Plastic and Reconstructive Surgery Practice Questions

Q: Best procedure for an injury to the leg with exposed bone and skin loss:

Pedicle flap. ***Pedicle flap*** - A pedicle flap provides **vascularized tissue** that can cover exposed bone, which requires a robust blood supply for healing and protection. - This method ensures good **tissue viability** and bulk, crucial for areas with high functional demands and potential for infection like the lower leg. *Full thickness grafting* - **Full-thickness skin grafts** are generally too thin to adequately cover exposed bone and do not provide sufficient vascularity or padding. - They rely entirely on the recipient bed for vascularization, which is poor over exposed bone, leading to a high risk of **graft failure**. *Skin flap* - While a generic "skin flap" implies a vascularized tissue transfer, it is less specific than a pedicle flap, which ensures continuous blood supply from the donor site until full integration. - The term "skin flap" alone doesn't specify if it's a local, regional, or free flap, and **pedicle flaps** are often the most direct and reliable solution for lower leg bone exposure. *Split skin grafting* - **Split-thickness skin grafts** are very thin and contain only a portion of the dermis, making them unsuitable for covering exposed bone or tendons. - They would likely **fail to take** due to lack of a vascular bed and offer no padding or protection against further injury.

Q: Skin grafts stored at 4°C can survive up to?

2 weeks. ***2 weeks*** - Skin grafts stored at 4°C, a standard method for preserving graft viability, can typically survive and be successfully transplanted for **up to 2 weeks**. - This storage temperature helps to slow down cellular metabolic processes, preserving cell integrity and reducing degradation. *1 week* - While skin grafts can certainly survive for 1 week at 4°C, this option does not represent the **maximum storage duration** under optimal conditions. - Selecting 2 weeks indicates a more complete understanding of the potential longevity of stored grafts. *4 weeks* - Storing skin grafts for **4 weeks** at 4°C generally leads to a significant decrease in cell viability and graft success rates. - Prolonged storage beyond 2 weeks increases the risk of cellular damage, necrosis, and reduced integration into the recipient site. *3 weeks* - Although some cellular activity might persist at 3 weeks, the viability and successful integration of skin grafts begin to significantly decline around the **2-week mark**. - Survival rates for storage beyond 2 weeks are often considerably lower, making 3 weeks less reliably successful for optimal graft outcomes.

Q: Thiersch graft consists of

Epidermis and variable portion of dermis. ***Epidermis and variable portion of dermis*** - A **Thiersch graft** is another name for a **split-thickness skin graft (STSG)**. - It includes the entire epidermis and only a portion of the dermis, allowing the donor site to heal spontaneously from adnexal structures like hair follicles and sweat glands. *Only epidermis* - This describes an **epidermal graft** which is much thinner and less commonly used for reconstructive purposes compared to split-thickness grafts. - Pure epidermal grafts have very limited structural integrity and are primarily used for cell delivery or very superficial wounds. *Epidermis and entire dermis* - This composition describes a **full-thickness skin graft (FTSG)**. - A full-thickness graft provides excellent cosmetic results and minimal contracture but requires primary closure of the donor site, which limits the size of the graft. *Dermis and subcutaneous tissue* - This combination is characteristic of a **dermo-fat graft** or a **composite graft** if other tissue types are included. - These are typically used for tissue augmentation or specific reconstructive needs, not for resurfacing large wounds.

Q: Kanavel's sign is diagnosed in

Flexor tendon sheath infection. ***Flexor tendon sheath infection*** - **Kanavel's signs** are a classic set of four criteria used to diagnose **flexor tenosynovitis**, which is an infection of the flexor tendon sheath. - The four signs are **uniform swelling** of the digit, **flexed posture** of the digit, **tenderness along the course of the flexor sheath**, and **pain on passive extension** of the digit. *Acute paronychia* - This is an **infection of the nail fold**, typically presenting with localized redness, swelling, and pain around the nail. - It does not involve the flexor tendon sheath and therefore does not exhibit Kanavel's signs. *Web space infection* - A web space infection, also known as a **collar button abscess**, occurs in the subcutaneous tissue of the interdigital space. - While painful, it presents with swelling between the digits and does not involve the flexor tendon sheath. *Mid palmar infection* - This refers to an infection in the **mid palmar space**, a deep fascial space in the palm of the hand. - It would present with diffuse palmar swelling and tenderness but would not typically involve the specific signs related to flexor tendon sheath inflammation.

