MCQs in Plastic Facial Skin Reconstruction

By Akeel Mosea

This comprehensive multiple choice questions style book covers most aspects of facial skin reconstruction. It uses real clinical scenarios with extensive answers based on textbooks and current literature. The reader will gain a broad understanding of different types of flaps and grafts used to reconstruct the lips, cheeks, nose, eyelids, ears, neck, forehead, temple and scalp. It also provides questions and answers on different types of skin cancers, Local anaesthetics, suture materials, facial anatomy and the physiology of wound healing. The second edition of this book is a refinement, with more up to date topics covered in scar revision, electrosurgery, laser surgery, rhinophyma and management of melanoma. We have also shed some light on dermatoscopy for pigmented lesions. The target audience for this book should be Maxillofacial, Plastic, Oculoplastic, Ear- Nose and Throat surgeons and any clinician who has an interest in facial surgery. The book will be of particular interest to candidates sitting any exit examinations.

• Language: English
• Publisher: Lulu.com
• Release date: Jul 14, 2021
• ISBN: 9781291273717

Book preview

Acknowledgement

Many thanks for Mr. M Millwaters MBBS, BDS, FDS RCS Eng, FRCS (OMFS), Consultant Oral and Maxillofacial surgeon for his ongoing support,  and for reviewing the content of this book.

Also, many thanks to Dr. Roberto Verdolini MD, FRCP consultant dermatologist at the Princess Alexandra Hospital for enriching our book with high quality dermatoscopy slides of pigmented lesions.

Copyright © 2021 Akeel Mosea

All rights reserved, including the right to reproduce this book, or portions thereof in any form. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse engineered, or stored, in any form or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical without the express written permission of the author.

ISBN: 978-1-291-27371-7

This work is dedicated to my parents, my wife and my children

Preface to second edition

It has been almost five years since the MCQs in Plastic Facial Skin Reconstruction was launched. I was incredibly pleased with the positive feedback we received worldwide, so many thanks to our readers across different specialties who had the chance to read it.

Indeed, this has inspired me to develop the book further to keep our readers up to date with literature in scar management, electrosurgery, laser surgery, dermatoscopy, and management of melanoma. We have also added more clinical scenarios in other random topics.

The spirit of the book in the second edition remains the same; It is simple to read, thorough, and rich in illustrative pictures and diagrams. We have also refined the old content and produced the book in colour. There is also an E-book format this time.

Akeel Mosea

Preface to first edition

The MCQs in Plastic Facial Skin Reconstruction is written to help any surgeon who has an interest in the facial field to understand and apply the principles of facial skin reconstruction in their daily practice. It can also be an invaluable aid for candidates sitting exit exams.

There are tens of textbooks on facial / plastic surgery, but I felt the library is critically lacking MCQs style review books in this field which is why I endeavoured to do this hard work. The format throughout is to use real case scenarios with a question/answer style. In the future, I am planning to write similar books in other aspects of maxillofacial surgery.

Finally, it is the author`s sincere thanks for Mr. M. Millwaters, MBBS, BDS, FDS RCS Eng, FRCS (OMFS), Consultant Oral and Maxillofacial surgeon for being my tutor and kindly reviewing this book.

Akeel Mosea

Questions and Answers

1- One of the folowing statements about melanoma is false:

a. Superficial spreading melanoma is the most common variant on the face.

b. Whenever possible, an excisional biopsy should be performed first in suspected lesions rather than an incisional biopsy.

c. Melanoma with a 3.5 mm depth can be excised with a 2.0 cm margin.

d. Breslow thickness is more important than Clark`s level in predicting tumour behaviour.

e. Isolated bone pain and elevated alkaline phosphatase should raise concerns regarding possible metastasis.

1- Answer: a

Superficial spreading melanoma is the most common histological variant on the skin. However, this type infrequently occurs in the head and neck. It usually arises from dysplastic naevi. Initially the growth is radially oriented before it turns into a vertical direction. On the other hand, Lentigo maligna melanoma which arises from Lentigo maligna (a type of melanoma in situ) is the most common form of melanoma on the face.

Other melanoma variants include:

Nodular melanoma: arises de novo without pre-existing lesion, most oral melanomas are of this variant.

Acral melanoma: acral means peripheral body parts, so this type of melanoma occurs in palms, toes (never on the face!). It can occur in all skin types.

Desmoplastic melanoma: the rarest variant, it has rather an aggressive perineural infiltration especially in the head and neck area with local recurrence.

Any suspected melanoma should be photographed and excised completely. The excision biopsy should include the whole tumour with a clinical margin of 2 mm of the normal skin, and a cuff of fat. This allows confirmation of the diagnosis by examination of the entire lesion; such that subsequent definitive treatment can be based on Breslow thickness.

Breslow thickness correlates well with the prognosis. It measures the vertical height from the granular layer to the point of deepest penetration of the skin by the tumour cells. On the other hand, Clark`s level refers to how deep the tumour has penetrated the layers of the skin. Research showed that Clark`s level is less predictive of prognosis than Breslow thickness. However, pathologists still use Clark`s level along with Breslow thickness to predict prognosis especially with less than 1.0 mm deep melanomas.

