Key Clinical Topics in Plastic & Reconstructive Surgery Tor Wo Chiu, Tze Yean Kong
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FM1Plastic and Reconstructive SurgeryFM2
FM3Plastic and Reconstructive Surgery
Tor Wo Chiu BMBCh (Oxon) FRCS (Glasg) FHKAM (Surg) Consultant in Plastic Surgery Director of Burns Service Prince of Wales Hospital Chinese University of Hong Kong Hong Kong SARPR China Tze Yean Kong BA MB BCh BAO (Hons) MA MRCS FRCS (Plast) Associate Consultant Department of Plastic Surgery KK Women's and Children's Hospital Singapore
FM4
© 2015 JP Medical Ltd.
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
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9781907816246
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Commissioning Editor:
Steffan Clements
Editorial Assistant:
Sophie Woolven
Design:
Designers Collective Ltd
FM5Foreword by Fu-Chan Wei
Key Clinical Topics in Plastic and Reconstructive Surgery provides plastic surgery trainees, medical students, nurses and general practitioners with a concise yet essential framework for learning. The relevant content, clear descriptions and lists of important points make this book unique and valuable. Drs Tor Chiu and Tze Kong, recognised specialists in plastic and reconstructive surgery, are to be congratulated for their great contribution to the education of our field and beyond.
I believe that Key Clinical Topics in Plastic and Reconstructive Surgery will serve as a vital tool for all plastic and reconstructive surgery students and trainees around the world.
Fu-Chan Wei MD, FACS
Professor, Plastic and Reconstructive Surgery
Taipei, Taiwan
Foreword by Taimur Shoaib
The FRCS(Plast) exam is arguably the toughest exam any plastic surgeon in training is likely to sit. Authoring a book on such a huge subject matter is, therefore, a major undertaking.
The authors, Drs Kong and Chiu, both specialist plastic surgeons, have worked hard to condense plastic surgery into key topics. I have had the pleasure of working with both of them during my career, both as a plastic surgeon in training and subsequently as a consultant plastic surgeon. It comes as no surprise to me that they have been able to convey the clarity of thought which is so important when it comes to successfully passing any plastic surgery exam, but more so the FRCS(Plast) exam.
The book summarises the vast subject of plastic surgery in alphabetically arranged topics. Each topic is presented from a starting point of knowledge that would be held by a senior plastic surgeon in training. It also aids the more junior plastic surgeon who is studying clinical cases prior to seeing procedures in the operating theatre and patients in out-patient clinics.
It is, of course, difficult to know where to stop writing such a potentially large book. In one volume it would be impossible to discuss the technical aspects of operative procedures, the scientific knowledge that plastic surgeons require in relation to research and ethical aspects of plastic surgery, and other subjects that constitute a plastic surgeon's lifelong education. However, the authors have achieved a good balance between discussing aspects of plastic surgery that could be considered minutiae, and topics that are either too large to condense into a book of this size or are better taught in clinical environments.
In summary, the book delivers core knowledge that all plastic surgeons need, without inappropriately burdening them with detail they are likely to obtain in clinical and surgical settings. The level of information delivered is high, but it is delivered with just the right amount of detail.
Taimur Shoaib MD, FRCSEd(Plast)
Consultant Plastic Surgeon
Glasgow, United KingdomFM6
FM7Preface
This book came about from regularly teaching plastic and reconstructive surgery to medical students and surgical trainees in the United Kingdom and Hong Kong. This makes it fundamentally different from many of the other short books that tend to be a set of revision notes, usually more useful to writer than reader.
The main text is a focused and concise distillation of current knowledge, while lists are also used for clarity. Numerous figures have been included to clarify key points. Relevant and key articles are discussed and further reading suggestions are included at the end of each topic. Discussion is to be encouraged; the systematic critical evaluation of the literature is an important skill to acquire.
Tor Chiu
Tze Kong
August 2014
Acknowledgements
To my mentors: Arup, who enabled me to process my thoughts more efficiently; Ben, whose invaluable insights dissect difficult problems down to their finest detail; Eva, who showed me what precision and consistency can achieve; Miki and Alain, whose support and nurturing took me to where I am today. Last, but not least, to Cristina for putting up with me when I was doing all of this, and even more when I was not.
Tze Kong
The publishers wish to thank Series Advisors Dr Tim M. Craft and Dr Paul M. Upton for their assistance during the planning of the Key Clinical Topics series.
