cosmetic

Question 1

A 52-year-old woman comes to the office because she has had progressive hardening of the left breast for the past two months. She underwent augmentation mammaplasty with implantation of saline-filled prostheses three years ago. On physical examination, the left breast is firm and elevated compared with the right. It is cool and painful. The patient’s symptoms are most consistent with which of the following Baker classification levels?
A) I
B) II
C) III
D) IV

Answer 1

D.

Question 2

The superficial musculoaponeurotic system is continuous with which of the following?
A) Superficial layer of the deep temporal fascia and the deep cervical fascia
B) Superficial layer of the deep temporal fascia and the platysma
C) Superficial temporal fascia and the deep cervical fascia
D) Superficial temporal fascia and the platysma
E) Temporalis muscle and the platysma

Answer 2

D.

The superficial musculoaponeurotic system (SMAS) is continuous with the superficial temporal fascia (or temporoparietal fascia) above and the platysma below. Superiorly to inferiorly, the superficial layer continuous with the SMAS consists of galea, superficial temporal fascia, SMAS, platysma, and superficial cervical fascia.
The deep cervical fascia (DCF) makes up the most inferior extent of the layer deep to the SMAS. Superiorly to inferiorly, this layer consists of cranial periosteum, deep temporal fascia (DTF), parotidomasseteric fascia, and DCF.
The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly toward the zygomatic arch. The superficial and deep layers of the DTF extend anteriorly and posteriorly to the zygomatic arch, respectively. The superficial layer then becomes the parotidomasseteric fascia, and the deep layer becomes the posterior masseteric fascia.
The temporalis muscle lies deep to the DTF and, therefore, is also deep to the superficial temporal fascia, which is continuous with the SMAS.

Question 3

A 65-year-old man has a 3-cm-diameter open wound of the medial cheek inferior to the lower eyelid after undergoing Mohs’ micrographic surgery for excision of nodular basal cell carcinoma. Snap-back test of the lower eyelid shows poor tone. Reconstruction of the defect is performed with a cervicofacial flap. Which of the following is the most appropriate next step in management to avoid a deformity of the lower eyelid?
A) Application of adhesive bandages to the lower eyelid and daily massage B) Placement of a temporary tarsorrhaphy (Frost) suture
C) Reconstruction with a tarsoconjunctival flap
D) Horizontal shortening of the lower eyelid and lateral canthopexy
E) Full-thickness skin grafting of the lower eyelid

Answer 3

D. horizontal shortening of the lower lid and lateral cathopexy

This patient is at increased risk for the development of ectropion of the lower eyelid, eversion of the lid margin away from the globe. The snap-back test can be used to assess horizontal laxity of the eyelid. After being pulled away from the eye, the time it takes for the lid to resume a normal position is measured. The result is graded from 0 (time indicating normal tone and laxity) to IV (time indicating loss of tone and severe laxity). Different lateral canthopexy and canthoplasty procedures have been described to prevent malposition of the lower eyelid and can be performed adjunctly with shortening of the lower eyelid. These procedures include repositioning of the inferior limb of the lateral retinaculum on the orbital rim; suturing of the lateral orbicularis oculi muscle to the orbital rim; suspension of a deepithelialized lower eyelid dermal pennant on the orbital rim; and suspension of a lateral orbit periosteal pennant on the orbital rim. All of the procedures commonly suspend or support the lateral canthus.
Ectropion of the lower eyelid may also result from vertical deficiency of the anterior lamella of the lid. Cicatricial changes with consequent vertical lid shortening may result from skin disease, trauma, and previous surgical procedures. Local therapy such as pressure and massage may be used to treat mild cicatricial changes. Further therapy to augment the anterior lamella with a full-thickness skin graft may also be required.
The use of tarsorrhaphy is a temporary means to protect the cornea from exposure. The suture itself will not prevent lower eyelid malposition. The tarsoconjunctival flap, which is elevated from the upper eyelid, may be used to reconstruct defects of the lower eyelid. In this case, there is no such defect.

Question 4

A 22-year-old woman sustains an injury to the middle third of the external ear when she is bitten by a dog. She is concerned about her appearance because she works as a model. Physical examination shows a full-thickness defect (2.5 × 2 cm) involving the rim, antihelical fold, and concha. Which of the following techniques for reconstruction of the ear will best maintain symmetry of the ears?
A) Postauricular transposition skin flap
B) Postauricular “revolving door” island flap
C) Rim advancement
D) Triangular kite flap
E) Wedge resection with direct closure

Answer 4

A. post auricular transposition flap

In the older patient, a partial middle ear defect can be treated by wedge resection and direct closure. In a younger patient, the cupping of the ear resulting from this approach would be aesthetically unacceptable; therefore, a more complete reconstruction is required. A full- thickness loss of rim, antihelical fold, and a variable amount of concha can be reconstructed only with a flap.
The postauricular transposition skin flap is the best solution. This flap is based at the edge of the hairline, and the width of the flap is equal to that of the defect. After 10 days, the base of the flap is divided and the remainder of the flap is used to resurface the posterior part of the ear. The donor area, if small, will heal spontaneously or a skin graft may be used.
A rim defect can be treated with a small triangular kite flap or a rim advancement flap. The postauricular “revolving door” island flap is ideal for defects of the conchal area.

Question 5

A 38-year-old woman comes to the office for consultation regarding surgical correction of sagging of the breasts. She breast-fed three children during the past five years; her youngest child was weaned two years ago. Physical examination shows second-degree ptosis. For this patient, which of the following is an advantage of mastopexy with augmentation over mastopexy alone?
A) Decreased risk of loss of nipple sensation
B) Decreased risk of nipple malposition over time
C) Decreased stretch deformity of surgical scars D) Increased longevity of correction of ptosis
E) Increased upper pole volume

Answer 5

E. upper pole fullness

The combination of implantation of a prosthesis with mastopexy can enhance the size and contour of the breast. This procedure often reduces the length of the incisions required to correct the ptosis because of the volume enhancement delivered by the implant.
There is no known difference in the degree of loss of sensation between the two methods. The weight of the prosthesis places additional tension at the site of incision, causing more rapid recurrence of ptosis. This is especially true for larger prostheses placed in the subglandular position. There is an increased risk of nipple malposition because the nipple is moved at the same time as the implant.

Question 6

A 38-year-old woman has severe congestion and edema of the left nipple-areola complex four hours after undergoing bilateral reduction mammaplasty. Examination shows rapid capillary refill. Which of the following surgical interventions is the most appropriate initial management?
A) Debridement and healing by second intention
B) Release of the suture line and exploration of the pedicle
C) Conversion of the nipple-areola complex to a free composite graft
D) Central wedge resection under the nipple-areola complex
E) Removal of additional tissue from the breast

Answer 6

B) Release of the suture line and exploration of the pedicle

Conversion of the pedicle/nipple-areola complex to a free composite graft should be considered if release of the pedicle does not yield any improvement in the blood flow or if no correctable cause can be identified. Debridement and open packing of the wound is an appropriate management option when the tissues are already necrotic. Further reduction mammaplasty would release the tension on the skin flaps but would not necessarily improve the vascularity of the nipple-areola complex. Wedge resection of the central portion of the breast usually leaves unsightly scarring superior to the nipple-areola complex.

