364 | ||
| 32. What are the reconstructive goals of the lip? | 365 | ||
| 33. Anesthetic blockade of the lower lip can be accomplished by infiltration of anesthesiaat the mental nerve foramen located beneath the apex of which mandibular tooth? | 365 | ||
| 34. During surgical resection and reconstruction, the vermilion–skin junction should becrossed at what angle? | 365 | ||
| 35. In the staircase or stepladder technique for lip reconstruction, what is the measureof the horizontal component of the step excisions? | 365 | ||
| 36. What are the indications for an Abbe flap? | 365 | ||
| 37. How are defects of the commissure addressed? | 366 | ||
| 38. Which flap restores lip continuity with preservation of the motor and sensoryfunction? | 366 | ||
| 39. The Bernard operation advances full-thickness local flaps with concomitanttriangular excisions to allow proper mobilization. What does the Webstermodification of the Bernard-Burow cheiloplasty include? | 366 | ||
| 40. What are the options for restoration of the hair-bearing skin for lip reconstruction? | 366 | ||
| 41. In commissure reconstruction, restoration of what structure is critical? | 367 | ||
| Cheek | 367 | ||
| 42. What are the aesthetic units of the cheek? | 367 | ||
| 43. The cheek can be anesthetized by infiltration of local agents around what nerves? | 367 | ||
| 44. What is the motor nerve supply to the muscles of the cheek? | 367 | ||
| 45. Reconstruction over the malar eminence may impinge upon what importantstructures? | 368 | ||
| 46. Small defects of the cheek area are best reconstructed with what type of flaps? | 368 | ||
| 47. Defects approaching 4 ¥ 6 cm are best reconstructed with what type of flap? | 368 | ||
| 48. Describe the submental mycocutaneous flap and blood supply. What regions of theface/neck can be reconstructed with this flap? | 368 | ||
| 49. What are the advantages of a cervicopectoral flap? | 368 | ||
| Head And Neck | 368 | ||
| 50. What are the optimal characteristics of a technique required for head and neckreconstruction? | 368 | ||
| 51. How are defects of the head and neck classified? | 368 | ||
| 52. Which flap, based on the superficial temporal vessels, can cover large external orintraoral defects? | 369 | ||
| 53. The blood supply of the sternocleidomastoid myocutaneous flap is derived from whatthree sources? | 369 | ||
| 54. Based on the transverse cervical artery, which flap can be elevated in a lateral ordescending direction? | 369 | ||
| 55. Which versatile flap is based on the pectoral branch of the thoracoacromial artery? | 369 | ||
| 56. What is the dominant blood supply of the latissimus dorsi muscle? | 369 | ||
| Bibliography | 369 | ||
| Chapter 56: Forehead Reconstruction | 371 | ||
| 1. How is the forehead histologically similar to, and different from, the scalp? | 371 | ||
| 2. What is the vascular supply of the scalp? | 371 | ||
| 3. What is the innervation of the scalp? | 371 | ||
| 4. What are the risks of closing forehead defects via direct approximation of the wound margins? | 372 | ||
| 5. Describe the principles inherent to closing large forehead defects | 372 | ||
| 6. What reconstructive options are available in the forehead? What are their relative advantages and their limitations? | 372 | ||
| 7. What types of forehead wounds are optimal for direct closure? | 372 | ||
| 8. What are the advantages and disadvantages of direct closure? | 374 | ||
| 9. What are the advantages and disadvantages of closure by secondary intention? | 374 | ||
| 10. What is the “Crane principle”? | 374 | ||
| 11. What are the advantages and disadvantages of using local flaps in the forehead? | 374 | ||
| 12. Which local flaps are appropriate for the forehead? | 375 | ||
| 13. How are shutter flaps used in the forehead? | 375 | ||
| 14. What are the advantages of skin expansion during forehead reconstruction? | 375 | ||
| 15. What are the optimum locations for skin expander placement for forehead reconstruction? | 376 | ||
| 16. Describe a distant flap that can be used to reconstruct the forehead | 376 | ||
| 17. What are the advantages and disadvantages of reconstruction using microvascular composite tissue transplants? | 376 | ||
| 18. What flaps serve as appropriate sources for microvascular composite tissue transplants to the forehead? | 376 | ||
| 19. Describe a flap that can confer function to the forehead | 377 | ||
| 20. What characteristics are unique to eyebrows among hair-bearing areas? | 377 | ||
| 21. Describe the orientation of hair within the eyebrows | 377 | ||
| 22. What are the options for total eyebrow reconstruction? | 377 | ||
| 23. What are the advantages and disadvantages of hair plug transplants? | 377 | ||
| 24. When are hair strip grafts useful for eyebrow reconstruction? | 377 | ||
| 25. What technique should be used to reconstruct the complete eyebrow when the recipient bed is inhospitable to a graft? | 378 | ||
| Bibliography | 378 | ||
| Chapter 57: Nasal Reconstruction | 379 | ||
| 1. What are the nasal subunits? Are they important in reconstruction? | 379 | ||
| 2. What are the principles of subunit reconstruction? How are they applied? | 379 | ||
| 3. Is the quality of nasal skin uniform over its surface? | 379 | ||
| 4. How should a nasal defect be analyzed? What are the reconstructive implications? | 380 | ||
| 5. What are the advantages and disadvantages of potential donor sites for skin grafting in nasal reconstruction? | 380 | ||
| 6. What is the role of composite grafts? | 380 | ||
| 7. How are local flaps used in nasal reconstruction? | 380 | ||
| 8. What are the advantages of a bilobed flap? Where is it most useful? | 381 | ||
| 9. How is the nasolabial flap used in nasal reconstruction? What is its blood supply? | 381 | ||
| 10. What do you know about the history of nasal reconstruction? | 381 | ||
| 11. How can forehead tissue be transferred? | 381 | ||
| 12. Describe the blood supply to the paramedian forehead flap | 382 | ||
| 13. Is there enough skin to make a nose from the midline forehead? Is the reach too short? How wide should the pedicle be? Should I delay the procedure for safety? | 382 | ||
| 14. How and why are primary bone and cartilage grafts used in nasal reconstruction? | 382 | ||
| 15. When and how should bone or cartilage grafts be used? | 383 | ||
| 16. What donor tissues are available for nasal support? What are the advantages and disadvantages of each? | 383 | ||
| 17. Is tissue expansion helpful? | 383 | ||
| 18. Practically speaking, what is the most important anatomic layer in nasal reconstruction? | 384 | ||
| 19. What are the options for nasal lining? | 384 | ||
| 20. Is there a role for microsurgery in nasal lining reconstruction? | 384 | ||
| 21. What are the most frequent mistakes in nasal reconstruction? | 385 | ||
| Bibliography | 385 | ||
| Chapter 58: Eyelid Reconstruction | 386 | ||
| 1. What are the components of the posterior lamella of the upper lid? | 386 | ||
| 2. Describe the anatomy, innervation, and function of the orbicularis oculi muscle | 386 | ||
| 3. What is the vertical dimension of the upper and lower tarsus? | 386 | ||
| 4. How is levator palpebrae superioris function measured? | 386 | ||
| 5. What pathologic condition is caused by paralysis or laceration of Müller’s muscle? | 387 | ||
| 6. What structures must be transected to explore the orbital floor through a transconjunctival approach? | 387 | ||
| 7. What structures contribute to the lateral retinaculum? | 387 | ||
| 8. Where does the medial canthus insert? | 387 | ||
| 9. Which extraocular muscle originates from the anterior orbit? | 387 | ||
| 10. What defines the supratarsal fold? | 387 | ||
| 11. The fascial framework of the orbit is composed of what structures? | 387 | ||
| 12. What are the most common malignant tumors of the eyelids? What is the most common location for a malignant tumor of the eyelids? | 387 | ||
| 13. Which region of the eyelid is most likely to have a recurrent or an advanced tumor? | 388 | ||
| 14. What factors predict postoperative dry eye syndrome? | 388 | ||
| 15. What are the basic principles of eyelid reconstruction? | 388 | ||
| 16. A 38-year-old woman with a malignant tumor fixed to the upper tarsus undergoes a full-thickness resection. The resultant defect measures 30% of the horizontal... | 388 | ||
| 17. How much vertical height of upper tarsus is used in the design of a tarsoconjunctival flap for lower lid reconstruction? | 388 | ||
| 18. Is lower lid ectropion a common complication after a Cutler-Beard flap reconstruction? | 389 | ||
| 19. Is the contralateral eyelid a preferred site for skin graft harvest? | 389 | ||
| 20. Describe the evaluation of lid ptosis | 390 | ||
| 21. For most patients with lid ptosis, what is the most important factor in determining which operation to perform? | 390 | ||
| 22. What is the underlying cause of congenital ptosis? | 390 | ||
| 23. A patient who has lid ptosis secondary to an attenuated levator aponeurosis, 4 mm of ptosis, and a levator function of 8 mm is best treated by which ptosis procedure? | 390 | ||
| 24. Match the following | 390 | ||
| 25. What factors contribute to entropion? | 390 | ||
| 26. What factors contribute to ectropion? | 391 | ||
| 27. How does the Asian eyelid differ from the Occidental eyelid? | 391 | ||
| 28. Describe tear secretion and the composition of tear film | 391 | ||
| 29. What are the indications for performing dacryocystorhinostomy? | 391 | ||
| 30. During the reduction of an avulsed medial canthal tendon, injury to the nasolacrimal duct is suspected. What is the appropriate course of action? | 391 | ||
| 31. After selective cantholysis and medial transposition of the lid for reconstruction of a moderate upper lid defect, a patient complains of severe pain, photophobia, blurred... | 391 | ||
| Bibliography | 391 | ||
| Chapter 59: Ear Reconstruction | 393 | ||
| 1.What are the normal size, position, protrusion, and axis of the ear? | 393 | ||
| 2. Using Figure 59-1, name the landmarks of the external ear | 393 | ||
| 3.What is the vascular supply of the ear? | 393 | ||
| 4.Can an amputated ear be replanted? | 393 | ||
| 5.Describe the nerve supply of the auricle. Why can a patient with an oropharyngeal carcinoma present with ear pain? | 394 | ||
| 6.What is the embryologic origin of the external ear? Why is this knowledge significant in treating malignant tumors of the external ear? | 394 | ||
| 7.What is the incidence and etiology of microtia? | 394 | ||
| 8.What factors enter into the timing of microtia reconstruction? | 394 | ||
| 9.In what cases and at what time is middle ear surgery indicated? | 394 | ||
| 10.What are the basic steps in microtia reconstruction? | 394 | ||
| 11.Which costal cartilages are harvested for construction of the framework in microtia reconstruction? | 395 | ||
| 12.What options are available if the skin envelope is insufficient? | 395 | ||
| 13 Discuss some of the complications of ear reconstruction. How would you remedy them? | 395 | ||
| 14.Faced with a patient with a traumatic avulsion of the ear, you are unable to identify any uninjured vessel to perform an anastomosis. What should be done with the avulsed part? | 397 | ||
| 15.What principles of treatment are observed for a burned ear? How are segmental defects reconstructed? | 397 | ||
| 16.What are the three most common cancers of the auricle? | 397 | ||
| 17.List the main causes of auricular chondritis. What is usually the causative organism in infectious cases? | 397 | ||
| 18.What is the typical clinical presentation of post piercing suppurative chondritis of the auricle? How is it treated acutely? | 397 | ||
| 19.Describe the appearance of a mature post chondritis deformity. What are the considerations in timing of reconstruction? | 397 | ||
| 20.How should the reconstruction of a post chondritis auricular deformity be performed? | 398 | ||
| Controversy | 398 | ||
| Bibliography | 398 | ||
| Chapter 60: Lip Reconstruction | 399 | ||
| 1.What are the key anatomic features of the lip? | 399 | ||
| 2.What is the significance of the vermilion border? | 399 | ||
| 3.What is Cupid’s bow? | 399 | ||
| 4.What is the primary function of the lips? | 399 | ||
| 5.What are the muscles of the upper and lower lips? | 400 | ||
| 6.What is the motor and sensory innervation of the upper and lower lips? | 400 | ||
| 7.Discuss the vascular anatomy of the lips | 400 | ||
| 8.Are the inferior labial arteries always bilateral and constant? | 400 | ||
| 9.Discuss the lymphatic drainage of the lips | 400 | ||
| 10.How is an infraorbital nerve block performed? | 400 | ||
| 11.How is a mental nerve block performed? | 400 | ||
| 12.Is the mental nerve block sufficient for anesthesia of the chin? | 400 | ||
| 13.Can the lip be locally infiltrated with an anesthetic agent? | 400 | ||
| 14.What are the principles of lip reconstruction? | 400 | ||
| 15.How should lesions near the vermilion border be managed? | 400 | ||
| 16.Should sutures be placed directly on the mucocutaneous junction to align the vermilion border? | 400 | ||
| 17.How much tissue loss still permits a satisfactory primary closure of the lips? | 401 | ||
| 18.How should full-thickness lip lacerations be repaired, and what suture material can be used? | 401 | ||
| 19.What is the distribution of lip cancers of the oral region? | 401 | ||
| 20.Why is the lower lip a more common site for tumors than the upper lip? | 401 | ||
| 21.What is the most common cancer of the lip? | 401 | ||
| 22.Which benign lesion closely resembles SCC? How is it distinguished? | 401 | ||
| 23.What is the biology of SCC? | 401 | ||
| 24.What are the key considerations in lip reconstruction? | 401 | ||
| 25.What is an important and common complication of lip reconstruction? | 401 | ||
| 26.Why is the lower lip a more suitable donor for reconstruction than is the upper lip? | 401 | ||
| 27.Do V wedge resections provide adequate margins for SCCs of the lower lip? | 401 | ||
| 28.What options are available for repair of localized mucosal and vermilion defects? | 401 | ||
| 29.What is a lip shave operation, and how do you reconstruct the resultant defect? | 402 | ||
| 30.How do you reconstruct the oral commissure? | 402 | ||
| 31.Describe the flaps commonly used for lip reconstruction | 405 | ||
| Bibliography | 406 | ||
| Chapter 61:Reconstruction of the Oral Cavity | 407 | ||
| 1.What are the borders and contents of the oral cavity? | 407 | ||
| 2.What are the borders and contents of the floor of the mouth? | 407 | ||
| 3.Which risk factors are associated with oral cancer? | 408 | ||
| 4.What are the benign and premalignant lesions of the oral cavity? | 408 | ||
| 5.What is the distribution of oral cavity cancers by location and histologic types? | 409 | ||
| 6.How can you predict the outcome and formulate a treatment of intraoral carcinoma? | 409 | ||
| 7.What are the objectives of oropharyngeal reconstruction? | 409 | ||
| 8.Squamous cell carcinoma of the tongue is most frequently located at the base. True or false? | 409 | ||
| 9.A tumor located in the floor of the mouth will preferentially metastasize to which lymph nodes? | 409 | ||
| 10.Describe the goals and methods for reconstruction of tongue defects. | 409 | ||
| 11.How are palatal defects reconstructed? | 409 | ||
| 12.What is the reconstructive strategy for floor of mouth defects? | 410 | ||
| 13.Buccal mucosa defects should not be left to heal by secondary intention. True or false? | 410 | ||
| 14.Periosteum is always a physiologic barrier for bone involvement in alveolar ridge malignancies. True or false? | 410 | ||
| 15.List the reconstructive options for oral malignancies. | 410 | ||
| 16.Are free tissue transfers always the preferred reconstructive method? | 410 | ||
| 17.What are the reconstructive options for a composite defect that includes a missing bony segment? | 410 | ||
| 18.What are the advantages and disadvantages of free flap applications in oral reconstruction? | 411 | ||
| 19.Which arteries and veins in the head and neck region are preferred as recipient vessels for microvascular anastomoses? | 411 | ||
| 20.Describe the elevation of the platysma flap and outline the indications for intraoral reconstruction. | 411 | ||
| 21.What are the limitations of the temporalis muscle and fascia flaps for oral reconstruction? | 411 | ||
| 22.Can the posterior auricular flap be used for tongue reconstruction? | 411 | ||
| 23.Explain the extension arc of nasolabial musculocutaneous flaps. | 411 | ||
| 24.Classify the lingual flaps. | 411 | ||
| 25.What is the role of palatal flaps in oral reconstruction? | 412 | ||
| 26.What are the drawbacks of the forehead flap? | 412 | ||
| 27.When should the latissimus dorsi muscle and musculocutaneous flaps be used? | 412 | ||
| 28.What are the limitations of the pectoralis major muscle and musculocutaneous flaps? | 412 | ||
| 29.Can the sternocleidomastoid musculocutaneous flap be raised over an inferior pedicle? | 412 | ||
| 30. Describe the variants of the trapezius muscle and musculocutaneous flaps for intraoral reconstruction | 412 | ||
| 31.What is the first-line choice in free flap reconstruction for tongue and FOM defects? | 412 | ||
| 32.What are the advantages of the radial forearm flap for intraoral reconstruction? | 412 | ||
| 33.What are the advantages and disadvantages of the jejunum free flap for intraoral reconstruction? | 412 | ||
| 34.Describe the vascular anatomy and harvest of the jejunum flap | 413 | ||
| 35.Evaluate the lateral arm flap for tongue reconstruction | 413 | ||
| 36.What is the role of the laser in oral cavity cancer? | 413 | ||
| Bibliography | 413 | ||
| Chapter 62:Mandible Reconstruction | 414 | ||
| 1.Who was Andy Gump? | 414 | ||
| 2.Describe the functional deficits associated with the Andy Gump deformity | 414 | ||
| 3.What functional deficits are associated with lateral mandibulectomy? | 414 | ||
| 4.What are the main goals and considerations in mandibular reconstruction? | 414 | ||
| 5.What are the advantages of immediate mandibular reconstruction? | 414 | ||
| 6.How do you manage a patient with a shotgun wound to the face? | 414 | ||
| 7.What are conventional techniques for mandibular reconstruction? | 414 | ||
| 8.What are the indications for a no-bone reconstruction? | 415 | ||
| 9.What is the role of nonvascularized bone grafts? | 415 | ||
| 10.What are the advantages of reconstruction plates, with or without soft tissue reconstruction? | 415 | ||
| 11.What are the disadvantages of reconstruction plates, with or without soft tissue reconstruction? | 415 | ||
| 12.What are the advantages of the radial forearm osteocutaneous flap? | 415 | ||
| 13.What are the disadvantages of the radial forearm osteocutaneous flap? | 415 | ||
| 14.What are the major reasons for donor radius fracture? | 415 | ||
| 15.How can donor radius fracture be prevented? | 415 | ||
| 16.What are the advantages of the iliac crest osteocutaneous flap? | 416 | ||
| 17.What are the disadvantages of the iliac crest osteocutaneous flap? | 416 | ||
| 18.What are the advantages of the scapular osteocutaneous flap? | 416 | ||
| 19.What are the disadvantages of the scapular osteocutaneous flap? | 416 | ||
| 20.What are the advantages of the fibular osteocutaneous flap? | 416 | ||
| 21.What are the disadvantages of the fibular osteocutaneous flap? | 416 | ||
| 22.Compare the common vascularized composite tissue transfers and donor sites for oromandibular reconstruction. | 416 | ||
| 23.Provide algorithms for microvascular mandibular reconstruction | 416 | ||
| 24.Is there a role for sequential free flaps? | 416 | ||
| 2.What is the role of dental rehabilitation by osseointegration? | 416 | ||
| 26.What are important considerations in reconstruction (or construction) of the pediatric mandible? | 418 | ||
| 27.Name three primary indications for mandibular reconstruction in the child | 418 | ||
| Bibliography | 418 | ||
| Chapter 63:Scalp Reconstruction | 420 | ||
| 1.What are the common causes of scalp defects? | 420 | ||
| 2.What are the five anatomic layers of the scalp? | 420 | ||
| 3.What is the arterial supply of the scalp? | 420 | ||
| 4.What is the sensory nerve supply of the scalp? | 420 | ||
| 5.How many fascial layers can be found in the temporoparietal region of the scalp? Describe the relationship of the frontal branch of the facial nerve to these fascial layers. | 420 | ||
| 6.Describe the course of the deep temporal fascia. | 420 | ||
| 7.What factors affect the selection of a scalp reconstruction method? | 421 | ||
| 8.What are the principles of the management of acute scalp wounds? | 421 | ||
| 9.What are Hatchet, Worthen, and Orticochea flaps? | 421 | ||
| 10.Describe the anatomy and uses of the temporalis myofascial flap | 422 | ||
| 11.What is aplasia cutis congenita? | 422 | ||
| 12.What are the indications and advantages of using a skin graft for coverage of scalp wounds? | 422 | ||
| 13.Can a skin graft be used to cover decorticated outer table skull? | 422 | ||
| 14.How do you manage scalp wounds after radiation therapy or tumor resection? | 422 | ||
| 15.Do periosteal flaps have any role in scalp reconstruction? | 422 | ||
| 16.What is the major indication for use of regional or distant flaps for scalp reconstruction? | 422 | ||
| 17.What are the indications for the use of free flaps for scalp reconstruction? | 422 | ||
| 18.What are the advantages of free flaps? | 422 | ||
| 19.What are the most commonly used free flaps for scalp reconstruction? | 422 | ||
| 20.What makes a radial forearm flap an ideal free flap for the scalp? | 423 | ||
| 21.What are the disadvantages of free flaps for scalp reconstruction? | 423 | ||
| 22.What are the available options for reconstruction of scalp bony defects? | 423 | ||
| 23.What is the role of tissue expansion in scalp reconstruction? | 423 | ||
| 24.What is the major drawback of tissue expanders? | 423 | ||
| 25.What is the main concern in the use of scalp tissue expansion in children? | 423 | ||
| 26.What are the potential complications of scalp tissue expansion? | 423 | ||
| 27.What are the advantages of an expanded free scalp flap? | 423 | ||
| 28.What is the role of scalp replantation? | 423 | ||
| 29.Is there a role for biomaterials in scalp reconstruction? | 423 | ||
| Bibliography | 423 | ||
| Chapter 64:Surgical Anatomy of the Facial Nerve | 425 | ||
| 1.From which foramen does the main trunk of the facial nerve exit the skull, and what type of fibers does it contain? | 425 | ||
| 2.How do you locate the main trunk of the facial nerve during a parotidectomy? | 425 | ||
| 3.“Great nerves travel together.” How does this apply to the relationship of the facial nerve to other cranial nerves? | 425 | ||
| 4.Does the facial nerve innervate the posterior or the anterior belly of the digastric muscle? | 425 | ||
| 5.What muscle does the facial nerve innervate in the middle ear, and what does it do? | 425 | ||
| 6.Which brachial cleft arch does the facial nerve arise from? Which brachial cleft arch does the trigeminal nerve arise from? | 425 | ||
| 7.What are the major branches of the facial nerve before and after it enters the parotid? | 425 | ||
| 8.What is the relationship of the facial nerve to the superficial musculoaponeurotic system? | 425 | ||
| 9.What is Bell’s palsy? | 426 | ||
| 1.Do the facial muscles of expression receive their innervation along their superficial or deep surface? | 426 | ||
| 11.What is the course of the frontal branch of the facial nerve? | 426 | ||
| 12.What is the relationship of the frontal branch of the facial nerve to the SMAS and temporoparietal fascia? | 426 | ||
| 13.What are the “facial danger zones”? | 427 | ||
| 14.What is the incidence of facial nerve injury during a standard rhytidectomy? Which nerve is damaged most often? What are the chances for recovery? | 428 | ||
| Controversy | 428 | ||
| Bibliography | 428 | ||
| Chapter 65:Reanimation of the Paralyzed Face | 429 | ||
| 1.Describe the embryogenesis of the facial nerve. | 429 | ||
| 2.What is the primary function of the facial nerve? | 429 | ||
| 3.Where is the motor nucleus of the facial nerve located? | 429 | ||
| 4.Which side of the brain controls voluntary facial expression? | 429 | ||
| 5.How does an upper motor neuron lesion present? | 429 | ||
| 6.What is the neural pathway of spontaneous facial expressions? | 429 | ||
| 7.What is “synkinesis,” and what causes these abnormal movements? | 430 | ||
| 8.How does an intratemporal lesion of the facial nerve differ in presentation from an extratemporal lesion? | 430 | ||
| 9.How can you differentiate an intratemporal from an extratemporal lesion of the facial nerve? | 430 | ||
| 10.When obtaining the history from a patient with facial paralysis, what are the key questions you should ask? | 430 | ||
| 11.What should you look for on physical examination? | 430 | ||
| 12.What other documentation is necessary in the office setting? | 430 | ||
| 13.How long after injury to the facial nerve can some function be restored with microsurgery? | 430 | ||
| 14.Once the diagnosis is made, how do you establish a strategy of reconstruction? | 431 | ||
| 15.Which branch of the facial nerve is most commonly injured during a routine facelift? | 431 | ||
| 16.What preoperative tests are mandatory in facial paralysis work? Why? | 431 | ||
| 17.What are the advantages and disadvantages of ipsilateral nerve grafting? | 431 | ||
| 18.What is CFNG? | 431 | ||
| 19.What are the advantages and disadvantages of CFNG? | 431 | ||
| 20.In the CFNG procedure, how do you determine when the regenerating facial nerve motor fibers have crossed the face? | 432 | ||
| 21.Describe the postoperative management after a completed CFNG procedure | 432 | ||
| 22.When are crossover procedures considered? Why? | 432 | ||
| 23.What is the “babysitter” principle? | 432 | ||
| 24.What are the indications for free muscle transfer in facial paralysis? | 432 | ||
| 25.What criteria determine the choice of foreign donor muscles? | 433 | ||
| 26.What are the advantages and disadvantages of the gracilis free muscle transfer (Fig. 65-3)? | 433 | ||
| 27.What are the advantages and disadvantages of the pectoralis minor muscle transfer? | 434 | ||
| 28.What are the advantages and disadvantages of local muscle transfers? | 434 | ||
| 29.What are the prerequisite criteria for the diagnosis of Möbius syndrome? | 434 | ||
| 30.What are the reconstructive goals in a child with Möbius syndrome? | 434 | ||
| 31.Discuss current microsurgical approaches for the paralyzed eye sphincter. | 435 | ||
| 32.What are the surgical options for correction of unilateral lower lip palsy? | 435 | ||
| 33.What are the indications for use of digastric versus platysma muscle in lower lip reanimation? | 435 | ||
| 34.What outcomes can be obtained with free muscle transfer for long-lasting facial paralysis? | 435 | ||
| Bibliography | 435 | ||
| Section VI: Breast Surgery | 437 | ||
| Chapter 66:Augmentation Mammaplasty | 439 | ||
| 1.What is augmentation mammaplasty? | 439 | ||
| 2.Who was the first to perform this procedure? | 439 | ||
| 3.What are the indications for breast augmentation? | 439 | ||
| 4.Does the preoperative shape of the breast affect the results obtained by augmentation mammaplasty? | 439 | ||
| 5.Is there an age limit to breast augmentation? | 439 | ||
| 6.Who performs breast augmentation procedures? | 439 | ||
| 7.What type of anesthesia is required? | 439 | ||
| 8.Should prophylactic antibiotics be used? | 440 | ||
| 9.How do you choose the size of the breast implant? | 440 | ||
| 10.What incisions are used for augmentation mammaplasty? | 440 | ||
| 11.Where is the implant placed in augmentation mammaplasty? | 440 | ||
| 12.What is the “dual-plane” technique? | 440 | ||
| 13.What types of breast implants are available? | 440 | ||
| 14.What are the advantages of anatomic implants? | 441 | ||
| 15.Are silicone gel-filled implants currently available for augmentation mammaplasty? | 441 | ||
| 16.What postoperative care is required after augmentation mammaplasty? | 441 | ||
| 17.What are the potential complications? | 441 | ||
| 18.What is capsular contracture? | 441 | ||
| 19.What is the classification of capsular contracture? | 441 | ||
| 20.How is capsular contracture treated? | 442 | ||
| 21.Is there a risk of rupture of the breast implant? | 442 | ||
| 22.How do you diagnose implant rupture? | 442 | ||
| 23.How is implant rupture treated? | 442 | ||
| 24.Can you breastfeed after undergoing breast augmentation? | 442 | ||
| 25.Is sensation to the nipple and areola affected after breast augmentation? | 442 | ||
| 26.Is there an increased risk for breast cancer in patients undergoing breast augmentation? | 442 | ||
| 27.How can you screen for breast cancer in a patient with breast implants? | 443 | ||
| 28.Are silicone gel-filled implants safe? | 443 | ||
| 29.Is breast augmentation covered by insurance? | 443 | ||
| Bibliography | 443 | ||
| Chapter 67:Reduction Mammaplasty | 444 | ||
| 1.What is the blood supply to the breast? | 444 | ||
| 2.What is the nerve supply to the breast? To the nipple? | 444 | ||
| 3.Why do pedicles other than the inferior ones seem to have as much sensation postoperatively? | 444 | ||
| 4.What are the most popular techniques used for breast reduction in the United States? | 445 | ||
| 5.What are the advantages and disadvantages of the vertical reduction technique? | 445 | ||
| 6.What are the advantages and disadvantages of the inferior pedicle reduction technique? | 446 | ||
| 7.What are some other methods of breast reduction, and what are the advantages and disadvantages of each? | 446 | ||
| 8.Why are the short scar techniques not popular in the United States? | 447 | ||
| 9.What are the primary differences between Dr. Lejour’s vertical reduction technique and Dr. Hall-Findlay’s modified technique? | 447 | ||
| 10.What technique(s) generates the most litigation? | 447 | ||
| 11.What are common indications for breast reduction? | 447 | ||
| 12.Do studies support the efficacy of breast reduction for symptomatic patients? | 447 | ||
| 13.At what age should breast reduction be performed? | 448 | ||
| 14.Is lactation possible after breast reduction? | 448 | ||
| 15.How has the postoperative hospital stay changed over the last 10 years? | 448 | ||
| 16.Is autologous blood donation recommended? | 448 | ||
| 17.Are drains necessary? | 448 | ||
| 18.Are patients satisfied with their results? | 448 | ||
| 19.When are free nipple grafts recommended? | 448 | ||
| 20.What is the incidence of occult breast cancer in reduction specimens? | 448 | ||
| 21.What are the most common complications of reduction mammaplasty? | 448 | ||
| 22.Do nipple grafts regain sensation? Erectile capacity? | 449 | ||
| 23.How can nipple viability be determined intraoperatively? | 449 | ||
| 24.What do you do if the nipples look compromised? | 449 | ||
| 25.What do you do with those lateral dog ears? | 449 | ||
| 26.What about medial dog ears? | 449 | ||
| Controversy | 449 | ||
| Bibliography | 449 | ||
| Chapter 68:Mastopexy | 451 | ||
| 1.What defines an aesthetically pleasing breast? | 451 | ||
| 2.Describe the form and dimensions of the normal breast | 451 | ||
