Plastic and Reconstructive Surgery Practice Questions

Q: A 45-year-old man underwent excision of a basal cell carcinoma from the nasal tip measuring 2x2 cm. The surgeon plans reconstruction with a bilobed flap. What is the ideal angle between the two lobes for optimal cosmetic outcome?

45 degrees each, total 90 degrees. ***45 degrees each, total 90 degrees*** - The **Zitelli modification** of the bilobed flap utilizes an angle of **45 degrees** between each lobe (totaling 90 degrees) to minimize **standing cone deformities** (dog-ears). - This narrow angle reduces **pincushioning** and tension, making it the gold standard for reconstructing defects on the **nasal tip** and **ala**. *70 degrees each, total 140 degrees* - A total angle of **140 degrees** is excessively wide and significantly increases the risk of **distorting adjacent structures** like the nasal ala or tip. - Larger angles create more **rotational tension**, which leads to suboptimal cosmetic outcomes and difficult primary closure of the final defect. *50 degrees each, total 100 degrees* - While **100 degrees** total is occasionally acceptable in lax skin, it deviates from the classic **45-degree rule** established for optimal outcomes in the modified design. - Slight increases in the angle beyond 45 degrees increase the likelihood of **tissue protrusion** at the pivot point of the flap. *60 degrees each, total 120 degrees* - Traditional designs like the **Esser flap** used larger angles, but they often resulted in significant **surgical dog-ears** and required more extensive revision. - A total angle of **120 degrees** is no longer the preferred standard because it places too much **lateral tension** on the donor site closure.

Q: What is the mechanism behind the delay procedure in flap surgery that improves flap survival?

Increases random blood supply through neovascularization. ***Increases random blood supply through neovascularization*** - The **delay procedure** induces a state of **sub-lethal ischemia**, which triggers the release of angiogenic factors and the dilation of **choke vessels**. - This process enhances **neovascularization** and reorients blood flow along the long axis of the flap, significantly improving **flap survival**. *Promotes immediate epithelialization* - Epithelialization is a component of surface **wound healing**, but it does not address the underlying **vascular supply** required for flap viability. - The delay phenomenon focuses on **hemodynamic changes** and vascular architecture rather than the immediate restoration of the skin barrier. *Reduces metabolic demands of the tissue* - While some metabolic adaptation may occur, the primary mechanism of the delay procedure is to **increase oxygen delivery** rather than lowering consumption. - Improving **perfusion** through vascular remodeling is the critical factor that prevents **tissue necrosis** during the final transfer. *Eliminates the need for microsurgical technique* - The delay procedure is a strategy utilized primarily for **random pattern** or pedicled flaps and does not replace the requirement for **microsurgery** in free flaps. - Microsurgical techniques involve direct **anastomosis** of vessels, whereas the delay procedure relies on the gradual enhancement of existing **collateral circulation**.

Q: Which of the following osteotomies is carried out for mandibular deformity?

All of the above. **Explanation:** Mandibular osteotomies are surgical procedures used to reposition the mandible to correct functional and aesthetic deformities such as mandibular prognathism, retrognathism, or asymmetry. The choice of technique depends on the direction and magnitude of the required movement. * **Intraoral Sagittal Split Osteotomy (SSO/BSSO):** This is the most versatile and commonly used procedure. It involves splitting the mandibular ramus sagittally, allowing for both advancement (moving forward) and setback (moving backward) of the mandible. It provides excellent bone-to-bone contact for healing. * **Inverted ‘L’ Osteotomy:** This technique is particularly useful for significant mandibular advancements or when the ramus is short. It is often combined with bone grafting and is preferred in cases of severe retrognathism or hemifacial microsomia. * **‘C’ Osteotomy:** A variation of the ramus osteotomy used primarily for mandibular advancement. It provides a stable platform for bone grafting if necessary. Since all three techniques—Inverted ‘L’, ‘C’, and Sagittal Split—are established surgical approaches to correct mandibular deformities, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Bilateral Sagittal Split Osteotomy (BSSO)** is the "Gold Standard" for most mandibular corrections. * **Complication:** The most common complication of BSSO is injury to the **Inferior Alveolar Nerve**, leading to lower lip numbness. * **Le Fort I Osteotomy** is the standard procedure for **maxillary** (not mandibular) deformities. * **Distraction Osteogenesis** is often the preferred method for severe mandibular hypoplasia (e.g., Pierre Robin Sequence).

Question 1

A 40-year-old man with total nasal reconstruction using paramedian forehead flap develops partial flap necrosis at the tip on post-op day 5. Doppler shows absent flow in distal 1 cm. Previous history reveals he is a heavy smoker (20 cigarettes/day). What would be the best surgical strategy if this procedure were to be revised?

Accepted Answer

Perform two-stage delay procedure before flap transfer and continue smoking cessation

Answer

Use a wider pedicle with earlier division at 2 weeks

Answer

Convert to free radial forearm flap with microsurgical anastomosis

Answer

Use bilateral nasolabial flaps instead of forehead flap

Question 2

A 45-year-old man underwent excision of a basal cell carcinoma from the nasal tip measuring 2x2 cm. The surgeon plans reconstruction with a bilobed flap. What is the ideal angle between the two lobes for optimal cosmetic outcome?

Accepted Answer

45 degrees each, total 90 degrees

Answer

70 degrees each, total 140 degrees

Answer

50 degrees each, total 100 degrees

Answer

60 degrees each, total 120 degrees

Question 3

What is the mechanism behind the delay procedure in flap surgery that improves flap survival?

Accepted Answer

Increases random blood supply through neovascularization

Answer

Promotes immediate epithelialization

Answer

Reduces metabolic demands of the tissue

Answer

Eliminates the need for microsurgical technique

Question 4

Which of the following osteotomies is carried out for mandibular deformity?

Accepted Answer

All of the above

Answer

Inverted 'L' Osteotomy

Answer

'C' Osteotomy

Answer

Intraoral sagittal split Osteotomy

Question 5

Which of the following surgical procedures is indicated for the correction of syndactyly?

Accepted Answer

V-Y advancement flap

Answer

Z plasty

Answer

Rhomboid flap

Answer

Rotation flap

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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