Plastic and Reconstructive Surgery Practice Questions

Q: Which of the following mandibular positions is least likely achievable with a bilateral sagittal split osteotomy?

Transverse. **Explanation:** The **Bilateral Sagittal Split Osteotomy (BSSO)** is the most versatile and commonly performed surgical procedure for correcting mandibular deformities. The technique involves a sagittal split of the mandibular ramus, dividing it into two segments: a **proximal segment** (containing the condyle) and a **distal segment** (containing the teeth and chin). **Why Transverse is the correct answer:** The BSSO is primarily designed to move the distal segment of the mandible along the sagittal and vertical planes. While it can achieve **Advancement** (for retrognathia), **Set back** (for prognathism), and **Rotation** (to correct asymmetries or open bites), it is **least effective for Transverse (width) changes**. Significant widening or narrowing of the mandible requires a **Midline Mandibular Osteotomy (Symphyseal split)** or distraction osteogenesis, as BSSO is limited by the anatomy of the ramus and the risk of condylar displacement/TMJ dysfunction if forced transversely. **Analysis of Incorrect Options:** * **Advancement (A):** The most common indication for BSSO; the distal segment is slid forward to treat mandibular hypoplasia. * **Set back (B):** Used to treat mandibular hyperplasia (prognathism) by sliding the distal segment posteriorly. * **Rotation (C):** BSSO allows for the correction of occlusal cants or midline shifts by rotating the distal segment before fixation. **High-Yield Clinical Pearls for NEET-PG:** * **Nerve at risk:** The **Inferior Alveolar Nerve (IAN)** is the most commonly injured structure during BSSO, leading to lower lip paresthesia. * **Stability:** BSSO is more stable for advancement than for set-back procedures. * **Fixation:** Usually performed using rigid internal fixation (screws/plates), which often eliminates the need for prolonged maxillomandibular fixation (MMF).

Q: A skin flap is used in the management of all the following conditions except:

Burn wound. The core concept in reconstructive surgery is the distinction between a **skin graft** and a **skin flap**. The choice depends on the vascularity of the recipient bed. ### Why "Burn Wound" is the Correct Answer In most cases of acute burns (specifically partial-thickness or full-thickness burns), the underlying wound bed is **vascular** (granulation tissue or dermis). Such beds can support a **skin graft**, which lacks its own blood supply and relies on the recipient site for nourishment (via plasmatic imbibition and inosculation). Using a flap for a standard burn wound is unnecessary, overly complex, and surgically inappropriate unless deep structures are exposed. ### Why the Other Options are Incorrect Flaps are mandatory when the recipient bed is **avascular** or "non-takeable" for a graft. A flap carries its own blood supply (pedicle), allowing it to survive over: * **Bone (A):** Cortical bone without periosteum cannot nourish a graft. * **Tendon (B):** Bare tendons (without paratenon) lack the vascularity required for graft survival. * **Cartilage (D):** Cartilage without perichondrium is avascular and requires flap coverage. ### High-Yield Clinical Pearls for NEET-PG * **The Reconstructive Ladder:** Always start with the simplest option. (Primary closure → Secondary intention → Skin Graft → Local Flap → Distant Flap → Free Flap). * **Graft vs. Flap:** If the bed is vascular (muscle, fat, periosteum), use a **Graft**. If the bed is avascular (bare bone, tendon, nerve), use a **Flap**. * **Exception:** If a burn is so deep that it exposes bone or tendon (4th-degree burn), a flap *would* be required, but for standard burn management, grafts are the gold standard.

Q: A Marjolin's ulcer, developing in a chronic burn scar, predisposes to which type of malignancy?