| 3.Describe the developmental phases of the breast | 451 | ||
| 4.What are the supporting structures of the breast? | 451 | ||
| 5.What are the characteristics of a ptotic or sagging breast? | 452 | ||
| 6.What factors contribute to breast ptosis? | 452 | ||
| 7.Describe the classification system for grading breast ptosis | 452 | ||
| 8.What are the goals of mastopexy? | 452 | ||
| 9.Are the effects of mastopexy permanent? | 452 | ||
| 10.What are the major drawbacks to mastopexy? | 452 | ||
| 11.What are the advantages and disadvantages of implants after mastopexy? | 453 | ||
| 12.How are scars tolerated on the breast? | 453 | ||
| 13.What are the blood supply and innervation to the breast? | 453 | ||
| 14.What are the pertinent anatomic features in planning a mastopexy procedure? | 453 | ||
| 15.What are the various surgical options available for treatment of breast ptosis? | 453 | ||
| 16.What is a Benelli mastopexy? | 454 | ||
| 17.What is tailor-tacking? | 454 | ||
| 18.What is meant by a constricted breast or inferior-pole hyperplasia? | 454 | ||
| 19.What are the common complications of mastopexy? | 455 | ||
| Bibliography | 455 | ||
| Chapter 69:Diseases of the Breast | 456 | ||
| 1.What are the incidence, risk probability, and mortality for female breast cancer? Does radiation increase survival? | 456 | ||
| 2.Which factors are known to increase the risk of breast cancer? What factors are known to decrease the risk of breast cancer? | 456 | ||
| 3.Can breast cancer be inherited? What is the increased risk if a woman carries BRCA1, BRCA2, or both? | 456 | ||
| 4.What is ductal carcinoma in situ? Is it a precancerous state? What is the risk of invasive cancer? What is the treatment? What about lobular carcinoma in situ? | 456 | ||
| 5.When should a woman begin mammographic screening? Are there exceptions? Has routine mammography reduced mortality? | 456 | ||
| 6.What features make a mammographic lesion suspicious for malignancy? Do all lesions require biopsy? | 456 | ||
| 7.Is there a role for fine-needle aspiration for palpable breast masses? Is there a role for mammography? | 457 | ||
| 8.What is the diagnostic accuracy of physical examination, mammography, and FNA combined? | 457 | ||
| 9.What are the borders of the axilla? | 457 | ||
| 10.Which nerves can be identified during an axillary lymph node dissection? What is their role? | 457 | ||
| 11.What features on presentation suggest a hereditary breast cancer? | 457 | ||
| 12.How does tamoxifen work? Who benefits? How much? | 457 | ||
| 13.What is the STAR trial? | 457 | ||
| 14.What are the current controversies surrounding chemotherapy benefit in female patients with breast cancer? | 458 | ||
| 15.What are the most common areas of recurrence? | 458 | ||
| 16.What is trastuzumab? | 458 | ||
| 17.What is the American Joint Committee on Cancer (AJCC) 5-year survival rate for breast cancer? | 458 | ||
| 18.What is the most common solid breast mass in women younger than 30 years? Does this lesion have malignant potential? | 458 | ||
| 19.What are the most common organisms cultured from nipple discharge in a woman with a breast abscess? What is the treatment? | 458 | ||
| 20.A woman presents with diffuse, bilateral breast pain associated with her menstrual cycle. Palpation reveals multiple nodular irregularities. What is the disorder? Is it premalignant? | 458 | ||
| 21.What is Her2? Why is it important? | 458 | ||
| 22.What is p53? Why is it important? | 458 | ||
| 23.Besides BRCA1 and BRCA2, name three other autosomal dominant syndromes that carry an increased risk of breast cancer | 458 | ||
| 24.What is atypical hyperplasia? Does it increase the risk of breast cancer? | 458 | ||
| 25.What is the Gail model? What are its limitations? | 459 | ||
| 26.What is chemoprevention? | 459 | ||
| Bibliography | 459 | ||
| Chapter 70:Breast Reconstruction | 460 | ||
| 1.What are the options for breast reconstruction following mastectomy? | 460 | ||
| 2.What are the indications for prophylactic mastectomy, and why is the incidence increasing? | 460 | ||
| 3.Why do some women have an immediate reconstruction and others a delayed reconstruction? | 460 | ||
| 4.What are the best methods of surveillance following breast reconstruction in women with a history of breast cancer? | 460 | ||
| 5.Is there an optimal time to perform breast reconstruction in the setting of radiation therapy? | 460 | ||
| 6.What is a TRAM flap? | 460 | ||
| 7.What is the delay procedure, and when should it be used? | 461 | ||
| 8.What is the importance of supercharging? | 461 | ||
| 9.What is a perforator flap, and why is it becoming a popular method of breast reconstruction? | 461 | ||
| 10.Are there functional and aesthetic differences between the TRAM flap and the DIEP flap? | 461 | ||
| 11.What are the ideal recipient vessels for microvascular breast reconstruction? | 461 | ||
| 12.How can microvascular complications be minimized? | 461 | ||
| 13.What are the indications for a latissimus dorsi flap? | 461 | ||
| 14.What are the indications for breast reconstruction with implants? | 462 | ||
| 15.How does a surgeon decide on the size, shape, texture, and filler material of an implant? | 462 | ||
| 16.What is the evidence that silicone gel breast implants are safe and effective devices? | 462 | ||
| 17.What are the reasons for premature removal of an implant or expander? | 462 | ||
| 18.How often are secondary procedures necessary following breast reconstruction? | 462 | ||
| 19.What are the options for nipple reconstruction? | 462 | ||
| 20.Is there evidence that quality of life is improved following breast reconstruction? | 462 | ||
| Bibliography | 463 | ||
| Chapter 71:Nipple-Areola Reconstruction | 464 | ||
| 1.Should nipple-areola reconstruction be an integral part of breast reconstruction or an added option for certain patients? | 464 | ||
| 2.Should nipple-areola reconstruction be performed at a second stage after primary reconstruction of the mound? | 464 | ||
| 3.Is banking of the nipple-areola in the groin area an appropriate alternative to reconstruction if the primary cancer is located away from the nipple-areola? | 464 | ||
| 4.Do options for nipple reconstruction include composite grafts from the toe or earlobe? | 464 | ||
| 5.What is the treatment of choice for nipple reconstruction? | 464 | ||
| 6.Is the best way to determine nipple-areola position by measurement from the other side? | 464 | ||
| 7.Are flap techniques for nipple reconstruction interchangeable and merely a matter of the surgeon’s preference? | 465 | ||
| 8.What type of nipple reconstruction is inherently unreliable? | 465 | ||
| 9.Do the best designs in nipple reconstruction allow closure of the donor site, thus avoiding the need for grafting? | 465 | ||
| 10.Is the skate flap the best design to use for matching an opposite large nipple? | 465 | ||
| 11.Is there a disadvantage to the use of a skin graft in the final outcome of the nipple-areola? | 466 | ||
| 12.Can subsequent intradermal tattoo hide spread donor-site scars after nipple reconstruction? | 466 | ||
| 13.What are the other disadvantages to spread scars after primary closure of nipple donor sites? | 466 | ||
| 14.When using a local flap to reconstruct the missing nipple, should the dimensions of the planned nipple match those of the opposite nipple? | 466 | ||
| 15.Are some nipples too large to match by nipple reconstruction? | 466 | ||
| 16.Does raising the skate flap with full-thickness wings produce a better overall result? | 466 | ||
| 17.Do the best results in areola reconstruction follow the grafting of skin that later becomes pigmented spontaneously? | 466 | ||
| 18.What is the treatment of choice for areola reconstruction? | 466 | ||
| 19.Are coloration or tattoo techniques at the time of nipple reconstruction helpful? | 466 | ||
| 20.When is the ideal time for nipple–areola tattoo? | 466 | ||
| 21.Is one of the most important attributes of nipple reconstruction a centric position within the areola? | 467 | ||
| 22.Is the best equipment for nipple–areola tattoo the delicate machinery supplied by manufacturers specializing in medical equipment? | 467 | ||
| 23.Does nipple–areola reconstruction require a long learning curve until acceptable results can be achieved? | 467 | ||
| 24.Should the final color immediately after tattoo match the opposite nipple-areola? | 467 | ||
| Bibliography | 467 | ||
| Chapter 72:Gynecomastia | 468 | ||
| 1.What is gynecomastia? | 468 | ||
| 2.What is the pathophysiology of gynecomastia? | 468 | ||
| 3.What is the histology in gynecomastia? | 468 | ||
| 4.Classify the etiologies of gynecomastia. | 468 | ||
| 5.In what age groups does gynecomastia occur? | 468 | ||
| 6.How common is gynecomastia in each age group? | 468 | ||
| 7.How often does gynecomastia occur bilaterally? Is one side more commonly affected? | 468 | ||
| 8.How does obesity correlate with gynecomastia? | 468 | ||
| 9.Are patients with gynecomastia symptomatic? | 468 | ||
| 10.What questions are pertinent in taking the history? | 468 | ||
| 11.What physical findings should be sought? | 469 | ||
| 12.What laboratory studies should be obtained? | 469 | ||
| 13.Should routine imaging studies be ordered? | 469 | ||
| 14.What are the most common causes of pathologic gynecomastia? | 469 | ||
| 15.Which tumors may lead to gynecomastia? | 469 | ||
| 16.Does gynecomastia ever resolve? | 469 | ||
| 17.What is the differential diagnosis? | 469 | ||
| 18.Which drugs may cause gynecomastia? | 469 | ||
| 19.What is pseudogynecomastia? | 469 | ||
| 20.Is there any relationship between gynecomastia and breast cancer in adult males? | 469 | ||
| 21.What is the role of medical therapy? | 469 | ||
| 22.What is the role of radiation therapy? | 470 | ||
| 23.What are the indications for surgery? | 470 | ||
| 24.Describe the surgical classification of gynecomastia. | 470 | ||
| 25.Discuss the surgical techniques used for gynecomastia | 470 | ||
| 26. What are the most common complicationsafter surgery? | 471 | ||
| 27.Which techniques may prevent unwanted results? | 471 | ||
| Bibliography | 472 | ||
| Section VII: Aesthetic Surgery | 473 | ||
| Chapter 73.Evaluation of the Aging Face | 475 | ||
| 1.Give examples of trigger events that may cause a person to seek consultation for aesthetic facial rejuvenation | 475 | ||
| 2.What elements compose the initial aesthetic facial surgery consultation? | 475 | ||
| 3.What factors contribute to the aged appearance of the face? | 475 | ||
| 4.What intrinsic changes of the skin may be seen in the aging face? | 475 | ||
| 5.Outline the chronologic appearance of signs of aging in the face and neck | 475 | ||
| 6.What changes in the facial skeleton occur with aging? | 476 | ||
| 7.Which anatomic structures of the face are vital to know when planning facial rejuvenation surgery? | 476 | ||
| 8.Which retaining ligaments provide support to the soft tissues and skin of the face over the bony skeleton? | 476 | ||
| 9.What signs of facial aging are correctable by aesthetic rejuvenative surgery? | 477 | ||
| 10.What signs noted on physical examination of the forehead can be corrected by aesthetic facial rejuvenative surgery? | 477 | ||
| 11.What is the normal or ideal position for the female eyebrow? | 477 | ||
| 12.What signs of aging in eyelids are correctable by aesthetic rejuvenative surgery? | 478 | ||
| 13.Is an ophthalmologic consultation required for all patients before undergoing aesthetic rejuvenation of the eyelids? | 478 | ||
| 14.What signs of aging in external ears can be corrected by aesthetic rejuvenation? | 478 | ||
| 15.What signs of aging of the nose are correctable by aesthetic rejuvenative surgery? | 478 | ||
| 16.What signs of aging in the perioral region can be corrected by surgical rejuvenation? | 478 | ||
| 17.What signs of aging in the neck can be corrected by aesthetic rejuvenation? | 478 | ||
| 18.Why are preoperative photographs necessary? | 479 | ||
| 19.What visual records are used to document preoperative appearance? | 479 | ||
| 20.What standard views of the face and neck are taken for photographic documentation? | 479 | ||
| 21.What additional views may be taken to demonstrate deformities? | 479 | ||
| 22.Does the consultation for aesthetic facial rejuvenative surgery differ for men and women? | 479 | ||
| 23.What differences are noted between men and women in evaluating patients for aesthetic facial surgical rejuvenation? | 479 | ||
| 24.As people age, is it better to “start early” and undergo procedures when signs of facial aging begin or to wait and have “everything done at once”? | 479 | ||
| 25.What is the best age at which to undergo aesthetic facial rejuvenative surgery? | 479 | ||
| 26.Is there an age at which the patient is “too old” to undergo facial rejuvenative surgery? | 479 | ||
| 27.How long do the results of facial rejuvenative surgery last? | 480 | ||
| 28.Where can facial rejuvenative surgery be performed? | 480 | ||
| 29.What type of anesthesia is most appropriate for facial rejuvenative surgery? | 480 | ||
| 30.Who may not be considered candidates for facial rejuvenative surgery? | 480 | ||
| 31.Who else may not be considered good candidates for aesthetic facial rejuvenative surgery? | 480 | ||
| 32.What five rare skin conditions may present as premature aging with or without skin laxity? Is facial aesthetic surgical rejuvenation indicated? | 480 | ||
| Bibliography | 480 | ||
| Chapter 74:Forehead and Brow Lift | 482 | ||
| 1.Describe the arterial and nerve supply to the forehead | 482 | ||
| 2.The supraorbital nerve has a deep and superficial division. Describe the course of each division and the area that it innervates | 482 | ||
| 3.Describe the anatomy of the frontal nerve | 482 | ||
| 4.What is the function of the musculi frontalis? | 482 | ||
| 5.Which three facial muscles oppose the brow-lifting activity of the musculi frontalis? | 482 | ||
| 6.Describe the orbital ligament and its significance in brow lifting | 482 | ||
| 7.Which muscles of the face are responsible for the deep transverse forehead lines, vertical glabellar creases, and transverse... | 482 | ||
| 8.Describe Ellenbogen’s criteria for the ideal eyebrow position and contour | 482 | ||
| 9.Which systematic approach should be used to evaluate the contour of the eyebrow? | 483 | ||
| 10.What are the indications for a forehead and brow lift? | 483 | ||
| 11.Where is the plane of dissection for the development of the forehead flap? | 483 | ||
| 12.What is the supraciliary eyebrow lift? | 483 | ||
| 13.What is a midforehead lift? | 483 | ||
| 14.What is a bitemporal lift? | 483 | ||
| 15.What is a limited incision (lateral) forehead lift? | 483 | ||
| 16.Before the development of the endoscope, what were the most popular techniques for forehead and brow lift? | 483 | ||
| 17.Which factors determine the preference for a standard bicoronal or modified anterior hairline incision? | 483 | ||
| 18.What are the potential complications of a forehead and brow lift? | 483 | ||
| 19.What are the major operative principles of an endoscopic forehead lift? | 484 | ||
| 20.What are the advantages of an endoscopic forehead lift? | 484 | ||
| 21.What are the disadvantages of an endoscopic forehead lift? | 484 | ||
| 22.Describe several fixation techniques for the endoscopic brow lift | 484 | ||
| Bibliography | 484 | ||
| Chapter 75:Blepharoplasty | 485 | ||
| 1.What is blepharoplasty? | 485 | ||
| 2.What is the difference between blepharochalasis and blepharodermatochalasis (dermatochalasis)? Between steatoblepharon and blepharoptosis? | 485 | ||
| 3.Is blepharoplasty the procedure of choice for brightening and refreshing the eye region? | 485 | ||
| 4.What is compensated brow ptosis? | 486 | ||
| 5.If blepharoplasty is not the procedure of choice, what is? | 486 | ||
| 6.What is the youngest age at which a patient should consider blepharoplasty? | 486 | ||
| 7.Is the preaponeurotic fat continuous with the deeper orbital fat? | 486 | ||
| 8.Is it important to remove most of the fat from the lateral or central-lateral upper eyelid during blepharoplasty? | 487 | ||
| 9.What structure is often mistaken for fat in the upper eyelid? | 487 | ||
| 10.Does removal of the palpebral lobe of the lacrimal gland have any deleterious consequences? What about the orbital lobe? | 487 | ||
| 11.What is a retrobulbar hemorrhage? What are the common causes and possible consequences? | 488 | ||
| 12.How is a retrobulbar hemorrhage treated? | 488 | ||
| 13.What are the advantages and disadvantages of a transconjunctival blepharoplasty? | 488 | ||
| 14.What effect does blepharoplasty or tissue removal from the upper eyelid have on the position of the eyebrows? | 488 | ||
| 15.Does lower lid skin or skin-muscle resection change the shape of the eye? If so, how? | 488 | ||
| 16.What are the most common causes of postoperative eyelid ptosis? | 489 | ||
| 17.How is blepharoptosis categorized? | 489 | ||
| 18.What is the treatment of postsurgical lagophthalmos? | 489 | ||
| 19.What forms the supratarsal fold? | 489 | ||
| 20.What is the double eyelid operation often requested by Asians or people of Asian ancestry? | 490 | ||
| 21.Where is the peripheral arterial arcade of the eyelid located? | 491 | ||
| 22.When is a coronal lift contraindicated? | 491 | ||
| 23.When is it appropriate to resect frontalis muscle? | 491 | ||
| 24.Why does the medial brow commonly drop after blepharoplasty and/or elevation of the lateral brow? | 491 | ||
| 25.How do you plan a medial epicanthoplasty? | 491 | ||
| 2.How do you avoid lash or lid eversion and areas of lid retraction associated with invagination or “double eyelid” blepharoplasty? | 492 | ||
| 27.Are wedge resections and tarsal strip canthopexies recommended procedures for tightening the lower lid? | 492 | ||
| 28.What are the pros and cons of the endoscopic forehead lift? | 492 | ||
| 29.Are transblepharoplasty methods of corrugator muscle resection and brow elevation effective for eliminating deformity? How do they compare with other techniques? | 493 | ||
| 30.When is a direct excision of lower eyelid skin indicated? | 493 | ||
| 31.What is the best method to rid a patient of the deep grooves commonly present near the junction of the eyelid and cheek skin? | 494 | ||
| 32.How do you permanently secure the brow into its desired (elevated) position? | 494 | ||
| 33.What is Whitnall’s ligament? | 494 | ||
| 34.What is Lockwood’s ligament? | 494 | ||
| 35.In patients with eyeliner and eyebrow tattoos, where should the blepharoplasty incisions be placed? | 494 | ||
| 36.Which cranial nerve innervates the lacrimal pump that drains the tears? | 495 | ||
| 37.What is the difference in the terms “canthopexy” and “canthoplasty” as applied to tightening procedures on the lower eyelids? | 495 | ||
| 38.During blepharoplasty, where is the “white” fat? | 495 | ||
| Bibliography | 495 | ||
| Chapter 76:The Nasolabial Fold | 496 | ||
| 1.What are the nasolabial crease, nasolabial fold, and malar fat pad? | 496 | ||
| 2.What are marionette lines? | 496 | ||
| 3.What is one of the more noticeable aesthetic changes between a young adult and the same person 30 years later? | 496 | ||
| 4.What is the anatomy of the NLF area? | 496 | ||
| 5.What are mimetic muscles? What is the relationship between the SMAS and the mimetic musculature near the NLF? | 496 | ||
| 6.What is the anatomic and clinical difference between the tissue medial and lateral to the NLC? | 496 | ||
| 7.What are the retaining ligaments of the face? | 496 | ||
| 8.Which of the retaining ligaments suspend the malar fat pad? | 497 | ||
| 9.Does any other anatomic structure contribute to supporting the malar fat pad? | 497 | ||
| 10.What is the cause of a prominent NLF? | 497 | ||
| 11.What are the sequential migration vectors of the cheek mass? | 497 | ||
| 12.What is the role of midface muscle in a prominent NLF? | 497 | ||
| 13.What is the effect of facial nerve paralysis on NLF appearance? | 498 | ||
| 14.What can you inject or insert in the NLC to improve its appearance? | 498 | ||
| 15.When should fat injection of the NLC be considered? | 498 | ||
| 16.When performing fat grafting, how much fat should be injected? | 498 | ||
| 17.What short-term injectable agents are available to treat the NLC? | 498 | ||
| 18.What are the two most commonly used longer lasting agents for the treatment of the NLC? | 498 | ||
| 19.Who is the best candidate for direct crease excision? | 498 | ||
| 20.What can you offer a patient with thick skin and slight fold prominence who prefers a minimally invasive procedure? | 498 | ||
| 21.How can the malar fat pad be repositioned? | 498 | ||
| 22.How extensive need the SMAS dissection be to elevate the malar fat pad to its original position and decrease NLF prominence? | 498 | ||
| 23.With the extended SMAS dissection, what step should be performed at the level of the zygomaticus major muscle to maximize resuspension of the malar fat pad? | 498 | ||
| 24.What change do you expect in the NLF with superior and lateral SMAS pulling without releasing the SMAS from the zygomaticus major muscle? | 499 | ||
| 25.In the malar fat pad suspension technique, the fat pad vector is the skin flap. Describe this approach. | 499 | ||
| 26.When the malar fat pad is based within a skin flap vector, what is the direction and the amount of fat pad lifting needed to correct the NLF? | 499 | ||
| 27.What is the role of suction-assisted lipectomy in corrective surgery of the NLF? | 499 | ||
| 28.What is the role of the subperiosteal approach in corrective surgery of the NLF? | 499 | ||
| 29.What is the recommended amount of undermining below the fat pad to address the NLF? | 499 | ||
| 30.Describe the anatomy of the subcutaneous fat deposits in the face. How do these deposits affect the appearance of the NLF and the aging face? | 499 | ||
| 31.What adjunct can be offered to the patient who requests treatment of the NLCs that is both minimally invasive and reversible? | 499 | ||
| 32.Which muscles of the face are most responsible for the smiling mechanism? Which is most responsible for forming the medial NLC? | 499 | ||
| 33.Which of the following approaches to rhytidectomy best addresses the NLF: Lateral SMAS-ectomy, conventional SMAS, extended SMAS, or composite rhytidectomy? | 500 | ||
| Bibliography | 501 | ||
| Chapter 77:Rhytidectomy | 502 | ||
| 1.What are the different types of face lift procedures? | 502 | ||
| 2.Describe the various face lift techniques used and give an example of a good candidate for each | 502 | ||
| 3.What are the retaining ligaments of the face? | 503 | ||
| 4.When does a patient need a deep-plane lift of the midface? | 503 | ||
| 5.How can the malar fat pad be repositioned? | 503 | ||
| 6.What are some of the common tell-tale signs of face lift surgery? | 504 | ||
| 7.What are the acceptable locations for the preauricular incision, and what are the indications for each? | 505 | ||
| 8.How does a surgeon avoid creating a “step” or surgical distortion of the occipital hairline? | 505 | ||
| 9.What is a “witch’s chin” deformity? | 505 | ||
| 10.How can jowls be corrected? | 506 | ||
| 11.What factors can lead to hematoma formation after face lift surgery? | 506 | ||
| 12.What is the treatment of an expanding hematoma? | 506 | ||
| 13.What is the incidence of hematoma formation requiring evacuation after rhytidectomy? | 507 | ||
| 14.Five days after an SMAS face lift a 50-year-old woman has a ballotable fluid collection of approximately 8 mL in the right | 507 | ||
| 15.Two days later the fluid has reaccumulated. What is the likely diagnosis? | 507 | ||
| 16.What may be the cause of persistent lower cheek fullness in a patient who has undergone a face lift? | 507 | ||
| 17.Which nerve is the most commonly injured during a rhytidectomy? | 507 | ||
| 18.If you recognize injury to the great auricular nerve at surgery, what should you do? | 508 | ||
| 19.What symptoms may occur after surgery if the great auricular nerve is injured? | 508 | ||
| 20.What is the motor innervation of the platysma muscle, and what role does it play in facial animation? | 508 | ||
| 21.Which of the following branches of the facial nerve lies superficial to the deep facial fascia? | 508 | ||
| 22.What is the topographical course of the frontal branch of the facial nerve? | 508 | ||
| 23.Four weeks after undergoing an extended SMAS rhytidectomy, a 57-year-old woman has persistence of dense hemiparesis over the distribution of the right marginal mandibular nerve... | 508 | ||
| 24.A 62-year-old woman who underwent subcutaneous rhytidectomy with SMAS plication 1 week ago notices that the left side of her upper lip does not elevate when she attempts to smile... | 510 | ||
| 25.In the aging face, which procedure is most likely to worsen the prominence of the nasolabial fold? | 510 | ||
| 26.A 58-year-old man with prominent nasolabial folds undergoes rhytidectomy. Sub-SMAS dissection is performed to the level of | 510 | ||
| 27.A 60-year-old woman requests rhytidectomy. She has smoked two packs of cigarettes daily for 20 years. What postoperative complication would most likely occur? | 510 | ||
| 28.After undergoing an uncomplicated primary rhytidectomy, a 59-year-old woman has early onset of ischemia and subsequent full-thickness skin slough of a 3 × 5-cm area anterior to the left earlobe... | 511 | ||
| 29.Prominence of the nasolabial folds in the aged patient results primarily from loss of support in which of the retaining ligaments? | 511 | ||
| 30.Which vessel is the dominant blood supply to the preauricular skin that is undermined during rhytidectomy? | 511 | ||
| 31.Why is rhytidectomy more difficult to perform in men than in women? | 511 | ||
| 32.A 58-year-old woman is scheduled to undergo full-face rhytidectomy followed by phenol chemical peeling for facial rejuvenation... | 511 | ||
| 33.Who is the ideal patient for a short scar rhytidectomy? | 511 | ||
| 34.What technical maneuvers are often necessary when performing a short scar rhytidectomy? | 511 | ||
| 35.What are the potential complications of submandibular gland excision for neck contouring in rhytidectomy? | 512 | ||
| 36.What are the criteria for a youthful neck as described by Ellenbogen and Karlin? | 512 | ||
| 37.When is suction lipectomy of the neck indicated for improvement of cervicomental contour? | 512 | ||
| 38.A 65-year-old woman desires facial rejuvenation and has an obtuse cervicomental angle, noticeable fat pads in the anterior neck, and vertical, diverging subcutaneous... | 512 | ||
| Bibliography | 513 | ||
| Chapter 78:Rhinoplasty | 514 | ||
| 1.The proximal, middle, and distal thirds of the nose are associated with what underlying anatomic structures? | 514 | ||
| 2.List the nasal subunits | 514 | ||
| 3.How are the nasal bones, upper lateral cartilages, and lower lateral cartilages situated in relation to each other? | 514 | ||
| 4.What are the major tip support mechanisms? | 514 | ||
| 5.What are the minor tip support mechanisms? | 514 | ||
| 6.How is the nasal length defined? | 514 | ||
| 7.What is the scroll? | 514 | ||
| 8.What is the keystone area? | 514 | ||
| 9.What is the “ideal” nasolabial angle in a male? In a female? | 514 | ||
| 10.What are the surgical approaches for rhinoplasty? | 514 | ||
| 11.How is tip projection determined? | 515 | ||
| 12.Name three ways to determine nasal tip projection | 515 | ||
| 13.What is the brow-tip aesthetic line? | 515 | ||
| 14.Which structures make up the internal nasal valve, and what should its angle be? | 515 | ||
| 15.What is the blood supply to the nasal tip? | 515 | ||
| 16.Where is the nasal starting point for rhinoplasty in a Caucasian patient? Is it different for an Asian patient? | 515 | ||
| 17.When performing septoplasty, how much cartilage should be left intact? | 515 | ||
| 18.What are the three main sources for grafting in rhinoplasty? | 515 | ||
| 19.What grafting technique(s) can the surgeon use to open/widen the internal nasal valve? | 516 | ||
| 20.Which structures make up the external nasal valve? How can external valve collapse be corrected? | 517 | ||
| 21.What is a common cause of postoperative supraalar pinching, and how can it be corrected? | 517 | ||
| 22.What techniques are available surgically to stabilize the base of the nose? | 517 | ||
| 23.What are the indications for each method of nasal base stabilization, and how is each performed? | 518 | ||
| 24.What action should be taken in a patient with an infected nasal allograft? | 518 | ||
| 25.What is a saddle nose deformity, and what are its causes? | 520 | ||
| 26.What is a pollybeak deformity and what are its causes? | 520 | ||
| 27.What is an “inverted V” deformity? | 520 | ||
| 28.What is a stairstep deformity? How can it be prevented? | 520 | ||
| 29.What is cephalic positioning of the lateral crura? | 520 | ||
| Bibliography | 523 | ||
| Chapter 79:Otoplasty | 524 | ||
| 1.What is a prominent ear? | 524 | ||
| 2.What are the pathologic characteristics of the prominent ear deformity? | 524 | ||
| 3.What are the embryologic origins of the ear? | 524 | ||
| 4.When does antihelical folding begin in utero? | 524 | ||
| 5.By what age has the ear attained 85% of adult size? When should otoplasty be performed? | 524 | ||
| 6.What is the nerve and vascular supply to the ear? | 525 | ||
| 7.What are the normal proportions of the ear? | 525 | ||
| 8.How is ear protrusion defined? | 525 | ||
| 9.What is the average distance of each third of the ear from the head? | 525 | ||
| 10.What is the normal incline of the ear? | 525 | ||
| 11.Should the helix be visible from the frontal view? | 525 | ||
| 12.What are the anatomic goals of otoplasty? | 525 | ||
| 13.Who performed the first otoplasty? | 525 | ||
| 14.Can skin excision alone correct the prominent ear deformity? | 525 | ||
| 15.What important concept did Luckett contribute to the principles of otoplasty? | 525 | ||
| 16.What is Gibson’s principle? | 526 | ||
| 17.What is the Stenstrom technique? | 526 | ||
| 18.What is the purpose of conchomastoidal sutures? | 526 | ||
| 19.Is there another way to reduce conchal projection? | 526 | ||
| 20.What is the purpose of Mustardé sutures? | 526 | ||
| 21.How is a prominent lobule corrected? | 526 | ||
| 22.Correction of which third of the ear is most important? | 526 | ||
| 23.What is a “telephone ear” deformity? | 527 | ||
| 24.What is the difference between cartilage-molding and cartilage-breaking techniques? | 527 | ||
| 25.What is the most common late deformity after otoplasty? | 527 | ||
| 26.What is the most likely cause of sudden onset of pain after otoplasty? | 528 | ||
| 27.Which organisms usually are responsible for cellulitis after otoplasty? | 528 | ||
| 28.Can chondritis occur after otoplasty? | 528 | ||
| 29.When can prominent ears be treated nonoperatively? | 528 | ||
| 30.Which is the best technique for correction of the prominent ear deformity? | 528 | ||
| 31.Describe patient management after otoplasty. | 528 | ||
| Controversy | 528 | ||
| Bibliography | 528 | ||
| Chapter 80:Abdominoplasty | 530 | ||
| 1.\x0BWhat is the blood supply of the anterior abdominal wall? | 530 | ||
