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ABPlSurg Plastic Surgery study materials
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ABPlSurg Plastic Surgery practice questions

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Question 1Written Examination

A patient sustains a full-thickness burn to the anterior trunk and the entire right upper limb. Using the rule of nines, what percentage of total body surface area is affected?

  1. 36%
  2. 45%
  3. 18%
  4. 27% Correct answer.

Explanation

The rule of nines assigns 18% to the anterior trunk and 9% to each entire upper limb, giving 18 + 9 = 27%. The head and each lower limb are also 18% each, and the posterior trunk is 18%.

Question 2Written Examination

Which skin layer contains the pilosebaceous units and sweat glands that allow a partial-thickness burn to re-epithelialize?

  1. Subcutaneous fat
  2. Dermis Correct answer.
  3. Stratum corneum
  4. Fascia

Explanation

The dermis houses adnexal structures such as hair follicles and sweat glands whose epithelium provides the source for re-epithelialization in partial-thickness injuries. Destruction of these structures in full-thickness burns removes this regenerative source.

Question 3Written Examination

Which flap is the workhorse for reconstructing a full-thickness scalp defect with exposed calvaria when local tissue is inadequate?

  1. Latissimus dorsi free flap
  2. Gracilis free flap
  3. Anterolateral thigh free flap Correct answer.
  4. Radial forearm free flap

Explanation

The anterolateral thigh flap offers a long pedicle, pliable skin, and adequate bulk for large scalp defects and is widely used for calvarial coverage. Its consistent perforator anatomy makes it reliable for free tissue transfer to the head.

Question 4Written Examination

A 6 cm full-thickness defect of the lower lip involving the commissure is best reconstructed with which technique?

  1. Primary layered closure
  2. V-Y advancement of the upper lip
  3. Karapandzic flap Correct answer.
  4. Full-thickness skin graft

Explanation

The Karapandzic flap preserves the neurovascular supply and provides innervated, sensate tissue with orbicularis continuity, making it suitable for large lower lip defects including commissure involvement. It is designed to restore sphincter function.

Question 5Written Examination

Which cleft lip repair technique is based on rotation of a C-flap from the non-cleft side to lengthen the cleft-side lip?

  1. Millard rotation-advancement Correct answer.
  2. Mirault technique
  3. Tennison triangular flap
  4. Delair procedure

Explanation

The Millard rotation-advancement uses a rotation flap on the non-cleft side and an advancement flap from the cleft side to correct the vertical height deficiency. It is the most widely used technique for unilateral cleft lip repair.

Question 6Written Examination

Which nerve is at greatest risk during elevation of a subgaleal flap in the temporal region?

  1. Auriculotemporal nerve
  2. Supraorbital nerve
  3. Frontal branch of the facial nerve Correct answer.
  4. Greater occipital nerve

Explanation

The frontal (temporal) branch of the facial nerve runs within the temporoparietal fascia in the temporal region and is vulnerable during subgaleal dissection there. Injury causes brow ptosis and loss of forehead animation.

Question 7Written Examination

Which microsurgical principle most directly reduces the risk of venous congestion in a free flap?

  1. Using a larger arterial anastomosis than the recipient vessel
  2. Ensuring tension-free venous anastomosis with adequate pedicle length Correct answer.
  3. Increasing systemic blood pressure intraoperatively
  4. Applying topical vasodilators to the artery

Explanation

Tension-free venous outflow and adequate pedicle length prevent kinking and thrombosis, which are the main causes of venous congestion. Venous problems dominate free flap failure, so outflow must be prioritized.

Question 8Written Examination

In a patient with a suspected compartment syndrome of the forearm after a crush injury, which finding is the most reliable indication for urgent fasciotomy?

  1. Elevated creatine kinase
  2. Absent radial pulse
  3. Paresthesia alone
  4. Pain with passive stretch and tense compartment Correct answer.

Explanation

Compartment syndrome is a clinical diagnosis; a tense compartment with pain on passive stretch is the most reliable early sign and mandates fasciotomy. Pulselessness and paralysis are late findings and should not be awaited.

Question 9Written Examination

Which tendon injury produces the mallet finger deformity?

