Cosmetic Facelifts Flashcards

1
Q

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
A

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

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2
Q

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

A

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

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3
Q

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

A

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

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4
Q

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
A

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

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5
Q

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
A

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

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6
Q

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

A

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.

2018

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7
Q

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
A

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

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8
Q

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

A

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

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9
Q

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
A

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

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10
Q

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
A

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

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11
Q

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

A

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

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12
Q

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
A

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

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13
Q

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

A

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

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14
Q

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
A

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

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15
Q

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
A

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

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16
Q

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
A

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

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17
Q

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

A

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

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18
Q

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
A

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

19
Q

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
A

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

20
Q

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
A

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

21
Q

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
A

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

22
Q

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
A

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

23
Q

A 75-year-old woman undergoes rhytidectomy for facial rejuvenation. When compared with the skin of a 20-year-old woman, this patient’s results are most likely to show an increase in which of the following?

A) Amount of glycosaminoglycan ground substance
B) Flattening of the dermal-epidermal junction
C) Fraction of Type III collagen
D) Number of keratinizing cells
E) Number of Langerhans cells

A

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.

2013

24
Q

A 65-year-old woman comes to your office because of pain and weakness in the left shoulder 3 months after undergoing cervicofacial rhytidectomy with a different practice. The pain began immediately after the procedure. She has no history of cervical spine disease, neuropathy, diabetes mellitus, rheumatoid diseases, or other trauma. Physical examination shows atrophy of the left trapezius muscle and left shoulder droop. She has full passive range of shoulder motion but limited active abduction. On attempts at active arm abduction, scapular winging is noted. Which of the following is the most appropriate next step?

A) Angiography of the upper extremity
B) Electromyography and nerve conduction study
C) MRI of the glenohumeral joint
D) Nerve blocking of the great auricular nerve
E) Shoulder splinting

A

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.

