Plastic and Reconstructive Surgery Practice Questions

Q: What is the degree of this burn shown below?

2nd degree. ***2nd degree*** - Characterized by **partial thickness burns** affecting the **epidermis and dermis**, typically presenting with **blisters** and a **moist, weeping surface**. - The burn is **painful** due to intact nerve endings and has good **healing potential** with proper care, usually within 2-3 weeks. *1st degree* - Involves only the **superficial epidermis**, presenting as **dry, red skin** without blisters or fluid loss. - Heals within **3-7 days** without scarring and is typically seen in mild **sunburn** cases. *3rd degree* - Involves **full thickness** destruction of epidermis and dermis, appearing **white, waxy, or charred** with a **leathery texture**. - The burn is **painless** due to destroyed nerve endings and requires **surgical intervention** as it cannot heal spontaneously. *4th degree* - Extends beyond the skin into **underlying tissues** including **muscle, bone, and tendons**, appearing **deeply charred or carbonized**. - Requires **extensive surgical debridement** and reconstruction, often resulting in **significant functional impairment** and potential amputation.

Q: Poland syndrome is characterized by all of the following abnormalities except:

Absence of the latissimus dorsi muscle. **Explanation:** Poland Syndrome is a rare congenital anomaly characterized by the underdevelopment or absence of the chest wall muscles and associated limb deformities on one side of the body. **Why Option A is the correct answer:** The hallmark of Poland Syndrome is the **absence of the sternocostal head of the pectoralis major muscle**. While other muscles like the pectoralis minor, serratus anterior, or latissimus dorsi *can* occasionally be hypoplastic, the **latissimus dorsi is typically present** and is, in fact, the **muscle of choice for reconstructive surgery** (transposition flap) to correct the chest wall defect in these patients. Therefore, its absence is not a characteristic feature. **Analysis of other options:** * **Option B (Absence of pectoralis major):** This is the defining feature of the syndrome. The sternocostal head is most commonly missing, leading to an asymmetrical chest appearance. * **Option C (Syndactyly):** Ipsilateral hand involvement is common, most frequently manifesting as **symbrachydactyly** (short, webbed fingers). * **Option D (Shortened digits):** Brachydactyly (shortening of the fingers, including the index finger) occurs due to hypoplasia of the middle phalanges. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Thought to be caused by a vascular insult (interruption of blood supply) in the **subclavian artery** during the 6th week of gestation. * **Laterality:** More common on the **right side** (approx. 75% of cases) and more frequent in males. * **Associated Findings:** May include nipple/areola hypoplasia (athelia/thelarche), rib anomalies, and occasionally **Möbius syndrome** (cranial nerve palsies). * **Dextrocardia:** If Poland syndrome occurs on the left side, it is sometimes associated with dextrocardia.

Q: The Abbe-Estlander flap is based on which artery?

Labial artery. The **Abbe-Estlander flap** is a classic cross-lip arterialized flap used for reconstructing full-thickness defects of the upper or lower lip. ### **Explanation of the Correct Answer** The flap is based on the **labial artery** (specifically the superior or inferior labial artery, depending on the donor site). These arteries are branches of the facial artery that run within the orbicularis oris muscle, approximately 2–3 mm deep to the vermilion-mucosal junction. The robust axial blood supply from the labial artery allows for a narrow vascular pedicle, which enables the flap to be rotated 180 degrees into the defect while maintaining viability. ### **Analysis of Incorrect Options** * **A. Facial artery:** While the labial arteries originate from the facial artery, the flap itself is specifically pedicled on the labial branch. In surgical anatomy, the most specific vessel is the correct answer. * **C. Maxillary artery:** This is a terminal branch of the external carotid artery that supplies deep facial structures (like the muscles of mastication and nasal cavity), not the superficial lip. * **D. Ascending pharyngeal artery:** This supplies the pharynx and soft palate; it does not contribute to the vascularity of the lips. ### **High-Yield Clinical Pearls for NEET-PG** * **Abbe Flap:** Used for **central** lip defects. It is a two-stage procedure (the pedicle is divided after 2–3 weeks). * **Estlander Flap:** Used for defects involving the **oral commissure** (corner of the mouth). It is a one-stage procedure but results in a rounded commissure that may require secondary commissuroplasty. * **Rule of Thirds:** These flaps are typically indicated for defects involving **1/3 to 2/3** of the lip width. * **Innervation:** The flap is denervated initially but may regain some sensory and motor function over several months.

Q: What type of graft is a Thiersch graft?

