Comprehensive

Question 1

23 yo F presents for augmentation mammaplasty. She wants smooth, round silicone gel implants. Which of the following best aligns with the current US FDA recommendations for implant rupture screening?

A. Mammo at 3 years then yearly
B. Mammo at 5 years then yearly
C. MRI at 3 years then every 2 yrs
D. MRI at 5 years then every 2 yrs
E. US every 3 years

Answer 1

D. MRI at 5 years then every 2 years

of note it can either be MRI or US

Question 2

25 yo ambulatory man is evaluated because of a recurrent sacral wound. one year ago, the patient had a prolonged hospitalization from COVID. During his hospitalization he developed a sacral pressure ulcer that was treated using bone debridement and bilateral gluteal fasciocutaneous glass that healed. On exam the wound probes to bone and healthy granulation tissue is visible. Which of the following is the most likely cause of the wound recurrence?

A. Malignancy
B. Malnutrition
C. Ongoing pressure
D. Osteo
E. Poor flap vascularity

Answer 2

D. osteo

vascular issues typically happen in the first few months post op not months ro years down the road

Question 3

an otherwise healthy 25 yo transgender man meets WHO guidelines from transgender affirming genital surgery. He chooses to undergo phalloplasty to achieve the ability to urinate while standing and also maintain a chance of penetrating intercourse. however, he would like to avoid scar along the forearm. He undergoes combination flap phalloplasty using ALT thigh tissue for penile shaft reconstruction and groin tissue for urethral reconstruction. Which of the following is the most likely vascular pedicle that will be used for groin flap?

A. Deep external pudendal
B. Deep inferior epigastric
C. Lateral circumflex femoral
D. Superficial circumflex iliac
E. Superficial external pudendal

Answer 3

D. superficial circumflex iliac

emerges from femoral system and courses laterally superficial to sartorius. Perforators from the superficial branch are located more medially while from the deep branch are more lateral.

Question 4

a 35 yo transgender man comes to the office to discuss top surgery for a masculine chest appearance. On exam, the patient has D-cup breasts and grade III ptosis. Which of the following is the most appropriate surgical option?

A. Circumvertical reduction mammoplasty
B. Liposuction only
C. mastectomy with free nipple graft
D. nipple starting mastectomy
E. Wise pattern reduction mammaplasty

Answer 4

C. mastectomy with free nipple graft

due to size and ptosis

patients with BMI >27 and nipple to IMF >7cm have better outcomes with fewer complications

Question 5

A 3 yo boy is brought by his parents for evaluation of a unilateral lesion that overlays the angle of his jaw and extends onto the neck. the boys parents state that the lesion has been present since birth and grown gradually, and they are concerned it may become more problematic as he ages. On exam, the lesion is easily noticeable, soft, translucent with a pen light. The patient is referred to IR for sclerotherapy. Use of which of the following is most likely to put this patient at increased risk for skin necrosis?

A. Bleomycin
B. Doxy
C. Ethanol
D. OK-432
E. sodium tetra decyl sulfate

Answer 5

C. Ethanol

All can be used but this has the highest complication rate.
what is described is a lymphatic malformation
For small microcytic lesions surgical resection is first line
for larger lesions the cyst is aspirated then infused with agent. The end result is induction of inflammation and collapse and scarring of the walls, decreasing the size. Complications of necrosis, nerve injury (ethanol 18% the rest 6%)

Question 6

A 34-year-old right-hand–dominant man presents after traumatic amputation of the right upper extremity at the mid forearm level. He undergoes replantation after 5 hours of warm ischemia. Which of the following types of tissue is most sensitive to warm ischemia time?

A. adipose
B. Bone
C. Muscle
D. Skin
E. Tendon

Answer 6

C. Muscle
Muscle tissue is the most sensitive to ischemia of the tissues given, and it shows irreversible changes at 4 to 6 hours of warm ischemia time. Skin, subcutaneous tissue, and bone all tolerate longer ischemia time than muscle does.

Question 7

A 65-year-old woman undergoes segmental mandibulectomy of the parasymphysis and left body for treatment of oral squamous cell carcinoma. The defect is reconstructed with an osteocutaneous free fibula flap. The flap is monitored with implantable venous Doppler and pencil Doppler. The day after surgery, the nurse reports that the implantable Doppler probe has become dislodged. On evaluation, the flap has a multiphasic transcutaneous arterial Doppler signal, dark coloration, and brisk capillary refill. Which of the following is the most appropriate next step in management?
A) Initiate heparin therapy
B) Initiate leech therapy
C) Perform bedside indocyanine green angiography
D) Perform serial physical examinations
E) Perform surgical exploration

Answer 7

E. surgical exploration

Question 8

A 70-year-old woman who is obese and has type 2 diabetes is evaluated because of a very painful violaceous plaque on the abdomen that has developed into a black eschar. The eschar is located at the site where the patient injects insulin. History also includes end-stage renal disease. Examination of a specimen obtained on biopsy at the border of the lesion shows calcification of small- and medium-sized vessels, microvascular thromboses, extravascular soft-tissue calcification, and panniculitis. Administration of which of the following is the most appropriate management for this condition?
A) Calcium carbonate
B) Corticosteroids
C) Iron infusion
D) Sodium thiosulfate
E) Warfarin

Answer 8

D. Sodium Thiosulfate

Debridement of nonviable tissue and pain control are the mainstay of treatment. Sodium thiosulfate has been shown to result in improvement or resolution of calciphylaxis in patients with renal failure, according to a recent meta-analysis. Sodium thiosulfate has chelating and vasodilatory properties. Thiosulfate is administered intravenously in the last 30 to 60 minutes of hemodialysis. It is not effective for nonuremic calciphylaxis.

