Review of Plastic Surgery – Donal W. Buck II

Necklift
289
28
Figure 28.6.  Subcutaneous facelift. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 208–215.)
$
%
Figure 28.7.  Subcutaneous flap with superficial muscular aponeurotic system (SMAS) plication. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.],
2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 208–215.)
Subgaleal
dissection
Subcutaneous
dissection, 4 cm
Subcutaneous tunnel
superior to arch
Only skin expected
to be removed is undermined
Subcutaneous dissection of neck from
mastoid to midline superficial to platysma

Rhytidectomy and Neck Rejuvenation
290
Figure 28.8.  Subcutaneous flap with loop sutures for minimal access cranial suspension (MACS) lift. SMAS, Superficial muscular
aponeurotic system. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 208–215.)
SMAS incision
Upper lateral
corner of SMAS
remains attached
to skin
Temporal branch,
facial nerve
Marginal mandibular
branch of facial nerve
Dissection from
beneath SMAS
over zygomaticus
major, thus releasing
restraint of investing
fascia
Figure 28.9.  Subcutaneous flap with superficial muscular
aponeurotic system (SMAS) excision (SMASectomy). (Reprinted
from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed.
Elsevier, 208–215.)

Necklift
291
28
Figure 28.10.  Superficial muscular aponeurotic system (SMAS) flap with skin attached (deep plane facelift). (Reprinted from Neligan, P.C.,
Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 208–215.)
$
Lateral SMASectomy
extends from tail of
parotid to lateral
canthus
Resection is at interface of
fixed and mobile SMAS.
Width of resection
determined by SMAS laxity
and desired debulking
Undermining posterior border
of platysma for advancement
to mastoid
%
Figure 28.11.  Profile view demonstrates the attributes of a youthful neck including
(1) a cervicomental angle of ~105 degrees; (2) a distinct inferior mandibular border;
(3) a slightly visible thyroid cartilage; and (4) a visible anterior border of the
sternocleidomastoid muscle. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic
Surgery, vol. 2, 3rd ed. Elsevier, 313–326.)
1
2
3
4

Rhytidectomy and Neck Rejuvenation
292
2. Techniques
• Liposuction
■ Preplatysmal fat removal with skin contraction
■ Ideal for young patients with good skin elasticity and
localized submental and submandibular fat
■ Avoid overcorrection.
■ Wear elastic compression garments postoperatively.
Figure 28.12.  Variations in platysma anatomy in the submental region. Type I, Interdigitation of the platysma muscle 1 to 2 cm posterior to
the mandibular symphysis. Type II, Interdigitation of the platysma muscles from mandibular symphysis to the thyroid cartilage. Type III, No
interdigitation of the platysma muscles. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed. Elsevier, 313–327.)
Type I
Occurs in 75% of cases (most common).
Demonstrates a limited decussation of
platysma muscles, extending 1 to 2 cm
below the mandibular symphysis.
Type II
Occurs in 15% of cases.
Demonstrates decussation of the
platysma from the mandibular
symphysis to the thyroid cartilage.
Type III
Occurs in 10% of cases.
Demonstrates no decussation
or interdigitations.
Figure 28.13.  Physical exam. The figure demonstrates pinching the soft tissue at rest and with muscle contraction to distinguish the
cervical bulk caused by preplatysmal fat from bulk caused by subplastysmal structures. Bulk due to subplastysmal structures “escapes”
from the pinch with contraction. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 231–242.)
Subcutaneous and subplatysmal
fat pinched
Subcutaneous fat only
• Suspension sutures
■ Create a permanent artificial ligament to correct the
neck deformities.
■ Long-term stability is questioned.
• Anterior/submental open neck lift
■ Uses a submental incision for open access to the neck
(see Figure 27.14)

Necklift
293
28
■ Lipectomy performed by direct excision or combination
of liposuction and direct excision
■ Platysmal banding treated with platysmaplasty
○ Midline plication,
○ Lateral plication, or
○ Transection
• Patients with severe skin laxity will require standard lower
facelift/necklift incisions, wide undermining, and skin
redraping or, in severe cases, direct excision in the midline
incorporating a Z plasty.
3. Complications
• Similar to those found following facelift
• Facial nerve injury for necklift most often involves the
marginal mandibular nerve.
Suggested Readings
Afifi, A.M., Djohan, R., 2013. Chapter 1: Anatomy of the head and neck. In:
Neligan, P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 3, 3rd ed. Elsevier,
pp. 1–22.
Marten, T.J., Elyassnia, D., 2013. Chapter 12: Secondary deformities and the
secondary facelift. In: Neligan, P.C., Warren, R.J. (Eds.), Plastic Surgery,
vol. 2, 3rd ed. Elsevier, pp. 277–312.
Mendelson, B., 2009. Chapter 6: Facelift anatomy, SMAS, retaining ligaments,
and facial spaces. In: Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.),
Aesthetic Plastic Surgery. Saunders, pp. 53–71.
Nahai, F., 2011. Chapter 50: Avoiding complications in facial aesthetic
surgery. In: Nahai, F. (Ed.), The Art of Aesthetic Surgery: Principles and
Techniques, 2nd ed. Quality Medical Publishing, pp. 1762–1792.
Thorne, C.H., 2007. Chapter 49: Facelift. In: Thorne, C.H. (Ed.), Grabb and
Smith’s Plastic Surgery, 6th ed. Elsevier, pp. 498–508.
Warren, R.J., 2013. Chapter 11.1: Facelift: principles. In: Neligan, P.C.,
Warren, R.J. (Eds.), Plastic Surgery, vol. 2, 3rd ed. Elsevier, pp. 184–207.
Warren, R.J., 2013. Chapter 11.2: Facelift: introduction to deep tissue
techniques. In: Neligan, P.C., Warren, R.J. (Eds.), Plastic Surgery, vol. 2,
3rd ed. Elsevier, pp. 208–215.
Weinfeld, A.B., Nahai, F., 2009. Chapter 20: Deep plane procedures in the
neck. In: Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic
Surgery. Saunders, pp. 231–242.
Zins, J.E., Morrison, C.M., Langevin, C.J., 2013. Chapter 13: Neck
rejuvenation. In: Neligan, P.C., Warren, R.J. (Eds.), Plastic Surgery, vol. 2,
3rd ed. Elsevier, pp. 313–326.
Figure 28.14.  Location of submental incision 2 mm posterior to the submental crease. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L.
[Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 231–242.)
Submental crease
Submental incision
0.5 cm posterior
to crease
3-5 cm long

Body Contouring and
Suction-Assisted Lipectomy
Chapter
29 
1. Body contouring
• Trunk: Removal of excess skin and subcutaneous tissue,
often after massive weight loss
■ Degree of skin excess, fatty excess, and muscular
diastasis assists with selection of appropriate procedure.
○ Suction-assisted lipectomy: Minimal skin excess,
moderate subcutaneous adiposity, no diastasis
○ Abdominoplasty: Excess anterior abdominal skin and
subcutaneous tissue, with appreciable diastasis. Lower
incision placed at least 5 to 7 cm superior to vulvar
commissure
◆ Miniabdominoplasty: Short scar, often no
transposition of umbilicus, minimal diastasis
◆ Full abdominoplasty: Full transverse incision;
requires umbilical transposition, and possible
diastasis repair
◆ Fleur-de-lis: Excess skin in both transverse and
vertical dimensions. By adding vertical excision,
can improve vertical excess
➔ In general, perform the vertical excision first.
◆ Lipoabdominoplasty: Combination of full
abdominoplasty and liposuction
○ Circumferential body lift/lower body lift: Excess skin
and subcutaneous tissue circumferentially with ptosis
of gluteal soft tissues
◆ Can perform gluteal lift/autoaugmentation with
gluteal artery flaps
○ Panniculectomy: Removal of abdominal pannus only
to achieve improvements in hygiene, skin irritation,
moisture
■ Complications: Reportedly occur in 15% to 25% of
patients (50% for active smokers)
○ Pulmonary embolism: Abdominoplasty is the
procedure most frequently associated with
postoperative mortality.
○ Skin necrosis: Most commonly occurs in
supraumbilical region
○ Seroma: Most common complication after
lipoabdominoplasty and with patients following
massive weight loss
○ Skin dehiscence: Most common complication when
combining skin resection procedures
◆ Often occurs late in massive-weight-loss patients
secondary to seroma; treatment is nutrition
improvement.
○ Bulge: Most commonly occurs superior to umbilicus
because of failure to plicate supraumbilical rectus
fascia during diastasis repair
◆ Men are more likely to have a wide upper rectus
muscle diastasis, whereas women are more likely
to have a lower rectus muscle diastasis.
○ Encephalopathy: Most commonly associated with
thiamine deficiency (Wernicke-Korsakoff
encephalopathy) in the massive-weight-loss patient
◆ Treatment: Intravenous thiamine supplementation,
100 mg daily; increase to 100 mg every 8 hours as
needed until resolution of symptoms.
○ Pain/numbness (see Figure 29.1)
◆ Lateral femoral cutaneous n.: Numbness/pain
along anterolateral thigh (see Figure 29.2)
➔ Danger zone: Passes through inguinal ligament
to the thigh 1 cm medial to anteriosuperior iliac
spine
◆ Iliohypogastric n.: Numbness/pain along the
inguinal crease and lateral gluteal region
➔ Danger zone: Lateral lower abdominal
transverse incisions near inguinal ligament
◆ Ilioinguinal n.: Numbness along the medial thigh
and scrotum/labia
➔ Danger zone: Lateral lower abdominal
transverse incisions near inguinal ligament
◆ Intercostal n.: Numbness along abdominal/flank
dermatomes T5 to L1
➔ Danger zone: Anterior intercostal nerves pass
between the internal oblique and the transversus
abdominis muscle, enter the rectus abdominis
m., and travel to the overlying fascia and skin.
Lateral branches penetrate the intercostal
muscles at the midaxillary line and travel within
the subcutaneous tissue.

Body Contouring and Suction-Assisted Lipectomy
295
29
Figure 29.1.  Abdominal nerves. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery, 1st ed. Elsevier, 79–90.)
Latissimus dorsi
Lateral cutaneous branches
of intercostal nerve
Lateral cutaneous
branches
Anterior lamina of
rectus sheath
Transversus abdominis
Anterior cutaneous
branch
Rectus abdominis (cut)
Arcuate line
Transversalis fascia
Serratus anterior
Intercostal nerve
10th intercostal nerve
11th intercostal nerve
Subcostal nerve
Iliohypogastric nerve
Ilio-inguinal nerve
External oblique (cut)
External oblique
Internal oblique (cut)
Inguinal ligament
Round ligament of
uterus
Figure 29.2.  Lateral femoral cutaneous nerve. (Reprinted from Waldman, S.D.,
2004. Lateral femoral cutaneous nerve block. In: Atlas of Interventional Pain
Management, 2nd ed. Saunders, Philadelphia, 457.)

Body Contouring and Suction-Assisted Lipectomy
296
○ Recurrence
◆ Can be exacerbated by further weight loss
➔ Best to perform brachioplasty even if still above
ideal body weight rather than encourage
additional weight loss
○ Nerve injury (occurs in up to 5%)
◆ Medial antebrachial cutaneous n.
➔ Arises from medial cord
➔ Runs in close proximity to the intramuscular
septum and penetrates fascia at 14 cm proximal
to the medial epicondyle; especially at risk of
injury here
 Therefore, always identify nerve at this level
and leave fat on deep fascia in this area.
➔ Leads to paresthesia of upper arm and anterior
proximal forearm
➔ Treat with hand therapy and local massage,
gabapentin; improves with time
◆ Medial brachial cutaneous n.
➔ Arises from medial cord
➔ Runs with basilic vein, sends out branches at
7 cm and 15 cm proximal to the medial
epicondyle
• Upper extremity/brachioplasty: Removal of excess skin and
adipose tissue of the upper arm (see Figure 29.3)
■ Critical anatomy
○ Ptosis of upper arm skin is secondary to relaxation of
the longitudinal fascial sling, which extends from
clavipectoral and axillary fascia.
■ Key technical point
○ Re-anchoring the posteromedial upper arm soft tissue
to axillary fascia with nonabsorbable suture
■ Complications: Reportedly occur in 25% to 50% of
patients
○ Hypertrophic scarring (occurs in up to 40%): Most
frequent complication of brachioplasty; often caused
by tension, tissue mismatch, poor nutrition
◆ Treatment: Conservative including compression,
silicone sheeting, steroid injection
○ Wound healing complications: Seroma, wound
dehiscence
○ Under-resection
○ Standing cone deformities
○ Lymphedema
Figure 29.3.  A, Sagittal view of arm anatomy.
$
Cephalic vein
Superficial fascia
Superficial fascia
Brachialis
Biceps brachii
Radial nerve
Triceps brachii
Lateral
Medial
Medial
brachial
cutaneous
nerve
Posterior brachial cutaneous nerve
Medial
antebrachial
cutaneous
nerve
Brachial artery
Anterior brachial cutaneous nerve
Median nerve
Ulnar nerve
Deep fascia
Basilic vein

Body Contouring and Suction-Assisted Lipectomy
297
29
%
Cephalic vein
Superficial fascia
Superficial fascia
Brachialis
Brachioradialis
Biceps brachii
Radial nerve
Triceps brachii
Lateral
Medial
Medial
antebrachial
cutaneous
nerve
Brachial artery
Median nerve
Ulnar nerve
Deep fascia
Basilic vein
Figure 29.3., cont’d  B, Distal portion of arm, highlighting nerves, arteries, veins, and fascial planes at this level. (Reprinted from Capella, J.F.,
2013. In: Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 617–633.)
➔ Injury leads to numbness and paresthesias of
the medial upper arm.
• Lower extremity/medial thighlift
■ Critical anatomy
○ Femoral triangle contains a high concentration of
lymphatics draining the leg as well as the femoral
neurovascular bundle (see Figure 29.4).
◆ Injury can lead to bleeding, bruising, lymphedema,
leg weakness, pain.
◆ Borders: Inguinal ligament, adductor longus m.,
sartorius m.
○ Colles’ fascia: Deep layer of the superficial perineal
fascia that is thin, aponeurotic, and has considerable
strength. It is continuous with the Scarpa’s fascia of
the abdomen anteriorly.
◆ Helps define the perineal/thigh crease and lies deep
to the subcutaneous adipose tissue of the perineum
➔ Posteriorly fuses with urogenital diaphragm
◆ High in elastin content, which gives it a yellow
hue, thereby distinguishing it from the muscular
fascia, which is white
■ Key technical points
○ Re-anchoring the medial thigh soft tissue to the
Colles’ fascia with nonabsorbable suture (analagous
to anchoring medial arm tissues to axillary fascia in
brachioplasty)
○ Near femoral triangle, make depth of incision only to
the subcutaneous layer to avoid injury to its contents.
○ With severe soft-tissue redundancy, can add a vertical
or longitudinal component to the excision.
■ Complications: Similar to brachioplasty
○ Seroma (occurs in 4% to 20%)
○ Hypertrophic scarring
○ Recurrence
○ Labial spreading
2. Suction-assisted lipectomy
• Indications: Removal of excess adipose tissue, often with
minimal excess skin
■ Mesotherapy: Subcutaneous injection of medications as
an alternative to liposuction; not approved by the FDA
■ Can perform reduction mammaplasty in select female
patients with liposuction alone (50% of the female breast
is adipose tissue)
• Wetting solutions: Combination of saline, lidocaine, and
epinephrine used to assist with anesthesia, hemostasis, and
emulsification of adipocytes. Differ based on ratio of
infiltrate volume to aspirate volume. In general, the
combination of infiltrate volume and intravenous volume
should be twice the aspirate volume.
■ Dry: No wetting solution
○ Greatest blood loss in aspirate

Body Contouring and Suction-Assisted Lipectomy
298
■ Surface irregularities/dimpling: Commonly occur
through aggressive superficial suctioning, use of
large cannulas, and use of a single port site without
cross-tunneling
○ Common with liposuction to buttocks due to fibrous
septae
■ Seroma: Most common complication of
lipoabdominoplasty; more common with ultrasound-
assisted liposuction than traditional suction lipectomy
■ Thermal burns: More common with ultrasound-assisted
liposuction
■ Fat embolism: Develop petechial rash and respiratory
failure. Treatment: Supportive
■ Supraventricular tachycardia develops after accidental
intravascular injection of wetting solution. Treatment:
Discontinue infiltration, check composition of the
infiltrate
Suggested Readings
Buck, D.W., II, Mustoe, T.A., 2010. An evidence-based approach to
abdominoplasty. Plast. Reconstr. Surg. 126 (6), 2189–2195.
Capella, J.F., Trovato, J.M., Woehrle, S., 2013. Chapter 29: Upper limb
contouring. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 617–633.
Cruz-Korchin, N., Korchin, L., Gonzalez-Keelan, C., et al., 2002.
Macromastia: how much of it is fat? Plast. Reconstr. Surg. 109, 64–68.
Friedland, J.A., Maffi, T.R., 2008. MOC-PS(SM) CME article: abdominoplasty.
Plast. Reconstr. Surg. 121 (Suppl. 4), 1–11.
Gingrass, M.K., 2007. Chapter 52: Liposuction. In: Thorne, C.H., Beasley,
R.W., Aston, S.J., et al. (Eds.), Grabb and Smith’s Plastic Surgery, 6th ed.
Lippincott Williams & Wilkins, Philadelphia, pp. 533–541.
Haeck, P.C., Swanson, J.A., Gutowski, K.A., et al., 2009. Evidence-based
patient safety advisory: liposuction. Plast. Reconstr. Surg. 124 (Suppl. 4),
28S–44S.
Iverson, R.E., Pao, V.S., 2008. MOC-PS(SM) CME article: liposuction. Plast.
Reconstr. Surg. 121 (Suppl. 4), 1–11.
Klein, J.A., 1990. Tumescent technique for regional anesthesia permits
lidocaine doses of 35 mg/kg for liposuction. J. Dermatol. Surg. Oncol. 16,
248–263.
Knoetgen, J., III, Moran, S.L., 2006. Long-term outcomes and complications
associated with brachioplasty: a retrospective review and cadaveric study.
Plast. Reconstr. Surg. 117 (7), 2219–2223.
Landfair, A.S., Rubin, J.P., 2011. Chapter 75: Applied anatomy in body
contouring. In: Nahai, F. (Ed.), The Art of Aesthetic Surgery: Principles and
Techniques, vol. 3. Quality Medical Publishing, St. Louis, pp. 2679–2708.
Matarasso, A., 2000. Suction mammaplasty: the use of suction lipectomy to
reduce large breasts. Plast. Reconstr. Surg. 105, 2604–2607.
Michaels, J., 5th, Coon, D., Rubin, J.P., 2011. Complications in postbariatric
body contouring: postoperative management and treatment. Plast. Reconstr.
Surg. 127 (4), 1693–1700.
Neligan, P.C., Buck, D.W. (Eds.), 2013. Chapter 4: Abdominoplasty. In: Core
Procedures in Plastic Surgery, 1st ed. Elsevier, pp. 79–90.
Ostad, A., Kageyama, N., Moy, R.L., 1996. Tumescent anesthesia with a
lidocaine dose of 55 mg/kg is safe. Dermatol. Surg. 22, 921–927.
Rubin, J.P. (Ed.), 2013. Body Countouring and Liposuction. Elsevier,
pp. 1–603.
Schuenke, M., Schulte, E., Schumacher, U., et al., 2006. Atlas of Anatomy:
General Anatomy and Musculoskeletal System. Thieme, New York.
Serletti, J.M., 2009. Chapter 5: Chest, abdomen, groin, and back. In: Wei,
F.C., Mardini, S. (Eds.), Flaps and Reconstructive Surgery. Elsevier, pp. 39–49.
Seruya, M., Baker, S.B., 2008. MOC-PS(SM) CME Article: venous
thromboembolism prophylaxis in plastic surgery patients. Plast. Reconstr.
Surg. 122 (Suppl. 3), 1–9.
Shermak, M.A. (Ed.), 2011. Body Contouring. McGraw-Hill Professional,
New York, pp. 1–304.
Shermak, M.A., 2012. Body contouring. Plast. Reconstr. Surg. 129 (6),
963e–978e.
Waldman, S.D. (Ed.), 2009. Chapter 67: The lateral femoral cutaneous nerve.
In: Pain Review. Saunders, p. 123.
Wells, J.H., Hurvitz, K.A., 2011. An evidence-based approach to liposuction.
Plast. Reconstr. Surg. 127 (2), 949–954.
■ Wet: 100 to 300 mL of infiltrate per area, regardless of
amount of aspirate
○ 25% blood loss in aspirate
■ Superwet: 1:1 ratio of infiltrate volume to aspirate volume
○ 1% to 4% blood loss in aspirate
○ Approximately 70% of infiltrate remains in the body
after superwet liposuction.
■ Tumescent: 2 to 3:1 ratio of infiltrate volume to aspirate
volume
○ Lowest blood loss in aspirate (1%)
○ Maximum safe dose of lidocaine: 35 mg/kg (doses up
to 55 mg/kg have been reported)
• Complications
■ Neuropraxia: Motor weakness after liposuction
○ Treatment: Reassurance with observation; most
neurapraxic injuries should resolve within 3 to 4
months.
■ Pulmonary embolism: Most common cause of death
following liposuction
○ Risk factors: Increased tumescent infiltrate volume,
multiple combined procedures, large-volume aspirate
(defined as >5 L by American Society of Plastic
Surgeons Committee on Patient Safety)
Figure 29.4.  Femoral triangle with femoral artery, vein, and nerve
with course of saphenous vein. (Reprinted from Serletti, J.M., 2009. In:
Wei, F.C., Mardini, S. [Eds.], Flaps and Reconstructive Surgery. Elsevier, 39–49.)
Anterior
superior
iliac spine
Inguinal
ligament
Lateral
cutaneous
nerve of thigh
Superficial
circumflex
iliac artery
Femoral nerve
artery vein
Profunda
femoris artery
Sartorius
Rectus femoris
Iliotibial tract
Fascia iliaca
and iliacus
Deep circumflex
iliac artery
Femoral ring
Lacunar
ligament
Pectineus and
pectinus fascia
Pubic
tubercle
Obturator nerve,
anterior division
1st perforating
artery
Adductor
longus
Gracilis
Great saphenous vein
Intermediate and
medial cutaneous
nerves of thigh

