Cosmetic

Question 1

This open roof nasal deformity is best corrected by:
(A) nasal septoplasty.
(B) shield graft placement.
(C) lateral nasal osteotomies.
(D) shaving upper lateral cartilages.

Answer 1

C

Question 2

Cephalic trimming of the lower lateral cartilages of the nose during rhinoplasty has which of the following effects on the nasal tip?
(A) Upward rotation
(B) Downward rotation
(C) Widening
(D) No effect

Answer 2

A

Question 3

Bilateral brisk bleeding 48 hours following septorhinoplasty is uncontrollable with anterior nasal packs. What is the next most appropriate step to control the bleeding?
(A) Attempt electrocautery for hemostatsis
(B) Schedule surgical exploration and vessel ligation
(C) Place anterior and posterior nasal packs
(D) Provide external nasal pressure and Afrin nasal spray

Answer 3

C

Question 4

hich of the following rhinoplasty procedures would lend itself to concomitant treatment with a Le Fort I advancement?
(A) Dorsal augmentation
(B) Nasal tip rotation
(C) Nasal tip narrowing
(D) Decreasing nasal projection

Answer 4

A

Question 5

he etiology of fullness in the lateral aspect of the upper eyelid is:
(A) orbital septum weakness and prolapse of the lacrimal gland. (B) orbicularis oculi laxity and herniation of temporal fat.
(C) disinersetion of the levator palpeprae aponeurosis.
(D) injury to CN III with Mueller’s muscle paresis.

Answer 5

A

Question 6

he most important factor determining the stability of counterclockwise occlusal plane rotations in bimaxillary orthognathic surgery is:
(A) preoperative removal of orthodontic compensations.
(B) favorable alteration of the posterior facial height.
(C) modest changes to the anterior facial height.
(D) minimizing muscle dissection in the mandible.

Answer 6

B

Question 7

Which of the following is true regarding the 2 layer SMAS (superficial musculoaponeurotic system) technique?
(A) Skoog popularized the procedure of undermining the superficial fascia and skin as a unit.
(B) The ability to adjust both vectors and the differential movement of skin and fat elevation
allows greater artistic precision.
(C) This procedure is synonymous with the composite procedure described by Hamra.
(D) This technique releases the superficial fascia from the retaining ligaments while retaining
its blood supply.

Answer 7

B

Question 8

Which of the following statements regarding the use of botulinum toxin for facial rejuvenation is true?
(A) The potency of Botox may be increased by aminoquinolones.
(B) The toxin crosses the blood-brain barrier.
(C) Following reconstitution, Botox must be used within 12 hours.
(D) The use of injected local anesthetic in conjunction with Botox injections is
contraindicated.

Answer 8

D

Question 9

Which of the following statements regarding the use of dermabrasion is correct?
(A) Dermabrasion is effective for the treatment of ice-pick scars.
(B) Scars that improve with manual stretching respond in greater than 50% of cases with a
single dermabrasion procedure.
(C) Repeat dermabrasion should ideally be done within the first 6 weeks following the
previous treatment.
(D) It is preferable to perform a rhytidectomy prior to a dermabrasion in a staged treatment
plan.

Answer 9

B

Question 10

This open roof nasal deformity is best corrected by:
(A) nasal septoplasty.
(B) shield graft placement.
(C) lateral nasal osteotomies.
(D) shaving upper lateral cartilages.

Answer 10

C

Question 11

Cephalic trimming of the lower lateral cartilages of the nose during rhinoplasty has which of the following effects on the nasal tip?
(A) Upward rotation
(B) Downward rotation
(C) Widening
(D) No effect

Answer 11

A

Question 12

Which of the following maneuvers is routinely performed in endoscopic brow lift surgery?
(A) Release of periosteum and depressor muscles
(B) Complete removal of glabellar motor innervation
(C) Sectioning of supraorbital and supratrochelar nerves
(D) Overcorrection of the medial brow contour

Answer 12

A

Question 13

Which muscle is primarily responsible for producing the transverse wrinkles over the bridge of the nose?
(A) Procerus muscle
(B) Corrugator supercilii
(C) Levator palpebre
(D) Zygomaticus major

Answer 13

A

Question 14

A facial skin chemical peel technique combining 30% trichloroacetic acid and Jessner’s solution is expected to penetrate to which level?
(A) Epidermis
(B) Papillary dermis
(C) Reticular dermis
(C) Subcutaneous tissue

Answer 14

C

Question 15

Regarding a medically compromised patient considering rhytidectomy, which of the following statements is true?
(A) Diabetics may undergo rhytidectomy, but broad spectrum antibiotics should be used to minimize the risk of infection.
(B) Medical history of chemotherapy for malignancy 1 year prior to surgery may compromise wound healing.
(C) Chronic use of corticosteroids does not compromise wound healing.
(D) A long history of cigarette smoking is an absolute contra-indication to elective cosmetic
surgery.

Answer 15

A

Question 16

Which of the following is true regarding the 2 layer SMAS (superficial musculoaponeurotic system) technique?
(A) Skoog popularized the procedure of undermining the superficial fascia and skin as a unit.
(B) The ability to adjust both vectors and the differential movement of skin and fat elevation
allows greater artistic precision.
(C) This procedure is synonymous with the composite procedure described by Hamra.
(D) This technique releases the superficial fascia from the retaining ligaments while retaining
its blood supply.

Answer 16

B

Question 17

Which of the following statements regarding the use of botulinum toxin for facial rejuvenation is true?
(A) The potency of Botox may be increased by aminoquinolones.
(B) The toxin crosses the blood-brain barrier.
(C) Following reconstitution, Botox must be used within 12 hours.
(D) The use of injected local anesthetic in conjunction with Botox injections is
contraindicated.

