SURGERY II | BREAST

Tutor: Dr.Lahoz | Lecture Date: April 8, 2022 | 2ND SEMESTER

● Young female: overlies the 2nd to the 6th ribs and their
costal cartilages and extends from the lateral margin of
TOPIC OUTLINE
the sternum to the midaxillary line.
I. Breast = Mammary Gland
● UPPER LATERAL EDGE: Extends around the lower border
II. Congenital Anomalies of the Breast
of the pectoralis major and enters the axilla.
III. Infectious and Inflammatory Disorders of The
● MIDDLE-AGED MULTIPAROUS: Maybe large and
Breast
pendulous
IV. Common Benign Disorders of the Breast
● MENOPAUSAL: Adipose tissue reduced, and
V. Breast Cancer
hemispherical shape is lost
● The mature female breast extends from the level of the
second or third rib to the inframammary fold at the sixth
BREAST = MAMMARY GLAND or seventh rib.
● The breasts are specialized
accessory glands of the skin that DESCRIPTION
secrete milk. ●
Child/Men: rudimentary
●
Female: after puberty, enlarges → hemispherical shape
●
The breast has a protuberant conical form.
LOCATION ●
The base of the cone is roughly circular, measuring 10-12
● Lies in the superficial fascia covering the anterior chest cm in diameter.
wall ● Considerable variations in the size, contour, and density
of the breast are evident among individuals.
● Rests on the fascia of the
pectoralis major, serratus
anterior, and external oblique
abdominal muscles, and the
upper extent of the rectus
sheath
● Cushioned in fat. ANATOMY

● The nipples are small and

surrounded by a colored
area of the skin called areola
● The breast tissue consists of
a system of ducts embedded
in connective tissue that
does not extend beyond the
margin of the areola.
● Composed of 15 to 20 lobes,
which are each composed of
several lobules.

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 ○ Remember that breast tissue extends to the axilla ● Suspensory ligaments
area so when you examine the breast, you have to ○ In between the lobules
include that area. ○ Fuse with the overlying superficial fascia, just under
● From each lobe, main duct and before termination at the dermis
areola, dilation is called AMPULLA. ○ Coalesce as the interlobular fascia in the breast and
● AREOLAR GLANDS – tiny tubercles at the areola parenchyma.
(Montgomery’s glands) ○ Join with the deep fascia of the breast over the
● Fibrous septa separate each lobe. pectoralis muscle.
● Rich in lymphatics

● Fibrous bands of connective tissue travel through the

breast (Cooper’s suspensory ligaments – related with
dimpling of the skin in breast cancer), insert
perpendicularly into the dermis, and provide structural ○ You have to be very aggressive when we encounter
support. breast mass with the possibility of breast cancer.
● The axillary tail of Spence extends laterally across the
anterior axillary fold. BLOOD SUPPLY (ARTERIES/VEINS)
● The upper outer quadrant of the breast contains a
greater volume of tissue than do other quadrants (also,
it is the most common area in breast cancer)

○ Lateral branches of the posterior intercostal arteries

○ Perforating branches of the internal mammary
artery
○ Branches from the axillary artery, including the
highest thoracic, lateral thoracic, and pectoral
branches of the thoracocranial artery.

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 LYMPHATIC DRAINAGE

● We have to be very careful when we remove the breast

from the pectoralis because there are several intercostal
arteries that are very hard to ligate if it is not properly
done.
○ This shows source of BS behind the breast.

● The lymph drainage of the mammary gland is of great

clinical importance because of the frequent
development of cancer in the gland and the subsequent
dissemination of the malignant cells along the lymph
vessels to the lymph nodes
● Lymphatic channels are abundant in the breast
parenchyma and dermis. Specialized lymphatic channels
collect under the nipple and areola and form Sappey’s
plexus.

SIX AXILLARY LYMPH NODE GROUPS

1. Axillary Vein Group (lateral)
● Three principal groups of veins: ○ Consists of 4-6 lymph nodes that lie medial or
○ Perforating branches of the internal thoracic vein posterior to the vein and receive most of the lymph
○ Perforating branches of the posterior intercostal drainage from the upper extremity.
veins 2. External mammary group (anterior or pectoral group)
○ Tributaries of the axillary vein ○ Consists of 5-6 lymph nodes that lie along the lower
border of the pectoralis minor muscle contiguous
● Batson’s vertebral venous plexus, which invests the with the lateral thoracic vessels and receive most of
vertebrae and extends from the base of the skull to the the lymph drainage from the lateral aspect of the
sacrum, may provide a route for breast cancer breast.
metastases to the vertebrae, skull, pelvic bones, and 3. Scapular group (posterior or subscapular)
CNS. ○ Consists of 5-7 lymph nodes that lie along the
posterior wall of the axilla at the lateral border ofthe
scapula contiguous with the subscapular vessels and
receive lymph drainage principally from the lower

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 posterior neck, the posterior trunk, and the posterior
shoulder.
4. Central group
○ Consists of 3-4 sets of lymph nodes that are
embedded in the fat of the axillary lying immediately
posterior to the pectoralis minor muscle and receive
lymph drainage both from axillary vein, external
mammary, and scapular groups of lymph nodes, and
directly from the breast.
5. Subclavicular group (apical)
○ Consists of 6-12 sets of lymph nodes that lie
posterior and superior to the upper border of the
pectoralis minor muscle and receive lymph drainage
from all of other groups of axillary lymph nodes.
6. Interpectoral group (Rotter’s lymph nodes)
○ Consists of 1-4 lymph nodes that are interposed
between the pectoralis major and pectoralis minor
muscles and receive lymph drainage directly from
the breast.

○ When you examine the breast, especially if you’re

considering breast cancer, we don’t just examine the
breast. Check the nodes on the anterior chest, the
axillary area, and the supraclavicular area.

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 ● Levels according to their anatomic relationship to the EMBRYOLOGY
pectoralis minor ● Something to do with some of the benign conditions
muscle: ● 5th-6th week: two ventral bands of thickened ectoderm
(mammary ridges/milk line) – extends from axilla to the
-These levels are inguinal area → accessory breast when regression falls
significant to the ● Primary bud → 15-20 secondary buds → epithelial cords
prognosis of the ● Lactiferous ducts develop → opens to mammary pit
patient ● Infancy: mammary pit to nipple
Level I: lymph nodes
located lateral to or
below the lower
border of the
pectoralis minor
muscle, which include
the axillary vein,
external mammary,
and scapular groups.
Level II: superficial or
deep to the pectoralis minor muscle, which include
the central and interpectoral groups.
Level III: medial to or above the upper border of the
pectoralis minor muscle, which consist of the
subclavicular group

DEVELOPMENT OF BREAST

NERVE SUPPLY
● Lateral cutaneous branches of the 3rd-6th intercostal
nerves provide sensory innervation of the breast (lateral
mammary branches) and of the anterolateral chest wall.
These branches exit the intercostal spaces betweenslips ● Birth: major ducts; only one nipple left behind, the rest
of the serratus anterior muscle. should have not developed
● Cutaneous branches that arise from the cervical plexus, ● Puberty: enlarges due to hormones → proliferation of
specifically the anterior branches of the supraclavicular epithelial and connective tissue elements
nerve, supply a limited area of the skin over the upper ● Pregnancy: becomes fully developed
portion of the breast. ○ Rapid increase in length and branching of the duct
● The intercostobrachial nerve is the lateral cutaneous system.
branch of the 2nd intercostal nerve and may be ○ Secretory alveoli develop at ends of smaller ducts.
visualized during surgical dissection of the axillary. ○ Vascularity increases
Resection of the intercostobrachial nerve causes loss of ○ Nipple enlarges and areola darkens.
sensation over the medial aspect of the upper arm. ○ Later: Colostrum
○ Absence of the breast (amastia) is rare and results

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 from an arrest in mammary ridge development that LACTOGENESIS
occurs during the sixth fetal week. ● Pregnancy
○ Accessory axillary breast tissue is uncommon and ○ Increased ovarian and placental estrogens and
usually is bilateral progestins → ductal and lobular epithelium
proliferates; areolar skin darkens, and Montgomery
glands become prominent
○ 1st-2nd trimester → minor ducts branch and
develops
○ 3rd trimester → progesterone and estrogen
decrease, prolactin acts, fat droplets accumulate in
the alveolar epithelium, and colostrum fills the
alveolar and ductal spaces.
○ NEURAL REFLEX originates in nerve endings of the
nipple-areolar complex.
○ Once a woman delivers, there is already OXYTOCIN
– contraction of myoepithelial cells, compression of
alveoli and expulsion of milk into the lactiferous
sinuses.
○ When a breastfeeding woman starts WEANING her
baby – prolactin and oxytocin release decreases.
○ Menopause, there is a decrease in the secretion of
estrogen and progesterone by the ovaries and
involution of the ducts and alveoli of the breast. The
● When a woman becomes pregnant, we now have your surrounding fibrous connective tissue increases in
lobules density, and breast tissues are replaced by adipose
tissues.
Effects of Hormones

CONGENITAL ANOMALIES OF THE BREAST

Polythelia ● Remember the
ventral buds.
● Supernumerary
nipples
occasionally
occur along a
line
corresponding
to the position
of the milk line.
Estrogen: initiates ductal development ● Sometimes
Progesterone: responsible for differentiation of epithelium mistaken as
and for lobular development mole.
Prolactin: lactogenesis

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 ● Cause is unknown but probably related to hormonal
Retracted or ● Failure in the
imbalance.
Inverted development of
● Physiologic gynecomastia usually occurs during three
Nipple the nipple
phases of life:
● Normal suckling
1. Neonatal gynecomastia is caused by the action of
of infants
placental estrogens on neonatal breast tissues.
cannot take
2. Adolescence: there is an excess of estradiol relative
place.
to testosterone and with senescence, the circulating
● If it is
testosterone level falls, which results in relative
congenital,
hyperestrinism. During puberty, the condition often
breastfeeding
is unilateral and typically occurs between ages 12
may not be
and 15 years.
possible.
3. Senescent gynecomastia is usually bilateral. In the
● Nipple prone to
nonobese male, breast tissue measuring at least 2
infection
cm in diameter must be present before a diagnosis
● Regularly clean
of gynecomastia may be made.
because of
● Dominant masses or areas of firmness, irregularity, and
accumulation of
asymmetry suggest the possibility of breast cancer,
dead tissue that
particularly in the older male.
may cause
● Gynecomastia generally does not predispose the male
infection
breast to cancer.
Micromastia ● Excessively
small breast on PATHOPHYSIOLOGIC MECHANISM OF GYNECOMASTIA
one side
occasionally
● Due to lack of
development

Macromastia ● Diffuse
hypertrophy of
one or both
breasts
occasionally
occur at
puberty in
otherwise
normal girls

GYNECOMASTIA

● Enlarged breast in males

● Unilateral or bilateral enlargement of the male breast

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 ● Common in postpartum: initiated by suckling infants.
● Management:
○ Antibiotics and repeated aspirations
○ Operative drainage (biopsy)
■ Most of the time, because of suppurations or
the fibrous septae, it’s hard to just aspirate so
most of the time they end up with operative
drainage.
■ You need to get some tissue for biopsy because
there could be some concomitant malignancy.
● Chronic breast abscess: TB mastitis (Philippines has this)
● Zuska’s disease, also called recurrent periductal
mastitis, is a condition of recurrent retroareolar
infections and abscesses; Smoking has been implicated
as a risk factor for this condition.

MYCOTIC INFECTION
● Blastomycosis or sporotrichosis
● Candida albicans – scaling
● Intraoral fungi that are inoculated into the breast tissue
by the suckling infant initiate these infections, which
present as mammary abscesses in close proximity to the
MANAGEMENT nipple-areola complex.
● Androgen deficiency, then testosterone administration ● Dx: scrapings – fungal elements like filaments and
may cause regression. binding cells
● Due medications, then these are discontinued if ● Occurs in immunocompromised women.
possible. ● Management
● Endocrine defects are responsible, then these receive ○ o Removal of predisposing factor
specific therapy (anti-estrogen) ○ o Topical or systematic
● Progressive and does not respond to other treatments,
surgical therapy is considered (local excision, HIDRADENITIS SUPPURATIVA
liposuction, or subcutaneous mastectomy (most ● Usually involves the nipple-areola complex or axilla.
commonly done) ● Chronic condition
● Attempts to reverse gynecomastia with danazol have ● Management: Antibiotic, I&D (incision and drainage),
been successful, but the androgenic side effects of the excision with grafts
drug are considerable (weigh the benefits and risks) ● Chronic inflammatory condition that originates within
the accessory areolar glands of Montgomery or within
INFECTIOUS INFLAMMATORY DISORDERS OF THE BREAST the axillary sebaceous glands
● Common in postpartum period (due to the milk, which
is a good medium for bacterial growth)
● Intrinsic: secondary to abnormalities within the breast
● Extrinsic: secondary to an infection in an adjacent
structure (periductal mastitis or infected sebaceous
cyst)

BACTERIAL INFECTION
● Staphylococcus aureus and Streptococcus species (most
common species)
● Typically breast abscesses are seen in staphylococcal COMMON BENIGN DISORDERS OF THE BREAST
infections and present with point tenderness, ABERRATIONS IN THE NORMAL DEVELOPMENT AND
erythema, and hyperthermia INVOLUTION (ANDI)
● Breast abscess (erythema, tenderness, hyperthermia) ● Basic Principle:

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 a. Benign breast disorders and diseases are related to ● Predominant in younger women (15-25 years old) (Most
the normal processes of reproductive life and to common)
involution. ● 1-2 cm, stable but may grow to larger size; well
b. There is a spectrum of breast conditions that ranges circumscribed (very movable on PE, feels like a marble)
from normal to disorder to disease. ○ NORMAL: <1cm
c. The ANDI classification encompasses all aspects of ○ DISORDER: <3cm
the breast condition including pathogenesis and the ○ DISEASE: >3cm (giant Fibroadenoma); multiple (>5
degree of abnormality. lesions in one breast)
● Precise etiology (?) – hormonal dependent
ANDI Classification of Benign Breast Disorders
CYCLICAL MASTALGIA
● Premenstrual enlargement of the breast (NORMAL)
● Painful nodularity symptomatic just give analgesic.
● DISORDER: if it persists >1 week after the menstrual
cycle.

INVOLUTION
● Dependent on specialized stroma
● MACROCYST - stroma involutes quickly, alveoli remain
and from microcyst (precursor to microcyst) - DOES NOT
REQUIRE TREATMENT
● SCLEROSING ADENOSIS - disorder of proliferative and
involutional phases
● DUCT ECTASIA – dilated subareolar ducts with thick
nipple discharge → stagnation of secretions, epithelial
*See last page for bigger and clearer photo. ulceration and leakage of duct secretion into periductal
tissue
● PERIDUCTAL MASTITIS → Periductal fibrosis
Fibrocystic Disease
● Non-specific; fibrocystic change, cystic mastopathy,
chronic cystic disease, fibroadenomatosis, etc.
● Refers to a spectrum of histopathologic changes.
● Diagnostic term to describe symptoms, to rationalize
the need for breast biopsy and to explain biopsy results.

Galactocele
● In lactating women
- A milk-filled cyst that is round, well circumscribed,
and easily movable within the breast.
- Generally, occurs after the cessation of lactation or
*See last page for bigger and clearer photo. when feeding frequency has declined significantly,
although galactoceles may occur 6-10 months after
FIBROADENOMA breastfeeding has ceased.
- Pathogenesis of galactocele is unknown, but
inspissated milk within ducts is thought to be
responsible.
- The cyst is usually located in the central portion of
the breast or under the nipple.
- Needle aspiration produces thick, creamy material
that may be tinged dark green or brown. Although it
appears purulent, the fluid is sterile.
- Treatment is needle aspiration; withdrawal of the

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 thick milky secretion confirms the diagnosis; surgery
is reserved for cysts that cannot be aspirated or that
become infected.

Proliferative Disorders without Atypia

● Central sclerosis and various degrees of epithelial
proliferation, apocrine metaplasia and papilloma
formation.
● RADIAL SCARS lesion up to 1cm.
● COMPLEX SCLEROSING LESIONS are larger lesions.
● VS invasive carcinoma – challenging in core needle
biopsy → excision biopsy

Intraductal Papilloma
● Arise in major ducts.
● Most commonly associated with NIPPLE DISCHARGE
● Premenopausal women
● <0.5cm – 5cm Management of Benign Breast Disorders/Diseases
● Complaint: NIPPLE DISCHARGE – serous or bloody (not Cyst
automatically cancer) ● Breast imaging – UTZ: differentiate tumor if solid or cystic.
○ What we usually do is express the breast and check
● Needle biopsy – 5-10 ml non-bloody aspirate (or more)
in which quadrant is the intraductal papilloma
diagnostic & therapeutic (exclude residual mass)
because sometimes we cannot feel any mass
● SIMPLE CYST vs COMPLEX CYST (residual mass) - biopsy.
○ Diagnosis: press the breast quadrant per quadrant,
then identify which of the quadrants produces
Fibroadenoma
bloody nipple discharge
● Self-limiting
● Rarely undergoes malignant transformation (unless ● UTZ + core needle biopsy (risk is low, not needed)
accompanied by atypia) ● MORE THAN 2 CM: surgical removal, cryoablation,
● Multiple papillomas in younger women less frequently vacuum assisted biopsy or OBSERVATION
associated with nipple discharge –susceptible to
malignant transformation.
● Management: Quadrantectomy

Atypical Proliferative Disease

● Same feature of CIS
● ATYPICAL DUCTAL HYPERPLASIA (ADH) – up to 2-3 mm
in size → high risk for development of breast cancer
● DUCTAL CARCINOMA IN SITU – larger than 3 mm
○ Excisional biopsy for classification
● ATYPICAL LOBULAR HYPERPLASIA www.cancer.org
○ Minimal distension of the lobular units with cells
similar to LCIS
Fibrosis and Simple Cysts
Fibrosis
● Refers to a large amount of fibrous tissue.
● Rubbery, firm, or hard to the touch.

Cysts
● Round, movable lump, which might also be tender to the
touch, suggests a cyst.
● Fluid-filled, round or oval sacs within the breast.
● Most often found in women in their 40’s, they can occur
in women of any age.
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 ● Monthly hormone changes often cause cysts to get bigger increased risk of breast cancer- about 1 ½ times the risk of
and become painful and sometimes more noticeable just women with no breast changes.
before the menstrual period. ● Complex fibroadenomas seem to increase the risk slightly
more than simple fibroadenomas.
Diagnosis
● Diagnosed based on symptoms, such as breast lumps, Treatment
swelling, and/or tenderness or pain. ● Many doctors recommend removing fibroadenomas
● Tend to be worse just before your menstrual period especially if they keep growing or change the shape of the
begins and may change as you move through different breast, to make sure that the cancer is not causing the
stages of your menstrual cycle. changes.
● An ultrasound may be done to see if the lumps are solid ● Sometimes these tumors stop growing or even shrink on
or are just filled with fluid (called a simple cyst.) If the their own, without any treatment. It’s important for women
ultrasound shows the lump is solid or if the cyst has both who have fibroadenomas to have regular breast exams or
fluid and solid components (a complex cyst), a biopsy may imaging tests to make sure that the fibroadenomas are not
be needed to make sure that it’s not a cancer. growing.There is no definite medicine yet for
● Neither fibrosis nor simple cysts increase your risk of later fibroadenomas
developing breast cancer. ● Sometimes one or more new fibroadenomas can grow
after one is removed. This means that another
Treatment fibroadenomas has formed- it does not mean that the old
● Cyst fluid doesn’t need to be removed unless it’s causing one has come back.
discomfort.
● Mild discomfort from fibrosis, you may get relief from
well- fitted, supportive bras, applying heat, or using over Phyllodes Tumor or Phylloides Tumor
the counter pain relievers (paracetamol or ibuprofen) ● These are rare breast tumors that start in the connective
● It can be drained by putting a thin, hollow needle into the (stromal) tissue of the breast.
cysts which might be done to confirm the diagnosis. ● Phyllodes tumors are most common in women in their
● For cysts that continue to come back and cause 40’s, but women of any age can have them.
symptoms, surgery to remove them might be an option. ● Most phyllodes tumors are benign (non-cancer; really big
tumors but are benign), but about 1 out of 4 these tumors
Fibroadenomas are malignant (cancer).
● Fibroadenomas are common benign (non-cancerous) ● First called cystosarcoma phyllodes
breast tumors made up of both glandular tissue and stromal ● Histologically, benign phyllodes tumors are similar to
(connective) tissue. fibroadenomas, but the whorled stroma forms larger clefts
● Fibroadenomas are most common in women in their 20’s lined by epithelium that resemble clusters of leaflike
and 30’s, but they can be found in women of any age. They structures.
tend to shrink after a woman goes through menopause. ● The stroma is more cellular than in a fibroadenoma, but
● Fibroadenomas can often feel like a marble within the the fibroblastic cells are bland, and mitoses are infrequent.
breast. Some fibroadenomas are too small to be felt, but
some are several inches across. Diagnosis
● Fibroadenomas tend to be round and have clear cut ● Painless lump, but some may hurt. (expansion/
borders. You can move them under the skin and they’re compression from other tissue) They tend to grow quickly
usually firm or rubbery but not tender. A woman can have and stretch the skin.
one or many fibroadenomas. ● Ultrasound or mammogram - hard to tell from
● Easy to remove since they are encapsulated. fibroadenomas;
● mammography has round densities with smooth borders
Diagnosis and are indistinguishable from fibroadenomas.
● Some fibroadenomas can be felt, but some are only found ● Ultrasonography may reveal a discrete structure with
on an imaging test (like a mammogram or ultrasound). cystic space.
● A biopsy (taking out breast tissue to check it in the lab) is ● An excisional biopsy- to know for sure that it’s a phyllodes
needed to know if a tumor is a fibroadenoma or some other tumor, and whether it’s malignant or not.Also used to
problem. differentiate it from fibroadenoma.
● Women with simple fibroadenomas have a slightly

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 Treatment
● Breast conserving surgery (lumpectomy) is the main
treatment.
● Because these tumors can come back, close follow-up
with frequent breast exams and imaging tests are usually
recommended after treatment.

Malignant phyllodes tumors

- Different from more common types of breast
cancer. They don’t respond to hormone therapy
and are less likely than most breast cancers to
respond to radiation therapy or the chemotherapy
drugs normally used for breast cancer.

