Derm Qbank: Surgical, Laser, Cosmetic

If the angle is too small in a Z-plasty, what are you at risk for?

Flap necrosis (especially if <30) as blood supply can be compromised on small flap pedicle

What type of suture is pictured here?

Horizontal mattress - can be utilized - good for hemostasis **good for thin dermis/epidermis to prevent tearing of the skin

Which fillers are derived from rooster comb?

Hyaloform

How is monocryl degraded?

Hydrolysis

Which fillers are rooster comb HA derived?

Hylaform and Hylaform+

What is a purse string closure?

Used to close circular or oval surgicals defects - it is great for oval or ircular defects on the dorsal hand

Why is vicryl better than monocryl for higher tension areas?

Vicryl and Monocryl both have similar absorption times (80-90 days), but monocryl loses tensile strength faster (at 55% after 1 week - vs. vicryl is 75% at 2 weeks)

Chromophore absorption based on wavelengths and laser:

***

List of fillers and what they're made of and common notes:

**hyaluronidase is also found in venom and saliva of several stinging and biting insects and helps move the cytotoxic and neurotoxic agenst through tissue - so if patients have known allergy to insect bites and stings, especially anaphylaxis - should be avoided or used with caution

What are lasers in the infrared wavelength (700 - 1,000,000)?

- Alexandrite (755) - Diode (800) - Nd:YAG (1064) - Erbium:glass (1540) - Thulium (1927) - Erbrium:YAG (2940) - CO2 10600

What are the filler characterstics that contribute to longevity?

- Degree of cross linking --> the more cross-linking the longer the durability - increase in elastic modules (G') --> increases movement and decreases spread so increases volume support after injection - concentration (is of both free and cross-linked HA) - but only the cross-linked HA helps with longevity - particle size = the body's reaction to foreign body material via phagocytosis also greatly determines longevity and particle size that is 15-20micrometers resists phagocytosis more.

Maximum quantity of opioids that JAAD recommending for post=operative pain was?

10 tablets of oxycodone 5mg **should be alternating 400mg ibuprofen and 1gm of acetaminophen

Wound healing based by week:

1 week = 5% 2 weeks = 5-10% 4 weeks = 30-40% 1 year = 80%

MC time for wound dehiscence?

1-2 weeks when epidermal sutures come out

What is a complex linear closure?

1. If wide undermining greater than or equal to the distance of maximum width of defect perpendicular to the closure line 2. exposure of bone, cartilage, tendon or named neurovascular structure 3. debridement of wound edges 4. involvement of free margins including helical rin, vermillion border, or nostril rim 5. placement of retention sutures

What is the standard formulation of Jessner's solution?

14g resorcinol, 14g salicylic acid, 14g lactic acid, and ethanol to make 100mLs - used to treat acne, PIH, melasma, lentigenes, and dyschromias - this is a superficial peel, but depth of penetratino can be adjusted by number of coats applied. - should use retinoids 2-6 weeks prior to speed and ehnace penetration (but stop few days before)

You're planning to do a paramedian forehead flap ipsilateral on R nasal ala. What site would you expect your vascular supply to start at?

1cm R of the glabellar midline - the supratrochlear artery

When does reinnervation of a FTSG start?

2-4 months - 2-4 weeks is when sensory re-innervation begins but 2 months to 2 years you get full sensation return

If deep chemical peel is being completed or laser resurfacing (C)2) how long should prophylaxis for HSV be?

8-14 days

If a patient with cSCC has PNI, according to a large systematic review, their DSD is approximately what? If a patient with cSCC has incidental but not clinical PNI, what is their DSD?

30% and still 12%

Using bellafill or zyplast (not used anymore) requires skin testing how many weeks prior to use of permanent filler?

4 weeks/30 days prior to injection to make sure there is no allergy (up to 5%) to bovine collagen

What is the correct angle between the defect and primary lobe in this repair design?

45˚ angle should be between the operative defect and the primary lobe, as well as between the primary lobe and secondary lobe (so total angle should be 90˚ total arc of transposition from primary defect to secondary lobe)

If you do a Mohs surgery and then also do a biopsy on a patient of a separate lesion that she feels is non-healing, what modifier would you put on that biopsy?

59 modifier = separate/distinct service on the same day of the procedure (separate procedure on a separate site)

If a patient reqiures Abx prophylaxis prior to Mohs but has penicillin allergy, what would be appropriate?

600mg clindamycin, 500mg azithroy, or 500mg clairthromycin

How many follicular units are ideally present per cm2 for hair transplant donor strip from the occipital scalp?

65 - 85 u/cm2, with hair density from these unites ranging between 125-200

Code for eyelid biopsy?

67810 = incisional biopsy of the eyelid including lird margin *vs 67840 = eyelid excision including eyelid margins

5 year cure rate of SCC with MMS?

92-97%

If you're doing a digital nerve block, what is the maximum volume of anesthetic for this per digit??

<4cc - basically <1cc to cover each of the 4 nerves (2 dorsal and 2 volar sensory nerves along the side of digits - recently described dorsal wing block at base of nail injecting 0.1-0.2cc of anesthetic subcutaneously (creating a wheal) proximal to the base of the nail midway between the cuticle and DIP

List of each of these for quizzing:

A = bandage scissors B = castroviejo (Westcott) scissors) C = bishop harmon forceps D = Hemostat E = needle holders (with tungsten carbide) F = iris scissors G = undermining scissors H/I = tissue forcepts J = 15 blade on beaver handle K = skin hooks L = punch tool M = hemostat

Which scissors are particularly useful for delicate eyelid dissection?

A = westcott scissors - have spring system that causes the blades to come together B = gradles scissors - can also be used for periorbital dissection C = metzenbaums - used for blunt dissection D = iris = can be curved or straight - used for delicate work on face

What is a basting stitch?

A stitch used to anchor tissue to a wound bed, like FTSG to recipient wound bed

Type of flap planned in this picture:

A to T (burrow's triangle displacement flap) or bilateral single tangent advancement flap

Which waveforms are emitted from lasers?

A, C and F - monochromaticity = all emitted photons are the same wavelength - coherence = photons travel in phase both in time and spafce - collimation = parallel beams of light

59 yo immunocompetent female presents to clinic for evaluation of non-healing 1.2cm lesion on L cheek. If you biopsy, what kind of lesion with AUC will not meet criteria for Mohs?

AK with focal changes of SCC in situ; recurrent lesion

What is one non-vascular skin lesion that PDL can also treat?

AKs - can be used in PDT with 5-ALA - which is taken up by rapidly dividing cells and the PDL will also be absorbed and lead to distruction

You have a patient with skin type IV who wants laser hair removal. You discuss various lasers and their safety in laser hair removal in darker skin types. In which phase of the hair cycle is the most responsive to laser removal?

ANAGEN - hair cells are most replete with melanin, protein, and other nutrients and makes it the most susceptible phase of the hair cycle to laser treatment.

Sclerotherapy is the mainstay for treatment of smaller telengiectasias and reticular veins. If one acciendetally injects a sclerosing solutoin intra-arterially, what should be done first?

APPLY ICE to areas distal to injection that are blanching white in order to minimize tissue damage is needed. - thrombolytics and vasodilation are considerations, in addition to necessary immediate transfer to hospital vascular surgery team.

