Example FRCS Plast questions
Head & Neck: FRCS(Plast) example questions
Our head and neck coverage spans the whole JCST curriculum - from skin cancer staging and neck dissection through to subunit reconstruction and facial reanimation - with illustrated questions and referenced explanations throughout.
H&N skin cancer
Oral and oropharyngeal cancer
Free flap reconstruction
Subunit reconstruction
Facial palsy
Head and neck anatomy
Back to Overview
Parry–Romberg syndrome (progressive hemifacial atrophy) is an acquired, self-limiting atrophy of subcutaneous fat - later muscle and bone, confined to one side of the face.
Onset is usually within the first two decades, with a female predominance.
Progression runs for roughly 2–10 years before burning out.
Supporting features include: enophthalmos, hemiatrophy of the tongue and lip, hyperpigmentation, alopecia and poliosis.
Trigeminal neuralgia, migraine and seizures occur in a minority, and ipsilateral MRI abnormalities are common.
Other answers:
Craniofacial microsomia - is congenital and non-progressive, with ear anomalies, mandibular hypoplasia and often facial nerve weakness.
Barraquer–Simons lipodystrophy - is bilateral and symmetrical.
En coup de sabre - is a linear paramedian frontoparietal band of induration; it lies on the same morphoea spectrum but is excluded here by the mid-face distribution and absent skin sclerosis.
Reconstruction should await quiescence, conventionally 1–2 years. Active disease warrants paediatric rheumatology referral for methotrexate with corticosteroids. Surgical options are autologous fat grafting for mild-to-moderate contour loss and free tissue transfer for severe volume deficit.
The modiolus and commissure will be resected, so the reconstruction must recreate a corner of the mouth, not simply restore lip length.
The Estlander flap is a single-stage, axial lip-switch flap based on the labial artery of the opposite lip.
As the pedicle is hinged at the commissure, there is no second stage to divide it.
It is designed as a triangle with its base approximately half the defect width measured along the vermilion, with the labial artery protected in a cuff of muscle.
The disadvantages are a blunted, rounded commissure and an insensate, denervated segment, so secondary commissuroplasty is usually planned at 3–6 months.
Other reconstructions:
Karapandzic - requires an intact commissure and would worsen microstomia in a dentate patient.
Webster–Bernard - is designed for subtotal or total lower lip loss.
Abbe - is a two-stage flap for central defects that spare the commissure.
Free flap - over-treatment for a one-third defect and gives poorer sphincter function.
NB - The lip is a high-risk cSCC site under BAD 2020 guidance - excise with ≥6 mm margins and discuss at the SSMDT.
A defect straddling the sidewall–tip junction crosses two subunits with very different skin. Sidewall skin is thin, smooth and mobile; tip skin is thick, sebaceous and fixed. Whatever is used has to sit across that boundary without pulling on the alar rim.
A full-thickness graft looks acceptable on the sidewall half but pale and shiny on the tip half, leaving a visible step at the junction. Secondary intention contracts over the convex tip and can notch or elevate the rim. A dorsal nasal (Rieger) flap resurfaces the upper sidewall well, but stretching it inferiorly to reach the tip lifts the alar rim. Interpolated nasolabial and forehead flaps need a second stage - excessive for a superficial defect of this size.
The bilobed flap recruits lax dorsal and upper sidewall skin, sharing tension between two lobes and directing it away from the rim. Zitelli's modification: defects ≤1.5 cm, total arc 90–110°, wide undermining. Warn about pincushioning.
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