BREAST CANCER
Facts
WHO/International Agency for Research on Cancer Also highest in INDIA.
 Leading killer of women ages 35-54
 1M develop the disease without knowing it
 Phils – highest incedence rate in Asia
 Phils – 9th highest in the world

● Incidence, Mortality and Survival

- Breast cancer is the leading site for both sexes
combined (19%) in 2015 and ranks 1st among
women (33%). An estimated 20,267 new cases are
estimated to occur among women.
- The incidence rate starts rising steeply at age of 30.
The incidence rate has been rising since 1980, with
an average annual percentage change of 1.2%.

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  Certain inherited genes - BRCA1 OR BRCA2
 Having family history of breast cancer
 Having personal history of breast cancer
 Your race and ethnicity
 Having dense breast tissue
 Certain benign breast conditions, LCIS AND
DCIS
 Starting menstruation early (before age 12
years)
 Going through menopause after age of 55
 Having radiation to your chest (when you do
CXR)
o Factors with unclear effects on breast cancer risk
 Diet and Vitamins
 Chemicals in the environment
 Tobacco smoke
 Night shift work (some studies have
suggested that women who work at night
Risk Factors such as nurses on a night shift, might have an
increased risk of breast cancer. This is a fairly
 HORMONAL – associated with estrogen level
recent finding, and more studies are looking
o Increased number of menstrual cycle (increased
at tis. Some researchers think the effect may
exposure to estrogen): early menarche,
be due to changes in levels of melatonin, a
nulliparity, late menopause- INCREASED RISK
hormone that’s affected by the body’s
o Moderate levels of exercise and longer lactation
exposure to light, but other hormones are
period- DECREASED RISK
also being studied)
o Older age of first live birth- INCREASED RISK
o Disproven or controversial breast cancer risk
o OBESITY- increased risk (especially if the someone
factors.
starts gaining weight after menopause; source of
 Antiperspirants
estrogen in postmenopausal women is conversion
 Bras (even with underwire)
of androstenedione to estrone by adipose tissue)
 Induced abortion
o Females after menopause should maintain normal
weight.
RISK MANAGEMENT
 NONHORMONAL
- When to use postmenopausal hormone
Risk Factors for Breast cancer can be classified as
replacement therapy – check first if there is a risk
o Lifestyle related breast cancer risk factor
for breast cancer.
 Drinking alcohol (Alcohol consumption is
- Age to perform mammography screening or MRI.
known to increase serum levels of estradiol.)
- When to use TAMOXIFEN to prevent breast cancer
 Being overweight or obese after menopause
– Tamoxifen increases the risk of uterine cancer.
 Not being physically active
- MASTECTOMY?
 Not breastfeeding
Can breast cancer be prevented? Lower the Risk:
 Birth control with hormones (pills, depo-
- Stay at healthy weight.
provera, implants, patches, etc)
- Be physically active
 Hormone therapy after menopause
- Limit or avoid alcohol
(Increased exposure to estrogen is associated
- Breastfeeding
with an increased risk for developing breast
- Hormone replacement therapy after menopause –
cancer, whereas reducing exposure is thought
think of non-hormonal options
to be protective)
- The first step in deciding if you should take a drug
 Breast implants
to help lower your chances of getting breast cancer
o Breast Cancer Risk Factors you cannot change
is to have a health care provider assess your breast
 Being women
cancer risk.
 Getting older
- The Breast Cancer Risk Assessment Tool (also called

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 the Gail Model) is commonly used to assess this breast
risk. It can estimate your risk of getting breast Risk Reducing Surgery
cancer in the next 5 years and over your lifetime, - Prophylactic mastectomy- reduced risk by 90%
based on many of the factors listed below - Carriers of BRCA Mutation (A study involving
women who were carriers of a breast cancer
susceptibility gene (BRCA) mutation found that the
benefit of prophylactic mastectomy differed
substantially according to the breast cancer risk
conferred by the mutations)
- High risk women (For women with an estimated
lifetime risk of 40%, prophylactic mastectomy
added almost 3 years of life, whereas for women
with an estimated lifetime risk of 85%, prophylactic
mastectomy added >5 years of life)
- Little to support (While studies of bilateral
prophylactic or risk-reducing mastectomy have
BRCA (Breast Cancer) MUTATIONS reported dramatic reductions in breast cancer
- Autosomal Dominant incidence among those without known BRCA
- Hereditary risk: mutations, there is little data to support a survival
- Obtain complete, multigenerational family benefit.)
history (it could be from their fathers) - PROPHYLACTIC OOPHORECTOMY (Risk-reducing
- Assess the appropriateness of genetic salpingo-oophorectomy was highly effective at
testing for a patient. reducing the incidence of ovarian cancer and breast
- Counseling the patient cancer in BRCA mutation carriers and was
- Interpreting the results associated with a reduction in breast cancer-specific
mortality, ovarian cancer-specific mortality, and all-
cause mortality)
Chemoprevention
Tamoxifen
- Selective estrogen receptor modulator (was
the first drug shown to reduce the
incidence of breast cancer in healthy
women)
- ER positive breast cancers (There have been
4 prospective studies published evaluating
tamoxifen vs. placebo for reducing the
incidence of invasive breast cancer. The
decrease was evident only in ER-positive
breast cancers with no significant change in
ER-negative tumors.)
- Phil. – cases are mostly ER +
- Recommended only for women:
- With Gail relative risk of 1.66% or
higher, aged 35 to 59
Cancer Prevention for BRCA Mutations Carriers - Women over age 60 with diagnosis
- Risk-reducing mastectomy and reconstruction of LCIS or atypical ductal or lobular
- Risk-reducing salpingo-oophorectomy hyperplasia
- Intensive surveillance for breast and ovarian cancer - Comorbidities
- Chemoprevention - Endometrial cancer
- MASTECTOMY does not remove all breast tissue - Cataract
and women continue to be at risk because a Raloxifen
germline mutation is present in any remaining - Selective estrogen receptor modulator

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 -No adverse effect on the uterus American Cancer Society Releases New Breast Cancer
-No effect on LCIS and DCIS ? Guideline
-An updated analysis revealed that
raloxifene maintained 76% of the efficacy of
tamoxifen in prevention of invasive breast
cancer with a more favorable side effect
profile.
Aromatase Inhibitors
- Lower estrogen levels by stopping an
enzyme in the fat tissue from changing
other hormones into estrogen.
- Though not yet approved in the USA to
lower breast cancer risk
- Side effects: symptoms of menopause (hot The New Recommendation
flushes, night sweats and vaginal dryness): - Women with an average risk of breast cancer –most
tend to speed up bone thinning women—should begin early mammogram at age
(osteoporosis) 45.
Breast Cancer Screening (Schwartz) - Women should be able to start the screening as
- Mammography – age 50 years early as age 40, if they want to. It’s a good idea to
- <50 years of age – controversial start talking to your health care provider at age 40
- greater breast density about when you should begin screening
- More false-positive results - At age 55, women, should have mammogram every
- Younger women less likely to have breast other year—though women who want to keep
cancer having yearly mammograms should be able to do so
- High risk women - <50 years old - Regular mammograms should continue for as long
- Family history as a woman is in good health.
- Breast density measurement - Breast exams, either from a medical provider or
- American cancer society (2015): self-exams, are no longer recommended.
- Annual screening 40 – 44 average risk *The guidelines are for women at average risk for a breast
- Annual Mammography ≥ 45 cancer. Women at high risk- because of family history, a
- Biennial Mammography ≥ 55 breast condition, or another reason-need to begin screening
- Clinical Exam – not recommended for earlier and/or more often. Talk to your medical provider to
average risk be sure.
Why is a clinical breast exam no longer recommended?
- Clinical breast examination is a physical exam done
by a health professional. During the beginning of
the mammography era, the combination of CBE and
mammography was associated with a lower risk of
dying from breast cancer, and CBE was shown to
offer an independent contribution to breast cancer
detection. Since then, as mammography has
improved and women’s awareness and responses
to breast symptoms has increased, the few studies
that exist suggest that CBE contributes very little to
early breast cancer detection in settings where
mammography screening is available and
awareness is high.

Why is breast-self-exam no longer an option for women in

these new guidelines?
- Evidence does not show that regular breast self-
exams help reduce deaths from breast cancer.
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 However, it is very important for women to be - Localized edema (peau d'orange) develops when
aware of how their breasts normally look and feel drainage of lymph fluid from the skin is disrupted.
and to report any changes to a health provider right - With continued growth, cancer cells invade the skin,
away. This is especially important if a woman and eventually ulceration occurs
notices a breast changes at some point in between
her regular mammograms.

NATURAL HISTORY (untreated)

- Median survival: 2.7 years
- 5 year survival: 18 %
- 10 year survival: 3.6%
- >15 years: 0.8%

- As the size of the primary breast cancer increases,

some cancer cells are shed into cellular spaces and
transported via the lymphatic network of the breast
to the regional lymph nodes.
- Lymph nodes that contain metastatic cancer are at
first ill-defined and soft but become firm or hard
with continued growth of the metastatic cancer.
- Eventually the lymph nodes adhere to each other
and form a conglomerate mass.
- Cancer cells may grow through the lymph node
capsule and fix to contiguous structures in the
axilla, including the chest wall.
- typically, axillary lymph nodes are involved
sequentially from the low (level I) to the central
(level II) to the apical (level III) lymph node groups.
Survival of women with untreated breast cancer - Approximately 95% of the women who die of breast
compared with natural survival. cancer have distant metastases, and traditionally
BREAST CANCER PATHOGENESIS the most important prognostic correlate of disease-
free and overall survival was axillary lymph node
status.

DIAGNOSIS OF BREAST CANCER

Presenting Signs and Symptoms
 BREAST MASS
 Breast enlargement or asymmetry
 Nipple changes, retraction, or discharge
 Ulceration or erythema of the skin of the breast
- More than 80% of breast cancers show productive  Axillary mass
fibrosis that involves the epithelial and stromal  Musculoskeletal discomfort
 History taking should include information on risk
tissues.
- With growth of the cancer and invasion of the factors.
 50% no physical signs of breast pathology
surrounding breast tissues, the accompanying
desmoplastic response entraps and shortens  Breast pain → usually Benign disease
Cooper’s suspensory ligaments to produce a  For male physicians, be sure that a female assistant is
characteristic skin retraction. present during examination.

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 Examination of the Breast

For male Physicians – be sure that a female assistant is

present. Palpation
 Using the pads of your finger, first apply light pressure
to the breast as you are checking the area just slightly
underneath the breast’s skin surface.
 Next apply medium pressure to the breast, checking
about midway inside the breast.
 And finally, apply deep pressure, feeling the area
deepest in the breast.
 You should use these three pressures to examine the
breast.
 Examine the axilla - palpate deep into the axillary
fossa

Breast Quadrants

Inspection
 arms up in the air
 hands on her hips (with and without pectoralis muscle
contraction)
 Leans forward to accentuate skin retraction.
 NOTE:
o Symmetry (it is normal that it’s slightly asymmetric)
o Size and shape
o Presence of edema; nipple or skin retraction or
erythema

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 Imaging Techniques - Mammography
 used to detect unexpected breast cancer in
asymptomatic women.
 The most common reason why women are hesitant to
undergo mammography is the PAIN.

Imaging Techniques - Ultrasonography

 Can detect the presence of cyst (solid or liquid mass)

The breast is pressed between the two limbs of this

machine.

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 Imaging Techniques - MRI CLASSIFICATION FOR INVASIVE BREAST CANCERS
Expensive Paget’s disease of the nipple
Invasive (infiltrating) ductal carcinoma – adenocarcinoma
with productive fibrosis (scirrhous, simplex. NST), 80% -
most common invasive breast cancer
Medullary carcinoma, 4%
Mucinous (colloid) carcinoma, 2%
Papillary carcinoma, 2%
Tubular Carcinoma, 2%
Invasive Lobular Carcinoma, 10%
Rare cancers (adenoid cystic, squamous cell, apocrine)

CLINICAL STAGING (P.E.)

 PATHOLOGIGIC STAGING – histopathologic results
 TNM STAGING
Breast Biopsy T - Tumor size
 FINE NEEDLE ASPIRATION BIOPSY (G22) N - Nodal status
o For cytologic evaluation M – Metastases
o If you’re not considering breast cancer  T – TUMOR SIZE
o FNAB is commonly used is in the evaluation of T1 </= 20MM
lymph nodes that are suspicious on either T2 >20 BUT =/<50 MM
physical examination or imaging, particularly high- T3 >50MM
resolution ultrasonography of the regional nodal T4 extension to chest wall ulceration inflammatory CA
basin.  REGIONAL NODES
o FNAB still has utility is in the evaluation of a NX - cannot be assessed
second suspicious lesion in the ipsilateral breast NO - none
of a patient with a known malignancy. N1 - level I & II movable
 CORE NEEDLE BIOPSY (G14 or tru cut needle) N2 - level I & II fixed
o Gold standard or preferred method N3 - level II, infraclavicular
o Breast tissue architecture (can determine if  DISTANT METASTASES
invasive) M0 - No clinical or radiographic evidence
o Low complication rate, minimal scarring, lower M1 - Distant detectable metastases
cost (vs excisional biopsy)
 OPEN BIOPSY (incisional or excisional)
o Incisional – just a portion of the mass
o Excisional – removing the entire tumor.
 Biopsy should be the last to resort.
 Do proper labelling of the specimens.

IN SITU CANCERS
 DUCTAL CARCINOMA IN SITU
o Also known as intraductal carcinoma
o Is a non-invasive or pre-invasive breast cancer.
 LOBULAR CARCINOMA IN SITU (LCIS)
o May also be called lobular neoplasia
 Not a cancer, though the name can be
confusing
o Cells that look like cancer cells are growing in the
lobules of the milk-producing glands of the
breast, but they don’t grow through the wall of
the lobules.

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 Breast Cancer Stages and data of 5-years corresponding
Younger women are high risk of invasive breast cancer. survival rate

TYPES OF THERAPY
 Depends on:
o Stage of the disease
o Biologic subtype
o General health status of the patient
o Clinical stage
o Histologic characteristics
o Biomarkers

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  Partial mastectomy
 Wide local excision
 Mastectomy
o A surgery in which the entire breast is removed,
including all of the breast tissue and sometimes
other nearby tissues. There are several different
types of mastectomies. Some women may also
get a double mastectomy in which both breasts
are removed.
o Without immediate breast reconstruction.
 Modified radical mastectomy
o remove the breast (including the inaxillary area)
and preserving the pectoralis major and minor
muscles.
o In a modified radical mastectomy, the level I and
II axillary lymph nodes are taken with the axillary
breast tissue
o 2 important nerves to preserve:
 Thoracodorsal nerve (latissimus dorsi)
 Long thoracic nerve – if this is not preserved,
Local Treatments this leads to winging of scapula.
 Target: where the tumor is located.
o Surgery
o Radiation
Surgery for Breast Cancers
 Factors to consider:
o Remove as much of the cancer as possible
(breastconserving surgery or mastectomy)
o Find out whether the cancer has spread to
the lymph nodes under the arm (sentinel
lymph node biopsy or axillary lymph node
dissection)
o Restore the breast’s shape after the cancer
is removed (breast reconstruction)
o Relieve symptoms of advanced cancer.
 Breast-conserving surgery
o also called a lumpectomy, quadrantectomy,
partial mastectomy, or segmental mastectomy/
o A surgery in which only the part of the breast
containing the cancer is removed.
o The goal is to remove the cancer as well as some
surrounding normal tissue.
o How much of the breast is removed depends on
the size and location of the tumor and other
factor.
o Resection of the primary breast cancer with a
margin or normal-appearing breast tissue,
adjuvant radiation therapy and assessment of
regional lymph nodes
o Resection:
 Segmental mastectomy
 Lumpectomy

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 weeks. It might also lead to fewer short-term
side effects.
 Intraoperative Radiation Therapy (IORT) - in
this approach, a single large dose of radiation
is given I the operating room right after BCS
(before the breast incision is closed).
 3D-conforma Radiotherapy - in this
technique, the radiation is given with special
machines so that it is better aimed at the area
where the tumor was removed (tumor bed).
This allows more of the healthy breast to be
spared. Treatments are given twice a day for
5 days. Because only part of the breast is
treated, this is considered to be a form of
Surgery to Remove Lymph Nodes accelerated partial breast irradiation.
 Sentinel Lymph Node Biopsy (SLNB) o Possible side effects of external radiation:
o A procedure in which the surgeon removes only  The main short-term side effects of external
he lymph node(s) under the arm to which the beam radiation therapy to breast are:
cancer would likely spread first.  Swelling in the breast
 Removing only one or a few lymph nodes  Skin changes in the treated area are
lowers the risk of side effects from the similar to a sunburn (redness, skin
surgery peeling, darkening of the skin)
 Axillary Lymph Node Dissection (ALND)  Fatigue
o A procedure in which the surgeon removes many o Late side effects:
(usually less than 20) lymph nodes from under the  Causes the breast to become smaller and
arm firmer.
o ALND is not done as often as it was in the past,  May affect your options for breast
but it might still be the best way to look at the reconstruction later on.
lymph nodes in some situations.  May have problems breastfeeding later on.
 Can damage some of the nerves to the arm.
Surgery for Advanced Breast Cancer This is called brachial plexopathy and can lead
 When the breast tumor is causing an open wound to numbness, pain, and weakness in the
ulceration in the breast (or chest) shoulder, arm, and hand.
 Usually done if the entire breast is affected.  Radiation to the underarm lymph nodes can
 To treat a small number of areas of cancer spread the cause lymphedema, a type of pain and
brain swelling in the arm or chest.
 When an area of cancer spread is pressing on the  In rare cases, radiation therapy may weaken
spinal cord the ribs, which could lead to a fracture.
 To treat a blockage in the liver  A very rare complication of radiation to the
 To provide relief of pain or other symptoms breast is the development of another cancer
 Either as a way to slow the spread of the cancer, or to called an angiosarcoma.
help prevent or relieve symptoms from it.  Internal Radiation (brachytherapy)
o For this treatment, a radioactive source is put
Radiation inside the body for a short time
 External Beam Radiation o Types:
o This type of radiation comes from a machine  Interstitial Brachytherapy - Catheters are
outside the body inserted into the breast around the area
o Types: where the cancer was removed and are left in
 Hypofractionated Radiation Therapy - in this place for several days. Radioactive pellets are
approach, radiation is given in larger doses inserted into the catheters for short periods
using fewer treatments – typically for only 3 of time each day and then removed.

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 Intracavitary Brachytherapy - Catheters are removed by surgery at the time of diagnosis
left in place. End of device is expanded. (called locally advanced cancers).
Treatments are typically given twice a day for  Also, by giving chemo before the tumor is
5 days as an outpatient. After the last removed, doctors can better see how the
treatment, the device is collapsed down again cancer responds to it.
and removed.  If the first set of chemo drugs doesn’t shrink
o Possible side effects of intracavity brachytherapy: the tumor, your doctor will know that other
 Redness at the treatment site drugs are needed.
 Bruising at the treatment site  It should also kill any cancer cells that have
 Breast pain spread but can’t be seen
 Damage to fatty tissue in the breast  Just like adjuvant chemo, neoadjuvant chemo
 Weakness and fracture of the ribs in rare can lower the risk of breast cancer coming
cases back.
 Fluid collecting in the breast (seroma) o For ADVANCED breast cancer:
 RADIATION IS USED:  Chemo can be used as the main treatment for
o After breast-conserving surgery (BCS), to help women whose cancer has spread outside the
lower the chance that the cancer will come back breast and underarm area, either when it is
in the breast or nearby lymph nodes diagnosed or after initial treatments
o After mastectomy, especially if the cancer was  The length of treatment depends on type of
larger than 5 cm (about 2 inches), or if cancer is cancer and how well the chemo is working
found in the lymph nodes. and how well you tolerate it.
o If cancer has spread to other parts of the body,  The most common drugs used for adjuvant and
such as the bones or brain. neoadjuvant chemo include:
o Anthracyclines, such as doxorubicin (Adriamycin –
Systemic Treatments most common) and epirubicin (Ellence) – cardiac
 Chemotherapy side effects
 Hormonal Therapy o Taxanes, such as paclitaxel (Taxol) and docelaxel
 Targeted Therapy (Taxotere)
o 5-fluorouracil (5-FU)
Chemotherapy o Cyclophosphamide (Cytoxan)
 The drugs travel through the bloodstream to reach o Carboplatin (Paraplatin)
cancer cells in most parts of the body. o NOTE: Most often, combination of 2 or 3 of these
 Uses anti-cancer drugs that may be given drugs are used. CAF OR CM
intravenously (injected into your vein) or by mouth.  Possible side effects of chemo for breast cancer
 When is Chemotherapy used? (some of the most common possible side effects
o AFTER surgery (adjuvant chemotherapy) include):
 Adjuvant chemo is used to try to kill any o Hair loss
cancer cells that might have been left behind o Nail changes
or have spread but can’t be seen, even on o Mouth sores
imaging test. o Loss of appetite or weight changes
 If these cells were allowed to grow, they o Nausea and vomiting
could form new tumors in other places in the o Diarrhea
body.  Chemotherapy targets the fast-growing cells; mitosis
 Adjuvant chemo can lower the risk of breast occurs more often in cancers cells.
cancer coming back.  Chemo can also affect the blood-forming cells of the
o BEFORE surgery (neoadjuvant chemotherapy) bone marrow, which can lead to:
 Neoadjuvant chemo can be used to try to o Increased c hance of infections (from low white
shrink the tumor so it can be removed with blood cell counts)
less extensive surgery. o Easy bruising or bleeding (from low blood platelet
 Because of this, neoadjuvant chemo is often counts
used to treat cancers that are too big to be o Fatigue (from low red blood cell counts and other
reasons)

