ABPS Preoperative Assessment & Postoperative Care 5 — Questions and Answers
Question 1: Which finding on a preoperative EKG would most likely require cardiology clearance before elective flap reconstruction?
- Sinus bradycardia at 55 bpm in an athlete
- New left bundle branch block (LBBB) (Correct answer)
- Isolated PVCs without structural disease
- Sinus arrhythmia
Correct answer: New left bundle branch block (LBBB)
A new LBBB may indicate acute cardiac pathology such as ischemia or cardiomyopathy and requires cardiology evaluation before elective surgery.
Question 2: What is the most appropriate postoperative drain management following modified radical mastectomy with immediate reconstruction?
- Remove drains at 24 hours regardless of output
- Remove drains when output is <30 mL per day for 2 consecutive days (Correct answer)
- Leave drains in place for exactly 2 weeks
- Irrigate drains daily with saline to maintain patency
Correct answer: Remove drains when output is <30 mL per day for 2 consecutive days
Standard protocol is to remove closed-suction drains when output falls below 30 mL/day for two consecutive days to reduce infection risk while preventing seroma.
Question 3: Which factor is most predictive of flap failure in free tissue transfer for breast reconstruction?
- Patient age over 55
- Prior radiation to the chest wall (Correct answer)
- Use of silicone implant in the contralateral breast
- Bilateral procedure in one stage
Correct answer: Prior radiation to the chest wall
Prior radiation causes microvascular damage and tissue fibrosis, significantly increasing the risk of anastomotic failure and fat necrosis in free flap reconstruction.
Question 4: A patient presents with erythema, warmth, and fluctuance over a breast implant site 10 days postoperatively. After aspiration reveals purulent fluid, what is the next step?
- Oral antibiotics for 7 days with close follow-up
- IV antibiotics and implant removal with washout (Correct answer)
- Implant exchange with antibiotic irrigation
- Aspiration alone repeated every 3 days
Correct answer: IV antibiotics and implant removal with washout
Established periprosthetic infection with purulent fluid requires implant removal, pocket washout, and IV antibiotics to eliminate the biofilm-colonized foreign body.
Question 5: What is the primary role of preoperative nutritional assessment in free flap surgery candidates?
- Calculating BMI for anesthesia dosing
- Identifying hypoalbuminemia and malnutrition that impairs wound healing (Correct answer)
- Determining caloric needs for postoperative TPN
- Screening for eating disorders
Correct answer: Identifying hypoalbuminemia and malnutrition that impairs wound healing
Hypoalbuminemia (<3.5 g/dL) and malnutrition are associated with impaired immunity, poor wound healing, and increased flap complication rates in reconstructive surgery.
Question 6: A patient undergoes free DIEP flap breast reconstruction. On postoperative day 1, flap monitoring reveals capillary refill >3 seconds and dusky color. What is the priority action?
- Increase IV fluid rate and observe for 2 hours
- Apply warm compresses and reposition patient
- Return to the operating room immediately for vascular exploration (Correct answer)
- Administer anticoagulation and observe overnight
Correct answer: Return to the operating room immediately for vascular exploration
Signs of venous or arterial compromise in a free flap demand immediate return to the OR for anastomosis exploration, as flap salvage rates drop sharply after 6 hours of ischemia.
Question 7: Which preoperative cardiac risk stratification tool is most commonly used for plastic surgery patients undergoing major elective procedures?
- CHADS2 score
- Revised Cardiac Risk Index (RCRI) (Correct answer)
- TIMI risk score
- HAS-BLED score
Correct answer: Revised Cardiac Risk Index (RCRI)
The Revised Cardiac Risk Index (RCRI) is the standard validated tool for estimating perioperative major cardiac event risk in non-cardiac surgery patients.
ABPS Preoperative Assessment & Postoperative Care 5
Which finding on a preoperative EKG would most likely require cardiology clearance before elective flap reconstruction?