Plastic Surgery (Prometric)

A 34-year-old industrial painter presents 3 hours after a high-pressure spray-gun injury to the nondominant index finger. The entry wound is only 3 mm, but pain and swelling are rapidly increasing. The finger rests flexed, sensation is reduced distally, and capillary refill is 3 seconds. Radiographs show radiopaque material tracking along both neurovascular bundles into the palm. He is afebrile, tetanus immunization is current, and intravenous antibiotics have been started. Compartment pressure is not yet elevated. What is the best next step?

A 7-month-old infant has progressive frontal bossing, a palpable ridge over the sagittal suture, and narrowing of the biparietal diameter. Head circumference has crossed from the 60th to the 25th percentile, and the child has intermittent vomiting but no seizures. CT demonstrates premature fusion of the sagittal suture without multisuture involvement or hydrocephalus. Ophthalmologic examination shows no papilledema. The infant is otherwise healthy, and the craniofacial team can schedule surgery within two weeks. Which management is most appropriate?

A 74-year-old man becomes breathless on the first day after an eight-hour scalp free-flap operation. He has shallow respirations from pain, reduced breath sounds over the right chest, oxygen saturation of 90%, and no fever or calf swelling. Hemoglobin and cardiac markers are stable. The radiograph demonstrates the decisive volume-loss pattern. Which initial management is most appropriate?

A 60-year-old man has a through-and-through lateral cheek defect after recurrent buccal carcinoma excision. The defect includes oral lining, buccinator, subcutaneous volume, and external skin; the mandible and oral commissure remain intact. Previous radiotherapy has left adjacent cheek tissue fibrotic, and neck vessels are suitable. The postoperative image demonstrates a reconstructed cheek with separate internal and external surfaces. Which design principle is most important?

A 60-year-old man undergoes circumferential pharyngolaryngectomy for recurrent hypopharyngeal carcinoma after chemoradiotherapy. The cervical esophagus is preserved below the defect, no external skin is missing, and neck recipient vessels remain usable. He has adequate abdominal vascular anatomy and no inflammatory bowel disease. The reconstructive priority is rapid restoration of a lubricated conduit for swallowing with minimal excess bulk. Which flap is most appropriate?

A 63-year-old woman has a symptomatic midline incisional hernia after two laparotomies. CT confirms an 8-cm fascial defect containing reducible bowel without loss of domain. At surgery, adhesiolysis permits tension-free midline fascial approximation, the retromuscular plane is intact, and there is no contamination or bowel resection. The technical image compares available mesh positions. Which repair is most appropriate?

A 27-year-old man has a mature volar-wrist burn scar 16 months after injury. He has a fixed 30° wrist-flexion contracture, reduced grip endurance, and limited tendon glide despite six months of supervised therapy and night splinting. The scar is stable, painless, and free of ulceration or infection. Perfusion and sensation are normal, and adjacent skin is mobile enough for local tissue rearrangement. Which treatment is most appropriate?

A 62-year-old woman underwent augmentation with macrotextured implants eleven years ago. She has no swelling, pain, mass, capsular contracture, or lymphadenopathy. Ultrasound shows intact implants without peri-implant fluid, and routine breast screening is normal. She recently learned that her implant model was recalled because of its association with BIA-ALCL and requests prophylactic removal despite having no symptoms. She understands that revision surgery carries anesthetic, bleeding, infection, and contour risks. Which recommendation is most appropriate?

A patient develops partial flap loss after reconstruction. Review shows that postoperative nursing observations repeatedly documented deterioration, but the resident was not contacted for six hours because escalation criteria were unclear. The consultant wants to prevent recurrence without blaming an individual staff member. Which quality-improvement response is most appropriate?

A 25-year-old man develops severe lower-leg pain after tibial fracture fixation. Six hours later, pain increases with passive toe extension, the compartments are tense, and sensation is reduced in the first web space. Compartment pressure is 42 mmHg with a diastolic blood pressure of 58 mmHg. Distal pulses remain palpable, and radiographs show stable fixation without vascular occlusion. Inspect the supplied operative image and choose the next management.