FM8Dedications
In memory of my father
謹以此書獻給先父
Tor Wo Chiu
For my parents who nourished me in unison
Tze Kong
FM9Abbreviations 5FU
5-fluorouracil
ABI
ankle brachial index
AFB
acid fast bacilli
ALT
anterolateral thigh
AP
anteroposterior
ARDS
acute respiratory distress syndrome
ASIS
anterior superior iliac spine
ATLS
Advanced Trauma Life Support
BAPN
beta-aminopropionitrile
BCC
basal cell carcinoma
BCG
Bacillus Calmette–Guérin vaccination for tuberculosis
BCS
breast conservation surgery
BSA
burn surface area
CFNG
cross-facial nerve grafting
CL
cleft lip
CL/P
cleft lip with or without associated cleft palate
CNS
central nervous system
CO
carbon monoxide
CP
cleft palate
CPO
cleft palate alone
CSF
cerebrospinal fluid
CT
computed tomography
CXR
chest X-ray
DD
Dupuytren's disease
DIEP
deep inferior epigastric perforator
DIPJ
distal interphalangeal joint
DNA
deoxyribose nucleic acid
DVT
deep vein thrombosis
ECG
electrocardiogram
EM
erythema multiforme
EMG
electromyogram
EMLA
eutectic mixture of local anaesthetics
ENT
ear, nose and throatFM10
ER
extensor retinaculum
FDA
Food and Drug Administration
FDP
flexor digitorum profundus
FDS
flexor digitorum superficialis
FFP
fresh frozen plasma
FNA/C
fine needle aspiration/cytology
FTSG
full-thickness skin graft
HBO
hyperbaric oxygen
HIV
human immunodeficiency virus
HLA
human leukocyte antigens
HPV
human papilloma virus
ICP
intracranial pressure
ICU
intensive care unit
IGF
insulin-like growth factor
IgG
immunoglobin G
IJV
internal jugular vein
IMA
internal mammary artery
IMF
intermaxillary fixation
INR
international normalised ratio
KA
keratoacanthoma
LD
latissimus dorsi
LDI
laser doppler imaging
LMWH
low molecular weight heparin
MALT
mucosa-associated lymphoid tissue
MCPJ
metacarpophalangeal joint
MGH
Massachusetts General Hospital
MM
malignant melanoma
MRI
magnetic resonance imaging
MRM
modified radical mastectomy
MRND
modified radical neck dissection
MRSA
methicillin resistant Staphylococcus aureus
MWL
massive weight loss
NA
needle aponeurectomy
ND
neck dissection
NF
necrotising fasciitisFM11
NF1
neurofibromatosis type 1
NICE
National Institute for Health and Care Excellence
NPWT
negative pressure wound therapy
OPG
orthopantomogram
ORIF
open reduction and internal fixation
PCR
polymerase chain reaction
PCWP
pulmonary capillary wedge pressure
PDE
phosphodiesterase
PDGF
platelet-derived growth factor
PDS
polydioxanone suture
PE
pulmonary embolism
PEEP
positive end expiratory pressure
PIPJ
proximal interphalangeal joint
PSA
pleomorphic salivary adenoma
PUVA
psoralen ultraviolet A
PVD
peripheral vascular disease
QS
Q-switched
QSRL
Q-switched ruby laser
RCT
randomised controlled trial
RFFF
radial forearm free flap
RND
radical neck dissection
RSTL
relaxed skin tension line
RTA
road traffic accidents
SCC
squamous cell carcinoma
SIGN
Scottish Intercollegiate Guidelines Network
SJS
Stevens–Johnson syndrome
SNB
sentinel node biopsy
SPE
streptococcal pyrogenic exotoxins
SPF
sun protection factor
SSD
silver sulphadiazine
SSG
split skin graft
TCA
transverse cervical artery
TCS
Treacher–Collins syndrome
TEN
toxic epidermal necrolysis
TFL
tensor fascia lata
TGF
transforming growth factorFM12
TNM
tumour node metastasis
TPA
tissue plasminogen activator
TPN
total parenteral nutrition
TRAM
transverse rectus abdominis myocutaneous
UAL
ultrasound assisted liposuction
USG
ultrasonogram
VAMP
vesicle associated membrane protein
VF
ventricular fibrillation
VPI
velopharyngeal incompetence
VRAM
vertical rectus abdominis myocutaneous
XP
xeroderma pigmentosa
YAG
yttrium-aluminium-garnet
ZF
zygomaticofrontal
FM13Introduction  
Examination structure
The FRCS (Plast) Intercollegiate examination is divided into sections 1 and 2. A pass is required in Section 1 prior to being allowed to attempt Section 2. A maximum of four attempts are permitted in each section, with no subsequent possibility for entry. Fees are repayable for each attempt.
