Facial Plastic and Reconstructive Surgery Practice Questions

Q: A 28-year-old woman undergoes open rhinoplasty. On table, after osteotomies, significant asymmetry is noted with deviation of nasal bones to the right. Analysis reveals the right osteotomy is more lateral than the left. What is the best explanation for the persistent deviation?

Asymmetric osteotomy created unequal bone segments. ***Asymmetric osteotomy created unequal bone segments*** - Placing the **right lateral osteotomy** more laterally than the left results in a wider right **nasal bone segment**, preventing the pyramid from shifting into a midline position. - This geometric imbalance causes the **nasal dorsum** to remain deviated toward the side with the larger bone segment, necessitating **revision osteotomy** for symmetry. *Postoperative edema causing temporary deviation* - While **edema** can mask underlying symmetry, it does not explain significant intraoperative deviation immediately following **osteotomies**. - Intraoperative asymmetry is typically **structural** rather than a result of soft tissue swelling occurring at that moment. *Incomplete mobilization of nasal bones due to retained periosteum* - **Periosteal attachments** can resist movement, but the scenario specifically identifies a **technical error** in the placement of the osteotomy lines. - Even if mobilized, the **unequal width** of the segments would still cause a structural deviation rather than simple stiffness. *Septal deviation pulling the dorsum to right* - A **deviated septum** can certainly cause nasal deviation, but the analysis in this case specifically links the issue to the **asymmetric osteotomy** placement. - The **"open-roof"** or lateral bone segments effectively determine the dorsal position; fixing the septum won't correct the asymmetry of **unequal nasal bones**.

Q: Why is the nasolabial flap preferred for reconstruction of lateral nasal wall defects?

It has axial blood supply from facial artery. ***It has axial blood supply from facial artery*** - The nasolabial flap is an **axial pattern flap** primarily supplied by the **angular artery**, which is a terminal branch of the **facial artery**. - This robust blood supply allows for reliable healing and the ability to design longer flaps to reach **lateral nasal wall** and **ala** defects. *It matches skin color and texture perfectly* - While it provides a **good aesthetic match** due to its proximity, the primary reason it is preferred surgically is its vascular reliability. - Differences in **sebaceous gland density** between the cheek and nose mean the match is excellent but rarely "perfect." *It is a random pattern flap with good reach* - This is incorrect because the nasolabial flap is categorized as an **axial flap**, not a **random pattern flap**. - **Random flaps** rely on the subdermal plexus, whereas axial flaps like this one have a named vessel providing superior perfusion. *It provides cartilage support* - The nasolabial flap is a **pedicled skin/subcutaneous flap** and does not inherently contain **cartilage**. - For full-thickness defects requiring structural support, a separate **cartilage graft** must be placed beneath the flap.

Q: Which artery is the primary blood supply to the paramedian forehead flap used in nasal reconstruction?

Supratrochlear artery. ***Supratrochlear artery*** - The **supratrochlear artery** is the primary blood supply for the **paramedian forehead flap**, originating as a terminal branch of the **ophthalmic artery**. - This artery consistently emerges from the **supraorbital rim** approximately **1.7–2.2 cm lateral** to the midline, allowing for a robust **axial-pattern flap**. *Superficial temporal artery* - This artery supplies the lateral aspect of the scalp and forehead but is not the pedicle for a **paramedian** flap. - It is commonly used for **temporoparietal fascia flaps** rather than central nasal reconstruction. *Supraorbital artery* - The **supraorbital artery** is located more laterally than the supratrochlear and is not the primary axial supply for the **paramedian** design. - While it provides collateral circulation to the forehead, it lacks the specific **medial positioning** required for the gold-standard nasal flap. *Angular artery* - The **angular artery** is the terminal branch of the **facial artery** and supplies the lateral nasal wall and medial canthus. - It is used in **nasolabial flaps** [1] for smaller nasal defects, but it does not supply the tissues of the forehead.

Question 1

A 35-year-old woman underwent rhinoplasty 6 months ago and now presents with nasal valve collapse and breathing difficulty. Examination shows pinched nasal tip and alar retraction. Preoperative photos show she had thin skin and weak lower lateral cartilages. Evaluate the most likely cause and best preventive strategy.

Accepted Answer

Excessive cartilage resection; should have preserved structural support and used spreader grafts

Answer

Infection causing cartilage dissolution; prophylactic antibiotics would have prevented this

Answer

Keloid formation; preoperative steroid injection indicated

Answer

Normal healing process; no preventive strategy needed

Question 2

A 28-year-old woman undergoes open rhinoplasty. On table, after osteotomies, significant asymmetry is noted with deviation of nasal bones to the right. Analysis reveals the right osteotomy is more lateral than the left. What is the best explanation for the persistent deviation?

Accepted Answer

Asymmetric osteotomy created unequal bone segments

Answer

Postoperative edema causing temporary deviation

Answer

Incomplete mobilization of nasal bones due to retained periosteum

Answer

Septal deviation pulling the dorsum to right

Question 3

Why is the nasolabial flap preferred for reconstruction of lateral nasal wall defects?

Accepted Answer

It has axial blood supply from facial artery

Answer

It matches skin color and texture perfectly

Answer

It is a random pattern flap with good reach

Answer

It provides cartilage support

Question 4

Which artery is the primary blood supply to the paramedian forehead flap used in nasal reconstruction?

Accepted Answer

Supratrochlear artery

Answer

Superficial temporal artery

Answer

Supraorbital artery

Answer

Angular artery

Question 5

Le Fort II facial fracture implies which of the following?

Accepted Answer

Fracture running through the zygomatic process of the maxilla, floor of orbit, and root of nose on both sides

Answer

Fracture running through the alveolar ridge

Answer

Fracture running through the midline of the palate and zygomaticomaxillary suture

Answer

Fracture running through the zygomatic process of the maxilla, floor of orbit, and root of nose on one side only

Facial Plastic and Reconstructive Surgery — MCQs

Facial Plastic and Reconstructive Surgery — MCQs

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