Plastic and Reconstructive Surgery Practice Questions

Q: Port wine stain is seen in which of the following conditions?

Sturge Weber Syndrome. **Explanation:** **Sturge-Weber Syndrome (SWS)**, also known as encephalotrigeminal angiomatosis, is a neurocutaneous disorder characterized by the presence of a **Port-Wine Stain (PWS)**. A PWS is a congenital capillary malformation (nevus flammeus) that typically presents as a flat, purple-red patch on the face, most commonly following the distribution of the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve. The underlying pathology involves a somatic mutation in the *GNAQ* gene, leading to malformed capillary-like vessels. **Analysis of Incorrect Options:** * **Von Hippel-Lindau (VHL) Syndrome:** Characterized by hemangioblastomas (cerebellum/retina), renal cell carcinoma, and pheochromocytoma. It does not typically feature port-wine stains. * **Denys-Drash Syndrome:** Defined by a triad of Wilms tumor, pseudohermaphroditism, and early-onset renal failure (nephropathy). * **Holt-Oram Syndrome:** An "heart-hand" syndrome involving radial ray defects (e.g., absent thumb) and cardiac septal defects (ASD/VSD). **Clinical Pearls for NEET-PG:** * **SWS Triad:** 1. Facial Port-Wine Stain; 2. Leptomeningeal angiomas (ipsilateral); 3. Glaucoma. * **Radiology:** Skull X-ray or CT may show **"Tram-track" calcifications** in the cerebral cortex due to leptomeningeal involvement. * **Management:** Pulsed Dye Laser (PDL) is the gold standard treatment for the Port-Wine Stain. * **Important Association:** If a PWS involves the eyelids, there is a high risk of associated glaucoma and intracranial involvement.

Q: The Abbe-Estlander flap is used for reconstruction of which anatomical structure?

Lip. **Explanation:** The **Abbe-Estlander flap** is a classic **cross-lip arterialized flap** used for the reconstruction of full-thickness defects of the lip. The procedure involves transferring a wedge-shaped portion of one lip (containing skin, muscle, and mucosa) to the opposite lip, based on the **labial artery** (a branch of the facial artery). * **Abbe Flap:** Specifically used for defects in the **middle** of the upper or lower lip. It is a two-stage procedure where the flap remains attached by a vascular pedicle for 2–3 weeks before being divided. * **Estlander Flap:** A variation used for defects involving the **oral commissure** (corner of the mouth). Unlike the Abbe flap, it is typically a one-stage procedure but may require secondary commissuroplasty. **Analysis of Incorrect Options:** * **B. Tongue:** Reconstruction usually involves primary closure (small defects) or microvascular free flaps like the Radial Forearm Free Flap (RFFF) for larger defects. * **C. Eyelid:** Common flaps include the **Hughes flap** (tarsoconjunctival) or **Tripier flap** (musculocutaneous). * **D. Ear:** Reconstruction often utilizes autologous costal cartilage grafts or local skin flaps like the **Nagata** or **Brent** techniques. **High-Yield Clinical Pearls for NEET-PG:** * **Vascular Basis:** The flap is based on the **inferior or superior labial artery**, which runs between the orbicularis oris muscle and the submucosa. * **Karapandzic Flap:** Another high-yield lip reconstruction flap; it is a semi-circular rotation-advancement flap that preserves the nerve and blood supply. * **Rule of Thirds:** Lip defects <1/3 are closed primarily; 1/3 to 2/3 defects often require an Abbe-Estlander flap.

Q: Down fracture of the zygomatic arch is a treatment modality for which condition?

Chronic subluxation. **Explanation:** **Chronic subluxation** of the Temporomandibular Joint (TMJ) occurs when the mandibular condyle moves anterior to the articular eminence and becomes unable to return to its normal position. The **down fracture of the zygomatic arch** (also known as the **Dautrey’s procedure**) is a surgical intervention designed to create a mechanical barrier. By fracturing the zygomatic arch and displacing it downward, the surgeon creates a physical obstruction that prevents the condyle from over-translating anteriorly, thereby preventing recurrent dislocation. **Analysis of Incorrect Options:** * **TMJ Ankylosis:** This involves the fusion of the joint (fibrous or bony), leading to restricted mouth opening. Treatment typically involves gap arthroplasty or interpositional arthroplasty, not the creation of a bony block. * **Condylar Fracture:** These are managed via closed reduction (maxillomandibular fixation) or open reduction with internal fixation (ORIF) using mini-plates. Down fracturing the arch would not stabilize a condylar fracture. * **Zygomatic Fracture:** These are traumatic injuries (e.g., Tripod fracture) requiring reduction and fixation to restore facial contour and volume. Down fracturing is a deliberate surgical maneuver, not a treatment for a pre-existing fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Dautrey’s Procedure:** Specifically refers to the down-fracturing of the zygomatic arch for chronic subluxation. * **Eminectomy:** Another surgical option for chronic dislocation where the articular eminence is removed to allow the condyle to move freely back into the fossa. * **Safety:** When operating on the zygomatic arch, the **temporal branch of the facial nerve** is the structure most at risk.

