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PLASTIC SURGERY MADE EASY Solved Past Papers
DR. HIJRAT ULLAH SHINWARI AESTHETIC PLASTIC SURGEON
La Chirurgie Cosmetic Surgery Center, Islamabad
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Dedication:
To my mentor
Dr. Muhammad Humayun Mohmand
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Preface:
I am honored and excited that I had an opportunity to help my colleagues. During my
preparation for exam I felt that the questions in our papers cannot be covered from a single
book (i.e. Grabb and Smith). From the school timings I had the habit of writing and making my
own notes, I pick up the things from different sources, which make me more comfortable. So,
here I am presenting you my collection of plastic surgery stuff. Hopefully some of you may get
benefitted. Thankyou
I only try to help people, just to please my ALLAH.
https://drhijrataestheticplasticsurgery.com/
https://www.instagram.com/dr.hijratplastic/
https://www.facebook.com/drhijratplasticsurgeon
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SECTION I: GENERAL PRINCIPLES
1. TECHNIQUES & PRINCIPLES IN PLASTIC SURGERY
2. WOUND HEALING
3. WOUND CARE
4. BLOOD SUPPLY OF THE SKIN FLAPS
5. BLOOD SUPPLY OF THE MUSCLE FLAPS
JULY 2017
Q18)
a) Name 4 study designs used for medical research.
b) Name any 4 statistical tests used to analyze your data.
c) How would you define the following:
-Value.
OCTOBER 2016
Q8) With regards to aseptic techniques in the operating theatre.
a) Enumerate the steps necessary for asepsis in OT.
b) How would you minimize the risk of infection preoperatively and postoperatively.
OCTOBER 2016
Q19) Regarding skin blood supply:
a) What do you understand by the term angiosomes? Give a brief account of the zones concept.
b) How can you increase the zone and its mechanism?
c) Classify the fasciocutaneous flaps.
OCTOBER 2016
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Q20) A 45 year old man involved in RTA few days back, presented in your clinic with skin loss of the lower leg in the
middle third. The wound is clinically clean and you plan to reconstruct with skin graft.
a) What is the suitability criterion for skin grafting.
b) What are the contraindications for skin grafting.
c) What is the mechanism of graft uptake.
d) Give the steps you would take to ensure better graft take.
e) Enumerate skin substitutes.
OCTOBER 2014
Q6) With regards to the classification of muscle flaps, assign the type to the following muscles, giving the pattern
of blood supply to each by naming the source vessels.
a) Sartorius.
b) Gastrocnemius.
c) Pectoralis Major.
d) Temporalis.
e) Trapezius.
OCT 2014
Q19) Non-vascularized bone grafts are commonly used in Plastic surgery.
a) Please name the common donor sites used, with their advantages and disadvantages.
b) Briefly give the mechanism if non-vascularized bone graft take.
c) What is the maximum length of graft that can successfully take?
MAR 2006, PII
Q.14 With regard to the posterior interosseous artery (P.1.A) Flap:
a) What is the proximal limit of the skin territory in the forearm?
b) Name the muscles between which the pedicle lies,
c) In the distally based P.I.A. flap where the pivot point located and which artery 'communicates with the P.I.A at
this point?
d) What is considered to be the safe distal limit on the thumb that the distally based P.I.A flap can reach?
e) What technical maneuver may be necessary if the flap appears congested on the operating table?
MAR 2013; JULY 2017
Q.17) Your head of department has asked you to set up a clinical photography unit for the department.
a) How would you ensure standardization and documentation of clinical photography?
b) How would you photo/document a patient scheduled for rhinoplasty and abdominoplasty?
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c) What is the importance of photography in Plastic surgery?
MAR 2013
Q.1.
a) You have changed the first dressing after STSG on 12x30 cm wound of a southern Punjabi aged 25 years. This
was his 5th post-operative day. You are delighted to see a 100% graft take. What is your long term management
plan?
b) For a smaller defect, what are possible donor areas for STSG, their merits/ Demerits?
MAR 2011
Q5.
a) Write a brief description of Latissimus Dorsi muscle flap.
b) What are its uses, contraindications and drawbacks?
c) What are the advantages and disadvantages of using this flap for breast reconstruction after mastectomy?
MAR28, 2013PI
Q.6.
a) What are the various flaps which can be elevated on the subscapular vascular axis?
b) Give a clinical example where the knowledge of this anatomical detail can be particularly beneficial
SEP 2004, PI
Q.9 Name the advantages of free vascularized osseous flaps
SEP 2005, PII
Q.14
a) What are the various structures which can be harvested/elevated on the superficial temporal arterial system?
b) Give one clinical application for each of the structures you have mentioned.
c) What are the disadvantages of the use of flaps based on this vascular
axis?
SEP 2003PII
Q.17 how can the knowledge of Anatomy of the Superficial Temporal Artery be exploited in plastic surgery? Give
examples
MAR 2006, PI
Q.4 Write a short essay on the patterns of blood supply to skin of human body. Enumerate at least one example of
clinical application of this knowledge for harvesting a skin flap from each region (Pattern).
JAN 2008, PI
Q.6
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a) What are the stages of Skin graft take?
What are advantages and disadvantages of thick and thin skin grafts?
What are the conditions not favoring graft take?
APRIL 2015
Q15) a) What is the angiosome principle and how does it explain the delay phenomenon?
b) What are the types of fasciocutaneous flaps, give brief anatomical details of each type.
c) What are compound flaps and how are they subdivided?
MAR28, 2013PII
A.15. In Planning and designing fascio-cutaneous flaps.
a) What is a perforator flap and how can the territory of perforator flap be extended using angiosome principle?
b) What perforator flaps can be used to cover at 5x5 cm defect over the proximal palm?
c) What is a free style perforator flap and in which clinical situation can it be useful?
MAR16, 2011PII
Q.15
a) Define and classify perforator flaps,
b) Give examples of perforator flaps which are commonly used for reconstruction of head and neck,
c) Write a short note on propeller perforator flap
AUG 2006, PI
0.1
What are perforator flaps?
Name the two main types of perforating vessels?
Name the two most commonly used perforator flaps?
What is the major advantage of perforator flaps?
AUG 2006, PI
Q.5 Enumerate various classifications of skin flaps giving one example of each
MAR 25,2009PI
Q.9 Regarding Vacuum assisted closure of wounds
a) What is the mechanism of action
b) What are the common clinical indications?
c) What are the potential limitations/complications?
AUG 2006, PI
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Q.6 Write a short essay an "Vacuum assisted wound closure" enumerating its definition, mechanism method of
application, advantages and disadvantages. Also enumerate the indications.
MAR 2005, PI
Q.2
a) What is the rationale for use of vacuum assisted closure?
b) What are the clinical indications for its use?
c) What are the common complications associated with its usage?
APRIL 23, 2014-P1
Q.1:
a) What are the factors affecting the wound healing?
b) Name the wound healing adjuncts?
c) How does vacuum assisted closure help in wound healing?
JUNE25, 2008PII
Q.15
a) What is the concept of angiosomes?
b) When would you delay a flap and how does it work?
c) What measures and pharmacological agents are useful in overcoming vascular spasm?
SEP 2004, PI
Q.7 regarding muscle flap
a. Give the Mathes and Nahai classification based on vascular pattern of supply.
b. Give the type and blood supply of the following muscles.
i) Latissimus Dorsi
ii) Rectus Femoris
iii) Rectus abdominis
iv) Gastrocnemius
v) Tibialis anterior
OCT, 2012PI
Q.8. a) How does a FTSG Take?
b) Acellular dermis covered with autologous partial thickness skin graft being frequently used in place of FTSG.
