Dermatologic and Cosmetic Surgery1) The tensile strength of a wound 2 weeks after surgery compared to intact skin is:

A. 10%Correct Choice

B. 50%

C. 30%

D. 70%

E. 100%

The tensile strength of a wound approaches 10% of normal skin strength at 2 weeks postoperatively. Wound healing is a process which takes many months, yet the tensile strength of a wound never exceeds 70-80% of the tensile strength of intact skin. The use of subcuticular sutures is therefore critical to minimize the tension on a healing wound and prevent scar widening

2) What risk does an organ transplant recipient have of developing melanoma?

A. Same risk as general population

B. Less risk than general population

C. 10- fold increased risk

D. 50-fold increased risk

E. 3-fold increased riskCorrect Choice

Organ transplant recipients are at risk for developing many cutaneous tumors. The risk of melanoma is 3-fold that of the general population whereas these patients have a 65-fold increased risk of developing squamous cell carcinoma

3) A Z- plasty is performed to:

A. Reorient a scar Correct Choice

B. Make use of skin from an area of laxity

C. Obtain wound eversion

D. Shorten the length of an excision

E. Close a wound on a convex surface

A Z-plasty is a type of transposition flap that may be used to reorient a scar, especially when the scar crosses skin tension lines. It is also used to change the scar length or vector and ease scar contractures

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4) A Mohs surgery fellow experiences burning and tingling of her fingertips 6 months after starting her fellowship. She most likely has been exposed to which one of the following chemicals?

A. Chlorhexidine gluconate

B. Povodine-iodine

C. Hematoxylin

D. Toluidine blue

E. Hexachlorophene Correct Choice

Hexachlorophene is an antibacterial agent that was first introduced in 1944. Its use was discontinued in the 1970s when it was discovered to have neurotoxic side effects

5) The role of imiquimod in the treatment of superficial basal cell carcinoma is based on the induction of which cytokine?

A. Tumor growth factor-alpha

B. Interferon-gamma Correct Choice

C. Tumor necrosis factor–beta

D. Interleukin-2

E. Interleukin-4

Imiquimod is an immunomodulator which induces the production of cytokines that are involved in cell-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 and antitumor activity in vivo

6) All of the following are branches of the internal carotid artery except:

A. Ophthalmic artery

B. Supratrochlear artery

C. Supraorbital artery

D. Angular arteryCorrect Choice

E. Dorsal nasal artery

Branches of the internal carotid artery include the opthamic artery, supraorbital artery, dorsal nasal artery, supratrochlear artery, palpebral artery, and lacrimal artery. Branches of the external carotid artery include the superficial temporal artery, facial artery (inferior labial, superior labial, angular branches), maxillary artery, posterior auricular, and occipital artery. The external and internal carotid arteries anastamose in the periorbital region

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7) How long after cutaneous infiltration of lidocaine with epinephrine is maximal vasoconstriction achieved?

A. 15 minutes Correct Choice

B. 7 minutes

C. 1 minute

D. 30 minutes

E. 1 hour

The use of epinephrine with local anesthesia has two main advantages. Firstly, the epinephrine is a vasoconstrictor and assists in controlling bleeding during surgery. Secondly, and also a direct result of 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 of lidocaine take effect within the first few minutes of infiltration, the vasoconstrictive effects of epinephrine require approximately 15 minutes to fully develop

8) Which of the following topical antibacterial agents demonstrates activity against Pseudomonas species?

A. Erythromycin

B. Mupirocin

C. Polymyxin Correct Choice

D. Bacitracin

E. Clindamycin

Polymyxins are peptides produced by the organism Bacillus polymyxa. They are bactericidal against Pseudomonas aeruginosa, Proteus mirabilis, Enterobacter, Klebsiella and Escherichia coli. Since they provide little coverage against gram-positive organisms, polymyxins are often combined with other antibacterial agents to increase their spectrum of activity

9) Healing by secondary intention will offer the most favorable cosmetic result at which location?

A. Malar cheek

B. Nasal tip

C. Chin

D. Medial canthusCorrect Choice

E. Forehead

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Indications 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, or granulation, can be utilized when the cosmetic result is anticipated to be superior or equal to reconstruction. Disadvantages of healing by granulation include prolonged wound healing time and somewhat unpredictable cosmetic results. Anatomic sites lending themselves best to second intention healing, with excellent results, are the concave areas on the face. These include the medial canthus, the nose-cheek junction, the auricular concha, the preauricular cheek, and the retroauricular scalp. The nasal tip, malar cheek, chin and forehead are all convex surfaces on the face

10) 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 Choice

E. 100%

Tissue remodeling allows the host to develop a scar that is approximately 70% of the original strength of the skin

11) The following flaps are types of transposition flaps except:

A. A to TCorrect Choice

B. Nasolabial

C. Bilobed

D. Z plasty

E. Rhombic flap

The Z plasty, Bilobed, Rhombic, nasolabial flaps are all examples of transposition flaps. In each of these, 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 the defect

12) Which of the following demonstrates the highest risk of metastasis?

A. SCC within a scar Correct Choice

B. SCC on the scalp

C. SCC on the nose

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D. SCC on the ear

E. SCC on the lip

Location of tumor is an important risk factor for metastasis of squamous cell carcinoma. Compared with a 10% likelihood of metastasis for tumors located on the ear or the lip, an SCC developing in the 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 following statements are true regarding wedge resection of the lower lip except?

A. the vermillion border is marked prior to excision

B. the repair involves a two layered closure of skin and mucosaCorrect Choice

C. up to 1/3 of the lip can be excised and closed primarily

D. the mental crease should not be crossed

E. a V-shaped excision is often used

The lower lip has such great elasticity that full-thickness lesions that involve up to 1/3 of the lip can be excised and repaired primarily with excellent cosmetic and functional results. This type of repair requires a three layered closure of mucosa, skin and muscle.

Larrabee W. In: Principles of Facial Reconstruction. Lippincott-Raven: Philadelphia, 1995; 182-183

14) Endocarditis prophylaxis is recommended for each of the following except:

A. Previous bacterial endocarditis

B. Atrial septal defectsCorrect Choice

C. Mitral valve prolapse with regurgitation

D. Prosthetic valves

E. Hypertrophic cardiomyopathy

Preoperative antibiotics are recommended for endocarditits prophylaxis in those patients with prostheitc valves, congenital cardiac malformations, previous bacterial endocarditis, rheumatic heart disease with valve dysfunction, hypeertrophic cardiomyopathy, and mitral valve prolapse with refurgitaion. Classically 1 gram of Dicloxacillin or cephalexin is given 1 hour preoperatively and an additional 500 mg is given 6 hours post op. Clindamycin can be givenin those patients who are penicillin allergic.

Preopertive antibiotics for endocarditis prohpylaxis are not required in those patients who have an Atrial Septal Defect (ASD). pacemaker, rheumatic fever without valve dysfunction, or history of Coronary Artery Bypass Graft (CABG

15) Which of the following is true regarding lidocaine:

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A. Allergy most commonly occurs to propylene glycol preservatives

B. Maximum dose with no epinephrine is 7mg/kg

C. Beta blockers increase lidocaine levelsCorrect Choice

D. 1% lidocaine is equal to 1g/10ml

E. Duration with no epinephrine is 4-6 hours

Beta blockers increase lidocaine levels. The rest of the answers are false. 1% lidocaine is equal to 1g/100ml or 10mg/ml. Duruation of lidocaine with no epi is 30-60 minutes. Maximum dose of lidocaine with no epi is 4.5 mg/kg, with epi it is 7 mg/kg. Allergy to lidocaine is most commonly due to paraben preservatives

16) On average, how much does a full-thickness graft contract when removed from a donor site?

A. 30%

B. 15%Correct Choice

C. 80%

D. 50%

E. 60%

On the average, how much does a full-thickness graft may contract by about 15% when removed from a donor site

17) The surgical instrument shown in the photograph is a:

A. Dermablade

B. No. 10 blade

C. No. 11 bladeCorrect Choice

D. No. 15 blade

E. Beaver blade

Surgical blades are made from either carbon steel or stainless steel and may be coated with Teflon to reduce their drag through tissue. A no.11 blade, which is a narrow blade that ends in a sharp point, is used to make stab incisions and is often employed in incision and drainage procedures

18) True statements regarding skin cancer in organ transplant recipients include all of the following except:

A. Mohs micrographic surgery indicated for in-transit metastases Correct Choice

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B. 65 fold increase in development of SCC compared with general population

C. Extent of tumor development related to degree of immunosuppression

D. Skin cancer is the most common cancer in transplant patients

E. Cutaneous malignancies develop 3-5 years after organ transplantation

In-transit metastases is a common manifestation of metastatic disease

19) Which of the following local anesthetics has the longest duration of action?

