Cosmetic Facelift 01-22, 24 Flashcards

Question

A 67-year-old woman with marked lower facial and neck laxity is scheduled to undergo an extended superficial musculoaponeurotic system (SMAS) rhytidectomy. Excessive trimming of the skin flap adjacent to the base of the earlobe is most likely to result in which of the following outcomes? ## Footnote A) Earlobe ptosis B) Lop ear deformity C) Pixie ear deformity D) Reverse telephone ear deformity E) Telephone ear deformity

Answer 1

The correct response is Option C. While there are a number of successful methods to perform a facelift, there are certainly common principles they share. These include: Making an artfully placed incision which follows anatomic contours Skin elevation to allow access to the superficial musculoaponeurotic system (SMAS) and release of any tethered points of the facial skin following SMAS manipulation Some method (elevation, plication, imbrication, or direct suturing) of tightening the mobile SMAS Anchoring of the SMAS in its new position with some stable method of fixation Re-draping the soft-tissues using appropriate vectors Careful skin closure where minimal tension is placed on the earlobe and posterior hairline incision Placement of significant tension on the earlobe caused by excessive trimming of the skin flap in the region of the otobasion inferius is well known to commonly produce a distinctive postoperative distortion of this structure, also known as a "pixie ear." The study by Mowlavi and associates showed an incidence of approximately 6% in a facelift population. A tension-free closure of the earlobe to the skin flap should be the goal, avoiding tension on the delicate earlobe tissues from the cheek flap, to avoid the issue of inferior and anterior migration of the otobasion. A number of corrective techniques have been described, ranging from local V-Y closures to readvancement of the facelift flap. Earlobe ptosis, in which the vertical height of the earlobe increases with aging, is unchanged by skin trimming errors. Telephone and reverse telephone deformities are complications in otoplasty for prominent ears, and do not apply to this case. Lop ear deformity is a congenital ear deformity involving the superior portion of the helix, and is not relevant to this case.

Answer 2

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

Answer 3

The correct response is Option E. The temporal branch of the facial nerve is found just deep to the temporoparietal fascia. The facial nerve exits the stylomastoid foramen and the main trunk, pes anserinus, can be found 1 cm inferior and posterior, midway between the tragal pointer and the posterior belly of the digastric muscle. It then arborizes into 5 branches; temporal, zygomatic, buccal, marginal and cervical. Interconnections between the zygomatic and buccal offer some additional regenerative potential if one of those branches is injured. Most mimetic facial muscles are innervated from the deep surface such as the temporalis. Exceptions are the buccinator, levator anguli oris, and mentalis. Injury to the temporal or cervical branches can leave more lasting deformities so management of injury is important. Avoiding injury is the best way to prevent injury. Therefore, when dissecting in the temporal zone it is critical to avoid entering deep to the temporoparietal fascia.

Answer 4

The correct response is Option A. Elective aesthetic procedures may be considered in patients with cutis laxa, a genetic disorder with variable inheritance and expressive patterns. The underlying defect is poor elastic tissues due to degeneration of elastic fibers, or a nonfunctioning elastase inhibitor. As a result, patients present with coarse, loose, excess skin throughout the body. In the autosomal dominant form of cutis laxa, the symptoms are confined only to the skin. In the recessive and X-linked forms, there may be other associated conditions such as congenital heart disease, hernias, aneurysms, emphysema, and pneumothorax. Although the effects of cutis laxa worsen with time, there is no underlying issue with wound healing. As a result, surgery may be considered to correct the facial appearance and any functional issues such as ectropion or ptosis. In the other diseases listed, surgery is contraindicated due to poor/unknown wound healing mechanisms. Ehlers-Danlos syndrome (cutis hyperelastica) includes a group of more than 10 different inherited disorders that all involve a genetic mutation affecting collagen and connective tissue synthesis and structure. The clinical presentation includes skin laxity, hyperextensibility and excessive thinness of the skin, joint hypermobility, and aortic aneurysms. Wound healing is poor and elective procedures should not be performed. Elastoderma is a disorder of unknown etiology. Clinical manifestations include pendulous skin laxity initially involving the trunk and extremities that progresses to involve the entire body. Because the effects on wound healing are unknown/unpredictable, elective surgery is not recommended. Werner syndrome is an autosomal recessive disorder characterized by pigmented, indurated, plaque-containing skin, osteoporosis, muscle atrophy, growth retardation, cardiovascular disease, and diabetes. Small vessel angiopathy and poor wound healing are associated. Progeria (Hutchinson-Gilford syndrome) is an autosomal recessive disorder of unknown cause. Findings are similar to premature aging and include lax, excess skin, growth retardation, craniofacial abnormalities, and cardiac disease. Wound healing is poor and the disease is associated with premature death.

Answer 5

The correct response is Option C. More procedures are performed in a freestanding ambulatory surgery center or office-based procedure room than in a hospital setting, according to ASPS statistics. Although each state can set policies on the upper limit of the duration of these procedures, these policies are not entirely evidence-based. Based on available literature and data, an ASPS Task Force has established guidelines to provide the best level of evidence for ambulatory surgery safety. In terms of duration, the current recommendations suggest that procedures be limited to less than 6 hours and begin early in the morning to decrease the risk of complications. A review of 2595 consecutive patients in a single practice who had office-based cosmetic surgery performed during general anesthesia using a propofol/remifentanil intravenous infusion in conjunction with airway protection via use of either a laryngeal mask or endotracheal intubation monitored by certified registered nurse anesthetists demonstrated no increase in major complications such as deep venous thrombosis (DVT), pulmonary embolism, reintubation, reoperation, hospitalization, major cardiac complications, and death. However, the only complications to reach statistically significant differences in procedures over 4 hours were urinary retention and postoperative nausea and vomiting. Additional studies have also demonstrated no increased risks of major complications in this setting.

Answer 6

The correct response is Option A. The risk for deep venous thrombosis (DVT) is decreased in many plastic surgical procedures when intravenous sedation is used instead of general anesthesia. Intravenous sedation avoids the need for muscle relaxant and the associated loss of peripheral vascular resistance. Many rhytidectomy patients are at elevated risk for DVT; however, utilizing chemoprophylaxis will increase the hematoma risk and potentially jeopardize the final surgical result. Switching to an intravenous sedation technique is a safe and easy alternative for lowering DVT risk. The incidence of hematoma, infection, and skin necrosis have not been linked with this type of anesthesia. Intravenous sedation can be associated with increased operative time for the rare patient who is resistant to sedation.

Answer 7

The correct response is Option C. Aesthetic analysis of the face may be simplified by dividing the face into equal horizontal thirds and vertical fifths. The length of the face is divided into equal thirds as follows: The upper third includes the forehead and brows, extending from the anterior hairline to the glabella and brows. The middle third includes the midface, eyes, and nose and extends from the glabella to the subnasale. The lower third includes the lower cheeks, jawline, and neck and extends from the subnasale to the menton. The width of the face may be divided into equal fifths by lines dropped from the lateral canthi and lines dropped from the medial canthi, with each partition approximating the width of the horizontal palpebral fissure. Of note, the lines dropped from the lateral canthi should approximate the width of the neck and the lines dropped from the medial canthi should approximate the distance between the left and right alar-facial grooves.