Question 7

A 20-year-old woman has pollybeak deformity of the nose 18 months after she underwent primary rhinoplasty for reduction of a dorsal hump. Which of the following procedures is most appropriate for correction of this patient’s deformity?
A) Injection of a corticosteroid into the soft tissue of the supratip B) Rasping of the radix
C) Weir excisions
D) Resection of the caudal septum
E) Placement of nasal tip grafts

Answer 7

E.

The pollybeak deformity, also known as a supratip deformity, is a convexity of the region just superior to the nasal tip (the supratip) when viewed in profile. The nasal tip lacks projection relative to the dorsum. The most common causes are overprojection of the caudal nasal dorsum and inadequate preservation of tip projection. This can be corrected by increasing nasal tip projection using cartilage grafts.
Injection of corticosteroids can be used to correct a supratip deformity when given within three months of the primary rhinoplasty and when the deformity is due to formation of fibrous tissue in the deadspace between the over-resected dorsum and remaining nasal skin envelope. Injection of corticosteroids is not indicated for any type of supratip deformity more than three months after the primary rhinoplasty.
Reducing the radix by rasping will not correct a pollybeak deformity and may accentuate the deformity by causing the nasal dorsum to appear more prominent relative to both the radix (root of the nose) and supratip regions.
Weir excisions are resections of the alar bases used to reduce wide or flaring nostrils.
Resection of the caudal septum is performed to correct a hanging columella and will not affect a supratip deformity.

Question 8

A 50-year-old woman comes to the office because she has irritation of and a scratching pain in the left eye four days after undergoing uncomplicated bilateral upper and lower blepharoplasty during intravenous sedation with local anesthesia. Physical examination shows mild edema and ecchymosis of the upper and lower eyelids bilaterally and severe swelling of the conjunctiva of the left eye. No ulceration of the cornea is noted on slit-lamp examination. Visual acuity is normal. Which of the following is the most appropriate next step in management?
A) Administration of dexamethasone ophthalmic ointment
B) Topical administration of an anesthetic
C) Intravenous administration of parenteral antibiotics
D) Temporary tarsorrhaphy
E) Lateral canthotomy

Answer 8

A) Administration of dexamethasone ophthalmic ointment

This patient suffers from chemosis, which is an annoying and fortunately unusual complication of blepharoplasty. Swelling of the conjunctiva, attributed to disrupted lymphatic drainage, causes separation of the lower lid from the sclera and results in exposure of the conjunctiva. This exposure results in more conjunctival swelling and worsening irritation. To break this cyclical problem, treatment includes application of dexamethasone sodium phosphate ointment, instillation of eye lubricants, and consideration of patching the affected eye. Temporary tarsorrhaphy may also be considered but is usually reserved until medical management has failed.
Topical administration of anesthetics does not treat chemosis.
Immediate canthotomy is appropriate management for retrobulbar hematoma but not for chemosis.

Question 9

A 56-year-old man comes to the office for consultation regarding short-scar rhytidectomy with a vertical vector of skin lift. After the physician describes the procedure, the patient is still concerned about visible scars. Further explanation for the patient includes that hair will grow through a temporal scar with which of the following patterns?
A) Beveled across the hair shafts
B) In front of the hairline
C) In a straight line
D) Parallel to the hair roots
E) Perpendicular to the skin

Answer 9

A.

Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair shaft and root to a small extent. This allows the hair follicle to continue to grow, and over time, the healing scar will produce a variable amount of hair. A zigzag pattern, as described in the minimal access cranial suspension lift, is a nice adjunct because it camouflages the scar in the temporal hairline in short-scar techniques that elevate the skin envelope in a vertical manner. Meticulous closure and elimination of tension on the skin also aid in camouflaging the scar. Incisions parallel to and beveled with the hairline preserve hair follicles on either side of the incision and can be used deep to the hairline. Incisions perpendicular to the skin surface closed in a precise manner typically do not have hair growth through the fine scar. An incision in front of the hairline (pretricheal) does not result in hair growing through the scar. However, a straight incision closed meticulously will result in a fine scar.

Question 10

A 2-month-old boy is brought to the office by his parents for consultation regarding congenital lop ear. On the basis of the physical examination, nonoperative correction of the deformity with thermoplastic splinting is planned. The parents ask how long their son will be required to wear the splint. The physician tells the parents that if their son wears the splint as directed, the most likely length of time between application of the device to full correction of the deformity is which of the following?
A) One week
B) Two months
C) Four months
D) Eight months
E) One year

Answer 10

B. two months

onsurgical treatment of various congenital auricular deformities has been reported in children of neonatal age. More recently, this has also been achieved in children who are several years of age. The splints are made from a malleable thermoplastic material and are applied to the ear by hand until a normal form is attained. Remodeling can be performed once per week until a desired correction is achieved. In one study involving 290 patients, 70% of cases could be treated with good results. The average time for treatment was 1.9 months (range, one week to four months). All patients showed remarkable improvement within the first one to two weeks after beginning the treatment. Young age, cooperation of the parents and patient, elasticity of the cartilage, and type of deformity are all contributing factors in the time required for treatment.

Question 11

A 15-year-old girl comes to the office with a six-month history of sudden, rapid, asymmetric enlargement of her left breast. On physical examination, there is a large palpable mass occupying the left breast, which also has marked nipple-areola stretching, prominent dilated veins, and skin ulceration superolateral to the nipple. Mammograms and sonograms show a dense, circumscribed, 6-cm-diameter homogeneous mass occupying the left breast. Which of the following is the most likely diagnosis?
A) Carcinoma
B) Cyst
C) Giant fibroadenoma
D) Juvenile breast hypertrophy
E) Phyllodes tumor

Answer 11

C. giant fibroadenoma

The differential diagnosis of a large lesion in the breast of an adolescent girl includes giant fibroadenoma, phyllodes tumor, and virginal hypertrophy. Fibroadenoma is the most common breast neoplasm in the adolescent patient, and giant fibroadenoma is characterized by size greater than 5.0 cm in diameter, presentation at or soon after puberty, and short doubling time. The lesion is usually solitary, firm, and nontender and presents as a rapid asymmetric breast enlargement with prominent veins over the tumor and occasional skin ulceration due to pressure. Giant fibroadenomas are benign lesions that can be excised by enucleation with minimal risk of local recurrence. Mastectomy is not necessary for management of these lesions, and no adjuvant treatment is indicated.
Phyllodes tumors are large, benign tumors that occur primarily in the perimenopausal patient. They are histologically distinct from giant fibroadenomas, and atypical changes in these tumors are rare in the adolescent.
Juvenile breast hypertrophy is a rare but well-described entity in young, early pubertal girls. It presents as diffuse enlargement of the breast without any nodularity or presence of a discrete mass. Management is reduction mammaplasty.