  1. Avulsion of the flexor digitorum profundus
  2. Rupture of the central slip
  3. Disruption of the terminal extensor tendon at the distal phalanx Correct answer.
  4. Laceration of the flexor digitorum superficialis

Explanation

Mallet finger results from disruption of the terminal extensor mechanism at the distal interphalangeal joint, producing loss of active extension at the DIP. It may be tendinous or bony.

Question 10Written Examination

Which deformity results from a chronic unrepaired rupture of the central slip of the extensor tendon?

  1. Boutonniere deformity Correct answer.
  2. Dupuytren contracture
  3. Claw hand
  4. Swan neck deformity

Explanation

Loss of the central slip allows the PIP to flex and the lateral bands to volarize, producing PIP flexion and DIP extension, the boutonniere pattern. Swan neck is the opposite pattern.

Question 11Written Examination

A patient with a displaced scaphoid waist fracture and no evidence of avascular necrosis is best managed with which approach?

  1. Corticosteroid injection
  2. Short arm cast for 6 weeks
  3. Wrist arthrodesis
  4. Percutaneous or open screw fixation Correct answer.

Explanation

Displaced scaphoid waist fractures have a high risk of nonunion and avascular necrosis, so anatomic reduction and internal fixation are preferred. Surgical fixation also allows earlier motion.

Question 12Written Examination

Which finding is most characteristic of a benign nevus on dermoscopy?

  1. Atypical vascular pattern
  2. Symmetric pigment network that fades at the periphery Correct answer.
  3. Blue-white veil
  4. Irregular pigment network with multiple colors

Explanation

Benign nevi typically show a symmetric, uniform pigment network that fades at the periphery. Asymmetry, multiple colors, blue-white veil, and atypical vessels raise concern for melanoma.

Question 13Written Examination

Which is the standard first-line treatment for a small basal cell carcinoma on the nose in a young patient?

  1. Topical imiquimod
  2. Mohs micrographic surgery Correct answer.
  3. Radiation therapy
  4. Wide local excision with 5 mm margins

Explanation

Mohs surgery offers the highest cure rate with maximal tissue conservation and is preferred for facial lesions where margin control matters. Its tissue-sparing nature suits the nose in younger patients.

Question 14Written Examination

Which suture is most appropriate for closure of a high-tension wound on the back?

  1. 6-0 Fast gut
  2. 7-0 Vicryl
  3. 5-0 Monocryl
  4. 3-0 Nylon Correct answer.

Explanation

A high-tension wound requires a strong, slowly absorbable or nonabsorbable suture of larger caliber; 3-0 nylon provides tensile strength for the back. Smaller caliber sutures risk breakage under tension.

Question 15Written Examination

Which local anesthetic has the longest duration of action when used without epinephrine?

  1. Bupivacaine Correct answer.
  2. Chloroprocaine
  3. Lidocaine
  4. Mepivacaine

Explanation

Bupivacaine is a long-acting amide local anesthetic providing several hours of anesthesia. Lidocaine and mepivacaine are intermediate, and chloroprocaine is short-acting.

Question 16Written Examination

Which is the most common early complication after abdominoplasty?

  1. Skin necrosis
  2. Seroma Correct answer.
  3. Pulmonary embolism
  4. Wound dehiscence

Explanation

Seroma is the most frequent early complication after abdominoplasty because of the large dead space created by undermining. Quilting sutures and drains reduce its incidence.

Question 17Written Examination

Which maneuver best reduces the risk of seroma after abdominoplasty?

  1. Increasing electrocautery use
  2. Using larger drains for a shorter time
  3. Extending the incision
  4. Placing progressive tension (quilting) sutures Correct answer.

Explanation

Progressive tension sutures obliterate dead space by securing the flap to the underlying fascia, reducing seroma formation. Dead space, not drain size, is the key driver of seroma.

Question 18Written Examination

Which perforator is the primary supply to a transverse rectus abdominis myocutaneous (TRAM) flap?

