Plastic Surgery Question Bank

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1. A 71-year-old woman with diabetes has a 4 x 3 cm ulcer over the lateral calcaneus with exposed bone. She has no palpable pedal pulses, and her toe pressure is 22 mmHg. The plastic surgery team is considering a free flap. What is the most appropriate next step?

A toe pressure below 30 mmHg indicates critical limb-threatening ischaemia, and wounds will not heal and flaps will fail without restoring inflow. The IWGDF and Global Vascular Guidelines recommend urgent vascular imaging (duplex, CTA, MRA or DSA) and revascularisation by endovascular or bypass surgery. Revascularisation ideally aims at the angiosome feeding the wound. Flap surgery is then planned once perfusion has improved, often within days to weeks. Free flaps can even act as distal runoff for a bypass. Operating on an unperfused foot risks necrosis. Primary amputation is premature without first assessing whether revascularisation is possible. Pearl: diabetic foot care works best as a joint vascular and plastic surgery team.

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2. A 22-year-old man has multiple basal cell carcinomas on the face and trunk, palmar pits, and a history of enucleation of two odontogenic keratocysts of the mandible. Skull radiograph shows calcification of the falx cerebri. Which treatment modality should be avoided for his skin cancers?

Gorlin (naevoid basal cell carcinoma) syndrome is an autosomal dominant disorder, mostly due to germline PTCH1 mutations, with multiple BCCs from a young age, odontogenic keratocysts, palmar and plantar pits, falx calcification, bifid ribs and medulloblastoma. Affected cells are hypersensitive to ionising radiation, which induces numerous new BCCs within the treatment field, so radiotherapy should be avoided and diagnostic radiation minimised. Tissue-sparing surgery, including Mohs, and field treatments such as photodynamic therapy, imiquimod and 5-FU are preferred. Standard excision remains appropriate for individual tumours. Pearl: hedgehog inhibitors reduce new BCC formation in Gorlin syndrome but are limited by side effects.

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3. A 78-year-old man had a cutaneous squamous cell carcinoma excised from the temple six months ago. He now has a 2-cm firm, non-tender mass in the parotid region. Facial nerve function is normal. What is the most appropriate next investigation?

The parotid and intraparotid nodes are the first echelon for scalp, temple, forehead and ear cSCC, and a new parotid mass after head and neck cSCC is a nodal metastasis until proven otherwise. Ultrasound-guided FNAC is the recommended first test (BAD 2020, NCCN), followed by CT or MRI of head and neck with chest imaging for staging, then parotidectomy with neck dissection and adjuvant radiotherapy. Open incisional biopsy of a parotid mass risks tumour spillage and facial nerve injury. Tumour markers have no diagnostic role. Sentinel node biopsy applies to clinically node-negative patients, not a palpable mass. Pearl: palpable nodes should be sampled before definitive surgery.

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4. A 30-year-old very slim woman (BMI 17.5 kg/m2) had subglandular augmentation with saline implants. She now has visible rippling of the upper and medial poles, worse when she leans forward. What is the most effective surgical correction?

Rippling reflects implant wall folds transmitted through thin soft tissue. It is more common with saline and textured implants, underfilling, and subglandular placement in thin patients. The most effective correction increases soft-tissue cover and reduces shell folding: convert to a cohesive silicone implant, which ripples less than saline, placed in a subpectoral/dual-plane pocket, with adjunctive fat grafting or acellular dermal matrix. Overfilling saline gives little benefit and may cause scalloping. Larger implants thin the tissue further. Capsulorrhaphy tightens the pocket but does not add cover. Pearl: rippling is a major reason to prefer submuscular cover in thin patients.

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5. A 51-year-old woman had nipple reconstruction with a skate flap after a completed breast reconstruction. She asks when the areola can be tattooed. The flaps have healed well and there is no sign of infection. What is the usual recommended timing?

Areolar tattooing is usually done about 2-3 months after nipple reconstruction, once the flap has healed and its final position and projection have largely settled. Tattooing is then applied to the areola and the reconstructed nipple for colour matching. Doing it at the same time risks pigment loss and flap compromise from needle trauma to fresh flaps. Tattooing after 1 week is too early. Waiting 2 years is unnecessary. Pigment fades with time, and repeat sessions are commonly needed. Some patients prefer three-dimensional nipple-areola tattooing alone, without a surgical nipple, which avoids further surgery and gives good aesthetic results. Pearl: tattoo pigment fades faster in irradiated skin.

