Cosmetic Chemical Peel/Skin, Fillers 01-22, 24 Flashcards
A 45-year-old woman underwent nonsurgical facial rejuvenation 2 days ago. The procedure included injection of neuromodulators into the forehead and glabella and hyaluronic acid into the tear troughs, nose, cheeks, and lips. The patient reports worsening pain, and discoloration of the nasal tip is noted. Which of the following is the most appropriate next step in management of this complication?
A) Antibiotic therapy
B) Aspirin therapy
C) Hyaluronidase injection
D) Hyperbaric oxygen therapy
E) Warm compress application

The correct response is Option C.
This patient has pustulation, erythema, and pain, which indicate intravascular injection and tissue ischemia. Complications with hyaluronic acid are categorized as early (<14 days), late (14 days to 1 year), or delayed (>1 year). Early but rare complications are frequently due to either infection (bacterial or viral) or the much-feared tissue necrosis/embolism. Avoiding these complications with careful technique and knowledge of anatomy is paramount, but understanding proper management of complications is also critical. This patient has signs of tissue necrosis, and the most critical intervention is to inject hyaluronidase (HYAL), an enzyme that catalyzes hyaluronic acid hydrolysis. Hyaluronidase should be injected immediately and liberally and titrated for effect to reverse signs and symptoms such as pallor, livedo reticularis pattern, erythema, and pain. Consider repeating daily as needed. There is no need to attempt to cannulate the vasculature since hyaluronidase will diffuse into the tissue. This product should be readily available to any clinician using hyaluronic acid fillers. Allergic reactions to hyaluronidase can also be noted (especially in patients with history of insect venom allergy).
Warm compresses, aspirin, and hyperbaric oxygen have all been advocated as adjunct measures when there is suspicion of vascular compromise to soft tissue. They are supplemental but not the primary treatment of choice. There are no clinical studies to support hyperbaric oxygen, but animal models suggest it is useful for ischemic injuries.
Empiric antibiotics are appropriate for early acute infection especially if there is obvious abscess or nonfluctuant cellulitis. However, the pustules and erythema in this patient are due to intravascular injection. Antibiotics may be added but should not be the primary or sole treatment plan.
A 52-year-old woman presents with deepening of the nasolabial and nasojugal folds along with loss of volume of the midface. She is interested in facial fillers to enhance volume in these areas. A hyaluronic acid filler with a higher elastic modulus (G’) value is most appropriate for this patient because which of the following is increased?
A) Injection viscosity
B) Longevity value
C) Product stiffness
D) Swelling factor
E) Tissue dispersion
The correct response is Option C.
G’ (elastic modulus) represents the ability of a hyaluronic acid filler to resist forces of deformation and return to its original shape. The higher the G’ value, the stiffer the product and the greater the tissue support that the product is intended to provide. A gel’s ability to expand as it binds water is its swelling factor and is a measure of its hydration.
Swelling factor is usually inversely related to G’, so swelling factor is incorrect. Tissue dispersion is incorrect since a more elastic or stiffer gel (higher G’) will be less likely to spread throughout the tissue when injected. Viscosity, or viscous modulus (G’’), is a measure of a gel’s ability to dissipate energy when shear force is applied to it. Neither viscosity nor longevity are represented as G’, thus making these choices also incorrect.
A 28-year-old woman comes to see the plastic surgeon because she is unhappy about her “square jaw” and desires a softer shape for her face without surgical intervention. Treatment of her masseter hypertrophy with botulinum toxin was recommended. The patient should be informed that the most likely effect from repeated injections is which of the following?
A) She can be assured that the use of botulinum toxin injection for masseter hypertrophy is within FDA guidelines
B) She should take NSAIDs in anticipation of headaches after botulinum toxin injection
C) She will not have any functional issues with eating and chewing after botulinum toxin injection
D) The volume and bulk of the masseter muscle will be significantly decreased with botulinum toxin injections
The correct response is Option D.
A recent study (Shome et al.) demonstrated that after a series of botulinum toxin injections, masseter volume reduction lasted up to 4 years. Therefore, this treatment does not only have short-term effects.
In a review (Peng et al.), 30% of patients reported temporary decrease in mastication force after botulinum injection. Headaches are infrequently reported and happen immediately after injection; they resolve after 2 to 4 days. When patients’ masseter volumes were measured before and after treatment, there was significant reduction in masseter volume (Chang et al.).
