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179 Cards in this Set

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Three branches of Cranial Nerve V.
Ophthalmic (V1), Maxillary (V2), Mandibular (V3)
Branches of Ophthalmic (V1) nerve
Supratrochlear, Infratrochlear, Supraorbital, External nasal branch of anterior ethmoidal nerve, Palpebral branch of Lacrimal nerve
Branches of Maxillary (V2) nerve
Infraorbital, Zygomaticotemporal, Zygomaticofacial
Mandibular (V3) nerve
Emerges from foramen ovale, Mental, Auriculotemporal (damage=Frey's), Buccal
Destruction of what nerve causes Trigeminal Trophic Syndrome?
CN V at the gasserian ganglion (surgery, encephalitis, or leprosy)
Name the branches of CN 7
Temporal, Zygomatic, Buccal, Marginal mandibular, Cervical
C2 sensation (lesser occipital)
scalp posterior to ear, superior portion of the posterior auricle
C2,C3 (greater auricular)
overlying the parotid, lower anterior ear, lower posterior ear, and mastoid process
C2 (greater occipital)
occipital scalp
C2,C3 (transverse cervical)
anterior portion of neck
C3, C4 (supraclavicular)
lower neck, clavicle and shoulder
C3, C4 (supraclavicular)
lower neck, clavicle and shoulder
Sural Nerve innervates:
posteriolateral sole
Posterior Tibial Nerve innervates:
anteromedial sole
Deep Peroneal Nerve innervates:
great toe and toe cleft b/tw 1st and 2nd toe
Superficial Peroneal Nerve innervates:
Dorsum of the foot
Name the six major arteries supplying the face
Facial, Superficial temporal, Maxillary, Posterior auricular, Occipital, Ophthalmic
Facial artery branches
Branches off in the following order: submental, inferior labial, superior labial, angular arteries
Superficial temporal artery branches
transverse facial, superficial temporal artery anterior & posterior branches, zygomatico-orbital artery, and frontal arteries
Maxillary artery branches
Infraorbital, buccal, inferior alveolar (mental) arteries
Ophthalmic artery branches (What is its origin?)
supraorbital artery, supratrochlear artery, palpebral artery, dorsal nasal artery, anterior ethmoidal artery, and lacrimal artery; OFF OF THE ICA
Where does the median nerve lie?
Within the carpal tunnel, deep and radial to the palmaris longus (PL) tendon and medial to the flexor carpi radialis (FCR) tendon
Where do you inject for a median nerve block?
between palmaris longus and flexor carpi radialis; 2-3 cm proximal to the distal crease of the wrist
What is being demonstrated?
Median Nerve block (between palmaris longus and flexor carpi radii)
Name the sensory nerves to the plantar foot.
How do you anesthetize the ankle?
5 nerves are required: a line along the anterior ankle (superficial peroneal nerves), deep peroneal nerve), saphenous nerve, sural nerve, posterior tibial nerve.
What five nerves are involved with an ankle block?
5 nerves are required: a line along the anterior ankle (superficial peroneal nerves), deep peroneal nerve), saphenous nerve, sural nerve, posterior tibial nerve. See picture.
What five nerves are involved with an ankle block?
Posterior Tibial Nerve, Saphenous Nerve, Deep Peroneal Nerve, Superficial Peroneal Nerve, Sural nerve
Where do you inject for a posterior tibial block?
Between Medial Maleolus and Achilles tendon (medial aspect). The posterior tibial artery runs appx 1 cm from the site marked.
Purpose of a Basting stitch
Anchors tissue to bed of wound (ensures aposition of a FTSG to recipient bed)
Purpose of a running locked stitch
for wounds under tension and to provide hemostasis
Purpose of a suspension or tacking suture
holds skin to periosteum or perichondrium to permanently elevate an area, maintain concavity or alter tension vector near a free margin
Purpose of a vertical mattress suture
relieves tension to place other sutures, produces eversion and approximation of skin edges to eliminate dead space
Purpose of a horizontal mattress suture
remove tension from the edges of the wound; assists with hemostasis
Purpose of a running subcuticular stitch
reduces track marks; use prolene due to low coefficient of friction
Purpose of a tip stitch
half-buried horizontal mattress - aligns tissue and prevents vascular compromise
