Plastic and Reconstructive Surgery Practice Questions

Q: Pulp space infection is known as:

Felon. ### Explanation **1. Why "Felon" is the Correct Answer:** A **Felon** is a subcutaneous infection of the **pulp space** of the distal finger. The anatomy of the fingertip is unique; it contains numerous vertical fibrous septa that connect the dermis to the periosteum of the distal phalanx. These septa create closed, high-pressure compartments. When infection occurs (usually due to *Staphylococcus aureus*), the resulting edema increases pressure within these tight spaces. If left untreated, this can lead to **compartment syndrome of the pulp**, causing ischemic necrosis of the bone (osteomyelitis) or the skin. **2. Why the Other Options are Incorrect:** * **Paronychia:** This is an infection of the **soft tissue folds around the nail** (the lateral nail fold). It is the most common hand infection and is usually superficial. * **Perionychia:** This is a general term referring to inflammation or infection of the **perionychium** (the entire structure surrounding the nail, including the paronychium and eponychium). * **Onychonychia:** This is not a standard clinical term for a specific hand infection; it is likely a distractor derived from "Onychia" (inflammation of the nail matrix). **3. Clinical Pearls for NEET-PG:** * **Management:** Incision and drainage (I&D) are mandatory if fluctuance or severe tension is present. The incision should be made where the tension is maximal to avoid injuring the digital nerves/vessels. * **Complication:** The most feared complication of an untreated felon is **distal phalangeal osteomyelitis** due to pressure necrosis of the bone. * **Kanavel’s Signs:** Remember these for **Flexor Tenosynovitis** (another high-yield hand infection): 1. Finger held in flexion, 2. Uniform swelling (fusiform), 3. Tenderness along the tendon sheath, 4. Pain on passive extension.

Q: What is true regarding Wolfe's graft?

Donor site is left open to granulate and contract. **Explanation:** A **Wolfe’s graft** is a **Full-Thickness Skin Graft (FTSG)**, consisting of the entire epidermis and the complete thickness of the dermis. **Why Option B is Correct:** Unlike Split-Thickness Skin Grafts (STSG), where the donor site retains adnexal structures (hair follicles, sweat glands) to allow for spontaneous re-epithelialization, a Wolfe’s graft removes the entire dermis. Consequently, the donor site **cannot regenerate on its own**. It must be managed by primary closure (suturing), a secondary skin graft, or, if small, **left open to heal by secondary intention (granulation and contraction)**. **Analysis of Incorrect Options:** * **A. Uptake of graft is easy:** Incorrect. Because FTSGs are thicker, they have higher metabolic demands. They require a more robust vascular bed for successful "take" (plasmatic imbibition and inosculation) compared to STSGs. * **C. Large grafts can be taken:** Incorrect. FTSGs are typically limited to small areas (e.g., face, hand) because the donor site defect is difficult to close if the graft is too large. * **D. Not useful for cosmetic surgeries:** Incorrect. Wolfe’s grafts are **highly preferred** for cosmetic areas (like the eyelid or nose) because they undergo minimal secondary contraction, maintain better color/texture match, and retain hair follicles. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Contraction:** Higher in Wolfe’s graft (due to more elastin in the dermis). * **Secondary Contraction:** Significantly lower in Wolfe’s graft (making it ideal for preventing ectropion or contractures over joints). * **Common Donor Sites:** Post-auricular area, supraclavicular fossa, and groin crease. * **Gold Standard for Face:** Wolfe’s graft is superior to STSG for facial reconstruction due to superior aesthetic outcomes.

Q: What type of knife is used for harvesting split-thickness skin grafts?

Humby's knife. **Explanation:** **Humby’s knife** (Option C) is the correct answer. It is a specialized surgical instrument designed specifically for harvesting **Split-Thickness Skin Grafts (STSG)**. The defining feature of Humby’s knife is an adjustable roller bar that allows the surgeon to calibrate the gap between the blade and the roller. This mechanism ensures a uniform thickness of the graft (usually containing the epidermis and a portion of the dermis) by preventing the blade from cutting too deep into the donor site. **Analysis of Incorrect Options:** * **Husson’s knife (A):** This is not a standard surgical instrument for skin grafting. It is likely a distractor or a misspelling of specialized orthopedic or ophthalmic tools. * **Bard Parker’s knife (B):** This refers to the standard surgical scalpel handle (e.g., BP handle No. 3 or 4). While a scalpel can be used for small "pinch grafts," it lacks the precision and roller mechanism required for harvesting large, uniform STSGs. * **Foley’s knife (D):** There is no standard "Foley’s knife" in surgery; Foley is famously associated with the indwelling urinary catheter. **High-Yield Clinical Pearls for NEET-PG:** * **Modifications:** The **Braithwaite** and **Cobbett** knives are common modifications of the Humby’s knife. * **Power Tools:** In modern practice, the **electric or air-powered dermatome** (e.g., Brown’s dermatome) is frequently used for more precise and rapid harvesting. * **Graft Thickness:** STSG donor sites heal by **re-epithelialization** from skin appendages (hair follicles, sebaceous glands) left in the dermis. * **Blades:** Humby’s knife typically uses a disposable **Watson blade**.

Q: Reconstruction of the tip of the nose after excision of basal cell carcinoma is best achieved by which method?

