1.

The false statement regarding suture in Plastic Surgery is:

a. Simple interrupted suturue is the Gold standart and the most commonly employed
suture
b. Vertical mattres suture (tidak terbaca) the most obvious and unsightly cross hatching
c. Horizontal mattress suture is disadvantageous in thick glabrous skin
d. Half based jorizontal mattress suture commonly used in nipple alveolar complex
e. Care should be taken so the subcuticular suture … in the same level
Pembahasan: Jawaban c
a. Simple interrupted suture is the gold standard and the most commonly employed
suture in cutaneous surgery (Nischal et al, 2012a).
b. This suture (a vertical mattress suture) tends to leave the most obvious and unsightly
cross-hatching if not removed early. The risk of cross-hatching is greater because of
increased tension across the wound and the four entry and exit points of the stitch in
the skin (Nischal et al, 2012b).
c. Horizontal mattress sutures are frequently used in areas with thick glabrous skin, such
as the hands and feet (Adigbli et al, 2016a)

2. The following statement about dermis are true, except:

a. Dermis is the deeper, thicker layer that provides strength and durability of the skin
b. Dermis contain blood supply and sensory nerve of the skin
c. Dermis contain adnexal structure
d. Their reservoir of epithelial cell will undergo mitosis and cand produce epithelial
covering
e. These layer provide important cushioning from trauma
Pembahasan: Jawaban b
The skin consists of two parts: the epidermis and the dermis. The epidermis is the
superficial thinner layer responsible for limiting evaporation of water from the body, and
is constantly replenished by cell division in the basal layer of the epidermis. The dermis
is the deeper thicker layer providing strength and durability. It contains the adnexal
strutures which provide an epithelial reservoir from which partial thickness wounds can
heal by a process known as reepithelialisation (Karpelowsky and Rode, 2009). Merkel
cells (cells of epidermis) are oval-shaped modified epidermal cells found in stratum
basale, directly above the basement membrane. These cells serve a sensory function as
mechanoreceptors for light touch, and are most populous in fingertips, thouch also found
in the palms, soles, oral, and genital mucosa. They are bound to adjoining keratinocytes
by desmosomes and contain intermediate keratin filaments and their membranes interact
with free nerve endings in the skin (Yousef et al, 2019).
 3. A W-plasty is an example of:
a. An advancement flap
b. A delayed flap
c. An island pedicle flap
d. A rotation flap
e. A transposition flap
Pembahasan: Jawaban
Local flaps can be traditionally classified as advancement flaps, rotation flaps, and
transposition flaps. These flaps should preferably have skin pedicles because although it
is technically easier to transfer island flaps to the recipient site than skin-pedicled flaps,
they release contractures less effectively. The postoperative extensibility of the flap
should be considered when determining which flap design is optimal for the individual
patient. With regard to the skin-pedicled flaps, the square flap method is particularly
useful for reconstructing major joint scar contractures because these flaps can
theoretically extend by threefold (Ogawa, 2019).

4. Below are true regarding type of needle and its indication, except:
a. Conventional cutting needle – skin
b. Reverse cutting needle – skin, mucosa, ophthalmic surgery, fascia, tendon/ligament
repair, prin, cartilage
c. Spatula needle – skin, cornea, microsurgery
d. Taper point needle – abdominal organ, myocardium, peritoneum, dura, facia,
subcutaneous tissue, gynecology
e. Blunt tip needle – abdominal organ, myocardium, peritoneum, dura, facia,
subcutaneous tissue, gynecology
Pembahasan: jawaban e
A cutting needle has at least two opposing cutting edges (the point is usually triangular).
This type is designed to penetrate dense, irregular, and relatively thick tissues. The point
cuts a pathway through tissue and is ideal for skin sutures. Sharpness is due to the cutting
edges. In reverse-cutting needles, the third cutting edge is on the outer convex curvature
of the needle (depth-seeking). These needles are stronger than conventional cutting
needles and have a reduced risk of cutting out tissue. They are designed for tissue that is
tough to penetrate (eg, skin, tendon sheaths, or oral mucosa). Reverse-cutting needles are
also beneficial in cosmetic and ophthalmic surgery, causing minimal trauma. Side-cutting
(spatula) needles are flat on the top and bottom surfaces to reduce tissue injury. These
needles allow maximum ease of penetration and control as they pass between and through
tissue layers. Side-cutting needles were designed initially for ophthalmic procedures.
Blunt point needles dissect friable tissue rather than cut it. The points are rounded and
blunt, ideal for suturing the liver and kidneys. Additionally, blunt needles are being
 developed for more conventional uses in an effort to reduce needlestick injuries (Mackay-
Wiggan et al. 2018).

5. The primary source of blood to the lower half of the central abdominal skin is the:
a. Superficial inferior epigastric artery
b. Deep inferior epigastric artery
c. Superior epigastric artery
d. Superficial circumflex iliac artery
e. Intercostal and segmental arteries
Pembahasan: jawaban b
The deep inferior epigastric artery provides the main blood supply to the lower abdominal
wall. Microdissection of the artery, its main branches, and the perforator vessels was
undertaken in 20 cadavers. The artery was found to be associated with two veins in most
of the cases (90 percent). The lateral division of the deep inferior epigastric artery and the
perforator vessels it gives are more dominant (80 percent of cases) than the medial
perforators (20 percent of cases). The lateral perforators were greater in number (80) and
more consistent than those that arose from the medial division (28). The
musculocutaneous perforators are the most important perforators supplying the anterior
abdominal wall. An average of 5.4 large perforators (>0.5 mm in diameter) were
dissected in each case. These perforators are mostly contained in the area lying laterally
and below the umbilicus, with an average distance of 4 cm from the umbilicus. The
musculocutaneous perforators may have a direct or indirect course. Larger perforators
(>0.5 mm in diameter) were found to have a direct course through the subcutaneous fat to
the skin. Smaller perforators do not reach the skin but terminate at the level of the deep
fat layer by branching after piercing the rectus sheath. The direct perforator vessels with
their associated veins (microdissection) keep a consistent diameter before dividing at the
subdermal level and end by contributing to the subdermal plexus (El-Mrakby and Milner,
2002).