Currently, botulinum toxin injection is an off-label use in treatment of masseter hypertrophy.
A 43-year-old man presents to the office after being treated with botulinum toxin type A for concerning horizontal rhytids in the forehead 3 weeks ago. The patient reports that he is dissatisfied with the results and can barely open his eyes. Physical examination shows ptosis of the left upper eyelid. Apraclonidine 0.5% eye drops are prescribed and the patient reports temporary improvement. Which of the following muscles is most likely the target of the eye drops and involved in the improvement of this patient’s condition?
A) Corrugator supercilia
B) Frontalis
C) Levator palpebrae superioris
D) Orbicularis oculi
E) Superior tarsal (Müller) muscle
The correct answer is E.
The superior tarsal muscle is a smooth muscle and also known as Müller’s muscle. An adverse effect of the injection of botulinum toxin type A into the upper third of the face is ptosis, or lid droop, and can occur up to 2 weeks after injections. Ptosis results from migration of the botulinum toxin type A to the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully. To avoid ptosis, injections should occur at least 1 cm above the eyebrow.
The superior tarsal muscle originates on the underside of the levator palpebrae superioris and inserts on the superior tarsal plate of the eyelid. The superior tarsal muscle receives its innervation from the sympathetic nervous system. Post-ganglionic sympathetic fibers originate in the superior cervical ganglion, and travel via the internal carotid plexus, where small branches communicate with the oculomotor nerve as it passes through the cavernous sinus. The sympathetic fibers continue to the superior division of the oculomotor nerve, where they enter the superior tarsal muscle on its inferior aspect. The superior tarsal muscle works to keep the upper eyelid raised after the levator palpebrae superioris has raised the upper eyelid. Apraclonidine is an ?2-adrenergic agonist, which causes Müller muscles to contract, quickly elevating the upper eyelid 1 to 3 mm.
In this situation, the frontalis muscle was the target of the botulinum toxin to temporarily alleviate cosmetic concerns of horizontal rhytids in the forehead. The patient was injected too close to the brow likely in an attempt to treat all forehead lines. Eyedrops would not help the frontalis muscle contract and elevate the brow. The levator palpebrae superioris is the primary elevator of the upper eyelid. Ptosis results from migration of the botulinum toxin to the levator palpebrae superioris muscle. This skeletal muscle is innervated by the oculomotor nerve (cranial nerve III) and not susceptible to activation by an alpha adrenergic agonist. The orbicularis oculi muscles is facial muscle responsible for closing the eye. The corrugator supercilii is a small, narrow, pyramidal muscle located at the medial end of the eyebrow, beneath the frontalis and just above the orbicularis oculi muscle. This muscle draws the eyebrow downward and medially, producing the vertical wrinkles of the forehead. This muscle when activated would not elevate the upper eyelid.
References
A 67-year-old woman presents for consultation to address deep facial rhytides and dyschromias. Medical history includes Fitzpatrick Type II. A chemical peel is planned. For which of the following chemical peeling agents is cardiac monitoring recommended?
A) Glycolic acid
B) Phenol
C) Resorcinol
D) Salicylic acid
E) Trichloroacetic acid
The correct response is Option B.
Phenol is absorbed through the skin and into the bloodstream. Most is excreted through the urine. Cardiac dysrhythmias are associated with phenol peels. There are no reported deaths related to phenol toxicity in the literature. As a result, it is recommended that patients who undergo a phenol peel have electrocardiographic monitoring and intravenous access.
The dysrhythmias can include supraventricular tachycardia, premature ventricular contractions, atrial fibrillation, and ventricular fibrillation. Although infrequent, they are associated with higher concentrations of phenol and full-face treatments. It is recommended that the treatment be performed in aesthetic units, allowing for 15 minutes to elapse between the treatment of each unit.
Resorcinol and salicylic acid are components of Jessner’s solution.
Cardiac arrhythmias are not a reported risk with trichloroacetic acid, salicylic acid, glycolic acid or resorcinol.
A 26-year-old Korean woman reports that she is unhappy about the “square appearance of her jawline” and desires a softer facial shape without surgical intervention. Treatment with botulinum toxin type A is recommended. Which of the following is true as it relates to botulinum for masseteric hypertrophy?
