IS Breast / Cosmetic 2019
A 52-year-old woman undergoes autologous breast reconstruction with unilateral deep inferior epigastric perforator (DIEP) flaps. According to the Hartrampf model of perfusion zones, if the lateral row perforator vessels are used, in which chronological order will the flap zones be perfused? A. I - II - III - IV B. I - III - II - IV C. II - I - III - IV D. II - I - IV - III E. IV - III - II - I
B. In medial perforator-based flaps, the zones are perfused in the order I - II - III - IV (A) as shown in the image. In lateral perforator-based flaps, however, the zones are perfused in the order I - III - II - IV (B).
A 27-year-old woman comes to the office with concerns about aesthetic deformity of the neck. Despite appropriate lifestyle modifications and BMI less than 25 kg/m2, the patient has an obtuse cervicomental angle caused by accumulation of preplatysmal adipose tissue. The patient opts for nonsurgical management of the submental fullness by undergoing treatment with deoxycholic acid (DCA). Which of the following best describes the mechanism of action of this agent? A. Disruption of cellular membrane B. Injury to endoplasmic reticulum C. Irreversible binding to cellular mitochondrion D. Protein binding of Golgi apparatus E. Targeted injury to cell nucleus
A. Deoxycholic acid (DCA) disrupts adipocyte cell membranes when injected subcutaneously into fat, inducing an inflammatory response to clear cellular debris and liberated lipids from the injection site. DCA is a nonspecific cytolytic agent that injures tissue by injuring the cellular membrane of cells that come into contact with the naturally found substance. ATX-101 was FDA approved in the United States and Canada in 2015 for treatment of patients diagnosed with moderate to severe amounts of fat accumulating in the submental fat pad. The treatment is a series/protocol of up to six treatments in patients requesting nonsurgical management of submental fullness. Patients are selected based on candidacy and their desire to avoid surgery. A youthful patient with mild to no skin laxity, minimal post-platysmal fat, mild to no digastric muscle hypertrophy, and minimally enlarged submandibular glands is a good candidate for the treatment.
An otherwise healthy 25-year-old woman is evaluated and scheduled for augmentation mammaplasty with silicone gel implants. Which of the following is most accurate regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)? A. All late breast implant-associated seromas should be evaluated B. BIA-ALCL is most often associated with an aggressive clinical course C. BIA-ALCL is most often associated with smooth implants D. It is not necessary to include BIA-ALCL in a standard breast augmentation/reconstruction consent E. Knowledge about BIA-ALCL's cause is based on strong evidence-based studies
A. Due to the potential critical relevance of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its tendency to present as a late seroma, correct diagnostic pathways should be carried out on all late breast implant-associated seromas to include cytologic examination and, if indicated further, fine-needle aspiration, flow cytometry, and immunohistochemistry for CD30. BIA-ALCL is a critical outcome in implant-associated breast augmentation/reconstruction. It is most commonly confined to peri-implant seroma fluid and follows a nonaggressive course amenable to implant and capsule removal, although there are aggressive variants. Discussion about this condition should be part of the consenting process for all breast implant cases. Finally, to this point evidence on cause is based on very low-evidence studies. ALCL is most often associated with textured implants.
A 45-year-old woman is undergoing abdominal and flank liposuction. When the superwet liposuction technique is used, estimated blood loss is closest to which of the following percentages of the lipoaspirate? A. 0.1% B. 1% C. 15% D. 30% E. 50%
B. The best estimate of blood loss during either superwet or tumescent technique liposuction is 1% of the lipoaspirate. There may, however, be differences in true blood loss based on interstitial extravasation. Techniques that employ smaller ratios of tumescent solution infusion generally lead to higher levels of blood loss, as high as 20 to 40% of the lipoaspirate.
A 42-year-old woman comes to the office for consultation on nonsurgical options for treatment of prominent nasolabial folds. The consultation covers injectable filler options. Compared with other types of injectable fillers, hyaluronic acid is distinguished by which of the following characteristics? A. Can be enzymatically reversed B. Cannot be combined with lidocaine C. Contains methylmethacrylate D. Is indicated for subperiosteal placement E. Is radiopaque on x-ray study
A. Hyaluronic acid (HA) fillers are among several agents currently available in the United States. HA is a naturally occurring polysaccharide derived from bacterial fermentation that exhibits no species or tissue specificity. Therefore, serial retreatment is unlikely to induce allergic reactions. Other types of filler products include finely ground methylmethacrylate, calcium hydroxyapatite and poly-L-lactic acid. Although complications may arise with any type of filler, intravascular injection/embolization can occur, and it requires urgent management to preclude tissue necrosis or, in the case of retinal artery occlusion, vision loss. Only HA can be dissolved with an injection of an enzyme, hyaluronidase. It is not radiopaque as is calcium hydroxyapatite. It may appear gray (Tyndall effect) if placed too near the surface. While certain formulations of HA can be injected into the subcutaneous plane, neither it nor any of the others are approved for injection into the subperiosteal plane. Lidocaine is mixed into many HA products to diminish injection site pain. More than 1 mL can be injected per patient in the same setting. Operator technique is most important to maximize safety when using any type of filler. Minor complications of fillers include hypersensitivity, acute infection, malposition of filler, and inflammatory nodules or granulomas.
A 48-year-old woman with moderate neck skin laxity, little submental fat, moderate cheek laxity, and moderate jowling undergoes short scar rhytidectomy using the two-suture minimal access cranial suspension technique. At completion of skin closure, a vertical fold of excess skin on the lateral neck is visible near the earlobe. Which of the following is the best method to address the vertical fold of skin? A. Extend the rhytidectomy incision postauricularly, with excision of excess skin B. Place a third purse-string superficial musculoaponeurotic system (SMAS) plication suture C. Re-rotate the cheek flap superiorly D. Use a subsideburn wedge excision E. Observe only
A. One of the potential drawbacks of the short scar rhytidectomy is in patients with significant skin excess. When a postauricular incision is not made, as in the classic minimal access cranial suspension technique, a vertical fold of excess skin may result in the lateral neck area, inferior to the earlobe, in patients who have moderate to severe neck laxity. This is best treated by extending the incision posteriorly in the traditional postauricular direction, elevating a postauricular skin flap, and excising the excess. Reopening the incision and rotating the flap will accentuate closure difficulties in the visible temporal area and will not address the horizontal neck skin excess. The third purse-string suture, described in the extended MACS lift, is used for mid face correction and does not help the skin excess. A subsideburn wedge excision, while a useful technique for vertical elevation of the cheek flap, does not provide the correct vector of pull for this problem. Observation only is not recommended, as the dog ear tends to persist and not resolve.