| 2.What are the layers of the anterior abdominal wall? | 530 | ||
| 3.What is the superficial fascial system? | 532 | ||
| 4.What are the basic elements of abdominal contour abnormalities? | 532 | ||
| 5.What is the basic surgical approach to abdominoplasty? | 532 | ||
| 6.What is a fleur-de-lis abdominoplasty? | 532 | ||
| 7.What are the indications for the so-called miniabdominoplasty? | 533 | ||
| 8.What are the contraindications for abdominoplasty? | 533 | ||
| 9.What is the difference between an abdominoplasty and a panniculectomy? | 533 | ||
| 10.Can liposuction alone be used to rejuvenate the abdomen? | 533 | ||
| 11.What is the role of liposuction in abdominoplasty? | 533 | ||
| 12.Can musculofascial laxity of the abdominal wall be repaired? | 533 | ||
| 13.Where and how should umbilicus be placed? | 533 | ||
| 14.What are the complications of abdominoplasty? How can they be minimized? | 535 | ||
| Bibliography | 535 | ||
| Chapter 81:Body Contouring | 536 | ||
| 1.What is the anatomic distribution of fat in men and women? | 536 | ||
| 2.Are there differences in the layers of fat? | 536 | ||
| 3.How is cellulite formed? | 536 | ||
| 4.If fat is removed, will it come back? | 536 | ||
| 5.What is liposuction? | 536 | ||
| 6.Who originally developed liposuction? When did it become accepted? | 536 | ||
| 7.What are the indications for liposuction? | 536 | ||
| 8.What is the difference between ultrasound-assisted liposuction and traditional liposuction? | 536 | ||
| 9.What is wetting solution? Why do we use it? | 536 | ||
| 10.What are the compositions of the more common wetting solutions? | 537 | ||
| 11.How are intravenous fluids managed during liposuction? | 537 | ||
| 12.What are the recommended aspirate volumes for outpatient liposuction? | 537 | ||
| 13.What is a maximal safe dose of lidocaine when administered as a wetting solution? | 537 | ||
| 14.Should you be concerned about lidocaine toxicity during the procedure? | 537 | ||
| 15.If you are planning a large-volume liposuction (>5 L), how should the infiltrate be modified? | 537 | ||
| 16.What are the most common sequelae of liposuction? | 537 | ||
| 17.What are the most common complications of liposuction? | 537 | ||
| 18.Is it safe to perform liposuction with abdominoplasty? | 538 | ||
| 19.What is the recommended treatment of gynecomastia? | 538 | ||
| 20.Does the excessive skin need to be resected after removal of fat via liposuction? | 538 | ||
| 21.How do you determine whether a patient will benefit from abdominoplasty versus liposuction? | 538 | ||
| 22.What is the treatment of arm ptosis and lipodystrophy? | 538 | ||
| 23.Where should the final scar in a formal brachioplasty lie? | 538 | ||
| 24.How do you prevent complications from a medial thigh lift? | 538 | ||
| 25.What is autologous fat transplantation? | 538 | ||
| 26.What are Autologen and Alloderm? | 538 | ||
| 27.Does the use of Autologen and Alloderm involve any risk? | 538 | ||
| Controversies | 538 | ||
| Bibliography | 539 | ||
| Chapter 82:Body Contouring After Massive Weight Loss | 540 | ||
| 1.What is the incidence of morbid obesity in the United States? | 540 | ||
| 2.What is the BMI, and how is it determined? | 540 | ||
| 3.What are the surgical options available for patients with morbid obesity? | 540 | ||
| 4.What is the impact of this on the field of plastic surgery? | 540 | ||
| 5.Why is body contouring in massive weight loss patients a greater challenge? | 541 | ||
| 6.What is the ideal time interval to initiate body contouring surgery? | 542 | ||
| 7.What is the role of liposuction in morbidly obese patients? | 542 | ||
| 8.What are some of the considerations of breast surgery in massive weight loss patients? | 542 | ||
| 9.How is gynecomastia in the male treated after massive weight loss? | 543 | ||
| 10. Describe some techniques used for brachioplasty after massive weight loss | 543 | ||
| 11. Explain the different terminologies used for contouring procedures of the abdomen and the lower body | 543 | ||
| 12.What is a lower body lift? An upper body lift? | 544 | ||
| 13.What are some considerations in markings for a lower body lift? | 544 | ||
| 14.What are positioning options for lower body lift? What precautions need to be taken with this positioning? | 545 | ||
| 15.What are the surgical options for inner thigh lift? | 545 | ||
| 16.What are some common risks of body contouring surgery after massive weight loss? | 545 | ||
| 17.What measures can surgeons take to reduce the risk of VTE? | 546 | ||
| Bibliography | 546 | ||
| Chapter 83:Chemical Peeling and Dermabrasion | 547 | ||
| 1.What is chemical peeling? | 547 | ||
| 2.What are the indications for chemical peeling? | 547 | ||
| 3.What agents are most commonly used for chemical peeling? What are the typical concentrations? | 547 | ||
| 4.What does Jessner’s solution contain? | 548 | ||
| 5.How do you choose a particular peeling agent to suit your patient’s skin type? | 548 | ||
| 6.Is pretreatment necessary before chemical peeling? | 548 | ||
| 7.Is taping necessary during chemical peeling? | 548 | ||
| 8.Can peeling be done simultaneously with surgery? | 548 | ||
| 9.Which should be done first: facial surgery or facial peeling? | 549 | ||
| 10.What complications may be encountered after peeling? | 549 | ||
| 11.What peeling solution may cause cardiac arrhythmias when it is applied too rapidly to too large an area? | 549 | ||
| 12.Regeneration of the epidermis and upper dermis occurs via dermal appendages. What previous procedures or medications affect the concentration of dermal... | 549 | ||
| 13.What histologic changes do chemical peels cause in the skin? | 549 | ||
| 14.Discuss the Glogau classification for photoaging and how treatment strategy changes for each group | 549 | ||
| 15.What are alpha-hydroxy acids? | 549 | ||
| 16.How do glycolic acid peels compare with standard chemical peels? | 550 | ||
| 17.Can the different peeling agents be used in combination? | 550 | ||
| 18.What is dermabrasion? | 550 | ||
| 19.What are the indications for dermabrasion? | 550 | ||
| 20.How do you know how deep to dermabrade? | 550 | ||
| 21.How long after dermabrasion does reepithelialization occur? | 550 | ||
| 22.Compare the effects of dermabrasion in the perioral area with the effects of phenol | 550 | ||
| 23.Should patients undergoing chemical peel or dermabrasion of the perioral area receive acyclovir prophylaxis? | 551 | ||
| 24.What is dermasanding? | 551 | ||
| 25.What is microdermabrasion? | 551 | ||
| 26.What are the indications for microdermabrasion? | 551 | ||
| 27.Compare the effects of microdermabrasion with those of dermabrasion and chemical peeling | 551 | ||
| 28.What histologic skin changes does microdermabrasion cause? | 551 | ||
| Bibliography | 551 | ||
| Chapter 84:Aesthetic Laser Surgery | 552 | ||
| 1.What does the acronym LASER mean? | 552 | ||
| 2.What was the predecessor of the laser? | 552 | ||
| 3.Who invented the laser? | 552 | ||
| 4.What is the visible spectrum of light? | 552 | ||
| 5.How is laser light different from other forms of light? | 552 | ||
| 6.What is power density and fluence? | 552 | ||
| 7.Define pulse width, wavelength, and spot size. What do these have in common? | 552 | ||
| 8.How does the laser interact with the skin? | 552 | ||
| 9.What is selective photothermolysis and thermal relaxation time? Why are these concepts important in aesthetic laser surger | 552 | ||
| 10.What is the difference between an ablative and a nonablative laser? | 553 | ||
| 11.What are the wavelengths of lasers commonly used in plastic surgery? | 553 | ||
| 12.What is the laser of choice for a port-wine stain? | 553 | ||
| 13.What is the mechanism of action of the Q-switched Nd:YAG laser? | 553 | ||
| 14.What does Q switched mean, and why is it important? | 553 | ||
| 15.What is the Fitzpatrick classification, and why is it important in laser surgery? | 553 | ||
| 16.How is the carbon dioxide laser used in aesthetic surgery? | 553 | ||
| 17.What is the erbium:YAG laser? | 554 | ||
| 18.A patient comes to your office 3 to 6 days after a 120-micron erbium laser facial resurfacing with a perioral, malodorous, pruritic, yellow crusting... | 554 | ||
| 19.What is a fractional photothermolysis? | 554 | ||
| 20.How do lasers remove hair? | 554 | ||
| 21.Will laser hair removal remove all hair in one treatment? | 554 | ||
| 22.Why is laser hair removal most successful in the winter? | 554 | ||
| 23.What is intense pulsed light? | 555 | ||
| 24.What perioperative precautions should be taken in a patient who is to undergo laser resurfacing and has a history of oral herpes infection? | 555 | ||
| 25.What happens when patients are pretreated with botulinum toxin prior to laser resurfacing? | 555 | ||
| 26.What medication can be applied before laser surgery to improve pain? | 555 | ||
| 27.What are the contraindications to facial laser resurfacing? | 555 | ||
| 28.How long before reepithelialization occurs after facial resurfacing? | 555 | ||
| 29.What are the side effects and complications following laser resurfacing? | 555 | ||
| 30.What are common topical treatments recommended or prescribed prior to resurfacing? | 556 | ||
| 31.Facial resurfacing should be avoided in patients taking what medication? | 556 | ||
| 32.What postoperative dressing is available following laser resurfacing? | 556 | ||
| 33.What are the safety issues related to the laser plume? | 556 | ||
| 34.What precautions should be taken in the operating room where a laser procedure is being performed? | 556 | ||
| 35.Summarize the types of lasers commonly used in plastic surgery | 556 | ||
| Bibliography | 558 | ||
| Chapter 85:Endoscopic Surgery | 559 | ||
| 1.Who is credited with the birth of modern endoscopy? | 559 | ||
| 2.What technologic advances enabled the rapid proliferation of endoscopic techniques in surgery? | 559 | ||
| 3.What is the Hopkins rod endoscope? | 559 | ||
| 4.How is endoscopic surgery different in plastic surgery compared with other specialties? | 559 | ||
| 5.Which procedures in plastic surgery are commonly performed endoscopically? | 559 | ||
| 6.What are the advantages and disadvantages of endoscopic transaxillary breast augmentation? | 560 | ||
| 7.Which muscles are responsible for forehead animation? | 560 | ||
| 8.The locations of which nerves are important during an endoscopic forehead lift? | 560 | ||
| 9.What are the important components of an endoscopic forehead lift? | 560 | ||
| 10.Who is the ideal candidate for endoscopic facial rejuvenation? | 560 | ||
| 11.What are the advantages and disadvantages of endoscopic surgery versus the traditional or open approach? | 561 | ||
| Bibliography | 561 | ||
| Chapter 86:Augmentation Of The Facial Skeleton | 562 | ||
| 1.Why is most augmentation of the facial skeleton done with alloplastic implants instead of autogenous bone? | 562 | ||
| 2.How does an implant’s surface characteristics affect the host’s response to the implant? | 562 | ||
| 3.What alloplastic implant materials are most commonly used to augment the facial skeleton? | 562 | ||
| 4.What areas of the face are most often augmented with implants? | 563 | ||
| 5.What surgical approaches are used for placement of malar implants? | 563 | ||
| 6.What is the most common complication after placement of a malar implant? | 563 | ||
| 7.What are the advantages of wide subperiosteal exposure of the skeletal area to be augmented? | 563 | ||
| 8.Why should I consider fixing an implant to the skeleton with a screw? | 564 | ||
| 9.What is considered an ideal chin projection relative to the lips? | 564 | ||
| 10.How does the inclination of the labiomental angle impact chin augmentation? | 564 | ||
| 11.What is the soft tissue response to augmentation of the chin? | 564 | ||
| 12.What muscle is most frequently injured during chin implant surgery? | 564 | ||
| 13.How would you treat a patient who complains that the silicone chin implant placed several years ago is too large and asymetric? | 564 | ||
| 14.Can fat grafts substitute for alloplastic implants to augment the facial skeleton? | 564 | ||
| 15.A patient has a large nose and weak chin. In what order should rhinoplasty and chin augmentation with an implant be performed? | 565 | ||
| 16.What are common complications after placement of alloplastic facial implants? | 565 | ||
| Bibliography | 565 | ||
| Chapter 87:Aesthetic Orthognathic Surgery | 566 | ||
| 1.What is orthognathic surgery? | 566 | ||
| 2.What is dental compensation? | 566 | ||
| 3.Why is it important to discuss orthodontic camouflage versus surgical treatment prior to initiating orthodontic therapy? | 566 | ||
| 4.What is orthodontic decompensation? | 566 | ||
| 5.What is the ideal vertical position of the maxilla? | 566 | ||
| 6.How does the clinician determine the anteroposterior position of the jaws? | 566 | ||
| 7.What is skeletal expansion and why is it important? | 566 | ||
| 8.How is a lateral cephalometric radiograph obtained? | 567 | ||
| 9.What is the difference between an absolute and relative crossbite? | 567 | ||
| 10.Is facial disproportion ever acceptable in facial aesthetics? | 568 | ||
| 11.Why is a final splint necessary? | 568 | ||
| 12.What is the least stable movement? | 568 | ||
| 13.What are the causes of malocclusion after skeletal fixation? | 568 | ||
| 14.How is lip length affected by closure of the circumvestibular incision? | 568 | ||
| 15.What is the role of alloplastic augmentation in orthognathic surgery? | 569 | ||
| 16.When should the nose be addressed in the orthognathic patient? | 569 | ||
| 17.What nasal changes are seen after orthognathic surgery? | 569 | ||
| 18.How can alar widening be reduced in maxillary surgery? | 569 | ||
| 19.What are the soft tissue changes in the upper lip that occur after Le Fort I osteotomy? | 569 | ||
| 20.What is the role of genioplasty in orthognathic surgery? | 570 | ||
| 21.What is the role of fat grafting? | 570 | ||
| Bibliography | 570 | ||
| Chapter 88:Genioplasty | 571 | ||
| 1.What is a genioplasty? | 571 | ||
| 2.How do you determine the relationship of the nose to the chin? | 571 | ||
| 3.What factors determine sagittal projection of the chin? | 571 | ||
| 4.What is the relationship of the soft tissue to hard tissue when the chin is moved? | 571 | ||
| 5.What factors determine the vertical position of the chin? | 571 | ||
| 6.What factors determine the transverse position of the chin? | 571 | ||
| 7.What imaging is necessary prior to osseous genioplasty? | 572 | ||
| 8,How does the concept of skeletal expansion apply to the chin? | 572 | ||
| 9.When is an osseous genioplasty preferable to a chin implant? | 572 | ||
| 10.What are the advantages of alloplastic chin augmentation? | 572 | ||
| 11.Where should the incision be placed for a chin implant? | 572 | ||
| 12.What potential adverse aesthetic effects are associated with advancement genioplasty? What is a Pharaoh deformity? | 572 | ||
| 13.What potential adverse esthetic effects are associated with setback genioplasty? | 572 | ||
| 14.How much subperiosteal dissection is recommended to perform an osseous genioplasty? | 572 | ||
| 15.Where are the osteotomy cuts made? | 573 | ||
| 16.What are the various types of genioplasties? | 573 | ||
| 17.What are the potential complications of an osseous genioplasty? | 573 | ||
| 18.What are the potential complications of a chin implant? | 575 | ||
| 19.What is a witch’s chin deformity? | 575 | ||
| Bibliography | 576 | ||
| Chapter 89: Non-Surgical Rejuvenationof the Aging Face | 577 | ||
| 1.According to the American Society of Aesthetic Plastic Surgeons, how many nonsurgical cosmetic procedures were performed in the United States in 2005? | 577 | ||
| 2.What are the clinical and histopathologic manifestations of photodamage to the skin? | 577 | ||
| 3.What is tretinoin, and how can it be used for facial rejuvenation? | 577 | ||
| 4.What is the dosing, application, and safe duration of use of tretinoin? | 577 | ||
| 5.What are the side effects, complications, or warnings about tretinoin you should tell your patients? | 577 | ||
| 6.What is ascorbic acid, and how is it used for facial rejuvenation? | 577 | ||
| 7.What is Botox? | 577 | ||
| 8.How does Botox work? | 578 | ||
| 9.How was the Botox unit calculated? | 578 | ||
| 10.How is Botox reconstituted? | 578 | ||
| 11.How long can Botox be used after it has been reconstituted, and how should it be stored? | 578 | ||
| 12.What are the contraindications to Botox use? | 578 | ||
| 13.What is the most common side effect and complication of Botox injection? | 578 | ||
| 14.What type of syringe and anesthetic can be used for Botox injection? | 578 | ||
| 15.What are the postinjection instructions to the patient? | 578 | ||
| 16.What is the glabellar complex, and what are the recommended Botox dosages to treat this area? | 578 | ||
| 17.A new physician asks you to teach a medical student how to inject Botox into the crow’s feet of a patient. What pearls would you give the student to optimize... | 579 | ||
| 18.A patient calls your office 24 hours after Botox injection and states that she wants her money back because she sees no effect from the treatment... | 579 | ||
| 19.What is hyaluronic acid? | 579 | ||
| 20.What are four commonly used Food and Drug Administration–approved hyaluronic acid formulas available in the United States? | 579 | ||
| 21.Why is periorbital injection of soft tissue fillers problematic? | 579 | ||
| 22.In which layer is periorbital tissue filler placed? | 579 | ||
| 23.What are technical considerations for filler injection? | 579 | ||
| 24.Can Restylane be used in conjunction with other cosmetic procedures? | 579 | ||
| 25.Shortly after Restylane is injected into the nasolabial fold of a 36-year-old healthy woman, her right ala turns blue. Twenty-four hours later a small, painful ulcer develops... | 580 | ||
| 26.A palpable and visible lump of recently injected hyaluronic acid has been identified by one of your patients. What is one chemical that you could use to alleviate the problem? | 581 | ||
| 27.What is the Tyndall effect, and how is it important in filler placement? | 581 | ||
| 28.What is a percutaneous suture meloplication? | 581 | ||
| 29.Who are ideal candidates for barbed suture placement? | 581 | ||
| 30.What are the long-term effects and complications associated with barbed suture lifting of the face? | 581 | ||
| 31.What is microdermabrasion, and how is it used in facial rejuvenation? | 581 | ||
| 32.What influences the degree of tissue ablation achieved during microdermabrasion? | 581 | ||
| 33.What are the histologic changes following microdermabrasion? | 581 | ||
| 34.What is the frequency of microdermabrasion treatments, and what do you tell your patients to expect? | 581 | ||
| Bibliography | 582 | ||
| Section VIII: Trunk and Lower Extremity | 583 | ||
| Chapter 90:Chest Wall Reconstruction | 585 | ||
| 1.When do the skeletal components of the chest wall form embryologically? | 585 | ||
| 2.What are the muscular layers of the chest wall? | 585 | ||
| 3.What are the functions of the chest wall? | 586 | ||
| 4.What are the most common indications for chest wall reconstruction? | 586 | ||
| 5.What are the principles of chest wall reconstruction? | 586 | ||
| 6.What type of tissue is most often used for reconstruction? | 586 | ||
| 7.What are the indications for free tissue transfer? | 586 | ||
| 8.What options are available for skeletal stabilization? | 586 | ||
| 9.What is the incidence of median sternotomy infection? | 586 | ||
| 10.What is the significance of sternal wound infections? | 586 | ||
| 11.Should serial débridement be performed after sternal wound dehiscence? | 586 | ||
| 12.Is there a correlation between use of the internal mammary artery for bypass grafting and the incidence of sternal wound infections? | 586 | ||
| 13.How are sternotomy wound infections classified? | 587 | ||
| 14.How are median sternotomy wounds reconstructed? | 587 | ||
| 15.How can the pectoralis major muscle be used as a “turnover” flap? | 587 | ||
| 16.When is the rectus abdominis muscle used? | 588 | ||
| 17.Can the rectus abdominis muscle be used when the ipsilateral IMA has been harvested for bypass grafting? | 588 | ||
| 18.What role does the greater omentum play? | 588 | ||
| 19.What is a sternal cleft? | 588 | ||
| 20.Which congenital anomalies are associated with developmental abnormalities of the ribs? | 588 | ||
| 21.Which congenital chest wall anomaly is associated with ipsilateral hand deformities? | 589 | ||
| 22.What is Poland’s syndrome? | 589 | ||
| 23.Do the reconstructive goals differ in females and males with Poland’s syndrome? | 589 | ||
| 24.What is pectus excavatum? | 589 | ||
| 25.How is pectus excavatum treated? | 591 | ||
| 26.What is pectus carinatum? How is it related to pectus excavatum? | 591 | ||
| Bibliography | 591 | ||
| Chapter 91:Abdominal Wall Reconstruction | 592 | ||
| 1.What is the functional role of the abdominal wall? | 592 | ||
| 2.What are the layers of the abdominal wall? | 592 | ||
| 3.What are the origins and insertions of the abdominal wall muscles? | 592 | ||
| 4.What are the functions of the abdominal wall muscles? | 592 | ||
| 5.What fascial layer lines the entire abdominal wall? | 592 | ||
| 6.What is the arterial supply to the abdominal wall? | 593 | ||
| 7.Describe the three vascular zones of the abdominal wall | 593 | ||
| 8.What are the venous and lymphatic drainages of the abdominal wall? | 593 | ||
| 9.What is the motor and sensory innervation to the abdominal wall? | 593 | ||
| 10.Describe the mechanism by which an adynamic abdominal wall contributes to lumbosacral pain | 594 | ||
| 11.What are the most frequent causes of abdominal wall defects? | 594 | ||
| 12.What are important considerations in the evaluation of abdominal wall defects? | 594 | ||
| 13.What studies aid in the evaluation of abdominal wall defects? | 594 | ||
| 14.How are acquired abdominal wall defects managed? | 594 | ||
| 15.What are the reconstructive options? | 595 | ||
| 16.What is the “components separation” technique? What size defect can be closed using this technique? | 595 | ||
| 17.Describe the concept of staged abdominal reconstruction. | 595 | ||
| 18.What is the incidence of incisional hernia formation after laparotomy? What are commonly associated risk factors? | 597 | ||
| 19.What suture material and technique are associated with the lowest rate of incisional hernia formation? | 597 | ||
| 20.What is the natural history of incisional hernia formation? | 597 | ||
| 21.What are the primary goals in abdominal hernia repair? | 597 | ||
| 22.What are the criteria for use of synthetic mesh? | 597 | ||
| 23.How has the application of mesh affected the surgical approach and outcomes in abdominal hernia repair? | 597 | ||
| 24.Describe the experience with prosthetic materials | 598 | ||
| 25.What is the clinical course of prosthetic materials capable of incorporation? | 598 | ||
| 26.Describe the technique for prosthetic material placement during abdominal wall reconstruction | 598 | ||
| 27.What are the advantages and disadvantages of using bioprosthetics in abdominal wall reconstruction? | 598 | ||
| 28.What is gas gangrene of the abdominal wall? How do you differentiate it from anaerobic clostridial cellulitis? | 598 | ||
| 29.What are the most important congenital defects of the abdominal wall? | 599 | ||
| 30.What is an omphalocele? What causes it? | 599 | ||
| 31.What is gastroschisis? | 599 | ||
| 32.Besides the physical findings of the abdominal wall, what characteristics do patients with gastroschisis have in common? | 599 | ||
| 33.How does gastroschisis differ from omphalocele? | 600 | ||
| 34.What is the treatment of patients with gastroschisis or omphalocele? | 600 | ||
| 35.What is “prune belly” syndrome? | 600 | ||
| 36.What are the options for lower abdominal wall reconstruction? | 600 | ||
| 37.What are the options for upper abdominal wall reconstruction? | 600 | ||
| 38.What is commonly described as the “flap of choice” for abdominal wall reconstruction? | 600 | ||
| 39.What is the role of the rectus femoris in abdominal wall reconstruction? | 600 | ||
| 40.What is the “mutton chop” flap? | 601 | ||
| 41.What is the role of the omentum in abdominal wall reconstruction? | 601 | ||
| 42.What is the role of tissue expansion in abdominal wall reconstruction? | 601 | ||
| 43.What is the incidence of herniation following TRAM flaps? | 601 | ||
| Bibliography | 601 | ||
| Chapter 92:Reconstruction of the Posterior Trunk | 603 | ||
| 1.What are the most common reconstructive problems of the posterior trunk? | 603 | ||
| 2.What types of flaps can be used for coverage of posterior trunk defects? | 603 | ||
| 3.Describe the principles of wound management prior to reconstructive surgery of the posterior trunk. | 603 | ||
| 4.Which factors impact the surgeon’s choice of flap when approaching a posterior trunk defect? | 603 | ||
| 5.What are the functional goals of posterior trunk reconstruction? | 603 | ||
| 6.In what ways do defects of the posterior trunk differ from those of the anterior chest wall? | 603 | ||
| Anatomyof Posterior Trunk Flaps | 603 | ||
| Regional Approachto Posterior Trunk Defects | 606 | ||
| Spina Bifida | 607 | ||
| Bibliography | 607 | ||
| Chapter 93:Reconstruction of the Lower Extremity | 608 | ||
| 1.How does a plastic surgeon become involved in lower extremity reconstruction? | 608 | ||
| 2.What types of pathology may require lower extremity reconstruction? | 608 | ||
| 3.What are common coverage methods for the thigh? | 608 | ||
| 4.What are the alternatives and considerations for soft tissue coverage of the knee? | 608 | ||
| 5.What is appropriate soft tissue coverage for the proximal tibia? | 608 | ||
| 6.What are appropriate choices of soft tissue coverage of the mid-tibial region? | 608 | ||
| 7.What local coverage is available for ankle or distal tibial exposure? | 608 | ||
| 8.What factors increase the complication rate for sural flaps? | 608 | ||
| 9.What are common coverage methods for wounds of the foot? | 609 | ||
| 10.Why are the wounds of the distal leg so problematic for coverage? | 609 | ||
| 11.What are the indications for free tissue transfer to cover the distal lower extremity? | 609 | ||
| 12.List absolute indications for flap coverage of the lower extremity. | 609 | ||
| 13.What are the six angiosomes of the foot and ankle region? | 609 | ||
| 14.What is the significance of the angiosome territories? | 609 | ||
| 15.What are special considerations for plantar foot coverage? | 609 | ||
| 16.What is the most appropriate source of free tissue transfer for coverage of extensive plantar foot defects? | 609 | ||
| 17.How can abnormal weight-bearing in the neuropathic foot be corrected? | 609 | ||
| 18.What advantage does the VAC device provide for lower extremity wounds? | 610 | ||
| 19.Are there any contraindications for the vacuum-assisted closure device in the lower extremity? | 610 | ||
| 20.What are the muscle groups and major nerves and arteries of each of the four compartments of the lower leg? | 610 | ||
| 21.Why should we invest significant resources to salvage an ulcerated diabetic limb when the patient can just as well have a below-knee amputation and prosthesis? | 610 | ||
| 22.What is tarsal tunnel syndrome? What are its clinical findings? How is it treated? | 610 | ||
| 23.What is compartment syndrome? | 610 | ||
| 24.Is pulselessness a reliable sign of compartment syndrome? | 611 | ||
| 25.How is compartment syndrome recognized and treated? | 611 | ||
| 26.How are the foot sensory nerves evaluated? | 611 | ||
| 27.What are indications for primary amputation in patients with tibial level injury? | 611 | ||
| 28.What are the contraindications to salvage of a Gustilo IIIC injury of the lower extremity? | 611 | ||
| 29.What are the indications for lower extremity replantation? | 611 | ||
| 30.What are absolute contraindications for lower extremity replantation? | 612 | ||
| 31.Are there any other considerations for the use of an amputated part? | 612 | ||
| 32.In planning flap coverage of the lower extremity, what considerations are involved for concomitant or future bone reconstruction? | 612 | ||
| 33.Can bone transport (Ilizarov technique) be done across or through a free flap? | 612 | ||
| 34.Why may free flaps fail in the leg? | 612 | ||
| 35.How do you determine the zone of injury when preparing recipient vessels? | 612 | ||
| 36.Provide an appropriate algorithm for primary operative care of lower extremity trauma. | 612 | ||
| 37.Is a muscle or a fasciocutaneous flap better for open fracture treatment? | 613 | ||
| Bibliography | 613 | ||
| Chapter 94:Leg Ulcers | 614 | ||
| 1.What are the most common chronic wounds seen in our population? | 614 | ||
| 2.How often is ulceration the precursor to amputation? | 614 | ||
| 3.What is the differential diagnosis of leg ulcers? | 614 | ||
| 4.How do you evaluate a patient who presents with leg ulcers? | 615 | ||
| 5.What are the goals of leg ulcer treatment? | 615 | ||
| 6.What is the most common cause of leg ulceration? | 615 | ||
| 7.What is venous hypertension? | 615 | ||
| 8.What causes venous hypertension? | 615 | ||
| 9.How do you diagnose venous hypertension? | 615 | ||
| 10.Name the major veins of the leg. | 616 | ||
| 11.Describe the anatomy of the veins of the leg | 616 | ||
| 12.What are perforating veins? | 616 | ||
| 13.What is the difference between “primary” and “secondary” chronic venous disorders? | 616 | ||
| 14.What are varicose veins? | 616 | ||
| 15.What is a varicose ulcer? | 616 | ||
| 16.What are the etiology and pathogenesis of venous ulcers? | 616 | ||
| 17.Describe the role of inflammation in the development and perpetuation of chronic venous ulcers. | 616 | ||
| 18.Where are venous ulcers located? | 617 | ||
| 19.Describe conservative management of venous ulcers. | 617 | ||
| 20.What is an Unna boot? | 617 | ||
| 21.How does an Unna boot work? | 617 | ||
| 22.Describe the surgical management of venous ulcers | 617 | ||
| 23.What is a Linton flap? | 617 | ||
| 24.Who should get a skin graft for a venous leg ulcer? | 617 | ||
| 25.What are the goals for long-term cure of recalcitrant venous ulcers? | 617 | ||
| 26.What is the role of free tissue transfer in the management of venous ulcers? | 617 | ||
| 27.Who should get a free flap for a venous leg ulcer? | 618 | ||
| 28.What kind of free flap is best for a venous ulcer? | 618 | ||
| 29.What intrinsic role does the flap tissue play in treatment of venous ulcers? | 618 | ||
| 30.How does one approach the patient with mixed arterial and venous ulcers? | 618 | ||
| 31.What is the CEAP classification? | 618 | ||
| 32.How is the CEAP classification used? | 618 | ||
| 33.What are the relationships among ulceration, diabetes, arterial occlusive disease, and amputation? | 618 | ||
| 34.What is the etiopathogenesis of diabetic foot ulcers? | 619 | ||
| 35.Discuss two common misconceptions about diabetic foot infections | 619 | ||
| 36.What is the fate of the contralateral foot in diabetics? | 620 | ||
| 37.What is the diabetic Charcot foot? | 620 | ||