A) Botulinum toxin type A injection is approved by the Food and Drug Administration for the treatment of masseter hypertrophy
B) Effects are invariably short-term
C) Headaches, while infrequently reported, usually are reported to occur several weeks after injection
D) Muscle bulk will not show significant volume reduction on CT scan
E) Temporary decrease in mastication force is the most common effect
The correct response is Option E.
A recent study by Shome et al demonstrated that after a series of botulinum toxin injections, masseter volume reduction lasted up to 4 years. Therefore, this treatment’s effects are not only short-term.
In a review by Peng et al, 30% of patients reported temporary decrease in mastication force after botulinum injection. Headaches, while infrequently reported, happen immediately after injection and resolve within 2 to 4 days after injection. When patients’ masseter volumes were measured before and after treatment, there was significant reduction in masseter volume (Chang et al).
Currently, botulinum toxin injection is an off-label use in treatment of masseter hypertrophy. Botulinum toxin is approved by the Food and Drug Administration for use in bladder dysfunction, migraine, glabellar lines, primary axillary hyperhidrosis, blepharospasm, strabismus, cervical dystonia, and upper limb spasticity.
A 67-year-old woman presents for consultation to address deep facial rhytides and dyschromias. Medical history includes Fitzpatrick Type II. A chemical peel is planned. For which of the following chemical peeling agents is cardiac monitoring recommended?
A) Glycolic acid
B) Phenol
C) Resorcinol
D) Salicylic acid
E) Trichloroacetic acid
The correct response is Option B.
Phenol is absorbed through the skin and into the bloodstream. Most is excreted through the urine. Cardiac dysrhythmias are associated with phenol peels. There are no reported deaths related to phenol toxicity in the literature. As a result, it is recommended that patients who undergo a phenol peel have electrocardiographic monitoring and intravenous access.
The dysrhythmias can include supraventricular tachycardia, premature ventricular contractions, atrial fibrillation, and ventricular fibrillation. Although infrequent, they are associated with higher concentrations of phenol and full-face treatments. It is recommended that the treatment be performed in aesthetic units, allowing for 15 minutes to elapse between the treatment of each unit.
Resorcinol and salicylic acid are components of Jessner’s solution.
Cardiac arrhythmias are not a reported risk with trichloroacetic acid, salicylic acid, glycolic acid or resorcinol.
A 50-year-old woman with Fitzpatrick type II skin and deep perioral rhytides is interested in nonsurgical rejuvenation for her perioral rhytides. Which of the following treatment options is most likely to have the best outcome in a single treatment?
A) Jessner peel
B) 0.4% Croton oil (Hetter) peel
C) 20% glycolic acid peel
D) 20% trichloroacetic acid (TCA) peel
E) 88% phenol peel
The correct response is Option B.
The patient is noted to have deep perioral rhytids, and for adequate resolution, a stronger peel is required. Deeper peels, however, will have a longer recovery time.
The glycolic peel is the lightest, followed by the Jessner and trichloroacetic acid (TCA).
While TCA can be used for a perioral peel, it would require a concentration of 35 to 40% to be effective in this scenario. A 20% TCA peel would not give the desired outcome.
In a Hetter peel, the Croton oil is the active peeling agent, not the phenol. Strengths of 0.4% to 0.8% Croton oil are typically used in the perioral area. With this technique, lighter concentrations of Croton oil in phenol are used for more delicate areas, like the lower eyelids or neck, medium concentrations for the cheeks, and heavier concentrations for the perioral area.
Of note, phenol by itself (88% USP), when unoccluded, only gives a light to moderate peel. It is not as strong as the 0.4% Croton oil peel.
Glycolic acid peels are superficial peels and are not effective for deep perioral rhytides.
A 43-year-old man presents to the office after being treated with botulinum toxin type A for concerning horizontal rhytids in the forehead 3 weeks ago. The patient reports that he is dissatisfied with the results and can barely open his eyes. Physical examination shows ptosis of the left upper eyelid. Apraclonidine 0.5% eye drops are prescribed and the patient reports temporary improvement. Which of the following muscles is most likely the target of the eye drops and involved in the improvement of this patient’s condition?
A) Corrugator supercilia
B) Frontalis
C) Levator palpebrae superioris
D) Orbicularis oculi
E) Superior tarsal (Müller) muscle
The superior tarsal muscle is a smooth muscle and also known as Müller’s muscle. An adverse effect of the injection of botulinum toxin type A into the upper third of the face is ptosis, or lid droop, and can occur up to 2 weeks after injections. Ptosis results from migration of the botulinum toxin type A to the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully. To avoid ptosis, injections should occur at least 1 cm above the eyebrow.
