Plastic and Reconstructive Surgery Practice Questions

Q: The rectus abdominis free flap is supplied by which artery?

Epigastric artery. The **Rectus Abdominis muscle** is a classic **Type II muscle flap** (according to the Mathes and Nahai classification), meaning it has one dominant vascular pedicle and several minor pedicles. ### Why the Correct Answer is Right The primary blood supply to the rectus abdominis muscle comes from two major vessels: 1. **Deep Inferior Epigastric Artery (DIEA):** A branch of the external iliac artery. This is the **dominant pedicle** used for free flaps (e.g., DIEP flap or TRAM flap) because it has a larger diameter and a longer pedicle length. 2. **Superior Epigastric Artery:** A terminal branch of the internal mammary (thoracic) artery. In the context of a "free flap," the **Deep Inferior Epigastric Artery** is the vessel of choice for microvascular anastomosis. ### Why Other Options are Wrong * **A. Intercostal Artery:** These provide segmental sensory innervation and minor blood supply to the overlying skin (perforators), but they are not the primary supply for a free flap. * **B. Iliolumbar Artery:** This is a branch of the internal iliac artery supplying the iliacus muscle and psoas; it does not supply the anterior abdominal wall. * **D. Thoraco-lumbar Artery:** This is not a standard anatomical term for the supply of the rectus muscle; the blood supply is strictly longitudinal (Superior and Inferior Epigastric). ### High-Yield Clinical Pearls for NEET-PG * **TRAM Flap (Transverse Rectus Abdominis Myocutaneous):** Used for breast reconstruction. If used as a **pedicled flap**, it relies on the *Superior Epigastric Artery*. If used as a **free flap**, it relies on the *Deep Inferior Epigastric Artery*. * **DIEP Flap:** A refinement of the TRAM flap where only the skin and fat are taken, sparing the muscle to reduce donor site morbidity (incisional hernia). * **Arcuate Line:** Below this level, the posterior rectus sheath is absent. Harvesting the muscle below this line increases the risk of postoperative ventral hernia.

Q: Thompson's Operation for Lymphoedema is:

Both excisional and shunting procedures. **Explanation:** **Thompson’s Operation** (also known as the Buried Dermal Flap procedure) is a surgical technique used for chronic lymphedema. It is classified as a **combined procedure** because it incorporates elements of both reduction and physiological drainage. 1. **Why Option D is Correct:** * **Excisional Component:** The procedure involves the excision of redundant, lymphedematous skin and subcutaneous tissue from the limb. * **Shunting/Physiological Component:** A "buried dermal flap" is created by de-epithelializing a strip of skin and tucking it into the deep muscle compartment. The theory is that the dermal lymphatics will form new connections (shunts) with the deep subfascial lymphatic system, allowing fluid to bypass the obstructed superficial system. 2. **Why Other Options are Incorrect:** * **Option A & C:** These refer to purely physiological procedures (like Lymphaticovenular Anastomosis or Lymph Node Transfer) which aim to restore flow without removing tissue. Thompson’s involves significant tissue removal. * **Option B:** While it involves excision, calling it *only* excisional ignores the specific "buried flap" mechanism intended to create a physiological shunt. Purely excisional procedures include the **Charles Operation** (radical excision and skin grafting). **High-Yield Clinical Pearls for NEET-PG:** * **Charles Operation:** The most radical excisional procedure; involves removing all skin and subcutaneous tissue down to the deep fascia, followed by skin grafting. * **Sistrunk’s Procedure:** A wedge excision of skin and fat used for milder cases. * **Homan’s Procedure:** A staged subcutaneous excision under skin flaps. * **Gold Standard Diagnosis:** Lymphoscintigraphy is the investigation of choice for lymphedema. * **Conservative Management:** Always the first line (Complex Decongestive Therapy, compression garments).

Q: What is the ideal graft for a leg injury with a 10 x 10 cm exposed bone area?