A 68-year-old woman wants improvement of the appearance of her upper eyelids. She wears contact lenses daily without need for lubricating eye drops. When compared with the left eyelid, the right upper eyelid has a more elevated lid crease and the marginal reflex distance-1 (MRD-1) is 1.5 mm. The MRD-1 for the left eyelid is 3.0 mm. Levator excursion is 12 mm bilaterally. Which of the following eye tests is the most appropriate next step in this patient's evaluation for surgery? A. Phenylephrine test B. Schirmer test C. Tear breakup time D. Visual acuity test E. Visual field test
A. The patient presents with unilateral ptosis of the right eyelid. The elevated lid crease suggests levator aponeurosis attenuation or dehiscence as the mechanism for ptosis. This is known as senile ptosis and is the most common etiology. The challenge in these patients is to determine whether the contralateral eye is also ptotic and requires surgery. This phenomenon is explained by Hering's law (equal and simultaneous innervation of both levator palpebrae muscles). When one eye has ptosis, the brain signals both eyelids to raise. The less ptotic contralateral eye can look normal. The problem occurs when only the more ptotic eye is surgically repaired. The impulse to raise the eyelids is decreased and the contralateral eyelid now descends and appears ptotic. Evaluation demands a way to determine whether contralateral ptosis repair is required. Phenylephrine eye drops put into the more ptotic eye stimulate the Müller muscle to raise the eyelid. In turn, the afferent signals to raise the eyelids decrease. If the contralateral eyelid then falls over the next 10 to 15 minutes, the phenylephrine test is positive and suggests the need for bilateral ptosis repair. Other tests include patching the ptotic eye to decrease the afferent signals or manually raising the ptotic eyelid. Marginal reflex distance-1 (MRD-1) is the distance in millimeters from the light reflex on the patient's cornea to the level of the upper eyelid margin with the patient in primary gaze. Normal MRD-1 values are greater than 2.5 mm. Most of the population has MRD-1 values of 4 to 5 mm. The following tests are appropriate for evaluation of blepharoplasty patients, but they are not the most important next step in surgical planning for this patient with unilateral ptosis. Schirmer test evaluates tear production, and tear breakup time measures how quickly the tears evaporate. These tests are appropriate; however, dry eyes are unlikely in this patient because she is able to wear contact lenses without symptoms. Visual field tests are more important for insurance documentation than surgical planning. Visual acuity is for baseline information, not surgical planning.
Chemical peel neutralization using 1% sodium bicarbonate would be recommended with which of the following peeling agents? A. Glycolic acid B. Jessner solution C. Phenol-croton oil D. Salicylic acid E. Trichloroacetic acid (TCA)
A. The requirement for neutralization is specific to each peel and must be thoroughly understood before application. For instance, the trichloroacetic acid peel approach is a dynamic process that depends largely on clinical judgment and experience to assess the extent of frosting relative to peel depth in an effort to optimize results and minimize complications. Furthermore, peel neutralization is typically carried out with a basic solution such as 1% sodium bicarbonate, and is generally required only for specific acids, such as glycolic acid, whereas phenol-croton oil peels and Jessner solution cannot be neutralized. Salicylic acid does not need to be neutralized. TCA penetrates deep to the dermal-epidermal junction and is counteracted by dilution with saline. TCA cannot be neutralized at the end of treatment because it has penetrated too deeply.
Which of the following arteries provides the blood supply to the superomedial pedicle in reduction mammaplasty procedures? A. Internal mammary B. Lateral third intercostal C. Posterior fourth intercostal D. Thoracoacromial E. Thoracodorsal
A. The superomedial pedicle used in some reduction mammaplasty cases is supplied by arterial blood flow from the ipsilateral internal mammary artery and its intercostal branches. The other arteries are incorrect.
A 7-day-old infant is brought to the office for evaluation of widened conchal-mastoid angle and an absent antihelical fold of the left ear. There is a history of maternal hepatitis and oligohydramnios. Which of the following is the most appropriate initial step in management? A. Immediate initiation of rigid ear molding system B. Otolaryngology consultation for inner ear evaluation C. Reassurance that the deformity will correct itself D. Reevaluation in 6 weeks E. Surgical repair at 5 years of age
A. This infant has a "prominent/cup ear," the most common type of ear deformity, which is characterized by a widened conchal-mastoid angle and an absent antihelical fold. The traditional approach on ear deformities has been observation, but studies have concluded that only approximately 30% will self-correct. Ear molding techniques provide tremendous benefit to the lives of many children whose misshapen ears do not self-correct. This is possible because the higher postpartum circulating maternal estrogen will increase the amount of hyaluronic acid, a key component of the ear cartilage, and will cause a temporary malleability to the infant's ear cartilage. Timing is important. Waiting more than 6 weeks will cause the loss of the window of opportunity to reshape the ear as the maternal estrogen is decreased. A rigid ear molding system applies a combination of anterior and posterior forces to selectively shape and expand the targeted areas (i.e., helical rim, scapha, antihelix, superior crus, concha, and lobule). Molding in the neonatal period corrects the auricular deformities long before the onset of peer teasing and bullying. It also decreases the need for surgical correction and the associated pain and costs of surgical corrections. The results may exceed what can be achieved with the surgical alternative. Surgery is required for deformities that cannot be corrected with ear molding and is usually performed after the age of 6 years. Since there is no inner ear pathology associated with "prominent/cup deformity," otolaryngology consultation is not needed.
Which of the following is associated with the transconjunctival blepharoplasty with the skin pinch technique, when compared with transcutaneous blepharoplasty with a skin-muscle flap? A. Decreased incidence of scleral show B. Easier access to the lateral fat compartment C. Easier access when performing retinacular suture canthopexy D. Increased incidence of middle lamellar scarring E. Ineffective resection of lower eyelid skin
A. Transconjunctival blepharoplasty with the skin pinch technique has a low rate of scleral show, compared with rates seen in studies of the transcutaneous blepharoplasty using a skin-muscle flap. However, because it uses a transconjunctival approach to the fat compartments of the lower eyelid, access is not improved but can be challenging, particularly for the lateral fat pad. This is considered a disadvantage of the transconjunctival method. Skin resection is believed to be more thorough with the skin pinch method than with the classical skin-muscle flap. The incidence of middle lamellar scarring with the technique is believed to be less, since the orbicularis oculi muscle is not violated. Performance of canthopexy is not changed by the selection of this technique.
A 26-year-old woman is evaluated because she has difficulty breathing out of her right nostril. Physical examination shows the nasal septum is deviated to the right. The nasal dorsum is straight, and the nasal tip is slightly underprojected. A septoplasty is planned. Which of the following incisions is most appropriate for accessing the septum? A. Intercartilaginous B. Killian C. Marginal D. Rim E. Weir
B. A Killian incision is made 1-2 cm posterior to the caudal edge of the septum and provides access to the septum for a septoplasty. It is the most appropriate of the choices listed. While the Killian incision does not provide access to the caudal septal angle, it preserves tip support. The transfixion incision, which obtains access to the septum by incising both sides of the membranous septum at its junction with the caudal septum, is sometimes used. Both provide access to the septum, but the transfixion incision disrupts the septal ligaments, which can deproject the nasal tip inversely. When nasal tip deprojection is desired, the transfixion incision is used, and when the nasal tip is slightly under projected, a Killian incision can be considered. The Weir incision is made at the alar base. The marginal incision is made at the caudal aspect of the lower lateral cartilage, and the rim incision is made at the rim. Though often grouped together, these incisions are distinct. The intercartilaginous incision is made between the upper lateral and lower lateral cartilages. These incisions are not used for septoplasty. The septum can also be accessed through a transcolumellar approach, which is an open approach.
The dominant blood supply to the nipple-areola complex comes from which of the following arteries? A. Anterior lateral intercostal B. Internal mammary C. Lateral thoracic D. Superior epigastric E. Thoracoacromial
B. Although the internal mammary artery, anterior intercostal arteries, lateral thoracic arteries, and thoracoacromial artery all supply the nipple-areola complex (NAC), the internal mammary artery provides the most consistent contribution, which has been confirmed in multiple cadaver studies as well as in vivo MRI studies. The superior epigastric artery arising from the internal mammary artery supplies the anterior abdominal wall. Indeed, some authors have suggested that the decreased incidence of NAC necrosis with an inframammary fold incision when compared with a periareolar incision may be due to the preservation of the blood supply to the NAC using the former incision. The design of pedicles for reduction mammaplasty, similarly, has been historically informed by the blood supply to the NAC.