6. Occlusion is
a. Relationship between mesiobuccal cusp of maxillary 1st molar and the buccal
groove of mandibular 1st molar
b. Relationship between mesiolingual groove of maxillary 1st molar and the buccal cusp
of mandibular 1st molar
c. Relationship between mesiobuccal groove of maxillary 1st molar and the buccal cusp
of mandibular 1st molar
d. Relationship between mesiobuccal groove of maxillary 2nd molar and the buccal cusp
of mandibular 1st molar
e. Relationship between mesiobuccal cusp of maxillary 2nd molar and the buccal groove
of mandibular 2nd molar
Pembahasan: jawaban a
Angle (1899) had provided the first clear definition of normal occlusion. The normal
occlusion was when the upper and lower molars were in a relationship whereby the
mesiobuccal cusp of the upper molar occluded in the buccal grove of the lower molar and
the teeth were arranged in a smoothly curving line of occlusion (Hassan and Rahimah,
2007).
7. Component of wound defect are, except:
a. Location
b. Size
c. Extend of defect
d. Condition of surrounding tissue
e. Wound history
Pembahasan: jawaban e
Cutaneous wounds close by epithelial resurfacing and wound contraction. Dependent on
the species, one or the other process dominates the progress of wound repair. For
example, rodents heal mainly by contraction, whereas in humans, reepithelialization
accounts for up to 80% of wound closure. Skin wound epithelialization is reliant on the
wound specifics such as the location, the depth, the size, microbial contamination as well
as patient-related health conditions, genetics and epigenetics (Sorg et al, 2017).

8. The following is the appropriate treatment post operatively for patients with split skin
grafts to the lower limb:
a. 2 weeks of full immobilization
b. Discharged 1-day post operatively
c. Antibiotics
d. Opioid analgesics
e. None of the above
Pembahasan: jawaban c
The second most common cause of graft failure is infection. It has been suggested that
graft failure secondary to infection is caused by dissolution of fibrin by plasmin and
proteolytic enzymes, which are abundant in bacteria-infected wounds. Fibrin is central to
graft survival via an adherent action at the interface between the graft and the bed. One
can avoid infection by ensuring the wound bed is clean and well prepared, by using
quiltling sutures, permitting egress of wound fluids by meshing or pie-crusting the graft
surface, and by applying and frequently changing saline-soaked dressings. Other
proposed methods include administering low-dose erythromycin for 5 days post-graft,
 administering vitamin C and zinc for up to 10 days, and avoidance of alcohol (Adigbli et
al, 2016b).

9. The true statement regarding non operative management of keloid is:

a. Using corticosteroid injection once every week
b. The most commonly used regiment of corticosteroid 10-100 mg/ml
c. Using silicone gel sheet for 12-24 months
d. Using pressure garment with pressure 35-50 mmHg
e. Using radiotherapy for 6-12 session
Pembahasan: jawaban c
Keloid and hypertrophic scar therapy is challenging and controversial. Both conditions
respond to the same therapies, but hypertrophic scars are easier to treat. The large number
of treatment options is a reflection of the poor quality of research on this topic, with no
single proven best treatment or combination of treatments. First-line options include
silicone sheeting, pressure treatment, and corticosteroid injections, but all of these require
exemplary adherence and follow-up. Corticosteroid injections for prevention and
treatment of keloids and hypertrophic scars are perhaps the first-line option for family
physicians. Corticosteroids suppress inflammation and mitosis while increasing
vasoconstriction in the scar. Triamcinolone acetonide suspension (Kenalog) 10 to 40 mg
per mL (depending on the site) is injected intralesionally, which, although painful, will
eventually flatten 50 to 100 percent of keloids, with a 9 to 50 percent recurrence rate.
Silicone elastomer sheeting is a noninvasive and extensively studied approach to the
prevention and treatment of keloids and hypertrophic scars. Silicone sheets are thought to
work by increasing the temperature, hydration, and perhaps the oxygen tension of the
occluded scar, causing it to soften and flatten. To be effective, sheets must be worn over
the scar for 12 to 24 hours per day for two to three months (Juckett and Hartman-Adams,
2009).

10. Interleukin-1 (IL-1) is released from:

a. Platelets
b. Collagen
c. Neutrophils
d. Fibroblast
e. Endothelium
Pembahasan: jawaban c
Interleukin-1 (IL-1) is a highly proinflammatory cytokine produced by multiple cell
types, including epithelial cells, macrophages, dendritic cells, endothelial cells and B
cells (Theise et al, 2018).
 11. Concerning fetal wound healing:
a. Scarring is similar to adults
b. There are higher concentrations of type III collagen
c. There are lower concentrations of hyaluronic acid
d. There are higher concentrations of type IV collagen
e. Concentrations of hyaluronic acid are the same
Pembahasan: jawaban b
Both fetal and adult wounds heal with collagen deposition. In fetal wounds, collagen is
deposited in a fine reticular pattern indistinguishable from the surrounding uninjured
tissue. In postnatal wounds, collagen is deposited in densely arranged parallel bundles.
Although all wounds heal with predominantly type I collagen, there is a greater ratio of
type III collagen to type I collagen deposited in fetal wounds compared with postnatal
wounds. Type III collagen fibers are smaller compared with type I fibers and may allow a
more reticular deposition of fibers in the wound. Also, type I collagen is found in more
rigid tissues, whereas type III is found in more elastic tissue. This association with
decreased amount of cross-linked collagen fibers may lead to a more flexible wound
which may contribute to scarless repair. Additionally, in response to profibrotic growth
factors such as TGF-β1, fetal fibroblasts have a characteristic response in collagen
deposition compared with postnatal fibroblasts. This suggests fetal fibroblasts are
programmed to form a more regenerative ECM (Leung et al, 2012).