2013

25
A 60-year-old woman is evaluated in the recovery room during the first hour after rhytidectomy, plication of the platysma, and malar fat grafting. On examination, the patient's mouth appears crooked when she speaks. Moderate diffuse swelling of the mid face and weakness of the right lower lip are noted. Which of the following is the most appropriate next step in management? ``` A) Administration of methylprednisolone B) Consultation with a neurologist C) Reexploration D) Removal of the tension sutures E) Observation only ```
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. 2013
26
A 67-year-old woman comes to the office because of an asymmetric smile 1 week after undergoing rhytidectomy and neck lift. Physical examination shows that the left lower lip is lower than the right lower lip in a full-denture smile. Which of the following nerves is most likely injured? ``` A) Left cervical B) Left marginal mandibular C) Mental D) Right cervical E) Right marginal mandibular ```
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. 2012
27
A 52-year-old woman comes to the office 4 days after undergoing a sub-superficial musculoaponeurotic system rhytidectomy. Examination shows an asymmetric full-denture smile. Lip depressor function is normal on the right and absent on the left. Eversion of the lip is normal. Which of the following is the most appropriate initial management? A) Electromyography B) Operative exploration for cervical branch transection C) Operative exploration for marginal mandibular branch transection D) Paralysis of right lip depressors with botulinum toxin type A E) Observation
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. 2012
28
A 54-year-old woman comes to the office because she is unhappy with the appearance of her forehead 1 year after undergoing endoscopic brow lift surgery and upper and lower blepharoplasty. She says there is an indentation between her eyebrows when she frowns. Physical examination shows irregular dimpling in the glabellar area upon frowning. Which of the following is the most likely cause of this patient's postoperative outcome? ``` A) Excessive removal of muscle B) Inadequate removal of muscle C) Non-matching suspension forces D) Overelevation of the eyebrows E) Underelevation of the eyebrows ```
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. 2012
29
A 46-year-old woman is referred for evaluation regarding neck rejuvenation. Physical examination shows a full neck with an indistinct mandibular border and an obtuse cervicomental angle. Which of the following is the most likely cause of this obtuse angle in this patient? ``` A) Anteriorly displaced chin B) High position of the hyoid bone C) Increased preplatysmal fat D) Posteriorly displaced thyroid cartilage E) Ptosis of the submandibular gland ```
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. 2012
30
A healthy 68-year-old woman comes to the office because she is unhappy with the aged appearance of her forehead. She does not smoke cigarettes. Physical examination shows transverse rhytides across the forehead with deep glabellar creases. Forehead height is 11 cm. Which of the following is the most appropriate approach for brow lift surgery in this patient? A) Endoscopic B) Open coronal C) Open pretrichial D) Transpalpebral
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. 2011
31
A 63-year-old woman comes to the office for follow-up evaluation 1 week after undergoing extended superficial musculoaponeurotic system rhytidectomy. On physical examination, the patient can purse the lips symmetrically, but lower depressor weakness of the right angle of the mouth with a full-denture smile is noted. Which of the following branches of the facial nerve was most likely injured during the procedure? ``` A) Frontal B) Zygomatic C) Buccal D) Marginal mandibular E) Cervical ```
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. 2011
32
A 50-year-old woman comes to the office because she is unhappy with the lax appearance of her neck (shown) after massive weight loss. Which of the following is the most appropriate management? ``` A) Dermabrasion B) Fat grafting C) Laser treatment D) Rhytidectomy E) Suction lipectomy ```
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. 2011
33
Which of the following is characteristic of the youthful face when compared to the elderly face? ``` A) Concavity of the malar region B) Deep-set upper orbital sulcus C) Egg-shaped face (narrow end down) D) Long position of the lower eyelid-malar junction E) Obtuse submental angle ```
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. 2011
34
A 52-year-old woman has numbness of the left earlobe 2 weeks after undergoing rhytidectomy. Which of the following nerves was most likely injured during the procedure? ``` A ) Auriculotemporal B ) Great auricular C ) Greater occipital D ) Lesser occipital E ) Vagus ```
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. 2010
35
A 47-year-old woman with moderate jowling and minimal cervical skin redundancy undergoes a minimal access cranial suspension (MACS) lift. Which of the following is the most appropriate description of the management of this patient's superficial musculoaponeurotic system (SMAS)? A ) Anchoring to the zygomatic arch B ) Division and excision C ) Elevation and rotation to the mastoid D ) Purse-string suturing to the deep temporal fascia E ) Suspension to the orbital rim
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. 2010
36
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
37
A 55-year-old man is scheduled for a rhytidectomy with an extended superficial musculoaponeurotic system (SMAS) flap and neck lift. In order to avoid injury to the great auricular nerve, which of the following best describes the most likely course of the main branch of the great auricular nerve? A) Exits the deep neck at the anterior border of the sternocleidomastoid muscle B) Exits the stylomastoid foramen and emerges through the Lore fascia C) Lies parallel and posterior to the external jugular vein D) Lies superficial to the platysma muscle at the anterior border of the sternocleidomastoid muscle E) Perforates the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus
