Plastic and Reconstructive Surgery Practice Questions

Q: Which flap is commonly used in breast reconstruction?

TRAM flap. **Explanation:** The **TRAM (Transverse Rectus Abdominis Myocutaneous) flap** is a gold-standard option for autologous breast reconstruction. It utilizes the skin and subcutaneous fat from the lower abdomen, which mimics the consistency and volume of natural breast tissue. The flap is based on the **superior epigastric artery** (when used as a pedicled flap) or the **deep inferior epigastric artery** (when used as a free flap). It is preferred because it provides a large volume of tissue and offers the secondary cosmetic benefit of an "abdominoplasty" (tummy tuck) at the donor site. **Analysis of Incorrect Options:** * **Serratus anterior flap:** While used in reconstructive surgery (e.g., for small defects or covering implants), it lacks the bulk required for total breast reconstruction. * **Flap from arm:** Historically, the "Taliacotian" or Italian method used arm flaps for nasal reconstruction, but it is not a standard approach for breast reconstruction due to inadequate volume and donor site morbidity. * **Deltopectoral flap:** This is a fasciocutaneous flap based on the internal mammary artery perforators. It was traditionally used for **head and neck reconstruction** (e.g., pharyngoesophageal defects), not for breast volume replacement. **High-Yield Clinical Pearls for NEET-PG:** * **DIEP Flap (Deep Inferior Epigastric Perforator):** The modern evolution of the TRAM flap. It spares the rectus muscle, significantly reducing the risk of postoperative abdominal wall hernias. * **Latissimus Dorsi (LD) Flap:** Another common choice for breast reconstruction, often used in combination with an implant if the muscle bulk is insufficient. * **Blood Supply:** Remember that the **Superior Epigastric Artery** is the continuation of the Internal Mammary Artery.

Q: Which carcinoma is known for perineural invasion?

Adenoid cystic carcinoma. **Explanation:** **Adenoid Cystic Carcinoma (ACC)** is the correct answer because it is classically characterized by its high propensity for **perineural invasion (PNI)**. This tumor often spreads along nerve sheaths (neurotropism) far beyond its palpable margins, which accounts for the high rates of local recurrence and the common clinical presentation of early-onset pain or nerve palsies (e.g., facial nerve palsy in parotid tumors). **Analysis of Options:** * **Mucoepidermoid Carcinoma:** This is the most common malignant salivary gland tumor. While it can be aggressive, its hallmark is a mix of mucus-producing, intermediate, and epidermoid cells, rather than a specific predilection for nerve invasion. * **Pleomorphic Adenoma:** This is the most common **benign** salivary gland tumor. Being benign, it does not exhibit invasive features like perineural spread. * **Squamous Cell Carcinoma (SCC):** While SCC can exhibit perineural invasion (especially in the head and neck), it is not the "classic" or defining feature associated with it in the same way it is for ACC. **High-Yield Clinical Pearls for NEET-PG:** * **Histology of ACC:** Look for the characteristic **"Swiss Cheese" appearance** (Cribriform pattern). * **Location:** Most common malignant tumor of the **minor** salivary glands and the submandibular gland. * **Spread:** ACC is notorious for **hematogenous spread** (especially to the lungs) rather than lymphatic spread. * **Prognosis:** It has a deceptively indolent growth but a poor long-term prognosis due to late recurrences and distant metastasis.

Q: A bilobed graft is typically used in which of the following anatomical locations?

Nose. **Explanation:** The **Bilobed Flap** (often referred to as a bilobed graft in clinical shorthand, though technically a transposition flap) is a double-lobed local transposition flap. It is the "gold standard" for reconstructing small to medium-sized defects (up to 1.5 cm) on the **Nose**, particularly the nasal tip and alar sidewall. **1. Why the Nose is Correct:** The primary challenge of nasal reconstruction is the lack of redundant skin. The bilobed flap solves this by recruiting skin from the upper nasal bridge (where there is more laxity) and transferring it in two stages. The first lobe fills the primary defect, and the second lobe fills the site of the first lobe. This distributes tension over a wider area, preventing distortion of the nasal tip or alar rim. **2. Why other options are incorrect:** * **Eyelid:** Reconstructed using techniques like the **Hughes flap** (tarsoconjunctival) or **Tripier flap** (musculocutaneous). The skin here is very thin, and a bilobed flap would be too bulky. * **Cheek:** Usually managed with primary closure, **Mustarde flaps**, or large rotation flaps due to the significant amount of available skin laxity. * **Fingertips:** Commonly reconstructed using **V-Y advancement flaps** (Atasoy/Kutler) or **Moberg flaps**. **Clinical Pearls for NEET-PG:** * **Design:** Originally described by **Esser** (90°/90° angles), later modified by **Zitelli** (45°/45° angles) to reduce "dog-ear" deformity and "pincushioning." * **Key Advantage:** It allows for the movement of skin around a pivot point to areas with zero laxity. * **High-Yield Association:** Whenever you see "Nasal Tip Reconstruction <1.5cm," think **Bilobed Flap**.