The superior tarsal muscle originates on the underside of the levator palpebrae superioris and inserts on the superior tarsal plate of the eyelid. The superior tarsal muscle receives its innervation from the sympathetic nervous system. Post-ganglionic sympathetic fibers originate in the superior cervical ganglion, and travel via the internal carotid plexus, where small branches communicate with the oculomotor nerve as it passes through the cavernous sinus. The sympathetic fibers continue to the superior division of the oculomotor nerve, where they enter the superior tarsal muscle on its inferior aspect. The superior tarsal muscle works to keep the upper eyelid raised after the levator palpebrae superioris has raised the upper eyelid. Apraclonidine is an ?2-adrenergic agonist, which causes Müller muscles to contract, quickly elevating the upper eyelid 1 to 3 mm.
In this situation, the frontalis muscle was the target of the botulinum toxin to temporarily alleviate cosmetic concerns of horizontal rhytids in the forehead. The patient was injected too close to the brow likely in an attempt to treat all forehead lines. Eyedrops would not help the frontalis muscle contract and elevate the brow. The levator palpebrae superioris is the primary elevator of the upper eyelid. Ptosis results from migration of the botulinum toxin to the levator palpebrae superioris muscle. This skeletal muscle is innervated by the oculomotor nerve (cranial nerve III) and not susceptible to activation by an alpha adrenergic agonist. The orbicularis oculi muscles is facial muscle responsible for closing the eye. The corrugator supercilii is a small, narrow, pyramidal muscle located at the medial end of the eyebrow, beneath the frontalis and just above the orbicularis oculi muscle. This muscle draws the eyebrow downward and medially, producing the vertical wrinkles of the forehead. This muscle when activated would not elevate the upper eyelid.
A 25-year-old man presents to the clinic because of a 5-year history of excessive bilateral sweating in the axillae. He states that he uses antiperspirant daily, but despite this, he sweats through his shirts multiple times per day. He finds it embarrassing and distracting at his work. Injection of botulinum toxin type A into each axilla is planned. Which of the following is the most appropriate dosage (per side) of the toxin for this therapy?
A) 15 units
B) 25 units
C) 50 units
D) 100 units
E) 150 units
The correct response is Option C.
The patient presents with primary hyperhidrosis. His complaints suggest that he is a 3 or 4 out of 4 on the hyperhidrosis disease severity scale. He has fulfilled criteria for treatment in demonstrating two of the following: duration greater than 6 months, frequency greater than once weekly, bilateral symmetrical sweating, onset before the age of 25, positive family history, and cessation while sleeping. Additionally, he has failed antiperspirant therapy for at least 6 months, as a result, intervention is indicated at this time. The appropriate dosing for axillary botulinum toxin type A is 50 units per side. Palmar injections use 100 units and plantar injections 150 to 250 units per side. Treatment for axillary hyperhidrosis has been shown to have good improvement, with 90% of patients having relief for at least 3 months.
A 36-year-old woman undergoes treatment of forehead wrinkles. Preoperative examination shows transverse rhytides when raising the eyebrows. Her eyebrows are 1 cm above the supraorbital rim. The central forehead is treated with 24 units of botulinum toxin type A. Two weeks later, the patient is unsatisfied with the appearance of her eyebrows. On examination, the medial eyebrow is located 1 cm above the supraorbital rim. Lateral eyebrows are raised significantly, creating an abnormal arch. Injection of additional botulinum toxin type A into which of the following muscles is the most appropriate treatment at this time?
A) Corrugator supercilia
B) Lateral frontalis
C) Levator palpebrae
D) Orbicularis oculi
E) Procerus
The correct response is Option B.
This patient has a “Spock’s eyebrow” deformity which occurs when the eyebrow has an excessive arch—the lateral brow is significantly higher compared the medial brow. This can happen when the medial frontalis is overtreated, resulting in a paradoxical effect on the lateral brow and an unnatural elevation of the lateral brow. Treatment of the deformity is with botulinum toxin type A injection into the lateral frontalis muscle (2 cm above the brow) which will allow the lateral brow to descend.