Both sections are held bi-annually and alternate sequentially. The Joint Committee on Intercollegiate Examinations (JCIE) will permit the candidate to sit Section 2 at the next sitting after Section 1 is passed. The shortest possible interval to pass both sections is 3 months, and this can be achieved by taking and passing Section 1 and 2 in the summer and autumn of the same year. The pass rates of both sections are independent of season (summer/autumn vs. winter/spring sittings) and therefore should not govern your choice of sitting.
 
Section 1
The Section 1 examination is entirely computer based and comprises two papers; Single Best Answer (SBA) and Extended Matching Items (EMI), which are separate mini-examination sessions on the same day, with a break in-between. The SBA will seem difficult, the EMI seemingly the easier of the two. However, most candidates score worse in the EMI.
The SBA has 110 multiple-choice questions (MCQ) with five choices (A to E) each, and is completed in 2 hours. This allows 65 seconds per question and usually means that there is little opportunity to review questions that you are unsure about. As the examination is not negatively marked, all questions should be attempted. There is a facility to flag questions for review, but a provisional answer should be entered in case of inadequate time for review. As the examination is computer-based, the time limit is precise to the second. The time pressure is greater for the SBA section than the EMI. Ensure that you are able to complete questions within the 65-second limit, otherwise guess and move on.
The EMI section comprises 45 main question headings from which an average of three questions will stem. Each of these is equally weighted, giving a total possible score of 135. These must be completed within a timeframe of 2.5 hours, averaging 66 seconds each. Again, there is little opportunity for review due to time constraints and a provisional answer should be entered before moving on to the next question.
For the Section 1 examination it should be noted that the only timer available is the countdown timer in the top right-hand corner of your screen (watches are disallowed and clocks are frequently absent). All questions must be done in sequential order, starting from 1. Pacing strategies, such as answering MCQs in reverse order (to ease computation of the number of questions remaining) are not permitted.
If you are unsure of the answer your choice should be governed by a process of elimination, based on your knowledge of the options that are definitely incorrect: choose any one of the remaining answers (remembering you will not lose marks if it is wrong).FM14
 
Section 2
The Section 2 examination is split into the clinical and oral sections that are examined on two consecutive days. The clinical section is held on the first day and accounts for 64% of the total mark. Candidates often score worse in this section, implying that a good score in the oral examination on the second day is essential.
 
Understanding the scoring system
The examination is unconventionally marked in a custom-based system that has a minimum mark of 4 and a maximum of 8, which must be allocated as a whole number. It is vital you understand the marking descriptors for each score, as the average score of 6 required to pass requires not only the demonstration of competence but higher order thinking (see below).
The examination has a maximum score of 400 and a minimum of 200, with a rigid pass mark of 300, with no cumulative adjustment. There are thus 50 scoring opportunities. All candidates are marked in duplicate by a pair of examiners who will each give an independent score. Of the 25 events that can be scored, 16 occur in the clinical section, with the remaining 9 in the oral section.
The values of the individual components are shown in . As a conversion rate rule of thumb, 1 long case = 3 short cases = 1 entire oral station.
 
Strategies for answering questions
As time is extremely limited, especially in the 6-minute short cases, every sentence of your answer must have as many point-scoring opportunities as possible. This requires succinct structure and clarity.
It is inevitable that you will be stronger in some topics than others. Despite the stress of the examination environment, try to avoid making basic errors. The answer to the first question of each case or section will set the tone of the remaining answers. If you answer this incorrectly, you will not be able to achieve a score above 6.
‘Front-loading’ is the most useful strategy to combat time constraints. This involves stating the main points first, followed by justifications afterwards from the history, examination and investigative findings. This is not limited to diagnoses, and can be used to mention key issues or concerns. This demonstrates higher order thinking, focussed perspective, insight into diagnosis, disease extent and therapy required. It also allows the examiner to cut you off in the least important part of the answer (this happens frequently) as the relevant points will already have been scored.
The strength of your knowledge of a topic may exceed that of the examiner and is one of the criteria to score an 8. This is helped by the fact that examiners are not supposed to examine in their chosen field of subspecialisation.