Q: Full thickness skin grafts can be harvested from which of the following sites except?

Back of neck. **Explanation:** Full-thickness skin grafts (FTSG), also known as **Wolfe grafts**, consist of the entire epidermis and the complete thickness of the dermis. The primary requirement for a donor site in FTSG is that the skin must be thin, pliable, and the resulting defect must be capable of being closed primarily. **Why "Back of Neck" is the correct answer:** The skin on the **back of the neck** (and the back in general) is among the thickest in the human body. It has a very dense dermis and lacks the necessary elasticity for easy primary closure after harvesting a full-thickness segment. Furthermore, thick skin does not revascularize (take) as easily as thin skin in FTSG procedures. **Analysis of incorrect options:** * **Upper Eyelids:** This is the thinnest skin in the body and is an ideal donor site for FTSG, especially for reconstructing defects in the contralateral eyelid or facial areas. * **Supraclavicular area:** A very common donor site for facial defects because the color and texture match are excellent, and the skin is relatively thin. * **Elbow (Antecubital fossa):** The flexor creases of the body (elbow, wrist, groin) provide thin, hairless skin that allows for primary closure along the flexion lines. **High-Yield Clinical Pearls for NEET-PG:** * **Common FTSG Donor Sites:** Post-auricular (most common), supraclavicular fossa, upper eyelid, groin (for large grafts), and antecubital fossa. * **The "Take":** FTSGs rely entirely on **Inosculation** and **Neovascularization**. Because they are thicker than Split-Thickness Skin Grafts (STSG), they have higher metabolic demands and a higher risk of failure. * **Contraction:** FTSGs have significant **primary genetic contraction** (immediate recoil due to elastin) but minimal **secondary contraction** (shrinkage during healing), making them superior for functional areas like the face and hands.

Q: The subdermal plexus forms the vascular basis for which type of flap?

Randomized flaps. ### Explanation The vascular supply of the skin is organized into several horizontal plexuses. The **subdermal plexus**, located at the junction of the dermis and subcutaneous fat, is the most important superficial network for skin flap survival. **1. Why "Randomized Flaps" is Correct:** Random (or cutaneous) flaps lack a named, specific nutrient artery. Instead, they rely on the **subdermal plexus** for their blood supply. This plexus is fed by small, unnamed musculocutaneous perforators that enter the base of the flap. Because the blood must travel through this disorganized network, these flaps have a limited length-to-width ratio (typically 2:1 in the body, 3:1 or 4:1 in the face) to prevent distal necrosis. **2. Why Other Options are Incorrect:** * **Axial Flaps:** These are based on a **named, specific longitudinal artery** (e.g., the superficial temporal artery for a forehead flap) that runs along the long axis of the flap within the subcutaneous tissue. * **Fasciocutaneous Flaps:** These rely on the **prefascial and subfascial plexuses**, which are supplied by perforators reaching the deep fascia. They are more robust than random flaps. * **Mucocutaneous Flaps:** These involve the transition zones between skin and mucosa (e.g., lips, eyelids) and are typically supplied by specific named arteries (like the labial arteries). **3. High-Yield Clinical Pearls for NEET-PG:** * **Delay Phenomenon:** A surgical technique used to increase the survival of random flaps by partially incising the flap 7–14 days before transfer. This "stresses" the tissue, causing the subdermal plexus to realign and dilate. * **Angiosome Concept:** A three-dimensional block of tissue supplied by a specific source artery. * **Primary supply of skin:** Musculocutaneous perforators are the most common source of blood to the skin across the majority of the body.

Q: Split skin graft take-up is good if:

Light compression wraps are applied as dressing.. ### Explanation The success of a Split-Thickness Skin Graft (STSG) depends on the graft remaining in intimate contact with a vascularized wound bed to allow for **plasmatic imbibition** (initial 24–48 hours) and subsequent **neovascularization** (inosculation). **Why Option B is Correct:** Light compression wraps (often applied as a **Tie-over/Bolster dressing**) are crucial for graft "take." They serve three primary functions: 1. **Immobilization:** Prevents shearing forces that can disrupt delicate new capillary connections. 2. **Elimination of Dead Space:** Ensures constant contact between the graft and the recipient bed. 3. **Prevention of Hematoma/Seroma:** Minimizes fluid accumulation under the graft, which is the most common cause of graft failure. **Why the Other Options are Incorrect:** * **A. Avascular wound bed:** Grafts require a vascular supply (like granulation tissue, periosteum, or perichondrium) to survive. They will not "take" on avascular structures like bare bone, bare tendon, or infected necrotic tissue. * **C. Purulent discharge:** Infection is a major contraindication. Bacteria (especially *Streptococcus pyogenes* and *Pseudomonas*) produce enzymes like fibrinolysins that dissolve the fibrin bond between the graft and the bed, leading to failure. * **D. Insensitive wound area:** The sensory status of the wound bed does not influence the biological process of revascularization. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of Graft Take:** 1. Plasmatic Imbibition (0–48h) → 2. Inosculation (48h–72h) → 3. Revascularization/Angiogenesis (Day 4+). * **Most common cause of graft failure:** Hematoma formation. * **Most common organism causing failure:** *Beta-hemolytic Streptococcus*. * **STSG vs. FTSG:** STSG has a better "take" rate and can cover larger areas, but undergoes more **secondary contraction** compared to Full-Thickness Skin Grafts (FTSG).