Q: The names Manchot, Salmon, and Taylor are related to which of the following?

Arterial supply to skin flaps. The correct answer is **B. Arterial supply to skin flaps**. ### **Explanation** The names **Manchot, Salmon, and Taylor** are synonymous with the historical and anatomical evolution of our understanding of the **vascular territories of the skin**. 1. **Manchot (1889):** He was the first to map the skin into specific vascular territories based on the distribution of cutaneous arteries. 2. **Salmon (1936):** He refined this work using lead oxide injections and radiography, identifying approximately 80 distinct anatomical territories. 3. **Ian Taylor (1987):** He introduced the modern **"Angiosome" concept**. An angiosome is a three-dimensional block of tissue (skin, fascia, muscle, and bone) supplied by a specific source artery. This concept is the foundation of modern reconstructive surgery, allowing surgeons to design reliable skin and composite flaps. ### **Why other options are incorrect:** * **A & C:** While the skin has complex lymphatic and nerve networks, these specific researchers focused exclusively on the macro and micro-circulation (arterial supply). * **D:** Nerve supply to muscles is described by different anatomical principles (e.g., Hilton’s Law), not the angiosome theory. ### **High-Yield Clinical Pearls for NEET-PG:** * **Angiosome:** The composite unit of tissue supplied by a single source artery. * **Choke Vessels:** These are reduced-caliber vessels that connect adjacent angiosomes. They act as "safety valves" that can dilate to maintain flap viability if a neighboring source artery is cut. * **Venosome:** The corresponding venous drainage territory of a specific vein. * **Clinical Application:** The angiosome concept is vital in planning **pedicled and free flaps** (e.g., Radial Forearm Flap, ALT flap) and in managing peripheral vascular disease (revascularizing the specific angiosome where an ulcer is located).

Q: A free skin graft is typically rejected when transplanted onto which of the following tissues?

None of the above. ### Explanation The survival of a **free skin graft** depends entirely on the vascularity of the recipient bed. For a graft to "take," it must undergo three stages: **plasmatic imbibition** (first 24–48 hours), **inosculation** (alignment of capillaries), and **revascularization** (neovascularization). **Why "None of the above" is correct:** A skin graft can successfully survive on any recipient bed that has an adequate blood supply. **Muscle, fat, and deep fascia** are all vascularized tissues capable of supporting a graft. Therefore, a graft is **not** typically rejected by any of these tissues. **Analysis of Options:** * **A. Muscle:** This is an excellent recipient bed due to its high vascularity and rich capillary network, which facilitates rapid inosculation. * **B. Fat:** While subcutaneous fat is less vascular than muscle, a healthy, non-infected layer of fat can still support a skin graft. * **C. Deep Fascia:** Fascia is a well-vascularized connective tissue that provides a stable and receptive surface for grafting. **When does a graft fail?** A graft will fail (be "rejected" or fail to take) if placed on **avascular surfaces**. High-yield examples of poor recipient beds include: 1. **Cortical bone** (without periosteum) 2. **Cartilage** (without perichondrium) 3. **Tendons** (without paratenon) 4. **Infected wounds** or tissues with heavy bacterial load (>10⁵ organisms/gram). **NEET-PG High-Yield Pearls:** * **Gold Standard:** The best recipient bed is healthy **granulation tissue**. * **Primary Contraction:** Occurs immediately after harvesting (highest in Full-Thickness Skin Grafts - FTSG). * **Secondary Contraction:** Occurs during healing (highest in Split-Thickness Skin Grafts - STSG). * **The "Take":** If a graft is placed on bare bone or tendon, a **flap** (which carries its own blood supply) is required instead of a graft.

Q: A 12-year-old girl presents to the emergency department following a skiing crash in which the left side of her mid torso hit a tree. She presents with left side lower chest and upper abdominal pain. She also complains of left shoulder pain. What is the most likely diagnosis?

