9 Facial Plastics

Question 1

1 What are the layers of the skin from superficial to deep?

Answer 1

1. Epidermis
2. Basement membrane
3. Dermis (papillary and reticular)
4. Subcutis

Question 2

2 What are the layers of the epidermis from superficial to deep?

Answer 2

1. Stratum corneum
2. Stratum lucidum
3. Stratum granulosum
4. Stratum spinosum
5. Stratum basale

Question 3

3 What are epidermal appendages?

Answer 3

Skin-associated structures including hair follicles, apocrine glands, sebaceous glands, and eccrine (sweat) glands

Question 4

4 What is the predominant type of collagen in the basement membrane?

Answer 4

Type IV collagen

Question 5

5 What are the three phases of wound healing? (▶ Fig. 9.1)

Answer 5

Inflammation, proliferation, and remodeling. Some authors also include hemostasis as the first phase.

Question 6

6 What are four general categories of wound healing?

Answer 6

• Healing by primary intention: Two wound edges are brought together as the primary intention of the surgeon.
• Delayed primary healing: Two wound edges are not brought together immediately but are reapproximated and closed at a later time.
• Healing by secondary intention: A full-thickness wound where the edges are not reapproximated and the wound is allowed to heal by granulation and contracture
• Epithelialization: Occurs in partial-thickness wounds as epithelial cells migrate and replicate over the wound

Question 7

7 What cell types are primarily involved in the inflammatory phase?

Answer 7

After vasoconstriction and subsequent vasodilation, polymorphonuclear neutrophils arrive and predominate for the first 24 to 48 hours after injury. Following this, monocyte migration occurs.

Question 8

8 What cell type synthesizes collagen?

Answer 8

Fibroblasts

Question 9

9 What cell type is responsible for wound contraction during healing?

Answer 9

Myofibroblasts containing microfilaments capable of producing contractile forces. These cells predominate the fibroblast population during the second week of wound healing.

Question 10

10 What major events occur during the proliferative phase of wound healing?

Answer 10

• Re-epithelialization
• Neovascularization
• Collagen deposition
• Wound contraction

Question 11

11 During which phase of healing are keratinocytes, fibroblasts, and endothelial cells recruited to the wound?

Answer 11

Proliferative phase

Question 12

12 During the proliferative phase, which cytokine modulates angiogenesis and neovascularization?

Answer 12

Vascular endothelial growth factor (VEGF)

Question 13

13 How does hyperbaric oxygen therapy encourage wound healing?

Answer 13

It promotes angiogenesis, fibroblast proliferation, leukocyte activity, and is synergistic with antibiotic therapy.

Question 14

14 What is the predominant type of collagen in an early scar?

Answer 14

Type III collagen

Question 15

15 What is the approximate tensile strength of a healing wound at 3 months?

Answer 15

50% of normal tissue

Question 16

16 When is the remodeling phase of wound healing usually complete?

Answer 16

12 months

Question 17

17 What are the tenets of Halsted?

Answer 17

• Gentle handling of tissues
• Aseptic technique
• Sharp anatomical dissection of tissues
• Careful hemostasis, using fine, nonirritating suture materials in minimal amounts
• The obliteration of dead space in the wound
• Avoidance of tension

Question 18

18 How can local tissue factors impact wound healing?

Answer 18

Wound healing is compromised by any tissue effect that decreases oxygenation, increases infection risk, prolongs inflammation, delays neovascularization, or otherwise alters the normal process of healing. Examples include local infection, ischemia resulting from pressure necrosis (e.g., diabetic neuropathy, hematoma), alteration in tissue structure resulting from radiation therapy, locally destruc tive processes (neoplasia, wound desiccation).

Question 19

19 What patients should be counseled about increased risk for postoperative infection or wound breakdown?

Answer 19

Patients with medical comorbidities, medications, or history of recent treatments, which alter the normal healing process or suppress the immune system. For example, patients who have undergone chemotherapy and radiation therapy, are taking immunosuppressants, or have diseases that affect the vasculature (e.g., peripheral vascular disease, diabetes, current smoker) are at increased risk for wound complications.

Question 20

20 What are relaxed skin tension lines?

Answer 20

They are the lines of minimal tension on the skin. They run parallel to natural wrinkle lines and are usually perpendicular to the force of action of the underlying muscles of facial expression

Question 21

21 What are some of the technique- and patient related factors that may lead to an aesthetically unacceptable scar?

Answer 21

• Patient variables: Diabetes, chronic steroid use, systemic vasculitis, vitamin deficiency, poor overall nutrition, chronic renal disease, wound infection, collagen vascular disease, sun exposure
• Technical variables: Failure to clean the wound adequately, excessive tension on epidermal sutures, step-off between wound edges, rough handling of tissue, prolonged suture retention, failure to orient incision parallel to relaxed skin tension lines, delayed wound closure

Question 22

22 What are some of the performance differences between monofilament and braided suture?

Answer 22

Monofilament suture has “memory” and usually requires more knots to secure a tie.

Braided suture has more tensile strength but creates more resistance through tissue, induces a stronger inflammatory response, and is more likely to serve as a reservoir for microorganisms.

Question 23

23 What type of surface contour is most favorable for wound healing by secondary intention? (▶ Fig. 9.2)

Answer 23

Concave surfaces

Question 24

24 What are some surgical options for scar revision?

Answer 24

Excision and closure with straight line, broken geometric line, W-plasty, Z-plasty, or local flap; excision and placement of a skin graft

Question 25

25 What medications may be injected into a scar to improve its appearance?

Answer 25

Steroids (triamcinolone diacetate), antimitotic agents (5-FU and bleomycin)

Question 26

26 What is the role of silicone in scar revision?

Answer 26

The mechanism by which silicone sheeting reduces the appearance of hypertrophic scars has not been clearly elucidated. One hypothesis is that direct pressure exerted by silicone sheeting on the wound decreases scar hypertrophy. Another theory is that silicone’s ability to maintain a hydrated environment inhibits fibroblast production of collagen and glycosaminoglycans.

Question 27

27 What is the primary difference between keloid formation and hypertrophic scarring?

Answer 27

Keloids spread beyond the boundaries of the original scar, whereas hypertrophic scars do not extend outside the wound perimeter.

Question 28

28 Review some treatment options for keloids and hypertrophic scars.

Answer 28

Occlusive dressings, intralesional steroid injections, cryo therapy, radiation therapy, 5-FU, BOTOX injection, tacrolimus, retinoic acid, laser therapy, re-excision combined with above treatments

Question 29

29 What is dermabrasion, and what is its role in scar revision?

Answer 29

Dermabrasion is a mechanical method of removing the epidermis and creating a papillary to upper reticular dermal wound. Injuries to the epidermis and papillary dermis heal without scarring. Dermabrasion changes the depth of the scar to help it blend with surrounding normal tissue. It also seeks to create a wound with texture and color closely matching normal skin.

Question 30

30 What layer of the dermis contains the predominant blood supply of the skin?

Answer 30

Reticular dermis

Question 31

31 Dermabrasion injury to the papillary dermis results in production of what tissue elements?

Answer 31

• Type III procollagen
• Type I procollagen
• Transforming growth factor-β1

Question 32

32 Routine prophylaxis for what infection is typically offered to patients before they undergo dermabrasion?

Answer 32

Herpes simplex virus, typically beginning 24 hours preoperatively and continuing for 5 days

Question 33

33 Which Fitzpatrick skin types have the greatest risk of pigmentary dyschromia (hyper-pigmentation or hypopigmentation) after resurfacing?

Answer 33

Fitzpatrick type III through VI

Question 34

34 What is the mechanism of action of hydroquinone?

Answer 34

Hydroquinone blocks tyrosinase from developing melanin precursors, thereby impeding new pigment formation as the new epidermis heals after a chemical peel.

Question 35

35 What are the major indications for a medium depth chemical peel?

Answer 35

• Destruction of epidermal lesions
• Resurfacing of moderate photoaging skin
• Correction of pigmentary dyschromias
• Repair of mild acne scars
• Blending of photoaging skin with laser resurfacing

Question 36

36 Baker-Gordon phenol is used to achieve what level of chemical peeling?

Answer 36

Deep chemical peel

Question 37

37 What toxicities are associated with phenol chemical peels?

Answer 37

• Cardiotoxicity
• Hepatotoxicity
• Nephrotoxicity

Question 38

38 What methods may be used to limit the potential toxic effects of a phenol chemical peel?

Answer 38

• Administering intravenous hydration before and during the procedure
• Increasing the duration of application
• Electrocardiographic monitoring
• Oxygen administration
• Screening for patients with arrhythmias or hepatic/renal compromise or patients taking medications that may increase the risk of cardiac arrhythmias

Question 39

39 What does the acronym LASER stand for?

Answer 39

Light amplification by stimulated emission of radiation

Question 40

40 What is the role of lasers in scar revision?

Answer 40

Lasers create thermal injury leading to collagen retraction. They can also be used for skin resurfacing to correct pigmentary defects.

Question 41

41 What is the role of pulsed dye laser in scar revision?

Answer 41

A 585-nm wavelength pulse dyed laser can decrease the vascularity of scar tissue and reduce scar redness. The laser may also decrease the number and activity of fibroblasts.

Question 42

42 What is the wavelength of the CO2 laser? (▶ Fig. 9.3)

Answer 42

10,600 nm, infrared spectrum

Question 43

43 What characteristic of CO2 lasers allows them to vaporize superficially and provide, for the most part, a what-you-see-is-what-you-get type of tissue interaction, similar to electrocautery?

Answer 43

They have increased absorption by tissues with high water content.

Question 44

44 What is the primary chromophore for both the CO2 and Er:YAG laser?

Answer 44

Water. Er:YAG has strong tissue water absorption, approximately 12 times that of the CO₂ laser.

