Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery Indian Medical PG Practice Questions and MCQs

Question 151: Which flap is commonly used in breast reconstruction?

A. Serratus anterior flap
B. TRAM flap (Correct Answer)
C. Flap from the arm
D. Deltopectoral flap

Explanation: **Explanation:** Breast reconstruction following mastectomy can be achieved using implants or autologous tissue. The **TRAM (Transverse Rectus Abdominis Myocutaneous) flap** is considered a gold standard in autologous reconstruction. It utilizes the skin and subcutaneous fat from the lower abdomen, based on the **superior epigastric artery** (pedicled) or **inferior epigastric artery** (free flap). It is preferred because it provides a large volume of tissue that mimics the natural consistency of the breast and offers the secondary benefit of an "abdominoplasty" (tummy tuck). **Analysis of Options:** * **Serratus anterior flap:** While used occasionally to cover the lateral aspect of a breast implant, it lacks the bulk required for total breast reconstruction. * **Flap from the arm:** Historically, the Tagliacozzi flap (from the arm) was used for nasal reconstruction, not breast surgery. Modern arm-based flaps (like the TUG flap) use the inner thigh, not the arm. * **Deltopectoral flap:** This is a fasciocutaneous flap based on the internal mammary artery perforators, primarily used for **head and neck reconstruction** (e.g., pharyngoesophageal defects). **High-Yield Clinical Pearls for NEET-PG:** * **DIEP Flap (Deep Inferior Epigastric Perforator):** The modern advancement of the TRAM flap. It spares the rectus muscle, significantly reducing the risk of postoperative abdominal wall hernias. * **Latissimus Dorsi (LD) Flap:** Another common option, often used with an implant if the patient lacks sufficient abdominal fat. * **Blood Supply:** The pedicled TRAM flap is based on the **superior epigastric artery**, whereas the free TRAM/DIEP flaps are based on the **inferior epigastric artery**.

Question 152: A skin graft is performed on a wound using skin taken from an identical twin brother. What type of graft is this?

A. Isograft (Correct Answer)
B. Allograft
C. Autograft
D. Xenograft

Explanation: ### Explanation The correct answer is **Isograft (Option A)**. In plastic and reconstructive surgery, grafts are classified based on the genetic relationship between the donor and the recipient. An **Isograft** (also known as a syngeneic graft) is a tissue transfer between two genetically identical individuals of the same species, such as **monozygotic (identical) twins**. Because the HLA (Human Leukocyte Antigen) profiles are identical, there is no immune response, and the graft is not rejected. **Analysis of Incorrect Options:** * **B. Allograft (Homograft):** This involves tissue transfer between two genetically different members of the same species (e.g., human to human). Unlike isografts, these require immunosuppression to prevent rejection. * **C. Autograft:** This is the transfer of tissue from one site to another on the **same individual** (e.g., taking skin from the thigh to cover a wound on the arm). This is the "gold standard" as there is zero risk of rejection. * **D. Xenograft (Heterograft):** This is a graft between members of different species (e.g., porcine/pig skin or bovine/cow valves used in humans). These are often used as temporary biological dressings. **High-Yield NEET-PG Pearls:** * **Order of Graft Survival:** Autograft = Isograft > Allograft > Xenograft. * **Skin Graft "Take":** The process occurs in three stages: **Plasmatic imbibition** (first 24–48 hours), **Inosculation** (alignment of capillaries), and **Revascularization** (neovascularization). * **Primary vs. Secondary Contraction:** Full-thickness grafts (FTSG) have more *primary* contraction (immediate recoil) but less *secondary* contraction (wound shrinkage) compared to split-thickness grafts (STSG).

Question 153: Which layer is involved in blister formation in a superficial partial thickness burn?