Pedicle graft. **Explanation:** The management of soft tissue defects depends primarily on the **vascularity of the recipient bed**. **Why Pedicle Graft is Correct:** The key phrase in this question is **"exposed bone."** Cortical bone (without periosteum), tendons (without paratenon), and nerves do not have a sufficient blood supply to support a free skin graft. A **Pedicle Graft** (or Flap) carries its own blood supply through a vascular stalk. This is essential for coverage over "avital" or "non-take" areas like exposed bone, as it provides both stable coverage and brings a new blood supply to the wound to promote healing. **Why Other Options are Incorrect:** * **Split Thickness (STSG) & Full Thickness (FTSG) Skin Grafts:** These rely on "plasmatic imbibition" and "inosculation" from the recipient bed for survival. Since exposed bone is relatively avascular, a graft will fail to "take" and will undergo necrosis. * **Amniotic Membrane:** This is primarily used as a biological dressing for superficial burns or ophthalmic procedures; it does not provide the structural integrity or vascularity required for a deep 10x10 cm defect. **High-Yield Clinical Pearls for NEET-PG:** 1. **Reconstructive Ladder:** Always move from simplest to most complex (Secondary intention → Primary closure → Delayed primary → STSG → FTSG → Flaps). However, if bone/tendon is exposed, you must "skip" to **Flaps**. 2. **Size Matters:** For a large 10x10 cm defect on the leg, a local muscle flap (like Gastrocnemius for the upper third or Soleus for the middle third) or a free flap is typically required. 3. **Graft vs. Flap:** A **Graft** is tissue transferred without its own blood supply; a **Flap** (Pedicle) is tissue transferred with its blood supply intact.

Q: Down fracture of the zygomatic arch is a treatment modality for which condition?

Chronic subluxation. **Explanation:** **Chronic subluxation** of the Temporomandibular Joint (TMJ) occurs when the mandibular condyle moves anterior to the articular eminence and becomes unable to return to its normal position. The **down fracture of the zygomatic arch** (also known as the **Dautrey’s procedure**) is a surgical intervention designed to create a mechanical barrier. By fracturing the zygomatic arch and displacing it downward, the surgeon creates a physical obstruction that prevents the condyle from over-translating anteriorly, thereby preventing recurrent dislocation. **Analysis of Incorrect Options:** * **TMJ Ankylosis:** This involves the fusion of the joint (fibrous or bony), leading to restricted mouth opening. Treatment typically involves gap arthroplasty or interpositional arthroplasty, not the creation of a bony block. * **Condylar Fracture:** These are managed via closed reduction (maxillomandibular fixation) or open reduction with internal fixation (ORIF) using mini-plates. Down fracturing the arch would not stabilize a condylar fracture. * **Zygomatic Fracture:** These are traumatic injuries (e.g., Tripod fracture) requiring reduction and fixation to restore facial contour and volume. Down fracturing is a deliberate surgical maneuver, not a treatment for a pre-existing fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Dautrey’s Procedure:** Specifically refers to the down-fracturing of the zygomatic arch for chronic subluxation. * **Eminectomy:** Another surgical option for chronic dislocation where the articular eminence is removed to allow the condyle to move freely back into the fossa. * **Safety:** When operating on the zygomatic arch, the **temporal branch of the facial nerve** is the structure most at risk.

Q: The names Manchot, Salmon, and Taylor are related to which of the following?

Arterial supply to skin flaps. The correct answer is **B. Arterial supply to skin flaps**. ### **Explanation** The names **Manchot, Salmon, and Taylor** are synonymous with the historical and anatomical evolution of our understanding of the **vascular territories of the skin**. 1. **Manchot (1889):** He was the first to map the skin into specific vascular territories based on the distribution of cutaneous arteries. 2. **Salmon (1936):** He refined this work using lead oxide injections and radiography, identifying approximately 80 distinct anatomical territories. 3. **Ian Taylor (1987):** He introduced the modern **"Angiosome" concept**. An angiosome is a three-dimensional block of tissue (skin, fascia, muscle, and bone) supplied by a specific source artery. This concept is the foundation of modern reconstructive surgery, allowing surgeons to design reliable skin and composite flaps. ### **Why other options are incorrect:** * **A & C:** While the skin has complex lymphatic and nerve networks, these specific researchers focused exclusively on the macro and micro-circulation (arterial supply). * **D:** Nerve supply to muscles is described by different anatomical principles (e.g., Hilton’s Law), not the angiosome theory. ### **High-Yield Clinical Pearls for NEET-PG:** * **Angiosome:** The composite unit of tissue supplied by a single source artery. * **Choke Vessels:** These are reduced-caliber vessels that connect adjacent angiosomes. They act as "safety valves" that can dilate to maintain flap viability if a neighboring source artery is cut. * **Venosome:** The corresponding venous drainage territory of a specific vein. * **Clinical Application:** The angiosome concept is vital in planning **pedicled and free flaps** (e.g., Radial Forearm Flap, ALT flap) and in managing peripheral vascular disease (revascularizing the specific angiosome where an ulcer is located).