Suture Plasticity

Ability of a suture to e molded and retain a new shape ***Prolone = good plasticity and allows for stretching to adapt to edema

Suture elasticity

Ability of a suture to regain its original structure (like length) after being stretched ***good for continued tension after swelling has improved, like Novafil (polybutester)

Suture Memory

Ability of a suture to retain natural configuration ***the higher the memory, the poorer the handling and knot strength (think Nylon or Prolene)

Suture capillarity

Ability to absorb Multifilament has > capillarity than monofilament (so Vicry and Dexon which are braided absorb twice as fast as PDS or Maxon

Which laser mediumsa re solid (crystal)?

Alexandrite Erbium-YAG Holmium-YAG Nd-YAG Potassium titanyl phosphate Ruby

Which fillers are derived from Streptococcus equi??

All the bacterial derived HA fillers = restylane, juvederm, belotero and perlane

Which anesthetics are metabolized by CYP3A4 system in liver?

Amides --> Two I's --> contraindicated in end stage liver disease

Which local anesthetics are processed in the plasma and which are processed in the liver?

Amides are in the liver, esters are in the plasma via pseudocholinesterase

Which things can potentiate botox??

Aminoglycosides, CCBs, anticholinergics, cyclosporine. - should avoid due to risk of paralytic effect of the toxin.

When there is a breach of oral mucosa, what antibiotics for prophlyaxis should you consider?

Amoxicillin 2g PO x1 OR if PCN allergy - clindamycin 600mg PO x1, azithromnycin/clarithromycin 500mg PO x1

Which laser mediums are gas?

Argon CO2 Copper vapor Helium-neon Krypton Xenon chloride (excimer)

Adding _______ to superficical TCA 10-25% peel can help for treatment of melasma?

Ascorbic acid (has shown significant reduction with 5% AA and 20% TCA than just TCA alone)

Injection of botox in which area is highest risk for causing ptosis?

Corrugator at the mid pupillary line (C) -

Which muscle causes the vertical glabellar lines?

Corrugator supercilli and medial orbicularis oculi

What medication is absolutely contraindicated in tumescent liposuction?

BUPIVACAINE - cardiac toxicity is not responsive to resuscitation, and is not preceded by convulsions or CNS toxicity like lidocaine - also should do med check to check for meds that interact with lidocaine = amiodarone, azoles, benzos, beta blockers (will allow unrestricted alpha of epi), cocaine, phenytoin, triazole antifungals

A patient undergoes lip augmentation with juvederm. What is juvederm derived from?

Bacterial hyaluronic acid - HA is composed of acid mucopolysaccharides which are a normal component of the dermal ECM, binds water to create volume in the dermis

Which antiseptic can be used prior to other antiseptics by putting it over surgical markings and then wiping after 30 seconds to help keep surgical markigns?

Betadine (povidone iodine) - this leads to less discoloration of surgical markings

What is the MOA of triclosan (coated on suture)?

Binds to and inhibits enoyl-acyl carrier protein.

If you have a patient with a pacemaker who is still bleeding despite using electrocautery, what is the safest and best next step?

Bipolar biterminal (electrocoagulation) less likely to cause interference and then if this doesn't work do monoterminal monopolar (electrofulguration or dessication)

What is the next safest electrosurgery for ICD patients when electrocautery is ont controlling bleeding?

Bipolar electrocoagulation (which is bioplar or 2 tips and biterminal with no grounding plate but bipolar forceps into 2 ports plugged in)

Patient comes to your office for rhinophyma reduction using loop cautery and CO2 laser ablation. AFter consenting, you recommend a nerve block. What nerves will you target in the block??

Both V1 and V2 branches of the trigeminal nerve provide sensation to the external nose - external branch of anterior ethmoidal (V1) = nasal tip and columella (block is intercartilaginous where bone meets cartilage) - infratrochlear (V1) is nasal dorsum and supratip (block at superomedial border of orbit along medial wall) - infraorbital nerve (V2) is lower and lateral aspects of nose (block at mid orbital rim and inject just inferior) - nasopalatine (V2) is distal columella and underside of nose (block at base of columella)

Ratio of Botox to dysport units

Botox 1:Dysport 3

Which local anesthetic as the longest duration of action?

Bupivicaine = 3-5 hours and Ropivacaine = 2-6 hours

Which sutures provide the best wound eversion and wound edge approximation?

Buried vertical mattress suture (heart shaped - B) and simple interrupted stitches (I) **vertical mattress (F) is good for eversion in high tension areas

Based on the picture, which flap is being planned?

Burow's triangle displacement flap (H-flap)

What type of flap is this out of the four major categories?

Burow's triangle displacement flap (or tissue advancement) that requires extensive undermining and depends on skin laxity and tissue elasticity)

Which part of the suture describes the shape (arc) of the needle body?

C vs. A = type and size of the needle overall

Which suture type is showing a vertical mattress sutur?

C is a vertical mattress - helps to oppose wound edges in high tension areas

Tumescent liposuction can be used for what? And what can it not be used for?

CANNOT BE USED FOR WEIGHT LOSS AS A REPLACEMENT FOR DIET AND EXERCISE - Can be used to treat local adiposities, lipomas, hyperhidrosis, bromohidrosis (due to removal of apocrine and eccrine sweat glands in the fat), gynecomastia, lymphedema, hematoma evacuation and buffalo hump removal

What is TCA CROSS and what is it used for?

CROSS = Chemical Reconstruction of Skin Scars --> this is high percentage TCA (65-100%) that you use with a tooth pick over top of the scar being careful into to come into contact with normal skin - healing takes place over next few weeks with granualtion, fibroplasia and new collagen **should not be used to roller acne scarring due to risk of severe scarring

You are using EMLA on a 6 month old before removing accessory tragus prior to injecting anesthesia. What is your main worry with EMLA?

Can lead to methemoglobinemia, especially in infants <1

If you have a non-oral site but high risk surgical site (lower extremity, groin, wedge of lip or ear, skin flaps on nose, grafting or extensive inflammatory skin disease), what are your first choice antibiotics??

Cephalexin or dicloxacillin 2g PO x1 OR if PEN allergic - clindamycin 600mg PO x1, or azithromycin/clarithromycin 500mg x1 ***alikhan for lower extremity recommends bactrim DS or levofloxacin if PCN allergy for lower extremity or groin.

Which surgical prep is NOT recommended around the eye or ears?

Chlorhexidine = due to risk of keratitis and ototoxicity *should use betadine around the eye and in or near the conchal bowl

If pt with anaphylactic PCN allergy requires prophylaxis of possible but unlikely infected cyst prior to removal, what wioll you give?

Clindamycin 600mg one time dose

Which wavelength does water start being absorbed?

Close to infrared range ~700

Which local anesthetic used in otolaryngology during minor procedures of nasal mucosa has inherent vasoconstrictive properties?

Cocaine

Which suture characteristics are associated with increased knot security?

Coefficienct of friction and configuration - COF = eas of pulling it through the tissue - configuration = either monofilament or multifilament (braided, spun or twisted)

Which type of sterilization is primarily ineffective in derm surgery?

Cold sterilization (with glutaraldehyde) because it is inadequate for incisional surgery

Which type of graft has the highest failure rate?

Composite graft = modified full thickness graft (grafting two or more tissue types like skin/cartilage, skin and fat, skin and perichondrium)

What are areas of the face that are cosmetically acceptable to heal by secondary intention?

Concave surfaces (nose, eye, ear, temple) are much better areas to heal by secondary intention as the surgical wound will contract and decrease the defect size **vs convex surfaces would contract and dsifigure area

If you require a FTSG of a nonperforating 0.5cm defect of the right nasal ala, which area has the closest adnexal/sebaceous gland density to the lower one third of the nose?

