Cosmetic Facelifts Flashcards
A 55-year-old woman comes to the office requesting treatment of fine rhytides due to smoking and photoaging. Topical retinoid therapy is planned. Which of the following effects is most likely to occur with topical retinoid treatment?
A) Decreased collagen production
B) Decreased hyaluronic acid production
C) Thinning of the dermis
D) Thinning of the epidermis
E) Thinning of the stratum corneum
The correct response is Option E.
Tretinoin (all-trans-retinoic acid) is one of the best long-term topical therapies available for chronically photoaged skin. Long-term use of tretinoin is associated with improved skin texture, decreased sallowness, a reduction in fine rhytides and actinic keratoses, fading of pigmented macules, and an overall improvement in skin appearance. Histologic effects of tretinoin include the following: increased epidermal and dermal layer thickness, elimination of dysplasia, atypia, and microscopic actinic keratoses, uniform dispersion of melanin granules, increased collagen and glycosaminoglycan deposition in the papillary dermis, diminished dermal elastosis, angiogenesis, and compaction/thinning of the stratum corneum.
The mechanism of action of retinoids is regulated through specific nuclear receptors. Ultraviolet radiation activates a series of phosphokinases that stimulate c-Fos and c-Jun proto-oncogenes, and thereby activate activator protein 1 (AP-1) transcription factor. AP-1 causes activation of metalloproteases, such as collagenase, gelatinase, and stromelysin which then break down collagen. Tretinoin results in a 70% inhibition of AP-1 transcription factor binding to DNA and a significant reduction in protease activity.
Tretinoin side effects include erythema, photosensitivity, and desquamation. Patients are initially started on a low dose with nightly application until tolerance is achieved. Because tretinoin is a photosensitizer, sunscreen use is absolutely imperative. Topical retinoids should be used for a minimum of 3 to 4 months, with the greatest improvement after 1 year of use. Patients who use alpha-hydroxy acids concomitantly with topical retinoids will see a synergistic effect and this combination is tolerated well in most patients.
2018
A 63-year-old woman undergoes a rhytidectomy with brow lift. Ipsilateral weakness of the forehead muscles is noted in the recovery room. The suspected injury is most likely immediately deep to which of the following?
A) Deep layer of the deep temporal fascia
B) Subdermal connective tissue
C) Superficial layer of the deep temporal fascia
D) Superficial temporal fat pad
E) Temporoparietal fascia
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.
2018
The superficial musculoaponeurotic system is continuous with which of the following?
A) Parotidomasseteric fascia and deep cervical fascia
B) Superficial layer of deep temporal fascia and deep cervical fascia
C) Superficial layer of deep temporal fascia and platysma
D) Temporalis muscle and platysma
E) Temporal parietal fascia and platysma
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.
2018
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?
A) Earlobe ptosis
B) Lop ear deformity
C) Pixie ear deformity
D) Reverse telephone ear deformity
E) Telephone ear deformity
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.
2018
A 50-year-old woman returns to the office 2 weeks after undergoing an endoscopic brow lift and reports numbness in the central forehead. Which of the following nerves is most likely injured?
A) Frontal branch of the facial
B) Infraorbital
C) Supraorbital
D) Zygomaticofacial
E) Zygomaticotemporal
The correct response is Option C.
Central forehead paresthesias are typically related to traction injury to the supraorbital nerve, a division of ophthalmic (V1) nerve. The supraorbital and supratrochlear nerves supply the central forehead. The frontal branch of the facial nerve is a motor nerve to the frontalis muscle and, although at risk during brow lift, it has no sensory supply. The zygomaticotemporal nerve supplies the anterior temporal area. The zygomaticofacial nerve supplies the skin of the lateral orbit and cheek. The infraorbital nerve supplies the central face and upper lip.
2018
A 65-year-old woman comes to the office for consultation regarding rhytidectomy. On physical examination, skin pinch demonstrates greater than 2 inches of excess neck skin on each side of the face. In the illustration shown, all incisions (A to D) begin at the pre-hairline of the temporal area, extend to the tragal edge, and then go around the ear lobule to the posterior auricular sulcus. Which of the following incision paths is most appropriate to correct the patient’s neck deformity?