Question 12

A 50-year-old woman comes to the office for consultation regarding body contouring one year after undergoing a gastric bypass procedure. She has lost 160 lb since the procedure was performed. Preoperative photographs are shown above. Which of the following is the most appropriate surgical procedure for improvement of the thigh and buttock regions in this patient?
A) Direct excision of gluteal skin folds
B) Suspension of a dermal fat flap
C) Augmentation of the gluteal region
D) Liposuction
E) Lower body lift

Answer 12

E. lower body lift
In this patient, the best option for improvement of the buttock and thigh regions is a lower body lift. This procedure is indicated in patients with relaxation and resultant ptosis of the buttock and thigh tissues. In addition to moderate or more severe skin laxity, the potential for laxity to develop after liposuction is an indication for an excisional lifting procedure over liposuction alone. In this patient, placing the incision at the level used in the lower body lift will create a better hip contour as well as lift the descended thigh and buttock tissue. This can be combined with thigh liposuction to address any thigh lipodystrophy.
Direct excision of the gluteal fold can result in flattening of the buttocks, asymmetry, and hypertrophic scarring. Suspension of a dermal-fat flap is performed using a gluteal fold incision. Flattening of the buttocks and loss of gluteal fold definition, as well as hypertrophic scarring, can also result from this technique. Gluteal implants have the associated risks of implant extrusion, infection, and malposition. Furthermore, these three techniques do not address the primary pathology of the descent of tissue and do not restore the tissues to a more anatomic position. Liposuction can be used in the patient with good skin quality where adequate retraction is likely. However, if there is potential for skin laxity, liposuction may result in a worsening of the deformity as the tissue is deflated. Liposuction also carries a risk of worsening buttock ptosis, loss of gluteal fold definition, and contour irregularities. Liposuction can be used as an adjunct to excisional techniques.

Question 13

A 7-year-old boy is brought to the office by his parents for consultation regarding prominence of the entire ears. On physical examination, the antihelical folds are intact. On the basis of this finding, which of the following deformities is the most likely cause of prominence of the ears in this patient?
A) Hypertrophy of the concha
B) Hypertrophy of the helix
C) Hypertrophy of the tragus
D) Lobular protrusion
E) Prominent antitragus

Answer 13

.A.
Conchal hypertrophy is the second most common deformity and is usually bilateral. The most common deformity is loss of the antihelical fold. The ear deformities can be classified as: 1) absent or insufficient antihelical folding, 2) conchal hypertrophy, 3) both absent or insufficient antihelical folding and conchal hypertrophy, 4) any of the aforementioned deformities with lobular protrusion. If the patient is also lacking an antihelical fold, a large concha can be reduced by placing the antihelical fold more medially in the concha, thus reducing its height. If this is not enough, plication of the concha to the fascia can be performed with permanent sutures. In cases in which further correction is needed, a posterior wedge can be taken out of the conchal cartilage.

Question 14

A 40-year-old woman undergoes rhinoplasty for correction of boxy tip deformity. Which of the following is the primary purpose of a transdomal suture during this procedure?
A) Decrease in tip projection
B) Improvement of columellar projection
C) Narrowing of the domes
D) Rotation of the tip
E) Strengthening of the tip

Answer 14

C) Narrowing of the domes

Transdomal sutures are horizontal mattress sutures placed at the dome or in the lateral crus of the lower lateral cartilage during tip rhinoplasty. The primary purpose of the transdomal suture is to narrow the domes. The secondary purpose of the transdomal suture is to narrow the convexity of the lateral crura. At times, the transdomal suture may also have a tertiary effect of slight increase in tip projection.
Regarding suture technique for tip rhinoplasty, columellar projection and tip projection are more commonly affected by the interdomal suture. The columella-septal suture rotates the tip. Both the interdomal and columella-septal suture strengthen the tip. Both interdomal and transdomal sutures may control tip symmetry.

Question 15

A 57-year-old man comes to the office for consultation regarding enlargement of the breasts. Physical examination shows bilateral large, ptotic, female-appearing breasts with firm, tender, glandular-like tissue deep to each nipple. Laboratory studies show increased beta-human chorionic gonadotropin level. Which of the following studies is the most appropriate next step in establishing the diagnosis?
A) Biopsy of the breast
B) CT scan of the abdomen
C) Mammography
D) MRI of the brain
E) Ultrasonography of the testes

Answer 15

E. US of testes

In adults with gynecomastia, thorough medical evaluation is required. History and physical examination should identify new medications, drug and alcohol abuse, and endocrine, hepatic, or pulmonary disease. Laboratory studies should measure electrolytes, blood urea nitrogen, creatinine, testosterone (total and free), estradiol, follicle-stimulating hormone, luteinizing hormone, beta-human chorionic gonadotropin (β-hCG), prolactin, liver function, and thyroid function. Radiography should also be performed. These tests are intended to rule out germ cell tumors, primary hypogonadism, hyperthyroidism, androgen resistance, pituitary tumors, secondary hypogonadism, and lung cancer. Mammography is not routinely used unless there is a finding on physical examination that shows possible presence of breast cancer; there is no known association between gynecomastia and breast cancer (except in Klinefelter syndrome). Imaging of the brain is not routinely ordered unless there is some other finding suggestive of a brain tumor. If the β-hCG concentration is increased, ultrasonography of the testes is indicated to rule out germ cell and non–germ cell tumors. CT scan of the abdomen should be ordered only if ultrasonography of the testes is negative.

Question 16

A 54-year-old woman has increasing pain around the right eye and visual impairment one hour after undergoing bilateral upper and lower blepharoplasty. Physical examination shows proptosis of the right eye and ecchymosis of the right upper and lower eyelids. Decreased visual acuity is noted, but the patient is able to perceive light in the right eye. Which of the following is the most appropriate initial management?
A) Consult with an ophthalmologist and monitor for a change in vision
B) Administer intravenous mannitol and acetazolamide and monitor for a change in vision
C) Administer intravenous and topical dexamethasone
D) Open the incisions and explore for a bleeding vessel
E) Open the incisions and release the septum orbitale and lateral canthus

Answer 16

E.

Retrobulbar hemorrhage is a rare but serious complication of blepharoplasty that must be acted on immediately to prevent blindness. Retrobulbar hemorrhage is characterized by pain, exophthalmos, and ecchymosis of the eyelid. If these three findings are present and vision is normal, opening of the incisions, evacuation of the hematoma, and exploration for a bleeding source are indicated. If there is any sign of visual impairment, which could range from minor difficulties such as blurred vision to severe problems such as no perception of light, immediate surgical decompression of the orbit, including a lateral canthotomy and release of the septum orbitale, is indicated. Further medical treatment such as the administration of mannitol, acetazolamide, dexamethasone, and a 95% oxygen/5% carbon dioxide mixture may also be used to reduce intraocular pressures further and to dilate intraocular vessels, but these treatments should not be used instead of surgical decompression.

Question 17

A 45-year-old woman who underwent reconstruction of the left breast with a TRAM flap followed by radiation two years ago is evaluated for a second reconstruction procedure on the left breast (shown). She requests that only reconstruction with her own tissues be performed and is opposed to surgery of the right breast to restore symmetry. On physical examination, the breast is shrunken and firm. After removal of the unsalvageable left breast, which of the following is the most appropriate reconstruction technique at this time?
A) Deep inferior epigastric perforator (DIEP) flap
B) Free TRAM flap
C) Latissimus dorsi myocutaneous flap
D) Superior gluteal artery perforator (SGAP) flap
E) Thoracoepigastric flap

Answer 17

D.