How does is differ from STSG in its Take.
c) How cellular dermis can replace flaps in different clinical situations
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APRIL 2015
Q18) Acellular dermal matrix has gained popularity in recent years in plastic surgery.
a) What is acellular dermal matrix?
b) What are its types?
c) Enumerate the applications of ADM in plastic surgery.
SEP 2004
Q.16 Write a short essay on principles of skin grafting and after care.
AUG 2007
Q.16
What are the common sites for harvesting split skin graft.
Gives advantages & disadvantages of any three donor sites.
What factors determine the possibility of reharvesting a graft from previous donor sites.
How will you choose a donor site for a particular defect
MAR28, 2011
Q.18 a) What is meant by flap prefabrication and prelamination?
What do you understand by the term secondary critical ischemia time?
What are the requirements/properties of an ideal monitor after free tissue transfer?
Name free flap monitoring methods.
SEPT 2010
Q.9: What is the concept of prefabrication of a flap in plastic surgery?
a) What are the various methods & components of raising such a flap?
b) Give one example in detail.
SEP 2005
Q.17 what is an axial pattern flap
Name seven axial pattern fasciocutaneous flaps of the upper limb and their blood supply
AUG 2006
Q.18 Write a short essay on "Fetal Wound Healing" enumerating the factors responsible for "Fetal Wound Healing”
MAR 2005; FEB 2007
Q.1; Q.14
a) How do non-vascularized bone grafts heal?
b) What are the three common donor sites for these grafts?
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c) Give 2 advantages and 2 disadvantages of each donor site.
Feb 2007
Q.15: What factors must be considered when planning incisions on the face?
a) Draw a diagram of the face and mark upon it suitable incisions in different areas.
b) Give the preferred suturing technique for facial wound closure giving the pros and cons for each technique.
MARCH 20, 2012 PI
Q.9 a) what are vascular investigative tools available for pre-operative planning of perforator flaps?
b) Outline the operative steps of deep inferior epigastric perforator flap harvesting for post mastectomy breast
reconstruction
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Cross-sectional study: a study which differ on one key characteristic at one specific point in time.
Data is collected at same time from people who are similar in other characteristics but different in a key
factor of interest, age, sex, duration of injury.
Blinded study: a study is done in such a way that the patient, or subjects do not know (as blinded as to)
what treatment they are receiving to ensure that the results are not affected by a placebo effect.
Single blinded: experimenter knows, receiver don’t.
Double blinded: both don’t know.
Alpha (type I error): is rejection of a true null hypothesis.
When it is committed: if we reject null hypothesis when it is true.
Beta (type II error): is the non-rejection of a false, null hypothesis.
When it is committed: if we accept null hypothesis when it is false.
Null hypothesis: that there is no significant difference between specified populations, any observed
difference being due to sampling or experimental error.
Randomized control trial: a study in which people are allocated at random (by chance above) to
receive one of several clinical intervention (experimental group and control group).
Types of error
Accept null Reject null (assume difference)
Null Is true Correct decision Type I error (Alpha)
Null is false (true difference)
Type II error (beta) Correct decision
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Management: (in general)
Admit the patient
Proper history
Proper exam
Investigations (disease specific and general health condition)
Diagnosis
Counselling (disease, treatment option, outcome/prognosis)
Consent
Pre-op preparation
Treatment (non-surgical and surgical)
Post op care
Rehabilitation
Follow up.
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Study design:
1. Treatment studies: a. Randomized control trial (blind and non-blind) b. Adaptive clinical trial
c. Non randomized trial (quasi-experimental)
i. Interrupted time series design
2. Observational studies:
a. Descriptive:
i. Case report
ii. Case series
iii. Population study
b. Analytical:
i. Cohort study: particular form of longitudinal study that sample a cohort (a gp.
Of people who share a defining characteristic, typically who experienced a
common event, in a selected group (such as birth or graduation)
Prospective cohort
Retrospective cohort
Time series study
ii. Case- control study
Nested case control study
iii. Cross-sectional study:
Community survey ( a type of cross-sectional study)
iv. Ecological study
p-value: is the level of marginal significance within a statistical hypothesis test representing the
probability of the occurrence of a given event.
Incidence: is a measure of the probability of occurrence of a given medical condition in a population
with in specified period of time.
Prevalence: is the proportion of a particular population found to be affected by a medical condition.
Impact factor: (or journal impact factor) is a scientometric index which reflects the yearly average no. of
citation of recent articles published in that journal.
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Steps for better graft uptake:
Well adherence
Bolster dressing
Opsite
Vaccum dressing
Immbolization
Elevation
Antibiotic therapy
Wound bed preparation
Enumerate skin substitutes:
1. Integra (bilayer, dermal layer + silicon)
2. Epicel (cultured epidermal allograft)
3. Dermograft (polglactin mesh)
4. Apligraf (bilayer skin, outer protective skin layer (epi), inner contain collagen)
Fifteen years ago Pruitt and Levine191 listed attributes of the ideal skin substitute which are still current
today:
• little or no antigenicity
• tissue compatibility
• lack of toxicity, either local or systemic
• permeability to water vapor just like normal skin
• impenetrability to microorganisms
• rapid and persistent adherence to a wound surface
• porosity for ingrowth of fibrovascular tissue from the wound bed
• malleability to conform to an irregular wound surface
• elasticity for motion of underlying tissues
• structural stability to resist linear and shear stresses
• a smooth surface to discourage bacterial proliferation
• sufficient tensile strength to resist fragmentation
• biodegradability
• low cost
• ease of storage
• indefinite shelf life
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Steps necessary for asepsis in O.T:
Priniciple #1: scrubbed person function within a sterile field
Priniciple #2: sterile draps are used to create a sterile field
Priniciple #3: all items used within a sterile field must be sterile
Priniciple #4: all items introduced onto a sterile field should be opened, dispensed, and
transformed by methods that maintained sterility and integrity.
Priniciple #5: a sterile field should be maintained and monitored consistently.
Priniciple #6: all personal moving withing or around a sterile field should do so in
manner to maintain the sterile field.
Priniciple #7: policies and procedures for maintaining a sterile field should be written,
Reviewed annually, and readily available within the practice setting.
Minimizing Risk of pre- and post-op infection:
1. Host optimization
2. Bacterial count reduction
3. Wound management
Skin preparation
Antibiotics
Operating room
Wound/ bandage care
Glycemic control
Watch for sign of infection
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Angiosome: is an area of skin and underlying tissue vascularized by a source artery.
It is a concept that is used by plastic surgeon for the creation of perforator flaps and by interventional
radiologists for the endovascular treatment of critical limb ischemia.
Angiosome concept: was derived from plastic surgery for purpose of healing of skin flaps. An angiosome
is an anatomic unit of tissue (consisting of skin, subcutaneous tissue, fascia, muscle and bone) fed by a
source artery and vein drained by a specified vein. The entire body is divided into 40 angiosome
bilaterally and foot itself consists of six. The post. Tibial artery feeds three angiosome, the anterior tibial
feeds one, and peroneal artery feeds two.
Anatomic facts:
Vessels follows the connective tissue framework of the body.
Vessels radiate from fixed to mobile areas.
Vessels hitchhike with nerves.
Vessels size and orientation are a product of tissue growth and differentiation.
Vessels obey “the law of equilibrium”.
