Surgical and Cosmetic Dermatology

1. Which of the following is a braided, non-absorbable suture with high tissue reactivity?
A. Silk
B. Polyglactin (Vicryl)
C. Nylon (Ethilon)
D. Polypropylene (Prolene)
E. Polydioxanone (PDS)

Correct answer: (A) Silk.

Explanation: Silk can cause high reactivity since it is a natural/biological product. Polyglactin (Vicryl) is an absorbable
braided synthetic suture and loses half of its strength in 3 weeks as it absorbs. Nylon (Ethilon) is a nonabsorbable
nonbraided (monofilament) synthetic suture. Polypropylene (Prolene) is a nonabsorbable monofilament as well.
Polydioxanone (PDS) is an absorbable monofilament with longer lasting tensile strength.

2. Which of the following suture techniques would maximize wound eversion?

A. Simple running stich
B. Buried vertical mattress
C. Subdermal interrupted stitch
D. Subcuticular stich

Correct answer: (B) Buried vertical mattress.

Explanation: Buried vertical mattress is thought to be most effective at successful wound eversion. The other options are
less successful at everting the wound edges.

3. Which of the following best describes a paramedian forehead flap?

A. Axial pattern flap – supratrochlear artery
B. Axial pattern flap – supraorbital artery
C. Axial pattern flap – dorsal nasal artery
D. Random pattern flap – supratrochlear artery
E. Random pattern flap – supraorbital artery

Correct answer: (A) Axial pattern flap – supratrochlear artery.

Explanation: In dermatologic surgery, flaps are characterized by vascular supply. An axial pattern flap is based on the
named large arterial vessels, while a random pattern flap is based on arteries of the subdermal plexus. The paramedian
forehead flap recruits forehead skin for nasal reconstruction, it is based on the blood supply of the supratrochlear artery.
(B) (C) The supraorbital and dorsal nasal arteries may contribute secondarily to the vascular supply but are not the
arteries for which the flap is based.
(D) (E) Random pattern flaps are based on the non-specific, unnamed arteries from the subdermal plexus, not named
arteries.

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4. You are prepping a patient with an antiseptic prior to a cyst excision. Which of the following best describes the
mechanism and efficacy of chlorhexidine?
A. Directly binding and oxidizing microbial proteins to form salts; broad antimicrobial coverage and
sporicidal
B. Directly binding and oxidizing microbial proteins to form salts; gram positive coverage only
C. Disrupts microbial cell membranes causing precipitation of cell contents; broad antimicrobial and
viral coverage
D. Disrupts microbial cell membranes causing precipitation of cell contents; coverage against gram
positive cocci, poor gram negative and fungal coverage
E. Denatures proteins needed for microbial growth and disrupts cell wall; fast onset and short
duration
Correct answer: (C) Disrupts microbial cell membranes causing precipitation of cell contents; broad antimicrobial
and viral coverage.
Explanation: This best describes chlorhexidine’s mechanism of action and antimicrobial activity. It also covers
mycobacterium tuberculosis.
(A) Described here is the mechanism and activity of povidone-iodine.
(B) Described here is the mechanism of povidone-iodine with an inaccurate description of its activity.
(D) Described here is the mechanism and activity of hexachlorophene.
(E) Described here is the mechanism and activity of isopropyl alcohol.

5. Which portion of local anesthetics determines the rate of diffusion through nerve cell membranes?
A. Intermediate connecting chain that contains an ester or amide
B. Aromatic end
C. Secondary amine end
D. Tertiary amine end
E. All of the above

Correct answer: (B) Aromatic end.

Explanation: The aromatic portion of local anesthetics, both esters and amides, is what conveys the hydrophobic and
lipophilic properties necessary for the diffusion of the administered anesthesia through nerve cell membranes. These
properties are what determine the onset of action between local anesthetics of the ester and amide class.
(A) The intermediate chain determines whether or not the anesthetic is an ester or an amide. Each of these two forms of
local anesthesia has different properties, actions, and side effects, and should be selected appropriately by procedure
type and patient.
(C) (D) The amine portion, secondary or tertiary amine end is hydrophilic and allows the anesthesia to be water-soluble.
This property is required for the preparation, storing, and administration of the anesthetic.
(E) This is an incorrect answer. While all three portions of the chemical structure of local anesthetics are necessary for
proper function, it is only the aromatic portion that determines the rate of diffusion through the nerve cell membrane.

6. Skin cancers involving up to how much of the lower lip can be excised via a wedge excision?
A. 1/8
B. 1/4
C. 1/3
D. 1/2
E. 2/3

Correct answer: (C) 1/3.

Explanation: Tumors involving up to 1/3 of the lower lip can be excised via a wedge excision, which is traditionally a
three layered excision involving skin, muscle, and mucosa, and then repaired with three respective layers of sutures.

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7. What type of surgical instrument is shown and what is the primary function?

A. Mayo scissors; acrochordon removal

B. Gradle scissors; acrochordon removal
C. Gradle scissors; used for both sharp and
blunt dissection
D. Westcott scissors; used for both sharp and
blunt dissection

Correct answer: (D) Westcott scissors; used for both sharp and blunt dissection.
Explanation: These curved scissors are used for both sharp and blunt dissection. They utilize a spring-assisted system to
provide low effort dissection.
(A) Mayo scissors are larger scissors used for dissection.
(B) (C) Gradle scissors are used for acrochordon removal, but do not have a spring assisted design.

8. Which of the following suture types has the lowest capillarity?

A. Polyglactin 910
B. Vicryl
C. Braided polyester
D. Polydioxanone
E. Silk

Correct answer: (D) Polydioxanone.

Explanation: Capillarity is the ability to absorb and transfer fluid. Braided and uncoated sutures have greater capillarity
than monofilament sutures. Polydioxanone (PDS) is the only monofilament suture listed.
(A) (B) (C) (E) The other listed suture materials are braided.

9. The parent of a 6 month-old child seeks your advice as a second opinion regarding treatment of his child’s port-wine
stain located in the V1 and V2 distribution on the left side of her face. You begin to discuss the risks and benefits of
pulsed dye laser therapy as a beneficial modality for the treatment. All of the following are reasonable arguments for
the treatment of port-wine stains with pulsed dye laser EXCEPT?
A. The vessels of a port-wine stain do not involute
B. The surface area of a port-wine stain will increase proportionally as a child grows
C. The port-wine stain may grow thicker and develop nodules
D. The port-wine stain may impact a child’s social and cognitive development impacting adult social
relationships
E. All of the above are correct

Correct answer: (E) All of the above are correct.

Explanation: There are numerous physical and psychological reasons supporting the early and aggressive treatment of
port-wine stains with pulsed-dye laser therapy. In addition to the physical aspects regarding their change in size,
thickness, and permanence it is important to remember the sociological impact living with a cosmetically visible lesion

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 can have on a child. Several studies exist demonstrating the impact living with untreated lesions have had on the ability
of patients to form mature adult relationships, and all support and give further support for initiating early treatment.

10. What closure technique could be used to shorten a scar approaching the eyebrow?
A. Z-plasty
B. S-plasty
C. O-plasty
D. M-plasty

Correct answer: (D) M-plasty.