Answer 8

The correct response is Option E. Promising initial experience with vascularized composite facial allotransplantation has driven the procedure forward, with more than 30 face transplants successfully completed to date. Understanding how these facial allografts change relative to their recipient over time is crucial to the risk/benefit assessment, donor selection, and long-term treatment planning. Long-term outcome data have shown facial allotransplants to undergo severe changes in volume and composition over the first 3 years post-transplantation that morphologically resemble accelerated aging. Computed tomography (CT) volumetric and histological analysis has shown this effect to result from significant volume loss in the allotransplanted bone and non-fat subcutaneous soft tissues. Allograft bone volume decreased by approximately 21% and allograft non-fat subcutaneous soft tissue decreased by about 26% between 18 and 36 months post-transplantation, respectively. These volume losses are hypothesized to involve transient denervation changes of allograft muscle and possibly differential response to acute and chronic rejection within the allograft. In contrast to typical chronological facial aging, allograft fat (both deep and subcutaneous) underwent no significant change, and skin biopsies obtained throughout the 3-year time period showed no significant thinning of the epidermal or dermal thickness and no change in collagen or fat content.

Answer 9

The correct response is Option E. The most common cause of postoperative facial nerve weakness following rhytidectomy is residual effect from local anesthesia. This effect can take several hours to wear off and the most reasonable course of management is to observe and reexamine the patient to ensure return of function. Corticosteroid injection is not indicated in this situation. Aspirating under the flap would not prove beneficial and is typically reserved for a small seroma that can develop within days following a rhytidectomy, not immediately following surgery. If there is cause for concern that a hematoma is present, then the patient should be returned to the operating room for evacuation of this and hemostasis. A hematoma would not, however, cause weakness of the facial nerve immediately postoperatively. Although nerve entrapment from sutures is a possible explanation for facial nerve weakness, it is much less likely a cause than a residual effect from the tumescent anesthesia.

Answer 10

The correct response is Option D. While the overall incidence of nerve injury during rhytidectomy is low, consequences, depending on which nerve is involved, can range from minor annoyance to devastating aesthetic and functional sequelae. Identification of the location of nerves that are likely to be subject to sharp or blunt injury during rhytidectomy is key to prevention of injury. An intimate knowledge of the anatomy is imperative, particularly for the trunk and branches of cranial nerve VII, the auriculotemporal nerve, and the great auricular nerve (GAN). Cranial nerve VII branch laceration can result in deficits of brow elevation (frontal branch), paralysis of the orbicularis oculi (zygomatic branch), buccinator incompetence (buccal branch), asymmetry of the lip depressors (marginal mandibular branch), or loss of platysma tone (cervical branch). The auriculotemporal nerve innervates the external auditory meatus, upper helix, and temporal scalp. Gustatory sweating (Frey’s syndrome) occurs due to aberrant reinnervation of cutaneous sweat glands after disruption of auriculotemporal nerve branches, more likely after parotidectomy. Motor function of the posterior auricular muscle is provided by the temporal branch of cranial nerve VII. Transection of the GAN would result in a sensory disturbance to the lobule of the ear and may elicit dysesthesia, cold intolerance, or focally painful neuroma. It is the most frequently injured nerve during rhytidectomy, with an incidence estimated at up to 2.6%. It may be repaired with epineural suture to help prevent neuroma. A recently described method to avoid injury to the GAN locates it within a triangle constructed using the anterior limb perpendicular to the Frankfort horizontal and the posterior limb angled 30 degrees behind the first limb and passing through the midpoint of the earlobe.

Answer 11

The correct response is Option E. When superficial musculoaponeurotic system (SMAS) tightening procedures are performed, the tension of the facelift is secured at the SMAS level rather than the skin. With a skin-only facelift, the lift must depend solely on the skin sutures for support. The more tension on the skin, the more likely a spread or hypertrophic scar will occur. SMAS procedures do not decrease the longevity of results. Many surgeons believe that a SMAS facelift will produce better results and longer lasting results. Despite these opinions, there are no conclusive evidence-based studies to prove an increase in longevity of results. Hematoma formation is related to hypertension and extent of dissection, not whether a SMASectomy was performed. SMAS procedures put the facial nerve at greater danger than skin-only facelifts. The incidence of facial nerve injury is low with both techniques. Infection rates are low with both procedures.

Answer 12

The correct response is Option B. This patient’s symptoms relate to an injury to the spinal accessory nerve (cranial nerve XI). This nerve innervates the sternocleidomastoid and the trapezius muscles. The spinal accessory nerve exits the cranium through the jugular foramen. It then passes deep to the styloid process and under the sternocleidomastoid muscle. The nerve exits the posterior border of the sternocleidomastoid fascia within 2 cm superior to the great auricular nerve. After it exits the muscle, the nerve is vulnerable to injury because it is tightly sandwiched between the skin and the muscle fascia. It then runs obliquely and inferiorly to the anterior edge of the trapezius muscle. The course of the spinal accessory nerve usually follows a path drawn by a line perpendicular to and bisecting a line connecting the angle of the mandible and the tip of the mastoid process. Lore fascia is a dense tissue inferior to the auricle that can be used to anchor the superficial musculoaponeurotic system fascia. The facial nerve is 2.5 cm deep to this fascia. McKinney point is where the great auricular nerve consistently crosses the mid transverse belly of the sternocleidomastoid muscle approximately 6.5 cm below the caudal edge of the bony external auditory canal. The spinal accessory nerve is posterior to the platysma.

Answer 13

The correct response is Option C. Wound-healing issues and skin necrosis should initially be managed with local wound care. In many cases, the wounds will go on to heal without negative sequelae. In the remainder of the cases, a corticosteroid injection or scar revision may be all that is necessary. Debridement of the region is not recommended because the eschar acts as a biologic dressing. Skin grafting would be indicated for a very large area of full-thickness necrosis. Re-advancement of the flap would not be indicated at this time as conservative management works well. Furthermore, re-advancement of the flap at this time would likely place too much tension on the closure with its resulting stigmata. However, re-advancement may be indicated at the time of scar revision once the wound has healed and the skin laxity has returned.

Answer 14

The correct response is Option A. Secondary rhytidectomy patients are typically older than primary rhytidectomy patients, and have been demonstrated to have more comorbid medical diseases. Hence, a more thorough preoperative medical evaluation is prudent for these patients. One study found that depression, necessitating the use of a selective serotonin reuptake inhibitor, was the most common comorbid disease, in one quarter of the secondary rhytidectomy patients studied. Hypertension was the second most common medical condition. In secondary rhytidectomies, less skin is typically excised, but often, more care with tailoring and insetting the skin is required. The skin and superficial musculoaponeurotic system (SMAS) thicknesses are typically thinner than at a primary, which can make surgical elevation of SMAS flaps more difficult. Sub-SMAS scarring, however, does not preclude careful and safe re-elevation of a SMAS flap. Finally, vascular compromise of the skin is less likely in a secondary case, due to the delay phenomenon following the primary procedure.

Answer 15

The correct response is Option E. Young faces appear full because of well-supported facial fat. As one ages, deflation of facial fat occurs more visibly in areas with a high density of retaining ligaments (e.g., lateral chin and malar area). This deflation in conjunction with an intact mandibular ligament gives rise to marionette lines. Injectable fillers can minimize these lines. The integrity of the mandibular ligaments causes the marionette lines to be more prominent as they limit the descent of facial fat. Attenuation of these ligaments would soften the marionette lines. Viscoelastic stretching refers to the properties of skin when placed under tension (i.e., the relaxation of skin tightness following rhytidectomy). Dermal thinning occurs throughout the face and contributes to wrinkles. Repetitive mimetic muscle contraction is thought to contribute to the depth of nasolabial folds and facial radial expansion. It may contribute to marionette lines close to the oral commissure but is not the major contributing factor.