Concha bowl - although comments section mentions the forehead

What is the optimal conversion ratio between onabotulinumtoxin-A and abobotulinumtoxinA?

Conversion is 1:3

You clear an infiltrative BCC on the perialar/nasal dorsum region (pictured). What type of repair is this?

Crescentic advancement flap (burrow's triangle single tangent

Which is not a Rhombic, and which one of each are the different types of Rhombic?

D is not a rhombic A = tradiation Rhombic (Limberg) B = Dufourmental (secondary defect is more acute angle of 60˚) C = Webster (secondary defecgt is placed at 30˚ angle)

What is 11042 code?

Debridement code

What level o the skin does baker gordon peels reach?

Deep = mid-reticular dermis - made up of hexachlorophene, croton oil, and tap water and added to solution of phenol **Phenol is cardiotoxic, nephrotoxic and hepatotoxic

What type of vessel can a PDL not target?

Deep venous malformations - these are too deep below skin surface for PDL to reach

Absorbable sutures - which one's are braided (multifilament)?

Dexon (polyglycolic acid) and Vicryl (polyglactin 910)

A patient had a wedge closure of Mohs on the L ear five days ago and now complaining of ear pain and fever, at that time sent home on postop cephalexin. You see him and see his ear is red and swollen to twice the normal size. BEST NEXT STEPS?

Diagnosis = Chondritis, likely secondary to pseudomonal infeciton - should switch Abx to pseudomonas coverage as well as start NSAIDs

Suture USP size

Diameter required to achieve a given tensile strength

Which laser is the most effective for laser hair removal and what medium does it work through?

Diode = 800nm - works through solid: semiconductor as it's medium - has selective photothermolysis to target specifically melanin or blood and leaves surrounding tissue unharmed *vs. Nd-YAG is safest in skin of color for hair removal which is solid crystal medium

Suture Coefficient of Friction

Ease of pulling through tissue ***Prolene has low CoF, but knot security is poor due to this

Which technique is being using in this photo (one tip, but with grounding plate - not cutting through the tissue)?

Electrocoagulation --> this is BITERMINAL and monopolar (one tip) and is not electrosection because it is not cutting through the tissue

Which forms of electrosurgery have the highest voltage and the lower amperage?

Electrodessication and electrofulguration - both are monoterminal devices (single tip) and high voltage, low amperage

Which forms of electrosurgery require an indifferent electrode?

Electrosectioning and electrocoagulation with biterminal forceps

If a patient has a documented sulfa allergy and sensitivity to chemical sunscreens, which ansesthetics should you avoid?

Esters - associated with higher incidence of allergic reactions due to one of their metabolites, PABA - PABA can cross react with PPD, Azo dyes, sulfonamides and thiazides

Whcih anesthetics are metabolized by plasma pseudocholinsterase?

Esters = one I in the name

A 60 yo patient returns to your clinic for refractory tinea cruris. You recommend scouting biopsies. Biopsy shown, proliferation of atypical cells in epidermis positive for CK7, PAS, and GCDFP-15. Most appropriate next step is?

Evaluation for internal malignancy. - 10-30% of de novo cases are associated with internal malignancy - once this is ruled out, treatment with Mohs (higher cure rate than WLE) vs. WLE can be used.

What is the billing CPT for excision of a lipoma?

Excision of soft tissue tumors (this includes the simple and intermediate repairs) and it's based on size ***OF NOTE THIS HAS A 90 DAY GLOBAL PERIOD

When using cryotherapy to treat a common wart (or any benign or malignant lesion) what is the ideal velocity of the freezing and thawing components?

Fast freezing velocity, low thawing velocity - benign neoplasms require `25--50 degrees celsius for destruction (fast then slow favors intracellular ice formation)

Suture tensile strength

Force required to break the suture - synthetic materials are higher

What does a FTSG composed of?

Full epidermis and dermis - fat is trimmed due to adipose having poor vascular supply and poor medium for neovascularization

When doing a nail matrix biopsy (like for r/o melanoma), biopsy must go to the level of what?

Full thickness so should go town to level of periosteum. ***remember there is no subcutaneous fat in the nail matrix

Which peels are safe during pregnancy?

Glycolic acid and lactic acid peels deemed safe in pregnancy and breastfeeding

What are the two chemical peels that require neutralization to end it's action?

Glycolic acid and pyruvic acid - must be neutralized at clinical endpoint (erythema) - if no erythema is reached, should still be done after 5 minutes

This stain is used in MMS to improve detection of BCC among other tumors. The stain highlights nuclei staining them dark blue, but highlights what magenta to enhance stroma around BCC?

Glycosaminoglycans (mucopolysaccharides) (called the setting sun sign) ***and will not cause enhancement of the normal stroma that surrounds follicular structures

You are on your 3rd MMS layer of BCC periocular. The defect at this point reveals protruding orbital fat pad. What is the best next step?

Halt Mohs for furthe rworkup and MDS care - **BCC makes up 90% of cutaneous malignancies affecting the eyelids - frozen section and orientation of fat pad is nearly improssible, need to get oculoplastics involved - can be MRI for soft tissue involvement, CT for any bony invasion

What is the correct order for risk (not incidence) of necrosis of skin in sclerotherapy if the agent is extravasated?

Hypertonic saline > STS > polidocanol **remember STS is highest for DETERGENTS approved for sclerotherapy, but HTS is highest overall

What are the late side effects of lidocaine toxicity?

Hypotension - initially symptoms of CNS excitation include perioral numbness, parathesias, tinnitus, termors, drowiness and can even be initially excitation of CV system (so HTN and tachy) but then later is inhibited so (hypotension and bradycardia, and CA arrest)

A patient has an ear wedge closure of an SCC. Ciprofloxacin was prescribed following for 7 days. 2 weeks after, he still has some redness and tenderness, but no drainage or systemic symptoms. What is the best treatment?

Ibuprofen. Perichondritis and chondritis following full thickness repair of ear can last for up to 2 months. vs. pseudomonal suppurative chondritis is rare following MMS when prophylactic pseudomonal coverage is given.

When is a KA-type SCC appropriate for MMS??

If located anywhere and >1.1cm (excluding pretibial area, hands, feet, nails, and ankles)

What is not an advantage of running subcuticular sutures?

Increased risk of misalignment of the wound edges (less effective than simple interrupted) - many surgeons use 4-0 prolene for running subQ because it has low coefficient of friction (slides easily), great tensile strength to decrease risk of snapping, least reactive nonabsorbable and great plasticity for stretch to swelling

To perform a nerve block of medial cheek, upper lip, and nasal ala, which nerve are you targeting and where do you inject?

Infraorbital nerve - inject 1cm inferior to the orbital rim at the midpupillary line - typically 1-3mL of lidocaine is used here and can last for hours

What does it mean when polyglactin 910 (vicryl) suture comes with a + sign next to it?

It is antibiotic coated with triclosan - both antibacterial and antifungal and is regularly used in household products like toothpaste, soap, detergent, and toys.

What suture characteristics are multifilament sutures superior in?

Knot security, strength, pliability, and handling, but higher risk of infection and Vicryl higher risk of spitting

What are the L:W ratio for standard excision and which orientation is best on the trunk, limbs, and scalp?

L:W ratio should be 3-4:1, and the trunk should be mostly horizontal (except oblique ath shoulder or scapular region), scalp is coronal, and limbs are vertical

The abbe flap is based on which artery for survival?