12. Following split thickness skin grafting:

a. The mitotic activity is static
b. The nucleic acid cytoplasm decrease in size
c. The epithelium increases in thickness during the first 3 week
d. Enzyme activity increases in the first 3 days
e. The fibrocyte population increases in the first 3 day post-graft
Pembahasan: jawaban d
Principles of Skin Grafts STSGs show significant mitotic activity in the epidermis by the
third postgraft day, in contrast to FTSGs, in which mitotic activity is reduced. The graft
“scales off,” and the epithelium doubles in thickness in the first 4 days. This is due to
swelling of the nuclei and cytoplasm of the epithelial cells, epithelial cell migration
toward the graft surface, and accelerated mitosis of follicular and glandular cells.
Between days 4 and 8, rapid turnover of cells leads up to a sevenfold increase in
epithelium thickness. Not until approximately the end of the fourth week after grafting is
the epidermal thickness back to normal (van Roggen et al, 2019).
 13. After the age of 35:
a. The dermis gradually thickness
b. Skin elasticity increases
c. Sebaceous gland content increases
d. The dermis gradually thins
e. There is no loss of sebaceous gland content
Pembahasan: jawaban d
The sebaceous glands of man show age-related differences in their activity as determined
by quantitative and qualitative examination of sebum. Sebaceous secretion is low in
children and begins to increase in mid- to late childhood under the influence of
androgens. This rise continues until the late teens, after which no further significant
change takes place until late in life. In elderly men, sebum levels remain essentially
unchanged from those of younger adults until the age of 80. In women, sebaceous
secretion decreases gradually after menopause and shows no significant change after the
7th decade. The most likely explanation for the decrease in sebaceous gland secretion
with age in both men and women is a concomitant decrease in the endogenous production
of androgens. Although surface lipid levels fall with age, paradoxically the sebaceous
glands become larger, rather than smaller, as a result of decreased cellular turnover.
Nonetheless, as the higher surface lipid levels after administration of fluoxymesterone (a
synthetic testosterone derivative) indicate, the glands have the capacity to respond to
androgen (Pochi et al, 1979). The age-dependent decrease of skin thickness was studied
with a morphometric procedure on upper inner arm skin biopsies. Epidermal thickness
decreased somewhat faster in men (7.2% of the original value/decade) than in women
(5.7%). The total dermal thickness decreased at about the same rate in men and women
(6%/decade) (Branchet et al, 1990).

14. The correct statement for sequence of skin graft take:

a. Serum inhibition phase, inosculation phase, revascularization phase
b. Serum inhibition phase, inosculation phase, vascularization phase
c. Inosculation phase, serum inhibition phase, vascularization phase
d. Inosculation phase, revascularization phase, serum inhibition phase
e. Revascularization phase, serum inhibition phase, inosculation phase
Pembahasan: jawaban a
Phases of skin-graft survival. Imbibition- graft absorbs (imbibe) nutrients from
underlying recipient bed. Inosculation- blood vessels in skin graft grow to meet the
vessels (inosculate = kiss) of the recipient bed. Neovascularization- new blood vessels
from between the graft and recipient tissues (Hoffman and LaRoure, 1989).

15. The following statement is incorrect regarding local anesthetic administration:

 a. The maximum dose for lignocaine infiltration is 4 mg/kg
b. The maximum dose for lignocaine + adrenaline (epinephrine) infiltration is 7 mg/kg
c. Warming the solution may reduce the pain of administration
d. Rate of subcutaneous injection rarely influences the perception of pain by the
patient
e. Adding hyaluronidase is useful technique for the harvesting of split thickness skin
grafts
Pembahasan: jawaban
Rate of subcutaneous injection rarely influences the perception of pain by the patient.
This statement is incorrect; increasing the rate of subcutaneous injection increases the
patin. Warming and alkalinizing the anaesthectic with bicarbonate also reduces the pain
of infiltration. Although safe dose of lidocaine for direct infiltration is 4 or 7 mg/kg with
or without adrenaline (epinephrine), respectively, it can safely be used in much higher
ocncentrations such as during tumescent infiltration for liposuction (Shikrollahi et al,
2009).
16. Which of the following is not a function of skin?
a. Thermoregulatory
b. Immunological
c. Vitamin E synthesis
d. Physical barrier
e. Ultraviolet protection
Pembahasan: jawaban c
As a protective interface between internal organs and the environment, the skin
encounters a host of toxins, pathogenic organisms, and physical stresses. To combat these
attacks on the cutaneous microenvironment, the skin functions as more than a physical
barrier: it is an active immune organ. Immune responses in the skin involve an
armamentarium of immune-competent cells and soluble biologic response modifiers
including cytokines. Traversed by a network of lymphatic and blood vessels, the dermis
contains most of the lymphocytes in the skin, other migrant leukocytes, mast cells, and
tissue macrophages (Salmon et al, 1994). Skin is the largest organ of the body with a
complex network of multitude of cell types that perform plastic and dynamic cellular
communication to maintain several vital processes such as inflammation, immune
response including induction of tolerance and disease prevention, wound healing, and
angiogenesis. Of paramount importance are immunological functions of the skin that
protect from harmful exposure coming from external and internal environments.
Awareness of skin immunity can provide a better comprehension of inflammation,
autoimmunity, cancer, graft-versus-host disease, vaccination, and immunotherapy
approaches. The skin is not only a physical barrier between external and internal
environments actively protecting from stress caused by injury, microbial treat, UV
irradiation, and environmental toxins (Matejuk, 2018). Vitamin E is synthesized by plants
 and must be obtained through dietary sources. Richest sources are nuts, spinach, whole
grains, olive oil, and sunflower oil (Keen and Hassan, 2016).

