Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery Indian Medical PG Practice Questions and MCQs

Question 71: Which of the following cannot accept a split-thickness skin graft?

A. Fat
B. Muscle
C. Skull bone (Correct Answer)
D. Deep fascia

Explanation: **Explanation:** The success of a skin graft depends on **"take,"** a process where the graft survives via diffusion (plasmatic imbibition) and subsequent revascularization (inosculation) from the underlying recipient bed. For a graft to survive, the recipient bed must be **vascularized.** **Why Skull Bone is the Correct Answer:** Cortical bone, such as the outer table of the **skull bone** (when denuded of its periosteum), is a **relatively avascular surface.** It lacks a sufficient capillary network to provide the necessary nutrients for the graft to survive. To graft over bone, one must either ensure the **periosteum** is intact or drill holes into the outer cortex to allow granulation tissue to grow from the diploe. **Analysis of Incorrect Options:** * **Fat (Subcutaneous tissue):** While less vascular than muscle, healthy adipose tissue has enough capillary supply to support a split-thickness skin graft (STSG). * **Muscle:** This is a highly vascular bed and is considered one of the best surfaces for graft uptake. * **Deep Fascia:** Fascia is a vascularized connective tissue layer that provides an excellent bed for STSGs, often used in reconstructive procedures following debridement. **High-Yield Clinical Pearls for NEET-PG:** * **Avascular beds** that cannot accept a graft include: Bare bone (without periosteum), bare tendon (without paratenon), bare cartilage (without perichondrium), and infected/necrotic tissue. * **Stages of Graft Take:** 1. **Plasmatic Imbibition (0–48 hours):** Graft "drinks" nutrients via diffusion. 2. **Inosculation (48–72 hours):** Alignment of donor and recipient capillaries. 3. **Revascularization (Day 3–5):** Actual blood flow established. * **STSG vs. FTSG:** Split-thickness grafts have a higher "take" rate on less-than-ideal beds compared to Full-thickness grafts (FTSG) because they have lower metabolic demands.

Question 72: A full-thickness skin graft is also known as:

A. Wolfe graft (Correct Answer)
B. Thiersch graft
C. Thieme graft
D. Fernandez graft

Explanation: **Explanation:** A **Full-Thickness Skin Graft (FTSG)**, also known as a **Wolfe graft**, consists of the entire epidermis and the complete thickness of the dermis. Unlike split-thickness grafts, FTSGs include adnexal structures like hair follicles and sweat glands. They are preferred for aesthetically sensitive areas (like the face or eyelids) because they undergo less secondary contraction, provide better color match, and offer superior durability. **Analysis of Options:** * **A. Wolfe graft (Correct):** Named after John Reissberg Wolfe, it refers to the transplantation of the full depth of the skin. * **B. Thiersch graft:** This refers to a **Split-Thickness Skin Graft (STSG)**. It involves the epidermis and only a portion of the dermis. It is easier to "take" but prone to significant secondary contraction. * **C. Thieme graft:** This is a distractor. While "Thieme" is a well-known medical publisher, it is not a recognized eponym for a specific skin graft type. * **D. Fernandez graft:** This is not a standard term in skin grafting nomenclature. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Contraction:** FTSGs (Wolfe) have **high primary contraction** (immediate recoil due to elastin in the dermis) but **low secondary contraction** (shrinkage during healing). * **Vascularization:** FTSGs require a highly vascular recipient bed because they are thicker and take longer to revascularize via *inosculation* and *capillary ingrowth*. * **Donor Site:** The donor site of a Wolfe graft must be closed primarily (sutured) because no dermal elements remain to allow for spontaneous epithelialization. Common sites include post-auricular and supraclavicular areas.

Question 73: Which of the following is NOT a feature of a meshed skin graft?

A. Fenestrations allow for egress of wound fluid
B. Better cosmetic appearance (Correct Answer)
C. Good contour matching of the wound bed by the graft
D. Large surface area can be covered

