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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_813_Библиотеки_им_академика_М_И_Перельмана.pdf
18 Part I&Basic Considerations
STANDARD MASSIVE-WEIGHT-LOSS BRACHIOPLASTY AND LATERAL CHEST EXCISION SERIES
7. In a massive-weight-loss patient planned to undergo brachioplasty and chest wall skin excision, which of the
following arm positions is best for evaluating soft tissue excess of the upper arm?
D. Arms straight out with elbows bent at 90 degrees and hands forwards.
Photographs of massive-weight-losspatients should demonstrate the proportional relationships of the body
while highlighting skin laxity and areas of contour irregularities. W hen evaluatingsoft tissue excess and skin
laxity of the upper arm, photographs with the patients’ arms positioned straight out and elbows bent at 90
degrees will provide an efficient and standardized way of qualifying skin excess in relation to the other structure of the arm. This is also a common position that can be used for marking the skin excess in brachioplasty
and designing incisions.
1,2
REFERENCES
1. Gherardini G. Standardization in photography for body contour surgery and suction-assisted lipectomy. Plast
Reconstr Surg 1997;100:227
2. Williams AR. Clinical and operating room photography. In: Vetter JP, ed. Biomedical Photography. Boston: Focal
Press; 1992
INFORMED CONSENT
8. Which of the following methods is the most appropriate way of ensuring that a photograph of a patient's
face used for educational purposes is compliant with Health Insurance Portability and Accountability Act
(HIPAA) regulations?
D. Obtain full written authorization from the patient.
According to HIPAA guidelines, –patient authorization is not required for photographs that are fully deidentified of patient information. However, full-facial photographs cannot be de-identified, and subsequently always require authorization from the patient. Furthermore, editing of the photo, including hiding the patient's eyes, does not qualify as de-identification of the patient and written authorization from
the patient should still be obtained. Although masking the eyes is not explicitly addressed in the HIPAA
guidelines, it is highly recommended to obtain written authorization from the patient preemptively for
any facial photographs.
1,2
REFERENCES
1. Department of Health and Human Services. Standards for privacy of individually identifiable health information:
final rule. 45 CFR Parts 160 and 164. Federal Register 65, no. 250 (December 28, 2000).
2. Roach WH Jr, Hoban RG, Broccolo BM, et al, eds. Medical Records and the Law. Gaithersburg, MD: Aspen
Publishers; 1994
4. Medicolegal Considerations in Aesthetic Surgery
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 43–56
PATIENT SELECTION
1. What is the best first step in preventing malpractice claims?
A. Hire a good lawyer.
B. Become well-versed in state and local malpractice laws.
C. Proper patient selection.
D. Transition to a noninvasive practice.
E. Work for an academic hospital.
PATIENT SELECTION
2. Why is a patient's familial disapproval for undergoing aesthetic surgery a relative contraindication to
proceed?
A. The family may not support the patient postoperatively.
B. The risk of an “I told you so” reaction from the disapproving family.
C. The patient may regret disappointing the family.
D. They may not have the funds to pay for the procedure(s).
E. The family may not refer patient to the surgeon in the future.
PATIENT COMMUNICATION
3. Which of the following is an example of a communicative measure aesthetic surgeons can implement into
their practice to prevent inflated expectations and decrease litigations?
A. Take notes while the patient is speaking.
B. Highlighting only objective facts from the patient's history.
C. Limiting interactions to essential conversation topics.
D. Strive for repetition in explaining procedures during patient encounters.
E. Sit between the patient and the door in the examination room.
PATIENT COMMUNICATION
4. Which of the following is considered good standard of practice for documentation in aesthetic surgery?
A. Minimal documentation in order to avoid unnecessary charting errors.
B. Enter all patient information in electronic chart during the patient encounter.
C. Enter thorough details of all discussion points shortly after patient encounter.
D. Hire a scribe to complete all charting duties.
E. Rely on “smart text” entries to complete clinical notes.
PATIENT COMMUNICATION
5. A physician would be most likely to lose a jury trial if:
A. Despite demonstrating compassionate care, the surgical outcome was not optimal due to a postoperative
infection from incomplete dressing coverage.
B. The physician chose one standard therapy, which turned out not to be the best choice for the patient.
C. The patient claims to have had a lengthy conversation with the physician, even though the physician had
previously documented that no such conversation took place.
D. The physician wrote a handwritten note for a patient encounter, which is illegible, even though there is no
evidence that the physician was blatantly negligent.
E. Despite the physician's best judgment in the operating room, the patient experiences a complication due to
the surgical technique.
20 Part I&Basic Considerations
PATIENT COMMUNICATION
6. A local plastic surgeon was involved in a lawsuit. Which of the following did not help the plastic surgeon's
case when it went to court?
