Specialist & Consultant Plastic Surgery oral assessment prep

Knowledge: This is a major flame burn with inhalation injury and carbon monoxide poisoning, with possible cyanide toxicity from an enclosed-space fire. The airway is the first threat: hoarseness and soot predict progressive oedema, so early intubation by an experienced operator is safer than waiting. ABLS recommends starting crystalloid at 2 mL/kg per percent burn over 24 hours in adults, half in the first 8 hours from the time of injury, titrated to urine output of about 0.5 mL/kg/h. Over-resuscitation causes compartment syndromes and pulmonary oedema. Circumferential full-thickness limb burns threaten perfusion and need escharotomy.

Management: I secure the airway early with an uncut tube, give 100 percent oxygen and consider hydroxocobalamin if lactate stays high. I place two large-bore cannulas, through unburned skin if possible, start lactated Ringer's at the calculated rate from the time of injury allowing for fluid already given, and insert a urinary catheter. I adjust the rate hourly to urine output, not the formula, and consider albumin if requirements climb. I perform forearm escharotomies along the mid-medial and mid-lateral lines, extending into the hand if needed, and assess chest compliance for truncal release. I check the corneas, give tetanus prophylaxis, start early enteral feeding and avoid prophylactic antibiotics. Over the next days I plan early excision and grafting with allograft or dermal substitutes, and bronchoscopy for inhalation injury. Follow-up includes scar management, therapy, psychological support and reconstruction.

Ethics and communication: He will lose capacity after intubation, so I explain the plan briefly beforehand where possible and proceed under the emergency exception. As a workplace injury, the employer may call; information is shared only with his consent or as the law requires. Family are given honest survival estimates. Occupational safety reporting follows UAE law and facility policy.

Reference: ISBI Practice Guidelines for Burn Care, International Society for Burn Injuries, 2016; American Burn Association, Advanced Burn Life Support (ABLS) Provider Manual

Knowledge: The thumb provides about 40 percent of hand function, so thumb amputation is a strong indication for replantation whenever technically possible. Other strong indications are multiple digits, amputation at the palm or wrist, any level in a child, and single digits distal to the flexor digitorum superficialis insertion. A clean saw injury is favourable compared with crush or avulsion, which damage vessels over a long segment. Digits contain little muscle, so they tolerate many hours of cold ischaemia, but far less warm ischaemia. Smoking reduces success, and his occupation and priorities matter, but neither makes replantation contraindicated.

Management: I keep the thumb in moist saline gauze in a sealed bag on ice, never in direct contact with ice, and radiograph the hand and the part. I give tetanus prophylaxis and intravenous antibiotics and assess index finger perfusion. In theatre I tag structures on the part on the back table, then proceed with bone shortening and fixation, tendon repair, arterial anastomosis, nerve repair and venous anastomoses, using vein grafts rather than tension. The index finger is revascularised if needed and repaired. Afterwards I keep him warm, hydrated and pain-free with no smoking, and monitor colour, turgor, capillary refill and temperature hourly. Venous congestion is treated with leeches under antibiotic cover or re-exploration, and arterial insufficiency with early re-exploration. Hand therapy begins within days, and follow-up covers sensation, stiffness and cold intolerance.

Ethics and communication: He has capacity and may choose terminalisation, but only after an informed discussion. I explain that thumb loss permanently reduces function, while replantation means a longer recovery and stopping smoking. Work pressures are real for many expatriate workers, so I offer a letter for his employer containing only what he agrees to. If he declines, I document his reasons and close the stump well.

Reference: Wolfe et al, Green's Operative Hand Surgery, 8th ed, 2022

Knowledge: A late seroma, arising more than a year after implantation, in a woman with textured implants must be investigated for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a T-cell lymphoma strongly linked to textured surfaces. Other causes include infection, trauma, rupture and double capsule. The NCCN pathway requires ultrasound-guided aspiration with cytology, CD30 immunohistochemistry and flow cytometry, and further imaging if a mass is present. Most patients have disease confined to the fluid and capsule, usually cured by complete surgery. Draining and exchanging the implant without a diagnosis risks leaving disease behind.

Management: Today I examine both breasts and regional nodes and arrange ultrasound-guided aspiration, sending fresh fluid for cytology, CD30 and flow cytometry, plus culture. If BIA-ALCL is confirmed, I arrange PET-CT staging and multidisciplinary review with haematology-oncology. Treatment is total en bloc capsulectomy with implant removal and excision of any mass or involved node, and I discuss contralateral explantation because bilateral disease occurs. I do not place new implants at that operation. Systemic therapy or radiotherapy is reserved for residual or advanced disease. If cytology is negative, I manage the seroma according to its cause. Device details are recorded and reported in line with national requirements, and she is followed with clinical review and imaging.

Ethics and communication: She wants a quick fix, so I explain honestly why diagnosis comes first without causing undue alarm, as the condition is rare and usually curable. I do not criticise the original surgeon. Records from abroad are requested with her consent. Asymptomatic women with textured implants do not need removal, and I say so to avoid unnecessary surgery.