Partial thickness. **Explanation:** A **Thiersch graft** (also known as an **Ollier-Thiersch graft**) is a type of **Split-Thickness Skin Graft (STSG)** or partial-thickness graft. It consists of the entire epidermis and a variable portion of the underlying dermis. 1. **Why Option A is Correct:** Skin grafts are classified based on the amount of dermis included. A Thiersch graft is the thinnest form of STSG. Because it retains only a thin layer of dermis, it relies on "plasmatic imbibition" and "inosculation" for survival and can be harvested from donor sites that heal spontaneously via re-epithelialization. 2. **Why Other Options are Incorrect:** * **Full thickness (Wolfe’s graft):** These include the entire epidermis and the complete thickness of the dermis. They have less secondary contraction but require a well-vascularized bed and the donor site must be closed surgically. * **Pedicle:** This is a type of **flap**, not a graft. Flaps maintain their own blood supply (pedicle), whereas grafts are completely detached from the donor site and depend on the recipient bed for nourishment. * **Patch:** This refers to a technique of applying small pieces of skin (like "postage stamp" grafts) to cover large areas, rather than a specific histological classification. **High-Yield Clinical Pearls for NEET-PG:** * **Secondary Contraction:** Thiersch grafts (thin STSGs) undergo the **most** secondary contraction (shrinkage after healing) compared to full-thickness grafts. * **Primary Contraction:** Full-thickness grafts undergo the **most** primary contraction (immediate recoil after harvesting) due to higher elastin content in the dermis. * **Donor Site:** The most common donor site is the thigh, harvested using a **Humby’s knife** or a dermatome. * **Graft Take:** Occurs in three stages: Plasmatic imbibition (0–48h), Inosculation (48h–5 days), and Neovascularization (>5 days).

Q: The rectus abdominis free flap is supplied by which artery?

Epigastric artery. The **Rectus Abdominis muscle** is a classic **Type II muscle flap** (according to the Mathes and Nahai classification), meaning it has one dominant vascular pedicle and several minor pedicles. ### Why the Correct Answer is Right The primary blood supply to the rectus abdominis muscle comes from two major vessels: 1. **Deep Inferior Epigastric Artery (DIEA):** A branch of the external iliac artery. This is the **dominant pedicle** used for free flaps (e.g., DIEP flap or TRAM flap) because it has a larger diameter and a longer pedicle length. 2. **Superior Epigastric Artery:** A terminal branch of the internal mammary (thoracic) artery. In the context of a "free flap," the **Deep Inferior Epigastric Artery** is the vessel of choice for microvascular anastomosis. ### Why Other Options are Wrong * **A. Intercostal Artery:** These provide segmental sensory innervation and minor blood supply to the overlying skin (perforators), but they are not the primary supply for a free flap. * **B. Iliolumbar Artery:** This is a branch of the internal iliac artery supplying the iliacus muscle and psoas; it does not supply the anterior abdominal wall. * **D. Thoraco-lumbar Artery:** This is not a standard anatomical term for the supply of the rectus muscle; the blood supply is strictly longitudinal (Superior and Inferior Epigastric). ### High-Yield Clinical Pearls for NEET-PG * **TRAM Flap (Transverse Rectus Abdominis Myocutaneous):** Used for breast reconstruction. If used as a **pedicled flap**, it relies on the *Superior Epigastric Artery*. If used as a **free flap**, it relies on the *Deep Inferior Epigastric Artery*. * **DIEP Flap:** A refinement of the TRAM flap where only the skin and fat are taken, sparing the muscle to reduce donor site morbidity (incisional hernia). * **Arcuate Line:** Below this level, the posterior rectus sheath is absent. Harvesting the muscle below this line increases the risk of postoperative ventral hernia.

Q: Thompson's Operation for Lymphoedema is:

Both excisional and shunting procedures. **Explanation:** **Thompson’s Operation** (also known as the Buried Dermal Flap procedure) is a surgical technique used for chronic lymphedema. It is classified as a **combined procedure** because it incorporates elements of both reduction and physiological drainage. 1. **Why Option D is Correct:** * **Excisional Component:** The procedure involves the excision of redundant, lymphedematous skin and subcutaneous tissue from the limb. * **Shunting/Physiological Component:** A "buried dermal flap" is created by de-epithelializing a strip of skin and tucking it into the deep muscle compartment. The theory is that the dermal lymphatics will form new connections (shunts) with the deep subfascial lymphatic system, allowing fluid to bypass the obstructed superficial system. 2. **Why Other Options are Incorrect:** * **Option A & C:** These refer to purely physiological procedures (like Lymphaticovenular Anastomosis or Lymph Node Transfer) which aim to restore flow without removing tissue. Thompson’s involves significant tissue removal. * **Option B:** While it involves excision, calling it *only* excisional ignores the specific "buried flap" mechanism intended to create a physiological shunt. Purely excisional procedures include the **Charles Operation** (radical excision and skin grafting). **High-Yield Clinical Pearls for NEET-PG:** * **Charles Operation:** The most radical excisional procedure; involves removing all skin and subcutaneous tissue down to the deep fascia, followed by skin grafting. * **Sistrunk’s Procedure:** A wedge excision of skin and fat used for milder cases. * **Homan’s Procedure:** A staged subcutaneous excision under skin flaps. * **Gold Standard Diagnosis:** Lymphoscintigraphy is the investigation of choice for lymphedema. * **Conservative Management:** Always the first line (Complex Decongestive Therapy, compression garments).