Answer 16

The correct response is Option C. A subcutaneous fascia partitions the superficial subcutaneous facial fat. Anatomically, this fascia was recognized as early as 1799, when it was referred to as a cellular membrane. In 1859, Gray described the layer as the superficial subcutaneous fascia. In 1960, the usefulness of including the subcutaneous fascial layer in plicating sutures was noted. Later that decade, Tessier and Skoog, apparently working independently in France and Sweden, respectively, described the benefit of undermining and imbrication of this fascial layer in rhytidectomies. Residents from Tessier's unit then performed a number of anatomical studies to define the extent of the superficial subcutaneous fascia. Their classic anatomical study, published in 1976, described a superficial subcutaneous fascia that invested the platysma muscle and fused to the external surface of the parotid fascia. They named this fascia the superficial musculoaponeurotic system (SMAS). These findings have been corroborated by other authors, but the original study was not able to define the exact anterior extent of the SMAS. One of Tessier's residents later challenged this concept. He contended that there was no distinct parotid fascia and that the SMAS, rather than being an extension of the cervical investing fascia, was an embryologically distinct “primitive platysma.” Controversy over the exact nature and extent of the SMAS persists. However, the consensus of surgical opinion seems to be that the SMAS represents the facial extension of the cervical investing fascia. As such, the SMAS envelops the platysma in the neck and cheek. Anteriorly, the SMAS becomes attenuated but terminates as the investing layer of the superficial layer of the mimetic muscles. Laterally, the SMAS fuses with the multilayer parotid capsule. Superiorly, the SMAS passes over the zygomatic arch to join the superficial temporal fascia (temporoparietalis and galea).

Answer 17

The correct response is Option D. The high superficial musculoaponeurotic system (SMAS) technique, as described by Barton, divides the SMAS transversely at the superior-most portion of the zygomatic arch. Anatomical studies show that the procedure can be performed safely, as the frontal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch, not within the SMAS, in the zone of SMAS transection. The most common cause of facial nerve inactivity in this situation is related to the transient effects of local anesthesia injected during surgery. Reexamination once the effect of the local anesthesia has worn off is recommended. Intravenous corticosteroids, in a randomized controlled study, did not reduce facial edema, and would not benefit this patient. The diagnostic studies, neurology consult, and surgical reexploration are premature at this point in the patient’s course, but may be helpful later if there is no evidence of return of nerve function.

Answer 18

The correct response is Option A. In a cervical branch facial nerve injury, lip depression can be weak, but the mentalis and orbicularis oris innervation remain intact, so that the patient would be able to purse her lips. Neither the cervical nor marginal mandibular nerves provide sensation to the lip. It would not be necessary to obtain a nerve conduction study in this case, because physical examination would be enough to distinguish between injuries to these nerves. The mid-face motor nerves would not be involved.

Answer 19

The correct response is Option A. Tissue sealants, such as fibrin tissue adhesives and platelet-rich plasma, have been utilized to affect drainage, ecchymosis, and edema following rhytidectomy. Prospective studies have demonstrated decreased rate of ecchymosis, edema, seroma, and prolonged induration. Although no major differences exist, studies have shown only a trend toward drainage reduction. Tissue sealants have not been shown to affect scar formation.

Answer 20

The correct response is Option B. Aging skin can be identified histologically by an increase in the flattening of the dermal-epidermal junction. This results in a decreased area of contact between these two surfaces and predisposes older individuals to separation at this junction. The number of Langerhans cells, fraction of Type III collagen, and amount of glycosaminoglycan ground substance are all decreased with chronological aging. Other changes include disorganization of the major extracellular matrix components, such as collagen and other elastic fibers. The number of available keratinizing cells is also decreased with aging. It is hypothesized that this contributes to the problems associated with increased dry skin in the elderly.

Answer 21

The correct response is Option B. This patient has a spinal accessory nerve injury related to the recent rhytidectomy. The spinal accessory nerve (XI) may potentially be injured as it passes through the posterior triangle of the neck. Iatrogenic injury is the most common cause of spinal accessory nerve dysfunction. Patients with injury to the spinal accessory nerve present with shoulder pain and trapezius muscle palsy that subsequently results in drooping of the shoulder girdle inferior and laterally along with scapular winging. The diagnosis is confirmed and the level of injury assessed with the use of electromyography and nerve conduction studies. Loss of spinal accessory motor nerve function due to neurapraxia should be managed conservatively, while the remaining patients with no sign of clinical or electrical recovery by 3 months should undergo evaluation for surgical exploration with neurolysis, repair, or grafting. Patients often have pain secondary to loss of the ability to suspend the shoulder girdle appropriately. Physical therapy with strengthening of the remaining scapular stabilizers, prevention of trapezius stretch/lengthening, and maintaining full range of motion of the shoulder girdle are important to good function after the nerve recovers. Shoulder splinting is of no benefit. The great auricular nerve is not involved in the patient’s pathology, so nerve blocks would not be helpful. Similarly, MRI of the shoulder joint does not image the injured area, and does not help in patient management or surgical planning. Upper extremity angiography is of no benefit in the diagnosis or surgical planning of this disorder.

Answer 22

The correct response is Option E. Motor nerve dysfunction in the first few hours after surgery is common. This muscle weakness is attributable to the lingering effects of local anesthetic. For surgeons who inject the right and left sides of the face at different steps during the procedure, facial muscle asymmetry will be expected. Motor nerve dysfunction that is present days later is usually due to traction, cautery sutures, or transection. This patient underwent fat grafting to the mid face, and therefore, swelling is expected. Many surgeons routinely give intraoperative corticosteroids to decrease postoperative swelling. This patient does not need corticosteroids for her muscle weakness. Removal of the sutures and reexploration are not indicated.

Answer 23

The correct response is Option E. In the patient with weakness of the right lower lip depressors, the mentalis muscle, and the orbicular muscle of the mouth described, the nerve most likely to have been injured is the right marginal mandibular branch of the facial nerve. The marginal mandibular nerve is located deep to the platysma and superficial musculoaponeurotic system. However, in the area of the mandibular notch, these layers are thin and leave the nerve susceptible to injury from both inadvertent subplatysmal dissection and cautery injury. The anatomy of the marginal mandibular nerve varies, as it can travel as low as 1 to 2 cm below the mandible along its entire course. Injury to this nerve causes weakness of the ipsilateral lip depressors, resulting in the contralateral lower lip to appear lower in a full-denture smile. Injury to the nerve also causes weakness of the mentalis and orbicularis oris muscle, resulting in asymmetry upon pursing of the lips. Although injury to the marginal mandibular nerve can be permanent, spontaneous recovery is noted within 6 months in 80% of patients. Although cervical branch injury could also cause decreased function of lower lip depressors, it does not cause weakness of the mentalis or the orbicular muscle of the mouth (symmetry on pursing lips). The mental nerve is a sensory nerve.

Answer 24

The correct response is Option E. The patient described has marginal mandibular branch pseudoparalysis. Even if the cervical or marginal mandibular branch had been injured in the patient described, the best management would be to observe and allow the patient to retrain her smile to a more symmetric form. Electromyography studies are unnecessary. Operative exploration is not indicated. Depressor function should be expected to return between 3 weeks and 6 months. Marginal mandibular branch pseudoparalysis is a sequela of rhytidectomy surgery when an SMAS/platysma flap is dissected in the mandibular region. Transient dysfunction of lip depression in patients who exhibit a preoperative full-denture smile has been observed by many different authors who perform SMAS rhytidectomies. If the problem persists beyond 6 months, the use of botulinum toxin type A may be considered.