Question 9

9. An otherwise healthy 45-year-old woman is diagnosed with recurrent anal cancer. History includes a course of radiation therapy to the perianal region for the original treatment of her cancer. Abdominoperineal resection (APR) is planned with soft- tissue reconstruction of the perineal region using a pedicled anterolateral thigh flap at the time of extirpation. The surgeon must pass the flap under which of the following muscles to achieve a tensionless inset of the flap?
   A) Adductor longus and gracilis
   B) Adductor longus and sartorius
   C) Rectus femoris and gracilis
   D) Rectus femoris and sartorius
   E) Sartorius and gracilis

Answer 9

D. Rectus femoris and sartorius

The anterolateral thigh (ALT) flap is most commonly raised as a fasciocutaneous flap, though it may be raised as a musculocutaneous flap if the vastus lateralis is included. It is supplied by the descending branch of the lateral circumflex vessel, originating from the profunda femoris system. It is used either as a pedicled flap for regional reconstructions or as a free flap. To reach the perineal region, one usually needs to tunnel the flap under the rectus femoris as well as the sartorius muscles. One must take great care not to injure the femoral vessels since they travel just deep to the sartorius muscle in the territory where one is dissecting. The other potential danger to be mindful of is traction of the delicate perforators of the ALT flap as one passes the flap through these tunnels to get to the perineum.
The adductor longus and gracilis muscles need not be lifted to successfully pass the ALT flap to the perineum.

Question 10

10. A 4-month-old male infant is brought to the clinic with melanocytic nevi. He has 30 satellite nevi involving the extremities and a giant nevus in the midline covering the majority of the back and posterior scalp. Which of the following is the most appropriate imaging study to order next?
    A) CT scan of the brain and spine
    B) CT scan of the chest
    C) Liver ultrasonography
    D) MRI of the brain and spine
    E) Renal ultrasonography

Answer 10

D. MRI of brain and spine

This presence of more than 20 satellite nevi and midline involvement of the trunk and scalp increases the likelihood of neurocutaneous melanosis. Screening at age 4 to 6 months before normal brain myelination improves visualization of these abnormal melanin deposits. While many remain asymptomatic, there are two peaks in melanosis: age 2 to 3 years with increased intracranial pressure (ICP), hydrocephalus, or developmental delay, and age 20 to 30 years with space-occupying lesions, increased ICP, or spinal cord compression. Symptomatic neurocutaneous melanosis has a high mortality within 2 to 3 years, so these patients need careful observation and screening.

Question 11

A 25-year-old Caucasian man presents with a self-inflicted gunshot wound to the face resulting in significant soft-tissue and bony injuries. Following initial stabilization and debridement, there is a 12-cm mandibular defect extending from the right angle to the left parasymphysis. Which of the following is the most appropriate bony reconstruction for this defect?
A) Fibula osteocutaneous flap
B) Iliac crest bone graft
C) Medial femoral condyle osteocutaneous flap
D) Parascapular osteocutaneous flap
E) Radial forearm osteocutaneous flap

Answer 11

A. Fibula osteocutaneous flap
The fibula flap provides the greatest bony length for reconstruction which is necessary for this large defect. While leaving the proximal and distal 5-6 cm is critical to preservation of donor site function, often a 20+ cm flap can be harvested. The fibula is also able to tolerate multiple osteotomies to reconstruct the mandibular contour as well as adequate bone stock for subsequent dental implant rehabilitation.
The parascapular, radial forearm, and medial femoral condyle flaps do not provide adequate bony length for this defect. The parascapular flap is a versatile flap which can be harvested with large volume for soft tissue reconstruction as well as bone from the scapular tip. However, this bone is relatively small and thin, therefore not easily amenable to dental implants. Chimeric flaps containing skin, muscle, and bone can be also harvested on the pedicle for extensive defects. Unfortunately, the flap is typically harvested either in a lateral decubitus or prone position, which often requires patient repositioning during the reconstruction. The radial forearm flap is another common flap used in head and neck reconstruction, but the amount of bone that can be harvested is limited due to concerns for donor site morbidity (fracture of the residual radius). The radial forearm osteocutaneous flap is rarely used. The medial femoral condyle flap is a popular source for vascularized bone defects, but it also only provides a small block of corticocancellous bone and therefore is more popular in hand surgery or smaller defects. An iliac crest bone graft is nonvascularized and more commonly reserved for smaller defects (less than 4 to 5 cm). Large nonvascularized bone is likely to result in bony absorption and non-union.

Question 12

A 29-year-old woman presents after sustaining a traumatic avulsion of the scalp. A photograph is shown. She undergoes replantation after 5.5 hours of warm ischemia time. Which of the following cytokines is most likely to foster reperfusion injury?
A) Fibroblast growth factor 3
B) Interleukin-2
C) Transforming growth factor beta
D) Tumor necrosis factor alpha
E) Vascular endothelial growth factor

Answer 12

D. TNF-alpha
Tumor necrosis factor alpha is a key cytokine in reperfusion injury. This cytokine is proinflammatory and plays a role in mediating vasodilation, edema, and oxidative stress after restoration of perfusion.
Interleukin-2 is also proinflammatory, but it is not central to reperfusion injury. The other cytokines are growth-mediating cytokines.
Transforming growth factor beta and vascular endothelial growth factor are involved with vascular growth. Fibroblast growth factor 3 is involved with cellular growth and wound- healing.

