Appendix: FRCS Plast Classification Systems Contents • Aesthetic • Cancer Staging • Craniofacial • Congenital • General • Hand • Reconstruction/Flaps • Trauma • Incidences • Other Useful Bits for the Exam Aesthetic Baker, Capsule Formation 1975 I – No capsule II – Palpable III – Visible IV – Painful Heimburg, Tuberous breast, BJPS , 1996;49:339–345 Type 1: Hypoplasia of infero-medial quadrant Type 2: Hypoplasia of both inferior quadrants Type 3: Hypoplasia of both lower quadrants and subareolar skin shortage Type 4: Severely constricted base Matarasso Classification of Abdominoplasty Type 1: Excess fat only – liposuction Type 2: Mild skin excess, infra-umbilical divarification – mini- abdominoplasty infra-umbilical plication liposuction S. Hettiaratchy et al. (eds.), Plastic Surgery, 197 DOI 10.1007/978-1-84882-116-3, © Springer-Verlag London Limited 2012 198 Appendix: FRCS Plast Classification Systems Type 3: Moderate skin excess, infra and superior divarifica- tion – As above Type 4: Severe skin excess – Standard abdominoplasty with plication and liposuction Paysk zones around an expander Inner zone: Fibrin layer with macrophages Central zone: Fibroblasts and myofibroblasts Transitional zone: Loose collagen Outer zone: Blood vessels and collagen Regnault classification of ptosis 1st degree: Nipples at or above IMF 2nd degree: Nipples below IMF but above most dependant portion of the breast 3rd degree: Nipples below the most dependant portion of the breast • Pseudo-ptosis – where the majority of the breast mound lies below the IMF but nipple is above or on the IMF. Post BBR common Simon classification for gynaecomastia Stage 1: Slight volume increase no excess skin Stage 2a: Moderate volume increase without excess skin Stage 2b: Moderate volume increase with excess skin Stage 3: Marked volume increase with excess skin Cancer Staging Broder’s histological grading of SCC Grade I: Well differentiated Ratio Diff:Undiff 3:1 Grade II: Mod differentiated Ratio Diff:Undiff 1:1 Grade III: Poorly differentiated Ratio 1:3 Grade IV: Undifferentiated Appendix: FRCS Plast Classification Systems 199 TNM classification for cutaneous melanoma Classification Thickness (mm) Ulceration status/Mitoses T Tis NA NA T1 £ 1.00 a: Without ulceration and mitosis < 1/mm 2 b: With ulceration or mitoses ³ 1/mm 2 T2 1.01–2.00 a: Without ulceration b: With ulceration T3 2.01–4.00 a: Without ulceration b: With ulceration T4 >4.00 a: Without ulceration b: With ulceration N No. of metastatic nodes Nodal metastatic burden N0 0 NA N1 1 a: Micrometastasis * b: Macrometastasis † N2 2–3 a: Micrometastasis * b: Macrometastasis † c: In-transit metastases/ satellites without metastatic nodes N3 4+ metastatic nodes, or matted nodes, or in-transit metastases/satellites with metastatic nodes M Site Serum LDH M0 No distant metastases NA M1a Distant skin, Normal subcutaneous, or nodal metastases M1b Lung metastases Normal M1c All other visceral Normal metastases Any distant metastasis Elevated 200 Appendix: FRCS Plast Classification Systems AJCC classification 2009 Clinical staging Pathologic staging T N M T N M 0 Tis N0 M0 0 Tis N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 T2a N0 M0 T2a N0 M0 IIA T2b N0 M0 IIA T2b N0 M0 T3a N0 M0 T3a N0 M0 IIB T3b N0 M0 IIB T3b N0 M0 T4a N0 M0 T4a N0 M0 IIC T4b N0 M0 IIC T4b N0 M0 III Any T N > N0 M0 IIIA T1-4a N1a M0 T1-4a N2a M0 IIIB T1-4b N1a M0 T1-4b N2a M0 T1-4a N1b M0 T1-4a N2b M0 T1-4a N2c M0 IIIC T1-4b N1b M0 T1-4b N2b M0 T1-4b N2c M0 Any T N3 M0 IV Any T Any N M1 IV Any T Any N M1 Enneking sarcoma staging Stage Grade Anatomical location Metastasis 0 Benign (G0) Any None IA Low (G1) Intra-compartmental (T1) None IB Low Extra-compartmental (T2) None IIA High (G2) Intra-compartmental None IIB High Extra-compartmental None III Any Any Mets (M1) Appendix: FRCS Plast Classification Systems 201 AJCC for sarcoma Stage Grade Size (cm) Metastasis Relationship to fascia IA Low <5 None Any IB Low >5 None Superficial IIA Low >5 None Deep IIB High <5 None Any IIC High >5 None Superficial III High >5 None Deep IV Any Any Yes Any Trojani histological grading system: sarcoma • Basis of this grading system is based on the following − Histology − Mitosis − Necrosis − Differentiation − Stroma − Number of cells Tumours of the head and neck Oral cavity Nasopharynx Hypopharynx Maxillary sinus (cm) T1 <2 1 subsite 1 subsite Mucosal only T2 2–4 >1 subsite >1 subsite not Into bone below fixed Ohngrens linea T3 >4 Beyond nasal Into larynx Into bone above cavity Ohngrens linea T4 Invades Skull base Into neck soft Invades adjacent adjacent or CN tissues structures structures aMedial canthus to angle of the mandible For salivary gland tumours add A or B to the T stage to signify no local extension or local extension Nodal classification: N1: Single ipsilateral <3 cm N2a: Single ipsilateral 3–6 cm N2b: Multiple ipsilateral not >6 cm N2c: Bilateral or contralateral nodes 3–6 cm N3: Any node >6 cm 202 Appendix: FRCS Plast Classification Systems TNM staging for head and neck cancer Stage 1 T1 N0 M0 Stage 2 T2 N0 M0 Stage 3 T3 N0 M0 <T4 N1 M0 Stage 4 T4 N0 M0 Any T N2/3 M0 Any T Any N M1 Classification of neck dissection • Comprehensive − Radical 5 levels IJV, AN, SCM − Modified radical (functional) T1 – preserves the AN T2 – preserves the AN and SCM T3 – preserves AN, SCM and IJV − Extended radical May take parotid, mediastinal nodes or paratracheal nodes • Selective neck dissection − Supraomohyoid Oral cavity tumours Levels 1,2 and 3 − Anterolateral Laryngeal and hypopharynx tumours Levels 2,3 and 4 − Anterior Thyroid tumours Levels 2,3 and 4 with tracheo-oesophageal nodes − Posterior Posterior scalp Levels 2,3,4 and 5 WHO classification of salivary gland tumours 1. Adenoma (a) Pleomorphic (b) Warthin’s – Adenolymphoma (c) Oncocytoma Appendix: FRCS Plast Classification Systems 203 2. Carcinoma (a) Muco-epidermoid (i) Well, inter and poorly differentiated grades. Well and inter OK (b) Malignant mixed tumour – arising in PMA (c) Acinic cell (d) Adenocarcinoma (e) Adenoid cystic – Szanto’s grades (i) Grade 1 – cibrose, no solidity good prognosis (ii) Grade 2 – tubular, <30% solid (iii) Grade 3 – solid, poor prognosis (f) Squamous cell 3. Non-epithelial tumours 4. Malignant lymphomas 5. Secondary tumours (a) MM (b) SCC (c) Breast (d) Thyroid 6. Unclassifi ed 7. Tumour like (a) Oncocytosis (b) Sialadenosis (c) Cysts (d) Infection (e) Granulomatous disease Craniofacial Knight and North classification of malar fractures 1961 Type 1: Undisplaced fractures Type 2: Isolated # of the arch – STABLE AFTER REDUCTION Type 3: Unrotated body fracture Type 4: Medially rotated # of the body Type 5: Laterally rotated # of the body – STABLE AFTER REDUCTION Type 6: Complex 204 Appendix: FRCS Plast Classification Systems Manson classification of malar fractures – based on CT findings Type 1: Low energy fractures – result in little or no displacement. Often ZF# Type 2: Medium energy – # of all buttresses, mod displacement, comminution Often require intra-oral and eyelid incisions to fix Type 3: High energy – Frequently occur with Le Fort or panfacial #. Posterior dislocation of arch and malar eminence. Requires coronal, eyelid and intra-oral incisions Angle classification of dental occlusion • Occlusion defined as the relative position of the upper first molar. Mesiobuccal cusp should rest in mesiobuccal groove of mandibular first molar Class 1: Normal occlusion but other problems e.g., overcrowding Class 2: Overbite, retrognathism Class 3: Underbite, prognathism, negative overjet Le Fort classification of maxillary fractures LeFort I: Tooth bearing maxilla separated from midface. Fracture through pterygoid Plates to piriform aperture through maxilla LeFort II: Pyramidal fracture # Extends from frontonasal junction along medial orbital wall, IO Rim and posteriorly through pterygoid plates LeFort III: Craniofacial dysjunction .# Extends out through the lateral orbital wall through the zygoma and high through the pterygoid plates Classification of craniofacial anomalies – American Society of Cleft Lip/Palate 1. Clefts 2. Synostosis (a) Syndromal (b) Non-syndromal 3. Hypoplastic conditions (a) TC (b) Hemifacial microsomia – OMENS classifi cation (c) Hemifacial atrophy – Rombergs Appendix: FRCS Plast Classification Systems 205 4. Hyperplastic conditions Fibrous dysplasia – abnormal proliferation of bone form- ing mesenchyme, maxillary/mandibular mass, osseous lesions, Albrights including precocious puberty, cafe au lait, pituitary tumours Tessier’s classification for hyperteliorism Type 1: IOD 30–34 mm Type 2: IOD 35–39 mm Type 3: IOD 40 mm+ Veau’s classification 1931 1. Incomplete cleft of secondary palate 2. Complete cleft of secondary palate 3. Complete unilateral cleft lip and palate 4. Bilateral cleft lip and palate Striped Y classification 1. First described by Kernahan and Stark 1958 2. Modifi ed by Millard and Seider 1977 3. Pictorial classifi cation Craniofacial syndromes Aperts – 1:160,000 • Bicoronal synostosis – turricephaly/brachycephaly • Midface hypoplasia • Beaked nose • Class 3 occlusion • CP 20% • Complex syndactyly − T1 – Thumb and little finger separate − T2 – Thumb separate − T3 – Involves all the hand Crouzon – 1:15,000 AD • Bicoronal synostosis – turricephaly/brachycephaly • Midface hypoplasia • Exorbitism • Normal hands 206 Appendix: FRCS Plast Classification Systems Saethre-Chotzen • Bicoronal synostosis • Low hair line • Ptosis • Small posterior ears • Simple syndactyly Pfeiffer • Similar appearance to Aperts • Broad thumbs and toes Carpenter syndrome