When there is near-total loss of a TRAM flap for breast reconstruction, it is important that a second breast reconstruction procedure be successful, with special consideration for safety. When there is insufficient lower abdominal tissue for tissue expansion and transfer of a second flap, neither a free TRAM flap nor a deep inferior epigastric perforator (DIEP) flap recruiting soft tissue in the same lower abdominal areas is an option. A latissimus dorsi myocutaneous flap is a reliable source of autogenous tissue; however, considering the size of the contralateral breast in this patient, a latissimus dorsi myocutaneous flap would need to be supplemented by a permanent expander implant to provide sufficient volume. A staged breast reconstruction with tissue expander would also require permanent implantation of a prosthesis upon completion of the expansion process. A gluteus free flap is considered when the latissimus dorsi flap is not sufficient or available and the patient requests autogenous tissue breast reconstruction. The free sensate superior gluteal artery perforator (SGAP) flap is a free sensate flap based on the superior gluteal artery perforator. It has an abundance of adipose tissue (specimens up to 760 g), even in thin patients, a relatively long vascular pedicle, a discrete scar, improved projection compared with the DIEP and TRAM flaps, and preservation of the entire gluteus maximus muscle with extremely low donor site morbidity.

Question 18

A 56-year-old woman undergoes a brow lift procedure. Dissection is performed medial to the zone of fixation of the deep fascia of the temporalis muscle and the frontal bone periosteum. Which of the following structures is at greatest risk for injury in this patient?
A) Frontal branch of the facial nerve
B) Supraorbital artery
C) Supraorbital nerve
D) Supratrochlear artery
E) Supratrochlear nerve

Answer 18

C.
The deep division of the supraorbital nerve innervating the frontoparietal scalp runs from the orbital rim between the deep galea plane and periosteum under the glide plane space toward the temporal fusion line (zone of fixation). It then runs 5 to 15 mm parallel to the zone of fixation cephalad until it enters the scalp. The superficial division of the supraorbital nerve courses from the orbital rim fissure into the frontalis muscle, innervating the forehead and terminating variably in the anterior scalp. Therefore, the deep branch of the supraorbital nerve is at risk for injury when dissecting just medially to the temporal line in the subgaleal plane. The supratrochlear nerve is most at risk during dissection of the glabellar folds and procerus muscle. Lateral to the temporal fusion line, the frontal branch of the facial nerve is at risk for injury. Medial to the superficial orbital fissure, the superficial branch of the supraorbital nerve and the supratrochlear nerves are at risk for injury.

Question 19

A 25-year-old woman comes to the office because she has loss of sensation in the nipple- areola complexes three months after she underwent bilateral reduction mammaplasty. Which of the following intercostal nerves were most likely injured during the procedure?
A) First and second
B) Third and fourth
C) Fifth and sixth
D) Seventh and eighth
E) Ninth and tenth

Answer 19

B. 3rd 4th
Recently, two separate groups have shown patterns of cutaneous innervation of the breast through detailed anatomic studies in cadavers. In general, cutaneous branches of the intercostal nerves are noted to pass through the deep fascia of the chest wall at two anatomic points: the lateral cutaneous branches at the midaxillary line and the anterior cutaneous branches beside the sternum. The breast skin is innervated by the lateral and anterior cutaneous branches of the T1 through T7 intercostal nerves. However, the contributions of the T1 and T7 intercostal nerves are small, and thus the branches of the T2 through T6 intercostal nerves are likely more important. There is no contribution by the T8 through T12 intercostal nerves to innervation of the breast skin.
Innervation to the nipple-areola complex is supplied by the anterior and lateral cutaneous branches of the T3 through T5 intercostal nerves. While all of these nerves supply branches, the T4 intercostal nerve is the most consistent in its contribution to innervation to the nipple-areola complex. Also, the cutaneous area of sensation of the nipple-areola complex, supplied by the T4 intercostal nerve branches, is larger than that supplied by the T3 or T5 intercostal nerve branches. Therefore, the T4 intercostal nerve is the primary nerve for cutaneous innervation to the nipple-areola complex, but it is not the sole supplier of this innervation.

Question 20

A 34-year-old man undergoes rhinoplasty using local anesthesia. During resection of the nasal spine, the patient tells the surgeon that he feels pain. Inadequate anesthesia of which of the following nerves is the most likely cause?
A) Anterior ethmoid
B) Infraorbital
C) Internal nasal
D) Lesser palatine
E) Nasopalatine

Answer 20

E. nasopalatine
In the case described, the nasopalatine nerve was not adequately anesthetized. The nasopalatine nerve branches from the pterygopalatine ganglion to innervate the inferior septum and travels through the incisive foramen to join the greater palatine nerve from the palate.
The anterior ethmoid nerve supplies sensation to the tip of the nose and the lateral nasal vault. The internal nasal nerve is a branch of the anterior ethmoid nerve supplying the anterior nasal lining.
The infraorbital nerve supplies sensation to the lateral nasal walls and ala.
The lesser palatine nerve supplies sensation to the soft palate.

Question 21

A 34-year-old woman comes to the office for consultation regarding breast augmentation. She is 5 ft 2 in tall and wears a size 34A brassiere. Submuscular implantation of 300-ml prostheses is planned. She asks for information about silicone versus saline implants. The primary advantage of using saline-filled implants is which of the following?
A) Easier detection of rupture
B) Increased softness
C) Less capsular contracture
D) Less leakage
E) Less wrinkling

Answer 21

A) Easier detection of rupture

Question 22

A 50-year-old man who weighs 155.5 lb (70 kg) is scheduled to undergo liposuction of the abdomen, flanks, and chest with administration of epinephrine and lidocaine for tumescent anesthesia. Which of the following amounts of lidocaine is the maximum for this patient?
A) 7mg
B) 35mg
C) 150 mg
D) 490 mg
E) 2450 mg

Answer 22

E.
For subcutaneous infiltration with 1% lidocaine with 1:100,000 epinephrine, 7 mg/kg of lidocaine is generally recommended. It has been shown, however, that the use of “tumescent fluid” with 1:1,000,000 epinephrine can be safely given with lidocaine doses as high as 35 mg/kg. Lidocaine toxicity can have an excitatory effect on the nervous system, such as tingling, numbness, mental status changes, and, eventually, seizures.

Question 23

60-year-old woman undergoes Mohs’ micrographic surgery for resection of basal cell carcinoma of the nose. The roughly circular full-thickness resection leaves a defect of the nose measuring 25 mm in diameter that encompasses the lower 10% of the nasal dorsum and 80% of the nasal tip. Both lower lateral cartilages are exposed and denuded but intact. Which of the following reconstruction techniques is most likely to yield the best aesthetic result?
A) Excision of the remainder of the nasal dorsum subunit and coverage with a bilobed flap
B) Excision of the remainder of the nasal dorsum subunit and coverage with a forehead flap
C) Excision of the remainder of the nasal tip subunit and coverage with a bilobed flap
D) Excision of the remainder of the nasal tip subunit and coverage with a forehead flap
E) No further excision and coverage with a forehead flap

Answer 23

D.

The concept of aesthetic subunits was first proposed for reconstruction of the nose. When a defect encompasses more than 50% of a subunit, the remainder of the subunit should be excised and the entire subunit should be reconstructed. This usually yields a superior aesthetic result compared with a reconstruction involving a scar crossing an aesthetic subunit.
The forehead flap can provide sufficient tissue surface area to reconstruct the entire nasal skin surface. The bilobed flap, on the other hand, cannot reconstruct defects on the nose greater than approximately 15 mm in diameter.