Explanation: An M-plasty is used to shorten a scar. A Z-plasty is used to reorient and remove tension from a scar. An S-
plasty is often used over convex surfaces.

11. What is the main purpose of a running locked stitch?

A. hemostasis
B. wound edge eversion
C. decreasing the possibility of track marks
D. eliminating dead space
E. securing the tip of a triangle shaped flap

Correct answer: (A) Hemostasis.

Explanation: The purpose of a running locked stitch is to assist with hemostasis. It also prevents complete unraveling if
the suture breaks under the wound tension. Wound edge eversion can be achieved using many different suturing types,
however the vertical mattress suture is especially effective in creating this and it is therefore the main indication for its
use. The main purpose of a running subcuticular stitch is decreasing the possibility of track marks. Securing the tip of a
triangle shaped flap is best achieved using a half-buried horizontal mattress stitch, also known as a tip-stitch or a corner
stitch. Plicating sutures or deep buried dermal sutures are used to eliminate dead space.

12. A 65-year-old female is found to have a basal cell carcinoma on her left eyebrow. Mohs surgery is recommended for
this patient. During appropriate reconstructive repair for this patient, which plane is ideal for undermining?
A. Superficial subcutaneous tissue
B. Deep subcutaneous tissue
C. Subgalea
D. Any area above muscular fascia
E. At the level of the muscular fascia

Correct answer: (B) Deep subcutaneous tissue.

Explanation: Mid to deep subcutis, deep to the hair follicles, should be targeted when closing a defect in the eyebrow in
order to help maintain surrounding hairs.
(A) (C) (D) (E) Superficial subcutaneous tissue would likely produce unnecessary damage to surrounding hair follicles.
Undermining deeper than subcutis would be unnecessary and expose the potential to increased bleeding and
potential nerve damage.

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13. A 57 year old female undergoes Mohs surgery for a nasal tip basal cell carcinoma. She presents to your clinic to
discuss reconstructive options as the extent of resection was more than expected by the ablative surgeon. You
recommend a two stage paramedian forehead flap procedure for reconstruction. What is the arterial supply for this
flap relative to the defect?
A. Frontal branch of the superficial temporal artery
B. Ipsilateral supraorbital artery
C. Contralateral supratrochlear artery
D. Both ipsilateral supraorbital and supratrochlear arteries
E. Angular branch of the facial artery

Correct answer: (B) Contralateral supratrochlear artery.

Explanation: The supratrochlear artery supplies the paramedian forehead flap (PMFF). It typically runs in a vertical axis
and becomes more superficial along its course. Given its origin near the nasal root (radix) and good length, it is an
optimal axial flap for nasal reconstruction. Distally the supratrochlear artery runs superficially which allows for thinning
of the flap during the first stage of reconstruction without compromising blood supply. The flap is often harvested from
the side contralateral to the defect to reduce the angle of rotation and reduce rotational shortening.

14. A 34-year-old female with a history of basal cell nevus syndrome (requiring several procedures during pregnancy)
delivers a child who has poor muscle tone, low hoarse cry, poor interest in feeding, and macroglossia. Technetium
pertechnetate scan is performed to detect a structurally abnormal thyroid gland. Which of the following likely caused
the newborn findings?
A. Maternal exposure to povidone-iodine
B. Maternal exposure to large amounts of lidocaine
C. Maternal exposure to chlorhexidine
D. Basal cell nevus syndrome
E. Advanced maternal age

Correct answer: (A) Maternal exposure to povidone-iodine.

Explanation: This is a case of congenital hypothyroidism. If untreated for several months after birth, severe congenital
hypothyroidism can lead to growth impairment and permanent mental disability. Chronic maternal use of povidone-
iodine has been shown to produce hypothyroidism in neonates.
(B) Lidocaine is pregnancy category B is has not been reported to cause congenital hypothyroidism.
(C) Chlorhexidine can cause keratitis, conjunctivitis, and otitis, however, although it is pregnancy category C, no adverse
effects in the newborns have been reported. In fact, it has been used in vaginal disinfection prior to delivery.
(D) Basal cell nevus syndrome has a number of congenital anomalies, such as calcification of the falx and skeletal
abnormalities, however, there are no reports of thyroid abnormalities in these patients.
(E) At 34 years old, the mother is not considered at an advanced maternal age associated with high risk pregnancies.

15. All of the following are indications for Mohs surgery except:
A. a 0.5cm morpheaform BCC on the arm
B. a 0.5cm recurrent BCC on the neck
C. a 1cm well-differentiated SCC on the back
D. a 2cm well- differentiated SCC on the shoulder
E. a 1cm nodular BCC on the cheek

Correct answer: (C) A 1cm well-differentiated SCC on the back.

Explanation: Mohs surgery indications include skin cancers that are 1cm or greater on the face, 2cm or greater on the
trunk, aggressive growth pattern such as morpheaform BCC, history of recurrence, and history of immunosuppression.
Mohs surgery would not be indicated for a 1cm SCC on the back.

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16. What is the main purpose of a half-buried horizontal mattress stitch?
A. hemostasis
B. wound edge eversion
C. decreasing the possibility of track marks
D. eliminating dead space
E. securing the tip of a triangle shaped flap

Correct answer: (E) Securing the tip of a triangle shaped flap.

Explanation: The main indication for use of a half-buried horizontal mattress stitch, also known as a tip-stitch or a corner
stitch, is for approximation of angled skin flaps or corners without compromise of blood supply to the tissue tip. Wound
edge eversion can be achieved using many different suturing types, however the vertical mattress suture is especially
effective in creating this and it is therefore the main indication for its use. The purpose of a running locked stitch is to
assist with hemostasis. The main purpose of a running subcuticular stitch is to decrease the possibility of track marks.
Plicating sutures or deep buried dermal sutures are used to eliminate dead space.

17. Which of the following muscles is correctly paired with its nerve?
A. Platysma: buccal branch of facial nerve
B. Corrugator supercilii: posterior auricular branch of facial nerve
C. Occipitalis: posterior auricular branch of facial nerve
D. Levator anguli oris: marginal mandibular and cervical branch of the facial nerve

Correct answer: (C) Occipitalis: posterior auricular branch of facial nerve.

Explanation: Occipitalis is innervated by the posterior auricular branch of facial nerve. The platysma is innervated by the
marginal mandibular and cervical branch of the facial nerve. The Corrugator supercilii is innervated by the temporal
branch of the facial nerve. The Levator anguli oris is innervated by the buccal branch of the facial nerve.

18. Once used in wound closure, which of the following suture types maintains the most persistent tensile strength over
time?
A. Polyglactin 910
B. Poliglecaprone
C. Braided polyester
D. Polydioxanone

Correct answer: (C) Braided polyester.

Explanation: Polyester has high tensile strength that lasts indefinitely in the body.
(A) (B) (D) The other listed suture materials are not going to maintain tensile strength indefinitely; polyglactin 910
provides 65%, poliglecaprone provides 60%, and polydioxanone provides 80% of their original strength at 2 weeks.