Squamous cell carcinoma. **Explanation:** **Marjolin’s ulcer** refers to a malignancy arising in a site of chronic inflammation, trauma, or scarring. The most common precursor is a **chronic burn scar** (post-burn cicatrix), though it can also occur in chronic osteomyelitis sinuses, pressure sores, or venous ulcers. 1. **Why Squamous Cell Carcinoma (SCC) is correct:** The constant irritation, chronic infection, and poor lymphatic drainage in a scarred area lead to repeated cycles of cell damage and repair. Over time (typically a latent period of 10–25 years), this triggers malignant transformation of the keratinocytes. **Squamous cell carcinoma** is the histological type in approximately 75–90% of Marjolin’s ulcers. These are generally more aggressive and have a higher rate of metastasis than SCC arising in healthy skin. 2. **Why other options are incorrect:** * **Basal Cell Carcinoma (BCC):** While BCC is the most common skin cancer overall, it typically arises on sun-exposed skin. It occurs in Marjolin’s ulcers much less frequently than SCC. * **Adenocarcinoma:** This arises from glandular epithelium (e.g., GI tract, breast). It is not associated with cutaneous burn scars. * **Round Cell Carcinoma:** This is a category of highly undifferentiated tumors (like Ewing’s sarcoma or lymphomas) and is not related to chronic scar transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Latency:** The average time for transformation is **30 years**. * **Characteristics:** Marjolin’s ulcers are typically painless (due to destroyed nerve endings in the scar), have everted edges, and a foul-smelling discharge. * **Lymph Nodes:** Despite being aggressive, lymph node metastasis may be delayed because the dense scar tissue acts as a barrier to lymphatic spread. * **Management:** Wide local excision (2 cm margin) is the treatment of choice; Mohs surgery or amputation may be required depending on depth and location.

Q: Millard's 'Rule of Ten' includes all except?

10 months. The **Rule of Ten**, formulated by **Wilhelmsen and Musgrave** (and popularized by **Ralph Millard**), defines the minimum clinical criteria required to safely perform a **Cleft Lip repair** (Cheiloplasty). The primary goal of these criteria is to ensure the infant is physiologically mature enough to tolerate general anesthesia and has adequate healing capacity. ### **Explanation of Options:** * **10 months (Correct Answer):** This is **not** part of the rule. Cleft lip repair is typically performed much earlier, around **10 weeks** of age. Waiting until 10 months would unnecessarily delay surgery and potentially interfere with early feeding and parental bonding. * **10 lbs (Option A):** The infant should weigh at least 10 pounds (approx. 4.5 kg). This ensures adequate nutritional status and body mass for surgical stress. * **10 weeks (Option B):** The infant should be at least 10 weeks old. This allows for the maturation of the hepatic and renal systems, reducing anesthetic risk. * **10 gm % Hemoglobin (Option C):** A minimum hemoglobin of 10 g/dL is required to ensure adequate oxygen-carrying capacity during and after the procedure. ### **High-Yield Clinical Pearls for NEET-PG:** * **Cleft Lip vs. Cleft Palate:** While the Rule of Ten applies to Cleft Lip (10 weeks), **Cleft Palate** repair (Palatoplasty) is usually performed later, between **6 to 12 months** (before the child starts speaking) to prevent speech defects. * **WBC Count:** Some versions of the rule also include a **WBC count < 10,000/mm³** to ensure there is no active infection. * **Most Common Type:** Cleft lip is more common on the **left side** and in **males**, whereas isolated cleft palate is more common in **females**.

Q: Lahsal classification is used for:

Cleft lip and palate. **Explanation:** The **LAHSAL classification** is a standardized anatomical coding system used to describe the extent of **Cleft Lip and Palate**. It is a diagrammatic representation where the oral cavity is divided into six segments, represented by the acronym LAHSAL: * **L:** Lip (Right) * **A:** Alveolus (Right) * **H:** Hard Palate * **S:** Soft Palate * **A:** Alveolus (Left) * **L:** Lip (Left) In this system, a capital letter (e.g., 'L') denotes a complete cleft, a lowercase letter (e.g., 'l') denotes an incomplete cleft, and a dot or hyphen denotes no cleft. This allows for a quick, visual shorthand to communicate complex anatomical defects. **Analysis of Incorrect Options:** * **Option B (Tumor Staging):** Tumor staging typically utilizes the **TNM classification** (Tumor, Node, Metastasis) or specific systems like FIGO (for Gynae-oncology) or Ann Arbor (for Lymphoma). * **Option C (Neurological Assessment):** The gold standard for neurological assessment in trauma is the **Glasgow Coma Scale (GCS)** or the **Revised Trauma Score (RTS)**. **High-Yield Clinical Pearls for NEET-PG:** * **Kernahan’s Striped Y:** Another common classification for cleft lip and palate; LAHSAL is essentially a linear version of this. * **Rule of 10s (Millard):** Used to determine the timing for cleft lip repair (10 weeks of age, 10 lbs weight, 10 g/dL hemoglobin). * **Timing of Surgery:** Cleft Lip repair is usually done at **3–6 months**, while Cleft Palate repair is done at **6–12 months** (to allow for speech development but before significant speech habits form).