A. Mepivacaine

B. Benzocaine

C. Lidocaine

D. Procaine

E. BupivacaineCorrect Choice

Bupivacaine is an amide type of local anesthetic. Its duration of action is approximately 3-5 hours and is the longest one listed. Following bupivacaine is mepivacaine, lidocaine, and procaine. The duration of action is based on the amine portion of the molecule

20) Which needle shape is most commonly used in cutaneous surgery?

A. 1/4 circle

B. 5/8 circle

C. 3/8 circleCorrect Choice

D. compound curve

E. 1/2 circle

Needles are either straight or curved. Curved needles have their curvature described either as a fraction of a circle or a compound curve. The greater the fraction of a circle, the more pronation and supination of the wrist required by the surgeon to place the needle. The 3/8 circle needle is easy to use in large, superficial areas and is the most commonly used needle for cutaneous surgery

21) Which of the following is the earliest symptom of lidocaine toxicity:

A. Perioral tinglingCorrect Choice

B. Nystagmus

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C. Seizure

D. Tachycardia

E. Cyanosis

The maximum dosage of lidocaine is 4.5 mg/kg without epinephrine and 7.0 mg/kg with epinephrine. 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 of toxicity may cause nystagmus, muscle twitching, tremor and finally seizures and respiratory arrest

22) 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 Choice

D. Zyplast (collagen)

E. Silicone

Radiance is an injectable, biodegradable filler composed of calcium hydroxyapatite microspheres. It is a normal constituent of bone and is therefore biocompatible. Current studies are examining the role of hydroxyapatite in augmenting the craniofacial skeleton

23) Each of the following are branches of the internal carotid artery except:

A. Ophthalmic artery

B. Supraorbital artery

C. Supratrochlear artery

D. Angular artery Correct Choice

E. Dorsal nasal artery

The angular artery is a branch of the external carotid artery. It arises from the facial artery and courses 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 ophthalmic artery establishing a communication between the internal and external carotid arterial systems

24) Which of the following parameters determines the wavelength of a laser?

A. Fluence

B. Spot size

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C. Lens length

D. Medium Correct Choice

E. Pulse duration

Laser light is monochromatic light that is emitted at a single wavelength. The wavelength of the laser is determined by the medium in the optical cavity of the laser through which the light passes. The medium may be solid, liquid or gas

25) The cutaneous lip and chin are divided into cosmetic units by which anatomic boundary?

A. Philtral ridge

B. Mental creaseCorrect Choice

C. Nasolabial fold

D. Vermillion border

E. Marionette lines

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 is preferable to conceal incisions within the boundary lines of cosmetic units. The mental crease, as demonstrated in the photograph, divides the cutaneous lip and chin

26) Which statement is true regarding relaxed skin tension lines (RSTLs)?

A. incisional scars should be placed perpendicular to RSTLs

B. the long axis of a wound often lies in the direction of the RSTL Correct Choice

C. they lie parallel to the underlying muscles

D. they occur as a result of increased elastic tone

E. smiling minimizes the appearance of RSTLs

Relaxed skin tension lines are creases in the skin that are present at rest and develop as a consequence of the decreased elasticity that occurs with aging and solar damage. These lines lie perpendicular to the underlying musculature and can be accentuated by smiling or frowning. An undermined circular wound will often form an oval shape due to muscular tension, and will have its long axis oriented within these relaxed tension lines. Knowledge of RSTLs is important in cutaneous surgery because placing incisions within these lines will ensure the most favorable cosmetic result

27) Pre-testing for allergy to collagen is required for which cosmetic filler?

A. Silicone

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B. Artecoll Correct Choice

C. Radiance

D. Perlane

E. Cosmoderm

Artecoll is a nonbiodegradable injectable filler composed of microspheres of polymethylmethacrylate which are suspended in bovine collagen. As with other types of injectable bovine collagen, patients must be tested for allergy to bovine collagen prior to treatment

28) Damage to the zygomatic branch of the facial nerve leads to which of the following:

A. Facial asymmetry

B. Eyelid ectropion and inability to close eyelidCorrect Choice

C. Winged scapula

D. Inability to pucker lips

E. Unilateral eyelid ptosis

Damage to the zygomatic nerve causes eyelid ectropion and inability to close eyelid

29) A patient has a 2.0 cm surgical defect on the left lower eyelid after having Mohs surgery. Which management option would be the least appropriate?

A. Primary closure

B. Secondary intentionCorrect Choice

C. Rhombic flap

D. Full-thickness skin graft

E. Tripier flap

In lower eyelid reconstruction, tension should be oriented parallel to the lower eyelid to prevent the development of ectropion. Secondary intention would be the least appropriate management option in this location because normal wound contraction would increase the risk of ectropion

30) Cosmetic units are defined by each of the following anatomic boundaries except:

A. Nasofacial sulcus

B. Glabellar region

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C. Philtral ridge

D. Nasolabial folds

E. Nasal tip Correct Choice

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 is preferable to conceal incisions within the boundary lines of cosmetic units. In addition, moving skin from one cosmetic unit to another should be avoided when possible to minimize the appearance of apposed skin of dissimilar quality

31) The O to Z flap is what type of flap?

A. Pedicle

B. RotationCorrect Choice

C. Transposition

D. Bilobed

E. Advancement

The O to Z flap is a bilateral rotation flap in which tissue is moved from two ends to cover a central defect. It is often used on the scalp or lower extremities in locations where tissue laxity is not present.

32) A patient who had liposuction 5 weeks ago presents with multiple firm nodules at the cannula insertion sites. You suspect the diagnosis is:

A. Herpes simplex infection

B. Cold panniculitis

C. Mycobacterial infectionCorrect Choice

D. Foreign body granuloma

E. Organized hematoma

Atypical mycobacterial infections are occurring with increasing frequency after cosmetic surgery procedures. These infections typically occur 4-14 weeks after a procedure as a late-occurring complication. Firm nodules at the treatment site or dehiscence of a previously healed wound may be presenting signs of atypical mycobacterial infection

33) The main advantage of selecting 4-0 Vicryl rather than 5-0 Vicryl to suture a wound is:

A. Smaller suture diameter

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B. Smaller needle

C. Increased tensile strength Correct Choice

D. Increased suture memory

E. Increased knot security

Sutures are classified according to the United States Pharmacopeia (USP) criteria. This classification system specifies the diameter of a given suture material that is required to produce a certain tensile strength. The smaller the cross-sectional diameter of a suture material, the higher the USP number that is assigned. Thus, 4-0 Vicryl will have greater tensile strength and a larger cross-sectional diameter than 5-0 Vicryl

34) All of the following statements are true regarding the ‘MCW Melanoma Cocktail’ except:

A. it demonstrates micrometastases in sentinel lymph nodes

B. it is performed intraoperatively

C. it is a mixture of polyclonal antibodies to tyrosinaseCorrect Choice

D. it is a mixture of monoclonal antibodies to MART-1

E. it is a mixture of monoclonal antibodies to Melan-A

The ‘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 for rapid and accurate determination of micrometastases.

Shidham VB et al. Optimization of an immunostaining protocol for the rapid intraoperative evaluation of melanoma sentinel lymph node imprint smears with the ‘MCW Melanoma Cocktail’. Cytojournal 2004;1(1):2

35) The “trapdoor effect” that can occur with a flap can be avoided by which of the following techniques:

A. Using additional sutures

B. Avoid thinning the flap

C. Using a flap with length to width ratio of less than 3:1

D. Performing the flap in a two staged procedure

E. Wide underminingCorrect Choice

Wide undermining of the primary defect can release tension and prevent tenting or the trap door deformity of the flap

36)The nasolabial two stage flap uses depends on which artery for flap survival:

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A. Lateral Nasal artery

B. Angular arteryCorrect Choice

C. Superior labial artery

D. Inferior labial artery

E. Supratrochlear artery

Angular artery provides blood supply for the nasolabial transposition flap

37) A patient with end stage liver disease comes to your surgical practice. Which of the following anesthetics should be used with this patient?

A. Mepivicaine

B. Lidocaine

C. BenzocaineCorrect Choice

D. Etidocaine

E. Prilocaine

Benzocaine, an ester, should be used as it is the only anesthetic mentioned above that is metabolized by the kidney and not the liver

38) A 40 year-old woman from Southern California has wrinkles at rest on her forehead, scattered telangiectasia on her nose and a few seborrheic keratoses on her chest. What category in Glogau's photoaging classification scale does this patient represent?

A. Type 5

B. Type 2

C. Type 4

D. Type 1

E. Type 3 Correct Choice

Glogau’s photoaging scale is a classification system that employs clinical markers of photodamage to determine an individual’s level of photoaging. The scale ranges from Type 1 through Type 4, with Type 4 demonstrating the most extensive photodamage. Type 3 on the Glogau scale is classified as advanced photoaging and describes a patient who is typically 50 years of age or older, has wrinkles at rest, telangiectasias, obvious dyschromias and visible keratoses

39) Which post-operative complication is shown in the photograph?