Question 24

A 3-year-old boy is brought to the office by his parents because of new onset of bilateral epiphora. The boy’s parents say that similar symptoms occurred in one of their older children but resolved without treatment. On physical examination, the lashes of both lower eyelids rub against the inferior cornea. Which of the following is the pathophysiologic mechanism underlying this patient’s condition?
A) Abnormal attachment of the canthal tendons
B) Abnormal attachment of the orbital septum
C) Enophthalmos
D) Laxity of the tarsal plate
E) Redundancy of skin and orbicularis muscle

Answer 24

E.

The elevation of these tissues near the eyelid margin forces an upward and inward rotation of the lower lashes. A common result of this rotation is contact between the lower eyelashes and the cornea or inferior bulbar conjunctiva. Laxity of the tarsal plate may be seen as an atrophic change in adults with involutional entropion. Laxity of the canthal tendons is an involutional change and would not be expected in children. Abnormal septum attachments may occur as a postoperative or posttraumatic complication but are unlikely the cause of eyelash malposition.

Question 25

When performing liposuction using a tumescent technique, the ratio of infiltrate to aspirate is closest to which of the following?
A) 1:1
B) 1:2
C) 1:3
D) 2:1
E) 3:1

Answer 25

E. 3:1

Question 26

A 70-year-old man comes to the office for consultation regarding the hollowed, tired, and haggard appearance of his face. Physical examination shows prominent atrophy of the midface. For restoration of round, full, and youthful contour of the face using an implant, which of the following is the most appropriate positioning of the prosthesis?
A) Infraorbital rim lateral to the infraorbital nerve
B) Malar area lateral to the posterior zygoma
C) Malar to the mid-zygomatic arch
D) Paranasal area at the nasal maxillary suture line E) Submalar area over the upper masseter muscle

Answer 26

E.
Augmentation of the malar area medially or laterally would increase the size of the cheekbones and possibly produce a dramatic, chiseled look that may accentuate the atrophy of the midface and make the patient appear more haggard. Paranasal augmentation would not affect the tired appearance and is more commonly indicated for severe maxillary deficiency. A prosthesis in the submalar zone, bounded posteriorly by the masseter muscle, superiorly by the malar eminence, and medially by the nasal labial fold, would fill out the atrophy and round out a tired and haggard midface. Implantation of the prosthesis would produce the best results if performed in conjunction with rhytidectomy.

Question 26

A 55-year-old woman has nipples located 8 cm inferior to the inframammary fold and at the lowest point of the breast contour. Which of the following best describes the degree of breast ptosis in this patient?
A) Glandular ptosis
B) Grade 1
C) Grade 2
D) Grade 3
E) Pseudoptosis

Answer 26

D.

Ptosis is often graded on a scale of 1 to 3. Grade 1 ptosis exists when the nipple is at or above the level of the inframammary fold. Grade 2 ptosis exists when the nipple is below the level of the inframammary fold but not at the lowest point of the breast contour. Grade 3 ptosis exists when the nipple is at the lowest point of the breast contour. Pseudoptosis and glandular ptosis describe similar states in which the nipple is at or near the level of the inframammary fold, but there is breast tissue and a skin envelope that descends or hangs below the level of the inframammary fold.

Question 27

A 63-year-old man comes to the office for consultation regarding correction of large breasts. Detailed history and physical examination show no cause of his condition. The breasts are a size C cup with ptosis and excessive skin. The nipples are 5 cm in diameter. Mastectomy and free nipple grafts are planned. The desired new size and shape of each areola are closest to which of the following?
A) 1 cm, round
B) 2 cm, round
C) 2 cm, oval
D) 3 cm, oval
E) 4 cm, round

Answer 27

D. 3cm oval

Larger forms of gynecomastia with significant ptosis present a challenge to plastic surgeons with respect to the size, shape, and position of the nipple on the chest wall. In addition, the nipple-areola complex may need to be reconstructed due to loss from cancer or trauma.
Two recent studies investigated the anatomical parameters of the nipple-areola complex in men. These studies demonstrated the following characteristics. More than 90% of the male subjects had nipples that were oval in configuration. The average areolar diameter in one study was 2.8 cm. The average areolar diameter in the other study was 2.7 cm. Furthermore, in men, the position of the nipple on the chest wall is typically 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance in men is 21 cm.

Question 28

A 22-year-old man who is a professional boxer comes to the emergency department because he has a hematoma on the anterior surface of the left ear one hour after he sustained a direct blow to the ear during a match. Which of the following is the most appropriate management?
A) Application of pressure and ice to the ear
B) Application of a mold to the ear
C) Percutaneous drainage of the hematoma
D) Open drainage of the hematoma and application of a bolster dressing
E) Open drainage of the hematoma and reshaping of the cartilage

Answer 28

D.

ntreated subperichondrial hematomas can lead to formation of new cartilage and the appearance of a thickened and deformed ear (cauliflower ear). To maintain the natural contour of the ear, appropriate management consists of open drainage of the hematoma followed by closure of the incision and application of a tie-over bolster dressing. Percutaneous drainage techniques or simple cold compresses are generally not adequate in completely removing the hematoma. Molds can be used to shape the ear of an infant but not of an adult. Cartilage reshaping techniques, such as scoring, are not necessary in the management of acute auricular hematomas but may be needed for later reconstruction of cauliflower ear.

Question 29

A healthy 55-year-old woman comes to the office for consultation regarding reduction of frown lines between her eyebrows. Injections of botulinum toxin are planned. The patient has never undergone this treatment. Which of the following is the most appropriate initial dose of botulinum toxin type A for injection into the glabellar region in this patient?
A) 1U
B) 5U
C) 20U
D) 45U
E) 100U

Answer 29

C. 20 units

Question 30

A 65-year-old man comes to the office for follow-up examination three days after undergoing rhytidectomy. Physical examination shows a 6-cm postauricular hematoma that is not compromising the overlying skin. Which of the following is the most appropriate management?
A) Observation
B) Application of cold compresses
C) Aspiration of the hematoma
D) Placement of a percutaneous drain and application of a pressure dressing
E) Suture release and evacuation of the hematoma

Answer 30

E.

At five days postoperatively, the hematoma is still solid. Hematomas liquefy between the seventh and tenth days. Therefore, aspiration of the hematoma would not be possible at this time. Placement of a drain would not facilitate the removal of solid clot. Application of cold compresses would not help an already formed collection of blood. No treatment would result in skin firmness, irregularity, and discoloration that may persist for months.
Evacuation of the hematoma through release of several sutures and gentle pressure or suction is easily accomplished in the office. Large hematomas or expanding hematomas would require drainage in the operating room.

Question 31

A 34-year-old woman comes to the office for consultation regarding bilateral lower eyelid blepharoplasty. She has no skin excess and is mainly concerned with fullness of the lower eyelids. Transconjunctival blepharoplasty using an inferior fornix approach is planned. To resect the orbital fat, the structure the surgeon must divide is which of the following?
A) Capsulopalpebral fascia
B) Levator aponeurosis
C) Orbital septum
D) Suborbicularis oculi fat E) Tarsal plate

Answer 31

A
At the level of the inferior fornix, the transconjunctival incision proceeds first through the conjunctiva and then through the capsulopalpebral fascia, and next to the orbital fat. The dissection is posterior to the orbital septum and suborbicularis oculi fat (SOOF). The dissection is several millimeters posterior to the tarsal plate. The levator aponeurosis is a structure that is present in the upper eyelid.