What does the number on the suture mean?
specifies the diameter of that suture material that is required to produce a certain tensile strength (smaller the diameter the higher the number assigned)
Branches of Maxillary Artery
Middle meningeal artery; Inferior alveolar artery --> MENTAL ARTERY (aka mental branch of inferior alveolar artery); Deep temporal arteries; Masseteric artery; INFRAORBITAL ARTERY; sphenopalatine artery; descending palatine artery;
What are the major arteries off the ECA supplying the face?
Facial, Maxillary, Superficial temporal, Posterior auricular, Occipital
What are the major arteries off the ICA supplying the face
Opthalmic (branches are supraorbital, supertrochlear, palpebral, dorsal nasal, lacrimal)
The ICA & ECA anastamose where?
Angular artery (ECA from Facial a) to Dorsal nasal branch (ICA from Ophthalmic)
Damage to temporal nerve causes what?
Inability to raise eyebrow (lid ptosis), visual field compromise, flattened forehead lines (loss of expression)
What innervates the: Frontalis muscle
Temporal branch of facial nerve
What innervates the: Corrugator supercilli muscle
Temporal br of facial n
What innervates the: Orbicularis oculi muscle (upper portion)
Temporal br of facial n
What innervates the: Auricular muscle (aka temporoparietalis, anterior and superior)
Temporal br of facial n
What innervates the: Orbicularis oculi muscle (lower)
Zygomatic br of facial nerve
What innervates the: Nasalis muscle
Zygomatic br of facial n (alar portion); Buccal does the rest
What innervates the: Procerus muscle
Zygomatic br of facial n
What innervates the: Upper lip muscles
Zygomatic & Buccal br of facial n
What innervates the: Levator anguli oris muscle
Zygomatic br of facial nerve
What innervates the: zygomaticus major muscle
Zygomatic br of facial nerve
What defect occurs when zygomatic branch of facial nerve is damaged?
Inability to tightly close eyelid
What innervates the: buccinator muscle (mastication)
Buccal branch of facial nerve
What innervates the: depressor septi nasi muscle?
Buccal branch of facial nerve
Nasalis muscle (transverse portion) innervated by?
Buccal branch of facial nerve
Zygomaticus major muscle?
Buccal branch of facial nerve & Zygomatic branch of facial nerve
Zygomaticus minor muscle?
Buccal branch of facial nerve
Orbicularis oris muscle?
Buccal branch & Marginal Mandibular branch of facial nerve
Levator anguli oris muscle?
Buccal branch of facial nerve
Lower lip muscle - orbicularis oris muscle innervation?
Buccal branch of facial nerve & Marginal mandibular branch
What defect occurs when Buccal branch of facial nerve is damaged?
Accumulation of food between teeth and buccal mucosa with chewing
Depressor anguli oris muscle innervation?
Marginal Mandibular branch of the facial nerve
Depressor labii inferioris muscle innervation?
Marginal Mandibular branch of the facial nerve
Mentalis muscle innervation?
Marginal Mandibular branch of the facial nerve
Risorius muscle innervation?
Buccal n of facial n (Marginal Mandibular branch of the facial nerve - per Bolognia)
Platysma (upper portion)
Marginal Mandibular branch of the facial nerve
What defect occurs with damage to the Marginal Mandibular branch of the facial nerve
Cannot form symmetric smile, not appreciated when patient is at rest. Inability to pull lower lip down/lateral, cannot evert vermilion border
Damage to both zygomatic and buccal?
Drooling, food accumulation between cheeks/gingivae, muffled speech
Temporalis muscle innervation?
Motor of Trigeminal (V3)
Masseter muscle innervation?
Motor of Trigeminal (V3)
CN7 supplies sensation to what?
Conchal bowl & Anterior tongue (chorda tympani)
What is the only nerve that supplies the muscle on the superficial surface?
Buccinator
What nerves are at Erb's point?
Greater auricular, lesser occipital, spinal accessory
Sutures ability to stretch and return to its original form?
Elasticity
Suture's ability to stretch and maintain its new length?
Plasticity
Defines stiffness of the suture and its inherent ability to return to its original shape after deformation
Memory
Force required to cause knot slippage (depends on the smoothness and memory of the suture)
Knot strength