Answer 25

The correct response is Option B. An observation following endoscopic forehead rejuvenation is inadequate removal of the glabellar muscles, resulting in early recurrence of glabellar lines and frowning action. This can be avoided by removal of all of the muscle fibers between the frontal bone and the subcutaneous plane and replacement with fat grafts. Application of the fat graft in this area will not only improve the contour but also reduce the potential for the full gain of muscle function, even if some fibers are left intact. The residual or regenerated muscle fibers will not be as effective or as powerful without bone insertion. Furthermore, the fat graft will eliminate the flatness of the glabella as a consequence of aging. This flaw could also be the result of contraction of retained muscle fibers in those patients with very thin glabellar skin. These irregularities may only become noticeable on animation. Complete removal of the glabellar muscles and replacement with fat grafts will prevent this undesirable outcome. Non-matching suspension forces may result in eyebrow asymmetry. Overelevation of the eyebrows is caused by overzealous dissection and too high a suspensory force. Underelevation of the eyebrows can occur as a result of inadequate release of the eyebrow suspensory ligaments.

Answer 26

The correct response is Option C. Patient evaluation for neck rejuvenation should include assessment of skin laxity, degree of preplatysmal and subplatysmal fat, and position of the chin, hyoid bone, and thyroid cartilage. In addition, the presence of a malpositioned or ptotic submandibular gland should be noted. The ideal aesthetic neck has been described as having a cervicomental angle of 105 to 120 degrees, a distinct mandibular border with a subhyoid depression, a visible sternocleidomastoid muscle, and thyroid cartilage. An obtuse cervicomental angle can result from loose, excess skin; low position of the hyoid bone; excess preplatysmal or subplatysmal fat; and a retrodisplaced or small chin. Excess preplatysmal fat is the most common cause of an obtuse cervicomental angle. Removal of the preplatysmal fat is corrected through direct excision or liposuction. Often, removal of the subplatysmal fat may also be required to improve the overall contour of the neck. Excess skin laxity of the neck contributes significantly to the overall shape of the neck, resulting in poor definition of the mandibular border, sternocleidomastoid muscle, and the thyroid cartilage. Poor chin definition caused by lack of projection or size can also result in an obtuse cervicomental angle. The position of the hyoid bone can influence the aesthetic contour of the neck. The normal position for the hyoid bone lies in line with the fourth cervical vertebra. In patients with an obtuse cervicomental angle, the hyoid bone is low, projecting inferior to the fourth cervical vertebra and creating a full, obtuse neck contour. Position of the thyroid cartilage or ptosis of the submandibular gland does not influence the overall aesthetic contour of the neck.

Answer 27

The correct response is Option C. Several factors should be considered in planning a brow lift surgery. Generally, as patients age, the face and forehead both elongate. In addition, a receding hairline can also contribute to a long forehead. The forehead, measured from the hairline to the brow, should be approximately one third of facial length. In most individuals, this falls somewhere between 6 and 10 cm. In the patient described, the forehead height is 11 cm, making her forehead slightly long. Ptosis of the eyebrows may also occur in the aging process, and patients may compensate by using the frontalis muscle, which leads to deep transverse forehead rhytides. The corrugators depress the eyebrow, which leads to vertical glabellar lines. Often, patients with brow ptosis request blepharoplasty, and it is important for the clinician to recognize brow ptosis. This can be done by asking the patient to close his or her eyes and open them slowly. Automatic brow elevation with frontalis activation suggests brow ptosis. The approach to forehead rejuvenation used depends on the forehead and brow findings in the individual patient. An open pretrichial incision shortens the forehead and is effective on deep rhytides. It is the most appropriate approach in the patient described. Endoscopic procedures are most useful for people with an optimal forehead length. This is due to the technical difficulty of using the endoscope across a long, convex surface. The coronal approach elongates the forehead, and, as such, it is used most commonly in patients with a short forehead. A transpalpebral corrugator resection is most useful for patients with no eyebrow ptosis.

Answer 28

The correct response is Option E. Injury to the cervical branch can mimic injury to the marginal branch, producing lower lip depressor weakness with a full-denture smile. A cervical nerve injury is differentiated from a marginal nerve injury in that mentalis and orbicularis oris function remain intact, and patients can purse the lips symmetrically. In general, cervical branch weakness typically resolves within 4 to 12 weeks. Injury to the marginal mandibular nerve can occur in either subcutaneous or superficial musculoaponeurotic system dissection in the region along the angle of the mandible and mandibular border. Injury to the marginal mandibular nerve produces weakness of the lower lip depressors and the mentalis muscle. Although this injury can be permanent, as with other facial nerve injury, spontaneous recovery within 6 months is the expected outcome in most (80%) patients. Although spontaneous recovery is usually noted within 3 to 4 months, frontal branch injury tends to produce longer lasting facial weakness. The reported incidence varies, but it is most likely less than 1%. The obvious neurologic signs of injury are noted, such as inability to elevate the eyebrow and forehead on the involved side, ptosis of the eyebrow, and loss of forehead wrinkles. The injury can be caused by trauma from the cautery, a suture inadvertently encircling the nerve, or, most likely, neurapraxia caused by stretching. Nearly all types of frontal branch nerve weakness will improve over time. If nerve weakness is noted postoperatively, it is discussed with the patient, and he or she is informed of what has happened and what to anticipate. The motor nerve that is injured most commonly is the buccal branch of the facial nerve.

Answer 29

The correct response is Option D. Massive weight loss results in loss of soft-tissue volume with ptosis, increased laxity, and redundant skin of the face. Many patients present with advanced aging in the face because changes subsequent to massive weight loss mimic aging. Dermabrasion is a technique used to treat fine rhytides and irregular surface of the facial skin, such as those associated with chronic acne scarring. Laser treatments tighten skin but do not add volume. Both of these modalities have no applicability to neck rejuvenation and may cause irreversible scarring of the neck. Fat grafting may help fill the depressed nasolabial and perioral folds but does not help to tighten skin or treat platysmal bands. Rhytidectomy with upward suspension of the superficial musculoaponeurotic system and platysma, along with reduction of skin laxity, is the only valid procedure to treat the manifestations of massive weight loss illustrated in the patient described. Suction lipectomy will only exacerbate complications of decreasing soft-tissue fullness and will have little to no effect on skin tightening.

Answer 30

The correct response is Option C. A youthful, aesthetically pleasing face has an inverted cone or egg shape. With age, the cone is flipped over, and the broader end is situated inferiorly in the square jawline and jowls of the aged face. The concepts and principles of facial aesthetics evolve continually. In the past, the face was thought of in two-dimensional planes or layers that were pulled in various vectors to achieve a more youthful look; the concept of three-dimensional structures is now accepted. The orbital region of youth is full and extends convexly down to the eyelid, ending just above the ciliary border with only a few millimeters of eyelid skin visible. The aged eyelid has diminished upper orbital volume with deep-set sulcus, allowing greater visualization of eyelid skin for up to 1 cm or more. The lower orbital volume diminishes as well, producing the appearance of a lower malar-eyelid junction or long lower eyelid of the aged face. The mid face of youth is marked by convexity of the malar region, which gently curves into the submalar area to produce an inverted cone or egg shape with the narrow aspect at the chin. The youthful neck has a vertical component joined to the horizontal under-jaw, producing an acute angle of 90 degrees or less. As the understanding of the three-dimensional aspects of the youthful and aging face has evolved, so has the treatment.

