ETAS_MCQ_15 dermatologic and cosmetic surgery

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ETAS_MCQ_15 dermatologic and cosmetic surgery

  1. 1. Dermatologic and Cosmetic Surgery1) The tensile strength of a wound 2 weeks after surgery compared to intact skin is:A. 10%Correct ChoiceB. 50%C. 30%D. 70%E. 100%The tensile strength of a wound approaches 10% of normal skin strength at 2 weekspostoperatively. Wound healing is a process which takes many months, yet the tensile strength of awound never exceeds 70-80% of the tensile strength of intact skin. The use of subcuticular suturesis therefore critical to minimize the tension on a healing wound and prevent scar widening2) What risk does an organ transplant recipient have of developing melanoma?A. Same risk as general populationB. Less risk than general populationC. 10- fold increased riskD. 50-fold increased riskE. 3-fold increased riskCorrect ChoiceOrgan transplant recipients are at risk for developing many cutaneous tumors. The risk ofmelanoma is 3-fold that of the general population whereas these patients have a 65-fold increasedrisk of developing squamous cell carcinoma3) A Z- plasty is performed to:A. Reorient a scar Correct ChoiceB. Make use of skin from an area of laxityC. Obtain wound eversionD. Shorten the length of an excisionE. Close a wound on a convex surfaceA Z-plasty is a type of transposition flap that may be used to reorient a scar, especially when thescar crosses skin tension lines. It is also used to change the scar length or vector and ease scarcontractures4) A Mohs surgery fellow experiences burning and tingling of her fingertips 6 months after startingher fellowship. She most likely has been exposed to which one of the following chemicals?A. Chlorhexidine gluconateB. Povodine-iodineC. HematoxylinD. Toluidine blueE. Hexachlorophene Correct Choice 1
  2. 2. Hexachlorophene is an antibacterial agent that was first introduced in 1944. Its use wasdiscontinued in the 1970s when it was discovered to have neurotoxic side effects5) The role of imiquimod in the treatment of superficial basal cell carcinoma is based on theinduction of which cytokine?A. Tumor growth factor-alphaB. Interferon-gamma Correct ChoiceC. Tumor necrosis factor–betaD. Interleukin-2E. Interleukin-4Imiquimod is an immunomodulator which induces the production of cytokines that are involved incell-mediated immunity. These cytokines include interferon-alpha, interferon-gamma, interleukin-1,interleukin-10 and tumor necrosis factor-alpha. Induction of these cytokines results in antiviral andantitumor activity in vivo6) All of the following are branches of the internal carotid artery except:A. Ophthalmic arteryB. Supratrochlear arteryC. Supraorbital arteryD. Angular arteryCorrect ChoiceE. Dorsal nasal arteryBranches of the internal carotid artery include the opthamic artery, supraorbital artery, dorsal nasalartery, supratrochlear artery, palpebral artery, and lacrimal artery. Branches of the external carotidartery include the superficial temporal artery, facial artery (inferior labial, superior labial, angularbranches), maxillary artery, posterior auricular, and occipital artery. The external and internalcarotid arteries anastamose in the periorbital region7) How long after cutaneous infiltration of lidocaine with epinephrine is maximal vasoconstrictionachieved?A. 15 minutes Correct ChoiceB. 7 minutesC. 1 minuteD. 30 minutesE. 1 hourThe use of epinephrine with local anesthesia has two main advantages. Firstly, the epinephrine is avasoconstrictor and assists in controlling bleeding during surgery. Secondly, and also a direct resultof its vasoconstrictive effects, epinephrine helps prolong the duration of the anesthetic agent 100%to 200% by delaying its absorption from the surgical site. Although the anesthetic properties oflidocaine take effect within the first few minutes of infiltration, the vasoconstrictive effects ofepinephrine require approximately 15 minutes to fully develop8) Which of the following topical antibacterial agents demonstrates activity against Pseudomonasspecies? 2
  3. 3. A. ErythromycinB. MupirocinC. Polymyxin Correct ChoiceD. BacitracinE. ClindamycinPolymyxins are peptides produced by the organism Bacillus polymyxa. They are bactericidal againstPseudomonas aeruginosa, Proteus mirabilis, Enterobacter, Klebsiella and Escherichia coli. Since theyprovide little coverage against gram-positive organisms, polymyxins are often combined with otherantibacterial agents to increase their spectrum of activity9) Healing by secondary intention will offer the most favorable cosmetic result at which location?A. Malar cheekB. Nasal tipC. ChinD. Medial canthusCorrect ChoiceE. ForeheadIndications for healing of full-thickness skin wounds by secondary intention include infected wounds,patients who refuse reconstructive surgery or who are poor surgical risks for reconstructive surgery,and resection of tumors with high rates of recurrence. In addition, secondary intention, orgranulation, can be utilized when the cosmetic result is anticipated to be superior or equal toreconstruction. Disadvantages of healing by granulation include prolonged wound healing time andsomewhat unpredictable cosmetic results. Anatomic sites lending themselves best to secondintention healing, with excellent results, are the concave areas on the face. These include themedial canthus, the nose-cheek junction, the auricular concha, the preauricular cheek, and theretroauricular scalp. The nasal tip, malar cheek, chin and forehead are all convex surfaces on theface10) Compared to intact skin, what is the tensile strength of a wound 6 months after surgery?A. 30%B. 90%C. 50%D. 70%Correct ChoiceE. 100%Tissue remodeling allows the host to develop a scar that is approximately 70% of the originalstrength of the skin11) The following flaps are types of transposition flaps except:A. A to TCorrect ChoiceB. NasolabialC. BilobedD. Z plastyE. Rhombic flap 3
  4. 4. The Z plasty, Bilobed, Rhombic, nasolabial flaps are all examples of transposition flaps. In each ofthese, the flap is transposed over a normal piece of skin to be placed in the recipient site. Whereas,the A to T flap, is an advancement flap, in which tissue is moved in a linear direction to cover thedefect12) Which of the following demonstrates the highest risk of metastasis?A. SCC within a scar Correct ChoiceB. SCC on the scalpC. SCC on the noseD. SCC on the earE. SCC on the lipLocation of tumor is an important risk factor for metastasis of squamous cell carcinoma. Comparedwith a 10% likelihood of metastasis for tumors located on the ear or the lip, an SCC developing inthe scar, however, has been estimated to metastasize at a rate as high as 30-40%13) A surgeon plans to repair a defect on the lower lip with a wedge resection. All of the followingstatements are true regarding wedge resection of the lower lip except?A. the vermillion border is marked prior to excisionB. the repair involves a two layered closure of skin and mucosaCorrect ChoiceC. up to 1/3 of the lip can be excised and closed primarilyD. the mental crease should not be crossedE. a V-shaped excision is often usedThe lower lip has such great elasticity that full-thickness lesions that involve up to 1/3 of the lip canbe excised and repaired primarily with excellent cosmetic and functional results. This type of repairrequires a three layered closure of mucosa, skin and muscle.Larrabee W. In: Principles of Facial Reconstruction. Lippincott-Raven: Philadelphia, 1995; 182-18314) Endocarditis prophylaxis is recommended for each of the following except:A. Previous bacterial endocarditisB. Atrial septal defectsCorrect ChoiceC. Mitral valve prolapse with regurgitationD. Prosthetic valvesE. Hypertrophic cardiomyopathyPreoperative antibiotics are recommended for endocarditits prophylaxis in those patients withprostheitc valves, congenital cardiac malformations, previous bacterial endocarditis, rheumatic heartdisease with valve dysfunction, hypeertrophic cardiomyopathy, and mitral valve prolapse withrefurgitaion. Classically 1 gram of Dicloxacillin or cephalexin is given 1 hour preoperatively and anadditional 500 mg is given 6 hours post op. Clindamycin can be givenin those patients who arepenicillin allergic.Preopertive antibiotics for endocarditis prohpylaxis are not required in those patients who have anAtrial Septal Defect (ASD). pacemaker, rheumatic fever without valve dysfunction, or history ofCoronary Artery Bypass Graft (CABG 4
  5. 5. 15) Which of the following is true regarding lidocaine:A. Allergy most commonly occurs to propylene glycol preservativesB. Maximum dose with no epinephrine is 7mg/kgC. Beta blockers increase lidocaine levelsCorrect ChoiceD. 1% lidocaine is equal to 1g/10mlE. Duration with no epinephrine is 4-6 hoursBeta blockers increase lidocaine levels. The rest of the answers are false. 1% lidocaine is equal to1g/100ml or 10mg/ml. Duruation of lidocaine with no epi is 30-60 minutes. Maximum dose oflidocaine with no epi is 4.5 mg/kg, with epi it is 7 mg/kg. Allergy to lidocaine is most commonly dueto paraben preservatives16) On average, how much does a full-thickness graft contract when removed from a donor site?A. 30%B. 15%Correct ChoiceC. 80%D. 50%E. 60%On the average, how much does a full-thickness graft may contract by about 15% when removedfrom a donor site17) The surgical instrument shown in the photograph is a:A. DermabladeB. No. 10 bladeC. No. 11 bladeCorrect ChoiceD. No. 15 bladeE. Beaver bladeSurgical blades are made from either carbon steel or stainless steel and may be coated with Teflonto reduce their drag through tissue. A no.11 blade, which is a narrow blade that ends in a sharppoint, is used to make stab incisions and is often employed in incision and drainage procedures18) True statements regarding skin cancer in organ transplant recipients include all of the followingexcept:A. Mohs micrographic surgery indicated for in-transit metastases Correct ChoiceB. 65 fold increase in development of SCC compared with general populationC. Extent of tumor development related to degree of immunosuppressionD. Skin cancer is the most common cancer in transplant patientsE. Cutaneous malignancies develop 3-5 years after organ transplantationIn-transit metastases is a common manifestation of metastatic disease19) Which of the following local anesthetics has the longest duration of action? 5