To avoid damage to the medial antebrachial cutaneous nerve during brachioplasty, which of the following veins is most important to mark? A. Axillary vein B. Basilic vein C. Brachial vein D. Cephalic vein E. Innominate vein
B. Care is used to avoid damage to the medial antebrachial cutaneous nerve of the forearm in the distal third of the medial arm. The nerve divides into anterior and posterior branches around the basilica vein. The other veins, axillary, cephalic, and brachial are incorrect. The medial antebrachial cutaneous (MABC) nerve runs with or just anterior to the basilic vein and becomes superficial to the fascia about 14cm (8 to 21 cm) proximal to the medial epicondyle. It is the most commonly injured nerve in brachioplasty.
A 34-year-old woman with a history of grade I breast ptosis who is 6 years status post-augmentation mammaplasty with subglandular gel-filled implants returns to the clinic. Physical examination shows normal-appearing breasts, but there is mild firmness on palpation. Which of the following Baker grades best describes these findings? A. Grade I B. Grade II C. Grade III D. Grade IV
B. Many classification systems have been used to evaluate the severity of breast capsular contracture, which occurs when the peri-implant capsule undergoes fibrotic change. The most widely employed assessment tool remains the Baker grading system, which takes into account patient signs and symptoms. According to the Baker classification, only the highest degrees of contractures (grades III and IV) require surgical treatment. The descriptors for each grade are listed here: Grade I: the breast is soft and appears normal in size and shape Grade II: the breast is a little firm and appears normal Grade III: the breast is firm and appears abnormal Grade IV: the breast is firm, appears abnormal, and is painful Studies note decreased relative risk for Baker grade III to IV capsular contracture in patients who undergo primary breast augmentation through an inframammary fold incision, subpectoral pocket placement, and textured implants. There is an increased relative risk for capsular contracture when patients undergo a periareolar or axillary incision and subglandular placement of smooth implants.
The capsules from patients with breast implant-associated anaplastic large-cell lymphoma (ALCL) have significant presence of which of the following bacteria? A. Escherichia coli B. Ralstonia pickettii C. Staphylococcus aureus D. Pseudomonas aeruginosa E. Serratia marcescens
B. Most concerning in the past two decades is the incidence of breast implant-associated anaplastic large-cell lymphoma (ALCL). This entity was first diagnosed and associated with breast implants in 1997, and is almost only associated with a history of textured implants and/or tissue expanders. The most common presentation of these patients is late seroma, with some patients presenting with mass, tumor erosion, or lymph node metastasis. A recent review of the world literature on this entity include the following: (1) 173 cases were documented, (2) no cases were found in patients with documented smooth devices only (although this remains controversial, as the data in many cases are incomplete), (3) there may be an associated genetic predisposition as suggested for cutaneous T-cell lymphoma, and (4) the cause is likely multifactorial. Bacterial biofilm is thought to be an inciting factor for the development of both breast-implant related ALCL and Non-Tumor related capsule contractures. The capsules from patients with tumor had significant presence of Gram-negative bacteria (Ralstonia species) compared to nontumor capsules (Staphylococcus species). Such data may support the bacterial induction model, as there are also other types of implant-associated lymphomas.
A 40-year-old woman comes to the office for consultation on an augmentation mastopexy 2 years after giving birth to her second child. She is back to her pre-pregnancy weight. Physical examination shows involutional changes contributing to a deflated appearance of the breasts. This appearance is most likely due to a histologic decrease in which of the following? A. Area composed of stromal matrix B. Number of differentiated lobules C. Thickness of dermis D. Thickness of pectoralis muscle E. Volume of adipose tissue
B. Postpartum involutional changes can manifest clinically as breasts that appear deflated, commonly due to a loss of volume and skin that has been stretched. On a histologic level, these clinical manifestations occur due to a decrease in the number and area of differentiated lobules that were enlarged and specialized for milk production. As this occurs, it is hypothesized that the lobular area is then replaced by stromal matrix and eventually fat. Involutional changes do not refer to changes in the dermis, pectoralis muscle or chest wall structures.
Which of the following is the most likely chronic effect of post-mastectomy radiation therapy? A. Desquamation B. Dyspigmentation C. Edema D. Erythema E. Ulceration
B. Radiation therapy induces tissue injury that can be categorized as acute or chronic. The spectrum of acute injury includes erythema, edema, desquamation, hyperpigmentation, and ulceration, ranging from mild to severe. Acute radiation dermatitis occurs in upward of 85% of treated patients. Chronic injury involves skin atrophy, dryness, telangiectasia, dyspigmentation, and dyschromia. In the breast, it leads to chronic fibrosis of the skin and subcutaneous tissues. This fibrosis and surrounding injury can lead to pain and restricted movement of the arm. The chronic changes from radiation can take months to years to fully manifest.
A 46-year-old woman seeks to improve her facial appearance with soft-tissue fillers. Her rejuvenation plan includes administration of a highly cross-linked hyaluronic acid injectable filler to the mid face to restore volume loss. To properly add volume to and rejuvenate this area, the filler should be injected into which of the following soft-tissue layers? A. Intradermal B. Preperiosteal C. Subdermal D. Subperiosteal E. Throughout multiple layers of soft tissue from deep to superficial
B. Restoration of mid face volume loss is a highly effective maneuver that can be performed utilizing fat grafting or off-the-shelf injectable fillers. The most commonly used hyaluronic acid-based injectable fillers utilized for mid face rejuvenation and volume restoration include those that are highly cross-linked, thus increasing the stability, density, cohesivity, and longevity of the filler. The process of cross-linking hyaluronic acid results in larger, more stable molecules that have biocompatibility and viscoelastic properties similar to those of fat. Ideally, these highly dense fillers should be placed at the preperiosteal level to optimize results and minimize potential complications, such as intravascular placement of filler or visible lumps.
A 58-year-old woman is evaluated for seroma six weeks after undergoing a lower body lift following massive weight loss. The surgery was uneventful, and the drain had been removed. Repeated aspirations of the seroma were done without success. The surgeon is considering injection of a sclerosant agent into the seroma space. Which of the following agents is most likely to be used? A. Doxorubicin B. Doxycycline C. Erythromycin D. Gentamycin
B. Seroma presents as a common postoperative management problem in plastic surgery, particularly in body contouring for massive weight loss. The combination of potential injury to a rich lymphatic supply, possible excision of lymphoid tissue, and extensive subcutaneous dissection in adjacent areas, combined with shear forces and motion are the substrates to seroma formation. The most widely used treatment strategies for effusions include percutaneous aspiration, drainage, and injection of sclerosant agents through chest tubes. Doxycycline and bleomycin are the most common sclerosant agents used.
A 74-year-old woman comes to the office to discuss blepharoplasty. She has bilateral dermatochalasis and right lid ptosis secondary to levator dehiscence. She does not have dry eyes and states that her vision is much improved after recent corneal refractive surgery. Which of the following is the minimum amount of time after her corneal refractive surgery that this patient should wait before undergoing blepharoplasty? A. 3 Months B. 6 Months C. 9 Months D. 12 Months E. None; this patient is not a candidate for blepharoplasty
B. The current accepted time frame between corneal refractive surgery and blepharoplasty is a minimum of 6 months. Early post-corneal refractive surgery puts the patient at risk for worsening dry eyes and/or keratopathy. Due to loss of corneal reflex due to disruption of ciliary nerve.