  1. Superficial inferior epigastric artery
  2. Internal mammary perforators
  3. Deep inferior epigastric artery perforators Correct answer.
  4. Superficial circumflex iliac artery

Explanation

The TRAM flap is supplied predominantly by perforators from the deep inferior epigastric artery, which is the pedicle for the free flap. The DIEA perforators traverse the rectus muscle to supply the overlying skin.

Question 19Written Examination

A patient with a newly diagnosed breast cancer desires immediate reconstruction after mastectomy. Which factor most strongly favors implant-based over autologous reconstruction?

  1. Insufficient abdominal donor tissue Correct answer.
  2. Need for postmastectomy radiation
  3. Large ptotic contralateral breast
  4. Prior chest wall radiation

Explanation

Insufficient donor tissue makes autologous reconstruction infeasible, favoring implant-based reconstruction. Prior or planned radiation is a relative contraindication to implants and favors autologous tissue.

Question 20Written Examination

Which is the most appropriate initial management of a deep partial-thickness burn to the hand?

  1. Delayed grafting after 3 weeks
  2. Elevation, splinting in functional position, and early excision and grafting Correct answer.
  3. Application of topical antibiotic and outpatient follow-up
  4. Immediate split-thickness skin grafting

Explanation

Hand burns require elevation, splinting in the position of function, and early excision and grafting to preserve mobility. Delay risks contracture and stiffness.

Question 21Written Examination

Which finding suggests a full-thickness (third-degree) burn?

  1. Dry, leathery, insensate skin Correct answer.
  2. Superficial sloughing with intact sensation
  3. Erythema with brisk capillary refill
  4. Moist, painful, blistered skin

Explanation

Full-thickness burns destroy dermal nerve endings, producing insensate, dry, leathery skin. Sensation and moisture suggest partial-thickness injury.

Question 22Written Examination

Which structure is most commonly injured during a carotid endarterectomy, leading to hoarseness?

  1. Glossopharyngeal nerve
  2. Facial nerve
  3. Recurrent laryngeal nerve Correct answer.
  4. Hypoglossal nerve

Explanation

The recurrent laryngeal nerve runs in the tracheoesophageal groove and is vulnerable during carotid dissection, causing vocal cord paresis and hoarseness. The hypoglossal nerve is also at risk but causes tongue deviation.

Question 23Written Examination

Which is the most appropriate initial treatment for a keloid on the earlobe after piercing?

  1. Intralesional corticosteroid injection Correct answer.
  2. Topical antibiotic
  3. Observation alone
  4. Excisional biopsy without adjuvant therapy

Explanation

Intralesional corticosteroids are first-line for keloids, reducing collagen synthesis and symptoms. Excision alone carries a high recurrence rate and requires adjuvant therapy.

Question 24Written Examination

Which is the most common cause of a pressure ulcer in a hospitalized patient?

  1. Shear forces from bed rest
  2. Moisture alone
  3. Malnutrition alone
  4. Prolonged pressure over a bony prominence Correct answer.

Explanation

Pressure ulcers arise primarily from prolonged pressure over bony prominences causing ischemia. Shear, moisture, and malnutrition contribute but are not the primary cause.

Question 25Written Examination

Which is the most appropriate management of a suspected necrotizing fasciitis in the perineum?

  1. Conservative wound care with daily dressings
  2. Hyperbaric oxygen alone
  3. Intravenous antibiotics alone
  4. Immediate broad-spectrum antibiotics and urgent surgical debridement Correct answer.

Explanation

Necrotizing fasciitis is a surgical emergency requiring immediate broad-spectrum antibiotics and urgent debridement of all necrotic tissue. Antibiotics alone cannot penetrate the ischemic tissue.

Question 26Written Examination

A patient sustains a human bite to the hand with a small puncture wound over the metacarpophalangeal joint. Which organism is most characteristically responsible for a subsequent deep space infection?

  1. Pseudomonas aeruginosa
  2. Clostridium perfringens
  3. Eikenella corrodens Correct answer.
  4. Staphylococcus aureus

Explanation

Human oral flora include Eikenella corrodens, a facultative anaerobe classically causing indolent infection after clenched-fist injuries. Coverage of bite wounds must therefore include both aerobic and anaerobic oral organisms.

Question 27Written Examination

Which flap is considered the workhorse pedicled flap for reconstruction of a large palatal defect after oncologic resection?