Labial artery - this is an axial flap (not random pattern meaning it is based on one artery and not perforating, branches) - abbe flap designed with a width approximately half that of defect with heigh equal to the defect and pedicle is toward the side of the defect and where possible the central lower lip is used as a donor site

What laser targets are going to have longer pulse durations?

Large the chromophore size = the longer the pulse duration - this is because the thermal relaxation time = chromophore size squared and the pulse duration should be equal to or longer than thermal relaxation time - smaller particles, like melanocytes, can be targeted using nanoseconds (Q-switched)

Which of these exhibits PNI?

Letter C - PNI conveys greater risk of local recurrence, nodal mets and distant *overall risk of DSD in patients with clinical PNI is ~30%

What is the standard tumescent local anesthetic formulation?

Lidocaine 0.05% with 1:1,000,000 epinephrine plus sodium bicarbonate (to bring closer to physiologic pH that is closer to pKa of lidocaine)

You are numbing a patient for removal of severe atypical nevus of the forehead and use total of 12cc of 1% lido with 1:100,000 diluted epi with bicarb. She states her heart feels like it's racing. Her pulse is 110, BP 158/96. What is likely happening and next steps?

Likely a reactoin to the epi - tell her this wil resolve within a few minutes spontaneously.

You're treating telengiectasias on the cheek of your patient with a laser with wavelength of 585-600nm. What is the media used in this laser?

Liquid - PDL containes rhodamine dye dissolved in organic solvent (liquid medium)

Mohs AUC scores and what are some examples when it is uncertain?

MMIS on the arm is AUC of 5

What is the maximum dosage of lidocaine in children (<6 months and >6 months), as well as maximum dosages for adults? How much lidocaine is in 1cc if it is 10% and 20%?

Max dose for kids <6 months: 1.5-2mg/kg without epi, 3-4 with epi Max dose for kids >6 months: 4-4.5mg/kg without epi, 7mg/kg with epi max doses for adults: 5mg/kg without epi, 7mg/kg with epi 10% lido in 1cc = 10mg/cc; 20% lido in 1 cc = 20mg/cc

You excise an atypical spitz nevus on the shin of a 12 year old male. Patient plays basketball and asks how long he should avoid practice. You recommend a deep absorbable suture that maintains tensile strength of 60% at 4 weeks and is completely absorbed in 6 months? Which suture did you use?

Maxon = glycolic acid - has tensile strength of 80% at 2 weeks and 60% at 4 weeks (vs. PDS is 70 and 50% but also lasts 180 days for absorption time)

Prophylactic antibiotics should be used in which scenarios?

May also still be recommended in those without high risk cardiac conditions or total joint replacement if surgery on lower extremity or in groin, wedge excision of lip or ear, skin flaps on nose, skin grafting, or extensive inflammatory skin disease.

If you're doing a chemical peel on a patient with a history of HSV cold sores, which peels will need prophylaxis?

Medium and deep peels of the face - Prescribe valrex 1g BID for 7 days

Which tumor standard of practice requires sentinel lymph node biopsy in work up and management?

Merkel cell carcinoma - always do SLNB unless CI. **also do for high risk SCC and melanoma

Recent studies of patients with botox for many indications (cosmetic, migraine, hyperhidrosis, bladder instability and blepharospasm, spasticity, sialorrhea) showed what improved significantly?

Mood!

Which flap is commonly used for the lower eyelid-cheek junciton?

Mustarde flap - see lesion is excised as a triangle with base along the lower eyelash edge, apex of triangle directed toward the cheek and beginning at the lateral angle of the triangular defect, incision from lateral canthus up toward temple and out toward zygomatic area ***stay superficial to SMAS

When using botox or dysport, are there differences in efficacy based on the equivalent doses, the molecular weights, or aesthetic based on protein load?

NO - no evidence to support that the equivalent doses have differing efficacies, as well as no evidence that dysport (smaller MW) diffuses further from injection site or increases risk of diffusion (this is DOSE dependent). No evidence that protein load is relavent to therapeutic efficacy. ***Current evidence states that muscle activity AFTER botox may be beneficial and icing/cooling may lower efficacy.

Prior to excising BCC from cheek of 45 year old male, you find out the patient has a history of congenital heart defect as a child repaired in early childhood. He has an allergy to penicillin that causes respiratory compromise. What is the most appropriate Abx regimen?

NONE - Prophylaxis is only needed for oral mucosal, infected skin, or if previously infective endocaritis, proshetic heart valve, transplanted heart valve with valvulopathy, unrepaired congenital heart defect causing cyanosis, or repair of congenital heart defect within 6 months

A 4mm punch biopsy of the proximal nail unit would likely result in which of the following?

Nail dystrophy of the dorsal surface of the nail plate

Which laser can damage the retina, cornea and lens??

Nd:YAG - most common implicated laser in ocular injuries - because it has somem degree of affinity to all chromophores: water (lens and cornea), melanin (iris and retina), and Hb (retina) **also longer wavelength

Which areas of the face would have variable and possible poor outcomes healing by second intention?

Nose (convex areas), oral lips, cheeks and chin, helix of ear

Which part of the suture (total kit) tells you the size of the suture "track"?

P-# (so the size of the needle itself because the body of the suture is the widest and will make up the size of the suture tract)

Which absorbable suture has highest tensile strength at four weeks and is monofilament?

PDS (which is polydioxane) is 240, and then maxon (polyglyconate) is 180 - both are monofilament

When you administer local anesthesia, what is loss of sensation generally in what order?

Pain/temp --> touch --> pressure --> vibration ==> proprioception --> motor *larger fibers require higher concentration of local anesthetic than smaller fibers

This patient had previously had MMS of large nasal tip defect including cartilage grafting - based on the associated images, what type of repair was performed?

Paramedian forehead flap - the supratrochlear artery on ipsilateral side of defect provides vascular supply to body of the flap and any cartilage grafting - this is tissue important flap that is two steps (requires takedown at 3 weeks)

Absolute contraindications of tumescent lipo:

People using it for weight loss Morbid obesity History of body dysmorphic disorder excessive scarring n area of treatment

Which of the following accurately depicts a horizontal mattress? (picture)

Picture C - always think that if it's a horizontal mattress, the top sutures will always be vertical (opposite)

What are potential pitfalls of a bilobed transposition flap?

Pincushioning, alar rim distortion, intranasal fullness and partial loss of nasal tip sensation - goal of the lap is to direct all tension to the horizontal axis such that the flap simply drapes over postop defect

Which sclerosing agent is associated with disulfiram-like reactions, but also has natural properties that provide analgesia?

Polidocanol - this has the word "lido" within it

Which two sclerosing agents are more likely to cause disulfram like reactions?

Polidocanol, followed by STS

Which suture is most commonly associated with suture granuloma formation and spitting sutures?

Polyglactin 910 (Vicryl)

How do local anesthetics exert their action?

Preventing DEpolarization interfering with influx of sodium ions into cells

What is endovenous radiofrequency ablation of saphenous veins and what is a predisposing factor that increases risk of DVT development?

Previous DVT is only factor associated with true formation of fully occlusive clot in the deep venous system

Regardless of area of the body/face, what is always inappropriate for Mohs AUC?

Primary or recurrent AK with focal SCC in situ - does not matter the site this is never appropriate for Mohs

Which muscles cause the horizontal glabellar lines?

Procerus and depressor supercilli - both pull the brow inferiorly

What is the nonabsorbabe suture of choice for running subQ?