19. A full thickness skin graft is placed on a patient’s ear to repair a skin defect. At what point during a successful graft
placement is full circulation restored to the graft by new blood vessel formation in the recipient bed?
A. 24 hours
B. 48 hours
C. 7 days
D. 10 days
E. 2 weeks

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 Correct answer: (C) 7 days.
Explanation: The process in the question stem describes neovascularization, which occurs at 7 days.
(A) Serum imbibition, the process by which full-thickness skin grafts are nourished by exudate from the recipient bed,
occurs in the first 24 hours.
(B) Inosculation, the process by which anastomoses between pre-existing vessels of the recipient bed and the graft form,
occurs in at 48-72 hours.
(C) Epithelial proliferation occurs at 4-8 days.
(E) Sensory nerve restoration and re-innervation occur at 2 weeks.

20. What is the main purpose of a running subcuticular stitch?

A. hemostasis
B. wound edge eversion
C. eliminating dead space
D. decreasing the possibility of track marks

Correct answer: (D) Decreasing the possibility of track marks.

Explanation: The main purpose of a running subcuticular stitch is decreasing the possibility of track marks. Wound edge
eversion can be achieved using many different suturing types, however the vertical mattress suture is especially effective
in creating this and it is therefore the main indication for its use. The purpose of a running locked stitch is to assist with
hemostasis. Securing the tip of a triangle shaped flap is best achieved using a half-buried horizontal mattress stitch, also
known as a tip-stitch or a corner stitch. Plication or deep buried dermal sutures are used to eliminate dead space.

21. Upon taking the fourth layer of a Mohs excision of the lower face, you begin to visualize the posterolateral aspect of
the buccinator muscle. What anatomical structures are vulnerable to injury in this area?
A. Infraorbital nerve and the angular artery
B. Greater auricular nerve and the internal maxillary artery
C. Marginal mandibular branch of the facial nerve and the facial artery
D. Zygomatic branch of the facial nerve and the tranverse facial artery
E. Buccal branch of the facial and the parotid duct

Correct answer: (E) Buccal branch of the facial artery and the parotid duct.
Explanation: The parotid duct is at risk posterior to the buccinator (before it pierces the muscle and then runs deep to the
muscle). The buccinator is one of the only muscles that is innervated on its superficial surface, which is also why the
buccal branch of the facial nerve is at risk.
(A) These may be injured during procedures involving the lateral sidewall of the nose.
(B) These may be injured during procedures involving the angle of the jaw.
(C) The marginal mandibular nerve is inferior to the buccinator and is not at risk in this location.
(D) These may be injured during procedures near the angle of the jaw and the zygomatic bone.

22. Which of the following chemical peels requires either rinsing off with water or neutralization with 5% sodium
bicarbonate after 2-4 minutes to end its action?
A. Glycolic acid
B. Salicyclic acid
C. Trichloroacetic acid
D. Lactic acid
E. Jessner’s solution

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 Correct answer: (A) Glycolic acid.
Explanation: The only peeling agent that requires neutralization to end its action is glycolic acid. This may be performed
by rinsing with water or by application of 5% sodium bicarbonate solution. All of the other answer choices do not require
neutralization. Jessner’s solution is a combination of salicylic acid, lactic acid, resorcinol and ethanol.

23. Regarding nail matrix biopsy, which of the following is true?

A. Biopsy of the proximal nail matrix is preferred so as not to affect the dorsal nail plate
B. Of all the areas of the nail to biopsy, the proximal matrix has the greatest risk of scarring
C. Punch biopsies in the mid and distal matrix that are < 5mm do not need to be sutured
D. Nail matrix excision and repair often leads to a thickened nail plate
E. Biopsies should be oriented vertically whenever possible

Correct answer: (B) Of all the areas of the nail to biopsy, the proximal matrix has the greatest risk of scarring.
Explanation: The distal nail matrix is the preferred area for biopsy so as to minimize risk of affecting the dorsal nail plate,
since it produces the ventral surface of the nail plate. Punch biopsies of the nail matrix that are less than 3 mm may be
left to heal via second intent, and do not need to be sutured. Nail matrix excision and repair often leads to a thinner nail
plate, since the thickness of the nail plate is proportional to the length of the matrix. Biopsies in the nail matrix should be
oriented horizontally whenever possible.

24. You are near the end of a rhombic flap repair and you are evaluating the edge shown on the image shown. Which of
the following suture techniques would provide the best outcome to this edge of the flap?

A. Simple interrupted
B. Far Far Near Near suture
C. Quarter-buried mattress
D. Half buried horizontal mattress
E. Horizontal mattress

Correct answer: (D) Half buried horizontal mattress.

Explanation: A half-buried horizontal mattress, also known as a tip stitch, would be the ideal suture type for the corner of
a flap. The tip stitch provides increased blood flow leading to improved flap tip survival.
(A) (B) (C) (E) Tip necrosis and poor esthetic outcome can be expected with other forms of suture in this area.

25. A patient presents for follow up to your surgical clinic. Mohs surgery was performed several weeks prior with a split
thickness skin graft used for repair. Excess granulation tissue is clearly present over the graft today. What would be
the best method to remove this?
A. Application of silver nitrate
B. Cryotherapy
C. Laser treatment
D. Application of silicone
E. Electrodessication and curettage

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 Correct answer: (A) Application of silver nitrate.
Explanation: The best options to treat overgranulation are application of silver nitrate, and manual curettage/debulking.
All of the other answer choices are incorrect.

26. A patient presents to your procedure clinic for the removal of a 1.2 cm basal cell carcinoma on the right upper back.
You are discussing the procedure with him and inform him that a relatively larger area then the BCC itself will be
injected with a local anesthetic and epinephrine. The patient has a history of heart disease but no additional medical
history. Which of the following is an absolute contraindication for the use of epinephrine?
A. Pheochromocytoma
B. The use of beta-blockers
C. Coronary artery disease
D. Pregnancy
E. Open angle glaucoma

Correct answer: (A) Pheochromocytoma.

Explanation: Pheochromocytoma, a tumor that secretes norepinephrine and epinephrine with resulting significant
hypertension, and hyperthyroidism, are absolute contraindications for the use of epinephrine in local anesthetics.
Peripheral vascular disease is an absolute contraindication for the use of epinephrine near or around the digits.
(B) Epinephrine has strong beta and alpha agonistic properties, and patients taking beta-blockers may be at an increased
risk for severe hypertension secondary to unopposed alpha-adrenergic activity. This reaction, however, is not particularly
common, and is not an absolute contraindication to the concomitant use of epinephrine.
(C) Large amounts of epinephrine can exacerbate coronary artery disease when administered with a local anesthetic,
however, the levels used in most dermatologic procedures do not approach the volume these exacerbations would
require to take place.
(D) Similarly, the low doses of epinephrine are also safe to use in pregnancy while higher doses can induce labor.
(E) Narrow angle glaucoma may become exacerbated if epinephrine is utilized near the orbit leading to vision loss. This
should be avoided if possible, but is not an absolute contraindication. Open angle glaucoma is not known to be worsened
by use of epinephrine and is not an absolute contraindication.