Vessels have a relatively constant destination but may have a variable origin.
The vessels form a continuous unbroken network.
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Skin graft:
Suitability criteria for skin graft:
o Optimize systemic parameters.
Nutrition
Glucose control
Smoking cessation
o Debride nonviable tissues
o Reduce wound bioburden
o Optimize blood flow
Warmth
Hydration
Surgical revascularization
o Reduce edema
Elevation
Compression
o Use appropriate dressings
Moist wound healing
Exudate removal
Avoidance of trauma to wound or patient.
o Use pharmacologic therapy when necessary
o Close wounds surgically with grafts or flaps, as indicated.
Contraindication of skin graft:
Exposed bone (without periosteum)
Exposed cartilage (without perichondrium)
Exposed tendon (without paratenon)
Exposed vessels
Wound on which 2nd stage of reconstruction is predictable
Exposed hardware/prosthesis
Infected wound (105 organism per gram of tissue)
Mechanism of graft uptake: skin graft revascularization or “take” occurs in three phases.
First phase involves a process of serum imbibition and lasts for 24-48 hours (a fibrin
layer)
Inosculatory phase: in which recipient and donor end capillaries are aligned.
In 3rd phase, the graft is revascularized thorough these “kissing “capillaries.
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Photography:
Anatomical location Recommended views
Face Frontal, lateral, oblique
Breasts Frontal, lateral, oblique
Hand Dorsal, volar, lateral
Abdomen Frontal, lateral, oblique, also frontal with arm raised over head, lateral view with trunk but more than 45o and frontal and lateral views during Valsalva manoeuver
Buttocks Posterior, lateral
Legs and feet Dorsal, planter, lateral and posterior.
Importance of photography in plastic surgery:
1. Clinical:
a. Pre-op counselling
b. Intra-op
c. Post-op comparison
2. Academic:
a. Clear educational benefit
b. Benefit to trainee and medical community, and to society by improving quality
of care.
c. Surgeries which is rarely performed in specific center can be saved.
3. Medicolegal aspect.
Standardization and documentation of clinical photography:
Good quality camera
Appropriate lens
Appropriate focal length
Appropriate light
Appropriate background (single color, preferably non shiny light blue)
Appropriate patient position
Appropriate camera patient distance
Appropriate camera position (vertical and horizontal)
Use separate room/chamber for photography
Proper file/record with patient name, date, address and surgery.
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Photo/ document for Rhinoplasty:
Camera should be positioned vertical
Above clavicle upto head
Profile view
o Anterior
o Lateral (with and without smile)
Oblique view
Worm eye view
Bird eye view
Also chest picture and ear picture, if graft harvest is planed
Photo/ document for abdominoplasty:
Camera should be placed horizontal
Patient position, from mid-thigh to inframammary lines
Frontal view with hand hang by side and hands holding up
Side view with hands hanging down and up
Oblique view
Bending view
Close up view- to asses quality of skin
Non-vascularized bone grafts:
1. Common donor site:
Iliac crest, rib, calvarium, fibula, mandible
2. Mechanism of NVB graft uptake:
Inflammation
Osteoblast differentiation
Osteoinduction
Osteocnduction
Remodeling
3. Maximum length of NVB graft: about 6-8 cm and in some books it’s about 12cm.
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Fasciocutaneous Flaps:
Originally called an axial flap, include the skin, subcutaneous tissue and underlying fascia, which
may be distinct from fascia covering the underlying muscle.
Classification: On the basis, Mathes and Nahai have classified fascia and fasciocutaneous flaps
as type A, B, C. o Type A fasciocutaneous flap: have a vascular pedicle to the deep fascia and eventually
continuing its course superficial to deep fascia. This pedicle provide numerous
fasciocutaneous perforator to skin.
Examples:
Deep ext.
pudendal a,
Digital a,
Dorsal
metacarpal a,
Gluteal thigh
Great toe
Groin
Lateral
thoracic
(axillary)
pudendal-thigh
saphenous
scalp
second toe
standard
forehead
superficial
external
pudendal
superficial
inferior
epigastric a
temporo
parietal fascia
a
o Type B fasciocutaneous flap: have a septocutoneus pedicle which courses
between major muscle group, is an intermuscular septum or between adjacent
muscles. This pedicle is located within the intermuscular septum or the
potential space between adjacent muscles and supplies a regional fascial
vascular system.
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o Example:
ALT
Ant. Tibial a.
Deltoid
Dorsalis pedis
Inf. Cubital a.
Lateral arm
Lateral planter
a.
Lateral thigh
medial arm
medial planter
medial thigh
Peroneal a.
posterior
interosseous
radial forearm
radial recurrent
scapular
ulnar recurrent
o Type C fasciocutaneous flap: the design of fasciocutaneous flap can be based on
these dominant perforating vessels without incorporation of the underlying
muscle.
Example:
o ALT
o Deltopectoral
o Nasolabial
o Medial forehead
o Thoracoepigastric (transverse abdomen)
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Perforator flaps: Perforator flap have evolved from musculocutaneous and fasciocutaneous flap
without the muscles or fascial carrier. It has been shown that neither a passive muscle carrier nor the
underlying fascial plexus of vessels are necessary for flap survival.
Advantages Disadvantages
o Reduced donor site morbidity o Verstality in flap design o Muscle sparing (less functional deficit) o Imporved post op recovery of patient.
o Meticulous dissection needed o Increased operative time o Variability in position and size of
perforator vessels o Increased chances of vessels damage
Classification:
o Direct cutaneous
o Septocutaneous and
o Musculocutaneous perforators.
There are many perforators flaps, currently used and others that are of theoretical value.
As studied closely by Taylor and Palmer, there are many named perforating vessels to each angiosome
of the body.
Acceptable perforator flap donor site, have four common features.
1. Predictable and constant blood supply
2. At least one large (diameter ≥ 0.5mm) perforating vessel.
3. Sufficient pedicle length for the required anastomosis, unless the flap is being used as a pedicled
flap.
4. Ability to close the donor site primarily.
Commonly used perforator flap:
Deep inf. Epigastric artery perforator flap
Superior gluteal artery perforator flap
Thoracodorsal artery perforator flap
Anterolateral thigh perforator flap
Tensor fascia lata perforator flap and
Medial sural artery perforator flap.
*Free style perforator flaps are those without regard to any landmark and flap harvest is simpler and
faster.
=5*5cm defect of palm can be covered with SIEP (thin) and SCIP (thick resurfacing)
Investigative tools:
1.Perforator computed tomographic
angiogragpy (P-CTA) with multidetector-
row computed tomography (MDCT)
2.Doppler and 3.Dupplex U/S
4. CTA and 5.MRA
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Subscapular Vascular Axis:
Vessel diameter:
1. Subscapular artery- 3mm
2. CSA- 1.7mm
3. TD- 1.3mm
Combination include:
1. Scapular flap
2. Parascapular flap
3. Dorsal thoracic fascia
4. Serratus anterior
5. Serratus fascia
6. Latissimus dorsi
7. Vascularized lateral scapular border
8. Vascularized tip scapular (angular branch)
9. Ribs
Circumflex scapular artery:
1. Pedicle length 3-6cm
2. Arise 4 cm from the origin of subscapular artery
3. Travels with 2 venae commitant (subscapular has 1)
4. Emerges from lateral border of scapular at medial triangular space
(omotricipitale/medial axillary space) locate by:
Palpation
Line 2/5th along the lateral border of the scapular (from superior)
Distance of midpoint of middle of spine of tip- 1cm
5. No cutaneous nerves accompanied the pedicle
Flap may be neurotized using posterior cutaneous branch of intercostal nerve
(very small)- enter in medial to dissesction
6. Branches
Transverse- scapular flap
Descending- parascapular flap (i.e. 30*15cm)
Scapular flap:
o Skin paddle:
1. 2 cm from midline, 2 cm below spine, 2 cm above scapular tip, laterally to
posterior axillary fold.
