Plastic and Reconstructive Surgery Practice Questions

Q: In case of burns, which graft is better for acute wound coverage?

Thiersch graft. **Thiersch graft** - A **Thiersch graft**, also known as a **split-thickness skin graft**, is highly effective for covering large burn areas due to its ability to be harvested in thin sheets. - It has a high take rate because it requires less vascularization from the recipient bed, making it suitable for burn wounds which may have compromised blood supply. *Wolfe graft* - A **Wolfe graft** is a **full-thickness skin graft**, which includes both the epidermis and the entire dermis. - While it provides better cosmetic results and less contracture, its survival rate is lower in settings with compromised blood supply, such as large burn wounds, due to its higher metabolic demand. *Patch graft* - A **patch graft** often refers to a small, isolated piece of tissue and is not typically used for extensive burn wound coverage. - It lacks the coverage area and high take rate needed for optimal management of large burn surfaces. *Pedicle graft* - A **pedicle graft** remains attached to its original blood supply, making it a robust option. - However, it is usually employed for reconstructing deeper defects with exposed bone or tendon, not for routine coverage of large superficial burn areas, and it requires more complex surgical procedures.

Q: If severe bony undercuts exist, what is the best treatment?

Remove all undercuts so that no undercut exists. ***Remove all undercuts so that no undercut exists*** - **Severe bony undercuts** can prevent the proper seating and insertion of a removable prosthesis, leading to trauma and instability. - **Complete removal** of such undercuts creates a uniform, unobstructed path of insertion, ensuring the prosthesis can be placed and removed without damaging tissues. *Nothing but do only alveolar ridge contouring* - **Alveolar ridge contouring** alone might not be sufficient to address severe bony undercuts, as these often involve areas beyond the immediate ridge crest. - Leaving severe undercuts can still cause ongoing **trauma** to the soft tissues during prosthesis insertion and removal, leading to pain and ulceration. *Remove undercut on one side* - Removing undercuts on only one side while leaving others untreated can lead to a **compromised path of insertion**. - This approach may not fully resolve the problem, potentially still causing difficulty in seating the prosthesis or leading to **uneven stress distribution** upon insertion. *None of the above* - This option is incorrect because removing all severe bony undercuts is indeed a standard and often necessary treatment to ensure successful prosthetic rehabilitation.

Q: Which of the following structures is fixed first during reimplantation of an amputated digit -

Bone. ***Bone*** - **Bone fixation** is the crucial first step to stabilize the digit, providing a stable framework for subsequent soft tissue repair. - This **restores skeletal integrity** and allows for proper alignment, reducing tension on delicate vascular and nervous structures. *Vein* - **Vein repair** is typically performed after arterial repair to ensure adequate outflow and prevent congestion, but after bone fixation. - While critical for successful reimplantation, venous repair without prior bone stability is difficult and prone to compromise. *Nerve* - **Nerve repair** is generally performed later in the sequence, after bone and vascular repairs have been completed. - The focus is on restoring blood flow first to ensure tissue viability before addressing nerve continuity for sensation and motor function. *Artery* - **Arterial reconstruction** is paramount for revascularization and tissue viability, but it follows initial bone stabilization. - Attempting to connect arteries without a stable skeletal foundation would make the repair challenging and increase the risk of avulsion or damage.

Q: Deep skin burns are treated with:

Split thickness graft. ***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.

Q: In combined tendon and nerve injuries, the preferred sequence of repair is:

Nerves should be repaired before tendons. ***Nerves should be repaired before tendons*** - Nerve repairs are **more delicate** and require precise microsurgical technique with minimal tension - Repairing nerves first allows optimal **anatomical positioning** and coaptation without interference from tendon manipulation - Tendon repair involves **greater tissue handling and tension**, which could disrupt a freshly repaired nerve if done first - This sequence is the **standard teaching** in hand surgery (Green's Operative Hand Surgery, Campbell's Operative Orthopaedics) - Once nerves are secured, tendons can be repaired with the necessary tensioning without risk to neural structures *Tendons should be repaired before nerves* - This would subject the **fragile nerve repair to mechanical stress** during subsequent tendon manipulation - Tendon repair requires **forceful suturing and tensioning** that could displace or damage a previously repaired nerve - This sequence makes nerve repair technically more difficult as tendons may obstruct access *Tendons should not be repaired simultaneously with nerves* - While the exact sequence matters, both structures are typically repaired **in the same surgical setting** - The statement is confusing as "simultaneously" could mean same surgery (which is done) versus same moment (which is avoided) - Modern practice favors complete repair in one operation when possible *None of the above* - There is a well-established preferred sequence in combined tendon and nerve injuries - The principle of nerve-before-tendon repair is supported by surgical literature and clinical practice

Q: What does "Take in" mean in case of skin grafting?

