Plastic and Reconstructive Surgery — MCQs

A 6-year-old girl presents with a several-week history of an anterior cervical midline mass and throat pain. Following a course of antibiotics, her inflammation and erythema resolved, but the mass persisted. Her mother recalls similar symptoms when the child was 3 years old, which resolved spontaneously. The mass appears to rise upward when the girl sticks out her tongue. What is the most common diagnosis?

Q27Medium

A 3-year-old boy is referred after his initial pediatrician's assessment for an undescended testicle. On exam, his left testicle is normal and in place. He has no evidence of hernias. However, his right hemiscrotum is empty, and there is a testicle-sized mass palpable at the pubic tubercle. What is the most appropriate next step?

Q28Easy

A 1-month-old infant presents with an umbilical hernia. The hernia is reducible but prolapses again almost immediately. What is true regarding this defect?

Q29Medium

What is the best treatment for capillary nevus?

Q30Medium

A young boy presents with a scald injury of the arm. The lesion is pink, oozing, and painful to pinprick. What is the most appropriate management?

Plastic and Reconstructive Surgery Indian Medical PG Practice Questions and MCQs

Question 21: Pulp space infection is known as:

A. Felon (Correct Answer)
B. Paronychia
C. Perionychia
D. Onychonychia

Explanation: ### Explanation **1. Why "Felon" is the Correct Answer:** A **Felon** is a subcutaneous infection of the **pulp space** of the distal finger. The anatomy of the fingertip is unique; it contains numerous vertical fibrous septa that connect the dermis to the periosteum of the distal phalanx. These septa create closed, high-pressure compartments. When infection occurs (usually due to *Staphylococcus aureus*), the resulting edema increases pressure within these tight spaces. If left untreated, this can lead to **compartment syndrome of the pulp**, causing ischemic necrosis of the bone (osteomyelitis) or the skin. **2. Why the Other Options are Incorrect:** * **Paronychia:** This is an infection of the **soft tissue folds around the nail** (the lateral nail fold). It is the most common hand infection and is usually superficial. * **Perionychia:** This is a general term referring to inflammation or infection of the **perionychium** (the entire structure surrounding the nail, including the paronychium and eponychium). * **Onychonychia:** This is not a standard clinical term for a specific hand infection; it is likely a distractor derived from "Onychia" (inflammation of the nail matrix). **3. Clinical Pearls for NEET-PG:** * **Management:** Incision and drainage (I&D) are mandatory if fluctuance or severe tension is present. The incision should be made where the tension is maximal to avoid injuring the digital nerves/vessels. * **Complication:** The most feared complication of an untreated felon is **distal phalangeal osteomyelitis** due to pressure necrosis of the bone. * **Kanavel’s Signs:** Remember these for **Flexor Tenosynovitis** (another high-yield hand infection): 1. Finger held in flexion, 2. Uniform swelling (fusiform), 3. Tenderness along the tendon sheath, 4. Pain on passive extension.

Question 22: Which anatomical structure of significance is encountered in the Gillies approach?

A. Superficial temporal artery (Correct Answer)
B. Facial artery
C. Lingual nerve
D. All of the above

Explanation: **Explanation:** The **Gillies approach** (temporal approach) is a classic surgical technique used for the reduction of isolated fractures of the **zygomatic arch**. 1. **Why Option A is correct:** The incision is made approximately 2.5 cm superior and anterior to the helix of the ear, within the hairline. This incision is placed directly over the **superficial temporal artery** and its accompanying vein. Surgeons must be cautious to identify, retract, or ligate these vessels to prevent significant hemorrhage and hematoma formation. The dissection then proceeds through the superficial temporal fascia (temporoparietal fascia) to reach the deep temporal fascia, where an elevator is inserted to reduce the fracture. 2. **Why other options are incorrect:** * **Facial artery:** This artery crosses the inferior border of the mandible at the anterior border of the masseter. It is far inferior to the temporal surgical site. * **Lingual nerve:** This is a branch of the mandibular nerve (V3) located in the submandibular region and floor of the mouth. It is not encountered during extra-oral approaches to the zygoma. **High-Yield Clinical Pearls for NEET-PG:** * **Anatomical Plane:** In the Gillies approach, the elevator is passed **deep to the deep temporal fascia** but **superficial to the temporalis muscle**. This "potential space" leads directly to the medial surface of the zygomatic arch. * **Nerve at Risk:** The **temporal branch of the facial nerve** is the most significant neural structure at risk. To protect it, the incision must be made posterior to its course, and dissection must stay deep to the superficial temporal fascia. * **Alternative:** The **Keen approach** is the intra-oral equivalent for zygomatic arch reduction (incision in the gingivobuccal sulcus).