Explanation: **Explanation:** A **meshed skin graft** is a split-thickness skin graft (STSG) that has been passed through a mesher to create multiple small incisions (fenestrations). This allows the graft to be expanded to cover a larger surface area. **Why "Better cosmetic appearance" is the correct answer (NOT a feature):** Meshed grafts result in a characteristic **"fish-net" or "checkerboard" appearance** once healed. Because the gaps between the skin bridges heal by secondary intention (epithelialization), the texture and color match are inferior compared to sheet grafts. Therefore, they are generally avoided on aesthetically sensitive areas like the face or hands. **Analysis of Incorrect Options:** * **A. Fenestrations allow for egress of wound fluid:** This is a primary advantage. The holes prevent the accumulation of blood (hematoma) or serum (seroma) under the graft, which are the most common causes of graft failure. * **C. Good contour matching:** Because the mesh is flexible and "stretchy," it conforms better to irregular, concave, or convex wound beds compared to a stiff sheet graft. * **D. Large surface area can be covered:** Meshing allows expansion ratios (e.g., 1.5:1, 3:1, or even 6:1), making it ideal for massive burns where donor skin is limited. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Burns:** Meshed STSG is the preferred method for extensive burn injuries. * **Graft Take:** The most critical factor for graft survival is **vascularization** (plasmatic imbibition → inosculation → capillary ingrowth). * **Sheet Grafts:** These provide the best cosmetic results and are used for the face, neck, and hands but carry a higher risk of seroma formation. * **Storage:** Skin grafts can be stored in saline-soaked gauze at **4°C** for up to 2 weeks.

Question 74: A full-thickness skin graft is indicated in which of the following situations?

A. Deep burns
B. Burns over large areas
C. Fascial regions for cosmetic effect (Correct Answer)
D. Over the back

Explanation: ### Explanation **1. Why Option C is Correct:** A **Full-Thickness Skin Graft (FTSG)**, also known as a Wolfe graft, includes the entire epidermis and the complete thickness of the dermis. Because it contains a higher density of dermal collagen and elastic fibers, it undergoes **minimal secondary contraction** (shrinkage after healing). This makes it the gold standard for reconstructive surgery in aesthetically and functionally sensitive areas, such as the **face (facial regions)**, eyelids, and hands. It provides a better color match, texture, and contour compared to split-thickness grafts. **2. Why the Other Options are Incorrect:** * **Options A & B (Deep/Large Area Burns):** These require **Split-Thickness Skin Grafts (STSG)**. STSGs are preferred for large surfaces because the donor site heals spontaneously (re-epithelialization from skin appendages), allowing for "re-harvesting." FTSG donor sites must be closed primarily, limiting the amount of tissue available. * **Option D (Over the Back):** The skin on the back is exceptionally thick. Using an FTSG here is impractical due to the large surface area and the fact that cosmetic requirements are lower. STSGs are typically used for large trunk defects. **3. High-Yield Clinical Pearls for NEET-PG:** * **Primary Contraction:** Immediate recoil after harvesting (Greater in **FTSG** due to more elastin). * **Secondary Contraction:** Shrinkage during healing (Greater in **STSG**; minimal in **FTSG**). * **Graft Take:** FTSGs are more "demanding" and have a higher failure rate than STSGs because they require more robust vascularization (revascularization takes longer). * **Ideal Donor Sites for FTSG:** Post-auricular (best color match for face), supraclavicular, and groin crease.

Question 75: During breast reconstruction surgery, which of the following structures is preserved?

A. Pectoralis minor
B. Pectoralis major (Correct Answer)
C. Serratus anterior
D. Nipple areola complex

Explanation: ### Explanation In modern breast reconstruction, particularly **implant-based reconstruction**, the **Pectoralis major** muscle is the most critical structure preserved and utilized. **Why Pectoralis Major is the Correct Answer:** Traditionally, breast implants are placed in a **subpectoral (retropectoral) pocket**. The surgeon elevates the Pectoralis major muscle from the chest wall, keeping its superior and medial attachments intact. The muscle acts as a vascularized "internal brassiere," providing soft tissue coverage for the upper pole of the implant. This prevents implant visibility (rippling), reduces the risk of extrusion, and provides a more natural aesthetic contour. **Analysis of Incorrect Options:** * **Pectoralis minor:** This muscle lies deep to the pectoralis major. While it is usually not excised, it is not "preserved" for the purpose of reconstruction; in fact, it is often detached or bypassed to create adequate space for the implant pocket. * **Serratus anterior:** While parts of the serratus fascia may be used to cover the lateral aspect of an implant, the muscle itself is not a primary structural component preserved specifically for the reconstruction process. * **Nipple Areola Complex (NAC):** While "Nipple-Sparing Mastectomies" exist, the NAC is frequently removed during standard oncological resections (Modified Radical Mastectomy) to ensure surgical margins. Therefore, it is not a *universal* requirement for reconstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** The Pectoralis major is a **Type V muscle flap** (Mathes and Nahai classification), supplied by the thoracoacromial artery (dominant) and segmental internal mammary perforators. * **TRAM Flap:** The most common autologous reconstruction uses the **Transverse Rectus Abdominis Myocutaneous (TRAM)** flap, based on the superior epigastric artery. * **DIEP Flap:** The "Gold Standard" for autologous reconstruction is the **Deep Inferior Epigastric Perforator (DIEP)** flap, as it spares the rectus muscle entirely, reducing donor site morbidity.