Injectables, Skin Resurfacing,
Lasers, and Hair Restoration
Chapter
30 
Injectables
1. Substances that are injected into the dermis or subcutaneous
tissue to alter facial shape, appearance, and/or aesthetics
• There is no ideal injectable and each carries its own
individual risk/benefit profile.
• Do not inject any injectables obtained by a patient from
any other location than your office.
2. General complications of injectables
• Inadvertent arterial injection: Immediately stop the
injection and attempt to aspirate the substance. Can reduce
risk by injecting slowly, using a small needle
• Inadvertent venous injection: Treatment is conservative
and includes massage, warm compresses, and
nitroglycerine patch.
• Inadvertent placement of injectable: If the patient
develops problems, can try to debulk the filler (i.e.,
hyaluronidase)
3. Types of injectables (see Table 30.1)
• Hyaluronic acid
■ Synthetic compound used to “fill” soft tissues (i.e., deep
rhytids, etc.)
○ Nasolabial fold, perioral rhytids: Inject into
subdermal space
○ Tear-trough deformity: Inject subperiosteally
■ Example products
○ Juvederm
○ Restylane
○ Perlane
■ Reversible with hyaluronidase
• Botulinum toxin A (botulinum toxin type-A cosmetic,
Dysport)
■ Chemodenervation
○ Mechanism of action: Inhibition of acetylcholine
release at the neuromuscular junction
○ Useful for dynamic rhytids
■ FDA approved for glabella rhytids and crow’s feet
○ May be used off-label for other sites legally but
cannot be advertised for these off-label uses
■ Onset of action: 24 to 72 hours, but may take up to 2
weeks for maximum effect
■ Duration of action: 3 to 4 months
■ Example products
○ Botox cosmetic
○ Dysport
◆ Cannot be used in patients with milk allergy
■ Potentiating medications
○ Penicillamine, quinine, calcium-channel blockers, and
aminoglycosides
■ Common uses
○ Glabellar rhytids: Chemodenervation of the
corrugators
○ Crow’s feet: Chemodenervation of the lateral
orbicularis oculi
◆ Can lead to lateral brow elevation due to
unopposed action of the frontalis m.
○ Bunny lines: Chemodenervation of the levator labii
superioris alaeque nasi and nasalis
○ Forehead rhytids: Chemodenervation of frontalis m.
◆ Hyperactive frontalis m. can mask eyelid ptosis;
thus, chemodenervation of the frontalis can lead to
upper eyelid ptosis.
➔ Treatment includes α-adrenergic eyedrops (e.g.,
Iopidine), which causes stimulation of Mueller’s
m. and elevation of the upper eyelid by 2 mm.
○ Horizontal nasal lines: Chemodenervation of the
procerus m.
■ Complications
○ Unexpected brow position changes (elevation or
ptosis)
◆ Depends on which muscles are denervated
◆ Elevators of the medial brow: Orbicularis oculi,
corrugator supercilii, depressor supercilii and
procerus
◆ Elevators of the lateral brow: Frontalis
○ Upper eyelid ptosis
◆ Diffusion of drug through the orbital septum to
the levator m. (most common), which usually
occurs with primary treatment to the glabellar
region
◆ Chemodenervation of hyperactive frontalis m.
• Botulinum toxin type B
■ FDA approval for treatment of cervical dystonia and
hemifacial spasm

Injectables, Skin Resurfacing, Lasers, and Hair Restoration
300
Table 30.1  Common Facial Fillers Currently Available for Use in Soft-Tissue Augmentation
FILLER
TYPE
NAME
(MANUFACTURER)
INDICATION
DURABILITY
ADVANTAGES
DISADVANTAGES
MARKET
STATUS
Autologous
products
Viable fat
Deep defects
Variable;
months to
years
Abundant supply,
safe, inexpensive
Donor site morbidity,
variable reproducibility,
requires processing
No FDA/EEA
approval
required
Autologous
collagen/
autolagen
Collagenesis, Beverly,
MA; Isolagen, Exton, PA
Moderate to deep
defects
Months to
years;
processed from
excised skin
Can be stored up
to 6 months, safe
Donor morbidity, painful,
costly
FDA
approved/
CE mark
Bovine
collagens
Zyderm 1 (3.5% dermal
collagen) (INAMED,
Santa Barbara, CA)
Superficial defects,
fine lines, acne scars
2 to 4 months
Safe, reliable,
contains
lidocaine, ease of
administration
Allergic reaction in 1% to
3%, short-term results,
requires skin testing
before use, reactivation
of herpes is possible
with lip injections
FDA
approved/
CE mark
Zyderm 2 (6.5%
collagen) (INAMED,
Santa Barbara, CA)
Moderate defects,
deeper acne scars,
lip augmentation
2 to 6 months
Same as Zyderm
1
Same as Zyderm 1
FDA
approved/
CE mark
Zyplast (3.5% cross-
linked collagen)
(INAMED, Santa
Barbara, CA)
Deep defects, lip
augmentation
2 to 6 months
Same as Zyderm
1, more viscous
and resistant to
degradation
Can cause skin necrosis
if used in glabella,
allergies in 3%, requires
skin testing
FDA
approved/
CE mark
Cadaveric
collagens
AlloDerm (acellular
human dermis; comes
in sheets of varying
sizes) (LifeCell,
Branchburg, NJ)
Deep wrinkles or
scars, lip
augmentation
6 to 12
months
Safe, no allergy
testing required
Expensive, surgically
implanted, often causes
temporary swelling,
occasionally palpable,
shrinkage with time
FDA
approved/
CE mark
Cymetra (micronized,
injectable form of
AlloDerm) (LifeCell,
Branchburg, NJ)
Deep wrinkles or
scars, lip
augmentation
3 to 6 months
Safe, no allergy
testing required,
contains lidocaine
Can cause skin necrosis
if used in glabella,
costly, often clumps
within needle
FDA
approved/
CE mark
Cell-
cultured
collagen
Cosmoderm (35 mg/mL
collagen) (INAMED,
Santa Barbara, CA)
Superficial defects,
shallow wrinkles and
acne scars
3 to 4 months
Safe, no allergy
testing required,
contains lidocaine
Short-term results, most
common side effects
include cold symptoms
(4%), flu symptoms (2%)
FDA
approved/
CE mark
Cosmoplast (35 mg/mL
cross-linked collagen)
(INAMED, Santa
Barbara, CA)
Deeper defects and
wrinkles, lip
augmentation
3 to 4 months
Same as
Cosmoderm
Same as Cosmoderm
FDA
approved/
CE mark
Avian-
derived
hyaluronic
acids
Hylaform gel (INAMED,
Santa Barbara, CA)
Moderate defects, lip
augmentation
3 to 4 months
Safe, reliable, no
allergy testing
required
Short-term results,
immunologic reactions in
patient allergic to avian
products (eggs)
FDA
approved/
CE mark
Hylaform Plus (INAMED,
Santa Barbara, CA)
Moderate to deeper
defects, facial
wrinkles, and folds.
3 to 4 months
Same as hylaform
gel
Same as hylaform gel,
superficial injection may
lead to skin discoloration
FDA
approved/
CE mark
Bacterial-
cultured
hyaluronic
acids
Restylane/Restylane
Fine (Medicis,
Scottsdale, AZ)
Superficial (Restylane
Fine)-to-moderate
defects, deeper
wrinkle reduction,
nasolabial folds,
glabellar creases, lip
augmentation
6 to 12
months
Safe, reliable,
predictable
results, no allergy
testing required,
longer lasting
than bovine
collagens
Rare immunologic
reactions, higher
incidence of bruising,
pain, and postprocedure
swelling vs. bovine
collagens, higher cost
FDA
approved/
CE mark
Perlane (Medicis,
Montreal, Canada)
Deeper defects,
shaping facial
contours, lip
augmentation
6 to 12
months
Same as
Restylane
Same as Restylane
FDA
approved/
CE mark
Captique (INAMED,
Santa Barbara, CA)
Superficial defects,
fine lines and
wrinkles
3 to 6 months
Safe, no allergy
testing required,
similar to
Restylane
Relatively new product,
short-term results
FDA
approved/
CE mark
Juvederm 18, 24, 30
(L.E.A. Derm, Paris)
Superficial (18),
moderate (24), and
deep (30) defects
3 to 6 months
Safe, predictable
results, no allergy
testing needed
Short-term results, rare
immunologic reactions,
relatively new product
FDA
approved
Continued

Injectables
301
30
FILLER
TYPE
NAME
(MANUFACTURER)
INDICATION
DURABILITY
ADVANTAGES
DISADVANTAGES
MARKET
STATUS
Synthetics
Sculptra (poly-L-lactic
acid microparticles)
(Dermik Laboratories,
Berwyn, PA)
Deep defects
1 to 2 years
Long-term results,
safe
Rare, foreign body
reaction, limited U.S.
results/studies
Approved
for
lipoatrophy;
off-label for
cosmetic
purposes/CE
mark
Radiesse (calcium
hyodroxyapatite
microspheres) (Bioform
Medical, Franksville, WI)
Deep defects,
nasolabial folds,
vertical lip lines,
acne scars,
marionette lines,
volume restoration
around cheeks
1 to 2 years
Long-term results,
no allergy testing
required, no
concern for
antigenic or
inflammatory
reactions
Can rarely develop
nodules if injected
superficially
FDA
approved/
CE mark
Artecoll/ArteFill
(polymethylmethacrylate
microspheres in 3.5%
bovine collagen and
0.3% lidocaine) (Artes
Medical, San Diego, CA)
Deep defects,
glabella, nasolabial
folds
Permanent
after nearly
50% resorption
Unrivaled
longevity, probably
safe, but reports
of persistent
erythema at
injection site
Palpable if placed
superficially or
excessively; thus, avoid
injecting into the lips
and areas with thin
overlying skin; requires
allergy testing
Preliminary
FDA
approval for
cosmetic
purposes/CE
mark
Reviderm Intra (dextran
beads in a hylan gel)
(Rofil Medical
International, Breda,
The Netherlands)
Deep defects, lip
augmentation
Months to
years
Long-term results,
safe
Postprocedural swelling,
relatively new product to
U.S.
Not FDA
approved/
CE mark
Silicone/Silikon-1000
(liquid silicone) (Alcon
Laboratories, Fort Worth,
TX)
Deep defects, lip
augmentation
Permanent
Permanent, safe,
long clinical
experience
Migration, foreign body
reactions, poor
reputation
Off-label for
cosmetic
purposes
Endoplast 50 (elastin
and collagen)
(Laboratories Filorgra,
Paris)
Deep defects, lip
augmentation
12 months
Long-term results
Allergy tests required,
limited experience
Not FDA
approved/
CE mark
Bio-Alcamid (96% water,
4% polyalkylimide) (Pur
Medical Corp, Toronto,
Canada)
Deep defects
Permanent
Long-term results,
removable, no
allergy testing
required,
biocompatible
Limited experience,
inflammatory reactions,
infectious complications,
migration
FDA
approved/
CE mark for
HIV
lipoatrophy
Aquamid (polyacrylamide
hydrogel) (Contura
International)
Deep defects, lip
augmentation
Permanent
Long-term results,
compound
plasticity
High rate of granuloma
formation, infectious
complications
Not FDA
approved/
CE mark
Adapted from Johl, S.S., 2006. Curr. Opin. Ophthalmol. 17 (5), 471–479; Murray, C.A., Zloty, D., Warshawski, L., 2005. Dermatol. Clin. 23,
343–363; Broder, K.W., Cohen, S.R., 2006. Plast. Reconstr. Surg. 118 (Suppl. 3), 7S–14S; Eppley, B.L., Dadvand, B., 2006. Plast. Reconstr.
Surg. 118 (4), 98e–106e; Sengelmann, R.D., Tull, S. Dermal Fillers. Available at:
CE, Certification; EEA, European Economic Area; FDA, Food and Drug Administration; HIV, human-immunodeficiency virus.
Table 30.1  Common Facial Fillers Currently Available for Use in Soft-Tissue Augmentation—cont’d

Injectables, Skin Resurfacing, Lasers, and Hair Restoration
302
○ Recommended to begin treatment starting 1 to 2 days
before resurfacing and continue until
reepithelialization completed
■ Acyclovir can be used after resurfacing as treatment for
lesions to reduce the duration of the outbreak.
3. Peels: Use of a chemical substance to damage skin and result
in resurfacing; can result in hypo- or hyperpigmentation (see
Table 30.2)
• Glycolic acid peel
■ Light peel
• Tricyclic acid (TCA) peel
■ Neutralized within the superficial dermis
■ Depth of penetration can vary (light, medium, or deep;
see Figure 30.1), depending on mixture.
• Jessner’s solution
■ Light peel
■ Often used as a preparation for a TCA peel
■ Ingredients: Resorcinol USP, salicylic acid USP, and
lactic acid USP; 14% each in ethanol USP
• Phenol peel
■ Deep peel
○ Penetrates into the reticular dermis (deeper than TCA
peels)
○ Liquid soap can be used to decrease depth of peel
■ Disadvantages: Longer recovery time because of depth,
requires cardiac monitoring because of rare risk of
arrhythmia at application
■ Comparison with toxin A
○ Acidic (more painful on injection), stable as a liquid,
longer shelf life, shorter duration of action, faster
onset, greater radius of diffusion
■ Can be used if patient develops antibodies to Botox
cosmetic
■ Example products
○ Myobloc
• Bovine collagen
■ Example products
○ Zyderm I and II, Zyplast
■ Approximately 3% of patients will exhibit
hypersensitivity reactions.
○ Must test skin 4 weeks before injecting
• Poly-L-lactic acid
■ FDA approved for human-immunodeficiency virus
(HIV) lipoatrophy
■ Injected subcutaneously in the cheek, submuscularly in
the orbital region, and subperiosteally in the temples
region
■ Example products
○ Sculptra
■ Patients require multiple injections every 4 to 6 weeks
for several months.
■ Advantages: Results may last for more than 2 years.
■ Disadvantages: Can result in nodule formation in
dynamic muscles of the face (especially the lip and eye)
• Fat grafting
■ “Autologous filler”
■ Advantages: No risk of hypersensitivity
■ Disadvantages: Requires a donor site (harvest of
adipocytes), with processing, before injection; resorption;
unpredictable graft survival; longer recovery time
■ Method
○ Aspiration
○ Sedimentation
◆ Balanced centrifugation
◆ Gravity (optimal but lengthy)
○ Injection into the deep dermis
◆ Small amount of fat per pass
■ Optimizing survival
○ Avoid: Large canula aspiration, filtration, rinsing,
straining, or drying
Chemical and Mechanical Skin Resurfacing
1. Use of chemical or mechanical methods to damage superficial
skin (epidermis and superficial dermis) to create
inflammation that leads to predictable healing, resulting in
skin tightening and improved skin-surface appearance
2. Pretreatment considerations
• Personal history of perioral herpetic lesions
■ Recommended to pretreat with Acyclovir (valacyclovir
or famciclovir) to reduce risk of posttreatment outbreak
○ Estimated 50% likelihood of outbreak without
pretreatment
Table 30.2  Classification of Ablative Procedures
by Depth
CLASSIFICATION
RESURFACING
PROCEDURES
DEPTH OF
ABLATION
Superficial
α- or β-hydroxy acid
chemical peels (salicylic
acid, 10% to 70% glycolic
acid, 10% to 25%
trichloracetic acid [10% to
35%]), microdermabrasion
<60 µm (stratum
granulosum to
immediately
above superficial
papillary dermis)
Jessner’s solution (lactic acid, 14 mL; salicylic acid, 14 g;
resorcinol, 14 g)
Medium
Jessner’s solution+35%
TCA or 70% glycolic acid
60 to 450 µm
(papillary dermis
to upper reticular
dermis)
Phenol 88% (full strength)
Dermabrasion
Laser and plasma resurfacing, depending on fluence and number
of passes
Deep
Baker-Gordon phenol peel
450 to
800 µm (up
to midreticular
dermis)
Dermabrasion
CO2 laser resurfacing, depending on fluence and number of passes
Adapted from Matarasso, S.L., Glogau, R.G., 1991. Chemical face
peels. Dermatol. Clin. 9, 131–150.
TCA, tricyclic acid.

Chemical and Mechanical Skin Resurfacing
303
30
4. Dermabrasion
• Mechanical removal of epithelium for skin resurfacing
• Depth determined by clinical endpoints encountered
during the treatment process
■ Epithelium removed first
■ Dermal-epidermal junction characterized by smooth
texture and no bleeding
■ Superficial papillary dermis characterized by sparse,
punctate bleeding
■ Papillary dermis characterized by coarse texture with
greater bleeding
■ Superficial reticular dermis is characterized by brisk,
confluent bleeding on a coarse-tissue background.
○ This is the preferred endpoint.
○ Further dermabrasion beyond this level can lead to
permanent scarring.
• Although reepithelialization typically occurs within 7 to 10
days following dermabrasion, erythema may persist for as
long as 6 weeks after treatment.
• Disadvantages: Longer recovery, potential for permanent
scarring
5. Lasers
• Light amplification by stimulated emission of radiation
• Use of light to generate heat-induced injury of the skin,
leading to inflammation and repair, resulting in skin
rejuvenation/tightening, depigmentation, and/or hair
removal
■ Ablative: Causes epidermal vaporization to create
intended effect of collagen remodeling within the dermis
■ Nonablative: Selectively injures the dermis without
injuring the epidermis
• Posttreatment erythema following laser resurfacing can be
treated with ascorbic acid application.
■ Erythema is more severe when a CO2 laser is used,
compared to a fractionated CO2 laser or the
erbium:yttrium-aluminum-garnet (Er:YAG) laser.
• Hyperpigmentation is the most common side effect of laser
resurfacing and is more common in patients with darker
skin.
■ Treat with hydroquinone and Tretinoin.
• Type of laser wavelength selected is based on depth and
target chromophore properties (see Table 30.3).
Figure 30.1.  Illustration of depth of superficial, medium, and deep resurfacing procedures. (Reprinted from Meduri, N.B., 2007. Op. Tech. Otolaryn.
Head Neck Surg. 18 [3], 172–180.)
Superficial
(mid-epidermis)
Medium depth
(papillary dermis)
Deep
(reticular dermis)

Injectables, Skin Resurfacing, Lasers, and Hair Restoration
304
■ The progeny of these cells become displaced from below
and mature and then produce keratin.
• Outermost layer: Hair cuticle, composed of hard keratin
and responsible for anchoring the hair in its follicle
• Infundibulum: Upper portion of the hair follicle above the
sebaceous duct, lined by surface epithelium
• Outer root sheath covers the inner root sheath and extends
upward from the matrix cells to the entrance of the
sebaceous gland duct
■ Basal layer contains inactive, pigmented, amelanotic
melanocytes that can produce melanin after injury, such
as chemical peels or dermabrasion, and migrate toward
the epidermis.
• Sebaceous glands produce sebum and open into the hair
follicle.
• In the scalp, hair follicles are found in the subcutaneous
layer (see Figure 30.2)
2. Hair growth
• A normal cycle of growth and rest characterized by three
stages
■ Anagen: Active phase, lasts 1000 days in men and 2 to
5 years longer in women (85% to 90% hairs in this
phase)
6. Tretinoin
• Retinoic acid receptor activation with epidermal
hyperproliferation, leading to
■ Normalization of epidermal disarray, which results in
thickening of the epidermis
■ Stimulation of collagen and glycosaminoglycan
deposition, which increases skin turgor and elasticity
■ Reduction in collagen degradation
■ Increased transit of keratinocytes through the epidermis.
• Improves photoaged skin by decreasing pigmentation and
fine and coarse wrinkles
• Histologic effects
■ Epidermis: Thinning of the stratum corneum, reversal of
cellular atypia, and thickening of the epidermis
■ Dermis: Increased collagen and more organized melanin
granule deposition
• Example products: Retin-A
Hair Restoration
1. Hair anatomy
• Each hair is produced through the proliferation of matrix
cells at the base of the hair follicles within reticular dermis.
Table 30.3  Lasers in Plastic Surgery
LASER
WAVELENGTH (NM)
TARGET/MECHANISM
USES/BENEFITS
DRAWBACKS
Pulsed dye
595
Oxyhemoglobin
Red, yellow, orange pigments/
selective fragmentation and
phagocytosis
Port-wine stains, vascular lesions,
scars
Can be painful,
posttreatment bruising,
multiple treatments
necessary for effect
Q-switched ruby
694
Melanin: Rupture of cells
Black, blue, violet pigments/
selective fragmentation and
phagocytosis
Very effective on dark pigments,
nevus of Ota, road rash, hair
reduction
Minimal collateral thermal injury
Not effective on red or
yellow pigments, may
cause breaks in the
skin
Q-switched Nd:YAG
(neodymium:yttrium-
aluminum-garnet)
532+1064
Red, brown, orange pigments/
selective fragmentation and
phagocytosis
Wider spectrum of uses, pigmented
lesions, hair reduction
Superior red pigment removal (532)
Uneffective on darker
pigments
Alexandrite
755
Melanin
Green and black pigments
Tattoos, hair reduction
Uneffective on red
pigments
Intense pulsed light
(IPL)
510 to 1200
Sun damage (pigmented lesions),
telangiectasia, rosacea, hair
reduction
Simple and easy to use, no
sedation necessary, nonablative,
minimal complications
Nonselective, multiple
treatments necessary
for effect
Erbium
2940
Water
Skin resurfacing
One pass yields 10 to 30 µm of
ablation, affinity for H2O is 10× that
of CO2 laser, minimal collateral
damage
No visual endpoint to
ablation, no limit to
ablative depth, less
collagen remodeling,
ablative
Carbon dioxide (CO2)
10,600
Water
Skin resurfacing
One pass yields 150 to 200 µm of
ablation, immediate collagen
tightening, increased neocollagen
formation, visual color change
highlights endpoint
Dermis devoid of H2O prevents
further ablation
Increased collateral
tissue damage,
pigmentary alterations,
postoperative
erythema; ablative,
sedation required
Reprinted from Weinzweig, J. (ed.), 2010. Plastic Surgery Secrets Plus, 2nd ed. Elsevier, 554–560.