| 38.Describe the status of the arterial system in diabetics. | 620 | ||
| 39.Describe considerations in the surgical management of diabetic patients with a leg or foot ulcer. | 620 | ||
| 40.Describe the management of plantar forefoot ulcers | 620 | ||
| 41.Describe the management of plantar midfoot ulcers | 621 | ||
| 42.Describe the management of hindfoot (heel) ulcers | 621 | ||
| 43.How are multiple tarsal and metatarsal ulcers managed? | 621 | ||
| 44.What methods are used to prevent foot ulcers? | 621 | ||
| 45.What is the bacteriology of lower extremity infections? | 621 | ||
| 46.What are the basic rules for treating any lower extremity infection? | 621 | ||
| 47.What is the role of the vascular surgeon and plastic surgeon in salvage of the diabetic foot? | 621 | ||
| 48.Describe the rehabilitation team for the diabetic foot | 622 | ||
| 49.Describe the nature of sickle cell ulcers | 622 | ||
| 50.What role does skin grafting play in the management of sickle cell ulcers? | 622 | ||
| 51.What other reconstructive options are available for patients with homozygous sickle cell disease? | 622 | ||
| 52.What is the role of free tissue transfer for limb salvage in patients with homozygous sickle cell disease? | 622 | ||
| 53.Is there any evidence to support vacuum-assisted closure in the treatment of chronic leg ulcers? | 622 | ||
| Bibliography | 623 | ||
| Chapter 95:Pressure Sores | 624 | ||
| 1.What is the pathophysiology of pressure ulcers? | 624 | ||
| 2.What are the Braden scale and the Norton scale? | 624 | ||
| 3.What are the primary risk factors for developing pressure ulcers in chair-bound people or people with impaired ability to reposition? | 624 | ||
| 4.Which areas of the body are more prone to pressure ulcerations? | 624 | ||
| 5.What is the staging system for pressure sores? | 624 | ||
| 6.In patients with spinal cord injury, what is the pathophysiology of lower extremity spasms? | 624 | ||
| 7.How do you manage spasticity in paraplegic patients? | 624 | ||
| 8.What is the best modality for evaluation of pelvic osteomyelitis in patients with pressure sores? | 625 | ||
| 9.What other tests are helpful in establishing the diagnosis of pelvic osteomyelitis? | 625 | ||
| 10.What is the treatment for pelvic osteomyelitis? | 625 | ||
| 11.How does vacuum-assisted closure assist in pressure sore care? | 625 | ||
| 12.How does the collection of third-space fluid interfere with wound healing? | 625 | ||
| 13.List the surgical steps for pressure sore closure | 625 | ||
| 14.What is the blood supply to the gluteus maximus muscle? | 625 | ||
| 15.What are the various designs for the gluteus maximus musculocutaneous flap? | 625 | ||
| 16.What is the innervation of the gluteus maximus muscle? Can the gluteus maximus flap be used in nonparaplegic patients without functional deficit? | 625 | ||
| 17.What are the advantages of the gluteal perforator flap versus the classic gluteus maximus design? | 625 | ||
| 18.Which are the most significant anatomical considerations for the gluteal perforator flap? | 626 | ||
| 19.Which are the most significant technical considerations for the gluteal perforator flap? | 626 | ||
| 20.What is the blood supply to the gracilis musculocutaneous flap? | 626 | ||
| 21.What is the blood supply of the lumbosacral back flap? What are its applications? | 626 | ||
| 22.What is the blood supply to the vastus lateralis muscle? | 626 | ||
| 23.What is the blood supply to the rectus femoris muscle? | 626 | ||
| 24.What is the blood supply to the gluteal thigh flap? | 626 | ||
| 25.What is the blood supply to the tensor fascia lata flap? | 626 | ||
| 26.Describe the surgical anatomy and applications of the posteromedial thigh fasciocutaneous flap. | 626 | ||
| 27.Which flap can be used to cover perineal pressure sores? | 627 | ||
| 28.When is a total thigh flap recommended? | 627 | ||
| 29.What measures does a successful total thigh flap include? | 627 | ||
| 30.Which are the indications and technical consideration for use of the rectus abdominis musculocutaneous flap in patients with pressure sores? | 627 | ||
| 31.What are the advantages of close collaboration between the plastic surgery and rehabilitation medicine services in the treatment of pressure sores? | 627 | ||
| Bibliography | 627 | ||
| Chapter 96:Lymphedema | 628 | ||
| 1.What are lymphatics? | 628 | ||
| 2.Describe the anatomy of the lymphatic system. | 628 | ||
| 3.Are lymphatics present throughout the body? | 628 | ||
| 4.What are the functions of the lymphatic system? | 628 | ||
| 5.What is lymphedema? | 628 | ||
| 6.Does lymphedema affect the superficial, deep, or both areas of the extremity? | 629 | ||
| 7.Classify lymphedema | 629 | ||
| 8.Describe the epidemiology of lymphedema | 629 | ||
| 9.What is the differential diagnosis of lymphedema? | 629 | ||
| 10.How do you diagnose lymphedema? | 629 | ||
| 11.How do you measure the severity of lymphedema and follow treatment response? | 630 | ||
| 12.What is the best imaging modality to confirm the diagnosis of lymphedema? | 630 | ||
| 13.What are the complications of lymphedema? | 630 | ||
| 14.How do you manage cellulitis in a lymphedematous extremity? | 631 | ||
| 15.What is the first-line treatment of symptomatic lymphedema? | 631 | ||
| 16.How does pressure reduce limb volume? | 631 | ||
| 17.What are the indications for surgical treatment of lymphedema? | 631 | ||
| 18.Describe the surgical treatment options for lymphedema | 631 | ||
| 19.List the types of physiologic procedures that have been described for the treatment of lymphedema | 631 | ||
| 20.List the types of excisional procedures that have been described | 632 | ||
| 21.What are the benefits of suction-assisted lipectomy compared with staged subcutaneous excision? | 632 | ||
| 22.Is suction-assisted lipectomy effective for treatment of lower extremity lymphedema? | 632 | ||
| 23.What is the mechanism of liposuction edema reduction? | 632 | ||
| 24.Is circumferential suctioning of the extremity safe? | 632 | ||
| Controversies | 632 | ||
| Bibliography | 633 | ||
| Chapter 97:Reconstruction of the Genitalia | 634 | ||
| 1.Describe the anatomy of the penis, including the fascial layers | 634 | ||
| 2.Name the origin and branches of the common penile artery | 634 | ||
| 3.What is the role of testosterone in genital development? | 634 | ||
| 4.Describe the common features of hypospadias. | 634 | ||
| 5.Where is the most common location of the meatus in hypospadias? The least common? | 634 | ||
| 6.What are the goals and components of hypospadias repair? | 634 | ||
| 7.Describe the distribution of the dorsal nerves to the penis. Why is it important to consider in surgical techniques for the correction of congenital penile curvature? | 635 | ||
| 8.What are the causes of chordee? | 635 | ||
| 9.What are the two most common complications of a hypospadias repair? | 635 | ||
| 10.Should you look for other congenital anomalies in a patient with hypospadias? | 635 | ||
| 11.What are the classic features of the exstrophy/epispadias complex? | 635 | ||
| 12.How does exstrophy occur? | 635 | ||
| 13.What are the goals of extrophy reconstruction? | 635 | ||
| 14.What is the most common cause of ambiguous genitalia? What is the most common enzyme abnormality? | 635 | ||
| 15.List the categories of ambiguous genitalia. | 635 | ||
| 16.What considerations contribute to gender assignment? | 636 | ||
| 17.What are the anatomic divisions of the urethra? | 636 | ||
| 18.Name three causes of urethral stricture disease | 636 | ||
| 19.What studies are involved in the preoperative evaluation of urethral stricture? | 636 | ||
| 20.What tissues are available for reconstruction of the urethra? | 636 | ||
| 21.Who was Peyronie? | 636 | ||
| 22.What is the cause of Peyronie’s disease? What is the most commonly associated physical finding other than penile curvature? | 636 | ||
| 23.If a patient presents with significant penile curvature, what are the important considerations for recommending treatment? | 636 | ||
| 24.What materials or tissues have been used in plaque incision or excision and grafting? | 636 | ||
| 25.What additional procedure should be considered in patients with erectile dysfunction and Peyronie’s disease? | 637 | ||
| 26.After exploration to determine the extent of the injury, how should you manage a degloving injury to the penis? | 637 | ||
| 27.What is Fournier’s gangrene? | 637 | ||
| 28.What is the most common technique for penile reconstruction and phallic construction? | 637 | ||
| 29.What are the options for construction of a vagina? | 637 | ||
| Bibliography | 637 | ||
| Section IX: Burns | 639 | ||
| Chapter 98: Thermal Burns | 641 | ||
| 1.List three functions of the skin that are lost when thermal injury occurs. What are the consequences? | 641 | ||
| 2.What is the incidence of burn injury in the United States? | 641 | ||
| 3.What are the criteria for referring a patient to a specialized burn center? | 641 | ||
| 4.What are the immediate concerns about the airway of patients with a thermal injury? | 641 | ||
| 5.What three factors suggest an inhalation injury? | 641 | ||
| 6.What diagnostic measures can be used to confirm inhalation injury? | 641 | ||
| 7.What are the concerns in transporting a burn victim from a community hospital to a specialized burn center? | 641 | ||
| 8.How is inhalation injury managed acutely? | 642 | ||
| 9.When are prophylactic antibiotics and/or steroids indicated for inhalation injury? | 642 | ||
| 10.Describe the resuscitation of thermally injured patients | 642 | ||
| 11.Describe the initial resuscitation of a child with burn injuries | 642 | ||
| 12.How is the size of the burn estimated? | 642 | ||
| 13.How is the depth of the wound classified? | 642 | ||
| 14.Describe the management of burn wounds involving the extremities | 642 | ||
| 15.Why is pain control important in burn patients? | 643 | ||
| 16.What is burn wound anemia? | 643 | ||
| 17.What are the various options available for managing the partial-thickness burn wound? | 643 | ||
| 19.How and when is a skin graft done? | 644 | ||
| 20.What are the reasons for graft failure? | 644 | ||
| 21.What is a meshed graft versus a sheet graft? | 644 | ||
| 22.What is Integra artificial skin? When should it be used? | 644 | ||
| 23.How are thermal injuries to the perineum and genitalia managed? | 644 | ||
| 24.Describe the management of foot burns. | 645 | ||
| 25.How is wound healing affected by the aging process? | 645 | ||
| 26.Why is nutrition important in the burn patient, and how are nutritional requirements determined? | 645 | ||
| Bibliography | 645 | ||
| Chapter 99: Electrical Injuries | 646 | ||
| 1.What is an electrical injury? | 646 | ||
| 2.How common are electrical injuries in the United States? | 646 | ||
| 3.What are the mechanisms for electrical injury? | 646 | ||
| 4.Why is the term “electrical burn” imprecise? | 646 | ||
| 5.To what does the term “entrance and exit points” refer? | 646 | ||
| 6.What is the voltage of typical wall outlets in the home? | 646 | ||
| 7.Describe how to calculate the current that a victim might be exposed to during an electrical injury | 646 | ||
| 8.What is the minimum voltage necessary for soft tissue injury? | 647 | ||
| 9.Describe the common modes of exposure to damaging electric fields | 647 | ||
| 10.How are electrical injuries classified? | 647 | ||
| 11.What additional portions of the history, as they relate to the electrical exposure, must be explored? | 647 | ||
| 12.What laboratory studies are appropriate at the time of admission? | 648 | ||
| 13.What are the findings of compartment syndromes in the extremities, and when is treatment appropriate? | 648 | ||
| 14.What is the role of magnetic resonance imaging in the identification of compromised, electrically injured tissue? | 648 | ||
| 15.How are fluid requirements calculated in electrical injury resuscitation? | 648 | ||
| 16.What is the significance of myoglobinuria? | 648 | ||
| 17.How are hemoglobinuria and myoglobinuria diagnosed and treated? | 648 | ||
| 18.In the midst of a lightning storm, describe the safest location to avoid lightning injuries. | 648 | ||
| 19.Can victims of electrical injury develop delayed neurologic sequelae? | 649 | ||
| 20.What advice would you give the parents of a child with an electrical injury of the oral commissure? | 649 | ||
| 21.What are the ocular manifestations of electrical injury, and what is the most common of these? | 649 | ||
| 22.Describe neuropsychological changes following electrical injury | 649 | ||
| Bibliography | 649 | ||
| Chapter 100: Chemical Injuries | 650 | ||
| 1. Why is the management of chemical injuries important? | 650 | ||
| 2. What common items are associated with chemical injuries? | 650 | ||
| 3. Which substances can cause more tissue destruction: Acids or alkalis? | 650 | ||
| 4. What are some systemic effects associated with chemical injuries? | 650 | ||
| 5. What are the criteria for hospital admission of patients with chemical burns? | 650 | ||
| 6. How do you acutely treat a chemical burn victim? | 650 | ||
| 7. How long should you irrigate a chemical burn wound? | 650 | ||
| 8. What are common pitfalls in treating chemical injuries? | 651 | ||
| 9. What is the difference between thermal and chemical burns? | 651 | ||
| 10. Describe the nature and appearance of acid burns | 652 | ||
| 11. What is hydrofluoric acid? | 652 | ||
| 12. Why are hydrofluoric acid burns so severe? | 652 | ||
| 13. What is the first sign of hypocalcemia after a hydrofluoric acid burn? | 652 | ||
| 14. What are the signs of acute systemic fluoride toxicity? | 652 | ||
| 15. How do you treat a hydrofluoric acid burn? | 652 | ||
| 16. What substances account for the majority of alkali burns? | 652 | ||
| 17. What type of alkali injuries merit special attention? | 652 | ||
| 18. How does cement cause a chemical burn? | 653 | ||
| 19. What is a boot-cuff burn injury? | 653 | ||
| 20. What chemical burns should never be treated with water irrigation? | 653 | ||
| 21. How do you treat these burning metals? | 653 | ||
| 22. How are tar and grease best removed? | 653 | ||
| 23. What chemical burn has the characteristic smell of garlic? | 653 | ||
| 24. What is white phosphorous? | 653 | ||
| 25. How do you treat a white phosphorous burn? | 653 | ||
| 26. What metabolic and systemic complications are associated with white phosphorous burns? | 653 | ||
| 27. What chemical injury is treated with polyethylene glycol (antifreeze)? | 653 | ||
| 28. What is phenol? | 653 | ||
| 29. How quickly can systemic phenol toxicity manifest itself? | 654 | ||
| 30. How do you treat phenol injuries? | 654 | ||
| 31. What chemical injury is often accompanied with frostbite? | 654 | ||
| Bibliography | 654 | ||
| Chapter 101: Frostbite | 655 | ||
| 1. What are the three common types of cold injury? | 655 | ||
| 2. What is frostbite? | 655 | ||
| 3. What is chilblain (pernio)? | 655 | ||
| 4. What is trenchfoot? | 655 | ||
| 5. What are the symptoms of trenchfoot? | 655 | ||
| 6. What is cold urticaria? | 655 | ||
| 7. What predisposing risk factors contribute to frostbite? | 655 | ||
| 8. How is frostbite classified? | 655 | ||
| 9. What is the pathophysiology of frostbite? | 655 | ||
| 10. What vascular changes occur with frostbite? | 657 | ||
| 11. What immunogenic factors play a role in frostbite? | 657 | ||
| 12. How is frostbite treated? | 657 | ||
| 13. What is the role of surgery in the treatment of frostbite? | 657 | ||
| 14. What is the role of hyperbaric oxygen in the treatment of frostbite? | 657 | ||
| 15. What other diagnostic modalities are used in determining the extent of frostbite? | 657 | ||
| 16. Is any adjuvant therapy useful in the treatment of frostbite? | 657 | ||
| 17. What are the late sequelae of frostbite? | 658 | ||
| Bibliography | 658 | ||
| Chapter 102: Metabolism and Nutrition | 659 | ||
| 1. What are the daily requirements of carbohydrates, lipids, and proteins? | 659 | ||
| 2. What methods are used to determine a patient’s daily caloric requirement? | 659 | ||
| 3. How is protein synthesis hormonally regulated? | 659 | ||
| 4. How does stress or injury alter metabolism? | 659 | ||
| 5. What is the effect of stress or injury on blood sugar levels? | 659 | ||
| 6. What is gluconeogenesis? | 659 | ||
| 7. What is the effect of insulin therapy in critically ill patients? | 659 | ||
| 8. List several host factors that can impair wound healing | 660 | ||
| 9. What is the effect of protein malnutrition on wound healing? | 660 | ||
| 10. How is a malnourished patient identified? | 660 | ||
| 11. Which are the best indicators of overall nutritional status? | 660 | ||
| 12. What are signs of malnutrition that can be identified on physical examination? | 660 | ||
| 13. Which serum proteins are used to assess a patient’s nutritional status? | 660 | ||
| 14. Which comorbid conditions can lead to decreased levels of nutritional indexes irrespective of a patient’s nutritional state? | 660 | ||
| 15. Describe several adverse consequences of malnutrition in a surgical patient | 660 | ||
| 16. How soon after surgery or trauma should exogenous nutritional supplementation be initiated? | 660 | ||
| 17. What deleterious effects have been attributed to total parenteral nutrition versus enteral nutrition? | 660 | ||
| 18. What is immunonutrition? | 660 | ||
| 19. Name several proposed immunonutrients and their theorized modes of action. | 661 | ||
| 20. What benefits have been identified using immunonutrition? | 661 | ||
| 21. What effects does the oxygen tension have on wound healing? | 661 | ||
| 22. What is the hypermetabolic response to burn injury? | 661 | ||
| 23. What are the responsible mediators? | 661 | ||
| 24. How can the hypermetabolic response to burns be blunted? | 661 | ||
| 25. When does the metabolic rate return to normal? | 661 | ||
| 26. Describe burn wound resuscitation. | 661 | ||
| 27. What effect does insulin therapy have on the immune response to burn? | 661 | ||
| 28. What effect does oxandrolone have on the immune response to burn? | 662 | ||
| bibliography | 662 | ||
| Chapter 103: Burn Reconstruction | 663 | ||
| 1. What are the general principles of burn rehabilitation? | 663 | ||
| 2. Is a burn scar unique? | 663 | ||
| 3. What is the primary goal of burn rehabilitation? | 664 | ||
| 4. Why do burn scars contract? | 664 | ||
| 5. How do you prevent burn scar formation? | 664 | ||
| 6. How do you prevent burn scar contracture? | 664 | ||
| 7. What are the best ways to treat burn scar contracture? | 665 | ||
| 8. What does burn rehabilitation include, and when does it begin? | 666 | ||
| 9. What are the differences between scald, flame, and electrical injuries in terms of the care needed after the injury heals? | 666 | ||
| 10. What are compression dressings and how are they used? What are compression garments? | 666 | ||
| 11. How do compression garments work? | 667 | ||
| 12. What is the role of silicone? | 667 | ||
| 13. Who developed the use of compression? | 667 | ||
| 14. Is there any advantage to early burn wound surgical intervention? | 667 | ||
| 15. Which anatomic sites should take precedence in burn reconstruction, even in the earliest phases of burn care? | 667 | ||
| 16. When was the first recorded treatment of a burn? What was the recommended treatment plan? | 667 | ||
| 17. What are the most common complaints that burn survivors have? | 668 | ||
| 18. What are the delayed wound complications associated with burn injury? | 668 | ||
| 19. What is heterotopic calcification? | 668 | ||
| 20. What are the most common burn contracture deformities and how may they be prevented or minimized? | 668 | ||
| 21. What is microstomia? | 668 | ||
| 22. How do neck contractures affect function, and how are they treated? | 669 | ||
| 23. How long after surgery for burn scar reconstruction is it possible to begin scar management? | 669 | ||
| 24. What are the appropriate grafts for burned hand reconstruction (Fig. 103-6)? | 669 | ||
| 25. What underlying pathology results in an intrinsic minus hand in the recently burned upper extremity, and how should it be treated? | 669 | ||
| 26. What are escharotomies, and what do they do? | 669 | ||
| 27. What are the clinical signs of ischemia in a circumferentially burned extremity? | 670 | ||
| 28. When does the need for an escharotomy first appear? | 670 | ||
| 29. Spill scalds of the chest are common in toddlers. What are the long-term consequences? | 670 | ||
| 30. What is burn alopecia, and how is it treated? | 670 | ||
| 31. What are the long-term consequences of burn scars 20 years or more after a burn injury? | 670 | ||
| 32. What are the long-term consequences of lightning injuries? | 671 | ||
| Controversies | 671 | ||
| Bibliography | 671 | ||
| Section X: Tissue Transplantation | 673 | ||
| Chapter 104: Principles of Skin Grafts | 675 | ||
| 1. Who performed the first skin graft? | 675 | ||
| 2. What are the different types of skin grafts? | 675 | ||
| 3. What are the advantages and disadvantages of STSG versus FTSG? | 675 | ||
| 4. Which epithelial appendages are present in the skin? | 675 | ||
| 5. How do hair follicles and sebaceous glands affect skin grafts? | 675 | ||
| 6. How do sweat glands affect skin grafts? | 676 | ||
| 7. What happens to the epidermis in the postgraft period? | 676 | ||
| 8. Describe the cellular and fibrous components of the dermis in skin grafts. | 676 | ||
| 9. What is the function of the extracellular matrix? | 676 | ||
| 10. Describe the healing process of a skin graft. | 676 | ||
| 11. How does a skin graft take? | 676 | ||
| 12. What are the most common causes of autologous skin graft failure? | 677 | ||
| 13. What sensory changes occur as a skin graft becomes reinnervated? | 677 | ||
| 14. What are the choices for donor sites? | 677 | ||
| 15. What is a dermatome? | 677 | ||
| 16. What is meshing? When are meshed grafts used? | 677 | ||
| 17. What are the advantages and disadvantages of meshing? | 677 | ||
| Advantages | 677 | ||
| Disadvantages | 677 | ||
| 18. What methods of graft expansion are available besides meshing? | 678 | ||
| 19. Compare primary and secondary contraction. | 678 | ||
| 20. What factors in the wound bed promote skin graft take? | 678 | ||
| 21. What is the optimal dressing for a skin graft? | 678 | ||
| 22. How can skin graft pigmentation mismatch be minimized? When does hyperpigmentation or hypopigmentation occur? | 678 | ||
| 23. What types of dressings are used for donor sites? | 678 | ||
| 24. How many times can a split-thickness graft be harvested from the same site? | 679 | ||
| 25. What is dermal overgrafting? | 679 | ||
| 26. Compare allografts and xenografts. | 679 | ||
| 27. What other effective temporary biologic dressings exist as a bridge to autografting in patients with extensive burns (total body surface area >50%)? | 679 | ||
| 28. What is tissue-cultured skin? | 680 | ||
| 29. What are unilaminar and bilaminar skin substitutes? | 680 | ||
| 30. What are the applications of fibrin glue in skin grafting? | 680 | ||
| 31. What is a free dermal-fat graft? | 680 | ||
| 32. What is the role of skin grafting in the treatment of vitiligo? | 680 | ||
| Bibliography | 680 | ||
| Chapter 105: Principles of Skin Flap Surgery | 682 | ||
| 1. How do main distributing arteries reach the cutaneous circulation of a flap? | 682 | ||
| 2. What are the three main characteristics of skin-containing flaps? | 682 | ||
| 3. Classify skin-containing flaps in terms of their composition. | 682 | ||
| 4. Classify skin-containing flaps in terms of their blood supply (Fig. 105-1). | 682 | ||
| 5. Classify skin-containing flaps in terms of their method of movement (Fig. 105-2). | 683 | ||
| 6. Classify the following flaps according to their three major characteristics. | 683 | ||
| 7. In what year did plastic surgeons successfully introduce free tissue transfer as a reconstructive option? What type of procedure was performed? | 683 | ||
| 8. What is an angiosome? What is its significance in flap design? | 683 | ||
| 9. What is the “delay procedure”? What is the “delay phenomenon”? | 684 | ||
| 10. What does the term critical ischemia time mean? | 684 | ||
| 11. What is primary versus secondary ischemia? | 684 | ||
| 12. What does the term ischemia–reperfusion injury mean? | 684 | ||
| 13. What mechanisms may lead to the failure of a pedicled flap? A free flap? | 685 | ||
| 14. How can you optimize the viability of a pedicled flap? | 685 | ||
| 15. What methods are used to monitor the viability of a free flap that contains a cutaneous component? | 685 | ||
| Bibliography | 685 | ||
| Chapter 106: Principles of Fascia and Fasciocutaneous Flaps | 686 | ||
| 1. What exactly is a fasciocutaneous flap? | 686 | ||
| Basic Anatomy | 686 | ||
| 2. Describe the vascular contributions to the “fascial plexus.” | 686 | ||
| 3. Where are “fascial feeders” found? | 686 | ||
| 4. What are the six patterns of perforators of the deep fascia that can each supply adistinct type of fasciocutaneous flap? | 686 | ||
| 5. Are direct septocutaneous vessels and septocutaneous perforators actuallydifferent? | 687 | ||
| 6. The dorsal thoracic fascia is synonymous with the territory of what fasciocutaneousflaps? | 687 | ||
| 7. Is a “muscle” perforator flap just a type of fasciocutaneous flap? | 687 | ||
| 8. Simplify the stratification of the types of deep fascial perforators as being either“direct” or “indirect” perforators. | 687 | ||
| 9. What role does the deep fascia have in most fasciocutaneous flaps? | 687 | ||
| 10. Can a fasciocutaneous flap be neither fascial nor cutaneous? | 687 | ||
| 11. Describe the composition of the subcutaneous flap and the adipofascial flap. | 687 | ||
| 12. Define the three subtypes of fasciocutaneous flaps using either the Cormack-Lamberty or Nahai-Mathes schema. | 687 | ||
| 13. In what body regions do direct fascial perforators predominate when compared withmusculocutaneous perforators? | 688 | ||
| Basic Physiology | 688 | ||
| 14. Explain how the axis determines the proper orientation for designing afasciocutaneous flap. | 688 | ||
| 15. How can the maximum potential length of a fasciocutaneous flapbe estimated? | 688 | ||
| 16. What is the point of rotation of a fasciocutaneous flap? | 688 | ||
| 17. What is the arc of rotation of a fasciocutaneous flap? | 688 | ||
| 18. Who is Pontén, and what are his “superflaps”? | 689 | ||
| 19. Define a distal-based fasciocutaneous flap. Why is it more dependable than itsmuscle flap counterpart? | 689 | ||
| 20. State the primary advantage of a distal-based fasciocutaneous flap. | 689 | ||
| 21. Are distal-based fasciocutaneous flaps and retrograde flow-flaps thesame entity? | 689 | ||
| 22. How does venous regurgitation occur in a retrograde flow flap? | 689 | ||
| 23. How is Allen’s test relevant to the Chinese flap? | 689 | ||
| 24. What is the superficial ulnar artery trap? | 689 | ||
| Applied Anatomy | 690 | ||
| 25. Why has the radial forearm flap fallen into disrepute in some quartersof the world? | 690 | ||
| 26. What is the Becker flap? | 690 | ||
| 27. Why has the groin flap fallen into disfavor? | 690 | ||
| 28. The importance of the triangular space of the thorax is because what direct fascialperforator emanates through it? | 690 | ||
| 29. Name the muscles that define the boundaries of the triangular space. | 690 | ||
| 30. What important structures pass through the quadrilateral space to form theneurovascular pedicle for a sensate upper arm fasciocutaneous flap? | 691 | ||
| 31. Name the structures that define the boundaries of the quadrilateral space. | 691 | ||
| 32. Perhaps the most notorious liability of the fasciocutaneous flap is the riskof morbidity at the donor site, especially if a skin graft has been requiredfor closure. Describe at least three ways in which this specific risk can beminimized. | 691 | ||
| 33. Name some advantages of fasciocutaneous flaps when compared withmuscle flaps. | 691 | ||
| 34. Identify the source vessel and type of perforator in these 10 commonly used fasciaflaps. | 691 | ||
| Bibliography | 693 | ||
| Chapter 107: Principles of Muscle and Musculocutaneous Flaps | 695 | ||
| Basic Anatomy | 695 | ||
| 1. Why can a muscle be used as a flap? | 695 | ||
| 2. Where do the vascular pedicles enter a muscle? | 695 | ||
| 3. Differentiate the terms “dominant,” “minor,” and “segmental” in reference to thevascular pedicle of a muscle. | 695 | ||
| 4. What is the importance of a “secondary segmental” vascular pedicle? | 695 | ||
| 5. Classify muscle flaps according to their source of vascular supply. | 695 | ||
| 6. If based on vascular pedicle type only, which muscles would be the most and whichthe least versatile for use as a flap? | 695 | ||
| 7. Classify muscle flaps according to their mode of innervation. | 696 | ||
| 8. Identify the most common vascular pattern for muscles. | 696 | ||
| Basic Physiology | 696 | ||
| 9. According to their vascular pattern, which muscle types would be the most or theleast reliable as a flap? | 696 | ||
| 10. Define the standard arc of rotation of a muscle flap. | 696 | ||
| 11. In contrast, what is the arc of rotation of a “reverse” muscle flap? | 697 | ||
| 12. Explain the concept of function preservation when using a muscle flap. | 697 | ||
| 13. How are the arterial territories linked within a muscle that has multiple vascularpedicles? | 697 | ||
| 14. What is the relationship of veins to the corresponding arteries found in muscles? | 697 | ||
| 15. How are venous territories linked together within a given muscle? | 697 | ||
| Musculocutaneous Flap Physiology | 697 | ||
| 16. How do myocutaneous flaps differ from musculocutaneous flaps? | 697 | ||
| 17. Describe how the skin paddle of a musculocutaneous flap normally obtains its bloodsupply. | 697 | ||
| 18. Why is the muscle considered only a passive carrier of the skin in a compositemusculocutaneous flap? | 697 | ||
| 19. Can any skin configuration overlying a muscle be expected to survive as amusculocutaneous flap? | 697 | ||
| 20. Are there nonoperative modalities to assist the preoperative identification ofmusculocutaneous perforators to ensure their inclusion? | 698 | ||
| 21. List several methods to maximize viability of the skin paddle of amusculocutaneous flap. | 698 | ||
| 22. It has been postulated that the “delay” of a musculocutaneous flap is best achievedby the alteration of its venous physiology by what mechanism? | 698 | ||
| 23. Does neovascularization occur more rapidly in a muscle or musculocutaneous flap toallow pedicle independence? | 698 | ||
| Applied Anatomy | 698 | ||
| 24. What are the advantages of muscle flaps when compared with cutaneous flaps? | 698 | ||
| 25. Although never a concern with cutaneous flaps, what is the greatest liability if usinga muscle flap? | 698 | ||
| 26. Why are muscle flaps infrequently used for coverage in the upper extremity? | 698 | ||
| 27. Name the two “workhorse” muscle flaps of the leg and state their correspondingrange. | 699 | ||
| 28. Which of the two heads of the gastrocnemius muscle has the longer reach? | 699 | ||