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A. Temporal nerve paralysis

B. Ectropion Correct Choice

C. Trap door deformity

D. Hypertrophic scar

E. Eclabium

Ectropion occurs when the eyelid margin turns outward away from the eye. In lower eyelid reconstruction, tension should be oriented parallel to the lower eyelid to prevent the development of ectropion

40) Which of the following facial rejuvenation techniques creates microthermal zones?

A. Radiofrequency

B. Intense pulsed light

C. Dermabrasion

D. Fractional photothermolysisCorrect Choice

E. CO2 laser

Fractional photothermolysis utilizes an infrared laser to create thousands of microthermal zones with 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 procedures

41) Preliminary studies with phosphatidylcholine demonstrate efficacy in the treatment of:

A. Soft tissue augmentation

B. Acne scarring

C. Periorbital fat padsCorrect Choice

D. Postinflammatory hyperpigmentation

E. Superficial rhytids

Phosphatidylcholine is a lecithin-derived phospholipid which induces lipolysis when injected into adipose tissue. Dissolution of fat is likely due to a detergent effect produced by the phosphatidylcholine

42) A patient with a deep vertical frown line in the glabellar region requests Botox. Treatment will mostly target which one of the following muscles?

A. Orbicularis oculi

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B. Depressor superciliaris

C. Orbicularis oculi

D. Levator palpebrae superioris

E. Corrugator superciliaris Correct Choice

Although the procerus and orbicularis oculi muscles are contributory, the development of vertical glabellar frown lines is mostly due to the overactivity of the corrugator supercilaris. These muscles function to pull the eyebrow inferomedially

43) Botulinum toxin type A cleaves which protein in the presynaptic neuron?

A. Acetylcholine

B. Synaptobrevin (VAMP)

C. Snap-25Correct Choice

D. Serotonin

E. Syntaxin

Botulinum toxin type A is FDA approved for the treatment of glabellar wrinkles. Botulinum toxins act by a three step process of binding, internalization by receptor medicated endocytosis and enzymatic activation. It has specific light chain intracellular binding sites and different sites of action on different SNARE (synaptosomal associated protein receptor [SNAP]) proteins. The SNARE proteins are intimately involved in releasing acetylcholine at presynaptic terminals. Botulinum toxin A cleaves SNAP-25 whereas B cleaves synaptobrevin

44) In a patient who is allergic to paraphenylinediamine, which of the following anesthetics should be avoided?

A. BenzocaineCorrect Choice

B. Bupivicaine

C. Prilocaine

D. Mepivicaine

E. Etidocaine

Paraphenyelenediamine is a common allergen found in permanent hair dyes. In individuals who are allergic to paraphenylendiamine, may also have allergic reactions to ester anesthetics, like benzocaine. The other answer choices are amide anesthetics. Other crossreactants to paraphenyelediamine include the preservative parabens, sulfonamides, and thiazide diuretics

45) The anatomic structure identified in the photograph is called the:

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A. Philtral ridge

B. Nasal groove

C. Nasal ala

D. Soft triangle

E. ColumellaCorrect Choice

The columella is one of the cosmetic subunits of the nose. It is formed by the medial crura of the alar cartilage

46) All of the following thrombotic complications have been reported after discontinuing aspirin therapy prior to surgery except:

A. Stroke

B. Transient ischemic attack

C. Pulmonary embolismCorrect Choice

D. Cerebral embolism

E. Myocardial infarction

Kovich et al. reported thrombotic complications in patients who had stopped either coumadin or aspirin 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, myocardial infarction, cerebral embolism and death. No DVT or pulmonary embolus was reported

47) Which of the following immunosuppressive agents may exert a protective effect against the development of skin cancers in organ transplant patients?

A. RapamycinCorrect Choice

B. Tacrolimus

C. Corticosteroids

D. Cyclosporine

E. Azathioprine

Rapamycin (also called sirolimus) is a macrolide antibiotic and a structural analog of FK 506. It is a potent immunosuppressive agent which inhibits mTOR (a member of P13K family kinases). Despite its immunosuppressive effects, preliminary data show a decreased incidence of skin cancer in organ transplant patients treated with rapamycin and postulate that it may exert a protective effect against cutaneous malignancies

48) Injection of Botox at the location identified in the photograph would denervate which muscle?

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A. Frontalis

B. Corrugator superciliaris

C. Levator palpebrae superioris

D. Orbicularis oculi

E. ProcerusCorrect Choice

The 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 eyebrow inferomedially

49) A safe dose of lidocaine with epinephrine when used in tumescent anesthesia is:

A. 3 mg/kg

B. 7 mg/kg

C. 4.5 mg/kg

D. 20 mg/kg

E. 50 mg/kg Correct Choice

The maximum recommended dosage of lidocaine in adults is 4.5 mg/kg without epinephrine, 7.0 mg/kg with epinephrine, and 55 mg/kg in tumescent anesthesia for liposuction

50) Which of the following determines the wavelength of a laser?

A. Spot size

B. Medium Correct Choice

C. Pulse duration

D. Fluence

E. Q switch

The wavelength of a laser is determined by the medium

51) Which of the following cosmetic injectables has the longest duration of action?

A. Sculptra (poly L-lactic acid)Correct Choice

B. Restylane (hyaluronic acid)

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C. Cosmoderm (collagen)

D. Myobloc

E. Botox

Sculptra (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 of the filler at two years post-treatment.

Valantin MA et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA. AIDS. 2003;17:2471-2477

52) Which is the most important criterion for performing Mohs micrographic surgery?

A. Aggressive histology

B. Size of tumor > 2cm

C. Tumor recurrence

D. Tumor is contiguous Correct Choice

E. Location of tumor

Tumor 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 and thereby lead to a false-negative pathology interpretation. Size, location, recurrence and histology are all indications for Mohs micrographic surgery rather than absolute requirements

53) The use of topical vitamin K has been shown to:

A. Induce keratinocyte differentiation

B. Increase collagen production

C. Minimize the appearance of telangiectasia

D. Reduce the severity of laser-induced purpura Correct Choice

E. Decrease the appearance of infraorbital pigmentation

Treatment of benign vascular lesions with the pulsed dye laser often produces significant postoperative purpura. Topical vitamin K has been shown to decrease the severity of laser-induced purpura although its mechanism of action has yet to be determined. No other cosmetic effects of topical vitamin K have been proven to be statistically significant

54) Which of the following is the major antioxidant in the human epidermis?

A. Ascorbic acid

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B. Coenzyme Q10

C. Alpha-tocopherol Correct Choice

D. Superoxide dismutase

E. Glutathione

Research into the preventive role of topical antioxidants in photoaging is based on the free radical theory 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 this vitamin has been shown to be an early and sensitive marker of environmental oxidative damage

55) The photograph demonstrates which of the following?

A. Composite graft

B. Full-thickness skin graft Correct Choice

C. Mohs layer

D. Split-thickness skin graft

E. Dog ear

A full-thickness skin graft (FTSG) is composed of the entire epidermis and dermis. Subcutaneous tissue must be removed since the fat may compromise the viability of the graft

56) Treatment of acne scarring would be most effective with which modality?

A. Nd:YAG laserCorrect Choice

B. Intense pulsed light

C. Pulsed dye laser

D. Photodynamic therapy

E. Radiofrequency

Treatment with the nonablative 1064-nm Q-switched Nd:YAG provides significant improvement in skin 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 treatment

57) Which structual component of local anesthetics (e.g. lidocaine) is responsible for the onset of activity?

A. Amine end

B. None of the above

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C. Length of the carbon chain

D. Aromatic ringCorrect Choice

E. Intermediate chain

Local anesthetics like lidocaine contain 3 principle structural elements. The aromatic ring determines the onset of activity, the intermediate chain defines the class (amide vs. ester), and the amine end is responsible for the duration of action

58) While removing sutures from an excision performed on the lateral neck, your patient reports decreased sensation of the helix and lobule of the ipsilateral ear. Which of the following nerves was likely injured during surgery?

A. Spinal accessory nerve

B. Greater auricular nerve Correct Choice

C. Auricular branch of vagus nerve

D. Lesser occipital nerve

E. Auriculotemporal nerve

Sensory innervation of the ear is provided by the greater auricular nerve, the auriculotemopral nerve, the lesser occipital nerve and the auricular branch of the vagus nerve. The greater auricular nerve is composed of the C2 and C3 branches of the cervical plexus and lies in the posterior triangle of 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 is also subject to injury in the lateral neck but would cause motor deficits rather than sensory deficits

59) Paradoxical darkening has been associated with Q-switched ruby, Q-switched alexandrite, Q-switched Nd:Yag treatment of which tattoo color?

A. Green

B. Black

C. Blue

D. Yellow

E. RedCorrect Choice

Paradoxic darkening of flesh-tone, red, and white tattoo inks with QSRL, Q-switched Nd:YAG, and Q-switched alexandrite lasers has been reported. The tattoo pigments most associated with this phenomenon are iron oxide and titanium dioxide. Ferric sulfide is converted to ferrous sulfate by the laser

60) Which tattoo pigment is most commonly associated with allergic reactions, eczematous and granulomatous?