Answer 17

D

Question 18

Which of the following statements regarding the use of dermabrasion is correct?
(A) Dermabrasion is effective for the treatment of ice-pick scars.
(B) Scars that improve with manual stretching respond in greater than 50% of cases with a
single dermabrasion procedure.
(C) Repeat dermabrasion should ideally be done within the first 6 weeks following the
previous treatment.
(D) It is preferable to perform a rhytidectomy prior to a dermabrasion in a staged treatment
plan.

Answer 18

B

Question 19

The superior tarsal crease is important in upper lid blepharoplasty as it usually coincides with the:
A. Inferior aspect of the blepharoplasty skin incision
B. Superior aspect of the blepharoplasty skin incision
C. Fusion of tarsus to the skin
D. Fusion of the orbital septum to the skin

Answer 19

ANSWER: A
RATIONALE:
The inferior aspect of the blepharoplasty incision is placed at the superior eyelid crease. This eyelid crease is formed due to the fusion of the levator superioris with the orbicularis oculi and skin. Although, usually seen to be within 8-12 mm of the lid margin in Caucasians, the position varies with age and racial characteristics. The superior aspect of the skin incision is dictated by the amount of skin removal needed. The “pinch test” gives a good idea for placement of the superior incision. The orbicularis oculi is a sphincter-like muscle beneath the skin and it extends throughout the upper eyelid. Its position does not directly correlate with the upper eyelid skin fold/crease. The orbital septum lies beneath the orbicularis oculi and is an extension of the periosteum of the orbit. It fuses to the levator muscle and not directly to the skin.

Question 20

When planning blepharoplasty procedures, the surgeon must realize that the inferior oblique muscle lies between:
A. lacrimal gland and middle fat pad
B. middle and lateral fat pads
C. nasal and middle fat pads
D. nasal fat pad and medial canthus

Answer 20

ANSWER: C
RATIONALE:
The Lacrimal gland is found in the upper eyelid and not in the lower eyelid. The middle and lateral fat pads are close to each other and are not separated by a muscle. The inferior oblique muscle lies in between the nasal and middle fat pads and must be protected during fat excision in this area. It is especially prone to damage in transconjuctival lower eyelid blepharoplasty procedures. The inferior oblique muscle lies lateral to the middle fat pad and not medial to it.
REFERENCE:
Karesh JW: Blepharoplasty. Esthetic surgery of the aging face, Atlas of the Oral and Maxillofacial Surgery Clinics of North America. September 1998
Loeb R: Esthetic surgery of the eyelids. Springer-Verlag, New York. 1989

Question 21

The “nasal tripod” concept in rhinoplasty procedures refers to:
A. Upper lateral and lower lateral cartilages and nasal septum
B. Fusion of the upper lateral and lower lateral cartilages
C. Medial and lateral crura of the lower lateral cartilages
D. Nasal septum and medial crura of the lower lateral cartilages

Answer 21

ANSWER: C
RATIONALE:
The two upper lateral cartilages fuse with the nasal septum to form the
Internal nasal valve area. The lower lateral cartilages and septum provide support for the nasal tip. The upper and lower lateral cartilages do not directly fuse with each other. The close relationship through a fibrous attachment contributes to tip support and an intercartilagenous incision will interrupt this attachment. The medial crura are taken together to form one leg of the tripod and the lateral crurae form one leg each of the tripod. Changes in tip rotation and position may be visualized in terms of modification of this tripod during rhinoplasty. The nasal septum and medial crura are closely associated to form a primary tip support mechanism. Full transfixion incisions interrupt this attachment and may cause tip drooping.
REFERENCE:
Kennedy BD, Kinnebrew MC: Indications and Techniques for Rhinoplasty. In Peterson LJ (ed). Principles of Oral and Maxillofacial Surgery, JB Lippincott, Philadelphia

Question 22

Which of the following surgical incisions are made during external rhinoplasty procedures?
A. Marginal and transcollumellar incisions
B. Ttranscollumellar and intercartilagenous incisions
C. Intercartilagenous and transfixion incisions
D. Hemi-transfixion and marginal incisions

Answer 22

ANSWER: A
RATIONALE:
The marginal rim incision is made along the caudal margin of the lower lateral cartilage. The transcollumellar incision is a skin incision across the mid-columella. Bilateral marginal and the transcollumellar incisions help complete external skeletonization of the nasal skeleton. The intercartilagenous incision is used in endonasal rhinoplasty techniques. The blade passes deep to the lateral crura and superficial to the upper lateral cartilage. The transfixion incision is generally used in endonasal rhinoplasty procedures for exposure of caudal septum. A complete transfixion incision transects the attachment of both medical crura to the septum, and thus some loss of tip support results. The hemitransfixion incision is also used in endonasal rhinoplasty procedures for exposure of caudal septum. As it is only made on one side and usually stops short of the anterior nasal spine, it preserves some tip support as compared to a complete transfixion incision.
REFERENCE:
Zide MF: Applied surgical anatomy of the nose. In: Cosmetic Oral and Maxillofacial Surgery. Oral and Maxillofacial Surgery Clinic of North America, vol 2 (2), 1990
Kennedy BD, Kinnebrew MC: Indications and Techniques for Rhinoplasty. In Peterson LJ (ed). Principles of Oral and Maxillofacial Surgery, JB Lippincott, Philadelphia

Question 23

A medium depth chemical peel using 35 to 40% Tricholoracetic acid (TCA) is expected to penetrate:
A. epidermis and papillary dermis
B. epidermis, papillary dermis and upper reticular dermis
C. epidermis, papillary dermis, upper and mid-reticular dermis
D. epidermis, papillary dermis, upper, mid and lower reticular dermis