Question 45

45 What is the wavelength of the Er:YAG laser?

Answer 45

2940 nm, infrared spectrum

Question 46

46 What is the definition of laser fluency?

Answer 46

The amount of energy (joules) that is applied to the surface area of tissue (centimeters squared), expressed as J/cm²

Question 47

47 The effect of a laser on specific tissue depends on what four factors?

Answer 47

• Laser wavelength
• Laser energy density
• Pulse duration
• Tissue absorption

Question 48

48 How is laser power density altered?

Answer 48

By changing the focal length of the lens or changing the working distance

Question 49

49 How does the pulsed delivery of a laser allow a higher energy delivery with less thermal injury?

Answer 49

By using the heat sink effect of the adjacent tissue and blood flow during the interpulse intervals

Question 50

50 What is the term used to describe the characteristic of a laser’s ability to have photons move in the same temporal and spatial phase?

Answer 50

Coherence

Question 51

51 What terms describe the laser-tissue surface interaction?

Answer 51

Absorption, transmission, reflection, scatter

Question 52

52 Which botulinum neuromodulator serotype demonstrates the longest duration of effect?

Answer 52

Serotype A (3-4 months)

Question 53

53 What is the mechanism of action of BOTOX?

Answer 53

BOTOX prevents presynaptic neurosecretory vesicles from docking/fusing with the nerve synapse plasma membrane (degrades the SNAP-25 protein) and releasing acetylcholine into the neuromuscular junction.

Question 54

54 Vertical glabellar furrows are most likely caused by which muscle?

Answer 54

Corrugator supercilii

Question 55

55 What muscle arises in the medial end of the orbit/nasal prominence and interdigitates with the orbicularis oculi muscle laterally and the frontalis muscle superiorly?

Answer 55

Corrugator supercilii

Question 56

56 What medication can be given to patients who develop botulinum toxin-related blepharoptosis, and what is its mechanism of action?

Answer 56

• Apraclonidine eye drops. An α2-adrenergic agonist, which causes Müller muscle to contract.
• Phenylephrine can be used when apraclonidine is not available.

Question 57

57 A patient does not appear to have further benefit after repeated botulinum toxin injections. What is the most likely cause?

Answer 57

Formation of neutralizing antibodies rendering resistance to the paralytic effect of the toxin. Often responds to switching to an alternate type.

Question 58

58 What muscle may be treated with botulinum toxin to decrease the “peau d’orange” or dimpled chin appearance with facial animation?

Answer 58

The mentalis muscle

Question 59

59 What is the role of fillers in scar revision?

Answer 59

To provide bulk to bring a depressed scar level with surrounding normal skin

Question 60

60 List examples of tissue-derived injectable fillers?

Answer 60

• Bovine collagen (Zyderm, Zyplast)
• Human particulate “dermal matrix” (Cymetra)
• Cultured autologous fibroblasts (Isologen)

Question 61

61 List examples of implantable soft tissue fillers.

Answer 61

• Human acellular dermis (AlloDerm)
• Porcine acellular dermis (Surgisis)

Question 62

62 List examples of synthesized selective bioactive (resorbable) injectable fillers.

Answer 62

• Calcium hydroxyapatite particles (Radiesse)
• Polylactic acid particles (Sculptra)

Question 63

63 What is an example of an implantable synthetic polymer?

Answer 63

Expanded polytetrafluoroethylene (Gore-Tex)

Question 64

64 Which implant particle size is not readily phagocytized by macrophages?

Answer 64

20 to 60 μm. Particles smaller than this have been shown to precipitate a chronic inflammatory response, whereas larger particles cannot be easily phagocytized and therefore elicit minimal inflammatory reaction.

Question 65

65 What are the challenges associated with the use of polymethylmethacrylate?

Answer 65

The final phase of polymerization is associated with an exothermic reaction that can cause tissue injury. It can become loose with time despite immobilization. The need for implant removal is higher if in contact with nasal or frontal sinus tissue.

Question 66

66 What is the primary advantage of dermal fat grafts over free adipose grafts?

Answer 66

There is less resorption than with free adipose grafts, although even up to 70% of dermal fat grafts are resorbed.

Question 67

67 Describe some uses of facial fat grafting in facial aesthetic surgery.

Answer 67

• Lip augmentation
• Effacement of glabellar rhytids
• Tear trough deformity
• Deep nasolabial folds
• Replacing volume in areas of facial fat atrophy and to fill in depressed scars

Question 68

68 When using tissue expanders, as a general rule of thumb, how much larger should the surface area of the base of the expander be than the defect size?

Answer 68

2.5 times

Question 69

69 In the context of tissue expanders, what is mechanical creep?

Answer 69

Rapid collagen and elastin realignment and dispersion of interstitial fluid and ground substance during applied soft tissue stretch

Question 70

70 Review some complications from use of tissue expanders.

Answer 70

• Hematoma
• Infection
• Extrusion
• Migration
• Necrosis of overlying tissue
• Loss of hair
• Pain
• Erosion of underlying bone

Question 71

71 Why are gold and platinum the current metals of choice for eyelid-loading surgery?

Answer 71

Chemically inert and relatively dense

Question 72

72 What muscles of facial expression are responsible for the horizontal rhytides of the glabella?

Answer 72

Procerus

Question 73

73 What two dissection planes are commonly used during brow lift surgery?

Answer 73

• Subgaleal
• Subperiosteal

Question 74

74 What nonsurgical technique can be used for browplasty?

Answer 74

Selectively paralyzing the temporal brow depressors (lateral orbicularis muscle) with BOTOX type A which then allows unopposed elevation of the frontalis muscle

Question 75

75 List the various surgical techniques used for brow rejuvenation

Answer 75

Temporal lift; direct brow, midforehead, temporal extension of rhytidectomy incision; coronal, pretrichial/trichophytic, endoscopic

Question 76

76 What anatomical structure lies between the intermediate temporal fascia and the deep temporal fascia?

Answer 76

Intermediate fat pad

Question 77

77 What surgical brow rejuvenation techniques involve subcutaneous tissue dissection?

Answer 77

Midforehead and direct brow

Question 78

78 What is the sentinel vein?

Answer 78

A zygomaticotemporal vessel encountered between the deep temporal fascia and the temporoparietal fascia during dissection in the temporal region during brow lift surgery. It has been shown to point to the frontal branch of the facial nerve as it courses through the temporoparietal fascia.

Question 79

79 What is the Pitanguy line?

Answer 79

A line that runs from the lobule to the lateral canthus. This line crosses the zygoma roughly at the midpoint from the helical root to the lateral canthus and approximates the location of the frontal branch of the facial nerve.

Question 80

80 What is the aesthetic ideal for brow position in a man?

Answer 80

Horizontal, resting on the superior orbital rim

Question 81

81 What is the aesthetic ideal for brow position in a woman? (▶ Fig. 9.4)

Answer 81

The brow should arc above the orbital rim with its highest point centered over the lateral limbus.

Question 82

82 What incision placement strategy should be used during midforehead brow-lift surgery?

Answer 82

Centering incisions over existing rhytids and selecting two different vertical forehead creases to stagger the incisions

Question 83

83 What brow-lift surgery technique is best used in a man with a receding hairline?

Answer 83

Midforehead

Question 84

84 Currently, what is the surgical technique of choice for correction of both brow ptosis and forehead and glabellar rhytids?

Answer 84

Endoscopic blepharoplasty

Question 85

85 What are contraindications to a coronal lift for brow ptosis?

Answer 85

• High female hairline
• Male-pattern baldness
• Brow asymmetries

Question 86

86 In what percentage of patients will the supratrochlear or supraorbital nerves arise from a true foramen, putting them at risk for transection?

Answer 86

10 to 30%

Question 87

87 What muscle is considered the primary elevator of the brow?

Answer 87

Frontalis

Question 88

88 The galea aponeurosis is contiguous with what two other anatomical structures?

Answer 88

The SMAS of the face below and the temporoparietal fascia (TPF) laterally.

Question 89

89 What are the four standard clinical measurements used for evaluating someone with ptosis?

Answer 89

1. Palpebral fissure height
2. Marginal reflex distance
3. Upper eyelid crease distance
4. Levator excursion

Question 90

90 How does one assess eyelid ptosis?

Answer 90

Eyelid ptosis should be evaluated in primary gaze with the frontalis relaxed and the brow fixed. The average vertical palpebral fissure is approximately 10 mm. The levator function is tested by measuring the vertical excursion of the eyelid (normal 12 to 18 mm). The margin-to-reflex distance is the distance between the central corneal light reflex and the upper eyelid margin (normal ~ 4.5 mm).

Question 91

91 What is the normal position of the upper eyelid relative to the limbus?

Answer 91

The upper eyelid margin typically rests 1.5 mm below the superior corneal limbus, with the highest point just medial to the pupil.

Question 92

92 Describe the ideal upper eyelid configuration.

Answer 92

The lid crease is 6 to 8 mm from the lash line in a man and 8 to 10 mm in a woman. The upper lid covers approximately 1.5 mm of the iris and does not reach the level of the pupil during primary gaze

Question 93

93 What two muscles are responsible for elevation of the upper eyelid? (▶ Fig. 9.5)

Answer 93

Levator palpebrae superioris and Müller muscle

Question 94

94 Where does the levator palpebrae superioris originate and insert?

Answer 94

It originates from the lesser wing of the sphenoid and inserts on the superior tarsal plate.

Question 95

95 What is the innervation of the levator palpebrae superioris?

Answer 95

The oculomotor nerve

Question 96

96 Where does Müller muscle originate and insert?

Answer 96

It originates from the undersurface of the levator palpebrae superioris and inserts on the superior aspect of the tarsus.

