Plastic and Reconstructive Surgery Practice Questions

Q: The best cure rates for keloids are achieved by:

Intralesional excision followed by radiotherapy. ***Intralesional excision followed by radiotherapy*** - This combined approach offers the **highest cure rates** for keloids by removing the bulk of the lesion and then inhibiting fibroblast proliferation and collagen synthesis using radiation. - **Postoperative radiotherapy** significantly reduces the recurrence rate compared to excision alone, as keloids have a high tendency to recur. *Intralesional injection of triamcinolone* - While effective for some keloids, particularly smaller or flatter ones, **corticosteroid injections alone** have a lower long-term cure rate and are more often used for primary treatment or to reduce inflammation. - This method targets inflammation and fibroblast activity but may not fully prevent recurrence or completely flatten larger, more established keloids. *Surgical excision* - **Surgical excision alone** has a very high recurrence rate (up to 45-100%) for keloids because the removal of the keloid can itself trigger an exaggerated healing response. - It is rarely recommended as a monotherapy due to the significant risk of creating a larger or more aggressive keloid. *Localised irradiation* - **Radiotherapy alone** can be effective in some cases, particularly for preventing recurrence after excision, but it is generally not considered the primary treatment for an existing, bulky keloid. - Using radiation without prior excision might lead to incomplete regression and can be associated with side effects if the keloid is large.

Q: Optimum age for surgery for a child with cleft lip is:

3 - 6 months. ***3 - 6 months*** - This age range allows the infant to **grow sufficiently** and gain weight, which is important for tolerating anesthesia and surgery. - It's also early enough to minimize the development of **feeding difficulties** and **speech problems** often associated with unrepaired cleft lips. *4 weeks* - At 4 weeks, infants are generally considered too young and **fragile** for cleft lip repair due to their small size and immature physiological systems. - The risk of **anesthesia-related complications** and surgical stress is higher in very young infants. *4 - 6 weeks* - Similar to 4 weeks, this period is still too early for optimal surgical outcomes, as the infant's facial structures are still developing and they may not have reached an adequate weight. - Waiting a few more months allows for better **wound healing** and reduces the overall risks associated with the procedure. *6 - 18 months* - While cleft lip repair can be done during this period, it's generally considered **later than optimal** for isolated cleft lip. - Delaying surgery beyond 6 months can increase the likelihood of developing **feeding and speech issues**, as well as potential psycho-social impacts.

Q: In Split thickness graft, which part of the skin is/are included?

Epidermis and part of dermis. ***Epidermis and part of dermis*** - A **split-thickness skin graft** includes the entire **epidermis** and only a **portion of the dermis**. - This allows for easier engraftment and donor site healing due to less deep tissue removal. *Epidermis and dermis* - This describes a **full-thickness skin graft**, which includes the entire epidermis and the entire dermis. - While it provides better cosmetic results and less contraction, it requires a more complex donor site closure. *Epidermis only* - A graft consisting only of the epidermis would be too thin to be clinically useful and would likely not survive. - The dermis provides structural support and a blood supply critical for graft viability. *Epidermis, dermis and part of subcutaneous tissue* - This typically refers to a **composite graft** or a **flap**, not a split-thickness skin graft. - These grafts include deeper tissues, such as subcutaneous fat, to provide bulk and specialized structures.

Q: Which of the following is NOT true about Dupuytren's Contracture?

Not familial. ***Not familial*** - This is the **CORRECT answer** because this statement is **FALSE** - Dupuytren's contracture **IS familial** and has a strong genetic predisposition. - The condition often runs in families, exhibiting an **autosomal dominant inheritance pattern**. - Its familial nature is a well-established risk factor, making "not familial" the incorrect statement about Dupuytren's contracture. *Autosomal dominant* - This statement is **TRUE** about Dupuytren's contracture, which is frequently inherited in an **autosomal dominant pattern**. - A single copy of an altered gene is sufficient to cause the condition. - This genetic link explains why it often runs in families and is more prevalent in certain populations (especially Northern Europeans). *Associated with alcoholism, smoking and hypothyroidism* - This statement is **TRUE**; Dupuytren's contracture has known associations with several risk factors including **alcoholism**, **smoking**, and **hypothyroidism**. - Other risk factors include diabetes mellitus and epilepsy. - These conditions are thought to influence cellular processes that contribute to the proliferation of fibroblasts and collagen deposition in the palmar fascia. *Occurs in elderly men* - This statement is **TRUE**; Dupuytren's contracture is more common in **males** and typically presents in **middle-aged to elderly individuals**. - While it can occur in women, it is more prevalent (male:female ratio ~7:1) and often more severe in men. - Peak incidence is in the 5th to 7th decades of life.