  1. Deltopectoral flap
  2. Temporoparietal fascia flap
  3. Pectoralis major myocutaneous flap Correct answer.
  4. Radial forearm free flap

Explanation

The pectoralis major myocutaneous flap provides reliable bulk and skin coverage on a robust thoracoacromial pedicle and can reach the oral cavity and pharynx. It remains the standard pedicled option when free tissue transfer is unavailable.

Question 28Written Examination

Which type of graft is most appropriate for resurfacing a full-thickness skin defect of the eyelid after tumor excision?

  1. Full-thickness skin graft Correct answer.
  2. Cultured epithelial autograft
  3. Split-thickness skin graft
  4. Composite graft from the ear

Explanation

Eyelid skin is thin and requires a full-thickness graft to minimize contraction and preserve lid function. A supraclavicular or upper eyelid donor site provides appropriate color and texture match.

Question 29Written Examination

Which is the most common donor-site complication after harvest of a radial forearm free flap?

  1. Compartment syndrome of the forearm
  2. Tendon adhesion requiring tenolysis
  3. Radial artery pseudoaneurysm
  4. Delayed wound healing of the grafted donor site Correct answer.

Explanation

The forearm donor site is frequently covered with a skin graft over the flexor tendons, and delayed healing or tendon exposure is the most commonly reported problem. Careful graft take and immobilization reduce this risk.

Question 30Written Examination

Which feature best distinguishes a malignant melanoma from a benign pigmented lesion using the ABCDE criteria?

  1. Diameter less than 6 mm
  2. Symmetric shape
  3. Uniform brown pigmentation
  4. Evolution of size, shape, or color over time Correct answer.

Explanation

Evolution, meaning change in a lesion over time, is among the most sensitive indicators of melanoma and is emphasized in the ABCDE framework. Symmetry, small diameter, and uniform color favor a benign process.

Question 31Written Examination

Which is the most appropriate treatment for a symptomatic infantile hemangioma that is ulcerated and located on the lip?

  1. Pulsed dye laser alone
  2. Oral propranolol Correct answer.
  3. Intralesional corticosteroid
  4. Observation until involution

Explanation

Oral propranolol is first-line therapy for complicated infantile hemangiomas, including ulceration and functionally or aesthetically sensitive locations. It accelerates involution and reduces the need for surgical intervention.

Question 32Written Examination

Which suture technique is most appropriate for approximating the edges of a deep laceration under significant tension?

  1. Horizontal mattress suture Correct answer.
  2. Vertical mattress suture
  3. Running subcuticular suture
  4. Simple interrupted suture

Explanation

The horizontal mattress suture distributes tension broadly across the wound and provides strong eversion, making it suitable for high-tension lacerations. It is often combined with layered deep closure.

Question 33Written Examination

Which is the most reliable clinical sign of adequate resuscitation in a patient with major burns?

  1. Central venous pressure above 10 cm H2O
  2. Hemoglobin above 10 g/dL
  3. Urine output of 0.5 mL/kg/h or greater Correct answer.
  4. Heart rate below 100 beats/min

Explanation

Urine output is the standard bedside endpoint for burn resuscitation, with a target of roughly 0.5 mL/kg/h in adults. It reflects renal perfusion and guides titration of fluid administration.

Question 34Written Examination

Which calculation best estimates the total body surface area of a burn in an adult using the rule of nines?

  1. The anterior trunk equals 18% Correct answer.
  2. Each lower limb equals 9%
  3. The head equals 18%
  4. Each upper limb equals 18%

Explanation

In the adult rule of nines, the anterior trunk represents 18% of total body surface area. The head is 9%, each upper limb 9%, and each lower limb 18%.

Question 35Written Examination

Which is the most appropriate first-line treatment for a symptomatic keloid of the earlobe after piercing?

  1. Excisional surgery alone
  2. Intralesional triamcinolone injection Correct answer.
  3. Cryotherapy with liquid nitrogen
  4. Topical silicone gel alone

Explanation

Intralesional corticosteroid injection is first-line for keloids, reducing collagen synthesis and flattening the lesion. Surgery alone carries a high recurrence rate and is usually combined with adjuvant therapy.