17. Below are correct regarding zone of statis of burn except:

a. Circulation of this area is sluggish
b. Untreated this zone will become necrotic
c. This area undergo inflammatory reaction under mediator
d. Clinically this seen as progression of burn
e. Area of compromise vasculature where damage to tissue causes by inflammatory
process
Pembahasan: jawaban d
Zone of stasis—The surrounding zone of stasis is characterised by decreased tissue
perfusion. The tissue in this zone is potentially salvageable. The main aim of burns
resuscitation is to increase tissue perfusion here and prevent any damage becoming
irreversible. Additional insults—such as prolonged hypotension, infection, or oedema—
can convert this zone into an area of complete tissue loss (Hettiaratchy and Dziewulski,
2004). Zone of stasis is at the periphery of zone of coagulation. The circulation is
sluggish in this zone but it can recover after early and adequate resuscitation, and proper
wound care (Tiwari, 2012).

18. 35 years old adult came into your hospital 6 hours after the incident. He was burn in the
face, neck and left forearm and left leg. In first hospital, he was administered 2 kolf of
kristaloid, given antibiotic and tetanus injection. How much fluid need to be administered
into this patient in your hospital? (BW: 60 kg)
a. Administered 5480 ml kristaloid for 18 hours
b. Administered 6480 ml kristaloid in 18 hours
c. Administered 2240 ml kristaloid in first 2 hours, and the rest later
d. Administered 3740 ml kristaloid in first 2 hours, and the rest later
e. Administered 3240 ml kristaloid in first 2 hours, and the rest later
Pembahasan: jawaban c
Patients with burns of more than 20% - 25% of their body surface should be managed
with aggressive IV fluid resuscitation to prevent “burn shock." A variety of formulas
exist, like Brooke, Galveston, Rule of Ten, etc.4, but the most common formula is the
Parkland Formula. This formula estimates the amount of fluid given in the first 24 hours,
starting from the time of the burn. The Formula. Four mL lactated ringers solution ×
percentage total body surface area (%TBSA) burned × patient's weight in kilograms =
total amount of fluid given in the first 24 hours. One-half of this fluid should be given in
the first eight hours. TBSA: face, neck and left forearm and left leg (7% + 2% + 3% +
 20% = 32%). 4 mL x 60 kg x 32% TBSA = 7680 mL, 3840 in the first eight hours
(Schaefer and Lopez, 2019).

19. The following is not including in cleft palate classification:

a. Complete cleft lip
b. Incomplete cleft lip
c. Submucous cleft lip
d. Unilateral/bilateral cleft lip
e. Complex cleft lip
Pembahasan: jawaban
CLP is traditionally classified by phenotype, which can have variable expression ranging
from microform to complete clefting, and may involve the alveolar ridge and palate.
Phenotypes have been correlated with specific genetic linkage patterns, suggesting a
possible correlation. CLP and CP are embryologically distinct processes from disruption
at different stages of development and possess unique epidemiologic and genetic features.
CLP refers to a clinical spectrum of cleft lip with or without associated cleft palate. Palate
involvement generally denotes a related but more severe form of this anomaly, although
they may have epidemiologic differences. Lip clefting may be complete (involving the
full vertical height of the lip) or incomplete. Complete cleft lips are often associated with
an alveolar cleft. The soft tissue bridge spanning the cutaneous lip or alveolus in an
incomplete cleft lip is termed Simonart’s band and consists primarily of skin with
variable amounts of orbicularis oris muscle fibers. Unilateral cleft lip (Figure 1) is
associated with typical deformities caused by asymmetric forces on the premaxilla during
facial growth. The presence of Simonart’s band may reduce the extent of facial deformity
with growth by exerting a restorative force. There is rotation and distortion of the
vermillion with loss of Cupid’s bow and philtral landmarks on the cleft side. Orbicularis
oris muscle fibers are asymmetrically oriented along the cleft margins and may be
continuous across Simonart’s band in milder forms. Histologic studies have shown that
the degree of disorientation of muscle fibers near the cleft correlate with cleft severity.
Muscle volume does not appear to be reduced in the non-cleft portions of the lip. The
typical nasal deformity is displacement of the ipsilateral lateral crus of the alar cartilage
laterally, inferiorly, and posteriorly. The tip is flattened and deflected to the non-cleft
side. The ipsilateral nostril is oriented horizontally rather than vertically. The columella is
significantly shortened and deviates to the non-cleft side along with the caudal septum.
The nasal cartilages may or may not be deficient. In bilateral cleft lip, the premaxilla
grows independently of the maxillae on either side and may protrude considerably,
particularly in complete clefts. The prolabium, consisting of soft tissues of the premaxilla
without muscle fibers, also lacks Cupid’s bow and philtral columns bilaterally. The
columella is severely shortened or absent while the lateral crura are displaced laterally,
producing a broad, flat nasal tip. Subclinical phenotypes likely lie within the extended
spectrum of non-syndromic CLP. Examples include lip anomalies, dental anomalies, and
 facial morphometric features. Perhaps the best studied are orbicularis oris muscle defects
in the absence of a visible cleft. These are assessed by high-resolution ultrasound and
seem to preferentially occur in immediate relatives of those with cleft lip. Identification
of subclinical phenotypes may expand the search for susceptible genes. In contrast to
CLP, cleft palate (CP) is primarily characterized by disorientation of palatal muscles
which lead to feeding difficulties, velopharyngeal insufficiency, and speech problems.
The spectrum ranges from a submucosal cleft to complete clefting of the primary and
secondary palate. They are more likely to be syndromic compared to CLP (Shkoukani et
al, 2013).