A. Epidermis
B. Dermis
C. Papillary dermis (Correct Answer)
D. Reticular dermis

Explanation: **Explanation:** In burns, the depth of tissue injury determines the clinical presentation. A **superficial partial-thickness burn** (Second-degree burn) involves the entire epidermis and extends into the **papillary dermis** (the superficial layer of the dermis). **Why Papillary Dermis is correct:** Blister formation is the hallmark of superficial partial-thickness burns. It occurs because the heat causes damage to the **dermal-epidermal junction**. This leads to inflammatory mediator release and increased capillary permeability in the rich vascular plexus of the papillary dermis. Fluid then leaks out and collects between the epidermis and the dermis, lifting the epidermis to form a blister. These burns are exquisitely painful because the sensory nerve endings located in this layer remain intact but exposed. **Analysis of Incorrect Options:** * **A. Epidermis:** Damage limited only to the epidermis is a **first-degree burn** (e.g., sunburn). These are characterized by erythema and pain but **no blisters**. * **B. Dermis:** This is too broad. The dermis is divided into two distinct layers (papillary and reticular) with different clinical outcomes. * **D. Reticular dermis:** Involvement of the deeper reticular dermis indicates a **deep partial-thickness burn**. These appear mottled white/pink, have decreased sensation, and typically do not form the classic thin-walled blisters seen in superficial burns. **High-Yield NEET-PG Pearls:** * **Superficial Partial Thickness:** Blisters present, very painful, blanches on pressure, heals in 7–21 days without scarring. * **Deep Partial Thickness:** Fixed staining (non-blanching), reduced sensation, heals with hypertrophic scarring/contractures. * **Full Thickness:** Leathery, charred, or pearly white; painless (nerves destroyed); requires skin grafting.

Question 154: Which statement regarding cleft palate repair is false?

A. Hemoglobin level should be at least 10 grams%
B. Patient weight should be at least 10 pounds
C. Repair should be performed immediately after birth (Correct Answer)
D. It is a 2-stage procedure if associated with cleft lip

Explanation: ### Explanation **1. Why Option C is False (The Correct Answer):** Cleft palate repair is **never** performed immediately after birth. Surgical closure requires a more mature anesthetic profile and sufficient oral cavity growth to allow for tissue mobilization. Performing it too early can lead to severe midface growth retardation due to interference with the maxillary growth centers. The standard timing for cleft palate repair (Palatoplasty) is typically between **6 to 12 months** of age, ideally before the child begins to develop speech patterns to prevent compensatory articulation errors. **2. Analysis of Other Options:** * **Options A & B (The Rule of 10s):** These are classic criteria (Wilhelmsen and Musgrave) traditionally used for **Cleft Lip** repair, but they serve as a general safety baseline for pediatric facial surgery. The "Rule of 10s" includes: * Weight: **10 pounds** * Hemoglobin: **10 grams%** * Age: **10 weeks** (specifically for lip repair) * WBC count: <10,000/mm³ * **Option D:** When both cleft lip and palate are present, it is standard practice to perform a **2-stage procedure**. The lip is repaired first (around 3 months), followed by the palate later (6–12 months). **3. High-Yield Clinical Pearls for NEET-PG:** * **Primary Goal of Palatoplasty:** To achieve normal **speech** (by creating a functional velopharyngeal valve) and prevent regurgitation. * **Common Techniques:** Von Langenbeck (bipedicled flaps), Veau-Wardill-Kilner (V-Y pushback), and Furlow (Z-plasty). * **Most Common Muscle Affected:** Tensor veli palatini (leads to Eustachian tube dysfunction and **Chronic Otitis Media with Effusion** in almost all cases). * **Sequence of Management:** Lip (3 months) → Palate (6–12 months) → Bone grafting for alveolar cleft (9–11 years).

Question 155: A 65-year-old male presents with a 5 cm high-grade liposarcoma on the back of his lower thigh. What is the best management?

A. Amputation of the limb at mid-thigh
B. Wide local excision (Correct Answer)
C. Chemotherapy
D. Radiotherapy

Explanation: **Explanation:** The primary goal in the management of soft tissue sarcomas (STS), such as liposarcoma, is achieving local control while preserving limb function. **1. Why Wide Local Excision (WLE) is correct:** Wide local excision is the **gold standard** treatment for localized soft tissue sarcomas. The objective is to remove the tumor along with a 1–2 cm cuff of healthy surrounding tissue (negative margins). For a 5 cm high-grade tumor on the thigh, limb-salvage surgery (WLE) followed by adjuvant radiotherapy is the preferred approach, as it offers survival rates equivalent to amputation while maintaining a functional limb. **2. Why other options are incorrect:** * **Amputation:** Historically common, it is now reserved only for cases where the tumor involves major neurovascular structures or if a functional limb cannot be reconstructed. It does not provide a survival advantage over WLE. * **Chemotherapy:** STS are generally poorly responsive to chemotherapy. It is typically reserved for metastatic disease or as a palliative measure, rather than primary treatment for a localized 5 cm mass. * **Radiotherapy:** While often used as an **adjuvant** (post-operative) treatment to reduce local recurrence in high-grade or large (>5 cm) tumors, it is not a substitute for surgical resection. **High-Yield Clinical Pearls for NEET-PG:** * **Staging:** The most important prognostic factor for STS is the **histological grade**, while the most important factor for local recurrence is the **surgical margin**. * **Biopsy:** If a biopsy is required, a **Core Needle Biopsy** is preferred over incisional biopsy. The biopsy tract must be excised during the definitive surgery. * **Limb Salvage:** >90% of extremity sarcomas are now managed with limb-sparing surgery. * **Liposarcoma Subtypes:** Well-differentiated/dedifferentiated, Myxoid/round cell, and Pleomorphic. Myxoid is the most common subtype.