Question 76: Which of the following is the ideal time for the repair of cleft palate?

A. 9-12 months (Correct Answer)
B. 2-3 years
C. 5-6 years
D. 18-24 months

Explanation: **Explanation:** The primary goal of cleft palate repair (Palatoplasty) is to facilitate **normal speech development**. The timing is a delicate balance between allowing for maxillary growth and intervening before the child begins to develop complex speech patterns. **1. Why 9-12 months is correct:** Speech development typically begins around 12 months of age. Repairing the palate between **9 and 12 months** ensures a functional velopharyngeal mechanism is in place before the child starts articulating sounds. This prevents compensatory speech habits (like glottal stops) that are difficult to correct later. Modern surgical techniques and anesthesia safety have shifted the standard toward this earlier window. **2. Why the other options are incorrect:** * **18-24 months (Option D):** While previously common, this is now considered late. Delaying surgery beyond 18 months significantly increases the risk of permanent speech defects and hypernasality. * **2-3 years & 5-6 years (Options B & C):** These are far too late for primary repair. At these ages, the child has already established speech patterns, and surgery would likely require extensive secondary speech therapy. However, 5-6 years is often the age for secondary procedures like alveolar bone grafting. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s:** Used for **Cleft Lip** repair (10 weeks old, 10 lbs weight, 10 g/dL Hemoglobin). * **Cleft Lip Repair Timing:** Usually 3–6 months. * **Cleft Palate Repair Timing:** Usually 9–12 months (latest by 18 months). * **Most Common Type:** Isolated cleft palate is more common in females; cleft lip (with or without palate) is more common in males. * **Feeding:** Use specialized bottles (e.g., Haberman feeder); breastfeeding is often difficult due to the inability to create negative pressure.

Question 77: Which of the following is NOT true regarding split-thickness skin grafts?

A. They do not sweat.
B. They do not adhere to exposed bone.
C. They are hairless.
D. They are cosmetically superior. (Correct Answer)

Explanation: ### Explanation **Split-thickness skin grafts (STSG)** consist of the epidermis and a variable portion of the dermis. The correct answer is **D**, as STSGs are **cosmetically inferior** to full-thickness skin grafts (FTSG). #### Why Option D is the Correct Answer (The Concept) STSGs lack the full dermal thickness required for natural texture and color matching. They undergo significant **secondary contraction** (shrinking after being placed on the wound) and often result in a "shiny" or "patchy" appearance. In contrast, FTSGs contain more dermis, undergo less secondary contraction, and provide a better color and texture match, making them the preferred choice for aesthetically sensitive areas like the face. #### Analysis of Other Options * **A. They do not sweat:** Sweat glands and sebaceous glands are located deep in the dermis. Since STSGs only include a superficial portion of the dermis, these structures are usually excluded. Consequently, the graft remains dry and requires lubrication. * **B. They do not adhere to exposed bone:** Skin grafts require a vascularized bed (periosteum, perichondrium, or granulation tissue) to survive via plasmatic imbibition and inosculation. They will not "take" or adhere to bare, cortical bone or exposed tendon lacking a vascular sheath. * **C. They are hairless:** Hair follicles are located deep in the dermis or subcutaneous fat. STSGs are too thin to include intact follicles, resulting in a hairless graft. #### NEET-PG High-Yield Pearls * **Primary Contraction:** Immediate recoil due to elastin (Higher in **FTSG**). * **Secondary Contraction:** Shrinkage during healing due to myofibroblasts (Higher in **STSG**). * **Graft Take Stages:** 1. Plasmatic Imbibition (first 24–48h) 2. Inosculation (alignment of vessels) 3. Revascularization/Angiogenesis. * **Donor Site:** STSGs allow the donor site to heal spontaneously via re-epithelialization from remaining adnexal structures (hair follicles/sweat glands).

Question 78: Split skin grafts in young children should be harvested from which anatomical location?