Shave biopsies should not be performed as they may lead to incorrect diagnosis due to sampling error and make accurate pathological staging of the lesion impossible. For the same reasons partial removal of naevi for diagnosis must be avoided as it may result in a clinical and pathological picture like melanoma (pseudo melanoma).

Incisional or punch biopsy is occasionally acceptable, for example in the differential diagnosis of lentigo maligna on the face. It is acceptable in certain circumstances to excise the lesion entirely but without repair, and to dress the wound while awaiting definitive pathology i.e. suspected large melanoma of the scalp.

The recommended excision margin for melanoma is:

Melanoma in situ: 5.0 mm.

≤1.0 mm Breslow thickness: 10 mm.

1.1 mm- 2.0 mm Breslow thickness: 10 mm.

2.1 mm- 4.0 mm Breslow thickness: minimum 10 mm, maximum 20 mm.

> 4.0 mm Breslow thickness: minimum 20 mm, maximum 30 mm.

Ref:

Booth. P.W. Maxillofacial surgery. In: Cutaneous lesions of the maxillofacial region I C Martin, J AA Langtry, (1st ed., Vol. 1) 1999 Edinburgh: Churchill Livingstone.

J.R. Marsden, J.A. Newton-Bishop, et al. Revised U.K. guidelines for the management of cutaneous melanoma 2010. British Journal of Dermatology 2010 163, pp238–256. 

http://emedicine.medscape.com/article/1295718-overview.

2- One of the following is considered a major feature in the Glasgow 7- points check list for detecting early melanoma arising from naevi:

a. Pruritis.

b. Crusting.

c. Change in size.

d. Diameter > 7mm.

e. All the above.

2- Answer: c

The ABCDE of melanoma are

A- Asymmetry.

B- Border irregularity.

C- Colour variation.

D- Diameter over 6 mm.

E- Evolutionary changes in colour, size, symmetry, surface characteristics and symptoms.

Glasgow 7- point check for melanoma:

Images/Glascowscale.png

Ref:

Fearfield L, GP oncology fact file: early diagnosis of melanoma, The Royal Marsden NHS Foundation, 2011.

3- You are seeing a 25 year old lady in the clinic, who has been referred for a fast growing 18.0 x 8.0 mm mole on her neck as in the picture:

Neckmelanoma.jpg

One of the following is false:

a. Most melanomas arise from pre exisitng moles.

b. Pale skin, blue eyes, and lots of freckles are risk factors for melanoma.

c. Asymmetry, ragged borders, colour  variation, big diameter, and surface elevation can be sinister features in this mole.

d. The width and lenght of this mole are not relevant factors for the melanoma TNM staging system.

e. An urgernt biopsy is always necessary for definitve diagnosis and staging.

3- Answer: a

Most melanomas start as a spot from unblemished skin. Approximately 33% of melanomas are derived directly from benign, melanocytic naevi. Excessive expousre to UV light is a major factor in the deveopment of melanoma in the head and neck area.

Staging of melanoma depends on depth of the tumour. Scales used for staging:

·      Breslow scale: Looks at the thickness of melnoma in the skin, measured in millimeters.

·      Clark scale: Describes the different levels within the skin that melanoma might have reached.

TNM system is based on:

T: from Breslow thickness +- ulceration.

N: >0 (Stage 3).

M: >0 (Sage 4 ).

There are 3 ways melanoma can spread:

Stage 3 melanoma can be spread to regional lymph node or to an area between the primary and the nearby lymph node). Staging of melanoma is complex. The following table is for illustration:

Ref:

Damsky WE, Bosenberg M. Melanocytic nevi and melanoma: unravelling a complex relationship. Oncogene. 2017;36(42):5771–5792. doi:10.1038/onc.2017.189

World Cancer Report 2014. World Health Organization. 2014. pp.Chapter 5.14. ISB 978-9283204299.

https://www.curemelanoma.org/about-melanoma/melanoma-staging/understanding-melanoma-staging/

4- You decided to perform an excisional biopsy for the lesion in the previous question. Histology confirmed a melanoma that reached 2mm deep into the skin. Clinically there is no regional palpable lymphadenopathy. The most ideal next step would be:

a. Radical neck dissection.

b. Selective neck dissection.

c. Sentinel lymph node biopsy.

d. Regional lymphadenectomy.

e. Ultrasound scan guided FNA.

4- Answer: c

In suspected melanomas, an excisional bisopsy with 1-2mm margin of normal tissues and cuff of fat is essential, so Breslow thickness and Clark levels can be determined for staging, and to prescribe the margin for the subsequent wide local excision (WLE).  The specimen might also be tested for BRAF gene. Up to 50% of melanoma cases test positive for BRAF gene, this test can  help in prescribing targeted cancer drugs especially in stage 3 or 4 melanoma.

A sentinel lymph node biospy (SLNB) should be recommended here. This can be done at the same time as WLE. A combination of blue dye and a weak radioactive chemical is injected around the scar