Question 156: What is the most common type of skin carcinoma on the face in light-skinned individuals?

A. Squamous cell carcinoma
B. Basal cell carcinoma (Correct Answer)
C. Bowen's disease
D. Erythroplasia of Queyrat

Explanation: **Explanation:** **Basal Cell Carcinoma (BCC)** is the most common skin malignancy worldwide and specifically the most common type of skin carcinoma on the face in light-skinned individuals. It typically arises from the basal layer of the epidermis. The primary risk factor is chronic exposure to ultraviolet (UV) radiation. It most frequently occurs on sun-exposed areas, particularly the "upper two-thirds" of the face (above a line joining the angle of the mouth to the earlobe). **Analysis of Options:** * **A. Squamous Cell Carcinoma (SCC):** This is the second most common skin cancer. While also related to sun exposure, it is more common on the "lower third" of the face (e.g., lower lip) and has a higher potential for lymphatic metastasis compared to BCC. * **C. Bowen’s Disease:** This is a clinical term for **Squamous Cell Carcinoma in-situ**. It presents as a slow-growing, red, scaly patch. It is a precursor to invasive SCC, not the most common primary carcinoma. * **D. Erythroplasia of Queyrat:** This is a specific form of SCC in-situ that occurs on the glans penis or prepuce. It is not a facial malignancy. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** A pearly, translucent papule with telangiectasia and a "rolled-out" border. It may centralize to form a "Rodent Ulcer." * **Metastasis:** BCC is locally invasive but **rarely metastasizes**. * **Treatment of Choice:** Surgical excision with safe margins. For high-risk areas (face), **Mohs Micrographic Surgery** is the gold standard to ensure complete margin control while sparing tissue. * **Inherited Syndrome:** Gorlin Syndrome (Basal Cell Nevus Syndrome) is associated with multiple BCCs, odontogenic keratocysts, and bifid ribs.

Question 157: Which of the following is the best treatment for this condition?

A. Intralesional injection of triamcinolone (Correct Answer)
B. Wide excision and grafting
C. Wide excision and suturing
D. Deep X-ray therapy

Explanation: ***Intralesional injection of triamcinolone*** - **First-line treatment** for keloid scars, as **corticosteroids** reduce collagen synthesis and have anti-inflammatory effects that flatten the lesion. - **Non-invasive approach** with lower recurrence rates compared to surgical excision, making it the preferred initial treatment. *Wide excision and grafting* - **High recurrence rate** (up to 90%) when used alone for keloids, as surgical trauma can stimulate more aggressive scar formation. - **Grafting** does not address the underlying tendency for abnormal collagen production in keloid-prone individuals. *Wide excision and suturing* - **Surgical excision alone** has the highest recurrence rate for keloids, often resulting in larger lesions than the original. - **Primary closure** under tension can worsen keloid formation due to increased mechanical stress on the wound. *Deep X-ray therapy* - Used as **adjuvant therapy** following surgical excision, not as primary treatment for keloids. - **Radiation therapy** alone is not recommended as first-line treatment and carries risks of malignant transformation with prolonged use.

Question 158: Lahsal classification is used for:

A. Cleft lip and palate (Correct Answer)
B. Tumor staging
C. Neurological assessment of trauma patient
D. None of the above

