Cosmetic Flashcards
A 55-year-old man is scheduled for a rhytidectomy with an extended superficial
musculoaponeurotic system (SMAS) flap and neck lift. In order to avoid injury to the
great auricular nerve, which of the following best describes the most likely course of the
main branch of the great auricular nerve?
A ) Exits the deep neck at the anterior border of the sternocleidomastoid muscle
B ) Exits the stylomastoid foramen and emerges through the Lore fascia
C ) Lies parallel and posterior to the external jugular vein
D ) Lies superficial to the platysma muscle at the anterior border of the
sternocleidomastoid muscle
E ) Perforates the sternocleidomastoid muscle 6.5 cm inferior to the external auditory
meatus
The correct response is Option C.
The great auricular nerve (GAN) is the most commonly injured named nerve during a
rhytidectomy. Multiple studies have estimated the incidence at 6%. The course and
avoidance of injury to this nerve is important in minimizing the risks for painful neuroma,
allodynia, and permanent numbness. The GAN is a purely sensory nerve that arises from the
C2 and C3 spinal roots and then fuses into the main trunk of the GAN. It exits the deep neck
along the posterior border of the sternocleidomastoid muscle (SCM) and then travels parallel and posterior to the external jugular vein (EJV). It usually bifurcates into anterior and posterior branches. There are anomalous courses that can occur in rare cases.
Guidelines in avoiding injury of the GAN include the following:
1. Raising the platysma at the anterior border of the SCM will protect the nerve from injury.
2. To avoid suture injury to the nerve, platysma/superficial musculoaponeurotic system suspension sutures should be placed posterior to a vertical line drawn from McKinney’s point to a point 1.5 cm posterior to the insertion of the lobule.
The GAN does not perforate the SCM, but lies on top of it. McKinney’s point is located
along the midwidth of the SCM approximately 6.5 cm inferior to the external auditory
meatus. This represents where the GAN usually exits from beneath the SCM fascia and
becomes more superficial and is increasingly susceptible to injury.
Chemical peel neutralization using 1% sodium bicarbonate would be recommended
with which of the following peeling agents?
A ) Glycolic acid
B ) Jessner solution
C ) Phenol-croton oil
D ) Salicylic acid
E ) Trichloroacetic acid (TCA)
The correct response is Option A.
The requirement for neutralization is specific to each peel and must be thoroughly
understood before application. For instance, the trichloroacetic acid peel approach is a
dynamic process that depends largely on clinical judgment and experience to assess the
extent of frosting relative to peel depth in an effort to optimize results and minimize
complications. Furthermore, peel neutralization is typically carried out with a basic solution
such as 1% sodium bicarbonate, and is generally required only for specific acids, such as
glycolic acid, whereas phenol-croton oil peels and Jessner solution cannot be neutralized.
Salicylic acid does not need to be neutralized. TCA penetrates deep to the dermal-epidermal
junction and is counteracted by dilution with saline. TCA cannot be neutralized at the end of
treatment because it has penetrated too deeply.
A patient who had massive weight loss comes to the office to discuss reconstruction.
The surgeon determines that the patient would benefit from a lower body lift.
Advancement of the flaps in this procedure will be best achieved by undermining which
of the following zones of adherence?
A ) Distal posterior thigh
B ) Gluteal crease
C ) Inferolateral iliotibial tract
D ) Lateral gluteal depression
E ) Mid medial thigh
The correct response is Option D.
Continuous or discontinuous release of the lateral gluteal depression would be the most
effective in allowing the advancement of the flaps in a lower body lift. Though the gluteal
crease is in proximity of the flaps, release here would undesirably blunt this crease. The
other choices are not in proximity and their release would have little effect on advancing the
flaps.
2019
A 26-year-old woman is evaluated because she has difficulty breathing out of her right
nostril. Physical examination shows the nasal septum is deviated to the right. The nasal
dorsum is straight, and the nasal tip is slightly underprojected. A septoplasty is planned.
Which of the following incisions is most appropriate for accessing the septum?
A ) Intercartilaginous
B ) Killian
C ) Marginal
D ) Rim
E ) Weir
The correct response is Option B.
A Killian incision is made 1-2 cm posterior to the caudal edge of the septum and provides
access to the septum for a septoplasty. It is the most appropriate of the choices listed. While
the Killian incision does not provide access to the caudal septal angle, it preserves tip
support. The transfixion incision, which obtains access to the septum by incising both sides
of the membranous septum at its junction with the caudal septum, is sometimes used. Both
provide access to the septum, but the transfixion incision disrupts the septal ligaments, which can deproject the nasal tip inversely. When nasal tip deprojection is desired, the transfixion incision is used, and when the nasal tip is slightly under projected, a Killian incision can be considered.
The Weir incision is made at the alar base. The marginal incision is made at the caudal
aspect of the lower lateral cartilage, and the rim incision is made at the rim. Though often
grouped together, these incisions are distinct. The intercartilaginous incision is made
between the upper lateral and lower lateral cartilages. These incisions are not used for
septoplasty.
The septum can also be accessed through a transcolumellar approach, which is an open
approach.
A 12-year-old girl is evaluated for correction of congenital left unilateral upper eyelid
ptosis. She demonstrates moderate left levator muscle function of 8 mm. Which of the
following methods is most appropriate for correction of this child’s blepharoptosis?
A ) Fasanella-Servat procedure with removal of the tarsus, conjunctiva, and Müller
muscle
B ) Frontalis muscle flap advancement
C ) Frontalis suspension procedure with autogenous fascia lata
D ) Müller muscle-conjunctival resection
E ) Resection and advancement of the levator aponeurosis
The correct response is Option E.
