Q 46) First stage of healing in a skin graft is
d. None of the above
Imbibtion is the 1st stage in 24-48 hrs. It involves fibrin formation between the graft and bed
After 48 hours - Inosculation by which time new capillary buds develop
3rd stage is revasularization
Q 47) Primary symptom in De Quervain’s tenosynovitis is pain in the:
a. Radial wrist
b. Ulnar wrist
c. Dorsal wrist
d. Volar wrist
Radial wrist pain
DE Quervain's disease is tenosynovitis of Abductor Pollicis Longus and Extensor pollicis bravis in the 1st dorsal wrist extensor compartment
It is characterized by radial wrist pain, tenderness, swelling and positive Finklestein test
Q 48) True about Trigonocephaly is all except:
a. Premature fusion of metopic suture
b. Triangle shape head
d. Developmental delay
Ans c Its Hypotelorism
Ref Bailey Table 43.6
Trigonocephaly is a type of craniosyntosis. Craniosynostosis is the premature fusion of one (simple craniosynostosis) or more (complex craniosynostosis) cranial sutures, preventing growth perpendicular to the suture.
In Trigonocephaly, Metopic suture is involved and clinically there is triangle shaped head.
Syndromic craniosynostosis, often associated with abnormalities of the fibroblast growth factor receptor genes, is accompanied by developmental delay and other abnormalities.
Patients often have hypotelorism, strabismus, and upslanting palpebral fissures (this is sometimes referred to as the trigonocephalic "sequence").
Ref G& S page 226
Q 49 which of the following are muscles of Second extensor compartment?
- APL & EPB
- ECRL & ECRB
Answer 49 B. (REF Grabb and smith 8th edition. Fig 77.1)
Extensor compartment -
I - APL & EPB
II - ECRL ECRB
III - EPL
IV - EDC & EIP
V - EDM
VI - ECU
Q 50 - A patient presented with laceration to the thumb just proximal to the IP joint dorsal. Patient is unable to extend the IP joint. On local exploration, the tendon seems to have retracted. The surgeon should look for the tendon in which extensor compartment?
answer -50 C (ref grabb and smith 8th edition, Fig 77.1)
The clinical picture is suggestive of injury to the EPL tendon. If retracted, an incision is given in the wrist corresponding to the Third extensor compartment to locate the tendon.
Q 51Skin expansion was first described by
- Austad and Rose
Ans 51 B- page 365
- The foundation for tissue expansion technique actually has its derivation from distraction osteogenesis. At the turn of the 20th century, Codvilla applied the principles of external distraction directly to bones. One of the earliest descriptions of skin expansion came several years later in 1957 when Neumann became the pioneering surgeon to first use gradual distention of a rubber balloon through an externally exposed tube with a stopcock to expand local skin and subcutaneous tissue to reconstruct a partial ear defect. More than two decades later, Radovan reinvigorated the concept of expansion through the use of an internally placed port. Further work by Austad and Rose elucidated much of the physiology behind tissue expansion through the use of an osmotically driven, self-inflating expander in a guinea pig model.
Q 52) All are changes in skin and soft tissue after expansion, except?
- Epidermis – increased mitotic activity
- Dermis – dermal thinning
- Muscle – Increased size and number of mitochondria
- Fat – temporary decrease in fat cells and thickness
ans 52 D- 366 (table 11.1)
- Epidermis - Increased mitotic activity. No significant decrease in thickness
- Dermis- Dermal thinning. Collagen synthesis markedly increased. Increase fibroblasts and myofibroblasts. Realignment of collagen fibers. Decreased hair follicle density
- Muscle - Increased thinning. Function unchanged. Myofibril and myofilament disorganized arrangement. Increased size and number of mitochondria
Fat Permanent decrease in fat cells and thickness. Fat necrosis and fibrosis may occur with aggressive expansion
Q 53 Which of the following is false regarding tissue expanders?
a) Distal ports have the advantage of minimizing risk of iatrogenic rupture by accidental puncture.
b) Integrated ports have the advantage of not having the need to make a separate dissection for the port.
c) Tubing between expander and port gets obstructed in case of integrated ports.