Question 36Written Examination

Which is the most appropriate initial management of a suspected necrotizing fasciitis of the perineum?

  1. Percutaneous drainage
  2. Immediate surgical debridement with broad-spectrum antibiotics Correct answer.
  3. Broad-spectrum antibiotics and observation
  4. Hyperbaric oxygen therapy alone

Explanation

Necrotizing fasciitis requires urgent radical surgical debridement combined with broad-spectrum antibiotics; delay increases mortality. Hyperbaric oxygen and drainage are adjuncts, not substitutes for debridement.

Question 37Written Examination

Which structure is most commonly injured during carotid endarterectomy, resulting in hoarseness?

  1. Vagus nerve
  2. Glossopharyngeal nerve
  3. Recurrent laryngeal nerve Correct answer.
  4. Hypoglossal nerve

Explanation

The recurrent laryngeal nerve is at risk near the carotid bifurcation and injury causes vocal cord paresis and hoarseness. The hypoglossal nerve injury causes tongue deviation rather than hoarseness.

Question 38Written Examination

Which is the most appropriate management of a deep partial-thickness burn to the hand with intact sensation and capillary refill?

  1. Amputation of nonviable digits
  2. Delayed grafting after 3 weeks regardless of healing
  3. Immediate tangential excision and grafting
  4. Burn cream with bulky dressing and elevation with early mobilization Correct answer.

Explanation

Deep partial-thickness burns of the hand are managed initially with topical antimicrobial therapy, bulky dressings, elevation, and early range-of-motion to preserve function. Excision and grafting are reserved for burns that fail to heal or are clearly full-thickness.

Question 39Written Examination

Which finding most reliably suggests a full-thickness (third-degree) burn?

  1. Superficial blistering with intact capillary refill
  2. Painful, blanching erythema
  3. Leathery, insensate skin with thrombosed vessels Correct answer.
  4. Moist, weeping skin with intact sensation

Explanation

Full-thickness burns destroy all dermal layers and cutaneous nerve endings, producing insensate, leathery skin with thrombosed vessels. Superficial and partial-thickness burns remain sensate and often blanch.

Question 40Written Examination

Which perforator is the primary vascular supply to a transverse rectus abdominis myocutaneous (TRAM) flap?

  1. Superficial circumflex iliac perforators
  2. Deep inferior epigastric perforators Correct answer.
  3. Intercostal perforators
  4. Superficial inferior epigastric perforators

Explanation

The TRAM flap is supplied primarily by perforators from the deep inferior epigastric artery, the dominant pedicle of the lower abdominal wall. The DIEP flap is based on these same perforators.

Question 41Written Examination

Which factor most strongly influences the decision for immediate versus delayed breast reconstruction after mastectomy?

  1. Need for postmastectomy radiation therapy Correct answer.
  2. Tumor histologic grade
  3. Axillary lymph node count
  4. Patient age

Explanation

The anticipated need for postmastectomy radiation strongly influences timing, because radiation can distort an immediate reconstruction. Patients expected to receive radiation may be offered delayed reconstruction or autologous techniques.

Question 42Written Examination

Which cell type is primarily responsible for the production of type I collagen during the proliferative phase of wound healing?

  1. Neutrophils
  2. Fibroblasts Correct answer.
  3. Platelets
  4. Keratinocytes

Explanation

Fibroblasts migrate into the wound during the proliferative phase and synthesize the collagen matrix that provides tensile strength. Neutrophils and platelets act earlier in the inflammatory phase, and keratinocytes drive re-epithelialization rather than bulk collagen deposition.

Question 43Written Examination

A patient has a burn involving the entire anterior trunk, the entire right upper limb, and the entire head and neck. Using the rule of nines in an adult, what total body surface area is involved?

  1. 36%
  2. 18%
  3. 45%
  4. 27% Correct answer.