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A. Cadmium sulfide

B. Titanium dioxide

C. Cobalt

D. Mercuric sulfideCorrect Choice

E. Carbon

Allergic reactions have been reported with several different types of tattoo pigment. The most commonly associated tattoo pigment however is mercuric sulfide. Tattoo with mercuric sulfide produces a red color

61) Which dye is used to stain the Mohs section shown in the photograph?

A. Eosin

B. Toluidine blueCorrect Choice

C. Cytokeratin 7

D. Hematoxylin

E. Myeloperoxidase

Toluidine blue is the stain in the photographed Mohs section. Since mast cells have been associated with tumor growth and are seen in increased numbers with basal cell carcinoma, staining of their metachromatic granules with toluidine blue can be an effective way of visualizing basal cell carcinoma on Mohs sections, particularly when the tumor is associated with fibrosis

62) The most common adverse reaction seen with betadine is:

A. Ototoxity

B. Seizures

C. Corneal damage

D. Allergic contact dermatitisCorrect Choice

E. Teratogenicity

Most common side effect seen with betadine is allergic contact dermatitis, secondary to the iodine componen

63) Which tattoo pigment has been most commonly associated with pseudolymphomatous reactions?

A. Mercuric sulfideCorrect Choice

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B. Malachite

C. Cadmium sulfide

D. Phthalocyanine dyes

E. Cobalt

Some delayed type hypersensitivity reactions may lead to pseudolymphoma, most commonly caused by red tattoo pigment (mercuric sulfide

64) Which nerve provides the sensory innervation to the tragus?

A. AuriculotemporalCorrect Choice

B. Auricular branch of vagus

C. Facial

D. Glossopharyngeal

E. Greater auricular

The auriculotemporal nerve which is a branch of the mandibular branch of the temporal nerve innervates the tragus. The sensory innervation to the auricle is provided by the greater auricular nerve, and to a lesser extent the lesser occipital nerve. The external auditory canal, concha, and posauricular sulcus supplied variably by 3 nerves - the auricular branch of the vagus (CNX), the facial nerve (CN7), and the glossopharyngeal (CNIX

65) Treatment with which modality would be most effective for the patient shown?

A. Pulsed dye laser

B. Photodynamic therapy

C. Radiofrequency

D. Erbium:YAG laser

E. Intense pulsed lightCorrect Choice

The patient shown has multiple solar lentigines. Targeting the melanosomes in these benign, superficial pigmented lesions would be most successfully accomplished with the intense pulsed light source

66) The surgical instrument shown in the photograph is a:

A. Stevens tenotomy scissor Correct Choice

B. Metzenbaum scissor

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C. Castroviejo scissor

D. Mayo scissor

E. Iris scissor

The instrument shown is a Stevens tenotomy scissor. This scissor is useful in dermatologic surgery for tissue cutting and blunt dissection

67) All of the following are alpha-hydroxy acids except:

A. Tartaric acid

B. Citric acid

C. Glycolic acid

D. Lactic acid

E. Salicylic acidCorrect Choice

Alpha-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 the intensity of the peel include the concentration of the acid, pH, degree of buffering, vehicle formulation, frequency of application, conditions of delivery, and the length of time the acid is placed on the skin. Salicylic acid is a type of beta-hydroxy acid

68) Formation of granulomas is a potential complication of treatment with:

A. Silicone Correct Choice

B. Hydroxychloroquine

C. Isotretinoin

D. Autologous fat

E. CO2 resurfacing

Silicone 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 for the ophthalmic treatment of complicated retinal detachment. The number 1000 refers to the product’s viscosity which is measured in centistokes. As a reference, water has a viscosity of 100 centistokes and mineral oil has a viscosity of about 350 centistokes. With respect to cosmetic applications, silicone is not FDA-approved for soft tissue augmentation. In addition to the occurrence of hypersensitivity reactions and product migration, there have been many reports of granuloma formation after silicone injection, even many years post-treatment

69) Which ocular structure is at most risk of injury from an erbium:YAG laser?

A. Pupil

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B. Iris

C. Retina

D. Lens

E. Cornea Correct Choice

The erbium:YAG laser is an ablative laser whose target chromophore is water. The cornea is an aqueous structure and is therefore the most susceptible to damage from this laser

70) Activation of the procerus muscle causes

A. Accentuation of the melolabial folds

B. Perioral wrinkles

C. Periocular wrinkles

D. Wrinkles at the nasal rootCorrect Choice

E. Wrinkles on the forehead

The procerus muscle causes wrinkling at the nasal root and is often targeted with Botox therapy for improved cosmesis

71) The cutaneous lip and chin are divided into cosmetic units by which anatomic boundary?

A. Vermillion border

B. Nasolabial fold

C. Mental creaseCorrect Choice

D. Philtral ridge

E. Marionette lines

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 is preferable to conceal incisions within the boundary lines of cosmetic units. The mental crease, as demonstrated in the photograph, divides the cutaneous lip and chin

72) Treatment with which of the following lasers has been effective in psoriasis?

A. Pulsed dye laser

B. Alexandrite laser

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C. Ruby Laser

D. Carbon dioxide laser

E. Excimer laswerCorrect Choice

The excimer laser is a 308 nm wavelength laser that has been used to treat psoriasis. The excimer laser has some advantages over ultraviolet therapy. By treating only involved skin, higher doses can be used and clearance may occur with fewer treatments

73) Which laser would not be a good choice for the treatment of a red cosmetic tattoo around the lips?

A. Carbon dioxide

B. Pulsed dye

C. Nd:YAG

D. Q-switched rubyCorrect Choice

E. Alexandrite

Q-switched lasers can be effectively used to remove tattoos. However, immediate darkening of white, 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 after heating by the laser and produce dramatic darkening

74) The anatomic structure identified in the photograph is called the:

A. Antihelix

B. Scaphoid fossa

C. Concha

D. Triangular fossaCorrect Choice

E. Tragus

The triangular fossa of the ear is shown in the photograph. This anatomic structure is bordered by the crura of the antihelix

75) Which of the following cosmetic injectables can be seen on routine dental x-rays?

A. Botox

B. Radiance Correct Choice

C. Restylane

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D. Zyplast

E. Cosmoderm

Radiance is an injectable, biodegradable filler which is composed of calcium hydroxylapatite microspheres. Calcium hydroxylapatite is a normal constituent of bone and thus can be seen on radiographic 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 acid

76) The type of repair depicted in the photograph is a:

A. Full-thickness skin graft

B. Nasolabial flap

C. Rotation flap

D. Rhombic flap

E. Island pedicle flap Correct Choice

The island pedicle flap is a type of advancement flap commonly used for medial cheek defects. The closure can often be camouflaged in the melolabial fold

77) The use of dermabrasion to improve the cosmesis of a scar is best performed how long after the initial surgery?

A. 1 year

B. 1 week

C. 6 months

D. 6 weeksCorrect Choice

E. 3 weeks

Dermabrasion is the process of surgically planing or abrading the epidermis and dermis and is usually carried out with a rapidly rotating wire brush or diamond fraise.Following dermabrasion, reepithelialization from adnexal structures occurs with remodeling and replacement of collagen bundles in the papillary and reticular dermis. This can result in improvement 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 dermabrasions are routinely carried out under local anesthesia. Post-procedure complications include scarring, pigmentary alterations, persistent erythema, and infection. Contraindications for dermabrasion include recent use of isotretinoin and recent facelift, browlift or other procedure involving extensive undermining. Reactivation of herpes labialis can be prevented in the lip area by administering antiviral prophylaxis

78) Which cosmetic injectable provides dermal augmentation through the harvesting of a patient’s fibroblasts?

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A. Juvaderm

B. Dermalogen

C. Hylaform

D. IsolagenCorrect Choice

E. Restylane

Isolagen is an emerging technology whereby a patient’s own fibroblasts are isolated from a skin biopsy, reproduced and then re-introduced into the patient’s treatment site

79) The tensile strength of a wound 6 months after surgery compared to intact skin is:

A. 70% Correct Choice

B. 15%

C. 30%

D. 50%

E. 100%

The tensile strength of a wound approaches 70% of normal skin strength at 8 weeks postoperatively. Wound healing is a process which takes many months, yet the tensile strength of a wound 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 widening

80) Epinephrine should be avoided with anesthetics in which of the following conditions?

A. Renal failure

B. Hypothyroidism

C. Liver failure

D. PheochromocytomaCorrect Choice

E. Diabetes Mellitus

Epinephrine should be avoided in patients with a pheochromocytoma

81) Which ocular structure is at most risk of injury from an erbium: YAG laser?

A. CorneaCorrect Choice

B. Iris

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C. Retina

D. Vitreous humor

E. Lens

Injury from lasers may occur via direct or indirect ocular exposure. Damage is generally wavelength specific. Laser that target hemoglobin or pigment may cause damage to the retinal pigment or vasculature while lasers that target water as a chromophore (carbon dioxide and erbium) can damage the cornea

82) Which one of the following lasers would be effective in the treatment of rhinophyma?