Polygalactin 910?
Vicryl (braided, absorbable)
Polyglycolic Acid?
Dexon (braided, absorbable)
Poliglecaprone 25?
Monocryl (monofilament, absorbable) - highest initial strength and knot security of absorbables
Polglyconate: glycolide and trimethylene carbonate?
Maxon (monofilament, absorbable) - higher initial strength but absorbed faster than PDS
Polydioxanone?
PDS (monofilament, absorbable); slowest absorption; best tensile strength (more than vicryl, dexon & maxon).
Other names for Nylon?
Ethilon, Dermalon, Nurolon, Surgilon (monofilament, braided, nonabs)
Polybutester?
Novafil (monofilament, nonabs) - expansile and contractile elasticiy, good for swelling tissue
Polyester, uncoated?
Mersilene (braided, nonabs) - soft yet high tensile strength, second only to metal sutures
Polyester, coated?
Ethibond (braided, nonabs) - soft yet high tensile strength, second only to metal sutures; has less friction than mersilene.
Polypropylene
Prolene (monofilament, nonabs) - very low friction coefficient
Silk?
braided/twisted, non-abs; best for mucosal surfaces
Stainless steel?
Monofilament/braided/twisted
How are esters metabolized?
pseudocholinesterase in plasma
What do esters cross react with?
sulfa, thiazides, PABA, PPD
Longest acting ester? shortest acting?
Tetracaine is longest (2-3 hours); Procaine is shortest (15-60 min)
How are amides metabolized?
Cytochrome P450 3A4
Longest acting amides?
Bupivicaine/Levobupivacaine (2-4 hours); Etidocain (3 hours); Ropivacaine (2-4 hours)
Shortest acting amides?
Lidocaine, mepivacaine, prilocaine (0.5-2hrs)
What can prilocaine cause?
Methemoglobinemia (avoid use in children)
Does adding sodium bicarb increase its onset of action?
Yes
What is wrong with keeping pre-mixed solution of lidocaine with sodium bicarb around?
Epinephrine is stable only in an acidic environment (epinephrine activity is lost at a rate of 25% per week in neutral or alkaline environment)
Why do anesthetics work less in tissue with low pH?
Its all about the proportion of the anesthetic that is in the ionized form;
The HIGHER the pH – the HIGHER the proportion in the ionized form;
HIGH pH correlates to FASTER onset of action;
Alkalinization of the anesthetic solution increases the amount of base and the anesthetic’s onset of action
What are the three portions of chemical structure of anesthetics? And, what do they determine?
1. Aromatic ring - onset of activity;
2. Intermediate (middle) chain - determines class (amide vs ester)
3. Amine - determines duration
Loss of sensation/function occurs in what order with local anesthetic?
Temperature, pain, touch, pressure, vibration, proprioception, motor function
How many miligrams of lidocaine are in 1cc of 2% lidocaine?
2% = 0.02g/ml = 20mg/ml
Max total of 1% lido w/o or w/ epi (1:100,000)
Without: Adults 4.5mg/kg = 300mg/70kg (30cc); Child 1/3-1/2 mg/kg
With: Adults 7mg/kg = 500mg/70kg (50cc); Child 3-4.5mg/kg
Recommended dose for tumescent anesthesia?
Recommended 35-55mg/kg;
Lidocaine 0.1% (klein's formula) with Epi (1:1,000,000) 1mg/L
How many miligrams of lidocaine are in 1cc of 2% lidocaine?
2% = 0.02g/ml = 20mg/ml
Max total of 1% lido w/o or w/ epi (1:100,000)
Without: Adults 4.5mg/kg = 300mg/70kg (30cc); Child 1/3-1/2 mg/kg
With: Adults 7mg/kg = 500mg/70kg (50cc); Child 3-4.5mg/kg
Recommended dose for tumescent anesthesia?
Recommended 35-55mg/kg;
Lidocaine 0.1% (klein's formula) with Epi (1:1,000,000) 1mg/L
Class B or C? Bupivicaine, Lidocaine, Prilocaine, Mepivacaine, Etidocaine
Category C: Bupivicaine (cardiotoxic risk), Mepivacaine (BM is bad)
Category B: Lidocaine, Prilocaine, Etidocaine
What is methemoglobinemia?
Hemoglobin Fe2+ gets oxidized to Fe3+ which reduces its oxygen carrying capacity
Treatment of methemoglobinemia?
< 30% removal of drug, O2, observe; >30% Tx with IV methylene blue 1-2mg/kg as a 1% solution (or Ascorbic acid 300-1000 mg/day iv in three to four doses for G6PD deficiency patients)
What drug prevents methemoglobinemia with Dapsone use?
Cimetidine (reduces hepatic oxidation of dapsone to hydroxylamine, thereby limiting methemoglobinemia formation)
Hexachlorophene
Phisohex
- Gram+
- Do NOT use on children or pregnant women