Prolene

How is Gut broken down in the skin?

Proteolysis

A visibily split nail is most likely secondary to biopsy of which of the following?

Proximal nail matrix - highest risk to cause nail dystrophy if >3mm weidth

Which filler can be easily seen with plain radiograph?

Radiesse = calcium hydroxylapatite - normal component of bone (so low risk of hypersensitivity) and will appear on plain radiographs, as well as can appear as linear streaks or clumps on CT and MR and FDG-PET CI in lips due to risk of mucosal granulomas

What is the primary goal of an advancement flap?

Redistributes the standing cones to a more favorable location that is not necessarily contiguous with the defect

Another name for the dorsal nasal flap?

Reiger flap - a great reconstructive option for closing small defects involving the distal half of the nose

What is a complex repair?

Requirements of an intermediate repair as well as one of the following: - exposure of bone, cartilage, tendon or named neurovascular structure - debridgement of wound edges (traumatic lacerations or avulsoins) - extensive undermining (distance equal or greater than maximum width of defect measured perpendicular to the defect line) -

What is a vein that measures 2-4mm?

Reticular vein

You have a defect on the lateral upper cutaneous lip, what would be an ideal closure type and what's the primary advantage of this repair? (can look at photo but do not look at answer)

Rotation flap - this will recruit laxity from multiple tissue directs to redirect closure tension - in this case, tissue is recruited from the nasolabial fold (which has excess)

Which type of suture is this?

Running subcuticular

80yo male undergoes WLE of pleomorphic sarcoma on crown of scalp. Defect extends 2cm peripherally from border of the lesion and to level of periosteum. Which of the following options would be most apporpriate method to close defect?

STSG - donor site from anteromedial thigh - STSG can be placed directly over periosteum, perichondrium, perineurium and peritenon, whereas full thickness grafts shoul be avoided overlying these beds without first allowing granulation tissue to form. - will have increased survivial than full thickness - thin will have less to revascularize and good for areas of poor vasculr supply ***do have GREATER contraction compared to full meshing of the graft improves graft survivial

What should your pulse duration be of your laser to target the chromophore you want?

Should be shorter or equal to your thermal relaxation time of target chromophore to ensure absorption of target without collateral thermal damage

Which suture has low memory and high pliability?

Silk - easy to handle and has low memory (does not retain natural configuration)

5 layers of the scalp

Skin Connective tissue Aponeurosis Loose connective tissue Pericranium

Which sclerosant has the highest incidence of arrhythmias?

Sodium morrhuate

A patient would like sclerotherapy for spider veins of her legs. She has had it in the past with development of ulcerations following injection. Which FDA approved detergent sclerosant has high incidence of skin ulceration?

Sodium tetradecyl sulfate (STS) - skin ulceration is most frequently reported with STS, followed by polidocanol ***hypertonic saline is also frequent cause of necrosis with ulceration but is NOT a detergent 4 FDA approved detergents = STS, polidocanol sodium morrhuate, and ethanolamine oleate

Which fillers are permanent fillers and require surgical incisions for implantation?

Softform and Goretex (both of which are polytetrafluoroethylene)

Which laser can remove violet tattoo pigment?

Specifically this is Frequency doubled Nd:YAG 532nm --> the pigment in violet = manganese violet

Look at photo - what is this type of graft?

Split thickness skin graft - more color and textural mismatch than FTSG due to lack of adnexal structures, but STSG better over avascular structures like periosteum, perichondrium, perineurium

For electrosurgical units in dermatology offices - what standard outlet frequency needs to be convered to at least to avoid nerve and muscle stimulation?

Standard outlet is 50-60hz Need converted to above 10,000Hz as nerve and muscle are stimulated below this (get to higher frequencies around 500,000 to 3 million)

74 year old caucasian male presents for MMS of recurrent SCC of the lower lip. He's clearead in one stage. Full LN exam reveals no lymphadenopathy. If SCC were to be metastatic, which nodes would be involved?

Submental and submandibular lymph nodes - lower lips drains to submental, upper lip drains to submandibular - lateral portion of lower lip drains to submandibular as well.

A paitent has MMS of an infiltrative BCC of the R medial forehead with linear repair. He then describes a lack of sensation to parts of the forehead and frontal and temporal scalp. Which of the following nerves has been most likely compromised?

Supraorbital nerve - supplies sensory to the upper eyelid, forehead, and scalp (extending to lamboidal suture which includes parts of the frontal, parietal and temporal scalp) ***vs supratrochlear (which is also a branch of the frontal nerve off of the V1 ophthalmic nerve) which supples the medial eyelid, anteromedial forehead and frontal scalp

You have a patient with a fleshy, pedunculated 1cm papule on the lower back. Biopsy shown here. What is the next steps?

Surgical excision with 4mm margins - this is fibroepithelioma of pinkus

A rhombic is what type of flap and what locations are good places to use it?

THis is a transposition flap (single stage) in which lifting of tissue over intervening normal sin to reorient tension of the secondary defect occurs - good locations = medial and lateral canthus, lateral forehead, cheek, upper lateral nose, perioral (overall best on the face)

What is a tacking stich?

Tack skin to the perichondrium or periosteum, allows for permanent elevation of an area

Which portion of the local anesthetic is related to onset of action?

The amine group (purple box) - Hcl works as an off off switch that determines whether it is positively charged or not to penetrate the neuron (alkalinizing makes it more lipophilic and speeds up onset of action)

What is the secondary tension vector of a flap?

The direct of force at the donor closure site

What is the primary tension vector of a flap?

The direction of force that counterats the movement of the flap, so in this photo that is C

What is the secondary tension vector of a flap?

The directional force that is created by the closure of the donor site, so in this case A

Which portion of the anesthetic molecule determines the class of the anesthetic??

The linkage of the intermediate chain (green box) - vs. the amine group determines the onset of duration by either being in tertiary form (3 bonds - lipophilic) or quaternary (4 bonds - water soluble) which makes it act like on off switch - when HCl in the solution makes it quaternary and water soluble, so it will not penetrate the neuron. when infected sites - pH decreases and proportion of ionized (quaternary) is higher and thus less likely to diffuse through tissue and makes for more volume needed.

You have a patient with a multicolored tattoo that she would like removed. Which lasers would be best to target each color?

The red, yellow and orange can be targeted by Nd:YAG (frequency doubled) at 532nm The blue, green and black can be targeted by Ruby at 694nm

How do you calculate thermal relaxation time?

Thermal relaxation time is the size of chromophore squared - so the smaller the particle size, the smaller the thermal relaxation time

What are the measurements of a thin, medium, and thick STSG?

Thin = 00.05 - 0.012 in. Medium = 0.012 - 0.018in. Thick = 0.018 - 0.030in

What are the advantages of an M plasty repair?

This is a modification to standard linear closure used in derm surg for few things: - shorten the length of excision/closure to not extend in undesired location - increases width of scar at end where mod is - useful near a free margin - apical angles of each of the standing cones is 30 degrees - billed as a linear closure and does not alter tension vectors

What is the primary advantage of this flap in photo?

This is a nasolabial/melolabial transposition flap - takes skin laxity from an adjacent area to fill a surgical defect by crossing over normal/uninvolved skin

Your patient has a large defect on the nasal tip - you decide to close it with this flap - what is the flap and characteristics?

This is a tissue importation flap called a paramedian forehead flap - this is an axial flap that utilizes the supratrochlear artery for both the flap and the cartilage graft

What type of flap does the photo depict, and what artery(s) supply this flap?