2. 24 cm long
3. 8-12 cm width (primarily closed)
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o Raised from medial to lateral superficial to fascia over rhomboid infraspinatus- very
messy if deep to this fascia.
o Identify in cleft between teres major and minor (i.e. space is filled with a fat pad)
Triangular space:
The triangular space (also known as the medial triangular space, upper triangular space,
medial axillary space or foramen omotricipitale) is one of the three spaces found at the axillary
space. The other two spaces are the quadrangular space and the triangular interval.
o Boundaries: It has the following boundaries:
Inferior: the superior border of the tere major,
Lateral: the long head of the triceps,
Superior: Teres minor or subscapularis
o Contents: contains the scapular circumflex vessels.
Propeller perforator Flap:
Term first used in 1991 by Hyakusoku et al. to describe an adipocutaneous flap based on a
central subcutaneous pedicle, with a shape resembling a propeller that was rotated 900.
Advantages:
o They allow for a great freedom in design and choice of donor site based on quality and
volume of soft tissue required and on scar orientation.
o They represent a simpler and faster alternative to free flaps and expand the possibilities
of reconstructing difficult wound with local tissues.
o Their harvest is easy and fast, provided that appropriate dissection technique is applied.
o Donor site morbidity is kept very low, avoiding the sacrifice of any necessary tissue.
Classification:
o “Island flap that reaches the recipient site through an axial rotation”- advisory panel of
Tokyo 2009.
o They can be classified according to type of nourishing pedicle:
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I. Subcutaneous pedicle-propeller flap: is based on random subcutaneous pedicle
and allow for rotation up to 900.
II. Perforator pedicle propeller flap: is based on a skeletonized perforator pedicle.
This is most commonly used type of propeller flap and can be rotated up to
1800.
III. Supercharged propeller flap: is modification of the perforator pedicled propeller
flap, in which a superficial or perforating vein of the flap is anastomosed to a
recipient vein or an extra artery is anastomosed to a recipient vein or an extra
artery is anastomosed to a second arterial pedicle of flap, to increase venous
outflow or arterial inflow.
o Post op care:
I. Limb should be kept in splint
II. Compression on flap should be avoided
III. Keep limb elevated
IV. Flap monitoring any 02 hour for 2 days.
o Complications:
Complication Prevention Management
Arterial insufficiency Venous insufficiency Partial necrosis
Accurate planning // // // // // //
Rerotate in original plane
Mild- leech therapy Significant- reexploartion and venous supercharging After eschar removal
(D/d)- skin grafting or secondary intention healing
Compound flap: by definition incorporate many diverse tissue component into an interrelated unit.
1. Solitary:
a. Composite: multiple tissue components with a single vascular supply and
dependent parts.
2. Combined flaps:
a. Siamese flaps: multiple flap territories, dependent due to some common
physical junction, yet each retaining their independent vascular supply
b. Conjoint flaps: multiple independent flaps each with an independent vascular
supply, but linked by a common indigenous source vessel. And
c. Sequential flaps: multiple independent flaps, each with an independent vascular
supply, and artificially linked by a micro anastomosis.
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Wound healing:
Factors that contribute to wound healing impairment:
Age
Ischemia
Reperfusion injury
Infection or bacterial bioburden
Malnutrition
Foreign bodies
Diabetes
Steroids
Uremia
jaUnDdice
Cancer
Genetic causes (e.g., Ehlers-Danlos, Werner syndromes)
Irradiation
Chemotherapy
Tobacco use
Alcohol use
Edema
Pressure
BASIC FUNDAMENTALS OF WOUND CARE
Optimize systemic parameters
Nutrition
Glucose control
Smoking cessation
Debride nonviable tissue
Reduce wound bioburden
Optimize blood flow
Warmth
Hydration
Surgical revascularization
Reduce edema
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Elevation
Compression
Use appropriate dressings
Moist wound healing
Exudate removal
Avoidance of trauma to wound or patient
Use pharmacologic therapy when necessary
Close wounds surgically with grafts or flaps as indicated
Adjuncts to wound care/healing:
Debridement
Negative pressure wound therapy
Hyperbaric oxygen
Growth factors
Enzymes
Dressing
Skin substitutes
VACCUM ASSISTED CLOSURE (NPWT):
NPWT works through multiple important mechanisms including: Reduction of edema Removal of wound fluid rich in deleterious enzymes both patient and bacteria
derived Encouraging granulation tissue formation
In addition, the cyclic compression and relaxation of the wound tissue likely stimulate
mechanotransduction pathways that result in
Increased growth factor release,
Matrix production, and
Cellular proliferation.
Indication Contraindication
Lymphatic leaks,
Venous stasis wounds,
Diabetic wounds,
Wounds with fistulae,
Sternal wounds,
Orthopedic wounds, and
Abdominal wounds.
Presence of a malignancy,
Use on wounds characterized by ischemia,
As well as inadequately debrided or
Badly infected wound
Muscle flaps: Mathes and Nahai classification:
1. Type I: single vascular pedicle: a single vascular pedicle enters,the muscle and the
muscle may be safely elevated on this pedicle.
Examples:
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TFL
Gastronemius
Abd. Digiti minmi (hand), abd pollicus brevis, anconeus, frist dorsal
interosseous
2. Type II: Dominant vascular pedicle(s) and minor vacular pedicle(s): flap muscle survive
on dominant vascular pedicle.
Example:
Gracilis
Trazepius
Rectus Femoris
Abd. Digiti minimi (foot), abd halluces, brachioradialis,
corachobrachialis, flexor carpi ulnaris, soleus.
3. Type III: Dominant Pedicles: two large vascular pedicle, each of which may support
entire muscle.
Example:
Gluteus maximus,
Rectus abdominas,
Temporalis,
Intercostal, orbicularis oris, pect minor, serratus
4. Type IV: Segmental Vascular Pedicle: this group of muscles contain a series of segmental
pedicles, generally of equal size- that enter the muscle along its course. Generally
division of two or more is feasible for muscle transposition.
Example:
Sartorius
Tibialis anterior
Ext. digitorum longus, ext. halluces longus, ext. oblique, flexor digitorum
and halluces longus
5. Type V: Dominant vascular pedicle(s) and secondary segmental vascular pedicle(s):
These muscle receives a large vascular pedicle that will reliably provide circulation to the
muscle when it is elevated solely based on this particular vascular pedicle. Secondary
vascular pedicle generally enters from one side, and dominant vascular pedicle from
opposite side.
Example:
Latissimus dorsi
Pect. Major
Internal oblique
29
Acellular Dermal Matrix: Is a soft connective graft generated via a decellurizition process that preserves
the intact extracellular skin matrix.
Schematic overview of a cellular dermal matrix preparation:
Types:
o Alloderm
o Allomax
o FlexHD
o Micronized HADM
o Human Acellular Dermal Matrix (HADM)
o Procine Acellular Dermal Matrix (PADM)
Application:
o Implant based breast,
o Abdominal wall,
o Chest wall,
o Pelvis reconstruction and
o Lip augmentation
Micronized HADM also available and used for laryngoplasty and as soft tissue filler.