Splenic injury. ### Explanation **Correct Option: D. Splenic injury** The clinical presentation of left-sided lower chest/upper abdominal pain following blunt trauma, coupled with left shoulder pain, is a classic description of **Splenic Injury**. The referred pain to the left shoulder is known as **Kehr’s sign**. It occurs due to blood in the peritoneal cavity irritating the phrenic nerve (C3-C5) at the level of the diaphragm. In pediatric and adolescent patients, the spleen is the most commonly injured organ in blunt abdominal trauma. **Analysis of Incorrect Options:** * **A. Rib fractures:** While common in blunt trauma, they do not typically cause referred shoulder pain unless associated with underlying organ injury. * **B. Liver injury:** This typically presents with **right-sided** upper abdominal pain. Referred pain from liver injury or gallbladder irritation would be felt in the **right shoulder** (Boas' sign). * **C. Ruptured diaphragm:** While it can cause shoulder pain, it is less common than splenic injury and usually presents with significant respiratory distress and bowel sounds heard in the chest cavity on auscultation. **NEET-PG High-Yield Pearls:** * **Kehr’s Sign:** Classic sign of splenic rupture (referred pain to the left shoulder). * **Ballance’s Sign:** Fixed dullness to percussion in the left flank and shifting dullness in the right flank (indicates splenic hematoma/rupture). * **Investigation of Choice:** **CECT Abdomen** is the gold standard for hemodynamically stable patients. **FAST** (Focused Assessment with Sonography for Trauma) is the initial screening tool for unstable patients. * **Management:** In children, **Non-Operative Management (NOM)** is the preferred strategy even for high-grade injuries, provided the patient is hemodynamically stable.

Q: What is the name of the flap shown in the image?

Rhomboidal Flap. ***Rhomboidal Flap*** - A **geometric transposition flap** with specific **60° and 120° angles** forming a **parallelogram shape**, designed by Limberg for precise defect closure. - Functions as a **local transposition flap** that rotates adjacent tissue into the defect, commonly used for **facial**, **trunk**, and **extremity** reconstructions. *Rotational Flap* - A **semicircular flap** that pivots around a **fixed point** to cover defects, requiring a **curved incision** rather than geometric angles. - Lacks the specific **parallelogram geometry** and **angular measurements** characteristic of the rhomboidal design. *Transposition Flap* - A **generic category** of flaps that move laterally over intervening tissue, but without the **specific 60°/120° geometry**. - The rhomboidal flap is actually a **specialized type** of transposition flap, making this option less specific. *Advancement Flap* - Involves **direct forward movement** of tissue without rotation, using **straight-line incisions** parallel to the defect. - Does not involve the **angular geometry** or **rotational movement** seen in rhomboidal flap design.

Question 1

What is the typical thickness range for split-thickness skin grafts used in maxillofacial surgery?

Accepted Answer

0.3 to 0.5 mm

Answer

2 to 3 mm

Answer

1 to 2 mm

Answer

1.3 to 1.5 mm

Question 2

Port wine stain is seen in which of the following conditions?

Accepted Answer

Sturge Weber Syndrome

Answer

Von Hippel Lindau Syndrome

Answer

Denys-Drash Syndrome

Answer

Holt Oram Syndrome

Question 3

To avoid suture marks, when should sutures on the face be removed?

Accepted Answer

3-5 days

Answer

72 hours

Answer

1 week

Answer

2 weeks

Question 4

The Abbe-Estlander flap is used for reconstruction of which anatomical structure?

Accepted Answer

Lip

Answer

Tongue

Answer

Eyelid

Answer

Ear

Question 5

Down fracture of the zygomatic arch is a treatment modality for which condition?

Accepted Answer

Chronic subluxation

Answer

Temporomandibular joint (TMJ) ankylosis

Answer

Condylar fracture

Answer

Zygomatic fracture

Question 6

Which neuromuscular preserving flap is used in lip reconstruction?

Accepted Answer

Karpandzic flap

Answer

Abbe flap

Answer

Webster flap

Answer

Johansen flap

Question 7

The names Manchot, Salmon, and Taylor are related to which of the following?

Accepted Answer

Arterial supply to skin flaps

Answer

Lymphatic supply to skin

Answer

Nerve supply to the skin

Answer

Nerve supply to muscle

Question 8

A free skin graft is typically rejected when transplanted onto which of the following tissues?

Accepted Answer

None of the above

Answer

Muscle

Answer

Fat

Answer

Deep fascia

Question 9

A 12-year-old girl presents to the emergency department following a skiing crash in which the left side of her mid torso hit a tree. She presents with left side lower chest and upper abdominal pain. She also complains of left shoulder pain. What is the most likely diagnosis?

Accepted Answer

Splenic injury

Answer

Rib fractures

Answer

Liver injury

Answer

Ruptured diaphragm

Question 10

What is the name of the flap shown in the image?

Accepted Answer

Rhomboidal Flap

Answer

Rotational Flap

Answer

Transposition Flap

Answer

Advancement Flap

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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