Hair Restoration
305
30
○ Female-pattern hair loss (FPHL): Androgenetic
alopecia with sparing of frontal hairline
◆ 10% to 40% found to be hyperandrogenic
○ Polycystic ovary syndrome (PCOS): Look for
menstrual irregularity, acne, hirsutism
• Alopecia areata (AA): Recurrent, nonscarring type of hair
loss that can affect any hair-bearing area
■ Presents with many different patterns; medically benign
but causes severe emotional and psychosocial stress
■ Etiology unknown (although possibly a T-cell-mediated
autoimmune condition in genetically predisposed
patients)
○ Corticosteroids have been used successfully to treat
alopecia areata.
○ Intralesional steroids are the first-line treatment in
localized conditions.
◆ Intradermal injection every 4 to 6 weeks
○ Hair growth may persist for 6 to 9 months after a
single injection.
■ For patients with extensive AA (>40% hair loss), little
data exist on the natural evolution; 24% experienced
spontaneous, complete or nearly complete regrowth at
some stage during the observation period of 3 to 3.5
years.
■ Surgery does not have a role in this condition.
• Male-pattern alopecia
■ Genetically triggered condition in susceptible men
(X-linked dominant gene)
■ Observed increase in the activity of 5-α-reductase in the
susceptible follicles; plasma testosterone levels are
normal in these patients.
○ Minoxidil (increases hair growth; not useful in
extensive loss situations) or Propecia (Finasteride:
■ Catagen: Degradation phase, follows anagen, lasts weeks;
follicular bulb atrophies and degrades.
■ Telogen: Resting phase, begins after catagen and lasts 2
to 4 months (10% hairs in this phase)
○ On average, 50 to 100 telogen hairs fall out every day
and are replaced with new growing hairs.
○ Male-pattern alopecia occurs when the anagen
(active) phase is shortened and the telogen (resting)
phase is prolonged.
○ Telogen effluvium is a temporary increase in telogen
phase cycles caused by pregnancy, stress, eating
disorders, chemotherapy, etc.
• Female hair loss
■ Differs from male alopecia because of the numerous
hormonal and medical causes for hair loss in women
■ Generalized hair thinning with discrete areas of alopecia
is the most common pattern of hair loss in women and
is responsive to surgical restoration.
■ Traumatic or surgical scar alopecia may also respond to
surgical restoration.
■ Women with frontal temporal alopecia may be treated
in a similar manner as patients with male-pattern
hair loss.
■ Etiologies
○ Hormonal/medical causes including chronic telogen
effluvium (persistent, increased telogen hair
shedding); usually unresponsive to surgical hair
restoration
○ Psoriasis/tinea capitis: Hair loss associated with scalp
changes including crusting/scaling
○ Trichotillomania: Traction alopecia from compulsive
hairpulling (not diffuse, patchy)
○ Alopecia totalis: Total hair loss over entire scalp
Figure 30.2.  Anatomy of a hair follicle. (Reprinted from Habif, T., 2004. Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 4th ed. Mosby, St Louis.)
Hair cuticle
Hair cortex
Hair medulla
Hyaline
basement
membrane
Melanocyte
Fibrous sheath
Papilla
Outer root
sheath
Cuticle of inner
root sheath
Huxley’s layer
Henle’s layer
Inner
root
sheath
Pool of
undifferentiated
cells in shaft
Matrix

Injectables, Skin Resurfacing, Lasers, and Hair Restoration
306
5-α-reductase inhibitor) recommended in treating
male-pattern alopecia
◆ Halts the hair loss, increases number of hairs and
diameter of existing hairs; only effective in patients
with mild to moderate baldness
Figure 30.3.  Norwood classification of androgenic alopecia. (Reprinted from Unger, M.G., Cotterill, P.C., 2000. Hair transplantation. In: Achauer, B.M.,
Eriksson, E., Guyuron, B., et al. [Eds.], Plastic Surgery: Indications, Operations, and Outcomes, vol. 5: Esthetic Surgery. Mosby, St Louis, 2487; redrawn from
Norwood, O.T., 1975. Male pattern baldness: classification and incidence. South Med. J. 68, 1359–1365.)
II
III
III Vertex
IV
V
VI
VII
I
■ Occurs in 60% to 80% of Caucasian men; can begin as
early as 20 years of age
■ Hamilton-Norwood classification system (see Figure
30.3): Classifies male-pattern alopecia based on the
appearance of the anterior hairline and hair loss at the
vertex

Special Considerations
307
30
Special Considerations
1. Laser hair removal
• Melanin is the target chromophore for laser and intense
pulsed-light (IPL) hair reduction (wavelength 250 to
1200 nm).
■ Thermal injury to the melanin-containing cells of the
bulb and matrix results in destruction of the hair follicle.
■ Patients with greater melanin content have darker hair
and are more likely to have effective laser or IPL hair
reduction.
■ In very fair-haired individuals, the limited melanin
content makes hair reduction less effective.
2. Eyebrow reconstruction
• Absence of the eyebrow resulting from trauma: Composite
grafting from the scalp is the most appropriate
reconstructive option.
• Microplug hair transplantation is unreliable over scar
tissue, especially traumatized soft tissue and radiated scars
Suggested Readings
Avram, M.R., Keene, S.A., Stough, D.B., et al., 2012. Chapter 157: Hair
restoration. In: Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. (Eds.), Dermatology,
3rd ed. Elsevier, pp. 2535–2545.
Born, T.M., Airan, L.E., 2013. Chapter 4: Soft-tissue fillers. In: Neligan, P.C.
(Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 44–59.
Buck, D.W., Alam, M., Kim, J.Y.S., 2009. Injectable fillers for facial
rejuvenation: a review. J. Plast. Reconstr. Aesthet. Surg. 62, 11–18.
Carruthers, A., Carruthers, J., 2012. Chapter 159: Botulinum toxin. In:
Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. (Eds.), Dermatology, 3rd ed.
Elsevier, pp. 2561–2572.
Kane, M.A.C., 2013. Chapter 3: Botulinum toxin (BoNT-A). In: Neligan, P.C.
(Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 30–43.
Lemperle, G., 2009. Chapter11: Avoidance and treatment of complications
after dermal filler injections. In: Cohen, S.R., Born, T.M. (Eds.), Techniques
in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Filler. Elsevier,
pp. 135–154.
Monheit, G.D., Chastain, M.A., 2012. Chapter 154: Chemical and mechanical
skin resurfacing. In: Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. (Eds.),
Dermatology, 3rd ed. Elsevier, pp. 2493–2508.
Saedi, N., Rotunda, A.M., Jones, D.H., et al., 2012. Chapter 158: Soft
tissue augmentation. In: Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. (Eds.),
Dermatology, 3rd ed. Elsevier, pp. 2547–2560.
3. Treatment
• Scalp reduction: The most appropriate surgical
management of male-pattern alopecia
■ Removal of the hairless scalp will diminish the total area
that requires grafting and will assist with conservation of
donor sites.
■ Sagittal excision patterns are preferred because they will
remove the greatest amount of bald skin due to the
excess of scalp laxity seen in the sagittal plane.
• Micrografting hair growth cycle: Hair growth for 1 month
(false growth), followed by hair loss (telogen phase), and
then normal growth after 3 months at a rate of 1 cm/month
■ Typically, 6 months required for onset of permanent
hair growth in grafted area
■ Hair in healthy scalp grows in 1 to 4 hairs, each with
their own associated neurovascular bundles, sebaceous
glands, sweat glands, and piloerectile muscles
surrounded by collagen.
○ When used as micrografts, these units (“hair follicles
with dermal elements”) have been shown to provide
excellent results in hair transplantation.
○ The macroscopic hair transplantation technique of
hair plugs with multiple hair follicles, intervening
skin, subcutaneous tissue, and epicranial and
subepicranial tissue can successfully transplant hair
but results in an unnatural appearance.
■ Donor dominance concept: Each hair follicle possesses
its own individual, genetically defined life span.
Therefore, hair follicles located in those areas that tend
to have a longer life span will continue to possess the
same life span even after they have been transplanted.
○ Occipital scalp hairs have the longest genetically
defined life span in most patients (also an esthetically
acceptable donor site).
○ Sideburns often have a life span that is genetically
similar to the occipital area, but the donor site is
quite small and usually unacceptable.

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Appendix Q&A
Self-Assessment Questions
Chapter 1
1. A 55-year-male undergoes a liposuction procedure with a
tumescent technique. Approximately 6600 cc were aspirated
from multiple areas. Which of the following would represent
an early sign of lidocaine toxicity?
a. Chest pains
b. Shortness of breath
c. Headache with sensory changes on tongue
d. Seizure
e. Monocular blindness
2. A 36-year-old female previously healthy with no prior surgical
history is scheduled to undergo a breast augmentation and
liposuction of her abdomen and waist. She undergoes general
endotracheal anesthesia without complication. Twenty
minutes after the infiltration of local anesthetic along her
breast augmentation incisions during the dissection of the
implant pocket, what would be the initial suggestion that the
patient may be experiencing malignant hyperthermia?
a. Rapid increase in core temperature
b. Muscle rigidity
c. Increased end-tidal CO2
d. Acidosis
e. Profuse bleeding
3. You manage a busy solo private practice and are recruiting a
new practice manager. Which of the following topics can you
legally inquire about?
a. Race
b. Child-care responsibilities
c. Marital status
d. Customer service experience
e. Religion
4. You excise a 1-cm benign nevus. To close the acquired defect,
you undermine local tissue and rotate local skin to facilitate
reconstruction. Which of the following accurately codes the
procedure for billing Medicare?
a. Excision of benign mass 1 cm with intermediate repair
1 cm
b. Excision of benign mass 1 cm with complex repair 1 cm
c. Excision of benign mass 1 cm with adjacent tissue transfer
closure 4 cm2
d. Fasciocutaneous flap closure
e. Adjacent tissue transfer closure (4 cm2)
5. You performed an abdominal component separation
reconstruction of a recurrent ventral hernia with your general
surgeon colleague, who separately performed the required
lysis of bowel adhesions. Which modifier should surgeons
use?
a. 22 modifier
b. 52 modifier
c. 51 modifier
d. 59 modifier
e. 62 modifier
6. A-64-year-old woman is scheduled to undergo an abdominal
panniculectomy after losing 75 lb. Her body mass index
(BMI) is 31, and her past history is significant for
hypertension (which resolved after weight loss) and insulin-
dependent diabetes. She has a normal hemoglobin A1C level.
Her American Society of Anesthesiologists (ASA)
classification is
a. ASA 1
b. ASA 2
c. ASA 3
d. ASA 4
7. Malignant hyperthermia can be triggered by which of the
following?
a. Propofol
b. Halothane
c. Bupivacaine
d. Rocuronium
8. A 67-year-old man undergoes an incisional hernia repair with
components separation performed by you. Which of the
following may be billed to Medicare in addition to the
components separation?
a. Meeting with the patient in the preoperative holding area
to obtain hospital consent and mark the abdomen
b. Office visit to remove drains on postoperative day POD 12
c. Half-hour meeting on POD 4 with patient, family, and
social worker to discuss rehab placement
d. Office visit 6 months postop to evaluate result of repair
9. You are interviewing a candidate for your plastic surgery
residency program. The candidate’s personal statement
indicates that her interest in plastic surgery stemmed from
needing plastic surgery after a car accident. The personal
statement also indicates that her favorite activity in her spare
time is playing with her children. Which of the following is
an acceptable question to ask during the interview?
a. What type of child care would you use during your
residency?
b. Do you speak any foreign languages?
c. What kind of injuries did you sustain in your accident?
d. Is your spouse able to help you with home responsibilities?

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6. A 29-year-old male presented to the emergency room 3 hours
ago with a deep, vertical laceration over the left posterior
zygomatic arch. On exam, the patient is unable to elevate
the left eyebrow. How long after the injury is it possible to
electrically stimulate the transected distal nerve end and
evaluate muscle contraction?
a. 12 hours
b. 24 hours
c. 48 hours
d. 72 hours
7. The facial nerve courses in which fascial layer within the
temporal region?
a. Superficial temporal fascia
b. Superficial layer of deep temporal fascia
c. Temporal fat pad
d. Deep layer of deep temporal fascia
8. Your 39-year-old patient presents to the emergency room
with pronounced ipsilateral cheek edema 2 days status post
direct end-to-end repair of a transected buccal branch of
the facial nerve. The patient noted the increased edema after
resuming eating. What injury was most likely missed at the
time of presentation?
a. Facial artery transection
b. Parotid duct transection
c. Submandibular parenchymal injury
d. Intraoral laceration
9. A 45-year-old female presents to your office 6 months after
resolution of Bell’s palsy with concerns regarding difficulty
opening her eyes when moving her mouth. These symptoms
began only in the last 2 to 3 weeks. She does not have
difficulty opening her eyes at any other time. What is the
most likely diagnosis?
a. Hypertonicity
b. Atrophy
c. Ectropion
d. Synkinesis
10. A 3-year-old male is brought to your clinic with his parents
for evaluation of a mass on the central neck. The mass has
been draining fluid for 2 weeks. On exam, the mass does not
appear acutely infected, and you note that it moves when the
patient swallows and protrudes his tongue. In addition to the
mass, what structure will most likely require excision?
a. Central portion of the hyoid bone
b. Anterior edge of sternocleidomastoid muscle
c. Thyroid cartilage
d. Lymph node
10. A 16-year-old male is scheduled to undergo a rectus
abdominis free flap to the distal right leg using a pfannensteil-
type incision for harvest, with split-thickness skin graft to the
flap. Which of the following maneuvers can be billed in
addition to the free flap?
a. Elevation of the lower abdominal skin to expose the
rectus
b. Exposure of the posterior tibial vessels for anastomosis
to the flap through a separate incision and creation of a
tunnel to the defect
c. Split thickness skin graft
d. Complex closure of the abdomen
Chapter 2
1. What anatomic landmark can be used to identify the
approximate location of the mental nerve as it travels through
the mental foramen to provide sensory innervation to the
lower lip and chin?
a. Third molar
b. Canine
c. Central incisor
d. Second premolar
2. Your 55-year-old female presents to your office 3 days after
undergoing a facelift procedure. She is complaining of
numbness to her right earlobe. What nerve was most likely
injured during the procedure to account for this finding?
a. Auriculotemporal
b. Greater occipital
c. Great auricular
d. Lesser occipital
3. A 34-year-old female presents to your office 1 day after
suffering a deep laceration to the right cheek and neck,
which was repaired in the emergency room. She now has an
asymmetric smile concerning for concomitant nerve injury.
The function of what muscle can help distinguish between
a marginal mandibular nerve injury and a cervical branch
injury?
a. Mentalis
b. Orbicularis oris
c. Risorius
d. Buccinator
4. What structure passes through the foramen rotundum?
a. Internal carotid artery
b. Maxillary division of the trigeminal nerve
c. Facial nerve
d. Mandibular division of the trigeminal nerve
5. Which of the following structures does NOT pass through the
superior orbital fissure?
a. Oculomotor nerve
b. Abducens nerve
c. Optic nerve
d. Trochlear nerve

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5. With regard to vascular malformations and hemangiomas,
choose the correct pairs:
a. Vascular malformations are present at birth;
hemangiomas usually appear within the first 4 weeks of
life.
b. Vascular malformations demonstrate proportionate
growth with age; hemangiomas have a rapid growth phase
followed by involution.
c. Low-flow venous malformation can be treated by
sclerotherapy followed by surgical excision; asymptomatic
hemangiomas may be observed.
d. Vascular malformations of an extremity are present in
Klippel-Trenaunay syndrome and retinal hemangiomas
are present in von Hippel-Lindau syndrome.
e. All of the above
6. An otherwise healthy 68-year-old man is evaluated for
bilateral 1.5-cm parotid masses. Physical examination does not
demonstrate facial muscle weakness. Fine-needle aspiration
of one of the lesions reveals mucoid fluid, lymphoid tissue
nodules, and papillary cysts. What is the most likely
diagnosis?
a. Squamous cell carcinoma (SCC)
b. Pleomorphic adenoma
c. Mucoepidermoid carcinoma
d. Warthin’s tumor
7. A 58-year-old woman underwent left superficial
parotidectomy for a pleomorphic adenoma 2 years ago. She
presents with complaints of occasional perspiration and
redness of the left cheek and ear after eating. Which of the
following nerves is the most likely source of these complaints?
a. Great auricular
b. Frontal branch of the facial nerve
c. Auriculotemporal
d. Lingual
8. Which of the following is the most appropriate initial
treatment for a 4-year-old boy with a painful venous
malformation of the cheek and neck with obvious facial
asymmetry?
a. Resection
b. Embolization
c. Sclerotherapy
d. Systemic corticosteroid therapy
9. Which of the following is the most appropriate treatment for
a T4aN0M0 floor-of-mouth SCC with mandibular cortical
invasion?
a. Wide local excision, neck dissection, and segmental
mandibulectomy
b. Wide local excision alone
c. Wide local excision and segmental mandibulectomy
d. Wide local excision and neck dissection
Chapter 3
1. Related to salivary gland tumors, all of the following
statements are correct, except
a. Hemangioma is the most common parotid tumor in
children.
b. Mucoepidermoid carcinoma is the most common salivary
gland malignancy.
c. Adenoid cystic carcinoma usually presents as a painless,
nonfixed mass without facial nerve dysfunction.
Superficial parotidectomy with nerve preservation is the
treatment of choice.
d. Pleomorphic adenoma is treated by superficial
parotidectomy and facial nerve preservation.
2. A 25-year-old male presents with a mandibular swelling. On
imaging, a large well-demarcated radiolucency in the
posterior mandible is identified. An incisional biopsy
confirms an odontogenic keratocyst (keratocystic odontogenic
tumor). All of the following with respect to management of
this tumor are correct except
a. For smaller cysts, enucleation with removal of the entire
cyst lining is appropriate.
b. For larger, multilocular lesions, enucleation alone is
associated with higher recurrence rates.
c. If multiple cysts are present, nevoid basal cell carcinoma
syndrome (Gorlin syndrome) must be ruled out.
d. Close follow-up of the patient is unnecessary.
3. In tongue reconstruction, identify the incorrect treatment
plan for a given defect or tumor.
a. Small defect: can often be closed primarily or with skin
graft
b. Larger tumor involving 1/3 to 1/2 of the tongue and
requiring adjuvant radiotherapy: A flap that provides
adequate lining and prevents tethering of the remaining
tongue is required, such as radial forearm free flap.
c. Subtotal glossectomy: A flap that provides bulk for
restoration of speech and facility with oral diet is
necessary, such as the anterolateral thigh (ALT) flap.
d. Total glossectomy: skin graft
4. Risk factors for developing bisphosphonate-related
osteonecrosis (medication-related osteonecrosis of the jaw
[MRONJ]) include
a. Oral bisphosphonates
b. Intravenous bisphosphonates
c. Dental infection, periodontal disease, or tooth extraction
d. Chemotherapy
e. All of the above

