Essentials of Plastic Surgery: Q&A Companion (eBook)

2.General Management of Complex Wounds

See Essentials of Plastic Surgery, third edition, pp. 12–20

BLOOD GLUCOSE CONTROL

1.A diabetic patient is scheduled to undergo abdominal wall reconstruction. Preoperative hemoglobin A1C is 12% and random blood glucose (RBG) level is 200 mg/dL. Which one of the following is correct?

A.A normal A1C should be 8.5 when expressed as a percentage of glycosylated hemoglobin.

B.The A1C represents the patient’s average glucose control over the previous 180 days.

C.Postoperative infection risk is significantly increased for this patient because the blood glucose level is higher than 180 mg/dL.

D.Tight blood glucose control (<70 mg/dL) during the perioperative period will reduce the postoperative mortality risk.

E.An elevated A1C level linearly correlates with an increased risk of surgical site infections.

PREOPERATIVE ASSESSMENT OF NUTRITION

2.When assessing a patient’s preoperative nutritional status before major surgery by monitoring blood albumin levels, which one of the following is correct?

A.The half-life of albumin is 3 days.

B.A preoperative value of 4.3 g/dL is outside the normal range.

C.Assessment is based on the “rule of fives.”

D.Severe malnutrition would be suggested by preoperative values less than 3.0 g/dL.

E.A low preoperative level is a strong predictor for postoperative mortality risk.

IMAGING IN COMPLEX WOUNDS

3.A 67-year-old smoker has exposed hardware after a wound breakdown over his tibial fracture. The hardware has been removed, but his wound is not progressing. His dorsalis pedis pulse is not palpable, and the posterior tibial pulse is weak. Which one of the following modalities is the most accurate and least harmful for imaging of this patient’s peripheral arterial disease status and leg vessel anatomy?

A.Magnetic resonance angiography (MRA)

B.Plain radiographs

C.Computerized tomography angiography (CTA)

D.Ultrasound

E.Contrast angiography

VASCULAR ULCER MANAGEMENT

4.After assessing a patient who is malnourished and has a punched-out ulcer on the lower lateral leg, you decide to perform an ankle-brachial pressure test, which shows a value of 0.4. What does this result suggest?

A.Normal lower limb vasculature.

B.Imminent ischemic gangrene is likely.

C.Critical stenosis is present that warrants further intervention.

D.Vessels are significantly calcified.

E.Predominantly venous disease.

TISSUE RECONSTRUCTION AND WOUND CLOSURE

5.What was the main limitation of the original reconstructive ladder concept?

A.It did not include free tissue transfer.

B.The concept could only be practiced by plastic surgeons.

C.It did not include dermal matrices or negative pressure therapy.

D.The reconstructive process was performed in a stepwise manner.

E.Primary closure was the first rung on the ladder.

NEGATIVE PRESSURE WOUND THERAPY

6.You are planning to temporize an abdominal wound with a negative pressure dressing after debridement. Which one of the following is correct regarding negative pressure wound therapy?

A.It increases local blood flow and granulation tissue production.

B.It reduces fluid exudate.

C.It is contraindicated in recently debrided wounds.

D.It can be useful for treating fistulas.

E.It reduces mitotic activity in the wound.

WOUND DEBRIDEMENT

7.A 47-year-old paraplegic patient presents with a grade 3 sacral pressure sore. Examination shows a 7 ᵡ 8 cm chronic wound with eschar, fibrinous exudate, and granulation in the wound bed. In order to optimize accuracy at the time of surgical debridement, which one of the following adjuncts would be most useful intraoperatively?

A.Quantitative tissue cultures

B.Frozen section biopsy

C.Iodine brown solution

D.Methylene blue dye

E.Indocyanine green dye

COMPLICATIONS OF RADIOTHERAPY

8.A 68-year-old male has undergone postsurgical radiotherapy to the right side of the neck and mandible for management of an intraoral squamous cell carcinoma (SCC). He now presents with symptoms of pain and swelling over the mandible and has reduced mouth opening. Examination shows bone exposed through the skin surface (sequestrum). Which one of the following would be the most useful for treatment of this clinical problem?

A.Hyperbaric oxygen

B.Transcutaneous oxygen tension

C.Stem cell therapy

D.Platelet-rich plasma

E.Tissue biopsy and cultures

SELECTION OF SKIN SUBSTITUTES

9.You are considering the use of a biologic skin substitute in a patient with a burn. Your patient is concerned about the use of tissues from animals and states that he would only consent to products that are purely synthetic or human derived. Which one of the following products is acceptable for use in this patient?

A.Biobrane

B.Apligraf

C.Transcyte

D.SurgiMend

E.AlloDerm

BIOLOGIC SKIN SUBSTITUTES

10.Which one of the following biologic dressings is a bilayer construct containing bovine collagen, human fibroblasts, and keratinocytes?

A.Matriderm

B.ReCell

C.Acelagraft

D.Epicel

E.Apligraf

Answers

BLOOD GLUCOSE CONTROL

1.A diabetic patient is scheduled to undergo abdominal wall reconstruction. Preoperative hemoglobin A1C is 12% and random blood glucose (RBG) level is 200 mg/dL. Which one of the following is correct?

C.Postoperative infection risk is significantly increased for this patient because the blood glucose level is higher than 180 mg/dL.

In patients with or without diabetes, perioperative hyperglycemia (>180 mg/dL) carries a significantly increased risk of postoperative wound infection.1

The hemoglobin A1C is a blood test used to assess the long-term control of blood glucose. Because hemoglobin molecules remain in the blood for 3 months, it is possible to gauge glucose control over a 120-day period (not 180 days) by measuring glycosylated hemoglobin levels. A normal hemoglobin A1C is around 6%. Tight blood glucose control with intensive insulin therapy and normoglycemia (<110 mg/dL) has shown a reduction in hospital deaths in some trials.2 However, where glucose control is <7 mg/dL, there is an increased risk of death in critically ill patients.3 Although postoperative hyperglycemia and undiagnosed diabetes increase the risk of surgical site infections, elevated hemoglobin A1C does not linearly correlate.4,5

REFERENCE

1.Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg 2013;257(1):8–14

2.Vanhorebeek I, Langouche L, Van den Berghe G. Tight blood glucose control: what is the evidence? Crit Care Med 2007;35(9, Suppl):S496–S502

3.Finfer S, Liu B, Chittock DR, et al; NICE-SUGAR Study Investigators. Hypoglycemia and risk of death in critically ill patients. N Engl J Med 2012;367(12):1108–1118

4.King JT Jr, Goulet JL, Perkal MF, Rosenthal RA. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann Surg 2011;253(1):158–165

5.Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS Jr. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001;22(10):607–612

PREOPERATIVE ASSESSMENT OF NUTRITION

2.When assessing a patient’s preoperative nutritional status before major surgery by monitoring blood albumin levels, which one of the following is correct?

E.A low preoperative level is a strong predictor for postoperative mortality risk.

Albumin can provide a useful indication of nutrition. Its half-life is 20 days, and a normal value is 3.6–5.4 g/dL. A value of 2.8–3.5 g/dL suggests mild malnutrition, 2.1–2.7 g/dL suggests moderate malnutrition, and less than 2.1 g/dL indicates severe malnutrition. A large study published in 1999 involving more than 50,000 patients showed that as preoperative albumin levels decreased, early postoperative mortality and morbidity increased exponentially.1 The authors concluded that albumin was a useful predictor of outcome in major surgical procedures.

Prealbumin, rather than albumin, has a half-life of 3 days and can be assessed by the rule of fives. A normal value is greater than 15 mg/dL, mild...