Answer 23

ANSWER: B
RATIONALE:
Chemical peels are classified according their depth of penetration into superficial, medium, and deep depth peels. Superficial peels penetrate into the epidermis and papillary dermis. Examples of superficial peel agents include TCA (up to 30%), Jessner’s solution, and Glycolic acid (10-30 %). Medium depth peels penetrate into epidermis, papillary dermis and upper reticular dermis. Examples of medium peel agents include TCA (35-50 %), phenol (88%), and Jessner’s solution plus TCA (35%). Deep depth peels penetrate into epidermis, papillary dermis, upper and mid reticular dermis. Examples of deep peel agents include Bakers phenol and Litton’s phenol. Extension of chemical peeling agents into the lower reticular dermis produces scarring and is not indicated.
REFERENCE:
Demas PN, Braun TW: Chemical skin resurfacing. In: James Hupp (ed). Esthetic surgery of the aging face, Atlas of the Oral and Maxillofacial Surgery Clinics of North America. 1998

Question 24

A 40 year-old female requesting cosmetic facial laser resurfacing is classified as a Fitzpatrick skin type II patient. She is likely to have which of the following characteristics:
A. Red hair, light skin, blue-green eyes, never tans
B. Black hair, dark skin, black eyes, easily tans
C. Brown-black hair, medium-dark skin, brown-black eyes, easily tans
D. Blond hair, light skin, blue eyes, tans with difficulty

Answer 24

ANSWER: D
RATIONALE:
Fitzpatrick type 1 patients give a history of always having a skin burn with sun exposure. Fitzpatrick type V patients give a history of very rarely burning on sun exposure. Fitzpatrick type IV patients rarely if ever, burn on sun exposure. Fitzpatrick type II patients give a history of usually burning on sun exposure. Fitzpatrick divided skin types into six categories based on the skin color and their reactivity to the sun exposure
Skin type I
II III IV V VI
REFERENCE:
skin color white white white brown
dark brown black
tanning response always burns never tans
usually burns, tans with difficulty sometimes mild burn, tan very easily. rarely burn, tan with ease
very rarely burn, tan very easily no burn, tan very easily
Guttenberg SA, emery RW: Aesthetic cutaneous laser surgery and chemical peels. In: Fonseca R, Baker S, Wolfor LM (eds). Oral and Maxillofacial Surgery, Vol 6, WB Saunders, Philadelphia, 2000
Brian Harsha: preoperative considerations for laser resurfacing, cosmetic facial surgery oral and maxillofacial surgery clinics of north America Nov 2000

Question 25

A 65 year old female with cervicofacial rhytidosis has completed a cervicofacial rhytidectomy within the past 15 hours. Her facial bandage is in place and she is having extreme pressure and pain under the bandage on the right side. The most likely cause of this pain is?
A. Cervical Nerve injury
B. Infection
C. Muscle Injury
D. Hematoma

Answer 25

ANSWER: D
RATIONALE:
A hematoma is the most common and significant cause of pain after a cervicofacial rhytidectomy. Most hematomas occur within 1 to 15 hours after surgery, but can occur up to 48 hours after the procedure. The incidence has been reported to be 10 to 15 % of all patients undergoing this procedure. Prevention with good surgical technique and hemostasis is important. Some surgeons place drains to assist with prevention of a hematoma. Infections following cervicofacial rhytidectomies are rare, and are usually occur 3 to 4 days out if they occur at all. Muscle injury while quite rare could cause pain in the neck region, however it is usually not associated with pressure sensations. Cervical nerves are less likely to be injured , but the great auricular nerve is the most commonly injured of the cervical chain with an incidence reported from 0.53% to 2.6%. Most nerve injuries during this procedure do not cause pain, but anesthesia.
REFERENCE:
Rees, TD, Aston, SJ, Thorne, CH. Postoperative Considerations and Complications. In Aesthetic Plastic Surgery. Rees TD and Latrenta, GS. Second Edition Vol II. W. B Saunders Company 1994.

Question 26

Botulinum Toxin A prevents wrinkles of the skin by what neuroactivity at the neuromuscular junction?
A. Blocks the release of acetylcholine
B. Blocks the release of norepinephrine
C. Prevents binding of acetylcholine
D. Prevents binding of norepinephrine

Answer 26

ANSWER: A
RATIONALE:
Botulinum Toxin A is being used frequently in cosmetic surgical practices to inhibit the function of the muscles of facial expression. Botulinum Toxin is an endotoxin produced by the bacterium Clostridium botulinum. Botulism (caused by consumption of C. botulinum- contaminated food) is not an infection per se but is a side affect caused by the ingestion of the endotoxins that are produced by this bacteria. This toxin can be lethal when consumed in excess dosages. The FDA has approved the use of a preparation of botulinum toxin Type A (Botox) for muscular disorders, but not for cosmetic use. The mechanism of action is that the Botox molecule binds to the neuromuscular endplate and blocks the release of acetylcholine. Botulinum toxin does not effect the binding of acetylcholine, and has no effect on norepinephrine release or binding.
REFERENCE:
Niamtu, J. The use of Botulinum Toxin in Cosmetic Facial Surgery. Oral and Maxillofacial Surgery Clinics of North America. Vol 12, No 4, 2000.

Question 27

What is the normal nasolabial angle in Caucasian females?
A. 60-74
B. 75-90
C. 95 to 110
D. 115-130

Answer 27

ANSWER: C
RATIONALE:
The nasolabial angle is the defining element of nasal tip elevation as the nose relates to the upper lip. The average Caucasian female nasolabial angle is 95-110.
REFERENCE:
Larrabee WF. Facial analysis for rhinoplasty. Otolaryngol Clin North Am 20:653-674, 1987. Willet JM: How to assess the nose for rhinoplasty. J Otolaryngol 25: 23-25, 1996.