  6. 6. A. MepivacaineB. BenzocaineC. LidocaineD. ProcaineE. BupivacaineCorrect ChoiceBupivacaine is an amide type of local anesthetic. Its duration of action is approximately 3-5 hoursand is the longest one listed. Following bupivacaine is mepivacaine, lidocaine, and procaine. Theduration of action is based on the amine portion of the molecule20) Which needle shape is most commonly used in cutaneous surgery?A. 1/4 circleB. 5/8 circleC. 3/8 circleCorrect ChoiceD. compound curveE. 1/2 circleNeedles are either straight or curved. Curved needles have their curvature described either as afraction of a circle or a compound curve. The greater the fraction of a circle, the more pronation andsupination of the wrist required by the surgeon to place the needle. The 3/8 circle needle is easy touse in large, superficial areas and is the most commonly used needle for cutaneous surgery21) Which of the following is the earliest symptom of lidocaine toxicity:A. Perioral tinglingCorrect ChoiceB. NystagmusC. SeizureD. TachycardiaE. CyanosisThe maximum dosage of lidocaine is 4.5 mg/kg without epinephrine and 7.0 mg/kg withepinephrine. Signs of lidocaine toxicity start at 1-5 microgm/ml with increased anxiety,talkativeness, tinnitus, numbess/tingling around lips, metallic taste, double vision. Higher levels oftoxicity may cause nystagmus, muscle twitching, tremor and finally seizures and respiratory arrest22) Which of the following cosmetic injectables does not illicit an inflammatory response?A. Artecoll (polymethylmethacrylate)B. Sculptra (poly L-lactic acid)C. Radiance (hydroxyapatite)Correct ChoiceD. Zyplast (collagen)E. SiliconeRadiance is an injectable, biodegradable filler composed of calcium hydroxyapatite microspheres. Itis a normal constituent of bone and is therefore biocompatible. Current studies are examining therole of hydroxyapatite in augmenting the craniofacial skeleton 6
  7. 7. 23) Each of the following are branches of the internal carotid artery except:A. Ophthalmic arteryB. Supraorbital arteryC. Supratrochlear arteryD. Angular artery Correct ChoiceE. Dorsal nasal arteryThe angular artery is a branch of the external carotid artery. It arises from the facial artery andcourses superiorly along the nasofacial angle until it reaches the area of the medial canthal tendon.At this location, the angular artery anastamoses with the dorsal nasal branch of the ophthalmicartery establishing a communication between the internal and external carotid arterial systems24) Which of the following parameters determines the wavelength of a laser?A. FluenceB. Spot sizeC. Lens lengthD. Medium Correct ChoiceE. Pulse durationLaser light is monochromatic light that is emitted at a single wavelength. The wavelength of thelaser is determined by the medium in the optical cavity of the laser through which the light passes.The medium may be solid, liquid or gas25) The cutaneous lip and chin are divided into cosmetic units by which anatomic boundary?A. Philtral ridgeB. Mental creaseCorrect ChoiceC. Nasolabial foldD. Vermillion borderE. Marionette linesThe term cosmetic unit is used to define regions of the face by specific characteristics such as color,texture, presence of hair, and prominence of sebaceous glands. In dermatologic surgery, it ispreferable to conceal incisions within the boundary lines of cosmetic units. The mental crease, asdemonstrated in the photograph, divides the cutaneous lip and chin26) Which statement is true regarding relaxed skin tension lines (RSTLs)?A. incisional scars should be placed perpendicular to RSTLsB. the long axis of a wound often lies in the direction of the RSTL Correct ChoiceC. they lie parallel to the underlying musclesD. they occur as a result of increased elastic toneE. smiling minimizes the appearance of RSTLsRelaxed skin tension lines are creases in the skin that are present at rest and develop as aconsequence of the decreased elasticity that occurs with aging and solar damage. These lines lieperpendicular to the underlying musculature and can be accentuated by smiling or frowning. An 7
  8. 8. undermined circular wound will often form an oval shape due to muscular tension, and will have itslong axis oriented within these relaxed tension lines. Knowledge of RSTLs is important in cutaneoussurgery because placing incisions within these lines will ensure the most favorable cosmetic result27) Pre-testing for allergy to collagen is required for which cosmetic filler?A. SiliconeB. Artecoll Correct ChoiceC. RadianceD. PerlaneE. CosmodermArtecoll is a nonbiodegradable injectable filler composed of microspheres of polymethylmethacrylatewhich are suspended in bovine collagen. As with other types of injectable bovine collagen, patientsmust be tested for allergy to bovine collagen prior to treatment28) Damage to the zygomatic branch of the facial nerve leads to which of the following:A. Facial asymmetryB. Eyelid ectropion and inability to close eyelidCorrect ChoiceC. Winged scapulaD. Inability to pucker lipsE. Unilateral eyelid ptosisDamage to the zygomatic nerve causes eyelid ectropion and inability to close eyelid29) A patient has a 2.0 cm surgical defect on the left lower eyelid after having Mohs surgery. Whichmanagement option would be the least appropriate?A. Primary closureB. Secondary intentionCorrect ChoiceC. Rhombic flapD. Full-thickness skin graftE. Tripier flapIn lower eyelid reconstruction, tension should be oriented parallel to the lower eyelid to prevent thedevelopment of ectropion. Secondary intention would be the least appropriate management optionin this location because normal wound contraction would increase the risk of ectropion30) Cosmetic units are defined by each of the following anatomic boundaries except:A. Nasofacial sulcusB. Glabellar regionC. Philtral ridgeD. Nasolabial foldsE. Nasal tip Correct Choice 8
  9. 9. The term cosmetic unit is used to define regions of the face by specific characteristics such as color,texture, presence of hair, and prominence of sebaceous glands. In dermatologic surgery, it ispreferable to conceal incisions within the boundary lines of cosmetic units. In addition, moving skinfrom one cosmetic unit to another should be avoided when possible to minimize the appearance ofapposed skin of dissimilar quality31) The O to Z flap is what type of flap?A. PedicleB. RotationCorrect ChoiceC. TranspositionD. BilobedE. AdvancementThe O to Z flap is a bilateral rotation flap in which tissue is moved from two ends to cover a centraldefect. It is often used on the scalp or lower extremities in locations where tissue laxity is notpresent.32) A patient who had liposuction 5 weeks ago presents with multiple firm nodules at the cannulainsertion sites. You suspect the diagnosis is:A. Herpes simplex infectionB. Cold panniculitisC. Mycobacterial infectionCorrect ChoiceD. Foreign body granulomaE. Organized hematomaAtypical mycobacterial infections are occurring with increasing frequency after cosmetic surgeryprocedures. These infections typically occur 4-14 weeks after a procedure as a late-occurringcomplication. Firm nodules at the treatment site or dehiscence of a previously healed wound may bepresenting signs of atypical mycobacterial infection33) The main advantage of selecting 4-0 Vicryl rather than 5-0 Vicryl to suture a wound is:A. Smaller suture diameterB. Smaller needleC. Increased tensile strength Correct ChoiceD. Increased suture memoryE. Increased knot securitySutures are classified according to the United States Pharmacopeia (USP) criteria. This classificationsystem specifies the diameter of a given suture material that is required to produce a certain tensilestrength. The smaller the cross-sectional diameter of a suture material, the higher the USP numberthat is assigned. Thus, 4-0 Vicryl will have greater tensile strength and a larger cross-sectionaldiameter than 5-0 Vicryl34) All of the following statements are true regarding the ‘MCW Melanoma Cocktail’ except:A. it demonstrates micrometastases in sentinel lymph nodes 9
  10. 10. B. it is performed intraoperativelyC. it is a mixture of polyclonal antibodies to tyrosinaseCorrect ChoiceD. it is a mixture of monoclonal antibodies to MART-1E. it is a mixture of monoclonal antibodies to Melan-AThe ‘MCW Melanoma Cocktail’ is an immunostain made up of monoclonal antibodies to MART-1,Melan-A and tryrosine. It is used intraoperatively during sentinel lymph node biopsy and allows forrapid and accurate determination of micrometastases.Shidham VB et al. Optimization of an immunostaining protocol for the rapid intraoperativeevaluation of melanoma sentinel lymph node imprint smears with the ‘MCW Melanoma Cocktail’.Cytojournal 2004;1(1):235) The “trapdoor effect” that can occur with a flap can be avoided by which of the followingtechniques:A. Using additional suturesB. Avoid thinning the flapC. Using a flap with length to width ratio of less than 3:1D. Performing the flap in a two staged procedureE. Wide underminingCorrect ChoiceWide undermining of the primary defect can release tension and prevent tenting or the trap doordeformity of the flap36)The nasolabial two stage flap uses depends on which artery for flap survival:A. Lateral Nasal arteryB. Angular arteryCorrect ChoiceC. Superior labial arteryD. Inferior labial arteryE. Supratrochlear arteryAngular artery provides blood supply for the nasolabial transposition flap37) A patient with end stage liver disease comes to your surgical practice. Which of the followinganesthetics should be used with this patient?A. MepivicaineB. LidocaineC. BenzocaineCorrect ChoiceD. EtidocaineE. PrilocaineBenzocaine, an ester, should be used as it is the only anesthetic mentioned above that ismetabolized by the kidney and not the liver 10
