Free FRCS (Plast) practice questions

This is suture extrusion ('spitting'), a sterile foreign-body reaction that expels buried suture through the skin. It is most frequent with braided polyglactin, which is reactive, wicks fluid along its braid and persists for about 90 days. Poliglecaprone 25 is a monofilament with low reactivity, loses its strength within three weeks and is cleared by around 100 days, and limited evidence shows less extrusion than polyglactin, so it is the better choice for revision. A triclosan coating does not alter the braid or its reactivity; polydioxanone is monofilament but is stiff, persists for about six months and its bulky knots are prone to extrude; a heavier 2-0 polyglactin simply adds more braided material; and buried nylon is permanent, so a reaction gives a persistent sinus. Reference: Janis, Essentials of Plastic Surgery 3e, ch. 3; Key Notes on Plastic Surgery 2e.

Laser and diathermy plume from HPV-infected tissue contains viable viral DNA, and laryngeal papillomatosis and HPV-related tonsillar carcinoma are reported in surgeons who treated warts unprotected; plume also carries carbonised particles of 0.1–5 micrometres and toxic volatiles. Protection needs both source control and respiratory protection: a dedicated smoke evacuator with an ULPA/HEPA filter held within about 2 cm of the site captures the plume, and FFP3 respirators filter the fine particulate that passes straight through a fluid-resistant surgical mask. A surgical mask with evacuation leaves the residual fraction unfiltered; a respirator with intermittent theatre suction misses most of the plume and contaminates the suction system; and visors with laminar flow protect eyes and wound, not airway. Reference: Key Notes on Plastic Surgery 2e (laser plume); HSE research on surgical plume; Control of Artificial Optical Radiation at Work Regulations 2010.

A scar-like, ill-defined, indurated plaque with thin basaloid strands set in a dense fibrous (sclerotic) stroma is the morphoeic (sclerosing) BCC, the most aggressive common subtype, with a high incomplete-excision rate because subclinical spread far exceeds the visible lesion; it is high-risk and best treated by Mohs or wide excision with delayed reconstruction. Infiltrative BCC also has jagged strands and islands but lacks the prominent sclerotic stroma; micronodular tumours form small rounded nests the size of hair bulbs; nodular BCC forms large well-circumscribed lobules with peripheral palisading and a pearly clinical appearance; basosquamous carcinoma shows areas of squamous differentiation with transitional zones. Reference: Key Notes on Plastic Surgery 2e; BAD guidelines for the management of adults with basal cell carcinoma 2021.

New sensory loss and neuralgic pain in the infraorbital nerve territory after a cutaneous SCC of the cheek indicate clinical perineural invasion, with tumour tracking along the infraorbital nerve towards the pterygopalatine fossa and skull base. Contrast-enhanced MRI is the investigation of choice: it shows nerve thickening and enhancement, obliteration of fat in the foramina and intracranial extension, and defines the field for radiotherapy or the extent of resection. CT demonstrates foraminal widening and bone erosion only late and misses early neural spread; ultrasound and PET-CT assess nodal and distant disease rather than nerve involvement; biopsy of a soft, clinically normal scar has a low yield and does not map the nerve. Clinical perineural invasion is very high-risk disease requiring specialist MDT management. Reference: BAD guidelines for the management of people with cutaneous squamous cell carcinoma 2020.

This is an auricular (subperichondrial) haematoma. Blood strips the perichondrium from the cartilage; if it is not evacuated and the perichondrium re-apposed, cartilage necrosis and disorganised neocartilage produce a permanent cauliflower ear. At three days the clot is organising, so needle aspiration alone is usually incomplete and re-accumulation is common; incision along a helical fold, evacuation and through-and-through mattress bolster sutures (or a moulded splint) obliterate the dead space and hold the perichondrium down. Antibiotics or compression alone leave the collection in place, and waiting for fibrosis accepts the deformity, which is then only partially correctable. Reference: Janis, Essentials of Plastic Surgery 3e; Key Notes on Plastic Surgery 2e.

This is the standard manoeuvre for protecting the frontal branch. It runs within or under the temporoparietal fascia, superficial to the deep temporal fascia, and in the 2 cm above the arch lies in the loose innominate fascia superficial to the fat pad, so continuing in the subgaleal plane here brings the dissection onto the nerve. Incising the superficial layer of the deep temporal fascia where the fat pad begins and dissecting deep to it, through the fat onto the arch periosteum, keeps fascia and fat between the instrument and the nerve. A subcutaneous plane or dissection within the temporoparietal fascia puts the nerve directly at risk, and going deep to temporalis is unnecessary and leads into the infratemporal fossa. Reference: Janis, Essentials of Plastic Surgery 3e (temporal fascial layers, frontal branch course); Key Notes on Plastic Surgery 2e.