Question 97

97 What is the innervation of Müller muscle?

Answer 97

Sympathetic nervous system from the superior cervical ganglion to the carotid plexus and along the oculomotor nerve

Question 98

98 Describe the margin crease distance.

Answer 98

The distance from the upper eyelid crease to the upper eyelid margin measured during downgaze

Question 99

99 Where should the inferior incision be placed during upper eyelid blepharoplasty?

Answer 99

At the natural lid crease, which is at the upper margin of the underlying superior tarsal plate (8 to 10 mm above the lid margin in women and 6 to 9 mm in men)

Question 100

100 What are milia?

Answer 100

Milia are 1- to 2-mm cysts that appear as white, smooth nodules on the face. Histologically, they are identical to epidermoid cysts except for their smaller size.

Question 101

101 Describe the marginal reflex distance-1?

Answer 101

Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze

Question 102

102 What is the marginal reflex distance-2?

Answer 102

The space between the lower eyelid margin and the pupillary light reflex during primary gaze (normally ~ 5 mm)

Question 103

103 What is the difference between blepharoptosis and blepharochalasis?

Answer 103

• Blepharoptosis (ptosis) refers to an abnormally low-lying upper eyelid margin during primary gaze.
• Blepharochalasis refers to a condition of unilateral or bilateral episodic painless, periorbital edema that leads to lid redundancy.

Question 104

104 What is pseudoptosis?

Answer 104

When the upper eyelid appears to be low as a result of malposition of the globe or brow rather than eyelid dysfunction

Question 105

105 What is the cause of an undesirable hollowed-out appearance after cosmetic blepharoplasty?

Answer 105

Excessive resection of orbital fat

Question 106

106 What is the anatomical basis for the difference between the Asian and white upper eyelid?

Answer 106

In the Asian eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full, thickened or puffy eyelid. In the white eyelid, the levator aponeurosis penetrates the orbital septum and orbicularis muscle attaching to the overlying dermis, creating a superior palpebral fold.

Question 107

107 What is the primary risk of epicanthoplasty in the Asian patient?

Answer 107

Web formation in the medial canthal region

Question 108

108 What percentage of Asians demonstrate a “single eyelid,” and what percentage have an epicanthal fold?

Answer 108

50% and 90%, respectively; the size of the fold is usually relatively small.

Question 109

109 What is the most common form of ptosis?

Answer 109

Acquired aponeurotic or senile ptosis

Question 110

110 What is a common clinical sign of acquired aponeurotic ptosis?

Answer 110

Normal or near normal levator function with an abnormally elevated upper eyelid crease

Question 111

111 What is the most common type of congenital ptosis?

Answer 111

Congenital myogenic ptosis. Caused by dysgenesis of the levator palpebrae superioris in which the muscle fibers are replaced by fibroadipose tissue.

Question 112

112 What percentage of congenital ptosis is unilateral?

Answer 112

Approximately 75%

Question 113

113 What coexisting ocular condition is present in a significant number of patients with congenital ptosis?

Answer 113

Amblyopia

Question 114

114 Describe the phenylephrine test for evaluating ptosis?

Answer 114

This test involves placing dilute phenylepherine in the eye. After waiting 5 minutes, the palpebral fissure and marginal reflex distance are measured and compared with baseline. If there is a good response, then the Müller muscle conjunctival resection should be considered. If there was no response, the external levator advancement should be considered

Question 115

115 Describe the clinical manifestation of myogenic ptosis secondary to myasthenia gravis.

Answer 115

Nearly all patients with myasthenia gravis develop ocular symptoms, including ptosis and diplopia. Ptosis is generally bilateral and worsens throughout the day. Symptoms may alternate from one eye to the other

Question 116

116 What surgical technique can be used for treatment of ptosis with poor or absent levator function?

Answer 116

Frontalis sling

Question 117

117 What are the clinical manifestations of Marcus Gunn jaw-winking ptosis?

Answer 117

Elevation of a ptotic eyelid during ipsilateral activation of the mandibular division of the trigeminal nerve (chewing, jaw opening)

Question 118

118 What are the most common causes for needing eyelid reconstruction?

Answer 118

Eyelid tumor excision followed by trauma

Question 119

119 What are the lamellae of the eyelid?

Answer 119

Anterior, middle, and posterior

Question 120

120 What structures make up the anterior, middle and posterior lamellae of the eyelid?

Answer 120

• Anterior: Skin and orbicularis oculi
• Middle: Orbital septum, orbital fat, and the suborbicularis fibroadipose tissue
• Posterior: Eyelid retractors, tarsal plate, and conjunctiva

Question 121

121 Describe the anatomy of the medial canthus?

Answer 121

The medial canthus consists of the lacrimal drainage system and the medial canthal tendon.

The medial canthal tendon surrounds the lacrimal sac (creating a “pump”) and splits to form anterior and posterior heads attaching to the anterior and posterior lacrimal crests. The medical canthal tendon diverges to join the suspensory ligaments of the eyelid, the orbicularis oculi muscle, and the tarsal plate.

Question 122

122 What types of defects of the upper eyelid can be allowed to heal by secondary intention with acceptable results?

Answer 122

Medial canthal region less than 1 cm and the upper eyelid when not involving the lid margin and less than 5 mm in diameter

Question 123

123 What is the maximum defect size of an eyelid that can be closed primarily?

Answer 123

25% in an adult and up to 45% in elderly patients with significant lid laxity

Question 124

124 What is the most commonly used reconstructive option for a defect that involves more than 50% of the upper eyelid?

Answer 124

Cutler-Beard flap

Question 125

125 After a Cutler-Beard flap reconstruction of the upper eyelid, what will the newly reconstructed eyelid lack?

Answer 125

Eyelashes and tarsus. Tarsus can be reconstructed if desired, but this is not typically done.

Question 126

126 Describe a Tenzel rotation flap?

Answer 126

Semicircular musculocutaneous rotation flap that recruits redundant skin from the lateral orbit and can be used to reconstruct defects up to 60% of the width of the upper or lower eyelids

Question 127

127 Lower eyelid defects of 50% or greater are most commonly reconstructed with what type of flap?

Answer 127

Hughes tarsoconjunctival flap

Question 128

128 What anatomical layer of the eyelid does the Hughes tarsoconjunctival flap reconstruct?

Answer 128

Posterior lamella

Question 129

129 When are Hughes tarsoconjunctival flaps and Cutler-Beard flaps most commonly divided after initial surgery?

Answer 129

4 to 6 weeks

Question 130

130 Describe the Fitzpatrick scale of skin typing.

Answer 130

(▶ Table 9.1)

Question 131

131 Describe the Glogau classification of photoaging skin.

Answer 131

• Class I: Little wrinkling, ages 28 to 35 years, mild pigment changes without keratosis
• Class II: Wrinkles with motion, ages 35 to 50 years, early pigment changes and early actinic keratosis
• Class III: Wrinkles at rest, ages 50 to 65 years, gross discoloration, visible keratosis, and telangiectasia
• Class IV: Severe wrinkling, 60 years and older, prior skin cancers, diffuse wrinkling with color changes

Question 132

132 Describe the Frankfort horizontal line. (▶ Fig. 9.6)

Answer 132

An imaginary line that extends from the superior aspect of the external auditory meatus to the inferior orbital rim

Question 133

133 How is the ideal facial height described?

Answer 133

The facial height can be divided into three equal parts. The superior third is measured from trichion to glabella, middle third from glabella to subnasale, inferior third from subnasale to menton

Question 134

134 How is the lower third of the face subdivided? (▶ Fig. 9.7)

Answer 134

The upper third is determined by the subnasale to stomion and lower two-thirds by the stomion to mentum.

Question 135

135 Describe how the face is divided into vertical fifths.

Answer 135

On frontal view, the face is divided into five equal proportions using the lateral-most projection, the lateral canthi, and the medial canthi.

Question 136

136 With what layer in the neck is the SMAS layer contiguous?

Answer 136

The platysma

Question 137

137 What leads to jowl formation?

Answer 137

Relaxation of the masseteric cutaneous ligament and the parotid cutaneous ligament (Lore fascia) allows for inferomedial migration of the buccal fat pad. The descent of the fat pad is halted when it reaches the mandibular cutaneous ligament, leading to formation of the jowl and deepening of the prejowl sulcus (Marionette line).

Question 138

138 What structures are responsible for creating the nasolabial fold?

Answer 138

The distal portions of the zygomaticus major and zygomaticus minor muscles insert into the dermis at the lateral aspect of the upper lip, creating the nasolabial fold.

Question 139

139 What is the process of aging that leads to the nasojugal/tear trough deformity?

Answer 139

Atrophy and descent of the suborbicularis oculi fat and malar fat pad collecting at the nasolabial fold, leaving the infraorbital region exposed and the infraorbital rim more prominent

Question 140

140 What surgical approach is most common for malar implant placement?

Answer 140

Intraoral (canine fossa)

Question 141

141 Anterior to the parotid gland, what layer separates the branches of the facial nerve from the SMAS?

Answer 141

The parotidomasseteric fascia

Question 142

142 What is the vector of pull for the soft tissues of the face during rhytidectomy?

Answer 142

Posterior and superior

Question 143

143 During rhytidectomy, what determines whether the preauricular incision curves into the hairline or stays below the inferior edge of the preauricular tuft?

Answer 143

The level of the hairline. If the preauricular tuft is 1 to 2 cm below the superior portion of the helical insertion, the incision can curve into the hairline. If there is a high preauricular tuft, the incision should be immediately below this

Question 144

144 Review some risk factors associated with skin necrosis following rhytidectomy.

Answer 144

• Tobacco use
• Superficial dissection
• Excessive wound tension
• Untreated hematoma
• Systemic conditions associated with microvascular disease

Question 145

145 Smoking increases the risk of flap necrosis following rhytidectomy by what factor?

Answer 145

Thirteen times

Question 146

146 Which facelift technique is most prone to hypertrophic scarring?

Answer 146

Skin-only facelift

Question 147

147 What is the most commonly injured nerve during rhytidectomy?

Answer 147

Greater auricular nerve (1 to 7%)

Question 148

148 When elevating the cervical skin flap during rhytidectomy, the great auricular nerve is inadvertently transected. How should this complication be managed?