A) High transverse extending into the posterior scalp
B) Posterior scalp pre-hairline with an inferior extension into the hair-bearing scalp
C) Low transverse in the non-hair-bearing neck skin
D) Extension to the lower aspect of the posterior auricular sulcus
The correct response is Option B.
A patient with significant excess neck skin laxity requires excision of skin. The goals of this surgery must be rejuvenation while maintaining a normal appearing hairline with inconspicuous scars. An incision that follows the hairline of the posterior scalp allows neck skin to be removed without creating irregular and misplaced hair lines. The final extension into the scalp hair allows better camouflage of the end of the scar.
Incision A is appropriate when the excess neck skin is mild to moderate. When there is a large neck skin excess, this incision design will pull non-hair-bearing skin into the scalp.
Incision C will effectively remove excess neck skin; however, the low transverse component leaves a scar that is easily seen.
Incision D stops at the lower retro-auricular sulcus. This incision is used in a short scar facelift. It is effective for improving jowling; however, only minor neck skin laxity can be improved with this technique. A superior vector pull of the face/neck skin is necessary to tighten the neck in a short scar technique. Skin bunching at the ear lobule and skin draping deformities are a risk.
A 24-year-old woman comes to the office requesting facial rejuvenation because of premature aging and extensive cervicofacial skin laxity and skin excess. A congenital cause for this patient’s condition is suspected. This patient is a candidate for elective surgery if the cause of her condition is found to be which of the following disorders?
A) Cutis laxa
B) Ehlers-Danlos syndrome
C) Elastoderma
D) Progeria
E) Werner syndrome
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.
2017
For aesthetic analysis, the face can be divided into which of the following segments?
A) Equal horizontal fifths and vertical fifths
B) Equal horizontal fifths and vertical thirds
C) Equal horizontal thirds and vertical fifths
D) Equal horizontal thirds and vertical thirds
E) There is no regular division of the face into horizontal or vertical proportions
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.
2017
A 55-year-old woman comes to the office for facial rejuvenation surgery. Rhytidectomy with a high superficial musculoaponeurotic system flap and plication of the platysma are planned. In comparison with general anesthesia, the primary advantage of intravenous sedation in this patient is decreased risk for which of the following?
A) Deep venous thrombosis
B) Hematoma
C) Infection
D) Prolonged operative time
E) Skin necrosis
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.
2017
An otherwise healthy 48-year-old woman with no history of smoking comes to an accredited facility to undergo rhytidectomy and neck lift, as well as facial laser resurfacing during general anesthesia. The length of the procedure is 4 hours and 15 minutes, and state regulation allows office-based procedures of this length to be performed in an office-based facility. Which of the following complications is most likely to occur?
A) Cardiac arrest
B) Hospitalization
C) Postoperative nausea and vomiting
D) Reintubation
E) Reoperation
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.
2017
The morphologic appearance of accelerated facial aging seen within 3 years following vascularized composite facial allotransplantation has been shown to be most markedly associated with which of the following processes?
A) Atrophy of fat from the superficial subcutaneous tissue
B) Attenuation of integumentary supporting ligaments
C) Depletion of fat from the deep facial soft-tissue compartments
D) Disproportionate thinning of the epidermis and dermis with pronunciation of facial lines
E) Reduction of bone and non-fat subcutaneous soft tissues
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.
2017
A healthy 64-year-old woman undergoes rhytidectomy with superficial musculoaponeurotic system (SMAS) plication and platysmaplasty. Preoperatively, 150 mL of tumescent solution is infiltrated into the face and neck. In the recovery room, the patient has buccal branch weakness of the right side. Overall facial swelling is noted, but the right side is slightly more swollen than the left side; the swelling and bruising are symmetric. Which of the following is the most appropriate next step in management of the right side of the face?
A) Injection of corticosteroid
B) Percutaneous aspiration
C) Reexploration
D) Release of potential nerve entrapment from sutures
E) Observation only
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.
2016
Accidental division of the great auricular nerve during rhytidectomy most commonly results in which of the following outcomes?
A) Gustatory sweating
B) Inability to elevate the brow
C) Loss of sensation to the temporal scalp
D) Numbness of the earlobe
E) Paralysis of the posterior auricular muscle
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.