A. Carbon dioxide laserCorrect Choice

B. Alexandrite laser

C. KTP laser

D. Pulsed dye laser

E. Ruby laser

The carbon dioxide laser is a 10,600 nm laser that can be used to treat rhinophyma. The advantage of the carbon dioxide laser over steel or dermabrasion is that the laser is relatively bloodless. The erbium YAG can also be used to treat rhinophyma

83) A patient has a 1.5cm surgical defect on the right nasal sidewall that reveals the lateral cartilage. Which management option would be the least appropriate?

A. Cheek transposition flap

B. Primary closure

C. Full-thickness skin graft Correct Choice

D. Forehead flap

E. Secondary intention

Full-thickness skin grafts (FTSGs) depend upon a viable, vascular bed at the recipient site in order to survive. Exposed cartilage is an avascular tissue and therefore would not be able to support the metabolic requirements of a FTSG

84) Aging skin demonstrates all of the following characteristic changes except:

A. Decreased number of Langerhans cells

B. Increase in subcutaneous fat Correct Choice

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C. Hypertrophy of sebaceous glands

D. Decreased dermal collagen

E. Loss of elasticity

The loss and redistribution of subcutaneous fat is a characteristic finding of the aging face. The forehead, 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 of the aging face to one which includes augmentation rather than one of simply lifting and tightening the skin

85) The classic purpose for serrated scissors is:

A. For work on delicate areas around the eyes and the ears

B. For tissue undermining

C. For work on thicker tissues (back)

D. For sharp dissections of tissue

E. For gripping tissue while cuttingCorrect Choice

Serrated scissors are used primarily for gripping tissue to prevent sliding while cutting

86) Which of the following lasers may cause milia formation as a post-procedure complication?

A. Pulsed Dye

B. ErbiumCorrect Choice

C. ND-Yag

D. KTP

E. Excimer

The erbium (2940 nm) and carbon dioxide (10,600 nm) lasers may both cause milia formation after laser skin resurfacing

87) Which of the following surgical prepatory solutions is teratogenic?

A. Povidine-iodine

B. Ethyl and Isopropyl alcohol

C. Benzalkonium chloride

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D. Chlorhexidine

E. HexachloropheneCorrect Choice

Hexachlorophene or pHisoHex has shown to be toxic to developing embryos in animal studies and thus is prohibited for use in pregnant females. Chlorhexidine is a common ingredient in oral rinses(Peridex) and surgical prep solutions(Hibiclens) can cause ototoxicity if in contact with the middle ear and ocular toxicity if in contact with the eyes. Ethyl alcohol is effective against both gram positive and gram negative organisms, but only when the skin is dry. Both Povidine-Iodine (Betadine)and Benzalkonium chloride (Zephiran) can cause an allergic contact dermatitis

88) What is the most appropriate management of the following surgical complication?

A. Antibiotic therapy

B. Observation Correct Choice

C. Incision and drainage

D. Debridement

E. Pulse dye laser

If the epidermal surface of a graft becomes black and necrotic, it does not necessarily signify graft failure. The epidermal portion of the graft may slough with subsequent re-epithelialization. In this situation, the best treatment is observation

89) A physician using a carbon dioxide laser to treat verruca should be aware that all of the following complications can occur except:

A. Recurrence of lesion

B. Ocular damage

C. Transmission of viral disease

D. PurpuraCorrect Choice

E. Scarring

The carbon dioxide laser uses a 10,600 nm wavelength to target water as a chromophore. Lasers that target water may damage the cornea. The carbon dioxide laser can be used to destroy epidermal and dermal lesions such as warts. HPV virus has been recovered in the laser plume after treatment with carbon dioxide laser. Bovine papilloma virus recovered in the plume was even found to transmit disease to calf skin. Scarring and recurrence have also been found to be potential complications

90) A Z-plasty is performed to:

A. Correct dog-ears

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B. Obtain wound eversion

C. Shorten the length of an excision

D. Decrease tension on a wound Correct Choice

E. Make use of excess tissue

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 the orientation of a scar, and camouflage a scar by breaking it up into smaller components

91) Which of the following cosmetic injectables is FDA-approved for the treatment of lipoatrophy?

A. Botox

B. Radiance

C. Silicone

D. SculptraCorrect Choice

E. Isolagen

Sculptra (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 was approved by the FDA in August 2004 for the treatment of HIV-associated lipoatrophy

92) A history of anaphylaxis is a contraindication to treatment with which cosmetic injectable?

A. Cosmoderm

B. Radiance

C. Sculptra

D. RestylaneCorrect Choice

E. Myobloc

Restylane is a hyaluronic acid gel produced by the Streptococcus species of bacteria. The package insert for Restylane warns that its use is contraindicated in patients with “severe allergies manifested by a history of anaphylaxis or the presence of multiple severe allergies

93) What part of the eye may be damaged by exposure to irradiation from the carbon dioxide laser?

A. Sclera

B. Lens

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C. Retina

D. CorneaCorrect Choice

E. Iris

The carbon dioxide laser operates at a wavelength of 10,600 nm and targets water as a chromophore. Because of the high water content of the cornea, it may be damaged by exposure to irradiation from the carbon dioxide laser. Exposure to the erbium may cause corneal damage as well

94) All of the following statements are true regarding nerves blocks on the face except:

A. Anesthesia is placed around a nerve trunk

B. Lidocaine with epinephrine may be used

C. Numbness occurs in areas other than the operative site

D. Hemostasis is achieved using epinephrineCorrect Choice

E. Tissue distortion is minimized

While regional nerve blocks offer many advantages in cutaneous surgery, hemostasis is not one of them. Since the anesthetic is injected distant to the operative site, the vasoconstrictive effects of the epinephrine, and hence hemostasis, are not provided at the surgical site

95) The post-operative complication shown in the photograph is most commonly seen with which type of reconstruction?

A. Full-thickness skin graft

B. Rhombic flap

C. Nasolabial flap Correct Choice

D. Secondary intention

E. Rotation flap

Trap door deformity is believed to result from insufficient undermining. This surgical complication is most often associated with the nasolabial transposition flap. Intralesional corticosteroids may be beneficial in improving the cosmetic outcome

96) The pain associated with Botulinum A Exotoxin injection is attributed to the:

A. Needle gauge

B. Preservative-free salineCorrect Choice

C. Temperature

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D. PH

E. Exotoxin

Botulinum A exotoxin is used for multiple reasons, most often for the treatment of dynamic facial lines. In a double-blind, randomized controlled study, investigators found that botulinum A exotoxin reconstituted with preservative-containing saline less painful than with preservative-free saline

97) An M-plasty is performed to:

A. Make use of excess tissue

B. Reorient a scar

C. Decrease tension on a wound

D. Obtain wound eversion

E. Shorten the length of an excision Correct Choice

An M-plasty is a variation of the fusiform excision where either one or both ends of the ellipse are modified. The main advantages to performing an M-plasty are to shorten the length of an excision and to correct dog-ears

98) Botulinum toxin A (Botox) is FDA-approved for the treatment of:

A. Platysmal bands

B. Migraine headaches

C. HyperhidrosisCorrect Choice

D. Masseter hypertrophy

E. Crow’s feet

Botox 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 variable reimbursement rates by insurance companies

99) The antiptosis subdermal suspension threads used in facial rejuvenation are composed of:

A. Polyglycolic acid

B. Poly-L-lactic acid

C. Polydioxanone

D. Polyglactin

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E. PolypropyleneCorrect Choice

The Aptos subdermal suspension thread technique is a minimally invasive procedure which targets the ptotic changes seen with facial aging. 2-0 and 3-0 polypropylene threads are tunneled in the dermis to lift and suspend the skin and subcutaneous tissue

100) Which one of the following best estimates the percent strength of a wound one month after surgery with a primary closure?

A. 90%

B. 70%

C. 80%

D. 30%

E. 50%Correct Choice

One month after surgery with a primary closure a wound is approximately at 50% strength. Two weeks after surgery it is at 5% strength. Three weeks after surgery it is at 20%. It never reaches 100% of its original strength, its maximum strength is 90%

101) Topical vitamin K has been shown to:

A. Increases epidermal differentiation

B. Improve skin hydration

C. Decrease epidermal pigmentation

D. Reduce severity of postoperative purpuraCorrect Choice

E. Improve fine winkling

Topical vitamin K reduced post later treatment purpura when applied after (not before) treatment of telangectasia with the 585 nm pulsed dye laser

102) Which type of collagen is the first to be deposited in a healing wound?