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4. A 2-year-old girl presents to your office with orbital dystopia
and a growing skull fracture. Nine months ago, she fell and
fractured her right superior orbital rim and orbital roof and
was treated nonoperatively. Which of the following is the
most likely etiology of her presentation?
a. Unrecognized craniofacial cleft
b. New craniofacial trauma
c. Unrecognized dural tear at the time of her initial injury
d. Metabolic disorder
5. A 34-year-old female presents to the emergency room after a
motor vehicle accident. On examination, she has bilateral
periorbital ecchymosis, telecanthus, and upturning of the
nasal tip. A CT scan reveals a type-III naso-orbital ethmoid
fracture. Which of the following is the appropriate position
for placement of the medial canthal tendon at the time of
repair?
a. Posterior and superior to the lacrimal fossa
b. Anterior and superior to the lacrimal fossa
c. Posterior and inferior to the lacrimal fossa
d. Anterior and inferior to the lacrimal fossa
6. A 45-year-old male presents to the emergency department
after a head-on motor vehicle collision. Examination shows a
stellate laceration and a palpable deformity in the frontal
region. A CT scan shows a displaced and comminuted
fracture of the anterior wall of the frontal sinus and a
nondisplaced fracture of the posterior wall. The frontonasal
duct is not patent. Which of the following is the most
appropriate treatment?
a. Open reduction and internal fixation (ORIF) of the
anterior wall of the frontal sinus
b. Obliteration of the sinus and nasofrontal duct
c. Cranialization of the sinus and obliteration of the
nasofrontal duct
d. ORIF of the anterior wall of the frontal sinus and stenting
of the nasofrontal duct
7. A 27-year-old male was struck in the face during an
altercation. Examination demonstrates right periorbital
ecchymosis and edema. A CT scan shows a right orbital floor
and comminuted medial orbital wall fracture. Which incision
is preferred?
a. Bicoronal
b. Subciliary
c. Transconjunctival
d. Subtarsal
8. Which of the following is the optimal treatment of
noncomminuted mandibular body fracture?
a. A Champy plate
b. Maxillomandibular fixation (MMF)
c. Inferior border compression plate and superior miniplate
d. Inferior border locking plate and arch bar
10. A 69-year-old woman who underwent previous resection,
radiation, and chemotherapy for oropharyngeal cancer
presents with halitosis and left-sided jaw pain. Intraoral
examination reveals a 1-cm area of exposed yellow
mandibular bone. A subsequent computed tomography (CT)
scan does not reveal any evidence of fracture. What is the
most appropriate initial management?
a. Hyperbaric oxygen (HBO) therapy
b. Antimicrobial mouthwash, antibiotics, and observation
c. Resection of the exposed mandible and reconstruction
with a fibular free flap
d. Debridement of the exposed bone
Chapter 4
1. A 45-year-old male presents to the emergency room after a
motor vehicle collision. He is unconscious and intubated. On
examination, he has right periorbital ecchymosis and swelling.
When a light is shined on his left eye, both pupils constrict,
and when the light is shined on his right eye, the right pupil
dilates. Which of the following is the most likely etiology of
this finding?
a. Entrapment of the inferior rectus muscle
b. Injury to the optic nerve
c. Hyphema
d. Enophthalmos
2. A 29-year-old male was involved in a bicycle accident and
presents to the emergency room with a palpable step-off of
the left hemimandible and malocclusion. A CT scan reveals a
displaced fracture of the left mandibular body near the 3rd
molar. Which of the following is an indication for extraction
of the 3rd molar during fixation of this fracture?
a. The 3rd molar is near the fracture line.
b. The 3rd molar enamel is chipped and would require
dental treatment.
c. The 3rd molar is impacted.
d. The 3rd molar contains dental caries.
3. An 8-year-old boy presents to the emergency room after
being struck in the face with a baseball. On examination, he
has left periorbital ecchymosis and swelling with restricted
upward gaze. He is vomiting and bradycardic. A CT scan
reveals a minimally displaced orbital floor fracture. Which
of the following is the most appropriate treatment?
a. Reassurance and observation
b. Ophthalmology follow-up
c. Emergent operative reduction and orbital floor
reconstruction
d. Elective operative reduction and orbital floor
reconstruction within 7 days

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5. A 3-year-old presents to your office with bilateral malar
deficiency, lower eyelid coloboma, and retrognathia. Which of
the following is the most likely diagnosis?
a. Treacher Collins syndrome
b. Robin sequence
c. Apert syndrome
d. Craniofacial microsomia
6. A facial bipartition is planned for a 7-year-old female with an
anterior interorbital distance of 40 mm (normal mean =
21.5 mm). Which of the following diagnoses best accounts for
these findings?
a. Craniofrontonasal dysplasia with hypertelorbitism
b. Craniofrontonasal dysplasia with telecanthus
c. Goldenhar syndrome with epibulbar dermoids
d. Crouzon syndrome with exorbitism
7. A Pi procedure is planned for an infant with sagittal
craniosynostosis. Which of the following best characterizes
the objectives of this procedure?
a. AP lengthening, biparietal widening
b. AP shortening, biparietal narrowing
c. AP lengthening, biparietal narrowing
d. AP shortening, biparietal widening
8. Which of the following features is consistent with a right
unilateral lambdoid craniosynostosis as opposed to right
posterior deformational plagiocephaly?
a. Anterior displacement of the right ear
b. Right occipitomastoid flattening
c. Right frontal bulging
d. Parallelogram-like head shape from the posterior view
9. A newborn is evaluated in the NICU for respiratory distress.
The examination is notable for down-slanting palpebral
fissures, eyelid colobomata, malar hypoplasia, severe
mandibular retrognathia, and bilateral hypoplastic thumbs. A
CT scan shows abnormal temporomandibular joints. The
patient’s features are most consistent with which craniofacial
syndrome?
a. Pfeiffer
b. Nager
c. Treacher Collins
d. Apert
10. A 17-year-old female with Binder syndrome is scheduled to
undergo orthognathic surgery to address deficiency at the
level of the nasion and maxillary occlusal plane. This is best
achieved with
a. Fronto-orbital advancement
b. LeFort I osteotomy
c. LeFort II osteotomy
d. Surgically assisted rapid palatal expansion (SARPE)
9. A 25-year-old female presents with a displaced
zygomaticomaxillary complex fracture and a palpable step-off
along the inferior orbital rim. Proper alignment of which of
the following structures is most important to confirm
adequate reduction?
a. Zygomaticofrontal suture
b. Zygomaticomaxillary buttress
c. Zygomaticotemporal suture
d. Zygomaticosphenoid suture
e. Inferior orbital rim
10. A 30-year-old male presents to the emergency department 2
weeks after ORIF of a parasymphyseal and angle fracture of
the mandible. On exam, he has significant facial swelling and
purulent drainage from his intraoral incision. A CT scan
shows fluid collection, but the hardware is still in place
without evidence of osteomyelitis. He still has his arch bars
on but is not in MMF. The most appropriate management
would be
a. intravenous (IV) antibiotics
b. Incision and drainage (I&D)
c. I&D with plate and arch bar removal
d. I&D with plate removal and use of the arch bars to put
him in MMF
Chapter 5
1. Robin sequence is a clinical diagnosis characterized by
a. Micrognathia
b. Glossoptosis
c. Upper airway obstruction
d. All of the above
2. A 7-month-old boy presents to your clinic with the chief
complaint of abnormal head shape since birth. Physical exam
shows flattening of the right forehead and supraorbital rim
with elevation of the eyebrow. Which of the following is your
recommended treatment?
a. Total vault reconstruction
b. Endoscope-assisted strip craniectomy and helmet therapy
c. Fronto-orbital advancement
d. Cranial distraction
3. A 2-month-old presents with eyelid ptosis, telecanthus,
bilateral frontal retrusion, increased head height, and low
frontal hairline. A CT scan shows bilateral coronal synostosis.
The most likely genetic mutation involves
a. FGFR2
b. FGFR3
c. TWIST1
d. TCOF1
4. Which of the following sutures is the first to close?
a. Sagittal
b. Metopic
c. Coronal
d. Lambdoid

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6. A pregnant mother suffers an insult while she is in the 9th
week of gestation. She is concerned about the potential of a
cleft deformity. During a prenatal consult with this family,
what type of cleft(s) should you discuss as a likely possibility?
a. Cleft lip only
b. Cleft palate only
c. Cleft lip and palate
d. Cleft lip and primary palate
7. A child with a previously repaired cleft palate presents with a
new diagnosis of velopharyngeal insufficiency. As
videonasoendoscopy is being performed, the otolaryngologist
notes clear evidence of pulsatility in the posterior pharynx.
What is the likely diagnosis on this patient?
a. van der Woude syndrome
b. Treacher Collins syndrome
c. Stickler syndrome
d. 22q11.2 deletion syndrome (DS)
8. Which of the muscles of the velopharynx is NOT innervated
by the pharyngeal plexus (IX, X, and XI)?
a. Levator veli palatini
b. Tensor veli palatini
c. Palatoglossus
d. Superior pharyngeal constrictor
9. A 10-year-old girl presents with velopharyngeal dysfunction
and severe sleep apnea. Videonasoendoscopy and
videofluoroscopy are performed, demonstrating little to no
velar or lateral wall movement of the palate during speech
examination. Her speech is pervasively hypernasal. Which
management strategy is most reasonable for this patient?
a. Furlow double-opposing Z plasty
b. Pharyngeal flap
c. Sphincter pharyngoplasty
d. Palatal prosthesis
10. An 18-year-old female enters for orthognathic evaluation. On
examination, she has class-III occlusion with a negative
overjet of 9 mm. Cephalograms demonstrate an SNA angle of
75 degrees and an SNB angle of 80 degrees. What procedure
should be offered to this patient?
a. LeFort I advancement and bilateral sagittal split
osteotomies (BSSOs) of the mandible
b. LeFort I advancement alone
c. BSSOs of the mandible alone
d. LeFort I osteotomy with distraction
Chapter 7
1. A 65-year-old man presents to you with a large SCC of the
superior helix. What nodal basin primarily drains this region?
a. Level-I cervical nodes
b. Level-II cervical nodes
c. Level-III cervical nodes
d. Parotid nodes
2. Which of the following is the primary blood supply to the ear?
a. Superficial temporal artery
b. Occipital artery
c. Posterior auricular artery
d. Transverse facial artery
Chapter 6
1. A 3-month-old child presents with Goldenhar syndrome
characterized by microtia, macrostomia, VIIth nerve palsy,
epibulbar dermoid, hypoplastic mandibular ramus without a
defined right mandibular condyl/glenoid fossa, and a
hypoplastic maxilla. Which branchial arches are involved with
this condition?
a. 2nd and 3rd branchial arches
b. 1st and 2nd branchial arches
c. 1st, 2nd, and 3rd branchial arches
d. 2nd and 4th branchial arches
2. NICU consults plastic surgery to see a 2-day-old infant with
the following findings: small recessed lower jaw, a high-
arched U-shaped cleft palate, and chest retractions. Which of
the following syndromes can be associated with these
findings?
a. Stickler syndrome, velocardiofacial syndrome (VCFS)
b. Crouzon syndrome, Apert syndrome
c. Parry Romberg syndrome, cherubism
d. van der Woude, ectrodactyly–ectodermal dysplasia–cleft
syndrome (EEC)
3. A child presents with a typical cleft lip that starts at what
would have been the left philtral column but courses more
laterally, disrupting the left alar base cheek junction as it
continues superiorly to the medial lower eyelid canthal
region. The child presents with which Tessier cleft number?
a. Tessier 4 cleft
b. Tessier 2 cleft
c. Tessier 3 cleft
d. Tessier 5 cleft
4. Parents bring a 16-year-old girl to your office because she is
unhappy with the appearance of her nose and chin. She has a
history of a left cleft lip and palate. She presents with a
significantly asymmetrical nasal tip and alar base. Additional
physical findings that would be consistent include
a. Caudal septal deviation to the right
b. The dome of the left lower lateral cartilage is higher than
the dome on the right side.
c. Caudal septal deviation to the left
d. Proximal septal deviation to the right
5. Further examination of the 16-year-old girl interested in cleft
nasal rhinoplasty revealed that she has an acute nasal labial
angle, short vertical lip, and no show of her front teeth
(–2 mm). When asked to smile, she does not show any
gingiva, and she has a significant anterior cross bite (–9 mm)
missing the left lateral incisor, and left posterior crossbite.
Lateral cephalometric radiographs show that she a sella-
nasion-subspinale (SNA) angle of 76° (82°) and an SNB of 85°
(80°). The appropriate surgical sequence would be
a. Cleft rhinoplasty followed by LeFort I with setback
genioplasty
b. Bilateral sagittal split osteotomy (BSSO) setback followed
by cleft rhinoplasty
c. Cleft rhinoplasty with genioplasty setback
d. LeFort I advancement and BSSO setback followed by cleft
rhinoplasty

314
9. Which of the following statements is false regarding the
proper anatomy, dimensions, and proportion of the auricle?
a. The auricle is located 6.5 to 7.5 cm posterior to the lateral
orbital rim.
b. The axis of the auricle is inclined 10 to 20 degrees
posteriorly.
c. A well-proportioned auricle width is 50% to 55% of the
length.
d. The top of the auricle is on line with the lateral canthus.
10. What is the optimal timing for nonsurgical correction of
external ear deformity using external splinting?
a. Immediately after birth
b. Three months after birth
c. Before the age of 1 year
d. At any age
Chapter 8
1. Describe the dominant arterial blood supply to the breast.
a. Intercostal artery perforators
b. Lateral thoracic artery perforators
c. Second and third internal mammary artery (IMA)
perforators
d. Thoracoacromial artery perforators
2. In the youthful, nonptotic breast, what is the normal distance
between the nipple and the inframammary fold (IMF)?
a. Nine to 10 cm
b. Ten to 11 cm
c. Five to 6 cm
d. Seven to 8 cm
3. What is the normal diameter of the nipple-areolar complex
(NAC)?
a. Twenty to 30 mm
b. Twenty-five to 35 mm
c. Thirty five to 45 mm
d. Forty to 50 mm
4. The pectoralis major muscle originates on the medial sternal
half of the clavicle and lateral aspect of the sternum/
costochondral region and is the major component of the
anterior axillary fold. Which nerve provides motor
innervation to the lateral and inferior portion of the
pectoralis major muscle?
a. Lateral pectoral nerve
b. Medial pectoral nerve
c. Third and fourth medial intercostal nerves
d. Long thoracic nerve
5. A 35-year-old female undergoes bilateral breast reduction with
an inferior pedicle design. What is the dominant arterial
supply to the inferior pedicle of the breast?
a. Intercostal artery perforators
b. Lateral thoracic artery perforators
c. Second and third IMA perforators
d. Thoracoacromial artery perforators
3. Which of the following is not a common cause of prominent
ear?
a. Conchoscaphal angle >90 degrees
b. Deepened conchal bowl
c. Prominent lobule
d. Auriculocephalic angle <25 degrees
4. A 7-year-old boy is brought to your office by his parents
regarding their concern for the appearance of his right ear.
On examination, the superior helix of the right ear is
abnormally adherent to the temporal skin. Gentle retraction
on the helix allows it to be pulled out to a normal position.
What is the most likely diagnosis?
a. Lop ear
b. Stahl’s ear
c. Cup ear
d. Cryptotia
5. A 45-year-old female was involved in an accident and suffered
an injury to her left ear. On examination, she has a defect of
the superior helical rim that is ~1.5 cm in length. Which of
the following is the best method for reconstruction of this
defect?
a. Primary closure
b. Posterior auricular transposition flap
c. Antia-Buch chondrocutaneous flap
d. Orticochea chondrocutaneous flap
6. Which of the following statements is not true for autogenous
total auricular reconstruction?
a. The Tanzer method uses full-thickness lobule rotation.
b. The Nagata method uses split-lobule rotation.
c. When creating a skin pocket for cartilage framework
implantation, 5 mm is the ideal thickness of the skin flap
for optimal definition.
d. There is often insufficient costal cartilage for an adequate
autogenous reconstruction if the chest circumference is
less than 60 cm.
7. Which of the following statements is not true regarding
microtia associated with craniofacial deformities?
a. Microtia in hemifacial microsomia is associated with
low-set, anteriorly located vestige skin and low hairline.
b. Microtia in hemifacial microsomia is associated with an
atypical course of superficial temporal vessels.
c. For bilateral microtia with craniofacial deformities, it is
imperative to refer the child for hearing assistance;
bone-anchored hearing aids (BAHA) or external hearing
aids need to be placed at an earlier age to help the
development of the child.
d. Autogenous auricular reconstruction is contraindicated in
microtia with severe craniofacial deformities.
8. What is the embryologic origin of the superior helix?
a. First branchial arch
b. First branchial cleft
c. Second branchial arch
d. Second branchial cleft

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12. A 16-year-old female presents with a rapidly enlarging mass
in her left breast. The growth has caused considerable
asymmetric enlargement of the breast. You suspect a giant
fibroadenoma. What is the most appropriate next step in the
management of this patient?
a. Reassurance and follow-up in 6 months
b. Core needle biopsy
c. Surgical excision
d. Mammography
13. A 42-year-old male presents with complaints of bilateral
breast enlargement. On exam, he has moderate breast
enlargement with excess skin overlying the breast tissue. What
Simon grade correctly correlates with his physical exam
findings?
a. Grade I
b. Grade IIA
c. Grade IIB
d. Grade III
14. A 15-year-old male presents with a chief complaint of bilateral
breast enlargement. Laboratory studies reveal elevated human
chorionic gonadotropin (HCG) and estrogen/androgen ratio.
Luteinizing hormone (LH), follicle-stimulating hormone
(FSH), and thyroid function tests are within normal limits.
Which of the following should be ordered as a follow-up to
the elevated HCG and estrogen/androgen ratio?
a. Adrenal CT scan
b. Liver function tests
c. Chest X ray
d. Ultrasound of the testes
15. Which of the following medications is known to cause
gynecomastia as a side effect?
a. Ketoconazole
b. Amoxicillin
c. Losartan
d. Cephalexin
16. A 61-year-old woman post-3-vessel coronary artery bypass
graft using the IMA presents with symptomatic mammary
hypertrophy. Her cardiac function is excellent and she has
clearance from her cardiologist to have a reduction
mammaplasty. Based on optimizing the vascularity to the
NAC, which pedicle would place the nipple at highest risk?
a. Inferior
b. Medial
c. Superior
d. Central mound
17. A 15-year old girl presents to the clinic because of abnormal
right breast development. Physical findings include a normal
left breast, presence of the pectoralis major muscle, and
absence of glandular tissue with a nipple present. What is the
most likely diagnosis?
a. Poland syndrome
b. Atheia
c. Jeune syndrome
d. Amastia
6. An 11-year-old female presents to her primary care physician
for a routine physical exam. On exam, she has a palpable
breast bud and the areola is slightly elevated. She meets
criteria for which Tanner stage of breast development?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
7. Incomplete involution of the mammary ridge during
gestation results in accessory breast tissue (polymastia) and
supernumerary nipples (polythelia). What is the most
common location of accessory breast tissue and
supernumerary nipples, respectively?
a. Inframammary area and axilla
b. Supramammary area and pelvis
c. Axilla and inframammary area
d. Axilla and supramammary area
8. During dissection along the lateral border of the pectoralis
major muscle, a nerve is injured resulting in reduced
sensation to the NAC. Which nerve was likely injured?
a. Supraclavicular branches of the cervical plexus
b. Cutaneous branch of 4th intercostal nerve
c. Cutaneous branch of 3rd intercostal nerve
d. Cutaneous branch of 6th intercostal nerve
9. The internal mammary/parasternal lymph nodes receive
efferent lymph drainage from what portion of the breast
parenchyma?
a. Upper inner quadrant
b. Lower inner quadrant
c. Upper inner and lower inner quadrants
d. All breast quadrants
10. A 14-year-old female presents with bilateral diffuse breast
enlargement. She complains of shoulder pain, tender breasts,
and a chronic rash along the IMFs bilaterally. Which of the
following is true regarding juvenile breast hypertrophy?
a. The breast enlargement is always bilateral.
b. Estrogen levels are typically elevated in these patients.
c. Hormone receptors are overexpressed in the breast
parenchyma of these patients.
d. First-line therapy is reduction mammoplasty.
11. A 17-year-old female presents with right unilateral Poland
syndrome with severe breast hypoplasia, including a
superiorly malpositioned NAC. What is the likely etiology of
her disrupted pectoralis major development?
a. Abnormal migration of mesenchymal tissue during the
eighth and ninth weeks of gestation
b. Hypoplasia of the branches of the brachial artery
c. An extrinsic disturbance in morphogenesis such as
amniotic bands
d. Hypoplasia of the internal thoracic artery

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4. A surgeon can increase the safety of the dissection of a
perforator flap by
a. Creating and maintaining a dry surgical field
b. Working with a wide exposure of the surgical field
c. Starting the dissection from one side only
d. Staying close to the perforator vessels
e. Preserving every perforator until a bigger one is found
f.
All of the above
5. Which of the following statements on autologous breast
reconstruction is incorrect?
a. Tissue expanders do not work well for radiated chest-wall
breast reconstructions.
b. The nipple must always be resected in cases of invasive
breast cancer at <2.5 cm of the areola.
c. Primary reconstruction is usually better than secondary
reconstruction.
d. Skin-sparing mastectomy yields more local recurrences.
e. Breast reconstruction with autologous tissue has no
interference on local recurrences.
6. The lifetime risk of breast cancer for women with the BRCA
mutation is
a. 55%
b. 65%
c. 75%
d. 85%
7. Which of the following mammographic findings are
suggestive for malignancy?
a. Popcorn-like calcifications
b. Large rod-like calcifications
c. Linear or branching calcifications
d. Dystrophic/coarse calcifications
8. Which of the following conditions, although often treated as
cancer, is not actually cancer?
a. Ductile carcinoma in situ (DCIS)
b. Invasive ductal carcinoma
c. Invasive lobular carcinoma
9. Contraindications to breast conservation therapy include
a. Large tumor relative to breast size
b. History of previous radiation therapy to the breast area
c. Multifocal breast cancer
d. All of the above
10. The risk of breast cancer recurrence following a skin-sparing
mastectomy is __ % at 4 years?
a. 1%
b. 2%
c. 6%
d. 8%
11. Options for women for whom the need of radiation therapy
is unknown include
a. Placement of a tissue expander keeping all options open
b. Free transverse rectus abdominis myocutaneous (TRAM)
flap
c. Delayed reconstruction
d. All of the above
18. A 20-year-old woman presents with irregular breast
development and an unusual shape. She is diagnosed with a
tuberous breast deformity. All of the following are
characteristic of a tuberous breast except
a. Constricted IMF
b. Herniation of the NAC
c. Lowered IMF
d. Narrowed breast base
19. A 25-year-old woman presents for bilateral breast
augmentation. Physical examination demonstrates a “pigeon’s
chest” appearance. The most likely diagnosis is
a. Thoracic hyperplasia
b. Thoracic hypoplasia
c. Pectus excavatum
d. Pectus carinatum
20. A 35-year-old woman presents for correction of a Poland
deformity. The classic findings include all of the following
except
a. Absence of the clavicular head of the pectoralis major
b. Hypoplasia or aplasia of the breast or nipple
c. Deficiency of subcutaneous fat and axillary hair
d. Abnormalities of the rib cage
e. Upper extremity anomalies
Chapter 9
1. Which is the extra information you can get from an angio-CT
before starting a free perforator flap breast reconstruction
compared to a duplex Doppler study?
a. Determination of the size and position of the dominant
perforator
b. Better evaluation of the recipient site
c. Three-dimensional (3D) anatomy of the branches of the
perforator in between the skin and the deep fascia
d. Quantification and direction of flow
e. Determination of the course of the perforator through the
muscle
2. Which of the statements below is NOT true? Autologous
breast reconstruction, compared to implants, provides
a. Better sensation of the breast
b. Easier oncologic follow-up
c. Better control of the breast cancer
d. Ultimately less expensive treatment
e. More esthetically pleasing and long-lasting result
3. For a patient undergoing lumpectomy and irradiation, the
following treatment is the least indicated:
a. No reconstruction
b. Contralateral breast reduction
c. Reconstruction with a thoracodorsal artery perforator
(TDAP) or pedicled latissimus dorsi flap
d. Temporarily filling the lumpectomy cavity with liquids or
a small prosthesis
e. A small deep inferior epigastric artery perforator (DIEAP)
flap