Question 32

A 38-year-old man who plays ice hockey undergoes rhinoplasty for correction of a deformity caused by repetitive injury to the nose. During the procedure, spreader grafts are placed. This intervention is most appropriate to achieve which of the following?
A) Decrease the angle of the internal valve
B) Narrow the mid vault
C) Recreate the dorsonasal line
D) Rotate the nasal tip
E) Stabilize the external valve

Answer 32

C.

Spreader grafts are a very useful adjunct in rhinoplasty procedures because they can recreate the dorsonasal line. The dorsonasal line extends from the eye to the nasal tip, making its aesthetics of special concern during rhinoplasty. The graft can be placed above the septal plane to be visible or below the septal plane to be more concealed. When placed above the septal line, the graft will more aggressively define the dorsal aesthetic line. Spreader grafts can be sutured to the septum and to the upper lateral cartilages at the level of the apex of the internal valve. Spreader grafts can also reconstruct the dorsonasal roof, widen the internal nasal valve, or straighten and buttress a high dorsally deviated septum. The spreader grafts would make the internal valve angle more obtuse and open the airway; they would not narrow the mid vault but make it more augmented as well as prevent or treat the inverted V deformity.

Question 33

A 30-year-old woman undergoes augmentation mammaplasty with silicone gel prostheses. During the procedure, smooth prostheses are positioned subglandularly. The subglandular placement increases this patient’s risk of which of the following complications?
A) Capsular contracture
B) Double-bubble appearance
C) Infection of the implant
D) Rippling of the implant
E) Rupture of the implant

Answer 33

Capsular contracture remains one of the main drawbacks to the use of silicone breast prostheses. Submuscular placement is a well-established method of reducing the rate of contracture. The introduction of implant-surface texturing in the late 1980s has greatly reduced the contracture rate for prostheses placed subglandularly.
Development of capsular contracture is clearly more common in the first two years after subglandular implantation, regardless of the implant type. The large difference in the rate of contracture between textured and smooth prostheses in the subglandular position seems to be negligible in subpectoral placement; both types of implant have low contracture rates.
The causes of capsular contracture and the effect of surface texturing and implant position in reducing its incidence are still not clear. Capsule formation is a normal response to the introduction of foreign material and, like most physiologic responses, varies by degree and timing. Additionally, there are general patient factors and local breast factors. The literature suggests that capsule response may be altered by other factors such as infection, diffusion of silicone gel, and smoking.
The introduction of surface texturing alters the capsule response. Texturing may produce a more disorganized collagen pattern in the capsule. It has been suggested that subpectoral prostheses have a lower rate of capsular contracture, regardless of surface texturing, because of the massaging action of the overlying pectoralis major

Question 34

A 36-year-old woman who underwent panniculectomy three weeks ago has infection of the surgical wound requiring open drainage and packing with daily dressing changes. Medical history includes Roux-en-Y gastric bypass surgery 20 months ago. Physical examination shows a 35 × 12-cm open wound that has not decreased in size since completion of the procedure. No significant formation of granulation tissue is shown, but the wound is otherwise clean; no signs of fat deposits or necrosis are noted. Which of the following interventions is the most appropriate management?
A) Administration of an antibiotic
B) Nutritional supplementation
C) Hyperbaric oxygen therapy
D) Primary closure
E) Surgical debridement

Answer 34

B
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure and combines elements of restrictive and malabsorptive procedures. The size of the stomach is reduced by stapling, and a variable segment of small bowel is bypassed using a Roux limb. Major elective surgery will require an increased calorie and protein consumption of approximately 25%.
Most bariatric patients who have stabilized in their weight loss should be able to meet these needs. However, burns, trauma, infection, and large open wounds can substantially increase these nutritional requirements to the point at which they cannot be met through oral intake. In addition to increased metabolism resulting from these pathologic processes, a substantial amount of protein can be lost from a large wound. Exudate from an open wound may contain up to 44 mg/ml protein and result in losses that the bariatric patient cannot match. In this patient, the large open wound has failed to show expected progress in healing. Aggressive nutritional evaluation and supplementation should be performed. If oral intake with protein supplements is not adequate, endoscopic placement of an enteral feeding tube or total parenteral nutrition may be necessary. Hyperbaric oxygen therapy is unlikely to improve healing in this case. Surgical debridement is not necessary because the wound is free of necrosis. Wound biopsy would be appropriate for a chronic non-healing wound to exclude malignancy.

Question 35

For reconstruction mammaplasty, which of the following is an advantage of the extended latissimus dorsi flap over the standard latissimus dorsi myocutaneous flap?
A) Better flap perfusion
B) Decreased need for breast implant
C) Fewer donor-site seroma
D) Less sacrifice of latissimus dorsi muscle
E) Smaller donor-site scar

Answer 35

B.
Variations of the LD flap have been described to increase its volume and avoid the addition of a prosthesis. The first “extended” LD (ELD) flap was described by Hokin in 1983 and included lumbar fat extensions of the LD flap. Others have used the buried de-epithelialized LD myocutaneous flap for breast reconstruction. McCraw and Papp modified this technique by using a fleur-de-lis skin paddle design to carry additional fat on the surface of the LD muscle, creating the totally autogenous LD breast reconstruction.
The design of the ELD flap has evolved to include the parascapular and scapular “fat fascia” in addition to the lumbar fat for additional volume. The main advantage of the ELD flap is that it can provide autogenous tissue to replace breast volume without an implant and with acceptable donor site contour and scar. Because the ELD flap transports additional tissue from the back so a breast prosthesis is not required, this avoids all potential problems associated with implants, e.g., development of capsular contracture and deformation of the reconstructed breast.
With ELD flaps, donor site complications, including seroma formation and wound necrosis, can be a significant problem.

Question 36

A 70-year-old man who underwent total resection of the right ear followed by radiation because of squamous cell carcinoma one year ago comes to the office for consultation regarding reconstruction of the ear. He says he needs the ear to support his eyeglasses. Medical history shows chronic obstructive pulmonary disease. Which of the following reconstruction techniques is most appropriate in this patient?
A) Fixation of autogenous cartilage under local flaps
B) Implantation of osseointegrated auricular prostheses
C) Placement of porous polyethylene framework and coverage with a radial forearm free flap
D) Placement of silicone rubber (Silastic) framework and coverage with a temporoparietal flap
E) Tissue expansion and placement of porous polyethylene framework

Answer 36

B

older patient, more high risk
radiation excludes expansion

Question 37

A 24-year-old woman comes to the office for consultation regarding surgical correction of the breast deformity shown above. Which of the following is the most appropriate management?
A) Augmentation with Wise-pattern mastopexy of both breasts
B) Augmentation with periareolar mastopexy of both breasts
C) Latissimus dorsi myocutaneous flap reconstruction of the left breast and periareolar mastopexy of the right breast
D) Extended dorsi myocutaneous flap reconstruction of the left breast and periareolar reduction of the right breast
E) Transaxillary augmentation of the left breast and periareolar mastopexy of the right breast

Answer 37

B.
The patient described has tuberous breast deformity, which is characterized by three components: herniation of the breast tissue into the nipple-areola complex with a cylindrical projection accompanied by a relatively large areola; deficiency of the lower pole of the breast in both vertical and horizontal axes; and hypoplasia. Periareolar mastopexy with augmentation will give access for radial-releasing incisions, which will allow expansion of the base of the breast

Question 38

A 25-year-old man has congestion of the right ear 10 hours after he underwent replantation of the auricle due to near-total amputation of the ear in a motor vehicle collision. During microscopic surgery, a single small artery was anastomosed to relocated superficial temporal vessels. No vein could be located. Which of the following is the most appropriate management of this patient’s current symptom?
A) Elevation of the head
B) Topical application of nitroglycerin
C) Leech therapy
D) Vein grafting
E) Surgical reexploration

Answer 38

C.