Answer 31

The correct response is Option B. The ear is innervated by multiple nerves. The great auricular nerve is a branch of C2 and C3. It travels on the superficial surface of the sternocleidomastoid muscle and enters the lower, posterior surface of the ear. Its branches supply the lobule as well as the helix, antihelix, and most of the cranial surface of the ear. The auriculotemporal nerve is a branch of the third division of the trigeminal nerve and enters the ear near the tragus. It supplies the tragus and the root of the helix. The greater occipital nerve, which is a branch of C2 and C3, supplies the posterior scalp. The lesser occipital nerve is also a branch of C2. It sends off an auricular branch that supplies the upper third of the cranial surface of the ear. The vagus (X) nerve supplies the concha via its branch called the Arnold nerve.

Answer 32

The correct response is Option D. In a MACS lift, the SMAS is purse-string sutured to the deep temporal fascia. The MACS lift is a short scar rhytidectomy technique that elevates the deep tissues and skin using a vertical vector only. The skin flap is elevated through a preauricular and pretemporal hairline incision only. Following elevation of the skin, the deep facial tissues are suspended using purse-string sutures into the SMAS tissue. They are then anchored to the deep temporal fascia above the zygomatic arch, avoiding the facial nerve. In the simple MACS lift, two purse-string sutures are placed in the SMAS to correct the neck and lower third of the face. In the extended MACS lift, an additional third purse-string suture is placed in the SMAS to suspend the malar fat pad. As with the SMAS, a vertical vector is utilized to redrape and inset the skin. Although there are many techniques for modification of the SMAS, the MACS lift does not involve SMAS plication, excision, elevation, or SMAS suspension to the zygomatic arch.

Answer 33

The correct response is Option C. The supraorbital nerve has two divisions. The superficial division supplies sensation to the central forehead and hairline. The deep division supplies sensation to the central frontoparietal scalp. The supratrochlear nerve supplies sensation to the nasal radix and part of the central forehead. Both of these nerves are at risk of injury during resection of the corrugator muscles. The auriculotemporal nerve and zygomaticotemporal nerve supply sensation to the temporal scalp. The frontal branch of the facial nerve is a motor nerve and does not have any sensory function.

Answer 34

The correct response is Option B. Hematomas are the most common complication after rhytidectomy and vary from large collections that threaten the viability of the skin flaps, and even the airway, to small collections. The treatment of a hematoma is evacuation. Blood pressure control is the most important preventive measure. Ranking next in importance is the avoidance of medications that interfere with the clotting mechanism, such as ginkgo, garlic, and vitamin E. Every attempt should be made to avoid vomiting, coughing, anxiety, or pain. Drains do not prevent hematomas, but they help in an early diagnosis if the output changes character to frank blood and is increased. Firm compressive dressing is important; however, it must not compromise the viability of the skin flaps.

Answer 35

The correct response is Option A. Removal of excessive fat from the eyelids may improve the convexity of the periorbital region temporarily, but it can cause a cadaveric appearance over the long term. Correction of the tone of the lower eyelid with tightening of the muscle and canthal tendon, combined with correction of the tear trough deformity by fat repositioning over the orbital rim, will lead to a smooth lower eyelid-cheek junction. Ectropion may be caused by involutional or cicatricial changes but is not caused by the absence of fat. Enophthalmos may be caused by an enlarged bony orbit or orbital fat atrophy but is not caused by a lack of preaponeurotic fat. A negative vector is assessed by noting the position of the most anterior projection of the globe as compared to the malar eminence on lateral view of the patient. Patients with negative vectors are predisposed to eyelid malpositioning after blepharoplasty and may require variations in technique, such as conservative skin and muscle resection, lateral canthoplasties, and horizontal eyelid-tightening procedures. A tear trough deformity is the depressed and discolored groove at the junction of the cheek and lower eyelid.

Answer 36

The correct response is Option B. Patients who have excess skin and a negative vector relationship of the globe to the orbital rim are at risk for lower eyelid malposition when undergoing procedures to rejuvenate the lower eyelid. The Hertel ophthalmometer can be used to measure eye prominence. Normal measurement is 15 to 17 mm; a measurement greater than 18 mm is indicative of a prominent globe. In the patient described, the pinch blepharoplasty will remove excess skin. The mid face lift will correct the descended lid-cheek junction and provide support in conjunction with the lateral canthopexy of the lower eyelid. Laser resurfacing will tighten the lower eyelid skin but will have an associated risk for eyelid malposition. It will not correct the descended lid-cheek junction or the nasojugal groove. Placement of an infraorbital rim implant will correct the negative vector relationship but alone will not address the mid face descent or laxity of lower eyelid skin. Skin-muscle blepharoplasty will manage the excess skin, but there is an increased risk of lower eyelid malposition. However, it will not correct the descent of the lid-cheek junction. Transconjunctival blepharoplasty with fat redraping will correct the nasojugal groove but will not address the excess lower eyelid skin.

Answer 37

The correct response is Option A. Performing an anesthetic motor block of the left depressor labii inferioris muscle is the most appropriate initial step in restoring symmetry of the smile of the patient described because it will demonstrate the potential outcome of resection of this muscle. If the patient is satisfied with these temporary results, then longer-lasting (Botox) or permanent resection of the left depressor labii inferioris muscle can be performed. Marginal mandibular nerve palsy is a known complication of facelift procedures. After two years, the neuromuscular junctions in the denervated muscle will not likely recover function. Repairing the nerve will have little effect on the patient €™s smile. Resuspension with a dynamic temporalis sling is adequate for restoration of oral competence and establishment of movement in patients with global facial nerve palsy. It will not likely result in the restoration of a symmetric smile. Although resection of the left oral depressor muscles or transection of the left marginal mandibular nerve may also improve the symmetry of the patient €™s smile, these procedures are permanent and may not have the desired effect.

Answer 38

The correct response is Option E. The earlobe is innervated by the great auricular nerve, which follows closely with the external jugular vein and runs on the same plane. The vein and the nerve run superficial to the platysma and can often be injured while raising the tissue plane for rhytidectomy. Injury can occur when the plane is adherent between the sternocleidomastoid muscle and the lateral border of the platysma muscle. Asymmetry of the lower lip would result from injury to the marginal mandibular nerve, which lies deep to the platysma. The great occipital nerve may also be injured, which would cause numbness of the mastoid area, but this nerve runs in a more posterior direction than the external jugular vein and great auricular nerve. Difficulty swallowing may occur with injury to the ansa cervicalis or to the pharyngeal musculature. Pharyngeal muscles are innervated by the branches of trigeminal (V) nerve running deep within the carotid sheath. Hoarseness would result from injury to the recurrent laryngeal nerve, which runs much deeper along the tracheoesophageal groove, caudal to the thyroid.

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

The correct response is Option B. The galea is analogous to the SMAS layer because the galea-frontalis, temporal parietal fascia, SMAS, orbicularis oculi, and platysma form a continuous single layer. Awareness of this anatomic relationship is essential to avoiding injury to the facial (VII) nerve during dissection for a facelift and browlift. The nerve lies just under the layer of the SMAS, facial muscles, and galea. The deep temporal fascia, innominate fascia, parotid-masseteric fascia, pericranium, and cervical fascia are all part of an analogous, deeper anatomic grouping beneath the more superficial SMAS system.