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6. A 26-year-old female presents with an enlarged areola further
deformed by parenchymal herniation, a narrow base
diameter, and constricted lower pole. Which of the following
procedures should not be offered to this patient?
a. Staged reconstruction with placement of a tissue expander
followed thereafter by a breast implant
b. Aggressive capsular lower pole parenchymal scoring
followed by placement of a form-stable breast implant
c. Autoaugmentation of the breast with an inferiorly based
parenchymal flap through a periareolar approach
d. Autologous fat grafting
e. Lateral intercostal artery perforator flap (LICAP)
7. From which commonly used dermoglandular pedicle is blood
supply to the nipple areola the least robust?
a. Medial pedicle
b. Bipedicle (superior and inferior)
c. Inferior pedicle
d. Superomedial pedicle
e. Lateral pedicle
8. Form-stable breast implants confer all of the following
advantages relative to smooth, round, silicone implants when
placed in a submuscular or biplanar location, except
a. Less rippling
b. Lower rate of capsular contracture at 8 years
c. Greater range of device volumes
d. Lower leak rates at 8 years
e. Greater upper pole fullness
9. Which combination of implant location and shell surface
characteristic is associated with the highest rate of capsular
contracture?
a. Submuscular; textured
b. Biplanar; smooth
c. Biplanar; textured
d. Subglandular; smooth
e. Subglandular; textured
10. Which etiology is least associated with capsular contracture?
a. Patient age
b. Subclinical infection or biofilm formation
c. Radiation
d. Incision selection for implant placement
e. Perioperative hemostasis
Chapter 11
1. For complex abdominal-wall reconstruction with synthetic
mesh, it is widely accepted that increasingly contaminated
wound classes are associated with progressively higher
complication rates. Which Centers for Disease Control
(CDC) wound classification is associated with the worst
major complication profile (i.e., recurrent hernia, mesh
infection, mesh explantation) for complex abdominal-wall
reconstruction with bioprosthetic mesh?
a. Class I (clean)
b. Class II (clean-contaminated)
c. Class III (contaminated)
d. Class IV (dirty/infected)
e. None of the above
12. Reported complications from the transverse upper gracilis
(TUG) myocutaneous flap include which of the following?
a. Size limitation
b. Visibility of donor site scar
c. Lower extremity lymphedema
d. All of the above
13. Management considerations in mastectomy skin flap loss
associated with an expander reconstruction include
a. The presence of muscle or vascularized tissue beneath the
area of necrosis
b. Need for postoperative chemotherapy/radiation therapy
c. Both A and B
d. Neither A nor B
Chapter 10
1. Relative to subglandular breast implant placement, placement
of a breast implant deep to the pectoralis major muscle will
result in
a. Increased risk of visible rippling
b. Increased risk of pseudoptosis
c. Decreased risk of capsular contracture
d. Increased risk of edge visibility
e. Increased risk of implant movement with muscle
contraction
2. Which of the following is NOT part of triple-antibiotic breast
irrigation solution?
a. Cefazolin
b. Gentamycin
c. Clindamycin
d. Bacitracin
3. Which of the following is NOT a characteristic of the
tuberous breast deformity?
a. Herniation of breast tissue through NAC
b. Constricted breast base
c. High IMF
d. Increased distance from IMF to nipple
4. A 26-year-old woman will undergo breast augmentation with
a transaxillary approach for subpectoral placement of breast
implants. Which of the following nerves is at greatest risk of
injury during a transaxillary approach for breast
augmentation?
a. Axillary nerve
b. Fourth intercostal nerve
c. Thoracodorsal nerve
d. Intercostobrachial nerve
e. Long thoracic nerve
5. A 42-year-old woman presents with an acutely swollen breast
8 years after having breast augmentation. During surgery, a
periprosthetic fluid collection is found that appears to be
consistent with a late seroma. What immunohistochemical
marker should be tested for when sending periprosthetic fluid
for cytology?
a. CD8
b. CD20
c. CD30
d. CD38

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7. A 24-year-old male with a 10-year history of T10 paraplegia
from a traumatic motor vehicle accident now presents with a
large stage-4 right greater trochanteric decubitus ulcer. MRI
shows communication with the hip joint. What is the most
appropriate next step in management?
a. IV antibiotics followed by flap coverage in 6 weeks
b. Coverage with a posterior thigh flap
c. Coverage with a pedicle ALT flap
d. Coverage with a tensor fascia lata flap
e. Resection of the femoral head
8. A 30-year-old male with history of multiple previous
abdominal procedures now presents for evaluation of a large
ventral hernia with a 25-cm fascial defect. Abdominal-wall
reconstruction using the technique of component separation
and mesh is planned. What is the plane of dissection to
maintain innervated muscle flaps?
a. Between skin and the fascia
b. Between the fascia and the external oblique
c. Between the external oblique and the internal oblique
d. Between the internal oblique and the transversalis fascia
e. Between the transversalis fascia and the peritoneum
9. A 48-year-old female with history of rectal cancer status
postradiation and low anterior resection is now presenting
with recurrent rectal cancer. Imaging studies are consistent
with invasion into the posterior vaginal wall in addition to
perineal involvement. She is scheduled to undergo abdomino-
perineal resection, hysterectomy, and posterior vaginal
resection. What would be the best single-stage reconstructive
option for this patient?
a. Pedicle vertical rectus abdominis muscle flap
b. Bilateral Singapore flaps
c. Primary closure of perineal and vaginal defects
d. Skin grafting
e. Vastus lateralis flap
10. A 32-year-old female is scheduled to undergo female-to-male
gender reassignment surgery. A radial fasciocutaneous flap is
being designed for creation of a neophallus. The procedure
involved neurorrhaphy of the lateral antebrachial cutaneous
nerve to the terminal branch of which of the following nerves?
a. Pudendal nerve
b. Lateral femoral cutaneous nerve
c. Posterior femoral cutaneous nerve
d. Ilioinguinal nerve
e. Iliohypogastric nerve
Chapter 12
1. Two days ago, a 45-year-old male suffered a sharp laceration
to his hand. He presented to the emergency room, where the
wound was cleaned and primarily closed. At present, he notes
numbness and tingling primarily at the small finger. What is
the best course of action?
a. Observation for recovery
b. Electrodiagnostic studies
c. Exploration and repair/graft as needed
d. Reverse end-to-side transfer to the ulnar nerve
2. For patients undergoing abdominal-wall reconstruction,
which of the following medical comorbidities has not been
shown to be associated with a fourfold increase in surgical site
infection rates?
a. Obesity
b. Diabetes
c. Steroid use
d. Smoking
e. Chronic obstructive pulmonary disease (COPD)
3. A 60-year-old diabetic male with a 15 × 20-cm2 recurrent
ventral hernia that was originally repaired with bridged
synthetic mesh presents for a second operation to address his
defect. He now presents with wound breakdown and
exposure of the mesh. Which is the most appropriate
technique to repair this patient’s recurrent ventral hernia?
a. Minimally invasive component separation with inlay
bioprosthetic mesh
b. Primary fascial closure without mesh
c. Open components separation with onlay synthetic mesh
d. Bridging technique with bioprosthetic mesh
4. An 87-year-old male with advanced Alzheimer’s disease
presents from an extended care facility with a left-sided
pressure sore overlying his greater trochanter. The wound
extends through the entire thickness of the skin down to
visible tendon, but no bone is visible at the base of the
wound. What is the stage of this pressure sore?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
5. A 36-year-old, otherwise healthy paraplegic woman presents
with a clean, recurrent, stage-3 sacral decubitus ulcer. This
sacral pressure ulcer was previously closed with bilateral V-Y
gluteus maximus advancement flaps. Which of the following
is the most appropriate surgical technique to surgically close
her wound?
a. Tensor fascia lata flap
b. Gluteus maximus musculocutaneous rotation flap
c. Readvancement of V-Y gluteus maximus flaps
d. Transverse back flap
6. An ambulatory 45-year-old male with spina bifida presents
with a 7-cm stage-4 sacral decubitus ulcer. The most
appropriate management would be reconstruction using
which of the following?
a. Full-thickness skin graft
b. Bilateral gluteal myocutaneous advancement flaps
c. Unilateral superior gluteal perforator flaps
d. Unilateral inferior gluteal artery myocutaneous rotational
flap
e. Posterior thigh flap

319
7. Diminished amplitude on a nerve conduction study (NCS) is
indicative of which of the following changes to the structure
of the nerve being evaluated?
a. Decreased myelination
b. Decreased number of intact axons
c. Fewer nodes of Ranvier
d. Fewer Schwann cells
e. Increased Schwann-cell senescence
8. A 32-year-old man sustained injuries to the right upper
extremity after being ejected from a motor vehicle. Four
weeks later, he presents to your office with a flaccid and
insensate left upper extremity, with NCSs demonstrating
preservation of sensory nerve action potentials. Testing of the
paravertebral muscles, biceps, triceps, and deltoids reveals
fibrillations and denervation in the motor action potentials.
The nerve injury is most likely located at which of the
following levels of the nerve?
a. Lateral cord
b. Suprascapular nerve
c. Preganglionic root
d. Posterior division
e. C5 and C6 trunk
9. A 60-year-old man presents with numbness and difficulty in
moving his ring and little fingers for the past year. Physical
examination shows inability to abduct and adduct the ring
and little fingers as well as first web-space atrophy and a
positive Froment’s sign. Sensation
to light touch is diminished. Electromyography (EMG) and
NCS are consistent with severe cubital tunnel syndrome. In
addition to ulnar nerve release at the elbow, which of the
following is the most appropriate management to restore
intrinsic muscle function?
a. Simultaneous Guyon’s tunnel release
b. End-to-side anterior interosseous nerve (AIN)-to-ulnar
nerve transfer
c. Sural nerve grafting at the elbow
d. Fascicular neurolysis
e. Vascularized nerve grafting at the elbow
10. A 29-year-old football player presents 3 months following a
right knee hyperextension injury that resulted in extensive
ligamentous injury in addition to a peroneal nerve palsy.
EMG/NCS obtained immediately prior to his office visit
demonstrated a persistent peroneal mononeuropathy. What
procedure has the best chance of providing the patient with
active dorsiflexion?
a. Ankle/foot orthosis
b. Peroneal decompression at the fibular head
c. Sural nerve grafting of the damaged peroneal nerve
segment
d. Partial tibial nerve transfer to the tibialis anterior
e. Peroneal neurolysis in the posterior fossa
2. A 27-year-old computer programmer presents 3 years after he
inadvertently put his arm through a plate glass window. Ever
since then, he notes loss of finger and thumb extension. He
was just covered by health insurance and wants surgery to
restore the best function possible. What do you recommend?
a. Distal median-to-radial nerve transfers to restore
individual finger and thumb flexion
b. Supinator-to-posterior interosseous nerve transfer
c. Tendon transfer of FCR to finger extensors and PL to
thumb extensor
d. Direct repair and decompression of the posterior
interosseous nerve
3. Which of the following is TRUE of nerve root avulsion
brachial plexus injuries?
a. Peripheral nerves do not undergo regeneration.
b. The Schwann cell body for motor nerves is located in the
descending columns.
c. Regeneration can occur across a gap of 2 cm or less.
d. The sensory nerve action potential (SNAP) is intact.
4. Which of the following would be present in a neurapraxia-
type nerve injury?
a. An advancing Tinel’s sign as recovery occurs
b. Normal distal and proximal conduction
c. Wallerian degeneration within but not between fascicles
d. None of the above
5. A patient has an extensive ulnar nerve injury at the level of
the elbow. All of the following are reasonable approaches
EXCEPT
a. Exploration and direct repair with the elbow flexed to
allow for tension-free repair
b. Exploration and repair using an interposed sural nerve
graft
c. Exploration and distal tendon and/or nerve transfers to
restore critical function
d. Exploration and repair using interposed medial
antebrachial nerve graft
e. Exploration, ulnar nerve transposition, and direct
tension-free repair.
6. A 19-year-old man presents to the emergency room shorty
after an altercation in which he was stabbed just above the
right clavicle. On exam, he demonstrates normal elbow
flexion and extension but decreased strength with wrist
flexion. There is also weakness of index, long-, ring-, and
little-finger flexion and difficulty with palmar abduction
against resistance. Finger, thumb, and wrist extension is
intact. Which structure is most likely to be injured?
a. Median nerve
b. Lateral cord
c. Middle trunk
d. Ulnar nerve
e. Medial cord

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4. Which of the following descriptions of surgical procedures for
treatment of upper limb lymphedema is incorrect?
a. Vascularized lymph node flap transfer is one of the most
effective surgical approaches for the treatment of
extremity lymphedema and is the first choice for all stages
of lymphedema.
b. Superficial groin lymph nodes are mostly located below
the inguinal ligament and are medial to the sartorius. This
group of lymph nodes can be transferred partially, as an
entire flap, or combined with a lower abdominal flap to
treat upper limb lymphedema.
c. There are at least 3 recipient sites available for
vascularized lymph node flap transfer for upper limb
lymphedema, including axilla, elbow, and wrist.
d. There is evidence showing that the wrist as a recipient site
for vascularized groin lymph node flap transfer had better
circumferential reduction in the elbow than using the
elbow as a recipient site.
5. Which of the following descriptions of surgical procedures for
treating lymphedema is incorrect?
a. Lymphovenous anastomosis, lymphaticovenular
anastomosis, lymphovenous bypass, and lymphovenous
shunting are almost the same terms regarding drainage of
excessive lymph into the venous system.
b. Lymphovenous anastomosis was further modified to
lymphaticovenular anastomosis by using
supermicrosurgery for the subdermal venular vessels and/
or for lymphatic ducts <0.8 mm.
c. Indocyanine green with fluorescence can be
preoperatively used to detect the functional lymphatic
ducts for better surgical outcome of lymphovenous
anastomosis.
d. With recent indocyanine lymphography, lymphovenous
anastomosis is very effective in early and advanced lower
limb lymphedema.
6. Several irreversible pathological changes occur when
lymphedema progresses. Which of the following is TRUE of
morphological characteristics in collecting lymphatic
channels?
a. Increase in endothelial cells
b. Constriction of valves
c. Destruction of smooth-muscle cells
d. None of above
7. A 52-year-old woman presents to the clinic with lymphedema
in the right upper extremity. When she underwent radical
mastectomy 2 years ago, edema of the right upper extremity
appeared and continued for 6 months, with ineffective use of
compression therapy. What is the most appropriate next step
for surgical treatment?
a. Debulking operation
b. Liposuction
c. Lymph node transfer
d. Lymphovenous bypass
Chapter 13
1. Which of the following descriptions of the etiology of
lymphedema is incorrect?
a. Filariasis is the most common primary lymphedema in
the world.
b. Lymphedema praecox is defined as the onset of primary
lymphedema between ages 2 and 35.
c. Secondary lymphedema is attributed to the obstruction of
lymphatic channels and an imbalance between the
production of lymph and the excretion of lymph in the
affected region.
d. Breast-cancer-related upper limb lymphedema is the most
common secondary lymphedema in developed countries.
2. Which of the following descriptions of nonsurgical
procedures for treatment of lymphedema is incorrect?
a. Risk-reduction education is important for the cancer
survivor to maximize self-management and adherence to
treatment.
b. Complete decongestive therapy is the first choice. In
addition, the effective combination of techniques to
decongest soft-tissue swelling of lymphedematous limbs is
also important.
c. There is no requirement that lymphedema patients who
undergo liposuction of the extremity continuously wear
compression garments 6 months after surgery.
d. Skin care, avoiding limb constriction, and use of
compression garments are important risk-reduction
practices.
3. Which of the following descriptions of surgical procedures for
treatment of lymphedema is incorrect?
a. Charles procedure and liposuction are the options for
reduction of the volume and soft tissue of
lymphedematous limbs.
b. Charles procedure was first introduced for the treatment
of scrotum lymphedema and is now used for advanced-
stage lymphedematous limb, a lower limb lymphedema.
c. Toe infections and cellulitis will not occur after Charles
procedure because there is almost no soft tissue preserved
on the affected extremity.
d. Radical reduction of the lymphedematous limb may be
combined with the preservation of perforator technique
for reducing complications such as skin loss and blood
loss during surgery.

321
6. A 3-month-old child presents with facial anomalies and
bilateral hand complex syndactyly, consistent with Apert
syndrome. What gene or mutation is involved with these
anomalies?
a. Sonic hedgehog (SSH)
b. Fibroblast growth factor receptor type 2 (FGFR-2)
c. Wnt7a
d. Trisomy 13
e. 22q11.2 deletion
7. You are asked to consult on a newborn child with absent
thumbs bilaterally. On exam, you identify a prominent heart
murmur. What syndrome is likely to be the diagnosis?
a. Fanconi anemia
b. Turner syndrome
c. Thrombocytopenia–absent radius syndrome
d. Holt-Oram syndrome
e. Amniotic band syndrome
8. A 3-year-old presents with curvature of the right small finger
and a radiograph showing a triangular-shaped phalanx. The
diagnosis is
a. Camptodactyly
b. Symbrachydactyly
c. Clinodactyly
d. Pouce flottant
e. Brachydactyly
9. The development of the upper limb and hand is completed by
which gestational week?
a. 4 weeks
b. 5 weeks
c. 6 weeks
d. 8 weeks
10. A mother brings her 18-month-old boy with thumb
hypoplasia to learn about his surgical options. On exam, the
patient demonstrates instability of the carpometacarpal
(CMC) joint, and on radiographs the patient demonstrates a
hypoplastic CMC joint. A Blauth type-IIIB classification is
made. The most appropriate surgical intervention is
a. Amputation of the residual thumb
b. Big-toe-to-thumb transfer
c. Opponensplasty with ulnar collateral ligament repair
d. Second-toe-to-thumb transfer
e. Amputation of the residual thumb and index pollicization
Chapter 15
1. A 25-year-old right-hand-dominant accountant reports
persistent pain in the proximal phalanx of his left middle
finger for several months. The pain is relieved by ibuprofen.
X rays of his wrist and hand suggest osteoid osteoma. What is
the most likely radiographic appearance of the lesion?
a. Poorly defined lytic lesion with stippled calcifications,
cortical expansion, soft-tissue extension
b. Small lucency surrounded by a rim of sclerotic bone
c. Well-defined lobulated lytic lesion
d. Moth-eaten lytic appearance with an aggressive
“sunburst” periosteal reaction
8. Which of the following is NOT an aggravating factor for
lymphedema?
a. Postoperative radiotherapy
b. Sex
c. Recurrent phlegmone
d. Lymph node dissection
9. A 68-year-old woman presents to the clinic with skin changes
on her right arm. She underwent radical mastectomy and
adjuvant postoperative radiation therapy 20 years ago and
had long-standing lymphedema in her right arm afterward.
Clinical examination revealed numerous bluish skin nodules.
Which of the following is the most likely diagnosis?
a. Lymphangiosarcoma
b. Melanoma
c. Blue nevus
d. Basal cell carcinoma
10. Which of the following correctly describes the state of
lymphedema?
a. It is immunologically vulnerable.
b. It is characterized by an increase in lymph fluid
circulation.
c. The skin becomes soft.
d. It is associated with a high resistance to infection.
Chapter 14
1. The standard time to release a simple, incomplete syndactyly
of the 3rd webspace is
a. Newborn period
b. Under 6 months of age
c. Between 1 and 2 years of age
d. Over 2 years but before school age
2. Following surgical correction of a Wassel-type-IV radial
polydactyly, long-term complications include all of the
following EXCEPT
a. Diminished size of retained thumb
b. Angular deformity
c. Stiffness
d. Diminished sensation
3. The most common congenital hand malformation is
a. Syndactyly
b. Polydactyly
c. Amniotic band syndrome
d. Radial dysplasia
4. Which of the following structures is NOT typically divided
during a standard pollicization?
a. Index-finger metacarpal
b. A1 pulley
c. Digital artery
d. Thumb metacarpal
5. The following clinical features may be useful in distinguishing
symbrachydactyly and amniotic band syndrome EXCEPT
a. Multiple limb involvement
b. Fenestrations (sinus tracts) between the fingers
c. Absent family history
d. Absent ipsilateral pectoralis major muscle