2016
A 55-year-old woman comes to the office to discuss a facelift. A rhytidectomy with SMASectomy (superficial musculoaponeurotic system) is planned. Compared with a skin-only facelift, a SMAS tightening procedure is associated with a decrease in which of the following?
A) Facial nerve injury
B) Hematoma formation
C) Infection rate
D) Longevity of result
E) Tension on the skin closure
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.
2016
A 55-year-old woman has pain and weakness of the shoulder, and inability to lift her shoulder girdle 2 weeks after undergoing rhytidectomy, advancement of an extended superficial musculoaponeurotic system flap, and plication of the platysma with complete transection. A nerve injury is suspected. During which of the following parts of the rhytidectomy was the nerve most likely injured?
A) Anchoring the superficial musculoaponeurotic system flap to Lore fascia
B) Dissection of the lateral neck
C) Flap elevation at McKinney point
D) Subplatysmal fat resection
E) Transection of the platysma
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.
2015
A 62-year-old woman comes to the clinic for postsurgical assessment 2 weeks after rhytidectomy. In the right preauricular region, there is a 2 × 3-cm area of ischemic changes to the skin with a central eschar. Which of the following is the most appropriate next step in management?
A) Debridement of the eschar
B) Full-thickness skin grafting
C) Local wound care
D) Re-advancement of the flap
E) Split-thickness skin grafting
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.
2014
A 68-year-old woman comes to the office with recurrence of laxity of the neck and lower face following an uncomplicated rhytidectomy 10 years ago. She does not smoke cigarettes. Which of the following is most likely?
A) Associated comorbid medical conditions are now more likely to be present
B) More skin will typically be excised during the second rhytidectomy than the first rhytidectomy
C) Superficial musculoaponeurotic system (SMAS) layers scarring now precludes the re-elevation of a SMAS flap
D) The thickness of the skin and SMAS layers would be comparable to those seen during the first rhytidectomy
E) Vascular compromise of the skin flap is now more likely
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.
2014
A 62-year-old woman is concerned that she has developed deep creases from the corner of her mouth to her chin (marionette lines). Which of the following is the most likely cause of these findings?
A) Attenuation of mandibular ligaments
B) Dermal thinning
C) Mimetic muscle contraction
D) Viscoelastic stretching
E) Volume deflation
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.
2014
The superficial musculoaponeurotic system invests the platysmal muscle and fuses to the external surface of which of the following?
A) Cervical investing fascia
B) Galea
C) Parotid masseteric fascia
D) Superficial temporal fascia
E) Temporoparietal fascia
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).
2014
A 65-year-old woman undergoes rhytidectomy using a high superficial musculoaponeurotic system technique. On examination 1 hour postoperatively, the patient is unable to raise her right eyebrow. No other abnormalities are noted. The patient’s family is anxious, and they want to call a neurologist. Which of the following is the most appropriate course of action at this time?
A) Administer intravenous corticosteroids
B) Consult a neurologist
C) Order nerve conduction studies
D) Reexamine the patient in 24 hours
E) Surgical reexploration
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.
2014
A 58-year-old woman comes to the office because of muscle weakness of the lower face after undergoing rhytidectomy. Which of the following findings is most likely to indicate an injury to the cervical branch facial nerve in this patient, rather than the marginal mandibular nerve?
A) The patient can still purse her lips
B) The patient has lower lip depression weakness
C) The patient has lower lip numbness
D) The patient has mid-facial weakness
E) The patient has upper lip numbness
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.
2014
A 59-year-old woman comes to the office for evaluation of rhytidectomy for facial aging. Use of a fibrin glue during rhytidectomy is planned. Which of the following is most commonly associated with use of tissue sealants after rhytidectomy?
A) Decreased ecchymosis
B) Decreased period of induration
C) Decreased scar formation
D) Increased drainage
E) Increased edema
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.
2014
A 65-year-old woman comes to the office for consultation regarding facial rejuvenation. She is bothered by deepened nasolabial folds and what she describes as a “hollowness” of her cheeks. Which of the following factors is most important in the development of this patient’s facial aging?