Question 13

A 36-year-old man undergoes wide local resection of a malignancy on his right lower extremity, resulting in an exposed tendon. Which of the following flaps is most likely to require minimal subcutaneous undermining?
A ) Bilobed
B) Bipedicled
C ) Keystone
D ) Propeller
E) Rhomboid

Answer 13

C. Keystone
A keystone flap does not require significant undermining. Wide undermining would compromise flap perfusion. Various modifications exist, but one standard keystone flap marking includes lines drawn 90 degrees from the superior and inferior edges of a lenticular defect with a width equivalent to that of the defect (X in the photographs). Closure of the donor site is essentially a double V to Y. The other flaps listed require wide undermining to appropriately transpose the flap. A propeller flap is a perforator flap that involves two limbs centered around a perforator. The flap is undermined completely, although the tissue is centered about the perforator. The limb most distal from the defect is rotated 180 degrees to the defect. Rhomboid flaps and bilobed flaps also require undermining and rely on random dermal perfusion. A bipedicled flap is random with a dual dermal blood supply and requires wide undermining.

Question 14

A 48-year-old transgender woman (assigned male at birth) is evaluated by an endocrinologist for hormone therapy to induce breast development. History is significant for factor V Leiden mutation. Which of the following hormone therapies would put this patient at greatest risk for developing deep venous thrombosis?
A) Oral ethinyl estradiol
B) Oral progesterone
C) Oral tamoxifen
D) Subcutaneous testosterone
E) Transdermal estradiol

Answer 14

A. oral ethinyl estradiol

Question 15

15. An otherwise healthy 30-year-old woman undergoes bilateral reduction mammaplasty. Intravenous ketorolac is administered postoperatively in the recovery room for pain management. Compared with a patient who does not receive this medication, which of the following clinical outcomes is most likely in this patient?
    A) Equal hematoma risk and decreased opioid requirement
    B) Equal hematoma risk and equal opioid requirement
    C) Increased hematoma risk and decreased opioid requirement
    D) Increased hematoma risk and equal opioid requirement

Answer 15

A. equal hematoma risk and decreased opiod

Question 16

A 38-year-old man is brought to the emergency department after he sustained a Gustilo Type IIIB injury to the distal left lower extremity in a motor vehicle collision. Photographs and an x-ray are shown. A free flap is planned for soft-tissue coverage, and a temporary antibiotic bone cement spacer is placed in the 5-cm bone gap. Which of the following is the optimal time for using this induction membrane technique to perform the second- stage bone graft?
A ) 1 week
B ) 3 weeks
C ) 6 weeks
D) 12 weeks

Answer 16

C. 6 weeks
The Masquelet technique (induction membrane technique) is an effective two-stage technique for managing large bone gaps (even greater than 20 cm). After appropriate debridement and soft-tissue coverage, the first stage involves meticulous debridement of the nonviable bone with placement of an antibiotic cement spacer to promote the creation of an organized pseudosynovial membrane rich in inductive molecules. During the second stage, the membrane is incised and cancellous bone graft is placed. The optimal time between the two stages is 4 weeks, but if delays are anticipated (especially with compromised vascularity or soft-tissues), the second stage can be performed at 6 to 8 weeks. The three largest published clinical series used 6 to 8 weeks for the second stage. At 1 to 2 weeks, the membrane has not formed adequately. Levels of growth factor release are lower before 4 weeks. After 4 weeks, the osteogenic capacity begins to decrease, so waiting 8 to 12 weeks has no advantage and may increase the risk for failure or nonunion.

Question 17

A 35-year-old transgender man (assigned female at birth) meets World Professional Association for Transgender Health guidelines for gender-affirming genital surgery. He chooses to undergo radial forearm flap phalloplasty. During flap harvest, the plastic surgeon identifies the cutaneous nerve near the cephalic vein; the nerve is later coapted to the ilioinguinal and dorsal clitoral nerves for sensory reconstruction. This cutaneous nerve originated from which of the following more proximal nerves?
A ) Axillary
B ) Median
C) Musculocutaneous
D) Radial
E) Ulnar

Answer 17

C. musculocutaneous

The nerve in question is the lateral antebrachial cutaneous nerve, which originates from the musculocutaneous nerve. The musculocutaneous nerve innervates the coracobrachialis, biceps brachii, and brachialis muscles before terminating as the lateral antebrachial cutaneous nerve in the forearm. The lateral antebrachial cutaneous nerve is usually coapted to the ilioinguinal nerve for protective sensation, given the proximity of the two nerves to the radial forearm flap vascular pedicle and its anastomoses.
Another cutaneous nerve of the forearm that is routinely harvested during radial forearm flap phalloplasty is the medial antebrachial cutaneous nerve. This nerve originates from the medial cord of the brachial plexus, which also gives off the medial brachial cutaneous nerve as well. The radial nerve gives off the posterior antebrachial cutaneous nerve, which is usually not involved in the sensory reconstruction of free radial forearm phalloplasty. Axillary and ulnar nerves do not give off cutaneous nerves in the proximal forearm.

Question 18

A 69-year-old woman is evaluated for a pigmented lesion on the lateral cheek which has been present for 3 years. Physical examination shows a 3.7-mm–wide asymmetric lesion with irregular borders. Excisional biopsy shows a 2.2-mm–thick superficial spreading malignant melanoma. Which of the following is the most appropriate wide local excision margin for this lesion?
A. 0.5 cm
B. 1.0 cm
C. 1.5 cm
D. 2.0 cm
E. 3.0 cm

Answer 18

D. 2.0cm
Melanoma in situ, Tis stage, is best excised with a 0.5- to 1-cm margin.
Melanomas less than or equal to 1.0-mm thickness, T1 stage, are best excised with a 1.0-cm margin.
Melanomas between 1.0- and 2.0-mm thickness, T2 stage, are best excised with a 1.0- to 2.0-cm margin.
Melanomas between 2.0- and 4.0-mm thickness, T3 stage, are best excised with a 2.0-cm margin.
Melanomas with a thickness greater than 4.0 mm, T4 stage, are best excised with a 2.0-cm margin.