  11. 11. 38) A 40 year-old woman from Southern California has wrinkles at rest on her forehead, scatteredtelangiectasia on her nose and a few seborrheic keratoses on her chest. What category in Glogausphotoaging classification scale does this patient represent?A. Type 5B. Type 2C. Type 4D. Type 1E. Type 3 Correct ChoiceGlogau’s photoaging scale is a classification system that employs clinical markers of photodamageto determine an individual’s level of photoaging. The scale ranges from Type 1 through Type 4, withType 4 demonstrating the most extensive photodamage. Type 3 on the Glogau scale is classified asadvanced photoaging and describes a patient who is typically 50 years of age or older, has wrinklesat rest, telangiectasias, obvious dyschromias and visible keratoses39) Which post-operative complication is shown in the photograph?A. Temporal nerve paralysisB. Ectropion Correct ChoiceC. Trap door deformityD. Hypertrophic scarE. EclabiumEctropion occurs when the eyelid margin turns outward away from the eye. In lower eyelidreconstruction, tension should be oriented parallel to the lower eyelid to prevent the development ofectropion40) Which of the following facial rejuvenation techniques creates microthermal zones?A. RadiofrequencyB. Intense pulsed lightC. DermabrasionD. Fractional photothermolysisCorrect ChoiceE. CO2 laserFractional photothermolysis utilizes an infrared laser to create thousands of microthermal zoneswith normal skin remaining between these zones. The zones of normal skin support rapid re-epithelialization and result in much faster healing times than with traditional resurfacing procedures41) Preliminary studies with phosphatidylcholine demonstrate efficacy in the treatment of:A. Soft tissue augmentationB. Acne scarringC. Periorbital fat padsCorrect ChoiceD. Postinflammatory hyperpigmentationE. Superficial rhytids 11
  12. 12. Phosphatidylcholine is a lecithin-derived phospholipid which induces lipolysis when injected intoadipose tissue. Dissolution of fat is likely due to a detergent effect produced by thephosphatidylcholine42) A patient with a deep vertical frown line in the glabellar region requests Botox. Treatment willmostly target which one of the following muscles?A. Orbicularis oculiB. Depressor superciliarisC. Orbicularis oculiD. Levator palpebrae superiorisE. Corrugator superciliaris Correct ChoiceAlthough the procerus and orbicularis oculi muscles are contributory, the development of verticalglabellar frown lines is mostly due to the overactivity of the corrugator supercilaris. These musclesfunction to pull the eyebrow inferomedially43) Botulinum toxin type A cleaves which protein in the presynaptic neuron?A. AcetylcholineB. Synaptobrevin (VAMP)C. Snap-25Correct ChoiceD. SerotoninE. SyntaxinBotulinum toxin type A is FDA approved for the treatment of glabellar wrinkles. Botulinum toxins actby a three step process of binding, internalization by receptor medicated endocytosis and enzymaticactivation. It has specific light chain intracellular binding sites and different sites of action ondifferent SNARE (synaptosomal associated protein receptor [SNAP]) proteins. The SNARE proteinsare intimately involved in releasing acetylcholine at presynaptic terminals. Botulinum toxin Acleaves SNAP-25 whereas B cleaves synaptobrevin44) In a patient who is allergic to paraphenylinediamine, which of the following anesthetics shouldbe avoided?A. BenzocaineCorrect ChoiceB. BupivicaineC. PrilocaineD. MepivicaineE. EtidocaineParaphenyelenediamine is a common allergen found in permanent hair dyes. In individuals who areallergic to paraphenylendiamine, may also have allergic reactions to ester anesthetics, likebenzocaine. The other answer choices are amide anesthetics. Other crossreactants toparaphenyelediamine include the preservative parabens, sulfonamides, and thiazide diuretics45) The anatomic structure identified in the photograph is called the:A. Philtral ridge 12
  13. 13. B. Nasal grooveC. Nasal alaD. Soft triangleE. ColumellaCorrect ChoiceThe columella is one of the cosmetic subunits of the nose. It is formed by the medial crura of thealar cartilage46) All of the following thrombotic complications have been reported after discontinuing aspirintherapy prior to surgery except:A. StrokeB. Transient ischemic attackC. Pulmonary embolismCorrect ChoiceD. Cerebral embolismE. Myocardial infarctionKovich et al. reported thrombotic complications in patients who had stopped either coumadin oraspirin peri-operatively. Thrombotic complications in patients who stopped warfarin included stroke,TIA, myocardial infarction, cerebral embolism, death, DVT, pulmonary embolus, and blindness.Thrombotic complications in patients who stopped aspirin included stroke, TIA, myocardialinfarction, cerebral embolism and death. No DVT or pulmonary embolus was reported47) Which of the following immunosuppressive agents may exert a protective effect against thedevelopment of skin cancers in organ transplant patients?A. RapamycinCorrect ChoiceB. TacrolimusC. CorticosteroidsD. CyclosporineE. AzathioprineRapamycin (also called sirolimus) is a macrolide antibiotic and a structural analog of FK 506. It is apotent immunosuppressive agent which inhibits mTOR (a member of P13K family kinases). Despiteits immunosuppressive effects, preliminary data show a decreased incidence of skin cancer in organtransplant patients treated with rapamycin and postulate that it may exert a protective effectagainst cutaneous malignancies48) Injection of Botox at the location identified in the photograph would denervate which muscle?A. FrontalisB. Corrugator superciliarisC. Levator palpebrae superiorisD. Orbicularis oculiE. ProcerusCorrect ChoiceThe development of vertical glabellar frown lines is due to the overactivity of the orbicularis oculi,procerus and corrugator supercilaris muscles. These muscles function to pull the eyebrowinferomedially 13
  14. 14. 49) A safe dose of lidocaine with epinephrine when used in tumescent anesthesia is:A. 3 mg/kgB. 7 mg/kgC. 4.5 mg/kgD. 20 mg/kgE. 50 mg/kg Correct ChoiceThe maximum recommended dosage of lidocaine in adults is 4.5 mg/kg without epinephrine, 7.0mg/kg with epinephrine, and 55 mg/kg in tumescent anesthesia for liposuction50) Which of the following determines the wavelength of a laser?A. Spot sizeB. Medium Correct ChoiceC. Pulse durationD. FluenceE. Q switchThe wavelength of a laser is determined by the medium51) Which of the following cosmetic injectables has the longest duration of action?A. Sculptra (poly L-lactic acid)Correct ChoiceB. Restylane (hyaluronic acid)C. Cosmoderm (collagen)D. MyoblocE. BotoxSculptra (called New-Fill outside of the US) is a biodegradable filler composed of poly-L-lactic acid,the same material used in absorbable sutures. Preliminary studies have demonstrated longevity ofthe filler at two years post-treatment.Valantin MA et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infectedpatients: results of the open-label study VEGA. AIDS. 2003;17:2471-247752) Which is the most important criterion for performing Mohs micrographic surgery?A. Aggressive histologyB. Size of tumor > 2cmC. Tumor recurrenceD. Tumor is contiguous Correct ChoiceE. Location of tumorTumor that grows as a contiguous mass is an absolute requirement for Mohs micrographic surgery.If a tumor exhibits discontiguous growth, discrete foci may be missed in the thin tissue layers andthereby lead to a false-negative pathology interpretation. Size, location, recurrence and histologyare all indications for Mohs micrographic surgery rather than absolute requirements 14
  15. 15. 53) The use of topical vitamin K has been shown to:A. Induce keratinocyte differentiationB. Increase collagen productionC. Minimize the appearance of telangiectasiaD. Reduce the severity of laser-induced purpura Correct ChoiceE. Decrease the appearance of infraorbital pigmentationTreatment of benign vascular lesions with the pulsed dye laser often produces significantpostoperative purpura. Topical vitamin K has been shown to decrease the severity of laser-inducedpurpura although its mechanism of action has yet to be determined. No other cosmetic effects oftopical vitamin K have been proven to be statistically significant54) Which of the following is the major antioxidant in the human epidermis?A. Ascorbic acidB. Coenzyme Q10C. Alpha-tocopherol Correct ChoiceD. Superoxide dismutaseE. GlutathioneResearch into the preventive role of topical antioxidants in photoaging is based on the free radicaltheory of aging. All of the choices above are antioxidants which are naturally found in the skin,however, alpha-tocopherol is the major antioxidant in human epidermis. Epidermal depletion of thisvitamin has been shown to be an early and sensitive marker of environmental oxidative damage55) The photograph demonstrates which of the following?A. Composite graftB. Full-thickness skin graft Correct ChoiceC. Mohs layerD. Split-thickness skin graftE. Dog earA full-thickness skin graft (FTSG) is composed of the entire epidermis and dermis. Subcutaneoustissue must be removed since the fat may compromise the viability of the graft56) Treatment of acne scarring would be most effective with which modality?A. Nd:YAG laserCorrect ChoiceB. Intense pulsed lightC. Pulsed dye laserD. Photodynamic therapyE. Radiofrequency 15
  16. 16. Treatment with the nonablative 1064-nm Q-switched Nd:YAG provides significant improvement inskin topography in patients with atrophic acne scars. The further improvements that are seen at 6-month follow-up suggest that dermal remodeling is a process that continues long after treatment57) Which structual component of local anesthetics (e.g. lidocaine) is responsible for the onset ofactivity?A. Amine endB. None of the aboveC. Length of the carbon chainD. Aromatic ringCorrect ChoiceE. Intermediate chainLocal anesthetics like lidocaine contain 3 principle structural elements. The aromatic ring determinesthe onset of activity, the intermediate chain defines the class (amide vs. ester), and the amine endis responsible for the duration of action58) While removing sutures from an excision performed on the lateral neck, your patient reportsdecreased sensation of the helix and lobule of the ipsilateral ear. Which of the following nerves waslikely injured during surgery?A. Spinal accessory nerveB. Greater auricular nerve Correct ChoiceC. Auricular branch of vagus nerveD. Lesser occipital nerveE. Auriculotemporal nerveSensory innervation of the ear is provided by the greater auricular nerve, the auriculotemopralnerve, the lesser occipital nerve and the auricular branch of the vagus nerve. The greater auricularnerve is composed of the C2 and C3 branches of the cervical plexus and lies in the posterior triangleof the neck. It provides sensation to the helix, antihelix, antitragus, posterior auricle and the lobule.The spinal accessory nerve is a motor nerve which innervates the trapezius muscle. This nerve isalso subject to injury in the lateral neck but would cause motor deficits rather than sensory deficits59) Paradoxical darkening has been associated with Q-switched ruby, Q-switched alexandrite, Q-switched Nd:Yag treatment of which tattoo color?A. GreenB. BlackC. BlueD. YellowE. RedCorrect ChoiceParadoxic darkening of flesh-tone, red, and white tattoo inks with QSRL, Q-switched Nd:YAG, andQ-switched alexandrite lasers has been reported. The tattoo pigments most associated with thisphenomenon are iron oxide and titanium dioxide. Ferric sulfide is converted to ferrous sulfate by thelaser60) Which tattoo pigment is most commonly associated with allergic reactions, eczematous andgranulomatous? 16