The most appropriate method for correction of this child’s congenital ptosis is resection and
advancement of the levator aponeurosis. This technique is appropriate in patients with
greater than 5 mm of levator function. This child has 8 mm of levator function and is
therefore a candidate for levator resection and advancement.
Frontalis suspension procedures are reserved for patients with poor levator function
or congenital Marcus Gunn jaw-winking syndrome.
The Fasanella-Servat procedure is for correction of minimal ptosis and may alter eyelid
contour.
The Müller muscle-conjunctival resection surgery is recommended for patients with fairly
good levator function and does not allow for intraoperative adjustment of eyelid height.
This child has unilateral blepharoptosis, and achievement of symmetry with the opposite
eyelid is crucial.
The frontalis muscle flap is recommended for use in patients with severe ptosis with levator
function of less than 4 mm.
2019
A 55-year-old woman is evaluated for facial rejuvenation. She is concerned about brow
ptosis and dynamic frown lines. Physical examination shows brow ptosis, dynamic and
static frown lines, a long forehead, and thick hair. Which of the following is the best
approach for brow lift surgery for this patient?
A ) Endoscopic
B ) Endotemporal
C ) Pretrichial
D ) Transcoronal
E ) Transpalpebral
The correct response is Option C.
The pretrichial incision is the appropriate approach to perform a brow lift and to address a long forehead. Of the options listed, the pretrichial incision alone can specifically address a long forehead.
An endotemporal approach is useful for patients with thin hair or lateral ptosis, and
endoscopic and transpalpebral approaches are useful for a brow lift but cannot address a
long forehead.
A transcoronal incision is most useful in a patient with a short forehead and
deep rhytides.
2019
A 30-year-old woman wants improvement of the bulbous tip of her nose. Open
rhinoplasty and thinning of the tip is planned. Intraoperative examination shows the
cause of the bulbous tip is widely convex lower lateral cartilages that are thick and
relatively inflexible. The domal width is greater than 6 mm. The angle of divergence is
normal. Which of the following surgical maneuvers is most likely to correct the
deformity?
A ) Alar rim grafting
B ) Cephalic trimming of the lower lateral cartilage
C ) Crural spanning sutures
D ) Lateral crural strut grafting
E ) Subdomal spreader grafting
The correct response is Option D.
A bulbous/boxy tip can be caused by a convex lower lateral cartilage with a wide domal
width (less than 4 mm), widened angle of divergence (less than 30 degrees), or a
combination of both. This patient’s deformity is a widely convex lower lateral
cartilage. The best choice is a lateral crural strut graft. This graft is usually harvested from
the septum and sutured to the undersurface of the lower lateral cartilage. These grafts are
strong and can reshape a thick inflexible lower lateral cartilage. Crural spanning sutures can
straighten the convexity of these cartilages if the cartilages are flexible; however, in this
patient it would unlikely be successful.
Transgenu sutures are often needed to further refine the domal width; however, in very
boxy tips, a lateral crural strut graft would also be needed for a better result. Cephalic trim
of the lower lateral cartilage is often performed to narrow the cartilage. This maneuver
would not correct the deformity. When performing the cephalic trim, it is important to leave at least 6 mm of cartilage for support. An alar rim graft is a strip of cartilage places is a
subcutaneous pocket along the alar rim. This graft is placed caudal to the lower lateral
cartilage. It can strengthen a buckled rim but would not straighten a stiff convex lower
lateral. Subdomal spreader grafts are used to correct a pinched tip deformity.
A 52-year-old woman comes to the office after undergoing uncomplicated rhytidectomy
1 week ago. The patient reports that she cannot feel her left earlobe. Damage to a
sensory nerve is suspected. The affected nerve was most likely injured intraoperatively
in which of the following locations?
A ) Along a line from the external auditory canal to the lateral edge of the inferior orbit
B ) At the anterior border of the sternocleidomastoid muscle
C ) Half the distance from mastoid process to the clavicular origin of the
sternocleidomastoid muscle
D ) One centimeter caudal to the external jugular vein as it crosses the
sternocleidomastoid muscle
E ) One-third the distance from external auditory canal to the clavicular origin of the
sternocleidomastoid muscle
The correct response is Option E.
The great auricular nerve (GAN) is the most commonly injured nerve in rhytidectomy. The
GAN complication rate is approximately 6.5%. GAN injury can result in pure anesthesia,
partial parasthesia, as well as painful neuromas in the distribution of the nerve. Permanent
complete numbness has been reported in up to 5% of patients. This may cause
difficulty wearing earrings, using the telephone, shaving, or combing one’s hair. Although
not as catastrophic as a facial nerve injury, this complication can present as a functional
impairment and nuisance to the patient and surgeon alike.
It is critical to be aware of this nerve when embarking upon rhytidectomy in order to
prevent iatrogenic injury. Once the GAN emerges onto the anterior surface of the
sternocleidomastoid muscle, it resides in a superficial plane and is vulnerable to injury
during elevation of facial flaps. The GAN is found at its most superficial location
approximately one third the distance from the external auditory canal to the clavicular
origin of the sternocleidomastoid (SCM). A similar distance ratio exists from the mastoid
process to the clavicular origin of the SCM. It also lies approximately one centimeter
cranial to the external jugular vein on the anterior surface of the sternocleidomastoid
muscle. With these anatomical landmarks, the surgeon can accurately predict the location of
the GAN at its most vulnerable site and reliably proceed with flap dissection in the lateral
neck during rhytidectomy procedures.
2019