Q: Kraissl's lines are:

Relaxed tension lines in skin. ***Relaxed tension lines in skin*** - **Kraissl's lines** represent the orientation of **relaxed skin tension lines (RSTL)**, which are natural lines of tension in the skin. - Making surgical incisions parallel to these lines results in **better cosmetic outcomes** and **less prominent scarring** due to reduced tension on the wound. *Collagen and elastin lines in stab wounds* - While collagen and elastin are fundamental components of skin, **Kraissl's lines** refer to the macroscopic tension patterns, not microscopic collagen/elastin orientation in the context of stab wounds. - The lines described by Kraissl are primarily used for **surgical planning** to minimize scar formation, rather than analyzing stab wound characteristics. *Point of maximum tension in a fracture* - This option incorrectly relates Kraissl's lines to fractures; they are concerned with **skin tension**, not bone mechanics. - The point of maximum tension in a fracture is related to **biomechanical stress** on bone, which is a different concept. *Point of tension in hanging* - This option is unrelated to Kraissl's lines, which describe the natural tension patterns in the skin. - The 'point of tension in hanging' refers to forces applied to the neck during strangulation, a concept entirely distinct from skin tension lines.

Q: The best skin graft for open wounds is -

Autograft (tissue from the patient's own body). ***Autograft (tissue from the patient's own body)*** - **Autografts are the gold standard** for permanent wound closure because they are derived from the patient's own body, eliminating the risk of immunologic rejection - They provide the **best cosmetic and functional results**, as the transplanted tissue is genetically identical to the recipient's unaffected skin - Permanent solution with optimal healing and integration *Isograft (tissue from a genetically identical individual)* - While an isograft (from an identical twin) would also avoid immune rejection due to genetic identity, it is rarely a practical option as most patients do not have an identical twin - Isografts are essentially a specialized form of autograft but with a donor other than the patient themselves - Not the "best" choice since it requires an identical twin donor *Allograft (tissue from a donor of the same species)* - Allografts (from another human donor) are used as **temporary biological dressing** for large burns or wounds when autograft sites are limited, but they are eventually rejected by the recipient's immune system - Helpful for providing temporary wound coverage, reducing fluid loss, and preventing infection, but they **do not provide permanent closure** - Used as a bridge until autograft is available *Xenograft (tissue from a different species)* - Xenografts (from a different species, e.g., pig skin) are used as **temporary biological dressing**, primarily for burn wounds, to close the wound and provide a barrier against infection and fluid loss - Always rejected by the immune system within a few weeks and cannot provide permanent coverage due to significant antigenic differences - Only a temporary measure for wound protection

Q: The given instrument is used for harvesting the graft from a healthy area in split-thickness skin graft. What is this called?

Humby knife. ***Humby knife*** - The **Humby knife** is a type of **hand-held dermatome** commonly used for harvesting **split-thickness skin grafts**. - It features an adjustable roller, allowing for precise control over the thickness of the harvested graft. *Silver's knife* - **Silver's knife** is a **surgical instrument** primarily used in procedures involving **tendons**, such as tendon release or repair. - It is not designed for harvesting skin grafts. *Catlin amputating knife* - A **Catlin amputating knife** is a large, sturdy knife historically used for **amputations of limbs**. - Its purpose is to cut through muscle and bone, not to harvest thin layers of skin. *Dermatome* - While a **dermatome** is the general term for an instrument used to harvest skin grafts, the question asks for the specific name of the depicted instrument. - **Dermatomes** can be manual (like the Humby knife), air-powered, or electric, but "dermatome" is a broad category, not the specific tool.

Q: A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?

Rhomboid flap. ***Rhomboid flap*** - The **rhomboid flap** (**Limberg flap**) is a common and effective surgical technique for pilonidal sinus, offering good wound closure and reduced recurrence rates. - It involves excising the sinus tract *en bloc* and closing the defect with a **rhomboid-shaped skin flap**, which distributes tension evenly. - This is a **transposition flap** that moves tissue laterally into the defect while maintaining blood supply. *Free flap* - **Free flaps** involve transplanting tissue with its own blood supply from one part of the body to another using microsurgery. - This method is overly complex and unnecessary for a typical pilonidal sinus repair, which usually only requires local tissue rearrangement. *Rotational flap* - A **rotational flap** is a type of local flap where tissue is rotated on a pivot point to cover a defect. - While rotational flaps (such as the **Karydakis flap**) can be used for pilonidal sinus surgery, the **rhomboid flap** is more commonly referenced as the standard flap-based technique due to its reliable outcomes and specific geometric design. - The rhomboid flap is technically a **transposition flap**, not a rotational flap, though both are local tissue rearrangement techniques. *Circular flap* - **Circular flaps** are generally not a standard design for closing excisional defects, especially in areas like the sacrococcygeal region where linear tension and dead space management are crucial. - Such a flap would likely create dog-ears and poor cosmetic outcomes, making it unsuitable for pilonidal sinus surgery.