  17. 17. A. Cadmium sulfideB. Titanium dioxideC. CobaltD. Mercuric sulfideCorrect ChoiceE. CarbonAllergic reactions have been reported with several different types of tattoo pigment. The mostcommonly associated tattoo pigment however is mercuric sulfide. Tattoo with mercuric sulfideproduces a red color61) Which dye is used to stain the Mohs section shown in the photograph?A. EosinB. Toluidine blueCorrect ChoiceC. Cytokeratin 7D. HematoxylinE. MyeloperoxidaseToluidine blue is the stain in the photographed Mohs section. Since mast cells have been associatedwith tumor growth and are seen in increased numbers with basal cell carcinoma, staining of theirmetachromatic granules with toluidine blue can be an effective way of visualizing basal cellcarcinoma on Mohs sections, particularly when the tumor is associated with fibrosis62) The most common adverse reaction seen with betadine is:A. OtotoxityB. SeizuresC. Corneal damageD. Allergic contact dermatitisCorrect ChoiceE. TeratogenicityMost common side effect seen with betadine is allergic contact dermatitis, secondary to the iodinecomponen63) Which tattoo pigment has been most commonly associated with pseudolymphomatousreactions?A. Mercuric sulfideCorrect ChoiceB. MalachiteC. Cadmium sulfideD. Phthalocyanine dyesE. CobaltSome delayed type hypersensitivity reactions may lead to pseudolymphoma, most commonlycaused by red tattoo pigment (mercuric sulfide64) Which nerve provides the sensory innervation to the tragus? 17
  18. 18. A. AuriculotemporalCorrect ChoiceB. Auricular branch of vagusC. FacialD. GlossopharyngealE. Greater auricularThe auriculotemporal nerve which is a branch of the mandibular branch of the temporal nerveinnervates the tragus. The sensory innervation to the auricle is provided by the greater auricularnerve, and to a lesser extent the lesser occipital nerve. The external auditory canal, concha, andposauricular sulcus supplied variably by 3 nerves - the auricular branch of the vagus (CNX), thefacial nerve (CN7), and the glossopharyngeal (CNIX65) Treatment with which modality would be most effective for the patient shown?A. Pulsed dye laserB. Photodynamic therapyC. RadiofrequencyD. Erbium:YAG laserE. Intense pulsed lightCorrect ChoiceThe patient shown has multiple solar lentigines. Targeting the melanosomes in these benign,superficial pigmented lesions would be most successfully accomplished with the intense pulsed lightsource66) The surgical instrument shown in the photograph is a:A. Stevens tenotomy scissor Correct ChoiceB. Metzenbaum scissorC. Castroviejo scissorD. Mayo scissorE. Iris scissorThe instrument shown is a Stevens tenotomy scissor. This scissor is useful in dermatologic surgeryfor tissue cutting and blunt dissection67) All of the following are alpha-hydroxy acids except:A. Tartaric acidB. Citric acidC. Glycolic acidD. Lactic acidE. Salicylic acidCorrect ChoiceAlpha-hydroxy acids are naturally occurring carboxylic acids found in many foods. The alpha-hydroxy acids include glycolic, lactic, malic, citric, and tartaric acids. Factors that determine theintensity of the peel include the concentration of the acid, pH, degree of buffering, vehicleformulation, frequency of application, conditions of delivery, and the length of time the acid isplaced on the skin. Salicylic acid is a type of beta-hydroxy acid 18
  19. 19. 68) Formation of granulomas is a potential complication of treatment with:A. Silicone Correct ChoiceB. HydroxychloroquineC. IsotretinoinD. Autologous fatE. CO2 resurfacingSilicone is a synthetic, viscous compound which is composed of long polymers of dimethylsiloxanes.Silikon-1000 is one silicone product which is available in the United States and is FDA-approved forthe ophthalmic treatment of complicated retinal detachment. The number 1000 refers to theproduct’s viscosity which is measured in centistokes. As a reference, water has a viscosity of 100centistokes and mineral oil has a viscosity of about 350 centistokes. With respect to cosmeticapplications, silicone is not FDA-approved for soft tissue augmentation. In addition to theoccurrence of hypersensitivity reactions and product migration, there have been many reports ofgranuloma formation after silicone injection, even many years post-treatment69) Which ocular structure is at most risk of injury from an erbium:YAG laser?A. PupilB. IrisC. RetinaD. LensE. Cornea Correct ChoiceThe erbium:YAG laser is an ablative laser whose target chromophore is water. The cornea is anaqueous structure and is therefore the most susceptible to damage from this laser70) Activation of the procerus muscle causesA. Accentuation of the melolabial foldsB. Perioral wrinklesC. Periocular wrinklesD. Wrinkles at the nasal rootCorrect ChoiceE. Wrinkles on the foreheadThe procerus muscle causes wrinkling at the nasal root and is often targeted with Botox therapy forimproved cosmesis71) The cutaneous lip and chin are divided into cosmetic units by which anatomic boundary?A. Vermillion borderB. Nasolabial foldC. Mental creaseCorrect ChoiceD. Philtral ridgeE. Marionette linesThe term cosmetic unit is used to define regions of the face by specific characteristics such as color,texture, presence of hair, and prominence of sebaceous glands. In dermatologic surgery, it is 19
  20. 20. preferable to conceal incisions within the boundary lines of cosmetic units. The mental crease, asdemonstrated in the photograph, divides the cutaneous lip and chin72) Treatment with which of the following lasers has been effective in psoriasis?A. Pulsed dye laserB. Alexandrite laserC. Ruby LaserD. Carbon dioxide laserE. Excimer laswerCorrect ChoiceThe excimer laser is a 308 nm wavelength laser that has been used to treat psoriasis. The excimerlaser has some advantages over ultraviolet therapy. By treating only involved skin, higher doses canbe used and clearance may occur with fewer treatments73) Which laser would not be a good choice for the treatment of a red cosmetic tattoo around thelips?A. Carbon dioxideB. Pulsed dyeC. Nd:YAGD. Q-switched rubyCorrect ChoiceE. AlexandriteQ-switched lasers can be effectively used to remove tattoos. However, immediate darkening ofwhite, flesh colored, and pink/red tattoos has been reported after treatment with Q-switched lasers.Both ferric oxide and titanium dioxide (found in tattoo pigments) may be both be reduced afterheating by the laser and produce dramatic darkening74) The anatomic structure identified in the photograph is called the:A. AntihelixB. Scaphoid fossaC. ConchaD. Triangular fossaCorrect ChoiceE. TragusThe triangular fossa of the ear is shown in the photograph. This anatomic structure is bordered bythe crura of the antihelix75) Which of the following cosmetic injectables can be seen on routine dental x-rays?A. BotoxB. Radiance Correct ChoiceC. RestylaneD. ZyplastE. Cosmoderm 20
  21. 21. Radiance is an injectable, biodegradable filler which is composed of calcium hydroxylapatitemicrospheres. Calcium hydroxylapatite is a normal constituent of bone and thus can be seen onradiographic imaging. Botox is botulinum toxin; Zyplast is bovine collagen; Cosmoderm is a non-animal form of collagen; and Restylane is a non-animal form of hyaluronic acid76) The type of repair depicted in the photograph is a:A. Full-thickness skin graftB. Nasolabial flapC. Rotation flapD. Rhombic flapE. Island pedicle flap Correct ChoiceThe island pedicle flap is a type of advancement flap commonly used for medial cheek defects. Theclosure can often be camouflaged in the melolabial fold77) The use of dermabrasion to improve the cosmesis of a scar is best performed how long afterthe initial surgery?A. 1 yearB. 1 weekC. 6 monthsD. 6 weeksCorrect ChoiceE. 3 weeksDermabrasion is the process of surgically planing or abrading the epidermis and dermis and isusually carried out with a rapidly rotating wire brush or diamond fraise.Following dermabrasion, reepithelialization from adnexal structures occurs with remodeling andreplacement of collagen bundles in the papillary and reticular dermis. This can result inimprovement of surgical or acne scars. When used in the post-operative period for surgical scars,dermabrasion is usually carried out 6 to 8 weeks following the procedure. Regional dermabrasionsare routinely carried out under local anesthesia. Post-procedure complications include scarring,pigmentary alterations, persistent erythema, and infection. Contraindications for dermabrasioninclude recent use of isotretinoin and recent facelift, browlift or other procedure involving extensiveundermining. Reactivation of herpes labialis can be prevented in the lip area by administeringantiviral prophylaxis78) Which cosmetic injectable provides dermal augmentation through the harvesting of a patient’sfibroblasts?A. JuvadermB. DermalogenC. HylaformD. IsolagenCorrect ChoiceE. RestylaneIsolagen is an emerging technology whereby a patient’s own fibroblasts are isolated from a skinbiopsy, reproduced and then re-introduced into the patient’s treatment site79) The tensile strength of a wound 6 months after surgery compared to intact skin is: 21