Question 28

Four weeks following a malar augmentation utilizing a Silastic prosthesis the patient complains of severe pain and paresthesia in the infraorbital region on the right side only. What clinical decision protocol would be advised?
A. Place patient on narcotics for 4 weeks until the pain is controlled
B. Ignore the problem, this is common and should improve with time
C. Surgically explore the region and check the position of the implant
D. Place the patient on a muscle relaxant to relieve the pain

Answer 28

ANSWER: C
RATIONALE:
Malar augmentation with an alloplastic implant is generally a mildly painful procedure. The infraorbital nerve is in close proximity of the malar implant position, and could cause pressure on the nerve if malpositioned. Ignoring the problem long term could cause permanent paraesthesia. During surgical placement is important to place the implant in a pocket that is free from interference with the infraorbital nerve. Placing a patient on narcotics will assist with pain management, but will not eliminate the source of the problem. Ignoring ongoing pain for a prolonged period may create a chronic pain state, and the source of the pain may not improve. Early impingement management is important to avoid permanent nerve damage. Muscle relaxants will not improve nerve damage pain.
REFERENCE:
LaTrenta, GS. Facial Contouring. Ch 32 in Aesthetic Facial Surgery. Rees RD, and Latrenta, GS. Second Edition vol. II, WB Saunders Company, 1994.

Question 29

Following upper lid blepharoplasty, the most common cause of post-operative lagophthalmus of the upper eye lid is due to:
A. wound dehiscence.
B. debulking of orbicularis muscle. C. excessive amount of skin removal. D. pre-op ptosis condition.

Answer 29

ANSWER: C
RATIONALE:
Excess skin removal can lead to lagopthalmus. Assessment of visual status, including acuity and EOM, lacrimation, and pain is necessary. Management is directed by degree of lagopthalmus. Mild conditions may be managed by massage, time and proper ocular lubricants while the tightness may relax avoiding further surgery. If the corneal surface is compromised, a skin graft may be necessary. The posterior auricular area is usually best match for color and skin thickness. Ptosis is a frequent complication with this repair. Wound dehiscence usually leads to aesthetic compromise. Debulking of the orbicularis is to excessive skin removal, and minimizes the occurences of lagopthalmus. Pre-op ptosis would be addressed in your surgical treatment plan, and combine a Muller- conjuctival resection or levator aponeurosis procedure combined with blepharoplasty.
REFERENCE:
Putterman: Cosmetic Oculoplastic Surgery, 3rd edition,

Question 30

A peri-operative open roof deformity created during a rhinoplasty to remove a bony or cartilaginous hump is most commonly corrected with?
A. Onlay bone graft.
B. Septoplasty.
C. Suturing of the upper lateral cartilage.
D. Lateral nasal osteotomies.

Answer 30

ANSWER: D
RATIONALE:
Lateral nasal osteotomies are necessary events in rhinoplasty surgery to symmetrically narrow the lateral nasal sidewalls medially and create a more natural appearance. Onlay cartilage and bone grafts can be a treatment option during revision rhinoplasty to correct an open roof deformity, with soft tissue prolapse. Lateral osteotomies are performed after the dorsal reduction to give a stable bony platform to safely remove a nasal hump. Performing the lateral nasal osteotomies last in the surgical sequence, immediately preceeding the application of pressure splints, diminishes inta-operative swelling, oozing, post-operative swelling and ecchymosis.
REFERENCE:
Tardy: Rhinoplasty The Art and the Science, Volume 1

Question 31

Defects in the upper and lower lip that are greater than 1/3 but less than 2/3 of the length of the lip are best treated by which flap?
A. Gillies FAN Flap.
B. Abbe’ Flap.
C. V-Y Advancement Flap.
D. Nasolabial flap.

Answer 31

ANSWER: B
RATIONALE:
The Abbe’ flap is an excellent choice. This is a well vascularized flap based on the labial vessels. It allows reconstruction of the defect with lip tissue from the opposing lip. Disadvantages of this flap are that it is 2-stage repair and may cause relative microstomia. The flap does not provide a sensate reconstruction. The Gillies FAN flap is designed for defects greater than 75% of the upper or lower lip. Sensate reconstruction is achieved. The Abbe flap is not indicated in defects greater than 2/3 of the upper and lower lip. V-Y advancement flap is used to bring oral cavity mucosa to the vermillion. Close proximity of the donor site to the recipient site is needed. The nasolabial flap is indicated for the upper lip only.
REFERENCE:
Facial Plastic Surgery Clinics of North America, Nov 1996

Question 32

In performing facial scar revisions or new facial incisions, knowledge of resting skin tension lines (RSTLs) is relevant in aesthetic scar outcomes because?
A. Facial nerves run parallel to RSTLs.
B. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision parallels RSTLs.
C. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision runs perpendicular to RSTLs.
D. RSTLs have minimal effects on scar developments.

Answer 32

ANSWER: B
RATIONALE:
The facial nerve and its brances run both parallel and perpendicular to RSTLs.
Scar revisions or planned scars should be oriented with respect to RSTLs. These well documented, natural tissue planes display the least amount of tension and are ideal for scar placement. RSTLs very often correspond to nature’s wrinkles, running perpendicular to underlying muscle movement.
REFERENCE:
Scar Revison,Dermatologic Clinics,vol.16, January 1998

Question 33

The neurosensory innervation and vascular supply to the nose are derived from?
A. maxillary division of trigeminal nerve, internal and external carotid system
B. opthalmic division of trigeminal nerve, internal and external carotid system
C. maxillary and opthalmic division of trigeminal nerve, internal and external carotid system
D. maxillary and opthalmic division of trigeminal nerve, internal carotid only.