This is a thin-coverage breast with a lax, mildly ptotic lower pole — the classic indication for a dual-plane pocket. Releasing the inferior pectoral origin gives muscle cover to the upper pole where the pinch is under 2 cm, while freeing the parenchyma lets the loose gland redrape over the implant, expanding the lower pole and centring the nipple on the point of maximal projection. Subglandular and subfascial planes leave a palpable, visible implant edge with this little cover and carry higher contracture rates. Total submuscular and undivided subpectoral pockets restrict lower-pole expansion, so the implant rides high while the lax gland slides off it, producing a waterfall (type A double-bubble) deformity. Reference: Tebbetts, dual-plane breast augmentation (PRS 2001); Janis, Essentials of Plastic Surgery 3e, Breast Augmentation.

This is bottoming out, a pseudoptosis in which the gland and skin of the lower pole descend beneath a nipple that stays fixed — the nipple-to-fold distance exceeds half the base width and the nipple ends up high and upward-pointing. Correction removes the excess: an inferior wedge or horizontal ellipse of lower-pole skin and parenchyma, shortening of the vertical limb and re-fixation of the fold, which recentres the existing nipple on the mound. Any procedure that raises the nipple further — a repeat pedicled reduction, a crescent lift or a superomedial mastopexy — converts an already high nipple into an uncorrectable star-gazing deformity. An implant adds volume she does not need and loads the stretched lower pole, worsening the descent. Reference: Regnault, pseudoptosis; Janis, Essentials of Plastic Surgery 3e (bottoming out).

The anterior (Ramirez) component separation divides the external oblique aponeurosis 1–2 cm lateral to the linea semilunaris and develops the avascular plane between external and internal oblique, allowing each rectus complex to slide medially — up to around 8–10 cm per side at the umbilical level. Dividing the internal oblique or transversus would breach deeper layers and risk the intercostal neurovascular bundles running between them; incising the anterior rectus sheath describes a Gibson-type release, not component separation; and the posterior sheath is opened in retromuscular (Rives-Stoppa/posterior) approaches instead. Reference: Ramirez, components separation method (1990).

This is a complete rupture of the thumb MCP ulnar collateral ligament with a Stener lesion: the palpable lump is the retracted ligament end lying superficial and proximal to the adductor aponeurosis, which is interposed between it and its insertion so it cannot heal. Gross laxity with no end point confirms a complete tear, so acute open repair (bone anchor or pull-out suture) through the aponeurosis is indicated. Splint or cast immobilisation suits partial tears with a firm end point. Free tendon graft reconstruction is reserved for chronic instability when the remnant is irreparable, and adductor advancement is a dynamic salvage for chronic cases, not an acute repair. Reference: Janis, Essentials of Plastic Surgery 3e (phalangeal dislocations); Key Notes on Plastic Surgery 2e.

This is return to work after flexor tendon repair. The splint is typically discarded at around six weeks, with light functional use from then, graded resisted exercise from about eight weeks, and unrestricted heavy or forceful gripping deferred until about twelve weeks, when the repair has regained enough tensile strength to make late rupture unlikely. Returning now or at eight weeks exposes a still-remodelling repair to peak loads; and delaying to sixteen weeks or six months is unnecessary for an uncomplicated repair and prolongs time off work. Reference: Janis, Essentials of Plastic Surgery 3e, ch. 80 (postoperative care and rehabilitation).

This is a lower-plexus traction injury, and a preserved sensory nerve action potential (SNAP) in an anaesthetic territory localises it proximal to the dorsal root ganglion. In a preganglionic avulsion the sensory axons stay attached to their cell bodies in the ganglion, so they do not undergo Wallerian degeneration and still conduct, although the patient feels nothing. A postganglionic lower-trunk or medial-cord lesion separates axons from the ganglion, so the SNAP is lost; a combined pre- and postganglionic injury behaves the same way electrically. An ulnar lesion at the elbow cannot explain the median-innervated long flexors or medial forearm numbness and would also abolish the SNAP. Reference: Key Notes on Plastic Surgery 2e, traumatic brachial plexus injury.

This is a radial nerve palsy after humeral shaft fracture that has failed to recover. Most such palsies are neurapraxias that recover, which is why observation is standard initially, but by 4–6 months brachioradialis (the first muscle reinnervated) should show clinical or EMG recovery. A static Tinel's sign and denervation without motor units suggest a lesion that will not recover, so the nerve should be explored for neurolysis, repair or grafting while end plates remain viable. Further observation risks passing the window for reinnervation. Tendon transfers are for irreparable injuries or late presentation, and a pronator teres to ECRB 'internal splint' supplements, but does not replace, nerve reconstruction. Reference: Janis, Essentials of Plastic Surgery 3e, radial nerve palsy; Key Notes on Plastic Surgery 2e.