‘End-loading’ refers to ending the answer concisely with a relevant topic that you have studied well. The idea is to tempt the examiner to ask you about these topics, as the elaboration may lead to a higher score. Note that such elaboration will not be scored if it has not been specifically asked for, but it will cost valuable time. However, if successful, this strategy is useful to obtain a score of 7 or 8.FM15
Table i   Format and mark values of the FRCS(Plast) Section 2 components
Short-case circuit 1
Short case 1
6
1
16
4
Short case 2
6
1
16
4
Short case 3
6
1
16
4
Short case 4
6
1
16
4
Short case 5
6
1
16
4
Short-case circuit 2
Short case 1
6
1
16
4
Short case 2
6
1
16
4
Short case 3
6
1
16
4
Short case 4
6
1
16
4
Short case 5
6
1
16
4
Long-case circuit
Long case 1
15
3
48
12
Long case 2
15
3
48
12
Total:
90
16
256
64
Oral section
Station 1
3 out of the following 5:
1. Burns
Subtopic 1
10
1
16
4
2. Hand trauma
Subtopic 2
10
1
16
4
3. Maxillofacial trauma
Subtopic 3
10
1
16
4
4. Lower limb trauma
5. Pressure sores
Station 2
Head and neck
10
1
16
4
Cleft
10
1
16
4
Genitourinary
10
1
16
4
Station 3
Basic sciences
10
1
16
4
Aesthetics
10
1
16
4
Ethics and consent
10
1
16
4
Total:
90
9
144
36
Grand total:
180
25
400
100%
FM16
In subject areas you are relatively weak in, the balance of power will shift to the examiners. It is far easier to score a 5 than it is to score a compensatory 7. Under pressure, one of the most frequent candidate errors is to end-load with topics they are weak in. Examiners are tasked to uncover weaknesses in the candidate's knowledge. Combined with doubt (body language and factual), this may result in candidates being selectively quizzed on weak topics.
The tenet of cases is to demonstrate the following:
Stick to mentioning point-scoring items. It is acceptable to not know the diagnosis, but unacceptable to not know the process of arriving at a diagnosis. Lack of knowledge can sometimes be compensated for by identifying the relevant specialists who do. If you have exhausted your knowledge on the topic in question, say so, and the examiners will move on. Do not guess, as you will end-load badly and waste time.
 
Higher order thinking
The examination is set at a standard expected of a day one consultant plastic surgeon. The candidate's ability to take a full history and examination is already assumed. The expectation is for a contextualised history, examination and investigations tailored to achieve each of the basic tenets (see above). The candidate should also demonstrate the ability to argue and defend his or her choice with a logical process, substantiated by relevant evidence.
Table ii   Components of learning skills
1. Knowing
Recall
Burns can be full-thickness and need treatment
2. Understanding
Meaningful knowledge
If untreated will heal very slowly or may get infected
3. Applying
Using 1 and 2 to produce a useful effect
Excision and reconstruction is a good treatment
4. Analysing
Better understanding achieved by breaking down concept into smaller parts
The methods of reconstruction are full-thickness skin grafts, flaps or Integra with a delayed split skin graft, with pros and cons of each
5. Synthesis
Combine separate ideas to make something new
Slow reepithelialisation is not always a problem, as long as the defect is clean
Anaesthesia should be minimised in neonates
Neonates are relatively compliant
6. Evaluation
Judgement based on pros and cons
The benefits of debriding an extravasation full-thickness burn in a sick neonate may outweigh the risks of anaesthesia
7. Systems thinking
An appreciation of the workings of complex systems
Using a skin graft creates a donor site, expertise of the staff with skin grafts may be limited, and cosmesis of the recipient site is relatively poor without a dermal substitute
8. Creativity
Using insight and imagination to create something new
The neonate is in a clean and controllable environment with plenty of time for reepithelialisation. Debridement with Integra cover can be made a one-stage procedure by gradually peeling back the silicone layer and allowing reepithelialisation, avoiding a donor site and a skin graft, with better cosmesis overall
FM17
The eight components of learning are shown in . The first three items are intuitively recognisable and alone are insufficient to meet the examination requirements. Demonstration of higher order thinking involves items 4–7, with item 8 as a bonus.
 
Summary
Understand the examination rules, time frames and scoring system. Ensure that you are able to complete each MCQ question in Section 1 within 65 seconds. In Section 2, practice front-loading answers that demonstrate higher-order thinking. Avoid end-loading with topics you are unsure about. Desensitise and condition yourself to the examination format with lots of practice.