Complication:
o Infection
o Seroma and Necrosis.
30
Prefabrication and Prelimination:
Introduction:
o Flap prefabrication and prelamination are distinct techniques designed to
address complex reconstructive needs. While these techniques are generally not
primary reconstructive options, their usage has increased in response to
demands for more sophisticated reconstructive efforts. In reconstructive surgery,
a delicate balance exists between the availability of matching donor tissue and
the complexity of the recipient defect. Prefabrication and prelamination
techniques have been applied to areas where a special surface, contour, or
structure is desired and reconstructive goals cannot be met by conventional
means. Areas of the body where prefabrication (Fig) and prelamination have
played a role in reconstruction include facial subunits, facial cartilage, facial
skeleton, oropharynx/esophagus, and the penis (Tables). This chapter focuses on
problems of the head and neck region, where aesthetic, structural, and functional
needs are complex and demanding, with scarce reconstructive options.
31
Clinical applications of prefabrication and prelamination: Facial soft tissue subunits
Defect Technique Flap location Technique description References
Lips
(a)
Superficial
(hair-
bearing) lip
loss
(b)
Full-
thickness
upper lip
loss
(c)
Upper and
lower lip
(mouth) loss
Direct axial flap
Prefabrication
Prelamination
Prelamination
Scalp/submental
scalp Submental
forearm
Staged transfer of hair-bearing flap
from scalp/submental Vascular
pedicle implant + secondary transfer
Tissue expander + skin graft on
underside of submental platysma
flap Subfascial skin grafts in radial
forearm flap
Hyakusoku et al.
Pribaz and Guo
Pribaz and Fine
Costa et al.
Baudet
Cheek
(a)
Partial
thickness
(e.g., burn)
(b)
Full
thickness
Direct axial flap
Prefabrication
Prelamination
Submental
neck/upper chest
or distant forearm
Submental island flap to cheek
Implant vascular pedicle beneath
skin and over a tissue expander with
secondary transfer Subfascial skin
graft over a tissue expander in radial
forearm territory, or subfascial
mucosal graft and silicone sheeting
in radial forearm territory (± nerve)
Martin et al.
Faltaous et al.
Kim Khouri et al.
Pribaz et al.
Pribaz et al. Rath
et al. Rath et al.
Neck
Burn
contracture Prefabrication
Thigh forearm
upper chest
Implantation of pedicle
subcutaneously placed over a tissue
expander and subsequently
transferred to neck
Khouri et al.
Pribaz et al.
o
Clinical applications of prefabrication and prelamination: Facial soft tissue with cartilage
Defect Technique Flap
location Technique description References
Nose
(a)
Partial or full-
thickness loss
(b)
Total
Existing laminated
flap Prelamination
Prelamination
Ear
Forehead
Forearm
Ascending helical free flap based on
superficial temporal artery Skin graft
for lining and cartilage for support in
paramedian forehead flap Skin graft
for lining and cartilage for support in
radial forearm flap
Pribaz and Falco
Gilles Pribaz
et al. Costa et al.
Baudet
Ear
Absent ear Prelamination Forearm
Carved costal cartilage graft or silicone
framework covered with radial forearm
fascia and skin graft with secondary
transfer to ear
Costa et al.
Baudet Hirase
et al.
32
Defect Technique Flap
location Technique description References
Trachea/Larynx
(a)
Tracheal
defect/stenosis
(b)
Hemilarynx
defect
Prelamination
Prefabrication
Radial
forearm
Radial
forearm
fascia
Mucosa or ear cartilage prelaminated
onto antebrachial fascia for tracheal
defects Free radial forearm fascial flap
wrapped around upper trachea, which
is subsequently moved for hemilarynx
reconstruction
Vranckx et al.
Delaere et al.
Clinical applications of prefabrication and prelamination: Facial skeleton
Defect Technique Flap location Technique description References
Maxilla
(a)
Partial –
premaxilla
(b)
Extensive
defect
Existing
laminated flap
Prelamination
Second toe
proximal
phalanx
Scapular or
fibula
Osteointegrated implants placed into
proximal phalanx with composite flap based
on dorsalis pedis artery and transferred to
premaxilla Prelaminate scapular bone or
fibula dermal graft + wrap with silicone
sheeting ± osteointegrated implants
Pribaz and
Guo Holle
et al. Rohner
et al.
Mandible
Segmental or
total loss Prelamination Scapular
Cancellous bone in carrier tray placed in
scapular flap territory + secondary transfer to
mandible
Orringer et al
Clinical applications of prefabrication and prelamination: Oropharynx and esophagus
Defect Technique Flap
location Technique description References
Intraoral
Mucosa-lined
soft tissue loss Prelamination Forearm
Mucosal grafts placed over radial forearm and
later transferred for intraoral reconstruction
Rath et al.
Carls et al.
Chiarini et al.
Esophagus
(a)
Cervical
esophagus
(b)
Entire
esophagus
Prelamination
Prelamination
Radial
forearm
Tensor
fascia lata
(TFL)
Skin surface of the radial forearm flap is rolled
into a lumen during first stage to allow healing
of suture line; during second stage 2 weeks
later, microvascular transfer is completed
Longer defect requires TFL flap with skin
lumen prelaminated the same way
Chen et al.
33
Clinical applications of prefabrication and prelamination: Penis
Defect Technique Flap location Technique description References
Penis
Absence
secondary to
tumor or trauma
Prelamination
Lateral arm
radial forearm
fibula
Prelamination with skin tube for neo-urethra
reconstruction with subsequent transfer of
osteocutaneous flap when using fibula
Young et al.
Capelouto et al.
They terms flap “prefabrication” and “prelamination” are two distinctive entities in reconstructive surgery. Flap prefabrication , first introduced by Shen in 1982, describes a two-stage process: the introduction of a vascular pedicle into a body of tissue that bears desired characteristics of the area to be reconstructed, followed by a transfer of this neovascularized tissue into the defect based on its implanted vascular pedicle. Flap prelamination ,a term coined by Pribaz and Fine in 1994, also refers to a two-stage process, whereby one or more tissues are engrafted into a reliable vascular bed to create a composite flap. This flap is subsequently transferred on its original vascular supply, en bloc , for reconstruction. A clear understanding of these two techniques is helpful in choosing the appropriate method to deal with a specific clinical problem and also for scientific communication.