Facial rhytids are classified as static or dynamic. Botulinum toxin type A injections are useful for treating dynamic rhytids, which occur during muscle contraction. The effects of botulinum toxin type A are usually seen within 3 to 10 days and lasts for 3 to 6 months. The frontalis muscles are brow elevators and are the only elevators in the upper face.
The glabella is a commonly treated area and includes the corrugator supercilia and procerus muscles. Contraction of procerus results in horizontal rhytids and contraction of corrugators result in vertical rhytids. Both are brow depressors.
The orbicularis oculi muscle is targeted for the treatment of “crow’s feet lines” or lateral canthal lines along the lateral orbital rim. The orbital portion of the orbicularis oculi depresses the eyebrows.
The levator palpebrae is a muscle in the upper eyelid and functions to elevate and retract the upper eyelid. Eyelid ptosis can occur with botulinum toxin type A treatment of the glabella if there is diffusion of botulinum toxin type A that effects the levator palpebrae.
A 50-year-old woman with Fitzpatrick type II skin and deep perioral rhytides is interested in nonsurgical rejuvenation for her perioral rhytides. Which of the following treatment options is most likely to have the best outcome in a single treatment?
A) Jessner peel
B) 0.4% Croton oil (Hetter) peel
C) 20% glycolic acid peel
D) 20% trichloroacetic acid (TCA) peel
E) 88% phenol peel
The correct response is Option B.
The patient is noted to have deep perioral rhytids, and for adequate resolution, a stronger peel is required. Deeper peels, however, will have a longer recovery time.
The glycolic peel is the lightest, followed by the Jessner and trichloroacetic acid (TCA).
While TCA can be used for a perioral peel, it would require a concentration of 35 to 40% to be effective in this scenario. A 20% TCA peel would not give the desired outcome.
In a Hetter peel, the Croton oil is the active peeling agent, not the phenol. Strengths of 0.4% to 0.8% Croton oil are typically used in the perioral area. With this technique, lighter concentrations of Croton oil in phenol are used for more delicate areas, like the lower eyelids or neck, medium concentrations for the cheeks, and heavier concentrations for the perioral area.
Of note, phenol by itself (88% USP), when unoccluded, only gives a light to moderate peel. It is not as strong as the 0.4% Croton oil peel.
Glycolic acid peels are superficial peels and are not effective for deep perioral rhytides
A 36-year-old woman undergoes treatment of forehead wrinkles. Preoperative examination shows transverse rhytides when raising the eyebrows. Her eyebrows are 1 cm above the supraorbital rim. The central forehead is treated with 24 units of botulinum toxin type A. Two weeks later, the patient is unsatisfied with the appearance of her eyebrows. On examination, the medial eyebrow is located 1 cm above the supraorbital rim. Lateral eyebrows are raised significantly, creating an abnormal arch. Injection of additional botulinum toxin type A into which of the following muscles is the most appropriate treatment at this time?
A) Corrugator supercilia
B) Lateral frontalis
C) Levator palpebrae
D) Orbicularis oculi
E) Procerus
The correct response is Option B.
This patient has a “Spock’s eyebrow” deformity which occurs when the eyebrow has an excessive arch—the lateral brow is significantly higher compared the medial brow. This can happen when the medial frontalis is overtreated, resulting in a paradoxical effect on the lateral brow and an unnatural elevation of the lateral brow. Treatment of the deformity is with botulinum toxin type A injection into the lateral frontalis muscle (2 cm above the brow) which will allow the lateral brow to descend.
Facial rhytids are classified as static or dynamic. Botulinum toxin type A injections are useful for treating dynamic rhytids, which occur during muscle contraction. The effects of botulinum toxin type A are usually seen within 3 to 10 days and lasts for 3 to 6 months.
The frontalis muscles are brow elevators and are the only elevators in the upper face.
The glabella is a commonly treated area and includes the corrugator supercilia and procerus muscles. Contraction of procerus results in horizontal rhytids and contraction of corrugators result in vertical rhytids. Both are brow depressors.
The orbicularis oculi muscle is targeted for the treatment of “crow’s feet lines” or lateral canthal lines along the lateral orbital rim. The orbital portion of the orbicularis oculi depresses the eyebrows.
The levator palpebrae is a muscle in the upper eyelid and functions to elevate and retract the upper eyelid. Eyelid ptosis can occur with botulinum toxin type A treatment of the glabella if there is diffusion of botulinum toxin type A that effects the levator palpebrae.
