Plastic and Reconstructive Surgery — MCQs
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A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?
A 35-year-old female with carpal tunnel syndrome undergoes surgical release. Which structure is incised during the procedure?
Which type of skin graft is most appropriate for covering large full-thickness burn wounds?
Which of the following is true about breast reconstruction surgery?
After how many days post skin grafting does revascularization and angiogenesis typically begin?
Which myocutaneous pedicle graft is most commonly used for pelvis surgeries?
Which flap is commonly used in breast reconstruction?
Which of the following statements is NOT true regarding tenosynovitis of the finger?
What is the ideal angle for Z-plasty?
What is the most common complication associated with carpal tunnel release surgery?
Plastic and Reconstructive Surgery Indian Medical PG Practice Questions and MCQs
Question 201: A patient with ulnar nerve compression at the elbow (cubital tunnel syndrome) presents with early clawing of the ring and little fingers, numbness, and progressive weakness of hand intrinsic muscles. What is the most appropriate surgical intervention to prevent further deterioration of hand function?
- A. Ulnar nerve transposition; prevents further deterioration (Correct Answer)
- B. Carpal tunnel release; reduced pain
- C. Median nerve repair; restored thumb opposition
- D. Radial nerve decompression; enhanced wrist extension
Explanation: ***Ulnar nerve transposition*** - This procedure involves surgically relocating the ulnar nerve from its position behind the medial epicondyle to a new, less constricted position (anterior to the medial epicondyle), relieving compression at the **cubital tunnel** - By decompressing the nerve, it can **prevent further deterioration** of ulnar nerve function and may allow recovery of the **intrinsic hand muscles** (lumbricals, interossei), thus halting progression of the **claw hand deformity** - This is the definitive treatment for **cubital tunnel syndrome** with progressive neurological deficits - Note: For established, fixed claw deformity, **tendon transfer procedures** (like Zancolli lasso or modified Stiles-Bunnell) would be needed *Carpal tunnel release* - This procedure addresses compression of the **median nerve** at the wrist, causing symptoms like tingling and numbness in the thumb, index, middle, and radial half of the ring finger - Classic presentation includes nocturnal paresthesias, thenar atrophy, and weak thumb opposition - Would not address **ulnar nerve compression at the elbow** or ulnar-innervated muscle weakness *Median nerve repair* - This is performed for traumatic injuries causing **complete median nerve transection** and aims to restore motor function (pronation, wrist/finger flexion, thumb opposition) and sensation - Not appropriate for **ulnar nerve compression neuropathy**, which requires decompression, not repair *Radial nerve decompression* - This procedure targets compression of the **radial nerve** (commonly at the spiral groove or radial tunnel), which typically presents with **wrist drop** and weakness of finger/thumb extension - Sensory changes occur over the dorsal first web space - Not relevant for **ulnar nerve pathology at the elbow** causing intrinsic hand muscle weakness
Question 202: A 35-year-old female with carpal tunnel syndrome undergoes surgical release. Which structure is incised during the procedure?
- A. Flexor retinaculum (Correct Answer)
- B. Extensor retinaculum
- C. Palmar aponeurosis
- D. Ulnar bursa
Explanation: ***Flexor retinaculum*** - The **flexor retinaculum** (also known as the **transverse carpal ligament**) forms the roof of the carpal tunnel. - Incising this ligament during surgery relieves pressure on the **median nerve**, which is entrapped in carpal tunnel syndrome. *Extensor retinaculum* - The **extensor retinaculum** is located on the dorsal aspect of the wrist and holds the extensor tendons in place. - It is not involved in carpal tunnel syndrome, which affects structures on the palmar side. *Palmar aponeurosis* - The **palmar aponeurosis** is a thick fibrous fascia in the palm of the hand, superficial to the carpal tunnel. - While it can be involved in conditions like Dupuytren's contracture, it does not form the boundaries of the carpal tunnel directly. *Ulnar bursa* - The **ulnar bursa** is a synovial sheath that encloses the flexor digitorum superficialis and profundus tendons within the carpal tunnel. - It lies within the carpal tunnel but incising it would not relieve the primary compression on the median nerve.
Question 203: Which type of skin graft is most appropriate for covering large full-thickness burn wounds?