Explanation: **Explanation:** The **LAHSAL classification** is a standardized anatomical coding system used to describe the extent of **Cleft Lip and Palate**. It is a diagrammatic representation where the oral cavity is divided into six segments, represented by the acronym LAHSAL: * **L:** Lip (Right) * **A:** Alveolus (Right) * **H:** Hard Palate * **S:** Soft Palate * **A:** Alveolus (Left) * **L:** Lip (Left) In this system, a capital letter (e.g., 'L') denotes a complete cleft, a lowercase letter (e.g., 'l') denotes an incomplete cleft, and a dot or hyphen denotes no cleft. This allows for a quick, visual shorthand to communicate complex anatomical defects. **Analysis of Incorrect Options:** * **Option B (Tumor Staging):** Tumor staging typically utilizes the **TNM classification** (Tumor, Node, Metastasis) or specific systems like FIGO (for Gynae-oncology) or Ann Arbor (for Lymphoma). * **Option C (Neurological Assessment):** The gold standard for neurological assessment in trauma is the **Glasgow Coma Scale (GCS)** or the **Revised Trauma Score (RTS)**. **High-Yield Clinical Pearls for NEET-PG:** * **Kernahan’s Striped Y:** Another common classification for cleft lip and palate; LAHSAL is essentially a linear version of this. * **Rule of 10s (Millard):** Used to determine the timing for cleft lip repair (10 weeks of age, 10 lbs weight, 10 g/dL hemoglobin). * **Timing of Surgery:** Cleft Lip repair is usually done at **3–6 months**, while Cleft Palate repair is done at **6–12 months** (to allow for speech development but before significant speech habits form).

Question 159: A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

A. Rhomboid flap (Correct Answer)
B. Free flap
C. Rotational flap
D. Advancement flap

Explanation: ***Rhomboid flap***- The **Limberg flap** is a classic type of rhomboid transposition flap widely used for closing the deep, large defect left after wide excision of a pilonidal sinus.- This flap provides excellent tissue coverage, shifts the scar away from the midline natal cleft, and significantly reduces tension, leading to lower rates of **recurrence**.*Advanced flap*- An advancement flap involves moving tissue linearly forward, which often results in high tension when used to close the typical wide, ovoid defect remaining after pilonidal sinus excision.- They are less suitable for deep and wide midline defects compared to rotational or transposition flaps because they do not effectively flatten the **natal cleft** or distribute tension laterally.*Rotational flap*- While rotational flaps (like the **Karydakis flap**) are effective for pilonidal disease by excising the disease and closing the defect laterally, the **Limberg flap** is specifically a rhomboid transposition flap and is arguably the most classic answer for a geometric local flap used in this surgery.- Simple rotational flaps might be used, but the effectiveness and precision provided by the rhomboid geometry for large defects make the Limberg (rhomboid) technique particularly notable.*Free flap*- **Free flaps** involve microsurgical anastomosis to connect tissue from a distant site, a level of surgical complexity unnecessary for standard pilonidal sinus reconstruction.- These flaps are reserved for very large, complex defects, often requiring coverage where local tissue has been destroyed by cancer or **osteomyelitis**, which is usually not the case in routine pilonidal surgery.

Question 160: A patient underwent split-thickness skin grafting for a burn injury on the arm. On post-operative day 6, he develops stiffness of the arm during physiotherapy. What is the most appropriate next step in management?

A. Continue physiotherapy without intervention
B. Surgical excision of contracture
C. Remove the graft and regraft the area
D. Passive extension of the joint under direct visualization of the graft (Correct Answer)

Explanation: ***Passive extension of the joint under direct visualization of the graft***- Stiffness noted around post-op day 6 points to the formation of an **early, immature fibrous band** crossing the joint, often seen after split-thickness skin grafting.- Gentle but firm **passive extension** at this time is the standard management to **break the fibrous band** before it matures into a fixed contracture, while direct visualization prevents graft avulsion.*Surgical excision of contracture*- This intervention is reserved for **mature, established contractures** that have failed conservative management, typically occurring months post-injury.- Performing surgical release on post-op day 6 is premature and risks **damaging the viable graft** and exposing underlying structures.*Continue physiotherapy without intervention*- If **early stiffness** is present, continuing standard physiotherapy alone will not overcome the developing fibrous tether and will likely result in a **fixed joint contracture**.- **Forced extension** is needed at this stage to actively address the limitation in **range of motion (ROM)**.*Remove the graft and regraft the area*- This approach is indicated only for complications like **graft necrosis** or **complete graft failure**, not for the formation of stiffness or contractures.- The graft is viable and the issue relates to peri-articular scar formation, making **graft removal unnecessary** and harmful.

Practice by Chapter

Wound Healing

Practice Questions

Skin Grafts

Practice Questions

Flap Surgery Principles

Practice Questions

Local Flaps

Practice Questions

Regional Flaps

Practice Questions

Microsurgical Techniques

Practice Questions

Tissue Expansion

Practice Questions

Breast Reconstruction

Practice Questions

Hand Surgery Basics

Practice Questions

Craniofacial Surgery Principles

Practice Questions

Aesthetic Surgery Concepts

Practice Questions

Body Contouring

Practice Questions

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