20. Which statement concerning haemangioma incorrect?

a. Present in 10% of newborn with white skin
b. Occurs in female infants three times more commonly than in male infants
c. Incidence is higher in premature infants
d. Is rarely hereditary
e. Precursor (h…) marks are present in approximately 50% of children who
develop a haemangioma
Pembahasan: jawaban e
Hemangiomas are the most common tumors of infancy. The true incidence of infantile
hemangiomas is unknown (Kilclien and Frieden, 2008). Although they are classically
said to occur in up to 10 percent of Caucasian infants (Jacobs and Walton, 1976; Alper
and Holmes, 1983), 4 to 5 percent is probably a better estimate (Munden et al, 2014).
Infantile hemangiomas are generally noticed within the first few days to months of life
(Pratt, 1953; Jacobs, 1957). Although most hemangiomas occur sporadically, familial
transmission in an autosomal dominant fashion has been reported (Blei et al, 1998). In
one series of 136 patients/families, 34 percent had a family history of infantile
hemangiomas, most often in first-degree relatives (Castren et al, 2016). It is important to
note that in almost 60% (7/12) of female patients with growth of haemangiomas there
was no history of exposure to exogenous hormonal therapy (Glinkova et al, 2004).

21. Clefts:
a. Are more common in black races than Asians
b. Are more common in white races than Asians
c. Are more common in white races than black races
d. Are less common in younger siblings of those with cleft lip and palate
e. None of the above
Pembahasan: jawaban c
 (Canfield et al, 2017).

22. Cleft lip:

a. With or without cleft palate is different in etiologu to isolated cleft palate
b. Is associated with a 75% risk of further congenital abnormalities
c. Is inherited as an X-linked trait
d. Is best treated after the age of 3 years
e. When extending posterior to the incisive foramen is sometime referred to as a
complex cleft lip
Pembahasan: jawaban c
Surgery to repair a cleft lip usually occurs in the first few months of life and is
recommended within the first 12 months of life. Surgery to repair a cleft palate is
recommended within the first 18 months of life or earlier if possible (American Cleft
Palate Craniofacial Association, 2009). The pattern of inheritance for cleft palate is most
consistent with an X-linked recessive trait. The unilateral cleft lip and palate in the distant
female relative probably represents a separate genetic entity (Rushton, 1979).

23. The superficial penile arteries that supply the skin and prepuce of the penis come directly
from which artery?
a. Superficial circumflex iliac artery
b. Dorsal artery of the penis
c. Internal pudendal artery
d. External pudendal artery
e.
Pembahasan: jawaban c
 Blood supply to the skin of the penis is from the left and right superficial external
pudendal arteries, which arise from the femoral artery (see the image below). The
superficial external pudendal arteries branch into dorsolateral and ventrolateral branches,
which collateralize across the midline. In addition, branches in the skin form an extensive
subdermal vascular plexus. The blood supply to the ventral penile skin is based on the
posterior scrotal artery, a superficial branch of the deep internal pudendal artery
(Ellsworth and Gest, 2017).

24. ………………………….hypospadia except:

a. Scrotal bipartition
b. Chordae
c. ……………
d. Androgen hypersensitivity
e. Environmental oestrogens
Pembahasan: jawaban d
Hypospadias is characterized by ventral position of the meatus (ventral meatal dystopia),
dorsal hooded foreskin, ventral curvature on erection – chordee, deficiency of ventral
skin, clefting of the glans, in the most severe cases scrotal bipartition. Aetology of
hypospadias: environmental (oestrogenic chemicals), androgen hyposensitivity
(especially if associated with micropenis, severe hypospadias, hypogonadism,
undescended testis and inguinal hernia) (Stone, 2006).

25. Which of the following classified into transposition flap?

a. 1,2
b. 2,3
c. 3,4
d. 1,3
e. 1,4
Pembahasan: jawaban a
 (Crawford, 2012).

26. The palmar aponeurosis:

a. Covers the palm, including the central palm, thenar and hypothenar muscles
b. Is inserted into the flexor digitorum profundus tendons
c. Lies immediately deep to the neurovascular plane in the palm
d. Is inserted mainly into the bases of the proximal phalanges and the flexor sheaths
e. Consist of a direct extension of deep fascia of the forearm
Pembahasan: jawaban
Located over the palm of the hand and covers the flexor tendons and deeper structures of
the hand. The palmar aponeurosis extends distally and becomes continuous with the
fibrous digital sheaths (Morton et al, 2011). The palmar aponeurosis lies immediately
deep to the subcutaneous tissue of the palm. It extends distally from the flexor
retinaculum and divides into four slips, one to each finger, to be attached to the fibrous
 flexor sheath. The palmar aponeurosis is clinically important as it can be affected by
Dupuytren's contracture in its medial part. In this condition the aponeurosis undergoes
fibrosis to produce flexion deformity of the medial two fingers (Jacob, 2008).

27. How many zones in flexor tendon system?

a. 5
b. 6
c. 7
d. 8
e. 9
Pembahasan: jawaban a
The anatomic relationships of the flexor tendons are usually discussed in terms of zones,
shown in the image below. The 5 flexor tendon zones are modifications of Verdan's
original work, which based zone boundaries from distal to proximal on anatomic factors
that influenced prognosis following flexor tendon repair. The 5 zones discussed below
apply only to the index through small fingers—separate zone boundaries exist for the
thumb flexor tendon (Bates et al, 2013).

28. In the finger, what is the usual relationship of the digital nerve to the digital artery?
a. Dorsal
b. Volar
c. Proximal
d. Distal
e. Lateral
Pembahasan: jawaban a
The proper palmar digital arteries travel along the sides of the phalanges (along the
contiguous sides of the index, middle, ring, and little fingers), each artery lying just
below (dorsal to) its corresponding digital nerve.

29. This statement is true regarding the difference between FTSG and STSG
a. Scar from FTSG had better aesthetic outcome than STSG
b. Scar from STSG had better aesthetic outcome than FTSG
c. Donor from FTSG could be harvested from every area of the body
d. Wide burn wound should be covered by meshed FTSG
e. Donor of FTSG usually resulted in keloid
Pembahasan: jawaban
 Full-thickness skin grafts are the most commonly used graft in dermatology. FTSGs can
provide an excellent tissue match for the host site and heal with minimal scarring and
contracture. Composite grafts also have a high metabolic demand and typically are only
used in the nose and ear in situations where cartilage also needs to be replaced Split-
thickness grafts are typically less cosmetically appealing due to a lack of adnexal
structures and color mismatch. There is also a significant risk of contracture with STSG.
Split-thickness graft donor sites also tend to be more painful for the patient compared to
FTSG. (Prohaska and Cook, 2019).