Which of the following disorders is most likely to be successfully treated with botulinum toxin type A?
A) Bruxism
B) Cervical paroxysmal dyskinesia
C) Hemifacial dyskinesia
D) Tardive dyskinesia
E) Vertical maxillary excess
The correct response is Option C.
Botulinum toxin type A has good evidence demonstrating efficacy for the treatment of blepharospasms, hemifacial dyskinesia, cervical dystonia, post-stroke upper limb spasticity (not from paroxysmal dyskinesia—see below).
Bruxism is clenching/grinding of teeth and jaw and can occur either awake or asleep. Treatment includes splint therapy and pharmacotherapy. There have been published reports using botulinum toxin type A. However, while the amplitude of muscle contraction was decreased, it did not decrease the rhythm or number of bruxism episodes. At this time, there is no evidence that it is an effective treatment.
Tardive dyskinesia develops as a result of adverse effect of anti-psychotic medication. Botulinum toxin type A, which consists of VMAT2 (vesicular monoamine transporter 2) inhibitor such as deutetrabenazine or valbenazine, is not indicated in its treatment.
Paroxysmal dyskinesia is considered an immune-related movement disorder. It mainly affects the limbs but can also affect cervical muscles. Treatment includes systemic antibiotics, corticosteroids, and immune therapy such as rituximab. Botulinum toxin type A is not indicated.
Vertical maxillary excess is not treated with botulinum toxin type A.
Which of the following anatomic landmarks should be used during percutaneous injection of neurotoxin to treat benign masseteric hypertrophy?
A) Between the earlobe-to-oral commissure line and the inferior border of the mandible
B) Between the maxillary and mandibular occlusal planes
C) Between the tragus-to-infraorbital rim line and the cervicomental line
D) Between the tragus-to-mid upper lip line and the root of the helix to subnasale line
E) Between the zygomatic arch-to-mid upper lip line and the Frankfort horizontal
The correct response is Option A.
Benign masseteric hypertrophy can be treated by botulinum toxin type A or other neurotoxins. The masseter originates from the body of the zygoma, and inserts into the inferior border of the mandible, and therefore the inferior limit is the inferior border of the mandible. Below the transverse line from the earlobe to the corner of the mouth is a safe zone, as there are no important anatomic structures inferior to this line, and yet the majority of the masseter muscle hypertrophy will be in this region. The other choices contain other anatomic landmarks that are not related to neurotoxin injection for benign masseter hypertrophy.
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 53-year-old woman is evaluated because of horizontal rhytides at the root of the nose and between her eyebrows. Treatment will most specifically target which of the following muscles?
A) Corrugator supercilii
B) Depressor septi nasi
C) Frontalis
D) Orbicularis oculi
E) Procerus
The correct response is Option E.
The procerus stretches from the nasal bones to the dermis of the glabella, and contraction promotes horizontal rhytides in the glabellar region. The corrugator supercilii is more likely to promote vertical rhytides in the glabella. The orbicularis oculi serves as a sphincter around the eye and may also contribute to vertical glabellar rhytides. The frontalis is responsible for the horizontal forehead rhytides above the eyebrows. The depressor septi nasi does not impact forehead wrinkles.
A 35-year-old woman comes to the office for treatment of glabellar rhytides with botulinum toxin type A. A total of 20 units is used for the treatment, with 10 units injected into the region of each corrugator muscle. Ten days later, the patient returns to the office because of ptosis of the left upper eyelid. To help decrease the eyelid ptosis, an alpha-adrenergic agonist eye drop can be used to stimulate which of the following muscles?
A) Dilator pupillae
B) Frontalis
C) Levator palpebrae superioris
D) Müller
E) Orbicularis oculi
The correct response is Option D.
Eyelid ptosis is the result of an inadvertent effect of the botulinum toxin upon the levator palpebrae superioris muscle. This can occur during treatment of the glabellar region if the injection is performed within/below the orbital rim.
The ptosis that results from the weakening of the levator palpebrae superioris can be countered by the use of alpha-adrenergic eyedrops such as apraclonidine (Iopidine) or phenylephrine. These eyedrops will stimulate the Müller muscle, which is an accessory eyelid elevator that is located deep to the levator palpebrae superioris between the levator muscle and the conjunctiva of the upper eyelid. This can help improve the ptosis but not likely adequately resolve the problem until the effect of botulinum toxin type A has worn off.