Q: A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Rhomboid flap. ***Rhomboid flap***- The **Limberg flap** is a classic type of rhomboid transposition flap widely used for closing the deep, large defect left after wide excision of a pilonidal sinus.- This flap provides excellent tissue coverage, shifts the scar away from the midline natal cleft, and significantly reduces tension, leading to lower rates of **recurrence**.*Advanced flap*- An advancement flap involves moving tissue linearly forward, which often results in high tension when used to close the typical wide, ovoid defect remaining after pilonidal sinus excision.- They are less suitable for deep and wide midline defects compared to rotational or transposition flaps because they do not effectively flatten the **natal cleft** or distribute tension laterally.*Rotational flap*- While rotational flaps (like the **Karydakis flap**) are effective for pilonidal disease by excising the disease and closing the defect laterally, the **Limberg flap** is specifically a rhomboid transposition flap and is arguably the most classic answer for a geometric local flap used in this surgery.- Simple rotational flaps might be used, but the effectiveness and precision provided by the rhomboid geometry for large defects make the Limberg (rhomboid) technique particularly notable.*Free flap*- **Free flaps** involve microsurgical anastomosis to connect tissue from a distant site, a level of surgical complexity unnecessary for standard pilonidal sinus reconstruction.- These flaps are reserved for very large, complex defects, often requiring coverage where local tissue has been destroyed by cancer or **osteomyelitis**, which is usually not the case in routine pilonidal surgery.

Question 1

Which of the following mandibular positions is least likely achievable with a bilateral sagittal split osteotomy?

Accepted Answer

Transverse

Answer

Advancement

Answer

Set back

Answer

Rotation

Question 2

How does a skin graft vestibuloplasty prevent relapse?

Accepted Answer

By forming a barrier to reattachment of muscle to periosteum

Answer

By promoting osteogenesis to establish a bone barrier to loss of sulcus depth

Answer

By causing an inhibitory effect on fibroblasts in the underlying tissue

Answer

None of the above

Question 3

A 9 1/2-year-old girl presents with an approximately 1 1/4-cm nontender nodule in her neck, just to the left of the midline and below her cricoid cartilage. The nodule moves when she swallows. It has been enlarging over the last several months and was not noted by her pediatrician at her 9-year-old check-up. There is no family history of endocrine disorders. What is the most likely diagnosis?

Accepted Answer

Papillary thyroid cancer

Answer

Reactive viral lymphadenopathy

Answer

A brachial cleft cyst

Answer

A follicular adenoma of the thyroid

Question 4

A skin flap is used in the management of all the following conditions except:

Accepted Answer

Burn wound

Answer

Bone

Answer

Tendon

Answer

Cartilage

Question 5

Skin grafting is absolutely contraindicated in which skin infection?

Accepted Answer

Streptococcus

Answer

Staphylococcus

Answer

Pseudomonas

Answer

Proteus

Question 6

A Marjolin's ulcer, developing in a chronic burn scar, predisposes to which type of malignancy?

Accepted Answer

Squamous cell carcinoma

Answer

Basal cell carcinoma

Answer

Adenocarcinoma

Answer

Round cell carcinoma

Question 7

Dupuytren's contracture is associated with which of the following conditions?

Accepted Answer

Peyronie's disease

Answer

Hypospadias

Answer

Epispadias

Answer

Exstrophy

Question 8

Millard's 'Rule of Ten' includes all except?

Accepted Answer

10 months

Answer

10 lbs

Answer

10 weeks

Answer

10 gm % Hemoglobin

Question 9

Lahsal classification is used for:

Accepted Answer

Cleft lip and palate

Answer

Tumor staging

Answer

Neurological assessment of trauma patient

Answer

None of the above

Question 10

A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Accepted Answer

Rhomboid flap

Answer

Free flap

Answer

Rotational flap

Answer

Advancement flap

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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