  22. 22. A. 70% Correct ChoiceB. 15%C. 30%D. 50%E. 100%The tensile strength of a wound approaches 70% of normal skin strength at 8 weekspostoperatively. Wound healing is a process which takes many months, yet the tensile strength of awound never exceeds 80% of the tensile strength of intact skin. It is therefore critical to use long-lasting subcuticular sutures to minimize the tension on a healing wound and prevent scar widening80) Epinephrine should be avoided with anesthetics in which of the following conditions?A. Renal failureB. HypothyroidismC. Liver failureD. PheochromocytomaCorrect ChoiceE. Diabetes MellitusEpinephrine should be avoided in patients with a pheochromocytoma81) Which ocular structure is at most risk of injury from an erbium: YAG laser?A. CorneaCorrect ChoiceB. IrisC. RetinaD. Vitreous humorE. LensInjury from lasers may occur via direct or indirect ocular exposure. Damage is generally wavelengthspecific. Laser that target hemoglobin or pigment may cause damage to the retinal pigment orvasculature while lasers that target water as a chromophore (carbon dioxide and erbium) candamage the cornea82) Which one of the following lasers would be effective in the treatment of rhinophyma?A. Carbon dioxide laserCorrect ChoiceB. Alexandrite laserC. KTP laserD. Pulsed dye laserE. Ruby laserThe carbon dioxide laser is a 10,600 nm laser that can be used to treat rhinophyma. The advantageof the carbon dioxide laser over steel or dermabrasion is that the laser is relatively bloodless. Theerbium YAG can also be used to treat rhinophyma83) A patient has a 1.5cm surgical defect on the right nasal sidewall that reveals the lateralcartilage. Which management option would be the least appropriate? 22
  23. 23. A. Cheek transposition flapB. Primary closureC. Full-thickness skin graft Correct ChoiceD. Forehead flapE. Secondary intentionFull-thickness skin grafts (FTSGs) depend upon a viable, vascular bed at the recipient site in orderto survive. Exposed cartilage is an avascular tissue and therefore would not be able to support themetabolic requirements of a FTSG84) Aging skin demonstrates all of the following characteristic changes except:A. Decreased number of Langerhans cellsB. Increase in subcutaneous fat Correct ChoiceC. Hypertrophy of sebaceous glandsD. Decreased dermal collagenE. Loss of elasticityThe loss and redistribution of subcutaneous fat is a characteristic finding of the aging face. Theforehead, temporal fossae, malar cheeks and perioral region are the most commonly affected areas.Knowledge of senescent changes in fat distribution has altered the cosmetic surgeon’s approach ofthe aging face to one which includes augmentation rather than one of simply lifting and tighteningthe skin85) The classic purpose for serrated scissors is:A. For work on delicate areas around the eyes and the earsB. For tissue underminingC. For work on thicker tissues (back)D. For sharp dissections of tissueE. For gripping tissue while cuttingCorrect ChoiceSerrated scissors are used primarily for gripping tissue to prevent sliding while cutting86) Which of the following lasers may cause milia formation as a post-procedure complication?A. Pulsed DyeB. ErbiumCorrect ChoiceC. ND-YagD. KTPE. ExcimerThe erbium (2940 nm) and carbon dioxide (10,600 nm) lasers may both cause milia formation afterlaser skin resurfacing87) Which of the following surgical prepatory solutions is teratogenic?A. Povidine-iodine 23
  24. 24. B. Ethyl and Isopropyl alcoholC. Benzalkonium chlorideD. ChlorhexidineE. HexachloropheneCorrect ChoiceHexachlorophene or pHisoHex has shown to be toxic to developing embryos in animal studies andthus is prohibited for use in pregnant females. Chlorhexidine is a common ingredient in oralrinses(Peridex) and surgical prep solutions(Hibiclens) can cause ototoxicity if in contact with themiddle ear and ocular toxicity if in contact with the eyes. Ethyl alcohol is effective against both grampositive and gram negative organisms, but only when the skin is dry. Both Povidine-Iodine(Betadine)and Benzalkonium chloride (Zephiran) can cause an allergic contact dermatitis88) What is the most appropriate management of the following surgical complication?A. Antibiotic therapyB. Observation Correct ChoiceC. Incision and drainageD. DebridementE. Pulse dye laserIf the epidermal surface of a graft becomes black and necrotic, it does not necessarily signify graftfailure. The epidermal portion of the graft may slough with subsequent re-epithelialization. In thissituation, the best treatment is observation89) A physician using a carbon dioxide laser to treat verruca should be aware that all of thefollowing complications can occur except:A. Recurrence of lesionB. Ocular damageC. Transmission of viral diseaseD. PurpuraCorrect ChoiceE. ScarringThe carbon dioxide laser uses a 10,600 nm wavelength to target water as a chromophore. Lasersthat target water may damage the cornea. The carbon dioxide laser can be used to destroyepidermal and dermal lesions such as warts. HPV virus has been recovered in the laser plume aftertreatment with carbon dioxide laser. Bovine papilloma virus recovered in the plume was even foundto transmit disease to calf skin. Scarring and recurrence have also been found to be potentialcomplications90) A Z-plasty is performed to:A. Correct dog-earsB. Obtain wound eversionC. Shorten the length of an excisionD. Decrease tension on a wound Correct ChoiceE. Make use of excess tissue 24
  25. 25. A Z-plasty is a transposition flap used most commonly in the treatment of contractures and scars.The main advantages to performing a Z-plasty are to decrease the tension on a wound, change theorientation of a scar, and camouflage a scar by breaking it up into smaller components91) Which of the following cosmetic injectables is FDA-approved for the treatment of lipoatrophy?A. BotoxB. RadianceC. SiliconeD. SculptraCorrect ChoiceE. IsolagenSculptra (called New-Fill outside of the US) is a biodegradable filler composed of poly-L-lactic acid,the same material used in absorbable sutures. It is biocompatible and nonallergenic and wasapproved by the FDA in August 2004 for the treatment of HIV-associated lipoatrophy92) A history of anaphylaxis is a contraindication to treatment with which cosmetic injectable?A. CosmodermB. RadianceC. SculptraD. RestylaneCorrect ChoiceE. MyoblocRestylane is a hyaluronic acid gel produced by the Streptococcus species of bacteria. The packageinsert for Restylane warns that its use is contraindicated in patients with “severe allergiesmanifested by a history of anaphylaxis or the presence of multiple severe allergies93) What part of the eye may be damaged by exposure to irradiation from the carbon dioxide laser?A. ScleraB. LensC. RetinaD. CorneaCorrect ChoiceE. IrisThe carbon dioxide laser operates at a wavelength of 10,600 nm and targets water as achromophore. Because of the high water content of the cornea, it may be damaged by exposure toirradiation from the carbon dioxide laser. Exposure to the erbium may cause corneal damage as well94) All of the following statements are true regarding nerves blocks on the face except:A. Anesthesia is placed around a nerve trunkB. Lidocaine with epinephrine may be usedC. Numbness occurs in areas other than the operative siteD. Hemostasis is achieved using epinephrineCorrect ChoiceE. Tissue distortion is minimized 25
  26. 26. While regional nerve blocks offer many advantages in cutaneous surgery, hemostasis is not one ofthem. Since the anesthetic is injected distant to the operative site, the vasoconstrictive effects ofthe epinephrine, and hence hemostasis, are not provided at the surgical site95) The post-operative complication shown in the photograph is most commonly seen with whichtype of reconstruction?A. Full-thickness skin graftB. Rhombic flapC. Nasolabial flap Correct ChoiceD. Secondary intentionE. Rotation flapTrap door deformity is believed to result from insufficient undermining. This surgical complication ismost often associated with the nasolabial transposition flap. Intralesional corticosteroids may bebeneficial in improving the cosmetic outcome96) The pain associated with Botulinum A Exotoxin injection is attributed to the:A. Needle gaugeB. Preservative-free salineCorrect ChoiceC. TemperatureD. PHE. ExotoxinBotulinum A exotoxin is used for multiple reasons, most often for the treatment of dynamic faciallines. In a double-blind, randomized controlled study, investigators found that botulinum A exotoxinreconstituted with preservative-containing saline less painful than with preservative-free saline97) An M-plasty is performed to:A. Make use of excess tissueB. Reorient a scarC. Decrease tension on a woundD. Obtain wound eversionE. Shorten the length of an excision Correct ChoiceAn M-plasty is a variation of the fusiform excision where either one or both ends of the ellipse aremodified. The main advantages to performing an M-plasty are to shorten the length of an excisionand to correct dog-ears98) Botulinum toxin A (Botox) is FDA-approved for the treatment of:A. Platysmal bandsB. Migraine headachesC. HyperhidrosisCorrect ChoiceD. Masseter hypertrophy 26
  27. 27. E. Crow’s feetBotox has been recently FDA-approved for the treatment of hyperhidrosis.A CPT procedure code has been assigned to treatment with Botox for this indication with variablereimbursement rates by insurance companies99) The antiptosis subdermal suspension threads used in facial rejuvenation are composed of:A. Polyglycolic acidB. Poly-L-lactic acidC. PolydioxanoneD. PolyglactinE. PolypropyleneCorrect ChoiceThe Aptos subdermal suspension thread technique is a minimally invasive procedure which targetsthe ptotic changes seen with facial aging. 2-0 and 3-0 polypropylene threads are tunneled in thedermis to lift and suspend the skin and subcutaneous tissue100) Which one of the following best estimates the percent strength of a wound one month aftersurgery with a primary closure?A. 90%B. 70%C. 80%D. 30%E. 50%Correct ChoiceOne month after surgery with a primary closure a wound is approximately at 50% strength. Twoweeks after surgery it is at 5% strength. Three weeks after surgery it is at 20%. It never reaches100% of its original strength, its maximum strength is 90%101) Topical vitamin K has been shown to:A. Increases epidermal differentiationB. Improve skin hydrationC. Decrease epidermal pigmentationD. Reduce severity of postoperative purpuraCorrect ChoiceE. Improve fine winklingTopical vitamin K reduced post later treatment purpura when applied after (not before) treatment oftelangectasia with the 585 nm pulsed dye laser102) Which type of collagen is the first to be deposited in a healing wound?A. Type I collagenB. Type II collagenC. Type III collagenCorrect ChoiceD. Type IV collagen 27