Question 23: What is the most common nerve injured during facelift surgery?

A. Zygomatic branch of the facial nerve
B. Greater auricular nerve
C. Mandibular branch of facial nerve
D. Frontal branch of facial nerve (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Frontal branch of facial nerve**. In facelift surgery (rhytidectomy), the **frontal (temporal) branch of the facial nerve** is the most commonly injured nerve. This is due to its extremely superficial and vulnerable course as it crosses the middle third of the zygomatic arch. It lies within the sub-SMAS (Superficial Musculoaponeurotic System) plane, specifically just deep to the temporoparietal fascia. Because facelift dissections often occur in this exact plane to achieve skin and tissue elevation, the nerve is highly susceptible to traction or transection. Injury results in brow ptosis and the inability to wrinkle the forehead. **Analysis of Incorrect Options:** * **A. Zygomatic branch:** While it is at risk during midface dissection, it has extensive arborization (multiple interconnections) with the buccal branch, making clinical deficits rare even if a small twig is injured. * **B. Greater auricular nerve:** This is the most common **sensory** nerve injured during a facelift (often near the Erb’s point over the sternocleidomastoid). However, when a question asks for "nerve injury" without specifying sensory, the focus is typically on the motor morbidity of the facial nerve branches. * **C. Mandibular branch:** This is the second most common motor nerve injured. It is vulnerable near the angle of the mandible where it becomes superficial, but statistically, the frontal branch remains the most frequent site of injury. **High-Yield Clinical Pearls for NEET-PG:** * **Pitanguy’s Line:** A surface landmark used to identify the course of the frontal branch (from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow). * **Most common sensory nerve injured:** Greater Auricular Nerve (leads to numbness of the lower ear lobe). * **Danger Zone:** The "McGregor’s Patch" (zygomatic cutaneous ligaments) is a key area where dissection must be precise to avoid nerve damage.

Question 24: The term "universal tumor" refers to which of the following?

A. Adenoma
B. Papilloma
C. Fibroma
D. Lipoma (Correct Answer)

Explanation: **Explanation:** **Lipoma** is termed the **"universal tumor"** because it is the most common benign mesenchymal tumor and can occur in almost any part of the body where fat is present. It is most frequently found in the subcutaneous tissues of the trunk, neck, and proximal extremities, but it can also occur in internal organs (e.g., gastrointestinal tract, heart, or brain). **Why the other options are incorrect:** * **Adenoma:** This is a benign tumor of glandular origin (e.g., pleomorphic adenoma of the parotid). It is tissue-specific and not "universal." * **Papilloma:** This is a benign epithelial tumor growing exophytically (outward) in nipple-like projections. It is common in the skin, bladder, or breast ducts but lacks the ubiquitous distribution of lipomas. * **Fibroma:** While common, these are benign tumors of connective tissue that are less frequent than lipomas and do not carry the specific clinical moniker of "universal tumor." **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** Lipomas are typically soft, painless, mobile, and possess a characteristic **"slip sign"** (the tumor slips away from the finger on palpation). * **Dercum’s Disease (Adiposis Dolorosa):** A rare condition characterized by multiple painful lipomas, usually in postmenopausal women. * **Madelung’s Disease:** Symmetric lipomatosis involving the neck, head, and upper trunk, often associated with chronic alcoholism. * **Histology:** They are composed of mature adipocytes and are usually enclosed within a delicate capsule. * **Treatment:** Most are asymptomatic and require no treatment. If symptomatic or for cosmetic reasons, surgical excision or liposuction is performed.

Question 25: A scalp defect measuring 3-6 cm is best closed by which of the following methods?