27. The greatest effective penetration depth into skin occurs with which of the following combinations?
A. Small spot size and wavelengths greater than 1300 nm
B. Small spot size and wavelengths in the range of 600 to 1300 nm
C. Large spot size and wavelengths less than 600 nm
D. Large spot size and wavelengths greater than 1300 nm
E. Large spot size and wavelengths in the range of 600 – 1300 nm

Correct answer: (E) Large spot size and wavelengths in the range of 600 – 1300 nm.
Explanation: The greatest effective penetration in depth takes place when laser therapy is applied with a large spot size,
and a wavelength between 600 and 1300 nm. Smaller spot sizes enable increased photon scattering and loss of photons
from the beam as the laser enters into the skin. Larger spot size provides the ability for a greater number of photons to
maintain their presence in the beam enabling a greater percentage of skin penetration and a decrease in potential
scatter. Wavelength dependent penetration relies on the directly proportional relationship between depth reached and
increasing wavelength. Beyond 1300 nm, penetration decreases because of the amount of absorption of light by water.

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28. Which of the following may assist with protecting the nail matrix when performing an excision of a myxoid cyst?
A. use of an English nail splitter to partially avulse the nail during the procedure
B. injection of the nail matrix with saline
C. avulsion of the nail prior to the procedure
D. placement of a suture within the nail matrix
E. placement of a Freer septum elevator beneath the proximal nail fold

Correct answer: (E) Placement of a Freer septum elevator beneath the proximal nailfold.
Explanation: Placement of a Freer septum elevator beneath the proximal nailfold provides protection of the nail matrix
when excising a crescent of proximal nailfold containing a digital myxoid cyst.

29. Which of the following statements most adequately describes collimation

A. The existence of a well-defined wavelength
B. Light traveling in a parallel beam
C. Waves of light travelling in phase
D. Probability per unit of length that a photon of a specific wavelength will be absorbed
E. Specific molecules of similar nature that absorb light at well-defined wavelength

Correct answer: (B) Light traveling in a parallel beam.

Explanation: Light traveling in a parallel beam is the definition of collimation, and is an important property of laser light.
(A) This is the definition of monochromicity. The presence of a well-defined wavelength, as opposed to a broad band of
wavelengths, is a property that differentiates laser light from other forms of light.
(C) This is the definition of coherence, an important property of laser light. Light waves travelling in phase in time and
space, similar to water flowing from a small faucet is a required property that differentiates laser light from other forms
of light. Both coherence and collimation allow laser light to be focused to a very small spot size.
(D) This provides the definition of the absorption coefficient, or the probability per unit path length that a photon at a
particular wavelength will be absorbed.
(E) This coefficient is dependent on the concentration of targeted absorbing molecules or chromophores.

30. You are planning a nail matrix biopsy of a 64-year-old female with melanonychia striata. Which of the following is
not a potential cause of pigmentation visible through the nail fold?
A. A mutation in serine-threonine kinase 11
B. Side effect of a nucleoside reverse transcriptase inhibitor
C. Side effect of a non-nucleoside reverse transcriptase inhibitor
D. Side effect of an antibiotic that inhibits protein synthesis through the 30S ribosomal subunit
E. Benign nevus

Correct answer: (C) Side effect of a non-nucleoside reverse transcriptase inhibitor.

Explanation: There are no NNRTIs with reported side effects leading to nail pigmentation.
(A) Peutz Jeghers syndrome is a rare cause of melanonychia striata.
(B) Melanonychia striata is a side effect of zidovudine, an NRTI.
(D) Melanonychia striata is a side effect of minocycline.
(E) Benign nevus is a cause of melanoychia striata.

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31. Which of the following local anesthetics has a vasodilatory effect on cutaneous blood vessels?
A. Lidocaine
B. Procaine
C. Cocaine
D. Choices A and B only
E. All of the above

Correct answer: (D) Choices A and B only.

Explanation: All local anesthetics, except for Cocaine, exert a vasodilatory effect on the smooth muscles of cutaneous
blood vessels. This is problematic because when administered locally, vasodilation increases the circulation to and from
the cutaneous vasculature injected, decreasing the availability of the anesthetic to local tissue and preventing the
desired effect. It is for this reason, epinephrine, a vasoconstrictor, is often co-administered. Epinephrine prolongs the
duration of anesthesia through its vasoconstrictive effect and also serves to reduce intraoperative bleeding. Esters and
amides, like those listed in choice A and B are vasodilators as are all local anesthetics aside from Cocaine (Choice C).

32. What is the treatment of choice for dermatofibrosarcoma protuberans (DFSP) in children?
A. Wide excision with 2 to 4 cm margins or Mohs micrographic surgery are both first line treatments
in children.
B. Wide excision
C. Mohs micrographic surgery
D. Radiotherapy
E. Chemotherapy

Correct answer: (A) Wide excision with 2 to 4 cm margins or Mohs micrographic surgery are both first line
treatments in children.
Explanation: Dermatofibromasarcoma protuberans is a cutaneous soft tissue sarcoma, most commonly seen in adults
but can be found in all ages. It is characterized by a unique translocation, t(17;22)(q22;q13) which results in platelet
derived growth factor (PDGFB) under control of the collagen type 1 promoter (COL1A1). DFSPs have a propensity or recur
locally but a low risk of metastasis. DFSP invades surrounding tissue in an eccentric fashion which can lead to an
inadequate resection, clear surgical margins are the most important factor in patients with DFSP. Wide local excision is
the treatment of choice for DFSP in any age, with at least 2 cm margins to investing fascia or pericranium with clear
pathologic margins when clinically feasible.
The current standard first‐line therapy for DFSP recommended by the National Comprehensive Cancer Network (NCCN) is
wide local excision (WLE) with 2‐ to 4‐cm margins or Mohs micrographic surgery (MMS). Several studies have compared
the efficacy of these approaches. Although sWLE with microscopic margin clearance may be as effective as MMS, this
may not be feasible. Young children are mores likely to experience functional disability, gross mutilation, and poor
cosmetic outcomes. Mohs specimens are sectioned horizontally, allowing for visualization of 100% of the tumor margins
and subsequent removal of residual tumor. MMS therefore has the advantage of tissue conservation, leading to smaller
wound size and low incidence of reurrence.”

33. Pseudofrosting is characteristic of which of the following chemical peels?

A. Lactic acid
B. 10% Trichloroacetic acid
C. 70% Glycolic acid
D. Salicylic acid
E. 20% Trichloroacetic acid

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 Correct answer: (D) Salicylic acid.
Explanation: Salicylic acid is a lipophilic molecule that concentrates within the pilosebaceous apparatus. It is therefore
the preferred superficial peeling agent for acne and rosacea. This lipophilicity results in a perifollicular pseudofrosting
pattern (it produces a white color, which is not a true frosting but rather a precipitation of salicylic acid crystals). All of
the other answer choices are superficial peeling agents that do not concentrate around the pilosebaceous unit.

34. A 12-year-old male presents to clinic with a slow growing tumor on his great toe. Patient recalls injuring the toe in a
soccer game several months prior to onset. It is mildly tender and solid, and not fluid-filled. Radiography would likely
reveal which of the following?

A. Cup-shaped radiolucent defect

B. Well-circumscribed radio-opacity
C. Multiple radio-opacities
D. Central radiolucent defect
E. Osteoarthritis

Correct answer: (B) Well-circumscribed radio-opacity.