This is a tissue importation flap or interpolation flap - specifically a nasolabial interpolation flap - is is RANDOM pattern (so not one named specific artery) but supplied by the angular artery small perforators

What is a dufourmental flap?

Tissue reorientation flap/variant of Rhombicc transposition -Variation of rhombic flap where angles are 30 and 150 are used, but angles up to 90 are possible. This is used for covering defects that are rhomboid shaped. -Although used interchangably, a rhomboid is different from a rhombus in that it has i) acute angles of varying size; ii) only opposite sides are equal in length; iii) diagonals are not perpendicular; iv) diagonals are not equal in length -Planning is more complex, and it is often easier to convert it into a rhombic flap ie 120 & 60 angles

*look at photo - What type of repair is this?

Transposition = rhombic - see the question mark suture line -

If you have a patient who you feel is vasovagal, what do you do next?

Trendelenburg, cold compresses and reassurance, also check blood pressure

What is the waveform of electrosection WITHOUT coagulation?

Undampended, continuous waveform (letter D) - will have a low voltage current with high current density that results in rapid oscillation of alternating current and is continuous (unmodulated) vs. if slightly dampened with coagulation = option B - option A = markedly dampened which would be electrofulguration or electrodessication - option C = moderately dampened = electrocoag.

What is the name of a vein measuring 1-2mm?

Venelectasias

CO2 laser targets ____ and this has the strongest absorption band in the ____ region.

Water, infrared

Which step within a laser creates the initial spontaneous emission of photons?

When the electrons return from their excited state back to the ground state, they can spontaneously emit photons (Electromagnetic radiation) so at P

Patient with prosthetic heart valve coming in for 2.5cm SCC on R lower mucosal lip for mohs - do they need prophylaxis and if so, with what?

Yes - increased risk of infective endocarditis given prosthetic heart valve and location of lesion --> would give amoxicillin 2g 30-60min prior to surgery

You're using a TCA 40% peel on a patient for photoaging and deep rhytids. Do they require any HSV prophylaxis?

Yes - should do HSV prophylaxis starting the morning prior and then extend for 7-10 days as th risk of reactivation is much higher during re-epithelialization (which is 7-8 days after a medium depth peel, but 8-10 days after a deep peel)

Which fillers are derived from bovine collagen?

Zyderm/zyplast and artefill (rebranded as Bellafill)

If you're treating a patient's crows feet with botox (targeting orbicularis oculi) - which muscle could be inadvertently affected leading to asymmetric smile?

Zygomaticus major - if too inferior and medial/deep placement (but if you inject above "frankfort line" which is imaginery line at tragus then you're okay)

You have a friend who texts you in pain with a likely inflamed or ruptured FIC. What is the best next step?

`Bring into clinic for eval - likely will need an injection to decrase the inflammation

What are the 3 ingredients of neosporin?

bacitracin, neomycin, polymyxin B B = C55-pheno pyrophosphate that disrupts bacterial cell wall peptidoglycan P = increases cell membrane permeability N = binds 30S subunits of rib RNQA and decreases protein synthesis

Proposed MOA of microneedling:

controlled wounding of the superficial dermis stimulates collagen growth - physical destruction of collagen bundles releases PDGF, FGF, and transforming growth factor alpha and beta. Leads to stimualtion of new collagen and elastin.

What is the immediate clinical endpoint indicating appropriate energy fluences during the active laser treatment of tattoos?

lesional tissue whitening - can last up to 20 minutes

What is a 99204 code?

postoperatie follow -up --> does not result in a charge code for the patient (considered in the global window can use this code)

goal of rotation floap

recruit laxity from multiple directions to redirect closure tension wound

goal of advancement flaps

redirect standing cones to a more favorable location that is not necessarily contiguous with defect

What is thermal relaxation time equal to?

size of the chromophore squared - thus smaller chromophores need nanosecond pulses (Q-switched)

What are adjunctive treatments for keloids?

start compression following excision, cryotherapy, radiotherapy, ILK, intralesional chemotherapy (5-FU not to exceed 100mg/mL per session administered weekly or bleomycin), as well as radiotherapy

What is a vein that measurse 1mm in diameter?

telangiectasia

Which portion of the amide anesthetic molecule is responsible for the duration of action?

the AMINE (purple box) - also responsible for the onset of action aromatic ring = potency

What is the first step of a nasolabial interpolation flap?

typically repair of the nasal mucosa (hinge flap from nasalis above) and then after - free cartilage graft from antihelix and place across the defect in order to prevent collapse

When do suture granulomas normally arise?

typially 1-3 months following surgery

When does frosting normally occur at what percentage of TCA?

typically starts at 20-25%

Maximum dosage of lidocaine with epinephrine for local infiltration anestheisa in adults?

with epi - 7 mg/kkg WITHOUT = 4.5mg/kg in kids = 1.5-2mg/kg without epi and 3-4 with epi

Patient with acne scarring wants microneedling. What are the contraindications for microneedling?

- Ongoing inflammatory acne - Active herpes labialis - local infection - history of keloids - immunosuppression *note if history of herpes labialis (but not active) can start 1 week prophylaxis on day of treatment

Early signs of lidocaine toxicity

- Peri-oral & digital paresthesias - Metallic taste - Euphoria / restless / talkative - lightheaded - drowsiness

Why is epinephrine added to anesthetics?

- Prolongs the duration of action by a factor of 2 due to vasoconstrictive properties - Typical dilution = 1:100,000 or 1:200,000 - Risk of digital nerosis when using local anesthetics less likely due to epi and more likely secondary to tamponade and tight dressings

What are reasons to delay mohs or surgery:

- uncontrolled DM, acute CHF, uncontrolled HTN, INR >3.5

What are characteristics of an s-plasty?

- variation of standard linear closure - Used over convex surfaces (cheek, shoulder) and joints (like elbow or knee) - redistributes tension along several vectors - decreases tension on central portion of scar which can decrease risk of dehiscence and contracture - increawses total length of the scar

You biopsy a nBCC on L helix of 90yo man who's family does not want more surgery. They decide on cryotherapy. Destruction of this malignant lesion will require reaching which of the following tissue temperatures?

-55˚C - a tissue temperate of less than -50˚C is required to destroy malignant tissue - freeze time of 5-7 seconds is adequate for most benign lesions (

Botox muscle targets of forehead:

1. If you are targeting frontalis for horizontal lines of the forehead - should do 2/3 up of forehead to prevent drop 2. Should also inject brow depressors when denervating the frontalis to prevent pull of brow inferiorly (this is procerus and depressor supercilii pull it inferiori) and then corrugator supercilli and medial orbicularis oculi pull the brow medial

You are about to do Mohs on this patient's lip. What do you recommend starting and/or stopping for him?

1. Keep ASA and dabigatrin 2. Stop garlic and vitamin E and fish oil (all decrease platelet aggregation) 3. Give azithromycin 500mg x1 dose due to prosthetic heart valve (and PCN allergy)

3 phases of graft survival:

1. imbibition = 24-48 hours - where ischemic period and fibrin attaches graft to bed and sustained by passive diffusion of nutrients from plasma exudate 2. inosculation - 48-72 hours and lasts 7-10 days - revascularization that links dermal vessels between graft and recipient hose 3. neovascularization (day 7) - starts in inosculation - capillary and lymphatics from recipient to graft and edema resolves

Look at photo - which area would be best following MMS to let heal by second intention?

A - temple = concave surface

According to bolongnia for this flap, which site should be closed first?