Answer 148

Direct suture anastomosis

Question 149

149 During rhytidectomy, an uninterrupted bridge of tissue should be maintained between the temporal and preauricular elevations to protect what structure?

Answer 149

Frontal branch of the facial nerve

Question 150

150 The temporal branch of the facial nerve lies within or immediately deep to what structure? (▶ Fig. 9.8)

Answer 150

Superficial temporal fascia, also known as the temporoparietal fascia

Question 151

151 What is the cause of Satyr (devil’s) ear after rhytidectomy?

Answer 151

Downward tension on the earlobe leading to inferior displacement of the lobule

Question 152

152 What causes a cobra deformity after rhytidectomy?

Answer 152

Overaggressive submental lipectomy and/or inadequate platysmal plication

Question 153

153 What is the cause of the “turkey gobbler” deformity?

Answer 153

Diastasis and ptosis of the platysma muscle with accumulation of submental and cervical fat

Question 154

154 How is the mentocervical angle determined?

Answer 154

In lateral view, the angle created by a line drawn from the glabella to the pogonion and an intersecting line drawn from the menton to the junction of the neck and submental region

Question 155

155 What percentage of women undergoing rhytidectomy will experience depression after surgery?

Answer 155

50%

Question 156

156 How does liposuction lead to a decrease in subcutaneous fat?

Answer 156

By direct removal of adipocytes and induction of apoptosis

Question 157

157 For what type of fat deposits, congenital or acquired, is liposuction most effective?

Answer 157

Congenital fat accumulations that do not shrink with weight loss

Question 158

158 Describe the ideal chin position.

Answer 158

Draw a vertical line through the vermilion border of the lower lip. In men, the pogonion should touch this line and may lie up to 2 mm anterior. In women, the pogonion should touch this line and should not rest more than 2 mm posterior.

Question 159

159 What method is used to determine ideal chin projection? (▶ Fig. 9.9)

Answer 159

Gonzalez-Ulloa method: A line is made from the nasion perpendicular to the Frankfort horizontal. The ideal chin projection should be at this line. When the chin is posterior, and the patient has normal occlusion, a hypoplastic mentum is present.

Question 160

160 What is the difference between microgenia, micrognathia, and retrognathia?

Answer 160

• Microgenia is caused by an underdeveloped mentum with an otherwise normal mandible and normal occlusion.
• Micrognathia implies a hypoplastic retruded mandible with class 2 occlusion.
• Retrognathia implies a normal sized mandible with class 2 occlusion

Question 161

161 What is a useful landmark for identifying the mental foramina?

Answer 161

The mental foramina is variable but is usually found below the second premolar tooth.

Question 162

162 Where should the pocket for a chin implant be created?

Answer 162

Inferior to the mental foramen but above the muscle insertions of the inferior mandibular border (generally 8 to 10 mm of space). It may be placed transorally or transcutaneously through a submental crease incision.

Question 163

163 What are some of the indications for distraction osteogenesis of the mandible?

Answer 163

• Hemifacial microsomia
• Syndrome-related micrognathia
• Severe obstructive sleep apnea
• Deformity of the mandibular angle
• Mandibular hypoplasia causing malocclusion

Question 164

164 What are the subunits of the nose? (▶ Fig. 9.10)

Answer 164

Dorsum, tip, columella, root, sidewalls (two), soft tissue triangles (two), ala (two).

If more than 50% of a subunit is injured or resected, the remaining portion should be removed before reconstruction.

Question 165

165 Which arteries supply the nasal septum? (▶ Fig. 9.11)

Answer 165

• Sphenopalatine artery
• Anterior and posterior ethmoid arteries
• Superior labial artery
• Greater palatine artery

Question 166

166 Which arteries supply the external nose?

Answer 166

• Facial artery
• Angular artery
• Superior labial artery
• Infraorbital artery
• Ophthalmic artery

Question 167

167 What are some of the unique characteristics that may be found in the Asian nose?

Answer 167

Thick, sebaceous skin, low radix, weak lower lateral cartilages

Question 168

168 What are some of the typical differences in the appearance of a child’s nose compared with an adult’s nose?

Answer 168

A child’s nose displays a more obtuse nasolabial angle, more circular nares, shorter dorsum and columella, less defined and projected nasal tip, and decreased dorsal projection.

Question 169

169 What is the primary concern of septal surgery in prepubertal children?

Answer 169

Underdevelopment of the nose and maxilla

Question 170

170 How is the nasofrontal angle determined? (▶ Fig. 9.12)

Answer 170

A line tangent to the nasal dorsum is intersected with a line tangent to the glabella and nasion.

Question 171

171 How is the nasofacial angle determined?

Answer 171

In lateral view, it is the angle created by the intersection of a line parallel to the nasal dorsum intersecting the tip and nasion and a vertical line from the glabella to the pogonion.

Question 172

172 How is the nasolabial angle determined?

Answer 172

In lateral view, it is the angle created by a line drawn perpendicular to the Frankfort horizontal at the subnasale and a second line drawn through the midpoint of the nostril aperture.

Question 173

173 What is meant by the term tip-defining point in the context of nasal analysis?

Answer 173

The anterior most projection of the domes, which are represented by two distinct light reflexes on the skin of the nasal undertip

Question 174

174 Describe the Simons method of determining nasal projection.

Answer 174

A line drawn from the subnasale to the nasal tip is compared with a line drawn from the subnasale to the vermilion border of the upper lip. In an ideal nose, the length of these lines should be equal.

Question 175

175 Describe the Crumley method for determining nasal projection.

Answer 175

In lateral view, the nose is seen as a 3–4–5 triangle with points at the alar facial crease, tip, and nasion. The shortest arm of the triangle is between the tip and the alar facial crease. The longest arm is between the tip and the nasion. Another alternative is to measure the distance from the subnasale to the nasal tip and compare it with the distance from the subnasale to the vermilion border of the upper lip. If the distance from the subnasale to the tip is greater than the distance from the subnasale to the upper lip, the nose is overprojected.

Question 176

176 Describe the Goode method for determining nasal projection. (▶ Fig. 9.13)

Answer 176

A horizontal line drawn from the alar facial crease to the nasal tip is 0.55 to 0.6 the length of a line drawn from the nasion to the nasal tip. If the ratio is less than 0.55, the nose is underprojected. If the ratio is greater than 0.6, the nose is overprojected.

Question 177

177 How is the ideal width of the nasal base determined?

Answer 177

It should lie within vertical lines drawn inferiorly from the medial canthi.

Question 178

178 What is the ideal ratio of the nasal lobule and columella on basal view of the nose?

Answer 178

The nasal tip should occupy the upper third and the columella the lower two-thirds. The nasal tip should be approximately 45% the width of the base of the nose

Question 179

179 What is the ideal ratio of nasal lobule to columella on base view?

Answer 179

1:2

Question 180

180 On lateral view, what is the ideal amount of columellar show?

Answer 180

2 to 4 mm

Question 181

181 Describe the anatomy of the nasal bones.

Answer 181

Superiorly, the nasal skeleton is composed of paired nasal bones. The premaxilla and palatine bones constitute the floor. The lateral wall of the nose is formed by the medial walls of the maxilla. The superior, middle, and inferior conchal bones are attached to the lateral nasal walls. The cribriform plate is the roof of the nose. The bony septum is formed by the vomer and the perpendicular plate of the ethmoid

Question 182

182 Describe the skeletal support of the nose.

Answer 182

The upper third of the nose is supported by the nasal bones and the medial portion of the frontal process of the maxilla. The dorsal septum and upper lateral cartilages are the framework for the middle third of the nose. The anterior septal angle and the lower lateral cartilages suspend the lower third of the nose.

Question 183

183 What are the major tip-supporting structures of the nose?

Answer 183

• The intrinsic length and strength of the lower lateral cartilages
• Attachment of the medial crura to the caudal aspect of the quadrangular cartilage
• Attachment of the cephalic border of the lower lateral cartilages to the caudal aspect of the upper lateral cartilages

Question 184

184 What are the minor tip-supporting structures of the nose?

Answer 184

• Anterior nasal spine
• Attachment of the skin and soft tissue to the lower lateral cartilages
• Membranous septum
• Cartilagenous septal dorsum
• Sesamoid complex
• Interdomal ligament

Question 185

185 What is the rhinion?

Answer 185

The rhinion is the point that corresponds with the junction of the bony and cartilaginous dorsum

Question 186

186 Which structures form the internal nasal valve?

Answer 186

• Medially, the nasal septum
• Laterally, the caudal border of the upper lateral cartilage and piriform aperture
• Inferiorly and posteriorly, the head of the inferior turbinate

Question 187

187 What structures constitute the external nasal valve?

Answer 187

• Laterally, the pyriform aperture, lateral crus of the lower lateral cartilage, fibrofatty tissue, and alar rim
• Superolaterally, the caudal aspect of the upper lateral cartilage
• Medially, the septum and columella

Question 188

188 What are some surgical techniques to correct external nasal valve collapse?

Answer 188

The technique chosen depends on the cause of valve compromise. Options include alar batten grafts, lateral crural strut grafts, narrowing of a wide columella, repair of caudal septal deflection, and alar flaring sutures.