Explanation: This picture is characteristic for a subungual exostosis, a benign osteocartilaginous tumor of the distal
phalanx, frequently occurring beneath the nail bed. Radiography typically reveals a wel-circumscribed bony projection.
(A) A cup-shaped radiolucency is characteristic of a keratoacanthoma due to its endophytic nature.
(C) Multiple radio-opacities would not be characteristic of this solitary nodule, and can be due to a number of etiologies.
(D) A central radiolucency is characteristic of an enchondroma. These tumors are the most common tumor of the hand,
however, are typically not preceded by trauma or infection.
(E) This is not a Heberden’s node, which typically overlies a joint.

35. Which of the following statements most adequately describes coherence?

A. The existence of a well-defined wavelength
B. Light traveling in a parallel beam
C. Waves of light travelling in phase
D. Probability per unit of length that a photon of a specific wavelength will be absorbed
E. Specific molecules of similar nature that absorb light at well-defined wavelength

Correct answer: (C) Waves of light travelling in phase.

Explanation: This is the definition of coherence, an important property of laser light. Light waves travelling in phase in
time and space, similar to water flowing from a small faucet is a required property that differentiates laser light from
other forms of light. Both coherence and collimation allow laser light to be focused to a very small spot size.
(A) This is the definition of monochromicity. The presence of a well-defined wavelength, as opposed to a broad band of
wavelengths, is a property that differentiates laser light from other forms of light.
(B) Light traveling in a parallel beam is the definition of collimation, and is an important property of laser light.

12
 (D) This provides the definition of the absorption coefficient, or the probability per unit path length that a photon at a
particular wavelength will be absorbed.
(E) This coefficient is dependent on the concentration of targeted absorbing molecules or chromophores.

36. The time it takes for a specific heated tissue to cool halfway to its original temperature defines which of the following
principles of laser therapy?
A. Fluence
B. Power
C. Pulse duration
D. Thermal relaxation time
E. Energy

Correct answer: (D) Thermal relaxation time.

Explanation: As described in the question, the thermal relaxation time for a given chromophore is defined as the time it
takes for the target chromophore to dissipate its absorbed heat and reach the halfway point to its original temperature
prior to photon absorption and transference of heat. The goal during laser therapy is to denature the target
chromophore prior to heat dissipating to surrounding, non-targeted tissue. Pulse Duration (C), or pulse width, is the
amount of time a targeted chromophore is exposed to energy emitted by laser photons. The optimal pulse duration for
selective photothermolysis approaches equivalence to the targeted chromophores thermal relaxation time. Energy is the
fundamental unit of work, measured in Joules (E). Fluence (A) is the amount of energy (Joules) delivered per unit of area
(centimeters squared). Finally, power (B) is the rate at which energy is delivered and is measured in Watts.

37. A patient six weeks status post Mohs surgery for a basal cell carcinoma on his nose now notes firm nodularity at the
repair site. On examination, a trapdoor effect is noted. Which of the following factors is least likely to contribute to
development of this surgical complication?
A. Fibrofatty deposition
B. Shape of flap design
C. Scar contracture
D. Vascular devitalization of the tissue
E. Beveled wound edges

Correct answer: (D) Vascular devitalization of the tissue.

Explanation: Although lymphatic and venous obstruction have been suggested, devitalization is not a cause of the
trapdoor effect. (A) (B) (C) (E) Many theories have been reported to contribute to development of the trapdoor effect
associated with nasolabial flaps, including shape of the flap, lymphatic and venous obstruction, hypertrophy of the scar,
excessive fatty and redundant tissue, beveled wound edges, and contracture of the scar.

38. Which of the following should raise suspicion of subungual melanoma as the cause of longitudinal melanonychia?
A. involvement of the thumbnail
B. width >1mm
C. gray/blue color
D. younger patient
E. all of the above

Correct answer: (A) Involvement of the thumbnail.

Explanation: The mnemonic ABCDEF can be used for the characteristics that should raise one’s suspicion for subungual
melanoma: A= age of the patient (older is more likely) B= brown/black color, breadth >3mm C= change in the band D=

13
 digit involved (higher risk with thumb and great toe) E= extension onto the proximal nailfold (Hutchinson’s sign) F=
family history of melanoma

39. What type of surgical instrument is shown and what is the primary function?
A. Bard-Parker; periorbital region
B. Bard-Parker; sharp dissection
C. Beaver handle; used for small delicate areas such as eyes and conchal bowl
D. Beaver handle; allows control by twisting rather than saw motion
E. Spencer handle; reusable punch biopsy instrument

Correct answer: (C) Beaver handle; used for small delicate areas such as eyes and conchal bowl.
Explanation: This is a beaver handle with replaceable sharp blades providing a pencil grip with precise, delicate cutting
from all directions. A twisting motion is not used, as this provides multi-directional cutting.
(A) (B) (D) (E) This is not a Bard-Parker, which is a standard scalpel handle used to make excisions. Spencer scissors are
used for cutting suture.

40. What is the result of a Z-plasty?

A. Shorter scar
B. Longer scar
C. Transfer of dermis, epidermis and adnexal structures
D. Transfer of epidermis and partial dermis

Correct answer: (B) Longer scar.

Explanation: A Z plasty is a double transposition flap useful for scar revisions. It lengthens a contracted scar, realigns a
scar to fall in natural folds and helps to camouflage a scar by interrupting its continuity. The Z-plasty can also be used to
relieve tension along free margins such as the eye or lip.
(A) An M plasty is used to shorten a scar. Two separate 30 degree angles are created which decreases the excision of
normal tissue.
(C) Transfer of dermis, epidermis and adnexal structures describes a full thickness skin graft.
(D) Transfer of epidermis and partial dermis describes a partial thickness skin graft.

41. What is the maximum dose of lidocaine that can be used during tumescent anesthesia?
A. 3mg/kg
B. 4.5mg/kg
C. 7 mg/kg
D. 25mg/kg
E. 55mg/kg

Correct answer: (E) 55mg/kg.

Explanation: Tumescent lidocaine is diluted lidocaine and epinephrine that is used during liposuction. The maximum dose
that can be used is 55mg/kg. The maximum dose of lidocaine used in local anesthesia is 4.5mg/kg without epinephrine,
and 7mg/kg with epinephrine.

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42. Which of the following suture techniques has the highest risk of cross-hatching?
A. Vertical mattress
B. Half buried vertical mattress
C. Simple interrupted
D. Running interlocking
E. Subcuticular

Correct answer: (A) Vertical mattress.

Explanation: Vertical mattress sutures have the highest risk of crosshatching because of increased tension across the
wound and the 4 entry and exit points directly across from each other.
(B) (C) (D) (E) The other listed suture techniques all have a risk of crosshatching, however, vertical mattress has the
highest risk of the listed.

43. During cryotherapy, what minimum temperature is required for melanocyte destruction?
A. -5°C
B. -25°C
C. -50°C
D. -100°C
E. -196°C

Correct answer: (A) -5°C.