Q: Which type of skin graft is most appropriate for covering large full-thickness burn wounds?

Split-thickness graft. ***Split-thickness graft (Correct)*** - This type only includes the **epidermis** and a portion of the **dermis**, allowing for a large surface area to be harvested from a donor site. - Its ability to **engraft reliably** on various wound beds and cover large defects makes it ideal for extensive burn injuries. - Donor sites can **re-epithelialize** and be harvested again if needed for very extensive burns. *Full-thickness graft (Incorrect)* - Comprises the **entire epidermis and dermis**, offering better cosmetic results and durability but requiring a highly vascularized bed. - Harvesting sites are limited, and it is generally reserved for smaller, less contaminated wounds where cosmetic outcomes are critical. - **Not suitable for large burns** due to donor site limitations and need for excellent wound bed. *Composite graft (Incorrect)* - Consists of multiple tissue types (e.g., skin, cartilage, fat), used for reconstructive purposes in specific areas like the nose or ear. - It is not suitable for covering large, irregular burn wounds due to its bulk and specific tissue requirements. *Cultured epithelial autograft (Incorrect)* - Involves growing a patient's own epidermal cells in a lab, which can cover very large areas when donor sites are scarce. - While useful for extensive burns with limited donor sites, it is **fragile**, takes weeks to prepare, and is prone to contraction and scarring. - Not the **most appropriate initial choice** for immediate large wound coverage compared to split-thickness grafts.

Q: After how many days post skin grafting does revascularization and angiogenesis typically begin?

5. ***5*** - **Revascularization** and **angiogenesis** in a skin graft typically become well-established around **day 5** post-grafting. - While **inosculation** (direct anastomosis of vessels) may begin earlier around day 3-4, active **angiogenesis** (new vessel formation) is most prominent starting day 5. - This process involves the ingrowth of new blood vessels from the host bed into the graft, essential for its survival and integration. *4* - Day 4 marks the transition phase where **inosculation** is beginning and **plasmatic imbibition** is declining. - However, robust **angiogenesis** and active neovascularization are not yet fully established at this stage. - The graft is transitioning from passive diffusion to active vascular ingrowth. *6* - While revascularization is robust and well-established by day 6, the active initiation phase begins earlier around day 5. - Day 6 demonstrates a maturing vascular network, but the question asks about when the process typically begins. *7* - By day 7, the process of **revascularization** and **angiogenesis** is typically well-established and maturing. - The initial stages of capillary ingrowth and new vessel formation have already been completed by this point. - This represents the consolidation phase rather than the initiation phase.

Question 1

Best procedure for an injury to the leg with exposed bone and skin loss:

Accepted Answer

Pedicle flap

Answer

Full thickness grafting

Answer

Skin flap

Answer

Split skin grafting

Question 2

Skin grafts stored at 4°C can survive up to?

Accepted Answer

2 weeks

Answer

1 week

Answer

4 weeks

Answer

3 weeks

Question 3

Thiersch graft consists of

Accepted Answer

Epidermis and variable portion of dermis

Answer

Only epidermis

Answer

Epidermis and entire dermis

Answer

Dermis and subcutaneous tissue

Question 4

Kanavel's sign is diagnosed in

Accepted Answer

Flexor tendon sheath infection

Answer

Acute paronychia

Answer

Web space infection

Answer

Mid palmar infection

Question 5

Kraissl's lines are:

Accepted Answer

Relaxed tension lines in skin

Answer

Collagen and elastin lines in stab wounds

Answer

Point of maximum tension in a fracture

Answer

Point of tension in hanging

Question 6

The best skin graft for open wounds is -

Accepted Answer

Autograft (tissue from the patient's own body)

Answer

Isograft (tissue from a genetically identical individual)

Answer

Allograft (tissue from a donor of the same species)

Answer

Xenograft (tissue from a different species)

Question 7

The given instrument is used for harvesting the graft from a healthy area in split-thickness skin graft. What is this called?

Accepted Answer

Humby knife

Answer

Silver's knife

Answer

Catlin amputating knife

Answer

Dermatome

Question 8

A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?

Accepted Answer

Rhomboid flap

Answer

Free flap

Answer

Rotational flap

Answer

Circular flap

Question 9

Which type of skin graft is most appropriate for covering large full-thickness burn wounds?

Accepted Answer

Split-thickness graft

Answer

Full-thickness graft

Answer

Composite graft

Answer

Cultured epithelial autograft

Question 10

After how many days post skin grafting does revascularization and angiogenesis typically begin?

Accepted Answer

5

Answer

4

Answer

6

Answer

7

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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