- Potential neurotoxicity, therefore it was discontinued in 1970s (ex., Mohs fellow getting tingling in her fingers - Steifel question)
- Teratogenicity
Chlorhexidine
Hibiclens
- Gram +, Gram -
- Keratitis & allergic rxn if direct ocular contact
- Tympanic membrane damage
Iodophor or Povidone-iodine
Betadine
- Gram +, Gram -
- Allergic contact dermatitis
What two topical medications have polymyxin B?
Polysporin (Bacitracin/Polymyxin B) and Neosporin (Neomycin/Bacitracin/Polymyxin B)
Polymyxin B has pseudomonas coverage (vs the others - neomycin, bacitracin, bactroban, erythromycin)
Name three topical antibiotics with Gram negative coverage
Gentamicin (resistance seen), Neomycin (no pseudomonas coverage), Polymyxin B (pseudomonas coverage)
What is in polysporin?
Bacitracin & Polymyxin B
What is Neosporin?
Neomycin, bacitracin, polymyxin B
What are some side effects of silvadene?
Neutropenia, kernicterus, ACD with sulfa allergies
Thin Film Dressing Uses?
Skin tears, STSG donor site, laser resurfacting, Mohs
Foam dressing uses?
Chronic wounds, dermabrasion, burns, mohs, laser resurfacing; AVOID IN DRY WOUNDS
Hydrogel dressing uses?
Ulcers, dermabrasion, laser resurfacing, superficial thermal burns, chemical peels, graft donor sites; AVOID IN INFECTED WOUNDS
Alginate dressing uses?
Chronic highly exudate wounds, Full thickness burns, surgical wounds, STSG donor sites, Mohs
Hydrocolloid uses?
Chronic ulcers, burns, trauma wounds, surgery wounds, dermabrasion, bullous dz, inflammatory disease; AVOID IN INFECTED WOUNDS
What is the temperature of liquid nitrogen?
Temp: -196 C (or -320 F)
What is goal for temperature at the periphery of the ice ball in cryosurgery?
Temp: - 50-60C
What is resistance? what makes it higher or lower?
Resistance = ability of conductor to impede passage of electric current (ohms W)
- Proportional to length of substance
- Inversely proportional to its x-sectional area
- Fat has high resistivity
- Muscle has low resistivity
- Skin has variable resistivity
Ex., Dry skin 100 000 W and Wet skin 200 W
What is Ohm's Law?
Voltage = IR (current x resistance)
Biterminal?
Low resistance; Low voltage needed for adequate current
Monoterminal?
High resistance, requries high voltage for adequate current
Undamped wave?
Pure tissue separation with minimal hemostasis
Damped wave?
Marked tissue destruction - greater damping means increased tissue damage and hemostasis; lesser damping - less hemostasis/better healing
Continuous vs Discontinuous wave?
continuous wave results in greater tissue heating
Best waveform for pure cutting
Continuous, undamped (may also use discontinuous, undamped)
Best waveform for cutting and coagulation
Continuous, damped
Best wave form for desiccation and coagulation
Discontinuous, damped
Name the monoterminal circuits
Electrofulguration, Electrodessication (remember DEF Va (high voltage, low amperage)
Name the Biterminal circuits
Electrocoagulation, Electrosection with coagulation, Electrosection without coagulation (low voltage, high amperage)
Which electrosurgical technique has not circuit?
Electrocautery
What is the most important cell in the vascular phase of wound healing?
platelets
What is the most important cell for the inflammatory phase of wound healing?
Macrophages - the only cell that can tolerate low O2
What is a Life Tenant obligated to do?
(4 things - physical and financial):
(i) preserve the land and structures in a reasonable state of repair,
(ii) pay interest on mortgages (not principal);
(iii) pay ordinary taxes on the land;
(iv) pay special assessments for public improvements of short duration (improvements of long duration are apportioned between the life tenant and future interest holder).
What are the four stages of successful graft?
Imbibition, Inosculation, Neovascularization, Maturation (I'm In No Mood)
Explain in detail the stages of successful graft healing?
Imbibition (first 48 hours, graft sustained by RECIPIENT bed)
Inosculation (day 2-3, blood vessels from the GRAFT establish connection with the wound bed)
Neovascularization (Day 7 - ingrowth of new vessels INTO the graft)
Maturation (Months - sensory innervation)
Name the wavelengths of light
Gamma rays
X-rays