A. Type I collagen

B. Type II collagen

C. Type III collagenCorrect Choice

D. Type IV collagen

E. Type VII collagen

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Coagulation/Inflammation, tissue formation, and scar/remodeling are the three phases important in wound healing. Collagen deposition occurs during the second phase. Fibroblasts migrate into the wound along the fibrin-fibronectin matrix deposited in the initial clot. The fibroblasts subsequently produce type I and III collagen, elastin, and proteoglycans. Collagen type III is the predominant collagen in early wound healing

103) All of the following statements are true regarding imiquimod (Aldara) except:

A. It is FDA-approved for the treatment of actinic keratoses

B. It is FDA-approved for the treatment of a 1.9 cm superficial basal cell on the chest

C. It is FDA-approved for the treatment of a 2.0 cm superficial basal cell on the back

D. It is FDA-approved for the treatment of a 1.5 cm superficial basal cell on the leg

E. It is FDA-approved for the treatment of a 1.2 cm superficial basal cell on the scalpCorrect Choice

Imiquimod (Aldara) is FDA-approved for the treatment of actinic keratoses and the treatment of superficial basal carcinoma. With respect to basal cell carcinoma, treatment is indicated for primary tumors that are 2.0 cm or less, and that are located on areas of the body excluding the face, scalp and anogenital region

104) A patient has a 1.8 cm nodular basal cell carcinoma on his neck. Which of the following criteria would be an indication for Mohs micrographic surgery?

A. Anatomic location

B. Size of tumor > 1.5 cm

C. Tumor is contiguous

D. Previous radiationCorrect Choice

E. Histologic subtype

Previous irradiation is an indication for Mohs surgery because the effects of radiation are similar histologically and biologically to scarring. Specifically, the tissue can show fibrosis and alter the tumor’s growth pattern. In terms of location, the neck is not a high risk site. With respect to pathology, nodular basal cell is not an aggressive subtype of basal cell carcinoma. Size of tumor > 2 cm would be an indication for Mohs. Finally, that the tumor grows contiguously is not an indication but an absolute requirement for Mohs surgery

105) Which porphyrin is targeted in aminolevulinic acid-photodynamic therapy?

A. Uroporphyrinogen

B. Coproporphyrinogen

C. Porphobilinogen

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D. Protoporphyrin IXCorrect Choice

E. Coproporphyrin III

Protoporphyrin IX is the substrate for the final rate-limiting step of heme synthesis. This enzymatic reaction is catalyzed by ferrochelatase. The preferential uptake of aminolevulinic acid by cancerous and pre-cancerous cells results in higher concentrations of protoporphyrin IX. This can then be selectively targeted by photodynamic therapy

106) Which of the following sun protection agents is currently seeking FDA approval?

A. MexorylCorrect Choice

B. Titanium dioxide

C. Avobenzone

D. Zinc oxide

E. Octocrylene

Mexoryl is considered the best UVA sunscreen currently available. Its broad-spectrum characteristics allow sunscreens to be manufactured with very high SPF factors. Various formulations of mexoryl have long-been available in Europe, Canada, Australia, Asia, Mexico and South America

107) Which of the following local anesthetic agents should not be used in children?

A. Benzocaine

B. PrilocaineCorrect Choice

C. Etidocaine

D. Mepivicaine

E. Bupivicaine

Prilocaine should bot be used in children given the risk of methemoglobinemia.Methemoglobulinemia in children can occur from exposure to oxidizing substances such as aniline dyes, prilocaine or pyrimidine. In methemoglobinemia, the iron in hemoglobin is oxidized from the ferrous state (Fe 2+) to ferric (Fe3+) resulting in the inability to transport oxygen and carbon dioxide. Clinically, this condition results in cyanosis

108) When can a patient who undergoes follicular-unit hair transplantation expect hair growth of the grafted follicles to begin?

A. 2 to 3 months Correct Choice

B. 7 to 10 days

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C. 6 months

D. 9 months

E. 1 month

The use of follicular-unit grafts, which contain one to four hair follicles, represents the advancement in both surgical technique and aesthetic outcome in the field of hair transplantation. The grafted hair follicles typically begin to grow within 8 to 10 weeks of implantation and are expected to survive for the individual’s lifetime

109) Which of the following is a potential side effect of ambulatory tumescent liposuction?

A. Pulmonary embolus

B. Abdominal perforation

C. Decreased appetite

D. Muscle atrophy

E. Breast enlargement Correct Choice

Breast 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, some authors postulate shifting hormone ratios as the etiology of this paradoxical breast augmentation. Abdominal perforation, respiratory failure and pulmonary embolus are complications that are seen almost exclusively in liposuction patients that receive general anesthesia or intravenous sedation

110) A patient with a squamous cell carcinoma of the helical rim had excisional surgery followed by closure of the wound with an advancement flap. Which would be the most appropriate antibiotic for this patient to receive postoperatively?

A. Trimethoprim-sulfamethoxazole

B. Cephalexin

C. Ciprofloxacin Correct Choice

D. Erythromycin

E. Dicloxacillin

Infection after cutaneous surgery is typically due to Staphylococcal and Streptococcal organisms. However, Pseudomonas aeruginosa may be normal flora of the ear and thus can potentially complicate ear surgery by causing severe infection of the external ear canal (malignant otitis externa). Ciprofloxacin would be the antibiotic of choice for this patient because it is effective against Pseudomonas species

111) The repair demonstrated in the photograph is a:

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A. Advancement flap Correct Choice

B. Rotation flap

C. Full-thickness skin graft

D. Split-thickness skin graft

E. Transposition flap

The postauricular flap is useful for repairing extensive defects of the helical rim, particularly when cartilage is involved. It is an example of an advancement flap

112) The use of EMLA cream is contraindicated in patients with which of the following?

A. Sickle cell anemia

B. Peripheral neuropathy

C. MethemoglobinemiaCorrect Choice

D. Atopic dermatitis

E. Deomycin allergy

The 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 of oxygen leading to tissue hypoxia. Patients with congenital or idiopathic methemoglobinemia or infants under 1 year of age are at higher risk for the development of this side effect

113) The type of repair depicted in the photograph is a:

A. Rotation flap

B. Island pedicle flap

C. Full-thickness skin graft

D. Rhombic flap Correct Choice

E. Nasolabial flap

The rhombic flap is a type of transposition flap. The classic rhombic flap is designed with two 60 degree angles and two 120 degree angles. The point of maximum tension is at the closure of the donor site

114) In organ transplant recipients, all of the following factors increase susceptibility to the development of skin cancer except:

A. CD8 lymphocytopeniaCorrect Choice

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B. Fair skin (Fitzpatrick types I-III)

C. Duration of immunosuppression

D. History of chronic sun exposure

E. History of HPV infection

All 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 at further risk. CD4 lymphocytopenia, rather than CD8, is another identified risk factor as is older age, history of actinic keratoses and history of skin cancer

115) The anatomic structure identified in the photograph is called the:

A. Philtral ridgeCorrect Choice

B. Cupid’s bow

C. Vermillion border

D. Soft triangle

E. Columella

The philtral ridges are located at the upper middle lip and form part of the aesthetically important cupid’s bow

116) What is the tattoo pigment responsible for most lichenoid reactions?

A. Titanium dioxide

B. Mercuric sulfideCorrect Choice

C. Carbon

D. Chromates

E. Iron oxide

Lichenoid tattoo reactions are not as common as eczematous reactions, both of which are most commonly caused by mercuric sulfide. Lichenoid reaction are likely to be mediated by delayed hypersensitivity to a lymphocytic T-cell infiltrate

117) Which part of the eye is most likely to be damaged to exposure to a pulsed dye laser?

A. Sclera

B. Cornea

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C. RetinaCorrect Choice

D. Lens

E. Conjuctiva

The pulsed dye laser operates at 585-nm and targets hemoglobin as a chromophore. It can pass through the cornea and damage choroidal and retinal vasculature. Several infrared pigment-specific lasers (eg, ruby, alexandrite, Nd:YAG) may also damage the retina by targeting the retinal pigment

118) All of the following are true statements regarding the immunohistochemical stain Melan-A except:

A. Reliably stains desmoplastic melanoma Correct Choice

B. Sensitive marker for melanocytic nevi

C. Antigen present in 80-100% of melanomas

D. Effective in frozen and paraffin-embedded tissue

E. Recognized by CD8+ T cells

E 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 and melanoma and may be used on frozen tissue sections as well as paraffin-embedded tissue. Although the antigen is present in > 80% of melanomas, it does not reliably stain desmoplastic or spindle cell melanomas

119) A patient with a basal cell carcinoma on the lower eyelid has Mohs surgery. Once tumor-free margins were obtained, the surgeon repairs the wound with a full thickness skin graft. Which of the following statements is true about this repair method?

A. Healing by secondary intention would minimize the risk of ectropion

B. Graft should be at least 25% smaller than the defect

C. Graft should be the same size as the defect

D. Graft rarely survives in this location

E. Graft should be at least 25% larger than the defectCorrect Choice

To account for wound contraction and minimize the risk of ectropion, full thickness skin grafts on the lower eyelid should be sized such that the graft is at least 25% larger than the actual size of the wound.