  28. 28. E. Type VII collagenCoagulation/Inflammation, tissue formation, and scar/remodeling are the three phases important inwound healing. Collagen deposition occurs during the second phase. Fibroblasts migrate into thewound along the fibrin-fibronectin matrix deposited in the initial clot. The fibroblasts subsequentlyproduce type I and III collagen, elastin, and proteoglycans. Collagen type III is the predominantcollagen in early wound healing103) All of the following statements are true regarding imiquimod (Aldara) except:A. It is FDA-approved for the treatment of actinic keratosesB. It is FDA-approved for the treatment of a 1.9 cm superficial basal cell on the chestC. It is FDA-approved for the treatment of a 2.0 cm superficial basal cell on the backD. It is FDA-approved for the treatment of a 1.5 cm superficial basal cell on the legE. It is FDA-approved for the treatment of a 1.2 cm superficial basal cell on the scalpCorrect ChoiceImiquimod (Aldara) is FDA-approved for the treatment of actinic keratoses and the treatment ofsuperficial basal carcinoma. With respect to basal cell carcinoma, treatment is indicated for primarytumors that are 2.0 cm or less, and that are located on areas of the body excluding the face, scalpand anogenital region104) A patient has a 1.8 cm nodular basal cell carcinoma on his neck. Which of the followingcriteria would be an indication for Mohs micrographic surgery?A. Anatomic locationB. Size of tumor > 1.5 cmC. Tumor is contiguousD. Previous radiationCorrect ChoiceE. Histologic subtypePrevious irradiation is an indication for Mohs surgery because the effects of radiation are similarhistologically and biologically to scarring. Specifically, the tissue can show fibrosis and alter thetumor’s growth pattern. In terms of location, the neck is not a high risk site. With respect topathology, nodular basal cell is not an aggressive subtype of basal cell carcinoma. Size of tumor > 2cm would be an indication for Mohs. Finally, that the tumor grows contiguously is not an indicationbut an absolute requirement for Mohs surgery105) Which porphyrin is targeted in aminolevulinic acid-photodynamic therapy?A. UroporphyrinogenB. CoproporphyrinogenC. PorphobilinogenD. Protoporphyrin IXCorrect ChoiceE. Coproporphyrin IIIProtoporphyrin IX is the substrate for the final rate-limiting step of heme synthesis. This enzymaticreaction is catalyzed by ferrochelatase. The preferential uptake of aminolevulinic acid by cancerousand pre-cancerous cells results in higher concentrations of protoporphyrin IX. This can then beselectively targeted by photodynamic therapy106) Which of the following sun protection agents is currently seeking FDA approval? 28
  29. 29. A. MexorylCorrect ChoiceB. Titanium dioxideC. AvobenzoneD. Zinc oxideE. OctocryleneMexoryl is considered the best UVA sunscreen currently available. Its broad-spectrumcharacteristics allow sunscreens to be manufactured with very high SPF factors. Variousformulations of mexoryl have long-been available in Europe, Canada, Australia, Asia, Mexico andSouth America107) Which of the following local anesthetic agents should not be used in children?A. BenzocaineB. PrilocaineCorrect ChoiceC. EtidocaineD. MepivicaineE. BupivicainePrilocaine should bot be used in children given the risk ofmethemoglobinemia.Methemoglobulinemia in children can occur from exposure to oxidizingsubstances such as aniline dyes, prilocaine or pyrimidine. In methemoglobinemia, the iron inhemoglobin is oxidized from the ferrous state (Fe 2+) to ferric (Fe3+) resulting in the inability totransport oxygen and carbon dioxide. Clinically, this condition results in cyanosis108) When can a patient who undergoes follicular-unit hair transplantation expect hair growth ofthe grafted follicles to begin?A. 2 to 3 months Correct ChoiceB. 7 to 10 daysC. 6 monthsD. 9 monthsE. 1 monthThe use of follicular-unit grafts, which contain one to four hair follicles, represents the advancementin both surgical technique and aesthetic outcome in the field of hair transplantation. The graftedhair follicles typically begin to grow within 8 to 10 weeks of implantation and are expected tosurvive for the individual’s lifetime109) Which of the following is a potential side effect of ambulatory tumescent liposuction?A. Pulmonary embolusB. Abdominal perforationC. Decreased appetiteD. Muscle atrophyE. Breast enlargement Correct ChoiceBreast enlargement is a relatively common and unexpected side effect of tumescent liposuction.Since the majority of these patients report increased breast size in the absence of weight gain, 29
  30. 30. some authors postulate shifting hormone ratios as the etiology of this paradoxical breastaugmentation. Abdominal perforation, respiratory failure and pulmonary embolus are complicationsthat are seen almost exclusively in liposuction patients that receive general anesthesia orintravenous sedation110) A patient with a squamous cell carcinoma of the helical rim had excisional surgery followed byclosure of the wound with an advancement flap. Which would be the most appropriate antibiotic forthis patient to receive postoperatively?A. Trimethoprim-sulfamethoxazoleB. CephalexinC. Ciprofloxacin Correct ChoiceD. ErythromycinE. DicloxacillinInfection after cutaneous surgery is typically due to Staphylococcal and Streptococcal organisms.However, Pseudomonas aeruginosa may be normal flora of the ear and thus can potentiallycomplicate ear surgery by causing severe infection of the external ear canal (malignant otitisexterna). Ciprofloxacin would be the antibiotic of choice for this patient because it is effectiveagainst Pseudomonas species111) The repair demonstrated in the photograph is a:A. Advancement flap Correct ChoiceB. Rotation flapC. Full-thickness skin graftD. Split-thickness skin graftE. Transposition flapThe postauricular flap is useful for repairing extensive defects of the helical rim, particularly whencartilage is involved. It is an example of an advancement flap112) The use of EMLA cream is contraindicated in patients with which of the following?A. Sickle cell anemiaB. Peripheral neuropathyC. MethemoglobinemiaCorrect ChoiceD. Atopic dermatitisE. Deomycin allergyThe most serious adverse effect of eutectic lidocaine and prilocaine (EMLA) is methemaglobinemia.A metabolite of prilocaine oxidizes hemoglobin to methemoglobin, which is less efficient in release ofoxygen leading to tissue hypoxia. Patients with congenital or idiopathic methemoglobinemia orinfants under 1 year of age are at higher risk for the development of this side effect113) The type of repair depicted in the photograph is a:A. Rotation flapB. Island pedicle flap 30
  31. 31. C. Full-thickness skin graftD. Rhombic flap Correct ChoiceE. Nasolabial flapThe rhombic flap is a type of transposition flap. The classic rhombic flap is designed with two 60degree angles and two 120 degree angles. The point of maximum tension is at the closure of thedonor site114) In organ transplant recipients, all of the following factors increase susceptibility to thedevelopment of skin cancer except:A. CD8 lymphocytopeniaCorrect ChoiceB. Fair skin (Fitzpatrick types I-III)C. Duration of immunosuppressionD. History of chronic sun exposureE. History of HPV infectionAll organ transplant recipients are at increased risk for the development of cutaneous malignancies.However, the above-mentioned factors, with the exception of choice E, place these individuals atfurther risk. CD4 lymphocytopenia, rather than CD8, is another identified risk factor as is older age,history of actinic keratoses and history of skin cancer115) The anatomic structure identified in the photograph is called the:A. Philtral ridgeCorrect ChoiceB. Cupid’s bowC. Vermillion borderD. Soft triangleE. ColumellaThe philtral ridges are located at the upper middle lip and form part of the aesthetically importantcupid’s bow116) What is the tattoo pigment responsible for most lichenoid reactions?A. Titanium dioxideB. Mercuric sulfideCorrect ChoiceC. CarbonD. ChromatesE. Iron oxideLichenoid tattoo reactions are not as common as eczematous reactions, both of which are mostcommonly caused by mercuric sulfide. Lichenoid reaction are likely to be mediated by delayedhypersensitivity to a lymphocytic T-cell infiltrate117) Which part of the eye is most likely to be damaged to exposure to a pulsed dye laser?A. Sclera 31
  32. 32. B. CorneaC. RetinaCorrect ChoiceD. LensE. ConjuctivaThe pulsed dye laser operates at 585-nm and targets hemoglobin as a chromophore. It can passthrough the cornea and damage choroidal and retinal vasculature. Several infrared pigment-specificlasers (eg, ruby, alexandrite, Nd:YAG) may also damage the retina by targeting the retinal pigment118) All of the following are true statements regarding the immunohistochemical stain Melan-Aexcept:A. Reliably stains desmoplastic melanoma Correct ChoiceB. Sensitive marker for melanocytic neviC. Antigen present in 80-100% of melanomasD. Effective in frozen and paraffin-embedded tissueE. Recognized by CD8+ T cellsE Melan-A is a 22-kDa cytoplasmic melanosome-associated glycoprotein also known as MART-1(melanoma antigen recognized by T cells). It is a sensitive marker for both melanocytic nevi andmelanoma and may be used on frozen tissue sections as well as paraffin-embedded tissue. Althoughthe antigen is present in > 80% of melanomas, it does not reliably stain desmoplastic or spindle cellmelanomas119) A patient with a basal cell carcinoma on the lower eyelid has Mohs surgery. Once tumor-freemargins were obtained, the surgeon repairs the wound with a full thickness skin graft. Which of thefollowing statements is true about this repair method?A. Healing by secondary intention would minimize the risk of ectropionB. Graft should be at least 25% smaller than the defectC. Graft should be the same size as the defectD. Graft rarely survives in this locationE. Graft should be at least 25% larger than the defectCorrect ChoiceTo account for wound contraction and minimize the risk of ectropion, full thickness skin grafts onthe lower eyelid should be sized such that the graft is at least 25% larger than the actual size of thewound.Jewett BS and Shockley WW. Reconstructive options for periocular defects. Otolaryngol Clin NorthAm 2001; 34(3):601-625120) Which tattoo pigment has most commonly been associated with phototoxic reactions?A. Titanium dioxideB. Mercuric sulfideC. Cadmium sulfideCorrect ChoiceD. CarbonE. Iron oxide 32