A. Primary simple closure
B. Split skin grafting
C. Secondary closure
D. Local flaps (Correct Answer)

Explanation: ### Explanation The scalp is a unique anatomical structure characterized by its relative inelasticity and high vascularity. The management of scalp defects depends primarily on the **size of the defect** and the **integrity of the pericranium**. **Why Local Flaps are the Correct Choice:** For defects measuring **3–6 cm**, primary closure is usually impossible due to the extreme tension caused by the galea aponeurotica. **Local flaps** (such as rotation flaps, transposition flaps, or Orticochea "banana" flaps) are the gold standard here. They provide stable, hair-bearing skin and durable coverage with a similar color and thickness match, which is essential for both protection and aesthetics. **Analysis of Incorrect Options:** * **A. Primary simple closure:** This is only feasible for small defects (usually **<3 cm**) where the scalp laxity allows for tension-free apposition. * **B. Split skin grafting (SSG):** While SSG can cover large areas, it requires an intact pericranium to "take." However, it is aesthetically poor (no hair growth) and prone to trauma; it is generally reserved for very large defects or when the patient is unfit for complex surgery. * **C. Secondary closure:** This involves healing by granulation. It is avoided in the scalp as it leads to prolonged wound exposure, risk of osteomyelitis, and significant scarring/alopecia. **High-Yield Clinical Pearls for NEET-PG:** * **Defect <3 cm:** Primary closure (with subgaleal undermining). * **Defect 3–6 cm:** Local flaps (Rotation/Transposition). * **Defect >6 cm:** Large rotation flaps, tissue expansion, or microvascular free flaps (e.g., Latissimus dorsi flap). * **Exposed Bone (No Pericranium):** Skin grafts will not take. One must either use a flap or drill the outer table of the skull to reach the diploe (promoting granulation tissue) before grafting. * **The "Safe Plane":** Surgical undermining is always done in the **loose areolar tissue layer** (the 4th layer of the scalp) to minimize bleeding and preserve flap vascularity.

Question 26: A 6-year-old girl presents with a several-week history of an anterior cervical midline mass and throat pain. Following a course of antibiotics, her inflammation and erythema resolved, but the mass persisted. Her mother recalls similar symptoms when the child was 3 years old, which resolved spontaneously. The mass appears to rise upward when the girl sticks out her tongue. What is the most common diagnosis?

A. Lingual thyroid
B. Branchial cleft remnant
C. Thyroglossal duct cyst (Correct Answer)
D. Cervical neck abscess

Explanation: ### Explanation **Correct Option: C. Thyroglossal duct cyst** The clinical presentation is classic for a **Thyroglossal Duct Cyst (TGDC)**. It is the most common congenital neck midline mass. * **Pathophysiology:** It results from the failure of the thyroglossal duct to obliterate during the descent of the thyroid gland from the foramen cecum to its final pre-tracheal position. * **Key Diagnostic Sign:** Because the duct is anatomically connected to the base of the tongue (foramen cecum) via the hyoid bone, the cyst **moves upward on tongue protrusion** and swallowing. * **Clinical Course:** It often presents in childhood following an Upper Respiratory Tract Infection (URTI), which can cause the cyst to enlarge or become infected (explaining the history of inflammation and resolution with antibiotics). **Incorrect Options:** * **A. Lingual thyroid:** This represents a failure of the thyroid to descend. While it is a midline mass at the base of the tongue, it is usually found *within* the tongue base and would be visible on oral examination, not as a cervical mass. * **B. Branchial cleft remnant:** These are typically **lateral** neck masses (most commonly from the 2nd branchial cleft), located anterior to the sternocleidomastoid muscle. They do not move with tongue protrusion. * **D. Cervical neck abscess:** While the patient had inflammation, a persistent, recurrent midline mass that moves with the tongue is developmental rather than purely infectious. **High-Yield Pearls for NEET-PG:** 1. **Sistrunk Operation:** The definitive surgical treatment. It involves excision of the cyst, the entire tract, and the **central portion of the hyoid bone** to minimize recurrence. 2. **Ectopic Thyroid:** Always perform an ultrasound/thyroid scan pre-operatively to ensure the cyst isn't the patient's *only* functioning thyroid tissue (occurs in ~1-2%). 3. **Location:** 60-80% are infrahyoid. 4. **Malignancy:** Rare (<1%), but if present, the most common type is **Papillary Thyroid Carcinoma**.

Question 27: A 3-year-old boy is referred after his initial pediatrician's assessment for an undescended testicle. On exam, his left testicle is normal and in place. He has no evidence of hernias. However, his right hemiscrotum is empty, and there is a testicle-sized mass palpable at the pubic tubercle. What is the most appropriate next step?