Jewett BS and Shockley WW. Reconstructive options for periocular defects. Otolaryngol Clin North Am 2001; 34(3):601-625

120) Which tattoo pigment has most commonly been associated with phototoxic reactions?

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A. Titanium dioxide

B. Mercuric sulfide

C. Cadmium sulfideCorrect Choice

D. Carbon

E. Iron oxide

Cadmium sulfide produces a yellow tattoo. Phototoxic reactions are most commonly caused by cadmium sulfide tattoo pigment. Red tattoos have also been associated with phototoxic tattoo reactions. However, this is thought thought to be due to the addition of cadmium sulfide which enhances and brightens the red color

121) 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 Choice

The Nd: YAG laser emits energy at 1064nm near the infrared range and penetrates the skin to the level of the deep dermal blood vessels. The target chromophore for this laser is melanin, thus its primary use is in treating lesions such as nevus of Ota and removing black tattoo pigment. Although both the erbium:YAG and CO2 lasers have longer wavelengths than the Nd: YAG, they are ablative lasers which only penetrate to the level of the stratum corneum and superficial epidermis, respectively

122) Which of the following suture materials is most likely to cause infection?

A. PDS (polydioxanone)

B. Silk Correct Choice

C. Prolene (polypropylene)

D. Nylon

E. Vicryl (polyglactin)

Silk is a nonabsorbable braided suture which has been shown to aid in the production of infection. It is believed that the interstices of braided or twisted suture materials enhance the potential for developing infection by providing privileged sites which harbor bacteria

123) 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?

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A. 2 months

B. 6 months

C. 3 weeks Correct Choice

D. 3 months

E. 1 week

The forehead flap is often the reconstructive option of choice for large nasal defects. The flap has a vertically-oriented blood supply which is supplied primarily from the supratrochlear arteries. Pedicle division and inset of this flap are typically performed 3 weeks after the initial surgery

124) Which of the following criteria carries the worst prognosis for a patient with a squamous cell carcinoma?

A. Size of tumor > 1 cm

B. Perineural invasion

C. Depth of invasion > 4 mm Correct Choice

D. Immunosuppression

E. Anatomic location

Many factors contribute to the aggressive behavior of cutaneous squamous cell carcinoma. For example, tumors in immunosuppressed patients and tumors with the histologic subtypes desmoplastic and acantholytic are often biologically aggressive squamous cell carcinomas. Compared with other risk factors, depth of invasion >4 mm and size > 2cm demonstrate the greatest risk for metastasis.

125) The relaxed skin tension lines overlying the scapula are:

A. Oriented horizontally

B. Parallel to the underlying muscle groups

C. Oriented verticallyCorrect Choice

D. Do not exist over the scapula

E. Oriented circumferentially

Relaxed skin tension lines (RSTLs) are creases in the skin that are present at rest and develop as a consequence of the decreased elasticity that occurs with aging and solar damage. These lines lie perpendicular to the underlying musculature. They tend to run vertically on the upper back whereas on the central trunk, they are typically circumferential. Knowledge of RSTLs is important in cutaneous surgery because placing incisions within these lines will ensure the most favorable cosmetic result

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126) Which of the following cosmetic injectables binds water to create volume, has a low allergic reaction profile, and lasts 6 to 12 months?

A. Silicone

B. Calcium hydroxylapatite

C. Human-derived collagen

D. Botulinum toxin

E. Hyaluronic acid Correct Choice

Hyaluronic acid is a natural component of human connective tissue. As a cosmetic filler, hyaluronic acid is an attractive alternative to currently available filler substances: its ability to bind water creates volume and plumps the skin; its duration of action of approximately 6-12 months is appreciably longer than conventional collagen; and since hyaluronic acid is chemically identical across all species, hypersensitivity reactions are rare

127) Which of the forms of electrosurgery can work in a wet field?

A. ElectrocauteryCorrect Choice

B. Electrodessication

C. Electrocoagulation

D. Electrosection

E. Electrofulguration

Electrocautery is the only one to work in a wet field as it has no current and works via heat

128) Which of the following complications has been reported with infraorbital injections of Botox?

A. FestooningCorrect Choice

B. Photophobia

C. Blindness

D. Astigmatism

E. Nystagmus

Festooning 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 oculi muscle. The author postulates that festooning resulted from further muscle weakness due to Botox treatment

129) When is it appropriate to use this surgical technique?

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A. To shorten the length of the scar

B. To change direction of a scar that is deformingCorrect Choice

C. When there is insufficient tissue for rotation flap

D. To prevent bleeding

E. When it is desirable not to extend an ellipse

Z-plasty is used to change the direction of scar that is deforming or to elongate a scar that is contricting. Common sites are medial canthus, side of the face and forehead

130) Which of the following sutures is the first to be absorbed?

A. Polyglycolic acid

B. Polydioxanone

C. CatgutCorrect Choice

D. Polypropylene

E. Polyglactin 910

Catgut has a variable rate of absorption but typically lasts about 7-14 days. Thus, it would be the first suture to be absorbed. Polyglactin 910 (Vicryl) and polyglycolic acid (Dexon) are both absorbed in about 90 days. Polydioxanone (PDS) is an absorbable monofilament which lasts approximately 180 days. Polypropylene (Prolene) is not an absorbable suture.

131) The most appropriate suture for closing a wound on the buccal mucosa is:

A. Braided nylon

B. SilkCorrect Choice

C. Prolene

D. PDS

E. Monocryl

The most appropriate suture for closing a wound on the buccal mucosa is silk. Other sutures may be used as well, but classically, silk is used because of its soft nature

132) The most appropriate laser to treat a port wine stain on an infant’s cheek would have which of the following wavelengths?

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A. 488 nm

B. 585 nm Correct Choice

C. 532 nm

D. 810 nm

E. 694 nm

The 585nm pulsed dye laser (PDL) targets intravascular oxyhemoglobin and is considered the treatment of choice for most benign vascular lesions. The original PDL had a wavelength of 577 nm which was later modified to 585 nm to achieve deeper penetration yet still maintainvascular specificity

133) Which of the following absorbable sutures lasts the longest?

A. Polydioxanone Correct Choice

B. Catgut

C. Polypropylene

D. Polyglycolic acid

E. Polyglactin 910

Polydioxanone (PDS) is an absorbable monofilament which lasts approximately 180 days. Catgut has a variable rate of absorption but typically lasts about 7-14 days. Polyglactin 910 (Vicryl) and polyglycolic acid (Dexon) are both absorbed in about 90 days. Polypropylene (Prolene) is not an absorbable suture

134) The most important function of a postoperative wound dressing is:

A. Provide a barrier to infection

B. Decrease tension on the wound

C. Create a moist environment

D. Prevent suture dehiscence

E. Immobilize the wound Correct Choice

Providing hemostasis to a wound is the most important function of a wound dressing. This is particularly critical in the first few hours postoperatively when the vasoconstrictive effects of epinephrine are wearing off and the wound is at risk of bleeding or hematoma formation. The provision of a barrier to infection and creation of a moist, occlusive environment are also necessary functions of a dressing but are not as critical as immobilizing the wound and ensuring hemostasis

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135) While contemplating the repair of a large cheek defect after Mohs surgery, you begin to anesthetize an elderly lady who weighs 110 lbs. What is the maximum amount of 1% lidocaine with 2.5% epinephrine that this patient can receive?

A. 500 ml

B. 350 ml

C. 35 ml Correct Choice

D. 50 ml

E. 10 ml

he maximum recommended dosage of 1% lidocaine with 2.5% epinephrine in adults is 7mg/kg. The patient weighs 110 lbs (or 50 kg) which allows her 350 mg or 35 ml (1% lidocaine has 10mg of lidocaine perml) of the anesthetic

136) Which potential complications is seen exclusively with phenol peels?

A. Laryngeal edema Correct Choice

B. Prolonged erythema

C. Milia

D. Toxic shock syndrome

E. Hypopigmentation

The principle concept of chemical peeling is to utilize a chemical agent to produce a controlled wound in the skin. Many different types of side effects can occur with chemical resurfacing and are typically related to the depth of the wound. Complications which are common to all peeling agents include: milia; acne; pigmentary changes; contact dermatitis; scarring; infection; prolonged erythema; textural changes and cold sensitivity. Unlike other peeling agents, phenol has the potential to cause severe adverse reactions which are exclusive to its use only. They include atrophy, cardiac arrhythmias and laryngeal edema

137) Reticulate eythema is a side effect seen with which treatment?

A. Cryotherapy

B. Pulsed dye laser

C. Diode laserCorrect Choice

D. Mesotherapy

E. Sclerotherapy

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Reticulate erythema is a recently-reported side effect of diode laser treatment. High energy fluences and a history of chilblains are believed to be predisposing risk factors. Laser treatment should be discontinued at the first sign of this complication

138) Alopecia neoplastica is most commonly associated with which malignancy?