- A. Split-thickness graft (Correct Answer)
- B. Full-thickness graft
- C. Composite graft
- D. Cultured epithelial autograft
Explanation: ***Split-thickness graft (Correct)*** - This type only includes the **epidermis** and a portion of the **dermis**, allowing for a large surface area to be harvested from a donor site. - Its ability to **engraft reliably** on various wound beds and cover large defects makes it ideal for extensive burn injuries. - Donor sites can **re-epithelialize** and be harvested again if needed for very extensive burns. *Full-thickness graft (Incorrect)* - Comprises the **entire epidermis and dermis**, offering better cosmetic results and durability but requiring a highly vascularized bed. - Harvesting sites are limited, and it is generally reserved for smaller, less contaminated wounds where cosmetic outcomes are critical. - **Not suitable for large burns** due to donor site limitations and need for excellent wound bed. *Composite graft (Incorrect)* - Consists of multiple tissue types (e.g., skin, cartilage, fat), used for reconstructive purposes in specific areas like the nose or ear. - It is not suitable for covering large, irregular burn wounds due to its bulk and specific tissue requirements. *Cultured epithelial autograft (Incorrect)* - Involves growing a patient's own epidermal cells in a lab, which can cover very large areas when donor sites are scarce. - While useful for extensive burns with limited donor sites, it is **fragile**, takes weeks to prepare, and is prone to contraction and scarring. - Not the **most appropriate initial choice** for immediate large wound coverage compared to split-thickness grafts.
Question 204: Which of the following is true about breast reconstruction surgery?
- A. Nipple reconstruction cannot be performed under local anesthesia
- B. Simplest reconstruction is done using silicone gel implant (Correct Answer)
- C. Radiotherapy in post op period does not influence the outcome after breast reconstruction
- D. TRAM flap has less donor site morbidity than LD flap
Explanation: ***Simplest reconstruction is done using silicone gel implant*** - **Implant-based reconstruction**, typically using silicone gel or saline implants, is often considered the **simplest option** due to shorter operative times and less donor site morbidity compared to autologous tissue reconstruction. - While it has fewer surgical steps, it may require **tissue expanders** prior to definitive implant placement and carries risks such as capsular contracture. *TRAM flap has less donor site morbidity than LD flap* - This is **incorrect**. The **TRAM (Transverse Rectus Abdominis Myocutaneous) flap** is associated with **significant donor site morbidity** including abdominal wall weakness, bulging, and potential hernias due to removal of rectus abdominis muscle. - The **LD (Latissimus Dorsi) flap** generally has **less donor site morbidity** with better preservation of shoulder function, though some patients may experience minor shoulder weakness. - While TRAM flaps often provide better cosmetic results due to larger tissue volume, they carry greater donor site complications. *Nipple reconstruction cannot be performed under local anesthesia* - **Nipple reconstruction** is a relatively minor procedure that can often be performed **under local anesthesia** in an outpatient setting. - Various techniques, such as using local flaps or skin grafting, are available and well-suited for **regional nerve blocks** or local infiltration without the need for general anesthesia. *Radiotherapy in post op period does not influence the outcome after breast reconstruction* - **Postoperative radiotherapy** can significantly influence the outcome of breast reconstruction, often leading to **poorer aesthetic results** and an increased risk of complications. - Radiation can cause **capsular contracture**, skin changes (fibrosis, thickness), and affect tissue perfusion, making both implant-based and autologous reconstructions more challenging and less successful.
Question 205: After how many days post skin grafting does revascularization and angiogenesis typically begin?
- A. 4
- B. 5 (Correct Answer)
- C. 6
- D. 7
Explanation: ***5*** - **Revascularization** and **angiogenesis** in a skin graft typically become well-established around **day 5** post-grafting. - While **inosculation** (direct anastomosis of vessels) may begin earlier around day 3-4, active **angiogenesis** (new vessel formation) is most prominent starting day 5. - This process involves the ingrowth of new blood vessels from the host bed into the graft, essential for its survival and integration. *4* - Day 4 marks the transition phase where **inosculation** is beginning and **plasmatic imbibition** is declining. - However, robust **angiogenesis** and active neovascularization are not yet fully established at this stage. - The graft is transitioning from passive diffusion to active vascular ingrowth. *6* - While revascularization is robust and well-established by day 6, the active initiation phase begins earlier around day 5. - Day 6 demonstrates a maturing vascular network, but the question asks about when the process typically begins. *7* - By day 7, the process of **revascularization** and **angiogenesis** is typically well-established and maturing. - The initial stages of capillary ingrowth and new vessel formation have already been completed by this point. - This represents the consolidation phase rather than the initiation phase.