| 29. What two important structures help to demarcate the two heads of thegastrocnemius muscles? | 699 | ||
| 30. The internal oblique muscle has what in common with the pectoralis major andlatissimus dorsi muscles? | 699 | ||
| 31. Describe two ways the pectoralis major muscle can be transposed to coversternal defects. | 699 | ||
| 32. From the schematic (see Fig. 107-3), name the source vessel(s) and correspondingmuscle type based on blood supply of these 10 commonly used muscle flaps. | 699 | ||
| Bibliography | 700 | ||
| Chapter 108: Principles of Perforator Flaps | 702 | ||
| Basic Anatomy | 702 | ||
| 1. Define “perforator.” | 702 | ||
| 2. How do direct and indirect “perforators” differ? | 702 | ||
| 3. Where is the “fascial plexus”? | 702 | ||
| 4. What is a “mother” vessel? | 702 | ||
| 5. What is a “perforator flap”? | 702 | ||
| 6. What is a “true” perforator flap? | 703 | ||
| 7. Could muscle perforator flaps be considered a form of fasciocutaneous flap? | 703 | ||
| 8. Name different types of indirect perforator flaps. | 703 | ||
| 9. Must all perforator flaps be cutaneous flaps? | 703 | ||
| 10. Does the deep fascia have to be included with a perforator flap? | 703 | ||
| 11. In what body regions do musculocutaneous perforators practical formuscle perforator flaps predominate compared with direct perforators of thedeep fascia? | 704 | ||
| 12. Describe the course of the perforator veins. | 704 | ||
| 13. List some methods that allow preoperative identification of perforators. | 704 | ||
| 14. While thinning perforator flaps, Kimura found what three different branchingpatterns of musculocutaneous perforators through the subcutaneous tissues in theircourse to the subdermal plexus? | 704 | ||
| 15. Do different donor sites have predictable suprafascial branching patterns ofperforators? | 704 | ||
| Basic Physiology | 704 | ||
| 16. When exploring the potential vessels for a perforator flap, what is the smallest sizethat should be chosen? | 704 | ||
| 17. Although a single perforator could sustain an entire flap, state some goodreasons to include more. | 705 | ||
| 18. How can the potential territory of a perforator flap be estimated? | 705 | ||
| 19. What is the point of rotation of a perforator flap? | 705 | ||
| 20. Describe the arc of rotation of a local perforator flap. | 705 | ||
| 21. How can the arc of rotation of a local perforator flap be increased? | 705 | ||
| 22. How can venous congestion in a perforator flap be aborted? | 705 | ||
| 23. Is the immediate thinning of a perforator flap hazardous? | 705 | ||
| Muscle Perforator Flaps | 705 | ||
| 24. Describe the nomenclature for muscle perforator flaps. | 705 | ||
| 25. Based on the aforementioned four nomenclature systems for muscle perforatorflaps, label a flap from the anterolateral thigh if based on a lateral circumflexfemoral (LCF) perforator of the vastus lateralis muscle. | 705 | ||
| 26. Based on the aforementioned four nomenclature systems for muscle perforatorflaps, label a flap if based on a superior epigastric (SE) perforator of the rectusabdominis muscle. | 706 | ||
| 27. Does a muscle perforator flap capture the same territory as its correspondingmusculocutaneous flap? | 706 | ||
| 28. List the source vessels for the muscle perforator flaps identified here by thecorresponding muscle (Fig. 108-3): | 706 | ||
| Nonmuscle Perforator Flaps | 707 | ||
| 29. Explain the basis of circulation to a neurocutaneous flap. | 707 | ||
| 30. What is the axis of a neurocutaneous flap? | 707 | ||
| 31. Why were Pontén’s so-called “superflaps” so robust? | 707 | ||
| 32. What landmarks can be used to ensure the appropriate orientation of aneurocutaneous flap in the extremities? | 707 | ||
| Supermicrosurgery | 707 | ||
| 33. Define “supermicrosurgery.” | 707 | ||
| 34. What is Koshima’s perforator-based flap? | 707 | ||
| 35. Describe how to design a “free-style” local or free flap. | 707 | ||
| 36. How does “microdissection” more safely allow reduction of the thickness of aperforator flap? | 707 | ||
| 37. What is a “subdermal vascular network” flap? | 707 | ||
| Bibliography | 708 | ||
| Chapter 109: Principles of Microvascular FreeTissue Transfer | 710 | ||
| 1. What is a microvascular free tissue transfer? | 710 | ||
| 2. What are the indications for a microvascular free tissue transfer? | 710 | ||
| 3. What are the success rates of microsurgically transplanted tissues? | 710 | ||
| 4. Which donor tissue should be chosen? | 710 | ||
| 5. Who should perform microsurgery? | 710 | ||
| 6. What role do anticoagulants play in microsurgery? | 710 | ||
| 7. What is the no-reflow phenomenon? | 710 | ||
| 8. What methods can be used to minimize ischemia? | 711 | ||
| 9. Which is more successful, end-to-end or end-to-side arterial anastomosis? | 711 | ||
| 10. From where do you obtain vein grafts? | 711 | ||
| 11. What benefit do coupled anastomoses have? | 711 | ||
| 12. How can you tell if a flap is failing? | 711 | ||
| 13. What factors lead to free flap failure? | 711 | ||
| 14. How long before new endothelium covers the anastomosis site? | 711 | ||
| 15. What are some methods to relieve spasm? | 712 | ||
| 16. What is the order of vessel repair in a free flap? Artery or vein first? | 712 | ||
| 17. Should both arterial and venous repairs be completed before clamps are removed and flow is reestablished? | 712 | ||
| 18. Does smoking increase the risk of free flap failure? | 712 | ||
| 19. Name several options for skin/fasciocutaneous flap reconstruction. | 712 | ||
| 20. Name several free muscle flaps. Which muscles can be transplanted as functional muscles? | 712 | ||
| 21. Name several perforator flaps. | 712 | ||
| 22. Name several osseous flaps. | 713 | ||
| 23. Are there any other types of free flaps? | 713 | ||
| 24. What are chimeric flaps? | 713 | ||
| 25. Which free flaps are used for facial reanimation? | 713 | ||
| Controversies | 713 | ||
| Bibliography | 714 | ||
| Chapter 110: Free Flap Donor Sites | 715 | ||
| 1. What is a composite free flap? | 715 | ||
| 2. What is the quadrangle space? Which structures traverse it? | 715 | ||
| 3. What is the triangular space? Which structures traverse it? | 715 | ||
| 4. Describe the Mathes and Nahai classification of muscle circulation and list examples of muscles used for free transfers from each group. | 715 | ||
| 5. What are the advantages and disadvantages of including a skin paddle with a muscle flap? | 716 | ||
| 6. Which muscles are suitable for facial reanimation because of their size and segmental innervation? | 716 | ||
| 7. Name a reliable donor muscle for coverage of large defects. | 716 | ||
| 8. Name four muscles that are appropriate for functional free transfers. | 716 | ||
| 9. What are the uses and advantages of the gracilis flap? | 716 | ||
| 10. Which portions of the serratus anterior muscle can be safely harvested without risk of inducing winging of the scapula? | 716 | ||
| 11. What sensory deficit may result from injudicious harvest of the lateral gastrocnemius muscle? | 716 | ||
| 12. Describe one of the primary uses of the pectoralis minor flap. | 716 | ||
| 13. List 10 sensate cutaneous flaps and their innervation. | 716 | ||
| 14. What are the advantages of the anterolateral thigh free flap? | 717 | ||
| 15. What are the advantages of using the medial forearm flap in reconstruction of the face or hand? | 717 | ||
| 16. Under what circumstances can donor site appearance be improved in use of the cutaneous lateral arm flap? | 717 | ||
| 17. What are the limitations of one of the earliest free flaps, the groin flap? | 717 | ||
| 18. What are the two most commonly used vascularized free bone flaps? What are their advantages and disadvantages? | 717 | ||
| 19. With which pedicles can the iliac crest osteocutaneous flap be harvested? | 717 | ||
| 20. What morbidity is associated with harvest of the vascularized free iliac crest bone flap? | 717 | ||
| 21. What are the advantages of using the great toe for thumb reconstruction? | 717 | ||
| 22. What is the most commonly used free fascial flap? What are its advantages and disadvantages? | 717 | ||
| 23. Is patient positioning important when considering an appropriate donor site? | 718 | ||
| 24. What methods are used for closing donor site defects following flap harvest? | 718 | ||
| Bibliography | 718 | ||
| Chapter 111: Leeches | 719 | ||
| 1. What are leeches? Sneeches? | 719 | ||
| 2. How long have leeches been used in medicine? | 719 | ||
| 3. How long have leeches been used in plastic surgery? | 719 | ||
| 4. What are the indications for using leeches? | 719 | ||
| 5. What are the signs of arterial occlusion versus venous occlusion? | 719 | ||
| 6. How do leeches work? | 719 | ||
| 7. What are the possible complications of using leeches? What precautions are necessary? | 720 | ||
| 8. How are leeches administered? | 720 | ||
| 9. How many leeches should you use? | 720 | ||
| 10. Where do you get leeches in the middle of the night? | 721 | ||
| Bibliography | 721 | ||
| Chapter 112: Principles of Facial Transplantation | 722 | ||
| 1. What are the functions of the face? | 722 | ||
| 2. What are the established techniques for repairing the human face? | 722 | ||
| 3. Can you estimate the size of the skin needed to cover an entire face, scalp, front of neck, and ears? | 722 | ||
| 4. What types of face allotransplantations have been defined thus far? | 722 | ||
| 5. Name the current surgical and technical protocols of face allotransplantation? | 722 | ||
| 6. What are the goals of performing a face allotransplantation procedure? | 723 | ||
| 7. Which vessels are used for vascularization of the face allotransplant? | 723 | ||
| 8. Which nerves should be included in a facial/scalp allotransplant? | 723 | ||
| 9. Organ transplantations are commonly performed all over the world. Is there any difference between these transplantations and face transplantation? | 723 | ||
| 10. The face allograft includes diverse tissues such as skin, muscle, tendon, nerve, bone, and vessels. Which of these tissues express the highest antigenicity? | 723 | ||
| 11. What is the current immunosuppressive protocol used in the face allotransplantation? | 723 | ||
| 12. What methods are used to evaluate the signs of face allograft rejection? | 723 | ||
| 13. What are the earliest clinical signs of rejection seen in face allotransplantation? | 723 | ||
| 14. Describe the types of rejection of allograft transplants. | 724 | ||
| 15. What are the major causes of sensitization of the recipient facilitating the hyperacute/accelerated rejection? | 724 | ||
| 16. What is the treatment of choice when signs of rejection are present? | 724 | ||
| 17. What is the treatment of choice in acute rejection, if the initial treatment fails? | 724 | ||
| 18. What is the treatment of choice for chronic rejection? | 724 | ||
| 19. What is the estimated risk of acute and chronic face allotransplant rejection? | 724 | ||
| 20. What are the long-term side effects of the immunosuppressants used in facial allotransplantation? | 724 | ||
| 21. What factors influence the success rate of a face allotransplantation? | 724 | ||
| 22. What would be the fate of the patient if the face allograft is lost? | 725 | ||
| 23. What are the pretransplant assessments of candidates for facial allotransplantation? | 725 | ||
| 24. What should be included in the informed consent for candidates for facial allotransplantation? | 725 | ||
| 25. What are the next steps in the recovery of the patient who has undergone facial allotransplantation surgery? | 725 | ||
| Bibliography | 725 | ||
| Chapter 113: Principles of Hand Transplantation | 727 | ||
| 1. What is the first comprehensive account of upper extremity transplantation? | 727 | ||
| 2. Who performed the first hand transplantation under immunosuppression? | 727 | ||
| 3. Which team performed the second hand transplant in history? | 727 | ||
| 4. How many hand transplants have been performed around the world? | 727 | ||
| 5. The longest surviving hand transplant belongs to which patient? | 727 | ||
| 6. What is the overall graft and patient survival in recipients on immunosuppressive therapy? | 727 | ||
| 7. Explain the terms “induction” therapy and “maintenance” therapy. | 727 | ||
| 8. If the “ideal” immunosuppressive drug was available, how would you describe it? | 727 | ||
| 9. Define the term “acute” rejection. How is it classified or scored? | 728 | ||
| 10. Explain the importance of the human leukocyte antigen transplant rejection. | 728 | ||
| 11. Why is prior “sensitization” of recipients to donor HLA antigens a problem in hand transplantation? | 730 | ||
| 12. How is presence of anti-HLA antibodies measured, and what is their significance? | 730 | ||
| 13. Describe the phenomenon of “chronic” rejection. | 730 | ||
| 14. What are some immunologic and nonimmunologic factors that play a role in the etiopathogenesis of CR? | 730 | ||
| 15. Have any hand transplants been lost to rejection? | 730 | ||
| 16. How is the term “chimerism” defined? What is the difference between microchimerism and macrochimerism? | 730 | ||
| 17. Have any hand transplant recipients thus far shown evidence of chimerism? What about graft-versus-host disease? | 731 | ||
| 18. List the specific criteria that are used to select donors and recipients for hand transplantation. | 731 | ||
| 19. What is the International Registry of Hand and Composite Tissue Transplantation? | 731 | ||
| 20. Describe the effects of tacrolimus on nerve regeneration. | 731 | ||
| 21. In the United States, retrieval of donor organs/tissues is managed and controlled by OPOs. What does this acronym refer to? | 731 | ||
| 22. Describe the phenomenon of “brain plasticity” that has been observed after hand transplantation. | 731 | ||
| 23. How is hand transplantation different from replantation? What distinguishes it from solid organ transplants? | 731 | ||
| 24. Briefly describe the salient aspects of functional rehabilitation and assessment after hand transplantation. | 731 | ||
| 25. What are the important ethical considerations in undertaking hand transplantation? | 732 | ||
| 26. Can you elucidate the psychiatric evaluations that are necessary during recipient screening or follow-up? | 733 | ||
| 27. What complications have been noted in hand transplant recipients to date? | 733 | ||
| 28. What is one very special consideration in hand transplantation that may have implications on recipient identity? | 733 | ||
| 29. How can hand transplantation become a widespread clinically acceptable reconstructive option for upper extremity limb loss? | 733 | ||
| Bibliography | 734 | ||
| Section XI: The Hand and Upper Extremity | 735 | ||
| Chapter 114: Anatomy of the Hand | 737 | ||
| 1. What is the thickest skin in the hand? | 737 | ||
| 2. Why are most significant hand burns on the dorsum? | 737 | ||
| 3. Why can we get away with single layer closure in the palm? | 737 | ||
| 4. Does the thick stratum corneum affect the technique of skin closure in any other way? | 737 | ||
| 5. How is the palmar skin so firmly fixed in place? | 737 | ||
| 6. Name the three planes of the palmar fascia. | 737 | ||
| 7. Which of the three palmar fascia planes is never involved in Dupuytren’s disease? | 737 | ||
| 8. Does the palmar fascia extend into the fingers? | 737 | ||
| 9. What is the “assembly line”? | 737 | ||
| 10. What are the “checkrein ligaments”? | 737 | ||
| 11. Name two unique types of infection on the palmar side of the hand that are due to the firm fixation of the skin to underlying structures. | 738 | ||
| 12. Name another closed compartment in the hand in which bacterial infections can develop. | 738 | ||
| 13. What are the other closed spaces associated with infections? | 738 | ||
| 14. How can these compartments communicate with each other with the spread of an infection? | 738 | ||
| 15. Can the ulnar- and radial-sided synovial systems communicate? | 738 | ||
| 16. How does the unique anatomy of the fingertip shape the development of a paronychia? | 739 | ||
| 17. Can a felon spread around the distal phalanx and become a paronychia? Can a paronychia spread around the nail plate into the palmar pulp and become a felon? | 739 | ||
| 18. Which tissues contribute to growth of the nail plate? | 739 | ||
| 19. What is the lunula? | 739 | ||
| 20. What is the safe position for splinting the hand? | 739 | ||
| 21. Why is flexion the safe position for the MP joint? | 739 | ||
| 22. If flexion is the safe position for the MP joint, what do you do if you have to splint the joint in extension, as for extensor tendon repairs or palmar fascia excision for Dupuytren’s disease? | 740 | ||
| 23. Why is extension the safe position for the IP joints? | 740 | ||
| 24. The IP joint can be thought of as a box, with the articular surfaces of the phalanges forming the proximal and distal ends. What forms the other sides? | 740 | ||
| 25. Which is the most mobile carpometacarpal joint? | 740 | ||
| 26. Which are the least mobile CMC joints? | 740 | ||
| 27. What is the last muscle innervated by the ulnar nerve as it courses through the palm? | 740 | ||
| 28. What major peripheral nerve is responsible for extension of the thumb IP joint? | 741 | ||
| 29. How can you test for function of the EPL? | 741 | ||
| 30. There is much crossover of sensory innervation in the hand. Where do the median, ulnar, and radial sensory nerves supply sensibility with the least chance of crossover from neighboring territories? | 741 | ||
| 31. Where is the one place on the hand where all three sensory nerves may be expected to provide maximal crossover innervation? | 741 | ||
| 32. What three vascular arches provide anastomotic connections between the radial and ulnar blood supplies? | 741 | ||
| 33. Despite proper tourniquet application, the wound begins to bleed during repair of a spaghetti wrist. Why? | 741 | ||
| 34. How can you test the integrity of the vascular anastomotic connections between the two sides of the hand? | 741 | ||
| 35. What are the boundaries of the carpal tunnel? | 741 | ||
| 36. How many structures traverse the carpal tunnel? | 741 | ||
| 37. What are the boundaries of Guyon’s canal? | 741 | ||
| 38. Is the primary blood supply of the scaphoid distal or proximal? | 741 | ||
| 39. What are the six dorsal extensor compartments of the wrist? | 742 | ||
| 40. Which extrinsic tendons insert into carpal bones? | 742 | ||
| 41. When is the ECU not primarily an extensor of the wrist? | 742 | ||
| 42. Name the four insertions of the extrinsic extensor tendon. | 742 | ||
| 43. How do you identify the proprius tendons of the index and little fingers? | 742 | ||
| 44. What is the anatomic snuffbox? | 743 | ||
| 45. What is the retinacular system of the extensor mechanism? | 743 | ||
| 46. How do the lumbricals assist in IP joint extension? | 743 | ||
| 47. What is the primary flexor of the MP joint? | 743 | ||
| 48. What is the primary extender of the MP joint? | 744 | ||
| 49. Which extends the IP joint: the extrinsic system or the intrinsic system? | 744 | ||
| 50. When the intrinsic muscles are paralyzed, how is the finger affected? | 744 | ||
| 51. Which interosseous muscles are innervated by the median nerve? | 744 | ||
| 52. Which of the interosseous muscles abduct the fingers? Which adduct them? | 744 | ||
| 53. What does the oblique retinacular ligament do? | 744 | ||
| 54. What happens to the ORL in a boutonnière deformity? | 744 | ||
| 55. How, then, can the DIP joint be flexed while maintaining extension of the PIP joint, which would have to stretch the ORL? | 744 | ||
| 56. What is the smallest extrinsic flexor tendon? | 744 | ||
| 57. Which interosseous muscles have insertions into the bases of the proximal phalanges? | 744 | ||
| 58. Where else do the interosseous muscles insert? | 744 | ||
| 59. Which individual structures are maintained in dorsal position by the transverse retinacular ligament of Landsmeer? | 744 | ||
| 60. Which are the most important pulleys in the fibroosseous tunnel? | 745 | ||
| 61. Why do the profundus tendons usually not retract into the palm after transection in the fingers? | 745 | ||
| 62. Why can you not pull a superficialis tendon out through a palmar incision if you release it from its insertions in the middle phalanx? | 745 | ||
| 63. How is the long vinculum of the profundus tendon related to the short vinculum of the superficialis? | 745 | ||
| 64. Where in the tendon is the longitudinal intrinsic blood supply? | 745 | ||
| 65. How are the flexor tendons arranged in the carpal tunnel? | 745 | ||
| 66. How often is the palmaris longus tendon absent? | 745 | ||
| 67. What is the second most useful tendon for grafting in the hand? | 745 | ||
| 68. If the two primary tendon graft donors are missing, what is still available? | 745 | ||
| Bibliography | 746 | ||
| Chapter 115: Physical Examination of the Hand | 747 | ||
| 1. It takes 2 months for a complete nail plate to grow. True or false? | 747 | ||
| 2. Is it useful to have a proximal nail fold? | 747 | ||
| 3. What is the Hutchinson’s sign? What does it mean? | 747 | ||
| 4. What is the function of nails? | 747 | ||
| 5. What is the best test to appreciate the functional sensibility of the hand? | 747 | ||
| 6. How can you appreciate the sensory discrimination of a finger pulp? | 747 | ||
| 7. What is the normal value for the two-point discrimination test at the pulp of the finger? | 747 | ||
| 8. Why do patients with a low ulnar nerve palsy often have permanent abduction of the small finger? What is the name of this deformity? | 747 | ||
| 9. How do you test the flexor digitorum profundus tendons? | 748 | ||
| 10. How do you test the flexor digitorum superficialis tendons of the fingers? | 748 | ||
| 11. If I try to test the FDS of the little finger as described in Question 10, why does the patient flex only the MP joint and not the PIP joint? | 749 | ||
| 12. How can you determine whether there is an FDS in the index finger if the FDP of the index is independent? | 749 | ||
| 13. In patients with rheumatoid arthritis who are unable to extend the ulnar three digits, what are the possible diagnoses? | 749 | ||
| 14. How can you determine that the extensor pollicis longus tendon is intact and functional? | 749 | ||
| 15. If flexion of the MP joint is limited, how can you determine whether the extensor tendons are adherent at the dorsum of the hand or at the wrist level? | 749 | ||
| 16. What is Allen’s test? How do you perform it? | 749 | ||
| 17. How do you determine a rotational deformity of the finger: in flexion or in extension? | 749 | ||
| 18. Why is DIP joint flexion more important when the PIP joint is flexed than when the PIP joint is extended? | 749 | ||
| 19. In patients experiencing stiffness with extension of the PIP joint, which clinical test identifies contracture of the interosseous muscles? | 750 | ||
| 20. Which clinical test is specific for de Quervain’s tenosynovitis? How is it performed? | 750 | ||
| 21. Which clinical signs are suggestive of flexor carpi radialis tendinitis? | 751 | ||
| 22. If the IP joint of the thumb is flexed, why does the DIP joint of the index finger flex simultaneously? | 751 | ||
| 23. In a patient who has sprained an MP joint, how can you diagnose a ligamentous rupture with instability? | 751 | ||
| 24. What are the etiologies of a swan neck deformity of the fingers? | 751 | ||
| Bibliography | 752 | ||
| Chapter 116: Radiologic Examination of the Hand | 753 | ||
| 1. Who performed the first radiograph of the hand? | 753 | ||
| 2. Name some of the most common causes of diagnostic errors in interpreting radiographs of the hand after trauma. | 753 | ||
| 3. What is Brewerton’s view? | 753 | ||
| 4. Why is Rolando’s fracture considered a significant injury? | 753 | ||
| 5. How are intraarticular fractures of the base of the phalanges classified? | 754 | ||
| 6. List the radiographic hallmarks of rheumatoid arthritis (Fig. 116-3). | 754 | ||
| 7. How can the ulnar deviation deformity of rheumatoid arthritis be explained? | 754 | ||
| 8. What is the pattern of involvement of primary osteoarthritis? | 754 | ||
| 9. Which is the most common benign bone tumor of the hand? | 754 | ||
| 10. Why is the finding of multiple enchondromas significant? | 754 | ||
| 11. Which is the most common malignant bone tumor of the hand? | 755 | ||
| 12. Besides metastases and enchondromas, what is included in the differential diagnosis of multiple lytic bone lesions in the hand and wrist? | 755 | ||
| 13. What disorder typically produces well-defined erosions with overhanging margins? | 755 | ||
| 14. Which disease is characterized by the combination of periarticular soft tissue calcification and subperiosteal bone resorption? | 755 | ||
| 15. List the major causes of a short fourth metacarpal. | 755 | ||
| 16. What is the best way to image complex regional pain syndrome? | 755 | ||
| 17. Does ultrasound have a role in imaging tendons? | 756 | ||
| 18. Is magnetic resonance imaging useful in staging soft tissue tumors? | 756 | ||
| Controversies | 757 | ||
| Bibliography | 757 | ||
| Chapter 117: Anesthesia For Surgery of the Hand | 758 | ||
| Anatomy And Techniques | 758 | ||
| 1. Describe the relevant anatomy for upper extremity brachial plexus blocks. | 758 | ||
| 2. What is the concept of “plexus anesthesia”? | 758 | ||
| 3. What parts of the brachial plexus are anesthetized by the interscalene, subclavianperivascular, infraclavicular, and axillary techniques of brachial plexus block? | 759 | ||
| 4. What is the interscalene groove, and how is it located? | 759 | ||
| 5. Although the block needle enters the interscalene groove for both the interscaleneand subclavian perivascular blocks, the needle direction differs for the two blocks.Describe the needle direction for each. | 759 | ||
| 6. How is the correct location of the needle in the interscalene or subclavianperivascular space identified? | 759 | ||
| 7. Besides the subclavian perivascular and interscalene blocks, what other brachialplexus blocks are performed above the clavicle? Describe how these blocks areperformed. | 759 | ||
| 8. How is an infraclavicular block done? | 759 | ||
| 9. What other techniques of infraclavicular block are described, and how are theyperformed? | 759 | ||
| 10. Describe the axillary technique of brachial plexus block. | 759 | ||
| 11. Besides a nerve stimulator, what additional tool is being used to facilitate placementof brachial plexus blocks? | 760 | ||
| 12. What is the “multiple compartment” concept? | 760 | ||
| 13. What is the advantage of using a catheter technique for brachial plexus block, andhow is it done? | 760 | ||
| Choice Of Local Anesthetic | 760 | ||
| 14. What determines the choice of local anesthetic for brachial plexus block? | 760 | ||
| 15. What is ropivacaine, and what is its advantage over bupivacaine? | 761 | ||
| 16. What is the purpose of “alkalinization” of a local anesthetic? | 761 | ||
| Complications Of Brachial Plexus Block | 761 | ||
| 17. What are some potential complications associated with interscalene block? | 761 | ||
| 18. What is the mechanism of phrenic nerve block, how can it be diagnosed, and howcommon is it following interscalene block? | 761 | ||
| 19. How is injection into the vertebral artery and epidural or subarachnoid spacesavoided with an interscalene block? | 761 | ||
| 20. If the subclavian artery is punctured when performing a subclavian perivascularblock, the block needle should be redirected in which direction to locate the brachialplexus trunks? | 761 | ||
| 21. How is the risk of pneumothorax minimized when performing a subclavianperivascular block? | 761 | ||
| 22. How is a pneumothorax treated if it develops as a complication of interscalene orsubclavian perivascular brachial plexus block? | 761 | ||
| 23. What nerve distribution is frequently missed when an interscalene block is performed? | 762 | ||
| 24. Name some advantages of axillary block compared with interscalene or subclavianperivascular block. | 762 | ||
| 25. What nerves are frequently missed with an axillary block and why? | 762 | ||
| 26. If a postoperative nerve deficit develops and you suspect it may have been causedby the anesthetic, what should be done? | 762 | ||
| Blocks Around The Elbow | 762 | ||
| 27. Describe how the ulnar, median, and radial nerves can be blocked around the elbow. | 762 | ||
| Wrist Blocks | 762 | ||
| 28. How are wrist blocks performed? | 762 | ||
| Digital Nerve Blocks | 763 | ||
| 29. Why should a ring block for anesthetizing a digit be avoided? | 763 | ||
| 30. How can a digital block be obtained? | 763 | ||
| Intravenous Regional Anesthesia (Bier Block) | 763 | ||
| 31. Describe the technique for performing a Bier block. | 763 | ||
| 32. What are the advantages of a Bier block? | 763 | ||
| 33. List some disadvantages of the Bier block technique. | 763 | ||
| Bibliography | 764 | ||
| Chapter 118: Congenital Anomalies | 765 | ||
| 1. At what age of development does the limb bud appear? When are digital rays evident? | 765 | ||
| 2. What does syndactyly mean? Is it the most common congenital anomaly? | 765 | ||
| 3. What type of correction is best for syndactyly? | 765 | ||
| 4. What are the principles of syndactyly correction? | 765 | ||
| 5. What are the most common problems after syndactyly correction? | 765 | ||
| 6. What is the most important web space in the hand? | 765 | ||
| 7. What is the best method for surgical release of the first web space? | 766 | ||
| 8. What contributes to thumb–index contracture? | 766 | ||
| 9. How is syndactyly clinically classified? | 766 | ||
| 10. Do children need more surgery after syndactyly repair? | 766 | ||
| 11. Geneticists and pediatricians use the terms malformation, deformation, and disruption. What do they mean? | 766 | ||
| 12. What is the relative incidence of congenital hand duplications? How are they clinically classified? | 767 | ||
| 13. Is any special workup needed in newborns with a duplication? | 767 | ||
| 14. How do you treat a newborn in the nursery with a type I floppy nubbin attached to the fifth finger? | 768 | ||
| 15. Which side of a thumb duplication should be preserved? | 768 | ||
| 16. What are the basic principles of thumb duplication correction? | 768 | ||
| 17. What do you tell parents after a thumb duplication correction? Will the thumb be normal? | 768 | ||
| 18. What are the genetics and incidence of the constriction ring syndrome? | 768 | ||
| 19. What anatomic features distinguish CRS from other congenital anomalies of the upper limb? | 768 | ||
| 20. What other terms have been used to describe CRS? | 768 | ||
| 21. What is a constriction ring or anular (ring) band? | 769 | ||
| 22. How is CRS treated? | 769 | ||
| 23. Why are transverse absences associated with CRS ideal for toe-to-thumb transfers? | 769 | ||
| 24. What does symphalangism mean? What are the more common clinical presentations? | 769 | ||
| 25. How is symphalangism treated? | 769 | ||
| 26. In what position should PIP joints be fused? | 769 | ||
| 27. How can IP joints be reconstructed? | 769 | ||
| 28. What is the difference between clinodactyly and camptodactyly? | 769 | ||