Flap Prefabrication
Concept
The first step in planning a reconstruction is to delineate the specific needs. It is desirable to use flaps that provide a good color match and restore surface and contour. Regarding head and neck reconstruction, in particular, the recipient site may require further specialized flaps, such as hair-bearing or mucus-producing flaps, for optimal reconstruction. Although there may be local flap options with the desired characteristics, these may not have a reliable axial blood supply on which they can be transferred. The technique of flap prefabrication provides this by implanting an axial blood supply into the donor tissue, rendering that tissue transferable once neovascularization has occurred. Technique
A vascular pedicle includes at least an artery and its venae comitantes, surrounded by an adventitial cuff. It may be available locally or, if not, imported as a small free flap and implanted beneath the intended donor tissue. The distal end of the pedicle is ligated. To prevent scarring around the base of the pedicle and to facilitate secondary harvest of the prefabricated flap, a short segment of Gore-Tex (polytetrafluoroethylene) tubing or thin silicone sheeting can be placed around the pedicle up to the undersurface of the tissue that the new pedicle is expected to support ( Fig.). A nonadhesive sheeting may be placed under the implanted pedicle, away from the proposed flap, not only to facilitate secondary elevation of the flap but also to shunt the direction of neovascularization from the pedicle toward the flap to be prefabricated. A tissue expander is frequently used in this capacity. In experimental animal models, a neural island flap can also be prefabricated. In this model, a peripheral nerve can be placed under subcutaneous tissue and the intrinsic vasculature of the nerve can supply the flap following a delay period. Flap Maturation
Neovascularization between the implanted pedicle and the donor tissue matures by 8 weeks in humans. However, experimentally, maturation may possibly be hastened. Angiogenic factors, such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF), have been shown in animal models not to improve flap survival by increasing its vascularity. Flap delay has also been successfully employed, experimentally, to accelerate neovascularization. By virtue of the need to prefabricate the donor tissue (which lacks a good axial blood supply), the delay is accomplished by progressively raising
34
the flap tissue off its non-axial blood supply, thus rendering it dependent on the implanted pedicle. Although the contact area of the vascular pedicle did not seem to be significant in our initial experiments, others have found that there is a proportional relationship of pedicle size and the rate of neovascularization. Another helpful adjunct is the use of tissue expansion. Tissue expansion and flap prefabrication both are two-stage procedures and thus complement each other nicely. The implanted pedicle is placed directly underneath the donor tissue and above the expander. Expansion can start as early as 1 week and may be monitored by Doppler ultrasonography. Expansion can be as aggressive, as allowed by the continued presence of the Doppler signal of a patent pedicle and clinical observation of flap color. Tissue expansion accomplishes four things:
(1) It provides an abundance of tissue that facilitates donor site closure following final transfer; (2) It thins out the donor tissue flap, which is helpful in head and neck reconstruction; (3) It provides mechanical stretch that stimulates endothelial cells to proliferate, thereby enhancing the rate of neovascularization; and (4) It focuses the direction of the neovascularization from the implanted pedicle toward just the
side of the prefabricated flap. Assessment of flap vascularity and viability by modalities designed to evaluate perfusion may be useful in preoperative planning and optimizing flap harvest. Flap Transfer
During the second stage of flap prefabrication, the prefabricated flap is transferred to its final location, based on its newly acquired axial blood supply. This can be done locally as a pedicled flap if close to the defect or via microvascular anastomosis if prefabrication is at a remote site ( Fig). A commonly observed problem seen after flap transfer is transient venous congestion. This may be caused by unequal neovascularization of the lower-pressured venous system compared with the higher-pressured arterial system of the same pedicle. This problem can be ameliorated in several ways. All maneuvers that enhance neovascularization, including flap delay, lengthening maturation time, or increasing the contact area between the pedicle (usually in the form of a fascial flap) and the donor tissue, would help. Also, other strategies such as delayed insetting, temporary leeching (chemical or medicinal), avoiding flap folding or, if possible, performing an additional venous anastomosis using a native subcutaneous vein in the prefabricated flap can all help to minimize flap venous congestion. Finally, there was a recent report of a further surgical delay performed at 6–7 weeks after pedicle implantation and 2 weeks before flap transfer that was shown to minimize venous congestion in that series.
Deep Inferior Epigastric Artery Perforator (DIEP) Flap:
o Anatomic consideration:
35
Tissue: Skin and fat from the lower abdominal wall. The reliable area crosses the
midline. Zones 1, 2 and 3 are generally well perfused.
Innervation: Intercostal T11 and T12 dermatome via intercostal nerves. Not usually
harvested as a sensory flap. There are some who encourage this, but the benefit and
outcome are unclear.
Blood supply: The deep inferior epigastric artery and venae via perforators through the
rectus muscle. The perforators range in size from from 0.3 mm to 1 mm. Flaps can be
harvested reliably on a single large perforator system.
Artery: Large caliber artery from 2 to 4 millimeters.
Vein(s): The venae are typically paired, and often join to a common vessel at their
draining point on the external iliac. One vein is usually larger and comparable in caliber
to the artery.
Pedicle length: From the perforator point to the origin on the external iliacs. Very long
with significant freedom to position.
o Anatomy :
The deep inferior epigastric artery arises from the external iliac artery and runs
from lateral to medial under the rectus muscle. It can enter the substance of the
muscle or run deep to it, while sending branches into the muscle and through
the muscle. Perforators often travel through the tendinous inscriptions of the
rectus muscle, making their dissection somewhat more difficult. In most
patients the DIEP and its venae can supply adequate circulation for zones 1-3,
making the territory of perfusion larger than that of the SIEA flap.
The perforating branches pierce the rectus fascia to supply the abdominal fat
and skin. The DIEA and the accompanying veins are pictured in the illustration
entering the muscle below the junction of the middle and lower third of the
muscle. The DIEA can run laterally, medially or centrally under the muscle, as it
ascends superiorly. There often is symmetry with the contralateral vessels,
however this is not consistent.
36
o Flap Design:
The abdominal skin island is designed with the lower aspect of the incision
transversely placed above the pubic bone, in line with the typical transverse
Cesarean section incision. It extends laterally with a gentle curve superior to the
inguinal ligament finishing adjacent to the anterior superior iliac spines. The
upper incision is placed above the umbilicus and gently curves laterally to meet
the lower transverse incision marking. With the patient in the supine position and
the knees slightly flexed.
After flap harvesting, the abdominal skin and fat above the flap is elevated to the
costal margin (green arrows). The tissue plane is just superior to the rectus
sheath, centrally it is firmly attached to the rectus sheath while laterally this plane
is quite mobile. By beginning the elevation laterally and then focusing medially,
the elevation is simpler.
37
o Operative Procedure:
The patient is prepped and draped supine with the arms stretched out on an arm
board. The abdominal tissue can be pinched to determine the tightness of
postoperative closure and markings can be adjusted accordingly. This is best done
with the knees and hips slightly flexed. Perforators can optionally be assessed
with the pencil Doppler. If bilateral flaps are to be harvested, the Doppler signals
can be marked on the contralateral side as well. This is a good practice even in
unilateral flaps to find the largest and loudest perforators.
The flap is usually elevated from lateral to medial and the search for perforators
is begun when the territory of the rectus sheath over the lateral rectus muscle is
reached. This dissection can be performed with the electrocautery on a low
setting, or with bipolar forceps and scissors. If bilateral flaps are being prepared,
the midline incision can be made and the flap traced from medial to lateral as
well, in order to help surround the perforators. Note that the attachment of the
flap to the rectus fascia in the midline is much more adherent and the plane is
more difficult to dissect at this level.
38
The flap is usually elevated from lateral to medial and the search for perforators
is begun when the territory of the rectus sheath over the lateral rectus muscle is
reached. This dissection can be performed with the electrocautery on a low
setting, or with bipolar forceps and scissors. If bilateral flaps are being prepared,
the midline incision can be made and the flap traced from medial to lateral as
well, in order to help surround the perforators. Note that the attachment of the
flap to the rectus fascia in the midline is much more adherent and the plane is
more difficult to dissect at this level.
o
When a large dominant perforator is isolated, the rectus fascia is incised
longitudinally, around the perforator. Great care is required so as to not injure
the vessels, especially the vein, which can be quite delicate. The fascia is opened
for 10 to 12 centimeters and the perforator is traced through the muscle, using
gentle retraction of the muscle and the bipolar electrocautery. Small branches of
the perforator are coagulated or clipped as they sprout into the muscle and the
perforator is traced to the DIEA and the venae commitans.