A. Performing a good history of physical.
B. Eligible documentation.
C. Obtaining multiple medical consults with other subspecialities.
D. Attempting to help the patient by addressing her gynecologic concerns.
E. Letting the patient know all the foreseeable risks of the surgery.
PATIENT COMMUNICATION
7. Which of the following is always a predictable consequence of any surgical procedure?
A. Loss of neuronal sensitivity.
B. Wound dehiscence.
C. Skin sloughing.
D. Scarring.
E. Swelling.
PATIENT COMMUNICATION
8. Which of the following aesthetic procedures has the highest degree of unpredictability?
A. Breast augmentation.
B. Facelift.
C. Rhinoplasty.
D. Blepharoplasty.
E. Brow-lift.
PATIENT COMMUNICATION
9. Pulmonary embolism is most commonly associated with which of the following procedures?
A. Breast reduction.
B. Augmentation mastopexy.
C. Rhytidectomy.
D. Abdominoplasty.
E. Suction-assisted lipectomy.
Chapter 4&Medicolegal Considerations in Aesthetic Surgery 21
Answers
PATIENT SELECTION
1. What is the best first step in preventing malpractice claims?
C. Proper patient selection.
It is crucial as an aesthetic surgeon to be cognizant of the various “red f lags” evident in some patients
seeking procedures. Some examples of these could include patients who have excessively high
expectations for the outcomes of the procedure; excessively demanding patients; indecisive patients;
immature patients; secretive patients; patients who do not get along with other physicians; patients
with body dysmorphic disorder; or patients who have undergone excessive previous aesthetic
procedures. These patients end up more likely to sue their physician. The other answer choices can all
help but are not the best first step in preventing a malpractice claim. The best first step in preventing a
malpractice claim is operating on the right patients.
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice:
A Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PATIENT SELECTION
2. Why is a patient's familial disapproval for undergoing aesthetic surgery a relative contraindication to
proceed?
B. The risk of an “I told you so” reaction from the disapproving family.
Although family approval is not a requirement to undergo aesthetic surgery, familial disapproval is a relative
contraindication to proceed with surgery, as less-than-optimal results may produce an untimely “I told you
so…” reaction from the disapproving family members. Such a reaction may deepen a patient's feelings of
guilt, regret, or dissatisfaction. The other options do not target the underlaying reason.
1
1
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PATIENT COMMUNICATION
3. Which of the following is an example of a communicative measure aesthetic surgeons can implement into
their practice to prevent inflated expectations and decrease litigations?
D. Strive for repetition in explaining procedures during patient encounters.
It is estimated that the average patient retains only 35% of what is said; repetition can increase patient
comprehension, which can prevent inf lated expectations and decrease litigations. Repetition and increasing points of contact help. Taking notes can be helpful; however, surgeons should listen to and make eye
contact with patients, then jot down the key words needed to reconstruct the conversation shortly after
the consultation. The other options are not communication styles that can be helpful to avoid
litigation.
1,2
REFERENCES
1. Gorney M. Communication and patient safety. In: Anderson RE, ed. Medical Malpractice: A Physician's
Sourcebook. Totowa, NJ: Humana Press; 2005
2. Nichols R. Are You Listening? New York: McGraw Hill; 1957
22 Part I&Basic Considerations
PATIENT COMMUNICATION
4. Which of the following is considered good standard of practice for documentation in aesthetic surgery?
C. Enter thorough details of all discussion points shortly after patient encounter.
The digital age poses many new problems for physicians. Interacting with a laptop or notebook and not
with the patient can significantly interfere with the doctor–patient relationship. There must be a balance
of efficiency, accuracy, and attention paid to the patient. Do not rely on “smart text” entries that default
to a response, as they can often be inaccurate.
A lack of evidence is powerful evidence, as scant documentation because of a busy lifestyle will allow the
plaintiff attorney to allege that patient care was equally scant and rushed. Remember, a physician's duty to
patients includes not only good patient care, but thorough, accurate documentation of such care.
Minimal documentation can hurt the surgeon and make a legal team think the surgeon provides
sloppy care. Having an elect ronic medical record system or a scribe is not required to provide good
documentation and sometimes relying on “smart text” entries can actually impact documentation
negatively.
1
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PATIENT COMMUNICATION
5. A physician would be most likely to lose a jury trial if:
D. The physician wrote a handwritten note for a patient encounter, which is illegible, even though there
is no evidence that the physician was blatantly negligent.
Good trial attorneys have catchy themes or theatrical ploys that they run throughout their trials. One
such medical malpractice theme is: “Sloppy at documentation is sloppy at practice.” The duty of the
responsible physician is to read and correct everything entered before signing the document, and to
confirm that all is legible. Fortunately, handwritten patient notes are becoming less common with the
advent of electronic medical records. However, with the electronic world of charting comes a whole host
of other potential drawbacks and precautions, which must be addressed.
1
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PATIENT COMMUNICATION
6. A local plastic surgeon was involved in a lawsuit. Which of the following did not help the plastic surgeon's
case when it went to court?