A. Lymphoma

B. Squamous cell carcinoma

C. Breast carcinoma Correct Choice

D. Colon carcinoma

E. Melanoma

While various malignancies have a predilection for metastasis to the scalp where they can cause hair loss, alopecia neoplastica is most commonly associated with metastatic breast carcinoma.

139) The ‘snap test’ is performed prior to surgery at which anatomic location?

A. Mouth

B. Neck

C. Ear

D. Hand

E. EyelidCorrect Choice

The 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 ectropion formation. Ratner D et al. Cutaneous laser resurfacing. J Am Acad Dermatol 1999; 41(3):365-389

140) Which anesthetic has the shortest duration of action?

A. Tetracaine

B. ProcaineCorrect Choice

C. Mepivacaine

D. Bupivacaine

E. Prilocaine

Procaine has the shortest duration of action, only lasting about 30-60 minutes. It is an ester anesthetic and is commonly used in dentistry

141) For patients with AJCC stage III and IV melanoma, which of the following adjuvant treatments has shown the greatest increase in survival?

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A. Melacine

B. CanvaxinCorrect Choice

C. Interferon alpha-2B

D. Dacarbazine

E. M-Vax

The current paradigm for treatment of advanced-stage melanoma includes tumor reduction via surgery followed by adjuvant systemic therapy to manage residual occult disease. Although interferon alpha 2B and dacarbazine are FDA-approved adjuvant therapies, neither has significantly increased survival rates. Canvaxin is a polyvalent vaccine that contains more than 20 tumor and melanoma-associated antigens. Currently in phase 3 trials, postsurgical immunotherapy with Canvaxin has shown in retrospective matched-pair studies to prolong overall survival of stage III and IV melanoma patients by more than 175 percent

142) What is the ratio of sodium bicarbonate to 1% lidocaine in a buffered lidocaine solution?

A. 1:25

B. 1:5

C. 1:10Correct Choice

D. 1:1

E. 1:2

The 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 of approximately 3.5 – 5.0. The addition of sodium bicarbonate at a ratio 1:10 raises the pH to a more physiologic level, thereby reducing the stinging sensation associated with injection. However, the addition of bicarbonate also reduces the shelf-life of the lidocaine

143) The use of imiquimod (Aldara) for the treatment of superficial basal cell carcinoma is advocated at which treatment regimen?

A. Five times per week for 4 weeks

B. Five times a week for 6 weeks Correct Choice

C. Three times a week for 10 weeks

D. Three times per week for 4 weeks

E. Three times a week for 6 weeks

Imiquimod (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: results from two phase III, randomized, vehicle-controlled studies

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144) When would use of this technique be most beneficial?

A. To shorten the length of the woundCorrect Choice

B. To prevent post-operative bleeding

C. To prevent pincushioning

D. To prevent post-operative infection

E. To increase the width of the wound

M-plasty is used to shorten wound length and is often when it is not desirable to extend the ellipse into a nearby structure

145) Which anatomic structure is likely to be severed during this repair?

A. Marginal mandibular nerve

B. Labial artery Correct Choice

C. Mental nerve

D. Angular artery

E. Buccal nerve

The 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 mucosa and the underlying muscle

146) The rhytids identified in the photograph are referred to as:

A. Marionette lines

B. Bunny linesCorrect Choice

C. Nasolabial folds

D. Crow’s feet

E. Relaxed skin tension lines

Bunny lines are located on the dorsum of the nose and are formed by the contraction of the nasalis muscle

147) Which of the following topical antibacterial agents may cause neutropenia?

A. Silver sulfadiazine Correct Choice

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B. Mupirocin

C. Bacitracin

D. Polymyxin

E. Povodine-iodine

Silver sulfadiazine is most commonly used to prevent infection in second and third-degree burn patients. Rare cases of leukopenia, neutropenia and kernicterus have been reported in patients using this topical antibacterial agent. Consequently, silver sulfadiazine should be used cautiously and avoided in infants, nursing mothers and pregnant women. Silver sulfadiazine also has the potential to cause a hypersensitivity reaction in patients with sulfa allergy

148) Which material is used to coat the jaws of the needle holder in the photograph?

A. Tungsten carbideCorrect Choice

B. Copper

C. Gold

D. Nickel

E. Stainless steel

Tungsten carbide is believed to be a harder more durable material that allows for better grasping of the needle. Needle holders with tungsten carbide jaws usually have gold-plated handles

149) Jessner’s solution contains all of the following except:

A. Ethanol

B. Salicylic acid

C. Resorcinol

D. Lactic acid

E. Glycolic acidCorrect Choice

Jessner’s solution is a combination of resorcinol, salicylic acid, and lactic acid in ethanol that is used as a superficial peeling agent. The advantage of Jessner’s solution is that timing is unnecessary and neutralization is not performed. The lactic acid is an alpha hydroxy acid

150) The following are true statements regarding the design of an excisional ellipse except:

A. Ellipse includes pathologic and normal tissue

B. Incision lines are placed in relaxed skin tension lines

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C. Long axis of ellipse is oriented perpendicular to free margins

D. Length of ellipse is at least 3 times its total width

E. The angle at each of the apices is 15ºCorrect Choice

Thoughtful design of an elliptical excision is important for obtaining optimum tissue diagnosis, tumor clearance, wound closure and cosmetic result. The above statements are all true except that the angles at the apices of the ellipse should be 30º

151) Blue nodules in the skin are a potential complication of which cosmetic injectable?

A. Silicone

B. Radiance (hydroxyapatite)

C. Cosmoderm (collagen)

D. Restylane (hyaluronic acid)Correct Choice

E. Sculptra (poly L-lactic acid)

Although hyaluronic acid is believed to be inert in humans, rare reports exist of granulomatous foreign body reactions to this material. Skin biopsy of a Restylane nodule demonstrates multinucleated giant cells surrounding a blue amorphous material

152) Which of the following is true regarding a Baker-Gordon peel?

A. Croton oil is considered the most important component for efficacyCorrect Choice

B. It contains resorcinol

C. 88% phenol is the most important component for efficacy

D. It contains salicytic acid

E. It is considered a medium depth peel

Croton oil is considered the most important component for efficacy. It is a epidermolytic that enhances penetration. A Baker Gordon peel is a deep peel that contains 88% phenol, tap water, croton oil, and septisol

153) The surgical instrument shown in the photograph is a:

A. Towel clamp

B. Iris scissor

C. HemostatCorrect Choice

D. Gradle scissor

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E. Needle holder

A hemostat is shown in the photograph. This instrument is commonly used in cutaneous surgery for clamping off blood vessels

154) The use of EMLA cream is contraindicated in patients with which of the following?

A. Neomycin allergy

B. Methemoglobinemia Correct Choice

C. Atopic dermatitis

D. Peripheral neuropathy

E. Sickle cell anemia

EMLA 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 with glucose-6-phosphate deficiency and patients taking methemoglobin-inducing agents (dapsone, phenytoin, sulfonamides) are more susceptible to developing methemoglobinemia. In addition, care should be taken when using EMLA in infants less than 3 months of age because of the incomplete maturation of their NADH-methemoglobinemia reductase system

155) Signs and symptoms of lidocaine toxicity include all of the following except:

A. OtotoxicityCorrect Choice

B. Circumoral numbness

C. Seizure

D. Slurred speech

E. Nystagmus

The first signs of lidocaine toxicity are CNS symtpoms that resemble inebriation with alcohol. These symptmoms include stupor, dysarthria, circumoral numbenss and dizziness. Further increases in toxicity leads to nausea, metallic taste, twitching, and seizures. Ototoxicity is not one of the toxic manifestations seen with lidocaine toxicity. Without epinephrine the maximum dose of lidocaine 4mg/kg. For a 70 kg individual, this is 300 mg or 30 ml of a 1% lidocaine solution. For a preparation 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% solution

156) To avoid injury to the facial nerve, undermining in the region of the temple should be performed at which anatomic level?

A. Reticular dermis

B. Subcutaneous fat Correct Choice

C. Above the frontalis muscle

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D. Above superficial fascia (SMAS)

E. Dermal-epidermal junction

In the region of the temple, lateral to the eyebrow, the temporal branch of the facial nerve lies in the superficial fascia. Once above the eyebrow, the nerve is located deep to the frontalis muscle. In the region of the temple, it is therefore prudent to undermine in the superficial subcutaneous fat

157) Which of the following histochemical stains can be used intraoperatively during Mohs micrographic surgery to confirm the diagnosis of extramammary Paget's disease?

A. S-100

B. Myeloperoxidase

C. Toluidine blue

D. Neuron-specific enolase

E. Cytokeratin 7 Correct Choice

Cytokeratin 7 is a structural component of the cytoskeleton that stains poorly differentiated tumors of the epithelium. This low molecular weight cytokeratin positively stains Paget cells. Neuron-specific enolase stains merkel cell carcinoma, toluidine blue stains mast cells and myeloperoxidase stains cells with myeloid differentiation such as leukemia cells. S-100 protein is a non-specific stain that is commonly used as an adjunctive marker in the diagnosis of melanoma

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