Question 19

A 44-year-old woman comes to the clinic because of chronic intermittent infection, pain, and drainage of the right axilla. History is significant for obesity, type 2 diabetes, and smoking, as well as multiple courses of antibiotic therapy and abscess drainage. A photograph is shown. Which of the following skin appendages is most likely involved in the disease process in the photograph?
A) Apocrine glands
B) Eccrine glands
C) Hair follicles
D) Sebaceous glands
E) Stratum spinosum

Answer 19

A. apocrine glands

Question 20

A 9-year-old boy is brought by his parents to the clinic for evaluation of a lesion on the right cheek. The lesion has steadily grown since it first appeared 6 months ago. On examination, the lesion has overlying bluish skin discoloration with an associated mobile, firm, and well-defined subcutaneous mass. Excisional biopsy is performed, and pathology results show a calcified benign mass. Which of the following is the most likely diagnosis?
A) Lipoma
B) Nevus sebaceous
C) Pilar cyst
D) Pilomatrixoma
E) Sebaceous cyst

Answer 20

D. pilomatrixoma
Pilomatrixomas, also known as calcifying epitheliomas, are benign adnexal tumors arising from the hair follicle matrix cells. They are common in the pediatric population and often arise in the mid face region of the head and neck. They are typically nonresolving lesions that slowly grow and are firmer in comparison with inclusion or sebaceous-type cysts. Excisional biopsy is the preferred treatment with low recurrence rates (1.5%). Spontaneous regression has not been reported.

Question 21

A 29-year-old woman who is a professional violinist comes to a tertiary care center 45 minutes after sustaining an amputation through the base of the fingernail of the left middle finger while chopping vegetables. The amputated digit is wrapped in saline-moistened gauze and separately placed over a bag of ice slurry. Which of the following surgical treatment options is most likely to result in the best outcome for this patient?
A) Coverage with a thenar flap
B) Local wound care
C) Replantation with Kirschner wire fixation and neurovascular microanastomosis
D) Revision amputation
E) Use amputated remnant as a composite graft

Answer 21

C. replantation with K wire fixation and neuromuscular microanastomosis
Finger amputation is most often described using Tamai’s classification. Digital amputations are separated into five zones. Fingertip amputations are separated into Tamai Zone 1 (from the fingertip to the base of the nail) and Tamai Zone 2 (from the base of the nail to the distal interphalangeal joint). The flexor digitorum profundus tendon inserts at the base of the distal phalanx in Tamai Zone 2.

Question 22

A 63-year-old woman who underwent gastric bypass surgery is treated with a circumferential lower body lift. Four weeks postoperatively, she presents with unilateral leg swelling and is diagnosed with a deep venous thrombosis on venous duplex. She is started on a pharmacologic agent with indirect inhibition of factor Xa as the primary mechanism of action. Which of the following agents did she most likely receive?
A) Apixaban
B) Dabigatran
C) Enoxaparin
D) Fondaparinux
E) Warfarin

Answer 22

D. Fondaparinux

Fondaparinux is an indirect factor Xa (thrombin) inhibitor that is administered by subcutaneous injection. It has been demonstrated to be efficacious for prophylaxis or treatment of venous thromboembolisms.
Dabigatran and apixaban are direct thrombin inhibitors. Warfarin is a vitamin K antagonist. Enoxaparin is a direct factor Xa inhibitor.

Question 23

An otherwise healthy 50-year-old woman with right-sided breast cancer undergoes autologous breast reconstruction. Which of the following free flaps has the highest risk for loss secondary to vascular thrombosis?
A) Deep inferior epigastric perforator
B) Gluteal artery perforator
C) Muscle-sparing transverse rectus abdominis myocutaneous
D) Superficial inferior epigastric artery
E) Transverse rectus abdominis musculocutaneous

Answer 23

D. SIEA
The SIEA flap has the advantage of being the only abdominally based flap that does not violate the rectus sheath, and thus has the lowest abdominal wall morbidity in terms of weakness, bulges, or hernias. However, due to its smaller vessel caliber, shorter pedicle length, and higher propensity for spasm, as well as the location of the vessel in the subcutaneous plane and at the edge of the flap, it has been shown to have a higher rate of vascular thrombosis and overall flap loss. Studies suggest the rate is as high as 17% and 7%, respectively, compared with less than 1% for the other options.

Question 24

A 28-year-old woman is evaluated to discuss treatment options for a chronic history of bilateral axillary purulent drainage from multiple sinus tracts. History includes acne. She has smoked 1 pack of cigarettes daily for 10 years. BMI is 25.1 kg/m2. Which of the following factors in this patient is most commonly associated with increased severity of symptoms of her condition?
A) Age
B) BMI
C) Duration of disease
D) Sex
E) Smoking

Answer 24

E. Smoking

Question 25

A 58-year-old woman with type 2 diabetes and hypertension is scheduled to undergo pelvic exenteration for recurrent anorectal cancer previously treated with chemotherapy and radiation. Her only prior abdominal surgery was an abdominoplasty at age 33 years. There is a large soft-tissue defect in the pelvis, as well as a large skin defect. Which of the following is the most appropriate reconstructive option for this patient?
A) Bilateral gracilis muscle flaps
B) Bilateral pudendal thigh fasciocutaneous flaps
C) Omentum and musculocutaneous gracilis flaps
D) Unilateral pudendal thigh fasciocutaneous flap
E) Vertical rectus abdominis musculocutaneous flap