  33. 33. Cadmium sulfide produces a yellow tattoo. Phototoxic reactions are most commonly caused bycadmium sulfide tattoo pigment. Red tattoos have also been associated with phototoxic tattooreactions. However, this is thought thought to be due to the addition of cadmium sulfide whichenhances and brightens the red color121) Which of the following lasers has the greatest depth of penetration in the skin?A. Diode (800 nm)B. CO2 (10,600 nm)C. Erbium: YAG (2940 nm)D. Pulsed dye laser (585 nm)E. Nd: YAG (1064 nm) Correct ChoiceThe Nd: YAG laser emits energy at 1064nm near the infrared range and penetrates the skin to thelevel of the deep dermal blood vessels. The target chromophore for this laser is melanin, thus itsprimary use is in treating lesions such as nevus of Ota and removing black tattoo pigment. Althoughboth the erbium:YAG and CO2 lasers have longer wavelengths than the Nd: YAG, they are ablativelasers which only penetrate to the level of the stratum corneum and superficial epidermis,respectively122) Which of the following suture materials is most likely to cause infection?A. PDS (polydioxanone)B. Silk Correct ChoiceC. Prolene (polypropylene)D. NylonE. Vicryl (polyglactin)Silk is a nonabsorbable braided suture which has been shown to aid in the production of infection. Itis believed that the interstices of braided or twisted suture materials enhance the potential fordeveloping infection by providing privileged sites which harbor bacteria123) A patient with a large nasal tip defect had reconstruction of his wound with a forehead flap.After what postoperative interval should the patient schedule the inset of this flap?A. 2 monthsB. 6 monthsC. 3 weeks Correct ChoiceD. 3 monthsE. 1 weekThe forehead flap is often the reconstructive option of choice for large nasal defects. The flap has avertically-oriented blood supply which is supplied primarily from the supratrochlear arteries. Pedicledivision and inset of this flap are typically performed 3 weeks after the initial surgery124) Which of the following criteria carries the worst prognosis for a patient with a squamous cellcarcinoma?A. Size of tumor > 1 cm 33
  34. 34. B. Perineural invasionC. Depth of invasion > 4 mm Correct ChoiceD. ImmunosuppressionE. Anatomic locationMany factors contribute to the aggressive behavior of cutaneous squamous cell carcinoma. Forexample, tumors in immunosuppressed patients and tumors with the histologic subtypesdesmoplastic and acantholytic are often biologically aggressive squamous cell carcinomas.Compared with other risk factors, depth of invasion >4 mm and size > 2cm demonstrate thegreatest risk for metastasis.125) The relaxed skin tension lines overlying the scapula are:A. Oriented horizontallyB. Parallel to the underlying muscle groupsC. Oriented verticallyCorrect ChoiceD. Do not exist over the scapulaE. Oriented circumferentiallyRelaxed skin tension lines (RSTLs) are creases in the skin that are present at rest and develop as aconsequence of the decreased elasticity that occurs with aging and solar damage. These lines lieperpendicular to the underlying musculature. They tend to run vertically on the upper back whereason the central trunk, they are typically circumferential. Knowledge of RSTLs is important incutaneous surgery because placing incisions within these lines will ensure the most favorablecosmetic result126) Which of the following cosmetic injectables binds water to create volume, has a low allergicreaction profile, and lasts 6 to 12 months?A. SiliconeB. Calcium hydroxylapatiteC. Human-derived collagenD. Botulinum toxinE. Hyaluronic acid Correct ChoiceHyaluronic acid is a natural component of human connective tissue. As a cosmetic filler, hyaluronicacid is an attractive alternative to currently available filler substances: its ability to bind watercreates volume and plumps the skin; its duration of action of approximately 6-12 months isappreciably longer than conventional collagen; and since hyaluronic acid is chemically identicalacross all species, hypersensitivity reactions are rare127) Which of the forms of electrosurgery can work in a wet field?A. ElectrocauteryCorrect ChoiceB. ElectrodessicationC. ElectrocoagulationD. ElectrosectionE. ElectrofulgurationElectrocautery is the only one to work in a wet field as it has no current and works via heat 34
  35. 35. 128) Which of the following complications has been reported with infraorbital injections of Botox?A. FestooningCorrect ChoiceB. PhotophobiaC. BlindnessD. AstigmatismE. NystagmusFestooning of the lower eyelid is a recently reported complication of infraorbital Botox injections.The affected patient had a prior lower lid blepharoplasty which likely weakened the orbicularis oculimuscle. The author postulates that festooning resulted from further muscle weakness due to Botoxtreatment129) When is it appropriate to use this surgical technique?A. To shorten the length of the scarB. To change direction of a scar that is deformingCorrect ChoiceC. When there is insufficient tissue for rotation flapD. To prevent bleedingE. When it is desirable not to extend an ellipseZ-plasty is used to change the direction of scar that is deforming or to elongate a scar that iscontricting. Common sites are medial canthus, side of the face and forehead130) Which of the following sutures is the first to be absorbed?A. Polyglycolic acidB. PolydioxanoneC. CatgutCorrect ChoiceD. PolypropyleneE. Polyglactin 910Catgut has a variable rate of absorption but typically lasts about 7-14 days. Thus, it would be thefirst suture to be absorbed. Polyglactin 910 (Vicryl) and polyglycolic acid (Dexon) are both absorbedin about 90 days. Polydioxanone (PDS) is an absorbable monofilament which lasts approximately180 days. Polypropylene (Prolene) is not an absorbable suture.131) The most appropriate suture for closing a wound on the buccal mucosa is:A. Braided nylonB. SilkCorrect ChoiceC. ProleneD. PDSE. Monocryl 35
  36. 36. The most appropriate suture for closing a wound on the buccal mucosa is silk. Other sutures may beused as well, but classically, silk is used because of its soft nature132) The most appropriate laser to treat a port wine stain on an infant’s cheek would have which ofthe following wavelengths?A. 488 nmB. 585 nm Correct ChoiceC. 532 nmD. 810 nmE. 694 nmThe 585nm pulsed dye laser (PDL) targets intravascular oxyhemoglobin and is considered thetreatment of choice for most benign vascular lesions. The original PDL had a wavelength of 577 nmwhich was later modified to 585 nm to achieve deeper penetration yet still maintainvascularspecificity133) Which of the following absorbable sutures lasts the longest?A. Polydioxanone Correct ChoiceB. CatgutC. PolypropyleneD. Polyglycolic acidE. Polyglactin 910Polydioxanone (PDS) is an absorbable monofilament which lasts approximately 180 days. Catguthas a variable rate of absorption but typically lasts about 7-14 days. Polyglactin 910 (Vicryl) andpolyglycolic acid (Dexon) are both absorbed in about 90 days. Polypropylene (Prolene) is not anabsorbable suture134) The most important function of a postoperative wound dressing is:A. Provide a barrier to infectionB. Decrease tension on the woundC. Create a moist environmentD. Prevent suture dehiscenceE. Immobilize the wound Correct ChoiceProviding hemostasis to a wound is the most important function of a wound dressing. This isparticularly critical in the first few hours postoperatively when the vasoconstrictive effects ofepinephrine are wearing off and the wound is at risk of bleeding or hematoma formation. Theprovision of a barrier to infection and creation of a moist, occlusive environment are also necessaryfunctions of a dressing but are not as critical as immobilizing the wound and ensuring hemostasis135) While contemplating the repair of a large cheek defect after Mohs surgery, you begin toanesthetize an elderly lady who weighs 110 lbs. What is the maximum amount of 1% lidocaine with2.5% epinephrine that this patient can receive?A. 500 ml 36
  37. 37. B. 350 mlC. 35 ml Correct ChoiceD. 50 mlE. 10 mlhe maximum recommended dosage of 1% lidocaine with 2.5% epinephrine in adults is 7mg/kg. Thepatient weighs 110 lbs (or 50 kg) which allows her 350 mg or 35 ml (1% lidocaine has 10mg oflidocaine perml) of the anesthetic136) Which potential complications is seen exclusively with phenol peels?A. Laryngeal edema Correct ChoiceB. Prolonged erythemaC. MiliaD. Toxic shock syndromeE. HypopigmentationThe principle concept of chemical peeling is to utilize a chemical agent to produce a controlledwound in the skin. Many different types of side effects can occur with chemical resurfacing and aretypically related to the depth of the wound. Complications which are common to all peeling agentsinclude: milia; acne; pigmentary changes; contact dermatitis; scarring; infection; prolongederythema; textural changes and cold sensitivity. Unlike other peeling agents, phenol has thepotential to cause severe adverse reactions which are exclusive to its use only. They includeatrophy, cardiac arrhythmias and laryngeal edema137) Reticulate eythema is a side effect seen with which treatment?A. CryotherapyB. Pulsed dye laserC. Diode laserCorrect ChoiceD. MesotherapyE. SclerotherapyReticulate erythema is a recently-reported side effect of diode laser treatment. High energy fluencesand a history of chilblains are believed to be predisposing risk factors. Laser treatment should bediscontinued at the first sign of this complication138) Alopecia neoplastica is most commonly associated with which malignancy?A. LymphomaB. Squamous cell carcinomaC. Breast carcinoma Correct ChoiceD. Colon carcinomaE. MelanomaWhile various malignancies have a predilection for metastasis to the scalp where they can causehair loss, alopecia neoplastica is most commonly associated with metastatic breast carcinoma.139) The ‘snap test’ is performed prior to surgery at which anatomic location? 37