30. There are five important muscle in soft palate:

a. Tensor veli palatine, levator veli palatine, palatoglossus muscles
b. Depressor veli palatine, levator veli palatine, superior constrictor pharingeus muscles
c. Palatopharyngeus, uvulaes muscles, superior constrictor pharingeus muscles
d. Palatoglossus, palatopharingeus and depressor veli palatine muscles
e. Depressor veli palatine, tensor veli palatine, uvulaes muscles
Pembahasan: jawaban a
The soft palate consists of five muscles (levator veli palatini, tensor veli palatini, uvulae,
palatoglossus, and palatopharyngeus) covered with stratified squamous epithelium on the
oral surface and on most of the nasal surface. The soft palate has an important role in
speech and swallowing (Cannon et al, 2010).

31. According to the images, no 1 and 2 are the following:

a. Parasympheal and body fracture of mandible
b. Sympheal and body fracture o fmandible
c. Parasympheal and angle fracture of mandible
d. Sympheal and angle fracture of mandible
e. None of the above
Pembahasan: jawaban a
 (Banks et al, 2000)

32. Below are the bones involved in Lefort II fracture, except:

a. Frontal process of maxilla
b. Pterygoid plates
c. Orbital floor
d. Nasal bone
e. Anterior wall of maxilla
Pembahasan: jawaban e
 Le Fort II fractures are pyramidal in shape and involve the zygomaticomaxillary suture,
nasofrontal suture, pterygoid process of the sphenoid, and the frontal sinus. These
fractures cause disruption of the medial, lateral, upper transverse, and posterior maxillary
buttresses and produce discontinuity of the inferomedial orbital rims. Involvement of the
orbit seen in such fractures may lead to the development of complications including
extra-ocular muscle injury, orbital hematoma, globe rupture or impingement, and optic
nerve damage. Furthermore, damage to the medial maxillary buttress has been associated
with epistaxis, cerebral spinal fluid (CSF) rhinorrhea, lacrimal duct and sac injury, medial
canthal tendon injury, and sinus drainage obstruction (Philips and Turco, 2007).

33. Iliac crest graft is

a. Autograft, cortical graft, non vascularized bone graft
b. Autograft, cortical graft, vascularized bone graft
c. Autograft, cancellous graft, vascularized bone graft
d. Autograft, cancellous graft, non vascularized bone graft
e. None of the above
Pembahasan: jawaban a dan d
The iliac crest is currently the most common donor site for obtaining autogenous bone
graft. The iliac crest is currently the most common source for obtaining autogenous bone
for the purpose of grafting. The ilium has been identified as an excellent source of both
cortical and cancellous bone. Both the anterior and posterior portions of the iliac crest are
often used for the purpose of bone grafting (Seiler, 2000). Anterior iliac crest bone graft
is a surgical procedure for harvesting a cortical, cancellous, or corticocancellous block
graft from the anterior ilium (Carson, 2015). The iliac crest was initially used as a non-
vascularized graft. The advantage of this type of graft was the increased amount of bone
tissue available for reconstruction, as well as the low cost of this procedure. A
disadvantage of this type of reconstruction is that it has no vascularization of its own,
which has an unfavorable effect on the metabolism and volume stability of the bone graft
(Moldovan et al, 2015).

34. Which is the following cell predominantly peak at the hemostasis phase of wound
healing:
a. Neutrophil
b. Monosit
c. Eritrocyte
d. Lymphosit
e. Platelet
Pembahasan: jawaban a
 In a vascular inflammatory response, the lesioned blood vessels contract and the leaked
blood coagulates, contributing to the maintenance of its integrity. The coagulation
consists of an aggregation of thrombocytes and platelets in a fibrin network, relying on
the action of specific factors through the activation and aggregation of these cells. The
fibrin network, in addition to reestablishing homeostasis and forming a barrier against the
invasion of microorganisms, organizes the necessary temporary matrix for cell migration,
which in turn restores the skin’s function as a protective barrier, maintaining the skin’s
integrity. This also makes it possible for cell migration to the lesion’s microenvironment
and the stimulation of fibroblast proliferation. Cell response in the inflammatory stage is
characterized by the influx of leukocytes in the wound area. Such a response is very quick
and coincides with the key signs of inflammation, which are revealed by the edema and
the erythema at the location of the lesion. Normally, cell response is established within
the first 24 hours and can extend for up to two days. A quick activation of the immune
cells in the tissue may also occur, as happens with mastocytes, gamma-delta cells, and
Langerhans cells, which secrete chemokines and cytokines. Inflammation is a localized
and protective tissue response that is unleashed by the lesion, causing tissue destruction.
Inflammatory cells play an important role in wound healing and contribute to the release
of lysosomal enzymes and reactive oxygen species, as well as facilitate the clean-up of
various cell debris. Buckley argues that the interaction of leukocytes and stromal cells
during an acute inflammatory response resolves around the inflammatory focus.
Neutrophils are known for expressing many pro-inflammatory cytokines and a large
quantity of highly active antimicrobial substances, such as reactive oxygen species
(ROS), cationic peptides, and proteases at the location of the lesion. The inflammatory
response continues with the active recruitment of the neutrophils in response to the
activation of the complement system, platelet degranulation, and bacterial degradation
products. These are attracted by many inflammatory cytokines produced by activated
platelets, endothelial cells, and degradation products of pathogenic agents. In this manner,
the neutrophils are the primary activated and recruited cells that play a role in the clean-
up of the tissue, as well as contribute to the death of invading agents (Gonzalez et al,
2016).

35. This statement was true regarding keloid except:

a. Multimodal therapy is the best therapy for keloid
b. Corticosteroid injection is the first line therapy for keloid
c. Keloid predisposition is in ear, sternum, deltoid
d. Using only silicone gel sheet for 12-24 months is not effective for keloid
e. Surgery is the first line therapy for keloid
Pembahasan: jawaban e
 (Ogawa et al, 2019).

