Facial Skin Cancer Reconstruction — MCQs
Mohs micrographic excision for basal cell carcinoma is used for all the following Except
When osseous defects amenable to reconstruction are present, technique of choice is?
What is the primary mechanism responsible for skin graft survival within the first 48 hours after transplantation?
Deep skin burns are treated with:
Following a knife injury to the face causing facial nerve damage, secretion from which of the following glands would be LEAST likely to be impaired?
What is the eponymous term for a full-thickness skin graft?
For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?
Treatment of choice in complete traumatic facial nerve transection is:
Which thickened nerve is shown in the image?
Sensory nerve supply of gall bladder is through -
Facial Skin Cancer Reconstruction Indian Medical PG Practice Questions and MCQs
Question 1: Mohs micrographic excision for basal cell carcinoma is used for all the following Except
- A. Superficial basal cell carcinoma on the trunk (Correct Answer)
- B. Tumors with perineural invasion
- C. Tumors with aggressive histology
- D. Recurrent tumor
Explanation: ***Superficial basal cell carcinoma on the trunk*** - **Mohs micrographic surgery** is generally reserved for basal cell carcinomas (BCCs) in cosmetically and functionally sensitive areas, larger tumors, or those with aggressive features. - For **superficial BCCs** on the trunk, which is considered a low-risk area, standard excision, electrodessication and curettage, or topical therapies are often sufficient and preferred due to their less invasive nature and similar efficacy for this specific tumor type. *Tumors with perineural invasion* - **Perineural invasion** indicates a higher risk of recurrence and metastasis, making Mohs surgery an appropriate choice for complete tumor removal and margin control. - The precise, margin-controlled excision of Mohs helps ensure that all microscopic extensions along nerve sheaths are identified and removed. *Tumors with aggressive histology* - **Aggressive histologic subtypes** such as infiltrative, morpheaform, or micronodular BCCs have a higher risk of subclinical extension and recurrence. - Mohs surgery is highly effective for these types as it meticulously examines 100% of the surgical margins, maximizing tumor eradication while preserving healthy tissue. *Recurrent tumour* - **Recurrent BCCs** often have ill-defined borders and can grow more aggressively due to previous treatment altering the tissue architecture, making complete removal challenging. - Mohs surgery offers the highest cure rates for recurrent BCCs by precisely mapping and excising the tumor while preserving surrounding healthy tissue.
Question 2: When osseous defects amenable to reconstruction are present, technique of choice is?
- A. Sulcular flap
- B. Modified Widman flap
- C. Apically displaced flap
- D. Papilla preservation flap (Correct Answer)
Explanation: ***Papilla preservation flap*** - This technique is specifically designed to **preserve the interdental papilla**, which is critical for covering and protecting regenerative materials placed in osseous defects. - By maintaining the integrity of the papilla, it facilitates primary wound closure over the defect, enhancing the predictability of **guided tissue regeneration (GTR)** and bone grafting procedures. *Sulcular flap* - A sulcular flap involves an incision within the sulcus, which typically provides limited access and does not allow for adequate coverage of large **osseous defects**. - It does not offer the tissue volume needed for the stable primary closure essential for regenerative procedures. *Modified Widman flap* - While providing excellent access for debridement in periodontal pockets, the modified Widman flap's incisions often **transect the interdental papilla**, making primary closure over a regenerative defect less ideal. - Its primary goal is root debridement and pocket reduction, not necessarily **papilla preservation** for regenerative purposes. *Apically displaced flap* - An apically displaced flap is designed to **increase the zone of attached gingiva** or reduce pocket depths, by positioning the flap apically to its original position. - This flap design is not suitable for covering osseous defects amenable to reconstruction because it often exposes more root surface and does not provide the necessary coronal coverage for regenerative materials.
Question 3: What is the primary mechanism responsible for skin graft survival within the first 48 hours after transplantation?
- A. Amount of saline in graft
- B. Plasma imbibition (Correct Answer)
- C. New vessels growing from the donor tissue
- D. Connection between donor and recipient capillaries
Explanation: ***Correct: Plasma imbibition*** - **Plasma imbibition** is the initial process where the transplanted graft absorbs nutrients and oxygen from the recipient bed through diffusion. - This fluid uptake is crucial for the survival of the graft cells before revascularization occurs, typically within the first **24-48 hours**. - The graft acts like a sponge, absorbing serum and plasma from the vascular bed through capillary action and osmosis. *Incorrect: Amount of saline in graft* - While sterile saline is often used to keep donor tissue moist during harvesting and transport, its presence in the graft itself is not the primary mechanism for survival post-transplantation. - Excessive saline could even lead to **edema** and compromise graft take if not properly drained or if it prevents good contact with the recipient bed. *Incorrect: New vessels growing from the donor tissue* - Grafts themselves do not spontaneously grow new vessels; new blood vessels are formed by **angiogenesis** from the recipient bed into the graft over several days. - This process, called **inosculation** and subsequent neovascularization, provides long-term blood supply but is not the primary mechanism of survival within the *first 48 hours*. *Incorrect: Connection between donor and recipient capillaries* - The direct connection of donor and recipient capillaries (inosculation) is a later stage of graft vascularization, typically beginning after **3-5 days**, not within the first 48 hours. - Within the initial 48 hours, the graft relies on diffusion because a complete vascular connection has not yet been established.