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 Hormonal Therapy developing uterine cancer. More serious
 ER-positive and PR-positive breast cancer cells have side effect
receptors (proteins) that attach to estrogen, which  Blood clots are another uncommon, but
helps them grow. serious side effect. They usually form in
 Form of systemic therapy, meaning it reaches cancer the legs (called deep vein thrombosis or
cells almost anywhere in the body and not dust in the DVT), but sometimes a piece of clot may
breast. break off and end unblocking an artery in
 It’s recommended for women with hormone the lungs (pulmonary embolism or PE).
receptorpositive (ER-positive and/or PR-positive)  Rarely, tamoxifen has been associated
breast cancers, and it does not help women whose with strokes in postmenopausal women
tumors are hormone receptor-negative (both ER- and
PR-negative)  Treatments that Lower Estrogen Levels:
 Drugs that Block Estrogen Receptors: o AROMATASE INHIBITORS (AI)
o TAMOXIFEN  Drugs that stop estrogen production
 Tamoxifen can help lower the chances of the  Before menopause, most estrogen is made by
cancer coming back and raise the chances of the ovaries.
living longer.  But for women whose ovaries aren’t working,
 Most often used in postmenopausal women either due to menopause or certain
or those who undergone oophorectomy. treatments, a small amount of estrogen is still
 It can also lower the risk of getting a new made in the fat tissue by an enzyme (called
cancer in the other breast. aromatase)
 Tamoxifen can be started either after surgery  AIs work by blocking aromatase from making
(adjuvant therapy) or before surgery estrogen.
(neoadjuvant therapy) and is usually taken for  There are 3 AI’s that seem to work about
5 to 10 years. equally well in treating breast cancer:
 For early-stage breast cancer, this drug is  Letrozole (Femara)
mainly used for women who have not yet  Anastrozole (Arimidex)
gone through menopause.  Exemestane (Aromasin)
 For women who have been treated for ductal  Possible side effects (fewer compared to
carcinoma in situ (DCIS) that is hormone tamoxifen):
receptor-positive, taking tamoxifen for 5  Don’t cause uterine cancers and rarely
years lowers the chance of the DCIS coming cause blood clots.
back. It also lowers the chance of getting an  Muscle pain and joint stiffness and/or
invasive breast cancer. pain
 For women with hormone-positive breast  Bone thinning – osteoporosis
cancer that has spread to other parts of the  Ovarian Suppression:
body, tamoxifen can often help slow or stop o Oophorectomy
the growth of the cancer and might even  Surgery to remove the ovaries.
shrink some tumors.  This is a form of permanent ovarian ablation.
 It will not kill cancer cells. o Luteinizing Hormone-releasing Hormone (LHRH)
 In women at high risk of breast cancer, Analogs
tamoxifen can be used to help lower the risk  These drugs are used more often than
of developing breast cancer. oophorectomy.
 The most common side effects of tamoxifen  They stop the signal that the body sends to
and toremifene are: the ovaries to make estrogen, which causes
 Hot flashes temporary menopause.
 Vaginal dryness and discharge  Common LHRH drugs include goserelin
 Mood swings (Zoladex) and leuprolide (Lupron).
 Rare, but more serious side effects are also  They can be used alone or with other
possible: hormone drugs (tamoxifen, aromatase
 If a woman has gone through menopause, inhibitors, fulvestrant) as hormone therapy in
these drugs can increase her risk of premenopausal women.
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 o Chemotherapy Drugs  TARGETED THERAPY FOR HORMONE
 Some chemo drugs can damage the ovaries of RECEPTORPOSITIVE BC
pre-menopausal. o CDK4/6 INHIBITORS
 women so they no longer make estrogen.  Palbociclib, ribociclib, abemaciclib
 Block proteins in the cell called
Targeted Therapy cyclindependent kinases (CDKs); can help stop
 Designed to block the growth and spread of cancer the cells from dividing (slow cancer growth)
cells (vs. chemotherapy all cells that grow quicker o EVEROLIMUS
even normal cells)  Afinitor
 TARGETED FOR HERS – positive breast cancer –  Blocks mTOR, a protein in cells that normally
monoclonal antibodies helps them grow and divide
o Trastuzumab (Herceptin) – monoclonal antibody  Stops tumors from developing new blood
o Pertuzumab (perjeta) – monoclonal antibody vessels, which can help limit their growth
o Ado-trastuzumab emtansine (Kadcyla, also known  TARGETED THERAPY FOR WOMEN WITH BRCA GENE
as TDM-1) – monoclonal antibody MUTATIONS
o Lapatinib (Tykerb): this is a kinase inhibitor. o Olaparib and Talazoparib
o Neratinib (Nerlynx): this is a kinase inhibitor. o PARP inhibitors
 Side effects of targeted therapy for her2+ bc: o PARP proteins normally help repair damaged
o Heart damage, congestive heart failure (shortness o DNA inside cells. BRCA also help repair DNA but
of breath, leg swelling, severe fatigue) mutations can stop this from happening
o Severe diarrhea o Used to treat metastatic, HER2 negative women
o Can cause hand-foot syndrome with BRCA mutation

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  Benign breast disorders and diseases are related to
the normal processes of reproductive life and to
involution, and there is a spectrum of breast
conditions that ranges from normal to disorder to
disease (aberrations of normal development and
involution classification).
 To calculate breast cancer risk using the Gail model, a
woman’s risk factors are translated into an overall risk
score by multiplying her relative risks from several
categories. This risk score is then compared with an
adjusted population risk of breast cancer to
Sentinel Lymph Node Dissection – to assess the regional determine the woman’s individual risk. This model is
LN in women with early breast cancer not appropriate for use in women with a known
BRCA1 or BRCA2 mutation or women with lobular or
ductal carcinoma in situ.
 Routine use of screening mammography in women
≥50 years of age reduces mortality from breast cancer
by 25%. MRI screening is recommended in women
with BRCA mutations and may be considered in
women with a greater than 20% to 25% lifetime risk
of developing breast cancer.
 Core-needle biopsy is the preferred method for
diagnosis of palpable or nonpalpable breast
abnormalities.
 When a diagnosis of breast cancer is made, the
surgeon should determine the clinical stage, histologic
characteristics, and appropriate biomarker levels
before initiating local therapy.
 Sentinel node dissection is the preferred method for
staging of the regional lymph nodes in women with
Treatment pathways for stage IIIA and stage IIIB breast clinically nodenegative invasive breast cancer. Axillary
Cancer dissection may be avoided in women with 1 to 2
positive sentinel nodes who are treated with breast
KEY POINTS conserving surgery, whole breast radiation and
 The breast receives its principal blood supply from systemic therapy.
perforating branches of the internal mammary artery,  Local-regional and systemic therapy decisions for an
lateral branches of the posterior intercostal arteries, individual patient with breast cancer are best made
and branches from the axillary artery, including the using a multidisciplinary treatment approach. The
highest thoracic, lateral thoracic, and pectoral sequencing of therapies is dependent on patient and
branches of the thoracoacromial artery. tumor related factors including breast cancer subtype
 The axillary lymph nodes usually receive >75% of the
lymph drainage from the breast, and the rest flows
through the lymph vessels that accompany the
perforating branches of the internal mammary artery
and enters the parasternal (internal mammary) group
of lymph nodes.
 Breast development and function are initiated by a
variety of hormonal stimuli, with the major trophic
effects being modulated by estrogen, progesterone,
and prolactin.

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 Pink October – Breast Cancer Awareness Month.

Usually done at day 7 – 10 of their menstrual cycle.

Check for dimpling or retraction of the skin.

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Trans 1 | ESCORPIZO | FIALIWAN | GALLANONGO | GUILLEM | KINDICA | LAMORIN Page 29 | 30
 SAMPLE QUESTIONS: a. Central group
1. I. Dominant masses or areas of firmness, b. Apical group
irregularity, and asymmetry suggest the c. Rotter's lymph nodes
possibility of breast cancer, particularly in the d. NOTA
older male. e. AOTA
II. Gynecomastia generally predisposes the male 5. This joins with the deep fascia of the breast over the
breast to cancer. pectoralis muscles
a. Both statements are correct A. Oval ligaments
b. Both statements are incorrect B. Ligament of treitz
c. Only statement I is true C. Suspensory ligaments
d. Only statement II is true D. Round ligaments
2. All statements are true regarding retracted or E. NOTA
inverted nipples except. 6. What are the nodes to check if we are considering
a. Failure in the development of the nipple breast cancer?
b. Normal suckling of infants can take place. A. Back, axillary, inguinal
c. Nipple prone to infection B. Anterior chest, supraclavicular, axillary
d. Regularly clean because of accumulation of C. Axillary, cervical, aural
dead tissue that may cause infection D. Anterior chest, deep cervical, axillary
3. Which of the following statements is/are true
regarding the effects of hormones. Answer:
a. Progesterone: initiates ductal development 1. C
b. Estrogen: responsible for differentiation of 2. B
epithelium and for lobular development 3. C
c. Prolactin: lactogenesis 4. D
d. AOTA 5. C
4. The following are axillary lymph node groups 6. B
except:

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 SURGERYI
I|PEDI
ATRI
CBENI
GNANDMALI
GNANTTUMOR
Tut
or:Dr
.UCLARAY| Lect
ureDat
e:Apr
iL29,2022| 2NDSEMESTER

TOPICOUTLI NE Neur
obl
ast
oma 8
I. PRI NCI PLES OF PEDI
ATRIC
ONCOLOGY Sar
coma 7
I. BENI
I GNTUMORSI NCHI LDHOOD
a. NonMal i
gnantTumor softheLiver Wi
l
m’st
umor 6
b.Hepat i
cHemangi oma
c. Mes enchymalHamar toma Os
teos
arc
oma 5
d.Hepat ocell
ularAdenoma
e. FocalNodul arHyper plas
ia Ret
inobl
ast
oma 3
f. Gas t
rointest
inalStr
omalTumor s
g.Ter atoma and ot her Ger m Cell Li
vert
umor 1
Tumor s
h. SacrococcygealTumor s EPIDEMI OLOGY
II
I. MALI GNANTTUMORSI NCHI LDHOOD ● Chi ldhood c anc eri nc i
denc ei sgr eatestdur ing
a. Wi l
msTumor/Nephr obl ast
oma the1s tyearofl ife
b.Neur oblastoma ● Peaksagai nat2- 3year st hens lowl ydec lines
c. Livertumor s unt i
lage9
● I nc reas ess teadi l
yagai nt hroughadol es cence
I.PRI NCI PLESOFPEDI ATRI CONCOLOGY ● V ari
e s withg e nd er an dr a c
e
● Canc erinc hildr eni sunc ommon ○ Var iati
ons by gender ar e al s
o s een.
● Onl yabout2%ofal lcanc erc as es. Dis t
r i
but i
onbyr ac e.Whi tec hildrengener all
y
● Sec ond mos tc ommon c aus e ofdeat hi nc hi
ldren ha ve5 0% grea ter in ci
d enceo f ca ncer thand o
oldert han1yearofage blac kc hil
dr en.
● Canc eri st he s econd l eadi ng c aus e ofdeat hi n
childrenaf tert raumaandac count sforappr oximately CHI LDHOODCANCERANDHEREDI TY
11%ofal lpedi atricdeat hsi nt heUni tedSt ates. ● Cons t
itutional gene mut ations t hat ar e
● Sever alf eat ures di stingui sh pedi atri
cf rom adul t he r
e ditaryf or ex amp lep assedo nb yap aren tto
canc er s,i nc l
udi ng t hepr esenc eoft umor st hatar e ac hil
dornonher edi taryi nwhi cht her eisde
predomi nant l
y s een i n c hil
dr en, s uch as no vo mu tatio n in t h es p erm o fo ocyteb efore
neur obl as toma and ger m c el lt umor s , and t he fertil
ization- co ntri
b ute stoa ne stima ted1 0%t o
favor abler es pons et oc hemot herapyobs erved for 15%ofpedi atricc anc ers.
many pedi at ri
cs olid mal ignanc i
es ,even i n t he ● Co ns t
itutiona lc h romo s omalabnor mal iti
es ar e
pres enc eofmet astas es. the res ul
t of th e ab no rma l structu ral
● Leukemi a-mos tc ommonc anc er rear rang eme n to ft h e norma l 4 6 chromo so me
● Braint umor-mos tc ommons olidt umorofc hil
dhood andmaybeas soc i
at edwi thapr edi spos i
ti
ont o
● Lymphomaar et henextmos tc ommonmal i
gnanc yin canc er .
children f ollowed by neur obl astoma,s of tt i
ssue ○ E g.l eukemi as een wi tht risomy21 ( Down
sarc oma, Wi lm’ s t umor , ger m c ell t umor, s yndr ome )
osteos arcomaandr etinobl astoma ○ ger mc ellt umor swi thKl inef elters yndrome
● 15- 19year s-Hodgki nandGCT( Ger m Cel lTumor ) (47 XX Y).
aret hemos tf requent lydi agnos edmal ignanc y.
GENETI CSCREENI NG
● Al ong wi th an i nc r
eas e under s tandi ng oft he
FrequencyofCancerDi agnos esi nchi l
dhood mol ec ularbas isofher editaryofc hildhoodc anc er
hasc omet heoppor tuni t
yt oI dent ifyc hil
dr enwho
Typeofcancer APer cent ageofTot al
areathi ghr iskofmal ignanc y
Leukemi a 30 ● An di ns omec ase s toi n t
e rvenebef oret hec anc er
devel opsorwheni tiss ti
llcurable.
Br ainTumor s 25 ● Fami lialadenomat ouspol ypos i
s
○ Mut ati
onsoft headenomat ouspol ypos i
sc oli
Lymphoma 15 (APC)geneonc hr omos ome5q21.
○ Leadt ot hedevel opmentofi nvas i
vec olorec tal

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N
 carci
noma wit
hanabdomi nalpai
norabdominalmas
s
○ Hence,i
dentif
icat
ioninthispati
ent/indi
vi
dual
, ● Fet
alhydropshave been i
denti
fi
ed bypr enatal
Prophyl
act
iccolectomyisrecommended ul
tras
onography in some fetuses wit
h l iver
○ Alsoati
ncreasedriskofhepatobl
astoma. hemangi
oma.

● Famil
ialThyr
oidCancer. DIAGNOSIS
○ 100% as soci
ati
on between ger
mli
ne RET A.Laborator yTes t
mutati
ons ○ Ser um al phaf etoprot ei
n( AFP)i spres enti n
○ Prophylacti
cthyroi
dect
omyisr
ecommended veryhi gh c oncent r
ations( nor mally,nor mal
i
nnewbor n)atbir t
h( 48,000-35, 000ng/ ml )
II
.BENI GNTUMORSI NCHI LDHOOD ■ Rapi dlydec li
nest o adul tl evelsofl ess
than10ng/ mlby8mont hsofage
A.NonMal ignantTumor soft heLi ver ■ Mar kedlyel evat edAFPl evelsinac hi l
d
● Pri
maryl i
vert umor sc ons ti
tutel esst han 3% of withal ivermas sal mos tc ertai
nlymeans
tumorss eeni nthepedi at r
icpopul ati
on thatt hemas si smal ignant ;ifassoc i
at ed
● Onlyonet hir
doft hoset umor sar ebeni gn with a mas s,i t usual lyi s a par t of
○ Epi thelial (which c ompr i
ses f oc al nodular Kasabac h-Mer it
t s yndr ome r esulti
ng
hyper plasi
a, hepat ocel
lular adenoma) from presenceo f l
iver h ema ngioma
Mes enc hymal (hepat ic hemangioma, ○ Thromboc ytopenia
mes enc hymalhamar toma) ○ Hypot hyr oidism mayal s ooc curi nmul tipl
eor
○ Ot her( teratoma,inflammat oryps eudotumor ) diff
us ef or msofl iver.Thyr oi
df unc ti
on t es t
s
○ Nonpar asi
ti
c c ysts al so i ncluded bec aus e should be done r out i
nelyi nt hesec hil
dr en
alt
houghi ti snotaneopl asiabuti tisals
oa bec ausehypot hyroidisms ignificantlyi mpac t
s
commonnonmal ignantt umoroft heli
ver theirmoney?

Cl
inicalMani f
estation B.ImagingTechni ques
● Mos tc hi l
dren wi t h beni gn livert umor spr esent ○ Supi ne r adiogr aph oft he abdomen ( initi
al
withapai nlessr ightupperquadr antabdomi nal ima ging )
mas sorhepat omegal y. ■ Cal ci
f i
c ati
onswi thint hemas s
● Gas troint esti
nalc ompr ession,s uchasc onst i
pation, ○ Abdomi nalul trasonogr am wi thDoppl er
anor exi a,orvomi tingmayal s obepr esent. ○ Comput edt omogr aphy( CT)wi thi ntravenous
● Ift hemas sispai nf ul,t hapai nus uallyisdul land cont rast
achi ng and i sc aus ed byexpans i
on oft hel i
ver ○ Magnet icr esonanc ei magi ng( MRI )
caps ul eorc ompr es sionoft henor mals urroundi ng ■ When s urgi c
alr esec ti
on i spl anned and
struc ture. mor e det ail
ed i nf ormation about t he
● J aundi ceandwei ghtl ossar eunc ommon vas cul aranat omyr elati
vet ot het umori s
○ Exc ept i n i nf ant s wi th s ympt omat ic des i
r ed
hemangi omas ■ Ori ni nfant swi thhemangi omai nwhom
○ Rai ses uspiciont hatt hel esioni smal i
gnant anot her di agnos i
si s bei ng c ons i
der ed,
● Ac uteabdomi nalpai nmaybec aus edbybl eeding bec aus et he MRIappear ance may be
i
nt ot hemas sori nt ot heper i
toneum par ti
cularly diagnos t
ic
i
nhepat ocell
ularadenoma ○ Ar t
er i
ogr aphyr es ervedf orc hildrenwi thl i
ver
● Al thought hiscondi ti
onar erarelys eeni nc hil
dr en, he ma n gio ma o r A V ma l
forma t
ion w it
h a
childrenmaypr es entwi thc onges tivehear tfail
ure conges ti
ve hear tf ail
uref orembol ization of
(CHF)andt hromboc ytopeni a thebl oods uppl yt ot het umori sneededf or
○ Known as t he Kas abac h- Mer r
itts yndr ome treatment
whenas soc i
at edwi thavas cularanomal ys uch
asl iverhemangi oma B.Hepat i
cHemangi oma
● Cut aneoushemangi omasar es eeni nabouthal fof ● Mos tcommonbeni gnl i
vert umori nc hildren
children wi th al i
ver hemangi oma and r apid ● Mos tar ei dent i
fiedi nt henewbor nper iodor
enlar gement of t he l i
ver wi th a di f
fus el i
ver dur i
ngpr enat alul trasounds creening
hemangi omac anc aus eAbdomi nalCompar ment ● Cl
t ass
ifi
edas :
Syndr ome and r es pirator y di stress.Cut aneous ○ Foc al
hemangi oma maybe c l
ues i n di agnos ing l i
ver ○ Mul tif
oc al
hemangi oma es pec i
al l
yi ft he pat ientpr esent s ○ Diffuse

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 CT Cont rast Flowvoi ds —- ---
---
-
FOCAL MULTI
FOC DI
FFUSE enhanci ng maybe -
---
-
AL i
nt he presenti n
peripher y theles i
ons
Gros
s Varyins
ize General
ly Liveris ofthemas s andmay
f
indi
ngs butcanbe wi del
y near l
y withlitt
le i
ndi catethe
asl
argeas dispersed replaced contrastin presenc eof
8cm with thec enter arterioveno
l
es i
ons uss hunt s
Wec anno
l
ongers ee Managem No Corti
costero Cort
icoster
anynor mal ent tr
eatment i
ds( t
rial
) oi
d( s
ome
l
ivert i
ssue Regress Embol i
zati
o benefi
t)
spontaneo noft he Li
ver
Cl
ini
cal Usually +Hypot
hyr
o Abdomi nal usl
yby1 shunts tr
ansplanta
pr
esent
ati asympt oma idis
m compar tme yearofage ti
on
on ti
c CHF nt (r
ecommen
Found syndrome ded)
i
nc i
dent al
l
y (verylarge
onot her l
iver),
reasonf or mul t
isyste C.Mes enchymalHamar toma
exploratory m organ ● Painlessr i
ghtupperquadr antabdomi nalmass
l
apar otomy fail
ure,and i
nac hi
ldyoungert han2year s
death ● Ar i
sesf rom mes enc hymalr es tsthatbec omes
Severe i
s ol
at ed f r om t he nor mal por tal t ri
ad
hypot hyroi architectureand di fferentiatesi ndependent l
y
dism thust het umorc anpr es entas :
○ Pr edomi nant l
y c ys t
ic s truct
ur e t hat
enlarges r api dly bec aus e of f l
uid
Ass
oci
ati
o +/- +cutaneous —---
---
-- ac c
umul at i
on
n cut
aneous hemangiom ---
-- ○ Orpr edomi nant lyvas cular- >pres entwith
hemangi
om a CHF
as (Almost ● Serum AFP-nor malormi l
dlyel evated
always ● Radi ographi cfeat uresar econs i
stent
present) ● UTZ/ CT -s i
ngle,l ar gef luid- fi
ll
ed mas swith
fi
nei nternals ept ations ,NOc alcifi
cations
MRI Soli
tary Generall
y Centr
ipet
al
● TX:Compl et eoper ativer es ection( treatment
l
iverlesi
on widely enhancem
ofchoi ce)
thatis dis
persed, ent
○ Managementmus tbe t emper ed by t he
hypodens e spheri
cal
under standing t hatMH f oll
owsabeni gn
onT1- and
cours e al t
hough t here ar e r eports of
weighted homogeneo
mal i
gnantt rans format i
on
sequences usl
y
and enhancing
D.Hepat ocell
ularAdenoma
hyperint
en l
esions
● Chi
ldrentreatedwi thanabol i
cs teroids
seonT2-
● Multi
plebloodt ransfusi
onsforc hronicanemi a
weighted
● Chi
ldrenwi thtype1gl ycogens t or
agedi s ease
sequences
-thedevel opmentofhepat oc ellul
aradenoma
i
n pat i
ent wi th type 1 gl yc ogen s t
or age
di
seaseincluding:
○ r egi
onali mbalanc eininsul
inandgl ucagon
metabol i
sm bec auset hesehor monesar e
i
mpor t
anti nr egulati
onoft hehepat ocyte
prol
if
erationandr egenerationand
○ t heset umordevel op as a r es pons et o