Answer 44

The correct response is Option B. Because nerves generally are not severed during rhytidectomy, SMAS plication, and suction lipectomy, this patient=s deficit is most likely the result of neurapraxia. With neurapraxia, function normally returns spontaneously within three months. Therefore, a follow-up examination in one month is the most appropriate step at this time. Because the facial (VII) nerve travels deep to the muscles of facial animation, rhytidectomy with dissection in the subcutaneous plane does not pose a risk to the facial nerve branches. Deeper dissection can be more dangerous and should be performed with a clear understanding of the anatomy of the facial nerve. The frontal branch of the facial nerve becomes very superficial as it crosses the zygomatic arch. The other branches become superficial as they exit from within the parotid gland. SMAS surgery superficial to the parotid gland is generally safe. The anterior edge of the parotid gland lies no less than 3.5 cm from the tragus. Submental suction lipectomy is also very safe and poses minimal risk if the cannula stays superficial to the platysma. If the cannula passes beneath the platysma, the marginal mandibular branch of the facial nerve is at risk. Large studies of patients who have had suction lipectomy have shown a low rate (\<1%) of nerve injury. Nerves and blood vessels are generally not severed during suction lipectomy. Physical therapy with nerve stimulation is not necessary because nerve function will return spontaneously. Surgical exploration is not warranted because of the very low probability that the nerve has been severed. Marginal mandibular nerve grafting and temporalis muscle transfer are not indicated for facial reanimation because the deficit is likely to improve spontaneously. Also, temporalis muscle transfer to the right oral commissure would help elevate the commissure but not depress the lip.

Answer 45

The correct response is Option A. After rhytidectomy, skin slough requires careful observation. The injured skin forms an eschar that should be left in place until it begins to separate. The separated eschar may be trimmed as the wound epithelializes, which may take three to four weeks. The other interventions are not needed initially. Debridement is indicated if infection develops beneath the eschar. Skin grafting is used only for large areas of slough that do not close in a reasonable period of time. After skin laxity has returned, scar excision and flap advancement may be indicated to improve the appearance of the scar.

Answer 46

The correct response is A. Less than 2% of rhytidectomy patients are at risk for facial nerve palsy, with an average risk for injury of 0.9%. The buccal branch of the facial nerve is most frequently injured during rhytidectomy. However, the symptoms associated with buccal branch injury are typically subtle, and recovery of sensorimotor function occurs rapidly as a result of the overlapping neural patterns within the upper lip and cheek. The cervical and zygomatic branches of the facial nerve are injured less commonly than the buccal branch. Injury to these branches rarely produces symptoms because of their multiple crossover branches. Injuries to the marginal mandibular and temporal branches of the facial nerve are less common but have more noticeable symptoms; these injuries also resolve more slowly because these branches have minimal overlap with other facial nerve divisions. The marginal mandibular nerve is injured more frequently than the temporal branch because of its greater potential for retraction injury and direct sharp division during dissection of the platysma.

Answer 47

\*\*updated question 2014 demonstrates meta-analysis data that it is helpfor for both The correct response is Option E. Three prospective, randomized controlled trials with sample sizes of 30, 50, and 60 patients were recently undertaken to evaluate the effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy. According to evaluations performed by independent observers immediately after surgery and at a later interval, there was no difference in edema or ecchymosis between the control group and the group in whom corticosteroids were administered perioperatively. Therefore, the evidence that corticosteroids decrease facial swelling remains anecdotal and unsubstantiated. In addition to no demonstrable benefit, this course of treatment is associated with increased cost and risk for complications, including exacerbation of hypertension, deterioration of glucose control, an increased rate of infection, and the potential for avascular osteonecrosis. The studies mentioned above are small and statistically underpowered but provide Level I evidence (ie, prospective, randomized controlled trials) that perioperative administration of corticosteroids is unnecessary to control edema and ecchymosis.

Answer 48

The correct response is Option E. A primary advantage of the endoscopic approach to browlifting is prevention of sensibility changes in the scalp. Coronal incisions, which are performed for standard browlifting techniques, are associated with an increased incidence of postoperative neuralgia and development of neuroma. Because endoscopic browlifting minimizes scalp incisions, these sensory changes do not occur. Preauricular sideburns are affected by rhytidectomy procedures and not by browlifting. The incidence of injury to the frontal branch of the facial nerve, hematoma formation, and postoperative edema is similar with coronal and endoscopic procedures.

Answer 49

The correct response is Option A. This patient’s blepharoptosis is most likely caused by injection of botulinum toxin A into the corrugator supercilii muscle. Botulinum toxin is increasingly used for temporary dispersion of hyperkinetic facial rhytides and furrows. Although it does not replace cosmetic procedures, such as rhytidectomy, skin resurfacing, or soft-tissue augmentation, it can result in facial rejuvenation when used alone or in combination with other treatment options, leading to a more youthful appearance. Glabellar frown lines can be best managed with injection into the medial eyebrows (corrugator muscles). Lateral canthal rhytides (crow’s feet) and horizontal forehead furrows can also be treated. To minimize adverse effects, the surgeon should have a thorough knowledge of the soft-tissue anatomy of the face and the lowest effective doses of botulinum toxin. In this patient who has undergone injection into the corrugator supercilii muscle, diffusion of the toxin into the surrounding levator muscles has occurred, resulting in eyelid ptosis on the left. However, this side effect lasts only for a few weeks, because the dose of migrated toxin to the affected muscle from the site of injection typically becomes significantly reduced. Injection of botulinum toxin into the frontalis, lateral orbicularis oculi, or procerus muscles is not associated with the potential for diffusion into the levator muscles; therefore, eyelid ptosis is not likely. The levator labii superioris muscle is located in the upper lip and would not be injected during facial rejuvenation.

Answer 50

The correct response is Option A. Compared with primary rhytidectomy, secondary rhytidectomy is more likely to result in distortion of the hair line. Incision placement is often difficult in a secondary procedure because of the shifting of the hair line. If the same incision patterns are used, the patient may ultimately develop recession of the temporal hairline, obliteration of sideburn hair, and postauricular alopecia. Therefore, the surgeon should create new incisions when performing secondary rhytidectomy. Although the SMAS is thinner in patients undergoing secondary rhytidectomy, the overall risk for injury to the facial nerve is the same for both procedures. The risk for intraoperative bleeding and hematoma are lower following a secondary procedure than following the initial surgery, as flap dissection is technically easier. Because the facial skin is delayed surgically from the primary procedure, the vascular supply to the cervicofacial skin is typically healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal.

Answer 51

The correct response is Option D. The transverse rhytids along the root of the nose can be improved with resection of the procerus muscle, which originates from the surface of the upper lateral cartilage and nasal bones and inserts into the skin and glabellar region. Contraction of the procerus pulls the forehead downward and the root of the nasal tip upward, causing wrinkling. The corrugator supercilii muscles originate along the periosteum and medial orbital rim and insert into the dermis of the medial eyebrow. They contract to pull the medial brow downward, resulting in vertical glabellar wrinkling. The frontalis muscle is a vertical extension of the galea aponeurosis, which elevates the eyebrows. It inserts on the skin of the forehead, causing transverse forehead rhytids. The orbicularis oculi muscles surround the upper and lower eyelids and do not contribute to any vertical or transverse rhytids of the forehead.

Answer 52

The correct response is Option A. This patient's inability to elevate the left side of the upper lip is most likely caused by injury to the branch of the buccal nerve that innervates the levator labii oris muscle. The buccal nerve branches, which lie superficial to the parotid fascia, are positioned immediately beneath the submuscular aponeurotic system (SMAS) as they cross the masseter muscle and can be easily injured during dissection of the SMAS. Most deficits resulting from buccal nerve injury improve spontaneously over time because of the cross-innervation that occurs in this region. Injury to the cervical branch causes weakening of the platysma, resulting in an asymmetric smile. Injury to the frontal branch manifests as eyebrow ptosis or inability to raise the eyebrow. Because this branch is likely to be terminal, the deficit is often permanent. Injury to the zygomatic branch, which is rare, leads to a decrease in facial animation in the area overlying the zygomaticus major and minor muscles.