UVC = 200-290
UVB = 290-320
UVA = 320-400
Visible light = 400-760
IR > 760-1400

Microwaves
Radiowaves
What are the three important features of LASERs?
Coherent – waves of light are in phase in time & space
Represents uniform wave front --> allows energies to be ADDITIVE

Monochromatic – 1 wavelength ONLY

Collimated – Parallel, NON-divergent waves
I.E., Diameter of the beam changes minimally over distance focused

High Intensity (as per Dr. Ross)
Definition of:
Energy (Radiant Exposure)
Fundamental unit of work

Unit: Joules
Definition of:
Power
Rate at which energy is delivered

Unit: Watts = (J/s)
Definition of: Fluence
Amount of energy delivered per unit area

Unit: Joules/cm2
Definition of: Irradiance (Power density)
Power delivered per unit area

Watts/cm2
Definition of: Pulse Duration / Width
Laser exposure duration

Units: seconds
Definition of: Spot Size
Diameter of the laser beam on skin surface

Unit: mm
Definition of: Chromophore
Medium that absorbs light
Definition of: Thermal Relaxation Time
Time required for heated tissue to lose 50% of its heat through diffusion

Unit: seconds
Name the wavelengths of light
Gamma rays
X-rays

UVC = 200-290
UVB = 290-320
UVA = 320-400
Visible light = 400-760
IR > 760-1400

Microwaves
Radiowaves
What are the three important features of LASERs?
Coherent – waves of light are in phase in time & space
Represents uniform wave front --> allows energies to be ADDITIVE

Monochromatic – 1 wavelength ONLY

Collimated – Parallel, NON-divergent waves
I.E., Diameter of the beam changes minimally over distance focused

High Intensity (as per Dr. Ross)
Definition of:
Energy (Radiant Exposure)
Fundamental unit of work

Unit: Joules
Definition of:
Power
Rate at which energy is delivered

Unit: Watts = (J/s)
Definition of: Fluence
Amount of energy delivered per unit area

Unit: Joules/cm2
Definition of: Irradiance (Power density)
Power delivered per unit area

Watts/cm2
Definition of: Pulse Duration / Width
Laser exposure duration

Units: seconds
Definition of: Spot Size
Diameter of the laser beam on skin surface

Unit: mm
Definition of: Chromophore
Medium that absorbs light
Definition of: Thermal Relaxation Time
Time required for heated tissue to lose 50% of its heat through diffusion