Answer 25

C. Omentum and musculocutaneous gracilis flap

Unilateral or bilateral pudendal thigh fasciocutaneous (Singapore) flaps are useful for external skin defects and small soft-tissue defects, but they are not adequate for a large internal soft-tissue defect resulting from pelvic exenteration, unless combined with another flap such as the omentum flap. The vertical rectus abdominis musculocutaneous flap is the “workhorse” flap for reconstruction of large perineal defects, with better outcomes than thigh-based flaps; however, it is unavailable in this patient, who has had an abdominoplasty. As such, a muscle- only rectus abdominis flap would be an option if combined with another flap to address the external skin defect. Bilateral gracilis muscle flaps could be used for moderate-sized soft- tissue defects but do not address the large external skin defect in this patient.

Question 26

A 29-year-old transgender man (assigned female at birth) wishes to undergo gender affirmation surgery. Which of the following techniques is associated with the highest rate of urethral strictures?
A) Belgrade one-stage metoidioplasty
B) Flap prelamination with a skin graft
C) Second flap for urethral reconstruction
D) Tube-in-tube flap

Answer 26

B. flap prelamination with skin graft

The urethra can be created by prelamination of the flap with a graft, a single-flap tube-in-tube construct, or the use of a second flap for urethral reconstruction. A recent meta-analysis reported an overall urethral stricture and fistula rate of 48.9%. The highest rate of strictures was in the prelaminated group at 40.7%. The tube-in-tube group and second flap group had stricture rates of 15.5% and 18.3%, respectively.

Question 27

A 35-year-old woman comes to the clinic for evaluation because of a painful, pruritic scar following left shoulder surgery. Examination shows a 3 × 4-cm, firm, elevated, well- defined keloid scar on the left shoulder. Which of the following treatments has the lowest rate of recurrence for this lesion?
A) Carbon dioxide laser therapy
B) Excision and intralesional corticosteroid therapy
C) Excision and radiation therapy
D) Intralesional corticosteroid therapy
E) Topical 5-fluorouracil therapy

Answer 27

C. excision and radiation therapy

Question 28

An 18-year-old transgender man (assigned female at birth) presents for an initial consultation to plastic surgery to discuss top surgery. He has been taking testosterone shots for the past year. The patient wants to know the preoperative requirements for gender affirmation surgery. Which of the following best describes the 7th Edition World Professional Association for Transgender Health (WPATH) criteria for top surgery?
A) The patient must be at least 16 years of age to provide informed consent
B) The patient must be on hormone therapy for one year prior to surgery
C) The patient must have persistent, well-documented gender dysphoria
D) The patient must not have any other mental health concerns

Answer 28

C. the patient must have persistent well documented gender dysphoria

(WPATH) criteria for top surgery is that the patient must have persistent, well-documented gender dysphoria. The WPATH guidelines for female-to-male top surgery also require that the patient has the capacity to make a fully informed decision and consent for treatment and is the age of majority in a given country

Question 29

A 42-year-old man who works at an aquarium is evaluated because of a 9-month history of a painless, nonhealing, 1-cm solitary papulonodular cutaneous lesion on the right hand. Medical history is unremarkable. Examination of the hand shows no other abnormalities. Tissue histopathology demonstrates granulomatous inflammatory infiltrates. Microscopy and staining demonstrate a nonmotile, true- branching, acid-fast bacillus. Cultures are positive after several weeks’ incubation at 30.0°C (86.0°F). Which of the following is the most appropriate management?
A) Cefazolin therapy for 1 week
B) Doxycycline therapy for 3 months
C) Excision
D) Multi-antimicrobial therapy
E) Observation

Answer 29

B. doxy for 3 months

question taken out of exam. (treatment needs a cycline- Bactrim, doxy, clarithro, minocycline)

Mycobacterium marinum is a slow-growing nontuberculous mycobacterium (NTM) with an average incubation period of 3 weeks. Skin and soft-tissue infections (SSTI) secondary to M. marinum primarily occur in immunocompetent patients with minor trauma and exposure to fresh- or salt-water occupations or hobbies related to marine settings or aquatic animals (eg, fish, shells, aquariums). The most common cutaneous manifestation is a painless, solitary papulonodular lesion on a finger or hand, and it may appear in sporotrichoid form when spreading along the lymphatic vessels to the regional lymph nodes. There is often a several- month delay between the onset of the lesion and seeking medical care

Question 30

A 20-year-old woman presents to the clinic with bilateral lower extremity edema. The edema developed 3 years ago. She is a recent immigrant from India. Which of the following is the most likely cause of this patient’s lymphedema?
A) Abnormal development of lymphatic vessels
B) Destruction of lymph nodes and lymphatics
C) Lymphatic dysfunction due to increased amounts of adipose tissue
D) Obstruction of lymphatic vessels
E) Subendothelial lymphatic edema

Answer 30

D. obstruction of lymph vessels

The most common cause of lymphedema worldwide is filariasis. It is an infection caused by the roundworm (Wuchereria bancrofti). The infection is transmitted by mosquito bite, which deposits larvae on the skin. The larvae migrate into the lymphatics and cause lymphatic blockage.
primary lymphedema: mutation of endovascular growth factor C
oncologic: disruption of flow
podoconiosis: barefoot walkers exposed to silica (fibrosis and obstruction)
obesity: obstruction