Q: What is Cock's peculiar tumor?

Ulcerated sebaceous cyst. **Explanation:** **Cock’s Peculiar Tumor** is a clinical misnomer. It is not a true neoplastic malignancy but rather an **infected and ulcerated sebaceous cyst**, typically occurring on the **scalp**. **Why C is correct:** When a sebaceous cyst on the scalp undergoes infection, it can rupture and ulcerate. The lining of the cyst (the sebaceous material and granulation tissue) protrudes through the opening, creating a fungating, exuberant mass that mimics the appearance of a malignant tumor (specifically Squamous Cell Carcinoma). Despite its alarming, "fleshy" appearance, it remains a benign inflammatory condition. **Why the other options are incorrect:** * **Basal Cell Carcinoma (A):** While BCC is common on the face (Rodent ulcer), it typically presents with pearly borders and telangiectasia, not as a fungating mass arising from a pre-existing cyst. * **Squamous Cell Carcinoma (B):** This is the most common differential diagnosis. SCC presents with everted edges and induration. While Cock’s tumor mimics SCC clinically, histological examination reveals only inflammatory changes and cyst remnants. * **Cylindroma (D):** Also known as a "Turban tumor," this is a benign adnexal tumor. It presents as multiple smooth, domed nodules on the scalp but does not typically ulcerate or resemble a sebaceous cyst. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Almost exclusively found on the **scalp**. * **Clinical Feature:** It mimics malignancy due to its foul-smelling, fungating, and vascular appearance. * **Diagnosis:** Differentiated from SCC by the **absence of induration** at the base and confirmed via biopsy. * **Treatment:** Wide local excision is the treatment of choice.

Question 1

Which flap is commonly used in breast reconstruction?

Accepted Answer

TRAM flap

Answer

Serratus anterior flap

Answer

Flap from arm

Answer

Delto pectoral flap

Question 2

Which carcinoma is known for perineural invasion?

Accepted Answer

Adenoid cystic carcinoma

Answer

Mucoepidermoid carcinoma

Answer

Pleomorphic adenoma

Answer

Squamous cell carcinoma

Question 3

A bilobed graft is typically used in which of the following anatomical locations?

Accepted Answer

Nose

Answer

Eyelid

Answer

Cheek

Answer

Fingertips

Question 4

Full thickness skin grafts can be harvested from which of the following sites except?

Accepted Answer

Back of neck

Answer

Elbow

Answer

Supraclavicular area

Answer

Upper eyelids

Question 5

The subdermal plexus forms the vascular basis for which type of flap?

Accepted Answer

Randomized flaps

Answer

Axial flaps

Answer

Mucocutaneous flaps

Answer

Fasciocutaneous flaps

Question 6

Which of the following is NOT an advantage of a full-thickness skin graft over a split-thickness skin graft?

Accepted Answer

Large surface area can be covered

Answer

Better color matching

Answer

Less contraction

Answer

Less chance of injury after healing

Question 7

Split skin graft take-up is good if:

Accepted Answer

Light compression wraps are applied as dressing.

Answer

The wound bed is avascular.

Answer

There is increased purulent discharge from the wound.

Answer

The wound area is insensitive.

Question 8

What is Cock's peculiar tumor?

Accepted Answer

Ulcerated sebaceous cyst

Answer

Basal cell carcinoma

Answer

Squamous cell carcinoma

Answer

Cylindroma

Question 9

In a 6-year-old child with burns involving the whole of head and trunk, what is the estimated body surface area of burns?

Accepted Answer

44%

Answer

52%

Answer

55%

Answer

58%

Question 10

In replantation surgery, which of the following types of injuries has the worst outlook regarding survival and return of function?

Accepted Answer

Crush injuries with avulsed vessels

Answer

Clean sharp guillotine amputations

Answer

Minimal local crush amputations

Answer

Avulsion amputation with minimal proximal distal vascular injury

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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