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6. Which characteristic distinguishes a rapidly involuting congenital haemangioma (RICH) from an infantile haemangioma?

Congenital haemangiomas grow in utero and are fully formed at birth, lacking the postnatal proliferative phase of infantile haemangioma. They are GLUT1 negative. RICH involutes rapidly, often completing regression by 12–14 months and leaving atrophic skin or a fatty deficit. Non-involuting congenital haemangioma (NICH) grows with the child without regression, and partially involuting (PICH) forms an intermediate group. Infantile haemangiomas appear shortly after birth, proliferate mainly over the first 5 months and are GLUT1 positive. Persistence into adulthood describes NICH, not RICH. Pearl: RICH may transiently cause mild thrombocytopenia or cardiac failure but does not respond predictably to propranolol.

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7. A 52-year-old woman is 14 hours after a free anterolateral thigh flap to the lower leg. The skin paddle is purple, swollen and tense; capillary refill is under 1 second, and pinprick produces rapid dark blood. The hand-held Doppler signal over the perforator is still audible. What is the most appropriate next step?

The paddle shows classic venous congestion: blue-purple colour, oedema, brisk capillary refill and rapid dark bleeding. An arterial Doppler signal can persist for hours after venous thrombosis, so it does not reassure. Salvage rates fall steeply with delay, and most thromboses occur in the first 24-48 hours, so prompt re-exploration is mandatory. Leeches are for venous congestion when surgical revision is impossible (for example, no vein available), not a substitute for exploring a correctable anastomotic problem. Elevation alone wastes salvage time, and dextran has not been shown to rescue flaps and carries systemic risks.

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8. When harvesting a free fibula osteocutaneous flap, how much distal fibula should be preserved, and why?

About 6-7 cm of distal fibula must be kept to preserve the lateral malleolus and ankle mortise, preventing ankle instability and valgus deformity (especially in children, in whom syndesmotic fixation may be added). Proximally, about 4-6 cm is kept to protect the common peroneal nerve as it winds around the fibular neck and to preserve the knee's lateral ligament attachments. Up to about 25 cm of bone can be harvested between these limits. The sural nerve is not the reason for distal preservation. Preserving more bone does not change peroneal artery harvest.

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9. During dissection for a unilateral abdominal free flap in a 45-year-old woman requiring only hemiabdominal volume, the surgeon finds a superficial inferior epigastric artery 1.8 mm in diameter with a visible pulse, plus an accompanying large vein. What is the main advantage of using this vessel for the flap?

The superficial inferior epigastric artery (SIEA) flap is harvested entirely above the fascia, so the rectus sheath and muscle are untouched, avoiding the donor morbidity of even a DIEP. It is suitable only when the artery is adequate, generally at least 1.5 mm in diameter with a visible pulse, which occurs in a minority of patients (about 30%). It perfuses mainly the ipsilateral hemiabdomen, not all four zones. The pedicle is shorter and smaller than the deep inferior epigastric pedicle, which raises the risk of thrombosis. A microvascular anastomosis is still needed. Pearl: the superficial inferior epigastric vein is also a useful lifeboat to relieve venous congestion in DIEP flaps.

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10. A 27-year-old woman has primary epineurial repair of a clean median nerve laceration in the proximal forearm. The motor point of abductor pollicis brevis is about 20 cm distal to the repair. When is clinical reinnervation of abductor pollicis brevis most likely to be seen?

After a delay of several weeks for axonal sprouting across the coaptation, peripheral axons regenerate at roughly 1 mm/day (about 1 inch a month). So a 200 mm distance needs about 6-7 months, plus the initial delay. An advancing Tinel sign is used to monitor progress. Recovery at 3-4 weeks would be too fast for regeneration and would suggest neurapraxia. Delays of 2-4 years exceed the window of motor endplate survival (about 12-18 months), when functional recovery becomes unlikely. Pearl: proximal injuries have poorer motor outcomes because of this distance-time limit.