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 glyc ogenover loadand commont hangonadals itewher easi nadul t
sonl y
○ par tl
ys ec ondar yt oonc ogeneac tivat ion 10%abnor mal
● Res embl esHCCbutwi thoutmi tos es ● Ext ragonadalt umors i
tesabnor malmi gr ationof
● Ser um AFPandl i
verenz ymesar ewi thi nnor mal thepr imor dialger mc ellsr es ultsi nt hedepos it
ion
range ofc ellsint he
● Propens i
ty f or i nt ra abdomi nal s pont aneous ○ Sacr ococcygeal r egi on, r etroper itoneum,
rupt ur eandbl eedi ng medi as ti
num andpi nealgl andoft hebr ain
● TX:Compl etes ur gic alr es ec tion ● Ger m c el lt umor demons trate a bi modalage
dist
r i
but ionwi thpeaksat2and20year sofage
E.Foc alNodul arHyper pl as i
a
● I
rregul ar lys haped,non- tenderl i
vermas s Classi
fi
cat ion
● Frequent lyf oundi nc i
dent al lyatl apar otomy ● Semi nomaordys germi nomai sapr imiti
veger m
● Femal e- to- mal er at ioi sappr oximat ely4: 1 cellt umor t hat l ac ks t he abi l
ityf or f ur t
her
● CTt ypi cal lys howsahyper vasc ularl es i
onwi tha diff
er ent iation
dens es tellat ec ent rals car ○ I ffol l
owsnor malmi grat ioni ts ettleswi thint he
○ t hes e l esion r ar ely bec ome mal ignant or gonads i f abnor mal i t depos i
ts i n t he
hemor rhagi c ther ef or e expec t ant i s ext ragonadals i
tes .Ifi tunder goesneopl asti
c
appr opr iate when r emoval mi ght be differ ent i
ationandi tal readyl ackst heabi l
it
y
as s oc iat ed wi ths igni ficantmor bidityi ft he to di f
ferent iate t hes e c ells ar e c al
led
c hildi sas ympt omat icandt hedxhavebeen semi nomaordys ger mi noma,i ti sunus uali n
made c onc lusivel y by r adiogr aphi cs tudies childhoodandoc cur smos tfrequent lyint he
bei ngnor malAFPandbi ops y ○ Medi as ti
num,pi nealgl and and t he gonadal
● Arter i
ogr aphy or magnet ic res onanc e sitesdur ingt headol escentyear s
angi ogr aphy ● I fther ei sdi f
ferent i
ationi tbec omes Embr yonal
○ Hyper vas cular mas s wi th f eedi ng ar t
eries carcinomai sc ompos edofc ell
sc apabl eoff ur t
her
ent er ingt heper ipher yandc onver gi ngont he diff
er ent iationi nt oembr yoni corext raembr yoni c
c ent r alpor t i
onoft het umor ● Ter at omasar et hemos tc ommonger mc elltumor
● Mic ros c opi c exami nat ion s hows pr olifer at i
on of andar ec ompos edofel ement sf rom oneormor e
hepat oc ytes and bi l
e duc ts and t he oft he embr yoni c ger m c elll ayerand c ont ai
n
pat hognomoni cc ent ralf i
br os i
s ti
ssuef or eignt ot heanat omi csiteofor i
gin
● Tx:expec t antmanagement ● Mat ur eand i mmat uret erat omasar ec ons i
der ed
beni gnl es i
onsi tishoweveri mper ativet ohavea
F.Gas troi ntes t i
nalSt romalTumor s thoroughandac c uratepat hol ogi cr eviewbec ause
● Rar e mes enc hymal t umor s, or i
ginat e f rom 25% oft hes eger mc ellt umor si nc hil
dhoodar e
i
nt es tinalc el lofCaj al mixedwi t hmor et han1hi stolicf eat ure
● Cellul ar s pindl ec el l,epi thel i
oid,or oc c asional
pleomor phi c mes enc hymalt umor st hatexpr es s
theKI T( CD117)
● Mar ker ss uc h as CD34,s moot h mus cle ac tin,
des mi n,andS- 100pr otei n
● Themos tc ommon s itei st hes tomac h( 50% t o
70%) ,f ollowedbyt hes mal li ntes ti
ne( 20t o30%) ,
colonorr ec tum ( 10%) ,andes ophagus( 5%)
● Gener al izedabdomi nalpai n,dys peps i
a,andoc c ult
GIbl eedi ng,I DA( s houl dpr omptani nves tigation
toexc ludeGIt rac tmal ignanc yasac aus e)
● Palpabl eabdomi nalmas sori ntes tinalobs truc t
ion
● Plainabdomi nalXr ay,CT,endos c opy
● Tx:c ompl etes ur gic alexc is i
on
Classi
ficat i
ons ystem f orDevel opmentofGer m Cel l
B.Ter at omasandOt herGer m Cel lTumor s Tumor s
● 20%ofpedi atricger mc el ltumor sar emal ignant
● 1%t o3%ofal lmal ignantt umor si nc hil
dhoodand
adol es c enc e
● I
nc hildr en,t heext r agonadalt umors i
t ei smor e

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 St
ageI
I-I
Vtes
tes Surger
yandpost
-op
Chemo- PEBx3c
ycl
es
St
ageI
-IIext
ragonadal COG,AGCT0132

Hi
ghri
sk Surgeryandpos t-
op
St
ageI
II
-IVext
ragonadal chemot herapywi t
h
St
ageI
Vovary plati
num- based
etopos i
dephos phate
andbl eomyc i
ns ul
fate
(PEB)pos t-opor
adjuvantchemot herapy

H.SacrococcygealTumor s
● Mos tc ommonext ragonadalt umorinneonat esas
compar edt oadul tswhi charet hegonadalt umor
ofager mc el
ltumor
● Ac c
ount i
ng f orup t o 70% ofal lt eratomasi n
chil
dhood
● 3t o4:1f emaletomal erati
o
● A newbor n specifi
call
y pr esent with a mas s
prot r
udi ngf r
om t hes acralregion,andmanyar e
detec tedwi thprenat alult
rasonography
● I
famas shasbeennot edatbi rthandl eftinplace,
● Ger m c ellt umor demons t
rat e a bi modalage
ani ncreas erateofmal i
gnancyhasbeenobs erved
di st
ribution
● Tx:Compl etes urgicalexc i
si
on ass oon asi tis
● wi thpeakat2and20year sofage
diagnos ed
● Thepr es enceofani ntersexdi sorder→ i sknown
(increas ed r i
sk i n devel oping) f actor f or
CLASSIFI CATION AND ASSOCI ATION WI TH
GONADOBLASTOMAi sani ns i
tuger mc elltumor
MALI GNANCY
wi th an abi l
ity t o di fferentiate i nto a
● I nt he s tudy per for med by Out mann and
dys ger minoma, i n mat ure t eratoma, or yol k
coll
eagues ,t hey have f ound out t hat t he
subt umororc arci
nomawhi char eoft hemal ignant
mal i
gnanc yr at
ei nc reased wi th the mor e
for m
hidden ort ype 3 or4 l esions.Thi ss urvey
● One r i
s k group i nc l
ude t estos ter
one def iciency,
notedt hel ow r ateofmal ignanc yinneonat es
andr ogen i nsens i
tivi
tys yndr ome and 5- alpha
andyoungi nf antsl es st han2mont hsofage,
reduc t
as edef i
ciencywhi c har eandr ogendef icient
andhi gherr at einol deri nfantsandc hildren
mal es
mor ethan2mont hsofage.
● Gonadaldys genes isi sassoc iatedwi t
ht her iskof
● Sever als ubs equents tudies have c onfirmed
mal ignanc ywi th10% at20,and19% at30year s
thisand not ed mal ignanc yr at
esashi gh as
ofage
90%.
● Undes cended t esteshave an i ncreased ris k of
mal ignanc ywi thar atehighes tf orintraabdomi nal
● Thet ype1out mannc las si
fic
at i
onofSCTwoul d
tes t
is appr oximat ely .4% of al l males have
meanexc l
us ivelyout sidet het umor ,mos toral lof
undes cended t estishoweveri twasobs erved i n
thet umori snot edout s ideoft hes acrum.
3. 5to12%oft es t
icularcanc erpopul ati
on
● Type 2 - par tl
y ext ra- orpar tlyi nt
ra- sacral=
partlyintrapel vic
Risk-bas edScheme
● Type3-maj or it
yoft het umori sintrapelvic
Lowr i
sk Sur ger yalone ● Type4-al loft het umor i sl ocatedwi thi
nt he
Stage1ovar y COG,AGCT0132 pelvis
Stage1t es t
es
I
mmat uret eratoma *hi
gherr ateofmal ignanc yf ormor ehi ddent umor s
andf ort hoset umor sthatwer enotexc isewi thint he
I
nt ermedi ater i
sk fi
rsttwomont hsofl ife.Itisver yimpor tantthatwhen
StageI I-I
IIovar y yous eet hesepat ient sint henewbor nper i
odori nt he

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 f
ir
stt
wo monthsofli
fe,you r
ecommend t
hatt
he oft
het
umor
t
umormus
tber
emoved.
StagingofWT
I
II
.MALI
GNANTTUMORSOFCHI
LDHOOD Table 30-1 Chi
ldren’sOnc
ology Gr
oup (COG)and
Sociétéint
ernat
ionaled'
oncol
ogi
epédiat
ri
que(SI
OP)
A.Wi l
msTumor/Nephr oblastoma StagingSystems
● Wi l
ms ’t umor i st he mos tc ommon pr i
mar y
malignantt umoroft heki dneyinc hil
dr en
COGWi
l
lms
’TumorSt
agi
ng
● 2nd mos tc ommon abdomi nalt umori nchil
dr en
(only2ndt oneur obl as toma) St
ag Cr
iter
ia
● Mos tar edi agnos edbet ween1and5year swi th e
thepeaki ncidenceatage3.
● Thet umor sus uallydevel opi not her wiseheal thy I Thet umorisli
mitedt ot hekidneyandhas
chil
drenasanas ympt omat i
cmas sint hefl
ankor beenc ompletel
yr esected
upperabdomen Thet umorwasnotr upturedorbi opsi
ed
● Frequent l
yt he mas si sdi sc
over ed by a par ent pri
ort oremoval.
whilebat hingordr es singt hec hil
d Thereisnopenet rationoft herenalcaps
ule
● Others ympt omsi nc l
udeHyper tension,hemat uria, orinvolvementofr enals i
nusvessels
.
obstipati
on,andwei ghtl oss
● occas i
onally ,t he mas si sdi scovered f ol
lowi ng I
I Thet umorext
endsbeyondt hec apsuleof
bluntabdomi naltrauma thekidneybutwasc omplet
elyres ect
ed
● Near l
y97% ar es por adi c-i nt hattheyyoc curi n withnoevidenc eoftumoratorbeyondt he
theabs entofher itabl eorc ongeni t
alc auseorr i
sk mar gi
nsofresecti
on
factor Thereisnopenet r
ationoftherenalc apsul
e
● I
fwi thher i
tabler i
s kf ac t
or-pr esentatanear li
er orinvasi
onoft herenalsi
nusvess els
.
age( theaf fectedc hildof10%) ,andt het umor s
aref r
equent lybi l
ater al. I
II Grossormi cr
os copicres idualtumorr emai ns
postoper ati
vely,incl
udi ngi noperablet umor,
Geneticpredispositi
ont oWI lms’tumor posi
tives urgicalmar gins ,t
umors pi l
l
age
● WAGRs yndrome surf
ac es,regionallymphnodemet astases,
- Wi l
ms’ t umor , Ani ridia, Gyni t
our
inar
y posi
tiveper it
onealc ytol ogy,ortrans ected
abnormal it
ies,andment alRet ardati
on tumort hrombus .
- Knownt or esultsfr
om adel eti
onofonecopy Thet umorwasr upturedorbi opsiedpr iorto
eachoft heWI lms’tumorgene,WT1 removal.
● Bec kwith-Wi edemanns yndr
omei sanover gr
owth
syndrome I
V Hematogenousmetast
asesorl
ymphnode
- Vi scer
omegal y, macroglossia, and metast
asesoutsi
detheabdomen(
e.g.
,l
ung
hyperinsuli
inemi chypoglycemia l
iver
,bone,br
ain)
- Mut at
ionsatt he11p15,locus
V Bilat
eralrenalinvol
vementi
spr
esentat
● Hemi hyper tr
ophy
diagnosis
,andeac hsi
demaybeconsi
dered
tohaveas tage.
Preoperat
ive evaluat ion bef ore oper at
ion, pati
ents
suspect
edofWi ll
’stumors houldunder go: Ni
cet
oknow!
● Abdomi nalc hes tcomput er i
zedt omography
○ Char ac terizethemas s
SI
OPSt
agi
ng
○ I dentif
yPr esenceofmet astases
○ Pr ovide I nformati
on on t he oppos i
te St
age Cr
iter
ia
kidney
○ Pr esenc eofnephr ogeni crestswhichisa I Tumori sli
mi t
edt otheki dneyor
precurs orr eason t ot he developmentof sur r
oundedwi thaf i
brousps eudocapsul
e,
Wi l
l’
st umor . i
fout sidet henor malcont oursoft
he
● Abdomi nalUS kidney.Ther enalcapsuleor
○ Eval uat et he pres ence ofr enalvein or ps eudoc apsulemaybei nfil
tr
atedwiththe
vena caval ext ension whi ch i s a tumor ,buti tdoesnotr eac htheouter
contraindi c
ationofac ompleteresec
tion

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 surface,anditisc ompletel
yr esected.The uri
narybladdermus tbec ompl
etel
yremoved.
tumormaybepr otr
uding( bulgi
ng)intothe Al
sot hes uspect
edenlargedlymphnodemus t
pelvicsystem anddi ppingintot heureter, betakent ogetherwit
ht hespeci
men.
buti ti
snotinfil
trati
ngt hewal ls
.Theves sel
s ● Compl et
er emovalofkidneyuptodist
alur
eter
ofther enalsi
nusar enoti nvolved.Intr
arenal +LNs ampl ing
vesselsmaybei nvolved.
B.Neur oblas toma
I
I Thet umorext endsbeyondt hekidneyor
● Mos tcommonabdomi nalt umori nc hildren
penet r
at est hrought her enalc apsule
● Third mos tc ommon pedi atric malignanc y-
and/orf ibrousps eudoc aps uleintot he
10%ofal lc hi
ldhoodc anc ers
perir
enalf at ,buti tisc ompl etelyresected.
● Patientshaveadvanc eddi s easeatt het imeof
Thet umori nfil
tratest her enals i
nus
present ationunl ikewi tht heWi l
m’ st umori n
and/ori nvadesbl oodandl ymphat i
c
whic hc ur ei sexpec ted i nt hevas tmaj ori
ty.
vesselsout sidet her enalpar enchyma,but
The over alls urvivalof Neur obl
as toma i s
i
tisc ompl et elyres ected.Thet umor
si
gni f
icant lylowerc ompar edt oWi lm’ st umor.
i
nf i
l
tratesadj acentor gansorvenac ava,
● 80%ofc as espr esentbef or et heageof4year s,
butitisc ompl etelyres ec ted.Thet umor
andt hepeaksat2year sofage
hasbeens urgicallybi ops ied( wedge
● Arisefrom t heneur alcr estcel ls
biopsy)pr i
ort opr eoper ative
● Originatesf r
equent lyatt heAdr enalgl ands,
chemot her apyors urger y.
posteriormedi astinum,nec korpel vis( butcan
I
II Ther ei sincompl eteexc i
s i
onoft het umor, ari
sei nanys ympat het i
cgangl i
on)
whi chext endsbeyondr es ec ti
onmar gi
ns ● Thec l
inicalpr esent ationdependsont hesite
(gros sormi c r
osc opictumorr emai ns oft he pr imar yt umorand t he pres enc e of
pos toper ati
vely). met astases .
Anypos it
ivelymphnodesar einvol ved.
Tumorr upturesbef oreordur ings ur gery Cl
ini
calpresent ation
(i
rres pec t
iveofot herc ri
ter i
af ors tagi ng). ● ⅔ of t hist umor s ar ef irs
t not ed as an
Thet umorhaspenet ratedt heper i
t oneal Asympt omat icabdomi nalmas s .
surfac e.Tumori mpl antsar ef oundont he ● The t umormay c r
os st he mi dl ine and t he
peritoneals urface.Thet umort hrombi majori
tyofpat i
ent swi llalr
eadys how Si gnsof
presentatr esection,mar ginsofves selsor metastat i
cdi s
eas e-pai nfrom t het umormas s
ureterar etransec t
edorr emoved orfrom bonymet astases
piecemealbys urgeon. ○ I fyous eeac hil
dlimpi ng,c ompl aining,
unabl et owal korc ompl aini ngofany
I
V Hematogenousmet astas
es(l
ung,l
i
ver
, j
oi ntpai nwhi chisver yunl ikel
yf ora
bone,brain,etc.)orlymphnode child,wemi ghtbeabl et opal pat ean
metast
as esar eoutsidethe abdomi nalmas s.A neur obl astoma i s
abdominopel vicregi
on. highlyc ons i
der ed.
● Sever ewat erydi arrheaduet othes ecretionof
V Bi
lateralrenaltumorspresentat VIP (vas oactive i ntes t
inalpept i
de) by t he
di
agnos i
s.Eachsidehastobes ubstaged tumor
ac
c ordingt oaboveclas
sif
icati
ons. ● Cer ebellarataxi aorops oclonus
The COG s tagi
ng doesnoti nvol
ve a pr eoperat
ive Di
agnos
ticEval uation
chemot her
apy,itmeansthatthet umorbepr imaril
y ● Sympat het i
c ner vous s ystem - el evat
ed
resec
tedandt henanadjuvantchemos houldfoll
ow. catecholami nesandt heirmetaboli
tes
The SI OP pr ot
ocol, neoadj uvant, meani ng ○ Ser um cat echolmines - Dopami ne,
preoperati
vechemother
apymus tbei nst
itutedbefore Nor epinephri
ne
resec
tionofthetumor. ○ Ur ine cat echolamine met abol
i
tes -
VMA ( Vanil
l
ylmandelicAcid)andHVA
(Homovani ll
icAcid)
● BMA
Sur
gicalTr
eatment ● Abdomi nalCT-t ocharacteri
zethetumorand
● Radicalnephr
our
eter
ect
omy - meaning t
he i
tss usceptibil
ity
ent
ir
ekidneyuptothedis
talur
eterneart
he ● Met ast
at i
cwor kup

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 ○ Chestxray/CT ( any abnor
mal
it
y on ● Elevated AFP i n 90% of c hildren -
ches
txrays houldbefoll
owedbyches
t Hepat oblas
t oma>>HCC
CTscanforitsconfi
rmati
on) ● Abdomi nalCT t o ident i
fyt he lesion and
○ Bonemar rowbiopsy i
dent i
fythedegr eeoff ocalinvasi
venes s
○ Boneradionucl
idescan ● Biopsy- mus t be per f
ormed f or mal i
gnant
appear i
ng les i
onsunl esst he l
esion c an be
Pr
ognosti
cI ndicator s resect
edeas il
y.
● Anopenbi ops yisr equi redi nordert opr ovi de ● Hepat oblas
t oma i s usuall
y unifocali fitsis
ti
ssuef oranal ysist oc ategor izewhet hert he removemaj orit
ys urvi
ved
tumorhasf avor abl eorunf avor ablef eat ure. ● HCC i sof t
en ext ens i
velyinvasive and mul t
i
● ShimadaCl ass i
fi
cat ion centri
cbutonl yami nor i
tyofpat i
entshave
● Degr ee of di ffer ent i
at i
on, t he mi tos i
s- l
es i
ons amenabl et oc ompl eteresec t
ion at
karyor r
hex isi ndex, and t he pr es enc e or diagnosis.
abs enceofs c hwanni ans troma
● Ingener al,c hil
drenofanyagewi thl ocalized
neur oblastoma.Ani nf antyoungert hat1year St
agi
ngofPedi
atr
icl
ivercancer
ofagewi thadvanc eddi s easeandf avor able
diseas ec harac teristic shaveahi ghl i
kelihood
ofdi seasef rees ur vival . St
ageI No met as
tas
es, t
umor c
ompl
etel
y
● By c ontras t ol der c hildr en wi t
h advanc e
r
esec
ted
diseas ehaveas igni ficant l
ydec reas edc hanc e
ofc uredes pitedes pit eint ens i
vet her apy
● FAVORABLE
St
ageI
I Nomet astas
es ,t
umorgr os
s l
yr esec
ted
○ Hyper diploid DNA, Loc alized
tumor ,Les st han1yearol d with mi
croscopicresi
dualdisease( ie,
.
● UNFAVORABLE Posi
ti
vemar gins)ort umorr uptureor
○ N- mycampl i
fi
cation,Advanc ed tumorspi
llatthetimeofsurgery
diseas e,Ol dert han1yearol d.
● Ageofi mpor tanc e.
St
ageI
II No dist
ant met astases
, t umor
C.Li verTumor s unresec
table or r
esec t
ed wi t
h gr
oss
● >⅔ ofalllivert umor saremal ignant res
idualtumororposi
tivelymphnodes.
● 2maj orhi stologics ubgroups
a. Hepat oblastoma
- Mos tc ommon l i
ver mal i
gnancy in St
ageI
V Dis
tant metas
tasi
sr egar
dles
s of t
he
chil
dr en ext
entofli
veri
nvolvement
- Di agnos edbef oreage4
b. HEpat ocellularcarci
noma
- Peaksbet ween10and15year sofage ● Stagi ngs ystem bas edonpos tsurgicalext ent
● Theageofons etofl i
vercanc erinc hi
l
drenis oft umorands urgicalr es
ectabil
ity.Theover all
rel
atedtot hehi stologyoft het umor . survivalr at ef orc hi
ldr enwithhepat obl astoma
● Mali
gnantmes enc hymomaands ar
comasar e i
s70%,buti ti sonl y25% f orhepat ocellul
ar
muc h les s c ommon but c onsti
tut
e t he carcinoma.Chi ldren di agnosed wi ths tage I
remainderofmal ignanc y. and I Ihepat obl ast
oma have a c urer ate of
● The f i
nding of t he l i
ver mas s does not great ert han90% c ompar edt o60% f ors tage
necessaril
yi mpl yt hatmal ignanc yispresent
. I
IIandappr oximat ely20%f orstageI V.
Nearly 50% of al l mas s es ar e benign ● I
n c hi l
dren di agnos ed wi th hepat ocellul
ar
hemangi omasar et hemos tc ommon carcinoma,t hos e wi t
hs tage Ihave a good
out come,wher eass tagesI I
IandI Var eus uall
y
Cli
nicalpresentati
on fatal. The f i
br olamell
ar var iant of
● Pai nl
essabdomi nalmasswhichthe par
ents hepat ocellularc arc
inomamayhavea bet t
er
note whilechanging t
he chi
l
d’scl
othes or prognos is
whilebathi
ngthec hi
l
d.
● J aundic
e,anorexi
aandweightl
oss Goali
nmanagement
Evaluation ● Compl
ete Sur
gic
alRes
ect
ion- pr
imar
y goal