When a cephalic trim is performed during primary rhinoplasty, which of the following is the minimum width of caudal lower lateral cartilage that should be left behind? A. 4 mm B. 6 mm C. 8 mm D. 10 mm E. 12 mm
B. The nasal tip represents a complex nasal tripod. The paired lower lateral cartilages work synergistically to provide the main structural support for the nasal tip. Tip refinement is of course common in rhinoplasty, and a cephalic trim of excess lower lateral cartilage is a classic maneuver utilized in primary rhinoplasty. The cephalic trim acts to decrease vertical height of the lateral crura and to debulk to tip. It is crucial that enough cartilage be left behind when removing excess lower lateral cartilage from the cephalic portion. Classically, 6 mm (5 to 7 mm) of rim strip is the accepted standard of how much should be left behind at minimum to prevent stability compromise of the lower lateral cartilages. Resection in excess of this can weaken the lateral crus and cause retraction, notching, and/or external valve dysfunction.
A 25-year-old man who underwent septorhinoplasty 6 weeks ago is evaluated because of clear nasal discharge. He notes that the drainage worsens when he bends forward or strains, and the discharge tastes salty. Physical examination shows a small amount of watery drainage from the right nostril. Examination with a nasal speculum shows no other abnormalities. Which of the following is the most appropriate next step in management? A. MRI of the skull base B. Testing of fluid for beta-2 transferrin C. Testing of fluid for glucose D. Trial of a corticosteroid nasal spray E. Trial of an oral antihistamine
B. The patient in question presents with a history that is suggestive of cerebrospinal fluid (CSF) leak following septoplasty. Patients with such a leak typically have unilateral clear nasal discharge that tastes salty or metallic. Straining, Valsalva maneuver, or leaning forward typically make the drainage worse. Commonly, rocking or twisting forces applied during the septoplasty cause a traumatic injury to the cribriform plate, with a resultant CSF leak. The injury is more common (2:1) on the right side and is more common in men. Beta-2 transferrin testing on the CSF fluid is very specific for the injury. This protein is only found in CSF, but the test is not available in all centers. Testing the fluid for glucose is not specific and has a high false-positive rate. MRI of the skull base is not particularly helpful for CSF leaks. High-resolution CT is preferred. Steroid nasal spray and antihistamines are not used in the management of CSF rhinorrhea.
A healthy 40-year-old woman who weighs 126 lb (57 kg) undergoes tumescent liposuction of the hips and abdomen in an accredited ambulatory surgery facility. Three liters of tumescent fluid (each liter containing 300 mg of lidocaine and 1 mg of epinephrine) are infiltrated, and a total of 2500 mL of lipoaspirate is removed. The procedure is uneventful, and the patient is sent home the same day. After 24 hours, she reports feeling dizzy and light-headed when ambulating. She has a moderate amount of pain at the operative sites and is taking acetaminophen as directed with some relief. Which of the following is the most appropriate next step in management? A. Chest x-ray study B. Complete blood count C. CT angiogram D. Infusion of a 20% lipid emulsion intravenously E. Reassurance that the patient's symptoms are normal
B. The patient underwent a significant amount of liposuction and may be experiencing symptoms due to blood loss anemia. Traditionally, blood loss from tumescent liposuction has been calculated as a percentage of the lipoaspirate, but some studies show this number may underestimate true blood loss. In light of the patient's symptoms, the most appropriate next step would be to instruct her to obtain laboratory studies at the local hospital or emergency room. Offering reassurance would be inappropriate if the patient has a drop in her hemoglobin and is symptomatic. Dizziness and light-headedness can be early signs of lidocaine toxicity; however, she received a lidocaine dose within the accepted limit of 2000 mg (35 mg/kg), and her symptoms are presenting beyond the time frame of peak plasma absorption, which occurs around 12 hours. Intralipid infusion is not indicated for this patient. A chest x-ray study or CT angiogram may be appropriate if she is short of breath and penetration of the chest cavity, pneumothorax, pulmonary edema, or pulmonary embolism are suspected.
A 54-year-old woman undergoes a rhytidectomy with a SMAsectomy (superficial musculoaponeurotic system). The drains are removed on postoperative day 2. Several days later, significant fluid collection is noted on the right side, and the fluid is aspirated and appears clear. The fluid collection continues to recur, and analysis shows extremely high amylase levels. On examination, the parotid duct is intact. A bland diet is suggested, and a scopolamine patch is applied. Which of the following additional treatments is most likely to help improve this patient's condition? A. Anti-inflammatory medication B. Botulinum toxin type A injections C. Direct surgical repair of the injury D. Nerve grafting of the injury E. Surgical evacuation of the fluid
B. This patient has a salivary leak secondary to direct injury to the parotid gland, either from dissection or a suture being placed through the gland. Although typically self-limiting, these injuries can be frustrating to treat and upsetting to the patient. Treatment is directed at minimizing salivary secretions as much as possible by multimodal therapy while spontaneous healing is allowed to occur. Surgical treatment is not indicated and may cause further damage, thus exacerbating the situation. Spontaneous resolution is the general rule, although it may take several weeks and even months. Common treatment modalities to minimize salivary secretions include regular percutaneous drainage of the collection or placement of a temporary drain. In addition, compression is useful and should be maintained as much as tolerated. Antihistamines and scopolamine patches are used to slow down and minimize salivary production. A bland diet and avoiding sour, spicy, or acidic foods also helps to minimize excessive secretions. Recently, botulinum toxin type A injections directly into the gland have been used successfully to minimize salivary secretions.
A 45-year-old man is evaluated for a body lift after undergoing bariatric surgery and subsequent 100-lb weight loss. Which of the following characteristics would make this patient an inappropriate candidate? A. BMI of 30 kg/m2 B. History of deep venous thromboembolism C. Protein intake of 25 g daily D. Transverse abdominal scar E. Type 2 diabetes
C. Achieving satisfactory outcomes while minimizing morbidity requires careful assessment of the patient's comorbidities, nutritional deficiencies, and psychological issues. A history of venous thromboembolism is not a contraindication for body contouring procedures but requires evaluation of the patient by a hematologist and postoperative thromboembolism prophylaxis. Type 2 diabetes is not a contraindication for a circumferential body lift. BMI is a predictor of complications following body contouring procedures. Higher BMI (BMI >35) is associated with increased complication rates. Nutritional status in the postbariatric patient is important to achieving successful outcomes for the body lift patient. Deficiencies in calcium, vitamin B12, folate and thiamine should be corrected prior to surgery. Protein deficiencies have been shown to significantly lower healing rates among massive weight loss patients. Studies have indicated that a minimum of 60 to 100 g daily of protein is necessary to prevent malnutrition and avoid delayed wound healing in such patients. Daily protein intake of 25 g or less would produce severe malnutrition and be a contraindication for surgery.
A 36-year-old woman is evaluated because of spontaneous galactorrhea 6 days after undergoing augmentation mammaplasty. Which of the following factors most likely contributed to this outcome? A. Inframammary placement of the incision B. Subglandular versus dual-plane position of the device C. Surgical interruption of the intercostal nerves D. Use of silicone versus saline breast implants
C. Although no one knows exactly what leads to postoperative galactorrhea, it is observed to occur more often in parous women and theorized to occur due to a combination of factors which simulate suckling or change in the innervation of the chest wall and nipple-areola complex. This would include increased tissue pressure related to the implant placement and interruption of intercostal nerves. No relationship has been identified between incision placement (peri-areolar, inframammary, transaxillary, or even peri-thelial) and postoperative galactorrhea. Similarly no relationship has been identified between device positioning (dual-plane, subglandular, and submuscular) and postoperative galactorrhea. Again, no relationship has been observed in implant type, saline versus silicone, and postoperative galactorrhea.