Question 189

189 What muscles constitute the nasal compressor group?

Answer 189

Procerus, quadratus (levator labii and nasi superioris), nasalis (pars tranversalis and pars alaris), depressor septi

Question 190

190 What muscles constitute the nasal dilator group?

Answer 190

The dilator naris posterior and the dilator naris anterior

Question 191

191 What muscle lowers the nasal tip?

Answer 191

Depressor septi nasi muscle. Results in the unfavorable appearance of a rounded, depressed, and lengthened tip, which can be corrected during rhinoplasty by transecting the insertions of these muscles at the base of the columella.

Question 192

192 What is a marginal incision in rhinoplasty?

Answer 192

An incision made along the caudal aspect of the lower lateral cartilage

Question 193

193 What is a rim incision in rhinoplasty?

Answer 193

An incision made along the alar rim. This approach has been largely abandoned secondary to subsequent alar notching.

Question 194

194 What transcolumellar incisions may be used during external approach rhinoplasty?

Answer 194

V shaped, inverted-v, stair-step, or slightly curvilinear

Question 195

195 Describe the surgical approaches to the nasal tip.

Answer 195

Endonasal approaches can be divided into nondelivery and delivery techniques.

Nondelivery techniques include transcartilaginous and intercartilaginous with retrograde dissection.

Delivery techniques include making intercartilaginous and marginal incisions to create a chondrocutaeous flap.

An open (external) approach involves a midcolumellar and bilateral marginal incisions.

Question 196

196 List some techniques to increase nasal projection. (▶ Fig. 9.14)

Answer 196

• Lateral crural steal
• Shield graft
• Advancement of medial crura along the caudal septum
• Columellar strut graft
• Vertical dome division
• Interdomal suture placement
• Premaxillary graft

Question 197

197 List some techniques to decrease nasal projection.

Answer 197

• Combined medial and lateral crural flap
• Full transfixion incision
• Reduction of the nasal septum

Question 198

198 List some techniques to increase nasal rotation.

Answer 198

• Lateral crural steal
• Tip graft
• Vertical dome division

Question 199

199 Describe the Goldman technique of vertical dome division.

Answer 199

The lower lateral cartilages are delivered through marginal and intercartilaginous incisions. A vertical incision is made through the dome, resulting in a transfer of cartilage from the lateral crus to the medial crus. The incision goes through the overlying vestibular skin and mucosa. This results in increased length of the middle leg of the tripod, in turn increasing projection and improving tip refinement

Question 200

200 Describe the Simons modification of vertical dome division.

Answer 200

It is performed the same way as the Goldman technique except for the following:

• The vestibular skin and mucosa are not incised.
• A triangular piece of cartilage is excised in the region of dome division.
• The medial crura are resecured in a superiorly oriented vector.

Question 201

201 What are some factors that might predispose a patient to the development of internal nasal valve obstruction after rhinoplasty?

Answer 201

• Weak upper lateral cartilages
• Short nasal bones
• Thin skin
• History of prior surgery or trauma

Question 202

202 What techniques should be used to decrease the likelihood of postsurgical middle vault deformities after rhinoplasty?

Answer 202

• Preservation of middle vault mucosa
• Reattachment of the upper lateral cartilages with the nasal dorsum if disrupted
• Conservative dorsal hump reduction
• Avoidance of overaggressive osteotomies

Question 203

203 What are some surgical techniques used to correct internal nasal valve narrowing?

Answer 203

The technique chosen depends on the cause of valve compromise. Options include spreader grafts, valvulopasty, conchal cartilage butterfly graft, flaring sutures, septoplasty, and inferior turbinate reduction

Question 204

204 During rhinoplasty, how much lateral crural cartilage should be preserved after horizontal cephalic excision to minimize the risk of alar collapse?

Answer 204

6 to 8 mm

Question 205

205 Review some causes of saddle-nose deformity.

Answer 205

Prior surgery resulting in inadequate support of the upper lateral cartilages or loss of adequate dorsal and caudal septal struts (each should have at least 1-cm height); history of trauma with septal hematoma/abscess and loss of septal support; self-inflicted from use of cocaine or neurotic nasal picking; medical condition, including Wegener granulomatosis, relapsing polychondritis, and syphilis.

Question 206

206 What autologous tissues may be used for reconstruction of the dorsal nasal skeleton?

Answer 206

Rib cartilage, conchal cartilage, calvarial bone, iliac crest

Question 207

207 What are some contraindications to repair of a saddle-nose deformity?

Answer 207

• Use of intranasal cocaine
• Poor general health
• Poorly controlled relapsing polychondritis

Question 208

208 Describe the order in which medial, lateral, and intermediate osteotomies should be performed.

Answer 208

Medial osteotomies are performed first, followed by intermediate osteotomies (if needed), and finally lateral osteotomies. If lateral osteotomies are performed first, it is difficult for the osteotome to gain purchase for the medial osteotomies on a mobile segment of bone.

Question 209

209 What is the cause of inverted-V deformity following rhinoplasty?

Answer 209

Collapse of the upper lateral cartilages with narrowing of the angle between the upper lateral cartilages and nasal septum, resulting in pinching of the middle nasal vault and internal nasal valve collapse

Question 210

210 What is the cause of an open roof deformity following rhinoplasty?

Answer 210

Incomplete lateral osteotomies after osseous dorsum reduction that result in a gap between the bilateral nasal bones

Question 211

211 What is the cause of a step deformity following rhinoplasty?

Answer 211

A step deformity occurs when the lateral osteotomy is placed too far medially, resulting in a visible step off in the nasal sidewall.

Question 212

212 What is a rocker deformity?

Answer 212

If osteotomies are extended too far superiorly, the thicker frontal bone may be included in the fracture line. When the nasal bones are fractured in medially, the thicker superior frontal bone will “rock” out laterally.

Question 213

213 What is a pollybeak deformity?

Answer 213

Excessive supratip fullness in relation to the tip.

Question 214

214 What are some of the causes of pollybeak deformity?

Answer 214

Under-resection of the cartilaginous dorsal hump, over resection of the nasal bones, loss of tip support, and excessive scar formation in the supratip region

Question 215

215 What are nasal bossae?

Answer 215

Prominent, often sharply demarcated, protuberances of lower lateral cartilage in the domal region

Question 216

216 What are some causes of alar retraction after rhinoplasty?

Answer 216

Over-resection of the lateral crura, excision of vestibular mucosa, rim incision

Question 217

217 What is the most common donor site for composite grafts used in facial reconstruction?

Answer 217

The ear, incorporating auricular cartilage

Question 218

218 What is a tent pole deformity?

Answer 218

Excessive length of the medial crura relative to the lateral crura leading to a visible step-off and an overprojected, pinched tip, which may occur secondary to over-recruit ment of the lateral crura in a vertical dome division procedure

Question 219

219 What are some of the physical examination findings associated with a retruded premaxilla?

Answer 219

Acute nasolabial angle, difficulty maintaining the lips in a closed position at rest, nasal tip ptosis

Question 220

220 What are some of the materials that can be used for premaxillary augmentation?

Answer 220

• Autografts: Rib cartilage, split calvarial bone graft, iliac crest, conchal cartilage, septal cartilage
• Homografts: Cadaveric acellular human dermis, irradiated rib
• Synthetics: Silicone, hydroxyapatite, polytetrafluoroethylene

Question 221

221 Describe two early signs of rhinophyma.

Answer 221

Dilated (patulous) pores and telangiectatic vessels on the distal nose

Question 222

222 Rhinophyma may manifest as the final stage of what other skin disease?

Answer 222

Acne rosacea, although not all patients with rhinophyma have a history of rosacea

Question 223

223 What nasal disorder results from hypertrophy of the sebaceous glands in the nasal skin and fibrosis?

Answer 223

Rhinophyma

Question 224

224 What malignant condition can be associated with rhinophyma?

Answer 224

Basal cell carcinoma

Question 225

225 Which patient population(s) is most commonly affected by rhinophyma?

Answer 225

Whereas acne rosacea is more common in women (3:1) compared with men, rhinophyma almost always affects men (30:1). The disease typically afflicts white men in their 50 through 70 s.

Question 226

226 How is rhinophyma managed?

Answer 226

Inflammation can be managed conservatively, similar to rosacea. For significant hypertrophy, deformity, and nasal obstruction, surgical recontouring can be performed using, most commonly, a carbon dioxide laser with or without dermabrasion

Question 227

227 Describe the ideal orientation of the auricle relative to the skull.

Answer 227

The distance from the mastoid skin to the lateral helical rim is 2 to 2.5 cm. The average height of the ear is 5.9 cm in women and 6.4 cm in men. On superior view, the ear should protrude 20 to 30 degrees from the skull (auric ulocephalic angle).

Question 228

228 Describe the Mustarde technique of otoplasty. (▶ Fig. 9.15)

Answer 228

A postauricular incision is made and supraperichondrial dissection performed. The ear is folded into the desired configuration, and sutures are passed from the posterior surface of the auricle through the anterior surface but not through dermis. The distance between the medial and lateral aspect of each mattress suture is 16 mm. The vertical distance between the superior and inferior aspect of each mattress suture is 10 mm. Individual mattress sutures are placed 2 mm apart.

Question 229

229 Describe the Furnas technique of otoplasty.

Answer 229

Permanent horizontal mattress sutures are used to tack the posterior conchal bowl to the mastoid periosteum, with or without trimming of conchal cartilage.

Question 230

230 A patient undergoes a conchal setback procedure for treatment of prominent ear deformity. Postoperatively, the patient has narrowing of the external ear canal. What is the most likely cause of this complication?

Answer 230

The mastoid periosteal suture was placed too anteriorly, causing the conchal bowl to impinge on the external auditory meatus.