| 29. What is the main anatomic problem in camptodactyly? | 770 | ||
| 30. What are the radiologic signs of congenital camptodactyly? | 770 | ||
| 31. What are the indications for joint release in camptodactyly? | 770 | ||
| 32. What is the differential diagnosis of bilateral flexion deformities of the thumb? | 770 | ||
| 33. When should a trigger thumb be released surgically? | 770 | ||
| 34. What is the worst complication of a trigger release? | 770 | ||
| 35. What conditions should be considered in a child born with gross enlargement of a digit? | 770 | ||
| 36. What is the workup for macrodactyly? | 771 | ||
| 37. What is the difference between hemangioma and vascular malformation? | 771 | ||
| 38. Outline the five types of hypoplastic thumbs. | 771 | ||
| 39. What are the possible options for reconstruction of type 3B thumbs? | 771 | ||
| 40. What are the long-term functional limitations of a well-performed pollicization procedure? | 771 | ||
| 41. Describe the hand in patients with Apert syndrome. | 771 | ||
| 42. What is Poland syndrome? | 772 | ||
| 43. How is the chest wall reconstructed in children with Poland syndrome? | 772 | ||
| 44. What is the most persistent request of girls with Poland syndrome? | 772 | ||
| 45. A child is born with impending gangrene of portions of one or both forearms. What condition does the child have? What type of workup is indicated? | 772 | ||
| 46. What is Holt-Oram syndrome? | 772 | ||
| 47. What single operation is most beneficial for patients with a congenital hand anomaly? | 772 | ||
| 48. Describe the hand in a child with Freeman-Sheldon syndrome. | 772 | ||
| 49. A child presents with a swollen hand and forearm and an associated neck mass diagnosed as a “cystic hygroma.” What is the underlying pathophysiology? | 772 | ||
| 50. What is the difference between a typical and atypical cleft hand? | 773 | ||
| 51. Describe the upper limb in a child with severe arthrogryposis multiplex congenita. | 773 | ||
| Bibliography | 773 | ||
| Chapter 119: The Pediatric Hand | 774 | ||
| 1. How are the flexor tendons examined in an uncooperative or unconscious pediatric patient? | 774 | ||
| 2. How is sensation evaluated in young children? | 774 | ||
| 3. What is the O’Raine test? | 774 | ||
| 4. Why is a laceration of palmaris longus of special significance? | 774 | ||
| 5. What is a Kirner deformity? A pseudoepiphysis? The Pseudo-Terry Thomas sign? What is their significance? | 774 | ||
| 6. Why is an understanding of carpal, metacarpal, and phalangeal ossification patterns essential in diagnosing and treating pediatric hand fractures? | 775 | ||
| 7. What is a Seymour fracture? | 775 | ||
| 8. How are long bone fractures of the hand in children described and classified? | 776 | ||
| 9. Why are Salter-Harris type III fractures of the middle phalanx rare and Salter-Harris III fractures of proximal phalanx relatively common? | 776 | ||
| 10. How are metacarpal base, shaft, neck, and epiphyseal fractures treated? | 776 | ||
| 11. How much angulation of the metacarpal neck will be remodeled and therefore should be tolerated in children? | 776 | ||
| 12. How are phalangeal fractures treated in children? | 776 | ||
| 13. What is the “extra-octave fracture” and how is it fixed? What is a “cartilaginous cap” fracture? | 777 | ||
| 14. What is the most common carpal fracture in children, and how does fracture of this bone differ between children and adults? | 777 | ||
| 15. What is the youngest reported case of scaphoid fracture? | 777 | ||
| 16. When should a scaphoid fracture be suspected, and how is it radiologically diagnosed? | 777 | ||
| 17. What concomitant injuries are often associated with scaphoid fracture? | 777 | ||
| 18. What is the proper course of action if the clinical suspicion of scaphoid fracture is high and radiographic evidence is low? | 777 | ||
| 19. What are the three types of scaphoid fracture? | 778 | ||
| 20. What is the blood supply to the scaphoid, and why is this important? | 778 | ||
| 21. How are scaphoid fractures in children treated, and how is nonunion managed? | 778 | ||
| 22. What is the most frequent level of digital amputation in the pediatric population, and what is the youngest age at which replantation is contraindicated? | 778 | ||
| 23. What is the Allen classification of fingertip injuries? Discuss one special consideration of each type (Fig. 119-3). | 778 | ||
| 24. What is the typical order for finger tip replantation in children? Discuss one special consideration for each step. | 779 | ||
| 25. What is Volkmann’s ischemic contracture, what injury is most likely to cause it, and how is it treated? | 779 | ||
| 26. How is an impending compartment syndrome recognized? What are the signs of an acute compartment syndrome? | 779 | ||
| 27. List five major concepts in diagnosing and managing vascular tumors of the hand. | 779 | ||
| 28. When do pediatric hand burns typically need grafting? | 779 | ||
| 29. Which type of graft is most effective for grafting the hand: Split thickness or full thickness? | 779 | ||
| 30. How are hand contractures classified? | 780 | ||
| 31. What are the basic principles of contracture release in the pediatric hand? | 780 | ||
| Bibliography | 780 | ||
| Chapter 120: Problems Involving the Perionychium | 781 | ||
| 1. Describe fingernail anatomy and fingernail production. | 781 | ||
| 2. What function does the fingernail serve? | 781 | ||
| 3. Describe the surrounding structures and their importance. | 781 | ||
| 4. What is the lunula? | 781 | ||
| 5. What is the blood supply of the nail bed? | 781 | ||
| 6. What is the rate of nail growth? | 781 | ||
| 7. How is growth rate impacted by nailbed injury? | 781 | ||
| 8. What is the most common source of nail bed injuries? | 782 | ||
| 9. Which digit is most commonly injured? | 782 | ||
| 10. Describe several nail changes associated with trauma. | 782 | ||
| 11. What is the significance of a subungual hematoma? | 782 | ||
| 12. What are the different products that may be used as nail substitute/stent following injury? | 782 | ||
| 13. What is the most appropriate management in the case of delayed presentation of acute injuries to the nailbed? | 782 | ||
| 14. Describe several common nail changes that are manifestations of systemic disease. | 782 | ||
| 15. What are the usual patterns of infection associated with the fingernail? | 782 | ||
| 16. What are the most common benign periungual tumors? | 783 | ||
| 17. What is the glomus body? | 783 | ||
| 18. What is the differential diagnosis for pigmented subungual lesions? | 783 | ||
| 19. What are melanonychia striata? | 783 | ||
| 20. What is the current surgical therapy for nail apparatus melanoma? | 783 | ||
| 21. Is there a role for adjuvant therapy in NAM? | 783 | ||
| Bibliography | 784 | ||
| Chapter 121: Fingertip Injuries | 785 | ||
| 1. Which is the most frequently injured finger? | 785 | ||
| 2. Where is the greatest quantity of dermal lymphatics in the human body? | 785 | ||
| 3. What is the anatomic significant of the lunula? | 785 | ||
| 4. What is the clinical significance of the lunula? | 785 | ||
| 5. What are the goals for reconstruction of fingertip injuries? | 785 | ||
| 6. What are the reconstructive options? | 785 | ||
| 7. Do most injuries involving primarily skin loss from the fingertip heal better with skin grafts? | 785 | ||
| 8. Does conservative treatment result in a greater period of unfitness for work? | 785 | ||
| 9. If the nail has been destroyed, why not just shorten the digit to the level of the distal interphalangeal joint? | 785 | ||
| 10. Describe the lumbrical-plus finger. | 785 | ||
| 11. Why not preserve the profundus function and pad the stump by suturing it to the extensor tendon? | 786 | ||
| 12. Which local flap is most suitable for reconstruction of multiple fingertip injuries on the same hand? | 786 | ||
| 13. What vital structure is susceptible to injury during elevation of a thenar flap? | 786 | ||
| 14. Some authors have worried about permanent joint contractures after thenar flap use and cautioned against this technique in older patients. Is such concern warranted? | 786 | ||
| 15. Neglect of what key technical element in direct closure of a digital amputation typically results in a persistently painful finger? | 786 | ||
| 16. Anesthesia for fingertip injuries usually is accomplished by digital nerve block. What measures can significantly decrease the pain associated with local injection? | 786 | ||
| 17. What is glabrous skin? | 786 | ||
| 18. Are there any tricks to obtaining a graft of uniform thickness? | 786 | ||
| 19. Describe the terminal vascular anatomy of the finger. | 786 | ||
| 20. Do neurovascular island flaps eventually integrate sensorally with their new site after transfer? | 787 | ||
| 21. Aside from local flaps, what other techniques can be used to correct soft tissue losses to the fingertip? | 787 | ||
| 22. Cold intolerance after fingertip injury is common. When does it resolve? | 787 | ||
| 23. How is sensibility affected after advancement flap reconstruction of the fingertip? | 787 | ||
| 24. Flaps are composite tissues intended to replace missing soft tissues (and occasionally muscle, bone, or cartilage) with similar components. Their common denominator, when successful, is patency of arterial inflow and venous outflow. Associate the follow | 787 | ||
| 25. Is there a method of systematically describing fingertip injuries? | 787 | ||
| 26. Is composite grafting a reliable method for managing fingertip amputations? | 788 | ||
| 27. What factors have the greatest impact on composite graft survival in fingertip injuries? | 788 | ||
| 28. Is replantation possible in distal tip amputations? | 788 | ||
| 29. Match Figures 121-1 through 121-5 with the following flaps: | 788 | ||
| Bibliography | 791 | ||
| Chapter 122: Metacarpal And Phalangeal Fractures | 792 | ||
| 1. Describe the epidemiology of fractures of the metacarpals and phalanges. | 792 | ||
| 2. What is the distribution of fractures according to location? | 792 | ||
| 3. How are fractures classified? | 792 | ||
| 4. Describe the initial evaluation of patients with hand fractures. | 792 | ||
| 5. How is rotation of a finger fracture evaluated? | 792 | ||
| 6. What type of radiographs should be obtained? | 792 | ||
| 7. What is the Salter-Harris classification of epiphyseal injuries in children? | 792 | ||
| 8. What is a Seymour fracture? | 793 | ||
| 9. Describe the general principles for management of hand fractures. | 793 | ||
| 10. How are stable fractures managed? | 793 | ||
| 11. What is an unstable fracture? | 793 | ||
| 12. How are unstable fractures managed? | 794 | ||
| 13. What is the safe position for immobilization of the hand? Why is this important? | 794 | ||
| 14. Describe the different methods of internal fixation. | 794 | ||
| 15. What is the apex dorsal bending rigidity (Newton-meters) for the different internal fixation techniques in metacarpal fractures? | 794 | ||
| 16. What are the indications for internal fixation? | 794 | ||
| 17. What are the advantages of K-wire fixation? | 795 | ||
| 18. What are the disadvantages of K-wire fixation? | 795 | ||
| 19. How soon can motion be started? | 795 | ||
| 20. How long do fractures requiring open reduction or severely comminuted fractures with disruption of the periosteum take to heal? | 795 | ||
| 21. Describe the treatment of extraarticular fractures of the distal phalanx. | 795 | ||
| 22. What are the deforming forces in extraarticular fractures of the middle phalanx? | 795 | ||
| 23. What are the deforming forces in extraarticular fractures of the proximal phalanx? How are they treated? | 795 | ||
| 24. How are closed diaphyseal fractures of the phalanges treated? | 795 | ||
| 25. What are the complications of phalangeal fractures? | 796 | ||
| 26. What is the best view for diagnosing metacarpal head fractures? | 796 | ||
| 27. How are metacarpal head fractures treated? | 796 | ||
| 28. What are possible complications of metacarpal head fractures? | 797 | ||
| 29. What is a boxer’s fracture? | 797 | ||
| 30. What is the Jahss maneuver? | 797 | ||
| 31. How much angulation can be accepted in metacarpal neck fractures? How are they treated? | 797 | ||
| 32. How are metacarpal shaft fractures treated? | 797 | ||
| 33. What are the complications of metacarpal fractures? | 798 | ||
| 34. What is a Bennett fracture? | 798 | ||
| 35. What is the epidemiology of Bennett fractures? | 798 | ||
| 36. How are Bennett fractures treated? | 798 | ||
| 37. What is a reverse Bennett fracture? | 798 | ||
| 38. What is a Rolando fracture? | 798 | ||
| 39. What role does the CMC joint of the little finger play? | 799 | ||
| 40. How are open fractures treated? | 799 | ||
| 41. How are fractures with segmental bone loss treated? | 799 | ||
| 42. What is the “lag screw” technique of interfragmentary compression? | 799 | ||
| Bibliography | 799 | ||
| Chapter 123: Joint Dislocations and Ligament Injuries | 800 | ||
| 1. Explain the difference between true collateral and accessory collateral ligaments. | 800 | ||
| 2. What soft tissue structures provide stability to the proximal interphalangeal joint? | 800 | ||
| 3. How is the functional stability of a joint tested? | 800 | ||
| 4. What are the three types of dorsal PIP dislocations? | 800 | ||
| 5. What is the treatment for chronic PIP dorsal subluxations? | 801 | ||
| 6. What soft tissue injuries may occur with palmar PIP dislocation? | 801 | ||
| 7. What structure is primarily involved in posttraumatic fibrosis of the PIP joint? | 801 | ||
| 8. Are dislocations of the finger DIP and thumb interphalangeal joints common? | 801 | ||
| 9. With an injury to another part of the hand, what anatomic difference between the metacarpophalangeal (MCP) and PIP joints accounts for MCP joints being immobilized in flexion and PIP joints in extension? | 801 | ||
| 10. Describe the anatomic structures that contribute to a complex or irreducible MCP joint dislocation. | 801 | ||
| 11. Do digital carpometacarpal dislocations occur? | 801 | ||
| 12. What is a gamekeeper’s thumb? | 802 | ||
| 13. What is a Stener lesion? | 802 | ||
| 14. Is it clinically important to differentiate between partial and complete ruptures of the thumb MCP UCL? | 802 | ||
| 15. What soft tissue structure provides the most stability to the thumb CMC joint? | 802 | ||
| 16. Does joint subluxation occur at the thumb CMC joint? | 803 | ||
| 17. What is the most common complication following joint or ligament injury? | 803 | ||
| Bibliography | 803 | ||
| Chapter 124: Small Joint Arthrodesisand Arthroplasty | 804 | ||
| Small Joint Arthrodesis | 804 | ||
| 1. What are the indications for small joint arthrodesis? | 804 | ||
| 2. Describe the ideal position for fusion of the metacarpophalangeal, proximalinterphalangeal, and distal interphalangeal joints of the index, middle, ring, and littlefingers. | 804 | ||
| 3. What is the ideal position for fusion of the MP and IP joints of the thumb? | 804 | ||
| 4. A stiff finger is less cumbersome if it is slightly shorter, right? | 804 | ||
| 5. What general principles must be adhered to so that a successful fusion can beobtained? | 804 | ||
| 6. What are the internal fixation techniques available for small joint arthrodesis? | 805 | ||
| 7. Which internal fixation technique should be used? | 805 | ||
| 8. Discuss the situations when external fixation may be needed for arthrodesis. | 805 | ||
| 9. Is bone grafting necessary for small joint fusions? | 806 | ||
| 10. Should all chronic mallet deformities be fused? | 806 | ||
| 11. Is small joint arthrodesis ever performed in children with open physes? | 807 | ||
| 12. It is impossible to perform a digital fusion in children without interfering with digitalgrowth. True or false? | 807 | ||
| 13. What are the most common complications encountered with small joint arthrodesis? | 807 | ||
| 14. What are the most important considerations for a successful small joint arthrodesis? | 807 | ||
| Small Joint Arthroplasty | 808 | ||
| 15. What should be considered when choosing arthroplasty versus arthrodesis? | 808 | ||
| 16. When is arthroplasty in the small joints of the hand indicated? | 808 | ||
| 17. What are some of the underlying conditions for which arthroplasty in the hand areperformed? | 808 | ||
| 18. Arthroplasty in the hand for RA is being performed less frequently. True or false? | 808 | ||
| 19. What are the contraindications to arthroplasty? | 808 | ||
| 20. Name the structures necessary for a stable arthroplasty. | 808 | ||
| 21. Describe the different types of arthroplasty most commonly performed. | 808 | ||
| 22. What is the average arc of motion after PIP joint arthroplasty? | 808 | ||
| 23. What is perichondral arthroplasty? | 809 | ||
| 24. Which type of arthroplasty should be performed? | 809 | ||
| 25. Discuss the common complications encountered with the use of silicone implants. | 809 | ||
| 26. What are the early and late complications associated with small joint arthroplasty? | 809 | ||
| 27. What are the most important considerations for a successful small jointarthroplasty? | 810 | ||
| Bibliography | 810 | ||
| Chapter 125: Flexor Tendon Injuries | 811 | ||
| 1. Should acute flexor tendon lacerations be repaired primarily? | 811 | ||
| 2. What is the orientation of the flexor digitorum profundus and flexor digitorum superficialis tendons at the level of the proximal phalanx? | 811 | ||
| 3. Where does the flexor tendon sheath begin and end in the digit? Where are the various pulleys or thickened areas of the flexor sheath located? | 811 | ||
| 4. What are the two ways in which flexor tendons receive nutrition? | 811 | ||
| 5. What two areas of cellular activity contribute to flexor tendon healing? | 811 | ||
| 6. What is the effect of stress on healing tendons? | 812 | ||
| 7. During what period are flexor tendons weakest after repair? | 812 | ||
| 8. List three factors that may lead to tendon adhesion formation. | 812 | ||
| 9. What factors contribute to the strength of a repaired flexor tendon laceration? | 812 | ||
| 10. What causes gapping at the repair site? How does it affect tendon healing? | 812 | ||
| 11. How can the tendency for gapping at the repair site be decreased? | 812 | ||
| 12. What are the most commonly used techniques for flexor tendon repair? | 812 | ||
| 13. Describe the zones of flexor tendon injury. | 813 | ||
| 14. If the FDS is lacerated in a zone II flexor tendon injury, should it be repaired? | 814 | ||
| 15. In zone II flexor tendon laceration repairs, what area of the sheath can be opened for repair? What areas should be preserved? | 814 | ||
| 16. How do you retrieve a proximal tendon end that has retracted proximally down the tendon sheath? | 814 | ||
| 17. When the proximal ends of the lacerated FDS and FDP tendons retract into the palm, how can you correctly orient these tendons when they are brought out more distally into the digit? | 814 | ||
| 18. How should zone I FDP tendon avulsion injuries be repaired? | 815 | ||
| 19. Describe the three main types of avulsion injuries to the profundus tendon insertion. | 815 | ||
| 20. How should FDP avulsions in which the diagnosis is delayed for more than several months be treated? | 815 | ||
| 21. Should partial tendon lacerations be repaired? | 815 | ||
| 22. What are the indications for tenolysis after flexor tendon repair? | 816 | ||
| 23. What is the most frequent complication after early postoperative mobilization programs? | 816 | ||
| 24. How do ruptures occur after flexor tendon repairs? What is the treatment? | 816 | ||
| 25. Is a four-strand repair augmented by some type of running locked suture strong enough to allow early active motion therapy? | 816 | ||
| 26. When can strengthening exercises be initiated after flexor tendon repair and appropriate early therapy protocols? | 816 | ||
| 27. Outline the appropriate management of acute flexor tendon lacerations. | 817 | ||
| Controversies | 817 | ||
| Bibliography | 817 | ||
| Chapter 126: Extensor Tendon Injuries | 818 | ||
| 1. What are the eight zones commonly used to describe extensor tendon injuries? | 818 | ||
| 2. The thumb is typically divided into how many extensor zones? | 818 | ||
| 3. Do the extensor digiti minimi and extensor indicis proprius tendons run ulnar or radial to their respective communis tendons? | 818 | ||
| 4. Unlike the flexor tendons, the extensor tendons pass through discrete compartments at the level of the wrist. What is the orientation of the extensor tendons at the level of the wrist? | 818 | ||
| 5. Which muscles extend the MCP and IP joints? What is their innervation? | 819 | ||
| 6. Which finger and which zones are most commonly injured? | 819 | ||
| 7. Which general area has the better prognosis after extensor tendon injury: The proximal zone (V through VIII) or the distal zone (I through IV)? | 819 | ||
| 8. Following a crush injury to the hand, a man has limited flexion of his fingers. How do you determine whether this is due to intrinsic muscle fibrosis and scarring or due to extensor tendon adherence? | 819 | ||
| 9. What are the juncturae tendineae? | 820 | ||
| 10. What is a mallet finger or mallet deformity? | 820 | ||
| 11. What causes a mallet deformity? | 820 | ||
| 12. What are the different types of mallet fingers? | 820 | ||
| 13. How is a mallet finger treated? | 821 | ||
| 14. What is the most important consideration in extensor tendon repair: Strength of reconstruction or length of reconstruction? | 821 | ||
| 15. What is a boutonnière deformity? | 821 | ||
| 16. What is an acute boutonnière deformity? What biomechanical process produces it? How is it treated? | 821 | ||
| 17. What is the currently recommended repair technique for extensor tendons? | 821 | ||
| 18. What is the treatment protocol after extensor tendon repair? | 821 | ||
| Bibliography | 822 | ||
| Chapter 127: Tendon Transfers | 823 | ||
| 1. What is a tendon transfer? | 823 | ||
| 2. List the general principles of tendon transfers. | 823 | ||
| 3. How do you select the donor tendons? | 823 | ||
| 4. Does a muscle/tendon retain its strength after it is transferred? | 823 | ||
| Peripheral Nerve Injuries | 823 | ||
| 5. Which deficits in radial nerve palsy from a lesion at the midhumeral level requiretransfers? | 823 | ||
| 6. In a high radial nerve injury associated with a humeral fracture, is exploration of thenerve recommended? | 823 | ||
| 7. List the standard tendon transfers for radial nerve palsy. | 824 | ||
| 8. What area is affected by low median nerve palsy? What deficits are involved? | 824 | ||
| 9. What movements are necessary for effective thumb opposition? | 825 | ||
| 10. List the options for opposition transfers. | 826 | ||
| 11. Where do you insert your opposition transfer? | 826 | ||
| 12. What are the deficits in a high median nerve injury? | 826 | ||
| 13. List the standard tendon transfers for a high median nerve injury. | 826 | ||
| 14. What are the deficits in a low ulnar nerve palsy? | 828 | ||
| 15. What are the transfers for the correction of clawing? | 828 | ||
| 16. Which transfers primarily increase grip strength in the setting of a low ulnar nerveinjury? | 828 | ||
| 17. How can you restore thumb adduction? | 828 | ||
| 18. How can you restore index finger abduction? | 830 | ||
| 19. What is the transfer to correct abduction of the little finger (Wartenberg’s sign)? | 830 | ||
| 20. How might you improve sensibility in a low ulnar nerve injury? | 830 | ||
| 21. What are the deficits in a high ulnar nerve palsy? | 830 | ||
| 22. What are the standard tendon transfers for high ulnar nerve palsy? | 830 | ||
| Combined Nerve Injuries | 830 | ||
| 23. In a low median/ulnar nerve palsy (the most common combined nerve injury), whatare the key deficits? | 830 | ||
| 24. What are the recommended tendon transfers for reconstruction? | 830 | ||
| 25. What transfers, in addition to those for low median/ulnar nerve palsy, may be usefulin a high median/ulnar nerve palsy? | 831 | ||
| Cerebral Palsy | 831 | ||
| 26. List several common hand and upper extremity deformities seen in cerebral palsythat may benefit from tendon transfers. | 831 | ||
| 27. What procedures are used to correct the thumb-in-palm deformity? | 832 | ||
| 28. What transfers help correct the clenched fist? | 832 | ||
| 29. What soft tissue procedures correct the wrist flexion/ulnar deviation, with or withoutpronation, seen in cerebral palsy? | 832 | ||
| 30. If the wrist flexion, ulnar deviation, and pronation are due to a fixed bony deformity,what are the treatment options? | 832 | ||
| 31. Elbow flexion contractures are common in cerebral palsy, although they do not oftenrequire surgical release. What structures would need to be released? | 832 | ||
| Rheumatoid Arthritis | 832 | ||
| 32. What is caput ulnae syndrome? | 832 | ||
| 33. After the EPL, the digital extensor tendons are the most frequently ruptured tendonsin rheumatoid patients. They tend to rupture from ulnar (EDQ, EDCsmall,ring) to radial(EDCmiddle,index, EIP). What are the options for transfers if the EPL is intact? | 832 | ||
| 34. What are the choices for transfers if the EPL is ruptured? | 832 | ||
| 35. What other disorders are in the differential diagnosis of extensor tendon rupturesin rheumatoid patients? | 833 | ||
| 36. Flexor tendon ruptures are also seen in rheumatoid patients. Briefly discuss themajor options for transfers. | 833 | ||
| Tetraplegia | 833 | ||
| 37. In tetraplegic patients, elbow extension is important for transfer capabilities andto reach objects from a seated wheelchair position. How can elbow extension bereconstructed with tendon transfers? | 833 | ||
| 38. In C6 tetraplegics, the lowest functioning level is C6, and wrist extensors arefunctional. How can you provide useful grasp (key pinch)? | 833 | ||
| 39. In C7 tetraplegics with elbow and wrist extension, how can you achieve pinch? | 833 | ||
| 40. List the priorities of reconstruction of function in tetraplegia. | 833 | ||
| Obstetric Brachial Plexus Palsy | 833 | ||
| 41. What are the most common types of brachial plexus injury? | 833 | ||
| 42. What are the most important prognostic indicators in obstetric brachial plexus palsy? | 833 | ||
| 43. What are the primary considerations when contemplating primary brachial plexus surgery? | 833 | ||
| 44. For a patient with C5–C6 (upper trunk) palsy, what are the primary deficiencies?How might you address them? | 834 | ||
| 45. For a patient with C8–T1 (lower trunk) injury, what muscles are deficient? Whattransfers are useful? | 834 | ||
| Traumatic Brachial Plexus Palsy | 834 | ||
| 46. What is the recommended assessment protocol for a traumatic brachial plexus injury? | 834 | ||
| 47. What options exist for reconstruction/repair of a traumatic brachial plexus injury? | 834 | ||
| 48. What is the most important function to restore in a traumatic brachial plexus injury? | 834 | ||
| Arthrodeses | 834 | ||
| 49. What are the primary purposes for arthrodesis in patients with a nerve palsy,cerebral palsy, or rheumatoid arthritis? | 834 | ||
| 50. To facilitate thumb–index tip pinch and to provide proximal thumb abduction stabilityin combined nerve palsies, cerebral palsy, and quadriplegia, what arthrodeses canbe used? | 834 | ||
| 51. In combined nerve injuries, wrist stability is often a problem. Which arthrodesisis useful? | 835 | ||
| 52. If an adducted thumb cannot be stabilized by transfers (as in cerebral palsy,quadriplegia, and combined median/ulnar injury), which bony procedure maybe helpful? | 835 | ||
| 53. In an upper trunk brachial plexus palsy, shoulder weakness and/or instability maybe seen. What procedure apart from tendon transfer may be useful? | 835 | ||
| Bibliography | 835 | ||
| Chapter 128: Soft Tissue Coverage Of The Hand | 836 | ||
| 1. Which mechanisms of injury to the hand often result in significant soft tissue loss requiring reconstruction? | 836 | ||
| 2. What injuries present the most difficult challenges for soft tissue coverage? | 836 | ||
| 3. What are the indications for flap coverage? | 836 | ||
| 4. How is a wound prepared for flap coverage? | 836 | ||
| 5. What is the significance of random and axial flaps? | 836 | ||
| 6. Describe the venous anatomy of the upper extremity. | 836 | ||
| 7. How does blood bypass the valves in a retrograde flap? | 836 | ||
| 8. Can a fasciocutaneous flap be elevated from the dorsal aspect of the forearm? | 836 | ||
| 9. What is a distant pedicle flap? What are the indications for its use? | 837 | ||
| 10. What is the most commonly used distant pedicle flap? | 837 | ||
| 11. What is the significance of the groin flap? | 837 | ||
| 12. How is a groin flap designed? | 837 | ||
| 13. What are the disadvantages of the groin flap? | 837 | ||
| 14. How are anterior chest wall and abdominal wall flaps designed? | 838 | ||
| 15. What is a fillet flap? | 838 | ||
| 16. What are the indications for free tissue transfer? | 838 | ||
| 17. Which free flaps are most commonly used? | 838 | ||
| 18. Which flap is commonly used as a regional pedicle flap or free flap? | 839 | ||
| 19. How can the radial forearm flap be used as a regional pedicle flap? | 839 | ||
| 20. How is a radial forearm flap elevated? | 839 | ||
| 21. What is the main contraindication to use of the radial forearm free flap? | 840 | ||
| 22. Can a radial forearm pedicle flap be harvested without sacrificing the radial artery? | 840 | ||
| 23. What fasciocutaneous free flap can be harvested from the lateral arm? | 840 | ||
| 24. What is the thinnest free flap available for coverage of the dorsum of the hand? | 840 | ||
| 25. What is a functional free muscle transfer? | 840 | ||
| 26. What is a composite free flap? | 840 | ||
| 27. What are the advantages and disadvantages of composite free flaps? | 841 | ||
| 28. Describe the neurosensory functions of the hand. | 841 | ||
| 29. What are the indications for the use of a sensate free flap? | 841 | ||
| 30. Which sensate free flaps are commonly used? | 841 | ||
| 31. Does tissue expansion have a role in coverage of soft tissue defects of the hand? | 841 | ||
| Bibliography | 841 | ||
| Chapter 129: Infections of the Hand | 843 | ||
| 1. Who was Allen B. Kanavel? | 843 | ||
| 2. What was the mortality rate associated with hand infections in the preantibiotic era? | 843 | ||
| 3. What is the most common hand infection? | 843 | ||
| 4. What is the most common pathogen responsible for hand infections? | 843 | ||
| 5. What is the etiopathogenesis of felons? | 843 | ||
| 6. What are the possible consequences of untreated or inappropriately treated felons? | 843 | ||
| 7. What are the different types of incisions for drainage of felons? | 843 | ||
| 8. Describe the advantages and disadvantages of the incisions listed in Question 7. | 843 | ||
| 9. What are the advantages of the midvolar longitudinal incision? | 844 | ||
| 10. What complications may follow treatment of felons? | 844 | ||
| 11. What is the clinical presentation of herpetic whitlow? | 844 | ||
| 12. Is herpetic whitlow an aseptic felon? | 844 | ||
| 13. How is herpetic whitlow treated? | 844 | ||