36. The skeleton of human facial bones consist of:

a. 12 bones
b. 13 bones
c. 14 bones
d. 15 bones
e. 16 bones
Pembahasan: jawaban c
 (Jinkins et al, 2000)

For number 37-41, chose (A) if right option is 1,2,3 (B) for 1,3 (C) for 2,3 (D) for 4 and (E) for
all the options are corrects:
37. Collagen:
1. Type I : most abundant, dominant in skin, tendon and bone
2. Type II: cornea and hyaline cartilage
3. Type III: vessel and bowel walls, uterus and skin
4. Type IV: basement membrane only
Pembahasan: jawaban a
Type I collagen is the most abundant collagen found in connective tissues including skin,
tendon, and bone tissue. It is the major component and the primary determinant of tensile
strength of the ECM (Bonnomet et al, 2012). Type III collagen is a homotrimer encoded
by a gene on chromosome 2q31. The α1(III) chains have the Gly-X-Y repeats typical of
fibrillar collagen. Type III collagen is located in skin, blood vessel walls, and
pleuroperitoneal lining; bone has a minimal amount of type III collagen (Marini, 2015).
Type IV collagen is the main collagen component of the basement membrane. It is a
network-forming collagen that underlies epithelial and endothelial cells and functions as a
 barrier between tissue compartments. Type IV collagen has many binding partners and
forms the backbone of the basement membrane (Sand et al, 2016).

38. To optimize skin graft, the recipient site must be prepared:

1. Skin graft require vascularized bed
2. Immobilization of the graft is essential
3. Close contact between the skin graft and the recipient bed
4. Hematom and seroma under the skin graft
Pembahasan: jawaban a
The key difficulty of skin grafting is keeping the graft immobilized on uneven surfaces
involved with motion, such as the nuchal area, axilla, web spaces, and the perineal area
(Chang et al, 2001).
Key Principles (Skin Grafting) (Therattil and Agag, 2019)
• Before skin grafting a wound, consider whether the recipient site is ready to accept a
graft. The recipient site should have been debrided appropriately and should have a
healthy, well-vascularized bed to accept the graft.
• Consider the size of the graft needed and donor site morbidity before choosing a
donor site.
• Double-check all of the equipment needed before the beginning of graft harvest.
Lack of preparation or appropriate help can lead to poor graft harvest or donor site
morbidity.
• Management of donor sites after harvest should be tailored to the patient. Use the
approach that is least painful and easiest for the patient to handle.
• Common causes of skin graft loss include hematoma, seroma, shear forces across the
graft, and infection. Use of graft fenestration, proper bolstering, and adequate
debridement can minimize these factors. If there is any concern for a hematoma, the
bolster should be removed sooner and the graft inspected.

39. Below are the problem that was found in subacute phase of burn injury:
1. Infection
2. Nutrition
3. Wound coverage
4. Early mobilization
Pembahasan: jawaban a
To date, not a single therapeutic modality has been successful in completely reversing the
complex reactions induced by a burn injury; nevertheless, several non-pharmacological
 and pharmacological strategies have been found to effectively modulate burn-associated
metabolism. So far, early excision and closure of the burn wound have been described as
the greatest advancement in the management of patients with severe thermal injuries.
Since sepsis plays a major role in boosting burn-associated mortality and morbidity
related to hypermetabolic response, every effort should be made to control the rate of
sepsis by taking the appropriate measurements to prevent infection in burn patients.
Adequate nutrition and proper feeding are of utmost importance in the recovery process
of burn patients. Unlike oral nutrition alone, continuous enteral usually succeeds in
preserving total body weight and decreases hypermetabolic response in burn patients
(Kaddoura et al, 2017).

40. First aid of burn injury (pre hospital care)

1. Stop the burning process
2. Cooling the burning process is effective 24 hours after burn
3. Removal the victim from electrical corrent by turning off the sources and using
isolative
4. Effort to neutralize chemical burn are indicated
Pembahasan: jawaban a
Based on the evidence to date, the recommendations regarding the best first aid treatment
for burns should be to use cold running tap water (between 2 and 15 0C) and to not use
ice or alternative therapies. However, the optimum duration of first aid application and
the delay after the injury for which first aid can still be effective are two areas of research
which need further exploration. Cold water is believed to firstly act on burn wounds to
stop the burning process by cooling the tissue below the temperature required to cause an
injury. Cold water is also believed to assist burn wound healing by preventing cells
undergoing progressive necrosis 24–48 h after burn in the zone of stasis. Studies have
shown that in this thermally damaged area, cold water may act in a number of ways. It
has been shown to decrease cell metabolism, which would assist these cells to survive
such a hypoxic wound environment. It has also been shown to stabilize the vasculature,
by decreasing capillary leakage, increasing dermal perfusion and re-establishing blood
flow. Many studies also focus on the ability of cold water to decrease edema; however,
this mostly seems to be a transient effect and has not been shown to improve the healing
of the burn wound. Cold water has been found to dampen the inflammatory response, by
reducing the release of histamine and lactate, stabilizing prostaglandin levels and
decreasing thromboxane levels and inhibiting kallikrein activity in human plasma,
thereby decreasing kinin formation. Don't try to neutralize the burn with acid or alkali.
This could cause a chemical reaction that worsens the burn (Cuttle et al, 2009).
 41. Arch bar indication:
1. For temporary fragment stabilization in emergency cases before definitive
treatment
2. As a tension band in combination with rigid internal fixation
3. For long-term fixation in conservative treatment
4. For fixation of avulsed teeth and alveolar crest fractures
Pembahasan: jawaban e
Arch bars are preferred: For temporary fragment stabilization in emergency cases before
definitive treatment. As a tension band in combination with rigid internal fixation. For
long-term fixation in conservative treatment. For fixation of avulsed teeth and alveolar
crest fractures