Answer 53

The correct response is Option E. In this 52-year-old woman who desires facial rejuvenation, rhytidectomy, temporal lifting, and submental platysmal plication should be performed concomitantly. Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis. The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence. Topical application of retinoic acid and laser resurfacing will not address the soft-tissue component of the face. Rhytidectomy alone will not correct the lateral orbital hooding. Direct resection of platysmal bands and nasolabial folds will result in visible scarring.

Answer 54

The correct response is Option C. The most appropriate management in this patient with "heavy" appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids. Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosis. A coronal approach, which involves resection of skin posterior to the hair line, will actually lengthen the forehead and leave an unsightly scar in a patient with thinning hair. Upper eyelid blepharoplasty will not improve eyebrow ptosis. Injection of botulinum toxin will provide only temporary improvement of the glabellar rhytids.

Answer 55

The correct response is Option A. In this 50-year-old woman who has resorption of the malar soft tissues after undergoing advancement of the malar fat pads, the most likely cause is disruption of the angular artery branches. The angular artery vessels course medially into the fat pad, but branches of the transverse facial artery course deep into the pad. The results of one study showed the angular artery branches to provide the primary vascular supply to the fat pad. In patients undergoing fat pad advancement of more than 2 cm, submalar dissection will result in disruption of the angular vessels. The subdermal plexus cannot supply the vascularity needed in the large malar fat pads, and necrosis will develop. To prevent this, the surgeon should dissect in a cleavage plane superficial to the fat pad and thus sacrifice the subdermal plexus. In patients who have smaller fat pads and who are scheduled to undergo advancement of 2 cm or less, submalar dissection, with the blood supply based in the subdermal plexus, can be performed safely. The internal maxillary artery is one segment of an anastomotic channel supplying blood to the zygomatic, orbital, and transverse facial arteries through an arcade of vessels, receiving their vascular supply from the superior and inferior mesenteric and buccal branches. Disruption of the internal maxillary artery does not lead to necrosis of the malar fat pad.

Answer 56

The correct response is Option C. This 62-year-old woman desires correction of anterior banding of the platysma muscle and excess fat in the preplatysmal region, which has resulted in an obtuse cervicomental angle. This is best accomplished with lipectomy of preplatysmal fat performed concomitantly with anterior platysmaplasty. A small submental incision is made, and the fatty neck deposits can be excised directly or removed via suction lipectomy. Midline plication can then be performed to tighten the platysma muscle; this technique is repeated until the desired effect is achieved. Chin implantation will not improve the appearance of the neck. Direct excision of submental skin may not correct the obtuse cervicomental angle and is most likely to result in visible scarring. Because there is no diastasis of the strap muscles, any corrective procedure that involves these muscles is not an option. Suction lipectomy and injection of botulinum toxin do not address the anterior diastasis of the platysma.

Answer 57

The correct response is Option B. The temporal (or frontal) branch of the facial (VII) nerve courses deep to the superficial temporal fascia in the lateral forehead, above the zygomatic arch, as depicted in the illustration above. This nerve innervates the frontalis muscle. It does not course through the temporalis muscle. It is important to avoid injuring the nerve during rhytidectomy procedures, as injury may result in the development of eyebrow ptosis.

Answer 58

The correct response is Option C. The risk for development of hematoma following rhytidectomy has been reported in various studies to range from 0.3% to 8.1%; however, it is generally reported to occur in approximately 4% of rhytidectomy patients. Male gender and a previous history of hypertension are risk factors. Facial nerve injury is less common, occurring in approximately 1% of patients; hair loss occurs in 1.2% of those undergoing rhytidectomy. Infection is exceedingly rare (0.18% of patients) and is almost always caused by Staphylococcus organisms. Skin slough occurs in approximately 2% of rhytidectomy patients and is more common in those who smoke cigarettes.

Answer 59

The correct response is Option A. The most likely complication associated with secondary rhytidectomy is distortion of the hairline. Hairline shifts, especially in the temporal region, can result in difficulties with incision placement. Redraping of the facial skin superiorly can result in recession of the temporal hairline with elevation of the sideburn above the helical attachment. When planning a secondary rhytidectomy procedure, the anatomy of the hairline, ear lobes, and tragus should be analyzed. The risk for hematoma is lower following a secondary procedure than following the initial surgery, as flap dissection and undermining are easier and associated with less blood loss. Because the facial skin is delayed following primary rhytidectomy, the vascular supply to the cervicofacial skin is usually healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal. Secondary skin flaps are also able to endure greater tension. Most of the contouring performed during secondary rhytidectomy involves tightening of the lax superficial fascia and not the already tightened facial skin. Therefore, the amount of excess skin removed during the repeat procedure will be less, and skin laxity will not be seen.

Answer 60

The correct response is Option B. Pseudoherniation of the buccal fat pad results from a weakening of the buccopharyngeal membrane in which the fat pad is encased. The fat pad, which aids in suckling during infancy and has metabolic characteristics that differentiate it from subcutaneous fat, typically becomes less prominent with facial growth. However, in patients who develop pseudoherniation, there is a visible outpocketing of the fat. Affected patients have a well-demarcated walnut-sized mass in the lower cheek that can be manually reduced into the buccal space. Numerous factors including previous facial surgery, diabetes mellitus, or administration of corticosteroids can lead to a loss of strength of the buccopharyngeal membrane. In patients who have these findings, salivary gland tumors, hemangiomas, abscesses, and lymphadenopathy should first be ruled out. Once this is accomplished, intraoral excision should be performed. The buccinator muscle lies deep to the fat pad and is unaffected. The levator labii superioris and zygomatic muscles are not weakened in patients with pseudoherniation of the buccal fat pad. The parotid fascia lies posterior and superior to the fat pad and also demonstrates normal strength.

Answer 61

The correct response is Option E. The malar region has been divided into five anatomic zones for the purpose of facial analysis. Zone 1, which is comprised of the malar bone and initial third of the malar arch, is the largest zone of the cheek; augmentation in this zone will result in maximal cheek projection and the greatest change in cheek volume. Augmentation in zone 2, the middle third of the zygomatic arch, will result in increased lateral prominence of the cheek bones. A high-arched appearance will be seen because the upper third of the face will be broadened. Augmentation in zone 3, the paranasal zone that lies medial to the infraorbital nerve, will result in medial fullness in the face, producing a "chipmunk cheek" effect. This is rarely indicated for aesthetic purposes. Augmentation in zone 4, or the posterior third of the zygomatic arch, would provide an unnatural appearance to the cheek and should not be performed. Zone 5, also known as the submalar zone, is bordered superiorly by the malar eminence, medially by the lateral border of the nasolabial mound, and inferiorly by the limit of dissection between the masseter muscle and overlying facial muscles. Augmentation of this zone beneath the soft-tissue sulcus will create fullness of the midface, resulting in a more rounded appearance of the cheeks.