Answer 33

ANSWER: C
RATIONALE:
Virtually all of the sensory innervation to the nasal area is derived from either the opthalmic (V1) or maxillary (V2) division of the trigeminal nerve. The nose is highly vascular, possesing arterial contributions from both the internal and external carotid system. The outer nose and anterior septum are supplied from the external carotid system via the facial artery and its branches. The superior septum and orbital area are supplied through the internal carotid system via the ethmoidal branches of the opthalmic artery.
REFERENCE:
Rhinoplasty: The Art and the Science, Volume 1, Tardy

Question 34

When considering blepharoplasty, brow lift, or botox injections, the major muscles of the forehead and eyebrow which must be considered include:
A. procerus, corrugator supercillii, occipitofrontalis and orbicularis oculi
B. temporalis, occipitofrontalis, and corrugator supercillii
C. procerus, corrugator supercillii, and temporalis.
D. temporalis, corrugator supercillii, occipitofrontalis and orbicularis oculi

Answer 34

ANSWER: A
RATIONALE:
The occipitofrontalis allows the scalp to move anteriorly and posteriorly, elevating the eyebrows. The orbicularis oculi close the eyelid, in doing so it also pulls down the skin of the forehead, temple and cheek. The corrugator lowers and moves the brows medially, producing vertical wrinkles of the forehead. The procerus lowers the medial brow and produces horizontal wrinkles over the nose. In the forehead region, all muscles are innervated by the temporal branch of the facial nerve, except for the procerus, which is innervated by the buccal branch of the facial nerve.
REFERENCE:
Pre-operative evaluation of the blepharoplasty patient, Clinic. Plast. Surgery 1993

Question 35

Botulinum toxin A, when used for cosmetic purposes, can be expected to last:
A. permanently
B. 1-2 months
C. 4-6 months
D. 8-10 months

Answer 35

ANSWER: C
RATIONALE:
The effects of botulinum toxin are temporary, typically lasting for four to six months depending on the muscle injected and the amount of toxin used. Studies submitted to the FDA by the manufacturer report an average of four months therapeutic effect for cosmetic indications
REFERENCE:
Package Insert, Botox Cosmetic. Allergan, Inc. 2001
Coffield, JA, et al. The site and mechanism of action of botulinum neurotoxin. In: Jankovic, J, ed. Therapy With Botulinum Toxin. New York, NY: Marcel Decker; 1994:3-15.

Question 36

The generally accepted initial total dose for treatment of glabellar lines with botulinum type A toxin is:
A. 4 units
B. 20 units
C. 50 units
D. 100 units

Answer 36

ANSWER: B
RATIONALE:
For initial treatment of glabellar lines, the starting dose is recommended to be 20 units divided into five injection sites of 4 units each: two sites in each corrugator muscle and one site in the procerus muscle
REFERENCE:
FDA Study for the Approval of Botox Cosmetic (botulinum toxin type A) for the Treatment of Glabellar Lines. Allergan, Inc. 2000.
Niamtu, Joseph III. The Use of Botulinum Toxin in Cosmetic Facial Surgery. In: Oral and Maxillofacial Surgery Clinics of North America. November, 2000. Vol. 12 No. 4 pp 595-612.

Question 37

The most common complication that occurs when injecting botulinum toxin type A in the periocular region is:
A. blepharoptosis
B. ophthalmoplegia
C. Horner’s syndrome
D. loss of lateral gaze

Answer 37

ANSWER: A
RATIONALE:
The most common complication of injecting botulinum toxin type in the periocular region is blepharoptosis, due to diffusion of the toxin into the levator palpebrae superioris muscle. This can be minimized by injecting at least one cm above the bony supraorbital rim.
REFERENCE:
Package Insert, Complications/Untoward Events, Botox Cosmetic, Allergan, Inc. 2001. Niamtu, Joseph III. The Use of Botulinum Toxin in Cosmetic Facial Surgery. In: Oral and Maxillofacial Surgery Clinics of North America. November, 2000. Vol. 12 No. 4 pp 595-612.

Question 38

ommon medications prescribed preoperatively for facial skin resurfacing include all of the following except:
A. oral steroid
B. anti-viral agent
C. tretinoin cream
D. oral antibiotic

Answer 38

ANSWER: A
RATIONALE:
The use of antibiotics and antiviral agents pre and post-operatively has been well established as protocol in skin resurfacing to prevent bacterial infection and post surgical herpetic outbreaks. Tretinoin cream allows for removal of superficial cells to enhance the penetration of the CO2 laser. Steroids are contraindicated.
REFERENCE:
Harsha, BC. Preoperative Considerations for Laser Skin Resurfacing. Oral and Maxillofacial Surgical Clinics of North America. Vol. 12 No. 4. November 2000. pp. 555-565.

Question 39

In cosmetic blepharoplasty of the upper eyelid, the following tissue layer is not routinely incised, reduced or recontoured:
A. Eyelid skin
B. Orbicularis oculi muscle
C. Orbital septum
D. Mueller’s Muscle

Answer 39

ANSWER: D
RATIONALE:
In routine cosmetic upper eyelid blepharoplasty, excess skin, muscle and fat are removed. The fat is retroseptal, lying immediately beneath the orbital septum. The levator aponeurosis is the next visible layer and deep to that lies Mueller’s muscle which is assists with upper eyelid elevation. This muscle is not incised or recountoured in routine bepharoplasty of the upper eyelid.
REFERENCE:
E. Niamtu, J Cosmetic Facial Surgery
Oral and Maxillofacial Surgery Clinics of North America Volume 12, number 4, November, 2000 W.B. Saunders, Philadelphia Pages 673-76