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LAMORI
N
 andises sent ialf orcure SAMPLEX
● Controlofmet as tasi
sandr ecur
renc e 1. Al l ar e t rue about Fami li
al Adenomat ous
● Adequat epal l
iat i
on-f orends t
agec anc er Polypos isexc ept
● Fortumor st hatar eunr es ec t
able,preoper ati
ve a. Mut ations of t he adenomat ous
chemot herapy s hould be admi ni
s t
er ed t o pol ypos i
s c oli ( APC) gene on
reducet hes i
z eoft het umorandi mpr ovet he c hromos ome5q21.
possibili
tyf orc ompl eter emoval . b. Lead t ot hedevel opmentofi nvas i
ve
● Chemot herapy i s mor e s ucces s
f ul f or c olor ec talc arc inoma
hepat oblas toma t han f or hepat oc ellul
ar c . Pr ophyl ac tic thyr oidec t
omy is
carci
noma. r ecommended
● Areasofl oc al l
yi nvasivedi s
ease,s uchast he d. Al so at i nc reas ed ris
k of
diaphr agm,s houl dber es ectedatt het imeof hepat obl as toma.
surgery. 2. Among15- 19year sol d,t hes ec anc ersar ethe
● Forunr esec tabl et umor s,l i
vert r
ans plantat i
on mos tf requent lydi agnos edmal ignanc y.
may be of fer ed i n s elect pat i
ent s. The a. Hodgki nsandNon- hodgki n'
s
fi
brolamel lar var i
ant of hepat oc ellul
ar b. Hodgki nandGCT
carci
nomamayhaveabet terout comewi th c . GCTandLeukemi a
l
ivert ransplant at i
ont hanot herhepat oc ellul
ar d. Noneoft heabove
carci
nomas . 3.Pr i
mar yl ivert umor sc ons ti
tut esl esst han_ __of
tumor ss eeni nt hepedi atr i
cpopul ation
a. 1%
b. 3%
c . 5%
d. 10%
4.Allaret r ueofhepat oc ellul aradenomaexc ept ;
a. Tr eat ment i s c ompl ete s urgical
r esec tion
b. Res embl esHCCbutwi thoutmi toses
c . Ser um AFP and l i
ver enz ymes ar e
wi t
hi nnor malr ange
d. As soc i
at ed wi th t ype 1 gl yc ogen
s torgaedi seas e
e. Noneoft heabove
5.Origi
nat ef rom t hei ns tes tinalc ellofCaj al
a. Foc alnodul arhyper pl as i
a
b. Hepat oc ellularadenoma
c. GI ST
d. Ger mc elltumor s
6.Trueoff ollicul aradenomaexc ept ;
a. CTt ypi c all
ys howsahyper vasc ularl esi
onwi th
adens es tellatec ent rals c ar
b. Fr equent l
yf oundi nc ident allyatl apar otomy
c. Femal e- to- mal er at i
oi sappr oximat el y4: 1
d. Regul ar l
ys haped,non- tenderl ivermas s
7. Apr imi tiveger mc el lt umort hatl ackst heabi l
i
ty
forf
ur t
herdi ffer ent i
ation
a. Semi noma/ dys ger mi noma
b. Chor i
oc ar c
inoma
c. Ter atoma
d. Embr yoni cc arc i
noma
8.T/F:Inc hi l
dr engonadalt umors iteisunc ommon
9.Mos tc ommonger mc ellt umor .
10.Whati st he mos tc ommon pr imar y mal ignant
tumoroft heki dneyi nc hildr en?
11.I
nWAGRs yndr ome,As tandsf or ?

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LAMORI
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 a. Anuria
b. Ani
ridia
c. Al
coholism
d. Anaesthesi
a

12.Thefollowingar es
ympt
omsofnepr
hobl
ast
oma,
except
:
a. Hyper t
ension
b. Hemat uri
a
c. Obstipati
on
d. weightloss
e. AOTA

ANSWER:
1. C
2. B
3. B
4. E
5. C
6. D
7. A
8. T
9. Terat
oma
10.Wil
ms ’t
umor
11.WAGRs yndrome
- Wi lms’ t umor , Ani
ridi
a, Gynitour
inar
y
abnormali
ti
es,andment
alRetar
dat
ion
12.E

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 ● In 1 to 4 years of age
TOPIC OUTLINE: ○ Drowning was the leading cause of injury
I. EPIDEMIOLOGY OF CHILDHOOD INJURY death followed by
II. RESUSCITATION AND IMPACT IN OUTCOME ○ Transportation-related injury.
III. RESUSCITATION PRINCIPLES ● 5 to 9 years of age- lowest rate of unintentional
A. Prehospital care death
○ The most common cause of death in this age
B. Primary Surveys and Treatment of Life
group and also those children ages 10-14
Threatening Injuries years was motor vehicle occupant injury
C. Resuscitation Phase ● Male >> Female
IV. INJURIES TO THE CENTRAL NERVOUS ● In all age groups, male children are at higher risk
SYSTEM for unintentional injury than females. This can be
V. THORACIC INJURIES attributed to a variety of factors, including biology
A. Tension Pnerumothorax (differences in temperament), exposure to risky
behavior, gender socialization, and cognitive
B. Hemothorax
differences
C. Traumatic Asphyxia ● Race and ethnicity are also important factors in
VI. ABDOMINAL INJURIES the risk for unintentional injury in children.
A. Small Intestinal Injury ● Decreases in the injury death rate are due to
B. Solid organ injury multifaceted preventive strategy.
VII. CHILD ABUSE ● Intentional injury
VIII. SAMPLEX ○ result in a fatal outcome from homicide, child
abuse, or suicide.
● National and state effort in this regard have less
I. EPIDEMIOLOGY OF CHILDHOOD INJURY have result to considered reduction in homicide,
● Preventable injuries state an enormous financial child abuse and suicide and now this death
emotional and social tool on the injured children represents a smaller percentage of fatalities in
and their families as well as the society as a children in the united states.
whole. ● Recognition of this intent requires referral to the
● Worldwide, Childhood injuries are a growing child protection service for assessment
problem ● Resuscitation of this children is frequently a
● 875,000 children are killed per year challenge because Abuse may be chronic, which
● Nonfatal injuries affect the lives of between 10 to results in a child with a limited physiologic reserve
30 million born globally
● In United States, Unintentional injury is the
leading cause of death
● claiming more than 12,000 child lives annually,
or an average of 30 children each day.
● The leading cause of unintentional related death
varies according to the child's age and is
dependent on the developmental ability and
exposure to potential hazard. In addition to
parental perception is the child ability and injury
risk
● Falls were the leading cause of nonfatal injury-
15 years old. II. RESUSCITATION AND IMPACT IN OUTCOME
● Children less than 1 year of age have the highest ● Resuscitation of the injured child includes the
rate of unintentional injury-related death, with a Actions necessary to reverse and control the
rate more than twice with that of older children sudden alterations in physiologic homeostasis
○ Airway obstruction is a major pillar in this age that occur as the result of injury.
group

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 ● Children are remarkably resilient however, the ● Events transpire in a rapid sequence that is
initial period of stability has been shown to be dictated by a systematic protocol to recognize
significantly shorter as age decreases. and treat acute injuries
● Therefore, resuscitation is not complete. ● This approach is designed to standardize
Continues until injuries have been definitely diagnostic and treatment decisions so that
treated and displays physiologic stability without individual variations patterns of injury do not
continued intervention. distract caregivers from recognizing and treating
● Children vs Adult (Differences between children subtle injuries that can have a profound impact
and adult with respect to patterns of injury, upon outcome.
physiologic presentation, and management are ● This systematic frame-work comprises a
important ○ Primary survey.
● Physician who treat injured children must ■ Initial process in identifying and temporizing
recognize and understand the important injuries that are potentially life threatening
distinctions so that the resuscitation process ■ Follows chronologically the "ABCDE"
addresses the special needs of the children. sequence (Airway, Breathing, Circulation,
Disability, and Exposure).
I. III. RESUSCITATION PRINCIPLES ○ Resuscitation phase
A. PREHOSPITAL CARE ○ Definitive secondary survey.
● Systematic management following an injury is ● This system relies upon simple observations to
essential to survival. assess physiological derangement and
● The resuscitation process begins when immediate intervention to prevent death.
emergency transport personnel first encounter
the child in the field. AIRWAY
● The fate of any given child can turn on the ● To assess airway specific considerations apply to
decisions and interventions that transpire during trauma in children that might influence
the first crucial moments. management and outcome. This relate to the
● In general, children fare worse than adults in the mechanism of injury, anatomic portions in
out-of-hospital phase of resuscitation. children compare to adults and the physiologic
● The injury-adjusted death rate for children is differences.
twice that of adults ● Airway control is the first priority; respiratory
● The survival rate for out-of-hospital cardiac arrest arrest can proceed quickly to cardiac arrest
in children is only half that of adults. ● Pediatric airway is unique
● Unfamiliarity with pediatric resuscitation skills is ● Child’s anatomical differences:
understandable. trauma is the most common ○ Larynx - anatomically higher and more
indication for pediatric ambulance transport, but anterior; necessitating an upward angulation
accounts for less than 10% of total paramedic of the laryngoscope to place an ET tube
patient volume in most metropolitan areas. properly. Thus a gentle cricoid pressure is
● The most important objectives for emergency required for proper intubation
personnel in the field are: ○ Epiglottis - shorter, less flexible and tilted
1. Recognition and treatment of immediate life- posteriorly over the glottic inlet
threatening dysfunction ■ For direct control a straight blade is
2. Assessment of the mechanism of trauma and more appropriate to visualize the vocal
extent of injuries cords
3. Documentation of pertinent medical data ○ Vocal cords - more fragile and easily
4. Triage to the appropriate-level pediatric damaged
trauma facility ● Narrowest point is the SUBGLOTTIC TRACHEA
and CRICOID RING; as opposed to the glottis in
B. PRIMARY SURVEYS AND TREATMENT OF LIFE an adult patient
THREATENING INJURIES ● Passage of the ET tube thru the vocal cords does
● When you encounter an injured child for the first not guarantee safe advancement into the trachea
time, the most important initial step would be to or avoidance of subglottic injury
conduct a primary survey and treat immediately ● ET size selection
life-threatening injuries. ○ NB - internal diameter ranges from 3.0 to
3.5mm
○ 1 to 2 years old - 3.5 to 4.5 mm

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 ○ More than 2 years old - ID (internal diameter) D - With the blade in the proper position and the
= (Age in years/4) + 4 child’s neck slightly extended in the sniffing position,
■ eg. 4 years old= (4/4)+4 = 1+4 = 5; use a lifting the handle (positions 1, 2, and 3) raises the
french 5 ET tube epiglottis and brings the vocal cords into direct vision
○ Size of 5th digit may be used for
approximation
● Uncuffed ET in less than 8 years old to
prevent subglottic stenosis(because of
narrowed subglottic trachea)

ENDOTRACHEAL INTUBATION:

E- In all except newborns, the straight blade should

be placed over the epiglottis to lift it, along with the
base of the tongue, to expose the larynx. A stylet
A- Posterior neck roll optimizes visualization of the with the tip curved within the endotracheal tube
vocal cords in children. facilitates successful intubation.

B- Tongue is large relative to the space in a child’s

oral cavity, tongue should be moved to one side of
the oral cavity to facilitate exposure of the posterior F- The endotracheal tube is held in place while the
pharynx and supraglottic area laryngoscope is removed and secured after
verification of bilateral breath sounds.

● Technique of intubation depends on urgency of

establishing an airway
○ Orotracheal intubation: for hypotensive,
hypoxemic, comatose child; accomplished
without delay as an integral part of the
resuscitation
○ If it is a more elective situation, give adequate
preoxygenation and premedication before
C - The laryngoscope blade is inserted from the right intubation
side of the mouth and slides back along the vallecula.
BREATHING
● Breathing assessment
● Relief of gastric distention (gastric distention from
aerophagia) - cause respiratory compromise
○ Nasogastric tube - no head injury
○ Orogastric tube - CNS deficits
● Injured child: compromised breathing and
ventilation usually from either head injury

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 (impaired spontaneous ventilatory drive) or D- entrance into the pleural space should be made
thoracic injury (impaired lung expansion) just over and superior the rib to avoid injury to
● Pneumothorax or hemothorax should be treated intercostal vessels
promptly; this is following thoracic trauma

CHEST TUBE PLACEMENT

● The same as placement of chest tube in adults,
placed at the 5th ICS in the MCL to evacuate
blood or air, which is the presence of
hemothorax or pneumothorax

E- Lateral view of the technique

CIRCULATION AND VASCULAR ACCESS

● Even seriously injured children often have normal
VS
● Initially present with normal VS because of
A- incision made in the MAL just below the nipple in remarkable physiologic reserve
a male or inframammary fold in a female ● Delays early hemodynamic signs of hypovolemia
until relatively late and shows physiologic decline
● High index of suspicion is necessary
● Reliable sign of adequate perfusion - NORMAL
mental status
● Parameters consistent with successful
resuscitation are:
○ Slowing of heart rate (<100 beats/min)
○ Increased pulse pressure (>20 mmHg)
○ Return of normal skin color
○ Increased warmth of extremities
B- dissection in a cephalad direction, subcutaneously
○ Clearing of the sensorium (improving Glasgow
over two ribs
Coma Scale [GCS] score)
○ Increase in systolic blood pressure (>80
mmHg)
○ Urinary output of 1 to 2 ml/kg/hour in infants
and 1 ml/kg/hour in adolescents

● VASCULAR ACCESS
○ Providing of venous access in a hypovolemic
child is often a challenge due to collapsed
peripheral veins from massive blood loss
C- 4th ICS is the ideal place for thoracostomy tube ○ 2 functioning catheters is ideal
placement ○ Achieve venous access above and below the
diaphragm
○ Given the potential for extravasation of
resuscitation fluids from occult intra-
abdominal venous injuries. Nevertheless, in
children any peripheral venous access is
useful.
○ Two attempts should be made to place large
bore peripheral IVs in upper extremities
○ If percutaneous placement is unsuccessful

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 ■ Intraosseous (IO) line - child less than 6 characterize the nature and extent of the
years of age injuries and to avoid the complications of
■ Venous cutdown - more than 6 years old excessive fluid resuscitation. As perfusion is
(greater saphenous) restored, the rate of fluid infusion is gradually
reduced to avoid unnecessary fluid
Intraosseous (IO) line administration.
● is a simple, reliable, and a safe route for ● Pulmonary edema rarely occurs in normal lungs,
administration of fluids, blood products, and but considerable morbidity results from fluid
medication. ● If hemodynamic stabilization does not occur with
● The technique is applicable in children 6 years of fluid resuscitation
age and younger, because of the well-perfused - Intra abdominal or pelvic source of
marrow of early childhood. hemorrhage
● The preferred site for IO insertion is through the - Cardiac dysfunction because of tamponade
flat anteromedial surface of the tibia, about 2 to 3 - Contusion or tension hemopneumothorax
cm below the tibial plateau. secondary to lung injury
● The needle is angled 60 degrees from horizontal - Cerebrospinal injury such as atlanto occipital
and pointed toward the foot. dissociation
● The cortex is penetrated and the marrow cavity - Profound hypothermia
detected by aspirating blood and particulate
material. DISABILITY
● Alternative sites include : ● Rapid neurologic evaluation
- midline distal femur, 3 cm above the condyles - identify serious injuries that may have
directed cephalad in small children immediate consequences for airway
- distal tibia above the medial malleolus or the management.
proximal humerus in the adolescent. Specially ● AVPU mnemonic
designed IO needles should be available in - A rapid method for describing gross cerebral
the pediatric resuscitation room to facilitate function
this maneuver; however, a 14- to 16-gauge - Alert, voice responsive, pain responsive or
needle can be used. unresponsive
● The complication rate of IO is low but includes ● Pupillary responsiveness and symmetry
osteomyelitis, cellulitis, fracture, growth plate ● Transtentorial herniation secondary to an
injury, fat embolism, and compartment syndrome. expanding intracranial hematoma causes
● Thus utilization of the IO line should be minimized ipsilateral pupillary dilation and loss of light reflex
by only 24 hours. ● Direct trauma to the eye is an equally common
cause of unilateral anisocoria.
FLUID RESUSCITATION ● Decorticate or decerebrate indicates the loss of
● As soon as vascular access is established, fluid cortical or global brain function respectively .
resuscitation with a bolus of fluid is begun.
● Isotonic crystalloid solution (Lactated Ringer)= 20 MEASURES TO REDUCE INTRACRANIAL
mL/kg increments PRESSURE (ICP)
● Still hypovolemic after 40mL/kg → Blood ● In the comatose child with a unilateral fixed and
transfusion (PRBC) is initiated (10mL/kg) dilated pupil, measures to reduce intracranial
● Packed RBCs have the desirable qualities of pressure (ICP) are imperative.
raising colloid oncotic pressure and effecting a ● Early controlled endotracheal intubation -pCo2 30
more rapid and sustained intravascular expansion to 35 mm Hg with moderate hyperventilation
than crystalloid. ○ Cerebral vasoconstriction and decreases
● In addition, cerebral blood flow
● the red blood cell provides hemoglobin to ○ This lowers brain volume and ICP
increase oxygen carrying capacity. ○ Increase in cerebral perfusion pressure (CPP)
● All infused fluid(crystalloid, colloid, and blood) ● Reverse Trendelenburg position
must be warned to minimize hypothermia ○ in which the head is slightly elevated by 30
● Continual reassessment of response to degrees, can also reduce intracranial
resuscitation hypertension but should be employed in
- It is important to reassess the child’s children with normal cardiac function.
response to resuscitation continually to

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 EXPOSURE 2. Control of contamination from hollow-viscus
 Complete exposure injury
○ Thorough examination and identification of 3. Packing of the abdomen
injury 4. Temporary abdominal closure
○ A thorough primary survey on a stable child 5. Transport to the pediatric intensive care unit
with a normal GCS score can be performed (PICU)
without removing all items of clothing ● This abbreviated procedure is done in
simultaneously. hemodynamically unstable patients that cannot
○ Children are particularly apprehensive about tolerate completion of the surgical procedure
exposing an injury that have been previously needed for the particularly injured organ
covered ● These patients are brought in the ICU and
○ Attention to the special sensitivity of the child observe for equilibrium until such time that the
in this regard frequently result into more efficient patient achieved an acceptable hemeostasis -
resuscitation which is expected to be within 24-48 hours, and
○ In a child, hypothermia affects physiologic then the patient is brought back at the ICU when
parameters such as cognitive function, cardiac the patient is adequately stable for the
activity and coagulation, thus, it is very important completion of the procedure
to ● If a massive blood transfusion is expected a 1:1:1
 Maintain core temperature above 35 to 36 ratio of RBC to plasma to platelets should be
degrees Celsius utilize
○ Warm resuscitation room reserves core body
temperature and minimizes heat loss PAIN MANAGEMENT
○ Similarly, resuscitation Fluid and inhaled gases  GOAL: reduce the stress of the injured child and
should be warmed and humidified to improve outcome
 Overhead and bed warmers are essential/ but  Acute pain serves as a noxious stimulus → that
the radiant warmer is best for the injured infant leads to the activation of the physiologic stress
response
C. RESUSCITATION PHASE  Pain results in disruption in the neuroendocrine
 The cornerstone of resuscitation is the response
Continuous reappraisal of the child's response ○ Which has a profound and Deleterious effect
to therapeutic intervention upon metabolism, thermoregulation, wound
 Deterioration at any point requires repetition of healing, and immunity of the child
the primary survey
 After the ABCs are completed, and life- EVALUATION OF INJURY
threatening injuries are stable, Placement of  All patients should receive an X-ray of the
gastric tube/ urinary catheter followed by cervical spine, chest, and abdomen with pelvis
removal of blood for analysis and establishment  All Extremities suspected of fracture should also
of Cardiac monitor is essential be evaluated - by x-ray
 In this resuscitation phase, this is where we  Plain cervical xray is preferred over neck CT scan
request for Diagnostic imaging and laboratory  In most children, it is possible to diagnose
tests. clinically the cervical spine injury using this
approach while minimizing the degree of
DAMAGE CONTROL radiation exposure
● GOAL - reverse the sequelae of shock  Plain head CT using IV and oral contrast -
● Severely injured children are at risk for abdominal injuries
hypothermia, acidosis, and coagulopathy which  Focused abdominal US (FAST exam) - not widely
has a negative impact on survival used in pediatric trauma
● In these circumstances the child may require  The child with significant abdominal tenderness
Damage Control Surgery - an emergent and mechanism of injury that could cause
completion of the surgical procedure intraabdominal injury should undergo abdominal
● Fundamentals of DCS in children are the CT scanning using an IV and an oral contrast in
following: all cases, although past exam is extremely useful
1. Exposure and control of vascular or solid in the evaluation of adult abdominal trauma, it is
organ hemorrhage not widely used in the pediatric population
because in part this relates to the widespread