The postoperative CT scan shown (absence right pec muscle) is obtained to evaluate a wound dehiscence in a patient who underwent left-sided unilateral reduction mammaplasty for asymmetry six weeks ago. Which of the following upper extremity deformities is most likely to be found in this patient? A. Contralateral radial club hand B. Contralateral "pouce flottant" thumb C. Ipsilateral brachysyndactyly D. Ipsilateral radial head subluxation E. Ipsilateral type IV Wassel preaxial polydactyly
C. Assessment of the chest CT shows right-sided absence of the pectoralis major and minor muscles and breast hypoplasia. The patient suffers from Poland syndrome, which is a congenital disorder of unknown etiology with the prevailing theory being hypoplasia of the subclavian artery or its branches during the sixth week of embryogenesis. Variability exists in physical findings with the most common being: anterior axillary fold and pectoralis major sternal head absence, breast gland thinning, rib and cartilage hypoplasia, and ipsilateral brachysyndactyly. After local wound care and antibiotic therapy, the patient had resolution of her symptoms. A type IV Wassel preaxial polydactyly is the most common congenital thumb duplication but is not associated with Poland syndrome. Radial club hand is more common than ulnar club hand, but has no association with Poland syndrome. Both are congenital hand deformities, but unrelated to the pathological condition mentioned. Radial head subluxation is also known as "nursemaid's elbow." Nursemaid's elbow is a common injury of early childhood. It is sometimes referred to as "pulled elbow" because it occurs when a child's elbow is pulled and partially dislocates. There is no connection between Poland syndrome and increased incidence of radial head subluxation. Type IV Manske modification of the Blauth classification thumbs (the "pouce flottant" thumb) have rudimentary elements and are attached to the hand by a small skin bridge. These thumb anomalies are not associated with Poland syndrome.
A 35-year-old woman who is morbidly obese comes to the plastic surgery clinic to discuss body contouring. She is counseled that losing weight before undergoing contouring may be beneficial. Which of the following methods of weight loss is most likely to increase this patient's risk for surgical complications during body contouring? A. Exercise B. Gastric band/sleeve C. Gastric bypass D. Liposuction E. Low-carbohydrate diet
C. Multiple studies have demonstrated that results from body contouring after massive weight loss depend somewhat on the method of weight loss. Weight loss via gastric bypass has been shown to be associated with higher rates of surgical complications following body contouring than other weight loss methods. Due to nutritional deficiencies as bypass is a malabsorptive procedure.
A 32-year-old woman is evaluated for rhinoplasty. In the course of evaluation, the Cottle maneuver is performed. This test is most likely performed to evaluate which of the following? A. Collapse of the external nostrils B. Hypertrophy of the inferior turbinate C. Patency of the internal nasal valves D. Presence of septal perforation E. Septal mucosal thickening
C. Nasal airway obstruction is a common symptom among patients presenting for rhinoplasty. Evaluation of the nasal airway should be performed in all patients presenting for rhinoplasty. The key structures that affect nasal airflow include the external and internal nasal valves, the inferior turbinates, and the nasal septum. The patient should be examined for collapse of the external nasal valves on deep inspiration, and a Cottle maneuver should be performed to evaluate patency of the internal nasal valves. Internal nasal examination is aided with the use of a nasal speculum. Oxymetazoline nasal spray facilitates mucosal constriction if mucosal edema is present. Narrowing or collapse of the internal valves with inspiration should be noted, along with inferior turbinate hypertrophy, which typically occurs on the side opposite septal deviation.
A 55-year-old woman who underwent augmentation mammaplasty with retro-pectoral smooth saline implants 18 years ago comes to the office because she is dissatisfied with her breast shape. Physical examination shows glandular ptosis hanging off the implants. She has Grade I capsules. Which of the following is the most appropriate procedure to correct this patient's deformity? A. Implant exchange alone B. Implant exchange with capsulectomy C. Implant exchange with mastopexy D. Implant exchange with suture plication of the expanded inferior pocket E. Site change to subglandular placement
C. The described patient has a "snoopy nose deformity" or "waterfall breast deformity," with the ptotic breast hanging off of the implant. There is no pocket expansion. The implants have stayed in their original position while the native breast tissue has become ptotic with time and gravity. This is not superior malposition due to capsular contracture; both breasts are soft. Correction of this problem is best performed with an appropriately chosen form of mastopexy. In this case, replacement of the implants would also be performed because of their age. Implant exchange alone would not correct the ptotic breast. Capsulectomy is not indicated, since the breasts are soft, and no capsule is noted clinically. Similarly, suture plication of the pocket is not required, since the inframammary fold is in the correct position, and no second fold is seen. Site change would not correct the patient's grade III ptosis, but it may be used to correct this problem in cases without significant ptosis.
A 55-year-old man is scheduled for a rhytidectomy with an extended superficial musculoaponeurotic system (SMAS) flap and neck lift. In order to avoid injury to the great auricular nerve, which of the following best describes the most likely course of the main branch of the great auricular nerve? A. Exits the deep neck at the anterior border of the sternocleidomastoid muscle B. Exits the stylomastoid foramen and emerges through the Lore fascia C. Lies parallel and posterior to the external jugular vein D. Lies superficial to the platysma muscle at the anterior border of the sternocleidomastoid muscle E. Perforates the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus
C. The great auricular nerve (GAN) is the most commonly injured named nerve during a rhytidectomy. Multiple studies have estimated the incidence at 6%. The course and avoidance of injury to this nerve is important in minimizing the risks for painful neuroma, allodynia, and permanent numbness. The GAN is a purely sensory nerve that arises from the C2 and C3 spinal roots and then fuses into the main trunk of the GAN. It exits the deep neck along the posterior border of the sternocleidomastoid muscle (SCM) and then travels parallel and posterior to the external jugular vein (EJV). It usually bifurcates into anterior and posterior branches. There are anomalous courses that can occur in rare cases. Guidelines in avoiding injury of the GAN include the following: 1. Raising the platysma at the anterior border of the SCM will protect the nerve from injury. 2. To avoid suture injury to the nerve, platysma/superficial musculoaponeurotic system suspension sutures should be placed posterior to a vertical line drawn from McKinney's point to a point 1.5 cm posterior to the insertion of the lobule. The GAN does not perforate the SCM, but lies on top of it. McKinney's point is located along the midwidth of the SCM approximately 6.5 cm inferior to the external auditory meatus. This represents where the GAN usually exits from beneath the SCM fascia and becomes more superficial and is increasingly susceptible to injury. At the sternocleidomastoid muscle, the GAN lies deep to the platysma muscle and is a safe location to begin elevation of a platysma flap. The facial nerve exits the stylomastoid foramen, not the GAN.