Q: How does a skin graft receive nutrition on day 3 after transplantation?

Inosculation. ***Inosculation*** - **Inosculation** is the process where host capillaries directly connect with the graft's existing vessels (or newly formed ones) around day 2-3 post-transplantation. - This establishes blood flow and is the primary mechanism for **nutrient delivery** and waste removal by day 3. *Imbibition* - **Imbibition** is the initial phase (first 24-48 hours) where the graft passively absorbs nutrients from the recipient bed through diffusion. - While essential for initial survival, it is typically insufficient for sustained graft viability by day 3. *Neovascularization* - **Neovascularization** involves the formation of entirely new blood vessels into the graft, a process that typically begins after inosculation and continues for several days to weeks. - On day 3, while *initiation* of new vessel formation may be occurring, the main nutritional support is primarily from established connections through inosculation. *A & B* - While **imbibition** plays a role in the initial survival of the graft, by day 3, **inosculation** is the dominant and more effective mechanism for nutrient supply. - Therefore, selecting both A and B would be incorrect as imbibition's role diminishes significantly as inosculation progresses.

Q: What type of graft or dressing is used to cover the post-burn wound shown in the image?

Split thickness skin graft. ***Split thickness skin graft*** - The image shows a **meshed pattern** on the skin graft, which is characteristic of a **split-thickness skin graft** that has been expanded to cover a larger area. - This type of graft consists of the epidermis and a portion of the dermis, making it more flexible and able to **"take" more reliably** on various wound beds, commonly used for burn wounds. *Full thickness skin graft* - A **full-thickness skin graft** includes the entire epidermis and dermis and typically does not have a meshed appearance. - They are used for smaller defects where cosmesis is a priority, but have a **lower take rate** than split-thickness grafts, making them less suitable for large burn wounds. *VAC dressing* - A **VAC (Vacuum-Assisted Closure) dressing** is a system that applies negative pressure to a wound to promote healing and is not a skin graft itself. - It involves a foam or gauze dressing sealed with an adhesive film, connected to a vacuum pump, which is not what is depicted in the image. *Normal saline dressing* - A **normal saline dressing** is a simple wet-to-dry or wet-to-wet dressing for wound care, involving gauze soaked in normal saline. - This is a basic wound management technique and does not involve grafting or have the characteristic meshed appearance seen in the image.

Q: During reconstruction of an amputated limb which of the following is done first?

Fixation of the bone. ***Fixation of the bone*** - **Bone stabilization** is the crucial first step to create a rigid framework, allowing for subsequent precise vascular and nerve repairs. - This prevents movement and tension on delicate repairs, which could lead to failure of the reconnected vessels and nerves. *Arterial repair* - While critical for blood supply, arterial repair is performed *after* bone fixation to ensure the vessels are not disrupted by later bone manipulation. - It's typically done before venous repair to establish arterial flow and identify any potential venous back pressure that needs addressing. *Venous repair* - Venous repair is usually performed after arterial repair, as establishing arterial inflow can help distend the veins, making them easier to identify and repair. - Repairing veins first without establishing arterial flow immediately is less effective and may lead to congestion once arterial flow is restored. *Nerve anastomoses* - Nerve repair is typically the last major step in an amputation reconstruction, following bone stabilization and full vascular repair. - Nerves are fragile and require a stable, well-perfused environment to optimize the chances of successful regeneration.

Q: When osseous defects amenable to reconstruction are present, technique of choice is?