Question 31

A 5-year-old girl with a history of a myelomeningocele with primary repair during infancy undergoes a tethered cord repair. One week later, she returns to the hospital with cerebrospinal fluid leaking from the wound and a 4-cm2 area of wound dehiscence centrally. Which of the following methods is most appropriate for reconstruction of the wound?
A) Coverage with a local fascial flap
B) Gluteal muscle flap advancement
C) Placement of an acellular dermal matrix
D) Split-thickness skin grafting
E) Tissue expansion

Answer 31

A. coverage with a local fascial flap

A regional muscle flap, such as the gluteal muscle flap, is not the first-line option if the paraspinous muscles/fascia are available and can increase the risk for ambulatory problems. Placement of acellular dermal matrix is incorrect, since this is nonvascularized and will not allow for healing across the wound bed in the setting of leakage from the spinal cord. Similarly, a split-thickness skin graft directly over the dura/spinal cord would be unstable and less protective than a local fascial flap. Tissue expansion in the setting of an open wound with cerebrospinal fluid would be contraindicated.

Question 32

A 72-year-old man is evaluated because of a 1 × 1-cm skin defect on the lateral nose following Mohs micrographic excision of a basal cell carcinoma. On examination, the defect is located just superior to the ala, and the perichondrium is intact at the base of the wound. The patient wishes to have the best aesthetic outcome possible but prefers that any necessary interventions be completed in a single stage. Which of the following is the most appropriate treatment for this patient?
A) Bilobed flap reconstruction
B) Composite grafting
C) Healing by secondary intention
D) Paramedian forehead flap reconstruction
E) Split-thickness skin grafting

Answer 32

A. bilobed flap

A bilobed flap offers single-stage reconstruction and is particularly suitable for nasal defects on the lateral sidewall that are 1 cm or less in diameter. Since the procedure involves local tissue rearrangement, the color and skin thickness match offers a good aesthetic result. Healing by secondary intention is possible, but it can result in significant scarring and is not a good option for this patient, since he would like a single-stage procedure. A split-thickness skin graft can cover the wound in a single procedure but will not result in good color or skin thickness match with the surrounding tissue. The use of a full-thickness skin graft may be possible, and the benefits of a full-thickness graft versus a bilobed flap remain equivocal. A composite graft is often used for alar rim reconstruction but is not indicated for a skin and subcutaneous tissue-only defect. A paramedian forehead flap is not necessary for this small of a defect and could not be completed in a single stage for this patient.

Question 33

An otherwise healthy 45-year-old man with paraplegia is evaluated because of a clean, slow-healing ischial pressure ulcer. Closure of the ulcer with a proximally based posterior thigh fasciocutaneous transposition flap is planned. The axial blood flow to this flap is supplied by a branch of which of the following arteries?
A) Inferior gluteal
B) Lateral circumflex femoral
C) Profunda femoris
D) Superficial femoral
E) Superior gluteal

Answer 33

A. inferior gluteal (descending branch)

This vessel runs axially along the posterior thigh, along a course from the midpoint between the ischial tuberosity and the greater trochanter proximally, and the popliteal fossa distally. The vessel runs alongside the posterior cutaneous nerve of the thigh. The posterior thigh skin also has contributions from perforators from the profunda system, through the underlying thigh musculature, which is the main blood flow of the hamstring muscle/musculocutaneous flaps. However, in a true proximally based posterior thigh fasciocutaneous flap, those perforators are transected when the flap is raised.

Question 34

A 15-year-old girl is brought to the office for management of facial asymmetry. Over the past 2 years, the patient has progressively developed atrophy of the soft tissues of the left side of her face. She reports that the asymmetry is getting worse. Physical examination shows marked soft-tissue atrophy of the left mid face and lower face with a slight upward occlusal cant. Which of the following therapies is the most appropriate treatment for this patient’s condition?
A) Calcium carbonate
B) Clindamycin
C) Methotrexate
D) Sodium thiosulfate
E) Warfarin

Answer 34

C. methotrexate

This patient has progressive hemifacial atrophy (Parry-Romberg syndrome). This condition is characterized by atrophy of the hemi face typically in the mid and lower face (cranial nerve
V2 and V3 distribution), although the forehead may also be involved. The skin and subcutaneous tissue are most frequently involved, although it can also affect muscle, cartilage, and bone. Onset is in the first two decades of life in the majority of cases. The disease progresses for 2 to 10 years before it stabilizes (“burns out”). Parry-Romberg syndrome is thought to be an immune-mediated disease. There is currently no cure for the condition. Methotrexate is considered one of the first-line medical treatments to halt disease progression. It is frequently combined with prednisone for the first 3 months since methotrexate has a delayed effect on inflammation and fibrosis. Current evidence suggests that methotrexate therapy be administered for 12 to 24 months to induce prolonged remission. Methotrexate is administered in oral or intravenous form, at a dosage of 0.3 to 1 mg/kg/week with a maximum dose of 25 mg/week. Immunosuppressive drugs, like cyclosporine, mycophenolate mofetil, and cyclophosphamide, have been reported as treatments in isolated case reports. Other treatments that have been described are antimalarial, retinoids, penicillamine, tetracycline, and topical steroids with variable success.