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 used of nonoperative treatment for most solid V. THORACIC INJURIES
organ injury. In fact, non operative management ● Pediatric thorax is pliable due to incomplete
in solid organ injuries in adult population was calcification of the ribs and cartilages
derived from the successful management of ● In blunt chest injuries, (+) pulmonary contusion
solid organ injuries in the pediatric population in the absence of rib fracture
 Therefore, a positive abdominal ultrasound scan ○ Pulmonary contusion usually resolve with
would not alter the approach of the careful ventilator, management and judicious
hemodynamically stable patient volume resuscitation
*As long as the patient is hemodynamically stable ○ Children who have received massive blunt
even if we have a significant solid organ injury in the thoracic injuries may develop traumatic
PE and on abdominal CT scan - nonoperative asphyxia, this is characterized by cervical and
management is appropriate facial hemorrhages and cyanosis associated
with vascular engorgement and
IV. INJURIES TO THE CENTRAL NERVOUR subconjunctival hemorrhages. Management
SYSTEM includes ventilation, and treatment of
● CNS is the most commonly injured organ system abdominal injuries
and is the leading cause of death among injured ● Penetrating chest injuries from stabbing or
children gunshot wounds , may result in damage to the
● Nonaccidental trauma - most common cause of lung and disruption of bronchi of the great
serious head injury in toddlers vessels
● Findings suggestive of abuse includes the ● CXR for diagnosis
presence of: TENSION PNEUMOTHORAX
○ Retinal hemorrhages on fundoscopic ● Develop when a one-way valve effect occurs
evaluation ● Caused by pulmonary laceration or an injury to
○ Intracranial hemorrhage without signs of the airway
external trauma (indicates a Shaking injury) ○ Intrapleural pressure exceeds the atmosphere
○ Fractures at different stages of healing in x ray ○ Collapses ipsilateral lung
● Accidental head injury is more common in older ○ Mediastinal shift/tracheal deviation
children ○ Flattens diaphragm→ ventilatory compromise
○ Falls, vehicular related trauma of the opposite lung
● Initial head CT can also underestimate the extent
of injury in children ○ Reduces venous return → pulse rate
● Criteria in doing Head CT: respiratory rate increases and → severe
○ LOC, amnesia to the trauma respiratory compromise (respiratory distress)
○ Inability to assess CNS status in intubated ● The trachea is usually deviated away from the
patients involved site and the neck veins may be become
● Mild, isolated head injury (GCS 14-15) and engorged
negative CT scan ● The ipsilateral side of the chest is hyperresonant
○ Can be discharged if their neurologic status is to percussion with diminished breath sounds
normal after 6 hours of observation ● Tx: immediate needle-catheter drainage- 2nd
● Young children with multisystem involvement ICS MCL
should be admitted to the hospital for ○ Chest tube insertion
observation ○ No need to wait for a chest radiograph this is
● Any change in the neurologic status warrants an emergent procedure and placement of a
neurosurgical evaluation and repeat CT scanning needle and a chest tube is lifesaving
● Severe head injury (GCS 8 or less) HEMOTHORAX
○ Urgent neurosurgical consultation is required
these patient are evaluated for intracranial ● Massive blood in thorax→ SHOCK
pressure monitoring and for the need to ● When enough blood is loss into the thorax to
undergo craniotomy cause shock the tem is massive hemothorax
○ Decompressive craniotomy ● More common on penetrating than blunt trauma
● Tx: chest tube insertion-evacuate blood→ lung
expansion
○ Monitor rate of blood loss

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 ● Most bleeding from the lungs stops SMALL INTESTINAL INJURY
spontaneously because of low pressure of ● Jejunum - most commonly injured
pulmonary circulation ○ In the areas of the ligament of Treitz
● Treatment is intercostal drainage to prevent ● Caused by rapid deceleration in the setting of lap
clotted hemothorax and to monitor the rate of belt
total volume of blood loss  There may be hematoma of the anterior
● It is wise to establish two large-bore intravenous abdominal wall caused by lap belt which the so
catheters, begin treatment for shock, if present, called “Seat-belt sign”
and obtain blood for transfusion before draining ○ Signify a possibility of an underlying SB injury,
a massive hemothorax because it may you should alert the caregiver
precipitate further draining. However, drainage ○ Chance fracture - lumbar spine fracture
and reexpansion of the lung usually stops the
bleeding upon placement of the chest tube
● Thoracotomy is indicated if:
○ Initial drainage exceeds 20% to 25% of
estimated blood volume
○ Continued bleeding exceeds 2 to 4
ml/kg/hour
○ Bleeding is increasing
○ The pleural space cannot be drained of blood
and clots
TRAUMATIC ASPHYXIA
● Occurs with sudden compression of the
abdomen or chest (or both) against a closed
glottis
● Rapid rise in intrathoracic pressure, which is
transmitted to all the veins that drain into the
valveless superior vena cava.
● Extravasation of blood occurs into the skin of
the upper half of the body, sclerae, and possibly
the brain.
● The brain may also be damaged by hypoxia
● The clinical features: seizures, disorientation,
petechiae in the upper half of the body and
conjunctivae, and respiratory failure
● Tx: supportive because most patients recover
uneventfully

VI. ABDOMINAL INJURIES

● Small rib cage and minimal muscular coverage
of the abdomen can result in significant injury SOLID ORGAN INJURY
after seemingly minor trauma  Spleen >> Liver
● Liver and spleen- most commonly injured solid ○ The spleen is injured relatively more
organ in children commonly after blunt abdominal trauma in
● Duodenal injuries are usually the result of blunt children.
trauma  Current treatment involves a nonoperative
approach
○ Arise from child abuse or injury from bicycle
○ Avoids surgery in most cases even for
handlebar
(inaudible...) injury, assuming that the patient
● Duodenal hematomas usually resolve without
is hemodynamically stable. This approach
surgery avoids surgery in most cases.
○ Bowel rest with nasogastric decompression ○ Placed in ICU for close monitoring
with duration of 2 weeks ○ Type-specific blood should be available for
transfusion.
○ After successful NOM (non-operative
management), extended period of bed rest is

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 prescribed. This optimizes the chance for Table 27-1
healing and minimizes the likelihood of re- Signs and symptoms suggesting child abuse or
injury. A typical guideline is to keep the neglect
children on extremely restricted activity for 2 Subnormal growth
weeks, longer for 2 weeks at least for lower Weight, height, or both less than 5th percentile for age
grade injuries and up to 6 weeks restricted Weight less than 5th percentile for height
activity for higher grade or for spleenic injury. Decreased velocity of growth
○ In children who have ongoing fluid Head injuries
requirement, this means that there could be a Torn frenulum of upper or lower lip
failure in the non-operative management, Unexplained dental injury
hence an exploratory laparotomy is indicated. Bilateral black eyes with history of single blow or fall
Traumatic hair loss
Retinal hemorrhage
VII. CHILD ABUSE Diffuse or severe central nervous system injury with
 Child abuse is very rampant, not only in the history of minor to moderate fall (<3m)
Philippines, it is a worldwide problem. Skin injuries
 Child abuse encompasses physical abuse, Bruise or burn shaped like an object
sexual abuse, emotional abuse, and neglect. Bite marks
 Approximately 80% of all abusers are the parents Burn resembling a glove or stocking, or with some other
or caregiver distribution, suggest an immersion injury
○ Poor impulse control anti social behavior, and Bruises of various colors (in different stages of healing)
low self-esteem. Injury to soft tissue that are normally protected (thighs,
○ Were victims of abuse or witnessed domestic stomach, upper arms)
violence Gastrointestinal or genitourinary injuries
 Children less than 3 years age having the highest Bilious vomiting
rates of abuse because this subset of children: Recurrent vomiting or diarrhea witnessed only by
○ Require constant care and attention parent
○ Small in stature, unable to adequately defend Chronic abdominal or perineal pain with no identifiable
themselves cause
Presentation History of genital or rectal pain
 Withdrawn and avoid eye contact with their Injury to genitals or rectum
interviewers Sexually transmitted disease
Bone injuries
 Young children are prone to associative
Rib fracture in the absence of major trauma, such as a
fabrication which may influence or alter reality
motor vehicle accident
 Clinical History: Complex skull fracture after a short fall (<1.2m)
○ Family situation, unrelated caregivers, Metaphyseal long-bone fracture in an infant
substance abuse in the household, and any Femur fracture (any configuration) in a child younger
history of past abuse. Even the wide spectrum than 1 year
of abuse, presenting symptoms vary Multiple fractures in various stages of healing
accordingly. In the youngest victims, the Laboratory studies
diagnosis often depend on physical sign such Implausible or physiologically inconsistent laboratory
as: results (polymicrobial contamination of body fluids
 Bruising sepsis with unusual organisms, electrolyte
 Pattern burn injuries disturbances inconsistent with the child’s clinical state
 Retinal hemorrhages, and or underlying illness, wide an erratic variations in test
 Long bone fracture results)
 Among all these children presentation should Positive toxicologic tests in the absence of a known
raise a High level of suspicion in the clinician, ingestion or medication
which include the presence of: Blood cerebrospinal fluid (with xanthochromic
○ Multiple injuries in different stages of healing supernatant) in an infant with altered mental status
○ Injuries not consistent with the history and no history of trauma
provided by the caregiver *you can run through them and familiarize yourself
○ A history that changes when retold, with these telltales of injuries to abuse children
particularly when the incident was because you might be able to encounter them in your
“unwitnessed” private practice later on
○ Injuries to the perineum

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 In photo A. Why is it suspiscious? Because we all
know a 2 year old infant is still unable to ambulate. So
how could a 2 y/o infant get that kind of massive or
morbid condition when an unintentional event did not
happen? This is high risk for patients of child abuse.
Photo B. structure of the humerus with the history of Bruising in the perineum, scrotum and penis which is
fall but the patient also has a pulmonary contusion, almost always secondary to an intentional injury,
we all know that fall may fracture the long bone but it specifically sexual abuse.
does not coincide with the pulmonary contusion at the
same time.
VIII. SAMPLEX
1) The most important objectives for emergency
personnel in the field include all of the following
except.
a. Recognition and treatment of immediate life-
threatening dysfunction
b. Assessment of the mechanism of trauma and
extent of injuries
c. Documentation of non-pertinent medical data
d. Triage to the appropriate-level pediatric
trauma facility
2) All statements are true except.
a) Children less than 1 year of age have the
highest rate of unintentional injury-related
death
b) The most common cause of death in this 5-9
years and also those children ages 10-14 years
was infection related diseases.
Photo of pattern burns. Which almost always c) In all age groups, male children are at higher
pathognomonic intentional injury or child abuse. risk for unintentional injury than females.
d) NOTA
3) Initial process in identifying and temporizing
injuries that are potentially life threatening.
a) Primary survey
b) Secondary survey
c) General survey
d) Research survey
e) NOTA
4) This is the narrowest point in a child’s airway is/are:
a) Cricoid ring and subglottic trachea
b) Subglottic trachea and epiglottis
c) Glottis and trachea
d) Epiglottis and glottis
Laceration in the perineum, which might be indicative 5) Anatomical differences in a child’s airway:
for sexual abuse a) Larynx is posterior and higher
b) Larynx is lower and anterior
c) Larynx is higher and anterior
d) Epiglottis is shorter and tilted anterior

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 6) Which is true?
a) Pediatric patient present with normal VS
because of their unremarkable physiologic
reserve
b) When doing vascular access to diaphragm do
arterial access above and below the
diaphragm
c) Relieve gastric distention to avoid respiratory
compromise
d) Use orogastric tube if there is no CNS deficits
and nasogastric tube if there is CNS deficits
7. The following are consistent with successful
resuscitation are:
a) Increase in diastolic pressure
b) Slowing of heartbeat (>100bpm)
c) Increased coldness of extremities
d) Clearing of sensorium
8. The following are used/ can be done in a pediatric
patient, except:
a) Uncuffed ET for less than 8 years old
b) Straight blade except in newborns
c) Intraosseous line in less than 6 years old
d) Large bore peripheral IVs in the lower
extremities
9. T/F: Pediatric thorax is pliable due to incomplete
calcification of the ribs and cartilages.
10. Location of immediate needle-catheter drainage
a. 2nd ICS MCL
b. 3rd ICS MCL
c. 4th ICS MCL
d. 5th ICS MCL
11. Indication of thoracotomy except;
a. Bleeding is increasing
b. Initial drainage exceeds 20% to 25% of
estimated blood volume
c. The pleural space cannot be drained of blood
and clots
d. Continued bleeding exceeds 2 to 4
ml/kg/hour
e. AOTA
12. T/F: Traumatic asphyxia occurs with sudden
compression of the abdomen or chest (or both) ANSWER.
against a closed glottis. 1. C
13. Most commonly injured solid organ in children 2. B
a. Liver 3. A
b. Spleen 4. A
c. Kidney 5. C
d. A & B 6. C
e. AOTA 7. D
8. D
9. T
10. A
11. E
12. T
13. D

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 ● 1919: Tagliacozzi De Curtorum Chirurgia per
TOPIC OUTLINE Insitionem (first textbook of plastic surgery)
I. PLASTIC SURGERY ○ Describes a reconstruction of a nose using a
II. BASIC TECHNIQUE AND PRINCIPLES pedicled arm flap.
III. RECONSTRUCTIVE SURGERY
IV. PEDIATRIC PLASTIC SURGERY
V. FACIAL FRACTURES
*Purple: Synch class (Summary Session)
I. PLASTIC SURGERY
What is plastic surgery?
● No complete definition exists.
○ It defies any definition and has no organ
system of its own and is based on principles
rather than specific procedures therefore
allowing plastic surgeons to solve unusual
problems, allows them to operate from the Scope
top of the head to tip of the toe and applying ● Craniofacial
known procedure to other body parts and at ● Aesthetics
the same time allowing them to become ● Hand
innovative. ● Microsurgery
○ It is not organized on a specific organ ● Burns and wounds
system and has very loose boundaries and ● Trauma and oncology resection
no specific anatomic regions and overlaps ○ Plastic surgery goes beyond aesthetic
with a lot of other subspecialties. surgery
● Problem-solving specialty ○ A lot of programs in Plastic and
● The “Finishers” Reconstructive surgery incorporate
○ Plastic and Reconstructive Surgeons are microsurgical training/ background and are
called at the end of the operation or becoming the standard part of being a
treatment to reconstruct what has been lost. reconstructive surgeon.
● There is no clear boundary between
reconstruction and cosmetic surgery. II. BASIC TECHNIQUES AND PRINCIPLES
○ E.g. It is reconstructive if you try to repair a ● Will there be a scar
cleft lip on a child but the goal is for the ○ Whenever you incise a skin there will always
child’s features to function like a normal face. be a scar, however the question should be
(from here there was already an overlap of will there ever be a relatively inconspicuous
cosmetic and reconstructive surgery). or fine line scar.
○ The same with breast reduction surgery can ○ Final appearance of a scar depends on
be a cosmetic procedure and it also aims to many factors which includes individual
restore proper functioning of a person who is patient, type of skin, location in the body,
riddled with heavy weight due to back pain tension, direction of wound (the more
and difficulty to perform specific activities favorable the direction is, the better the scar
because of this limitation. (from here there will look),other local and systemic
was already an overlap of cosmetic and conditions, and the surgical technique itself.
reconstructive surgery). ○ Oily or pigmented lead to more anxiety scars
Background (Asians, Hispanics, African-American are
● Plastikos = to mold more prone to scarring compared to
○ Greek word for plastic and is found in Caucasian)
medical writings as early as 18th century ○ Wrinkled, pale, dry skin usually has more
● John Staige Davis – establish the name of the inconspicuous scars.
specialty

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 ○ Certain anatomic areas like the shoulder and cadavers that are already exhibited rigor
sternal area produce more hypertrophic or mortis while your
wider scars regardless of flawless initial ● Relaxed skin tension lines are described by
closure, no matter how perfect and how fine Borges
the initial closure is. ○ Lay perpendicular to and more accurately
○ Incisions in the eyelid almost always end up reflects the action of the underlying muscles
with a fine line scar but because skin there is ○ A lot can be similar to langer’s but RSTL in
also very thin. Eyelids have one of the general, for example in the forehead RSTL
thinnest skin thickness in the whole body. there is a horizontal line, the horizontal line
○ Skin will lose its elasticity with age, the reflects the underlying contraction of your
wrinkling that is produce actually makes the underlying frontalis muscles which is
scars less obvious and less prone to oriented vertically, so your line is
widening in older individuals comparing to perpendicular to the vertically oriented
children even though they heal faster they frontalis muscles, and when it contracts it
do not necessarily heal better produces a horizontal lines
○ In children, the scars look very nice ○ And we tend to position or incision parallel to
immediately after but because they continue your RSTL to make them less conspicuous
to grow, skin continues to expand and
stretch, scars will also follow making the A. SKIN INCISIONS
scars proportionately large. Wound Closure
● Most common method of closing a wound is with
● Tension suture
○ Resting state of tension: caused by gravity ● Precise approximation of the skin edges without
and its conformation over underlying tension
structures between sites that are tethered by ○ is essential in ensuring primary healing
subcutaneous fibrous tissue, which secure without scarring
the deep surface of the dermis to underlying ○ Skin under tension, the tendency for that is
points of fixation. for the skin to continue pulling it apart at the
○ Human skin actually exists in a state of incision line and will give a widened scar.
tension created by both internal and external ○ The most important layer we have to
factors. remember to approximate is the dermis
■ Externally it is acted on by gravity and which is why subdermal closure is important
clothing and internally it is subjected to because this layer contains the healing
the forces that are generated by the elements such as your blood supply and
underlying muscles, joints and tethering your cellular elements that will create that
of fibrous tissues. extracellular matrix that is essential for
○ Make sure to avoid tension because there's wound healing.
a chance to have dehiscence and tension ● Removal of devitalized tissue for traumatic
may apply stress on the healing wound and wounds
aggravate the scar. ● Elimination of deadspace
○ When you have tension, the scar can widen ○ Remember that having dead space in closed
so you will not achieve the fine line scar that area will allow your seroma, hematoma to
helps keep the scar less obvious. set in and all these will interfere with proper
○ When you excise a circular skin excision it wound healing
will assume an elliptical configuration ● Layered closure
paralleling the lines of greatest tension ○ Buried dermal sutures provide strength;
most important layer to approximate
● Langer’s Lines versus RSTLs (relaxed skin ● There is no technique that reliably prevents a
tension lines) wound from widening when it has an inclination
● Langer’s lines- described by Carl Langer to do so
○ These are skin tension vectors that are
observed in the stretch integument of your

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 Z-PLASTY ● Occasionally it is useful but unlike the Z-plasty it
● They can be applied to revise and redirect your lacks the applicability and universality of the z
existing scars and to provide additional length plasty
especially in contractures. ● It simply involved by incising the scar in small
● Each Z plasty angle has a corresponding triangles so that it will interdigitate although it
theoretical gain in length. can change the direction of the scar they would
● The greater the angle the longer the length but still lie in the same, some of the limbs it would
in practice what we usually use is the 60 degree only by chance and it does not lengthen a
z plasty angle that will give us 75% gain in contracted scar so therefore for that purpose it is
length. best to use a z plasty.

How to increase the likelihood of a good scar?

● Placement of sutures that will not leave
permanent suture marks/ prompt removal of skin
sutures
○ Leaving them on for a longer period of time
will actually make your wounds more
susceptible to producing “railroad tracks”-
scars on the side of previous incision
○ Suture removal: Face- 3-5 days; scalp- 7
days; trunk- 10 days; extremities-14 days
● Wound edge eversion and apposition
○ Because a step-off between each side of the
wound can cause a shadow that will
accentuate the presence of a scar
○ The stability between two wound edges is
important because the motion between the
two will prolong the inflammatory phase of
healing and will require additional collagen
to be deposited.

WOUND HEALING
● Internal and external factors and circumstances
● Tissue injury–hemostasis–inflammatory
W-PLASTY response

Reminder: Don’t get confused stages of wound

● Described by Borges healing to stages of grafting
● Another method of revising scar

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 Factors to consider in wound healing:
● In plastic surgery, there is more than 1 way or
PATIENT FACTORS OPERATIVE
FACTORS more than 1 technique to solve a myriad of
problems. Ranging from simple to complex
-Comorbidities -Prophylactic antibiotics options.
-Nutritional status -Thermoregulation
-Medications -Surgical technique ● In the reconstructive ladder shows that there
-Glucose control -Delayed closure of
contaminated wounds progression from your primary closure to a use
-Use of appropriate of skin graft then a local flap (from the same
sutures and dressings area), regional flap(same anatomic region) and
a Free flap.
● For surgical technique in particular the minimal
● The point of a reconstructive ladder is that,
use of ties and cautery esp for facial wounds
when you apply the simplest option to meet
doc use cautery if needed in order to produce a
your reconstructive requirement, then that will
better looking scar.
ensure a life-boat or a second option should
that initial option fail.
BIOFILM
● Colony of microorganisms enveloped with a
● In many situations however sometimes we
matrix of extracellular polymers
normally choose a higher rank of the ladder,
○ EPS - extracellular polymeric substance
especially for the goal to have a more superior
● Causes:
aesthetic result, for example when we want to
○ Antibiotic resistance
fix defects on the nose. Instead of using skin
○ Latency- making detection by immune
grafts we opt to use local flap so that there is
system more difficult
better skin match or choosing to use a flap.
○ Increase species diversity
○ Quorum-sensing-when bacteria engage in a
The RECONSTRUCTIVE ELEVATOR
decision making process in which their
behavior is coordinated through a chemical
vocabulary; interaction of organisms.

III. RECONSTRUCTIVE SURGERY

The RECONSTRUCTIVE LADDER

● Introduced by Gottlieb and Krieger, although it

still acknowledges the concept of increasing
levels of complexity, it suggested a freedom to
● This technique/principle we follow in plastic move from lower level and to ascend directly to
surgery, which is applicable to your cutaneous a higher level if necessary.
defects. Usually, when we analyze a wound
whether it is cutaneous or a more complex
wound, you evaluate your different options for
closure.