This is a deep tissue pressure injury. Prolonged loading against the sacrum generates the highest pressure and shear at the bone-muscle interface, and muscle, with its high metabolic rate, is the tissue least tolerant of ischaemia; a pressure injury therefore begins deep and extends outwards in a cone whose apex is at the skin, so intact purple, boggy skin signals a large volume of necrotic muscle and fat beneath that will declare itself as a category 3 or 4 ulcer over days to weeks. The epidermis and dermis are the most resistant and are damaged last; subcutaneous fat is involved but less than muscle; and periosteum is affected only in the deepest established ulcers. Management is complete offloading and observation without early debridement. Reference: EPUAP/NPIAP pressure injury classification; Key Notes on Plastic Surgery 2e (pressure sores).

This is an open fracture awaiting primary debridement. The BOA/BAPRAS standards limit emergency department wound handling to removing gross contamination, photographing the wound and covering it with saline-soaked gauze under an occlusive film; the photograph lets every later reviewer see the wound without exposing it again, as repeated inspection adds hospital-acquired contamination. Irrigation belongs in theatre alongside formal excision, not in the resuscitation room. Negative pressure dressings are applied only after surgical debridement. Pre-debridement swabs correlate poorly with the organisms that cause later infection, and antiseptic packing adds nothing and damages tissue. A loose dressing lifted at each review defeats the purpose of the photograph. Reference: BOAST Open Fractures (BOA/BAPRAS); Standards for the Management of Open Fractures (BOA/BAPRAS).

The picture is under-resuscitation: urine output well below the 0.5-1.0 mL/kg/hr target (12 mL/hr is about 0.17 mL/kg/hr) with tachycardia, haemoconcentration and a rising lactate. Burns formulae only estimate the starting rate, so fluids must be titrated up to the urine-output endpoint, and the correct step is to increase the crystalloid resuscitation rate. A vasopressor treats vasodilatation, not the hypovolaemia of burn oedema, and can worsen perfusion; furosemide is dangerous when the patient is under-filled; making no change ignores that the formula is only a guide; and switching to 0.9% saline risks hyperchloraemic acidosis without addressing volume. Reference: EMSB; British Burn Association resuscitation endpoints.

This describes an evolving upper-airway inhalation injury with impending obstruction: facial burns, singed vibrissae, carbonaceous sputum, hoarseness and progressive supraglottic oedema. EMSB/ATLS teaching is to secure the airway early with elective endotracheal intubation before oedema (which worsens over the first 24-48 hours) makes intubation impossible; hoarseness signals laryngeal involvement and a normal saturation is falsely reassuring. Waiting for stridor (D) is dangerous because stridor is a late pre-obstructive sign; nebulised adrenaline and steroids (A) and observation (B) do not arrest progressive oedema; deferring an awake technique until fasted (E) wastes the safe window in an emergency. Reference: EMSB airway guidance.

Symmetrical stocking-distribution burns with a clear horizontal upper tide-line and sparing of the flexion creases or soles indicate forced immersion in hot water, a classic inflicted-injury pattern, and warrant safeguarding referral. Accidental scalds typically show irregular margins, splash or satellite marks and a run-off pattern from a spilt liquid, or a contact pattern on the palm from grasping a hot object; pulling hot liquid from a height is the commonest accidental scald mechanism in toddlers. A delayed presentation adds concern but the immersion pattern is the strongest single feature. Reference: British Burn Association / NICE CG89 (child maltreatment: when to suspect).

This is intraoperative ischaemia of the umbilicus. The stalk is perfused by the subdermal plexus, direct branches of the deep inferior epigastric arteries, the ligamentum teres and the median umbilical ligament; skeletonising it removes the plexus contribution, and tight midline plication then constricts the remaining deep supply at the fascial base. The remediable cause is the constriction, so the plication sutures around the stalk are released to widen the fascial aperture and perfusion reassessed. Enlarging the skin aperture relieves nothing at fascial level. Amputating the stalk or converting the umbilicus to a graft are salvage options for a non-viable umbilicus, not first steps when the compromise is correctable. Closing and waiting risks full-thickness necrosis and a scarred, retracted umbilicus. Reference: Janis, Essentials of Plastic Surgery 3e (abdominoplasty: umbilical blood supply); Key Notes on Plastic Surgery 2e.

This tests the Montgomery standard of disclosure (Montgomery v Lanarkshire Health Board, 2015). A risk is material if a reasonable person in the patient's position would be likely to attach significance to it, or if the doctor is or should reasonably be aware that this particular patient would; for a presenter whose livelihood depends on facial animation, even a sub-1% risk of permanent weakness is plainly material and must be discussed alongside the alternatives. The Bolam professional-practice test no longer governs disclosure, so what other surgeons would say is not the yardstick. There is no percentage threshold for materiality, and the surgeon's own rate does not remove the risk. Waiting for a direct question inverts the duty: material risks must be volunteered, understood and recorded. Reference: Montgomery v Lanarkshire Health Board [2015] UKSC 11; GMC, Decision making and consent (2020).