Unit: seconds
Wavelength of:
Argon?
Argon pumped tunable dye?
Copper Vapor / Bromide?
KTP?
Nd:YAG?
Pulsed dye?
Ruby?
Alexandrite?
Krypton?
Argon? 488, 514
Argon pumped tunable dye? 577, 585
Copper Vapor / Bromide? 510, 578
KTP? 532
Nd:YAG? 532
Pulsed dye? 510, 585
Ruby? 694
Alexandrite? 755
Krypton? 568
What is wavelength of:
Woods Lamp
Blu U
Diode
Nd:YAG
Erbium
CO2
Excimer
Red U
Light therapy for neonatal hyperbilirubinemia
Woods Lamp 366nm
Blu U 400-410
Diode 810, 1450
Nd:YAG 1064
Erbium 2940
CO2 10,600
Excimer 308
Red U 630
Light therapy for neonatal hyperbilirubinemia 460
Fraxel Wavelength?
1550nm
What is Gold STD laser for vascular lesions?
PULSED DYE

585-95nm (PDL), 510nm (Pigmented PDL)

Green / Yellow

Vascular (red color), scars/striae, NON-ablative dermal remodeling
- GOLD STD for VASCULAR LESIONS

510nm --> Epidermal Pigment & Tattoos
- Red/orange/yellow tattoos (ROY)
What is Gold Standard for Hiar removal in types I-4 skin?
ALEXANDRITE
755nm

Borderline of Visible & Near IR spectrum

QS: Dermal pigment, Epidermal pigment, & **GREEN**/blue/black tattoos

PREFERRED LASER FOR GREEN TATTOO REMOVAL

Normal mode: hair removal, leg veins (blue color)

GOLD STD OF HAIR REMOVAL IN TYPES 1-4 SKIN
Best Tatoo for GREEN tatoos?
ALEXANDRITE
755nm

Borderline of Visible & Near IR spectrum

QS: Dermal pigment, Epidermal pigment, & **GREEN**/blue/black tattoos

PREFERRED LASER FOR GREEN TATTOO REMOVAL

Normal mode: hair removal, leg veins (blue color)

GOLD STD OF HAIR REMOVAL IN TYPES 1-4 SKIN
Best laser for Nevus of OTA?
RUBY

694nm
Red

QS: Dermal pigment, Epidermal pigment green/blue/black tattoos

GOLD STD FOR NEVUS OF OTA TREATMENT

Normal mode: hair removal & leg veins
Name the substance that creates the following tatoo pigment:
Red?
Blue?
Black?
Green?
Yellow?
Brown?
Violet/Purple?
White?
Red? Cadmium Selenide, Mercury, Cinnabar

Blue? Cobalt

Black? Carbon, Iron Oxide

Green? Chromium/Chromate, Cyanide

Yellow? Cadmium Sulfide

Brown (Ferric hydrate)? Ochre

Violet/Purple? Manganese

White? Titanium and Zinc Oxide
Best Laser for tatoo removal?
KTP = Red

Pigmented PDL = Yellow
*archaic laser seldom used today*

Alexandrite = Green

Nd:Yag = Blue, Black
Laser choices for Tatoo pigment?
Black/Blue:
Q-switched ruby (694)
Q-switched Alex (755)
Q-switched Nd:Yag (1064)***

Green
Q-switched Alex (755)***
Q-switched Ruby (694)

Red
- Freq doubled Q-switched Nd:Yag (532nm)***
-Pigmened pulsed dye (510)

Yellow
- Pigmented pulsed dye (510)
What is Jessner’s made of (4 components)?
Resorcinol, sal acid, lactic acid, ethanol
MN – JESS & SALI LACked the RESORces to buy EtOH
What is the Baker-Gordon Formula?
Deep Depth Peels:

Baker-Gordon Formula = most widely used
Contains 88% phenol, croton oil, septisol, H2O
Croton oil is keratolytic/epidermolytic that enhances phenol penetration
Variations:
Littons = glycerin for septisol
Beeson McCollough formula which uses defatting & heavier application of Baker-Gordon
Which chemical peel requires Neutralization?
Glycolic acid:
Can be neutralized with H2O or Sodium Bicarb
What is the active ingredient in sunless tan lotion?
What epidermis layer does it stain?
Dihydroxyacetone (DHA);
Stratum Corneum