Q: What is the ideal graft for a leg injury with a 10 x 10 cm exposed bone area?

Pedicle graft. **Explanation:** The management of soft tissue defects depends primarily on the **vascularity of the recipient bed**. **Why Pedicle Graft is Correct:** The key phrase in this question is **"exposed bone."** Cortical bone (without periosteum), tendons (without paratenon), and nerves do not have a sufficient blood supply to support a free skin graft. A **Pedicle Graft** (or Flap) carries its own blood supply through a vascular stalk. This is essential for coverage over "avital" or "non-take" areas like exposed bone, as it provides both stable coverage and brings a new blood supply to the wound to promote healing. **Why Other Options are Incorrect:** * **Split Thickness (STSG) & Full Thickness (FTSG) Skin Grafts:** These rely on "plasmatic imbibition" and "inosculation" from the recipient bed for survival. Since exposed bone is relatively avascular, a graft will fail to "take" and will undergo necrosis. * **Amniotic Membrane:** This is primarily used as a biological dressing for superficial burns or ophthalmic procedures; it does not provide the structural integrity or vascularity required for a deep 10x10 cm defect. **High-Yield Clinical Pearls for NEET-PG:** 1. **Reconstructive Ladder:** Always move from simplest to most complex (Secondary intention → Primary closure → Delayed primary → STSG → FTSG → Flaps). However, if bone/tendon is exposed, you must "skip" to **Flaps**. 2. **Size Matters:** For a large 10x10 cm defect on the leg, a local muscle flap (like Gastrocnemius for the upper third or Soleus for the middle third) or a free flap is typically required. 3. **Graft vs. Flap:** A **Graft** is tissue transferred without its own blood supply; a **Flap** (Pedicle) is tissue transferred with its blood supply intact.

Question 1

What is the degree of this burn shown below?

Accepted Answer

2nd degree

Answer

1st degree

Answer

3rd degree

Answer

4th degree

Question 2

Poland syndrome is characterized by all of the following abnormalities except:

Accepted Answer

Absence of the latissimus dorsi muscle

Answer

Absence of the pectoralis major muscle

Answer

Syndactyly of digits

Answer

Shortened index fingers

Question 3

In the treatment of hand injuries, what is the greatest priority?

Accepted Answer

Restoration of skin cover

Answer

Repair of tendons

Answer

Repair of nerves

Answer

Repair of blood vessels

Question 4

What is a partial-thickness skin graft also known as?

Accepted Answer

Thiersch graft

Answer

Wolfian graft

Answer

Pedicle graft

Answer

Patch graft

Question 5

All of the following statements about cleft palate are true, EXCEPT:

Accepted Answer

Approximately 50% of patients achieve normal speech following surgical repair.

Answer

Surgery is typically recommended around 1 year of age.

Answer

Cleft palate is associated with an increased risk of hearing loss.

Answer

Cleft palate is associated with cleft lip in approximately 45% of cases.

Question 6

The Abbe-Estlander flap is based on which artery?

Accepted Answer

Labial artery

Answer

Facial artery

Answer

Maxillary artery

Answer

Ascending pharyngeal artery

Question 7

What type of graft is a Thiersch graft?

Accepted Answer

Partial thickness

Answer

Full thickness

Answer

Pedicle

Answer

Patch

Question 8

The rectus abdominis free flap is supplied by which artery?

Accepted Answer

Epigastric artery

Answer

Intercostals artery

Answer

Iliolumbar artery

Answer

Thoraco-lumbar artery

Question 9

Thompson's Operation for Lymphoedema is:

Accepted Answer

Both excisional and shunting procedures

Answer

A bypass procedure

Answer

An excisional surgery

Answer

Physiological shunting

Question 10

What is the ideal graft for a leg injury with a 10 x 10 cm exposed bone area?

Accepted Answer

Pedicle graft

Answer

Amniotic membrane graft

Answer

Full thickness graft

Answer

Split thickness skin graft

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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