Plastics

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==== Dr. Chong ====
^ Question ^ Pearl ^
| Why leave the fascia on the muscle during the dissection? | So you will have a strong layer of tissue to suture too. |
| What suture style do you use for weaker tissue? | Figure of 8 because it has greater surface area and won't "cheese wire" the tissue. |
| What is Red Breast Syndrome? | Type IV hypersensitivity (delayed) reaction to acellular dermal matrix. |
| What is the incidence of Tissue Expander infections? | 7-10% |
| What is the blood supply to the pectoralis major muscle? | Type V Mathes and Nahai flap. Dominant supply pectoral branch of thoracoacromial trunk. Segmental supply of IMA perforators. |
| What is Pitanguy's line? | {{ https://www.theplasticsfella.com/content/images/2021/03/Facial-Nerve-Branching-Patterns-1.png?200 }} |
| What is Pitanguy's point? | FIXME |
| Why is this patient going to bleed? | Patients with uremia have platelet dysfunction. |
| Why smooth expanders? | Because smooth implants have been associated with ALCL and the only link is previous textured tissue expanders? |
| What are the aesthetic units of the breast? | FIXME |
| Primary venous drainage system of abdomen? | superficial system |
| What is blood supply to pectoralis major? | pectoral branch from thoracoacromial trunk, IMA perforators |
| What is dual plane for breast implants? | FIXME |
| Source of hematoma? | Hematoma could be from surrounding tissue or from a vein clot and now leaking from flap |
| Larger angle of diversion increases the amount of coning or projection of the breast. ||

|Liposuction ||
^ Question ^ Pearl ^
| Will ask to thoroughly explain procedure. || 
| If you are doing liposuction on neck and abdomen, which do you infiltrate first? | Neck first, because it is highly vascular (>>abdomen) and will absorb local anesthesia before you get to abdomen. This way you are not having peak absorption of local anesthesia at the same time. |
| Why wait after infiltrating to start liposuction? | For the onset of epinephrine. Onset time 8 minutes. Peak effect 26 minutes. |
| What does 1% solution mean? | This is 1000 milligrams in 100 milliliters of water. Which converts down to 10 mg per cc of solution. |
| How much epinephrine can you use? | This is an important question for cleft palate. It is a highly vascular region and absorbs quickly. It is rec that 10 μg/kg at 30 minute intervals be used. |
| How much lidocaine can you infiltrate? | 5mg/kg without epi\\ 7mg/kg with epi |
| How much lidocaine can you use as tumescent? | 35-55mg/kg. Reasons for higher concentration is low vascularity/absorptivity of fat, dilute, physical compression of blood vessels from fluid. |
| High volume liposuction is >5L and a hospital admission should be considered. Remember peak toxicity risk is approximately 12-20 hours after surgery. ||

| Sutures ||
^ Question ^ Pearl ^
| Strongest suture technique? | Vertical mattress |
| Best suture tech for everting? | Horizontal mattress |
| Most ischemic stitch? | Horizontal mattress |

**Amides vs Esters**\\
Amides need to be broken down by amidases, which aren't in the blood. \\ Esterases are in the blood and amides can cause more anaphylactic shock than or have a higher chance of causing anaphylactic shock than esters.

**Order of preferred vessels for Scalp Reconstruction**
  - STA for scalp or Facial for mid face
  - Superior thyroid artery
  - Carotid (need vein graft)
  - Transverse Cervical
  - Go into previous flap pedicle


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==== Dr. Mathes ====
| Breast Implants ||
^ Question ^ Pearl ^
| What incision should you use to remove an implant placed for augmentation? | You should go through an IMF incision even if the implant was placed in a different incision. This is because if you go through the nipple, you will create a retraction defect by going through all the breast tissue and making a new scar. |
| How can you prevent new capsular contracture after breast implant exchange? | Switch planes from sub-glandular to sub-muscular. Switch from smooth to textured implants. Alloderm can also decrease the chance of capsular contracture. |
| What are the grades of capsular contracture? | Grade I — the breast is normally soft and appears natural in size and shape\\ Grade II — the breast is a little firm, but appears normal\\ Grade III — the breast is firm and appears abnormal\\ Grade IV — the breast is hard, painful to the touch, and appears abnormal. |
| When you are making the keyhole for the new nipple in a breast reduction, why de-epilthelize? | In case the nipple becomes ischemic, you can thin it and graft it onto that surface. |
| Clip the artery or vein first on a flap? | The artery first so the flap isn't engorged with blood. |
| What are the rates of capsular contracture? | Rates are lower sub-pectoral (3-4%) compared to pre-pectoral (12%). Smooth implants are higher than textured implants (1% sub-pectoral). The mechanism is perhaps thought to be from micro-motion. |

| Tissue Expander ||
^ Question ^ Pearl ^
| Advantage of pre-pectoral? | Able to place TE more medially, less pain, no animation deformity, may be faster if you wrap. |
| Disadvantage of pre-pectoral? | Only being held by skin, subq so that breast implant may drop. You can also see the contour of the implant more easily. |
| Why use ADM (acellular dermal matrix)? | decreased capsular contracture, ?may decrease bottoming out of implant |
| Disadvantage of ADM? | seroma formation |
| What must you do if the patient wants a larger breast size? | Be sure to have the incision low at the IMF. If the incision is too high, the NAC will be distorted during filling of the TE. (ie the nipple will point downward because the expander will be too high). |

| DIEP ||
^ Question ^ Pearl ^
| Unilateral DIEP Flap: where is the ideal perforator? | From the medial row (more centrally) so it can perfuse more of the flap. A lateral row might not perfuse the contralateral side of the flap as well. |
| DIEP Flap: what perforator is more morbid, medial, middle or lateral row? | The lateral row perforators much more morbid because you're going to transect nerves more laterally and this is going to deinnervate more muscle. |