Microsurgical ear replantation provides another option in select cases of ear amputation, providing the potential for an unsurpassed aesthetic result. In those relatively few cases in which it is attempted, the small size of the vessel and the component of avulsion can make primary repair of the vessels difficult. Venous congestion occurs to some extent in nearly every case and is the most common cause of postreplantation complications. There have been several case reports of successful ear replantation without a venous anastomosis, although venous anastomosis is recommended whenever possible. Despite this, postoperative congestion can be managed with leech therapy for vascular compromise. Arterial compromise demands reexploration, whereas venous compromise can be managed nonoperatively. Topical vasodilators, such as nitroglycerin, are not recommended for venous congestion. Efforts should be made to improve outflow; therefore, conservative management is not recommended. Elevating the patient’s head may be useful but does not replace the proven effectiveness of leeches and heparin in clear cases of congestion.

Question 39

A 55-year-old woman undergoes periorbital rejuvenation. A combined upper and lower blepharoplasty, rhytidectomy, and lateral brow lift are performed. Release of which of the following structures will allow the greatest cephalad movement of the lateral brow in this patient?
A) Arcus marginalis
B) Brow depressors
C) McGregor patch
D) Orbital retaining ligament
E) Periosteum

Answer 39

D.

The orbital retaining ligament is located over the zygomatic frontal suture. It is also referred to as the zygomatic orbital retaining ligament in some texts. It is a 5-mm-long fibrous band that attaches the zygomatic frontalis suture line to the dermis. A neurovascular bundle passes through this structure, and its release allows superior-lateral movement of the forehead flap. Other attachments of the dermis to the periosteum are found at the anterior-inferior border of the mandible in the parasymphyseal region anterior to the jowl, the anterior-inferior border of the zygomatic arch posterior body of the zygoma – often referred to as McGregor patch – and the buccal maxillary ligaments from the zygomatic maxillary suture to the dermis. Together, these attachments are referred to as the “fence” of the cheek. These attachments are the true retaining ligaments, and their release allows free movement of the skin and soft tissue. These ligaments also can contain a neurovascular bundle that requires some care during dissection. Release of these structures allows movement of soft tissue during facialplasty, and their location is helpful during dissection.
Release of the arcus marginalis will allow freeing of the medial brow but often does not allow lateral brow mobility without release of the orbital retaining ligament. The periosteum does not need to be released for superior brow movement; however, a safer plane of dissection is subperiosteal within 1.5 cm of the orbital rim to avoid injury to the supraorbital and supratrochlear sensory nerves and arteries. Release of the brow depressors is performed to prevent recurrent brow ptosis, and their release is often not associated with further superior flap advancement. However, it is prudent to consider preoperative paralysis through injections of botulinum toxin to allow unopposed movement and preoperative evaluation of what their relaxation allows in terms of cephalad brow movement.

Question 40

A 68-year-old man comes to the office for consultation regarding rhinoplasty. Examination of the nose shows drooping and elongation of the tip complex. The primary cause of these findings is age-related loss of intrinsic support of which of the following structures?
A) Columella
B) Lower lateral cartilage C) Nasalis muscle
D) Septum
E) Upper lateral cartilage

Answer 40

B.
The most significant and distinctive changes in the patient with advancing age occur in the nasal tip. Therefore, it is usually the area that needs the most refinement. This manifests as a drooping, elongated tip complex. The mechanism is multifactorial; however, it is primarily due to loss of intrinsic lower lateral cartilage support.
Other factors that contribute to nasal tip changes are: weakening or loss of suspensory ligament support with loss of medial crural support; thickening and possible ossification of cartilages, leading to greater prominence; thickening of the overlying skin and subcutaneous tissue with concomitant increased vascularity, leading to increased bulkiness and weight of the tip; and maxillary alveolar hypoplasia with resultant divergence of the medial crural feet and columellar shortening.

Question 41

A 5-year-old girl is brought to the office by her parents for consultation regarding deformity of the left side of the chest and the left upper extremity. Physical examination shows athelia, brachydactyly, and absence of the left pectoralis major muscle. Which of the following additional findings is most likely?
A) Absence of the 12th rib
B) Bilateral syndactyly
C) Hypoplasia of the left rectus abdominis muscle D) Left brachial cyst
E) Shortened right ulna

Answer 41

A.

Poland
he most common finding in patients with Poland syndrome is absence of the sternal head of the pectoralis major muscle. Other muscles, including the external oblique, latissimus dorsi, pectoralis minor, and serratus muscles, may be absent or hypoplastic. The rectus abdominis muscle is not involved. Ribs and costal cartilages of the affected side may be absent. Other anomalies of the chest include athelia and hypoplastic skin covering the chest wall. Anomalies of the ipsilateral upper extremity include brachysyndactyly as well as foreshortening and hypoplasia of the forearm.

Question 42

A 13-month-old girl has had tearing and discharge from the right eye since birth. Which of the following is the most appropriate management?
A) Observation
B) Instruction of the parents in massage with antibiotic ointment
C) Silastic intubation
D) Probing of the nasolacrimal duct
E) Dacryocystorhinostomy

Answer 42

D.
A child with congenital tearing is likely to have a nasolacrimal duct problem. Punctual agenesis, lacrimal sac fistula, and other rare abnormalities should be ruled out with dye disappearance testing, which usually is markedly asymmetric in a nasolacrimal duct problem. Generally, a nasolacrimal duct problem should be treated with massage and antibiotic drops until the child is age 12 to 13 months. For about 70% of children with tearing at age 6 months, this conservative treatment leads to resolution by age 12 months. If tearing persists, probing of the nasolacrimal duct should be performed. The longer probing is delayed beyond age 13 months, the greater the number and complexity of the procedures needed to successfully treat congenital dacryostenosis. Therefore, initial probing and irrigation should be performed before age 13 months.

Question 43

A 28-year-old man comes to the office for consultation regarding a “small” chin. Which of the following is most likely to be achieved with implantation of a silicone prosthesis in this patient’s chin?
A) Addition of height to the lower face
B) Correction of asymmetries of the anterior mandible
C) Effacement of the labial mental fold
D) Enhancement of sagittal projection to the pogonion
E) Increase in the bigonial distance

Answer 43

D.