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 SKIN GRAFTS AND SKIN SUBSTITUTES of cosmetic appearance. When your mesh grafts
Skin anatomy heal they look like a net. You will forever have
meshed gloves in your hands.
● You will also prefer sheet grafts over joints so
that there is less contraction.
FTSG - full thickness skin graft
● Contain entire epidermis and dermis
● Usually we get it from behind the ear, from the
clavicular (supraclavicular/ infraclavicular),
sometimes from the arm. But you have to be
able to close the donor sight.
To Review: What you have to remember:
● You have your: THE GREATER THE DERMAL CONTENT, THE
○ Dermis LESSER PRIMARY CONTRACTION BUT LESSER
○ Epidermis SECONDARY CONTRACTION!
○ Subcutaneous layer ● GRAFT - is something that is removed from the
body completely devascularized, it is replaced in
Kinds of Grafts another location. It will require vascularization
● Autograft: taken from the same individual e.g., from your wound bed in order to survive.
skin graft ○ Any tissue that is not completely removed
● Isograft: from one individual to another individual prior to placement, is not a graft.
of the same genetic constitution, e.g., grafts ● Primary contraction - is the contraction of the
between identical twins graft once you harvest it from the body.
● Allograft: from different individual of the same ○ A decrease in size that is seen in a graft
species once it is removed from the body.
● Xenograft: from different species, e.g., animal to ○ Full thickness grafts will have as much as
man. (Porcine xenograft, tilapia grafts) 40% contraction in size.
○ Split thickness about 10% contraction.
Skin grafts ● Secondary contraction - is a contraction that
occurs when it is already placed on the body.
The contraction that is experienced, the regular
part of wound healing. *that all wounds have
some degree of contraction.
○ FTSG - because they have more dermis, the
LESSER secondary contraction.
○ STSG - few amount of dermis, will
GREATER secondary contraction.
STSG FTSG

Primary contraction lesser greater

Secondary contraction greater lesser

STSG - split thickness skin graft

● Contains all epidermis and varying amounts of
dermis
● Can be harvested and applied in sheets, or they
may have holes and can be called “meshed”
skin grafts.
● The mesh serves to increase the surface area of
the skin and to allow drainage of fluids.
● But cosmetically you would prefer your sheets
grafts specially on your hands and feet, because

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 GRAFT TAKE ● In the figure, initial reconstruction where they
● Occurs in 3 phases. used a part of the ear in order to reconstruct the
nose
● The donor site for composite tissue grafts must
be repaired with primary closure

FLAPS
● Flap – vascularized block of tissue, mobilized
from donor site and transferred to another
location
A. Plasmatic imbibition ● Graft vs flap
○ Flaps have own blood supply
○ Occurs within 24 to 49hrs
○ Flaps are used in re-surgery when to repair
○ Blood supply comes from wound bed underlying structures later on from the first
surgery
B. Inosculation ○ Grafts, cannot be separated from the
○ After 48 hrs there will be a fine vascular underlying structures anymore
network between the wound bed and the
graft, “Kissing capillaries”. ● TYPES OF FLAPS
A. By blood supply
○ Random (Blood supply: dermal subdermal
C. Revascularization plexus), use in reconstruction of small full
○ Already have the new vessel growth thickness defect which graft are not
applicable, accepted Length to width ratio is
● These phases usually complete by day 4 or 5. 3:1
Also usually the time we open grafts for ■ Rotation: similar to transposition but
inspection. semicircular
■ Transposition: fashioned adjacent to an
● During the initial few days your graft is most area needing reconstruction and rotated
susceptible to interference, either from infection into the defect (e.g., Z plasty, rhomboid
or from mechanical shearing and hematoma or flap)
seroma. ■ Advancement: tissue is moved forward
● Suspicion for infection or hematoma - you may from the donor site along the flap’s long
open it in 3 days for inspection and try to axis rather than being rotated about a
point (e.g., V-Y advancement flap,
remove the seroma or hematoma, and hopefully
rectangular advancement flap)
there will be more chance for the graft to survive. ○ Axial (BS more discrete well described
Composite Graft vessels)
■ Head and neck flaps
■ Groin flap
■ Posterior thigh flap

B. By composition
○ Fasciocutaneous flaps
■ Supplied from vessels communicating
with the underlying superficial or deep
fascia
■ Thinner compared to musculocutaneous
flaps
■ Do not create a functional loss of muscle
in the donor site

● Donor tissue includes subcutaneous fat and

even cartilage, perichondrium, and muscle

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 ● T1 flap – one vascular pedicle (e.g.,
gastrocnemius, tensor fascia lata)
● T2 flap – has a dominant and some minor
pedicles (e.g., gracilis, trapezius)
● T3 flap – 2 dominant pedicles (e.g., gluteus
maximus, serratus anterior)
● T4 flap – all segmental pedicles (e.g., sartorius,
tibialis anterior)
● T5 flap – has dominant and some segmental
pedicles (e.g., latissimus dorsi)
● Minor pedicles cannot supply the flap if the
dominant is cut
● Pedicle – block of tissue that contains main
blood supply for the flap
○ Myocutaneous flaps (musculocutaneous
flaps) C. By Contiguity
■ E.g., breast reconstruction using a ○ Local vs. regional vs. distant flaps (“Pedicled
latissimus dorsi myocutaneous flap attached vascularly to the donor site” vs free
■ Can help to repair visible surface contour flaps)
deformities ■ Local: donor site located immediately
■ Easily contour to fill spaces in a adjacent to the defect
complicated wound surface ■ Regional flaps: harvested from the same
■ Provide functional restoration hence anatomic region as the defect
used to restore motor function in patients ■ Distant flaps: harvested and transferred
with motor loss in the extremities or face from outside the anatomic region of the
defect
a. Flap pedicle: tissue transmitting the
blood supply
b. Pedicled flaps: remain attached to
the source anatomic region
c. Free flaps: completely detached from
the body, and their blood supply is
reinstated by microvascular
anastomosis to recipient vessels
close to the defect
○ The generally accepted reliable length-to-
width ratio for a random flap is 3:1.

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 ● The latissimus dorsi, going back to it, it’s based
on your lumbar arteries and your thoracodorsal
(not your thoracoacromial)

Perforator flaps
● Flap connected to vessel of the subdermal or
subcutaneous plexus (involve a connection to
more distal vascularity than a conventional flap)

● Usually for these flaps, you will have to really

identify the supplying vessels that usually
perforates through the fascia, or through the
muscles and then based it on that.
● Perforator flaps will allow you more mobility in
flaps, in positioning our flaps compared to your
other conventional flaps.

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 ● By the way, when we say pedicle that is usually
the block of tissue that contains your main blood
supply for your flap.
● Your flaps are based mainly in your
Angiosomes

○ Increases the amount of local, well-matched

tissue that can be advanced o transposed as
a flap while decreasing donor site morbidity
○ Usually, we inflate it in weekly intervals,
usually 2-3 weeks intervals via a port that is
also placed under the skin.
○ In expanded skin, you have thickened
dermis with diminished subcutaneous fat.
○ The blood supply is expanded, and the
○ Similar to a skin dermatome capsule that forms around the device is also
○ Entire skin surface is perfused by a highly vascularized because of course, it is a
multitude of angiosome units foreign body so the tendency of the body is
○ Correlated by the angiosome theory which to separate it from the rest and that capsule
was First studied by Marchot 1889, also contributes to the vascularity of that
expanded by Salmo 1930 and more recently expanded area.
by In Taylor IV. PEDIATRIC PLASTIC SURGERY
● Conditioning (delay phenomenon) – any ● This is where you will see the overlap between
procedure that increases the reliability of flap by ENT surgery and plastic surgery. Both
enlarging the angiosome of your pedicle artery specialties do cleft repair, there will be just
towards its potential angiosome. So you invoke differences in techniques and methods.
the delay phenomenon, referred to as vascular ● Cheiloplasty – lip repair
delay or ischemic preconditioning wherein a ● Palatoplasty – palate repair
tissue rendered partially ischemic undergo ● For complete Cleft lip and palate – goes beyond
neovascularization and enhance its vascularity just those two, you still have a lot of procedures
after the delay period. until they are of age. What’s important is that
you stress that it is a multidisciplinary approach.
● The concept of Tissue expansion – you put in an ○ Unilateral cleft lip
inflatable, usually silicon device under the skin ○ Bilateral cleft lip
usually above the fascia in order to expand the ○ Cleft palate
surface area of the skin, allowing you to use the
tissue that has been expanded to cover usually
an adjacent defect. By that, you decrease the
donor morbidity because you’ll only be using
extra skin.

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 ● Craniofacial surgery – which includes the repair
of clefts, it is a subspecialty of plastic surgery
dealing with hard and soft tissue deformities of
the craniofacial skeleton
○ You actually have to undergo additional
training for this specialty, another year to
train for craniofacial surgery fellowship
○ Interdisciplinary approach
● Craniofacial clefts

● Atrophy and hypoplasia (Pierre Robin sequence)

○ characterized usually with micrognathia (a
small mandible), glossoptosis, and may
have a respiratory distress, in some cases,
may have palatal cleft
○ and Romberg’s – a disorder still of unknown
etiology, may have a progressive hemifacial
atrophy of the skin, subcutaneous fat, even
muscle and bone as well as cartilage which
progresses for a variable period of time
before it spontaneously ceases or burns out
at about 2 to 10 years after it begins)

● Hyperplasia, Hypertrophy and Neoplasia

(including but not limited to vascular anomalies,
neurofibromatosis, hemifacial hypertrophy, and
○ Follow the Tessier Classification, they are bony conditions such as osteomas and fibrous
usually center around the orbit like spokes
dysplasia)
on a wheel, and they are numbered from 0-
○ Vascular anomalies
14
■ Hemangioma (congenital vascular
○ Usually when you have a cleft 0, you may anomalies that initially undergo a phase
have a corresponding cleft 14; a cleft 1 may
of rapid growth followed by a slow
have a corresponding cleft 13, and so on
regression) vs. vascular malformation
and so forth because they have your facial
(abnormal vascular channels that are
clefts which are from 0 to 7, may have some already seen at birth, they never regress
cranial extensions
unlike the hemangiomas and they have
● Craniosynostosis (results from the abnormal
the potential to expand)
obliteration or premature fusion of the cranial
sutures)
○ Can be seen in Apert, Crouzon, Pfeiffer’s
syndromes

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 VASCULAR MALFORMATIONS
Capillary Malformations

● Pink-red
macular
vascular
stains that
are present
at birth and
○ Infantile hemangioma persist
■ Most common birthmark throughout
■ Appears in early neonatalhood usually at life
2 weeks ● Become more verrucous and darker throughout
■ Rapid growth during first 6-8 months of life
infancy (proliferating phase) ● Port-wine stains (CMs of the head and neck)
■ Growth frequently peaks before the first associated with Sturge Weber syndrome
year, and then the lesions enter the (vascular involvement of the leptomeninges and
involuting phase – diminishing ocular pathology)
endothelial activity and luminal ● Pulsed dye laser treatment (better results in
enlargement infancy and young childhoods)
■ Involuted phase (in 50% by age 5, 70%
by 7 years, with continued improvement Lymphatic Malformations/ Lymphangiomas or
until age 10-12) cystic hygromas
■ In 50% of children, near normal skin is
● Never
restored
regress and
■ Treatment is largely observational
have the
■ Oral propranolol: first-line treatment for
potential to
complicated or high-risk infantile
affect
hemangiomas
underlying
muscle and
● When you administer this during the proliferative
bone
phase, the non-selective beta adrenergic
● Expand or
blockade causes rapid involution of your
contract with the flow of lymph, infection, or
hemangioma
intralesional hemorrhage
○ Vascular malformations
● Sclerotherapy - main treatment, usually done
■ Slow-flow lesions: usually these are
before surgery
capillary malformations and
● Although surgery rarely removes the entire
telangiectasias, lymphatic malformations,
lesion, surgical resection is the only possibility
and venous malformations.
for cure.
■ Fast-flow lesions: (if they have an arterial
○ Associated with significant blood loss
component) arterial malformations and
○ Potential exists for regeneration of lymph
arteriovenous malformations (AVMs)
channels and recurrence of the LMs
■ Combined capillary, lymphatic and
postoperatively
venous malformation: Klippel-Trenaunay
syndrome
■ CMs, LMs, and VMs are found; may be
associated with soft tissue and skeletal
hypertrophy in one or more of the limbs

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 Venous Malformations

● VMs: bluish, soft,

compressible
● Grow with the child,
may enlarge during
puberty
● With associated
stiffness and pain
with thrombosis
● Affect the skin,
muscle, and bone
● MRI* imaging of choice
● Preoperative sclerosis followed by surgical
extirpation – treatment of choice
● Recanalize and re-expand
● Elastic support stocking and low - dose aspirin
therapy (especially when involving lower
extremities)

Arterial Malformations
● Goals: remove (or at least reduce) the risk of
● Pure AMs are rare and more commonly present
malignant transformation (eg. for your giant
as AVMs (arterial and venous malformation)
melanocytic nevi, 0-5% risk of malignant
● AVMs: red violaceous skin with a palpable mass
transformation, malignant melanoma), we do
beneath.
surgery to preserve function and improve
● Local warmth, bruit, and thrill are frequently
cosmesis
present.
● Near the skin ng CMN, you expand the skin
● Ischemic changes, ulceration, intractable pain,
there, use an expander for that. Pag tinanggal
and intermittent bleeding
mo yung CMN, since you expanded the nearby
● Four stages: quiescence, expansion, destruction,
skin you can advance the expanded skin to that
and decompensation.
area (where the CMN is).
● Treatment is initiated when signs and symptoms
● You can also have Neurocutaneous
of ischemic pain, ulceration, bleeding, or
melanocytosis: a collection of melanocytes in
hemodynamic instability (stages 3 and 4) are
the leptomeninges.
evident
● Arterial embolization (to occlude nidus 24-72
V. FACIAL FRACTURES
hours before you remove it) before surgical
extirpation

Congenital Melanocytic Nevi

● Contain nevus cells and are usually present at
birth
● Most common locations: trunk, extremities, head
and neck
● At risk for melanoma and neurocutaneous
melanocytosis (large or giant CMNs)

● Main priority is to stabilize the patient and treat

life-threatening injuries
● We also repair facial fractures. Remember we
need to stabilize the patient and treat life
threatening injuries before we move on to facial
fractures themselves.

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 ● Not necessarily emergencies but associated
bleeding and respiratory distress are
emergencies.
● Most common life-threatening consideration:
airway maintenance, control of bleeding,
identification and treatment of aspiration, and
identification of other injuries

A. MANDIBLE FRACTURES

● Non-surgical treatment: minimal displacement,

preservation of the pre-traumatic occlusive
relationship, and normal range of motion
● Goals: restoration of pre-traumatic dental
occlusion, reduction and stable fixation of the
fracture, and repair of soft tissue
● Complications: infection, nonunion, malunion,
malocclusion, facial nerve branch injury, infra-
● Frequently multiple alveolar or mental nerve injury, and dental
● Angle classification system (describes the fractures
relationship of the maxillary teeth to the ● Once bumaba yung edema, assess mo post-
mandibular teeth) repair, usually within the first 2 weeks maluwag
○ Class I is normal occlusion, with the mesial pa yung mga fragments, pwede mo i-move and
buccal cusp of the first maxillary molar fitting fix in place, after 2 weeks, magcacallous na so
into the intercuspal groove of the mandibular you have to refracture the segments to align
first molar. them in proper position. You have to follow the
○ Class II malocclusion is characterized by proper position, not just for function but for the
anterior (mesial) positioning normal/pre-traumatic face orientation/shape.
○ Class III malocclusion is posterior (distal)
positioning of the maxillary teeth with B. FRONTAL SINUS FRACTURES
respect to the mandibular teeth ● Anterior table is relatively weak and subject to
fracture when it sustains a direct forceful blow,
making frontal sinus fractures relatively common
in facial trauma

● Treatment of a
frontal sinus
fracture depends
on the fracture
characteristics as
shown in the
algorithm

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 ● Orbital Apex Syndrome - most severe
circumstance in which superior orbital fissure
syndrome is combined with signs of optic
nerve (cranial nerve II) compression
manifested visual changes ranging up to
complete blindness
● You managed both with steroid therapy and
surgical decompression if needed

D. LE FORT INJURIES

(Note: please check the last page for larger picture)

C. ORBITAL FRACTURES

● Evaluation of visual acuity and possible globe

injury
● Most common orbital fracture: orbital floor blow- ● True Le Fort Injury is when there is involvement
out fracture (direct pressure to the globe and of Pterygoid plates
sudden increase in intraorbital pressure) ● T1 passes to the maxillary sinuses and lower
○ Orbital floor – weakest bone nasal septum and pterygoid plate
● Medial floor and inferior medial wall are made of ● T2 Oblique fracture passes zygomaticum
the thinnest bone, so fractures occur most maxillary line, inferior orbital rim through the
frequently at these locations nasal frontal suture or nasal bridge
○ Treated with observation only if they are ● T3 above zygomatic arch, through lateral and
isolated and small without signs of medial orbital walls and nasofrontal suture as
displacement or limitation of mobility of the well
globe
○ surgical treatment is generally indicated for E. NASO-ORBITAL-ETHMOID FRACTURES
large fractures or ones associated with (NOEF or NOE fractures)
enophthalmos (retrusion of the globe) ● Often part of a constellation of panfacial
fractures and intracranial injuries
● Superior orbital fissure syndrome: compression
of structures contained in the superior orbital
fissure in the posterior orbit
○ Cranial nerves III, IV, and VI, first sensory
division of cranial nerve V (V1)
○ Eyelid ptosis, globe proptosis, paralysis of
the extraocular muscles, and anesthesia in
the cranial nerve V1 distribution are
considered surgical emergency most
especially also if there’s the involvement of
CN II causing blindness and problems in the
visual acuity this causes the ORBITAL ● Involves the medial orbits, nasal bones, nasal
APEX SYNDROME processes of the frontal bone, and frontal
processes of the maxilla

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 ● Result in severe functional deficit and cosmetic
deformity
Telecanthus

● Produced by splaying
apart of the
nasomaxillary buttresses
to which the medial
canthal ligaments are
● Most common facial fracture (prominent
attached
location)
● Treatment: plating or
○ Intranasal examination (check for septal
wiring all bone
hematoma) important thing to consider
fragments meticulously,
○ If hematoma is present, it must be incised,
potentially with primary
drained, and packed to prevent pressure
bone grafting, to restore their normal
necrosis of the nasal septum and long-
configuration
term mid vault collapse. The septal
hematoma usually looks like a bluish or
F. TRIPOD FRACTURES
purplish collection of blood on the side of
nasal septum. Since the nasal septum is an
●
Zygomaticomaxi-
important support structure in the mid vault.
llary complex
The septum could collapse during necrosis,
fracture, also
and causes saddle nose deformity
known as a
● Closed reduction of nasal fractures may be
quadripod fracture,
performed under local or general anesthesia
quadramalar
● Many, if not most, show some deformity upon
fracture, and
final healing
formerly referred
to as a tripod
I. PANFACIAL FRACTURES
fracture or trimalar
fracture, has four components:
○ lateral orbital wall (zygomaticosphenoid and
zygomaticofrontal sutures)
○ separation of the maxilla and zygoma along
the anterior maxilla (near the
zygomaticomaxillary suture)
○ zygomatic arch
○ orbital floor
● Fractures of multiple bones in various locations
○ May involve frontal and maxillary sinus
G. NASAL FRACTURES
fractures, NOE fractures, orbital and ZMC
fractures, palatal fractures, and complex
mandible fractures
● Difficult to reestablish the normal relationships
between facial features in the absence of all pre-
traumatic reference points
● Without proper correction of bony fragment
relationships, facial width is exaggerated, and
facial projection is lost.
● The key point is first to reduce and repair the
zygomatic arches and frontal bar to establish the
frame and width of the face.

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 Samplex
5. Lay perpendicular to and more accurately
1. Established the name of the specialty reflects the action of the underlying muscles.
a. John Staige Davis a. Langer’s line
b. John Felix Anthony Cena b. RSTL
c. John Stuart Mill c. Both
d. John Travolta Depp d. NOTA

2. True about plastic surgery except 6. Method that can revise and redirect your
a. It defies any definition and has no organ existing scars and to provide additional length
system of its own and is based on principles especially in contractures but lacks the
rather than specific procedures applicability and universality
b. It is organized on a specific organ system a. Z plasty
and has very loose boundaries and has b. W plasty
specific anatomic regions and does not c. Both
overlap with a lot of other subspecialties. d. NOTA
c. Plastic and Reconstructive Surgeons are
called at the end of the operation or 7. How to increase the likelihood of a good scar?
treatment to reconstruct what has been lost. a. Placement of sutures that will not leave
d. AOTA permanent suture marks/ prompt removal of
skin sutures
3. “Plastikos” is a greek word which means b. Wound edge inversion and apposition
a. To hide c. Both
b. To connect d. NOTA
c. To cut 8. Colony of microorganisms enveloped with a
d. To mold matrix of extracellular polymers will cause
4. The most common facial fracture is? a. Latency
a. Tripod fracture b. Antibiotic resistance
b. Mandible fracture c. Increase species diversity
c. Nasal fracture d. Quorum-sensing
d. NOEF e. AOTA

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 SURGERY II | PLASTIC AND RECONSTRUCTIVE SURGERY (PART 2)
Tutor: Dr. DE GRANO | Lecture Date: May 13, 2022 | 2ND SEMESTER

● Alternatively, use of an Antia-Buch chondrocutaneous

TOPIC OUTLINE advancement flap combined with cartilaginous
I. Ear Reconstruction reduction allows for closure of defects.
II. Nasal Reconstruction
III. Lip Reconstruction
II.Nasal Reconstruction
IV. Eyelid Reconstruction
V. Scalp Reconstruction
VI. Head and Neck Reconstruction
VII. Breast Reconstruction
VIII. Trunk and Abdominal Reconstruction
IX. Extremity Reconstruction
X. Pelvic Reconstruction
XI. Pressure Sores
XII. Aesthetic Surgery
*Purple: Synch class (Summary Session)

I. Ear Reconstruction
● Small helical lesions - may be addressed by wedge
excision, primary closure
● Larger defects (especially upper and middle thirds of
your ear) - may be approached by antihelical and
● Reconstruction of the nose requires appreciation of
conchal cartilage reduction patterns to reduce the
the nine aesthetic subunits defined by normal
circumference of the helix to allow primary closure.
anatomic contours and lighting patterns.
● At the same time Local flaps may be used to close or
○ Dorsum
re-create the missing tissue.
○ Sidewall (2)
○ Tip
○ Ala (2)
○ Soft triangle (2)
○ collumella
● In general, if a defect involves >/= 50% of a subunit,
the remainder of the subunit should be excised and
included in the reconstruction.
● This is a 1 stage repair for microtia, usually they put in ● Three layers: skin cover, structure support, and
an implant material to recreate the cartilage. mucosal lining
● They expand the skin envelope and insert that ● When a defect or anticipated defect is evaluated, it is
preformed, carved ear rigid framework. useful to consider what layers of tissue will be missing
● They used the antia-buch flap, if you notice this is a so that a reconstruction can be devised that replaces
helical defect which resulted from the excision from each layer.
the lesion. What happened was, there was some ● Healing by secondary intention- used in concavities
cartilage reduction/ helical reduction flaps done, so e.g. alar grooves
that you can still close it to resemble an ear. Usually ● Split or full-thickness skin graft- used in superficial
you will end up with a smaller ear and it may also have defects of the nasal dorsum or sidewall
some cupping because of the decrease size. ● Composite grafts- used for the nasal tip or rim
● Post-auricular flaps created in staged proceduresmay ● Local random pattern flaps- useful in closing small
be manipulated to create a skin tube mimicking the defects of the dorsum or tip
furled helix and bridging the gap of a defect. - May be combined with cartilage grafts if
structural support is needed
● Axial pattern flaps- used for larger defects

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 -Advantage: being able to cover and revascularize ● TWO CATEGORIES OF LIP FLAP TECHNIQUE
underlying cartilage grafts and enjoy a close color - Cross-lip flaps
match to surrounding skin 1. Abbe flap – originally designed to reconstruct
● Workhorse flaps- used in nasal reconstruction include central upper lip (tubercle) defects.
the nasolabial flap and the parameters of the 2. Est lander flap – based laterally at the oral
paramedian forehead flap commissure and is used to reconstruct lateral
● Split calvarial cantilever bone grafts- may provide upper or lower lip lesions
nasal dorsum support

The picture above is an example of nasal

reconstruction. Part of the right labial fold was used to
reconstruct the area of defect at the right alar area. The
other reconstruction involves use of paramedian skin
The picture above is an example of Webster-Bernard flap
excision in the forehead to reconstruct the nasal soft
used to reconstruct the lower lip. The nasolabial area,
triangle and part of the tip.
lower lip area and chin to recreate a lower lip.