Question 231

231 What are the causes of telephone ear deformity?

Answer 231

Over-correction of the middle third of the prominent ear during otoplasty

Question 232

232 What are the subunits of the ear?

Answer 232

Helix, antihelix, scaphoid fossa, triangular fossa, concha cymba, concha cavum, tragus, anti-tragus, lobule

Question 233

233 What embryonic structures give rise to the pinna?

Answer 233

The six hillocks of His. Hillocks 1 through 3 develop from the first branchial arch, hillocks 4 through 6 arise from the second branchial arch. ● Hillock 1: Tragus ● Hillock 2: Helical crus ● Hillock 3: Helix ● Hillock 4: Antihelix ● Hillock 5: Antitragus ● Hillock 6: Lobule

Question 234

234 What arteries supply the auricle?

Answer 234

• Superficial temporal artery
• Posterior auricular artery
• Deep auricular artery (minor contribution)

Question 235

235 Describe the classification system for grading microtia.

Answer 235

• Class I: All structures of the external ear are present with slight underdevelopment.
• Class II: Structures are smaller and more dysmorphic than in type I microtia.
• Class III: Only a small vestigial structure (peanut) is present.
• Class IV: The external ear is absent (anotia).

Question 236

236 What congenital syndromes are associated with microtia?

Answer 236

• Goldenhar syndrome
• Hemifacial microsomia
• Treacher Collins syndrome
• Robinow syndrome
• Branchio-otorenal syndrome

Question 237

237 At what age is a patient considered an acceptable candidate for microtia repair?

Answer 237

At 6 years old, when the ear has neared full adult size and the quantity of rib cartilage is sufficient

Question 238

238 Describe the stages microtia repair using autolo gous costal cartilage.

Answer 238

• Stage 1: Harvest costal cartilage from the sixth, seventh, and eighth ribs; carve into auricular framework; and place in subcutaneous pocket posterior to the external auditory canal.
• Stage 2: Auricular remnant is rotated inferiorly to recreate the lobule.
• Stage 3: Elevation on neoauricle off mastoid and placement of a postauricular skin graft
• Stage 4: Tragal reconstruction

Question 239

239 When do most authorities recommend atresia repair in patients with microtia who desire autologous cartilage microtia repair?

Answer 239

Usually after the costal cartilage framework has been placed and elevated off the mastoid with a posterior skin graft. This sequence is preferred to optimize blood supply during initial microtia repair.

Question 240

240 What are the treatment options for lower-lip actinic cheilitis?

Answer 240

Small areas may be treated with cryosurgery, whereas more extensive lesions may require vermilionectomy or CO2 laser ablation

Question 241

241 What are some reconstructive options for a full thickness defect involving less than 30% of the length of the lip?

Answer 241

Wedge or W-excision with primary closure

Question 242

242 What are some reconstructive options for a full thickness defect involving 50 to 75% of the length of the lip?

Answer 242

• Abbe flap
• Estlander flap
• Gillies fan flap
• Karapandzic flap

Question 243

243 What are some reconstructive options for a full thickness defect involving more than 75% of the length of the lower lip?

Answer 243

• Bilateral nasolabial flaps
• Karapandzic flap
• Bernard-Burrow flap
• Fujimori Gate flap
• Microvascular reconstruction with radial forearm fasciocutaneous flap

Question 244

244 Describe the similarities and differences between an Abbe flap and an Estlander flap.

Answer 244

Both flaps involve transfer of a pedicled full-thickness flap between the upper and lower lip, both are used for defects involving 50 to 75% of the lip length, and both are based on a labial artery pedicle. The Estlander flap is used for defects of the oral commissure and lateral lip, whereas the Abbe flap is used for central defects.

Question 245

245 Off what artery is the Gillies fan flap based?

Answer 245

Superior labial artery

Question 246

246 Describe the embryologic development of the lip.

Answer 246

In the 4th week of gestation, the paired maxillary prominences, derived from the first branchial arch, are seen. Proliferation of mesenchyme ventral to the forebrain gives rise to the frontonasal prominences. Nasal placodes arise on each side of the frontonasal prominence. In week 5, invagination of the nasal placodes leads to development of nasal pits. The medial and lateral ridges of tissue around the pit are called the medial and lateral nasal prominences, respectively. Between weeks 5 and 7, the medial maxillary prominences grow medially to fuse with the medial nasal prominences, forming the upper lip. Fusion of the medial nasal prominences leads to formation of the philtrum, medial upper lip, columella and nasal tip. The lateral upper lip arises from the maxillary processes.

Question 247

247 Maternal use of which medication has been linked to a significant increase in the incidence of cleft lip and palate?

Answer 247

Phenytoin

Question 248

248 What are the classic physical examination findings in Pierre Robin sequence?

Answer 248

• Micrognathia
• Glossoptosis
• Cleft palate

Question 249

249 What is van der Woude syndrome?

Answer 249

An autosomal dominant disorder characterized by lower-lip pits, cleft lip and palate, congenital heart disease, syndactyly, and ankyloglossia

Question 250

250 What are some of the physical examination findings in velocardiofacial syndrome?

Answer 250

Facial asymmetry with a long midface, inferior displacement of the auricles, widened nasal base with bulbous nasal tip, micrognathia, microcephaly, medially displaced internal carotid arteries

Question 251

251 What is the difference between a complete and incomplete cleft lip?

Answer 251

A complete cleft is a full-thickness defect of the entire height of the lip with extension into the nose. An incomplete cleft does not involve the entire vertical height of the lip and contains a web of bridging tissue across the nasal aperture.

Question 252

252 Describe the anatomy of a bilateral cleft lip.

Answer 252

The orbicularis oris fibers travel parallel to the edges of the cleft. Medially, the muscle fibers insert into the columella, and laterally the fibers insert into the nasal ala. The prolabial segment is composed of nonfunctional fibrous tissue. The premaxilla and central maxillary alveolus are protruberant.

Question 253

253 What physical examination findings are associated with a submucous cleft palate?

Answer 253

• Bifid uvula
• Notching of the hard palate
• Palpable or visible diastasis of the midline palatal musculature

Question 254

254 Which muscles contribute to the velopharyngeal sphincter?

Answer 254

• Levator veli palatini
• Tensor veli palatini
• Palatoglossus
• Palatopharyngeus
• Superior pharyngeal constrictor
• Musculus uvulae

Question 255

255 Which muscle is primarily responsible for providing velopharyngeal closure during speech production?

Answer 255

Levator veli palatini

Question 256

256 In reference to cleft lip repair, describe “the rule of 10s.”

Answer 256

Cleft lip repair can be performed when the child is at least 10 weeks old, has a hemoglobin greater than 10 g /dl, and weighs at least 10 pounds

Question 257

257 What are some techniques used to repair a unilateral cleft lip?

Answer 257

• Millard rotation advancement flap
• LeMesurier quadrilateral flap
• Randall-Tennison triangular flap repair
• Skoog and Kernahan-Bauer upper and lower lip Z-plasty repairs

Question 258

258 What are some of the techniques described for cleft palate repair?

Answer 258

• Primary veloplasty
• Double-opposing Z-plasty (Furlow palatoplasty)
• Bipedicled flap palatoplasty (von Langenbeck)
• Palatal lengthening (V-Y pushback palatoplasty)

Question 259

259 What are some of the complications of palatoplasty?

Answer 259

• Bleeding
• Infection
• Oronasal fistula,
• Velopharyngeal insufficiency
• Wound dehiscence
• Airway obstruction
• Obstructive sleep apnea

Question 260

260 Describe the nasal deformities associated with a unilateral cleft lip.

Answer 260

There is an abnormally short medial crus, and an abnormally long caudally displaced lateral crus on the cleft side. The nasal floor is deficient, and the alar base is displaced posteriorly, laterally, and inferiorly. The tip, columella, and septum are deviated toward the non-cleft side.

Question 261

261 Describe the nasal deformities associated with a bilateral cleft lip.

Answer 261

The nasal tip is flat and broad. There is deficient skin and cartilage in the columella. The nostrils assume a horizontal orientation, and the alae are displaced laterally, inferiorly, and posteriorly.

Question 262

262 When should primary unilateral cleft lip rhinoplasty be undertaken?

Answer 262

At the same time as cleft lip repair, by 3 months of age

Question 263

263 What are the layers of the scalp?

Answer 263

Skin, loose connective tissue, galea or epicranial aponeurosis, loose areolar tissue, periosteum

Question 264

264 What are the five main arteries that supply blood to the scalp?

Answer 264

• Supratrochlear
• Supraorbital
• Superficial temporal
• Occipital
• Posterior auricular arteries

Question 265

265 What makes up the hair bulb?

Answer 265

Papilla combined with surrounding epidermal cells

Question 266

266 What is the function of the hair bulb?

Answer 266

Site of hair shaft formation

Question 267

267 What is a follicular unit?

Answer 267

A group of one to four hairs with an accompanying neurovascular plexus, arrector pili muscle, and sebaceous glands

Question 268

268 What are the phases of hair growth?

Answer 268

• Anagen
• Catagen
• Telogen

Question 269

269 What is the primary growth phase of the hair growth cycle?

Answer 269

Anagen phase

Question 270

270 What are some infectious and inflammatory causes of alopecia?

Answer 270

• Dermatophytes
• Demodex folliculorum
• Foliculitis
• Secondary syphilis
• Seborrheic dermatitis
• Psoriasis
• Pityriasis amiantacea

Question 271

271 What is the most common cause of male baldness?

Answer 271

Androgenic alopecia

Question 272

272 What hormone plays the most significant role in androgenic alopecia?

Answer 272

Dihydrotestosterone

Question 273

273 What is the most widely used classification system for hair loss?

Answer 273

Norwood classification (stages I through VII)

Question 274

274 What classification system is most commonly used for grading female androgenic alopecia?

Answer 274

Ludwig classification (grades 1 through 3)

Question 275

275 What is the mechanism of finasteride in the treatment of hair loss?

Answer 275

5α-Reductase inhibitor; blocks the conversion of serum testosterone into dihydrotestosterone

Question 276

276 What is the most common topical medication prescribed for alopecia?

Answer 276

Minoxidil. Treatment results in a lengthening of the anagen phase and an increase in the blood supply to the follicle.