A 55-year-old woman is evaluated for facial rejuvenation. She is concerned about brow ptosis and dynamic frown lines. Physical examination shows brow ptosis, dynamic and static frown lines, a long forehead, and thick hair. Which of the following is the best approach for brow lift surgery for this patient? A. Endoscopic B. Endotemporal C. Pretrichial D. Transcoronal E. Transpalpebral
C. The pretrichial incision is the appropriate approach to perform a brow lift and to address a long forehead. Of the options listed, the pretrichial incision alone can specifically address a long forehead. An endotemporal approach is useful for patients with thin hair or lateral ptosis, and endoscopic and transpalpebral approaches are useful for a brow lift but cannot address a long forehead. A transcoronal incision is most useful in a patient with a short forehead and deep rhytides. Brow to hairline greater than 6cm
A 46-year-old woman who is 5 ft 7 in (170 cm) tall and weighs 135 lbs (61 kg) is evaluated one year following bilateral nipple-sparing mastectomy and immediate reconstruction with placement of 350-mL smooth, round silicone gel implants beneath the pectoralis major muscle. Since the surgery, she has experienced hyperdynamic deformity of her breasts. On physical examination, the breast reconstruction appears natural, and there is significant movement of the breasts when the patient flexes her chest. Which of the following is the most appropriate management for this patient? A. Inject botulinum toxin into the pectoralis major muscle B. Inject triamcinolone-40 into the areas of tenderness using ultrasound guidance C. Move the implants to the prepectoral plane and cover them fully with acellular dermal matrix D. Perform a breast MRI to assess for rupture of the implants E. Refer the patient to a physical therapist for range of motion, massage, and ultrasound treatments
C. This patient is experiencing significant movement because her implants were placed beneath the pectoralis major muscles. While reconstruction options are limited in this otherwise healthy and very thin patient who is not a good candidate for fat grafting or pedicled or free tissue transfer, placing implants over the pectoralis major muscles and covering the implants fully with acellular dermal matrix would be the most appropriate method of reconstructing her breasts and addressing her concerns. Physical therapy and muscle relaxants are unlikely to produce long-term improvement. An MRI would likely be nondiagnostic, and even if her implants were ruptured, change to a prepectoral plane is still indicated. Botulinum toxin type A is likely not as effective for long-term significant improvement as reoperation. Triamcinolone would not be effective for hyperdynamic deformity.
A 30-year-old woman wants improvement of the bulbous tip of her nose. Open rhinoplasty and thinning of the tip is planned. Intraoperative examination shows the cause of the bulbous tip is widely convex lower lateral cartilages that are thick and relatively inflexible. The domal width is greater than 6 mm. The angle of divergence is normal. Which of the following surgical maneuvers is most likely to correct the deformity? A. Alar rim grafting B. Cephalic trimming of the lower lateral cartilage C. Crural spanning sutures D. Lateral crural strut grafting E. Subdomal spreader grafting
D. A bulbous/boxy tip can be caused by a convex lower lateral cartilage with a wide domal width (less than 4 mm), widened angle of divergence (less than 30 degrees), or a combination of both. This patient's deformity is a widely convex lower lateral cartilage. The best choice is a lateral crural strut graft. This graft is usually harvested from the septum and sutured to the undersurface of the lower lateral cartilage. These grafts are strong and can reshape a thick inflexible lower lateral cartilage. Crural spanning sutures can straighten the convexity of these cartilages if the cartilages are flexible; however, in this patient it would unlikely be successful. Transgenu sutures are often needed to further refine the domal width; however, in very boxy tips, a lateral crural strut graft would also be needed for a better result. Cephalic trim of the lower lateral cartilage is often performed to narrow the cartilage. This maneuver would not correct the deformity. When performing the cephalic trim, it is important to leave at least 6 mm of cartilage for support. An alar rim graft is a strip of cartilage places is a subcutaneous pocket along the alar rim. This graft is placed caudal to the lower lateral cartilage. It can strengthen a buckled rim but would not straighten a stiff convex lower lateral. Subdomal spreader grafts are used to correct a pinched tip deformity.
A patient who had massive weight loss comes to the office to discuss reconstruction. The surgeon determines that the patient would benefit from a lower body lift. Advancement of the flaps in this procedure will be best achieved by undermining which of the following zones of adherence? A. Distal posterior thigh B. Gluteal crease C. Inferolateral iliotibial tract D. Lateral gluteal depression E. Mid medial thigh
D. Continuous or discontinuous release of the lateral gluteal depression would be the most effective in allowing the advancement of the flaps in a lower body lift. Though the gluteal crease is in proximity of the flaps, release here would undesirably blunt this crease. The other choices are not in proximity and their release would have little effect on advancing the flaps.
A 35-year-old woman comes to the office for treatment of glabellar rhytides with botulinum toxin type A. A total of 20 units is used for the treatment, with 10 units injected into the region of each corrugator muscle. Ten days later, the patient returns to the office because of ptosis of the left upper eyelid. To help decrease the eyelid ptosis, an alpha-adrenergic agonist eye drop can be used to stimulate which of the following muscles? A. Dilator pupillae B. Frontalis C. Levator palpebrae superioris D. Müller E. Orbicularis oculi
D. Eyelid ptosis is the result of an inadvertent effect of the botulinum toxin upon the levator palpebrae superioris muscle. This can occur during treatment of the glabellar region if the injection is performed within/below the orbital rim. The ptosis that results from the weakening of the levator palpebrae superioris can be countered by the use of alpha-adrenergic eyedrops such as apraclonidine (Iopidine) or phenylephrine. These eyedrops will stimulate the Müller muscle, which is an accessory eyelid elevator that is located deep to the levator palpebrae superioris between the levator muscle and the conjunctiva of the upper eyelid. This can help improve the ptosis but not likely adequately resolve the problem until the effect of botulinum toxin type A has worn off. The levator, frontalis, and orbicularis will not be affected by the use of the eyedrops. The iris will dilate because of the effects of the eyedrops. This however, will have no effect on the ptotic position of the eyelid.
A 64-year-old woman who is postmenopausal asks why she has not been prescribed hormone replacement therapy with estrogen and progestin like her mother was. Supplementation with these hormones is associated with an increased risk for which of the following? A. Coronary artery disease B. Diabetes C. Endometrial cancer D. Invasive breast cancer E. Osteoporosis
D. Hormone replacement therapy has fallen out of favor because of a risk profile that is believed to exceed the potential benefits. Combined estrogen and progestin supplementation is thought to be associated with an increased risk for invasive breast cancer but may decrease the risk for diabetes and osteoporosis. It is thought to not impact the risk for coronary artery disease or endometrial cancer.
A 47-year-old woman who underwent bilateral augmentation mammaplasty with silicone implants to treat mammary hypoplasia 17 years ago is evaluated because of worsening pain, firmness, and distortion of her breasts. Which of the following diagnostic evaluations is most sensitive for evaluating this patient's silicone breast implants? A. Breast thermography B. CT scan C. Mammography D. MRI E. Ultrasonography
D. MRI scan would be the most sensitive and specific method for detection of silent rupture of a silicone breast implant in this patient. Classic MRI findings indicating rupture include the linguini sign or the teardrop sign. Current FDA recommendations are to obtain MRI screening for silent rupture three years after placement of silicone implants and every two years after that. CT scanning can show findings similar to those seen with MRI, but CT involves ionizing radiation, which can be harmful. CT has not been proven to be as sensitive as MRI in evaluating silicone breast implant rupture. Ultrasonography is a less costly method of implant evaluation but this method is highly operator-dependent. In asymptomatic women, a subsequent MRI scan is generally needed to confirm a positive ultrasound screen. Mammography is indicated for screening for breast cancer but not for implant rupture. Breast thermography utilizes digital infrared imaging to evaluate metabolic activity and vascular circulation of the breast to look for suspicious signs of breast cancer. It is not effective in the evaluation of silicone breast implant rupture.