Question 40

In submental liposuction, problems with skin dimpling, waviness, and depressions can be prevented with the following:
A. leaving an adequate layer of subcutaneous fat
B. allowing the skin to adhere to platysma
C. removing all subcutaneous fat
D. keeping the plane of fat removal deep to the platysma layer

Answer 40

ANSWER: A
RATIONALE:
A layer of subcutaneous fat is necessary to prevent adherence of the skin to the mylohyoid and the platysma muscles. Waviness and dimpling can occur if fat removal is uneven or when areas of skin are devoid of subcutaneous fat. Keeping the fat removal deep to the platysma layer will lead to minimal esthetic improvement and the possibility of facial nerve injury.
REFERENCE:
Kennedy,B. Suction Lipectomy of the Youthful Neck. Cosmetic Oral and Maxillofacial Surgery. Oral and maxillofacial Surgery Clinics of North America - Vol 2, No. 2, May 1990.

Question 41

A 40 year old woman consults with you regarding her microgenia. Her occlusion was corrected years ago with orthodontics, and she suffers from mild obstructive sleep apnea. Her condition would best be corrected with:
A. an alloplastic chin augmentation
B. an autogenous bone graft to the chin
C. a mandibular sagittal split osteotomy
D. an advancement genioplasty

Answer 41

ANSWER: D
RATIONALE:
Advancement of the genial tubercles and genioglossus muscle will help this patients cosmesis, and positively influence her obstructive sleep apnea. A sagittal split osteotomy alone will create a malocclusion. Neither a chin implant nor an onlay bone graft to the chin will advance her genial tubercles or suprahyoid musculature.
REFERENCE:
Lee, NR. Genioplasty Techniques. Cosmetic Facial Surgery. Oral and Maxillofacial Surgery Clinics of North America. Volume 12, Number 4, November,2000.

Question 42

Which agent is best used to treat hyperpigmentation following skin resurfacing?
A. Glycolic acid
B. Phenol
C. Hydroquinone
D. Isotretinoin

Answer 42

ANSWER: C
RATIONALE:
Hydroquinone inhibits melanin formation and increases melanocyte degradation. This causes a reversible hypopigmentation and melanocyte inhibition. Glycolic acid, phenol, and isotretinoin are all skin resurfacing agents and are not used for the treatment of hyperpigmentation.
REFERENCE:
Demas, Bridenstine, and Braun. Pharmacology of Agents Used in the Management of Patients Having Skin Resurfacing. J Oral Maxillofac Surg. 55:1255-1258, 1997.

Question 43

The most common complication following otoplasty is:
A. infection
B. perichondritis
C. hematoma formation
D. hypertrophic scar formation

Answer 43

ANSWER: C
RATIONALE:
Hematoma formation is generally seen in the retroauricular space. It is treated by evacuation and pressure dressings, while antibiotics should be considered.
REFERENCE:
DUDLEY, WH, et al. Otoplasty for Correction of the Prominent Ear. J Oral Maxillofac Surg. 53:1386-1391, 1995.

Question 44

Which of the following statements regarding esthetic evaluation of the midface is true?:
A. The zygomatic prominence should be located 2 cm inferior and 1.5 to 2 cm lateral to the lateral canthus of the eye.
B. The infraorbital rim should be 0 to 2 mm behind the cornea
C. Greater than 3-4 mm of sclera should be exposed inferiorly between the limbus and the
lower eyelid.
D. The zygomatic prominence should be located several mm superior to the Frankfort
horizontal plane.

Answer 44

ANSWER: A
RATIONALE:
The midface region is best evaluated in four basic views - frontal in repose and smiling, profile, three-quarter oblique, and basal. The zygomatic prominence is located 2 cm inferior and 1.5-2 cm lateral to the lateral canthus, and below the Frankfort Horizontal plane. The infraorbital rim should be 0-2 mm anterior to the cornea. Normal scleral show is less than 4 mm.
REFERENCE:
Zide and Epker. Systematic Aesthetic Evaluation of the the Cheeks for Cosmetic Surgery. Cosmetic Oral and Maxillofacial Surgery, Oral and Maxillofacial Surg

Question 45

When narrowing the nose at the end of a rhinoplasty procedure, the lateral nasal bone osteotomies are made superiorly to which soft tissue landmark?
A. Nasion
B. Radix
C. Medial canthus
D. Superior septal angle

Answer 45

ANSWER: C
RATIONALE:
The glabella and radix of the nose are incorrect and will result in carrying the osteotomy too far superiorly into thick bone, preventing infracturing and causing a surperior hinging. The correct answer is to carry the lateral ostetomies superiorally to the level of the medial canthus which corresponds to thinner bone allowing for backfracture of the nasal bones. The superior septal angle is a nonsensical distractor in this question.
REFERENCE:
Oral and Maxillofacial Surgery Updates, Vol 1(Part II) pp25-45, 1995.

Question 46

When performing lower lid blepharoplasty, how many fat pads are normally excised or reduced?
A. one
B. two
C. three
D. four

Answer 46

ANSWER: C
RATIONALE:
Lower lid blepharoplasty normally involves removal of fat from all three fat compartments. In the upper lid, there are two fat compartments and the lacrimal gland is located superior and lateral. Failure to identify and remove fat from all three fat pads in lower lid surgery can result in insufficient fat removal and/or asymmetry. Of course, exceptions exist and fat removal should be guided by clinical judgement. Care must be taken to identify and avoid injury to the inferior oblique muscle.
REFERENCE:
Langdon J D, Patel M F. Operative Maxillofacial Surgery. Chapman and Hall 1998: pp. 493- 498.