Bilobed flap. **Explanation:** Reconstruction of the nasal tip is surgically challenging due to the lack of laxity in the skin and the complex three-dimensional contour. **Why the Bilobed Flap is correct:** The **Bilobed flap** is the gold standard for small to medium-sized defects (0.5 cm to 1.5 cm) on the lower third of the nose (tip and alar sidewall). It is a **transposition flap** that allows for the movement of skin from areas of relative laxity (like the nasal bridge or sidewall) to the rigid nasal tip. By using two lobes, it distributes the tension over a wider area, preventing the "pin-cushioning" effect and minimizing alar rim distortion, which provides a superior aesthetic result compared to other methods. **Analysis of Incorrect Options:** * **Bipedicled flap:** These are generally used for larger defects or in areas like the eyelid or lip; they are bulky and not anatomically suited for the delicate contour of the nasal tip. * **Full thickness skin graft (FTSG):** While FTSG provides better color match than SSG, it often results in a "patch-like" appearance and contour depression because it lacks the subcutaneous thickness required for the nasal tip. * **Split skin graft (SSG):** This is the least preferred method for the face. It undergoes significant secondary contraction, has a poor color/texture match, and leads to a shiny, depressed scar. **Clinical Pearls for NEET-PG:** * **Defects 2 cm:** Forehead flap (Paramedian forehead flap) is the "Gold Standard" for large nasal defects. * **Donor site for Bilobed flap:** Usually the more mobile skin of the proximal nasal dorsum.

Q: What is the recommended length to width ratio for an elliptical incision?

3:1. ### Explanation The correct answer is **3:1**. **1. Why 3:1 is Correct:** An elliptical incision (also known as a fusiform incision) is the standard technique for excising skin lesions to allow for primary closure. The fundamental goal is to avoid **"dog-ear" deformities** (standing cone deformities) at the ends of the wound. * A **length-to-width ratio of 3:1** ensures that the apical angle at each end of the ellipse is approximately **30 degrees or less**. * This geometry allows the wound edges to be apposed smoothly without redundant tissue bunching up at the corners, resulting in a flat, linear scar. **2. Analysis of Incorrect Options:** * **4:1 (Option A):** While a 4:1 ratio provides an even flatter closure, it requires sacrificing a significant amount of healthy tissue and results in a much longer scar than necessary for most clinical scenarios. * **2:1 (Option B):** A 2:1 ratio results in an apical angle that is too obtuse. This leads to the formation of "dog-ears," where the skin puckers at the ends because the sides of the wound are too curved to lie flat. * **1:1 (Option D):** A 1:1 ratio describes a circle. Closing a circular defect directly results in significant puckering and tension, making it unsuitable for linear primary closure. **3. Clinical Pearls for NEET-PG:** * **Orientation:** Elliptical incisions should ideally be oriented parallel to **Langer’s lines** (Relaxed Skin Tension Lines - RSTL) to minimize tension and optimize scarring. * **Undermining:** To further reduce tension during closure, surgeons often "undermine" (separate the skin from underlying subcutaneous fat) for a distance roughly equal to the width of the defect. * **The 30-Degree Rule:** For a perfect closure, the angle at the apex of the ellipse should be kept under **30°**.

Question 1

Pulp space infection is known as:

Accepted Answer

Felon

Answer

Paronychia

Answer

Perionychia

Answer

Onychonychia

Question 2

A scalp defect measuring 3-6 cm is best closed by which of the following methods?

Accepted Answer

Local flaps

Answer

Primary simple closure

Answer

Split skin grafting

Answer

Secondary closure

Question 3

Take in of split skin graft occurs when?

Accepted Answer

Tight dressing is applied

Answer

Excessive discharge from wound

Answer

Streptococcus hemolyticus infection is present

Answer

Wound bed not vascularized

Question 4

A young boy presents with a scald injury of the arm. The lesion is pink, oozing, and painful to pinprick. What is the most appropriate management?

Accepted Answer

Collagen dressing

Answer

Paraffin gauze dressing with the wound left open

Answer

Excision and grafting

Answer

Application of 1% silver sulfadiazine

Question 5

What is true regarding Wolfe's graft?

Accepted Answer

Donor site is left open to granulate and contract

Answer

Uptake of graft is easy

Answer

Large grafts can be taken

Answer

Not useful for cosmetic surgeries

Question 6

In the temporal approach for reduction of a zygomatic arch fracture, the Boies zygomatic elevator is placed between which layers?

Accepted Answer

The temporal fascia and the temporalis muscle

Answer

Superficial fascia and the temporal fascia

Answer

The temporal bone and the temporalis muscle

Answer

The skin and superficial fascia

Question 7

What type of knife is used for harvesting split-thickness skin grafts?

Accepted Answer

Humby's knife

Answer

Husson's knife

Answer

Bard Parker's knife

Answer

Foley's knife

Question 8

Reconstruction of the tip of the nose after excision of basal cell carcinoma is best achieved by which method?

Accepted Answer

Bilobed flap

Answer

Bipedicled flap

Answer

Full thickness skin graft

Answer

Split skin graft

Question 9

All of the following nerves are commonly used for grafting except?

Accepted Answer

Musculocutaneous nerve

Answer

Medial antebrachial cutaneous nerve

Answer

Dorsal sensory branch of vagal nerve

Answer

Sural nerve

Question 10

What is the recommended length to width ratio for an elliptical incision?

Accepted Answer

3:1

Answer

4:1

Answer

2:1

Answer

1:1

Plastic and Reconstructive Surgery — MCQs

Plastic and Reconstructive Surgery — MCQs

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