A. Observation until age 5
B. Right orchiopexy
C. Right orchiopexy and right inguinal hernia repair (Correct Answer)
D. Right orchiopexy and right testicle biopsy

Explanation: **Explanation:** The clinical presentation describes a classic case of **Cryptorchidism (Undescended Testis)**. The palpable mass at the pubic tubercle confirms the presence of the testis in the inguinal canal. **Why Option C is Correct:** The definitive management for an undescended testis is **Orchiopexy**, ideally performed between **6 to 12 months of age**. The surgical procedure involves mobilizing the spermatic cord and fixing the testis in the scrotal pouch. Crucially, cryptorchidism is almost universally associated with a **patent processus vaginalis**, which constitutes a congenital indirect inguinal hernia. Therefore, a formal **herniotomy** (high ligation of the sac) is an integral and mandatory part of the orchiopexy procedure, even if a hernia is not clinically apparent on physical exam. **Why Other Options are Incorrect:** * **Option A:** Observation is incorrect. Spontaneous descent is rare after 6 months of age. Delaying surgery beyond 1–1.5 years increases the risk of germ cell depletion, infertility, and testicular malignancy. * **Option B:** While orchiopexy is the primary procedure, it is incomplete without addressing the associated patent processus vaginalis (hernia repair). * **Option D:** Routine biopsy is not indicated during orchiopexy in children unless there is a suspicion of intersex disorders or abnormal testicular morphology. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Age for Surgery:** 6–12 months (to preserve fertility and allow early screening for malignancy). * **Most Common Site:** Inguinal canal. * **Most Common Complication:** Infertility (more common in bilateral cases). * **Malignancy Risk:** Orchiopexy does *not* eliminate the risk of testicular cancer (Seminoma is most common), but it makes the testis accessible for clinical examination/self-screening. * **Investigation of Choice:** Clinical examination is the gold standard. Ultrasound has limited utility in locating non-palpable testes; Diagnostic Laparoscopy is the gold standard for non-palpable cases.

Question 28: A 1-month-old infant presents with an umbilical hernia. The hernia is reducible but prolapses again almost immediately. What is true regarding this defect?

A. It is present in all children at birth. (Correct Answer)
B. It will not close spontaneously.
C. It should be repaired if still present at 3 months of age.
D. It should be repaired at this time if it is greater than 1 cm in diameter.

Explanation: ### Explanation **1. Why Option A is Correct:** The umbilical ring is a natural defect in the abdominal wall through which the umbilical vessels pass during fetal life. At birth, the umbilical cord is ligated, and the ring begins to close. Technically, **every child is born with an umbilical hernia** (a patent umbilical ring) at the moment of birth. In most infants, the ring closes spontaneously as the rectus abdominis muscles approximate in the midline; however, if the ring remains patent, it is clinically recognized as an umbilical hernia. **2. Why the Other Options are Incorrect:** * **Option B:** This is incorrect because the vast majority (**>80-90%**) of umbilical hernias close spontaneously by the age of 3 to 4 years as the abdominal wall muscles strengthen. * **Option C:** Repair at 3 months is premature. Surgical intervention is generally delayed until the child is **4 to 5 years old**, as spontaneous closure can occur up until this age. * **Option D:** Size at 1 month of age is not an absolute indication for immediate surgery. Even large defects (up to 1.5 cm) often close without intervention. Immediate surgery in infancy is only indicated for complications like strangulation or incarceration, which are extremely rare in umbilical hernias compared to inguinal hernias. **3. Clinical Pearls for NEET-PG:** * **Associations:** Increased incidence in premature infants, infants with Down syndrome, Trisomy 13/18, Beckwith-Wiedemann syndrome, and congenital hypothyroidism. * **Indications for Surgery:** 1. Persistence beyond age 4–5 years. 2. Defect size >1.5 cm to 2 cm (less likely to close spontaneously). 3. Complications (Incarceration/Strangulation – rare). 4. Symptomatic (pain) or skin breakdown. * **Management:** Observation and parental reassurance are the mainstays of treatment in the first few years of life. Strapping or taping the hernia does not aid closure and may cause skin irritation.

Question 29: What is the best treatment for capillary nevus?