D. Attempting to help the patient by addressing her gynecologic concerns.
Aesthetic plastic surgeons have a duty to the patient but only within the scope of our practice. If a patient has
a generalized medical problem, we should have the patient follow-up with the primary care physician. The
other answer choices are things that help the plastic surgeon's case. Documenting a thorough history and
physical, as well as obtaining medical consults with other providers when in doubt, and documenting eligibly are important considerations. Also, we have an affirmative duty to disclose in detail the benefits, risks,
alternatives, possible complications, and unpleasant side effects for any procedure or surgery.
1
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
Chapter 4&Medicolegal Considerations in Aesthetic Surgery 23
PATIENT COMMUNICATION
7. Which of the following is always a predictable consequence of any surgical procedure?
D. Scarring.
This should always be included in the informed consent process preoperatively: No healing can occur
without a scar! Although scarring qualities differ based on genetics and skin properties, everyone scars to
some extent. As such, scar formation is a major genesis of patient dissatisfaction, and should be thoroughly discussed preemptively. The consequence in the other options can occur but do not consistently
take place with open surgery.
1,2
REFERENCES
1. Horton JB, Reece EM, Broughton G II, Janis JE, Thornton JF, Rohrich RJ. Patient safety in the office-based setting.
Plast Reconstr Surg 2006;117:61e
2. Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting.
Plast Reconstr Surg 2002;110:1337; discussion 1343
PATIENT COMMUNICATION
8. Which of the following aesthetic procedures has the highest degree of unpredictability?
C. Rhinoplasty.
Asymmetry, continued breathing difficulties (septorhinoplasty), allegations of improper functional
capacity, and evolving structural settling can all contribute to the unpredictability in rhinoplasty
outcomes. It is advisable to avoid inappropriate use of “brag books” containing only excellent results;
also, strictly counsel patients that these results cannot always be obtained.
1
REFERENCE
1. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PATIENT COMMUNICATION
9. Pulmonary embolism is most commonly associated with which of the following procedures?
E. Suction-assisted lipectomy.
Suction-assisted lipectomy (liposuction) is the most commonly performed elective aesthetic procedure in
the United States.
trol) and by a variety of practit ioners (many of whom are unqualified).3Mortality increases significantly
when liposuction is combined with other procedures,1or when a patient endures anesthesia for more
than 6 hours.3Although certainly not common, the risk of potential mortality associated with this procedure should always be discussed during the informed consent process.
1,2
Liposuction is typically performed in the outpatient setting (outside regulatory con-
REFERENCES
1. Horton JB, Reece EM, Broughton G II, Janis JE, Thornton JF, Rohrich RJ. Patient safety in the office-based setting.
Plast Reconstr Surg 2006;117:61e
2. Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting.
Plast Reconstr Surg 2002;110:1337; discussion 1343
3. Gorney M. Medical liability in plastic and reconstructive surgery. In: Anderson RE, ed. Medical Malpractice: A
Physician's Sourcebook. Totowa, NJ: Humana Press; 2005
PART II
Anesthesia
5. Basics of Anesthesia for the Aesthetic Surgery
Patient
Aaron M. Kearney, Sammy Sinno, Anmol Chattha
See Essentials of Aesthetic Surger y, pp. 59–84
SURGICAL JUDGMENT
1. What is one of the advantages of total intravenous anesthesia (TIVA)?
A. Simple administration.
B. Lower cost.
C. Easier titration of depth.
D. Reduced incidence of postoperative nausea and vomiting (PONV).
E. Does not require an anesthesiologist to be present.
RISK FACTORS
2. Which of the following comorbidities indicates a patient who is not suitable for general anesthesia in an
ambulatory surgical center or office?
A. End-stage renal disease (ESRD).
B. Atrial fibrillation.
C. Paraplegia.
D. Peripheral vascular disease.
E. Mild obstructive sleep apnea (OSA).
PREOPERATIVE TESTING
3. Which of the following is an accurate statement regarding hCG testing in females undergoing aesthetic
surgery?
A. Urine hCG must be obtained for all premenopausal females prior to undergoing surgery.
B. Anesthetic exposure in pregnant females is significantly linked to spontaneous abortion and premature birth.
C. The American Society of Anesthesiologists recommends “offering” rather than “requiring” hCG testing.
D. A point of care (POC) urine hCG test is not a reliable test before surgery.
E. Preoperative hCG testing is positive in 4% of cases.
RISK FACTORS
4. Which of the following factors is a reason to obtain a preoperative electrocardiogram (ECG) in a patient?
A. Any patient over the age of 60.
B. Diabetes mellitus on metformin.
C. Renal insufficiency.
D. End-stage liver disease.
E. Patient with body mass index (BMI) of 33.
RISK FACTORS
5. Which of the following is one of the Revised Cardiac Risk Index (RCRI) risk factors?
A. Peripheral artery disease with history of bypass.
B. Cerebral vascular disease with history of stroke or transient ischemic attack.
C. Poorly controlled hypertension.
D. Obesity.
E. Active smoking.