Question 206: Which myocutaneous pedicle graft is most commonly used for pelvis surgeries?
- A. Rectus abdominis muscle (Correct Answer)
- B. External oblique muscle
- C. Internal oblique muscle
- D. Transversus abdominis muscle
Explanation: ***Rectus abdominis muscle*** - The **rectus abdominis myocutaneous flap** is highly versatile due to its reliable vascular supply (superior and inferior epigastric arteries) and anatomical proximity, making it a common choice for pelvic reconstruction. - Its bulk and ability to carry a large skin paddle make it ideal for filling large defects in the **pelvic region**, such as after cancer resections. *External oblique muscle* - While it can be harvested, the **external oblique muscle** is less commonly used for large pelvic defects compared to the rectus abdominis due to its more complex vascular anatomy and limited bulk. - Harvesting this muscle can also lead to more significant deficits in **abdominal wall integrity** and function. *Internal oblique muscle* - The **internal oblique muscle**, although part of the abdominal wall, is generally thinner and has a less robust vascular pedicle compared to the rectus abdominis, making it less suitable for bulkier pelvic reconstructions. - Its primary role is in **abdominal wall support** and movement, and its harvest can compromise these functions. *Transversus abdominis muscle* - The **transversus abdominis muscle** is typically thinner and more intimately involved in core abdominal stability, making its use as a pedicled flap for large volume reconstruction in the pelvis less practical. - Its vascular supply is generally not as robust or as easily dissectible for long pedicles as the rectus abdominis, limiting its reach for **pelvic defects**.
Question 207: Which flap is commonly used in breast reconstruction?
- A. DIEP based on deep inferior epigastric perforator vessels (Correct Answer)
- B. Gluteal flap based on superior gluteal artery
- C. Latissimus dorsi flap based on thoracodorsal artery
- D. TRAM based on transverse rectus abdominis muscle
Explanation: ***DIEP based on deep inferior epigastric perforator vessels*** - The **DIEP flap** is currently the **most preferred autologous flap** for breast reconstruction and is increasingly commonly used in modern practice. - It uses tissue from the lower abdomen, providing excellent volume and a natural-feeling breast mound, while being nourished by **deep inferior epigastric perforator vessels**. - Key advantage: **Muscle-sparing technique** that preserves the rectus abdominis muscle, minimizing abdominal wall morbidity compared to older techniques like TRAM. - Considered the **gold standard** for abdominal-based breast reconstruction. *Gluteal flap based on superior gluteal artery* - While gluteal flaps (like the **SGAP** based on the **superior gluteal artery**) are used for breast reconstruction, they are typically considered a secondary option when abdominal tissue is unavailable or unsuitable. - Harvesting can be more challenging and may result in a less ideal breast shape compared to abdominal flaps. - Less commonly used compared to abdominal-based flaps. *Latissimus dorsi flap based on thoracodorsal artery* - The **latissimus dorsi flap** is a reliable and commonly used option, particularly for smaller breasts or partial reconstruction. - However, it often requires an implant to achieve sufficient volume (not purely autologous reconstruction). - It involves transferring muscle from the back, which can lead to back weakness or contour deformities. - While frequently used, it is not the preferred choice when autologous tissue from the abdomen is available. *TRAM based on transverse rectus abdominis muscle* - The **TRAM flap** was historically a very common choice for breast reconstruction but involves taking a significant portion of the rectus abdominis muscle. - This leads to higher rates of abdominal wall weakness, hernias, or bulges compared to muscle-sparing techniques. - It is currently **less commonly used** than the DIEP flap due to its higher donor site morbidity and has been largely superseded by the DIEP technique.
Question 208: Which of the following statements is NOT true regarding tenosynovitis of the finger?
- A. With involvement of the little finger, the infection does not spread to the index finger.
- B. Treatment is not always conservative and may require surgical intervention in severe cases.
- C. Fingers are more likely to be held in an extended position due to pain and swelling. (Correct Answer)
- D. Tenosynovitis of the little finger can spread to the thumb but not to the ring finger.