The levator, frontalis, and orbicularis will not be affected by the use of the eyedrops. The iris will dilate because of the effects of the eyedrops. This however, will have no effect on the ptotic position of the eyelid.
A 42-year-old woman comes to the office for consultation on nonsurgical options for treatment of prominent nasolabial folds. The consultation covers injectable filler options. Compared with other types of injectable fillers, hyaluronic acid is distinguished by which of the following characteristics?
A) Can be enzymatically reversed
B) Cannot be combined with lidocaine
C) Contains methylmethacrylate
D) Is indicated for subperiosteal placement
E) Is radiopaque on x-ray study
The correct response is Option A.
Hyaluronic acid (HA) fillers are among several agents currently available in the United States. HA is a naturally occurring polysaccharide derived from bacterial fermentation that exhibits no species or tissue specificity. Therefore, serial retreatment is unlikely to induce allergic reactions. Other types of filler products include finely ground methylmethacrylate, calcium hydroxyapatite and poly-L-lactic acid. Although complications may arise with any type of filler, intravascular injection/embolization can occur, and it requires urgent management to preclude tissue necrosis or, in the case of retinal artery occlusion, vision loss. Only HA can be dissolved with an injection of an enzyme, hyaluronidase. It is not radiopaque as is calcium hydroxyapatite. It may appear gray (Tyndall effect) if placed too near the surface. While certain formulations of HA can be injected into the subcutaneous plane, neither it nor any of the others are approved for injection into the subperiosteal plane. Lidocaine is mixed into many HA products to diminish injection site pain. More than 1 mL can be injected per patient in the same setting. Operator technique is most important to maximize safety when using any type of filler. Minor complications of fillers include hypersensitivity, acute infection, malposition of filler, and inflammatory nodules or granulomas.
A 46-year-old woman seeks to improve her facial appearance with soft-tissue fillers. Her rejuvenation plan includes administration of a highly cross-linked hyaluronic acid injectable filler to the mid face to restore volume loss. To properly add volume to and rejuvenate this area, the filler should be injected into which of the following soft-tissue layers?
A) Intradermal
B) Preperiosteal
C) Subdermal
D) Subperiosteal
E) Throughout multiple layers of soft tissue from deep to superficial
The correct response is Option B.
Restoration of mid face volume loss is a highly effective maneuver that can be performed utilizing fat grafting or off-the-shelf injectable fillers. The most commonly used hyaluronic acid-based injectable fillers utilized for mid face rejuvenation and volume restoration include those that are highly cross-linked, thus increasing the stability, density, cohesivity, and longevity of the filler. The process of cross-linking hyaluronic acid results in larger, more stable molecules that have biocompatibility and viscoelastic properties similar to those of fat. Ideally, these highly dense fillers should be placed at the preperiosteal level to optimize results and minimize potential complications, such as intravascular placement of filler or visible
A patient with facial hyperkinesia comes to the office for treatment with botulinum toxin type A for temporary improvement in the appearance of moderate to severe glabellar facial lines. How many units of botulinum toxin type A should be administered to this patient, according to the Food and Drug Administration?
A) 1
B) 10
C) 20
D) 50
E) 100
The correct response is Option C.
Two phase 3 randomized, multi-center, double-blind, placebo-controlled studies of identical design were conducted to evaluate botulinum toxin type A prior to FDA approval. The injection volume was 0.1 mL/injection site, for a dose/injection site in the active treatment groups of 4 units. Subjects were injected intramuscularly in five sites—1 in the procerus muscle and 2 in each corrugator supercilii muscle—for a total dose in the active treatment groups of 20 units.
Botulinum toxin type A blocks neuomuscular transmission by binding to acceptor sites on motor nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. One unit corresponds to the calculated median intraperitoneal lethal dose (LD50) in mice. Each vial of botulinum toxin type A contains either 100 units of Clostridium botulinum type A neurotoxin complex, 0.5 mg of albumin (human), and 0.9 mg of sodium chloride, or 50 units of C. botulinum type A neurotoxin complex, 0.25 mg of albumin (human), and 0.45 mg of sodium chloride in a sterile, vacuum-dried form without a preservative.