Question 47

When performing carbon dioxide laser skin resurfacing, the deep landmark of the ablation is the:
A. basement membrane
B. epidermis
C. papillary dermis
D. reticular dermis

Answer 47

ANSWER: D
RATIONALE:
Each patient is unique and requires tailoring of technique to adapt to individual skin morphology. However, the anatomic depth of laser resurfacing is the reticular dermis. If this anatomic plane is not known or recognized, significant complications may result. This is determined by a chamois (light tan) color occuring in the resurfaced area during the second pass with the carbon dioxide laser.
REFERENCE:
Oral and Maxillofacial Surgery, Vol VI. Fonseca. pp 408-455.2000.

Question 48

Which of the following periorbital tissues represent an extension of the periosteum?
A. Tarsal plate
B. Whitnall’s Tubercle
C. Orbital septum
D. Lockwoods ligament

Answer 48

ANSWER: C
RATIONALE:
The orbital septum is a direct extension from the periosteum of the orbit and separates the preseptal and postseptal orbital components. Whitnall’s tubercle is a slightly raised prominence in the lateral orbital rim on the zygoma which serves as an attachment for the lateral canthal ligament. The tarsal plates are comprised of dense connective tissue and are located in both the upper and lower eyelids. The tarsal plates help form and support the shape of the eyelids. Lockwood’s ligament is a fascial suspensory ligament which helps maintain the vertical position of the globe within the orbit.
REFERENCE:
Cook BE, Lemke BN: Cosmetic Blepharoplasty. Oral and Maxillofacial Surgery Clinics of North America. pp. 673-684, November, 2000

Question 49

In a standard facelift operation, which of the deeper tissues is commonly altered?
A. Parotidomasseteric fascia
B. Dermis
C. Erb’s point
D. Superficial musculoaponeurotic system

Answer 49

ANSWER: D
RATIONALE:
The SMAS is the anatomic plane for a standard facelift procedure and lies superficial to the major nerves and blood vessels, but deep to the subdermal plexus. It is normally imbricated or excised and repositioned during a face-lift surgery. Incisions are normally made through the dermis but the dermal layer itself is not altered during surgery. The parotidomasseteric fascisa covers the lateral masseter muscle and splits to envelop the parotid gland, but is not altered in a
standard facelift operation. Erb’s point in located on the side of the neck in the area of the 5th and 6th cervical nerves.
REFERENCE:
Facelift: Facial Plastic Surgery Clinics of North America. William H. Beeson, ed., Nov., 1993.

Question 50

Retrobulbar hematoma occurring after cosmetic blepharoplasty is best treated by:
A. warm compresses
B. atropine drops
C. emergent evacuation
D. intravenous antihypertensive medication

Answer 50

ANSWER: C
RATIONALE:
Retrobulbar hematoma is reported to occur in 0.04% of all blepharoplasty procedures. Blindness can result from a retrobulbar hematoma and immediate evacuation for decompression is the treatment of choice.
REFERENCE:
Cook BE, Lemke BN: Cosmetic blepharoplasty. Oral and Maxillofacial Surgery Clinics of North America, pp 684-686, Nov. 2000.

Question 51

Intradomal sutures are placed during rhinoplasty to:
A. narrow the alar bases
B. maintain the position of the upper lateral cartilages
C. narrow and/or elevate the nasal tip
D. close an open-roof deformity

Answer 51

ANSWER: C
RATIONALE:
The nasal tip or intradomal region is located at the junction of the medial and lateral crura. Intradomal sutures can control and position the nasal tip. The nasal cinch suture or alar reduction can narrow the alar base width. Lateral osteotomies are used to close an open-roof deformity. Suturing can be used to maintain upper lateral cartilage position in some cases.
REFERENCE:
Johnson CM, Toriumi DM: Open structure Rhinoplasty. WB Saunders, Philadelphia, 1990. Abubaker AO, Benson KJ: Oral and Maxillofacial Surgery Secrets. Hanley&Belphus, Inc., Philadelphia, 2001.

Question 52

The internal nasal valve is formed by the junction of which structures:
A. junction of the lower and the upper lateral cartilage
B. junction of the nasal bones with the nasal septum
C. junction of the upper lateral cartilage and nasal septum
D. junction of the lower lateral cartilage with the medial crura

Answer 52

ANSWER: C
RATIONALE:
The medial part of the upper lateral cartilage joins the quadrangular cartilage. The angle formed by the attachment should be around 10-15 degrees. The nasal valve angle should be accessed preoperatively and angle less than 10 should be corrected intraoperatively. The junction of the upper and the lower lateral cartilages is called the scroll area and is the site of the intracartilaginous incision. The junction of the lower lateral cartilage and the medial crura provides the tip support (tripod theory).
REFERENCE:
Mitchell Collins rhinoplasty page 1-14 Atlas of oral and maxillofacial surgery sept 95

Question 53

All of the following are primary nasal tip support mechanism except:
A. Shape, angulation, size, and springiness of the lower lateral cartilage
B. Attachment of the medial crura to the inferior cartilage septum
C. Attachment of the lower aspect of the upper lateral cartilage to the superior part of the
lower lateral cartilage
D. Junction of the upper lateral cartilage with the nasal septum

Answer 53

ANSWER: D
RATIONALE:
The nasal tip support mechanisms are divided into primary and secondary mechanisms which are choices A, B, C The six secondary tip support mechanisms include: 1- interdomal ligament. 2-strut effect of nasal cartilaginous septum. 3-prominence of the anterior nasal spine. 4-thickness of the skin. 5-membranous nasal septum. 6-fibrous and cartilaginous elements attaching lower lateral cartilage to the pyriform rim.
REFERENCE:
Robert Alexander 15-25 Atlas of oral and maxillofacial surgery Sept 95.