A 45-year-old woman who is obese is considering unilateral mastectomy and reconstruction of the left breast because of invasive ductal carcinoma. Which of the following patient characteristics is associated with the lowest risk for complications from a nipple-sparing mastectomy? A. BMI of 41 kg/m2 B. Grade III ptosis of the breast C. Nipple retraction D. Tumor distance from nipple of 5 cm E. Tumor size of 6 cm
D. Nipple-sparing mastectomy is increasing in popularity. To decrease the risk for surgical complications as well as oncologic complications, smaller tumors located further from the nipple in patients without morbid obesity or severe ptosis are considered better candidates for treatment with nipple-sparing mastectomy. Clinical involvement of the nipple, including retraction, would suggest that nipple-sparing mastectomy should not be performed.
A 28-year-old woman with history of lipodystrophy of the abdomen and waist plans to undergo suction-assisted lipectomy while receiving general anesthesia. The surgeon anticipates 1.5 L of lipoaspirate. With a superwet technique, how much fluid is the patient most likely to receive in the form of subcutaneous tissue infiltration? A. 0 mL B. 375 mL C. 750 mL D. 1500 mL E. 3000 mL
D. Originally, liposuction was performed without wetting solutions, but this technique was associated with reported estimated blood loss of up to 45% of aspirate. Infiltrating wetting solutions with a base of normal saline or Ringer's lactate with additives epinephrine and lidocaine prior to suctioning improves hemostasis and pain control. The current options for wetting solutions are dry, wet, superwet, and tumescent. The dry technique is rarely used and no wetting solution is infused. The wet technique employs injecting a standard 200 to 300 mL per anatomic area to be treated, irrespective of the anticipated lipoaspirate. The superwet technique is predicated on a 1:1 ratio of instilling 1 mL of solution per 1 mL of aspirate. True tumescent infiltration involves infiltration at a ratio of 2 to 3:1 of wetting solution per mL of expected lipoaspirate. 0 mL is a dry technique, 375 mL is a wet technique, 750 mL does not fall into any category, and 3000 mL is tumescent technique.
A 56-year-old man is evaluated because of gynecomastia. Physical examination shows mild, diffuse breast enlargement with no visible inframammary fold or ptosis. Which of the following is the most appropriate surgical correction of this patient's condition? A. En bloc resection of skin and breast tissue with free nipple grafting B. Open excision of breast tissue with mastopexy C. Subcutaneous mastectomy with nipple preservation D. Suction-assisted lipectomy E. Superior periareolar excision with skin excision
D. The treatment of gynecomastia is based on the degree of breast enlargement and the extent of ptosis that is noted on examination. Grade 1 gynecomastia is minimal breast hypertrophy without ptosis. Grade II gynecomastia is moderate hypertrophy without ptosis. Grade III gynecomastia is severe hypertrophy with moderate ptosis. Grade IV gynecomastia is severe hypertrophy with severe ptosis. The treatment of mild to moderate gynecomastia without ptosis is suction-assisted lipectomy. Direct periareolar excision with skin excision and subcutaneous mastectomy are not indicated for gynecomastia without ptosis. Mastopexy and free nipple grafting techniques are indicated for gynecomastia with severe ptosis.
A 39-year-old woman comes to the office with a 6-month history of progressive firmness and superior fullness of the left breast. History includes bilateral augmentation mammaplasty with textured saline implants placed in a submuscular dual-plane pocket 15 years ago. On physical examination, the left breast appears larger and firmer with more upper pole fullness in comparison with the right breast. Which of the following is the most appropriate next step? A. Capsulectomy and pocket change B. Mammography C. 3-Month trial of montelukast (Singulair) D. MRI E. Ultrasonography
E. Breast implant patients who present with late-onset enlargement of one of their breasts require evaluation for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This disease usually presents with spontaneous onset of peri-prosthetic fluid. A late-onset seroma is usually accepted as occurring 1 year after surgery; however, they have presented as early as 4 months. It is often difficult to determine if late-onset firmness of the implant is secondary to fluid, capsular contracture, or both. The initial workup should begin with an ultrasound to evaluate for peri-prosthetic fluid or capsular mass. If fluid is present, it should be sent for cytology, flow cytometry with immunohistochemistry looking for expression of T-cell CD30 cell surface protein. BIA-ALCL is overwhelmingly associated with textured implants. It is important to remember that BIA-ALCL is extremely rare and that most patients presenting with a late seroma will not have lymphoma, but will have peri-prosthetic fluid from the textured surface pulling away from the capsule and forming a double capsule. The treatment for localized BIA-ALCL is bilateral total capsulectomy and explantation. Treatment for the more likely double capsule or capsule contracture is capsulectomy and pocket change; however, surgery is not indicated until the diagnosis is made.
A healthy 62-year-old woman presents 1 week after undergoing uneventful rhytidectomy because her smile is now asymmetric. On physical examination, the left lower lip does not depress on smiling. Which of the following is the most appropriate management of this complication? A. Evaluate the patient for a cerebrovascular accident B. Explore the left cheek and neck for entrapment of the marginal mandibular nerve C. Perform a nerve conduction study to assess the marginal mandibular nerve D. Refer the patient to a physical therapist who specializes in facial reanimation training E. Reassure the patient that her smile should return to normal within 3 to 6 months
E. Injury to the marginal mandibular nerve can result in inability to depress the affected side of the lower lip. Nerve dysfunction may be attributable to traction, cautery, sutures, or surgical division. Spontaneous recovery is usually noted within 3 to 4 months. Usually, careful reassurance and close follow-up are necessary. Physical therapy would offer little benefit. A nerve conduction study also is likely to provide little additional information and no benefit especially one week after surgery. Without concern for intraoperative division of the nerve, surgical exploration should be delayed for several months to allow for nerve recovery.
A 12-year-old girl is evaluated for correction of congenital left unilateral upper eyelid ptosis. She demonstrates moderate left levator muscle function of 8 mm. Which of the following methods is most appropriate for correction of this child's blepharoptosis? A. Fasanella-Servat procedure with removal of the tarsus, conjunctiva, and Müller muscle B. Frontalis muscle flap advancement C. Frontalis suspension procedure with autogenous fascia lata D. Müller muscle-conjunctival resection E. Resection and advancement of the levator aponeurosis
E. The most appropriate method for correction of this child's congenital ptosis is resection and advancement of the levator aponeurosis. This technique is appropriate in patients with greater than 5 mm of levator function. This child has 8 mm of levator function and is therefore a candidate for levator resection and advancement. Frontalis suspension procedures are reserved for patients with poor levator function or congenital Marcus Gunn jaw-winking syndrome. The Fasanella-Servat procedure is for correction of minimal ptosis and may alter eyelid contour. The Müller muscle-conjunctival resection surgery is recommended for patients with fairly good levator function and does not allow for intraoperative adjustment of eyelid height. This child has unilateral blepharoptosis, and achievement of symmetry with the opposite eyelid is crucial. The frontalis muscle flap is recommended for use in patients with severe ptosis with levator function of less than 4 mm.