d) The Food and Drug Administration had cleared for the use of carbon dioxide–filled, remote-controlled tissue expanders
Ans 53 C- 368
The port can also be distal to the expander itself or integrated within the apparatus itself. Distal ports have the advantage of minimizing risk of iatrogenic rupture by accidental puncture. However, they have their own faults such as manipulation of the port itself (e.g., flipping, migration) if not placed into a proper pocket as well as obstruction of the tubing in between the port and the expander. Integrated ports have the obvious advantage of not having the need to make a separate dissection for the port along with any mechanical issues one would find with the distant ports. However, one has the main issue of iatrogenic injury to the tissue expander itself with the integrated port. Also, an integrated port is less ideal if there is lack of coverage secondary to the thinning of overlying soft tissue. More recently, the Food and Drug Administration had cleared for the use of carbon dioxide–filled, remote-controlled tissue expanders for further convenience of home expansion and obviating the need for percutaneous saline injections in breast reconstruction.
- Regarding expander placement false statement is:
- Direction of movement of flap will be parallel to the incision placed for expander
- Incisions are typically made at the border of the defect needing coverage or lesion needing excision
- Flaps can be of any type such as advancement, rotation, or interpositional flaps
- The injectable port should not be in an area of pressure or sensitivity
- A- 369
- Incisions are typically made at the border of the defect needing coverage or lesion needing excision. Flaps can be of any type such as advancement, rotation, or interpositional flaps, but the incision must take into account that the direction of movement will be perpendicular to the incision placed to maximize flap coverage and minimize tension during expansion. The injectable port should be superficial enough to be palpable, not be in an area of pressure or sensitivity, and not be in the line of a healing incision.
- After final serial expansion, second staged reconstruction is delayed by
- <1 week
- 1-2 weels
- 2-3 weeks
- 3-4 weeks
- D- 369
- Once the tissue expander has been placed and wounds have healed for 3 weeks, serial expansion can begin. Once the goal is met, it is best to wait 3 to 4 weeks before the second-staged reconstruction. The second stage may be for permanent implant exchange or flap placement and to take advantage of the stress-relaxation effect from prolonged positioning after the final serial expansion.
- Tissue expansion for scalp can be used for defects upto
- C- 370
- Tissue expansion has been widely accepted and used by plastic surgeons in reconstruction of these medium to large scalp defects. One can use this technique to cover large defects involving up to 50% of the scalp without significant thinning of the hair-bearing areas. The robust vascular nature of the scalp along with incorporation of a dominant vessel in the flap design will ensure a durable flap of good hairbearing quality. Even though expansion brings upon a decrease in hair density, this is usually unnoticeable. The expander is typically placed in the subgaleal plane under hair-bearing area.
- Breast augmentation in transgender females is done after how many years (at least) of estrogen therapy?
- B- 376
- Male-to-female transgender patients desiring breast augmentation may need tissue expanders to expand their skin and soft tissues to fit the size of implant they desire. The Endocrine Society recommends transgender females to delay breast augmentation until at least 2 years of estrogen therapy, as the breasts continue to grow during that time period.
- False statement regarding tissue expanders in trunk:
- They are uncomfortable and can interfere with daily activities of living
- Tissue expansion of the trunk is associated with high rates of morbidity and mortality
- High rates of primary fascial closure
- Hernia recurrences rates appear to be low
- B- 377
- Subcutaneously placed expanders are used for defects with minimal fascial tension, whereas intermuscularly placed expanders can close large defects involving the fascia and abdominal musculature. Although they are uncomfortable and can interfere with daily activities of living, tissue expansion of the trunk is associated with low rates of morbidity and mortality and high rates of primary fascial closure and incisions, while hernia recurrences rates appear to be low.
- Complication rate from tissue expansion is:
- C- 379
- Several factors play a role in complications from tissue expansion. These factors depend on patient characteristics, technique, site of expansion, and the aggressiveness of expansion schedule and volume. One study showed complications necessitating some form of revision to the original treatment plan in as high as 39% of cases. However, enough tissue was generated from the expansion itself to complete the reconstructive plan without affecting final outcomes. Fortunately, most complications from tissue expansion are minor, consisting of things such as seroma formation, widened scar, discomfort from the expansion itself, bone resorption, neuropraxia, remnant excessive soft tissue, and other aesthetic concerns.
- For forehead defects, expansion can be used to reconstruct defects of
- C- 373
- Expansion with direct advancement of tissues can be used to reconstruct 25% to 70% of forehead defects. Anything less may just require serial excisions, and anything more may require going up the reconstructive ladder to an expanded full-thickness skin graft or even a free flap.