Question 54

All of the following solutions are used for superficial chemical peel except:
A. 10-30% trichloracetic acid TCA.
B. Baker’s phenol solution.
C. glycolic acid 10-30%.
D. Jessner solution.

Answer 54

ANSWER: B
RATIONALE:
Chemical peels are classified as superficial, medium depth and deep depth peels depending on the degree of penetration into the epidermis. The superficial peel penetrates into the stratum basale or papillary dermis and the solutions used are TCA 10-30%, Jessner solution and alpha-hydroxy acid. Medium depth peels penetrates into the upper reticular dermis and the solutions used are TCA 35-50% and Jessner plus TCA 35%, or phenol 88%. The deep depth peel penetrates into the mid reticular dermis and the solutions used are the Baker’s phenol and the Litton’s formulation.
REFERENCE:
Chemical skin resurfacing, Peter N Demas, and Thomas W Braun1-25 atlas of oral and maxillofacial surgery Sept 98

Question 55

To identify the probability of ectropion following lower lid blepharoplasty which of the following test is performed?
A. Schrimer’s
B. snap
C. Cottle
D. confrontation

Answer 55

ANSWER: B
RATIONALE:
Schrimer’s test is used to determine the risk of the patient to develop a dry eye problems following blephroplasty by measuring tear production. The snap test is used to evaluate lower eyelid laxity. The lower eyelid is grasped and pulled gently forward and then quickly released the normal eyelid should snap immediately backward. If there is a delay of few seconds or the lid remains off the globe, then the risk of ectropin is high and a lid shortening procedure should be considered. Cottle’s test is used to evaluate the internal nasal valve function. Confrontation is a clinical method to evaluate visual fields.
REFERENCE:
James W karesh: blephroplasty. Atlas of oral and maxillofacial surgery clinics Sept 98 81-109 Mitchell Collins rhinoplasty page 1-14 Atlas of oral and maxillofacial surgery sept 95

Question 56

Which of the following materials will provide the most permanent result for lip and soft tissue augmentation:
A. Alloderm
B. Collagen
C. Autologous fat
D. Expanded poly tetra flouraline (PTFE)

Answer 56

ANSWER: D
RATIONALE:
Both fat and alloderm will give an intermediate-term result for 6-18 months. Collagen will give a short-term result of 6 months. PTFE, being non-resorbable, will give a more permanent result.
REFERENCE:
Ramirez A, et al current concepts in soft tissue augmentation. Facial plastics clinics of north America may 2000. page 235-251

Question 57

A patient with actinic keratoses and wrinkling present at rest is a Glogau’s classification:
A. Class I.
B. Class II.
C. Class III.
D. Class IV.

Answer 57

ANSWER: C
RATIONALE:
Photoaging groups- Glogau’s classification is divided into four groups: Group I- mild (usually age 28-35)
No keratoses, little wrinkling, no scarring, little or no makeup Group II- moderate ( usually age 35-50)
Early actinic keratoses, early wrinkling, mild scarring, little makeup Group III- advanced (usually age 50-65)
Actinic keratoses, wrinkling present at rest, moderate acne scarring, wears makeup always
Group IV- severe ( usually 65-75)
Actinic keratoses and skin cancer has occurred, wrinkling severe, severe acne scarring, wears makeup that does not cover but cakes on
REFERENCE:
Glogau RG: Chemical peel symposium American academy of dermatology
European Journal of Dermatology. Vol. 11, Issue 2, March - April 2001: 168-9, Meeting report

Question 58

The use of a spreader graft in rhinoplasty :
A. increases alar base width
B. has no effect on the internal nasal valve
C. increases the internal nasal valve patency
D. decreases the internal nasal valve patency

Answer 58

ANSWER: C
RATIONALE:
The use of the spreader graft allows an increase in patency of the internal nasal valves, thereby improving breathing. It also improves nasal esthetics in many cases.
REFERENCE:
Rohrich R, et al. use of spreader grafts in external approach to rhinoplasty. Clinics In plastic surgery 1996. page 255-262

Question 59

During facelifting surgery, Erbs point is located:
A. 4 cm inferior to the ear lobule and along the anterior sternomastoid border
B. 4 cm inferior to the ear lobule and along the posterior sternomastoid border
C. 6 cm inferior to the ear lobule and along the posterior sternomastoid border
D. 6 cm inferior to the ear lobule and along the anterior sternomastoid border

Answer 59

ANSWER: C
RATIONALE:
The greater auricular nerve and accessory nerves must be protected during rhytidectomy. Extra caution should be exercised when performing dissection in Erb’s point area. Remaining superficial to the fascia over the sternomastoid at Erb’s point ensures that injury to the greater auricular and accessory nerve is avoided
REFERENCE:
Bernstein G: Surface landmarks for the identification of key anatomic structures of the face and neck J Dermatol Surg Oncol 1986: 12, 722.

Question 60

Narrowing of the nasal tip during rhinoplasty is best achieved by:
A. Removal of a strip from the nasal septum
B. Osteotomies of the nasal bones and removal of a bony strip
C. Interdomal suturing
D. Removal of a strip from the upper lateral cartilages

Answer 60

ANSWER: C
RATIONALE:
Narrowing of the nasal tip can be achieved by removal of a cephalic 2-5 mm strip from the lower lateral cartilages and/or with interdomal suturing. The procedures often result in upward rotation of the tip. A shield graft can be placed from any removed septum to further define the tip. Narrowing of the nasal septum, excisiong upper lateral cartilage and nasal bone osteotomies will have no significant affect on the nasal tip width.
REFERENCE:
Kennedy BD: Cosmetic rhinoplasty. In, Oral and Maxillofacial Surgery, Volume 6. Fonseca R, Baker, Wolford LM (eds). WB Saunders, Philadelphia. 2000. pp 303-349