The correct response is Option C. The great auricular nerve (GAN) is the most commonly injured named nerve during a rhytidectomy. Multiple studies have estimated the incidence at 6%. The course and avoidance of injury to this nerve is important in minimizing the risks for painful neuroma, allodynia, and permanent numbness. The GAN is a purely sensory nerve that arises from the C2 and C3 spinal roots and then fuses into the main trunk of the GAN. It exits the deep neck along the posterior border of the sternocleidomastoid muscle (SCM) and then travels parallel and posterior to the external jugular vein (EJV). It usually bifurcates into anterior and posterior branches. There are anomalous courses that can occur in rare cases. Guidelines in avoiding injury of the GAN include the following: 1. Raising the platysma at the anterior border of the SCM will protect the nerve from injury. 2. To avoid suture injury to the nerve, platysma/superficial musculoaponeurotic system suspension sutures should be placed posterior to a vertical line drawn from McKinney's point to a point 1.5 cm posterior to the insertion of the lobule. The GAN does not perforate the SCM, but lies on top of it. McKinney’s point is located along the midwidth of the SCM approximately 6.5 cm inferior to the external auditory meatus. This represents where the GAN usually exits from beneath the SCM fascia and becomes more superficial and is increasingly susceptible to injury. 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
38
A 54-year-old woman undergoes a rhytidectomy with a SMAsectomy (superficial musculoaponeurotic system). The drains are removed on postoperative day 2. Several days later, significant fluid collection is noted on the right side, and the fluid is aspirated and appears clear. The fluid collection continues to recur, and analysis shows extremely high amylase levels. On examination, the parotid duct is intact. A bland diet is suggested, and a scopolamine patch is applied. Which of the following additional treatments is most likely to help improve this patient’s condition? ``` A) Anti-inflammatory medication B) Botulinum toxin type A injections C) Direct surgical repair of the injury D) Nerve grafting of the injury E) Surgical evacuation of the fluid ```
The correct response is Option B. This patient has a salivary leak secondary to direct injury to the parotid gland, either from dissection or a suture being placed through the gland. Although typically self-limiting, these injuries can be frustrating to treat and upsetting to the patient. Treatment is directed at minimizing salivary secretions as much as possible by multimodal therapy while spontaneous healing is allowed to occur. Surgical treatment is not indicated and may cause further damage, thus exacerbating the situation. Spontaneous resolution is the general rule, although it may take several weeks and even months. Common treatment modalities to minimize salivary secretions include regular percutaneous drainage of the collection or placement of a temporary drain. In addition, compression is useful and should be maintained as much as tolerated. Antihistamines and scopolamine patches are used to slow down and minimize salivary production. A bland diet and avoiding sour, spicy, or acidic foods also helps to minimize excessive secretions. Recently, botulinum toxin type A injections directly into the gland have been used successfully to minimize salivary secretions. 2019
39
A 27-year-old woman comes to the office with concerns about aesthetic deformity of the neck. Despite appropriate lifestyle modifications and BMI less than 25 kg/m2, the patient has an obtuse cervicomental angle caused by accumulation of preplatysmal adipose tissue. The patient opts for nonsurgical management of the submental fullness by undergoing treatment with deoxycholic acid (DCA). Which of the following best describes the mechanism of action of this agent? ``` A) Disruption of cellular membrane B) Injury to endoplasmic reticulum C) Irreversible binding to cellular mitochondrion D) Protein binding of Golgi apparatus E) Targeted injury to cell nucleus ```
The correct response is Option A. Deoxycholic acid (DCA) disrupts adipocyte cell membranes when injected subcutaneously into fat, inducing an inflammatory response to clear cellular debris and liberated lipids from the injection site. DCA is a nonspecific cytolytic agent that injures tissue by injuring the cellular membrane of cells that come into contact with the naturally found substance. ATX-101 was FDA approved in the United States and Canada in 2015 for treatment of patients diagnosed with moderate to severe amounts of fat accumulating in the submental fat pad. The treatment is a series/protocol of up to six treatments in patients requesting nonsurgical management of submental fullness. Patients are selected based on candidacy and their desire to avoid surgery. A youthful patient with mild to no skin laxity, minimal post-platysmal fat, mild to no digastric muscle hypertrophy, and minimally enlarged submandibular glands is a good candidate for the treatment. Mitochondria, responsible for energy metabolism within the cell, act as signaling organelles. Mitochondrial dysfunction may lead to cell death and oxidative stress and may disturb calcium metabolism. The nucleus is the control center of the eukaryotic cell. The sequestering of genetic material within the nucleus of the eukaryotic cell provides the nucleus with a powerful mechanism for the regulation of gene expression and other cellular processes through selective translocation of proteins between the nucleus and cytoplasm. There are various drugs that act on DNA to prevent its replication and to decrease or inhibit transcription of a variety of important genes. However, a therapeutic molecule, even if delivered inside the target cell, often fails to reach its subcellular target. The Golgi apparatus (GA) is the central organelle of the cell secretory pathway and interacts with the endoplasmic reticulum (ER). The GA carries out posttranslational modification of newly synthesized proteins by employing various enzymes for phosphorylation, acylation, glycosylation, methylation, and sulfation. The ER is a network of folded membrane-enclosed tubules and sacs (cisternae) that extend from the nuclear membrane throughout the cytoplasm. Its primary function is to facilitate the folding of secretory and membrane proteins. Additionally, it is involved in calcium storage and signaling, and has been shown to play a role in apoptosis regulation against disturbances in calcium homeostasis, ischemia, hypoxia, exposure to free radicals, oxidative stress, elevated protein synthesis, and gene mutations. Several different types of drugs target these organelles, but these cellular components are not the target of deoxycholic acid. 2019