A) Atrophy of the periosteal lining and its effects on the facial bones
B) Deflation of facial fat compartments and attenuation of facial retaining ligaments
C) Increased collagen deposition leading to facial skin changes
D) Loss of tone and volume of the underlying mimetic musculature
The correct response is Option B.
A significant factor that leads to the classic signs of facial aging is the loss of volume, or deflation of the fat compartments of the face in conjunction with attenuation and laxity of the anatomical retaining ligaments of the face, which compartmentalize the fat compartments. These two factors in concert lead to the classic appearance associated with facial aging and the associated description of volume loss and descent of the soft tissues of the face.
It is important to note that facial aging is influenced by both environmental, as well as anatomical factors. Controllable environmental factors, such as smoking, excessive alcohol consumption, extremes of BMI, and excessive unprotected sun exposure, can influence and even accelerate the aging process, but even without the presence of these factors, facial aging will occur due to anatomical changes.
Skeletal changes that occur with age influence the way in which the face appears over time. Numerous studies have evaluated changes in the bones of the orbits, mid face, and mandible and their effects on facial appearance. Not only does the bone structure change and influence appearance, but the effects of these skeletal changes also affect the appearance of the overlying skin and soft tissues, thus having a secondary effect. It is the actual change in facial bone shape, not the overlying periosteum, that causes these age-related changes in facial appearance.
Along with changes under the skin, so too does the skin change during the aging process. Chronic photodamage to the skin results in pigmentary changes as well as epidermal thinning. Dermal changes occur, including collagen disruption as well as collagen loss and increased elastin production.
Utilizing MRI, Gosain et al. disproved the once held notion that loss of volume of the underlying mimetic musculature and atrophy of the periosteum led to facial aging—related volume loss.
Pessa and Rohrich have shown that the retaining ligaments of the face help to compartmentalize the fat compartments of the face. As these fat compartments atrophy over time, one notices facial volume loss. In conjunction with this volume loss, as the retaining ligaments become attenuated, this leads to descent of the fat compartments, which leads to the appearance of skin laxity and deepened folds in specific anatomical sites, such as the nasolabial fold, tear trough, and jowl.
2019
A 55-year-old man is scheduled for a rhytidectomy with an extended superficial musculoaponeurotic system (SMAS) flap and neck lift. In order to avoid injury to the great auricular nerve, which of the following best describes the most likely course of the main branch of the great auricular nerve?
A) Exits the deep neck at the anterior border of the sternocleidomastoid muscle
B) Exits the stylomastoid foramen and emerges through the Lore fascia
C) Lies parallel and posterior to the external jugular vein
D) Lies superficial to the platysma muscle at the anterior border of the sternocleidomastoid muscle
E) Perforates the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus
The correct response is Option C.
The great auricular nerve (GAN) is the most commonly injured named nerve during a rhytidectomy. Multiple studies have estimated the incidence at 6%. The course and avoidance of injury to this nerve is important in minimizing the risks for painful neuroma, allodynia, and permanent numbness. The GAN is a purely sensory nerve that arises from the C2 and C3 spinal roots and then fuses into the main trunk of the GAN. It exits the deep neck along the posterior border of the sternocleidomastoid muscle (SCM) and then travels parallel and posterior to the external jugular vein (EJV). It usually bifurcates into anterior and posterior branches. There are anomalous courses that can occur in rare cases.
Guidelines in avoiding injury of the GAN include the following:
Raising the platysma at the anterior border of the SCM will protect the nerve from injury.
To avoid suture injury to the nerve, platysma/superficial musculoaponeurotic system suspension sutures should be placed posterior to a vertical line drawn from McKinney’s point to a point 1.5 cm posterior to the insertion of the lobule.
The GAN does not perforate the SCM, but lies on top of it. McKinney’s point is located along the midwidth of the SCM approximately 6.5 cm inferior to the external auditory meatus. This represents where the GAN usually exits from beneath the SCM fascia and becomes more superficial and is increasingly susceptible to injury.
At the sternocleidomastoid muscle, the GAN lies deep to the platysma muscle and is a safe location to begin elevation of a platysma flap.
The facial nerve exits the stylomastoid foramen, not the GAN.
2019