Explanation: Melanocytes are destroyed at -5°C. Malignant skin cancers typically require a temperature of -50°C for
destruction, whereas benign neoplasms require a temperature of -25°C. -196°C is the boiling point of liquid nitrogen.

44. All of the following are chromophores targeted by lasers EXCEPT?

A. Water
B. Hair
C. Melanin
D. Hemoglobin
E. All of the above are chromophores

Correct answer: (B) Hair.

Explanation: A chromophore is a molecule that absorbs a photon transmitted by a laser. Once the photon is absorbed by
the chromophore, energy is transmitted from the photon to the chromophore, the photon ceases to exist, and the
chromophore enters an excited state. This is one of the basic features of laser therapy. Three chromophores exist in the
skin; they are water, melanin, and hemoglobin. (B) Lasers targeting hair for depilation are actually targeting the melanin
inside of hair. This is the main reason why blonde or grey hair is not successfully removed by laser hair removal therapy.
(A) (C) (D) Each of the three chromophores has its own absorption spectrum in which specific lasers can be used to target
chromophores and their corresponding wavelength. The variation in absorption spectrum of each chromophore
delineates specific targets for specific lasers. Hair is not a chromophore.

45. Which of the following suture types has the best “ease of handling”?
A. Polyglactin 910
B. Poliglecaprone
C. Nylon
D. Polydioxanone
E. Silk

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 Correct answer: (E) Silk.
Explanation: Silk is considered the gold standard with regard to ease of handling, knot formation and knot stability with
which newer sutures are compared.
(A) (B) (C) (D) The other listed suture materials are listed as having fair to good ease of handling, but are not considered
the gold standard of ease.

46. Which of the following is true about the nail bed?

A. It has no subcutis
B. It has no dermis
C. It has no epidermis
D. It extends from the lunula to the proximal nail fold
E. It extends from the proximal matrix to the hyponychium

Correct answer: (A) It has no subcutis.

Explanation: The nail bed extends from the distal nail matrix to the hyponychium. It is composed of epidermis and
dermis, which lie immediately over periosteum, with no subcutis in between.

47. Which of the following hemostatic agents is least likely to be effective in a thrombocytopenic patient?
A. Microfibrillar collagen
B. Gelatin foams
C. Silver nitrate
D. Ferric subsulfate
E. Aluminum chloride

Correct answer: (A) Microfibrillar collagen.

Explanation: Microfibrillar collagen is derived from purified bovine collagen and provides a large surface area to act as a
matrix for platelet activation, aggregation, and thrombus formation. Their effectiveness is thus significantly reduced in
severe thrombocytopenia.
(B) (C) (D) (E) Silver nitrate, ferric subsulfate and aluminum chloride work by coagulating proteins leading to tissue
necrosis and eschar formation enhancing thrombus formation and hemostasis. Gelatin foam works from forming a
mechanical barrier to bleeding, regardless of platelet levels.

48. Which nerve fibers within the dermis exhibit the most rapid response to local anesthesia?
A. Unmyelinated C-fibers carrying pain sensation
B. Intermediate fibers carrying sensations of heat and cold
C. A-type fibers that carry pressure sensation
D. Motor neurons that innervate the skeletal musculature
E. Autonomic nerves that innervate smooth muscle

Correct answer: (A) Unmyelinated C-fibers carrying pain sensation.

Explanation: Unmyelinated nociceptors, or nerves that carry the sensations of pain, are the first to respond to local
anesthesia. Local anesthetics function by inhibiting the entry of sodium channels into cell membrane of neuronal axons.
This prevents depolarization of the nerve and halts the generation of an action potential.
(B) Intermediate fibers do not respond to anesthesia as quickly as the C-fibers, thus patients are more susceptible to the
sensations of heat and cold for some time following the use of local anesthetics.
(C) A-type fibers that convey the stimuli of pressure sensation are the last nerves to respond to local anesthesia, and
patients are often reminded that despite an absence of pain sensation, they will be prone to sensing pressure and
vibration.

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 (D) Motor neurons are not targets of local anesthesia in dermatology, however, regarding their rapidity in response to
local anesthetics, they are near in the time for A-type fibers to respond, usually last.
(E) Local anesthesia is not used in dermatology to target neurons that innervate smooth muscle. This is typically
accomplished by alternative forms of anesthesia and is reserved for patients undergoing complex surgical procedures
requiring general anesthesia.

49. A patient several weeks status post Mohs surgery for a basal cell carcinoma now has unilateral eyebrow droop and
loss of normal forehead furrows. Injury to what nerve and subsequently dernervated muscle led to this surgical
complication?
A. Injury to the zygomatic branch of the facial nerve; orbicularis oculi muscle
B. Injury to the supratrochlear nerve; superior oblique muscle
C. Injury to the temporal branch of the facial nerve; frontalis muscle
D. Injury to the ophthalmic branch of the trigeminal nerve; frontalis muscle
E. Injury to the supraorbital nerve; frontalis muscle

Correct answer: (C) Injury to the temporal branch of the facial nerve; frontalis muscle.
Explanation: The temporal branch of the facial nerve is very superficial as it crosses the zygomatic arch in the temple
region. It is vulnerable to injury in this area, especially in elderly patients with thin skin. Transection of the temporal
branch to the frontalis muscle results in unilateral eyebrow ptosis and loss of the normal forehead furrows.
(A) (B) (D) (E) Injury to the zygomatic branches supplying the orbicularis oculi muscle may result in difficulty closing the
eye or ptosis, however, it is far less common as it sits in a deeper plane than the temporal branch. The frontalis muscles is
the cause of loss of the forehead furrows and is not motor innervated by the supraorbital or ophthalmic branch of the
trigeminal nerve.

50. A patient presents to your Mohs clinic for the removal of a squamous cell carcinoma on the dorsum of the right hand.
He is right handed and wants to know how soon he will be able to use his hand to write and type. Which of the
following nerve fibers will be affected most rapidly by the anesthetic?
A. Unmyelinated C-fibers carrying pain sensation
B. A-β type fibers that carry pressure sensation
C. Motor neurons that innervate the skeletal musculature
D. Autonomic nerves that innervate smooth muscle

Correct answer: (A) Unmyelinated C-fibers carrying pain sensation

Explanation: Unmyelinated nociceptors, or nerves that carry the sensations of pain, are the first to respond to local
anesthesia. Local anesthetics function by blocking the sodium channels in the cell membrane of neuronal axons. This
prevents depolarization of the nerve and halts the generation of an action potential.
Incorrect answers:
(B) A-β type fibers that convey the stimuli of pressure sensation are the last nerves to respond to local anesthesia, and
patients are often reminded that despite an absence of pain sensation, they will be prone to sensing pressure and
vibration.
(C) (D) Both motor neurons that innervate as well as autonomic nerves that innervate the smooth musculature are not
targets for local anesthesia during the procedure described in the vignette, though they may be affected.

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51. A 65-year-old patient arrives for a pre-operative evaluation prior to Mohs surgery for a large squamous cell
carcinoma on his left elbow. The patient is excited about a golfing trip he has planned a month following the
procedure. What wound strength should the patient be told he is likely to have at one month after surgery?
A. 60%
B. 40%
C. 20%
D. 10%
E. 5%

Correct answer: (B) 40%.