A 53-year-old woman who underwent periareolar mastopexy 13 years ago comes to the office to request reoperation of her now DD-cup-sized breasts. She wants improvement in the appearance of her breasts with greater projection and a decrease in her brassiere size to a B cup. Physical examination of the breasts shows flattened nipple-areola complexes that are 72 mm in diameter surrounded by circumferential hypertrophic surgical scars. The breasts are wide and bottomed out with a 14-cm distance between the inferior areolar border and the inframammary fold. Which of the following is the most appropriate technique to achieve the desired result? A. Liposuction of the breasts with autologous fat transfer to the retroareolar region B. Liposuction of the breasts with placement of breast implants C. Liposuction of the lower poles of the breasts with excision of the hypertrophic areolar scars D. Periareolar mastopexy with open excision of excess breast tissue E. Wise pattern mastopexy with open reduction of excess breast tissue
E. The most appropriate technique to achieve this patient's desired result of improved appearance of her breasts with increased projection and significantly decreased cup size is a secondary Wise pattern mastopexy with open reduction of her excess breast tissue. This technique will allow reduction in the diameter of the areola, give increased breast projection, and decrease the chance for recurrence of widened hypertrophic periareolar scarring. Liposuction of the lower pole of the breast and periareolar scar revision could modestly decrease breast volume and possibly improve scar quality, but they would be ineffective at improving breast shape and projection, and in decreasing the areolar dimensions and excessive length of the lower pole of the breast. Periareolar mastopexy with open reduction of excess breast tissue will not increase central breast projection or adequately address the excessive length of the inferior areolar to inframammary crease distance. Liposuction of the breasts with placement of breast implants could improve central breast projection. This approach, however, would not provide the significant decrease in breast volume of three cup sizes which this patient desires, and would not improve the patient's periareolar scars or the bottoming out of the lower poles of the breasts. Liposuction of the breasts with fat grafting to the retro-areolar areas could increase central breast projection and decrease brassiere cup size, but it does not treat the hypertrophic areolar scarring or the abnormal lower pole dimensions of the breasts.
A 14-year-old girl comes to the office with a history of rapid significant increase in the size of her breasts with puberty. She wears a size 32H brassiere. The size of her breasts negatively affects her activities of daily living. Physical examination shows BMI is 21 kg/m2, and both breasts are enlarged with minimal asymmetry. Histology of the breasts is most likely to demonstrate a proliferation of which of the following types of tissue? A. Adipose B. Ductal C. Lobular D. Muscle E. Stromal
E. The patient is presenting with juvenile (virginal) hypertrophy of the breast. In this patient, the growth of the breast is due to the hypertrophy of the stromal component of the breast tissue. In this case, the patient has a normal range BMI, decreasing the chances that the size of the breast is related to her weight. The histology of the breast will demonstrate a predominance of stromal tissue. This is the connective tissue of the breasts, which includes the fibroblasts and fat. As noted, fatty tissue will be present in the breast; however, it is not a predominant component in true juvenile massive breast enlargement as compared with breast enlargement in the obese adolescent. Ducts will be present but not predominating, lobules will be absent or poorly formed, and muscle development is unrelated to breast size.
A 53-year-old woman is evaluated because of horizontal rhytides at the root of the nose and between her eyebrows. Treatment will most specifically target which of the following muscles? A. Corrugator supercilii B. Depressor septi nasi C. Frontalis D. Orbicularis oculi E. Procerus
E. The procerus stretches from the nasal bones to the dermis of the glabella, and contraction promotes horizontal rhytides in the glabellar region. The corrugator supercilii is more likely to promote vertical rhytides in the glabella. The orbicularis oculi serves as a sphincter around the eye and may also contribute to vertical glabellar rhytides. The frontalis is responsible for the horizontal forehead rhytides above the eyebrows. The depressor septi nasi does not impact forehead wrinkles.
A 26-year-old healthy woman comes to the office for consultation because she has constant pain 1 year after undergoing augmentation mammaplasty by another surgeon. She reports that he "botched" her surgery and that she is considering taking legal action against him. On physical examination, the breasts are quite firm and mildly tender. The relatively immobile subglandular implants are high on the chest wall. There are no overlying skin changes. Which of the following is the most appropriate response by the surgeon in this scenario? A. Decline to establish care B. Follow-up visit in one year C. Perform a diagnostic intercostal nerve block D. Prescribe a course of oral corticosteroids E. Recommend surgical intervention
E. This patient has developed Baker grade IV capsular contracture as evidenced by hard, painful breast implants that are malpositioned. This is a known complication of augmentation mammaplasty, and the patient should be informed that it is treatable with another surgery. It would be reassuring to the patient to hear that it is a known post-operative complication that happens not uncommonly, and that it is unlikely the other surgeon directly did anything to cause this. Thoughtful analysis and contextualization are helpful in high-tension consultations such as these. Providing the patient with a malpractice attorney's contact information may be what she thinks she wants, but diffusing the situation is best for all involved. Dismissing the patient's concerns outright without diagnosing her and suggesting a course of treatment would not be helpful. The new surgeon may even take it a step further by offering to speak with her previous surgeon to discuss the patient's concerns and the findings seen during consultation. The patient may refuse to allow this, and she may have lost faith in her other surgeon, but at least offering to speak with the other surgeon is prudent and may restore the relationship between this patient and her surgeon. A pain management specialist and physical therapy may help somewhat with symptoms, but her problem ultimately requires and should respond well to a surgical solution.
A 35-year-old woman comes to the office for correction of an irregularity of the nasal dorsum following rhinoplasty performed 1 year ago. The patient wants nonsurgical treatment. Hyaluronic acid filler (0.6 mL) is injected into the upper third of the nasal dorsum. Immediately after injection, the patient reports partial loss of vision and pain in the right eye. Which of the following is the most appropriate next step? A. Application of apraclonidine eye drops B. Intravenous infusion of tissue plasminogen activator C. Nasal subcutaneous injection of hyaluronidase D. Percutaneous lateral canthotomy E. Retrobulbar injection of hyaluronidase
E. This patient has symptoms of an intravascular injection of hyaluronic acid (HA) causing occlusion of the central retinal artery. This complication is extremely rare; however, when it occurs, treatment must be immediately instituted because the retinal circulation needs to be restored quickly (within 60 to 90 minutes) for possible reversal of symptoms. The first line of treatment is to bathe the retinal circulation with hyaluronidase. This is achieved with a retrobulbar injection. Using a 25-gauge needle or cannula, enter the orbit along the orbital floor between the inferior and lateral rectus muscles. Advance the needle along the orbital for at least 1 inch beyond the orbital rim and inject 2 to 4 mL of undiluted hyaluronidase. Hyaluronidase adjacent to an occluded vessel can dissolve an HA embolus. The likely mechanism of vascular occlusion is an intra-arterial injection of filler under pressure. In this case, the filler would have entered the dorsal nasal artery and traveled retrograde to the ophthalmic artery. Once the injection pressure is released, the filler would then flow antegrade into the central retinal artery which is the terminal branch of the ophthalmic artery. Tissue plasminogen activator would be indicated for hematologic thrombosis or blood clot embolism, not HA embolus. Subcutaneous injection of hyaluronidase is indicated for treatment for filler-related vascular compromise secondary to extravascular compression. The goal is to dissipate the extravascular compression of the artery. However, in patients with symptoms of vision loss, the likely diagnosis is a HA embolus and therefore the first injection should be retrobulbar. Lateral canthotomy is indicated for decompression or a retrobulbar hemorrhage. Reassurance is not a reasonable treatment option as this is an emergency. Apraclonidine is a sympathomimetic eye drop use to stimulate Müller muscle and improve botulinum toxin type A-related ptosis.