Question 4: Deep skin burns are treated with:
- A. Amniotic membrane
- B. Split thickness graft (Correct Answer)
- C. Full thickness graft
- D. Synthetic skin derivatives
Explanation: ***Split thickness graft*** - A **split-thickness skin graft (STSG)** involves transferring the epidermis and a portion of the dermis from a donor site to the burned area. - This type of graft is commonly used for deep partial-thickness or full-thickness burns because it provides good coverage with minimal donor site morbidity and has a high take rate. *Amniotic membrane* - **Amniotic membrane** is primarily used as a biological dressing for superficial burns or chronic wounds, promoting healing and reducing pain. - It does not provide permanent skin coverage for deep burns, which require viable skin for closure. *Full thickness graft* - A **full-thickness skin graft (FTSG)** includes the entire epidermis and dermis, resulting in better cosmetic and functional outcomes. - However, FTSGs are typically used for smaller, deeper defects or areas requiring maximum durability, rather than extensive deep burns, and their take rate is lower compared to STSGs. *Synthetic skin derivatives* - **Synthetic skin derivatives** (e.g., Integra, Biobrane) can be used as temporary dressings or matrices to facilitate wound healing in deep burns, but they typically require subsequent grafting. - They do not provide permanent, living tissue for definitive closure of large, deep burn wounds.
Question 5: Following a knife injury to the face causing facial nerve damage, secretion from which of the following glands would be LEAST likely to be impaired?
- A. Parotid gland (Correct Answer)
- B. Sublingual gland
- C. Lacrimal gland
- D. Submandibular gland
Explanation: ***Parotid gland*** - The **parotid gland** receives parasympathetic innervation for secretion via the **glossopharyngeal nerve (CN IX)**, specifically through the **lesser petrosal nerve** → **otic ganglion** → **auriculotemporal nerve**. - The **facial nerve (CN VII)** passes through the parotid gland but does not provide secretomotor innervation, so facial nerve damage would **not impair parotid secretion**. *Sublingual gland* - The **sublingual gland** receives parasympathetic innervation from the **facial nerve (CN VII)** via the **chorda tympani** → **submandibular ganglion**. - Damage to the facial nerve would impair secretion from the sublingual gland. *Lacrimal gland* - The **lacrimal gland** receives parasympathetic innervation from the **facial nerve (CN VII)** via the **greater petrosal nerve** → **pterygopalatine ganglion**. - Damage to the facial nerve would impair tear production from the lacrimal gland, leading to **dry eye** (keratoconjunctivitis sicca). *Submandibular gland* - The **submandibular gland** receives parasympathetic innervation from the **facial nerve (CN VII)** via the **chorda tympani** → **submandibular ganglion**. - Damage to the facial nerve would impair secretion from the submandibular gland.
Question 6: What is the eponymous term for a full-thickness skin graft?
- A. Wolfe's graft (Correct Answer)
- B. Thiersch graft
- C. Fernandez graft
- D. Reverdin graft
Explanation: ***Wolfe's graft*** - A **Wolfe's graft** is the eponymous term for a **full-thickness skin graft**, which includes the epidermis and entire dermis. - This type of graft provides superior cosmetic results and contracts less than split-thickness grafts, making it ideal for facial reconstruction. *Thiersch graft* - A **Thiersch graft** refers to a **split-thickness skin graft**, which only includes the epidermis and a portion of the dermis. - These grafts are easier to harvest and take better in less vascularized beds but are prone to greater contraction and can have a less aesthetic outcome. *Fernandez graft* - **Fernandez graft** is not a recognized eponymous term for a type of skin graft in common medical literature. - This term does not correspond to a standard full-thickness or split-thickness skin grafting technique. *Reverdin graft* - A **Reverdin graft** refers to very small, partial-thickness pieces of skin, essentially tiny bits of epithelium transplanted to promote epithelialization. - This is a **split-thickness** technique, not a full-thickness graft, and is used primarily for small granulating wounds.
Question 7: For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?
- A. Mohs surgery (Correct Answer)
- B. Superficial laser surgery
- C. Curettage and electrodesiccation
- D. Wide local excision
Explanation: ***Mohs surgery*** - **Mohs micrographic surgery** is the most popular and highly effective procedure specifically designed for **basal cell carcinoma (BCC)**, especially on the face and other cosmetically sensitive areas. - It involves the **progressive removal** of thin layers of skin, which are immediately examined under a microscope, allowing for complete tumor removal while preserving maximum healthy tissue. - Mohs surgery has the **highest cure rate** (95-99%) for BCC and is particularly preferred for high-risk locations, recurrent tumors, and poorly defined borders. *Superficial laser surgery* - While lasers can sometimes be used for very superficial skin lesions, **superficial laser surgery** is generally not the primary treatment for established **BCC** due to the risk of incomplete removal and recurrence. - It lacks the **histological margin control** provided by Mohs surgery, which is crucial for ensuring complete eradication of BCC. *Curettage and electrodesiccation* - **Curettage and electrodesiccation** is an alternative surgical treatment for small, low-risk BCCs in non-critical areas. - However, it has **lower cure rates** (85-95%) compared to Mohs surgery and does not provide histological margin assessment. - It is less preferred for facial BCCs where cosmetic outcome and complete removal are critical. *Wide local excision* - **Wide local excision** is a standard surgical approach that removes the tumor with predetermined margins (typically 4-5 mm for BCC). - While effective, it requires **larger tissue removal** compared to Mohs surgery and lacks the real-time microscopic margin control. - Mohs surgery remains more popular due to its tissue-sparing nature and higher cure rates, especially in cosmetically sensitive areas.