Revascularization of the graft. ***Revascularization of the graft*** - "Take in" refers to the process where the **graft establishes a new blood supply** from the recipient site, a critical step for its survival. - This **revascularization** allows the graft to receive oxygen and nutrients, preventing necrosis. *Non adherent graft is shed off* - This describes **graft failure** or sloughing, not successful integration. - A non-adherent graft is indicative of insufficient blood supply or infection, leading to its eventual loss. *Return of the sensation* - While sensation may eventually return to a grafted area, it is a much **later phenomenon** and not what "take in" specifically refers to. - The return of sensation depends on **nerve regrowth** and reinnervation, which can take months to years. *When the graft becomes adherent to recipient site* - Adherence is an **initial step** in graft healing, but it's not the complete definition of "take in." - Adherence is necessary for the subsequent revascularization process, but the graft can adhere without fully "taking in" if blood supply is not established.

Q: Which index is used to score the outcome of treatment in patients with cleft lip and palate?

Goslon Yardstick. ***Goslon Yardstick*** - The **Goslon Yardstick** is a widely accepted and validated index specifically designed to assess the **outcome of surgical treatment** in patients with **cleft lip and palate**. - It provides a **five-point scale** for evaluating dental arch relationships and occlusion based on study models, reflecting the severity of the **dental malocclusion** and the success of surgical intervention. *Index of Orthodontic Treatment Complexity (IOTC)* - The IOTC is used to estimate the **inherent difficulty** of orthodontic cases and the likely complexity of treatment, not as an outcome measure for cleft lip and palate. - It considers factors like **malocclusion severity**, presence of multiple anomalies, and anchorage requirements. *Index of Complexity, Outcome and Need (ICON)* - The ICON is a broad-ranging index used to assess the **need for orthodontic treatment** and to measure the complexity and outcome of general orthodontic cases. - While it can be applied to many orthodontic patients, it is **not specific** for the unique treatment outcomes of cleft lip and palate. *Summer's Index* - This likely refers to the **Handicapping Malocclusion Assessment Record (HMAR)**, sometimes associated with Summer, which quantifies the severity of **malocclusion** for public health screening and determining eligibility for publicly funded orthodontic treatment. - It is a general measure of malocclusion severity and **not specific** for the surgical outcomes in cleft lip and palate patients.

Q: Millard repair is used for treatment of:

Cleft lip. ***Cleft lip*** - **Millard repair** is a widely used surgical technique for the correction of a **unilateral cleft lip**. - It involves a **rotation-advancement flap** principle to reconstruct the cupid's bow, philtral columns, and nasal sill. *Cleft palate* - Surgical repair of a cleft palate typically involves procedures like the **von Langenbeck technique** or **two-flap palatoplasty**, aiming to close the palatal defect and restore speech function. - Unlike cleft lip, these techniques focus on repairing the hard and soft palate and do not involve rotation-advancement flaps specific to the lip. *Meningocele* - A meningocele is a type of **spina bifida** where the meninges protrude through a spinal defect. Its repair involves neurosurgical closure of the defect and excision of the sac. - This condition is a **neural tube defect** and is entirely unrelated to facial congenital anomalies or their repair techniques. *Saddle nose* - **Saddle nose deformity** involves a collapsed nasal bridge, often due to trauma or inflammatory conditions, and is corrected through rhinoplasty using **cartilage grafts** or other reconstructive methods. - This is an acquired or congenital nasal deformity, distinct from a cleft lip, and its correction does not involve Millard's technique.

Q: Which of the following is the POOREST recipient bed for a skin graft?