Q: What is the most likely diagnosis?

Cleft lip and palate. ***Cleft lip and palate*** - The image shows both a **visible cleft in the lip** extending from the nostril downward and a **discontinuity in the hard palate**, indicating involvement of both structures. - This combined defect occurs when **fusion failure** affects both the **primary palate** (lip and anterior alveolus) and **secondary palate** (hard and soft palate) during embryonic development. *Cleft lip* - Would only show a **gap in the lip** without involvement of the **hard or soft palate**. - The **palate would appear intact** on examination, which is not the case here. *Cleft palate* - Would present with **intact lip** but show defects only in the **hard and/or soft palate**. - There would be **no visible external facial deformity**, unlike what is demonstrated in this image. *Bifid uvula* - Represents a **minor form of cleft palate** with only the **uvula being split**. - The **hard palate remains intact** and there is **no lip involvement**, making it a much less severe presentation.

Q: A free skin graft is typically rejected when transplanted onto which of the following tissues?

None of the above. ### Explanation The survival of a **free skin graft** depends entirely on the vascularity of the recipient bed. For a graft to "take," it must undergo three stages: **plasmatic imbibition** (first 24–48 hours), **inosculation** (alignment of capillaries), and **revascularization** (neovascularization). **Why "None of the above" is correct:** A skin graft can successfully survive on any recipient bed that has an adequate blood supply. **Muscle, fat, and deep fascia** are all vascularized tissues capable of supporting a graft. Therefore, a graft is **not** typically rejected by any of these tissues. **Analysis of Options:** * **A. Muscle:** This is an excellent recipient bed due to its high vascularity and rich capillary network, which facilitates rapid inosculation. * **B. Fat:** While subcutaneous fat is less vascular than muscle, a healthy, non-infected layer of fat can still support a skin graft. * **C. Deep Fascia:** Fascia is a well-vascularized connective tissue that provides a stable and receptive surface for grafting. **When does a graft fail?** A graft will fail (be "rejected" or fail to take) if placed on **avascular surfaces**. High-yield examples of poor recipient beds include: 1. **Cortical bone** (without periosteum) 2. **Cartilage** (without perichondrium) 3. **Tendons** (without paratenon) 4. **Infected wounds** or tissues with heavy bacterial load (>10⁵ organisms/gram). **NEET-PG High-Yield Pearls:** * **Gold Standard:** The best recipient bed is healthy **granulation tissue**. * **Primary Contraction:** Occurs immediately after harvesting (highest in Full-Thickness Skin Grafts - FTSG). * **Secondary Contraction:** Occurs during healing (highest in Split-Thickness Skin Grafts - STSG). * **The "Take":** If a graft is placed on bare bone or tendon, a **flap** (which carries its own blood supply) is required instead of a graft.

Q: The Abbe estender flap is based on which artery?