A - the burow's triangles - should close the maximal tension should be sutured first prior to closing the remaining defect *this is U flap (double tangent advancement flap)

What is the correct curvilinear tangent advancement flap here?

A - this is a form of burrow's triangle rotation flap (also considered a Mustarde, karapandzic)

You have a patient who underwent Mohs of BCC of R upper lip that did not cross the vermillion border - what kind of repair was this?

Advancement flap = this is a V to Y advancement flap and inferior border is taken along the natural cosmetic boundary

You are excising a 0.5cm spitz nevus on the L scapular back of a 25 yo female. Which position should you place the patient before drawing the fusiform shape?

B - normal anatomic position standing and drawn parallel to resting skin tension lines

In looking at the suture package, what is the USP size?

B = 4-0 --> USP = united states pharmacopeia is the diameter required to achieve a given tensile strength and the diameter differs among suture types.

If you're planning to do botox on the palms for hyperhidrosis and you'd like to nerve block the palm - where do you inject?

B and C: - median nerve = between flexor carpi radialis and palmaris longis tendons at proximal wrist crease - ulnar nerve = between the ulna and flexor carpi ulnaris tendon at proximal wrist crease

What would be the drawing for a laser that has coherence?

Coherence = all wavelengths travel together in time and space so this would be A --> B Collimation = E-->F Monochromatic = C--D (all same wavelength.

Which sterilization method is the LEAST effective?

Cold sterilization - not a true sterilization method, more of a disinfecting technique *not always effective in killing bacterial spores or Hepatitis B and also rinsing with tap water after can cause contamination with Pseudomonas

Which type of sterilization requires six hours of time at 121˚C?

Dry Heat (oven) - inexpensive and no risk of corrosion or dulling (but takes longer and requires higher temps than in office cleaning (steam autoclave)

Which sterilization method is inexpenive and does not dull or corrode instruments?

Dry heat - but requires higher temperatures for longer periods of time compared to steam autoclave (most popular in office) - also cannot do cloth, paper or plastic

IHC staining with CK7 can be utilized in micrographic dermatologic surgery (Mohs) to fully evaluate margins on frozen sectioning of which of the following malignancies?

Extramammary paget's disease - primary is apocrine origin, secondary is extension of underlying adenocarcinoma (GI and GU is MC) - paget cells are mucin-producing, so can stain with colloidal iron, PAS, alcian blue and mucicarmine - MMS has higher cure rate than WLE for surgery which is gold standard

A patient comes in to discuss treatment for facial rhytides. She has had botox injections and filler in the past, specifically one which required two skin tests prior to treatment. Which type of filler was used?

Filler with Bovine collagen aka Zyplast (not on market anymore), artefill (now known as bellafill) which all can lead to HSN reactions

Which letter represents Nd:YAG?

H - 1064nm - deepest penetration A = excimer (308) B = argon (488-514) C = KTP (532) D = PDL (585-600) E = Ruby (694) F = Alexandrite (755) G = Diode (800) I = Erbium:glass (1540) J = Thulium (1927) K = Erbium:Yag (2940) I = CO2 = (10600)

Classic symptoms of vasovagal:

Hypotension, bradycardia, diaphoresis, hyperventiation, feeling like they're going to pass out and naseua, lightheaded, dizzy **vs epi will be HTN and tachy

You have a patient who has a red painful lump involving right nasolabial fold after having filler done 1 month ago. You ask her to come in for evaluation. You correctly diagnose her with an inflammatory nodule and start empiric antibiotics. Which Abx can you use?

If intermediate 3-14 days: macrolide or tetracycline for 2 -6 weeks if delayed 1 month to a year: clarithro + moxi, or cipro, or minocycline

If you increase spot size, you _____ your depth of penetration.

If you increase the spot size, you incrawse depth of penetration by decreasing scatter (think putting your finger on the front of a hose and it spraying everywhere)

You inject a patient with a superficial filler in the glabellar area for resting rhytids. Immediate after administration of the filler, the patient complains of a headache and states he is having trouble seeing out of his right eye. What is the most important next step?

Immediate arrangement for transfer to specialist eye hospital - this is called embolia cutis medicamentosa (ECM) another step following this while waiting for transport is hyaluronidase in the retrobulbar region - goal is to reduce intraocular pressure to allow for emboli to dislodge downstream and improve retinal perfusion - TREATMENT MUST START WITHIN 90 MINUTES

Mohs is used to excise a micronodular BCC from the L preauricular skin. Resulting defect is 1.3x1.2cm and extends to subcutaneous fat just above SMAS. Adjacent tissue is lax and small cones removed superior and inferior. Defect is closed linearly with dermal interrupted buried sutures and running surface sutures. What type of repair is this?

Intermediate - requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia in addition to the skim (epidermal and dermal) closure.

When you are coding for an adjacent tissue transfer repair following an EXCISION (NOT MOHS) - What do you bill for?

JUST the adjacent tissue transfer repair, not the excision and the repair (since it's included) need to add together the primary defect area plus the secondary defect area **this is not the case with mohs, so you would bill for mohs layers and then repair

Jessner solution is a chemical peel commonly used in cosmetic dermatology. Which of the four active ingredientws in this solution can be associated with the condition shown?

Jessners solution is made up of salicylic acid, lactic acid, resorcinol and ethanol - of these ingredients RESORCINOL can cause rarely ochronosis.

Which HA filler is the longest laster filler?

Juvederm voluma - can last up to 2 years in some patients vs. restylane is 4-6 months vs. perlane (restylane lyft) is 6-12 months vs. prevelle is 4-8 months

Places for dermatologic surgery that you would not want to heal by second intention:

Nasal tip and upper cutaneous lip - given texture, proximity to critical cosmetic subunits and free margins Vs. image is areas in which second intention healing would be great!

Most of the time in mohs processing, single section (tumor specimens processed and in one piece) is optimal, except?

Not ideal for specimens that contain cartilage or ones that are extremely concave or convex

L lateral brow mohs cleared with defect of 1cm remains. Which flap is used here?

O to T bilateral single advancement flap. *Great option above the brow to avoid cutting across the eyebrow.

Another name for bilateral single tangnt flap?

O to T or A to T - type of burow's triangle displacement flap

Which non-absorbable suture has the highest tensile strength and low reactivity - great for mucosal surfaces?

Polyester (ethibond, dacron) - it is braided and handles well, but is more expensive than silk

You do a WLE of a melanoma on the R lower abdomen. You use a deep suture that has a total absoprtion time of ~80 days with tensile strength being 75% at 2 weeks. It has good knot security and handles well. Which one?

Polyglactin 910 = vicryl - 75% at 2 weeks and 50% at 3 weeks

Which suture has the lowest coefficient of friction?

Polyprolene - monofilament - has lowest coefficient of friction, low tissue raectivity and high plasticity (ability to retain new length and form to being stretched) **but this means also weaker knot secruity/strength

What is polyglactin rapide?

Rapide means fastest absorbing synthetic absorbable sutur that is meant to simulate parameters of collagen (surgical gut) and so it has 50% strength at 5 days and 0 at 2 weeks. Used for superficial soft tissue of skin and mucosa.

If you're treating masseter hypertrophy, which muscle could you accidentally hit and lead to an asymmetric smile?

Risorius - if you inject too medial you can hit risorius and leads to drooping of lateral tips of the mouth during smiling, laughing

Secondary intent wound healing following Mohs surgery can be an effective modality for repair. What is true regarding secondary intent healing?