Fat. ***Fat*** - **Fat** is a poor recipient for a skin graft due to its **limited vascularity**, which hinders the necessary process of revascularization for graft survival. - The high metabolic demand of a graft cannot be adequately met by the relatively avascular subcutaneous fat, leading to graft failure. *Muscle* - **Muscle tissue** is an excellent recipient bed for skin grafts due to its **rich blood supply**. - Its robust vascularity effectively supports the revascularization and survival of the grafted tissue. *Deep fascia* - **Deep fascia** provides a good vascularized bed for skin grafts, as it has a reasonable blood supply from underlying muscles and surrounding tissues. - This vascularization is sufficient to nourish and ensure the take of a skin graft. *Skull bone* - **Skull bone** (specifically the periosteum covering it) can serve as an adequate graft bed due to its vascular supply. - If the **periosteum** is intact and healthy, it offers sufficient blood flow for graft survival.

Q: Amputated digits are preserved in:

Plastic bag in ice. ***Plastic bag in ice*** - The amputated digit should be placed in a **sterile plastic bag** and then immersed in a container with **ice water**. This method provides adequate cooling to preserve tissue viability without direct contact with ice, which can cause **frostbite**. - This approach slows down metabolic processes and reduces oxygen demand, extending the time window for successful **replantation**. *Deep freezer* - Placing an amputated digit directly into a deep freezer causes **ice crystal formation** within the cells, leading to severe **tissue damage** and making replantation impossible. - Extreme cold results in **cellular dehydration** and destruction, rendering the tissue non-viable for reattachment. *Cold ringer lactate* - While Ringer's lactate is an appropriate solution for **tissue irrigation** or to keep a digit moist in an emergency, it should not be used as the primary medium for prolonged preservation without adequate cooling. - For optimal preservation, Ringer's lactate could be used *inside* the plastic bag to bathe the digit, but the bag still needs to be placed on ice to achieve the necessary **hypothermic conditions**. *Cold saline* - Similar to Ringer's lactate, cold saline can be used to **cleanse** the amputated part or keep it moist temporarily. However, it is not ideal as the sole preservation method. - Direct immersion in saline with ice is better than plain saline at room temperature but still carries the risk of **tissue maceration** if not properly managed within a sealed bag on ice. The primary goal is cooling, not just hydration.

Question 1

In case of burns, which graft is better for acute wound coverage?

Accepted Answer

Thiersch graft

Answer

Wolfe graft

Answer

Patch graft

Answer

Pedicle graft

Question 2

If severe bony undercuts exist, what is the best treatment?

Accepted Answer

Remove all undercuts so that no undercut exists

Answer

Nothing but do only alveolar ridge contouring

Answer

Remove undercut on one side

Answer

None of the above

Question 3

Which of the following structures is fixed first during reimplantation of an amputated digit -

Accepted Answer

Bone

Answer

Vein

Answer

Nerve

Answer

Artery

Question 4

Deep skin burns are treated with:

Accepted Answer

Split thickness graft

Answer

Amniotic membrane

Answer

Full thickness graft

Answer

Synthetic skin derivatives

Question 5

In combined tendon and nerve injuries, the preferred sequence of repair is:

Accepted Answer

Nerves should be repaired before tendons

Answer

Tendons should be repaired before nerves

Answer

None of the above

Answer

Tendons should not be repaired simultaneously with nerves

Question 6

What does "Take in" mean in case of skin grafting?

Accepted Answer

Revascularization of the graft

Answer

Non adherent graft is shed off

Answer

Return of the sensation

Answer

When the graft becomes adherent to recipient site

Question 7

Which index is used to score the outcome of treatment in patients with cleft lip and palate?

Accepted Answer

Goslon Yardstick

Answer

Index of Orthodontic Treatment Complexity (IOTC)

Answer

Summer’s Index

Answer

Index of Complexity, Outcome and Need (ICON)

Question 8

Millard repair is used for treatment of:

Accepted Answer

Cleft lip

Answer

Cleft palate

Answer

Meningocele

Answer

Saddle nose

Question 9

Which of the following is the POOREST recipient bed for a skin graft?

Accepted Answer

Fat

Answer

Muscle

Answer

Deep fascia

Answer

Skull bone

Question 10

Amputated digits are preserved in:

Accepted Answer

Plastic bag in ice

Answer

Deep freezer

Answer

Cold ringer lactate

Answer

Cold saline

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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