42. This statement are true for open wound with necrotic tissue, except:
1. Surgical debridement is the best methods for this type of wound
2. Hydrogel usually preferred by medical wound therapist as autological debridement
3. Hydrogel usually combine with foam in wound care therapy
4. All true
Pembahasan: jawaban b
The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced
blood supply), slough (dead tissue, usually cream or yellow in colour), or eschar (dry,
black, hard necrotic tissue). Such tissue impedes healing. Necrotic tissue and slough may
be quantified as excessive (+++), moderate (++), minimal (+), or absent (−). Since
necrotic tissue can also harbour pathogenic organisms, removal of such tissue helps to
prevent wound infection. Necrotic tissue and slough should be debrided with a scalpel so
that the wound bed can be accurately assessed and facilitate healing. Eschar may be
adherent to the wound bed, making debridement with a scalpel difficult. Further
debridement, as part of wound management, may be required using other techniques
(Grey et al, 2006). Hydrogel dressings consist of a hydrophilic polymer, usually a starch
polymer such as polyethylene oxide, and up to 80% water. They are available as gels,
sheets, or impregnated gauze, which are absorbent, non-adherent, semitransparent, and
semipermeable to water vapor and gases. Their high water content gives them the ability
to rehydrate dry wounds, giving them a soothing and cooling effect. Hydrogels also act
on necrotic tissue by autolytic debridement, thereby facilitating granulation tissue
formation (Oh and Philips, 2012).

43. The true statement of debridement, except:

a. Specimen for autolytic debridement are hydocolloids and hydrogel
b. Enzymatic debridement worked by proteolysis, fibrinolysis and collagenase process
c. The principal of mechanical debridement is moist wound dressing
d. Biological debridement is debridement using Maggot Debridement Therapy
e. Surgical debridement is the most expensive and effective type of debridement
Pembahasan: jawaban c
Autolityc debridement is a painless and safe technique, but with slow action, so with high
costs, because dressing are usually changed once a day. With enzymatic debridement it is
the conservative approach preferred in home wound treatment. Autolityc dressing are
hydrogel, paste or granule with needed to be cover by a secondary occlusive dressing for
creating the optimal environment to activate macrophages (Mancini et al, 2017). Products
that can be used to facilitate autolytic debridement include hydrogels, hydrocolloids,
cadexomer iodine and honey (Vowden and Vowden, 2011).
Enzymatic Debridement. This is a selective method for debridement of necrotic tissue
using an exogenous proteolytic enzyme, collagenase, to debride Clostridium bacteria.
Collagenase digests the collagen in the necrotic tissue allowing it to detach. Enzymatic
debridement is a slow method of the debridement as from hair to mechanical and sharp
debridement. Collagenase and moisture retentive dressings can work in synergy
enhancing the debridement. Enzymatic debridement is not recommended for an advanced
process, or in patients with known sensitivity to the product's ingredients. A relative
contraindication of enzymatic debridement is its use in heavily infected wounds.
 Furthermore, collagenase should not be used in conjunction with silver-based products or
with Dakin solution (Manna and Morrison, 2019). Methods specifically aimed at
enhancing fibrinolysis include hydrocolloid dressings, aserbine, malatex, streptokinase
with streptodornase, travase, debrisan, stabilized crystalline trypsin, plasmin and
DNAase, Bromelain (a proteinase from the stem of the pineapple plant), and Krill (a
novel multienzyme preparation derived from Euphasia Superba, the antarctic krill)
(Sinclair and Ryan, 1994).
Mechanical debridement is a nonselective type of debridement, meaning that it will
remove both devitalized tissue and debris as well as viable tissue. It is usually carried
using mechanical force: wet-to-dry, pulsatile lavage, or wound irrigation. It is indicated
for both acute and chronic wounds with moderate to large amounts of necrotic tissue,
regardless of the presence of an active infection. The contraindications include,
depending on the modality of mechanical debridement used, the presence of granulation
tissue in a higher amount than the devitalized tissue, inability to control pain, patients
with poor perfusion, and an intact eschar with no gross clinical evidence of an underlying
infection (Manna and Morrison, 2019).
Biological debridement, also known as larval or maggot therapy, is performing selective
debridement by using maggots as live medical devices. The sterilized maggots are placed
on the wound surface within a net pouch, and fixed by an absorbent dressing (Kordestani,
2019).

44. The true statement of mental nerve, except:

a. Branch from mandibular division of trigeminal nerve
b. Disruption of this nerve will be seen as hypoesthesia at chin and lower lip
c. Drooling is one of his nerve parese complication
d. Mental nerve branched into 2 branches after depressor annuli cris muscle
e. Foramen mental located between two premolar of mandible
Pembahasan: jawaban d
Mental nerve is a sensory nerve which provides sensation to the front of the chin and
lower lip as well as the labial gingivae of the mandibular anterior teeth and the premolars.
It is a branch of the posterior trunk of the inferior alveolar nerve, which is itself a branch
of the mandibular division of the trigeminal nerve (CN V).
Numb chin syndrome (NCS), often synonymously named as “mental nerve neuropathy,”
is a sensory neuropathy characterized by numbness (hypoesthesia, paresthesia,
dysesthesia, and anesthesia) or, very rarely, pain of the chin and lower lip within the
mental or inferior alveolar nerve distribution (Wu et al, 2017).
The only muscle that the mental nerve has an anatomical association with is the depressor
anguli oris muscle. As the mental nerve exits the mental foramen, it divides into its three
 branches underneath or posterior to the depressor anguli oris muscle (Nguyen and Duong,
2019).

45. Below are true for examination for mobility of maxilla:

a. Mobility of the midface may be tested by grasping the posterior alveolar arch and
pulling forward while stabilizing
b. In Lefort II, one hand should be located in nasal radix
c. In Lefort II, one hand should be located in glabella
d. In Lefort II, one hand should be located in malar eminence
e. All statements are true
Pembahasan: jawaban b
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