Question 44

A 45-year-old woman with Bell’s palsy comes to the office because she has had inability to close the right eye, sagging of the right side of the mouth, and difficulty breathing through the right side of the nose for the past six months. Dysfunction of which of the following muscles of the external nose is the primary cause of this patient’s symptoms?
A) Corrugator supercilii
B) Depressor septi nasi
C) Nasalis
D) Procerus
E) Zygomaticus major

Answer 44

C.
The alar fibers of the nasalis muscle and the levator labii superioris are responsible for dilating the nasal apertures. The transverse fibers of the nasalis serve as nostril constrictors. The depressor septi nasi muscle functions to depress the nasal tip. These muscles comprise the inferior group of nasal musculature and are innervated by the buccal branch of the facial nerve.
The corrugator and procerus muscles are responsible for vertical frown lines and glabellar furrowing, respectively. They comprise the superior group of external nasal muscles and are innervated by the temporal branch of the facial nerve. The zygomaticus major elevates the oral commissure and is not considered part of the muscles of the external nose.
Facial paralysis can contribute to nasal airway obstruction.

Question 45

A 50-year-old woman comes to the office for consultation regarding closing of the right eye one year after she had an episode of Bell’s palsy on the right side. She says her right eye closes when she chews. Photographs are shown. Which of the following is the most appropriate management of this patient’s symptoms?
A) Injection of botulinum toxin into the orbicularis muscle
B) Repair of levator aponeurosis
C) Fascial suspension of the brow
D) Unilateral temporal brow lift
E) Upper blepharoplasty

Answer 45

A. botox into orbicularis

his patient has right-sided orbicularis oculi contracture with orbicularis oris contracture. Her symptoms and history of Bell’s palsy are consistent with recovered facial nerve animation with synkinesis. Her right eye closes when she eats. Injection of botulinum toxin to the orbicularis muscle would treat the synkinesis and allow the adverse effect of lower lid lagophthalmos. Repair of levator aponeurosis and fascial suspension of the brow treat forms of eyelid ptosis. A temporal brow lift would treat unilateral brow descent secondary to residual palsy of the temple branch of the facial (VII) nerve. Upper blepharoplasty would treat upper-eyelid excess skin only; however, this patient does not display eyelid or brow ptosis, and there is no significant excess of upper-eyelid skin

Question 46

A 16-year-old girl has persistent ptosis of the eyelid (shown) six months after undergoing reconstruction of the forehead and supraorbital bar for fibrous dysplasia. One month postoperatively, a wound developed from extrusion of hardware through the medial eyelid. Debridement of the wound with excision of the involved inflammatory tissue and reconstruction with a pericranial flap were performed at that time. On current examination, no levator function is noted medially in the eyelid and lateral movement of the eyelid is minimal. Which of the following interventions is the most appropriate next step in management?
A) Lysis of adhesions
B) Kuhnt-Szymanowski procedure
C) Fasanella-Servat procedure
D) Suspension to the frontalis muscle with fascia lata grafting
E) Advancement of the levator muscle

Answer 46

D) Suspension to the frontalis muscle with fascia lata grafting

This patient has traumatic ptosis as a complication of prior surgical procedures. At the time of debridement, either a portion of the levator muscle was excised or the muscle function is limited by scar tissue. In either case, the function as shown in the photographs is minimal, and the ptosis is best managed by a frontalis suspension procedure. It is generally agreed the fascia lata is the material of choice for the sling. Alloplastic materials, such as silicone slings, can also beused but have a risk of extrusion and infection. The advantage of alloplastic sling reconstruction is that there are no risks to the donor site.
The Fasanella-Servat procedure involves excision of a portion of the conjunctiva, tarsus, orbital septum, levator aponeurosis, and Müller muscle. It can be used in cases of mild ptosis (1-2 mm). Levator function must be present.
The Kuhnt-Szymanowski procedure is used to correct lower eyelid ectropion. It involves a wedge excision of the lower eyelid.
Levator advancement surgery could possibly be used in this case if, during exploration of the eyelid, the levator was noted to be present and not compromised by scar. However, in this case, the levator mechanism was likely excised in the process of debriding the wound tract and inflammatory tissue. Therefore, in light of the degree of ptosis, the noted limited elevation of the upper eyelid, and the mechanism of injury, frontalis suspension is a better choice for ptosis repair in this patient.
With no evidence of muscle function, it is unlikely that adhesions alone are the cause of restricted eyelid movement. Therefore, lysing the scar would likely be inadequate treatment.

Question 47

A 2-year-old boy with isolated unilateral microtia is brought to the office by his parents for consultation regarding reconstruction of the ear. Which of the following is the most appropriate management?
A) Delay of reconstruction of the ear until 6 years of age
B) Fitting of a prosthetic ear
C) Placement of a postauricular tissue expander
D) First-stage reconstruction of the ear using a cartilage rib graft
E) First-stage reconstruction of the ear using a polyethylene prosthesis

Answer 47

A) Delay of reconstruction of the ear until 6 years of age

Reconstruction of the ears should be delayed until at least 5 to 6 years of age and preferably until 7 to 8 years of age. At younger ages, patients often do not strongly desire the reconstruction, are more likely to have difficulty with postoperative compliance, and may not have rib cartilage large enough to create an auricular framework if autogenous cartilage is to be used. In addition, reconstructing an ear too early in life may result in an ear that is too small if it does not grow with the patient.
Tissue expansion of postauricular skin may be used during ear reconstruction but should be delayed until at least 5 to 6 years of age. A criticism of tissue expansion for ear reconstruction is that the expanded skin is less supple than unexpanded skin and is less able to conform to the anatomic details of an autologous or prosthetic ear cartilage framework.
Prosthetic ears are not appropriate for young children because they are usually too physically active to keep a prosthesis attached and are too young to care for a prosthesis.
First-stage ear reconstruction can be successfully accomplished using autologous cartilage or prosthetic material to recreate the underlying ear framework but should be delayed until this child is older.

Question 48

With the tumescent liposuction technique, which of the following percentages of the aspirate is blood?
A) 1% B) 4% C) 8% D) 12% E) 15%

Answer 48

A. 1%

Question 49

A 36-year-old woman comes to the office for consultation regarding breast reconstruction one year after she underwent right modified radical mastectomy. The procedure was followed by six weeks of radiation therapy. She has no history of other surgical procedures or serious medical illnesses. Height is 5 ft 4 in tall and weight is 135 lb. She wears a size 32B brassiere. Which of the following is the LEAST appropriate breast reconstruction procedure for this patient?
A) Extended latissimus dorsi flap
B) Latissimus dorsi flap with saline-filled prosthesis
C) Superior gluteal artery perforator (SGAP) flap
D) TRAM flap
E) Two-staged reconstruction with a tissue expander and saline-filled prosthesis

Answer 49

E.
Radiation therapy has significant negative effects on the outcome of breast reconstruction with prostheses. There is a significant increase in capsular contracture and other complications, which are unrelated to implant type.
Totally autologous reconstruction is the best option for managing the radiated breast. The extended latissimus flap might have adequate volume in this patient (size 32B brassiere) without use of a prosthesis. Even if a prosthesis is required, the new nonradiated skin and muscle of a latissimus flap are advantageous for softness and thickness. The superior gluteal artery perforator (SGAP) and TRAM flaps would also bring in new nonradiated tissue and foreign bodies would not be placed in the breast.
Although the final outcome of a two-stage reconstruction with tissue expanders and prostheses can be acceptable in the radiated field, it is generally not as good as those obtainable with autologous tissue alone.