Explanation: At one month, a wound is likely to be between 35-50% of its original wound strength. (A) (C) (D) (E) At 2
weeks, the wound has 3-5% wound strength. At 3 weeks, it has 20%. At 1 year, it has 80%.

52. A patient presents to your clinic with a hemi-facial vascular lesion that is pink to faintly erythematous and involves
the right side of the face in a V1 distribution. You discuss potential treatments and complications and he wishes to
proceed with laser therapy. Which of the following side effects is most common from the laser used to treat this
patient’s lesion?
A. Hyperpigmentation
B. Hypopigmentation
C. Scarring
D. Purpura
E. Skin atrophy

Correct answer: (D) Purpura.

Explanation: The patient in this vignette presents with a port-wine stain on the right side of the face. These capillary
malformations, when involving the face, tend to occur in a dermatomal distribution following the three branches of the
trigeminal nerve. The most common laser used to treat these lesions is the pulsed dye laser (585-595nm), and the most
commonly associated side effect to treatment with this laser is purpura. Purpuric lesions appear almost instantaneously
following the use of the laser, and some clinicians use this as a marker to determine which areas are responding to the
therapy and to prevent overlapping with repetitive passes. Longer pulse widths (> 6ms) can be used in order to avoid the
cosmetically unacceptable purpura that results from intravascular thrombosis, however, some degree of this thrombosis
may be necessary for the efficacious treatment of port-wine stains and may be unavoidable. (A) (B) (C) (E) While other
side-effects listed in choices (A), (B), (C), and (E) can occur, they do so in a much lower frequency, and adjustments to
cooling devices, pulse duration and fluence can be altered to prevent several of these anticipated complications.

53. A woman with visible solar keratoses, facial telangiectasias, and wrinkles at rest would be classified how on the
Glogau scale of aging?
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V

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 Correct answer: (C) Type III.
Explanation: The telangiectasias, visible keratoses and wrinkles at rest classify her as a Glogau Type III. The Glogau
photoaging scale is as follows:

 Type I - no wrinkles, no keratoses.

 Type II - wrinkles with movement, keratoses palpable but not visible, early lentigos, smile lines begin to appear.
 Type III - wrinkles at rest, keratoses visible, telangiectasias, obvious dyschromia.
 Type IV - wrinkles throughout with no normal skin, yellowish-gray color, skin malignancies.

54. A full thickness skin graft is placed on a patient’s ear to repair a skin defect. The patient calls the clinic the next day
complaining of discoloration of the graft. Upon examination, you find the graft to have a dusky blue color without
fluctuance. What is your next step?
A. Tell the patient a hematoma has likely formed and should be decompressed immediately
B. Ask the patient if he is smoking cigarettes
C. Culture the exudates
D. Reassure patient that this is a normal stage in a graft “taking”, due to vascular injury from tissue
handling
E. Recheck graft in 6 days

Correct answer: (E) Recheck graft in 6 days.

Explanation: There are four stages to a graft “take”. Initially the graft blanches. At 6 hours, it turns pale pink due to
vasodilation. At 24 hours, it turns dusky blue due to venous congestion.
(A) There is no fluctuance noted, thus it is unlikely the patient has a hematoma.
(B) Although cigarette smoking can contribute to graft failure due to nicotine-induced vasoconstriction, it is not the cause
of the 24 hour dusky blue discoloration.
(C) The patient has no evidence of infection, as this is a normal part of the grafting process.
(D) Excessive tissue handling contributes to graft failure, but is not the cause of the 24 hour dusky blue discoloration.

55. The most likely closure technique used to close this wound was:

A. a transposition flap
B. a rotation flap
C. an advancement flap
D. an interpolation flap
E. an island pedicle flap

Correct answer: (A) A transposition flap.

Explanation: This is an example of the scar created after a bilobed flap closure, which is a type of transposition flap. A
transposition flap is created when a flap is taken out of an adjacent donor site, moved over an incomplete bridge of skin,
and placed in the defect it is to fill. The secondary defect created at the donor site is then closed. Examples of
transposition flaps include: bilobed flap, rhombic flap and a Z-plasty. Some people consider transposition flaps like the
Bilobed and the Rhombic Flaps as a subtype of Rotation flap since you are rotating the donor skin on an axis and
transposing it into the defect.

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56. A woman returns to your clinic for the examination of a suspicious mole located on the left breast she had presented
with 6 months ago. On exam, you notice that it has become slightly irregular in symmetry and there is notable color
variation. You elect to perform an excisional biopsy. She informs you that she is 5 months pregnant. Which of the
following local anesthetics is most appropriate for use during this procedure?
A. Cocaine
B. Tetracaine
C. Bupivicaine
D. Mepivicaine
E. Lidocaine

Correct answer: (E) Lidocaine.

Explanation: Lidocaine is the only listed local anesthetic that is Category B and safe to use in pregnant women. Studies
performed on women who received Lidocaine during the first trimester of pregnancy demonstrated no increased risk of
the development of anatomic abnormalities in neonates. Regardless, because organogenesis occurs during the first
trimester and up to 4 months, it is recommended that lidocaine be used cautiously during this time period to prevent
teratogenicity. If possible, delaying any procedures until after the fourth month is an acceptable approach in the use of
local anesthetics in pregnant women. (A) (B) (C) (D) Choices A-D are all pregnancy Category C and are not deemed safe to
use during pregnancy. Cocaine is no longer used as a local anesthetic.

57. All of the following statements regarding the metabolism of local anesthetics are true EXCEPT?
A. Amides are metabolized by the CYP450 system
B. Esters are metabolized by plasma pseudocholinesterase
C. Esters are excreted by the kidneys
D. Amides are excreted by the liver into the entero-hepatic circulation
E. Para-aminobenzoic acid (PABA) is a metabolic by product of ester anesthetics

Correct answer: (D) Amides are excreted by the liver into the entero-hepatic circulation.
Explanation: Choice (D) is false. Amides are metabolized by the CYP450 hepatic enzyme system (Choice A), and the
kidneys excrete their metabolites. Patients with significant liver disease, such as cirrhosis, are placed at an increased risk
for anesthetic toxicity with the use of amide anesthetics. Esters are metabolized by plasma pseudocholinesterase (Choice
B). Patients with a deficiency of pseudocholinesterase may experience prolonged paralysis following the use of ester
anesthetics. This class of anesthesia should be avoided in such patients. Metabolites of esters are excreted by the kidneys
(Choice C). Para-aminobenzoic acid (PABA), is a metabolite of ester anesthetics (Choice E), and are responsible for allergic
reactions associated with this class of anesthesia.

58. A patient returns to clinic one week after you have treated her glabella with botulinum toxin A for rhytides. She
complains of having trouble keeping her right eye open and on exam there is significant lid ptosis on the right side.
Eye drops made of what substance can improve this complication?
A. acetylcholinesterase
B. beta adrenergic antagonist
C. beta adrenergic agonist
D. alpha adrenergic agonist
E. alpha adrenergic antagonist

Correct answer: (D) Alpha adrenergic agonist.