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7. A 44-year-old patient complains of 2-year history of episodic
severe sharp pain in his middle finger. Physical exam
demonstrates a slight ridge in the nail plate, the proximal
aspect of which is profoundly tender to palpation. X ray
shows localized scalloping on the dorsal aspect of the distal
phalanx. What is the most likely diagnosis?
a. Mucous cyst
b. Subungual melanoma
c. Glomus tumor
d. Giant cell tumor
e. Osteoid osteoma
8. A 56-year-old construction worker presents with painful
ulcerations on the small and ring fingers of his dominant
hand for the last 3 months. He has arterial Doppler signals in
all 5 digits. There is a palpable pulse in Guyon’s canal. What
would most likely be seen on ultrasonography?
a. Ulnar artery occlusion
b. Ulnar artery aneurysm
c. Incomplete palmar arch
d. Normal radial and ulnar arteries
e. Bacterial endocarditis
9. A patient with Dupuytren’s disease and proximal
interphalangeal (PIP) joint contracture is scheduled for open
palmar fasciectomy. Which specific cord type places the
neurovascular bundle at greatest risk for surgical injury?
a. Spiral cord
b. Central cord
c. Natatory cord
d. Lateral cord
e. Retrovascular cord
10. Which of the following anatomic structures does not
contribute to formation of Dupuytren’s cords?
a. Lateral digital sheet
b. Spiral band
c. Pretendinous band
d. Grayson’s ligament
e. Cleland’s ligament
Chapter 16
1. What allows for greater tolerance of apex dorsal angulation
deformity of 5th metacarpal neck fractures?
a. Greater flexion arc at 5th MPJ masks the angulation.
b. The cam effect of the 5th MPJ prevents further fracture
displacement.
c. Extension at 5th CMC joint helps compensate for the
apex dorsal angulation.
d. Relative laxity of the 5th MPJ volar plate prevents a
flexion deformity of the joint.
2. If a minimally displaced distal phalanx fracture presents with
an associated subungual hematoma involving a third of the
area of the nail plate, the most appropriate treatment is
a. Nail trephination and closed treatment of the fracture
b. Nail trephination and percutaneous pin fixation
c. Nail removal and closed treatment of the fracture
d. Nail removal and percutaneous pin fixation
2. A 36-year-old left-hand-dominant woman presents with
subungual longitudinal pigmentation that has been present
on her left thumb for 3 months. The lesion occupies 1/3 of the
width of her nail. She states that it has not changed in
appearance since it first appeared. What is your initial
management?
a. Nail-plate removal, matrix biopsy
b. Continued observation
c. Ray amputation
d. Complete excisional biopsy with sentinel lymph node
biopsy (SLNB)
3. Which of the following structures does not contribute to the
spiral cord in Dupuytren’s disease?
a. Pretendinous band
b. Lateral digital sheet
c. Cleland’s ligament
d. Grayson’s ligament
e. Natatory ligament
4. A 45-year-old construction worker comes to the clinic
complaining of ulnar-sided-palmar small and ring-finger
pain. On exam, there is a pulsatile mass over ulnar side of the
palm, and he has ulceration at the tips of his small and ring
fingers. Which of the following is not part of the typical
workup for this condition?
a. X ray
b. Ultrasound
c. Angiogram
d. EMG
5. A 21-year-old man sustained a distal radius fracture when his
left arm was pinned under a motorcycle. Closed reduction of
the distal radius was performed and a short arm splint
applied. Six hours later, he returned to the emergency room
with increasing pain in his forearm. His fingers are warm.
What is the next most appropriate step?
a. Administration of IV pain medication
b. Splint removal
c. Discharge with oral pain medication
d. Complete blood count (CBC), erythrocyte sedimentation
rate (ESR), C-reactive protein (CRP) test
e. CT scan
6. A 68-year-old patient presents with pain at the distal
interphalangeal (DIP) joint of her index finger. Palpation
reveals a 6-mm fixed mass at the dorsal aspect of the DIP. A
small osteophyte is seen on X ray. What is the most likely
etiology of the mass?
a. Synovial sarcoma
b. Mucous cyst
c. Osteoid osteoma
d. Glomus tumor
e. Enchondroma

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9. The most appropriate treatment of a comminuted 1st
metacarpal base (Rolando) fracture is
a. Cast immobilization with outrigger
b. ORIF
c. External fixator application with axial traction across
trapeziometacarpal joint
d. Trapeziectomy, ligament reconstruction, and tendon
interposition
10. A 33-year-old surgical resident presents with a fracture
dislocation of the dominant middle-finger PIP joint. The
lateral radiograph shows a <10% avulsion fragment involving
the base of the middle phalanx. Using live fluoroscopy in the
office, the joint becomes unstable at 20 degrees of PIP-joint
flexion. The most appropriate treatment is
a. Dorsal blocking splint set at 15 degrees of PIP flexion
b. Dorsal blocking pin allowing a 40 to 110 degree flexion arc
c. Force-coupler dynamic pinning
d. Volar plate arthroplasty
Chapter 17
1. A 43-year-old male is brought to the emergency room
immediately after sustaining a laceration of the left thumb
while using a table saw at home. He has loss of skin and
subcutaneous tissue on the volar aspect of the thumb from
the metacarpophalangeal joint (MPJ) flexion crease to the
interphalangeal joint flexion crease. The flexor tendon and
digital neurovascular bundles are exposed at the wound base,
but perfusion and sensation of the tip of the thumb are intact.
Which of the following is the most appropriate management?
a. Full-thickness skin grafting
b. Reconstruction with a first dorsal metacarpal artery
(FDMA) flap
c. Reconstruction with a thenar flap
d. Reconstruction with a volar advancement (Moberg) flap
2. Replantation is most likely to be contraindicated in which of
the following patients who have sustained an amputation of a
single digit at the level of the proximal interphalangeal joint?
a. A 4-year-old girl with an amputation through the index
finger
b. A 28-year-old construction worker with an amputation
through the index finger
c. A 33-year-old piano player with an amputation through
the long finger
d. A 45-year-old carpenter with an amputation through the
thumb
3. A 37-year-old male comes to the emergency room after
sustaining an amputation at the fingertip of the long finger of
the dominant hand while attempting to unclog a lawnmower.
Physical examination shows pulp loss of 1 × 1.2 cm. Which of
the following is the most appropriate method of
reconstruction to maximize sensation and function?
a. Cross-finger flap from the ring finger
b. Full-thickness skin graft harvested from the hypothenar
eminence
c. Moist dressing changes until healing is complete
d. V-Y advancement flap
3. A 35-year-old patient presents with a 3-month history of
finger swelling and stiffness after an axial load injury. Plain
films demonstrate a PIP joint fracture dislocation with no
associated arthrosis. The comminuted volar fracture fragment
involves 2/3 of the joint surface seen on the lateral plain film.
The most appropriate treatment is
a. Force-coupler dynamic pinning
b. ORIF
c. Closed reduction and percutaneous pinning
d. Hemi-hamate arthroplasty
4. Of the following, the best treatment for a symptomatic
gamekeeper’s thumb with >30 degrees of laxity compared to
the contralateral side is
a. Cast immobilization for 6 weeks
b. Percutaneous pin fixation
c. Primary ligament repair
d. Ligament reconstruction with tendon graft
5. The deforming forces of a Bennett fracture that must be
overcome during the reduction maneuver originate from
a. Abductor pollicis brevis and abductor pollicis longus
(APL)
b. Flexor pollicis longus and abductor pollicis brevis
c. Adductor pollicis and APL
d. Adductor pollicis and abductor pollicis brevis
6. A 35-year-old male sustains an axial load injury to his
nondominant middle finger with a gross flexion deformity.
Lateral plain films demonstrate a distal phalanx dorsal base
avulsion fracture involving 20% of the joint surface. The best
treatment is
a. ORIF
b. Closed reduction and percutaneous pin fixation
c. Closed treatment with clamshell splint
d. Excision of bony avulsion fragment and sutured anchor
repair of tendon insertion
7. A 40-year-old male presents to the emergency room after a
basketball injury that results in a nonreducible deformity of
the 3rd metacarpal phalangeal joint. Plain films demonstrate a
dorsal dislocation. After 3 attempts, the emergency room calls
for further assistance. Which of the following structures is
NOT typically implicated in the complex dislocation?
a. Flexor tendon
b. Volar plate
c. Lumbrical
d. Intermetacarpal ligament
e. A1 pulley
8. A patient presents 8 years after an untreated soft-tissue mallet
injury. What is the expected associated deformity?
a. Swan-neck deformity
b. Boutonnière deformity
c. Camptodactyly
d. Clinodactyly

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8. During coverage of a defect with a reverse cross-finger flap,
which of the following is the most appropriate location for
application of a full-thickness skin graft?
a. Dorsal surface of the middle phalanx of the donor finger
b. Dorsal surface of the middle phalanx of the recipient
finger
c. Volar surface of the distal phalanx of the donor finger
d. Volar surface of the distal phalanx of the recipient finger
9. A 31-year-old male comes to the office 12 weeks after
sustaining an amputation of the tip of the long finger that
healed by secondary intention and has resulted in a hook nail
deformity. Physical examination shows the residual nail
growing over the residual tip of the finger. Which of the
following is the most likely cause of this patient’s current
condition?
a. Dorsal-sided tissue loss with loss of eponychial fold
b. Dorsal-sided tissue loss with loss of germinal matrix
c. Volar-sided tissue loss with the nail bed folding over the
residual tip
d. Volar-sided tissue loss with nail-bed overgrowth by
eponychial fold
10. A 13-year-old girl is brought to the emergency room because
of persistent pain and bruising under the fingernail of her left
small finger 4 hours after sustaining a crush injury. Physical
examination demonstrates a subungual hematoma that is
contained to a portion distal to the lunula, consisting of
~40% of the nail. The surrounding nail plate is adherent and
intact, and the nail plate is not torn or lifted. Which of the
following is the most appropriate management for this
patient?
a. Digital block with epinephrine
b. Elevation
c. Nail-plate removal and sterile matrix graft
d. Trephination
Chapter 18
1. A 47-year-old female presents with pain, swelling, and limited
range of motion of the right wrist after sustaining a fall on the
outstretched hand. X-ray imaging of the wrist demonstrates a
distal radius fracture. All of the following are radiographic
indications for operative ORIF except
a. Intra-articular fracture with >2 mm of articular step-off
b. Radial shortening (positive ulnar variance) of >3 mm
c. Loss of >10 degrees of volar angulation
d. Nondisplaced intra-articular fracture with radial styloid
involvement
4. A 12-year-old girl is brought to the office 2 years after she
sustained a crush injury to the nail bed of her left ring finger.
Her mother says that the nail grows but then lifts off the
finger and catches onto her clothes. The patient complains
that the nail looks ugly. On examination, the germinal matrix
is intact, but 95% of the sterile matrix is scarred. Which of the
following is the most appropriate treatment to improve her
nail deformity?
a. Full-thickness nail-bed grafting from the long finger
b. Lateral paronychial-releasing incisions with central
advancement flap
c. Release of the sterile matrix scar and acellular dermal
matrix grafting
d. Split-thickness nail-bed grafting from the great toe
5. A 38-year-old male is brought to the emergency room 5 hours
after sustaining an amputation of the right thumb when it
was caught in a log-splitter. The amputated part was wrapped
in moist saline gauze and placed on ice within 15 minutes of
the injury. The amputated thumb has a long flexor tendon
attached to it, with remnants of muscle attached to the
proximal end of the tendon. Which of the following factors is
most likely to limit the success of replantation of the thumb?
a. Initial treatment of digit
b. Mechanism of injury
c. Possibility of infection
d. Warm ischemia time
6. A 28-year-old male sustains an avulsion injury to the index
finger of his nondominant left hand after it is caught in a
piece of machinery while at work. He says he needs to return
to his job as a manual laborer as soon as possible. The bone
of the proximal phalanx is exposed. The avulsed segment of
the finger includes the distal and middle phalanges and soft
tissue to the level of the midproximal phalanx, along with
segments of tendons, nerves, and vessels. Which of the
following is the most appropriate management?
a. Coverage with a groin flap
b. Microvascular replantation
c. Revision amputation
d. Skin grafting
7. A 52-year-old male is brought to the emergency room after
sustaining an injury to the right thumb and index finger from
a snowblower. Physical examination demonstrates
amputation of the right thumb at the CMC joint and
amputation of the index finger at the head of the middle
phalanx. The amputated thumb was wrapped in a moist
gauze towel immediately after the injury and appears to be
severely mangled. Which of the following would be the
optimal management of the thumb acutely?
a. Great-toe-to-thumb transfer
b. Osteoplastic thumb reconstruction
c. Replantation of the thumb
d. Residual index-finger pollicization

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6. A 35-year-old male suffers a complete tear of his scapholunate
(SL) interosseous ligament. Over time, if left untreated, which
of the following relationships would you expect to develop?
a. A dorsal intercalated segment instability (DISI) deformity,
including a SL angle of 90 degrees and a gap of >3 mm
between the scaphoid and lunate
b. A DISI deformity, including a SL angle of 45 degrees, and
a gap of >3 mm between the scaphoid and lunate
c. A volar intercalated segment instability (VISI) deformity,
including a SL angle of 90 degrees and a gap of >3 mm
between the scaphoid and lunate
d. A DISI deformity, including a SL angle of 90 degrees and
a gap of <2 mm between the scaphoid and lunate
e. A VISI deformity, including a SL angle of 45 degrees and
a gap of >3 mm between the scaphoid and lunate
7. A 28-year-old man falls from a second-story window and is
evaluated for pain in his right wrist. On exam, he has pain
with wrist extension and palpation in the snuffbox.
Radiographs reveal a radiolucency across the proximal
scaphoid with 2 mm of displacement. If not treated
appropriately, he is at risk for developing all of the following
except
a. Carpal arthritis
b. Humpback deformity
c. Proximal pole avascular necrosis
d. SL advanced collapse (SLAC) wrist
8. A 60-year-old male with chronic wrist pain presents to the
office. There is a remote history of an untreated scaphoid
fracture, and radiographs obtained in the office reveal
significant wrist arthritis. After unsuccessful conservative
measures have been attempted, a PRC is planned. Significant
arthritic changes of what articular surface would preclude
moving forward with this treatment plan?
a. Radioscaphoid
b. Scapholunate
c. Capitolunate
d. Lunotriquetral
e. Scaphotrapeziotrapezoidal
9. Four-corner fusion involves arthrodesis of all of the following
carpal bones EXCEPT
a. Scaphoid
b. Lunate
c. Triquetrum
d. Capitate
e. Hamate
10. A professional baseball player is evaluated for hand pain that
affects his ability to hit a ball. A hook of hamate fracture is
suspected. What type of radiograph will help identify this
fracture?
a. Roberts view
b. PA
c. Lateral
d. Oblique
e. Carpal tunnel view
2. A 26-year-old male presents with persistent wrist pain 3 weeks
following a fall from a ladder at work. Initial radiographs
obtained in the emergency department showed no evidence
of fracture or dislocation. A repeat standard anteroposterior
(AP) radiograph in the office demonstrates a 3-mm gap of the
SL interval. A SL ligament injury is suspected. Which of the
following additional radiographic views may be helpful in
making the diagnosis?
a. Radial deviated posteroanterior (PA) view
b. Clenched fist AP view
c. Pronated oblique view
d. Roberts view
3. An 18-year-old male has persistent pain and limited range of
motion at 6 months following nonvascularized bone grafting
from the ipsilateral distal radius for a scaphoid proximal pole
fracture nonunion. Radiographs in clinic are consistent with
persistent nonunion. What is the next best step in
management?
a. Repeat nonvascularized bone graft (iliac crest, tibia, distal
radius)
b. Total wrist arthroplasty
c. Vascularized bone graft (retrograde distal radius bone
flap, medial femoral condyle flap)
d. Total wrist arthrodesis
4. When considering partial wrist arthrodesis with a proximal
row carpectomy (PRC), which articular surfaces must be free
of arthritic/degenerative changes seeing as they will become
the main articulation (“hinge joint”) of the wrist following
excision of the proximal row?
a. Capitate and lunate fossa of the radius
b. Hamate and lunate fossa of the radius
c. Capitate and scaphoid fossa of the radius
d. Hamate and lunate fossa of the radius
5. A 62-year-old female with severe rheumatoid arthritis
complains of tenderness overlying the A1 pulley of the index
finger with intermittent flexion “locking” throughout the day.
An index trigger finger is diagnosed and corticosteroid
injection is performed. If steroid injection fails and operative
intervention is considered, which of the following should be
performed in this patient?
a. Release of the A1 pulley
b. Flexor tenosynovectomy and intratendinous nodule
excision
c. Release of the A1 pulley with pulley reconstruction
d. Release of the A1 and A2 pulleys

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3. Which of the following muscles is the prime wrist extensor?
a. Extensor carpi ulnaris
b. Extensor carpi radialis brevis (ECRB)
c. Extensor carpi radialis longus
d. Extensor digitorum communis (EDC)
4. A 45-year-old female presents to your office complaining of
right-radial-sided wrist pain. On examination, she has
tenderness and swelling proximal to the radial styloid. The
pain is exacerbated when the wrist is forced into ulnar
deviation with the thumb adducted into the palm. Which of
the following tendons are involved?
a. APL and extensor pollicis brevis
b. Extensor pollicis longus
c. Adductor pollicis
d. Extensor carpi radialis longus and ECRB
5. A 35-year-old male with cerebral palsy is brought to your
office by his mother for evaluation of his hand disorder. On
examination, he has flexion contractures of his digits, such
that it is difficult to get his fingers out of the palm for daily
hygiene. Which of the following tendon transfers could be
used to help correct this deformity?
a. PL to extensor pollicis longus (EPL) transfer
b. FCR to EDC transfer
c. FDS to flexor digitorum profundus (FDP) transfer
d. Extensor indicis proprius (EIP) to EPL transfer
6. A patient is brought to the operating room for a laceration in
zone 7 with loss of index- and long-finger extension. A
muscular mass that extends the long finger is encountered
adjacent to the EDC tendon. What is this anomalous muscle’s
innervation?
a. Median nerve
b. Ulnar nerve
c. Dorsal ulnar nerve
d. Posterior interosseous nerve
7. A boxer presents to your clinic with an inability to extend the
long finger after he makes a fist. This occurred suddenly after
a match. The patient had no laceration. When asked to
extend the finger, he extends at the MPJ of each digit, except
for the long finger. The PIP and DIP extend normally. When
passively extended, he can hold the position. There is a snap
with active flexion. What structure is injured?
a. Extensor digitorum longus
b. Terminal tendon
c. Sagittal band
d. Oblique retinacular ligament
8. Following repair of a deep laceration of the volar forearm
with multiple tendons involved, the patient bends her thumb
when attempting to bend the index. Which of the following
statements, if true, can be used to prevent this complication?
a. The FDS of the index finger is superficial to the palmaris
longus.
b. The flexor digitorum pollicis is deep to the FDS of the
index.
c. The flexor pollicis longus is radial to the FDP.
d. The flexor pollicis longus is ulnar to the FDP.
11. In a complete lunate dislocation (Mayfield stage-IV perilunate
dislocation), in order for the lunate to become dislocated out
of the lunate fossa, which two ligaments are completely torn?
a. SL and short radiolunate
b. SL and lunotriquetral
c. Lunotriquetral and radioscaphocapitate
d. Lunotriquetral and dorsal intercarpal ligament
e. Radioscaphocapitate and dorsal intercarpal ligament
12. Several months out from a distal radius fracture, a patient
suffers a tendon rupture. On exam, what action is most likely
to be impaired?
a. Thumb extension
b. Radial wrist extension
c. Extension of the index finger
d. Radial wrist flexion
e. Thumb abduction
13. A 25-year-old male injured his right wrist after a fall from a
motorcycle accident 1 year ago. Radiographs reveal no
fracture, but lateral X rays of his wrist reveal his scaphoid to
be in a flexed position and at a SL angle of 80 degrees. What
structure is most likely injured?
a. Lunotriquetral interosseous ligament
b. Radioscaphocapitate ligament
c. SL interosseous ligament
d. Short radiolunate ligament
e. Long radiolunate ligament
14. A 68-year-old male complains of constant hand pain. He has
difficulty opening jars and his grind test is positive. X rays
will likely reveal arthritic changes at the
a. Radioscaphoid joint
b. Thumb metacarpal phalangeal joint
c. Trapeziometacarpal joint
d. Index-finger proximal interphalangeal joint
e. Thumb interphalangeal joint
Chapter 19
1. Which of the following statements regarding the contents of
the carpal canal is false?
a. The flexor digitorum superficialis (FDS) tendons to the
ring and middle finger lie dorsal to the FDS tendons to
the index and small.
b. The FDP tendons lie on the dorsal floor of the carpal
canal.
c. The FPL tendon lies along the radial aspect of the carpal
canal.
d. The FDS tendons to the ring and middle finger lie volar
to the FDS tendons to the index and small.
2. Which of the following can adversely affect the strength of a
tendon repair?
a. Increasing number of core strands across the repair site
b. Epitendinous sutures
c. Immobilization
d. Locking sutures

327
4. Which of the following effects does negative pressure wound
therapy (NPWT) exert on a wound?
a. Macrodeformation of wound edges
b. Increases matrix metalloproteinases
c. Dessication of the wound
d. None of the above
5. Which of the following is the most likely mechanism by
which silicone affects wound healing?
a. Alters cytokine levels within the wound
b. Directly affects the healing cascade
c. Increases oxygen tension within the wound
d. Increases hydration within the wound
6. You are called on to evaluate a patient on the oncology
service who has just had an infiltration of an unknown
amount of intravenous chemotherapy medication into the
forearm. The skin around the infiltration site is cool, painful,
and quite swollen. In the hand, the fingers have good capillary
refill and the hand shows no sensory deficits. What is the
most reasonable option for treatment?
a. Decompressive fasciotomies of the compartments of the
forearm and hand
b. Decompressive fasciotomies of the compartments of the
forearm only
c. Injection of saline and hyaluronidase into the area of
infiltration injury
d. Operative debridement of the skin infiltrated with the
chemotherapy medication
7. What is a major benefit of enzymatic debriders in the
management of chronic wounds?
a. They are FDA approved as a means of enabling closure of
all types of wounds.
b. They are a gentle means of assisting removal of biofilm
from wounds.
c. They are a form of autolytic ointment.
d. They can be used with any dressing.
8. What are some reasons why chronic wounds do not heal?
a. Age
b. Ischemia
c. The presence of bacteria
d. All of the above
9. A 38-year-old female of Asian ancestry undergoes an
abdominoplasty. Six months after the procedure, she returns
complaining of a thickened, raised, red, and pruritic scar at
the midportion of the scar, which follows the borders of the
original incision. Which therapy is most likely to be useful in
managing this problematic scar?
a. Excision followed by focused external beam radiation
b. Cryotherapy
c. Laser treatment of the hypertrophic scar
d. Anti–transforming growth factor-β (anti-TGF-β)
antisense medication
9. Which pulleys are the most anatomically significant and must
be preserved or reconstructed in the event of injury?
a. A1 and A4
b. A2 and A4
c. C2 and C4
d. A2 and A3
10. A 60-year-old female patient presents to your office 9 months
following a degloving injury of the dorsal proximal forearm,
including avulsion of the radial nerve. She was reconstructed
with a free flap to cover widely exposed radius and ulna. Her
complaint is inability to extend the fingers, wrist, or thumb.
Passive motion is adequate. The distal forearm is uninvolved.
What is the most appropriate treatment strategy to improve
her motion?
a. FDS IV to ECRB, flexor carpi ulnaris (FCU) to EDC, PL
to EPL tendon transfers
b. Pronator teres (PT) to ECRB, FCU to EDC,
brachioradialis (BR) to EPL tendon transfers
c. PT to ECRB, FCU to EDC, PL to EPL tendon transfers
d. Wrist arthrodesis
Chapter 20
1. Two days ago, a 45-year-old male suffered a deep laceration
to his right lower extremity. He presented to the emergency
room where the wound was cleaned and primarily closed. At
present, what is the predominant cell type within the healing
wound?
a. Neutrophil
b. Fibroblast
c. Macrophage
d. Platelet
2. A 27-year-old male pedestrian was struck by a motor vehicle,
resulting in avulsion of 50% of his scalp. The wound was
closed temporarily with a split-thickness skin graft along with
the placement of scalp tissue expanders. Which of the
following correctly describes the properties of newly expanded
skin?
a. The total collagen content and surface area is increased,
and the tensile strength and elasticity are decreased.
b. The total collagen content, surface area, and tensile
strength is increased, and the elasticity is decreased.
c. The surface area is increased, and collagen content, tensile
strength, and elasticity are decreased.
d. The total collagen content, surface area, tensile strength,
and elasticity are increased.
3. Which of the following is TRUE of keloid scars?
a. Keloid scars have increased myofibroblasts.
b. Keloid scars are contained by the original boundaries of
the scar.
c. Keloid scars often produce contractures and occur over
flexor surfaces.
d. Keloid scars occur more frequently in darker pigmented
patients.