A. Buttocks
B. Thigh (Correct Answer)
C. Trunk
D. Upper limb

Explanation: **Explanation:** In plastic surgery, the selection of a donor site for a **Split-Thickness Skin Graft (STSG)** is guided by the surface area available, ease of harvesting, and concealment of the resulting scar. **Why the Thigh is the Correct Answer:** The **thigh** (specifically the lateral or anterior aspect) is the preferred donor site in both children and adults for several reasons: 1. **Surface Area:** It provides a large, flat, and uniform surface area, allowing for the harvest of large sheets of skin. 2. **Ease of Access:** It is easily accessible during most surgical procedures without requiring significant repositioning of the patient. 3. **Concealment:** The donor site morbidity (scarring and pigment changes) can be easily hidden by standard clothing. 4. **Healing:** The skin on the thigh is thick enough to allow for harvesting while leaving behind adequate dermal elements for rapid re-epithelialization. **Analysis of Incorrect Options:** * **A. Buttocks:** While the buttocks provide an excellent aesthetic result (hidden by underwear), harvesting is technically difficult as it requires the patient to be in a prone position, which can complicate airway management in young children under general anesthesia. * **C. Trunk:** The trunk is generally avoided unless the burn/wound is extensive, as harvesting from the chest or abdomen can be more painful, interfere with respiratory excursion, and result in more visible scarring. * **D. Upper limb:** The surface area is limited, and the skin is thinner. Harvesting from the arm often leads to highly visible scarring, making it a secondary choice. **NEET-PG High-Yield Pearls:** * **Components of STSG:** Includes the epidermis and a **variable portion of the dermis**. * **Post-harvesting:** The donor site heals by **secondary epithelialization** from the skin appendages (hair follicles, sebaceous glands) left in the dermis. * **Graft "Take":** Occurs in three stages: **Plasmatic imbibition** (first 24–48h), **Inosculation** (48–72h), and **Revascularization** (day 3–5). * **Instrument:** A **Humby’s knife** or a motorized dermatome is typically used for harvesting.

Question 79: What type of transplant involves organs transferred between genetically identical individuals?

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

Explanation: ### Explanation The classification of transplants (grafts) is based on the genetic relationship between the donor and the recipient. **Correct Answer: A. Isograft (Syngeneic graft)** An **isograft** refers to the transfer of tissue or organs between individuals who are **genetically identical**. In humans, this occurs exclusively between **monozygotic (identical) twins**. Because the Major Histocompatibility Complex (MHC) molecules are identical, there is no immune recognition of "non-self" antigens, and the graft is accepted without the need for long-term immunosuppression. **Incorrect Options:** * **B. Allograft (Homograft):** This is the most common clinical transplant type. It involves transfer between genetically different members of the **same species** (e.g., human to human). These require immunosuppression to prevent rejection. * **C. Autograft:** This involves moving tissue from **one site to another on the same individual** (e.g., Split-thickness skin graft from the thigh to the arm). There is no risk of rejection. * **D. Xenograft (Heterograft):** This involves transfer between members of **different species** (e.g., porcine heart valve to a human). These carry the highest risk of hyperacute rejection. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Immunogenicity:** Xenograft > Allograft > Isograft = Autograft. * **First Successful Human Kidney Transplant (1954):** Performed by Joseph Murray between identical twins (Isograft), which bypassed the then-unsolved problem of immune rejection. * **Orthotopic vs. Heterotopic:** An *orthotopic* graft is placed in its normal anatomical position (e.g., Liver), while a *heterotopic* graft is placed in a different site (e.g., Kidney transplant in the iliac fossa).

Question 80: Potts puffy tumor occurs as a complication of which sinusitis?

A. Frontal (Correct Answer)
B. Sphenoid
C. Ethmoid
D. None of the above

Explanation: **Explanation:** **Pott’s Puffy Tumor** is a rare but serious clinical entity characterized by **subperiosteal abscess** of the frontal bone associated with **osteomyelitis**. **Why Frontal Sinus is the Correct Answer:** The condition occurs as a direct complication of **acute or chronic frontal sinusitis**. The infection spreads from the frontal sinus to the frontal bone through two primary mechanisms: 1. **Venous Spread:** Through the thrombophlebitis of the diploic veins (Breschet’s veins) that drain the sinus mucosa. 2. **Direct Extension:** Through the thin posterior or anterior table of the frontal sinus. This leads to a localized, fluctuant, "puffy" swelling on the forehead, which is the hallmark of the disease. **Why Other Options are Incorrect:** * **Sphenoid Sinus:** Infections here typically lead to cavernous sinus thrombosis or orbital apex syndrome due to its deep anatomical location, rather than a forehead swelling. * **Ethmoid Sinus:** Complications usually involve the orbit (e.g., orbital cellulitis or subperiosteal abscess of the lamina papyracea) rather than the frontal bone. **High-Yield Clinical Pearls for NEET-PG:** * **Eponym:** Named after Sir Percivall Pott (1760). * **Clinical Presentation:** Forehead swelling, headache, fever, and rhinorrhea. * **Imaging of Choice:** **Contrast-enhanced CT** (to see bone destruction) and **MRI** (to rule out intracranial complications like epidural abscess or meningitis). * **Management:** Requires emergency IV antibiotics and surgical drainage (often via Frontal Sinotomy or FESS). * **Most Common Organism:** *Streptococcus* species, *Staphylococcus*, and anaerobes.

Practice by Chapter

Wound Healing

Practice Questions

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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