Question 8: Treatment of choice in complete traumatic facial nerve transection is:
- A. Facial nerve repair (Correct Answer)
- B. Facial sling
- C. Conservative management
- D. Systemic corticosteroids
Explanation: ***Facial nerve repair*** - In cases of **traumatic facial nerve injury** where there is a clear transection or significant damage, surgical repair (e.g., direct anastomosis or nerve grafting) is the gold standard to restore function. - The goal is to re-establish neural continuity as soon as possible to prevent **irreversible muscle denervation** and improve functional outcomes. *Facial sling* - A **facial sling** is a palliative procedure used for long-standing facial paralysis, often when nerve repair is not possible or has failed, to provide static support to the affected side of the face. - It does not address the underlying nerve damage or aim to restore active facial movement. *Conservative management* - **Conservative management** is appropriate for non-traumatic causes of facial palsy (e.g., Bell's palsy) or mild traumatic injuries where nerve continuity is presumed intact and swelling is the primary issue. - It involves observation and sometimes medication but does not repair a transected nerve. *Systemic corticosteroids* - **Systemic corticosteroids** are primarily used in inflammatory conditions causing facial nerve palsy, such as **Bell's palsy**, to reduce swelling and inflammation around the nerve. - They are not a treatment for direct physical damage or transection of the facial nerve due to trauma.
Question 9: Which thickened nerve is shown in the image?
- A. Facial Nerve
- B. Greater Auricular Nerve (Correct Answer)
- C. Vagus Nerve
- D. Glossopharyngeal Nerve
Explanation: ***Greater auricular nerve*** - The image clearly shows a **thickened, rope-like structure** running superficially on the side of the neck, ascending towards the earlobe. - This anatomical location and appearance are highly characteristic of an enlarged **greater auricular nerve**, often seen in conditions like **leprosy**. *Facial Nerve* - The **facial nerve** is primarily a motor nerve that innervates the muscles of facial expression and is located deeper within the parotid gland. - It would not typically present as a thickened, superficial structure visible on the surface of the neck or behind the earlobe. *Vagus Nerve* - The **vagus nerve** is a cranial nerve with extensive autonomic functions, running through the neck within the carotid sheath, much deeper than the structure shown. - It is not superficially visible or palpable in this manner under normal or pathological conditions that cause thickening. *Glossopharyngeal Nerve* - The **glossopharyngeal nerve** is another cranial nerve that exits the skull and descends in the neck, primarily involved in swallowing and taste. - Like the vagus nerve, it is located deep within the neck and would not be visible or thickened superficially as depicted.
Question 10: Sensory nerve supply of gall bladder is through -
- A. Vagus nerve (Cranial Nerve X) (Correct Answer)
- B. Celiac plexus (sympathetic fibers)
- C. Trigeminal nerve (Cranial Nerve V)
- D. Facial nerve (Cranial Nerve VII)
Explanation: ***Vagus nerve (Cranial Nerve X)*** - The **vagus nerve** provides the primary **sensory (visceral afferent) innervation** to the gallbladder, carrying information about distension, contraction, and physiological state. - These **parasympathetic sensory fibers** travel through the vagus nerve to medullary centers, monitoring gallbladder function and participating in reflex arcs. - The vagus nerve is the main pathway for **general sensory innervation** of the gallbladder as per standard anatomical texts. *Celiac plexus (sympathetic fibers)* - The **celiac plexus** contains **sympathetic afferent fibers** that primarily transmit **pain sensation** from the gallbladder, especially during inflammation or biliary colic [1]. - These pain fibers travel via sympathetic pathways to spinal segments **T8-T9**, mediating referred pain to the epigastric region and right upper quadrant [1]. - While important for pain transmission, the celiac plexus is not classified as the primary sensory nerve supply in anatomical nomenclature. *Trigeminal nerve (Cranial Nerve V)* - The **trigeminal nerve** provides **sensory innervation to the face** and motor innervation to muscles of mastication. - It has no role in innervation of abdominal viscera, including the gallbladder. *Facial nerve (Cranial Nerve VII)* - The **facial nerve** controls **facial expression muscles**, provides taste sensation to the anterior two-thirds of the tongue, and supplies parasympathetic fibers to lacrimal and salivary glands. - It does not innervate any abdominal organs.
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