Answer 62

The correct response is Option C. Platysmal bands, which were first described more than half a century ago, are often a source of dissatisfaction in patients undergoing rhytidectomy, usually because they are treated inadequately and often recur. Anatomic studies of the platysma have shown a varying pattern of midline decussation as well as medial and lateral pleating caused by laxity of the muscle, which occurs with aging. Consequently, midline mobilization and plication of the muscle through a submental incision is most appropriate for management. In this procedure, a hammock is created, and there is no residual anterior banding. The platysmal bands should be marked with the patient in a sitting position. In patients who have severe lateral banding, a lateral SMAS plication can be performed in addition to the midline plication, but if it is too tight, it will then result in dehiscence of the central plication. A recent study of 200 patients showed a reoperative rate of only 2.5% in patients who underwent midline plication; bowstringing was seen in only 1.5% of patients who underwent treatment with this method. Complications included hematoma (4%), scar revision (3.5%), and infection (2.5%). Direct excision of the bands has had varying results but, in most cases, is inadequate as the sole treatment. This technique results in the formation of a new edge, but the muscle does not tighten with animation. Platysmal bands were treated historically with lateral advancement of the SMAS alone; however, the results were often disappointing. Division of the platysma horizontally above the thyroid cartilage also had undesirable results, leading to a "skeletonized" appearance of the neck, and making the thyroid cartilage more prominent. Suction lipectomy is effective for removal of the submental fat but cannot be used to remove muscle and therefore is not appropriate management of an anterior platysmal band. Z-plasties of the skin and muscle will not change the redundancy and dynamic appearance of the platysmal band; instead, they will result in conspicuous scarring and will not sufficiently change the muscular sling.

Answer 63

The correct response is Option B. Both the position and shape of the brow may be changed following browlifting. Careful preoperative discussion can delineate the patient's aesthetic sense and operative desires. In one study of 11 aesthetic plastic surgeons and 9 cosmetologists who studied photographs of faces altered by computer graphics, both groups of evaluators preferred eyebrows that had a lateral apex rather than medially based apex or a flattened shape. Interestingly, this study also reviewed postoperative pictures of 100 patients in the literature and found that browlift surgery does not usually produce these ideal results. Brows are often too high and medially elevated following surgery. In another study, computer imaging was used to alter the eyebrows of fashion models, and then plastic surgeons and patients were surveyed. The eyebrow preferred by both groups began in a lower position medially and peaked from the lateral limbus to the lateral canthus, beginning its descent by the lateral orbital wall. The aesthetics of male brows were found to be different from the aesthetics of female brows. The male brow is lower, generally at the orbital rim, and the brow is usually horizontal without significant peaking. Familiarity with ideal eyebrow aesthetics will aid in the differential elevation and shape needed in browlifting procedures.

Answer 64

The correct response is Option D. The most appropriate way to manage full-thickness preauricular skin necrosis following rhytidectomy is to let the area fully demarcate and form an eschar. The tissues underneath will contract and heal by secondary intention, and the eschar will slowly lift off and can be trimmed as needed. Excisional debridement a few weeks out from surgery will result in a very large, open wound that is even more traumatic for the patient to accept than an eschar. Placing a skin graft following excision will result in a very obvious cosmetic deformity. Readvancement of the cheek skin would likely be impossible since the skin was already advanced during the initial operation, and tissues are usually swollen, indurated, and fragile a few weeks out from surgery. While the use of hyperbaric oxygen could be contemplated while the skin has not demarcated, once full-thickness necrosis has occurred, as in this scenario, it is of little utility.

Answer 65

The correct response is Option D. The short-scar rhytidectomy technique was developed to decrease both incision length (it does not extend into the postauricular hairline) and recovery times. Studies comparing the full-scar technique with the short-scar technique in identical twins have shown that the short-scar technique has comparable results for the jawline and nasolabial fold, but the full-scar technique leads to a significant improvement in the neck area. The study authors concluded that the short-scar technique may be appropriate for patients whose concerns are limited to the face, including the jawline and the neck, but the full-scar technique is best for patients who have neck concerns. The mid face and superficial musculoaponeurotic system can be addressed similarly through both techniques. While not directly measured in the studies, because the exposure is similar and mid face techniques can be performed through both incisions, one would not expect a difference.

Answer 66

The correct response is Option B. The facial fat compartments are categorized in superficial and deep pads. The superficial compartments are in the forehead (central, middle temporal, and lateral temporal cheek), periorbital (supraorbital and infraorbital), mid face (nasolabial, medial cheek, and lateral temporal cheek), and lower face (superior jowl, inferior jowl, and submental). The deep compartments including the deep midfacial fat compartments include the medial and lateral suborbicularis oculi fat, the deep medial cheek fat (which can be further divided into medial and lateral parts), and the medial portion of the buccal fat pad. According to multiple studies in facial aging, sequence of fat compartment deflation begins with the deep compartments as early as age 40 years. The superficial pads will lose the supporting volume of the deep fat pads, and in some areas such as the nasolabial fat pad, it undergoes hypertrophic changes. Facial fat atrophy in the forehead compartment has been noticed after age 70 years.

Answer 67

The correct response is Option C. This is an example of a cervical branch injury, termed "pseudo-paralysis" of the marginal mandibular nerve, described in two classic papers, initially by Ellenbogen (1979) and detailed by Owsley (2003). This term refers to the clinical situation where an abnormal lower lip posture can be caused by either a marginal mandibular branch or cervical branch problem. Clinical testing can typically sort out the difference between the two. Cervical branch injury can be distinguished from marginal mandibular nerve injury by the fact that the patient will be able to evert the lower lip because of a functioning mentalis muscle. The mentalis is innervated by the marginal mandibular branch, whereas the platysma, which also can function as a lower lip depressor, is innervated by the cervical branch. In Owsley's series of SMAS-platysma (superficial musculoaponeurotic system) rhytidectomies, the incidence of "pseudo-paralysis" due to a cervical branch injury was 1.7% with a full recovery in 100% of cases within a time period ranging from 3 weeks to 6 months. More recently, Sinno and Thorne performed cadaver dissections to further detail the anatomy of the cervical nerve, particularly in relation to commonly performed surgical techniques for rhytidectomy and neck lift. They found the nerve branches to the platysma were given off at "approximately the location of the facial vessels" and that innervation to the medial portion of the platysma remained after all of the tested surgical maneuvers. They postulate that this may be a reason for recurrence of medial platysmal bands.

Answer 68

The correct response is Option A. The diagnosis is Frey syndrome, or gustatory sweating. It is commonly seen after parotidectomy and rhytidectomy or in cases of Bell palsy. The mechanism is the aberrant regeneration of parasympathetic neurons to nearby denervated sweat glands and cutaneous blood vessels. This results in flushing and sweating in response to mastication and salivation. The previous sympathetic responses of sweating and flushing are now controlled by postganglionic parasympathetic fibers. Mastication, which releases acetylcholine from the parasympathetic nerve endings, now induces sweating and flushing, which was a sympathetic cholinergic response before synkinesis of parasympathetic nerve fibers. The facial (VII) nerve is responsible for motor innervation of the face; injury during rhytidectomy or parotid surgery would result in facial asymmetry and weakness. The facial nerve also supplies nerves that are involved in taste to the anterior two-thirds of the tongue and innervates the lacrimal gland. The greater auricular nerve is a superficial branch of the cervical plexus that provides sensory innervation to the skin overlying the parotid gland, external ear, and posterior auricular region. The masseter nerve is a motor branch of the mandibular nerve that innervates the masseter muscle and provides sensation to the temporomandibular joint. The buccal nerve is the only sensory branch of the anterior mandibular division of the trigeminal nerve. It innervates the major part of the buccal mucosa, the inferior buccal gingiva in the molar area, and the skin above the anterior part of the buccinator muscle.

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Cosmetic Facelift 01-22, 24 Flashcards

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