| 14. Is surgical drainage ever indicated for treatment of herpetic whitlow? | 844 | ||
| 15. What are acute paronychia? | 844 | ||
| 16. What is a “runaround” infection? | 844 | ||
| 17. How are acute paronychia treated? | 844 | ||
| 18. What are chronic paronychia? | 844 | ||
| 19. How are chronic paronychia similar to acute paronychia? | 845 | ||
| 20. How are chronic paronychia treated? | 845 | ||
| 21. How many cardinal signs did Kanavel originally describe? | 845 | ||
| 22. What are Kanavel’s four cardinal signs of flexor tenosynovitis? | 845 | ||
| 23. How is acute flexor tenosynovitis treated? | 845 | ||
| 24. What are the open and closed approaches to tendon sheath irrigation for acute flexor tenosynovitis? | 845 | ||
| 25. How is gonococcal flexor tenosynovitis treated? | 845 | ||
| 26. Which pathogens are most commonly responsible for acute flexor tenosynovitis? | 845 | ||
| 27. What are the complications of untreated or inappropriately treated acute flexor tenosynovitis? | 845 | ||
| 28. What are the fascial spaces in the hand? | 846 | ||
| 29. Name the fascial spaces of the hand. | 846 | ||
| 30. Why are the fascial spaces pertinent to hand infections? | 846 | ||
| 31. What is a “collar button” abscess? | 846 | ||
| 32. What are the causes of dorsal hand swelling? | 846 | ||
| 33. Describe the treatment of a dorsal hand abscess. | 846 | ||
| 34. What are the boundaries of the thenar space? | 846 | ||
| 35. What is the position of the thumb in thenar space infections? | 846 | ||
| 36. What incisions are used for drainage of thenar space abscesses? | 847 | ||
| 37. What are the boundaries of the midpalmar space? | 847 | ||
| 38. What incisions are used for drainage of a midpalmar space abscess? | 847 | ||
| 39. What structures are connected to form a “horseshoe” abscess? | 847 | ||
| 40. What factors lead to the development of osteomyelitis after a human bite? | 847 | ||
| 41. What organisms are encountered in a human bite infection? What is appropriate initial antibiotic therapy? | 847 | ||
| 42. What organisms are associated with wounds contaminated with river or sea water? What antibiotic therapy is appropriate? | 847 | ||
| 43. What factors predispose to the development of necrotizing fasciitis? What are the etiologic organisms? Describe the pathologic process. | 847 | ||
| 44. What organisms are frequently seen in dog and cat bites? | 847 | ||
| 45. Describe the clinical presentation of sporotrichosis in the upper extremity. How is it treated? | 848 | ||
| 46. What factors predispose to the development of gas gangrene? How is it treated? | 848 | ||
| 47. What organisms are frequently cultured from abscesses due to intravenous drug abuse? | 848 | ||
| 48. In diabetic hand infections, what factors correlate with an increased risk of amputation? | 848 | ||
| Bibliography | 848 | ||
| Chapter 130: Replantation and Revascularization | 849 | ||
| 1. What is the goal of replantation surgery? | 849 | ||
| 2. What important factors affect outcome in extremity replants? | 849 | ||
| 3. What are the indications for replantation? | 849 | ||
| 4. What are the contraindications to replantation? | 849 | ||
| 5. How do you store an amputated part? | 849 | ||
| 6. What do you evaluate first in an amputation patient? | 849 | ||
| 7. Is an operating microscope required to perform a replant? | 850 | ||
| 8. What closing pressure in a microvascular clamp can result in intimal injury? | 850 | ||
| 9. Describe the operative sequence in finger or hand replantation. | 850 | ||
| 10. In what situation is bone fixation postponed? | 850 | ||
| 11. What do you do if you cannot repair digital nerves primarily? | 850 | ||
| 12. How about the median and ulnar nerves? What if primary repair is not possible? | 850 | ||
| 13. What is the treatment of arterial insufficiency after replantation? | 850 | ||
| 14. Why do most replants fail? | 850 | ||
| 15. How many arteries need to be repaired to successfully revascularize a finger? | 850 | ||
| 16. How many veins need to be repaired? | 850 | ||
| 17. What is the treatment of venous insufficiency after replantation? | 851 | ||
| 18. How do you sacrifice a leech after it has been used? | 851 | ||
| 19. What kind of infection is associated with leeches? | 851 | ||
| 20. Which vessels are used in ear replantation? | 851 | ||
| 21. Which vessels are used in scalp replantation? | 851 | ||
| 22. How do you perform a penis replant? | 851 | ||
| 23. A man presents to the emergency room with a four-finger saw amputation. The thumb was not amputated. The fingers are replantable. The small and long fingers are easy to identify, but the index and ring fingers are difficult to tell apart because they ar | 851 | ||
| 24. What methods are used to monitor replants? | 851 | ||
| 25. Should isolated ulnar artery or radial artery injuries be repaired if hand perfusion is judged to be good? | 852 | ||
| Controversies | 852 | ||
| bibliography | 852 | ||
| Chapter 131: Thumb Reconstruction | 853 | ||
| 1. When was the first toe-to-thumb transfer performed for thumb reconstruction? | 853 | ||
| 2. What are the goals of thumb reconstruction? | 853 | ||
| 3. What is adequate thumb length for useful function? | 853 | ||
| 4. What methods are available for thumb reconstruction? | 853 | ||
| 5. In the era of microsurgery, why even consider prosthetics? | 853 | ||
| 6. Is the child with a congenitally missing part an “amputee”? | 853 | ||
| 7. Should you fit a prosthesis on a child? | 853 | ||
| 8. How and why does the reconstructive approach differ in congenital and acquired thumb deficiencies? | 853 | ||
| 9. What syndromes are associated with thumb hypoplasia, and what associated systemic disorders must be considered? | 854 | ||
| 10. What is the timing of reconstruction of the congenitally deficient thumb? | 854 | ||
| 11. How are congenital thumb deficiencies classified? | 854 | ||
| 12. What types of thumb deficiencies should be reconstructed? | 854 | ||
| 13. Why not a toe-to-thumb transfer? | 854 | ||
| 14. What techniques can be used for less severe hypoplasia of the thumb? | 854 | ||
| 15. How is the index finger pollicized? | 855 | ||
| 16. Why is the metacarpal head palmarly rotated? | 855 | ||
| 17. Which muscles of the index finger assume the function of which muscles of the thumb? | 855 | ||
| 18. What are the options for reconstruction of the distal third of the thumb? | 855 | ||
| 19. What are the options for reconstruction of the middle third of the thumb? | 855 | ||
| 20. What are the options for reconstruction of the proximal third of the thumb? | 856 | ||
| 21. What is osteoplastic reconstruction? | 856 | ||
| 22. Does loss of the first toe cause gait disturbance? | 856 | ||
| 23. What is the vascular pedicle of the transferred first toe? | 856 | ||
| 24. Can parts of toes be used? | 856 | ||
| 25. Describe the different options for toe-to-thumb transfer. | 856 | ||
| 26. When is pollicization preferable to toe transfer for reconstruction of a traumatically amputated thumb? What are the advantages and disadvantages compared with a toe-to-thumb transfer? | 857 | ||
| 27. Summarize the surgical options for thumb reconstruction. | 857 | ||
| Controversy | 857 | ||
| 28. Which toe is preferred for thumb reconstruction? | 857 | ||
| Bibliography | 857 | ||
| Chapter 132: The Mutilated Hand | 858 | ||
| 1. What is a mutilated hand? | 858 | ||
| 2. What is prehension? | 858 | ||
| 3. What are the main objectives in the treatment of a mutilated hand? | 858 | ||
| 4. Outline a treatment plan for the management of mutilating injuries of the hand. | 858 | ||
| 5. How are mutilating injuries of the hand classified? | 858 | ||
| 6. What is the “tic-tac-toe” classification system for mutilating injuries of the hand? | 859 | ||
| 7. What are dorsal mutilation injuries (type I)? | 859 | ||
| 8. What are palmar mutilation injuries (type II)? | 861 | ||
| 9. What are ulnar mutilation injuries (type III)? | 861 | ||
| 10. What are radial mutilation injuries (type IV)? | 862 | ||
| 11. What are transverse amputations (type V)? | 862 | ||
| 12. What is a phalangeal hand? | 865 | ||
| 13. What is a metacarpal hand? | 865 | ||
| 14. What is the Krukenberg procedure? | 865 | ||
| 15. What are degloving injuries (type VI)? | 865 | ||
| 16. What are combination injuries (type VII)? | 867 | ||
| 17. What is an emergency free flap? | 867 | ||
| 18. What is spare parts surgery? | 867 | ||
| 19. What is ectopic parts surgery? | 867 | ||
| 20. When is amputation indicated? | 867 | ||
| 21. What is the role of prostheses in the management of the mutilated hand? | 867 | ||
| Bibliography | 868 | ||
| Chapter 133: Vascular Disorders of the Upper Extremity | 869 | ||
| 1. What is Raynaud’s phenomenon? What is the difference between Raynaud’s disease and Raynaud’s phenomenon? | 869 | ||
| 2. What is the Wake Forest classification of occlusive/vasospastic disease? | 869 | ||
| 3. What are the surgical options for treatment of Raynaud’s disease? How can you preoperatively evaluate response to a s | 869 | ||
| 4. What is Buerger’s disease? | 870 | ||
| 5. What is the difference between a true and a false aneurysm? | 870 | ||
| 6. What is “steal phenomenon”? | 870 | ||
| 7. What is the treatment of an embolic event of the upper extremity? | 870 | ||
| 8. How does a typical hemangioma compare to a vascular malformation in a newborn? | 870 | ||
| 9. What are the phases of a developing hemangioma? | 870 | ||
| 10. What is the treatment of hemangiomas of the upper extremity? | 871 | ||
| 11. What is Maffucci syndrome? | 871 | ||
| 12. What are pyogenic granulomas? How are they treated? | 871 | ||
| 13. What is a glomus tumor? | 871 | ||
| 14. What are “Hildreth’s sign” and the “Love test”? | 871 | ||
| 15. What is Kasabach-Merritt syndrome? | 871 | ||
| 16. Why do arteriovenous malformations expand and involve surrounding tissues? | 872 | ||
| 17. What are the indications for amputation? | 872 | ||
| 18. How does a port-wine stain of the upper extremity compare to those of the head and neck? | 872 | ||
| 19. What are Klippel-Trenaunay syndrome and Parkes-Weber syndrome? | 872 | ||
| 20. How are venous malformations evaluated? | 872 | ||
| 21. What are the complications of VM treatment? | 872 | ||
| 22. What is blue rubber bleb nevus syndrome? | 872 | ||
| 23. What are lymphatic malformations? | 872 | ||
| 24. What is a cystic hygroma? | 873 | ||
| Bibliography | 873 | ||
| Chapter 134: Compartment Syndrome And Ischemic Contracture In The Upper Extremity | 874 | ||
| 1. What are the compartments of the forearm, and what structures do they contain? | 874 | ||
| 2. What are the most common causes of upper extremity compartment syndrome? | 874 | ||
| 3. What is the physiologic cause of ischemia in the upper extremity? | 874 | ||
| 4. How does elevation paradoxically worsen the compartment syndrome? | 875 | ||
| 5. What are the signs and symptoms of compartment syndrome? | 875 | ||
| 6. What is usually the first finding and the last? | 875 | ||
| 7. What tests can be used if the diagnosis is uncertain, and when should they be used? | 875 | ||
| 8. At what compartment pressure does ischemia ensue? | 875 | ||
| 9. What is the best way to improve outcome in forearm compartment syndrome? | 875 | ||
| 10. Describe the technique of upper extremity compartment fasciotomy and the important structures that should be released. | 875 | ||
| 11. Are there any other treatments of acute compartment syndrome? | 876 | ||
| 12. What situations might mandate an exploration of the deep compartments? | 876 | ||
| 13. What is the most common cause of hand compartment syndrome, and how is it treated? | 876 | ||
| Ischemic Contractures | 876 | ||
| 14. Who first described the long term sequelae of upper extremity ischemia? | 876 | ||
| 15. When was the pathophysiology leading to contracture and effective treatment outlined? | 876 | ||
| 16. What is the most common cause of Volkmann’s contractures in developing countries? | 876 | ||
| 17. What injury in children is most commonly associated with Volkmann’s contracture, and how does it occur? | 877 | ||
| 18. Which compartment is most commonly affected by compartment syndrome and why? | 877 | ||
| 19. Describe three levels of severity in established Volkmann’s contracture and their treatment options (Fig. 134-3). | 877 | ||
| Bibliography | 877 | ||
| Chapter 135: Peripheral Nerve Injuries | 878 | ||
| 1. Describe the functional anatomy of peripheral nerves. | 878 | ||
| 2. How are nerve injures classified? What is the clinical importance of classification? | 878 | ||
| 3. What is meant by wallerian degeneration? | 879 | ||
| 4. What are the bands of Büngner? | 879 | ||
| 5. What are the bands of Fontana? | 879 | ||
| 6. What is Tinel’s sign? | 879 | ||
| 7. How fast do nerves regenerate? | 879 | ||
| 8. If nerves regenerate at the rate of 1 inch/month and the tip of the ulnar two fingers is approximately 30 inches from the axilla, does this mean that a complete ulnar nerve injury at the level of the axilla will take 2.5 years to restore sensibility to t | 880 | ||
| 9. In the same situation as described in Question 8, will the ulnar-innervated hand intrinsic muscles regain function 2.5 years after injury? | 880 | ||
| 10. Do all proximal motor nerve injuries result in permanent loss of function? | 880 | ||
| 11. What are nerve transfers? | 880 | ||
| 12. Is a motor nerve transfer better than a tendon transfer? | 880 | ||
| 13. When should a motor nerve transfer be used instead of a nerve graft? | 880 | ||
| 14. Should all open wounds be explored? | 880 | ||
| 15. How long should you wait before operating on a closed nerve injury? | 881 | ||
| 16. What is the best way to treat peripheral nerve injuries resulting in segmental loss of continuity? | 881 | ||
| 17. What is the best method for surgical nerve repair? | 882 | ||
| 18. How are nerve repairs classified? | 882 | ||
| 19. Is primary repair always better than secondary repair? | 883 | ||
| 20. How do you know which repair should be used in which situation? | 883 | ||
| 21. Which quick intraoperative landmarks can be used to match fascicles during an end-to-end neurorrhaphy? | 883 | ||
| 22. Describe the clinical tests for nerve function in the hand. | 883 | ||
| 23. What is a Martin-Gruber communication or Martin-Gruber anastomosis? Why is it important in nerve injuries of the hand? | 883 | ||
| 24. What other anomalous motor nerve connections exist in the upper extremity? | 884 | ||
| Controversies | 884 | ||
| 25. Does end-to-side neurorrhaphy work? | 884 | ||
| 26. Are all nerve grafts the same? | 884 | ||
| Bibliography | 884 | ||
| Chapter 136: Nerve Compression Syndromes | 885 | ||
| 1. Which nerve compression syndromes affect the upper extremity? | 885 | ||
| 2. What area of sensibility is abnormal with pronator syndrome but not with carpal tunnel syndrome? | 885 | ||
| 3. What surgical technique used to treat cubital tunnel syndrome has been demonstrated to reduce intraneural pressure in the ulnar nerve in all degrees of elbow flexion and has the lowest published recurrence rate? | 885 | ||
| 4. What is the common name given to brachial plexus compression in the thoracic inlet? How can you make the diagnosis? | 885 | ||
| 5. How do you distinguish de Quervain’s tenosynovitis from radial sensory nerve compression? | 885 | ||
| 6. How do you distinguish tennis elbow from radial tunnel syndrome? | 886 | ||
| 7. What are the earliest physical findings of chronic peripheral nerve compression? | 886 | ||
| 8. Describe the pathophysiology of chronic nerve compression. | 886 | ||
| 9. Which nerve compression syndromes affect the lower extremity? | 886 | ||
| 10. What are the analogous peripheral nerves that become entrapped at the wrist compared with at the ankle (carpal tunnel vs tarsal tunnel)? | 886 | ||
| 11. Is Morton’s neuroma a true neuroma? | 887 | ||
| 12. Describe the sequence of recovery of sensory touch submodalities. | 887 | ||
| 13. What are the structures that must be released when treating the fibular canal syndrome (compression of the common peroneal nerve at the knee)? | 887 | ||
| 14. What is the most common nerve compression occurring in the face? | 887 | ||
| 15. Which nerve compressions masquerade as “failed carpal tunnel syndrome decompression”? | 887 | ||
| 16. What causes “meralgia paresthetica”? | 887 | ||
| 17. Where is the nerve entrapment site that causes scapular winging? | 887 | ||
| 18. Describe some of the limitations to classic electrodiagnostic testing. | 888 | ||
| 19. What is the difference between neuropathy and nerve compression? | 888 | ||
| 20. Can the arcade of Struthers cause compression of the ulnar nerve? | 888 | ||
| 21. Can decompression of peripheral nerves in the patient with diabetic neuropathy relieve pain, restore sensation, and prevent ulcer/amputation? | 888 | ||
| 22. What are the cutaneous nerves that can contribute to a painful incision after decompression of the four medial ankle tunnels (tarsal tunnel surgery)? | 888 | ||
| 23. What nerve compression is associated with chemotherapy-induced neuropathy from cisplatin or taxol? | 888 | ||
| 24. After nerve decompression surgery, how long should the patient be immobilized? | 889 | ||
| Bibliography | 889 | ||
| Chapter 137: Brachial Plexus | 891 | ||
| 1. Which nerve roots supply the brachial plexus? | 891 | ||
| 2. What is a prefixed plexus? A postfixed plexus? | 891 | ||
| 3. Which nerves form the trunks of the brachial plexus? | 891 | ||
| 4. Which nerves form the cords of the brachial plexus? | 891 | ||
| 5. How are the peripheral nerves formed in the brachial plexus? | 891 | ||
| 6. Where are lateral and medial pectoral nerves found in relation to each other? What is the clinical significance? | 892 | ||
| 7. What is the common mechanism of closed brachial plexus injury in adults? | 892 | ||
| 8. What is the best method to determine the level and severity of a brachial plexus injury? | 892 | ||
| 9. What are the common clinical patterns of closed brachial plexus injury in adults? | 892 | ||
| 10. What are the indications for an arteriogram after an injury to the brachial plexus? | 892 | ||
| 11. What is the significance of a preganglionic and postganglionic lesion of the brachial plexus? What findings suggest a preganglionic lesion? | 892 | ||
| 12. What is the histamine triple response? | 893 | ||
| 13. What findings are associated with root avulsions? What is the significance of a root avulsion? | 893 | ||
| 14. What are the goals of brachial plexus reconstruction? | 894 | ||
| 15. What techniques are used in reconstruction of the brachial plexus? What are some of the limitations of each? | 894 | ||
| 16. What nerves can be used as donor nerves for nerve grafting? | 894 | ||
| 17. What are the degrees of nerve injury? Why are they significant in brachial plexus reconstruction? | 894 | ||
| 18. Describe the optimal timing of exploration of an adult traction injury of the brachial plexus. | 895 | ||
| 19. What causes obstetric palsy? | 895 | ||
| 20. What are the indications and timing for exploration of obstetric palsy? | 895 | ||
| 21. What symptoms are associated with thoracic outlet syndrome? | 895 | ||
| 22. What is the anatomy of the thoracic outlet? | 895 | ||
| 23. What is the cause of thoracic outlet syndrome? | 895 | ||
| 24. Which physical examination techniques are useful in evaluation of thoracic outlet syndrome? | 896 | ||
| 25. What is the treatment of thoracic outlet syndrome? | 896 | ||
| 26. What is Parsonage Turner syndrome? What is the recommended treatment? | 896 | ||
| Controversies | 896 | ||
| 27. What is the indication for neurolysis of the brachial plexus? | 896 | ||
| 28. What is the clinical significance of the suprascapular nerve? | 896 | ||
| Bibliography | 896 | ||
| Chapter 138: Rheumatoid Arthritis | 898 | ||
| 1. What is the presentation of rheumatoid arthritis? | 898 | ||
| 2. How is the diagnosis of RA made? | 898 | ||
| 3. What is the pathophysiology of RA? | 898 | ||
| 4. What are the radiographic features of RA? | 898 | ||
| 5. What are the clinical features of RA? | 898 | ||
| 6. What are the most common expressions of RA in the hand and upper extremity? | 898 | ||
| 7. What is the caput ulnae syndrome? | 898 | ||
| 8. What are the causes of tendon ruptures in RA? | 899 | ||
| 9. What is the differential diagnosis for inability to extend the MP joints in RA? | 899 | ||
| 10. What is the medical treatment of RA? | 899 | ||
| 11. What are the four objectives of surgical treatment in the rheumatoid hand? | 899 | ||
| 12. How do you approach the rheumatoid hand? | 899 | ||
| 13. What are the general categories of surgical procedures performed for the rheumatoid hand and wrist? | 899 | ||
| 14. What are the indications for an extensor tenosynovectomy? | 899 | ||
| 15. What is the preferred treatment of extensor tendon ruptures? | 899 | ||
| 16. What are the typical deformities in the radiocarpal and intercarpal joints in RA? | 900 | ||
| 17. What are the indications for MP joint arthroplasty? | 900 | ||
| 18. What are the common finger deformities in the rheumatoid hand? | 900 | ||
| 19. What is the surgical approach to correction of the swan neck deformity? | 900 | ||
| 20. What is the mechanism leading to boutonnière deformity? | 900 | ||
| 21. What are the indications for thumb fusion in RA? | 900 | ||
| Bibliography | 900 | ||
| Chapter 139: Dupuytren’s Disease | 901 | ||
| 1. What is the cause of Dupuytren’s disease? | 901 | ||
| 2. What diseases are associated with DD? | 901 | ||
| 3. Is DD related to work or injury? | 901 | ||
| 4. What are the risk factors for developing DD? | 901 | ||
| 5. Does the diseased tissue exhibit specific patterns? | 901 | ||
| 6. Which fascia causes the various flexion contractures in the hand? | 902 | ||
| 7. By what mechanism is the neurovascular bundle displaced? | 902 | ||
| 8. To which group of diseases does DD belong? How are they classified? | 903 | ||
| 9. What are the histologic features of the nodules of DD? | 903 | ||
| 10. What is the role of the myofibroblast? | 903 | ||
| 11. What is different about the collagen of normal fascia and Dupuytren’s tissue? | 903 | ||
| 12. Where are nodules usually located? | 903 | ||
| 13. What clinical features and other conditions should be considered in the differential diagnosis of DD? | 903 | ||
| 14. Is there a role for nonoperative treatment? | 903 | ||
| 15. What are the indications for operative treatment? | 904 | ||
| 16. What are the goals of surgery? | 904 | ||
| 17. What are the options in designing an operation for DD? | 904 | ||
| 18. What is the rationale for using skin grafts? What are the indications? | 904 | ||
| 19. What is the difference between extension and recurrence? | 904 | ||
| 20. What are the complications of surgery? | 904 | ||
| 21. How are patients managed postoperatively? | 905 | ||
| Bibliography | 905 | ||
| Chapter 140: Stenosing Tenosynovitis | 906 | ||
| 1. What is stenosing tenosynovitis? | 906 | ||
| 2. Which tendons can be affected by ST? | 906 | ||
| 3. What causes ST? | 906 | ||
| 4. What are some of the risk factors for developing ST? | 906 | ||
| 5. What is the initial treatment of ST, and how successful is nonsurgical management? | 906 | ||
| 6. Who was de Quervain? | 906 | ||
| 7. What is the Finkelstein maneuver? | 907 | ||
| 8. What features distinguish de Quervain’s disease from basal joint arthritis? | 907 | ||
| 9. What anatomic structures and variations must be remembered during de Quervain’s surgical release? | 907 | ||
| 10. What is intersection syndrome? | 907 | ||
| 11. What is the most common digit affected in trigger finger? | 907 | ||
| 12. What is the etiology of trigger finger? | 907 | ||
| 13. Where are the typical incisions placed for trigger finger release? | 908 | ||
| 14. What anatomic relationship is critical in trigger thumb release? | 908 | ||
| 15. How should rheumatoid trigger finger be treated? | 908 | ||
| 16. How should an infant who presents with triggering be managed? | 909 | ||
| Bibliography | 909 | ||
| Chapter 141: Tumors | 910 | ||
| 1. What is the definition of a tumor? | 910 | ||
| 2. What types of tissues form hand tumors? | 910 | ||
| 3. Are most tumors of the hand benign or malignant? | 910 | ||
| 4. What are the basic tenets of hand tumor surgery? | 910 | ||
| 5. Are laboratory tests helpful in the diagnosis of hand tumors? | 910 | ||
| 6. Describe the evaluation, workup, and treatment plan for a suspicious hand mass. | 911 | ||
| 7. What is the most common soft tissue mass in the hand? How is it treated? | 911 | ||
| 8. Biopsy of a hand mass reveals an orange-brown tumor with multinucleated giant and xanthoma cells on histologic analysis. What is the most probable diagnosis? Will definitive treatment require an amputation? | 911 | ||
| 9. What is the most likely diagnosis of a painful hand mass relieved only by nonsteroidal antiinflammatory drugs? What is the workup and management of this mass? | 911 | ||
| 10. What different types of surgical margins can be used for tumors found in the hand? | 913 | ||
| 11. Name the most common malignant bone-forming tumor found in the hand. Describe its clinical and radiographic features along with its treatment | 913 | ||
| 12. A patient has exquisite point tenderness in her finger when she puts her hand in the refrigerator. What is the diagnosis? | 913 | ||
| 13. What is a pyogenic granuloma? What are treatment options? | 913 | ||
| 14. Describe the clinical course of a keratoacanthoma. Why is an excisional biopsy recommended? If a patient presents with multiple keratoacanthomas, what other diagnostic modalities should be performed? | 913 | ||
| 15. What are the most likely causes of carpal tunnel syndrome in a child? | 914 | ||
| 16. What is an epidermal inclusion cyst? What is the most appropriate treatment for removal of this mass? | 915 | ||
| 17. A 70-year-old man presents to your clinic with a firm, nontender, nodular mass on the volar aspect of his right index fin | 915 | ||
| 18. What is the most common skeletal tumor of the hand? | 915 | ||
| 19. What is the most common benign bone tumor? | 915 | ||
| 20. What is the potential for malignant transformation of a solitary enchondroma? What is Ollier disease? What is Maffucci disease? Is there a potential for malignant transformation among these disease processes? | 915 | ||
| 21. What is most important prognostic indicator based on histology in melanoma? What is the treatment of this lesion? | 916 | ||
| 22. What is the differential diagnosis of hyperpigmentation found in the eponychial fold of the finger? What is Hutchinson’s sign? Is this diagnostic of a melanoma? | 916 | ||
| 23. What physical findings in a pigmented skin lesion potentially make the lesion suspicious for a malignancy? What is the appropriate workup for a skin lesion of the hand that is diagnosed as a melanoma? | 916 | ||
| 24. What is an actinic keratosis? | 917 | ||
| 25. A previously diagnosed actinic keratosis starts to ulcerate and bleed. What is this lesion now, and how does it spread? | 917 | ||
| 26. What is a basal cell carcinoma? Which lesion has a higher potential to spread through the lymphatics: basal cell carcinoma or squamous cell carcinoma? | 917 | ||
| 27. A 12-year-old girl presents with a deep and painful mass in the hand located over the thenar eminence. A history of rapid enlargement is elicited from the patient and her parents. An excisional biopsy reveals a rhabdomyosarcoma. How common is this mas | 917 | ||
| 28. A mass similar to that described in Question 27 is found in a 40-year-old patient. However, the mass has recently ulcerated and drained fluid. Biopsy is consistent with a sarcoma, revealing epithelial cells with a central area of necrosis. What is this | 917 | ||
| 29. What is a hemangioma? Where does it occur in the upper extremity? What is the treatment of this lesion? | 918 | ||
| 30. What is Kasabach-Merritt syndrome? | 918 | ||
| 31. What are vascular malformations? Are they present at birth? | 919 | ||
| 32. A mass in the hand is extremely suspicious for a malignancy. Do you exsanguinate the hand prior to removing the mass? | 919 | ||
| 33. Name five common primary cancers that can metastasize to the hand. Which one is the most common? Which bone is commonly affected, and what does x-ray show? | 919 | ||
| 34. Describe a neurofibroma. What is Von Recklinghausen disease? Is malignant transformation possible? | 919 | ||
| 35. Are neurofibromas and neurilemomas the same? Does their treatment differ? Is a neurilemoma common in the hand? | 919 | ||
| 36. Describe the classification system developed by Enneking for staging of musculoskeletal tumors. | 920 | ||
| 37. Who should biopsy a mass in the hand? | 920 | ||
| Bibliography | 920 | ||
| Chapter 142: Complex Regional Pain Syndrome | 922 | ||
| 1. What is complex regional pain syndrome? | 922 | ||
| 2. What are the differences among reflex sympathetic dystrophy, sympathetically maintained pain syndrome, and CRPS I? | 922 | ||
| 3. Does experimental evidence suggest the involvement of sympathetic nerves in some chronic pain syndromes? | 922 | ||
| 4. Describe the functional anatomy of the sympathetic nervous system. | 923 | ||
| 5. What is the relevance of the sympathetic nervous system to pain? | 923 | ||
| 6. What is (or was) causalgia? | 923 | ||
| 7. Which is more common, CRPS I or CRPS II? | 923 | ||
| 8. What is the most common triggering event for RSD (CRPS I)? | 923 | ||
| 9. Who is more likely to be diagnosed with CRPS? | 923 | ||
| 10. Is CRPS overdiagnosed? | 923 | ||
| 11. Does CRPS occur only in the extremities? | 923 | ||
| 12. What is orofacial RSD, and why is it different? | 923 | ||
| 13. What are the stages of CRPS? | 924 | ||
| 14. How can you accurately diagnose SMPS? | 924 | ||
| 15. What are the principles of management of SMPS? | 924 | ||
| 16. How does physical therapy help? | 924 | ||
| 17. What complications may develop with CRPS? | 924 | ||
| 18. Which invasive therapies for SMPS are most effective? | 925 | ||
| 19. How does cigarette smoking affect RSD (CRPS I)? | 925 | ||
| Controversies | 925 | ||
| 20. Are certain people more prone to developing SMPS? | 925 | ||
| 21. Can you prevent RSD (CRPS I)? | 925 | ||
| 22. Are patients with CRPS depressed? | 925 | ||
| 23. Is RSD (CRPS I) an autoimmune disease? | 925 | ||
| Bibliography | 926 | ||
| Chapter 143: Rehabilitation of the Injured Hand | 927 | ||
| 1. What are the physiologic effects of early motion programs after tendon repair? | 927 | ||
| 2. Describe early passive mobilization after flexor tendon repair in the hand. | 927 | ||
| 3. When are early active mobilization protocols used after flexor tendon repair? | 927 | ||
| 4. Describe early passive mobilization protocols used for extensor tendons in zones V, VI, and VII. | 928 | ||
| 5. What is the short arc motion protocol for zone III and IV extensor tendon repairs? | 928 | ||
| 6. What are flexor tendon gliding exercises? | 928 | ||
| 7. Describe splinting after MCP implant arthroplasty. | 928 | ||
| 8. Name three possible long-term postoperative complications of MCP implant arthroplasty. | 929 | ||