A. Full thickness skin graft
B. Dermabrasion
C. Tattooing
D. Argon laser treatment (Correct Answer)

Explanation: **Explanation:** **Capillary Nevus (Port-Wine Stain)** is a congenital vascular malformation consisting of dilated capillary-like vessels in the dermis. The goal of treatment is to destroy these abnormal vessels while preserving the overlying epidermis and surrounding tissue. **Why Argon Laser is the Correct Choice:** The **Argon Laser** (wavelength 488–514 nm) is highly effective because its energy is selectively absorbed by **hemoglobin** (the target chromophore). This leads to selective photothermolysis, where the heat generated destroys the vessel walls without significant damage to the surrounding skin. While the **Pulsed Dye Laser (PDL)** is currently considered the "Gold Standard" due to a lower risk of scarring, the Argon Laser remains a classic and correct choice among the provided options for treating vascular nevi. **Why Other Options are Incorrect:** * **Full-thickness skin graft (FTSG):** This is an invasive surgical procedure. It often results in poor cosmetic outcomes, "patchwork" appearance, and donor site morbidity, making it unsuitable for benign cutaneous lesions. * **Dermabrasion:** This involves mechanical sanding of the skin. It is ineffective for capillary nevi because the vascular malformations are located deep within the dermis; dermabrasion would cause significant scarring before reaching the vessels. * **Tattooing:** This involves masking the lesion with skin-colored pigments. It is rarely used today as the pigment often looks unnatural, fades unevenly over time, and does not treat the underlying pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Pulsed Dye Laser (585 nm) is the treatment of choice for Port-Wine Stains. * **Sturge-Weber Syndrome:** Always screen patients with a capillary nevus in the V1/V2 distribution of the trigeminal nerve for glaucoma and intracranial vascular malformations. * **Progression:** Unlike strawberry hemangiomas, capillary nevi **do not involute** spontaneously; they grow proportionately with the child and may become thickened (nodular) in adulthood.

Question 30: A young boy presents with a scald injury of the arm. The lesion is pink, oozing, and painful to pinprick. What is the most appropriate management?

A. Collagen dressing (Correct Answer)
B. Paraffin gauze dressing with the wound left open
C. Excision and grafting
D. Application of 1% silver sulfadiazine

Explanation: ### Explanation **Diagnosis: Superficial Partial-Thickness (Second-Degree) Burn** The clinical presentation of a **pink, oozing (blistered), and painful** lesion indicates a superficial partial-thickness burn. The presence of pain and sensation to pinprick confirms that the nerve endings in the dermis are intact and the vascularity is preserved. **Why Collagen Dressing is Correct:** For superficial partial-thickness burns, the goal is to promote spontaneous epithelialization while minimizing pain and infection. **Collagen dressings** are ideal because they: * Act as a scaffold for cellular proliferation. * Reduce pain by covering exposed nerve endings. * Decrease the frequency of dressing changes, which promotes faster healing (usually within 10–14 days) and reduces scarring. **Analysis of Incorrect Options:** * **B. Paraffin gauze dressing:** While used in basic wound care, it does not provide the biological benefits of collagen and can stick to the wound, causing pain and trauma to new epithelium during removal. * **C. Excision and grafting:** This is the treatment of choice for **Deep Partial-Thickness** or **Full-Thickness** burns where spontaneous healing is unlikely. Superficial burns heal well without surgery. * **D. 1% Silver Sulfadiazine (SSD):** SSD is a common topical antimicrobial, but it is known to **delay epithelialization** and is generally avoided in superficial burns unless there is a high risk of infection. It also requires frequent, painful dressing changes. **NEET-PG High-Yield Pearls:** 1. **Depth Assessment:** * *Superficial (1st degree):* Erythema, painful (e.g., sunburn). * *Superficial Partial (2nd degree):* Blisters, moist, **very painful**. * *Deep Partial (2nd degree):* Waxy white, decreased sensation. * *Full Thickness (3rd degree):* Leathery, charred, **painless**. 2. **Jackson’s Zones of Burn:** Zone of Coagulation (necrosis), Zone of Stasis (potentially salvageable), and Zone of Hyperemia (recovers). 3. **Rule of 9s:** Used for TBSA calculation; remember that for children, the head is 18% and each leg is 14%.

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free