Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery Indian Medical PG Practice Questions and MCQs

Question 111: What is the degree of this burn shown below?

A. 1st degree
B. 2nd degree (Correct Answer)
C. 3rd degree
D. 4th degree

Explanation: ***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.

Question 112: Poland syndrome is characterized by all of the following abnormalities except:

A. Absence of the latissimus dorsi muscle (Correct Answer)
B. Absence of the pectoralis major muscle
C. Syndactyly of digits
D. Shortened index fingers

Explanation: **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.

Question 113: In the treatment of hand injuries, what is the greatest priority?

A. Repair of tendons
B. Restoration of skin cover (Correct Answer)
C. Repair of nerves
D. Repair of blood vessels

Explanation: In hand surgery, the management of complex injuries follows a strict hierarchy of priorities based on the principle of **"Life before Limb, and Cover before Reconstruction."** ### Why "Restoration of Skin Cover" is the Priority The primary goal in hand trauma is to convert an open, contaminated wound into a closed, clean wound. Skin provides the essential biological barrier that protects underlying "noble structures" (tendons, nerves, blood vessels, and bone) from desiccation, infection, and necrosis. Without adequate soft tissue coverage, any deep reconstruction—no matter how technically perfect—will fail due to exposure and subsequent fibrosis. Therefore, achieving stable skin cover is the prerequisite for all functional recovery. ### Why Other Options are Incorrect * **A. Repair of tendons:** Tendon repair is a functional restoration. If performed in the absence of good skin cover, the tendons will dry out, adhere to surrounding tissues, or become infected, leading to a "frozen hand." * **C. Repair of nerves:** Nerve regeneration requires a vascularized, healthy bed. Primary nerve repair is secondary to achieving a stable wound environment. * **D. Repair of blood vessels:** While revascularization is critical for viability in a devascularized limb (the "Life before Limb" rule), in a viable hand with a complex wound, skin closure remains the surgical priority to preserve the repaired structures. ### NEET-PG High-Yield Pearls * **The Reconstructive Ladder:** Always consider the simplest method first (Primary closure → Secondary intention → Skin graft → Local flap → Distant flap → Free flap). * **The "Golden Period":** Debridement and primary closure should ideally occur within 6–8 hours to minimize infection risk. * **Order of Repair in Replantation:** Bone fixation → Extensor tendons → Flexor tendons → Arteries → Nerves → Veins → **Skin closure** (Note: In replantation, bone is fixed first to provide a stable scaffold).

Question 114: What is a partial-thickness skin graft also known as?

A. Wolfian graft
B. Thiersch graft (Correct Answer)
C. Pedicle graft
D. Patch graft

Explanation: ### Explanation Skin grafts are classified based on the thickness of the donor tissue harvested. A **partial-thickness skin graft (PTSG)**, also known as a **split-thickness skin graft (STSG)**, includes the entire epidermis and a variable portion of the underlying dermis. **1. Why Option B is Correct:** The term **Thiersch graft** is the eponymous name for a very thin split-thickness skin graft. Historically, it refers to a graft that contains the epidermis and only the papillary layer of the dermis. These grafts have a high "take" rate because they require less revascularization, making them ideal for covering large raw areas or contaminated wounds. **2. Why Other Options are Incorrect:** * **Option A (Wolfian graft):** This refers to a **Full-Thickness Skin Graft (FTSG)**. It includes the epidermis and the entire thickness of the dermis. While they provide better cosmetic results and less secondary contraction, they have a lower "take" rate compared to Thiersch grafts. * **Option C (Pedicle graft):** This is not a free graft but a type of **flap**. It maintains its own blood supply through a bridge of tissue (the pedicle) connecting it to the donor site. * **Option D (Patch graft):** This is a general term for small pieces of skin used to cover a wound, often used in "postage stamp" grafting, but it is not a formal synonym for a partial-thickness graft. ### High-Yield Clinical Pearls for NEET-PG: * **Primary Contraction:** Occurs immediately after harvesting due to elastin fibers. It is **greater in FTSG** (Wolfian) than STSG. * **Secondary Contraction:** Occurs during healing due to myofibroblasts. It is **greater in STSG** (Thiersch) than FTSG. * **Donor Site Healing:** The donor site of a Thiersch graft heals by **re-epithelialization** from skin appendages (hair follicles, sebaceous glands), whereas a Wolfian graft donor site must be closed primarily or with another graft. * **Instrument:** A **Humby’s knife** or a dermatome is typically used to harvest Thiersch grafts.

