Question 26#

From the following options, which is the least appropriate for reconstruction of a 3cm diameter myelomeningocoele in a 3-month old with spina bifida?

A. Bipedicled flap

Free anterolateral thigh (ALT) flap. A free flap is not indicated here and is especially challenging in such a young child. Local flaps as described are effective with minimal donor morbidity.

Question 27#

In terms of breast reduction, which is true?

A. The breasts themselves may increase the body mass index

The breasts themselves may increase the body mass index. In the context of both abdominoplasty and breast reduction, the tissue requiring resection can itself contribute to the BMI in a minority of cases 1. Hall Findlay uses a superomedial pedicle. Lejour’s original description included standard liposuction and undermining, differentiating from Claude Lassus’s technique. However, further papers by Lejour showed modification of the technique to reduce the relatively high complication rates by minimising undermining and hence revisiting the concepts of Lassus. It is the inferior pedicle technique that has been criticised most for ‘bottoming out’.

References:
1. Dafydd H, Juma A, Meyers P, Shokrollahi K. The contribution of breast and abdominal pannus weight to body mass index: implications for rationing of reduction mammaplasty and abdominoplasty. Ann Plast Surg 2009; 62(3): 244-5. 

Question 28#

Good flap options for obliteration of defects of the pleural cavity include all except:

A. Rectus abdominis muscle flap

Latissimus dorsi myocutaneous flap. Latissimus dorsi is a useful flap for reconstruction of pleural defects as a muscle flap but not as a myocutaneous flap. The other flaps listed all have indications in this role.

Question 29#

A 65-year-old man who underwent three-vessel coronary artery bypass grafting (CABG) 5 weeks ago comes to the office because he has a draining lesion near the sternotomy incision. The CABG procedure included harvest of the patient’s left internal mammary artery. Temperature is 38.7°C (101.7°). Physical examination shows a 3mm papule at the manubrium of the healed sternotomy incision. A CT scan of the chest shows a sinus tract leading to the internal sternal plate. In addition to removal of sternal wires and debridement of the wound, which of the following is the most appropriate definitive management?

A. Continuous irrigation

Right pectoralis major muscle flaps.

References:

1.  Ascherman JA, Patel SM, Malhotra SM, Sameer M, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in techniques and outcomes analysis. Plast Reconstr Surg 2004; 114(3): 676-83.
2. Pairolero PC, Arnold PG. Management of infected median sternotomy wounds. Ann Thorac Surg 1986; 42 (1): 1-2.
3. Pairolero PC, Arnold PG, Harris JB. Long term results of pectoralis major muscle transposition for infected sternotomy wounds. Ann Surg 1991; 213(6): 583-90.
4. Gur E, Stern D, Weiss J, Herman O, Wertheym E, Cohen M, Shafir R. Clinicalradiological evaluation of poststernotomy wound infection. Plast Reconstr Surg 1998; 101(2): 348-55.

Question 30#

In delayed unilateral breast reconstruction with DIEP flaps:

A. The flap should be inset in the position of wherever the mastectomy scar was opened

The flap should be inset inferiorly in the IMF position and the skin between the new IMF and the mastectomy scar should in general be discarded. In delayed unilateral breast reconstruction with DIEP flaps, the aesthetic units of the breast should be taken into consideration. This means that the IMF and lateral border marked by the anterior axillary line should be kept in mind. The lateral part should stop at the anterior axillary line. The IMF should be mirrored to the opposite side but then cut to be 2cm higher as that side will come down slightly more than the unaffected side. All skin between the old mastectomy scar and the new IMF should be discarded to give the best aesthetic result.