Reference: Clemens et al, 2019 NCCN Consensus Guidelines on the Diagnosis and Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma; Neligan, Plastic Surgery, 5th ed, 2023

Knowledge: This is a Gustilo-Anderson IIIB open tibial fracture. It is a high-energy injury with periosteal stripping and a defect needing flap cover, without a vascular injury requiring repair. The BOA and BAPRAS standards call for joint orthoplastic care and definitive fixation with soft tissue cover within 72 hours of injury if not achieved at the first debridement, because infection and non-union rise with delay. Distal third defects are poorly served by local muscle flaps, so a free flap, such as an anterolateral thigh or a gracilis or latissimus dorsi flap, is usually needed. Plantar sensation alone should not drive decisions about amputation.

Management: I see him today, reassess the wound and vascular status, and request CT angiography to identify recipient vessels. I arrange a joint orthoplastic list as soon as possible, ideally within 24 hours, for repeat debridement, definitive fixation and free flap cover in a single session. Until then the wound is kept under a sealed negative pressure or antibiotic-impregnated dressing and antibiotics continue per protocol. I plan the anastomosis outside the zone of injury, end-to-side to preserve distal flow. After surgery the flap is monitored hourly for the first day with early re-exploration for compromise. Rehabilitation includes a dangling protocol, physiotherapy and surveillance of bone healing. I would not place definitive internal fixation without cover in the same session.

Ethics and communication: The delay beyond 72 hours is a system failure that I disclose to him openly and report through the incident system so that orthoplastic cover is fixed. I explain the risks of infection, flap failure, non-union and late amputation in plain language, with a professional interpreter if needed. Insurance or employer issues must not delay care. I document timings and the joint plan.

Reference: BOA and BAPRAS, Standards for the Management of Open Fractures, 2020

Knowledge: Preoccupation with a minimal defect, hours of mirror checking, social avoidance and repeated surgery strongly suggest body dysmorphic disorder, which is considerably more common among people seeking aesthetic surgery, particularly rhinoplasty, than in the general population. Cosmetic procedures rarely improve the condition and are associated with dissatisfaction, worsening symptoms, demands for further surgery and occasionally hostility toward the surgeon. Validated screening tools, such as the Body Dysmorphic Disorder Questionnaire, support assessment against DSM-5-TR criteria. Revision rhinoplasty also carries higher technical risk from scarring and cartilage depletion. Deadlines, filtered photographs and third-party pressure are recognised warning signs.

Management: I take a full history, request previous operative records, take standardised photographs and explore her expectations and the effect on her life. I use a validated screening questionnaire and, if positive, explain sensitively that I do not believe surgery will help how she feels and that the condition responds to cognitive behavioural therapy and medication. I offer referral to a psychiatrist or psychologist and, with her consent, contact her family doctor. I would not operate next week or offer fillers as a compromise. I document the consultation and my reasons for declining. I offer review after psychological treatment, when correction of a genuine minor irregularity could be reconsidered if she is well. If she expresses suicidal thoughts, I assess risk and arrange urgent mental health care.

Ethics and communication: She is an adult with capacity, so the decision is hers and not her mother's, and I see her alone for part of the consultation. A surgeon has no duty to perform a procedure unlikely to benefit and likely to harm, and declining is consistent with beneficence and with professional codes such as the ASPS Code of Ethics. The clinic's revenue must not influence the decision. Clinic advertising must avoid misleading before-and-after images.

Reference: American Society of Plastic Surgeons Code of Ethics; American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR), 2022

Knowledge: Sagittal synostosis is the commonest single-suture craniosynostosis and causes scaphocephaly, with growth restricted perpendicular to the fused suture. Positional head shape change has no ridge and responds to repositioning or helmets. Syndromic or multisuture forms need genetic testing because they carry higher risks of raised intracranial pressure and airway and eye problems. In isolated sagittal synostosis, raised pressure affects a minority but is real, so surgery addresses both shape and the risk to development. Early options are endoscopic strip craniectomy with helmet therapy or spring-assisted surgery, while open vault remodelling is done later in infancy. A helmet alone does not correct true synostosis.

Management: I examine for syndromic features and assess the eyes, airway and development. Given his age, I discuss endoscopic strip craniectomy with several months of helmet therapy, spring-assisted surgery, or open vault remodelling later if the parents prefer a single procedure. Pre-operatively I plan with paediatric anaesthesia, check haemoglobin, crossmatch blood and use tranexamic acid to reduce blood loss. Afterwards he is monitored in high dependency for bleeding, hyponatraemia and swelling. Follow-up includes head circumference and shape measurement, fundoscopy or optical coherence tomography for raised pressure, and developmental review through childhood, because pressure can rise after surgery. I would not reassure the parents that this is purely cosmetic or offer a helmet alone.

Ethics and communication: As he is a minor, his parents consent, and they need balanced information on benefits, risks including transfusion, and the uncertain evidence on neurodevelopment. If they decline surgery, I respect the decision while arranging monitoring for raised pressure. Any concerns about blood products are explored early. Photographs for teaching need separate consent.

Reference: Mathijssen et al, Updated Guideline on Treatment and Management of Craniosynostosis, 2021; Neligan, Plastic Surgery, 5th ed, 2023