A 52-year-old woman comes to the office to receive botulinum toxin type A injections to the corrugator and procerus. She returns to the office 1 week later because she is upset that her eyelids on both sides are droopy. Physical examination shows bilateral ptosis. Which of the following is the most appropriate treatment to improve this patient’s condition until the effects of the botulinum toxin type A subside?
A) Apraclonidine
B) Artificial tears
C) Botulinum toxin type A to the lateral orbicularis oculi
D) Ophthalmic tobramycin and dexamethasone
E) Tetracaine
The correct response is Option A.
This patient has developed true eyelid ptosis from her botulinum toxin type A treatments coming into contact and affecting the levator palpebrae superioris muscle within the eyelid. Although the effects of botulinum toxin type A on any muscle are irreversible with medications, attempts to lessen the severity of the ptosis have been made with the use of eyedrops to stimulate the Müller muscle, which is located deep to the levator. Apraclonidine is an alpha-adrenergic agonist and as such stimulates the Müller muscle to contract. This contraction may elevate the eyelid 1 to 3 mm and lessen the amount of ptosis to varying degrees in order to make the overall appearance of the eyelids more tolerable to the patient until the effects of botulinum toxin type A wear off on their own and levator function naturally returns. The most common dose of apraclonidine is 1 to 2 drops three times daily until ptosis resolves.
Tetracaine is a commonly used numbing agent for the corneal surface that enhances the comfort of using corneal protectors for periorbital surgery. Tobradex eyedrops are a combination of tobramycin and dexamethasone used for treatment of infection and/or its anti-inflammatory effect in the periorbital region. It has no effect on eyelid ptosis. Artificial tears are lubricating drops and have no effect on muscular action.
Accidental injection of hyaluronic acid filler into which of the following areas is most likely to cause blindness by retrograde occlusion of the central retinal artery?
A) Cheek
B) Geniomandibular groove
C) Lateral lip commissure
D) Nasal dorsum
E) Nasolabial fold
The correct response is Option D.
The dorsal nasal artery is a distal continuation of the ophthalmic artery from the internal carotid artery. During nasal dorsum augmentation, accidental injection of filler into this artery under pressure can push the filler retrograde into the ophthalmic artery. When the pressure is returned to normal, the filler then can flow distally occluding the retinal artery and causing blindness. Intravascular injection of fillers into the angular artery of the nasolabial line can also cause blindness, although this would more commonly result in skin mottling and necrosis of the nasal tip skin.
The cheek area overlying the malar bone, with few deep vessels, is a relatively safe place for injectables.
Intravascular injection of the geniomandibular groove and lateral lip commissure is more commonly associated with vascular compromise of the lips and chin.
A 50-year-old woman receives an injection of 0.5 mL of hyaluronic acid filler into each nasolabial fold. She returns to the office 30 minutes later because of pain and mottled skin discoloration of the nasal tip and right ala nasi. Which of the following is the most appropriate next step in management?
A) Doppler ultrasonography
B) Hyaluronidase injection
C) Lidocaine injection
D) Massage
E) Prostaglandin E1 injection
The correct response is Option B.
This patient presents with signs and symptoms consistent with an intra-arterial injection of hyaluronic acid (HA), which requires emergency treatment to restore circulation.
Accidental intra-arterial injection of fillers leading to arterial compromise is a rare occurrence. When it occurs, devastating outcomes include blindness, stroke, skin necrosis, and permanent scarring. The presenting signs and symptoms may include pain, skin blanching, mottled skin discoloration, and slow capillary refill. The mainstay of treatment for intra-arterial injection of HA products is local injection of hyaluronidase into the site of injection and the local area of skin mottling. Hyaluronidase is an enzyme that catalyzes HA hydrolysis.
Other treatments include massaging the area in order to promote distribution of hyaluronidase, topical nitropaste, aspirin, and warm compresses. Secondary treatments that can be considered after hyaluronidase injection include hyperbaric oxygen, papavarin, prostaglandin E1, heparin, and lidocaine. Radiologic evaluation with Magnetic resonance angiogram (MRA) or Doppler ultrasound would only delay treatment. Massage alone will not benefit this patient.
Recommendations for risk reduction include the following: using large-bore blunt cannulas (27 gauge and larger), injecting less than 0.1-mL bolus in any single injection site, avoiding high-pressure injections, awareness of likely position of named vessels in the treatment area, using local anesthesia with epinephrine, and caution with deep injections around the radix, lateral nasal wall, and periorbital area.