Papilla preservation flap. ***Papilla preservation flap*** - This technique is specifically designed to **preserve the interdental papilla**, which is critical for covering and protecting regenerative materials placed in osseous defects. - By maintaining the integrity of the papilla, it facilitates primary wound closure over the defect, enhancing the predictability of **guided tissue regeneration (GTR)** and bone grafting procedures. *Sulcular flap* - A sulcular flap involves an incision within the sulcus, which typically provides limited access and does not allow for adequate coverage of large **osseous defects**. - It does not offer the tissue volume needed for the stable primary closure essential for regenerative procedures. *Modified Widman flap* - While providing excellent access for debridement in periodontal pockets, the modified Widman flap's incisions often **transect the interdental papilla**, making primary closure over a regenerative defect less ideal. - Its primary goal is root debridement and pocket reduction, not necessarily **papilla preservation** for regenerative purposes. *Apically displaced flap* - An apically displaced flap is designed to **increase the zone of attached gingiva** or reduce pocket depths, by positioning the flap apically to its original position. - This flap design is not suitable for covering osseous defects amenable to reconstruction because it often exposes more root surface and does not provide the necessary coronal coverage for regenerative materials.

Q: In case of burns, which graft is better for acute wound coverage?

Thiersch graft. **Thiersch graft** - A **Thiersch graft**, also known as a **split-thickness skin graft**, is highly effective for covering large burn areas due to its ability to be harvested in thin sheets. - It has a high take rate because it requires less vascularization from the recipient bed, making it suitable for burn wounds which may have compromised blood supply. *Wolfe graft* - A **Wolfe graft** is a **full-thickness skin graft**, which includes both the epidermis and the entire dermis. - While it provides better cosmetic results and less contracture, its survival rate is lower in settings with compromised blood supply, such as large burn wounds, due to its higher metabolic demand. *Patch graft* - A **patch graft** often refers to a small, isolated piece of tissue and is not typically used for extensive burn wound coverage. - It lacks the coverage area and high take rate needed for optimal management of large burn surfaces. *Pedicle graft* - A **pedicle graft** remains attached to its original blood supply, making it a robust option. - However, it is usually employed for reconstructing deeper defects with exposed bone or tendon, not for routine coverage of large superficial burn areas, and it requires more complex surgical procedures.

Question 1

The best cure rates for keloids are achieved by:

Accepted Answer

Intralesional excision followed by radiotherapy

Answer

Intralesional injection of triamcinolone

Answer

Surgical excision

Answer

Localised irradiation

Question 2

Optimum age for surgery for a child with cleft lip is:

Accepted Answer

3 - 6 months

Answer

4 weeks

Answer

4 - 6 weeks

Answer

6 - 18 months

Question 3

Which of the following statements about mesh skin grafts is not correct?

Accepted Answer

They contract to the same degree as a grafted sheet of skin.

Answer

They allow egress of fluid collections under the graft.

Answer

They permit coverage of large areas.

Answer

They “take” satisfactorily on granulating bed.

Question 4

In Split thickness graft, which part of the skin is/are included?

Accepted Answer

Epidermis and part of dermis

Answer

Epidermis and dermis

Answer

Epidermis only

Answer

Epidermis, dermis and part of subcutaneous tissue

Question 5

Which of the following is NOT true about Dupuytren's Contracture?

Accepted Answer

Not familial

Answer

Autosomal dominant

Answer

Associated with alcoholism, smoking and hypothyroidism

Answer

Occurs in elderly men

Question 6

How does a skin graft receive nutrition on day 3 after transplantation?

Accepted Answer

Inosculation

Answer

Imbibition

Answer

Neovascularization

Answer

A & B

Question 7

What type of graft or dressing is used to cover the post-burn wound shown in the image?

Accepted Answer

Split thickness skin graft

Answer

Full thickness skin graft

Answer

VAC dressing

Answer

Normal saline dressing

Question 8

During reconstruction of an amputated limb which of the following is done first?

Accepted Answer

Fixation of the bone

Answer

Arterial repair

Answer

Venous repair

Answer

Nerve anastomoses

Question 9

When osseous defects amenable to reconstruction are present, technique of choice is?

Accepted Answer

Papilla preservation flap

Answer

Sulcular flap

Answer

Modified Widman flap

Answer

Apically displaced flap

Question 10

In case of burns, which graft is better for acute wound coverage?

Accepted Answer

Thiersch graft

Answer

Wolfe graft

Answer

Patch graft

Answer

Pedicle graft

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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