Question 35

An 18-year-old woman with congenital vaginal agenesis undergoes reconstruction with bilateral pudendal fasciocutaneous thigh flaps. Which of the following is the sensory innervation of these flaps?
A) Genitofemoral nerve
B) Lateral femoral cutaneous nerve
C) Obturator nerve
D) Pudendal nerve
E) Saphenous nerve

Answer 35

D. pudendal nerve

The pudendal thigh flap (also known as a Singapore flap) is a local fasciocutaneous flap used for vaginoplasty. It can be sensate with innervation from the posterior labial nerve branches of the pudendal nerve. The blood supply is terminal branches of the superficial perineal artery.
lateral femoral cutaneous–ALT
obturator—gracilis
saphenous n (branch of femoral)–medial thigh
genitofemoral–upper thigh, mons, labia, anterior scrotum

Question 36

A 38-year-old man presents with a large midline abdominal ventral hernia following colectomy. Physical examination shows a 16 × 9-cm midline fascial defect. Posterior component separation repair with transversus abdominis release and retrorectus mesh placement is planned. To maintain innervation to the rectus abdominis muscles, identification and preservation of which of the following nerves during dissection is most appropriate?
A) Iliohypogastric
B) Ilioinguinal
C) Intercostal
D) Lateral cutaneous
E) Subcostal

Answer 36

C. intercostal

iliohypogastric- innervation of transverses and internal oblique
subcostal– external oblique
ilioinguinal– sensation to mons, labia, scrotum

Question 37

A 47-year-old woman with a history of abdominoplasty presents for discussion of delayed unilateral right breast reconstruction following mastectomy. The patient is interested in autologous options. After discussion with the patient, the plastic surgeon elects to use a horizontally oriented profunda artery perforator flap from the upper posterior thigh. In this area, the dominant perforator most commonly courses through which of the following muscles?
A) Adductor brevis
B) Adductor longus
C) Adductor magnus
D) Gracilis
E) Rectus femoris

Answer 37

C. adductor Magnus

posterior to gracilis

Question 38

A 20-year-old woman is scheduled to undergo open rhinoplasty and bilateral lateral nasal osteotomies. Administration of which of the following agents is most appropriate to limit perioperative blood loss in this patient?
A) Ketorolac
B) Methylprednisolone
C) Thromboxane
D) Tranexamic acid
E) Vitamin K

Answer 38

D. TXA

Question 39

A 40-year-old man comes to the office with bilateral lower extremity swelling. The swelling has occurred over the course of the past few years. He reports no history of cardiac or renal dysfunction, no prior surgeries, and no travel outside the United States. BMI is 58 kg/m2. Physical examination shows bilateral lower extremity pitting edema and a positive Stemmer sign. There are no signs of venous insufficiency. Lymphoscintigraphy shows dermal back flow in both lower extremities. Which of the following is the most appropriate surgical treatment for this condition?
A) Bariatric surgery
B) Charles operation
C) Lymphovenous anastomosis
D) Suction lipectomy
E) Vascularized lymph node transfer

Answer 39

A. bariatric surgery

Question 40

A 52-year-old woman is evaluated because of an 18-month history of right upper extremity swelling and pain. History includes a right modified radical mastectomy for breast cancer 3 years ago. BMI is 25 kg/m2. The patient has tried 9 months of physical therapy, compression, and lymphatic massage with minimal improvement of symptoms. Which of the following is the most appropriate next step in management?
A) Initiate oral diuretic therapy
B) Perform liposuction
C) Perform vascularized lymph node transfer
D) Recommend weight loss
E) Refer for magnetic resonance lymphangiography

Answer 40

E. magnetic resonance lymphangiography

Question 41

A 21-month-old boy with Treacher Collins syndrome is scheduled to undergo mandibular distraction osteogenesis. Which of the following is the primary mechanism by which new bone will form for the mandibular lengthening associated with this procedure?
A) Endochondral ossification
B) Intramembranous ossification
C) Osteoconduction
D) Osteogenesis
E) Osteoinduction

Answer 41

B. intramembranous ossification

Distraction osteogenesis is a technique in which an osteotomy is first performed, and then distraction of the surrounding vascularized bone segments is performed with a mechanical device. The hallmark of this process is formation of new bone within the distraction gap. This technique is commonly used for reconstruction of certain bony defects in the craniofacial skeleton.
New bone is formed during distraction osteogenesis via the process of intramembranous ossification. The key is that the new bone is spontaneously formed without a cartilaginous intermediate. In addition to distraction osteogenesis, intramembranous ossification occurs during fetal development with the formation of the flat bones. It also occurs with primary bone healing.
Osteogenesis is the primary mechanism for healing of a vascularized bone graft. Osteoblasts that survive the bone graft transfer procedure and osteoblasts at the native recipient bone both participate in the formation of new bone to heal the bony interface.
Osteoconduction is the primary process for healing of cortical bone grafts. Blood vessels and cells from the recipient wound bed grow into the cortical bone graft, which functions as a template for the deposition of new bone.
Endochondral ossification involves formation of new bone via a cartilaginous intermediate. This process is seen during fetal long bone development and during bony fracture healing via a cartilaginous callus.
Osteoinduction, which is seen in healing of cancellous bone grafts, involves bone morphogenetic protein stimulating mesenchymal cells at the recipient site to differentiate into osteoprogenitor cells.