**What is the (Mathes and Nahai) Reconstructive Triangle?**\\
This is the idea that rather than a ladder or an elevator, you can apply different principles to treat different wounds as well as combinations of these principles. The triangle consists of (Local) Flaps - Microsurgery - Tissue Expansion. Really this is meant to instill in the young plastic surgeon a sense of choices. Dr. Janis published a paper called [[http://www.drjeffreyjanis.com/wp-content/uploads/2014/04/The-New-Reconstructive-Ladder-PMID21200292.pdf|The New Reconstructive Ladder]] which further expands this idea. He adds some of the new concepts such as use of negative pressure wound vac therapy and dermal matrices. Others have suggested adding distraction osteogenesis. (While first introduced by Dr. Ilizarov, this technique was adopted by the plastic surgeon Dr. McCarthy for Craniofacial Surgery.)\\

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==== Dr. Iorio ====
^ Question ^ Pearl ^
| You have a tourniquet up, but a half an hour into the case you start seeing dark blood seeping out from the wound. What's happening? | You have a venous tourniquet and the buildup of pressure is forcing the blood out through the path of least resistance which is the capillaries in your wound bed. This tends to happen with calcified vessels. | 
| A favorite question is the dorsal extensor compartments. Will ask you "what's this" in the OR. ||

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==== Dr. Malliaris ====
^ Question ^ Pearl ^
| Has been known to ask the course of the median nerve through the brachial plexus when doing a carpal tunnel. ||
| How to identify EIP? | Deep and ulnar (compared to EDC to index finger in both hand and at 4th dorsal compartment). Most distal muscle belly in forearm. No juncturae tendinae. |
| How to identify motor recurrent branch of median nerve? | It is approximately where the index finger naturally flexes to the thenar eminence. |
| What is Kaplan's cardinal line? | It is a line from the the apex of the first web space to the hook of hamate and represents the vascular palmar arch. The hook of hamate can be difficult to palpate and transposing a line parallel to the mid-palmar crease to the apex of the first webspace. |
| What is an intrinsic plus finger? | Force along FDP tendon is instead directed through lumbricals to lateral bands. This causes paradoxical extension of IPs during flexion. This sometimes occurs during OT sessions after FDP repair or after revision amps that remove the FDP insertion. |
| What is quadrigia? | Adjacent finger cannot flex completely because of a shortened tendon and a common FDP muscle belly. Term comes from chariots in ancient Rome with reins going to 4 horses. |
| What is the nutrition supply to tendons? | Vincula, direct diffusion through tendon sheath and from digital arteries. |
| Lumbrical innervation? | Radial two from median off common digital nerve. Ulnar two off ulnar common digital nerve. |
| How does the median nerve arborize in the hand? | Variable but usually splits into into radial and ulnar components before forming the common digital nerves. |
| What is a Stenner lesion? | FIXME |
| What does FPL lay in hand? | Between adductor and abductor policis brevis. |
| What is order of intrinsic muscles in hand from volar to dorsal for thenar and hypothenar eminence? | AFO |

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==== Dr. Kaoutzanis ====
^ Question ^ Pearl ^
| For thigh lifts or mass excisions, how do you prevent labial spreading? | Suture advanced dermis to Colle’s fascia. |
| For mandibular contouring, what structure on buccal mucosa near the first molar must avoid |Stenson/parotid duct |
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==== Dr. French ====
^ Question ^ Pearl ^
| Approaching the end of cleft lip surgery, the patient begins to bleed while final sutures are placed. Why? | The cleft palate is a highly vascular region, and blood pressure rises as anesthesia becomes less deep. |
| At what age does the sphenoid sinus complete pneumatization? | 7-8 years; MRI after this age will show complete pneumatization. |
| How to differentiate deformational plagiocephaly from mechanical forces vs craniostosis? | - Parallelogram vs Trapezoidal vertex shape\\ - Position of ears relative to flattening\\ {{ https://obgynkey.com/wp-content/uploads/2016/07/B9780323079327000235_f022-005ab-9780323079327.jpg }} | 
| On which side is cleft lip/palate more common? | Left. It is thought that the right side fuses first in development. |

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==== Dr. Khechoyan ====
^ Question ^ Pearl ^
| What are the layers of the scalp? | **S** Skin\\ **C** Connective Tissue\\ **A** Aponeurosis of Galea \\ **L** Loose Areolar Tissue\\ **P** Periosteum/Pericranium |
| When reflecting the scalp for calvarial procedures, what layer is separated? | Separate at layer of loose areolar tissue, reflect the scalp, then elevate the pericranium. |