Explanation: ***Fingers are more likely to be held in an extended position due to pain and swelling.*** - This statement is **FALSE** (making it the correct answer to a "NOT true" question). - In **flexor tenosynovitis**, the affected finger is characteristically held in **semi-flexion**, not extension. - This is one of **Kanavel's four cardinal signs** of pyogenic flexor tenosynovitis: the finger assumes a posture of slight flexion at all joints. - Extension increases tension on the inflamed tendon sheath, causing severe pain, so patients naturally keep the finger flexed. - The flexed position minimizes pressure within the tendon sheath and reduces pain. *With involvement of the little finger, the infection does not spread to the index finger.* - This statement is TRUE. - The little finger's flexor tendon sheath is part of the **ulnar bursa**, which can communicate with the **radial bursa** (thumb sheath) through the space of Parona in approximately 80% of individuals. - The index, middle, and ring fingers have **independent tendon sheaths** that terminate at the level of the palm. - Therefore, infection of the little finger typically does NOT spread directly to the index finger, though it can spread to the thumb via the communicating bursae. *Treatment is not always conservative and may require surgical intervention in severe cases.* - This statement is TRUE. - While early, mild tenosynovitis may respond to **conservative management** with intravenous antibiotics, splinting, and elevation, **severe or advanced cases** require surgical intervention. - **Surgical drainage and debridement** are indicated when there is purulent material, failure to respond to antibiotics within 12-24 hours, or signs of systemic toxicity. - Delayed treatment can lead to tendon necrosis, permanent stiffness, and loss of function. *Tenosynovitis of the little finger can spread to the thumb but not to the ring finger.* - This statement is TRUE. - The **ulnar bursa** (little finger) and **radial bursa** (thumb) communicate via the space of Parona in most individuals, allowing direct spread of infection between the little finger and thumb. - The ring, middle, and index fingers have **separate, independent sheaths** that do not communicate with the ulnar bursa. - While infection can spread to the midpalmar space and potentially affect other areas, direct sheath-to-sheath spread from the little finger to the ring finger does not typically occur.
Question 209: What is the ideal angle for Z-plasty?
- A. 90°
- B. 45°
- C. 60° (Correct Answer)
- D. 75°
Explanation: ***60°*** - An angle of **60°** is considered ideal for Z-plasty because it provides the best balance between **lengthening the scar** and maintaining **tissue viability**. - This angle typically results in a **75% gain in length** along the central limb of the Z-plasty, while ensuring the flaps have a broad enough base for adequate blood supply. *90°* - While a **90°** angle would provide the most lengthening (around 100%), it creates very **thin, narrow flap tips** that are highly susceptible to **ischemia and necrosis** due to compromised blood supply. - This angle is generally avoided in Z-plasty due to the high risk of **flap complications**. *45°* - A **45°** angle results in less lengthening (approximately 50% gain) compared to a 60° angle, which may not be sufficient for significant release of scar contractures. - While it offers excellent flap viability due to wider bases, the **suboptimal lengthening** makes it less efficient for many Z-plasty applications. *75°* - An angle of **75°** would yield greater lengthening than 60°, but it also compromises flap viability making the flap susceptible to **necrosis**. - The benefits of increased length are often outweighed by the increased **risk of complications** when using this angle.
Question 210: What is the most common complication associated with carpal tunnel release surgery?
- A. Malunion
- B. Avascular necrosis
- C. Finger stiffness (Correct Answer)
- D. Rupture of EPL tendon
Explanation: ***Finger stiffness*** - Among the options listed, **finger stiffness** is the most recognized complication of carpal tunnel release surgery. - **Post-operative pain, swelling, and scar tissue formation** can lead to reduced range of motion in the digits. - Patients may develop stiffness due to **immobilization**, **scar adhesions**, or apprehension in mobilizing the hand after surgery. - **Note:** In clinical practice, **pillar pain** (pain at the thenar and hypothenar eminences) is actually the most common complication (10-30% of cases), but it is not among the options provided. *Malunion* - **Malunion** refers to improper healing of a fractured bone. - Carpal tunnel release involves dividing the **transverse carpal ligament** (flexor retinaculum), which is a **soft tissue procedure**. - No bone is cut or fractured, so malunion is not relevant to this surgery. *Avascular necrosis* - **Avascular necrosis (AVN)** is bone death due to interrupted blood supply. - AVN affects bones with precarious blood supply (femoral head, scaphoid, lunate in Kienböck's disease). - Carpal tunnel release does not involve bone manipulation and **AVN is not a recognized complication** of this procedure. *Rupture of EPL tendon* - **Extensor Pollicis Longus (EPL) tendon rupture** is classically associated with **distal radius fractures** or inflammatory arthritis. - EPL runs through the **third dorsal compartment** and is anatomically distant from the carpal tunnel (volar wrist). - While median nerve injury is a rare but serious complication of carpal tunnel release, **EPL rupture is not associated** with this surgery.
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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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