Explanation: Application of apraclonidine eye drops, an alpha adrenergic agonist, causes Mueller’s muscle to contract,
leading to elevation of the upper lid by 1-3mm. This can partially correct ptosis resulting from a complication of
botulinum toxin therapy.

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59. Which of the following sets of lasing media and associated phases are INCORRECTLY paired?
A. Argon - Solid
B. Carbon Dioxide - Gas
C. Alexandrite - Solid
D. Krypton – Gas

Correct answer: (A) Argon - Solid.

Explanation: The above pairs listed in Choices (B) (C) (D) (E) are correctly matched between lasing media, and phase of
lasing media except for Choice (A). Argon is a gas media. Lasing media selection is important to consider when applying
Laser therapy for the treatment of various skin conditions. The excitation of lasing media in solid, liquid, or gas form
determines the wavelength of light emitted by the laser. The selection of specific wavelengths is necessary when
targeting the 3 main chromophores in laser therapy; melanin, hemoglobin, and water.

60. A laser that produces photons in which of the following wavelengths would be ideal for treatment of this patient?

A. 308 nm
B. 585 nm
C. 755 nm
D. 1,064 nm
E. 10,600 nm

Correct answer: (E) 10,600 nm.

Explanation: The photograph shows a patient with phymatous rosacea (rhinophyma). Ablation of sebaceous tissue using
the CO2 laser (10,600 nm) is an effective treatment.
(A) The excimer laser (308 nm) can thought of as a localized UVB therapy, it can be used to treat psoriasis or vitiligo.
(B) The pulsed dye laser (585 nm) targets hemoglobin and can be used to treat vascular lesions.
(C) The Alexandrite (755 nm) targets melanin and can be used for pigmented lesions, tattoos and hair removal.
(D) The Nd:Yag (1064 nm) laser targets melanin and hemoglobin and can be used for vascular and pigmented lesions

61. Which of the following suture techniques is most useful for high tension wound apposition?
A. Vertical Mattress
B. Horizontal mattress
C. Far-far near-near vertical mattress
D. Near-near far-far horizontal mattress
E. Far-near near-far vertical mattress

Correct answer: (E) Far-near near-far vertical mattress.

Explanation: Far-near near-far vertical mattress, aka the pulley stitch, provides the strongest wound apposition of the
listed by trading distance for effort through its redirections, as any pulley system would. (B) (D) The other listed suture
techniques provide less tensile strength than the pulley stitch. (A) (C) These are identical.

21
62. The frontalis muscle is innervated by which of the following nerves?
A. Facial nerve - temporal branch
B. Facial nerve - buccal branch
C. Facial nerve - marginal mandibular branch
D. Facial nerve - posterior auricular
E. Facial nerve - zygomatic branch

Correct answer: (A) Facial nerve - temporal branch.

Explanation: The frontalis muscle is innervated by the temporal branch of the facial nerve.

63. What is the main purpose of a vertical mattress stitch?

A. hemostasis
B. wound edge eversion
C. decreasing the possibility of track marks
D. securing the tip of a triangle shaped flap
E. eliminating dead space

Correct answer: (B) Wound edge eversion.

Explanation: The main indication for use of a vertical mattress stitch is wound edge eversion. Wound edge eversion can
be achieved using many different suturing types, however the vertical mattress suture is especially effective in creating
this and it is therefore the main indication for its use. The purpose of a running locked stitch is to assist with hemostasis.
The main purpose of a running subcuticular stitch is to decrease the possibility of track marks. Securing the tip of a
triangle shaped flap is best achieved using a half-buried horizontal mattress stitch, also known as a tip-stitch or a corner
stitch. Plicating sutures or deep buried dermal sutures are used to eliminate dead space.

64. Which of the following laser therapy targets has the longest thermal relaxation time?
A. Melanosomes
B. Capillaries
C. Leg vein
D. Hair follicles
E. Tattoo ink particles

Correct Answer: C. Leg vein.

Explanation: The thermal relaxation time (TRT) for a given chromophore is defined as the time it takes for the target
chromophore to dissipate its absorbed heat and reach the halfway point to its original temperature prior to photon
absorption and transference of heat. The goal during laser therapy is to denature the target chromophore prior to heat
dissipating to surrounding, non-targeted tissue. The thermal relaxation time for a given molecular target is proportional
to the square of the diameter of a chromophore (d2), or simply speaking, the larger the molecule, the longer the thermal
relaxation time. The diameter of a chromophore that is part of a leg vein is estimated to be 1mm, and its thermal
relaxation time is measured in seconds, usually 1-2 total. Of the above options, leg veins have the longest thermal
relaxation time.
Incorrect Answers:
A. Melanosomes, which have molecular chromophores approximating 0.5 microns in diameter, demonstrate a TRT in the
range of 150-300 nanoseconds.
B. In contrast, capillaries, having chromophores that are microns in diameter, demonstrate a TRT in in the tens of
microseconds.
D. Terminal hair follicles exhibit a TRT that is measured in the tens to one hundred milliseconds. Tattoo ink particles have
some of the smallest chromophore diameters in the tenths of microns, and corresponding to this, have some of the
shortest TRT’s, in the tens of nanoseconds.

22
65. All of the following are properties of light amplified by stimulated emission of radiation EXCEPT?
A. Coherence
B. Collimation
C. Monochromicity
D. Lasing Media
E. Choices A and B

Correct answer: (D) Lasing Media.

Explanation: Lasing media is a property of the laser system through which laser light is generated and emitted. It is not a
property of light amplified by stimulated emission of radiation (Laser).
(A) (B) (C) Coherence, collimation, and monochromicity are all properties of laser that distinguish this form of light from
other forms such as visible light.
(A) Coherence is when light waves travelling in phase in time and space, similar to water flowing from a small faucet is a
required property that differentiates laser light from other forms of light.
(B) Light traveling in a parallel beam is the definition of collimation, and is an important property of laser light. Both
coherence and collimation allow laser light to be focused to a very small spot size.
(C) Monochromicity, or the presence of a well-defined wavelength, as opposed to a broad band of wavelengths, is a
property that differentiates laser light from other forms of light.

66. Which of the following basal cell carcinomas does NOT have an indication for treatment with Mohs surgery?
A. a 0.7cm morpheaform basal cell carcinoma on the nose
B. a 1.8cm infiltrating basal cell carcinoma on the back
C. a 2.1 cm nodular basal cell carcinoma on the arm
D. a 1 cm basosquamous carcinoma on the chest
E. a 0.4 cm superficial basal cell carcinoma on the neck

Correct answer: (E) A 0.4 cm superficial basal cell carcinoma on the neck.
Explanation: Characteristics of basal cell carcinomas that indicate treatment with Mohs surgery include: recurrent
tumors, high risk anatomic locations or locations where tissue preservation is imperative, perineural invasion, poorly
defined clinical borders, histologic subtype, and size. Histologic subtypes that are indicated for treatment with Mohs
surgery include morpheaform, infiltrating and micronodular subtypes, as well as basosquamous carcinoma. Treatment of
large BCC’s (>2cm) has also been indicated as size has been directly related to recurrence rate. Superficial basal cell
carcinoma of 0.6-1.2 is appropriate for the Mohs procedure.

23