SI is more often utilized in patients with previous or current wound dehiscence/infeciton/flap necrosis, more likely used in elderly, more often in patients who have had previous skin cancers, and often follows extirpation of higher grade cutaneous malignancies.

You remove an MIS with WLE and intermediate repair on R lower back. Patient has this outcome (shown in picture). They drink alcohol, smoke, BMI >30. 3-0 Maxon adn 3-0 prolene suturues were used to close. What is the greatest risk factor for developing surgical wound dehiscence?

SMOKING - Major RF for SWD = smoking, BMI>35, DM, Age >65, extended duration of surgery or inadequate closure, wound infection (also peri-opderative hypothermia) *moderate and minor listed below - with dehiscence, wound approximation is not recommended especially for infection or areas with poor blood supply

What makes up the SNARE complex that botox targets?

SNAP-25, synaptobrevin, and syntaxin - botox A, C, and E cleave SNAP-25 - botox B, D, F, and G cleave synabtobrevin

Which filler is most associated with delayed idiopathic immunologic response after injection?

Sculptra - average latency of 19 months for associated delayed idiopathic immunologic response - will present as tender, inflammatory nodules and facial edema in and around areas of prior injection - FDA approved for HIV lipodystrophy of cheeks

You did MMS on a ladies cheek for a MAC 2 days prior. with large, complex linear repair. She presents back with "pain" in L cheek, with significant bruising, eyelid swelling and purple coloration, as well as yellowish discharge from the eye (picture). What are next steps?

Start an antibiotic and OPEN the wound and obtain hemostasis - Hematomas near the eye or airway are ALWAYS a medical emergency - pain is key in an expanding hematoma, as a stable one would not be painful. - antibiotic due to purulence of the eye in this case, and culture would likely be obtained prior to initiation of antibiotic (also hematomas provide medium for bacterial growth)

Followig 1 stage Mohs procedure for an invasive SCC, you're repairing a lower lip on a patient. Which combo of deep and suprifical sutures would have the highest reactivity?

Surgical gut (PLAIN) and Silk *vs. fasat absorbing gut has the LOWEST tissue reactivity

Suture pliability

Sutures ability to be bent ***Multifilament (like silk, vicryl and dexon)

Which site does Rimabotulinumtoxin act at?

Synaptobrevin = Botox- B

A recent review revealed positive sentinel lymph node biopsy rates for AJCC-8 stages T0, T2, and T3 for cSCC to be about ____, ___ and ___.

T0 = 0% T2 = 8% T3 = 25%

Which chemical peel provides the best cosmetic outcome for ice pick acne scarring?

TCA CROSS (65-100%) to specifically depressed scars

Where should you inject botox - intramuscular or intradermal?

Technically intradermal to prevent bruising

Which type of botox is prabotulinumtoxin-A (Jeauveau) and what does it target to prevent ACh release?

This is a botulinum toxin A family and cleaves SNAP-25

What type of flap is a crescentic advancement flap?

This is a burrow's triangle single tangent advancement flap

You just completed a 2-stage Mohs procedure for a well-differentiated SCC on the R helix. Resulting defect is outlined in red. Repair is outlined in purple (additional cuts are not visualized but indicated by gray dotted line). What type of closure is being planned?

This is a helical advancement flap or bilateral double tangent advancement flap (H-flap) - double tangent = two tangent lines, each with their own burow's triangle tangent line = line that touches at exactly one point but does not enter the circles interior single tangent's are also utilized on the ear.

What is this type of flap, and what ends up where?

This is a transposition flap or tissue reorinetation flap called a Rhomboid - B ends up where F is, C ends up where A is, and D ends up where B is - defect will end looking like a question mark

Type of flap used here and advantage:

This is burow's advancement flap - single tangent - redistributes standing cones to a more favorable location that is not necessarily contiguous with the surgical defect

What is the flap pedicle?

This is the base of the flap that contains the vascular source (C)

What is the primary tension vector of a flap?

This is the direction of force which counteracts the movement of the flap body

The use of the instrument shown in electrosurgery requires a _____ circuit and ___ employs a dispersive electrode to recycle current allowing ___ amperage and ____ voltage current.

This picture is bipolar - so you can assume it's biterminal to disperse the electrode from one tip to the other essentially, so the two biterminals are electrocoagulation and electrosection ***biterminal are ALWAYS employing a dispersive electrode to recycle current allowing INCREASED amperage and reduced voltage

If you increase the length:width ratio of an advancement flap, what are the advantages?

This will decrease the superior, inferior and deep tissue restraint and increase flap movement - *but it will not increase the vascular flow to the leading edge, it will decrease that vascular flow.

What category does this repair fall under following reconstruction following large defect of helical rim?

Tissue importation/interpolation flap - this is a retroauricular pedicle flap (book flap)

When you're performing a Z-plasty, which direction will tissue be gained?

Tissue is gained in the middle arm of the original Z

What is the main goal of a bilobed transposition flap?

Transposition is a lifting flap that lifts and transposes (leapfrogs) over normal intervening skin and reidrects primary tension vector to donor site *goal is to utilize nearby tissue reservoir (such as the dorsal nose) to close defects with minimal inherent laxity

Explain z-plasty in words from photo

Triangle BCA will rotation around point A, so that tip C will move to point D, ad then triangle DAC will rotate around point C so that tip A moves to point B.

You are closing a wound with simple interrupted sutures. What are the benefits of this suture and how can you amplify wound edge eversion?

Used to better approximate wound edges, should NOT be used to reduce wound edge tension **papers have shown that simple interrupted and running subcuticular sutures lead to comparable cosmetic outcomes

What type of repair did this patient have following her mohs surgery and alar crease defect?

V to Y advancement flap (island pedicle flap) - also called "kite" flap - for these, the superior incision is along the melolabial fold - this is a reconfiguration flap

A patient comes in with scars in this area from a previous BCC of the upper cutaneous lip. What type of repair did she have?

V to Y advancement flap (which is a tissue reconfiguration flap) that does tissue advancement dependent on pedicle movement

What is the most rapid cause of flap necrosis in an otherwise asymptomatic patient?

Venous congestion - can lead to rapid necrosis <4 hours where patient presents with purple skin color after flap inset and skin prick will show dark purple bleeding **from edema to apilllary and arterial slowing, with then leads to venous and arterial thrombosis, flap ischemia and finally necrosis **vs. seroma which accumulates over days/weeks **Vs. hematoma - which typically has acute pain and pressure **Vs. arterial insufficiency - which will have skni pallor, no bleeding on skin prick and viable >12 hours

If you have a preggo patient at 16 weeks but you have a mole highly suspicious for melanoma, what do you do?

You can use lidocaine without epi for biopsy, do not wait to biopsy if concerned for melanoma. **if strong suspicion for melanona do 1-3mm margins

Which type of flap is used to lengthen a contracted scar on the face?

Z-plasty = transposition flap (reorients scars) - create two triangular flaps and then transpose, by incraesing the flap angle size, the defect is reoriented and lengthened - for 30˚ angle = scar will lengthen by 25% - for 45˚ angle = scare will lengthen by 50% - for 60˚ angle = scar will lengthen 75%

THe greater the angle in a Z-plasty flap, the more likely what can happen?

one may experience redundancy of surrounding tissue (dog ear formation) and tension between two flaps at time of closure (especially if >60)

Local anesthetic systemic toxicity can occur with high doses of local anesthetic. What is the percentage of LAST that can occur >6 minutes after administration?

~25%