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3. A 60-year-old male with poorly controlled diabetes mellitus
presents to the emergency room with tachycardia, significant
hypotension, and leukocytosis. After initial stabilization,
physical examination demonstrates significant erythema and
crepitance of the scrotum and perineum, which his spouse
reports was not present yesterday. The most appropriate next
step should be
a. Urgent, radical, surgical debridement of scrotum and
perineum
b. STAT skin biopsy to evaluate for cellulitis
c. Scrotal ultrasound to evaluate for testicular torsion
d. Pelvic CT scan to evaluate for subcutaneous air
e. Intravenous metronidazole for anaerobic coverage
4. A 6-year-old girl presents with a 1-week history of a 4-cm area
of slowly increasing induration and swelling of her right thigh
with a 1-day history of a central opening with a small amount
of pus and necrotic-appearing tissue. Her pediatrician started
her on cephalexin 3 days ago. She has no allergies. After
performing an adequate bedside drainage, the Gram stain
shows Gram-positive cocci in clusters. What is the most
appropriate antibiotic for home therapy?
a. Vancomycin
b. Cephalexin
c. Linezolid
d. Sulfamethoxazole/trimethoprim
e. Tetracycline
5. A 40-year-old woman presents to the emergency room with a
24-hour history of worsening index-finger pain and swelling
after her cat bit that finger 2 days ago. Which of the following
signs would NOT be consistent with a suppurative flexor
tenosynovitis?
a. Flexion of the PIP joint at rest
b. Fusiform swelling of the digit
c. Pain on passive extension of IP/MCP joints
d. Pain on palpation along flexor tendon sheath into palm
e. Fingers held in an intrinsic plus position
6. A 63-year-old male presents to the emergency department
with a complaint of fever, lethargy, and severe pain of the
genitals and lower abdomen. He has a history of poorly
controlled diabetes mellitus. Examination is notable for a
BMI of 42 kg/m2, a temperature of 101, HR of 113 bpm, and
blood pressure of 87/25 mmHg. There is erythema and
tenderness of the scrotum extending into the groin and lower
abdomen. Following the administration of intravenous
hydration and antibiotics, what is the most appropriate next
step in management?
a. Observation alone
b. Hyperbaric oxygen
c. CT scan of the abdomen
d. Surgical debridement of affected tissues
10. A 55-year-old female patient with a history of heart disease,
severe rheumatoid arthritis, and right breast cancer treated 10
years prior with lumpectomy and radiation presents with a
nonhealing wound of her left lower back. It resulted from a
scratch and has enlarged during the last 6 weeks to a size of 2
× 3 cm. It is painful, bleeds easily, and has a mild amount of
slough on it. She is referred to you because her wound-care
doctor has been treating it with serial debridements and
silver-containing dressings without improvement and appears
to be progressively getting larger. What is a reasonable next
option in your plan for treatment?
a. Debridement followed by coverage with a skin graft
b. Hyperbaric oxygen treatment to enhance healing of the
wound
c. Biopsy of the wound
d. Treatment with systemic steroids
Chapter 21
1. A 20-year-old male presents to the emergency room with
significant hand and forearm tenderness 2 hours after being
bit in the hand by his friend’s pet rattlesnake. On
examination, he is mildly tachycardic with stable blood
pressure. Focused examination of his upper extremity reveals
mild diffuse swelling and moderate-to-severe pain with
palpation of the forearm and flexion/extension of the fingers.
Two small puncture wounds are noted in the first webspace.
The most appropriate first treatment is
a. Operative exploration of puncture wounds with aggressive
debridement and forearm compartment release
b. Administration of crotalidae polyvalent immune fab ovine
(CroFab)
c. Administration of piperacillin and tazobactam
d. Upper extremity elevation
e. Regional anesthetic block for pain control
2. An 18-year-old male presents to the emergency room with 24
hours of right-middle-finger pain and swelling over his
knuckle. He was in a fight two nights ago and has multiple
small wounds across the dorsum of his hand. On focused
examination, he has significant swelling and pain around the
middle-finger metacarpal phalangeal joint with further pain
on axial loading. His white blood cell count is 16,000 cells/
mL. Radiographs are negative for fracture and foreign bodies.
What is the most important step in management?
a. Irrigation of wounds in the emergency room
b. Administration of metronidazole IV
c. Elevation of extremity with close observation
d. Operative exploration of the MPJ
e. Operative exploration of flexor tendon sheath

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Chapter 22
1. A 50-year-old woman sustains full-thickness circumferential
burns to her entire left upper extremity, partial-thickness
burns to the anterior surface of her entire left lower
extremity, and first-degree burns to her entire face (not
scalp). What is the total body surface area (TBSA) of burn
used to calculate her fluid requirements?
a. 18%
b. 22%
c. 36%
d. 40%
2. A 30-year-old sustains a 25% TBSA burn injury. According to
the Parkland formula, the initial IV fluid used for
resuscitation therapy should be
a. Hypotonic saline
b. Normal saline
c. Ringer’s lactate
d. 5% dextrose and water
3. A 35-year-old worker spilled sodium hydroxide on his hand.
What is the initial Rx?
a. Apply calcium gluconate gel to neutralize.
b. Apply mineral oil to neutralize.
c. Rinse with a dilute solution of boric acid to neutralize.
d. Rinse with water.
4. A 35-year-old female applied a petrolatum-based hair-
straightening product to her hair and then lit a cigarette. She
presents with 6% TBSA burns of scalp and ears. What topical
treatment should be used on the ears to prevent chondritis?
a. Silver sulfadiazine
b. Silver nitrate
c. Mafenide acetate
d. Mupurocin
5. A 38-year-old homeless man presents with deep frostbite of
his hands. Initial treatment should be to
a. Warm hands in water bath at 37 °C
b. Warm hands in water bath at 40 °C
c. Warm hands with hot packs wrapped in a towel
d. Obtain arteriogram
6. A 35-year-old electrician sustains contact with a 10,000-V line.
He presents with fixed flexion of his right wrist with charring,
a pulseless hand, and a tense forearm. After cardiopulmonary
resuscitation, patient should undergo
a. EMG
b. Intravenous infusion of mannitol
c. Decompressive fasciotomies
d. Amputation at proximal wrist
7. A 4-year-old spilled hot noodles on his lap, sustaining
superficial and deep partial-thickness burns to the genitalia,
groin, and thigh, totaling 3% TBSA. According to American
Burn Association (ABA), this burn would be classified as a
a. Minor burn
b. Moderate burn
c. Intermediate burn
d. Major burn
7. A 27-year-old, otherwise healthy hiker is brought to the
emergency room complaining of a copperhead bite to his left
lower leg 2 hours earlier. The patient does not remember his
immunization history. His vital signs are stable, and
examination reveals a bite wound of the left lower leg with
mild surrounding edema. He has no other findings of note.
In addition to immobilization and administration of
broad-spectrum antibiotics, what is the most appropriate next
step in management?
a. Administration of antivenin
b. Administration of tetanus toxoid
c. Wide debridement of the bite wound and fasciotomy
d. Application of a tourniquet and elevation of the extremity
8. A 31-year-old female is referred to the office with a 10-year
history of recurrent pain and drainage in both armpits.
History includes multiple I&D procedures and courses of
antibiotics. Physical examination reveals affected areas >10 cm
in diameter, with multiple sinus tracts and tender nodules in
each axilla. Which of the following should be the next step in
management?
a. Laser hair removal
b. Injection of botulinum toxin
c. I&D of abscesses
d. Complete excision of the affected area
9. A 24-year-old male presents to the emergency room
complaining of increasing pain and stiffness in the right ring
finger. He states that he was involved in a fistfight three days
ago. Examination shows dorsal erythema and tenderness of
the MPJ of the right ring finger with an adjacent healing
laceration. Radiographs show no fractures. What is the most
appropriate next step in management?
a. Splinting and elevation
b. Discharge with oral antibiotics
c. Surgical drainage of the joint
d. Surgical washout of the flexor tendon sheath
10. A 52-year-old female has swelling and severe pain of the index
and middle fingers of her dominant hand for the past 2 days.
On physical examination, you note a sausage-like swelling of
the digits and tenderness on palpation of the volar surface of
the fingers. There is severe pain on passive extension.
Radiographs are unremarkable. In addition to administration
of broad-spectrum antibiotics, which of the following is the
most appropriate management?
a. Admission for observation
b. Incision and irrigation of the flexor sheaths
c. Wide debridement of the involved tissues
d. Amputation of the involved digits

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6. A 40-year-old man is referred for a tender raised lesion of
the helix rim of the ear, which did not respond to topical
steroids. A principal diagnostic consideration is
a. Chondrodermatitis nodularis helixis
b. Seborrhoeic dermatitis
c. Linear epidermal nevus of Ota
d. Inflamed hemangioma
7. One definitive treatment for the above is
a. Topical radiation
b. 5-fluorouracil
c. Wedge excision of underlying skin and cartilage
d. Continued observation
8. An individual cutaneous neurofibroma
a. Indicates a total body exam for cafe au lait spots
b. Obligates a family history for von Recklinghausen’s
c. Is usually located in the head and neck
d. Is a benign Schwann cell tumor
9. Congenital dermal melanocytosis (Mongolian spot)
a. Characteristically involves the lumbosacral skin
b. Persists into adult life
c. Is treated by wide excision and skin graft
d. Has a typical blue-black appearance
10. Which of the following statements about lipomata is untrue?
Lipomata
a. Are commonly multiple
b. Can be bilateral and symmetrical (Madelung’s disease)
c. Have subgroups or variants (hemangio-neuro)
d. Occur commonly after trauma
11. Epidermoid cysts are
a. Best excised while acutely inflamed
b. Have different cytology in different body areas
c. Treated as malignant if rapidly growing
d. Filled with a harmless, foul-smelling skin protein
Chapter 24
1. Which of the following lesions are not premalignant?
a. Leukoplakia
b. Hutchinson’s freckle
c. Keratoacanthoma
d. Clear cell acanthoma
2. All of the following are risk factors for basal cell carcinoma,
except
a. UVA radiation
b. UVB radiation
c. Gamma radiation
d. Gorlin syndrome
3. A 71-year-old male is referred to your clinic with biopsy-
proven squamous cell cancer of the scalp, measuring 10 mm
in diameter. What is the best course of treatment?
a. Curettage and electrodessication
b. Surgical excision with a 4-mm margin
c. Surgical excision with a 6-mm margin
d. Mohs micrographic surgery
8. What percent TBSA scald burn will trigger a systemic
inflammatory response (SIR) in most adults?
a. >10%
b. >15%
c. >20%
d. >30%
9. Electrical injury may be classified as low or high voltage. The
distinction between high and low voltage is at
a. >100 V
b. >1000 V
c. >10,000 V
d. >100,000 V
10. During initial fluid resuscitation, a burned child is more
susceptible than an adult to which of the following:
a. Hypoglycemia
b. Hyperglycemia
c. Hypophosphatemia
d. Hyperphosphatemia
Chapter 23
1. If left untreated, a nevus sebaceous may transform into which
of the following?
a. Atypical nevus
b. Melanoma
c. Basal cell carcinoma
d. Dermatofibrosarcoma protuberans
2. What are the recommended surgical margins for an atypical
pigmented nevus?
a. 1 mm
b. 5 mm
c. 10 mm
d. 20 mm
3. Which of the following is a syndrome characterized by the
development of multiple, symmetric lipomas?
a. Madelung’s disease
b. Wartenburg’s disease
c. Hirschsprung’s syndrome
d. Gorlin syndrome
4. Which of the following is an acceptable treatment for a
dermatofibroma?
a. Observation
b. Excisional biopsy
c. Local excision
d. All of the above
5. Which of the following is a common childhood skin lesion
that is characterized by dermal and subdermal calcifications
as well as ghost cells and basaloid cells on histology?
a. Pilomatrixoma
b. Nevus sebaceous
c. Pyogenic granuloma
d. Hamartoma

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Chapter 25
1. A 14-year-old male presents to your office with an oronasal
fistula. He has a history of a cleft lip and palate that was
repaired in China when he was an infant. The fistula
measures ~2 cm in diameter. What muscle is included with a
facial artery musculomucosal flap?
a. Palatopharyngeus
b. Palatoglossus
c. Buccinator
d. Levator labii superioris
2. A 74-year-old female has a sternal wound that you plan to
reconstruct with a pedicled rectus abdominis myocutaneous
flap. She has a history of coronary artery bypass grafting with
harvest of her bilateral IMAs. What would be the primary
blood supply of your flap in this instance?
a. Superior epigastric
b. Eighth intercostal artery
c. Inferior epigastric
d. Lateral epigastric
3. What is the dominant vascular pedicle to a reverse lateral arm
flap?
a. Radial recurrent artery
b. Posterior radial collateral artery
c. Radial artery
d. Brachial artery
4. A 25-year-old patient has a large lower abdominal wound for
which you plan to reconstruct using a pedicled rectus femoris
flap. What is the expected functional morbidity from use of
this flap?
a. None
b. Ten to 15 degrees of extensor lag
c. Immobility
d. No knee extension
5. Ten days ago, a 40-year-old male underwent reconstruction
of his abdominal wound with a transverse fascial lata
myocutaneous flap. He is noted to have persistent venous
congestion and you have decided to begin leech therapy.
Which of the following bacteria can be associated with
infection from this treatment?
a. Streptococcus pneumoniae
b. Staphylococcus aureus
c. Pseudomonas aeruginosa
d. Aeromonas hydrophila
6. The ALT flap
a. Is supplied by the transverse branch of the circumflex
femoral artery
b. Is supplied by perforators that can be found in a 3-cm
radius in the middle of a line drawn from the greater
trochanter to the superolateral border of the patella
c. Can be harvested with vastus lateralis for bulk but
requires a separate pedicle
d. Is supplied by perforators from the descending branch of
the lateral circumflex femoral artery
e. Is unreliable as a pedicled flap because of pressure on the
pedicle
4. Punch biopsy of a 38-year-old female with a suspicious dark
lesion reveals melanoma that has invaded the papillary dermis
but does not penetrate the reticular dermis. What is the Clark
classification of this lesion?
a. Level II
b. Level III
c. Level IV
d. Level V
5. A 45-year-old male with a recent punch biopsy showing
melanoma with a Breslow depth of 1.3 mm is referred to your
clinic. He does not have palpable lymph nodes. What is the
appropriate management?
a. Surgical excision with 1-cm margin
b. Surgical excision with 1-cm margin and SLNB
c. Surgical excision with 2-cm margins
d. Surgical excision with 2-cm margins and SLNB
6. A 42-year-old, fair-haired woman with Fitzpatrick skin-type I
presents to the office with an irregular, darkly pigmented skin
lesion on her left calf. After appropriate biopsy, it is
determined to be a melanoma. Which of the following is the
most common melanoma in the United States?
a. Lentigo maligna melanoma
b. Superficial spreading melanoma
c. Acrolentiginous melanoma
d. Nodular melanoma
7. Which of the following is the strongest indication for SLNB
in a patient with nodular melanoma?
a. Age younger than 35 years
b. Tumor location on the face and scalp
c. Tumor thickness of 2.0 mm
d. Palpable lymphadenopathy
8. A 55-year-old man presents with a 1.5-cm-diameter, firm,
painless nodule on his left forearm. Excisional biopsy shows a
Merkel cell carcinoma. Which of the following statements
about his disease is true?
a. This is a neuroendocrine tumor associated with systemic
immunosuppression.
b. Expected 5-year survival is less than 50% in the absence of
metastases.
c. Metastases are hematogenous and rarely involve the
lymph nodes.
d. Radiotherapy in not effective in the treatment of Merkel
cell carcinoma.
9. Which of the following features of SCC is most strongly
associated with high metastatic potential?
a. Verrucous and exophytic appearance
b. Tumors arising from sun-induced skin changes
c. Tumors developing on the trunk
d. Tumors associated with Margolin’s ulcer
10. Which of the following tumor types is least suitable for Mohs
micrographic excision of cutaneous malignancies?
a. Recurrent tumors in areas of previous radiation
b. Tumors with discontiguous growth patterns
c. Dermatofibrosarcoma protuberans
d. Extramammary Paget’s disease

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3. In patients with prominent eyes, Hertel exophthalmometer
measurements should be in excess of what value?
Measurements describe the distance from the corneal surface
to which bony landmark?
a. Ten mm; inferior orbital rim
b. Fourteen mm; lateral orbital rim
c. Sixteen mm; inferior orbital rim
d. Eighteen mm; lateral orbital rim
4. A patient underwent lower lid blepharoplasty 1 year before
her current presentation. She now presents with ectropion
and lower scleral show that is not correctable with the
examiner’s single digit pushing upward at the lateral canthus.
She does not have a skin shortage. In conjunction with a
lateral canthal tightening procedure, which adjuvant lower lid
treatment would be most effective in returning the lower lid
to its native resting position at the lower corneoscleral limbus?
a. Middle lamellar spacer graft
b. Skin graft from the postauricular location
c. Skin graft from the supraclavicular location
d. Levator recession procedure
5. A patient presents following Mohs excision of the lateral
lower lid with a full-thickness defect measuring ~40% of the
lower lid width. Which of the following reconstructive
options would be most appropriate for closure and
restoration of normal eyelid contour?
a. Hughes tarsoconjunctival flap
b. Cutler-Beard bridge flap
c. Nasolabial transposition flap
d. Tenzel rotation-advancement flap
6. A 58-year-old man presents for his first postoperative
appointment 1 week after transcutaneous lower eyelid
blepharoplasty with canthopexy. On examination, he
demonstrates severe chemosis of the left eye, impairing his
ability to close his eyelids. What is the best management plan?
a. Administration of 2.5% phenylephrine ophthalmic drops
b. Administration of tobramycin/dexamethasone ophthalmic
drops
c. Snip conjunctivotomy
d. Conjunctival plication
7. One year after undergoing an ORIF of an orbital floor
fracture, a 19-year-old man presents with right lower eyelid
ectropion and trichiasis. The surgeon reconstructed the floor
with titanium mesh through a transconjunctival approach.
What is the next step in management?
a. Eyelid massage
b. Intralesional kenalog injection into the lower eyelid fornix
c. Cicatricial release with posterior lamellar palatal grafting
d. CT scan followed by hardware removal
8. Injection of 1 to 2 U of botulinum toxin into the lateral aspect
of the upper eyelid creates what change on eyelid position?
a. Minimizes complications of lagophthalmos after
aggressive blepharoplasty
b. Simulates the effects of ptosis correction
c. Temporarily addresses the deformity of upper eyelid
retraction
d. No observable change of the eyelid esthetics
7. The superior gluteal artery perforator (SGAP) flap is supplied
by the SGA. This can be found lateral to the sacrum and
related to the piriformis muscle because
a. The artery is found at the junction of the middle and
lateral thirds of the piriformis.
b. The piriformis is found by drawing a line from the greater
trochanter to the tip of the coccyx.
c. The SGA is found just above the junction of the middle
and medial thirds of the piriformis.
d. The SGA lies just below the piriformis.
e. The SGA passes through the piriformis muscle at the
junction of middle and medial thirds.
8. The radial forearm flap donor site can be associated with
neuroma of
a. The posterior interosseous nerve
b. The superficial radial nerve
c. The median nerve
d. The ulnar nerve
e. All of the above
9. According to the Mathes-Nahai classification system, the
sartorius muscle is
a. Type 1
b. Type 2
c. Type 3
d. Type 4
e. Type 5
10. In harvesting the scapular system flaps based on the
circumflex scapular artery, the quadrangular space is an
important landmark. It is bordered by all of the following
except the
a. Latissimus dorsi
b. Teres major
c. Teres minor
d. Triceps
e. Scapular border
Chapter 26
1. Which branch of the facial nerve is responsible for normal
resting lid tone?
a. Zygomatic
b. Buccal
c. Temporal
d. Marginal mandibular
2. During lower lid blepharoplasty via an external approach, the
surgeon elects to redrape retroseptal fat across the orbital rim
to soften contours across the lid-cheek junction. To maximize
motion of the central and lateral fat pads, which structure
between these two fat pads should be released from the lower
orbital rim?
a. Whitnall’s ligament
b. Arcuate expansion of Lockwood’s ligament
c. Lateral horn of the levator palpebrae superioris muscle
d. Inferior crus of the lateral canthal tendon