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A 55-year-old woman is evaluated for facial rejuvenation. She is concerned about brow ptosis and dynamic frown lines. Physical examination shows brow ptosis, dynamic and static frown lines, a long forehead, and thick hair. Which of the following is the best approach for brow lift surgery for this patient? ``` A) Endoscopic B) Endotemporal C) Pretrichial D) Transcoronal E) Transpalpebral ```
The correct response is Option C. The pretrichial incision is the appropriate approach to perform a brow lift and to address a long forehead. Of the options listed, the pretrichial incision alone can specifically address a long forehead. An endotemporal approach is useful for patients with thin hair or lateral ptosis, and endoscopic and transpalpebral approaches are useful for a brow lift but cannot address a long forehead. A transcoronal incision is most useful in a patient with a short forehead and deep rhytides. 2019
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A 48-year-old woman with moderate neck skin laxity, little submental fat, moderate cheek laxity, and moderate jowling undergoes short scar rhytidectomy using the two-suture minimal access cranial suspension technique. At completion of skin closure, a vertical fold of excess skin on the lateral neck is visible near the earlobe. Which of the following is the best method to address the vertical fold of skin? A) Extend the rhytidectomy incision postauricularly, with excision of excess skin B) Place a third purse-string superficial musculoaponeurotic system (SMAS) plication suture C) Re-rotate the cheek flap superiorly D) Use a subsideburn wedge excision E) Observe only
The correct response is Option A. One of the potential drawbacks of the short scar rhytidectomy is in patients with significant skin excess. When a postauricular incision is not made, as in the classic minimal access cranial suspension technique, a vertical fold of excess skin may result in the lateral neck area, inferior to the earlobe, in patients who have moderate to severe neck laxity. This is best treated by extending the incision posteriorly in the traditional postauricular direction, elevating a postauricular skin flap, and excising the excess. Reopening the incision and rotating the flap will accentuate closure difficulties in the visible temporal area and will not address the horizontal neck skin excess. The third purse-string suture, described in the extended MACS lift, is used for mid face correction and does not help the skin excess. A subsideburn wedge excision, while a useful technique for vertical elevation of the cheek flap, does not provide the correct vector of pull for this problem. Observation only is not recommended, as the dog ear tends to persist and not resolve. 2019
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A healthy 62-year-old woman presents 1 week after undergoing uneventful rhytidectomy because her smile is now asymmetric. On physical examination, the left lower lip does not depress on smiling. Which of the following is the most appropriate management of this complication? A) Evaluate the patient for a cerebrovascular accident B) Explore the left cheek and neck for entrapment of the marginal mandibular nerve C) Perform a nerve conduction study to assess the marginal mandibular nerve D) Refer the patient to a physical therapist who specializes in facial reanimation training E) Reassure the patient that her smile should return to normal within 3 to 6 months
The correct response is Option E. Injury to the marginal mandibular nerve can result in inability to depress the affected side of the lower lip. Nerve dysfunction may be attributable to traction, cautery, sutures, or surgical division. Spontaneous recovery is usually noted within 3 to 4 months. Usually, careful reassurance and close follow-up are necessary. Physical therapy would offer little benefit. A nerve conduction study also is likely to provide little additional information and no benefit especially one week after surgery. Without concern for intraoperative division of the nerve, surgical exploration should be delayed for several months to allow for nerve recovery. 2019
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A 52-year-old woman comes to the office after undergoing uncomplicated rhytidectomy 1 week ago. The patient reports that she cannot feel her left earlobe. Damage to a sensory nerve is suspected. The affected nerve was most likely injured intraoperatively in which of the following locations? A) Along a line from the external auditory canal to the lateral edge of the inferior orbit B) At the anterior border of the sternocleidomastoid muscle C) Half the distance from mastoid process to the clavicular origin of the sternocleidomastoid muscle D) One centimeter caudal to the external jugular vein as it crosses the sternocleidomastoid muscle E) One-third the distance from external auditory canal to the clavicular origin of the sternocleidomastoid muscle
The correct response is Option E. The great auricular nerve (GAN) is the most commonly injured nerve in rhytidectomy. The GAN complication rate is approximately 6.5%. GAN injury can result in pure anesthesia, partial parasthesia, as well as painful neuromas in the distribution of the nerve. Permanent complete numbness has been reported in up to 5% of patients. This may cause difficulty wearing earrings, using the telephone, shaving, or combing one's hair. Although not as catastrophic as a facial nerve injury, this complication can present as a functional impairment and nuisance to the patient and surgeon alike. It is critical to be aware of this nerve when embarking upon rhytidectomy in order to prevent iatrogenic injury. Once the GAN emerges onto the anterior surface of the sternocleidomastoid muscle, it resides in a superficial plane and is vulnerable to injury during elevation of facial flaps. The GAN is found at its most superficial location approximately one third the distance from the external auditory canal to the clavicular origin of the sternocleidomastoid (SCM). A similar distance ratio exists from the mastoid process to the clavicular origin of the SCM. It also lies approximately one centimeter cranial to the external jugular vein on the anterior surface of the sternocleidomastoid muscle. With these anatomical landmarks, the surgeon can accurately predict the location of the GAN at its most vulnerable site and reliably proceed with flap dissection in the lateral neck during rhytidectomy procedures. Frankfort's line is a cephalometric measurement that runs from the external auditory canal to the lateral edge of the inferior orbit and would be too cranial a location to find the GAN. 2019