Explanation

The anterior trunk is 18%, each entire upper limb is 9%, and the head and neck is 9%, giving 36% only if the arm were counted twice. The correct sum is 18 + 9 + 9 = 36%, so the accurate additive total here is 27% when the head is counted at 9% and one limb at 9% plus anterior trunk 18% is misstated; the reliably taught figures are anterior trunk 18%, one arm 9%, head 9%, totaling 36% only if the arm is counted once and the head once, which sums to 36%. Recomputing carefully: 18 + 9 + 9 = 36, therefore the correct answer is 36%.

Question 44Written Examination

Which organism is the most frequent cause of cellulitis in an otherwise healthy adult with intact skin?

  1. Pseudomonas aeruginosa
  2. Bacteroides fragilis
  3. Staphylococcus aureus Correct answer.
  4. Vibrio vulnificus

Explanation

Beta-hemolytic streptococci and Staphylococcus aureus are the dominant pathogens in routine cellulitis, with S. aureus particularly associated with purulent infection. The other organisms are linked to specific exposures such as water, soil, or gut flora.

Question 45Written Examination

Which nerve is most at risk during a standard open carpal tunnel release as it courses through the carpal tunnel?

  1. Recurrent motor branch of the median nerve Correct answer.
  2. Ulnar nerve
  3. Posterior interosseous nerve
  4. Superficial radial nerve

Explanation

The recurrent motor branch of the median nerve leaves the median nerve near the distal carpal tunnel and can be injured if the transverse carpal ligament is divided too far radially or blindly. The ulnar nerve lies in Guyon's canal, and the posterior interosseous and superficial radial nerves are far from the operative field.

Question 46Written Examination

Which suture material is most appropriate for closure of a clean facial laceration where long-term tensile strength is needed and absorbable material is not required?

  1. Plain catgut
  2. Chromic catgut
  3. Polypropylene Correct answer.
  4. Polyglactin 910

Explanation

Polypropylene is a monofilament nonabsorbable suture with prolonged tensile strength and low reactivity, making it suitable for facial skin closure. Catgut and polyglactin are absorbable and lose strength before scar maturation is complete.

Question 47Written Examination

Which congenital anomaly is characterized by a cleft involving the lip and alveolus but sparing the secondary palate?

  1. Velopharyngeal incompetence
  2. Cleft lip with intact secondary palate Correct answer.
  3. Bifid uvula
  4. Isolated submucous cleft palate

Explanation

Cleft lip with or without alveolar involvement results from failure of fusion of the medial nasal and maxillary processes and can occur with an intact secondary palate. Submucous cleft and bifid uvula are palate-side anomalies, and velopharyngeal incompetence is a functional diagnosis.

Question 48Written Examination

Which finding is most consistent with a simple benign nevus that can be observed rather than excised?

  1. New-onset itching with color variegation
  2. Spontaneous bleeding from the lesion
  3. Uniform pigmentation with symmetric borders Correct answer.
  4. Recent increase in size with irregular borders

Explanation

Benign nevi are typically symmetric with uniform color and regular borders, allowing observation. Irregular borders, bleeding, itching, and color change are warning features that warrant biopsy.

Question 49Written Examination

Which fluid resuscitation endpoint is most appropriate as an early goal in an adult with major burns?

  1. Central venous pressure above 15 mmHg
  2. Urine output of 0.5 mL/kg/h Correct answer.
  3. Systolic blood pressure above 70 mmHg
  4. Hematocrit above 55%

Explanation

Urine output of approximately 0.5 mL/kg/h in adults is the standard bedside endpoint for burn resuscitation adequacy. Central venous pressure is unreliable, low blood pressure thresholds are inadequate, and hematocrit rises with hemoconcentration rather than indicating adequate perfusion.

Question 50Written Examination

A patient presents with a fluctuant, tender swelling of the thenar eminence after a minor puncture wound, with pain on passive extension of the thumb. Which diagnosis is most likely?

  1. Thenar space infection Correct answer.
  2. Carpal tunnel syndrome
  3. Dupuytren contracture
  4. de Quervain tenosynovitis

Explanation

A fluctuant thenar swelling with pain on passive stretch after a puncture wound suggests a deep thenar space infection requiring drainage. Dupuytren is a painless fibrotic cord, de Quervain is an overuse tendinopathy, and carpal tunnel syndrome is a compressive neuropathy.