| 9. Describe examples of joint protection techniques for patients with arthritis | 929 | ||
| 10. What factors must be evaluated to determine the cause of limited passive motion? | 929 | ||
| 11. When is it appropriate to initiate active motion after an intraarticular fracture of the PIP joint? | 929 | ||
| 12. What important principles must be followed in planning a treatment program after limited wrist arthrodesis to correct wrist instability? | 929 | ||
| 13. Why should a patient be referred for hand therapy after a nerve injury? | 929 | ||
| 14. What are the potential deformities and splinting needs for radial nerve injuries? | 929 | ||
| 15. What are the potential deformities and splinting needs for ulnar nerve injuries? | 929 | ||
| 16. What are the potential deformities and splinting needs for median nerve injuries? | 930 | ||
| 17. What readily available tests are used for determining early changes in sensibility due to nerve compression? | 930 | ||
| 18. What are the most common postural faults noted in patients with thoracic outlet syndrome that can be improved with therapy? | 930 | ||
| 19. Describe the benefits of hand therapy for patients with carpal tunnel syndrome or other forms of cumulative trauma. | 930 | ||
| 20. What are the key issues in conservative treatment of cubital tunnel syndrome? | 931 | ||
| 21. What are upper limb tension tests? | 931 | ||
| 22. What general principle can be used to activate a muscle after tendon transfer? | 931 | ||
| 23. What are some conservative interventions specific to treating musicians with cumulative trauma? | 931 | ||
| 24. What are some common problems that require treatment after a crush injury? | 931 | ||
| 25. During the first 48 to 72 hours status post burn, what is the appropriate position for splinting the hand with dorsal thermal injuries? | 931 | ||
| 26. Name three methods for preventing hypertrophic scarring after a burn to the hand. | 931 | ||
| 27. Describe examples of splints used after surgery for Dupuytren’s contracture. | 931 | ||
| 28. What are tests of maximal voluntary effort? | 931 | ||
| 29. What are some of the advantages and disadvantages of whirlpool treatment versus direct application of heat, such as a hot pack or paraffin bath? | 932 | ||
| 30. How can edema in the hand be measured? | 932 | ||
| 31. How should the edematous hand be treated? | 932 | ||
| 32. Define categories of splints used to gain joint motion. | 932 | ||
| 33. Why is it important to start therapy early, even while still casted, for example? | 932 | ||
| Controversy | 932 | ||
| 34. Describe a course of treatment of reflex sympathetic dystrophy (complex regional pain syndrome type I) | 932 | ||
| Bibliography | 933 | ||
| Section XII: The Wrist | 935 | ||
| Chapter 144: Anatomy of the Wrist | 937 | ||
| 1. What is the normal blood supply pattern of the scaphoid? The capitate? The lunate? The hamate? | 937 | ||
| 2. What is the normal percentage of force or load transmission through the ulnocarpal joint? | 937 | ||
| 3. Describe the ligaments that interconnect the bones of the proximal carpal row. | 937 | ||
| 4. How much of the proximal surface of the lunate normally articulates with the distal articular surface of the radius in the neutral wrist position? | 937 | ||
| 5. What are the normal radiolunate and scapholunate angles as measured on a lateral radiograph? | 938 | ||
| 6. How does the relative length of the radius and ulna, termed ulnar variance, change with forearm rotation? | 938 | ||
| 7. The proximal carpal row moves in what general motion during wrist radial and ulnar deviation? During wrist flexion and extension? | 939 | ||
| 8. Why is the radioscapholunate ligament no longer believed to be a significant mechanical stabilizer of the scaphoid and lunate? | 939 | ||
| 9. What are the normal anteroposterior and lateral intrascaphoid angles? | 939 | ||
| 10. Describe the normal arterial blood supply of the distal radius | 939 | ||
| 11. Name the four principal ligaments of the first carpometacarpal joint. | 940 | ||
| 12. Describe the anatomy of the triangular fibrocartilage complex | 940 | ||
| 13. Where is the center of rotation of the wrist? | 940 | ||
| 14. The midcarpal joint normally communicates with which carpometacarpal joints? | 941 | ||
| 15. Is it normal for the radiocarpal joint to communicate with the pisotriquetral joint? With the distal radioulnar joint? | 941 | ||
| 16. Are there any normal direct tendinous insertions to any of the carpal bones? | 941 | ||
| 17. Is there normally substantial motion between the bones of the distal carpal row? | 941 | ||
| 18. Is it normally possible for the lunate to articulate with the hamate? | 941 | ||
| 19. Describe the dorsal capsular ligaments of the wrist. | 941 | ||
| 20. What is carpal height ratio? How is it determined? | 942 | ||
| Bibliography | 942 | ||
| Chapter 145: Physical Examination of the Wrist | 944 | ||
| 1. What constitutes the first part of every thorough physical examination? | 944 | ||
| 2. Is it necessary to assess the range of motion of the wrist? | 944 | ||
| Radial Wrist Examination | 944 | ||
| 3. Which carpal bone is involved in more than 95% of all cases of degenerative joint disease of the wrist? | 944 | ||
| 4. Which aspect of the wrist, radial or ulnar, is involved in the majority of carpal pathology? | 944 | ||
| 5. How many maneuvers does the radial wrist exam include? Name them. | 944 | ||
| 6. Which maneuver directly examines the scapholunate joint? | 944 | ||
| 7. Which maneuver indirectly examines the wrist with exceptional sensitivity? | 945 | ||
| 8. Which maneuver specifically assesses synovitis of the scaphoid? | 945 | ||
| 9. Which maneuver directly assesses the STT joint? | 945 | ||
| 10. Which maneuver assesses the pathomechanics of the scaphoid? | 946 | ||
| 11. How is the SSM performed? | 946 | ||
| 12. Explain the biomechanical mechanism of the scaphoid shift maneuver | 946 | ||
| 13. What is the clinical significance of the scaphoid shift maneuver? | 947 | ||
| 14. What percentage of normal asymptomatic people have an abnormal scaphoid shift? | 947 | ||
| Ulnar Wrist Pain | 947 | ||
| 15. How do you examine a patient with ulnar wrist pain? | 947 | ||
| 16. How can you rule out pathology involving the DRUJ? | 947 | ||
| 17. How can you diagnose a TFCC injury or tear on physical examination? | 948 | ||
| 18. What is the ulnar snuffbox? | 948 | ||
| 19. What is the lunotriquetral compression test? | 948 | ||
| 20. What are ballottement tests? How can they assess LT instability? | 948 | ||
| 21. What is triquetral impingement ligament tear? How can it be diagnosed? | 948 | ||
| Radiocarpal And Midcarpal Joints | 949 | ||
| 22. How can instability of the radiocarpal or midcarpal joint be evaluated? | 949 | ||
| 23. What is the pivot shift test? | 949 | ||
| Carpometacarpal Joint | 949 | ||
| 24. Do all five carpometacarpal joints demonstrate equal motion? | 949 | ||
| 25. Which is the most important of the CMC joints? | 950 | ||
| 26. Degenerative joint disease most commonly involves which CMC joint? | 950 | ||
| 27. What three tests are used to examine the first CMC joint? | 950 | ||
| 28. What is the carpal boss? | 950 | ||
| 29. How can you diagnose a carpal boss on examination? | 950 | ||
| Extraarticular Causes Of Wrist Pain | 950 | ||
| 30. What is the Finkelstein test? | 950 | ||
| 31. What is a “wet leather” sign? | 950 | ||
| 32. How can you evaluate a problem involving the sheath of the ECU? | 950 | ||
| 33. How can you diagnose a fracture or degenerative disease of the pisiform? | 950 | ||
| 34. How can you diagnose an injury or fracture of the hook of the hamate? | 950 | ||
| 35. How can you diagnose flexor carpi radialis tendinitis? | 951 | ||
| 36. What is intersection syndrome? How can it be diagnosed on examination? | 951 | ||
| 37. What are substitution maneuvers? | 951 | ||
| Bibliography | 951 | ||
| Chapter 146: Radiographic Examination of the Wrist | 952 | ||
| 1. How should the standard posteroanterior roentgenogram for examination of the wrist be obtained? | 952 | ||
| 2. What criteria identify an adequate PA view? | 952 | ||
| 3. Why is it important to obtain adequate PA views of the wrist? | 952 | ||
| 4. How should the standard lateral view of the wrist be obtained? | 952 | ||
| 5. How can the lateral view be evaluated to see that the elbow was adducted to the patient’s side? | 952 | ||
| 6. What does the scaphoid bone do on a PA view obtained in ulnar deviation? | 952 | ||
| 7. What are the pronator quadratus and the scaphoid fat pads? What is their importance? | 952 | ||
| 8. What is a Colles fracture? | 952 | ||
| 9. How are Colles fractures classified? | 954 | ||
| 10. How can ulnar styloid fractures be classified? | 954 | ||
| 11. What is the importance of recognizing the various sites of ulnar styloid fractures? | 954 | ||
| 12. What is a Smith fracture? | 954 | ||
| 13. What is the definition of a Barton fracture? | 954 | ||
| 14. What is a fracture of the radial styloid process called? | 954 | ||
| 15. When a fracture line passes into the ulnar aspect of the scaphoid fossa or especially at the junction between the scaphoid and lunate fossae, what associated carpal abnormality should be questioned? | 954 | ||
| 16. What is the fastest and most economical way to evaluate for scapholunate joint disruption? | 954 | ||
| 17. What is the most frequently fractured carpal bone? | 954 | ||
| 18. What are the complications of scaphoid fractures? | 954 | ||
| 19. What is the difference between static instability and dynamic instability of the wrist? | 955 | ||
| 20. Are carpal instability patterns always unstable? | 955 | ||
| 21. What is rotary subluxation of the scaphoid? | 955 | ||
| 22. Are all communicating defects or holes in the scapholunate ligament, as can be seen on arthrography, magnetic resonance imaging, magnetic resonance imaging arthrography, arthroscopy, or arthrotomy, believed to be symptomatic? | 955 | ||
| 23. What are the two major types of carpal dislocations? | 955 | ||
| 24. What is the role of CT in carpal trauma? | 956 | ||
| 25. What are the advantages of magnetic resonance imaging for diagnosis of wrist disorders? | 956 | ||
| 26. What are the most common indications for MR arthrography of the wrist rather than nonarthrographic MR of the wrist? | 957 | ||
| 27. What are the three compartments of the wrist that have been most commonly injected for imaging? | 957 | ||
| 28. Which of the three compartments listed in Question 27 is most commonly injected for wrist MR arthrography? | 957 | ||
| 29. What is a potential pitfall with injecting only the radiocarpal joint? | 957 | ||
| Bibliography | 957 | ||
| Chapter 147: Biomechanics of the Wrist | 959 | ||
| 1. Why are multiple carpal bones present in the wrist? | 959 | ||
| 2. What is meant by the term kinematics? What is the difference between kinematics and kinetics? | 959 | ||
| 3. From a kinematic standpoint, what is the difference between rotational and translational movements? | 959 | ||
| 4. In what planes do the three basic wrist movements occur? | 959 | ||
| 5. What is the normal range of motion of the wrist? | 959 | ||
| 6. What is the functional range of motion of the wrist? | 959 | ||
| 7. What is the physiologic motion of the wrist? | 959 | ||
| 8. What is the columnar theory of carpal kinematics? | 959 | ||
| 9. What is the row theory of carpal kinematics? | 960 | ||
| 10. What is the ring theory of carpal kinematics? | 960 | ||
| 11. What is the four-unit concept of carpal kinematics? | 960 | ||
| 12. Which portion of the scapholunate interosseous ligament is strongest and most important for scapholunate stability? | 960 | ||
| 13. Which are stronger, intrinsic carpal ligaments or extrinsic carpal ligaments? | 960 | ||
| 14. What is force coupling? | 960 | ||
| 15. How does rotary subluxation of the scaphoid affect carpal kinematics? | 960 | ||
| 16. What is a DISI deformity? | 961 | ||
| 17. What is a volarflexion intercalated segmental instability deformity? | 961 | ||
| Bibliography | 961 | ||
| Chapter 148: The Pediatric Wrist | 962 | ||
| 1. By what gestational age does the carpus develop into eight distinct entities? | 962 | ||
| 2. What is the carpal boss? | 962 | ||
| 3. Describe the typical presentation of a carpal boss? | 962 | ||
| 4. What constitutes a metacarpal stress test? | 962 | ||
| 5. What is the etiology of a carpal boss? | 962 | ||
| 6. How is a carpal boss treated? | 962 | ||
| 7. What is the Madelung deformity? | 962 | ||
| 8. With which syndrome is the Madelung deformity most associated? | 962 | ||
| 9. Describe Leri-Weill syndrome. | 962 | ||
| 10. What are the two forms of Madelung’s deformity? | 963 | ||
| 11. What is the treatment of Madelung deformity? | 963 | ||
| 12. What is most important to preserve in the wrist abnormality associated with cerebral palsy and arthrogryposis? | 963 | ||
| 13. What is gymnast’s wrist? | 963 | ||
| 14. Why does gymnast’s wrist develop? | 963 | ||
| 15. What is “grip lock”? | 963 | ||
| 16. Describe the stages and treatment of gymnast’s wrist. | 963 | ||
| 17. What is the most common carpal bone fracture in the pediatric population? | 963 | ||
| 18. How is the diagnosis complicated in children? | 963 | ||
| 19. What is the scaphoid “fat stripe” sign? What is its significance? | 963 | ||
| 20. What are the most common fractures in children? | 963 | ||
| 21. What is a Galeazzi fracture? | 964 | ||
| 22. What is a ganglion? | 964 | ||
| 23. What are the etiology, location, and therapy for ganglia? | 964 | ||
| 24. What is the most common connective tissue disorder in children? | 964 | ||
| 25. Describe pauciarticular, polyarticular, and systemic-onset juvenile arthritis. | 964 | ||
| 26. What are the most common initial and long-term manifestations of juvenile arthritis? | 964 | ||
| 27. Describe the therapeutic options for juvenile arthritis. | 964 | ||
| Bibliography | 964 | ||
| Chapter 149: Fractures of the Carpal Bones | 965 | ||
| 1. What is the relative incidence of carpal fractures? | 965 | ||
| 2. What is the blood supply to the scaphoid? Why is it important ? | 965 | ||
| 3. What is the typical presentation of a scaphoid fracture? | 965 | ||
| 4. What is the anatomic snuffbox? | 965 | ||
| 5. What radiographic views should be included in the initial workup of a scaphoid fracture? | 965 | ||
| 6. What is an occult scaphoid fracture? | 966 | ||
| 7. What is the navicular fat stripe sign? | 966 | ||
| 8. What are the important classification systems of scaphoid fractures? | 966 | ||
| 9. How does a scaphoid fracture contribute to wrist instability? | 966 | ||
| 10. What are the essentials of closed treatment of scaphoid fractures? | 966 | ||
| 11. What are the indications for operation on a fracture of the scaphoid? | 966 | ||
| 12. What surgical options are available? | 968 | ||
| 13. What differences are seen in pediatric scaphoid fractures? | 968 | ||
| 14. Describe the surgical approaches to the scaphoid. | 968 | ||
| 15. Can the scaphoid be fixed arthroscopically? | 968 | ||
| 16. What is Kienböck’s disease? How is it related to fractures of the lunate? | 968 | ||
| 17. What is the typical presentation and workup of a triquetral fracture? | 968 | ||
| 18. How are pisiform fractures best diagnosed and treated? | 968 | ||
| 19. What rare carpal fracture is associated with cyclists? | 968 | ||
| 20. Which carpal fracture is associated with golf and racquet sports? | 969 | ||
| 21. What is scaphocapitate syndrome? | 969 | ||
| 22. How do scaphoid fractures contribute to wrist arthritis? | 969 | ||
| Bibliography | 969 | ||
| Chapter 150: Kienböck’s Disease | 970 | ||
| 1. What is Kienböck’s disease? | 970 | ||
| 2. What age-group and sex are most commonly affected? | 970 | ||
| 3. What is the cause? | 970 | ||
| 4. What is ulnar variance? | 970 | ||
| 5. What is the significance of ulnar variance to Kienböck’s disease? | 970 | ||
| 6. Does lunate vascular anatomy influence AVN? | 970 | ||
| 7. What are the symptoms of Kienböck’s disease? | 970 | ||
| 8. What are the physical findings? | 970 | ||
| 9. What are the radiographic findings? | 971 | ||
| 10. What features are found on magnetic resonance imaging? | 971 | ||
| 11. What role does magnetic resonance imaging serve in managing Kienböck’s disease? | 971 | ||
| 12. What is the differential diagnosis? | 971 | ||
| 13. Can children develop Kienböck’s disease? | 971 | ||
| 14. What are the clinical differences between Kienböck’s disease in adults and in children? | 971 | ||
| 15. Is treatment the same for Kienböck’s disease in adults and in children? | 971 | ||
| 16. What are the stages of Kienböck’s disease? | 971 | ||
| 17. How are the various stages of Kienböck’s disease treated? | 971 | ||
| 18. Does immobilization have a role in the treatment of Kienböck’s disease? | 971 | ||
| 19. How about simply excising the lunate? | 974 | ||
| 20. What about lunate excision arthroplasty? | 974 | ||
| 21. Does altering ulnar variance affect revascularization? | 974 | ||
| 22. Can a lunate be revascularized by direct vessel reimplantation? | 974 | ||
| 23. When should intercarpal arthrodesis be considered? | 974 | ||
| 24. Which intercarpal arthrodesis is most appropriate? | 975 | ||
| 25. What salvage procedures are preformed for advance disease? | 975 | ||
| Controversies | 975 | ||
| 26. Are radial wedge osteotomies (closing or opening) effective procedures for Kienböck’s disease? | 975 | ||
| 27. How about vascularized radial bone grafts? | 976 | ||
| 28. What procedure is best suited for patients with ulnar-positive variance? | 976 | ||
| Bibliography | 976 | ||
| Chapter 151: Carpal Dislocations and Instability | 977 | ||
| 1. How do carpal dislocations typically occur? | 977 | ||
| 2. How do patients with carpal dislocations typically present? | 977 | ||
| 3. What is the difference between a perilunate dislocation and a lunate dislocation? | 977 | ||
| 4. What is the “spilled teacup” sign? What does it signify? | 977 | ||
| 5. Where is the space of Poirier, and why is it clinically important? | 977 | ||
| 6. How can a dorsal perilunate dislocation be reduced? | 977 | ||
| 7. What is the best method for treatment of an acute perilunate/lunate dislocation or fracture/dislocation? | 978 | ||
| 8. Define lesser and greater arc injuries of the carpus. | 978 | ||
| 9. Why are chauffeur’s or radial styloid fractures especially concerning? | 978 | ||
| 10. Define the abbreviations CID, CIND, and CIC and describe their corresponding conditions. | 978 | ||
| 11. What are Gilula arcs, and what do their disruptions indicate? | 979 | ||
| 12. Explain the midcarpal shift test for midcarpal instability. | 979 | ||
| 13. What is the role of arthroscopy in evaluating carpal instability? | 979 | ||
| 14. What is a DISI deformity? A VISI deformity? | 979 | ||
| 15. Which conditions can lead to dorsal intercalated instability? To volar intercalated instability? | 979 | ||
| 16. What is the Watson test? | 979 | ||
| 17. What is the signet ring sign? | 980 | ||
| 18. Who was Terry Thomas? What is the significance of his name? | 980 | ||
| 19. What is a normal scapholunate angle? When is a scapholunate angle considered pathologic? | 980 | ||
| 20. Which radiographs help to make the diagnosis of scapholunate dissociation? | 980 | ||
| 21. Differentiate between static and dynamic scapholunate dissociation. | 980 | ||
| 22. What are the radiographic signs of scapholunate dissociation? | 980 | ||
| 23. How are dorsal wrist ganglia associated with carpal instability? | 980 | ||
| 24. What is a SLAC wrist, and what are its characteristics? | 980 | ||
| 25. What are treatment options for chronic scapholunate instability? | 980 | ||
| 26. Describe the typical history and examination of a patient with a lunotriquetral ligament tear. | 980 | ||
| 27. Describe a shear or ballottement test of the lunotriquetral joint. | 981 | ||
| 28. How can lunotriquetral instabilities be graded? | 981 | ||
| 29. Briefly list the key intercarpal ligaments. | 981 | ||
| Bibliography | 981 | ||
| Chapter 152: Ulnar Wrist Pain | 982 | ||
| 1. What five carpal bones make up the ulnar side of the wrist? | 982 | ||
| 2. Name 10 possible entities to be considered in a broad differential diagnosis of ulnar-sided wrist pain? | 982 | ||
| 3. What structure on the ulnar side of the wrist is frequently injured yet not seen on radiographs? | 982 | ||
| 4. Tears of the TFCC are most frequently caused by what mechanism? | 982 | ||
| 5. What intercarpal ligament is frequently injured along with the TFCC? | 983 | ||
| 6. Ulnar wrist pain in the hypothenar eminence in golfers is commonly caused by what type of fracture? | 983 | ||
| 7. What does tenderness to palpation over the pisiform bone often indicate? | 983 | ||
| 8. What structure on the ulnar side of the wrist is prone to age-related changes? | 983 | ||
| 9. What is ulnar variance? | 983 | ||
| 10. What diagnostic tests help in differentiating causes of ulnar-sided wrist pain? | 983 | ||
| 11. What technique has the best sensitivity, specificity, and accuracy for defining ulnar-sided wrist pain due to soft tissue injuries? | 983 | ||
| 12. During arthroscopy, loss of what finding may indicate tearing of the peripheral TFCC? | 983 | ||
| 13. What is the vascular anatomy of the TFCC? | 983 | ||
| 14. What is the main form of treatment of central TFCC tears? | 983 | ||
| 15. In patients who have undergone TFCC débridement but still have ulnar-sided wrist pain, what procedure can be used as an initial salvage procedure for relief of pain? | 983 | ||
| 16. What procedure may be considered as an alternative to an ulnar shortening osteotomy to reduce TFCC loading in patients with minimal ulnar-plus variance? | 984 | ||
| 17. What vascular anatomy can be associated with patients who use their hypothenar eminence as a hammer and have ulnar-sided wrist pain? | 984 | ||
| 18. What physical tests are used to examine for lunotriquetral ligament tears? | 984 | ||
| 19. What is the most common diagnostic and therapeutic procedure for lunotriquetral ligament tears? | 984 | ||
| 20. Why do some authors advocate a four-corner fusion rather than a lunotriquetral fusion for documented lunotriquetral ligament tearing? | 984 | ||
| 21. If pain is elicited by the lunotriquetral shear test, what other condition must be ruled out? | 984 | ||
| 22. What are the two classes of TFCC tears, and how are they usually treated? | 984 | ||
| Bibliography | 984 | ||
| Chapter 153: Rheumatoid Arthritis of the Wrist | 986 | ||
| 1. In patients with rheumatoid arthritis, how often is the wrist affected? | 986 | ||
| 2. How does RA affect the wrist? | 986 | ||
| 3. List the criteria necessary to make a diagnosis of RA. | 986 | ||
| 4. What are rheumatoid nodules? | 986 | ||
| 5. What is the utility of checking for serum rheumatoid factor? | 986 | ||
| 6. What is RF? | 986 | ||
| 7. What other laboratory values may be elevated in RA? | 987 | ||
| 8. Is there any utility to checking wrist joint synovial fluid in RA? | 987 | ||
| 9. Describe what a biopsy specimen of rheumatoid synovium might show. | 987 | ||
| 10. What diagnostic imaging of the wrist should be obtained in RA? | 987 | ||
| 11. What is a scallop sign? | 987 | ||
| 12. Describe the classic pattern of deformity of the radiocarpal joint and DRUJ. | 987 | ||
| 13. What are the other characteristic deformities in the rheumatoid hand? | 988 | ||
| 14. What are the three major pathophysiologic factors in RA that result in joint destruction? | 988 | ||
| 15. What is the natural course of rheumatoid disease in the wrist? | 988 | ||
| 16. How does the pattern of wrist destruction in RA differ from that in an osteoarthritic scapholunate advanced collapse wrist? | 988 | ||
| 17. How does tenosynovitis affect the wrist? | 988 | ||
| 18. What are the treatment options for wrist synovitis? | 988 | ||
| 19. What are the benefits of arthroscopic synovectomy? | 988 | ||
| 20. What pharmacologic options exist for treatment of RA? | 988 | ||
| 21. What is caput ulnae syndrome? | 988 | ||
| 22. What is a piano keyboard sign? | 989 | ||
| 23. Why is dorsal ulnar prominence at the wrist a problem? | 989 | ||
| 24. What are the causes of tendon rupture in RA? | 989 | ||
| 25. Which flexor tendons commonly rupture in RA of the wrist? | 989 | ||
| 26. Which extensor tendons commonly rupture in RA of the wrist? | 989 | ||
| 27. Why do patients with RA lose the ability to extend their fingers? | 989 | ||
| 28. How can you determine the cause of loss of finger extension? | 989 | ||
| 29. What are the surgical indications in RA of the wrist? | 989 | ||
| 30. What should be done during preoperative evaluation of a patient with RA? | 989 | ||
| 31. What are surgical options in managing DRUJ involvement in RA of the wrist? | 989 | ||
| 32. What is the Darrach procedure? | 990 | ||
| 33. Describe the Suave-Kapandji procedure. | 990 | ||
| 34. What does resection hemiarthroplasty involve? | 990 | ||
| 35. What is a distal ulna prosthesis reconstruction? | 990 | ||
| 36. What are the surgical options for treating radiocarpal involvement in RA? | 990 | ||
| 37. What are the indications for tenosynovectomy? | 990 | ||
| 38. How can intraarticular wrist synovectomy be performed? | 990 | ||
| 39. Describe the role of ulnar head resection. | 990 | ||
| 40. Why isn’t wrist arthroplasty more popular in treating RA? | 990 | ||
| 41. What are the types of wrist arthrodesis available in RA? | 990 | ||
| 42. How effective is wrist arthrodesis? | 991 | ||
| 43. Is there a role for midcarpal fusion in RA? | 991 | ||
| 44. How should tendon ruptures be managed? | 991 | ||
| 45. What can be done if both wrist and finger extensors have ruptured? | 991 | ||
| Bibliography | 991 | ||
| Chapter 154: Distal Radius Fractures | 992 | ||
| 1. Do fractures of the distal radius occur in all age-groups? What are the common mechanisms of injury? | 992 | ||
| 2. Is it correct to label all fractures of the distal radius as Colles fractures? | 992 | ||
| 3. What are the commonly used eponyms to describe fractures of the distal radius? | 992 | ||
| 4. What is the most comprehensive classification system used to classify fractures of the distal radius? | 992 | ||
| 5. What are the other common wrist injuries associated with fractures of the distal radius? | 993 | ||
| 6. What are the radiographic projections used in imaging a distal radius fracture? | 993 | ||
| 7. What are some of the cardinal measurements on radiographs of a distal radius? | 995 | ||
| 8. If plain radiographs of the wrist do not provide adequate information regarding the injury, what other investigations may be indicated? | 996 | ||
| 9. What should be included in the initial clinical examination of a patient with a fractured distal radius? | 996 | ||
| 10. What is the initial management of a displaced fracture of the distal radius? | 996 | ||
| 11. How is a “hematoma block” performed for a closed reduction of a distal radius fracture? | 996 | ||
| 12. How is a closed reduction of a distal radius fracture performed? | 996 | ||
| 13. What is the management of undisplaced intraarticular and extraarticular stable fractures of the distal radius? | 996 | ||
| 14. What are the features of the initial clinical assessment that indicate the need for surgical fixation of a distal radius fracture? | 997 | ||
| 15. What are the radiographic features that indicate the need for surgical treatment? | 997 | ||
| 16. What are some of the common forms of fixation of distal radius fractures? | 997 | ||
| 17. Which fractures are suitable for percutaneous pin fixation? | 997 | ||
| 18. How is percutaneous pin fixation performed? | 998 | ||
| 19. Is plate fixation for distal radius fractures performed volarly or dorsally? | 998 | ||
| 20. What are the common complications of distal radius fractures? | 998 | ||
| 21. What are the characteristics of CRPS, and how is it treated? | 998 | ||
| Bibliography | 999 | ||
| Chapter 155: Limited Wrist Arthrodesis | 1000 | ||
| 1. What is an intercarpal arthrodesis? | 1000 | ||
| 2. Which wrist joints are responsible for flexion and extension? | 1000 | ||
| 3. What is the functional range of wrist motion? | 1000 | ||
| 4. Is wrist motion lost after intercarpal arthrodesis? If so, how does the loss compare with motion lost after a total wrist arthrodesis? | 1000 | ||
| 5. What are the indications for an intercarpal arthrodesis? | 1000 | ||
| 6. Why is it critical that unaffected intercarpal joints be left unfused? Are there any exceptions? | 1000 | ||
| 7. Why must the normal external dimensions of the carpal bones included in a limited arthrodesis be preserved? Are there any exceptions? | 1000 | ||
| 8. Why must pin fixation include only bones involved in the arthrodesis? | 1001 | ||
| 9. Why is the scaphoid susceptible to degenerative arthritic change? | 1001 | ||
| 10. What is a triscaphe arthrodesis? | 1001 | ||
| 11. What is rotary subluxation of the scaphoid? How is it treated? | 1001 | ||
| 12. How is a triscaphe arthrodesis performed? | 1001 | ||
| 13. What is the key to performing a successful triscaphe arthrodesis? | 1002 | ||
| 14. Are there any absolute contraindications to a triscaphe arthrodesis? | 1003 | ||
| 15. What is SLAC wrist? | 1003 | ||
| 16. Which conditions predispose to the development of SLAC wrist? | 1004 | ||
| 17. Which joint in the wrist is virtually never involved in degenerative disease? Why not? | 1004 | ||
| 18. How is SLAC wrist reconstruction performed? | 1004 | ||
| 19. What is the key to performing a successful SLAC wrist reconstruction? | 1004 | ||
| 20. Are there any absolute contraindications to SLAC wrist reconstruction? | 1005 | ||
| 21. What are the most common patterns of degenerative disease of the wrist? | 1005 | ||
| 22. What is a congenital carpal synchondrosis? Which intercarpal joint is most commonly involved? | 1005 | ||
| 23. Why might a congenitally fused intercarpal joint require subsequent arthrodesis? | 1005 | ||
| 24. What are the indications for limited wrist arthrodesis of the lunotriquetral joint? | 1005 | ||
| 25. How is an LT arthrodesis performed? | 1005 | ||
| 26. Which intercarpal arthrodesis results in the greatest loss of wrist motion? Which results in the least loss of motion? | 1005 | ||
| 27. What is the optimal bone graft donor site for intercarpal arthrodesis? | 1005 | ||
| 28. How is bone graft harvested from the distal radius? The identification of which structure is helpful during graft harvest? | 1006 | ||
| 29. Can SL dissociation be treated with a SL limited wrist arthrodesis? | 1006 | ||
| 30. Both scaphoid–capitate arthrodesis and triscaphe arthrodesis are used to treat scaphoid instability. How do the procedures differ biomechanically? | 1006 | ||
| 31. What are the indications for a radiolunate arthrodesis in nonrheumatoid patients? | 1006 | ||
| 32. What is an absolute contraindication to radiolunate arthrodesis? | 1006 | ||
| 33. How is the wrist managed after intercarpal arthrodesis? | 1006 | ||
| 34. What is the incidence of complications after intercarpal arthrodesis? | 1007 | ||
| Bibliography | 1007 | ||
| Index | 1009 |