The DIEA vessels are then traced back to near their origin while retracting the
muscle away from the deep abdominal contents. When the entire flap is isolated
39
on the perforator and DIEA/DIEV, and the recipient area is ready, the DIEA and
the venae can be ligated and divided. The rectus sheath is closed with a running
large caliber non-braided suture.
The abdominal wall is undermined to the costal margin and the abdominal
incision is closed in layers over suction drains with the hips flexed and knees bent
in a semi-Fowler position. The umbilicus is brought through the abdominal wall
and sutured into position. The patient is allowed to mobilize when clinically
indicated for the recipient area. The patient ambulates with the hips flexed until
the tension of the closure slowly resolves.
40
6. TRANSPLANTATION BIOLOGY AND APPLICATIONS.
7. IMPLANT MATERIALS.
JANUARY 2017
Q14)
a) Please give classification of suture materials used in plastic surgery.
b) What are the common types of absorbable sutures used and what are uses and absorption times.
c) Please name some commonly used dermal substitutes with advantages and disadvantages.
MAR 2006, PII
Q.19 Categorize the available implantation materials for clinical use. Give at least two examples of each with the
clinical usage.
JAN 2008, PI
Q.18
a) What are the issues involved in face and hand transplantation?
b) Who will be an idea candidate for a full face transplant?
c) How do you envisage these procedures being done in our country?
MAR 17,2010PII
Q.11 Allo-transplantation has been discussed in various plastic surgery publications. What are the legal, ethical and
medical issues involved in this particular scenario?
March 20, 2012 PI
Q.5. A 35 Year old female sustained extensive acid burns to her face. She has had a multiple episodes of skin grafting
but it has left her with severe disfigurement.
a) Why do you feel she is suitable candidate for face transplant surgery? (to regain normal fascial appearance and
being able to reintegrate into a society in a meaningful way)
41
b) What are the drawbacks of face transplant surgery in this patient? (Immunosuppression therapy and its
complication, difficulty in recognition,)
Oct, 2012PI
Q.3 A 25 year old male sustained severe crush injury to both hands resulting in amputations at the level of the wrist.
He would like to explore the possibility of a hand transplant.
a) How would you counsel him about the procedure?
b) In which technique aspect does it differ from a re-implantation?
c) What are the long term results in patients who have received hand transplants?
OCT19, 2011P1
Q.3
a) Classify various suture materials with example of each one (no brand names).
b) Enumerate types of surgical needles giving their merits and demerits
Q.7
a) Describe three methods of cutting with a surgical knife with example of their clinical uses.
b) What is the difference between right handed and left handed surgical scissors? How it works?
c) Why a dog ear is formed? (excision of inadequate length, poor planning)
How it is corrected? Describe two methods? (1.making incision longer 2. Convert it to “Y” or 3. Convert it
to “L”.
42
Suture Material:
43
Surgical Needle:
44
45
Implant material:
Properties of an implant material:
o Minimal foreign body reaction
o Elastic or supple
o Easily tailored
o Good tissue incorporation
o Allow collagen ingrowth
o Promote permanent tissue repair
o Good tensile strength
o Tolerate infected environments
o Minimal wound complications
Impants materials:
o Metals
Stainless steel
Cobalt-chromium
Titanium
Gold
Platinum
o Polymers
Silicone
Polytetrafluoroethylene
Polyester
Polypropylene (Prolene, Marlex)
Polyethylene (Medpor)
Polymethyhnethac.rylate
Biodegradable polyesters
Polyamides (Supramid, Nylamid)
o Ceramics
Hydroxyapatite
46
Tricalcium phosphate
o Adhesives and glues
Fibrin tissue adhesives
Cyanoacrylates
o Biologic materials
Skin substitutes
Integra
Epicel
Dermagraft
Apligraf
Bioprosthetic mesh
Small intestinal submucosa
Human acellular dermal matrix
Porcine acellular dermal matrix
Bovine pericardium
Bovine fetal dermis
Method of Cutting with Surgical knife:
1. Fingertip Grip:
Involves the entire scalpel handle being held with the fingertips (without
contacting the palm of the hand).
Used for long incision.
47
2. Pencil grip:
Involves holding the scalpel handle between the thumb and index finger, as on
would hold a pencil.
Used for short incision ideally.
3. Palm grip:
Involves holding the scalpel handle within the palm of the hand.
Best suited for long incision required greater pressure; due to position of blade
on the skin, it results in better contact between blade and tissue.
4. Stab incision:
Tip of the scalpel blade can be used to create a stab incision onto a cavity
(abdomen) or a hollow viscus such as stomach, intestine or urinary bladder.
The scalpel is typically held with a pencil grip position to allow maximum control
of penetration depth.
48
Scissors:
Scissors are used to cut or dissect tissue and to cut inanimate objects, including paper drapes
and suture material. Cutting of inanimate objects should be limited to specific instruments. To
maintain functionality, scissors should be used only for their intended purpose. Three forces are
used when cutting with scissors: closing, shearing, and torque. Closing force causes the blades to
come together; shearing force pushes one blade flat against the other during closing; and
torque rolls the leading edges of each blade inward to touch the other. When standard surgical
scissors are used, creating shearing force is a natural action for the right-handed surgeon, but it
requires effort and practice on the part of the left-handed surgeon. The gripping motion
effectively combines these three forces to create precise cuts. A tripod grip is recommended
when using scissors, because it provides maximal control. A tripod grip is achieved by inserting
the tips of the thumb and ring finger through the rings and placing the index fingertip near the
fulcrum. (see fig)
49
8. PRINCIPLES OF MICROSURGERY.
9. PRINCIPLES OF NERVE SURGERY.
10. PRINCIPLES OF TISSUE EXPANSION.
11. PRINCIPLES OF OFFICE SEDATION FOR COSMETIC PROCEDURES.
12. LOCAL ANESTHETICS.
APRIL 2016
Q2) A 25 year old lady presents with atrophy of the right side hypothenar muscles and the inability to adduct her
thumb. She gives a history of laceration in the upper third of forearm 1 year ago, repaired primarily at a periphery
hospital.
a) What is the suspected injury and give the reason for not observing the typical deformity associated with this
injury? (ulnar nerve injury, reason for not observing typical--because its high ulnar nerve injury )
b) How would you manage this injury, if she had presented at 3 months? (NCS and EMG—if there is fribrillations
and MUAPs then wait for next 6 weeks, if not then go for surgery)
c) How would you manage this patient at this stage? (NCS and EMG—then manage accordingly, surgical
exploration and nerve graft or tendon transfer).
APRIL 2015
Q6)
a) What is the algorithm of nerve repair in an acute open nerve injury?
b) What are the indications for nerve allograft reconstruction and the mechanism of regeneration? (when there is
paucity of donor nerve graft)
c) What is the role of immunosuppression by agent FK506 in allograft nerve reconstruction? (immunosuppressant
and also augment neuroregeneration) The immunosuppressive protocol was initiated by the consulting
transplant nephrologist at the time of surgery and was discontinued at approximately 1 year or when the migrating
50
Tinel’s sign passed the distal anastomosis. The standard regimen consisted of basiliximab (Simulect)/(IL-2 receptor)
(days 0 and 5), tacrolimus (FK506), azathioprine (Imuran), and co-trimoxazole (Bactrim), whereas prednisone
reserve was not required in any of the patients
d) What is the advantage of processed acellular cadaveric nerve graft? (reduce antigenicity)
Pros - readily accessible, unlimited supply, bridge nerve gap, avoids donor site morbidity,
Cons – potential side effects of host immunosuppression
Oct, 2012
Q.4. An 18 year old boy sustained trauma to his right shoulder in a motor bike accident two months ago, He is
unable to abduct his shoulder and flex his elbow. Hand Function is preserved.
a) How will you evaluate this patient?
b) Give an outline of your treatment plan depending on the site of the lesion?