Question 277

277 How long should balding patients use minoxidil before they can expect to see noticeable results?

Answer 277

4 to 6 months

Question 278

278 What hair qualities yield better results with hair replacement surgery?

Answer 278

Hair color that matches skin color, coarse texture, high density, curly

Question 279

279 What is follicular unit extraction?

Answer 279

The process by which follicular units are harvested individually as opposed to the strip method in which a strip of scalp is removed and then cut into individual follicular units

Question 280

280 What are the advantages of follicular unit extraction?

Answer 280

Can be harvested from multiple different areas on the scalp. A long postoperative scar is avoided compared with the strip method of harvesting.

Question 281

281 What is the difference between follicular unit micrografts and minigrafts?

Answer 281

Micrografting involves transplantation of one or two hair follicles per unit used predominantly at the hair line, whereas minigrafts are three or four hair follicles used to fill in bulk areas.

Question 282

282 After transplantation, what phase of hair growth will transplanted hair enter?

Answer 282

Telogen phase. Patients should be told to expect that the transplanted hairs will fall out, with regrowth occurring by 3 to 4 months.

Question 283

283 Where is the donor strip of hair typically taken for hair transplantation?

Answer 283

Occipital region near the inion

Question 284

284 What are the primary advantages of scalp flaps over hair transplantation?

Answer 284

Scalp flaps maintain the blood supply to hair follicles, thus preventing them from entering the telogen phase; hair continues to grow immediately after the procedure; hair density is maximized with instantaneous results.

Question 285

285 What is the Juri flap?

Answer 285

The Juri flap is an axial scalp flap based on the superficial temporal artery that allows for the entire frontal hairline to be covered with a single flap.

Question 286

286 In the context of hair restoration treatments, what is scalp reduction?

Answer 286

Scalp reduction is a technique that reduces the surface area of the balding scalp using serial excisions. Areas of balding are excised and closed primarily or with various local flaps.

Question 287

287 Review the role of tissue expanders in hair restoration.

Answer 287

Tissue expanders do not increase the number of follicles but increase the distance between follicles to cover a larger surface area. Usually, they can be expanded by a factor of 2 without noticeable thinning.

Question 288

288 What are the benefits of a full-thickness skin graft over a split-thickness skin graft?

Answer 288

• Better color and texture match
• Less scar contraction
• No need for additional equipment (dermatome) for harvest
• Easier donor-site wound care and less contour irregularity

Question 289

289 What are the most common head and neck donor sites for full-thickness skin grafts used in facial reconstruction?

Answer 289

• Upper eyelid
• Preauricular or postauricular
• Supraclavicular
• Mesolabial fold
• Forehead

Question 290

290 How do full-thickness skin grafts survive initially during the first 24 to 48 hours?

Answer 290

Plasma imbibition: the diffusion of nutrition from the fluid at the recipient site, after which capillary inosculation takes place at 48 hours

Question 291

291 What are the primary causes of skin graft failure?

Answer 291

• Infection
• Shearing
• Fluid accumulation between the graft and recipient bed

Question 292

292 What is the function of a bolster dressing over a skin graft?

Answer 292

It ensures maximal graft to recipient bed contact and decreases shearing forces that might affect graft survival.

Question 293

293 What are the two general categories of local flaps based on blood supply?

Answer 293

• Random (based on subdermal plexus)
• Axial (based on named vessels)

Question 294

294 Define the term flap delay, and review its importance.

Answer 294

Surgical flap delay is the technique of elevating a flap on a pedicle and then returning it to the donor site for days to weeks before final transfer. It is believed to condition the flap to ischemic conditions and/or improve vascular supply of the pedicle.

Question 295

295 What are the four types of pivotal flaps used in head and neck reconstruction?

Answer 295

• Rotation
• Transposition
• Interpolated
• Island

Question 296

296 Defects of what shape are best suited for closure with rotational flaps?

Answer 296

Triangular defects

Question 297

297 What is the definition of an interpolated flap?

Answer 297

It is a local flap whose pedicle passes over or under intervening tissue to reach a nonadjacent defect. Typically, it requires a second stage in which the pedicle is divided.

Question 298

298 What is the definition of an advancement flap?

Answer 298

It is a flap with a linear configuration that closes a defect by sliding toward it.

Question 299

299 What are the some advantages and disadvantages of a Z-plasty closure?

Answer 299

• Advantages: It can orient scar parallel to resting skin tension lines, requires minimal excision of normal skin, interrupts forces of scar contracture, and creates broken line which is less noticeable than a straight line
• Disadvantage: Increases the overall scar length

Question 300

300 What is the approximate lengthening of the central limb of a Z-plasty when using 30-degree, 45-degree, and 60-degree angles? (▶ Fig. 9.16)

Answer 300

25%, 50%, and 75% respectively

Question 301

301 What are the internal angles of the rhombic flap?

Answer 301

60 degrees and 120 degrees

Question 302

302 Describe the technique of performing a bilobed flap as originally described by Esser. (▶ Fig. 9.17)

Answer 302

A double transposition flap, with the first flap oriented 90 degrees to the defect and measuring the same size as the defect. The second flap is oriented 180 degrees to the defect and is slightly smaller than the first flap. The first flap is rotated into the primary defect, the second flap is rotated into the defect created by the first flap, and the defect created by the second flap is closed primarily.

Question 303

303 Describe the Zitelli modification of the bilobed flap.

Answer 303

The angle of the first flap is oriented 45 degrees to the defect, and the second flap is oriented 90 degrees to the defect. It is designed to keep less tension on repair and reduce standing cone deformity.

Question 304

304 Describe the indications for a nasolabial flap in nasal reconstruction.

Answer 304

Superiorly based flaps are best suited for reconstruction of the lower two-thirds of the nose, including the inferior dorsum, alae, and tip. Inferiorly based flaps are used for reconstruction of the columella and nasal floor.

Question 305

305 What is the blood supply to the paramedian forehead flap?

Answer 305

Supratrochlear artery, located between 1.7 and 2.2 cm from the midline at the medial aspect of the brow

Question 306

306 How long after the first stage of a paramedian forehead flap is the pedicle typically divided?

Answer 306

Three weeks; however, in patients who are smokers or have other comorbidities, pedicle division can be delayed

Question 307

307 Why might regional control of oral cavity malignancies be of concern when using the submental island flap?

Answer 307

The flap incorporates a portion of the level I nodal basin, which can be involved with metastases

Question 308

308 When raising the facial artery musculomucosal flap, the facial artery lies immediately superficial to what muscle, a portion of which is incorporated into the flap?

Answer 308

Buccinator muscle

Question 309

309 What is the primary arterial supply to the temporalis flap?

Answer 309

Anterior and posterior deep temporal arteries, branches of the internal maxillary artery

Question 310

310 The temporalis is commonly used in facial reanimation of the mouth in patients with facial paralysis. What are the two contrasting ways the temporalis can be used for facial reanimation?

Answer 310

Temporalis myofascial flap and orthodromic temporalis tendon transfer

Question 311

311 What is the blood supply to the masseter when used as a pedicled flap in facial reanimation?

Answer 311

Masseteric artery, which is a branch of the internal maxillary artery

Question 312

312 What arteries supply the sternocleidomastoid muscle?

Answer 312

• Occipital artery (superior third)
• Superior thyroid artery (middle third)
• Suprascapular artery (inferior third)

Question 313

313 What is the blood supply to the superior trapezius myocutaneous flap?

Answer 313

Paraspinous perforating branches of the intercostal vessels

Question 314

314 Which type of trapezius pedicled flap can be successfully harvested after radical neck dissec tion?

Answer 314

Superior trapezius myocutaneus flap

Question 315

315 What is the blood supply to the deltopectoral flap?

Answer 315

Perforator arteries from the internal mammary artery

Question 316

316 The pectoralis major regional flap is based on what artery?

Answer 316

Pectoral branch of the thoracoacromial artery

Question 317

317 What nerves must be transected to allow for atrophy of the pectoralis major regional flap?

Answer 317

Medial and lateral pectoral nerves

Question 318

318 What are vessels leaving the axial blood supply of a free flap and passing through muscle on their way to supply the skin called?

Answer 318

Musculocutaneous perforators

Question 319

319 Review the clinical findings of acute arterial thrombosis of a free flap in the early postoperative period.

Answer 319

Loss of implanted Doppler signal (if placed); the flap is cool, pale, and without capillary refill, and there is no bleeding after pinprick.

Question 320

320 A free-flap arterial anastomosis is revised within the first 24 hours after surgery for presumed arterial thrombosis. Despite good blood flow through the artery after the revision, the flap’s appearance at the skin level does not improve; subsequently, it undergoes necrosis. What is the most likely reason for failure after revision surgery despite good blood flow through the artery?

Answer 320

No-reflow phenomenon: Despite restoration of blood flow through the major artery, the prior occlusion and ischemia have detrimental effects on the microvasculature, which caused subsequent necrosis.

Question 321

321 Review the clinical findings of venous congestion of a free flap in the early postoperative period.

Answer 321

• Congestion and edema
• Violaceous color with brisk bleeding of dark blood on pinprick
• Loss of venous Doppler signal

Question 322

322 What is the most common reason for venous occlusion of a free-flap vascular pedicle?

Answer 322

Mechanical obstruction from compression, twisting, or kinking

Question 323

323 What nonsurgical therapy can be used to treat venous congestion after free-flap reconstruction?

Answer 323

Leech therapy

Question 324

324 What is the most common free flap used for reconstruction of hemi-glossectomy defects?

Answer 324

Radial forearm free flap

Question 325

325 Describe the Allen test.

Answer 325

The patient makes a fist and elevates the hand. The radial and ulnar arteries are compressed. The hand is then opened and should appear blanched. Pressure is released from the ulnar artery. The hand should have capillary refill and return to a normal color in 5 to 7 seconds, indicating a patent ulnar artery and palmar arches.

