Example FRCS Plast questions

Chest wall: FRCS(Plast) example questions

Our chest wall coverage spans the whole JCST curriculum, from sternal wound breakdown and flap choice through to skeletal reconstruction, congenital deformity and salvage of failed reconstruction, with illustrated questions and referenced explanations throughout.

Sternal reconstruction

Flap reconstruction

Skeletal stabilisation

Congenital deformity

Oncological & irradiated defects

Complications & salvage

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Question 1

Chest Wall

A 14-year-old boy is referred to the plastic surgery clinic with a progressive symmetrical anterior chest wall depression that has worsened over the past 18 months. He is tall and slim with an arm span exceeding his height, has a high-arched palate, and reports exertional dyspnoea when playing football. His mother had aortic root surgery in her thirties. Haller index on imaging is 4.1.

What is the most appropriate next step?

CORRECT ANSWER

The phenotype - tall stature, arachnodactyly proxy (arm span > height), high-arched palate, progressive pectus excavatum, and a maternal history of aortic surgery, strongly suggests Marfan syndrome.

Pectus excavatum occurs in approximately two-thirds of Marfan patients and may be the presenting feature; missing the underlying connective tissue disorder risks fatal aortic dissection. Before any chest wall intervention, the candidate must undergo:

Echocardiography (aortic root, mitral valve prolapse)
Slit-lamp examination for ectopia lentis, and
Revised Ghent criteria assessment via clinical genetics

Other options:

Option A is wrong because surgery without ruling out aortopathy is unsafe and recurrence rates after pectus repair are higher in Marfan.
Option B misrepresents current NHS England policy: since the 2023 interim commissioning statement, pectus surgery is commissioned where the Haller index exceeds 3.25 and there is documented cardiorespiratory compromise (cardiac compression on MRI, arrhythmia, or dysphagia).
Options D and E address the deformity in isolation and miss the systemic diagnosis.

REFERENCES

Abdulmonem L Hashem D, Chan VSH, Hanneman K, Wald RM, Thavendiranathan P, Ouzounian M, et al. Association of Pectus Excavatum With Ventricular Remodelling and Mitral Valve Abnormalities in Marfan Syndrome. Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes. 2023;74(2):446-454.Kelly RE Jr. Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation. Seminars in pediatric surgery. 2008;17(3):181-93.Loeys BL, Dietz HC, Braverman AC, Callewaert BL, De Backer J, Devereux RB, et al. The revised Ghent nosology for the Marfan syndrome. Journal of medical genetics. 2010;47(7):476-85.

Question 2

Chest Wall

A 41-year-old man is admitted after a stab wound to the right axilla. He is haemodynamically stable with a normal radial pulse and no neurological deficit, and CT angiography is performed to exclude arterial injury. The study is reported as showing no extravasation or occlusion.

Which vessel does the arrow indicate?

AI-generated image

CORRECT ANSWER

The third part of the axillary artery gives off the subscapular artery, its largest branch. This divides almost immediately into two:

Circumflex scapular artery
Thoracodorsal artery

The circumflex scapular turns backwards through the triangular space to reach the scapula. In contrast, the thoracodorsal keeps heading downwards, running with the thoracodorsal nerve, and enters the deep surface of latissimus dorsi about 8 to 14 cm beyond the split. The arrow follows that downward course, so it marks the thoracodorsal.

The other two branches sit elsewhere:

Lateral thoracic - descends over the chest wall, much further medially.
Posterior circumflex humeral - heads laterally through the quadrangular space with the axillary nerve.

NB - Option E is incorrect for two reasons: the subscapular comes off the third part, not the second, and the arrow lies beyond the point where it divides.

Lose this artery and you lose the dominant pedicle of the latissimus dorsi flap - although the flap may still survive on retrograde flow through the serratus branch!

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Chest wall: FRCS(Plast) example questions

Better questions. Better preparation.

Better questions.
Better preparation.