JUNE 25,2008PII
Q.14 A 28 year old right handed laborer sustained glass injury to the ulnar side of his right wrist 3 months ago. His
ulnar nerve was repaired in emergency room. There is no clinical evidence of recovery' of nerve at presentation
now.
a) How will you evaluate him and manage his nerve Injury?
b) What post-operative precautions will he have to observe?
MAR 2006, PII
Q.12 Enumerate the factors contributing to failure of a microsurgical vascular anastomosis.
April 23, 2014-P1
Q.9: A 17 year old girl with post infective scar over vertex visits your clinic and desires to get rid of scar by tissue
expansion.
a) What is the principle of tissue expansion and how is it done clinically?
51
b) What are the types of tissue expanders?
c) Name complications associated with use of tissue expanders and how to manage them?
MAR 2004, PII
15 A child presents with a large black birthmark on the forehead. His parents have been advised regarding the
management plan for this child, which is tissue expansion followed by excision and reconstruction of the
birthmark,
a. Name the likely changes in the tissues undergoing operation.
b. Are there any problems in tissue expansion?
SEP 2005, PII
Q.13 in free tissue transfer surgery;
a) What routine measures are undertaken to prevent/minimize vasoconstriction?
b) Name 3 drugs that can 'be used as prophylaxis against coagulation.
c) Give the dose and duration of usage. The route of administration and mechanism of action of each. What is the
no-reflow phenomenon?
April 23, 2014-P11
Q.11:
a) What are the local anesthetics agents commonly used?
b) What are the different ways of using local anesthetics clinically?
c) What is the mechanism of lignocaine? How it is metabolized? What is the safe dose? (For head and neck and
subcutaneous infiltration).
d) How do you reduce pain at the injection site?
e) What are toxic effects of local anesthetics and its treatment?
SEP 2003PII
52
Q.13 A patient aged 60 years is to undergo a skin graft, on a granulating wound on the dorsum of hand. A skin graft
is to be taken from the right thigh under regional anesthesia.
a. Name the nerves to be blocked for the above procedure.
b. Give the safe dose, duration of action and complications of Bupivacaine
MAR 2006, PI
Q.7 At the start of a minor operation an otherwise fit young man suffers a seizure almost immediately after an
injection of local anesthetic.
a) What are the two likely causes?
b) How would you manage such a patient?
Sept 2010
Q.20:
a) Enumerate the various local anesthetics and their uses in plastic surgery along with their toxic doses and
common complications.
b) What measures would you take to reduce the pain of local anesthetic administration?
MAR 2005 PII
Q 16
a) What are the factors which influence the results of nerve repair?
b) Enumerate the basic principles of repair of median nerve in the mid forearm
MAR 2005, PII
Q.15 An 8 year old boy presents to you with a large nevus of the right
temporoparietal area 8x12 cm. You decide to start his management by using tissue expanders prior to excision.
a) Where will you place the incision for the expander?
b) How would you know that the tissue has expanded sufficiently?
53
c) What are the likely complications
SEP 2005
Q.10
a) Mention four clinically useful ways of monitoring of free flaps post operatively.
b) What other modalities are available for monitoring free flaps?
c) Of these which is the most commonly used and why?
FEB 2007
Q.19:
a) What are the causes of failure of free flaps?
b) How can you salvage a failing free flap?
c) What factors will you consider in selecting an option in a patient with a failed free flap?
FEB 2007
Q.13: A young male with a history of shrapnel injury dividing completely median and ulnar nerve in the mid-
forearm 6 months ago with no evidence of recovery of either motor or sensory.
a) what techniques can be utilized for restoration of nerve function?
b) What are the donor sites available for nerve graft, give you choice with reasons.
c) What particular deformity would develop due to the paralysis of intrinsics and methods to correct them.
Describe your choice of procedure.
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Algorithm of nerve repair:
Degree of injury Degree of
recovery
Rate of recovery Tinel EMG Nerve
Conduction Studies
I Neuropraxia Complete Fast<4months ____ Fib
-
MUP’s
N
II Axonotmesis Complete Slow 1” per month (+) Advacnes + +
III Incomplete Slow 1” per month (+) Advances + +
IV Neuroma in
continuity
None None Stationary + -
V Neurotmesis None None Stationary + -
VI Mixed injury (I to
V)
mixed Variable Depends on
degree of
injury (I-IV)
+ +
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Tissue Expansion:
Basic principle:
o Incison planning and implant selection
o Implant and distal port positioning
o Implant inflation strategy and technique.
Physiology:
o Mechanical creep
o Biological creep
Types:
o On basis of port:
Expander with distal port
Expander with integrated port
Self inflating expander
o On basis of shape:
Round
Rectangular and
Cresent
Complication Management
Major
(when implant removal is
necessary)
Implant failure
Infection
Implant exposure
Flap ischemia
Antibiotic therapy
Expander removal
Minor Transient pain (during
expansion
Pain killer
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Seroma formation
Dog ear at donor site
Widening of scar
Aspiration/drainage
Correction
Scar revision
Local anesthetics:
Commonly used agents:
o Short duration
Procaine (ester)
Chloroprcaine (ester)
o Moderate duration
Lidocaine (amide)
Mepivacaine (amide)
Prilocaine (amide)
o Long duration
Bupivacaine (amide)
Etiodcaine (amide)
Mechanism of action: (lidocaine)
o Interacts with voltage gated Na+ channels in the nerve cell membrane and blocks the
transient increase in permeability of excitable membrane to Na+. This prevents the
generation and conduction of nerve impulses and produces reversible loss of sensation.
Metabolism:
o Esters undergo hydrolysis in plasma by pseudocholinesterase
o Amides (lidocaine) metabolized in the liver.
Safe dose:
o Lidocaine: with epinephrine is 7 mg/kg and without epi is 3 mg/kg body weight
Toxicity:
o CNS Symptoms Minor Signs/Symptoms
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Tongue and perioral numbness Parasthesias Restlessness Tinnitus Muscle fasciculations + tremors
o Major Signs/Symptoms Tonic-clonic seizures Global CNS depression Decreased level of consciousness Apnea
o Neurologic symptoms typically precede cardiovascular symptoms in lidocaine toxicity o Cardiovascular Symptoms
Early Signs: Hypertension and tachycardia Late Signs
Peripheral vasodilation + profound hypotension
Sinus bradycardia, AV blocs
Conduction defects (Prolonged PR, Prolonged QRS)
Ventricular dysrhythmias
Cardiac arrest o Cardiovascular symptoms typically present first in bupivacaine toxicity
Treatment of local anesthetic toxicity:
o Hyperventilation with ambu bag
o Face mask with using 100% oxygen
o Hypercarbia may crosses CNS toxicity
o If patient has a full stomach, an ETT should be placed as soon as possible to prevent
aspiration
o Hyperventailation may terminate the seizures, but it it does not, diazepam 0.1 mg /kg or
thiopental 2mg/kg, intraneurally is usually effective
o If hypotensive, then IV fluids, peripheral vasoconstriction or phenylephrine and
Trendelenburg position
o An inotropic agent (i.e dopamine) may also be required.