Question 42

An 18-year-old woman presents to the clinic with absence of menses and reports her concern for vaginal agenesis. She is diagnosed with Mayer-Rokitansky-Küster- Hauser syndrome. The patient is interested in reconstruction of the vagina. Which of the following has the highest chance of restenosis?
A) Colonic interposition vaginoplasty
B) Reconstruction with pudendal thigh flaps
C) Serial dilation of the rudimentary vaginal pouch
D) Split-thickness skin grafting over a vaginal mold
E) Vulvovaginoplasty

Answer 42

C. serial dilation of pouch

Question 43

A 58-year-old woman presents with a 2-cm, raised, red ulcerative lesion on the left central cheek that has been growing for 2 years. Examination of a specimen obtained on biopsy discloses nodular basal cell carcinoma. Elliptical excision and complex closure is planned. Which of the following is the optimal surgical margin?
A) 1 to 2 mm
B) 4 to 6 mm
C) 10 to 12 mm
D) 2 cm
E) 3 cm

Answer 43

B. 4-6mm

Question 44

A 28-year-old man comes to the emergency department 2 hours after sustaining a sharp genital self-mutilation amputation at the base of his penis. The patient undergoes replantation and revascularization. In addition to anastomosis of the dorsal penile artery, reanastomosis of which of the following additional arteries is recommended in order to provide optimal blood flow to the penile skin?
A) Cavernosal
B) External iliac
C) Inferior external pudendal
D) Urethral

Answer 44

C. inferior external pudendal

Question 45

A 5-year-old girl presents to the clinic with a right temporoparietal cranial defect. History is significant for a nonaccidental trauma requiring a decompressive craniectomy 2 years ago. The initial bone flap was replaced but has resorbed due to a prior infection. The residual defect measures 10 × 8 cm. Which of the following materials is most appropriate for reconstruction of this defect?
A) Demineralized bone
B) Hydroxyapatite cement
C) Methyl methacrylate
D) Porous polyethylene
E) Split calvarial bone

Answer 45

E. split calvarial bone

Autologous split calvarial bone is the most appropriate material due to the large size of the defect, the age of the patient, and the prior history of infection. Calvarial bone can be split as early as age 3 years, when the diploic space has developed
demineralized bone–osteoinductive, not good for big gaps due to cost
hydroxyapatite– expensive, prone to fracture, high complication rate
methyl methacrylate–high risk of infection
PPE- expensive, can be used for large defects but won’t grow with the patient, not protective against infection

Question 46

A 64-year-old man undergoes pharyngectomy with anterolateral thigh free flap reconstruction. Blood loss is minimal and surgery is proceeding smoothly. The anesthesiologist reports persistent mild hypotension and would like to initiate vasopressor infusion. Vasopressor use would most likely have which of the following outcomes in this patient?
A) Decreased flap loss
B) Increased flap loss
C) Increased risk for adverse cardiac events
D) No effect on flap survival

Answer 46

D. no effect on flap survival

Question 47

A 16-year-old boy comes to the clinic for follow-up 1 year after sustaining third-degree burns to the scalp in a house fire. He lost about 30% of the scalp vertex because of the burn injuries and now has alopecia in this region. Initial treatment included debridement and split-thickness skin grafting of the scalp. Reconstruction of the scalp with staged tissue expansion to correct the skin graft alopecia is planned. Which of the following factors is most commonly associated with premature removal of the expander in this scenario?
A) Location of the tissue expander
B) Patient age
C) Sex of the patient
D) Use of multiple expanders

Answer 47

D. use of multiple expanders

The odds of premature removal are increased with younger age of patient, greater number of expanders placed at the initial operation, and expander placement in the lower extremity. Patient sex does not appear to affect this risk. The number of rounds of serial expansion and the indications for surgery do not appear to have a significant impact either.

Question 48

A 5-month-old infant presents with a raised, rubbery, bright red tumor. History shows that the lesion began as an area of telangiectasia at around eight weeks of age. Which of the following is most likely to be a characteristic of this lesion?
A) Decreased number of mastocytes
B) GLUT-1 positive immunohistochemistry
C) Growth proportionate with the child’s growth
D) Normal basement membrane
E) Normal endothelial cell cycle

Answer 48

B. GLUT-1 positive immunohisto

Features of hemangiomas that distinguish them from vascular malformations include GLUT- 1 positive immunohistochemistry, increased endothelial cell proliferation, thick basement membrane, a 5:1 female prevalence, rapid growth out of proportion to the child’s growth, and increased number of mastocytes.

Question 49

A 42-year-old woman is scheduled for an abdominoplasty with flank liposuction. A regional anesthetic block is planned to decrease postoperative pain and minimize the need for narcotics. The anesthetic should be placed between which of the following anatomic structures?
A) External oblique muscle and internal oblique muscle
B) Internal oblique muscle and transversus abdominis muscle
C) Skin and external oblique muscle
D) Transversus abdominis muscle and transversalis fascia
E) Transversalis fascia and peritoneum

Answer 49

B. internal and transversus

The transversus abdominis plane (TAP) block is a regional anesthetic that blocks sensory afferent nerve fibers that supply the anterior/lateral abdominal wall dermatomes of T6-L1. These sensory nerves travel below the internal oblique muscle in the plane above the transversus abdominis muscle. Traditionally, the technique is performed blindly by placing a needle through the triangle of Petit posteriorly until the needle reaches the TAP. Once in the appropriate plane, 20 mL of a long-acting local anesthetic, such as bupivacaine, are injected.

Question 50

A 38-year-old man undergoes reconstruction of a lower extremity wound with a muscle flap and skin graft. Which of the following best describes the immediate mechanism for skin graft survival after placement onto the recipient wound?
A) Dermal contraction
B) Encapsulation
C) Inosculation
D) Plasmatic imbibition
E) Revascularization

Answer 50

D. plasmatic imbibition

1. imbibition
2. revasc and inosculation

full thickness - greater primary contracture
STSG- greater secondary

Question 51

Laser type and color of tattoo
Red
Green
Black

Answer 51

Red: pulse dye (510) and doubled nd:YAG (532)
Green: alexandrite (755)
Black: ruby (694), alexandrite, and Nd:YAG (1064)

Question 52

Laser type and chromophore

Answer 52

Pulse dye 585 Oxyhemoglobin

Ruby 694 melanin (tattoos, hair)

ER:YAG 1000-2000 water