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6. A 52-year-old man presents with a chief complaint of
difficulty breathing. A Cottle maneuver is positive. Which of
the following would be best suited to correct this problem?
a. Septoplasty
b. Tip grafts
c. Spreader grafts
d. Inferior turbinate reduction
7. A 33-year-old woman undergoing cosmetic rhinoplasty
desires more projection of the nasal tip. Which of the
following would NOT increase tip projection?
a. Cartilage tip graft
b. Transdomal sutures
c. Columellar strut graft
d. Resection of the medial crura
8. Which of the following deformities can occur from excessive
reduction of the nasal dorsum?
a. Pollybeak deformity
b. Rocker deformity
c. Saddle nose deformity
d. Alar retraction
9. An 82-year-old woman undergoes Mohs micrographic surgery
to remove a SCC. The defect is a 1-cm partial-thickness defect
of the nasal dorsum in the middle third of the nose. Which of
the following flaps would NOT be the best option to
reconstruct this defect?
a. Miter flap
b. V-Y advancement flap
c. Forehead flap
d. Bilobed flap
10. A 25-year-old woman comes in seeking cosmetic rhinoplasty.
Her nasolabial angle is 87 degrees. What is closest to the ideal
nasolabial angle in this patient?
a. Less than 80 degrees
b. Ninety degrees
c. One hundred and five degrees
d. More than 120 degrees
Chapter 28
1. A 62-year-old female has complete numbness of the left
earlobe 4 weeks after undergoing rhytidectomy. The nerve
that was most likely injured can be found along the surface of
which of the following muscles?
a. Digastric
b. Sternocleidomastoid
c. Omohyoid
d. Trapezius
e. Stylohyoid
2. A 58-year-old male has increasing pain and swelling on the
left side of his face 8 hours after a rhytidectomy. Which of the
following perioperative interventions is most likely to have
prevented this complication?
a. Use of drains
b. Use of fibrin glue
c. Use of antianxiety medications postop
d. Control of blood pressure postop
e. Placement of a firm compressive dressing
9. Orbital fat resuspension during lower eyelid blepharoplasty
requires dissection and division of what structure?
a. Orbitomalar ligament
b. Capsulopalpebral fascia
c. Lateral orbital retaining ligament
d. Lockwood ligament
10. Six hours after undergoing a transconjunctival lower eyelid
blepharoplasty, a 61-year-old woman returns to the
emergency room complaining of severe pain. After ruling out
a retrobulbar hematoma, what is the next most likely
diagnosis?
a. Blepharospasm
b. Bacterial conjunctivitis
c. Dry eye syndrome
d. Corneal abrasion
Chapter 27
1. A 22-year-old woman with a crooked nose and bulbous nasal
tip will undergo rhinoplasty through an open approach.
Which of the following blood vessels will be disrupted?
a. Lateral nasal artery
b. Internal maxillary artery
c. Columellar artery
d. Dorsal nasal artery
2. A 38-year-old woman will undergo secondary rhinoplasty for
asymmetrical dorsal esthetic lines and internal valve collapse.
Which of the following maneuvers can improve internal valve
function?
a. Alar contour graft
b. Anatomic cap graft
c. Infratip graft
d. Spreader graft
3. Which of the following maneuvers should be avoided during
open rhinoplasty?
a. Transposition of the lower lateral crus
b. Alar base excisions that are inferior to the alar groove
c. Percutaneous lateral nasal osteotomies
d. Subdermal defatting of the nasal tip
4. A 62-year-old man will require subtotal nasal reconstruction
for a defect of the nasal skin that involves the nasal tip, right
and left nasal alae, and inferior half of the nasal dorsum. A
right forehead flap is planned. What is the pedicle of the
forehead flap?
a. Supraorbital artery
b. Anterior branch of the superficial temporal artery
c. Posterior branch of the superficial temporal artery
d. Supratrochlear artery
5. At the level of the orbital rim, where is the major blood
supply of the forehead flap located?
a. Subdermal plexus
b. Deep to the periosteum
c. Superficial to the periosteum
d. Within the frontalis muscle

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10. The SMAS layer is continuous with which tissue layer
superiorly?
a. Temporoparietal
b. Parotid fascia
c. Deep temporal fascia
d. Masseteric fascia
e. Temporal fat pad
Chapter 29
1. A 39-year-old female presents 3 months after
lipoabdominoplasty with complaints of tingling, numbness,
and burning sensation along the anterior and lateral aspect of
her thigh. What is the most likely diagnosis?
a. Iliohypogastric neuralgia
b. Lateral femoral cutaneous neuralgia
c. Ilioinguinal neuralgia
d. Intercostal neuralgia
2. A 45-year-old woman undergoes a brachioplasty procedure
and experiences postoperative numbness of the ulnar side of
the left forearm after surgery. After 6 weeks of conservative
management, the numbness continues. After 3 months of
further observation, the patient has developed a painful
nodule in the arm under her incision. Reexploration is
planned and the most likely intraoperative finding is
a. Severed lateral antebrachial cutaneous nerve of the arm
with neuroma formation.
b. Severed medial antebrachial cutaneous nerve of the arm
with neuroma formation.
c. Entrapment of the ulnar nerve at the elbow
d. Lymphocele
3. A 32-year-old female presents for consultation for body
contouring surgery. She had gastric bypass surgery and lost
120 lbs. She now has a hanging pannus that blocks a portion
of her genitals and thighs and a moderate upper role at the
umbilicus with laxity of the epigastric area. The best
treatment option for her is
a. Abdominoplasty with aggressive liposuction of the upper
abdomen
b. Abdominoplasty with fleur-de-lis vertical component
c. Miniabdominoplasty
d. Circumferential lower body lift
4. A 40-year-old woman who has had two successful
pregnancies presents for an abdominoplasty. Her BMI at the
time of surgery is 28. Eight weeks postoperatively, she
presents with superior abdominal fullness above the level of
the umbilicus. She states that she feels like it has been there
since surgery. The most likely diagnosis is
a. Seroma
b. Residual epigastric adiposity
c. Failure to adequately plicate the rectus fascia above the
umbilicus
d. Redundant skin laxity
3. A 65-year-old woman has a persistent asymmetric smile
following a facelift. Physical examination shows elevation of
the right oral commissure. She has a full denture smile
normally but is able to purse and evert her lower lip. Which
branch of the facial nerve was injured?
a. Zygomatic
b. Frontal
c. Marginal mandibular
d. Cervical
e. Buccal
4. A 55-year-old male with a history of hypertension undergoes
a routine rhytidectomy. Postoperatively, the nurse notifies the
surgeon that the patient has severe ear and facial pain on one
side. What is the most likely diagnosis?
a. Anesthetic reaction
b. Injury to Arnold’s Nerve
c. Hematoma
d. Injury to greater auricular nerve
e. Trigeminal neuralgia
5. What is the facelift technique called when it involves a
dissection beneath the superficial muscular aponeurotic
system (SMAS) layer?
a. Minimal access cranial suspension (MACS) lift
b. Short scar facelift
c. Subcutaneous facelift
d. Deep plane facelift
e. SMAS plication
6. What is the incidence of hematoma in a female patient?
a. 1%
b. 3%
c. 6%
d. 10%
e. 20%
7. What is the incidence of hematoma in a male patient?
a. 1%
b. 4%
c. 8%
d. 15%
e. 30%
8. A 58-year-old female patient presents for a neck lift. She has
had massive weight loss and is unhappy with her neckline.
What is the normal range of the cervical mental angle?
a. 85 to 100 degrees
b. 105 to 120 degrees
c. 125 to 140 degrees
d. 145 to 160 degrees
e. None of the above
9. On evaluation of a patient who presents for a neck lift, the
surgeon notes a prominent submandibular gland. What nerve
is at greatest risk with attempted resection of the gland?
a. Zygomatic
b. Frontal
c. Marginal mandibular
d. Cervical
e. Buccal

335
Chapter 30
1. A 32-year-old female with a history of cystic acne presents for
skin resurfacing. What is the recommended length of time
that the patient should be off Accutane (isotretinoin) prior to
her treatment?
a. 1 month
b. 3 months
c. 6 months
d. 1 year
2. A 63-year-old female presents for treatment of fine facial
rhytids. Which of the following is not a component of
Jessner’s Peel?
a. Salycilic acid
b. Lactic acid
c. Croton oil
d. Resocinol
3. A 72-year-old female patient with deep perioral rhytids
undergoes a deep chemical peel with phenol. What is the
most serious medical side effect of this treatment?
a. Hypopigmentation
b. Chemical necrosis of the outer layer of the skin
c. Increased collagen synthesis
d. Cardiac arrhythmias
4. How is the depth of a phenol peel controlled?
a. Croton oil concentration
b. Time of application
c. Number of applications
d. Strength of solution
5. A 33-year-old male presents for tattoo removal. Which of the
following pigments is not targeted by your Nd:YAG laser?
a. Green
b. Red
c. Brown
d. Orange
6. A 62-year-old female presents for laser resurfacing of fine
periorbital rhytids. Which of the following chromophores is
the target of your ablative CO2 laser?
a. Heme
b. Melanin
c. Orange pigment
d. Water
7. A 56-year-old female with facial volume depletion associated
with aging presents for treatment with injectable fillers.
Which of the following is not an ingredient in a currently
approved dermal filler?
a. Silicone
b. Hyaluronic acid
c. Poly-L-lactic acid
d. Calcium hydroxyapatite
8. A 45-year-old male presents with male-pattern baldness.
Which of the following is not a phase of hair follicle growth?
a. Anagen
b. Pilogen
c. Telogen
d. Catagen
5. A 23-year-old woman presents for liposuction of her flanks to
improve her waistline. In order to reduce the risk of blood
loss during the procedure, the best technique to achieve
this is
a. Dry technique
b. Wet technique
c. Superwet technique
d. Tumescent technique
6. A 49-year-old multiparous woman undergoes standard
abdominoplasty. When insetting the umbilicus, it should be
placed
a. At the midline, 14 cm above the pubis
b. At the midline, 14 cm below the xyphoid
c. At the intersection of a line connecting the highest point
of the iliac crest with the midline
d. At the intersection of a line connecting the anterosuperior
iliac spine with the midline
e. At the point where the umbilicus is found lying beneath
the abdominal flap
7. A 37-year-old woman has widening of the labia 3 months
after undergoing a medial thigh lift. Which of the following is
the most likely cause?
a. Failure to suture the flap to Colles’ fascia
b. Excessive adjunctive suction lipectomy
c. Abnormal scar contracture
d. Failure of appropriate preoperative markings
8. Which of the following is the most common complication
following ultrasound-assisted liposuction?
a. Pulmonary embolism
b. Thermal skin injury
c. Infection
d. Hematoma
e. Seroma
9. During brachioplasty, permanent suturing of the medial arm
skin flaps to which of the following structures will decrease
unfavorable scarring and contour irregularities?
a. Pectoralis major muscle
b. Triceps muscle
c. Latissimus dorsi muscle and fascia
d. Axillary fascia
e. Biceps brachii muscle and fascia
10. Two days after undergoing abdominoplasty, a 37-year-old
woman presents to the emergency room with a firm painful
cord in the medial thigh, tachycardia, hypoxia, and mental
status changes. Immediate workup should include evaluation
for
a. Pulmonary embolism
b. Incarcerated hernia
c. Infected seroma
d. Urinary tract infection
e. Acute psychotic episode

336
during face and neck rejuvenation procedures, resulting in numb­
ness in this region.
ANSWER 3: A. The marginal mandibular branch of the facial
nerve innervates the mentalis muscle. Thus, the ability to evert the
lower lip in the above setting suggests a functioning mentalis muscle
and injury to the cervical branch of the facial nerve, creating “pseu­
doparalysis of the marginal mandibular nerve.”
ANSWER 4: B. The foramen rotundum is a circular foramen
within the sphenoid bone of the skull base, through which the
maxillary division of the trigeminal nerve passes.
ANSWER 5: C. The superior orbital fissure is located within
the greater wing of the sphenoid bone and transmits the lacrimal
nerve, frontal nerve, trochlear nerve, and superior and inferior
branches of the oculomotor nerve, nasociliary nerve, and abducens
nerve. The optic nerve and ophthalmic artery travel through
the optic canal, which is located within the lesser wing of the
sphenoid.
ANSWER 6: D. Neurotransmitters remain sufficient in the distal
nerve end to allow muscular contraction with electrical stimulation
for 72 hours after transection.
ANSWER 7: A. The facial nerve courses in the superficial temporal
fascia, or temporoparietal fascia, in this region.
ANSWER 8: B. The patient most likely has a sialocele resulting
from injury to the parotid duct or parotid gland. The buccal
branches are typically located adjacent to the parotid duct.
ANSWER 9: D. Synkinesis refers to unwanted facial movements
that occur in addition to desired movements. Synkinesis is only a
regeneration phenomenon, making the history of recovered Bell’s
palsy important.
ANSWER 10: A. The patient most likely has a thyroglossal duct
cyst and is best managed with the Sistrunk procedure, which
includes excision of the central portion of the hyoid bone to
decrease risk of recurrence.
Chapter 3
ANSWER 1: C. Adenoid cystic carcinoma usually presents as a
painful, firm, and fixed mass to the underlying tissues, with involve­
ment of the facial nerve. Treatment is by total parotidectomy and
sacrifice of the involved facial nerve.
ANSWER 2: D. Recurrence rates after enucleation alone have been
reported to be between 2.5% and 62%. Although surgical bony
resection is more curative, it carries higher morbidity. Consideration
of the preferred treatment depends on the tumor and patient-
related factors. Close follow-up is an essential part of the manage­
ment of this pathology.
9. A 56-year-old male undergoes hair transplantation for
treatment of male-pattern baldness. When can he expect
restoration of normal hair growth?
a. 2 weeks
b. 1 month
c. 3 months
d. 1 year
10. A 59-year-old female presents for treatment of her glabellar
frown lines. Which of the following is the mechanism of
action of the botulinum neurotoxin?
a. Sodium-channel binding
b. Blockade of presynaptic acetylcholine release
c. β-adrenergic antagonism
d. Calcium-channel blockade
Self-Assessment Answers
Chapter 1
ANSWER 1: C.
ANSWER 2: C.
ANSWER 3: D.
ANSWER 4: E. Adjacent tissue transfer includes all tissue
re­arrangements but also includes excision of a lesion.
ANSWER 5: E. The 62 modifier identifies that the procedure was
performed with a cosurgeon, during which each surgeon does a
separately documented part of the operation.
ANSWER 6: B. This patient has well-controlled diabetes (systemic
disease). Past history of hypertension that is resolved does not
impact her current ASA status.
ANSWER 7: B.
ANSWER 8: D. Options a–c are included in the global period.
ANSWER 9: B. Fluency in a foreign language is a potential job
skill.
ANSWER 10: C. The remainder are global to the procedure.
Exposure to harvest the flap, closure of the donor site, and prepara­
tion of the recipient site are all inclusive to the flap code.
Chapter 2
ANSWER 1: D. The mental foramen can be found near the inferior
mandibular cortex at the level of the second premolar and first molar.
ANSWER 2: C. The great auricular nerve provides sensory inner­
vation to the earlobe and lower half of the ear. It can be injured

337
ANSWER 4: C. The patient’s dystopia and growing skull fracture
is most likely caused by a missed dural tear sustained at the time of
her initial injury. Because of the dural injury, the fracture line is
unable to heal, resulting in a growing defect as the skull enlarges
with age.
ANSWER 5: A. In type-III NOE fractures, there has been extensive
bony comminution of the NOE complex along with disruption of
the medial canthal tendon. When performing transnasal wiring of
the medial canthal tendon, it is important to position the canthus
posterior and superior to the lacrimal crest with slight
overcorrection.
ANSWER 6: B. Frontal sinus fractures can be assessed by whether
the fracture involves the anterior and posterior wall of the sinus and
by patency of the nasofrontal duct. If the nasofrontal duct is not
patent, obliteration of the sinus and duct is recommended to reduce
the risk of a mucocele or pyomucocele. If there is displaced or com­
minuted fractures of the posterior table in the presence of naso­
frontal duct injury, cranialization of the sinus with duct obliteration
is recommended.
ANSWER 7: C. Transconjunctival approach can be extended
medially as a transcaruncular approach to access the medial orbit.
A coronal incision also gives access to the medial orbit but not to
the orbital floor. Subciliary and subtarsal incisions do not allow
access to the medial orbit.
ANSWER 8: D. An inferior border locking plate will address the
compression forces, and the arch bar acts as a superior plate to
counteract the tension forces. Compression plates are not recom­
mended. A Champy plate is for angle fractures, and MMF alone is
less optimal than ORIF because of the morbidity of immobility.
ANSWER 9: D. Proper alignment and reduction of the lateral
orbital wall/zygomaticosphenoid suture is most important to
reduce the risk of postoperative enophthalmos and/or malar
flattening.
ANSWER 10: B. Management of infection requires adequate I&D.
It is important that rigid internal fixation be maintained until the
bone fracture segments have ossified, because nonrigid fixation,
such as external or maxillomandibular fixation, can lead to worsen­
ing of infection. Removal of the internal hardware is rarely neces­
sary unless the hardware is actively infected and loosened because
of bone involvement (osteomyelitis).
Chapter 5
ANSWER 1: D. Pierre Robin first described this clinical triad. This
developmental disorder is now thought to be initiated by mandibu­
lar undergrowth or retropositioning. There is an associated syn­
drome in 34% to 46% of patients with Robin sequence. Cleft palate
is present in up to 90% of patients with Robin sequence, although
it is not required to make the diagnosis.
ANSWER 3: D. Total glossectomy reconstruction requires ade­
quate bulk of vascularized tissue. These patients often require adju­
vant chemotherapy and radiotherapy. A flap that provides adequate
bulk and diversion of oral diet to minimized aspiration is desired.
A skin graft is inappropriate for this reconstruction.
ANSWER 4: E. Bisphosphonates, steroids, chemotherapy, dental
trauma, or infection are all associated with development of MRONJ.
The 2014 update of a position paper from the American Association
of Oral and Maxillofacial Surgeons recommended changing the
name of bisphosphonate-related osteonecrosis of the jaw (BRONJ)
to MRONJ due to the increased number of jaw osteonecrosis cases
that have been associated with other antiresorptive (denosumab)
or antiangiogenic agents.
ANSWER 5: E.
ANSWER 6: D. Warthin’s tumors typically occur in men, and 10%
of tumors are bilateral.
ANSWER 7: C. Aberrant regeneration of parasympathetic auric­
ulotemporal nerve fibers after parotidectomy is thought to underlie
Frey’s syndrome.
ANSWER 8: C. Sclerotherapy is the most appropriate initial treat­
ment for symptomatic venous malformations.
ANSWER 9: A. The most appropriate treatment for moderately
advanced oral cavity SCCs with mandibular cortical invasion is
wide local excision, segmental resection of the portion of mandible
with cortical tumor invasion, and staging with neck dissection,
given the high probability of occult metastases.
ANSWER 10: B. The most appropriate initial management of
medication-related osteonecrosis of the mandible in the absence of
pathologic fracture is antimicrobial mouthwashes, antibiotics, and
observation.
Chapter 4
ANSWER 1: B. The patient has an injury to the optic nerve, which
results in a “Marcus Gunn” pupil, characterized by abnormal pupil­
lary dilation in the presence of light.
ANSWER 2: D. The indications for tooth extraction in the setting
of mandible fractures include the presence of dental caries, the
presence of periapical infection, injury or fracture of the tooth root,
or inability to obtain proper fracture reduction because of the con­
dition of the tooth.
ANSWER 3: C. The patient has suffered a trapdoor orbital floor
fracture with entrapment of the inferior rectus muscle. He is exhib­
iting an oculocardiac reflex, which results in nausea and bradycar­
dia. This patient requires emergent operative reduction and orbital
floor reconstruction.