Question 326

326 What is the vascular supply to an osteocutaneous radial forearm free flap?

Answer 326

Perforators from the radial artery

Question 327

327 What nerves provide sensory innervation to the fasciocutaneous paddle of the osteocutaneous radial forearm free flap?

Answer 327

The medial and lateral antebrachial cutaneous nerves

Question 328

328 What added complication can occur when using an osteocutaneous radial forearm free flap as opposed to a fasciocutaneous radial forearm free flap?

Answer 328

Pathologic fracture of the radius

Question 329

329 What are some of the potential donor site complications of an osteocutaneous radial forearm free flap?

Answer 329

• Incomplete skin graft take
• Radius fracture
• Hand and forearm weakness and contracture
• Numbness
• Hematoma

Question 330

330 What are some potential donor sites for osseocutaneous free tissue transfer for reconstruction of segmental mandibular defects?

Answer 330

Fibula, radius, scapula, iliac crest

Question 331

331 Which osteocutaneous free flaps can accept dental implants?

Answer 331

Iliac crest and fibula. The scapula has a variable ability to accept dental implants.

Question 332

332 Review relative candidacy requirements for osseointegrated dental implant placement?

Answer 332

Absence of poorly controlled autoimmune or small vessel disease, which could impair healing; no trismus; good tongue mobility; adequate bone stock

Question 333

333 Describe the difference between segmental and marginal mandibulectomy.

Answer 333

In a segmental mandibulectomy, the entire vertical height of a portion of the mandible is removed.

In a marginal mandibulectomy, at least 1 cm of the inferior border remains in continuity.

Question 334

334 Review the general options for segmental mandibular defect reconstruction?

Answer 334

Reconstruction with hardware alone (large reconstruction bar for lateral defects), hardware combined with a local flap (large reconstruction bar with pectoralis muscle), hardware combined with free tissue transfer

Question 335

335 What are the reconstructive goals when repairing a segmental mandibulectomy defect?

Answer 335

• Maintenance of occlusion
• Restoration of bone continuity
• Oral competence
• Maintenance of facial symmetr
• Ability to place a dental prosthesis

Question 336

336 What are the major disadvantages to the use of a reconstruction plate alone for reconstruction of a segmental mandibulectomy defect?

Answer 336

• Plate extrusion
• Plate fracture
• Development of mandible osteomyelitis

Question 337

337 What is the vascular supply to the osteocutaneous fibular free flap?

Answer 337

The peroneal artery and the paired venae comitantes

Question 338

338 What is the most effective test to evaluate the lower extremities for adequate vasculature prior to fibula free flap harvest?

Answer 338

CT angiogram with three-vessel runoff of the lower extremities. Angiography is probably the gold standard but has largely been replaced by CT angiography.

Question 339

339 What are some of the potential donor site complications of an osteocutaneous fibular free flap?

Answer 339

• Compartment syndrome
• Peroneal nerve weakness
• Hematoma
• Decreased range of motion
• Ankle instability
• Foot ischemia

Question 340

340 What is the vascular supply to the osteocutaneous scapular free flap?

Answer 340

Circumflex scapular branch of the subscapular artery

Question 341

341 What are some of the potential complications of an osteocutaneous scapular free flap?

Answer 341

Potential donor-site complications include long thoracic nerve injury, winged scapula, upper-extremity weakness and decreased range of motion, wound dehiscence, hematoma, and seroma. Potential recipient-site defects include hematoma and flap necrosis.

Question 342

342 What is the most common type of perforating vessels encountered in the anterolateral thigh free flap?

Answer 342

Myocutaneous perforators

Question 343

343 The anterolateral thigh free flap is based on what artery?

Answer 343

Descending branch of the lateral femoral circumflex artery

Question 344

344 The rectus abdominis free flap is based on what artery?

Answer 344

Deep inferior epigastric artery

Question 345

345 The latissimus dorsi free flap is based on what artery?

Answer 345

Thoracodorsal artery from the subscapular system

Question 346

346 What donor site nerve is used for neurorrhaphy when the gracilis free flap is used for facial reanimation?

Answer 346

The obturator nerve

Question 347

347 What are the intratemporal segments of the facial nerve?

Answer 347

1. Canalicular (within the internal auditory canal)
2. Labyrinthine
3. Tympanic
4. Mastoid

Question 348

348 What are the extratemporal branches of the facial nerve?

Answer 348

1. Posterior auricular nerve
2. Nerve to the stylohyhoid
3. Nerve to the posterior belly of the digastric
4. Temporal
5. Zygomatic
6. Buccal
7. Marginal mandibular
8. Cervical branches

Question 349

349 What is the primary blood supply to the facial nerve distal to the stylomastoid foramen?

Answer 349

Posterior auricular artery

Question 350

350 What are some causes of facial nerve paralysis?

Answer 350

Ramsay Hunt syndrome, otitis media, otitis externa, mastoiditis, Lyme disease, birth injury (traumatic forceps delivery), penetrating facial trauma, cerebrovascular accident, AIDS, diabetes mellitus, Mobius syndrome, skull base fracture, acoustic neuroma, meningioma, temporal bone malignancy, parotid malignancy, iatrogenic injury (partoidectomy, mohs surgery, mastoidectomy), amyloidosis, Wegener’s granulomatosis, neurosarcoidosis, multiple sclerosis, Guillain-Barre syndrome, Bell palsy (idiopathic)

Question 351

351 Describe the House-Brackmann grading scale for facial paralysis.

Answer 351

• Grade I: Normal facial function
• Grade II: Complete eye closure, minimal asymmetry with facial movement
• Grade III: Symmetry at rest, complete eye closure with effort, slight mouth asymmetry with movement
• Grade IV: Symmetry at rest, incomplete eye closure, obvious asymmetry with movement
• Grade V: Asymmetry at rest, barely perceptible movement
• Grade VI: No facial movement

Question 352

352 What physical examination findings are associated with facial paralysis?

Answer 352

Brow ptosis, upper eyelid ptosis, lagophthalmos, ectropion, increased scleral show, loss of midfacial width, effacement of nasolabial fold, collapse of external nasal valve, inferior position of oral commissure, jowling, synkinesis

Question 353

353 Describe the role of electroneuronography (ENoG) in preoperative evaluation of facial paralysis.

Answer 353

ENoG measures the motor response of facial musculature to an electrical stimulus applied to the facial nerve near the ipsilateral stylomastoid foramen. Comparison is made between the paralyzed and non-paralyzed sides of the face. If the paralyzed side shows greater than 90% degeneration relative to the non-paralyzed side, the prognosis for return of satisfactory facial nerve function is poor

Question 354

354 What surgical options exist for the correction of brow ptosis resulting from facial paralysis?

Answer 354

• Direct brow lift
• Midforehead brow lift
• Pretrichial brow lift
• Endoscopic brow lift
• Coronal brow lift

Question 355

355 What surgical options exist for the correction of ectropion resulting from facial paralysis?

Answer 355

• Tarsorrhaphy
• Lateral tarsal strip procedure
• Canthoplasty
• Canthopexy
• Fascia lata sling
• Temporalis transfer
• Expanded polytetrafluoroethylene (e-PTFE) sling
• Suborbicularis oculi lift

Question 356

356 What surgical options exist for the correction of lagophthalmos resulting from facial paralysis?

Answer 356

• Tarsorrhaphy
• Gold weight placement
• Placement of upper eyelid spring

Question 357

357 What materials can be used to perform a static facial sling?

Answer 357

• Fascia lata
• Temporalis fascia
• Acellular human dermal allograft
• e-PTFE
• Permanent suture

Question 358

358 What are some potential complications of static sling placement for the treatment of facial paralysis?

Answer 358

• Stretching of graft material and loss of correction
• Infection
• Extrusion of graft
• Allergic reation to graft
• Hematoma
• Skin necrosis

Question 359

359 Describe the technique of direct VII–XII neuro rrhaphy with parotid release for the treatment of facial paralysis.

Answer 359

A mastoidectomy is performed, and the vertical segment of the facial nerve is decompressed to the stylomastoid foramen and divided just distal to the second genu. The facial nerve is then released from the fibrous attachments at the stylomastoid foramen and followed to the pes anserinus. The posterior parotid is then released from the surrounding soft tissue, providing additional length. The hypoglossal nerve is then found near the submandibular gland and direct end-to-side neurorrhaphy of the facial and hypoglossal nerve is performed

Question 360

360 Describe the technique of cross-facial nerve grafting for the treatment of facial paralysis.

Answer 360

Recipient nerves are identified on the paralyzed hemiface and followed back to the pes anserinus. Next, the contralateral facial nerve is identified proximally and followed out to the terminal branches. Regions with redundant innervation are selected using facial nerve stimulation to minimize donor-site morbidity. A sural nerve or great auricular nerve graft is then harvested and interposed between donor and recipient nerve endings.

Question 361

361 Describe the technique for temporalis muscle sling for the treatment of facial paralysis.

Answer 361

A curvilinear incision is extended superiorly from the helical root into the parietal scalp. Dissection is carried down to the deep temporalis fascia and the middle third of the muscle is incised, leaving an inferior pedicle. A subcutaneous tunnel is created from the oral commissure to the temporal region. The myofascial flap is brought through the subcutaneous tunnel, and the distal ends are secured to the superior and inferior orbicularis oris.