Labial artery. The **Abbe flap** (also known as the lip-switch flap or Estlander flap when involving the commissure) is a classic pedicled flap used for the reconstruction of full-thickness lip defects. ### Why Labial Artery is Correct The anatomical basis of the Abbe flap is the **labial artery** (specifically the superior or inferior labial artery). These arteries run within the orbicularis oris muscle, approximately 2–3 mm deep to the mucosal surface and just above the vermilion border. Because the labial arteries form a robust anastomotic circle around the mouth, a flap can be harvested from one lip and rotated 180 degrees into a defect on the opposing lip while remaining viable on a narrow vascular pedicle containing the artery. ### Why Other Options are Incorrect * **A. Lingual artery:** Supplies the tongue and floor of the mouth; it does not provide the superficial circulation required for lip flaps. * **B. Facial artery:** While the labial arteries are branches of the facial artery, the specific pedicle for the Abbe flap is the **labial branch** itself. In surgical exams, the most distal/specific vessel is the preferred answer. * **C. Internal maxillary artery:** Supplies deep facial structures, the maxilla, and teeth via branches like the infraorbital artery, but is not the primary supply for a lip-switch procedure. ### High-Yield Clinical Pearls for NEET-PG * **Abbe vs. Estlander:** The **Abbe flap** is used for central lip defects (does not involve the commissure). The **Estlander flap** is used for defects involving the oral commissure (corner of the mouth). * **Two-stage procedure:** The Abbe flap requires a second surgery (usually after 2–3 weeks) to divide the vascular pedicle once the flap has neovascularized from the recipient site. * **Innervation:** The flap is initially denervated; sensory and motor recovery takes several months.

Q: What is the name of the flap shown in the image?

Rhomboidal Flap. ***Rhomboidal Flap*** - A **geometric transposition flap** with specific **60° and 120° angles** forming a **parallelogram shape**, designed by Limberg for precise defect closure. - Functions as a **local transposition flap** that rotates adjacent tissue into the defect, commonly used for **facial**, **trunk**, and **extremity** reconstructions. *Rotational Flap* - A **semicircular flap** that pivots around a **fixed point** to cover defects, requiring a **curved incision** rather than geometric angles. - Lacks the specific **parallelogram geometry** and **angular measurements** characteristic of the rhomboidal design. *Transposition Flap* - A **generic category** of flaps that move laterally over intervening tissue, but without the **specific 60°/120° geometry**. - The rhomboidal flap is actually a **specialized type** of transposition flap, making this option less specific. *Advancement Flap* - Involves **direct forward movement** of tissue without rotation, using **straight-line incisions** parallel to the defect. - Does not involve the **angular geometry** or **rotational movement** seen in rhomboidal flap design.

Question 1

The rectus abdominis free flap is supplied by which artery?

Accepted Answer

Epigastric artery

Answer

Intercostals artery

Answer

Iliolumbar artery

Answer

Thoraco-lumbar artery

Question 2

Thompson's Operation for Lymphoedema is:

Accepted Answer

Both excisional and shunting procedures

Answer

A bypass procedure

Answer

An excisional surgery

Answer

Physiological shunting

Question 3

What is the ideal graft for a leg injury with a 10 x 10 cm exposed bone area?

Accepted Answer

Pedicle graft

Answer

Amniotic membrane graft

Answer

Full thickness graft

Answer

Split thickness skin graft

Question 4

Down fracture of the zygomatic arch is a treatment modality for which condition?

Accepted Answer

Chronic subluxation

Answer

Temporomandibular joint (TMJ) ankylosis

Answer

Condylar fracture

Answer

Zygomatic fracture

Question 5

Which neuromuscular preserving flap is used in lip reconstruction?

Accepted Answer

Karpandzic flap

Answer

Abbe flap

Answer

Webster flap

Answer

Johansen flap

Question 6

The names Manchot, Salmon, and Taylor are related to which of the following?

Accepted Answer

Arterial supply to skin flaps

Answer

Lymphatic supply to skin

Answer

Nerve supply to the skin

Answer

Nerve supply to muscle

Question 7

What is the most likely diagnosis?

Accepted Answer

Cleft lip and palate

Answer

Cleft lip

Answer

Cleft palate

Answer

Bifid uvula

Question 8

A free skin graft is typically rejected when transplanted onto which of the following tissues?

Accepted Answer

None of the above

Answer

Muscle

Answer

Fat

Answer

Deep fascia

Question 9

The Abbe estender flap is based on which artery?

Accepted Answer

Labial artery

Answer

Lingual artery

Answer

Facial artery

Answer

Internal maxillary artery

Question 10

What is the name of the flap shown in the image?

Accepted Answer

Rhomboidal Flap

Answer

Rotational Flap

Answer

Transposition Flap

Answer

Advancement Flap

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?