  38. 38. A. MouthB. NeckC. EarD. HandE. EyelidCorrect ChoiceThe snap test determines the laxity of the lower eyelid. It should be performed prior to surgery,laser resurfacing or Botox injections of the lower eyelid to assess the potential for ectropionformation.Ratner D et al. Cutaneous laser resurfacing. J Am Acad Dermatol 1999; 41(3):365-389140) Which anesthetic has the shortest duration of action?A. TetracaineB. ProcaineCorrect ChoiceC. MepivacaineD. BupivacaineE. PrilocaineProcaine has the shortest duration of action, only lasting about 30-60 minutes. It is an esteranesthetic and is commonly used in dentistry141) For patients with AJCC stage III and IV melanoma, which of the following adjuvant treatmentshas shown the greatest increase in survival?A. MelacineB. CanvaxinCorrect ChoiceC. Interferon alpha-2BD. DacarbazineE. M-VaxThe current paradigm for treatment of advanced-stage melanoma includes tumor reduction viasurgery followed by adjuvant systemic therapy to manage residual occult disease. Althoughinterferon alpha 2B and dacarbazine are FDA-approved adjuvant therapies, neither has significantlyincreased survival rates. Canvaxin is a polyvalent vaccine that contains more than 20 tumor andmelanoma-associated antigens. Currently in phase 3 trials, postsurgical immunotherapy withCanvaxin has shown in retrospective matched-pair studies to prolong overall survival of stage IIIand IV melanoma patients by more than 175 percent142) What is the ratio of sodium bicarbonate to 1% lidocaine in a buffered lidocaine solution?A. 1:25B. 1:5C. 1:10Correct ChoiceD. 1:1E. 1:2The use of sodium bicarbonate in 1% lidocaine reduces the acidity of the local anesthetic.Unbuffered lidocaine has pH of approximately 5.5 -7.0 and lidocaine with epinephrine has a pH ofapproximately 3.5 – 5.0. The addition of sodium bicarbonate at a ratio 1:10 raises the pH to a morephysiologic level, thereby reducing the stinging sensation associated with injection. However, theaddition of bicarbonate also reduces the shelf-life of the lidocaine 38
  39. 39. 143) The use of imiquimod (Aldara) for the treatment of superficial basal cell carcinoma isadvocated at which treatment regimen?A. Five times per week for 4 weeksB. Five times a week for 6 weeks Correct ChoiceC. Three times a week for 10 weeksD. Three times per week for 4 weeksE. Three times a week for 6 weeksImiquimod (Aldara) was FDA-approved in 2004 for the treatment of superficial basal cell carcinoma.The recommended treatment schedule is once daily, five times per week for a total of six weeks.Geisse J et al. Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: resultsfrom two phase III, randomized, vehicle-controlled studies144) When would use of this technique be most beneficial?A. To shorten the length of the woundCorrect ChoiceB. To prevent post-operative bleedingC. To prevent pincushioningD. To prevent post-operative infectionE. To increase the width of the woundM-plasty is used to shorten wound length and is often when it is not desirable to extend the ellipseinto a nearby structure145) Which anatomic structure is likely to be severed during this repair?A. Marginal mandibular nerveB. Labial artery Correct ChoiceC. Mental nerveD. Angular arteryE. Buccal nerveThe photograph demonstrates a wedge resection which is used to repair defects of the lower lip.During this repair, the labial artery will be severed since it courses superficially between the mucosaand the underlying muscle146) The rhytids identified in the photograph are referred to as:A. Marionette linesB. Bunny linesCorrect ChoiceC. Nasolabial foldsD. Crow’s feetE. Relaxed skin tension linesBunny lines are located on the dorsum of the nose and are formed by the contraction of the nasalismuscle147) Which of the following topical antibacterial agents may cause neutropenia? 39
  40. 40. A. Silver sulfadiazine Correct ChoiceB. MupirocinC. BacitracinD. PolymyxinE. Povodine-iodineSilver sulfadiazine is most commonly used to prevent infection in second and third-degree burnpatients. Rare cases of leukopenia, neutropenia and kernicterus have been reported in patientsusing this topical antibacterial agent. Consequently, silver sulfadiazine should be used cautiouslyand avoided in infants, nursing mothers and pregnant women. Silver sulfadiazine also has thepotential to cause a hypersensitivity reaction in patients with sulfa allergy148) Which material is used to coat the jaws of the needle holder in the photograph?A. Tungsten carbideCorrect ChoiceB. CopperC. GoldD. NickelE. Stainless steelTungsten carbide is believed to be a harder more durable material that allows for better grasping ofthe needle. Needle holders with tungsten carbide jaws usually have gold-plated handles149) Jessner’s solution contains all of the following except:A. EthanolB. Salicylic acidC. ResorcinolD. Lactic acidE. Glycolic acidCorrect ChoiceJessner’s solution is a combination of resorcinol, salicylic acid, and lactic acid in ethanol that is usedas a superficial peeling agent. The advantage of Jessner’s solution is that timing is unnecessary andneutralization is not performed. The lactic acid is an alpha hydroxy acid150) The following are true statements regarding the design of an excisional ellipse except:A. Ellipse includes pathologic and normal tissueB. Incision lines are placed in relaxed skin tension linesC. Long axis of ellipse is oriented perpendicular to free marginsD. Length of ellipse is at least 3 times its total widthE. The angle at each of the apices is 15ºCorrect ChoiceThoughtful design of an elliptical excision is important for obtaining optimum tissue diagnosis, tumorclearance, wound closure and cosmetic result. The above statements are all true except that theangles at the apices of the ellipse should be 30º151) Blue nodules in the skin are a potential complication of which cosmetic injectable? 40
  41. 41. A. SiliconeB. Radiance (hydroxyapatite)C. Cosmoderm (collagen)D. Restylane (hyaluronic acid)Correct ChoiceE. Sculptra (poly L-lactic acid)Although hyaluronic acid is believed to be inert in humans, rare reports exist of granulomatousforeign body reactions to this material. Skin biopsy of a Restylane nodule demonstratesmultinucleated giant cells surrounding a blue amorphous material152) Which of the following is true regarding a Baker-Gordon peel?A. Croton oil is considered the most important component for efficacyCorrect ChoiceB. It contains resorcinolC. 88% phenol is the most important component for efficacyD. It contains salicytic acidE. It is considered a medium depth peelCroton oil is considered the most important component for efficacy. It is a epidermolytic thatenhances penetration. A Baker Gordon peel is a deep peel that contains 88% phenol, tap water,croton oil, and septisol153) The surgical instrument shown in the photograph is a:A. Towel clampB. Iris scissorC. HemostatCorrect ChoiceD. Gradle scissorE. Needle holderA hemostat is shown in the photograph. This instrument is commonly used in cutaneous surgery forclamping off blood vessels154) The use of EMLA cream is contraindicated in patients with which of the following?A. Neomycin allergyB. Methemoglobinemia Correct ChoiceC. Atopic dermatitisD. Peripheral neuropathyE. Sickle cell anemiaEMLA is a topical anesthetic composed of a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine.The major concern when using EMLA is the potential risk of methemoglobinemia. Patients withglucose-6-phosphate deficiency and patients taking methemoglobin-inducing agents (dapsone,phenytoin, sulfonamides) are more susceptible to developing methemoglobinemia. In addition, careshould be taken when using EMLA in infants less than 3 months of age because of the incompletematuration of their NADH-methemoglobinemia reductase system155) Signs and symptoms of lidocaine toxicity include all of the following except: 41
  42. 42. A. OtotoxicityCorrect ChoiceB. Circumoral numbnessC. SeizureD. Slurred speechE. NystagmusThe first signs of lidocaine toxicity are CNS symtpoms that resemble inebriation with alcohol. Thesesymptmoms include stupor, dysarthria, circumoral numbenss and dizziness. Further increases intoxicity leads to nausea, metallic taste, twitching, and seizures. Ototoxicity is not one of the toxicmanifestations seen with lidocaine toxicity. Without epinephrine the maximum dose of lidocaine4mg/kg. For a 70 kg individual, this is 300 mg or 30 ml of a 1% lidocaine solution. For apreparation of lidocaine without epinephrine the maximum dose is 7mg/kg. For a 70 kg individual,this is 500 mg or 50 ml of a 1% solution156) To avoid injury to the facial nerve, undermining in the region of the temple should beperformed at which anatomic level?A. Reticular dermisB. Subcutaneous fat Correct ChoiceC. Above the frontalis muscleD. Above superficial fascia (SMAS)E. Dermal-epidermal junctionIn the region of the temple, lateral to the eyebrow, the temporal branch of the facial nerve lies inthe superficial fascia. Once above the eyebrow, the nerve is located deep to the frontalis muscle. Inthe region of the temple, it is therefore prudent to undermine in the superficial subcutaneous fat157) Which of the following histochemical stains can be used intraoperatively during Mohsmicrographic surgery to confirm the diagnosis of extramammary Pagets disease?A. S-100B. MyeloperoxidaseC. Toluidine blueD. Neuron-specific enolaseE. Cytokeratin 7 Correct ChoiceCytokeratin 7 is a structural component of the cytoskeleton that stains poorly differentiated tumorsof the epithelium. This low molecular weight cytokeratin positively stains Paget cells. Neuron-specific enolase stains merkel cell carcinoma, toluidine blue stains mast cells and myeloperoxidasestains cells with myeloid differentiation such as leukemia cells. S-100 protein is a non-specific stainthat is commonly used as an adjunctive marker in the diagnosis of melanoma 42

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