III. Lip Reconstruction

● Importance: articulate speech, eating, maintenance
of oral competence, facial expression and aesthetic
harmony of the lower face
● Layers: skin, muscle, mucosa
● Blood supply: Facial arteries, branches to the lip;
superior and inferior labial arteries
● Lip defects: may arise from trauma, burns, neoplasms,
congenital lesions, clefts or infection.
● Goals:
- Restoration of the competent oral sphincter with
vermilion apposition
- Preservation of sensation
- Avoidance of microstomia
- Preserve a near – normal static and dynamic
appearance.
The picture above is an example of an Abbe flap. Part of
● Lower lip defect <1/3 (¼ for the upper lip, and up to
the lower lip is used to increase the horizontal length of
1/3 for the lower lip) – primary closure without using
the upper lip. This is usually used in bilateral cleft lip
flaps.
because they tend to have contracted or short upper
● Lip shave (advancement of the labial mucosa)-
correction of vermillion-only defects in the upperand
IV. Eyelid Reconstruction
lower lip

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 ● UPPER EYELID: Defects comprising <25% of the
upper/lower eyelid can generally be closed primarily
in pentagonal approximating fashion to avoid any
“dog ears" and wound contraction that could lead to
an exposed cornea.

The above picture is a lower eyelid reconstruction using a

rotational flap.
● Defects involving 25-50% - lateral canthotomy and
cantholysis, often combined with the use of a lateral
semicircular flap
● Defects larger than 50% - reconstructed with a Cutler-
Beard full-thickness advancement flap or a modified
Hughes tarsoconjunctival advancement flap
● LOWER LID: reconstruction is parallel with the upper
lid. Similar reconstructive methods may be used,
including direct closure, semicircular flaps, and
advancement flaps
● PTOSIS
- Mild ptosis – Fasanella-Servat procedure (involves
excision of the superior tarsal edge, conjunctiva,
and levator aponeurosis, and mullerectomy
- Moderate ptosis with good levator function –
levator aponeurosis shortening procedure
- Severe ptosis with poor levator function –
requires use of an alternative eyelid motor
(Frontalis muscle fascial sling technique)
The picture above is called Cutler Beard flap which is a full
thickness flap from the lower lid used to reconstruct an
upper eyelid defect. The eyes are closed for about3weeks
for the graft to adapt.

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 V. Scalp Reconstruction ● Calvarian graft – partial thickness bone harvested
● Partial defects from an intact portion of the calvarium.
- Defects <3cm – amenable to primary closure ● Rib bone may be used, unfortunately may give an
- Larger full thickness defects (4-8 cm) – scalp flaps unappealing “washboard” appearance of the scalp.
- >8-10cm full thickness defects – best treated with
microsurgery

Scalp Anatomy

Above picture is a titanium mesh plate also used to

reconstruct calvarium defects.
The above picture is an example of vertex defect.Adouble
VI. Head and Neck Reconstruction
opposing scalp flap was used to close the defect.
● Head and neck region has a compact arrangement of
critical and complex structures encasing the essential
Trapezius flap can also be used to close a scalp defect as
routes to the gastrointestinal and respiratory systems.
seen below. I use this a lot in burn patients.
● The tissues of the face, interface of the mouth, and
cavities serve as a primary communication with the
external environment through facial and verbal
expression.
● Therefore, cancer resections with adequate safety
margins can be severely and multiply debilitating.
● Tumor-ablative surgery: freedom available to the
ablative surgeon to completely excise a tumor is
limited, at least partly, by the capability of the
reconstructive surgeon to restore anatomic continuity
and achieve successful wound healing meaning you
CALVARIAL RECONSTRUCTION should be reconstructing it with function.
● Autogeneous bone remains the material of choice. ● A neck dissection to remove cervical lymphatics and
- Advantage: resistance to infection and ability to nodes may be performed for prophylactic or curative
heal with strength intent, for more accurate prognostication by
● Alternative materials: methyl methacrylate, titanium operative staging, and/or for solidification of plansfor
and hydroxyapatite etc. adjunctive treatments.
● Scalp avulsion – attempt for scalp replantation ● (TNM) classification and staging of head and neck
cancers.
- T: tumor location
- N and M parameters are fairly constant for most
head and neck cancers
● PRINCIPLES OF RECONSTRUCTION. The
reconstructive surgeon aims to restore lost anatomic
components adequately.
- Residual deficits, seemingly inconsequential,may
progress to psychological morbidity, societal
malacceptance, and social withdrawal.

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 -
Uncomplicated and timely wound healing is
important to allow adjuvant therapies when
indicated and smooth discharge to home and
occupation
● RECONSTRUCTIVE OPTIONS BY REGION
- Intraoral structures. The reconstructive choice
for floor of mouth, tongue, and other intraoral
defects is dictated by the dimension of the defect,
the volume of tissue lost, and residual tongue
mobility.
- Mandible and Midface - Mandibular defects may
arise from the ablation of tumors involving the
bone itself or from the need to satisfy clearance
The above picture is a pectoralis major skin and muscle
margins for adjacent soft tissue tumors.
flap used to reconstruct part of the oral area.
Segmental mandibular defects can be classifiedas
isolated bone defects, compound defects (bone
and oral lining or skin), composite defects (bone,
oral lining, and skin), or extensive composite
defects (bone, oral lining, skin, and soft tissues).
- Esophagus and Hypopharynx - The goals of
reconstruction for esophageal and
hypopharyngeal defects, which may be
circumferential or partial, are to maintain luminal
patency, restore speech and swallowing, and
avoid strictures, fistulas, and gastro intestinal
anastomotic leaks. Reconstructive options for
partial defects include primary closure, if luminal
The picture below shows fibula bone free flap used to
narrowing is insignificant, and skin (or dermal)
reconstruct a bone defect. Since removing part of fibula
grafts for partial-lining defects.
doesn’t affect gait and stability. Myocutaneous flap is
● FACIAL REANIMATION
used to close the defect.
- The long-term goals include normal static
appearance, symmetry with movement, and
VII. Breast Reconstruction
restoration of voluntary muscular control.
● Timing (immediate vs. delayed, *delayed immediate
Although the best results usually require multi-
● Immediate reconstruction: the initiation of
staged, complex surgeries, the elderly patient is
reconstructive process at the time of the surgery, and
better served by a single-stage procedure that
usually done in a patient with an early stage of disease
provides immediate improvement
for whom there is a low expectation of any
- Neural techniques - Traumatic injuries to the
postoperative radiation therapy
facial nerve without segmental nerve loss are best
● It takes advantage of the preserve supple skin
treated with primary end-to-end neurorrhaphyof
envelope usually made possible by using a skin
the facial nerve stumps. The success of this repair
sparing mastectomy approach so in general it will
depends on accurate approximation of nerve
allow aesthetically pleasing and symmetric
ends and this repair depends on accurate
reconstruction it is also psychologically advantageous
approximation of nerve ends and achievementof
because it will avoid having to live with a mastectomy
a tension-free epineural repair with fine sutures.
deformity as in delayed reconstruction and you will
have fewer operations than when you proceed with
stage procedures.
● If you do reconstruction prior radiotherapy for
example if you use an implant it can deformed the

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 implant that you put in and also even if you use a flap tumor and usually use reduction mammoplasty
there’s also a chance that it can affect the quality of techniques on the other breast to make them
the flap symmetrical, one flap that is used is the lateral
● Possible disadvantage of immediate reconstructionis thoracodorsal flap which is especially useful forlateral
the potential delay of adjuvant therapy should there breast defects (ex. is photo below)
be any complications and you can have partial
necrosis of your mastectomy skin flaps and it might
require an anticipated postoperative radiation
therapy
● Delayed reconstruction is initiated 3-6 months after
mastectomy it avoids any problems with your
mastectomy flaps should it be unreliable and the
effects of radiation therapy however have the patient
will be subjective to an additional operative
procedures and overall the cosmetic result is often
worse especially with autologous tissue
reconstruction because by then the skin has already
contracted and stuck to your chest wall so there will
be scars and if you have radiation therapy prior then
it will also already affect your reconstructive site. Implant-based reconstruction
● Delayed immediate- middle ground; insertion of an
expander rather than an implant, the expander is left
in and also inflated at intervals until a sufficient skin
envelop is achieved so it will avoid having toworkwith
skin that is already plastered to the chest wall and at
the same time even if the patient is subjected tosome
form of radiation therapy since the expander will be
removed and will be replaced either with an implant ● Immediate breast reconstruction may either be
or with an autologous reconstruction later on it won't through the use of an implant or autologous
really matter in the sense that that is not yet the final reconstruction
reconstructive stage. ● For implant we tend to put it underneath pectoralis
● Remember immediate reconstruction usuallythe best muscle in order to give more coverage for the implant
option you can also do delayed immediate or delayed, to avoid extrusion or deformities and it will require
so delayed immediate is again when you put an that there enough skin leftover after removal of the
expander so that makes it immediate but delayed breast tumor usually via skin sparing approach or
because you have to expand the device underneathto nipple sparing approach
create a skin envelope where you put in your new ● (Right pictures) tissue expander is Inflated over time
implant usually after radiotherapy kasi if you put even if the patient have radiotherapy that’s okayeven
implant then mag radiotherapy it can deformed the if it is deformed a little that's okay as long as you are
implant. able to maintain a skin envelope because after
radiotherapy you can remove tissue expander and
Partial Breast reconstruction replace it with an implant
Oncoplastic surgery
● set of techniques developed to lessen breast Total autologous reconstruction
deformity from partial mastectomy, both in the
delayed and the immediate settings
● One of the most common methods of minimizing
defect visibility in large breasted is to rearrange the
breast parenchyma at the time of the removal of the

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 ● Above picture shows total autologous breast
reconstruction using transverse rectus abdominis
myocutaneous flap, which uses abdominal skin, fat
and one of rectus abdominis muscles in order to
recreate the breast mount.

Implant + autologous tissue ● If they don’t want to use autologous reconstruction,

you can use tattooing in order to recreate the nipple-
areola complex.

VIII. Trunk and Abdominal Reconstruction

● Done by removing a part of the chest wall.

○ In cases where patients do not have enough

autologous tissue, implant + autologous tissue is
used.
○ Lateral Latissimus dorsi is usually used to cover
the implant.
○ The most commonly used donor site is the
abdomen.
○ Most women in the breast cancer patient
population have redundant skin and fat in the ● The Thoraco Vascular surgeon recreates the rib using
lower abdomen that may be transferred to the a foreign material/rigid material then covers it with
chest wall and fashioned into a breast mound. mesh and covers it with a latissimus dorsi muscle from
the back to cover the chest defect.
Nipple-areola complex reconstruction
● Done after about 3 months after breast
reconstruction.
● Using local skin, flaps are created and sutured in a
way that will resemble a nipple and skin can be
harvested and resutured to that area so when it
heals it will look like an areola.

● One of the methods used is the separation of the

components procedure/components separation and
is used to close large midline defects without
resorting to the use of a mesh, which can be expensive
and hard to procure.
● This procedure involves an advancement of the
bilateral myofascial flaps consisting of the anterior
rectus fascia, internal oblique, and transverse
abdominis muscle complex.

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 ● The mobility of these components is possible via the
release of external oblique muscle at the semilunate
line.
● Midline defects measuring 10cm superiorly or above
umbilicus, 1 8cm centrally or at the umbilical level,
and 8cm inferiorly or below the umbilicus can be
closed by separation of components.
● Supraumbilical is up to 10 cm (5 on each side),
centrally is 18 cm then infraumbilically 8cm (or 4 on
each side)

● The above picture shows the use of tensor fascia latae

flaps to close abdominal defect.

IX. Extremity Reconstruction

● Post resection
● Diabetic ulcers – multidisciplinary approach ● The best management is to involve a multidisciplinary
○ The pathophysiology of primary diabetic lower team.
limb complications has three main components:
peripheral neuropathy (motor, sensory, and X. Pelvic Reconstruction
autonomic), peripheral vascular disease, and
immunodeficiency.
○ Plastic surgical management starts with thorough
debridement of devitalized or infected tissues,
purulent cavities, and osteomyelitic bone.
Methods of wound closure are dictated by the
extent and location of the post debridement
defect
● Lymphedema – no universally accepted remedies,
however there are treatment methods including
reconstructive surgery that is effective in carefully
selected patients.
○ The mainstays of management for lower
extremity lymphedema are patient educationand
nonsurgical measures, including one or more of
the following: use of external compressive
garments and devices, limb elevation,
administration of antibiotics for episodes of
● This is the use of thigh flap particularly gracilis muscle
cellulitis, and specialized complex physical
flap which is used to reconstruct or repair a recto
therapy.
urethral fistula.

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 XI. Pressure Sores ● Upper left and right photos: This is a gluteal flap which
● Tissue injury, usually a bony prominence, due to acts like a rotational flap, rotated on a sacral ulcer.
pressure or a combination of pressure and shear ● Lower left and right photos: This is a tensor fascia lata
forces. flap, which is a myocutaneous flap. The tensor Fascia
is underneath there and was advanced/transposed
into this trochanteric defect.
● A lot of times depending on the case, you can do
conservative management or proper wound care lang
talaga especially if the patient’s support is not that
good, better to do wound care.
● However, kapag good candidate yung patient or has a
good prognosis, like for example naging bedridden
lang sya for a while (e.g. stroke patients) tapos
nagkaroon ng pressure sores tapos nakarecover
naman, they are very good candidates for
reconstruction.

XII. Aesthetic Surgery

● Reconstructive surgery is usually performed on the
structure of the body that are abnormal due to
congenital defects or developmental abnormalities,
trauma, infection or disease and generally performto
improve function but may also be done to
approximate a normal appearance
● Aesthetic surgery on the other hand is a “Surgery
performed to reshape normal structures of the body
and to improve the patient’s appearance and self-
esteem”
○ This has an impact on psychosocial health, a well-
● Stage I and II ulcers are treated conservatively with documented influence on employment
dressing changes and basic pressure ulcer prevention opportunity advancement and earnings of
strategies as already discussed. physical attractiveness.
● Patients with stage III or IV ulcers should be evaluated ● Blepharoplasty and Brow Lift
for surgery.

○ Upper right and left photos: Blepharoplasty or eye

bag removal which shows upper and lower lid
surgery. Notice crispier lines, removal of excesslid
skin, and disappearance of the eye bags.

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 ○ Lower right and left photos: You will see a brow applying lateral traction on the cheek skin toopen
lift. You can see the elevated, more arch the valve and observing whether airflow
appearance of the brows. improves.
○ Youthful brow in women is above the brow bone ○ Aesthetic deformities of the tip of the nose are
and on the brow bone for men. treated by reducing the width of the lower lateral
cartilages and/or sewing the cartilages together
● Facelift to reduce tip width.
○ Removal of sagging skin folds due to aging ○ Small tips can be augmented with cartilage grafts
○ Most common complication is hematoma harvested from septum or auricle.
○ Makes you look 10-15 years younger and could ○ COMPLICATION: induction of new nasal airway
also last for 10-15 years obstruction and a variety of aesthetic deformities
○ Correction of jowls, nasolabial folds, and ○ Nonsurgical rhinoplasty - fillers din yan
redundant neck skin can be accomplished with a ○ Not fully achieved using implants, you have touse
facelift procedure that both removes skin and cartilage (ear, rib and —)
tightens the superficial musculoaponeurotic
system (SMAS) layer. ● Excisional body contouring – If a patient has excessive
○ COMPLICATION: hematoma (most common); rare skin laxity and willing to trade skin for scar.
nerve injury, temporal and marginal mandibular ○ Abdominal/panniculectomy
branch injury ■ most common body-contouring procedure
○ Botox and fillers can be combined for this but not and can range from a limited-incision skin
permanent. Buccal fat reduction- pagsisisihanmo removal in the lower abdomen to a major skin
pagtanda mo since maghohollow-out yan, pero excision with transposition of the umbilicus
pwede ding hindi, makikita mo na lang pagtanda and plication of the rectus muscles to further
mo enhance contour.
○ There are also injections for your double chin ■ COMPLICATION: skin necrosis, persistent
called Kybella (deoxycholic acid injection - only paresthesias of the abdominal wall, seroma,
FSA-approved injectable treatment for adultsthat and wound separation.
destroys fat cells under the chin to improve your ■ Lipoabdominoplasty: fats in the waist are the
profile) ones that are very hard to lose via exercise,
very stubborn fat deposits, as we age there
are ; you can do liposuction of the flanks
together with abdominoplasty; good
procedure for those who have given birth
many times, there’s diastasis recti for these
women so we do abdominal wall contouring
○ Brachioplasty or arm lift
● Rhinoplasty – common for Asians for having low nose ■ Leaves a visible longitudinal scar on the upper
bridge and bulbous nose ( picture below) arm. Therefore, it is reserved for patientswith
excessive skin in that region. The patient
willing to accept the scar can be happy with
the results.
■ COMPLICATION: distal seroma and wound
separation, paresthesia, wound contracture
in the axilla
○ Evaluation of the rhinoplasty patient not only
○ Thigh and buttock lift
should include the aesthetic complaints, but also
■ Treatment of loose skin on the thighs and
should consider the function of the nasal airways.
buttocks involves a spectrum of operations
○ COTTLE SIGN: Obstruction at the internal nasal
customized to the individual patient.
valve, which is the junction of the upper lateral
■ Circumferential lower body lift
cartilage and septum, can be identified by

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 ● combination of abdominoplasty, thigh
lift, and buttock lift
■ COMPLICATION: seroma, wound separation,
skin necrosis, change in the shape of the
genital region

● Abdominal pannus as seen above could be removed

via panniculectomy but if only skin contouring is done
it is called abdominoplasty
● Decreasing the distance between the rectus muscles,
which is done in these procedures help strengthenthe
abdominal wall and prevent diastasis recti commonly
seen in pregnancy.
● Reduction Mammoplasty – performed to treat
symptoms of macromastia, most commonly
consisting of the triad of upper back pain, bra strap …
and rashes under the fold of the breast. for those na
masyadong overlying
● Mastopexy – in contradiction to mass reduction, you
only reshape the breast and usually you have very
little to no removal of any volume. Otherwise one of
the breast lift, you just want to reposition the breast
without removing any volume.

There is a great decrease in size, although in mastopexy

we also decrease already the size of the areola and even
the nipples

There is a real breast reduction, there is a real difference

in the volume
● Augmentation mammoplasty – Usually done through
implants but apart from implants you can also use fat
transfer or fat injection
● Gynecomastia surgery – (in males) which can be
treated with liposuction and/or skin excision forthose

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 with excess glandular tissue that cannot be remove by traumatic, oncologic, or congenital processes. Like in
liposuction. this patient

Patient with gynecomastia may also have large areolasso

we can also do areola reduction
● Suction lipectomy/liposuction
● There is an atrophy of the temporal area treated with
autologous fat transfer. Even in an aging face, you can
also do contour correction.
● Advantage: all natural as opposed to when you used
fillers which will dissolved in about a year, but fat
grafting is of course, also not all the fats survive, it can
be a range for even as low as (I think) 20% to about
● – involves the removal of adipose tissue through
more or less, peak at most, for some in general about
minimal incisions using a hollow suction cannula.
Although the scarring is quite innocuous, a key 60%, 70% survived. Thus, you may need additional
sessions.
principle of liposuction is that the fat being removed
without skin tightening. Therefore, you rely on
patient’s inherent skin elasticity to provide retraction
over the treated adipose tissue. If you have a lot of
excess skin, you have to tell the patient that youmight
eventually have to do excision of that excess skin. So
in which case, the patient maybe a better candidate
of abdominoplasty with liposuction. It is worth
mentioning that liposuction, and this is my personal
practice, that it is not considered as a wait lost
treatment rather it should be for addressing
unwanted ad troublesome adipose tissue. Typically,
the best candidate for liposuction are those who are
already close to their goal weight and only have some
focal adipose deposits that are resistant to diet and
exercise.
● Autologous fat grafting – Key to the technique is the
processing step in which the sterile collected fat is
separated from the aqueous and free lipid fractions,
and it is done through centrifugation and/or filtering.
Specific applications include fat grafting to augment
areas where fat atrophy is common place like the
ageing of face and hands. So usually you get it from
your own, from areas that may have excess adipose
tissue like the tummy area, sometimes from the
thighs. After processing, you can inject it to the areas
that need augmentation or for those that need
contour correction which can be cause by iatrogenic,

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 SAMPLEX ANSWER:
1. Surgery performed to reshape normal structures 1. A
of the body and to improve the patient’s 2. B
appearance and self-esteem 3. C
a. Aesthetic Surgery 4. B
b. Reconstructive Surgery 5. A
c. Orthopedic Surgery 6. C
d. Dermatologic Surgery 7.
2. Tissue injury, usually a bony prominence, due to
pressure or a combination of pressure and shear
forces.
a. Peer Pressure
b. Pressure Sore
c. Pressure Feelings
d. NOTA
3. Nipple-areola complex reconstruction is done
after how many months after breast
reconstruction.
a. 9 months
b. 12 months
c. 3 months
d. 6 months

4. Initiation of reconstructive process of breast at

the time of the surgery.
a. Delayed- Immediate reconstruction
b. Immediate reconstruction
c. Delayed reconstruction
5. Known as the middle ground or insertion of an
expander rather than an implant.
a. Delayed- Immediate reconstruction
b. Immediate reconstruction
c. Delayed reconstruction

6. Set of techniques developed to lessen breast

deformity from partial mastectomy, both in the
delayed and the immediate settings.
a. Oncology surgery
b. Oncogenic surgery
c. Oncoplastic surgery

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