Question 115: All of the following statements about cleft palate are true, EXCEPT:

A. Surgery is typically recommended around 1 year of age.
B. Approximately 50% of patients achieve normal speech following surgical repair. (Correct Answer)
C. Cleft palate is associated with an increased risk of hearing loss.
D. Cleft palate is associated with cleft lip in approximately 45% of cases.

Explanation: **Explanation:** The correct answer is **B**. This statement is false because the success rate for speech following cleft palate repair is significantly higher than 50%. With modern surgical techniques (like the Von Langenbeck or Furlow Palatoplasty) and multidisciplinary care, approximately **80–90%** of children achieve normal or near-normal speech. Only about 10–20% develop Velopharyngeal Insufficiency (VPI) requiring secondary procedures or intensive speech therapy. **Analysis of other options:** * **Option A (Correct statement):** The ideal timing for palatoplasty is between **6 to 12 months** of age. This timing balances the need for normal speech development (which requires an intact palate before the child starts speaking) against the risk of midface growth retardation caused by early surgery. * **Option C (Correct statement):** Cleft palate leads to dysfunction of the **Tensor Veli Palatini** muscle, which fails to open the Eustachian tube. This results in chronic middle ear effusion (Glue ear) and conductive hearing loss, often requiring myringotomy and grommet insertion. * **Option D (Correct statement):** Epidemiologically, isolated cleft palate occurs in about 25% of cases, isolated cleft lip in 25%, and **combined cleft lip and palate in approximately 50%** (roughly 45-50% depending on the study). **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s (for Cleft Lip):** 10 weeks of age, 10 lbs weight, 10 gm hemoglobin. * **Muscle of Cleft Palate:** The Levator Veli Palatini is abnormally attached to the posterior border of the hard palate (forming the **Bundle of Braithwaite**). * **Veau Classification:** Used to categorize the extent of the cleft. * **Main Goal of Palatoplasty:** To provide a competent velopharyngeal valve for normal speech.

Question 116: The Abbe-Estlander flap is based on which artery?

A. Facial artery
B. Labial artery (Correct Answer)
C. Maxillary artery
D. Ascending pharyngeal artery

Explanation: 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.

Question 117: What type of graft is a Thiersch graft?

A. Partial thickness (Correct Answer)
B. Full thickness
C. Pedicle
D. Patch

Explanation: **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).

Question 118: The rectus abdominis free flap is supplied by which artery?

A. Intercostals artery
B. Iliolumbar artery
C. Epigastric artery (Correct Answer)
D. Thoraco-lumbar artery

Explanation: 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.

Question 119: Thompson's Operation for Lymphoedema is:

A. A bypass procedure
B. An excisional surgery
C. Physiological shunting
D. Both excisional and shunting procedures (Correct Answer)

Explanation: **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).

Question 120: What is the ideal graft for a leg injury with a 10 x 10 cm exposed bone area?

A. Amniotic membrane graft
B. Pedicle graft (Correct Answer)
C. Full thickness graft
D. Split thickness skin graft

Explanation: **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.

Practice by Chapter

Wound Healing

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Skin Grafts

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Flap Surgery Principles

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Local Flaps

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Regional Flaps

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Microsurgical Techniques

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Tissue Expansion

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Breast Reconstruction

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Hand Surgery Basics

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Craniofacial Surgery Principles

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Aesthetic Surgery Concepts

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Body Contouring

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